Vertebroplasty/Kyphoplasty: A Novel Approach for Treatment of Spine Fractures
Neeraj Jain
Senior Consultant Spine & Pain Specialist, Spine & Pain Clinics & Sri Balaji Action Medical Institute,
Max Hospital, Pitampura, New Delhi, India.
Abstract: As life expectancy is increasing so is the incidence of vertebral body (VB) fractures now being the commonest fracture of the body.
Percutaneous Vertebroplasty/ Kyphoplasty (PVP) is an established interventional technique in which bone cement is injected under local anaesthesia
via a needle into a fractured VB with imaging guidance providing instant pain relief, increased bone strength, stability, decreasing analgesic medicines,
increased mobility with improved quality of life and early return to work in days. In this era of minimally access surgery replacing open surgeries, PVP
is a novel procedure & should be in the first line of management in place of conservatism or major spine surgery for painful uncomplicated compression
fracture spine. PVP is a novel procedure with high benefit to risk ratio, which is highly underutilized in relation to the high prevalence of the vertebral
fractures. Vertebroplasty is a palliative procedure and does not correct the underlying cause of the vertebral fracture. Medical management of
osteoporosis or malignancy must therefore be initiated and continued.

INTRODUCTION
Discovering the fact that fracture /# vertebrae is the commonest # of
body, its incidence >the # hip, it becomes imperative to take it more
seriously. With increasing life span there is more of aged osteoporotic
population, more so due to sedentary indoor lifestyle and post menopausal
osteoporosis. Diabetics, smokers & alcoholics are at higher risk of
developing osteoporosis. I have seen such alcoholic patient developing
six spine fractures in just three months time from a single fracture being
on complete bed rest.
Stable VB # are normally treated conservatively with bed rest, strong
analgesics, removable braces, a programmed progressive ambulation and
physiotherapy. Fractures with > 50% of anterior VB collapse or > 20%
of sagital angulations are potentially unstable and may require posterior
instrumentation and fusion if not cemented in time. For burst # pedicle
instrumentation with extension segmental constructs are required. PVP
is not ideal for # dislocations or # distractions. Spine surgeon has to be
consulted if patient needs operative spine stabilization.
Quick fix of fracture spine makes patient walk back same day instead of
bed rest of months together avoiding morbidity & mortality of prolonged
bed rest, making bedridden patient walk, in a way bringing patient back
to normal life.
VERTEBROPLASTY: AN OVERVIEW
Percutaneous Vertebroplasty (PVP) is an established interventional
technique in which rapidly hardening surgical polymethyl methacrylate
bone cement is injected under local anesthesia via a large bore needle
into a vertebral body (VB) under imaging guidance providing increased
bone strength, stability, pain relief, decreased analgesics, increased
mobility with improved QOL and early return to work. Kyphoplasty has
the added advantage of addressing fracture with spinal deformity and
appears to be associated with fewer instances of bone cement
extravasations.
As per Greek mythology pain was thought to be due to intrusion of particles
into soul, now pain relief is done by intrusion of particles into bone. The
bone of content is to fill bone with content. In this era of MAS replacing
open surgeries, PVP is a novel procedure & should be in the first line of
management in place of painful conservatism or major spinal surgery
with a list of complications in polytrauma settings for painful
uncomplicated VB #; especially when the spine surgery is relatively
complicated or patient refuses due to surgery phobia or cost involved or
there may be comorbid conditions /injuries deterrent for surgery. PVP is
a big help in polytrauma setting when stabilizing spine does lot of good
to the patient’s overall management.
Collapsed 1 year old # Both spine & Implant fractured! # Spine with bowel & bladder
involved
INDICATIONS
Started in 1984 by Galibert PVP is done in host of indications: Senile
osteoporotic compression # remains the commonest Indication (83%).
Both men and women are at risk for spinal fractures, with over 700,000
new fractures occurring every year. In fact, one in four women over 50
will suffer an osteoporosis related spinal fracture. Even more startling,
spinal fractures are twice as likely as hip fractures. And they’re three
times more common than breast cancer. Yet as many as two-thirds of
spinal fractures go untreated.
• Painful new or progressive osteoporotic collapse # refractory to
medical therapy or dosage of analgesia leads to unacceptable side
effects.
• Complicating Co-morbid diseases, on steroids & received transplant.
• To reduce loss of vertebral height and possibility of continued collapse
• Metastatic VB #, Multiple Myeloma VB # (3%). Approximately 30%
of patients with various neoplastic conditions develop symptomatic
spinal metastases during the course of their illness & pain is the
presenting complaint in the majority of cases.
• Aggressive painful VB haemangioma
• Vertebral osteonecrosis
• For strengthening VB before major spinal surgery.
• The benefit has been extended to the traumatic uncomplicated VB
compression # (VCF) (14%) which is commoner in younger age
group with active life profile and prime of their career where strict
bed rest and acute or chronic pain are unacceptable and they are
more demanding for proactive treatment approach so as to be back
to work ASAP.
CONTRAINDICATIONS
• Pre-existing neurological deficit
• Burst fractures (relative C/I)
• Fracture related spinal canal stenosis
• Uncorrectable coagulation disorders
• Allergy against bone cement or contrast media
• Unable to lie prone
LONG-TERM MORBIDITY &
CONSEQUENCES OF VERTEBRAL
COMPRESSION FRACTURES
Whether painful or not, the long-term consequences of VCF can be
devastating and can include:
• Traumatic VB # is painful condition requiring bed rest restricting
daily activities markedly as “spine cripples”.
• Left untreated it can cause DVT, increase osteoporosis, loss of VB
height, respiratory & GI disturbances, emotional & social problems
secondary to unremitting pain, loss of independence with high cost
of rehabilitation.
• High risk of primary or consequential damage to neural, bony or disc
elements.
• Increased wedging, deformity & increase incidence of fall and
adjacent VB #.
• Chronic debilitating pain of kyphosis & altered spine mechanics.
• Uncomfortable braces & sleep disturbance because of pain &
discomfort with its sequels.
• Decreased pulmonary function and increased lung disorders , 9%
reduction in vital capacity per #
• Decreased appetite and potential for malnutrition due to stomach
compression & visceral crowding.
• Five-fold increased risk of future vertebral fractures after the first
and 75-fold increased risk after 2 or more vertebral fractures coupled
with low bone mass
• Increased dependence on family and friends
• 40% Clinical anxiety and/or depression
• Loss of self-esteem and compromised social roles
MORBIDITY & COMPLICATIONS OF SPINAL
SURGERY
• Cost of surgery and hospital treatment
• Cost of implants
• Phobia of surgery
• Prolonged recovery period & Extensive rehabilitation
• Changed spinal mechanics & transition syndrome
• Major surgery & anesthesia with its own complications
• Anaesthesia related • DVT • Mechanical Pulmonary
• Medical morbidity • Infection • Hardware related
Persistent pain
• Implant migration • Spinal cord/nerve injury
Pseudoarthrosis
• Sexual dysfunction • Transition syndrome
PRE-OPERATIVE WORKUP
Detailed history & investigation including coagulation profile.
Neurological battery checkup of motor / sensory / reflexes should be done
pre & post operatively & notified. In neurological deficiency wait for 72
hrs for spinal shock to wean off if there was any and then take decision
accordingly
X-ray spine in A/P & lat view. CT is more informative of bone & #
morphology. MRI is good for soft tissue injuries e.g. spinal cord/ root
damage, hematoma, canal stenosis and ligamentous injury
Ask for pedicle size in all dimensions and construct a 3D image aiming
needle placement and cement filling mentally in scan room itself as
rehearsal of PVP. This reduces operative time & gives better results.
Outcome with risk & complication should be well informed & consented
HOW TO PERFORM PVP STEP BY STEP
Sedate with fentanyl & midazolam. To have a feedback in case of any
eventuality instantly, only sedate the patient. Start oxygen, monitor vitals.
Prone positioning with adequate padding.
Fix fluoroscope view as desired & check for its movements.
Total aseptic precautions of major surgery. Cleaning & fully draping of
the patient and the C-Arm.
Do skin marking & measurements & Give liberal local anaesthesia from
skin up to the bone.
Adjust fluoroscope from P/ A to oblique to see “Scottie dog” with pedicle
in maximum oval view with flattened end plates, hit the superior lateral
quadrant of pedicle oval for transpedicular approach. Alternatively
parapedicular route is used in thoracic region & antero-lateral approach
for cervical vertebra.
• 23-34 % increased age adjusted mortality compared with patients
without VCF
• Women unaware that they have vertebral fractures have a 16%
increased mortality compared to women without fracture
• Nine-fold increased risk of mortality in 4 years, compared with 7-
fold increased risk with hip #
• Women with vertebral fractures are 2-3x more likely to die of
pulmonary causes than those without fractures

Conventionally PVP is done by hammering the vertebroplasty needle
through the bone. Here we used light weight drill to bore through the
vertebra. With drill one can do a graduated drilling starting from smaller
gauze wire, this allows extra scope for maneuvering needle to the desired
most location in VB which is difficult to attain with hammered bone
biopsy needle which by its impact cause unacceptable distraction of #
fragments & intense pain.
It is important to set the needle at exact entry site & side with right
trajectory aiming the # defects
In lateral view needle should go through middle of the pedicle going up
to anterior 1/3 of VB.
In P/A view the needle can be in midline or paramedian depending upon
# & if uni/bipedicular approach is planned
Wash haematoma of VB with saline. Do bone biopsy if there is any doubt
about # lession. Do dye test (vertebral venography). Always wash dye
with saline before injecting cement to have good view of cement flow.
Make cement more radiopaque by adding barium /or tungsten. Then inject
cement with 1 or 2 ml leurlock syringes strictly under fluoroscope in
lateral view & cross checking in P/A view. Stop injecting either there is
adequate filling or at the first sight of ectopic cement leak. Total cement
volume varies as per fracture morphology, osteoporotic cavitation & level
of vertebra. Keep sample cement to see for hardening. Remove needle
with rotational movement before cement hardens.
COMPLICATIONS OF PVP/ KYPHOPLASTY
• PVP is generally safe with low risk.
• Ectopic cement leak is frequent but generally inconsequential..
• Symptomatic cement extravasation incidence depends upon etiology
of fracture.
• Osteoporosis 1-2%
• Neoplasm 5-10%
• Location of ectopic cement leaks
• Epidural
• Foraminal
• Paravertebral
• Disc
OUTCOME
• PVP is a novel procedure with high benefit to risk ratio, which is
highly underutilized in relation to the high prevalence of the vertebral
#.
• Different studies show an immediate pain relief in (85 - 90)% of
patients with low complication rate ranging from (1-5)% depending
upon the type of lesion.
• PVP does augment height of VB but ideal would be kyphoplasty.
• Patient is either off medicine or on reduced doses.
• Patient feels so well that he almost forgets about VB #.
Pain relief is by virtue of different mechanisms postulated :
• Cementing of # fragments
• Thermal neurolysis of VB nerve ending, sinu-vertebral nerve & DRG
due to heat of polymerization
• Washing away of nociceptor chemicals
• Neurolytic action of liquid monomer
• By allowing early ambulation decreasing pains of immobility & bed
rest
NEW DEVELOPMENTS
• Non PMMA cements
• Bioactive glass
• Hydroxyapatite
• Osteoconductive coral granules
• Composite cements
• Ideal cement volumes
• Variations of technique
Kyphoplasty or Balloon Vertebroplasty is cementing the fractured
vertebra after creating cavity, is ideal for collapse osteoporotic # with
Varied Vertebrae Anatomy PVP in lat. view
PVP in A/P view Cross-section of PVP
Vertical collapse All six vertebrae cemented & secured
One & three year old # Cemented with preemptive fill in next Habitual #
osteoporotic patient
# Spine patient ventilated/ Normal after cementing

CONCLUSION
• With rich experience in osteoporotic PVP one can comfortably pass
the benefit to traumatic # where -it is more rewarding & satisfying.
• With PVP you just don’t manage pain rather you treat it. It is also
important to remember to address the underlying condition of
osteoporosis. Improve patients bone health and reduce risk for future
fractures through a combination of medication, diet, exercise and
lifestyle modifications.
• Very few people die of pain, many die in pain and even more live in
pain, some of them are sequel to spine traumatic fractures, a reversible
suffering.
• We have to keep pace with patients needs.
• PVP may be is the future of uncomplicated VCF management.
• kyphoplasty has the added advantage of addressing spinal deformity
and appears to be associated with fewer instances of bone cement
extravasation.
• Pain means punishment, we can avoid the chronic punishment of
VCF with PVP avoiding all D’s of disability, depression, drugs
dependence, deformity, dissociation & dejection.
• In future we are looking for high radiopaque biodegradable or
bioactive bone pastes or cement or glues with more procedural time
relaxation which will strengthen the bone while inducing new bone
growth.
• Vertebroplasty is a viable treatment and possible standard
management of the pain and disability of vertebral fractures needing,
height loss & can be employed in selected traumatic wedge collapse VB
# with height loss.
Balloon kyphoplasty
• Restores vertebral body height
• High pressure ballooning (150-400 psi) followed by cement injection
into cavity created by balloon
• fewer complications resulting from cement extravasation
• reduction in morbidity of kyphosis
Clinical outcome data
• 22 published observational studies
• Retrospective designs
• Short term follow up
• Concurrent treatment modalities
• Three series of >250 patients
• Gangi et al Radiographics 2003(868 patients)
Clinical outcome data balloon kyphoplasty
• Five published case series
• Largest describes 188 procedures in 78 patients with minimum 1
year follow up (Coumans JV et al J Neurosurg2003)
• No comparisons with vertebroplasty or conservative therapy
• Pain relief scores similar to those achieved by vertebroplasty
• Adequate training
• Meticulous technique
• Careful patient selection
• If you don’t take up the job the Robots will take over.
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Correspondence: Dr Neeraj Jain, Senior Consultant Spine & Pain
Specialist, Spine & Pain Clinics & Sri Balaji Action Medical Institute,
Max Hospital, Pitampura, New Delhi & Sant Parmanand Hospital, New
Delhi. e-mail: managepain@yahoo.com www.spinenpain.com