Kyphoplasty for the Treatment of Vertebral Compression Fractures Jessica Brock Advised by Sam Powdrill

Vertebral Compression Fractures The most common complication of osteoporosis Estimated 700,000 VCFs occur annually 200,000 are refractory to medical management Cost $10-15 billion annually Can result in spinal deformity: kyphosis/lordosis Cause acute and chronic pain leading to disability Cause of reduced vital capacity

The Downward Spiral Osteoporosis VCFs Spinal Deformity Decreased lung capacity Decreased physical function Early Satiety Sleep problems Decreased activity More bone loss Increased fracture risk Decreased pulmonary function Increased mortality

Prevention Bone Density Testing in women > 65 year, men > 70 years Adequate intake of calcium, vitamin D, and regular weight bearing exercise Pharmacology: bisphosphonates, calcitonin, SERMS Reduce the risk of falling Identify bone health and risk for fracture Bisphosphonates and calcitonin both decrease osteoclastic activity. Selective estrogen receptor modulators increase bone density and reduce fracture risk. Assess pt’s fxnal status, eliminate fall risk in the environment, review medications that affect the individual.

Signs and Symptoms Consider VCF in any patient > 50 years if they complain of acute or chronic back pain Get a AP and lateral x-ray of the spine Look for wedge shaped vertebral bodies MRI with T2 sequence shows state of fracture healing

Conservative Therapy NSAIDS Opiods Muscle relaxants Bed rest Orthotic bracing VCF healing should occur in 6-12 weeks Refractory in 15-20% of patients Worry about the consequences of immobility for that time, and that medications could make falling/osteo worse.

Kyphoplasty Minimally-invasive Percutaneous Can restore lost vertebral height Immediate pain reduction Fewer complications compared to vertebroplasty By 2005, performed on 170,000 patients

Kyphoplasty 2 fluoroscopy units for visualization Patient is supported in prone position 4 cm bilateral incision via the pedicles using trocar, guidewire, cannula, bone tamp, cement Maximum of 3 vertebral bodies

Fig. 1 Sixty-two year-old female Fig. 1 Sixty-two year-old female. a Preoperative sagittal T2-weight image shows gas filled fracture cleft in L2 vertebra. b Postoperative lateral radiograph shows considerable increase in anterior vertebral height. c Radiograph 16 months after procedure shows refracture of the cemented vertebra with focal kyphosis

Complications Cement Extravasation Adjacent VCFs post surgery—20-30% Pulmonary embolism Abscesses Disc damage Adjacent VCFs post surgery—20-30% General complication rate 1-2%

Conclusions Kyphoplasty is a safe and effective treatment for back pain due to osteoporotic VCFs. Providers should include kyphoplasty in the discussion of options for the VCF patient Reimbursement available by Medicare and private insurance companies

References ACP medicine, Dale, D, and Federman, D. 3rd edition. WebMD Professional Publishing. New York, NY. 2007, Vol. I, 707-711 Albertico, RA. Balloon Kyphoplasty for Multilevel Spinal Metastases from Breast Cancer. J Support Oncol 2007;5:243-246 Garfin, SR, Buckley, RA, and Ledlie, J. Balloon kyphoplasty for symptomatic vertebral body compression fractures results in rapid, significant, and sustained improvements in back pain, function, and quality of life for elderly patients. Spine, 2006. 31(9), p.2213-20. Hanna, J, and Letizia, M. A treatment for osteoporotic vertebral compression fractures. Orthopedic Nursing. Vol 26(6). 2007. pg 342-346. Harrison, AL. Changes in the Bone Associated with Aging. Lecture at the University of Kentucky. Summer 2007. Howland, RD, and Mycek MJ. Pharmacology. 3rd edition. Lippincott Williams & Wilkins. Philadelphia. 2006. Ledlie, JT and Renfro, MB. Kyphoplasty treatment of vertebral fractures: 2-year outcomes show sustained benefits. Spine, 2006. 31(1): p.57-64 Pateder, DB, Khanna AJ, and Lieberman, IH. Vertebroplasty and Kyphoplasty for the Management of Osteoporotic Vertebral Compression Fractures. Orthop Clin N Am 38 (2007) 409-418. Robinson, Y., Tschoke, SK., Stahel, PF, Kayser, R., and Heyde, CE. Complications and safety aspects of kyphoplasty for osteoporotic vertebral fractures: a prospective follow-up study in 102 consecutive patients. Patient Safety in Surgery 2008, 2:2. Surgeon General’s Report on Bone Health and Osteoporosis. 2004. Taylor, RS, Fritzell, P, and Taylor, RJ. Ballon kyphoplasty in the management of vertebral compression fractures: an updated systematic review and meta-analysis. Eur Spine J (2007) 16:1085-1100. Vajnar, J. Compression Fractures in a Man with Osteoporosis. JAAPA Sept 2007, 20(9). Resources: National Osteoporosis Foundation www.nof.org Kyphon, Inc. Sunnydale, CA