Kyphoplasty and Vertebral Augmentation

A vertebral compression fracture is a break in the block-shaped body of a vertebra, which crumples under load. Because the broken surfaces move against each other, the fracture is painful with every change of position. Vertebral augmentation fills that break with polymethylmethacrylate bone cement, which hardens inside the bone and prevents further movement and collapse. Vertebroplasty injects the cement directly into the fractured bone. Kyphoplasty first inserts a balloon tamp, inflates it to compact the broken bone and create a cavity, then withdraws it and fills the cavity with cement at lower pressure, which reduces the chance of cement escaping and can recover some of the height lost from the collapse. Both are performed through a small skin puncture, with no incision and no stitches.

The usual indication is an acute or subacute vertebral compression fracture that remains painful despite a period of conservative treatment with analgesia, activity modification and, where appropriate, a brace. It is also considered earlier when the pain prevents a person from standing and walking at all, since immobility in older patients rapidly leads to further bone loss, pneumonia and blood clots. Magnetic resonance imaging is used to confirm that the fracture is recent and still healing, because an old, healed fracture will not respond. Augmentation is also used for vertebrae weakened or destroyed by multiple myeloma or by metastatic cancer, often alongside radiotherapy, and occasionally for painful vertebral haemangioma. It is not appropriate where the fracture involves the back wall of the vertebra with bone pushed into the spinal canal, where there is infection, or where the pain clearly comes from another source.

The patient lies face down. Under local anaesthesia with sedation, or a short general anaesthetic, the skin over the affected level is prepared and a fine needle is advanced into the vertebral body, usually through the pedicle, under continuous fluoroscopic guidance from two directions. In kyphoplasty a balloon is passed down the cannula and inflated with contrast under pressure control, compacting the trabecular bone and lifting the collapsed endplate where the fracture allows; the balloon is then deflated and removed. Bone cement, mixed to a thick consistency, is injected slowly under live imaging so that its spread is watched throughout and injection is stopped at once if it approaches the veins or the spinal canal. The cement hardens within minutes. The needles are withdrawn, the puncture is covered with a small dressing, and a check image confirms the fill. Two levels are often treated in the same session where two fractures are painful.

A suitable candidate has a painful, recent fracture confirmed on magnetic resonance imaging, pain that matches the level seen on the scan, and no infection. Assessment includes radiographs and cross-sectional imaging, blood tests including clotting, and, when the cause is not clearly osteoporosis, investigation for myeloma or a primary cancer. Bone density measurement and blood tests for calcium and vitamin D are arranged, since treating the underlying osteoporosis is as important as fixing the fracture. Blood thinning medicines are paused on medical advice. For international patients, the magnetic resonance images are the key document to send in advance, because they determine whether the fracture is still treatable; a repeat scan on arrival may be needed if the images are more than a few weeks old.

Most patients lie flat for one to two hours while the cement cures fully, then sit and walk with the physiotherapist the same day. Many are discharged the same evening or the next morning. Pain from the fracture usually eases markedly within 24 to 48 hours, though soreness at the puncture site lasts a few days. Ordinary daily activity resumes within a few days, with heavy lifting avoided for a few weeks. Bone protection treatment is started or reviewed before discharge and is the single most important step in avoiding the next fracture, together with calcium, vitamin D, exercise and a review of medicines and falls risk. For treatment abroad, plan about 3 to 5 days: this covers the imaging review, the procedure, the check radiograph and a consultation about long-term bone health, with the ongoing osteoporosis treatment arranged near home.

Vertebral augmentation is a low-risk procedure when performed under good imaging by an experienced operator. The main technical risk is leakage of cement outside the vertebral body; small leaks into the disc or surrounding veins are seen on imaging in a proportion of cases and are usually of no consequence, while leakage towards the spinal canal or a nerve root is rare but can cause pain or neurological symptoms and occasionally needs surgery. Cement entering the venous system can travel to the lungs, which is uncommon and usually silent. Other risks include bleeding, infection, a rib or pedicle fracture from positioning and pressure, and an allergic reaction. New fractures at other levels occur in people with osteoporosis whether or not they have been treated, which is why bone protection is emphasised. Most patients report substantial and lasting pain relief and a return to walking, and kyphoplasty typically restores part of the lost height and reduces the forward angulation at the treated level.