Kyphoplasty is a minimally invasive surgical procedure designed to treat vertebral compression fractures (VCFs), most commonly associated with osteoporosis. These fractures can lead to severe pain, deformity, and decreased quality of life. Kyphoplasty aims to restore vertebral height, stabilize the fracture, and reduce pain. This article delves into all aspects of kyphoplasty, from indications and preoperative evaluation to surgical techniques, postoperative care, complications, and recent advances. Indications for Kyphoplasty Kyphoplasty is primarily indicated for patients with painful vertebral compression fractures. The most common cause of these fractures is osteoporosis, but other causes include metastatic cancer, multiple myeloma, and traumatic injury. Key indications for kyphoplasty include: Symptomatic Vertebral Compression Fractures: Patients with acute or subacute pain due to compression fractures are prime candidates for kyphoplasty. The procedure is most effective within eight weeks of the fracture. Failed Conservative Treatment: Kyphoplasty is considered when conservative treatments such as bed rest, analgesics, or bracing fail to relieve pain after a few weeks. Progressive Vertebral Collapse: Patients showing signs of progressive vertebral body collapse or worsening kyphosis may benefit from kyphoplasty to prevent further deformity. Vertebral Body Height Loss: Kyphoplasty can be beneficial in cases where significant loss of vertebral body height has occurred, leading to spinal deformity and increased risk of further fractures. Preoperative Evaluation A thorough preoperative evaluation is crucial to determine the suitability of kyphoplasty for each patient. This includes: Clinical Assessment: A detailed medical history and physical examination focusing on the patient’s symptoms, duration of pain, and any neurological deficits. The assessment should also evaluate the patient’s overall bone health and risk factors for osteoporosis. Imaging Studies: X-rays: Initial imaging with X-rays helps to confirm the presence of a vertebral compression fracture and assess the degree of kyphosis. MRI: MRI is essential for evaluating the acuity of the fracture, the presence of edema, and ruling out other causes of back pain such as disc herniation or spinal cord compression. CT Scan: CT scans provide detailed images of the bone structure and are useful in planning the procedure, especially in complex cases. Bone Density Testing: Dual-energy X-ray absorptiometry (DEXA) scans should be performed to assess bone mineral density and confirm osteoporosis as the underlying cause of the fracture. Laboratory Tests: Routine preoperative laboratory tests should include a complete blood count, coagulation profile, and renal function tests. Additional tests may be required based on the patient’s medical history. Contraindications While kyphoplasty is a beneficial procedure for many patients, there are specific contraindications that must be considered: Asymptomatic Compression Fractures: Kyphoplasty is not recommended for patients with vertebral compression fractures that do not cause pain. Severe Vertebral Collapse: If the vertebral body has collapsed to less than one-third of its original height, kyphoplasty may not be effective. Infection: Active spinal infections such as osteomyelitis or discitis are contraindications for kyphoplasty due to the risk of spreading the infection. Neurological Deficits: Patients with significant neurological deficits due to spinal cord or nerve root compression require a more extensive surgical approach rather than kyphoplasty. Coagulopathy: Patients with bleeding disorders or those on anticoagulant therapy that cannot be safely managed perioperatively may not be suitable candidates. Surgical Techniques and Steps Kyphoplasty involves several key steps, which must be meticulously followed to ensure the best outcomes for the patient: Patient Positioning: The patient is placed in the prone position on a radiolucent table, allowing for optimal access to the vertebral body and accurate imaging. Anesthesia: Kyphoplasty can be performed under local or general anesthesia, depending on the patient’s overall health and the complexity of the case. Percutaneous Access: Using fluoroscopic guidance, a small incision is made, and a working cannula is inserted into the vertebral body through a transpedicular or extrapedicular approach. Balloon Inflation: A balloon tamp is inserted through the cannula and carefully inflated within the vertebral body. This creates a cavity and helps to restore vertebral height, reducing kyphosis. Cement Injection: Once the cavity is prepared, polymethylmethacrylate (PMMA) bone cement is injected into the void under low pressure. The cement quickly hardens, stabilizing the fracture and preventing further collapse. Closure: The cannula is removed, and the small skin incision is closed with sutures or adhesive strips. The entire procedure typically takes 30 to 60 minutes per vertebra. Postoperative Care Postoperative care is crucial to ensuring successful outcomes and minimizing complications: Immediate Postoperative Period: Patients are monitored for any immediate complications such as cement leakage or neurological deficits. Pain management is provided, and most patients can be discharged on the same day or after a brief overnight stay. Activity Restrictions: Patients are advised to avoid heavy lifting and strenuous activities for several weeks postoperatively. Gradual return to normal activities is encouraged. Physical Therapy: Early mobilization and physical therapy can help improve functional outcomes. Strengthening exercises for the back muscles are recommended to support spinal stability. Follow-up: Regular follow-up appointments are necessary to monitor the patient’s progress, assess for any complications, and manage osteoporosis to prevent further fractures. Possible Complications While kyphoplasty is generally safe, potential complications include: Cement Leakage: One of the most common complications, cement leakage can occur into the spinal canal or adjacent disks, potentially causing nerve compression or embolization. Infection: Though rare, there is a risk of infection at the puncture site or deeper within the spine. Adjacent Level Fractures: The altered biomechanics of the spine following kyphoplasty can sometimes lead to fractures in adjacent vertebral levels. Neurological Injury: Although uncommon, improper needle placement or cement leakage can lead to nerve root or spinal cord injury, resulting in neurological deficits. Allergic Reactions: Reactions to the bone cement or other materials used during the procedure can occur in rare cases. Different Techniques Kyphoplasty has evolved, and several techniques have been developed to enhance outcomes: Bipedicular vs. Unipedicular Approach: The traditional bipedicular approach involves accessing the vertebral body from both sides, while the unipedicular approach accesses it from one side. The choice depends on the fracture’s location and the surgeon’s preference. Vertebral Augmentation: In some cases, additional materials such as hydroxyapatite or calcium phosphate may be used to augment the vertebral body and promote bone healing. Navigated Kyphoplasty: The use of image-guided navigation systems has improved the precision of needle placement and reduced the risk of complications. Balloon-Expandable Stents: In some instances, stents are deployed within the vertebral body to provide additional support before cement injection. Prognosis and Outcome Kyphoplasty offers excellent outcomes for most patients, with significant pain relief and improved quality of life. The procedure has a high success rate in restoring vertebral height and reducing kyphosis, leading to better spinal alignment and reduced risk of future fractures. Long-term outcomes are favorable, especially when combined with ongoing management of osteoporosis. Alternative Options For patients who are not suitable candidates for kyphoplasty, alternative treatments include: Vertebroplasty: A similar procedure where cement is injected into the fractured vertebra without balloon inflation. Vertebroplasty is typically used for fractures with minimal height loss. Conservative Management: Pain management, bracing, and physical therapy may be sufficient for some patients, particularly those with stable fractures. Surgical Stabilization: In cases of severe deformity or neurological compromise, open surgical stabilization with instrumentation and fusion may be required. Average Cost The cost of kyphoplasty can vary depending on factors such as geographic location, the number of vertebrae treated, and the healthcare facility. On average, the procedure can range from $10,000 to $15,000 per vertebra, including hospital fees, surgeon’s fees, and anesthesia costs. Insurance coverage may significantly reduce out-of-pocket expenses for eligible patients. Recent Advances Recent advancements in kyphoplasty include: 3D Printing: Customized implants and tools created using 3D printing technology offer improved precision and patient-specific treatment options. Biodegradable Cements: Research is ongoing into the use of biodegradable cements that may offer similar benefits to PMMA while reducing long-term complications. Robotics: Robotic-assisted kyphoplasty is being explored to enhance the accuracy and safety of the procedure. Biologic Augmentation: The use of biologics such as bone morphogenetic proteins (BMPs) in conjunction with kyphoplasty is being studied to promote bone healing and reduce the risk of future fractures.
