Kyphoplasty and Vertebroplasty: Treatment of Vertebral Fractures

Kyphoplasty and vertebroplasty are minimally invasive percutaneous techniques for treating vertebral compression fractures, most commonly related to osteoporosis. Performed under local or general anesthesia, they involve injecting surgical cement into the fractured vertebra to stabilize it and relieve pain. Kyphoplasty additionally uses a balloon to restore vertebral height.

Vertebral Compression Fractures

Vertebral compression fractures, also known as compression fractures, represent one of the most common complications of osteoporosis and constitute a major public health problem, particularly among elderly individuals.

Main Causes

Osteoporosis accounts for more than 80% of vertebral compression fractures. This metabolic bone disease is characterized by decreased bone density and altered bone tissue microarchitecture, making vertebrae fragile and susceptible to fracture even during minimal exertion such as coughing, sneezing, or simply bending forward.

Trauma represents the second cause, generally occurring after a fall from height or motor vehicle accident in patients whose bone quality is already compromised.

Bone metastases and primary vertebral tumors can also weaken vertebrae and cause pathological fractures. In these cases, cement augmentation can play an important palliative role in relieving pain and stabilizing the spine.

Epidemiology and Impact

In France, approximately 150,000 vertebral compression fractures occur annually. This figure is likely underestimated as many fractures remain undiagnosed, with some patients attributing their back pain to normal aging.

These fractures primarily affect postmenopausal women, with risk increasing significantly after age 65. In men, the risk becomes significant after age 75.

Symptoms and Complications

Acute back pain is the primary symptom, appearing suddenly and often described as intense pain localized to the fractured vertebra. This pain is aggravated by standing, walking, and trunk movements, and partially relieved by lying down.

Without treatment, the fracture can lead to progressive spinal deformity with development of kyphosis (hunched back), commonly called "dowager's hump." This deformation is not merely cosmetic: it can compromise respiratory function, reduce gastric capacity, and significantly impair quality of life.

Patients often develop loss of autonomy, with difficulty performing activities of daily living, increased risk of new falls, and significant psychological impact related to chronic pain and activity limitation.

Vertebroplasty: The Basic Technique

Vertebroplasty, developed in France in the 1980s, is the foundational technique of vertebral cement augmentation. It revolutionized the management of painful vertebral fractures by offering an effective minimally invasive alternative.

Principle of the Technique

Vertebroplasty involves injecting PMMA surgical cement (polymethyl methacrylate) directly into the fractured vertebral body via a percutaneous approach. This cement, identical to that used for cementing hip or knee prostheses, solidifies within minutes and stabilizes the vertebra.

Procedure Details

The procedure takes place in an interventional radiology suite or operating room equipped with fluoroscopy (real-time radiological imaging). The patient is positioned prone (face down).

After local anesthesia with or without sedation (or general anesthesia in some cases), the surgeon makes one or two small skin incisions of just a few millimeters. Through these incisions, a special needle called a trocar, approximately 2 mm in diameter, is introduced through the paravertebral muscles and vertebral pedicle to reach the center of the vertebral body.

Needle positioning is continuously monitored by fluoroscopic imaging, ensuring millimeter precision. Once optimal position is confirmed, the cement is prepared and slowly injected into the vertebra under continuous radiological monitoring.

Practical Features

Total procedure duration is generally 20 to 30 minutes for one vertebra, slightly longer if multiple levels are treated.

Local anesthesia is often sufficient, allowing the procedure to be performed on an outpatient basis (patient goes home the same day). This possibility is particularly valuable for elderly or frail patients for whom general anesthesia would represent an additional risk.

After injection, the patient remains lying down for 1 to 2 hours while the cement hardens completely, then can generally stand and walk under supervision.

Results

The efficacy of vertebroplasty for pain is remarkable: 85 to 90% of patients report significant improvement, often within the first few hours following the procedure. The pain does not always disappear immediately and completely, but the reduction is sufficient to allow rapid return to activities.

Kyphoplasty: Restoring Vertebral Height

Kyphoplasty, developed in the 1990s, represents a technical evolution of vertebroplasty. It shares the same cement augmentation principle but adds an intermediate step aimed at restoring the height of the collapsed vertebra.

Balloon Technique

After introducing the trocar into the fractured vertebra using the same approach as for vertebroplasty, the surgeon inserts one or two inflatable balloons into the vertebral body.

These balloons are then gradually inflated under controlled pressure and fluoroscopic monitoring. As they expand, they push back the compacted spongy bone from the fracture and create a cavity within the vertebra. This expansion allows partial or complete restoration of lost vertebral height from the compression.

Once optimal height is achieved, the balloons are deflated and removed, leaving a cavity that will then be filled with PMMA cement. The major advantage is that cement is injected into a preformed space at low pressure, which considerably reduces the risk of leakage to adjacent structures.

Specific Advantages

Restoration of vertebral height is the main differentiating advantage of kyphoplasty. By regaining height, kyphotic deformity is reduced and sagittal spinal alignment is restored, which has long-term biomechanical benefits.

Improved cement control through low-pressure injection into a preformed cavity significantly reduces the risk of cement leakage, the main risk of these procedures. Studies show a symptomatic leakage rate of less than 5% with kyphoplasty, versus 10 to 15% with traditional vertebroplasty.

Kyphoplasty also allows better cement distribution within the vertebra, optimizing mechanical stabilization.

Practical Details

The procedure generally takes 45 to 60 minutes for one vertebra, longer than vertebroplasty due to the additional balloon dilation step. It is most often performed under general anesthesia or deep sedation, although some centers offer local anesthesia for patients with high anesthetic risk.

Hospitalization may be outpatient or require one night of observation depending on clinical context and patient's general condition.

Vertebroplasty vs Kyphoplasty: Comparative Table

The choice between vertebroplasty and kyphoplasty is discussed case by case with Dr Dimitriu, based on fracture age, degree of compression, patient's general condition, and therapeutic objectives.

Indications for Vertebral Cement Augmentation

Cement augmentation (vertebroplasty or kyphoplasty) is not systematic for all vertebral fractures. It responds to specific indications evaluated during a specialized consultation.

Painful Osteoporotic Fractures

The main indication concerns recent painful osteoporotic vertebral fractures that resist well-conducted medical treatment for at least 3 weeks. Medical treatment includes relative rest, analgesics, anti-inflammatory drugs, and possibly wearing a brace.

When pain persists disablingly despite this conservative treatment, cement augmentation becomes a therapeutic option of choice. The procedure is particularly indicated when pain prevents the patient from getting up, walking, or performing essential activities of daily living.

Cement augmentation may also be considered earlier, before 3 weeks, in very elderly or frail patients for whom prolonged immobilization presents significant risks (muscle wasting, thromboembolic complications, deconditioning).

Stable Traumatic Fractures

In the context of trauma (fall, accident), cement augmentation may be proposed for fractures considered mechanically stable (without posterior wall involvement, without ligamentous instability) but very painful.

The objective is to accelerate pain relief and allow rapid mobilization, thus avoiding complications of prolonged bed rest.

Painful Vertebral Metastases

Vertebral bone metastases weaken the vertebra and cause intense pain. In this palliative context, cement augmentation allows rapid pain relief and vertebral stabilization, significantly improving patients' quality of life.

The decision is made in consultation with the oncologist, based on the patient's general condition, prognosis, and other ongoing treatments (chemotherapy, radiotherapy).

Contraindications

Certain situations contraindicate cement augmentation: fracture with posterior wall retropulsion and spinal cord compression, active vertebral infection, uncontrolled coagulation disorders, old consolidated fracture (beyond 6 months).

Results and Benefits

Pain Relief Efficacy

Scientific studies, including the famous VERTOS III trial published in the Lancet in 2018, confirm the remarkable efficacy of cement augmentation for pain. Between 85 and 90% of patients report significant pain improvement.

The pain relief effect manifests very rapidly, within the first 24 to 48 hours following the procedure. This speed of action is a major advantage compared to conservative treatment which often requires several weeks before obtaining comparable relief.

Pain reduction allows rapid decrease or even complete cessation of analgesics, thus avoiding their side effects (digestive disorders, drowsiness, risk of opioid dependence).

Functional Recovery

Return to daily activities is generally possible within days following the procedure. Walking is authorized the next day, and patients gradually regain their autonomy.

For elderly patients, this rapid mobilization is crucial to avoid deconditioning and maintain autonomy. Many patients who were confined to bed or wheelchair due to pain can move again and perform their essential activities.

Prevention of Bed Rest Complications

By allowing early mobilization, cement augmentation prevents complications related to prolonged bed rest: phlebitis, pulmonary embolism, urinary and pulmonary infections, pressure sores, muscle wasting, and general deconditioning.

Quality of Life

The improvement in quality of life is significant and measurable by validated scores. Patients regain better sleep (not disrupted by pain), better mood, and can again participate in social and family activities.

Follow-up and Recurrence Prevention

Osteoporosis Treatment is Essential

It is fundamental to understand that cement augmentation treats the consequence (the fracture) but not the cause (osteoporosis). Without management of underlying osteoporosis, the risk of new fractures on other vertebrae remains very high.

A complete osteoporosis workup should be performed, including bone densitometry (DXA bone density measurement) and blood tests to identify possible secondary causes of osteoporosis.

Medical Treatment

Osteoporosis treatment relies on several pillars:

Bisphosphonates (alendronate, risedronate, zoledronate) constitute first-line treatment. These medications inhibit bone resorption and increase bone mineral density, significantly reducing the risk of new fractures.

Vitamin D and calcium are systematically prescribed as supplements. Vitamin D is essential for calcium absorption and bone health. Most elderly people have vitamin D deficiency, particularly marked in winter.

Other treatments may be proposed depending on cases: denosumab (monoclonal antibody), teriparatide (parathyroid hormone analogue for severe osteoporosis), raloxifene (selective estrogen receptor modulator).

Lifestyle Measures

Regular physical activity is crucial. It stimulates bone formation, maintains muscle mass, improves balance, and reduces fall risk. Walking, gentle gymnastics, tai chi, or pool exercises are particularly recommended.

A calcium-rich diet (dairy products, calcium-rich mineral waters, green vegetables) contributes to maintaining bone capital.

Smoking cessation and limiting alcohol consumption are recommended, as these substances have a deleterious effect on bone metabolism.

Fall Prevention

In elderly people, fall prevention is paramount. It involves home modifications (removing rugs, adequate lighting, grab bars in bathroom), wearing appropriate footwear, correcting visual disorders, and reviewing medications that may promote falls (sleeping pills, anxiolytics).

Regular Follow-up

Regular medical follow-up with your primary care physician and/or rheumatologist is necessary to adjust treatment, monitor efficacy (bone density monitoring every 1 to 2 years), and detect possible new fractures early.

Frequently Asked Questions

Sources: French National Authority for Health (HAS) - Recommendations on vertebral fracture management, French Society for Spinal Surgery (SFCR) - Best practices in cement augmentation, VERTOS III Trial - Lancet 2018: Percutaneous vertebroplasty versus conservative therapy, AOSpine - International guidelines for vertebral augmentation.