Pain from acute vertebral fracture appears to be due in part to instability (non-union or slow union at the fracture site), while more than 1/3 of patients become chronically painful. Traditional treatment for patients with painful VCFs includes bed rest, narcotic analgesics and bracing, resulting in increased pain because of acceleration bone loss and muscle weakness.

1. Vertebroplasty vs Kyphoplasty
George Sapkas
Associate Professor
1st
Orthopaedic Dpt
Medical School
Athens University

2. • PainPain from acutefrom acute
vertebral fracturevertebral fracture
appears to be due in partappears to be due in part
toto instabilityinstability (non-union(non-union
or slow union at theor slow union at the
fracture site), while morefracture site), while more
thanthan 1/31/3 of patientsof patients
become chronicallybecome chronically
painful.painful.

3. • Traditional treatmentTraditional treatment forfor
patients with painful VCFspatients with painful VCFs
includes bed rest, narcoticincludes bed rest, narcotic
analgesics and bracing,analgesics and bracing,
resulting in increased painresulting in increased pain
because of acceleration bonebecause of acceleration bone
loss and muscle weakness.loss and muscle weakness.
UthoffUthoff: JBJS 1978: JBJS 1978
ConvertinoConvertino: Med Sci Exerc 1997: Med Sci Exerc 1997

4. Investigations
Plain x-rays

5. CT-scan

6. M.R.I.

7. Bone scanning

8. 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

9. Spinal fixation
Posterior stabilization
Vertebral body -pedicle
enforcement
• Matchstick Cortical
Bone-graft
• Cancellous Bone
• Carbonated Apatite
• Methylmethacrylate
etc

10. Spinal fixation
Anterior - Posterior
stabilization

12. Spinal fixation
Vertebroplasty
plus

13. Complications

14. Intra-operative
Cement leakage

15. Early post-operative hardware
failure

16. Late post-operative hardware failure

17. Minimal invasive
techniques
Vertebroplasty - Kyphoplasty

18. Vertebroplasty – Kyphoplasty
Indications
• Vertebral fractures
(compression ± burst)
• Osteoporotic fractures
(compression ± burst)
• Pathologic fractures of the spinal
vertebra (metastasis)
• Haemangioma of the vertebra
• Multiple myeloma

19. • 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
Contraindications

20. Vertebroplasty

21. Vertebroplasty
technique

23. Extrapedicular - Transpedicular

25. Contrast material
leakage

27. Kyphoplasty

29. Identification of landmarks and optimalIdentification of landmarks and optimal
position of instrumentationsposition of instrumentations
Transpedicular Correct PlacementTranspedicular Correct Placement

30. Identification of landmarks and optimalIdentification of landmarks and optimal
position of instrumentationsposition of instrumentations
Too MedialToo Medial
Nerve root orNerve root or
Cord InjuryCord Injury
CSF leakageCSF leakage
SolutionSolution
Constant MonitoringConstant Monitoring
of Insertion Pinof Insertion Pin
TrajectoryTrajectoryCorrectCorrect

31. Identification of landmarks and optimalIdentification of landmarks and optimal
position of instrumentationsposition of instrumentations
CorrectCorrect Too LateralToo Lateral
Burst fracture ofBurst fracture of
Vertebral wallVertebral wall
SolutionSolution
Constant MonitoringConstant Monitoring
of Insertion Pinof Insertion Pin
TrajectoryTrajectory

33. Transpedicular
T9 – L5 Upper thoracic spine
> T9
T8T8
Extrapedicular

34. Haemagioma – T8

36. COMPLICATIONS

37. • The frequency of
complications is 1.3% in
osteoporosis
Service de neuroradiologie Charcot hospital
de la Pitie-Salpetiere, Paris, France
vertebroplasty

38. • Cement leakage
(intevertebral disc)
• In vertebroplasty cementIn vertebroplasty cement
leakage isleakage is 65%65% inin
metastases andmetastases and 30%30% inin
osteoporotic fractures.osteoporotic fractures.
CottonCotton: Radiology 1996: Radiology 1996
ChirasChiras: J Neuro Radiol 1997: J Neuro Radiol 1997
vertebroplasty

39. • Cement leakage
o spinal canal
o intervertebral disc
vertebroplasty

40. • Cement displacement
anteriorly
(vertebra plana)
vertebroplasty

41. Vertebral cortex fracture
Vertebral collapse
Kyphoplasty

45. SKy bone expander system
for
percutaneous Kyphoplasty
Unilateral - Bilateral

46. SKy bone expander system
for
percutaneous Kyphoplasty

47. SKy bone expander system
for
percutaneous Kyphoplasty

48. SKy bone expander system
for
percutaneous Kyphoplasty

49. OBSERVATIONS

50. VERTEBROPLASTY KYPHOPLASTY

51. Vertebroplasty 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 al
Spine 2001
Grobs J.S. et al
J. Spinal Disord. 2005

52. Vertebroplasty 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 al
Radiology 2993
Meltron LI et al
Osteoporosis 1999

53. Vertebroplasty 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 al
Spine 2002

54. Vertebroplasty 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 embolism
o Neurological complications
o Allergic reactions
Grobs J.S. et al
J. Spinal Disord. 2005

55. Vertebroplasty vs Kyphoplasty
Ballon
Kyphoplasty
Significance Vertebroplast
y
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 al
J. Spinal Disord. 2005

56. Vertebroplsaty 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= 0.0004
P=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= 0.005
NS
4.6 (0.6 – 6.3)
52 (32-67)
P=0.03
NS
Grobs J.G. et al
J. Spinal Disord. 2005

57. CONCLUSIONS

58. Vertebroplasty - Kyphoplasty
are indicated in:
• Vertebral fractures
(compression ± burst)
• Osteoporotic fractures
(compression ± burst)
• Pathologic fractures of the spinal
vertebra (metastasis)
• Haemangioma of the vertebra
• Multiple myeloma

59. • 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:

60. Vertebroplasty - Kyphoplasty
advantages
• May be performed
under local
anaesthesia as a day
case

61. Vertebroplasty - Kyphoplasty
advantages
• Provide significant
relief of pain

62. • Is unable to restore the
lost height of the
vertebra
VERTEBROPLASTY
disadvantages

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

64. VERTEBROPLASTY
• No substantial loss
of the obtained
correction at the
follow up

65. Balloon Kyphoplasty
advantages
• Restores sufficiently the height
of the collapsed vertebra
• Is associated with inferior
possibility of cement leakage

66. Balloon Kyphoplasty
disadvantages
• The risk of fracture in the adjacent levels is
enhanced in the balloon kyphoplasty
• Increased operative time and radiation
exposure

67. Kyphoplasty
SKy 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

68. Kyphoplasty
SKy 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