Watchful Waiting or Watchful Worsening?

Spinal fractures and the associated pain and dysfunction often cause substantial decrement in quality of life. (1,2) In addition, the at-risk population isn't limited to patients with primary/secondary osteoporosis - a more realistic patient cohort also includes patients with cancer or a history of treatment for same. Given the staggering number of spinal fractures that occur each year (over 750,000 in the U.S. alone), isn't it time to reconsider best practice guidelines for this pervasive and debilitating disorder? (3)

Conservative treatments, such as bedrest and decreased physical activity, accelerate bone loss and can lead to subsequent fracture. Fractures that are not reduced eventually heal in a deformed state, disrupting normal spinal alignment. The spinal deformity can become so severe that pulmonary and gastrointestinal function are affected and risk for death increased. In short, spinal fractures not only affect lifestyle, but lifespan. (4-7)

Progression of a T-12 Vertebral Compression Fracture
Courtesy of Michael Hisey, MD - Texas Back Institute

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February

May

Two treatment options available for this generally elderly and frail spinal fracture population are vertebroplasty and balloon kyphoplasty. Both involve percutaneous injection of bone cement into the affected vertebra(e); however, balloon kyphoplasty has the potentially added benefit of restoring vertebral body height. This height restoration can help reduce spinal deformity and may, in turn, help preserve pulmonary and gastrointestinal function.

With vertebroplasty, bone cement is injected into the fractured vertebral body under high pressure. This technique "sets" the vertebra in its deformed state.

In contrast, balloon kyphoplasty attempts to restore pre-fracture anatomy by using orthopedic balloons to gently expand the compressed vertebral body before cement is injected. Inflation and deflation of the balloons not only effects fracture reduction, but creates a cavity into which bone cement is injected under low pressure, thereby reducing the likelihood of cement extravasation. (8)

For more information about balloon kyphoplasty for the treatment of spinal fractures due to osteoporosis, cancer or benign lesions, please visit www.kyphon.com.

Any type of surgery involves risk. Although the complication rate for balloon kyphoplasty is low, serious adverse events, some of which can be fatal, can occur, including myocardial infarction (heart attack), cerebrovascular accident (stroke), pulmonary embolism (blood, fat or cement clot that migrates to the lungs), and cardiac arrest (heart stops beating). Other risks (relevant to the anatomy being treated) include deep or superficial wound infection, leakage of bone cement into the muscle and tissue surrounding the spinal cord and nerve injury that can, in rare instances, cause paralysis. Patients are encouraged to discuss these and other risks with their physician.

An asterisk (*) denotes that some/all of the authors are paid Kyphon consultants. A cross (†) indicates that research cited may have been funded partially, or in whole, by Kyphon Inc.

1. Silverman SL. The clinical consequences of vertebral compression fracture. Bone 1992;13 Suppl 2:S27-31.

2. *†Gold DT, Silverman SL. The downward spiral of vertebral osteoporosis: consequences (Monograph). Cedars-Sinai Medical Center 2003.

3. Melton L J 3d. Epidemiology of spinal osteoporosis. Spine. 1997;22:2S-11S.

4. Kado DM, Browner WS, Palermo L, Nevitt MC, Genant HK, Cummings SR. Vertebral fractures and mortality in older women: a prospective study. Study of Osteoporotic Fractures Research Group. Arch Intern Med 1999;159(11):1215-20.

5. *Johnell O, Kanis JA, Oden A, et al. Fracture risk following an osteoporotic fracture. Osteoporos Int 2004;15(3):175-9.]

6. Lindsay R, Silverman SL, Cooper C, et al. Risk of new vertebral fracture in the year following a fracture. Jama 2001;285(3):320-3.

7. Kado DM, Huang MH, Karlamangla AS, Barrett-Connor E, Greendale GA. Hyperkyphotic posture predicts mortality in older community-dwelling men and women: a prospective study. J Am Geriatr Soc 2004;52(10):1662-7.

8. *†Garfin, S.R., R.A. Buckley, and J. Ledlie, 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(19): p. 2213-20.