What are the criteria for kyphoplasty in patients with vertebral compression fractures?

Criteria for Kyphoplasty in Vertebral Compression Fractures

Kyphoplasty should be considered 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

Clinical Requirements

• Pain severity: Disabling back pain that significantly impairs quality of life and function, typically with pain scores ≥7/10 on visual analog scale 3
• Failed conservative therapy: Minimum 6 weeks of optimal non-invasive treatment including analgesics, bed rest, back braces, physical therapy, rehabilitation, and walking aids 2
• Medical optimization: Initiated treatment with calcium, vitamin D, and antiresorptive agents as appropriate 3
• Documented bone health evaluation: Bone mineral density assessment and osteoporosis education must be documented 2

Radiographic Requirements

• Vertebral height loss: At least 25% height loss/compression for painful osteoporotic acute or subacute fractures 2
• Structural integrity: Vertebra must retain at least 1/3 of its original height with intact posterior cortex 2
• Fracture confirmation: MRI or bone scan confirmation of acute or subacute fracture with bone marrow edema 2
• Exclusion of other pathology: CT and MRI to rule out infection, malignancy (unless treating known metastatic disease), or other causes 2

Timing Considerations

• Acute fractures (<10 weeks): Optimal candidates with best height restoration potential—60% achieve ≥89% of estimated normal vertebral height 4
• Subacute fractures (10-16 weeks): Still good candidates with reasonable height restoration 4
• Chronic fractures (>4 months): Remain candidates primarily for pain relief, though height restoration is less predictable (only 26% achieve ≥89% restoration) 4
• Optimal window: Kyphoplasty performed within 3 months of fracture onset achieves >50% improvement in kyphosis and best height restoration 5

Special Population: Cancer-Related Fractures

For patients with cancer and vertebral fractures, kyphoplasty has stronger evidence and should be considered earlier in the treatment algorithm. 1

• Superior outcomes: Kyphoplasty is definitively superior to conservative therapy for cancer patients with disabling back pain from vertebral fractures (AHA Class IIA, Level of Evidence B) 1
• Functional benefits: 75% of kyphoplasty patients improve to Karnofsky Performance Status score ≥70 (threshold for self-care) compared to 39% with conservative treatment 3
• Earlier intervention: Mean time from randomization to kyphoplasty was 7 days in cancer patients, with fractures averaging 6 weeks old at enrollment 3
• Pain relief timeline: Significant pain reduction from baseline score of 7.3 to 3.5 at 7 days post-procedure versus 7.0 with conservative management 3

Contraindications to Screen For

• Active infection: Systemic or local spinal infection 1
• Coagulopathy: Uncorrected bleeding disorders, particularly important in anticoagulated patients 1
• Fracture characteristics: Complete vertebral collapse, burst fractures with posterior cortex disruption, or fractures with neurological compromise requiring decompression 2
• Allergy to bone cement components 1

Expected Outcomes

Pain Relief

• Immediate benefit: 90% of acute and 87% of chronic fractures achieve pain relief by 2 weeks post-procedure 4
• Sustained improvement: Pain reduction from VAS 8.2 preoperatively to 4.4 immediately postoperatively, maintained at 3.6 at 1 year 6
• Durable effect: Pain relief persists at 12-18 months follow-up with minimal deterioration 6, 7

Functional Improvement

• Quality of life: 5.2-point greater improvement in SF-36 Physical Component Summary score compared to conservative management at 1 month 3
• Disability reduction: Oswestry Disability Index improves from 58 preoperatively to 38 at 1 year 6
• Performance status: Mean Karnofsky Performance Status increases by 15.3 points at 1 month in cancer patients 3

Height Restoration

• Acute fractures: Mean vertebral height improves from 58% to 86% of estimated normal height 4
• Chronic fractures: Mean vertebral height improves from 56% to 79% of estimated normal height 4
• Kyphosis correction: Local Cobb angle improves from 15° to 8° in acute fractures and 15° to 10° in chronic fractures 4

Common Pitfalls to Avoid

• Premature intervention: Do not proceed without documenting full 6-week trial of optimal conservative management for osteoporotic fractures 2
• Inadequate imaging: Failure to obtain MRI confirmation of acute/subacute fracture or to rule out malignancy in patients without known cancer 2
• Missing height measurements: Not documenting baseline vertebral height loss percentage before procedure 2
• Delayed treatment in cancer patients: Waiting too long in cancer-related fractures when earlier intervention shows superior outcomes 1
• Ignoring anticoagulation status: Proceeding without addressing bleeding risk in anticoagulated patients 1