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

What our patients say ...

Consultant Spine Surgeon
Consultant Spine Surgeon
Consultant Spine Surgeon

This surgical technique consists of a percutaneous approach for the treatment of small to medium size hernias of the intervertebral disc by laser energy. The main objective is to reduce the intradiscal pressure in the nucleus pulposus

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