Vertebroplasty and Kyphoplasty – Benefits and risks

Vertebroplasty Kyphoplasty

Summary

Vertebroplasty and kyphoplasty are minimally invasive forms of spine surgery used to treat pain resulting from compression fractures of the spine (vertebrae).

Vertebral compression fractures are usually caused by osteoporosis. This disease causes 700,000 vertebral fractures each year in the United States, according to the National Osteoporosis Foundation. Patients may experience limited mobility, a reduction in height, stooped posture, kyphosis (exaggerated forward curve in the upper back), reduced breathing capability and back pain.

Prior to performing a vertebroplasty or kyphoplasty, a physician must determine the cause of a patient’s back pain. This is because vertebroplasty and kyphoplasty do not help other spinal conditions that can cause back pain, such as herniated discs  or severe arthritis. Certain imaging tests such as x-rays, MRIs or CAT scans are usually performed to confirm the presence of a vertebral compression fracture and to rule out the presence of other possible causes for the pain.

If such a fracture exists, conservative treatments (e.g., bed rest, analgesics, back bracing) may first be attempted. If these treatments are ineffective, or a patient’s pain is severe, a vertebroplasty or kyphoplasty may be recommended.

During a vertebroplasty, a hollow needle is used to fill the damaged vertebrae with a cement-like material. The cement fills cavities and cracks in the bone, dries and fuses the crushed bone pieces into a single, solid structure. This stabilizes and strengthens the area, reducing or eliminating a patient’s pain and improving mobility.  

Kyphoplasty is similar to vertebroplasty, but before injecting the cement, an uninflated balloon-like device is inserted into the area. When the balloon is inflated, it restores height to the vertebrae. It is then deflated and removed, and the open space it leaves behind is filled with cement. This restores vertebral height, which can restore lost height or lessen spinal deformities a patient may have due to the compression fracture.

Vertebroplasty is often recommended for patients with vertebral compression fractures who are experiencing pain that is not responsive to conservative treatment methods (e.g., bed rest, back brace, analgesics, physical therapy). Kyphoplasty is usually reserved for patients who also have spinal deformities such as a significantly stooped posture or kyphosis.

Vertebroplasty and kyphoplasty are most often performed as outpatient procedures. The procedure can take a few hours, before a patient is allowed to leave the healthcare facility. Many patients experience immediate pain relief. Follow-up spinal x-rays are usually performed to check the status of the repaired and neighboring vertebrae.

Although generally considered safe, there are risks of complications from vertebroplasty and kyphoplasty. These include cement leakage (which may increase a patient’s pain), an immune system reaction to the cement, and the formation of blood clots. Patients should consult their physician about the risks and benefits of the procedures to determine the most appropriate treatment for them.

About vertebroplasty and kyphoplasty

Vertebroplasty and kyphoplasty are minimally invasive forms of spine surgery used to repair compression fractures of vertebrae. They stabilize and strengthen fractured spinal bones, reducing a patient’s pain and increasing physical functioning.

A compression fracture occurs when weakened vertebrae break and collapse. This crushing of bone tissue causes the affected vertebrae to be shorter than others, and puts additional pressure on other vertebrae. When the front of the vertebrae collapse, the spine shortens and falls forward. The vertebrae in the chest area and lower spine tend to be most affected by compression fractures.

Vertebral compression fractures usually result from the loss of bone mass and density due to osteoporosis. As osteoporosis progresses, the weight of the head, neck and chest may be enough to cause the bones in the back to fracture during daily activities, such as getting out of a car or turning over in bed. According to the National Osteoporosis Foundation, the disease causes 700,000 vertebral fractures each year in the United States. Other possible causes of vertebral compression fractures include tumors and physical trauma to the spine.

Vertebral compression fractures can have varying signs and symptoms. A patient may experience acute back pain. The pain is likely to be worse when standing due to added pressure on the vertebrae. In addition, touching the area can cause pain. Other possible indicators of vertebral fractures include limited mobility, a reduction in the patient’s height, stooped posture, kyphosis (exaggerated forward curve in the upper back) and reduced breathing capability. If the vertebral compression fracture puts pressure on the nerves, it may also cause leg pain. Pressure on the lungs can cause breathing problems.

Many vertebral compression fractures eventually heal themselves. In cases where a patient’s pain is severe or does not respond to noninvasive techniques (e.g., bed rest, back brace, analgesics), a vertebroplasty or kyphoplasty may be recommended. The use of opioid pain relievers may be discouraged for older patients, as this may increase the risk of accidental falls and more bone fractures.

Vertebroplasty was developed and first used in the early 1980s. In this procedure, a special cement-like material is injected into a collapsed vertebra. The cement fills hollow spaces and cracks in the bone and solidifies the pieces into one hard structure. The cement used in a vertebroplasty is generally less dense (more runny) than that used in kyphoplasty. This allows easier diffusion of the material, allowing it to get into all areas around the crushed bones. The cement essential forms an internal cast, stabilizing fractured bones.

Kyphoplasty is similar, but before the cement is injected, a balloon-like device is introduced into the area and inflated within the damaged vertebra. This helps to restore the height of the damaged vertebra. How much height can be restored may depend on the age of the fracture. The balloon is then removed and the cavity is filled with the cement. The advantage of kyphoplasty over vertebroplasty is that it can restore vertebral height, helping a patient to regain lost height and/or lessen spinal deformity due to the compression fracture.

Vertebroplasty is often recommended for patients with vertebral compression fractures who are experiencing pain that is not responsive to conservative treatment methods. Kyphoplasty is usually reserved for patients who also have spinal deformities such as a significantly stooped posture or kyphosis.

These procedures are designed to treat compression fractures of the spine. They do not help other spinal conditions that can cause back pain, such as herniated discs or severe arthritis. In addition, neither procedure is recommended for patients with active infections or blood-clotting disorders. Patients with fractures that have already healed are unlikely to benefit from these procedures. 

In addition, timing of treatment is important. Vertebroplasty and kyphoplasty appear to be most effective within three months of the fracture (when a patient’s symptoms began).

Vertebroplasty and kyphoplasty are typically performed as outpatient procedures. The procedure can take about an hour for each vertebra repaired. Multiple vertebral fractures may be repaired in a single visit.

Some people treated with vertebroplasty or kyphoplasty experience complete or significant pain relief and are able to return to activities they enjoyed prior to the fracture.

During the vertebroplasty or kyphoplasty

A typical procedure begins with the patient lying face down, although other positions may be used if necessary. An intravenous sedative may be used in conjunction with local anesthesia applied where the injection will occur. Fluoroscopic x-rays and/or CAT scans (computed axial tomography) may be used during the procedure to guide needle placement.

During a vertebroplasty, a hollow needle is inserted through the skin of the back and into the crushed vertebrae. A mixture of a contrast agent and cement-like material is injected directly into the fractured vertebra. The contrast agent provides a physician a clearer view of the area upon imaging, and helps the physician to avoid blood vessels during the procedure. The cement fills cavities and cracks in the bone and the needle is removed. The cement then cures and fuses the fractured bone pieces into a single, solid structure.

Kyphoplasty is similar to vertebroplasty. The primary difference is the insertion of an uninflated balloon-like device into the fractured vertebra prior to injecting the cement. When the device is in place, it is inflated, returning height to the vertebra. The balloon is then deflated and removed, and the open space it created in the vertebra is filled with cement. In many cases, kyphoplasty helps patients regain some lost height or lessen spinal deformation due to vertebral compression fractures.   After cement has been injected into the area, a patient is generally required to lie flat until the cement can harden, and to avoid cement leakage from the area. This may take one to two hours. The patient is then assessed for pain relief. The vertebrae may be examined by x-ray. After the area is adequately supported by the hardened cement, patients will be able to leave the healthcare facility, although they will need someone to drive them home.

After the vertebroplasty or kyphoplasty

Some patients experience immediate relief from pain after a vertebroplasty or kyphoplasty. Sometimes, it may take a few days before pain relief is experienced. However, they may feel pain at the site of the needle insertion for up to a week after the procedure. Applying ice to the area may help relieve soreness.

Most people are able to resume regular activities within 24 hours after the procedure. Patients may be advised to avoid any heavy lifting for several weeks after the procedure. A follow-up visit and spinal x-ray may also be recommended to check the status of the repaired and neighboring vertebrae.

Potential benefits and risks of the procedure

Vertebroplasty and kyphoplasty procedures offer patients a way to reduce pain. However, there is no guarantee that they will reduce or eliminate the pain.  Patients may be able to discontinue use of pain medications and may experience a return of lost mobility. A kyphoplasty may also help restore a patient’s height or lessen spinal deformities due to vertebral compression fractures.

Vertebroplasty and kyphoplasty are generally found to be safe forms of spine surgery. However, as with most treatment procedures, there are some risks involved. These may include:

  • Cement leakage. If the cement-like material leaks outside the area repaired, it may irritate nerves and cause pain. If the material gets into the spinal canal, it may require an additional procedure to protect the nerves. Cement leakage is more likely during a vertebroplasty due to the less dense (more runny) nature of the cement used.
  • Bleeding. Bleeding may occur if a blood vessel is punctured during the procedure. This may occur during either procedure.
  • Blood clots in veins. During a vertebroplasty, there is a risk that the cement may get into the bloodstream and create a blockage. This can take the form of a potentially fatal pulmonary embolism that compromises a patient’s ability to breathe. However, this complication is rare.
  • Pain and fever due to immune system reaction to the presence of a foreign substance (cement) in the body. Pain and fever may also occur for several hours after the procedure due to heat generated by the cement curing process.  

Additional fractures may also occur. This may be due to a patient’s osteoporosis or other condition or as a change in body mechanics or increased activity following the procedure rather than the procedure itself, though some research has found that vertebroplasty may increase risk of fractures in adjacent vertebrae.

In 2002, the U.S. Food and Drug Administration (FDA) issued a public health notice concerning serious complications resulting from the use of acrylic cements not labeled for use in treating compression fractures of the spine. Patients are encouraged to consult their physician about using cement-like material – either bone cements or bone void fillers – that have specifically been approved for use in vertebroplasty or kyphoplasty.

Questions for your doctor

Preparing questions in advance can help patients have more meaningful discussions with their physician regarding their condition. Patients may wish to ask their doctor the following questions about vertebroplasty and kyphoplasty:

  1. How are vertebroplasty and kyphoplasty different?
  2. Which do you recommend for me? Why?
  3. Will the procedure eliminate my back pain?
  4. Can I have this procedure performed on an outpatient basis or will I have to stay in the hospital?
  5. How long does the procedure take?
  6. How soon afterwards can I expect to feel an improvement in my condition?
  7. What are the risks of the procedure?
  8. Has the cement-like material you will be using been approved for this use by the FDA?
  9. Are there other treatment options available to me?
  10. Will I need any additional treatment for my condition?
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