Side Effects and Complications of Kyphoplasty
Kyphoplasty is a relatively safe procedure with major complications occurring in less than 1% of patients with osteoporotic fractures and less than 5% in those with neoplastic involvement, though cement leakage occurs frequently (27% of treated vertebrae) and remains mostly asymptomatic. 1
Overall Complication Rates
The threshold all-complication rate should not exceed 2% for osteoporotic fractures and 10% for neoplastic fractures—rates above these benchmarks warrant immediate review of local practice patterns. 1
Common Complications
Cement Leakage (Most Frequent)
- Occurs in 27% of treated vertebrae when assessed by intraoperative fluoroscopy and post-operative x-rays 1
- Most leakages are asymptomatic and occur into endplates, discs, or segmental veins 1
- Kyphoplasty has lower leakage rates than vertebroplasty due to balloon creation of a low-resistance cavity allowing more viscous cement placement at lower pressure 1
- Symptomatic cement leakage averages only 1.3% for kyphoplasty 2
- No spinal canal leakages or cement embolisms were reported in the FREE trial 1
Pulmonary Complications
- Pulmonary embolism from cement, air, or fat emboli 1
- In pathologic fractures specifically, PE risk is significantly elevated (3.5% vs 1.2% in non-pathologic fractures) requiring closer monitoring 3
- Pneumothorax (particularly at thoracic levels) 1
Neurological Complications
- Nerve or spinal cord injury resulting in paralysis, bowel/bladder dysfunction, or requiring emergent decompression 1
- Office-based procedures show higher odds of nerve injury compared to inpatient/ASC settings 4
Serious but Rare Complications (Each <1%)
- Infection: osteomyelitis (0.6%), epidural abscess 1, 3
- Bleeding: vascular injury, paraspinal or soft tissue hematoma 1
- Fractures: rib, pedicle, or vertebral body 1
- Cardiovascular: hypotension or depressed myocardial function (from free methylmethacrylate monomer or fat emboli) 1
- Death: from cardiovascular collapse or anaphylaxis to cement 1
Secondary Fractures
No increased risk of adjacent vertebral fractures compared to conservative management—18.8% in conservative treatment vs 19.4% in vertebroplasty/kyphoplasty groups over 2 weeks to 2 years (not statistically significant). 1 However, office-based procedures show higher odds of secondary fractures 4.
Risk Factors for Complications
Based on multivariate analysis, independent predictors of 30-day complications include 5:
- Dependent functional health status preoperatively (OR 1.78)
- Pre-operative sepsis/SIRS (OR 2.52)
- COPD history (OR 1.62)
- Disseminated cancer (OR 1.94)
- Pre-operative wound infection (OR 3.47)
- Inpatient admission status (OR 3.22)
Risk factors for cement leakage specifically include 6:
- Hypertension
- Degree of vertebral collapse
- Disrupted cortical continuity
- Posterior wall defects
- Specific segments (T6, T8)
- Volume of bone cement injected
Setting-Specific Considerations
Office-based kyphoplasty demonstrates 4:
- Lower rates of: acute kidney injury, cardiac arrest, DVT, pneumonia, transfusion, UTI, site/wound complications, readmissions, and infections
- Higher rates of: nerve injury and secondary fractures
- Appropriate only for carefully selected patients
Critical Pitfalls to Avoid
- Cement viscosity is crucial—premature application before optimal viscosity is the primary cause of leakage 2
- Continuous fluoroscopic monitoring during cement injection is mandatory to detect early leakage 2
- Procedures should be performed only at centers capable of managing emergent spinal cord compression surgically 2
- Closer PE monitoring is essential in patients with pathologic (malignant) fractures 3