Why Kyphoplasty for Osteoporotic Vertebral Fractures?

Introduction

For osteoporotic vertebral compression fractures, there are two treatment options. These are the KP and VP processes. This study uses narrative analysis of recent data to compare two therapies.

Osteoporosis is a systemic disease of bones that causes bone density to decrease and a loss of bone microarchitecture, weakening bone and more. It is a headache in about 40 per cent of postmenopausal women, and thus it is a serious health concern of the population.¹ However, the men are also affected by osteoporosis, albeit with a lower prevalence rate. More than 700,000 vertebral fractures occur each year in the world due to osteoporosis, and the geriatric population is vulnerable. The medical costs associated with the condition, coupled with associated morbidity and mortality, are pretty high. One of the most frequent sequelae of osteoporosis is the so-called VCFs, which, in a debilitating way, worsen the quality of life of patients with the manifestation of constant pain, physical disability, and loss of mobility. Such diseases also include secondary fractures that occurred due to the primary or even metastatic malignancy of spinal origin, complicating the clinical situation.^2–4

It is a pathophysiological disease caused by the imbalance of bone resorption and bone formation, which leads to the net loss of bone density. In most cases, the condition is further aggravated by hormonal variations, particularly the lack of production of estrogen during menopause and age, eating disorders, and poor lifestyle, including lazy behavior and even smoking. People also become predisposed to getting a fracture by pedestrian accident or even in regular behaviour due to the consequences of the bone fragility.⁵ Fractures of the vertebrae, especially, cause progressive deformity of the spine, height loss, and chronic discomfort, which, in turn, cause functional deterioration of such individuals, leading to the loss of independence.⁶ OVCF management has changed extensively in the last couple of decades. Conservative measures that have been applied in prior treatment include bed rest, bracing, pain medication, and physical therapy. Nevertheless, since they prove beneficial in others, they cannot always alleviate pain or correct spinal straightening in the cases of severe fractures or patients with a low coping threshold to long-term immobilization. Moreover, conservative treatment fails to address the structural instability caused by the fracture, which will lead to longitudinal spine deformity and paraplegia.^3,7,8

Alternatively, alternative interventions exist, e.g., minimally invasive procedures, i.e., vertebroplasty (VP) and kyphoplasty (KP). First, Galibert and Deramond in 1987 carried out a VP, injecting under fluoroscopic guidance in the case of a vertebral hemangioma of C2: the process was the introduction of a cement in polymethylmethacrylate, commonly known as PMMA, into the fractured vertebral body. This procedure is aimed at stabilizing the fracture, eliminating the pain, and preventing further collapse of the vertebral. In 1998, a further modification of KP as a VP was introduced by Mark Reiley, who inserted a balloon into a vertebral body, making a cavity where the cement would be inserted. Other than relieving the pain and stabilizing the vertebrae, this will enable restoration of vertebral height and correction of kyphotic deformity.^3,7,8 Cadaveric experiments have identified the biomechanical benefits of KP over VP, such as improved distribution of cement and enhanced restoration of vertebral height due to cavitation of the vertebral body before cement injection.⁹ Also, KP is connected with a reduced rate of cement leakage, which is one of the complications of VP and can result in the occurrence of such fatal incidents as a pulmonary embolism, spinal cord pressure, or nerve root damage. Nevertheless, the procedures are generally regarded as effective and safe when operated by an experienced operator. The surgeon’s preferences between VP and KP depend on several factors, such as the patient’s clinical condition, the extent of the fracture, and the opportunity that the surgeon provides.^2,10,11

Under local anaesthesia, KP is most frequently performed. Nonetheless, sedation or general anaesthesia can be administered in such patients, as they cannot face the pain or find it a burden. The technique entails introducing a cannula and a balloon into the vertebral bodies using a fluoroscope and inflating the balloon in the cavity. The balloon is then deflated and excised, filling the cavity with PMMA cement. It takes only minutes to set, and hardened cement stabilizes the fracture. Overall, KP’s treatment results are positive; most patients showed significant symptomatic and functional improvements within a few days after the surgery. This involves recovering vertebral height and kyphotic restoration/radiological outcomes.^2,10 KP also has its demerits despite its numerous benefits. Cement leakage, pulmonary or cement embolism, infection, fever, and neurological deficits are the complications of the operation. The most frequent complication, cement leakage, can present with no symptoms but turn disastrous when the leakage occurs around the spinal canal and/or neural structures. Other potential risks include postoperative level fracture due to how this alter the spinal mechanics post-surgery.¹² These risks should be kept to a minimum, and outcomes maximized through a careful patient selection process, a careful implementation of the procedure, and meticulous preoperative planning.^2,11

Investigations of alternative fillers to KP have gained momentum over recent years, with calcium phosphate cement and bioactive glasses being the most promising alternatives to PMMA since they present the most advantages: biocompatibility and osteoconductivity. However, PMMA is most frequently utilized due to its effectiveness, convenience, and demonstrated mechanical stability. Additional investigations have started to improve KP’s safety and efficacy and widen its indications in different fractures and patients with co-morbidity.^2,10 The KP functional and radiologic outcome reports have been numerous, and most patients have high satisfaction levels, and significant advances have been experienced regarding pain, movement, and quality of life. Nevertheless, these long-term studies on a large scale are yet necessary to learn more in-depth about how lasting these outcomes are and what factors are likely to contribute to the effectiveness of such a procedure. KP is also a subject of research on the possible cost-effectiveness compared to conservative management and other surgery types, regarding the growing number of cases of osteoporosis and the necessity for effective options of its treatment.^2,11

This research contributes to what the authors know about KP in the treatment of osteoporotic vertebral compressions. The functional and radiological results of kyphoplasty for osteoporotic vertebral compression fractures (OVCF) were assessed. This aided in the comprehension of public information. The functional and radiological outcome measures include pain relief, the restoration of vertebral height, the correction of Kyphotic deformity, and complication rates. We make this finding available to advance the body of knowledge regarding the potential benefit of KP in caring for patients with OVCFs and to assist with making clinical decisions on behalf of this severely incapacitated patient population. In short, vertebral compression fractures sequelae and osteoporosis are a significant global social health problem, given the considerable percentage of vertebral compression fractures that contribute to the overall economic burden of health care through genomic health care financing in countries around the world.¹³ To ascertain the clinical efficacy, complication rates, and results of kyphoplasty in osteoporotic vertebral compression fractures (OVCF), the literature was examined. We used criteria to choose the articles.

Nonetheless, KP is one of the revolutions in OVCF management that has baffled conservative management regarding its applicability and effectiveness, and offers lasting pain relief and structural stabilization procedures. This review evaluates the impact of KP on patient outcomes by drawing on a number of earlier research. Results include pain management, spinal height restoration, and therapy of kyphotic deformities. As the world population is ageing, these techniques are likely to remain even more common and indeed up and coming; further research and innovations will occur in this field. To contribute towards that desired end, we are endeavoring to document our experience of KP in as detailed a manner as possible in the hope that we enhance the outcomes of patients with osteoporotic vertebral deformities. The systematic review was conducted, which included bias assessments.¹⁴ This guaranteed the reliability and correctness of the review. The objectives include a concise assessment of the methodological rigour and evidence supporting the use of KP to treat osteoporotic spinal compression fractures, as well as transparency and consistency in the analysis of prior studies. It’s easier to be open and consistent.

Research methodology

Radiological evaluation

Preoperatively, early postoperatively (within 24 hours), and 1 month postoperatively, radiological assessments were performed. Vertebral height measurements are illustrated in Figure 1. The following parameters were evaluated:

• 1. The lateral direct radiographs measured the heights of the affected vertebrae’s anterior, middle, and posterior walls.

• 2. The Cobb technique calculated the kyphosis angle on lateral radiographs in a neutral posture.

• 3. Diagnosis, fracture morphology, cement behavior, and possible complications, such as cement leakage, were confirmed with Direct radiographs, CT, and MRI.

Figure 1. Biomechanical comparison of vertebroplasty, kyphoplasty, vertebrae stent for osteoporotic vertebral compression fractures.

Results

In this study, 32 patients with secondary osteoporosis vertebral collapse fractures were included. The sample consisted of 8 males (25%) and 24 females (75%), ranging from 29 to 88 years of age. The study population had a mean age of 63.09, 50.5 years for the male patients and 67.29 years for the female patients. Thirty-six percutaneous kyphoplasty procedures were performed (4 two-level and 28 single-level). Twenty five percent (n = 9) were at L1, 16.6% (n = 6) at L2, 13.8% (n = 5) at L3, 13.8% (n = 5) at L4, 16.6% (n = 6) at T12, 8.3% (n = 3) at T11, 2.7% (n = 1) at T10 and 2.7% (n = 1) at T7.

Pain assessment using visual analogue scale

The VAS scores were 8.56 (severe pain) for preoperative and 3.87 (mild pain) for postoperative. The mean VAS score went down by 31.54 on average in the early postoperative period, from 8.55 to 5.83, which indicated a significant reduction of pain in the study group. Then, by the first postoperative month, the VAS score decreased by 92.64% compared to the preoperative score, reaching an average of 0.63, which marks minimal or no pain. The study showed that the KP procedure provides substantial, sustained improvement with pain relief. Changes in VAS scores are shown in Figure 2.

Figure 2. Preoperative and postoperative measurement of vertebrae height.

Dıscussıon

Bones are weakened and fracture risk is increased by systemic osteoporosis. Vertebral compression fractures (VCFs), which are the usual result of this illness, lead to spinal anomalies, pain, and problems with quality of life.¹⁶ VCFs have a number of adverse effects. There is mechanical instability at the fracture site. This instability exacerbates pain by causing micromovements and inflammation. Persistent pain and dysfunction brought on by structural instability cannot be resolved by conventional therapy. Bracing, bed rest, and therapy are examples of conservative therapies.

Minimally invasive osteoporotic vertebral compression fracture treatments include KP and VP. In kyphoplasty, unstable vertebrae are opened using an inflated balloon. After treatment, polymethylmethacrylate bone cement is used to fill this void.^6,11 The structural and functional consequences of spinal compression fractures are addressed by this technique. Surgery elevates the spine, fixes kyphotic abnormalities, and stabilises the fracture.

Research into KP’s analgesic qualities has lasted for years. Pain was expected to be reduced by heat and chemical changes that occurred in PMMA during polymerisation. According to a recent study, KP prevents vertebral collapse, reduces inflammation and mechanical strain, and stabilises microfractures. The spine becomes more aligned and less deformed as it is stabilised. Our study showed that KP reduced VAS pain by 92.64%. According to Kim et al., KP significantly raised the spinal height and kyphosis angle. This outcome is supported by previous studies.^17,18

Although KP offers a number of advantages, its primary drawback is cement leakage. Cement leakage is the primary problem.¹⁹ Thirty percent of cement leaks are symptomless. It cause pulmonary embolism, myelopathy, or injury to nerve roots. When evaluating the danger of leaks, take into account the volume, viscosity, and spinal cortical structure of the cement. To minimise problems and guarantee accurate cement application, some surgeons use high-viscosity cement with advanced imaging. Due to careful patient selection and superior operation, our study revealed no serious problems.

Kyphoplasty is often preferred over vertebroplasty in cases of severe spinal collapse or kyphotic deformity. particularly when their spines are malformed. especially in contrast to vertebroplasty. While both involve cement injection, KP treats kyphosis and spinal height using a balloon-filled chamber. In both cases, cement is injected. KP is safer and smarter at times.^8,19,20 Phases stop cement from leaking. These findings are supported by our data, which show significant improvements in spinal height and kyphosis correction.

Adjacent-level fractures are feared in kyphoplasty. PMMA cement stiffens the vertebral body, putting stress on neighbouring vertebrae and raising the risk of fracture, according to several medical research. KP did not forecast local fractures in our investigation.²¹ This resulted from our short follow-up and unipedicular method. Long-term research is necessary to identify this risk.

Whether using unipedicular or bipedicular approaches, performance is important. According to a recent research, the unipedicular strategy is just as successful as the bipedicular one. Unipedicular therapy reduces problems, radiation, and recovery time. Even still, stability was the usual reason for choosing the bipedicular approach. Unipedicular is often used in our practice since it yields positive results with little hassle.

Following kyphoplasty, rapid mobility lowers PE and DVT associated with bed rest. Last but not least, this is crucial. Three to six hours after surgery, either the same day or the next day, research participants were released from the hospital.^22,23 The lives of individuals with osteoporotic visceral compression fractures are enhanced with minimally invasive KP. KP’s quick recovery indicates that it is less invasive.

Lastly, osteoporotic spinal compression fractures are repaired by minimally invasive kyphoplasty. Our research found that KP restores spinal height and reduces kyphosis pain. These findings are consistent with earlier research. Expertise in operation and careful selection help minimise cement leakage. Research on long-term KP effects is necessary. This aids in the analysis of how KP lessens spinal fragility and affects adjacent fractures.

Conclusion and future recommendations

In conclusion, percutaneous kyphoplasty (KP) is a safe, effective, and minimally invasive treatment for osteoporotic vertebral compression fractures (VCFs). The procedure delivers on its core objectives: providing rapid and remarkable pain relief, significantly restoring lost vertebral height, and correcting pathological kyphosis to improve spinal alignment. These radiological improvements directly translate to tangible clinical benefits, including a superior quality of life and enhanced patient functional status. When performed by experienced surgeons adhering to proper technical protocols, KP is associated with a notably low risk of complications, further solidifying its position in the treatment algorithm. However, adopting KP is not without its ongoing debates and challenges. Primary among these concerns is the risk of subsequent fractures at levels adjacent to the treated vertebra, which the stiffness of the bone cement used influence.

Furthermore, questions persist regarding the optimal technical execution of the procedure, including cement volume, viscosity, and injection pressure, to maximize benefits while minimizing risks. Therefore, while the current evidence strongly supports KP as a vital therapeutic option, future research must address several key areas to refine its application and outcomes. First, large-scale, long-term prospective studies are essential to fully understand the decade-long durability of the procedure, its impact on overall spinal biomechanics, and its definitive role in preventing chronic pain and disability. Second, an investigation into alternative filling materials is a critical frontier. Developing novel biomaterials, such as osteoconductive and bioresorbable cements, holds the promise of integrating with natural bone, reducing stiffness mismatch, and potentially eliminating the risk of adjacent-level fractures. Research into the ideal material properties, a balance between strength, elasticity, and biocompatibility is paramount. Finally, efforts must continue to improve KP performance techniques. This includes the advancement of real-time imaging guidance to enhance cement placement accuracy, the refinement of patient selection criteria to identify the ideal candidates, and the potential integration of robotic-assisted surgery for unparalleled precision. By focusing on these future directions—long-term outcomes, innovative materials, and technical refinements the medical community can further optimize the safety and efficacy of kyphoplasty, ensuring it remains a leading, evidence-based solution for improving the lives of patients with osteoporotic VCFs.