Vertebroplasty vs Kyphoplasty

George Sapkas

Associate Professor1st Orthopaedic Dpt

Medical SchoolAthens University

• PainPain from acute vertebral from acute vertebral fracture appears to be fracture appears to be due in part todue in part to instability instability (non-union or slow union (non-union or slow union at the fracture site), while at the fracture site), while more than more than 1/31/3 of patients of patients become chronically become chronically painful.painful.

• Traditional treatmentTraditional treatment for for patients with painful VCFs patients with painful VCFs includes bed rest, narcotic includes bed rest, narcotic analgesics and bracing, analgesics and bracing, resulting in increased pain resulting in increased pain because of acceleration bone because of acceleration bone loss and muscle weakness.loss and muscle weakness.

UthoffUthoff: JBJS 1978: JBJS 1978ConvertinoConvertino: Med Sci Exerc 1997: Med Sci Exerc 1997

Investigations

Plain x-rays

CT-scan

M.R.I.

Bone scanning

Management of fractures in patients with osteoporosis

• In general early functional treatment is used to allow early restoration of function and weight bearing

• Fracture treatment should always be accompanied by an investigation of the bone mass in these patients

• Nutritional support and calcium and vitamin supplementation should be provided during the healing phase

Orthop. Clin. North Am 1990 Jan:21(1) 125-141

Spinal fixation

Posterior stabilization

Vertebral body -pedicle enforcement

• Matchstick Cortical Bone-graft

• Cancellous Bone • Carbonated Apatite • Methylmethacrylate

etc

• Matchstick Cortical Bone-graft

• Cancellous Bone • Carbonated Apatite • Methylmethacrylate

etc

Spinal fixation

Anterior - Posterior stabilization

Spinal fixation

Vertebroplasty plus

Complications

Intra-operative

Cement leakage

Early post-operative hardware failure

Late post-operative hardware failure

Minimal invasive techniques

Minimal invasive techniques

Vertebroplasty - KyphoplastyVertebroplasty - Kyphoplasty

Vertebroplasty – KyphoplastyIndications

• Vertebral fractures (compression ± burst)

• Osteoporotic fractures (compression ± burst)

• Pathologic fractures of the spinal vertebra (metastasis)

• Haemangioma of the vertebra• Multiple myeloma

• Destruction of the posterior spinal elements

• Burst fractures (±)• Neurologic compression syndromes

(due to dislocated bony fragments)• Destruction of dorsal structures

(vertebral arch and facet joints) • Vertebra plana• Spinal infection • Allergy

(methylmethacrylate etc)• Coagulopathy • Untreated cardiovascular disturbances

Vertebroplasty – KyphoplastyContraindications

Vertebroplasty

Vertebroplasty technique

Extrapedicular - Transpedicular Extrapedicular - Transpedicular

Contrast materialleakage

Contrast materialleakage

Kyphoplasty Kyphoplasty

Identification of landmarks and optimal Identification of landmarks and optimal position of instrumentationsposition of instrumentations

Transpedicular Correct PlacementTranspedicular Correct Placement

Identification of landmarks and optimal Identification of landmarks and optimal position of instrumentationsposition of instrumentations

Too MedialToo Medial

Nerve root or Nerve root or Cord Injury Cord Injury CSF leakageCSF leakage

SolutionSolutionConstant MonitoringConstant Monitoring

of Insertion Pin of Insertion Pin TrajectoryTrajectoryCorrectCorrect

Identification of landmarks and optimal Identification of landmarks and optimal position of instrumentationsposition of instrumentations

CorrectCorrect Too LateralToo Lateral

Burst fracture of Burst fracture of Vertebral wall Vertebral wall

SolutionSolution

Constant MonitoringConstant Monitoringof Insertion Pin of Insertion Pin

TrajectoryTrajectory

TranspedicularTranspedicular

T9 – L5T9 – L5 Upper thoracic spine> T9

Upper thoracic spine> T9

T8T8T8T8

ExtrapedicularExtrapedicular

Haemagioma – T8Haemagioma – T8

COMPLICATIONS

• The frequency of complications is 1.3% in osteoporosis

Service de neuroradiologie Charcot hospital de la Pitie-Salpetiere, Paris, France

vertebroplastyvertebroplasty

• Cement leakage

(intevertebral disc)• In vertebroplasty cement In vertebroplasty cement

leakage is leakage is 65%65% in in metastases and metastases and 30%30% in in osteoporotic fractures.osteoporotic fractures.

CottonCotton: Radiology 1996: Radiology 1996ChirasChiras: J Neuro Radiol 1997: J Neuro Radiol 1997

vertebroplastyvertebroplasty

• Cement leakageo spinal canal

o intervertebral disc

vertebroplastyvertebroplasty

• Cement displacementanteriorly(vertebra plana)

vertebroplastyvertebroplasty

Vertebral cortex fractureVertebral collapse

Vertebral cortex fractureVertebral collapse

Kyphoplasty

SKy bone expander system for

percutaneous Kyphoplasty

Unilateral - BilateralUnilateral - Bilateral

SKy bone expander system for

percutaneous Kyphoplasty

SKy bone expander system for

percutaneous Kyphoplasty

SKy bone expander system for

percutaneous Kyphoplasty

OBSERVATIONS

VERTEBROPLASTYVERTEBROPLASTY KYPHOPLASTYKYPHOPLASTY

Vertebroplasty vs KyphoplastyVertebroplasty vs Kyphoplasty

• The risk of fracture in the adjacent levels is enhanced in the balloon kyphoplasty group

• The risk seems to be higher in patients with non recent fractures than in patients with recent fractures

Belkoff SM et alSpine 2001

Grobs J.S. et al J. Spinal Disord. 2005

Vertebroplasty vs KyphoplastyVertebroplasty vs Kyphoplasty

• It remains unclear whether these new fractures above or below the enhanced vertebra(e) are due to the course of osteoporosis or to the increased stiffness of the stabilized vertebral body

Uppin AA et alRadiology 2993

Meltron LI et alOsteoporosis 1999

Vertebroplasty vs KyphoplastyVertebroplasty vs Kyphoplasty

• Cement leakage is a significant problem related mainly with vertebroplasty

• In 25% of the vertebral bodies in the vertebroplasty group cement leakage to the epidural space or segmental vessels was detected.

• The reasons were o The lower viscosity of the PMMA.

o The destruction of the integrity of the vertebral structure

Philips FM et alSpine 2002

Vertebroplasty vs KyphoplastyVertebroplasty vs Kyphoplasty

• It remains unclear whether these extravertebral deposits of PMMA cause deterioration of the local blood supply and contribute to the ongoing pain and other complications such as :o pulmonary embolismo Neurological complicationso Allergic reactions

Grobs J.S. et al J. Spinal Disord. 2005

Vertebroplasty vs KyphoplastyVertebroplasty vs Kyphoplasty

Ballon Kyphoplasty

Significance Vertebroplasty

Significance

Decrease of wedge (%)

6.0 (0-9.5) P= 0.000004

0.0 (0.0 – 0.3) NS

Increase of height (%)

5.8 (0-10.6) P= 0.00001 0.0 (0.0 – 0.0) NS

Grobs J.G. et alJ. Spinal Disord. 2005

Grobs J.G. et alJ. Spinal Disord. 2005

Vertebroplsaty vs KyphoplastyVertebroplsaty vs Kyphoplasty

Visual analog scale

Ballon Kyphoplasty

Significance Vertebroplasty Significance

Post operative 3.5 (2.5-5.9) P= 0.00003 3.0 (2.0 – 4.o) P=0.002

1. Year ODI (%)

2.7 (1.6-3.8)42 (25-52)

P= 0.0004P=0.03

5.7.0 (3.8 – 6.6)47 (31-56)

P=0.04

NS

2. Years ODI (%)

2.0 (0.5-5.3)56 (44-70)

P= 0.005NS

4.6 (0.6 – 6.3)52 (32-67)

P=0.03

NS

Grobs J.G. et alJ. Spinal Disord. 2005

Grobs J.G. et alJ. Spinal Disord. 2005

CONCLUSIONS

Vertebroplasty - Kyphoplastyare indicated in:

• Vertebral fractures (compression ± burst)

• Osteoporotic fractures (compression ± burst)

• Pathologic fractures of the spinal vertebra (metastasis)

• Haemangioma of the vertebra• Multiple myeloma

• Destruction of the posterior spinal elements

• Burst fractures (±)• Neurologic compression syndromes

(due to dislocated bony fragments)• Destruction of dorsal structures

(vertebral arch and facet joints) • Vertebra plana• Spinal infection • Allergy

(methylmethacrylate etc)• Coagulopathy • Untreated cardiovascular disturbances

Vertebroplasty - Kyphoplasty

are contraindicated in:

Vertebroplasty - Kyphoplastyadvantages

• May be performed under local anaesthesia as a day case

Vertebroplasty - Kyphoplasty advantages

• Provide significant relief of pain

• Is unable to restore the lost height of the vertebra

VERTEBROPLASTY disadvantages

VERTEBROPLASTY

• It seems to be more favourable in recent vertebral fractures (osteoporotic etc) without major deformity

VERTEBROPLASTYVERTEBROPLASTY

• No substantial loss of the obtained correction at the follow up

• No substantial loss of the obtained correction at the follow up

Balloon Kyphoplasty advantages

• Restores sufficiently the height of the collapsed vertebra

• Is associated with inferior possibility of cement leakage

Balloon Kyphoplasty disadvantages

• The risk of fracture in the adjacent levels is enhanced in the balloon kyphoplasty

• Increased operative time and radiation exposure

KyphoplastySKy bone expander system

Advantages • Expandable rigid polymer

device rather than a hydraulic one

• This enables improved control over devices’ position and expansion direction and eliminates risk of device failure

KyphoplastySKy bone expander system

• The fact that the SKy bone expander always expands to the same predefined shape and size is highly beneficial in treating vertebral fractures, when reconstruction controllability is of paramount importance