Kyphoplasty

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Broken lumbar vertebra
The same vertebra after kyphoplasty

The Kyphoplasty is a minimally invasive method for treating vertebral fractures . Today the procedure is available in two forms: as substance -destroying balloon kyphoplasty (BKP) and as substance -preserving radio-frequency kyphoplasty (RFK).

In the original, substance-destroying technique, balloons are inserted into the fractured vertebra using two cannulas with a diameter of approx. 4 mm. By filling the balloons with a contrast medium , the collapsed vertebra is then partially straightened, but at the cost of displacing healthy, intact cancellous bone . The vertebra is then fixed in place by injecting bone cement into the cavity that has been created, which hardens within a few minutes and thus stabilizes the broken vertebra. In addition to the bone cement, other implants such as containers, stents, etc. may remain in the vertebra as additional foreign bodies.

Substance-preserving techniques usually only require monopedicular (= one-sided) access to the broken vertebral body. Then the vertebral body is prepared with a flexible (bendable) needle, and if necessary, individual cement sheets are laid (= pedestal). Finally, a highly viscous, almost rubber-like bone cement is mechanically introduced into the vertebral body, which is then distributed in a fan shape. The cement is distributed between the healthy, intact cancellous bone, encloses it and erects the vertebra like a stamp.

indication

The indication is for vertebral fractures osteoporotic ( M80._8 ), traumatic ( S.22.0_ and / or S32.0_ ) or tumorous ( C79.5 + and M49.5_ *) pathogenesis . If this is accompanied by persistent back pain with evidence of a fracture by imaging procedures in the specified area of ​​the spine, according to the current guideline of the German umbrella organization for osteology, there is an indication for kyphoplasty or alternatively for vertebroplasty ; however only after unsuccessful conservative treatment .

technology

The procedure is typically performed in the prone position under fluoroscopy. It can be performed under local anesthesia , more often the operation is performed under anesthesia . The patient sleeps on their stomach, the back is disinfected and covered with sterile towels. Under X-ray control, depending on the technique, one or two cannulas are inserted into the vertebral body via the vertebral arches and then the interior of the vertebral body is prepared for the material implantation (usually bone cement based on PMMA ). In the conventional procedure, one or two balloons are introduced, filled with contrast medium and the surrounding cancellous bone is thereby crushed. The resulting large-volume cavity is filled with normal bone cement. Duration: approx. 45 min.

The newer technology of radio frequency kyphoplasty usually only requires one access to the vertebral body, and only very small cavities or ducts are created inside the vertebra. This serves to distribute the cement more evenly and to interlock the vertebral body structure and bone cement. The highly viscous, radio-frequency activated cement is introduced into the minimally invasive interior of the vertebral body through a special cannula. Continuous, instrument-controlled filling at 1.3 ml / min results in very good cement filling and very good interlocking with the vital cancellous bone. At the same time, the vertebral body is further straightened like a stamp. Duration: approx. 25 min.

Typical setup in the operating room

Radiofrequency kyphoplasty (RFK) and older balloon kyphoplasty (BKP) were compared in a study from 2012, both with regard to the sustained pain relief (measured with VAS in mm, 6 months after the operation) and with regard to the complication that cement can leak into the surrounding tissue during the operation (measured as the extravasation rate in%). The radiofrequency technique proved to be superior in each case: 59.2 mm or 6.1%, compared to 73.0 mm or 27.8% with the balloon technique. The authors concluded: “The RFK has proven to be a clinically very effective method that is superior to the BKP in terms of long-lasting pain relief. With regard to the safety aspect, the RFK offers the advantage of a guaranteed lower proportion of cement extrusions during the operation. "

Complications

Similar to vertebroplasty, the major complications of cement filling are leakage of the liquid bone cement from the vertebral body (= 72%). In balloon kyphoplasty, a slightly thicker PMMA cement can be used by forming a cavity; at the same time, the balloon compresses any cracks in the bone with cancellous bone, so that overall the rate of cement leakage is lower in direct comparison with vertebroplasty (= 27% per vertebral body; 35% per patient). A major complication of the so-called substance-destroying techniques is stress shielding. The cement seals remaining in the vertebral body only interlock insufficiently with the interior of the vertebra and lead in the long term to rashes and / or a higher risk of subsequent fractures.

The newer, bone-preserving techniques work with very high-viscosity cements, which have adhesive properties and thus further reduce the leakage rate. It can also be used to treat riskier fracture sites.

Aftercare

No bed rest or the like is required after a kyphoplasty, the patient can get up immediately and usually without great pain and move normally. As with all vertebral augmentations, a short-term brace is recommended in some cases as a warning orthotic to protect against excessive actionism (due to the freedom from pain).

literature

  • Stephan Becker, Michael Ogon (eds.): Ballon kyphoplasty. Springer, Vienna / New York 2006, ISBN 978-3-211-23592-8 .

Web links

Individual evidence

  1. ↑ a b Stephan Becker et al .: Disadvantages of balloon kyphoplasty with PMMA - a clinical and biomechanical statement. Journal for Mineral Metabolism & Musculoskeletal Diseases 2010; 17 (special issue 1), 10–14 ( PDF ).
  2. ↑ a b Drees et al .: Biomechanics and interlocking in vertebral body fractures. Where are we today A current literature comparison. Journal of Mineral Metabolism & Musculoskeletal Diseases, 2011; 18 (3): 118-120 ( PDF ).
  3. ^ A b Andreas A. Kurth (Ed.): Orthopädische Osteologie . UNI-MED Science, 1st edition 2011
  4. ↑ DVO Guideline Osteoporosis 2014 ( Memento of the original from October 18, 2017 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. , Short and long version, p. 234. @1@ 2Template: Webachiv / IABot / www.dv-osteologie.org
  5. ↑ F. Elgeti, B. Gebauer: The radio frequency kyphoplasty for the treatment of osteoporotic and neoplastic vertebral body fractures. First experience and clinical results after 6 months. Journal for Mineral Metabolism & Musculoskeletal Diseases 2010; 17 (4): 136-139 ( PDF ).
  6. ↑ R. Pflugmacher et al .: Comparison of clinical and radiological data in the treatment of patients with osteoporotic vertebral compression fractures with radiofrequency kyphoplasty or with balloon kyphoplasty . In: Journal of Orthopedics and Trauma Surgery 2012; 150 (1): 56-61. doi : 10.1055 / s-0031-1280122
  7. ↑ CA Klazen et al .: Vertebroplasty versus conservative treatment in acute osteoporotic vertebral compression fractures (Vertos II): an open-label randomized trial. In: Lancet. Volume 376, number 9746, September 2010, pp. 1085-1092, doi : 10.1016 / S0140-6736 (10) 60954-3 , PMID 20701962 .
  8. ^ D. Wardlaw et al .: Efficacy and safety of balloon kyphoplasty compared with non-surgical care for vertebral compression fracture (FREE): a randomized controlled trial. In: Lancet. Volume 373, number 9668, March 2009, pp. 1016-1024, doi : 10.1016 / S0140-6736 (09) 60010-6 , PMID 19246088 .
  9. ↑ D. Dabirrahmani, S. Becker, M. Hogg, R. Appleyard, G. Baroud, M. Gillies: Mechanical variables affecting balloon kyphoplasty outcome – a finite element study. In: Computer methods in biomechanics and biomedical engineering. Volume 15, number 3, 2012, pp. 211-220, doi : 10.1080 / 10255842.2010.522183 , PMID 21469000 .