What is the recommended treatment approach for patients with vertebral compression fractures using kyphoplasty?

Kyphoplasty for Vertebral Compression Fractures

Primary Recommendation

Kyphoplasty is a reasonable therapeutic option for patients with severe back pain from vertebral compression fractures that remains refractory after at least 6 weeks of optimal conservative medical therapy, with stronger evidence supporting its use in cancer-related fractures than osteoporotic fractures. 1, 2

Patient Selection Criteria

Before considering kyphoplasty, patients must meet specific requirements:

• Minimum 6 weeks of documented optimal non-invasive therapy including analgesics, physical therapy, bracing, and osteoporosis medical management 2
• At least 25% vertebral height loss/compression with the vertebra retaining at least 1/3 of its original height and intact posterior cortex 2
• Pain localized to the fracture level confirmed by clinical examination and imaging correlation 2
• Acute or subacute fracture confirmed by MRI showing bone marrow edema on STIR or T2-weighted fat-saturated sequences 2, 3

Timing Considerations

Earlier intervention is warranted for cancer-related fractures where kyphoplasty demonstrates superior outcomes compared to conservative therapy in reducing pain, disability, and improving performance status (AHA Class IIA, Level of Evidence B). 1

For osteoporotic fractures, acute fractures (less than 10 weeks old) achieve better height restoration than chronic fractures:

• 60% of acute fractures achieve ≥89% restoration of normal vertebral height compared to only 26% of chronic fractures 4
• Fracture reduction is significantly better in acute cases (p=0.01), though pain relief remains reliable in both acute and chronic fractures 4

Expected Clinical Outcomes

Pain Relief

• Dramatic pain reduction occurs rapidly, with VAS scores decreasing from 8.2 preoperatively to 4.4 immediately postoperatively, maintained at 3.6 at one year 5
• Kyphoplasty achieves significant pain relief 86 days earlier than conservative treatment (30 days vs 116 days) 1
• 90% of acute fractures and 87% of chronic fractures achieve pain relief by 2 weeks post-procedure 4

Functional Improvement

• Oswestry Disability Index improves from 58 preoperatively to 38 at one year, representing sustained functional benefit 5
• 75% of cancer patients improve to performance status ≥70 (threshold for self-care) compared to 39% with conservative treatment 1

Height Restoration

• Acute fractures restore from 58% to 86% of estimated normal vertebral height (p<0.001) 4
• Chronic fractures restore from 56% to 79% of estimated normal vertebral height (p<0.001), though less effectively than acute fractures 4
• Kyphoplasty prevents further vertebral body collapse more effectively than vertebroplasty, with only 1.95% decrease in vertebral compression ratio compared to 4.39% with vertebroplasty 6

Procedural Risks and Complications

Cement Leakage

• Cement leakage occurs in 19.3% of cases but is usually asymptomatic 6
• No significant difference in cement leakage risk between kyphoplasty and vertebroplasty 6
• Rare but serious complications include pulmonary embolism from cement leakage into the venous system 1

Other Risks

• Infection and bleeding are procedural risks, with bleeding particularly important in anticoagulated patients 1
• Clinically relevant complications are rare when proper technique and patient selection are employed 6

Post-Procedure Management Protocol

Immediate Post-Operative Care

• Bed rest with regular monitoring of vital signs and neurological function for the first 24-48 hours 2, 3
• Supervised ambulation after appropriate observation period, with most patients discharged same-day or after overnight observation 1, 2
• 76% of patients require continued analgesia initially, though 24% can discontinue pain medications within 24 hours 3

Follow-Up Requirements

• Near-term follow-up is mandatory to assess pain levels, mobility, and analgesic requirements 2, 3
• Patient education is essential: counsel patients to immediately report sudden increase or new back pain, as this may indicate a new fracture 1, 3
• Initiate osteoporosis treatment with bisphosphonates, denosumab, or teriparatide to prevent future fractures 3

Red Flags Requiring Emergency Intervention

If increased pain develops post-procedure, obtain immediate cross-sectional imaging (CT or MRI) to evaluate for cement leakage and new fractures. 3

• Progressive neurological deficit (new/worsening lower extremity weakness, sensory loss, or bowel/bladder dysfunction) requires emergency imaging and possible surgical decompression 3
• New or sudden increase in back pain after initial improvement strongly suggests a new compression fracture at an adjacent level 3
• Severe uncontrolled pain despite adequate analgesia suggests significant complication requiring imaging 3

Alternative Considerations

Vertebroplasty is a less expensive alternative (approximately 2.5 times less costly than kyphoplasty) with similar pain relief and complication profile, though it provides less effective prevention of further vertebral collapse. 1, 6