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.

Ms Lisa Martin
Ms Lisa Martin
Spinal Decompression and Stabilisation My experience at the London Spine Unit was excellent. Referred by a friend who had previously had a back operation and was very satisfied. All my lower back and leg pain gone and was up and walking two hours after procedure. Would highly recommend thank you Mr Akmal and Dr Lock 😊
The Best spine Surgeon I was recommended to see Dr Mo Akmal . After years of back issues with chiropractors, Physio’s , acupuncture snd finally tens machine. In the last six months the pain was excruciating every night and I couldn’t walk without limping ! I was recommended spinal lumbar fusion which was arranged within 3 weeks. Immediately after surgery I felt better , no leg pain and my posture was amazingly upright , in fact within three hours from surgery I was eating a meal with my wife in the Marlybone fish restaurant , although I don’t recommend this ! On day one I went out for a mile walk with the dogs , by day 4 I’d walked 3 miles and on day 7 I was able to walk 8 miles , amazing . I’m a keen cyclist and really wanted to get back to training , as of today 15 days after surgery I was able to train on Zwift ( a cycling ) without any adverse pain . It took a lot for me to go ahead with the lumbar fusion but I can highly recommend Dr Mo , you can fully trust him and he’s got so much time to explain everything to you . He’s the best spine surgeon you’ll get , don’t bother looking any further .
Danielle Breckon
Danielle Breckon
L5/S1 Primary Posterior Lumbar Fusion with Instrumentation. After suffering with back pain for most of my 20s, I am so happy I found Mr Mo Akmal. I had many years of misdiagnosis and never really felt my condition was understood. After my first consultation with Mr Akmal I felt like he understood me and I knew I was in safe hands. We went through all of my options and after a year of treatment, decided it was time for a L5/S1 Primary Posterior Lumbar Fusion with Instrumentation. The whole process was really easy and straightforward and I was able to leave the hospital the same day. The recovery period was tough at times, but I can honestly say so worth it. The difference it has made to my life is amazing. I am now 4 months post-op, I feel incredible and am back to normal daily life without back pain. After suffering for so long, I feel like a huge wait has been lifted and that is all thanks to Mr Akmal and his team. All of whom were incredibly professional and kind. I would like to give a special thanks to Mr Akmal and Dr Lok for the reassuring phone calls during my recovery period at home - I'm not sure if they realise just how reassuring they were. I have no hesitation in recommending their services. Thank you so much.
Alan Hargraves
Alan Hargraves
A miracle Having suffered moderate back pain for almost 2 years and severe pain for 3 months with many visits to chiropractors i discovered the London Spine Unit. At the consultation with Mr Akmal, he explained my mri scan, what was wrong with my back and what operation could be done. All as a day patient!!! On the day of my operation I struggled to walk from the nearby car park and yet just 7 hours later after a L4/L5 decompression/discectomy and dynamic stabilisation i walked out the door pain free. Quite amazing. That was 6 weeks ago and have been back at work for 3 weeks. I can not thank Mr Akmal and his team enough for giving me my life back. My only regret is that I didn't go and see Mr Akmal sooner. My whole experience with the London Spine Unit from start to finish has been fantastic. Thank you very much.
Thank you to the team for your excellent care I have been a patient of Mr Akmal's at the London Spine Unit for four years now due to deterioration of disc and facet joints caused by congenital fusion of one side of L5/S1. The team have always given exemplary care and advice whilst we stepped through the conservative options (steroid injections, nerve radio frequency ablation). Due to further deterioration a Coflex device was fitted two months ago. I walked out of the day surgery and I am delighted with the results. The pain and stiffness has resolved. Thank you to the team for your excellent care.
Jason Richards
Jason Richards
Dr Akhmal is by far the finest Dr i… Dr Akhmal is by far the finest Dr i have ever met. I have suffered a horrific cervical spine injury due to a violent osteopathic correction that left me with life changing neurological symptoms. Dr akhmal not only listened to my issues with great humility but also listened to my extensive research into the cause and correction of the injury. Dr Akhmal performed exacting prolotherapy treatments on me using dextrose and prp and my issues have drastically reduced allowing me to function again.I will be having more prolotherapy under Dr akhmal to complete my return to full health.
Danny H
Danny H
L5/S1 Discectomy_ Mo Akmal and his team I am thrilled with my L5/S1 discectomy operation that was performed by Mo Akmal and his team. Immediately after the operation I felt like a different person, no pain whatsoever on my back or right leg as if a mountain was shifted over from my back. To go home the same day and be able to sleep all night on my back without pain was almost a miracle to me after enduring more than two months of continues pain. I am writing this review 3 weeks after my operation and I feel great and I am actually going back to work next week. I am very grateful to Dr Mo Akmal and his team. I absolutely recommend him to anyone with back problem. He preformed my surgery with just 1.5cm cut and he managed it without cutting any piece of bone on my back which means my bone structure stayed intact. He also explained the surgery before the operation in a very clear and friendly way which helped me to understand it well and erased all my fears and concerns about deciding whether to do an operation or not. I also want to commend his team including Dr Lok, Mr Kaleel Ahmad and all the nurses whom all were super friendly during my half day stay at Harley Street Hospital. Thanks again.
I was really please with the Mr Akmal… I was really please with the Mr Akmal and his team. They fully explained to me all of my possible options regarding my persistant disc pertrusion (18 months). I opted for a discectomy, which was successful and am currently pain free. On the day of my operation the whole team had an excellent bedside manner and I was made to feel very comfortable in the hospital.
ashwak choudhury
ashwak choudhury
Awesome service Awesome service, very attentive, readily available and conveniently able to fit around personal commitments. Highly recommended for specialist spine care. Extremely clean and a very hygenic environment to be in. I've had two sets of spinal injections and a laser disc ablation. I have been under the care of Mo Akmal and he has been nothing short of amazing! Thank you for the amazing and friendly service.
Candida Mead
Candida Mead
Laser Cervical spine surgery Laser Cervical spine surgery I received outstanding care from Mr Akmal and his team and would highly recommend them. After trying many non invasive treatments for relentless and debilitating neck and arm pain I was referred to The London Spine Unit. I received a swift diagnosis on my first visit of a C7 herniation and given a reassuring trajectory of possible procedures to relieve my symptoms. Since I had not responded to injections I opted for Laser Cervical Spine Surgery to remove the offending disc, which was performed as a day case. Following the procedure I walked out of the hospital with vastly improved symptoms, within a week I was pain free and 2 and a half months on I continue to feel great. I could not have been in more skilled hands, this is medicine at its best.
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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