19 Harley St, London, W1G 9QJ, UK

Balloon Kyphoplasty & Vertebroplasty

Mr Mo Akmal
BSc (Hons) MD FRCS(Orth)

Consultant Orthopaedic Spinal Surgeon

Vertebral Compression Fractures
Fragility Fracture
• Definitions of Fragility Fracture;
– Fracture resulting from a low trauma event.
– Fall from a standing height or less

• Diagnosis of Osteoporosis;
– BMD measurement by DEXA on 2 sites preferably Spine and Hip.
– Conventional Xrays and Bone turnover biochemical markers have no role in the diagnosis of OP or in the section of patients for BMD measurement

Osteoporosis Epidemiology – UK
• Prevalence
– 1 in 3 women and 1 in 12 men over age 50

• Osteoporotic fracture every 3 minutes
– 70,000 hip fractures/year
– 50,000 wrist fractures/year
– 120,000 spinal fractures/year

• Costs the NHS and government over £1.7 billion each year (i.e. £5 million each day!)

? 438,750 clinically diagnosed VCFs per year in the EU (117 per 100 000 person years 1 )

Healthcare Implications
• Morbidity following symptomatic vertebral fracture
– 41% with constant pain
– 71% difficulty standing
– 75% early awakening due to pain
– 59% pain on walking

? Spinal deformity and pain impair function, decrease mobility1,2
? Decreased activity leads to more bone loss1
? Decreased appetite, sleep disorders1
? Increased depression, dependence on others3
? Diminished social roles, lower self esteem3

Cost to Society
• Annual incidence 1% patients at age 65 yrs
• 1/3rd clinically significant
• 1/3rd Hospitalised
• Cost £5000 to £7000 per hospitilisation
• Length of stay 6 days
• Cost of Hospital stay 63% of cost for hip fracture
Increased Pulmonary Disorders
VCF reduces pulmonary function1

? One thoracic VCF causes 9% loss of forced vital capacity 2

? Lung function (FVC, FEV1) is significantly reduced in patients with thoracic and lumbar fracture1
Downward Spiral
NICE Guidelines
• >75yrs – any fragility fracture alone

• 65-75 – fragility fracture + BMD T<-2.5

• 50-65 – fragility fracture + T <-3 or another risk factor
» Low body mass index (<19 Kg/m2)
» Family History of maternal hip Fracture before the age of 75 yrs
» Untreated premature menopause
» Certain medical disorders independently assoc with bone loss (ie chronic IBD, RA, Coeliac Disease, Hyperthyroidism)
» Conditions assoc with prolonged immobility
Is this a benign process?
“they all heal…..”

Signs of VCF

• Decrease in gait velocity1
• Change in balance1
• Increased muscle fatigue1
• Increased risk of falls and additional fractures1
• Risk of VCF increases 5 fold after first VCF2

• 23% of patients have further fracture within 2yrs

Vertebral Fractures Beget Vertebral Fractures
RR with 1 prevalent deformity = 3
RR with 2 prevalent deformities = 10
RR with 3 prevalent deformities = 23
when compared to patients without baseline deformity
Risk of Subsequent VCF’s
• Wide variation in clinical studies

– 3% future risk (Garfin et al 2001)

– 11% in Primary and 48% in Secondary (steroid induced) osteoporosis (Harrop et al 2004)

– 26% (Fribourg et al 2004)

– Risk of VCF increases 5 fold after first VCF

– 23% of patients have a further fracture within 2 years (Ross et al, Annals Int Med 1991 & Lindsay et al JAMA 2001)

Multicenter Balloon Kyphoplasty Study (FREE) 2 year Outcomes
• 155 Patients 214 fractures
• 85% pain free
• SF-36 and VAS scores significantly better.

• Following the procedure, patients had significant, immediate and sustained improvement in measurements of pain, function, and quality of life.

VCF Treatment
Careful patient assessment
• Pain when erect posture
• Spinal tenderness
• Deformity
• MRI Scan
• Pain lying on back
• Exclude other pathology !

VCF Treatment Objectives
• Relief of Pain
• Restoration of anatomy1
– Early diagnosis and treatment2

1 Colton, “The History of Fracture Treatment,” Skeletal Trauma, Ch. 1, Vol. 1, Pg. 25, ©1998 W.B. Saunders Company

2 Brakoniecki, “Anesthetic Management of the Trauma Patient with Skeletal Injuries,” Skeletal Trauma, Ch. 7, Vol. 1, Pg. 171-172, ©1998 W.B. Saunders Company
VCF Treatment Options
Management for Pain
Medical management
? Bed rest — Exacerbates bone loss
? Narcotic analgesics — May fail to relieve pain, cause confusion
? Braces — May not provide long-term functional improvement

Open Surgical Treatment

Only in very rare cases of neurological deficit —
Invasive procedure with poor outcomes in osteopenic bone

II VCF Treatment Options
Management for Pain


Deramond & Galibert, France, 1984


? Pain ? in 80% of patients
? No cement failures
? Well-tolerated

? Up to 65% extra-vertebral cement leak
? Transient radicular pain in 3%
? Cement pulmonary embolism reported
? Cement in canal reported
Pulmonary Effects of Vertebroplasty
• Pressurized cement into cancellous bone
– Cement embolism
– Fat/marrow embolism
– PMMA monomer effects on lungs

Levine SA et al.Manag Care 2000
Padovani B et al. Am J Neuroradiol 1999
Perrin C et al. Rev Mal Respir 1999
Aebli N et al. Spine Vol. 27#5 2002


Cement leakage

• Injection: 10-15 minutes
• Cement to set: 7 minutes
• Whole procedure = 30 minutes
• Check neurology
• Sit up after procedure
• As out patient need 4-6 hours
• No specific precautions
• Back care advice
• Gradual strengthening of muscles
• Rapid return to normal function

? Local Anaesthesia
– Patient preference
– Patient may move
– Severe cardiopulmonary compromise

? Sedation + Local Anaesthetic
– Preferred method
– Patient most comfortable

Balloon Kyphoplasty
Balloon Kyphoplasty

IBT Insertion

? Insert IBT to within 4 mm of anterior cortex

? Inflate balloon to 50 psi (3.4 atm) to secure position while placing instruments through opposite pedicle into the vertebral body

IBT Inflation
? Once contralateral balloon is placed, inflate both IBT’s in 0.5cc increments

? Take A-P, lateral, and oblique images to monitor IBT position in relation to cortices

? Sequentially inflate until an inflation endpoint is reached
IBT Inflation Endpoints
? Realignment of vertebral endplates

? Maximum 400 psi (20.4 atm) without decay

? Maximum volume of balloon: 4cc for 15/3 and 10/3; 6cc for 20/3

? Prepare a cement mix that is visible under fluoroscopy

– It is CRITICAL to wait until cement becomes highly viscous before delivery (does not drip from distal end of BFD).

– Impatience will result in extravasation (leakage) into the venous system or spinal canal.

Kyphoplasty vs Vertebroplasty
The issues
• Pain reduction
• Deformity correction
– Sagittal balance
– Risk of future fractures
– Risk of cement migration
• Safety
– Cement leakage
– Incident reporting
• Cost

Deformity Correction

Deformity Correction
Pre-op Post-op o Change
Thoracic VCFs 38o 29o +9o
Lumbar VCFs 10o 17o +7o
All VCFs +8o
Reducible VCFs* +14o
Degree of compression measurement
Correct Measurements
Deformity Correction
Kyphoplasty – Deformity Correction
• Studies have suggested that kyphoplasty will restore vertebral body height by about 50% in 70% patients with VCFs

– Lieberman et al. Spine 2001
– Wong & Garfin J. Womens Imaging, 2000

Adjacent and New Fractures
Future Fracture Risk


Complications of Leakage
• Kyphoplasty reduces risk of further fracture by 50%.
• Bisphosphonates reduce risk of further fracture by 30%

• At 1year – cost neutral
• After 1 year – cost saving
Why a surgeon ?

– Diagnosis ! Exclude other pathology !
– Decisions on when to operate
– Options of treatment
– Biomechanics
– We know bone !

– Multidisciplinary approach !
Is this an osteoporotic Fracture ?
Staph Osteomyelitis
Availability of surgical facilities
• Operating Room – sterility, safety,

Imperial  College Protocol for VBCF’s
Multidisciplinary Working
Vertebroplasty for subsidence
Case 8 : LS 85 yrs old Female TB
Our practice
• High thoracic
• Minimal compression
• Early fractures without compression
• Previous multilevel fractures
• Unsuitable for GA

Revolutionary Keyhole surgical technique to vaporise bulging discs

Dr Mo Akmal Medical Director
Dr Mo Akmal MD - Lead Spinal Surgeon

Laser Disc Surgery can be performed under local anaesthetic at The Harley Street Hospital.

Martin Williams
Martin Williams
I've just completed 3 months with Spine Central and set to continue. after using other Chiro's before I can't tell you how much of a level up this is. My overall health, posture and 'lack of back pain' have really opened me up to a better future. being a Dad of a young 3 year old, I can enjoy the time so much with my Boy. thank you Spine Central.
Lisa P
Lisa P
Mo Akmal & his team at The Spine unit were absolutely fantastic! My mother walked into the hospital in terrible pain & walked out a few hours later pain free ! She is 87 and now feels like 67 ! The attention she got was excellent I would highly recommend!
Miles McWilliams
Miles McWilliams
I have known Dr Akmal and his team for the past 8 years, I have seen him and his team ON and OFF for issues regarding my neck, C4/5, C5/6 , C6/7. I first had 3 lots of injections into this area back at the start of things. This helped me for 3 years. Dr Akmal did not want to operate at the time due to my age still been under 40 then. After 3 years I had to see Dr Akmal and his team again. We tried the injection route again but after a few attempts we then had to make the call to cut. I had C5/6 and C6/7 +/- C4/5 anterior cervical decompression and fusion / disc replacement carried out. This was a success and I was out of the hospital within 3 days and recovery took place for the next few months. This year I was operated on the back of my neck for a posterior cervical foraminotomy on the left side at the C5/6 and C6/7 levels. We tried the injections last year but this did not help. Due to Covid to this should have been carried out last year. Dr Akmal explained the risks include nerve injury, dural tear and pain post-operatively but the procedure is fairly routine and the risks are relatively low. Surgery has now taken place back in February. I was released the same day later that evening and been back for my check ups and things are looking up. I am currently training for a half triathlon that I will take part in second week of July. I am doing anything from 120 km to 170 km a week on the bike and running now upto 10 km a day on my running days. I have not been able to swim yet due to pools been closed but I have no issues with movement in me neck. I am very happy I chose Dr Akmal from the start. I did seen two others before him, they were happy to just cut and not look at what was best for me. I also strongly believe the newer technology Dr Akmal uses has really helped me any my life style I lead with sports. I know I would not have had the same results if I did not take the route with Dr Akmal. I really can’t say much more but I am very happy I met Dr Akmal when I did, he has been great and so has his team. Patient Miles McWilliams 😊
Saima Kash
Saima Kash
It was a fantastic experience for my mother in law right from the beginning when she had her first appt with Mr Akmal and was recommended to have a spinal surgery. He has been fantastic, extremely helpful and professional in helping her understand her own condition and pros and cons of the surgery and support her through out the whole process. I would highly recommend him for his excellent professional skills and experience in dealing with patients specially elderly patients.
Radu Ghebaru
Radu Ghebaru
Quick and easy to book appointments (online and over the phone). Very helpful receptionist. I had a consultation with dr Akmal who is very professional , patient , kind and understanding. he explained me in details my problem. Trustful and confident in his job, I decided to follow his advice and treatment. I had yesterday a spinal injection . No sides effects so far. A bit in pain but it’s normal. I am aware that I will see the results in one week time only. Great team , exceptional staff (from the receptionist to the nurses and dr Akmal). I would recommend Harley Street Hospital - London Spine Unit to anyone who is having back pains.
Ashraf Elawad
Ashraf Elawad
I had difficult times with my disc prolapse in my lower back. The pain was getting worse despite pain killers and physiotherapy. I was a bit nervous considering surgical treatment as a definte solution. The consultation with Mr. Mo Akmal was informative and reassuring and helped me to make a decision going ahead for the surgical option. On the day of the procedure, the staff was welcoming and looked experienced and knew exaclty what they were doing. Mr. Mo Akmal spoke to me before and after the procedure. In less than 2hrs, after the porcedure, I was able to stand, walk, and sit down with no pain. I strongly recommend Mr. Mo Akmal for anybody who has a similar condition.
Joe massimo
Joe massimo
I had minimally invasive spinal surgery for a Bulging disc at L5/S1 impinging on my S1 nerve root. Before surgery I couldn’t walk without a limp and would be in too much pain to walk further than a mile. Being only 21 years old and a keen athlete and student Osteopath, with an interest in sports rehabilitation, I wanted to get back to complete health and fitness from this injury. There is definitely a fear with spinal surgery that a lot of people have in the sports and therapy world however I knew I needed the operation to gain my leg function back and with Mr Mo Akmal and the team at the London spine Unit, I felt in great hands and they were very professional from start to finish with the process. They made me feel very comfortable and safe. I’d highly recommend Mr Mo Akmal and the Team at the London Spine Unit, they are very friendly and take great care of you. I’m feeling much better and am glad I chose to get the surgery done here.
Very good treatment from Mr. Akmal and the staff with amazing results. After the first spinal injection I was sure the treatment won't work but as the team encouraged me to keep going to the second injection it then total disappeared. They were also very helpful with all the documents needed for the insurance cover. Much appreciated! I was struggling
In February 2021 I felt excoriating pain in my lower back. I was unable to stand up straight with my right leg having spasms occurring every hour. The sciatic pain accelerated within days I was bed bound to the point I needed help with basic daily activities such as making a cup of tea. I read the reviews about Dr Akmal, which I found beneficial and decided to book a consultation to see him. I was booked for a Consultation with Dr Akaml as well as an MRI scan & blood tests. I was pleasantly surprised to find out that I would get the results on the same day with the treatment options. Dr Akmal was very friendly he discussed the MRI scan with me that showed disc L4-L5 impinging the nerve, he suggested two options. One was the laser treatment to shrink the disc or the second the option was a discectomy. This would be a day procedure with no overnight stay. At no point did I feel pressured to decide on the procedures. Dr Akmal is incredibly knowledgeable this was evident through his years of experience with spinal procedures, I was 100% that the best option would be the discectomy and the best Surgeon was Dr Akmal. I was so impressed with the service and care that was offered at the clinic it was no less than first class to be honest, with no waiting time at all. On the day of the procedure I was in a private room, a lovely healthcare assistant was there to help me get into the hospital gown. Every staff member was ever so kind, they all made me feel at ease. Once I woke up I felt no sciatic pain at all which was an amazing feeling, an emotional moment to finally be rid of that burning sensation. Of course, there was some slight discomfort where the procedure had taken place. After surgery, I was able to stand on my two feet as well as being able to walk without any discomfort. Finally making my own cooked breakfast was a heavenly feeling! I can say with complete confidence that I trust Dr Akmal he is no doubt, on top of his field, a great human being who I’m so grateful to have met. If you want your life back I would highly recommend you book yourself in for a consultation with Dr Akmal, he is worth every single penny! Thank you Dr Akmal!
Good treatment, uncomplciated, great solution,
Treatment of all spinal disorders

The London Spine Unit specialises in Minimally Invasive Treatments allowing rapid recovery and return to normal function.

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Mr Mo Akmal has developed revolutionary techniques to perform Day Case Spinal Surgery. We avoid traditional General Anaesthetic for all surgery.

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