Kyphoplasty for Chronic Compression Fractures
Kyphoplasty is a reasonable and effective treatment option for chronic compression fractures when conservative therapy has failed, providing reliable pain relief and functional improvement, though height restoration is less optimal compared to acute fractures. 1, 2
When to Consider Kyphoplasty for Chronic Fractures
Kyphoplasty should be offered to patients with persistent pain despite 3 months of conservative management, including analgesics, physical therapy, and osteoporosis treatment. 1 The American Heart Association supports kyphoplasty as a reasonable therapeutic option for severe back pain from vertebral compression fractures refractory to conservative medical therapy (Class IIA, Level of Evidence B). 2
Key Clinical Evidence in Chronic Fractures
Chronic fractures (>4 months old) treated with kyphoplasty achieve 87% pain relief rates, comparable to acute fractures (90% pain relief), demonstrating that chronicity does not preclude successful pain outcomes. 3
Height restoration is reduced but still achievable in chronic fractures: mean vertebral height improves from 56% to 79% of estimated normal height, compared to 58% to 86% in acute fractures. 3 Only 26% of chronic fractures achieve ≥89% restoration of normal height versus 60% of acute fractures. 3
Kyphosis correction remains significant in chronic cases, with mean local Cobb angle improving from 15° to 10° (p<0.001), though less than the 15° to 8° improvement seen in acute fractures. 3
Timing Considerations: A Critical Pitfall
Do not rush to kyphoplasty in the first 3 weeks. Approximately 65% of patients respond successfully to conservative treatment alone. 4 The evidence shows that while kyphoplasty provides superior outcomes in the first month, by 3 months there is no significant difference in pain or disability scores between kyphoplasty and conservative treatment. 4
Risk Factors Predicting Conservative Treatment Failure
Consider earlier intervention (after 3 weeks) in patients with: 4
- Age >78.5 years
- Severe osteoporosis (T-score <-2.95)
- BMI >25.5
- Vertebral collapse rate >28.5%
Clinical Outcomes in Chronic Fractures
Pain relief is rapid and substantial: 90% of patients experience significant pain reduction by 2 weeks post-procedure, with improvement in Oswestry Disability Index scores. 3
Functional recovery occurs earlier with kyphoplasty: patients achieve significant pain relief at 30 days versus 116 days with conservative treatment. 2
Quality of life improvements are significant, with 75% of kyphoplasty patients achieving performance status scores ≥70 (threshold for self-care) compared to 39% with conservative treatment. 2
Kyphoplasty vs. Vertebroplasty: The Cost-Benefit Question
No head-to-head studies have compared kyphoplasty with vertebroplasty, making definitive superiority claims impossible. 5 However, key differences exist:
Kyphoplasty costs approximately 2.5 times more than vertebroplasty due to additional equipment, anesthesia, and hospital costs. 5, 2
Height restoration may be superior with kyphoplasty, with some evidence suggesting better correction of spinal deformity. 1 Recent data shows kyphoplasty prevents further vertebral body collapse more effectively (1.95% decrease) compared to vertebroplasty (4.39% decrease). 6
Pain relief and complication rates are similar between procedures, with cement leakage rates showing no significant difference (19.3% overall). 6
Both procedures provide rapid and significant pain relief (mean VAS reduction from 6.82 to 0.76 for vertebroplasty; 7.15 to 0.81 for kyphoplasty). 6
Important Caveats and Contraindications
Radiographic fracture presence does not necessarily correlate with the source of back pain—clinical correlation is essential. 1
Cement leakage is common (19.3%) but usually asymptomatic, though rare serious complications like pulmonary embolism from venous cement leakage can occur. 2, 6
Subsequent compression fractures occur in approximately 5-8% of patients during the first year post-procedure, regardless of treatment modality. 4
Procedural risks include infection and bleeding, particularly important in anticoagulated patients. 2
Post-Procedure Management
Bed rest with observation, regular vital signs and neurological assessment, and supervised ambulation are standard. 2
Most patients can be discharged same-day or after overnight observation. 2
Counsel patients to report any sudden increase or new back pain, as this may indicate a new fracture. 2
Prevention of future fractures is critical: ensure calcium and vitamin D supplementation, bisphosphonates as first-line therapy, and consider denosumab for refractory cases. 1