Balloon Kyphoplasty for Acute T8 Compression Fracture
11G AVAmax® vertebral balloon and AVAflex® curved needle
A 97-year old osteoporotic female presented with a 4-day history of progressively worsening atraumatic back pain. She refused to sit, walk or lay on her side due to the severity of her pain. Patient reported pain as 10/10.
Besides osteoporosis (untreated prior to presentation in my clinic), the patient had no other co-existing conditions.
Aside from pain, her neurological examination was negative.
Strength and sensation in her lower extremities was intact.
MRI of the thoracic spine demonstrated marrow edema at the T8 vertebral body, indicating a recent osteoporotic compression fracture.
T8 vertebral compression fracture
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An 11G cannula was selected as the smallest cannula for kyphoplasty. Placement of the cannula into the posterior one-third of the T8 vertebral body proceeded under fluoroscopic imaging, using a unipedicular approach from the patient's left.
At this point, an 11G AVAmax® vertebral balloon was inserted through the cannula, then completely inflated for three minutes prior to its removal, creating a cavity for cement deposition.
Next, the AVAflex® curved needle was inserted for targeted cement placement. Approximately 4 ccs of polymethylmethacrylate (PMMA) were percutaneously injected under continuous fluoroscopic imaging.
Post procedure imaging demonstrated PMMA distribution within the T8 vertebral body, opacifying the anterior two-thirds with satisfactory midline crossage.
Neuroradiologist's Treatment Rationale
The new 11G AVAmax vertebral balloon enabled a balloon kyphoplasty procedure to be performed at a higher level in the vertebral column which, in my practice, has generally been limited to vertebroplasty.
As part of the patient's procedure after care, a DEXA scan, vitamin D and calcium measurements, with aggressive pharmacologic treatment of osteoporosis to promote healing and reduce the incidence for future fracture was prescribed. In my practice, abnormal DEXA scans are followed to ensure adequate response to therapy.
Five hours following the procedure, the patient reported a 50% improvement of original pain symptoms. The following morning the patient reported her pain had completely resolved. She regained her mobility and was discharged from the hospital.
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1500 Waukegan Road
McGaw Park, IL 60085
Treatment methodologies for osteoporotic compression fractures remain unclear and recently have been met with significant controversy among proponents and detractors. This case presents points of concern to appease both sides of this debate. As a proponent of balloon augmentation for osteoporotic compression fractures, I must admit that data supporting its use have not firmly established when to use or not use this technique. A 90-year-old female with 4-day history of back pain is presented as a candidate for augmentation in the face of prior T7 fracture, osteoarthritis and sub-acute injury at T8. Early results are often encouraging yet pale in the face of longer follow-up.
Dr. Brown’s application of the technique is technically without major concern. The size of balloon expansion demonstrated by images provided by Dr. Brown suggests a significant void of bony tissue within the T8 vertebra. Dr. Brown reports application of 4 ccs of PMMA. Typically, we are able to apply a larger volume of PMMA. However, use of larger volumes would increase the likelihood of PMMA extravasation. At T8, potential extravasation of PMMA posteriorly into the spinal canal is a concern we all approach cautiously. Unipedicular augmentations are used in situations where anatomic considerations limit a bilateral approach due to pedicle size or inadvertent iatrogenic pedicle compromise. Despite Dr. Brown’s comment, upper-level balloon augmentations have been accomplished without complication and with excellent result for several years.
Detractors of balloon or needle augmentation for osteoporotic compression fractures may point to the rapid application of a costly technique in treatment of a potentially self-limiting process. Proponents may question a 4-day history of pain yet recognize multiple cases, in their experience, of rapid vertebral collapse as an indication for early versus late treatment. In addition, proponents continue to debate the amount of PMMA or alternate support matrix applied as well as unilateral versus bilateral pedicle approaches for vertebra augmentation in cases of osteoporotic compression fracture. As a final comment, although this patient is not sitting in front of me complaining of acute changes in her pain, I may have delayed balloon augmentation to assess self-healing two or three weeks prior to providing care similar to Dr. Brown.