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Fracture after kyphoplasty


Introduction

Kyphoplasty is a minimally invasive technique for the treatment of pathological compression fractures and osteoporotic compression fractures of the spine. This procedure represents a valuable treatment option for patients and their families, especially in terms of pain relief and improvement of the quality of life. Kyphoplasty successfully relieves acute pain in the vast majority of patients with pathological and osteoporotic fractures and increases the biomechanical stability by partially restoring vertebral height. Several complications can occur including extrusion of cement into the spinal canal, hematoma, osteomyelitis, and adjacent vertebral fractures. However, refracture after cemented vertebral augmentation by kyphoplasty is relatively rare. Refracture occurs at 3.4 months after kyphoplasty on average and has an incidence rate of 12.5%. The pathogenesis of this condition is linked to technical factors and patient-related conditions, such as advanced osteoporosis, high body mass index, and low bone mineral density (BMD). Conservative treatment, such as antiosteoporosis medication and back brace, are effective for the treatment of refracture. Nevertheless, surgical decompression and stabilization can be required in the setting of a new neurological deficit. Herein, we present the case of a 69-year-old woman with acute back pain 1 day after a kyphoplasty.

Example case

  • Chief complaint: back pain

  • History of present illness: This is a 69-year-old female who has acute worsening of back pain after an L1 kyphoplasty 1 day prior. She has no leg symptoms and no genitourinary symptoms. Because of the worsening back pain, she underwent x-rays ( Fig. 26.1 ) and magnetic resonance imaging ( Fig. 26.2 ) that demonstrated refracture at the previous kyphoplasty site. Computed tomography scans (not shown) showed bilateral L1 pedicle and posterior element fractures.

    Fig. 26.1, Preoperative x-rays. (A) Anteroposterior (AP) and (B) sagittal x-rays demonstrating interval vertebral augmentation at L1 with partial restoration of vertebral body height. Mild inferior end plate compression deformity at T12 that was new since prior examination.

    Fig. 26.2, Preoperative magnetic resonance images. (A) T1 and (B) T2 sagittal images demonstrating interval vertebral augmentation of the L1 compression fracture with mild central spinal stenosis at the L1 level. In addition, there is a prominent Schmorl’s node in the anterior inferior aspect of the T12 end plate, with mild loss of vertebral body height and marrow edema.

  • Medications: bisphosphonates

  • Allergies: no known drug allergies

  • Past medical and surgical history : mastectomy for stage 1 BRCA neg cancer 10 years previous

  • Family history: none

  • Social history: no smoking, no alcohol

  • Physical examination: awake, alert, and oriented to person, place, and time; cranial nerves II–XII intact; bilateral deltoids/biceps/triceps 5/5; interossei 5/5; iliopsoas/knee flexion/knee extension/dorsi, and plantar flexion 5/5

  • Reflexes: 2+ in bilateral biceps/triceps/brachioradialis; 2+ in bilateral patella/ankle; no clonus or Babinski; negative Hoffman; sensation intact to light touch; FABER negative; hip motion testing negative; straight leg raise negative

  • Michelle J. Clarke, MD

  • Neurosurgery

  • Mayo Clinic

  • Rochester, Minnesota, United States

  • Christopher J. Dewald, MD

  • Orthopaedic Surgery

  • Rush University Medical Center

  • Chicago, Illinois, United States

  • Jeff D. Golan, MD

  • Neurosurgery

  • McGill University

  • Montreal, Quebec, Canada

  • Luiz Robert Vialle, MD

  • Orthopaedic Surgery

  • Pontifical Catholic University of Parana

  • Curitiba, Brazil

Preoperative
Additional tests requested

  • DEXA

  • Endocrinology evaluation

  • Standing x-rays in brace

  • Standing x-rays

  • ESR/CRP

None

  • Axial MRI

  • CT T-spine

  • T12 needle biopsy if lesion seen

Adjuvant therapy

  • Osteoporotic treatment

  • TLSO brace

None

  • Osteoporotic treatment

  • Jewett brace

None
Surgical approach selected Conservative management If convinced this is the source of pain and depending on standing balance and SVA, Stage 1: T10-L3 fusion with posterior column osteotomies as needed Stage 2 (if needed based on SVA): T12-L2 discectomy with interbody fusion and possible L1 corpectomy Conservative management If convinced this is the source of pain, L1 corpectomy and T10-L2 fusion

  • Surgical approach if 21 years old

  • Surgical approach if 80 years old

  • Same approach

  • Same approach

  • Same approach

  • Same approach

  • Same approach

  • Same approach

  • Anterior or posterior

  • Same

Goal of surgery Stabilization, improve sagittal balance Decompression, stabilization
Perioperative
Positioning

  • Stage 1: prone on Jackson table

  • Stage 2: right lateral decubitus

Lateral
Surgical equipment

  • Fluoroscopy

  • Bone cement

  • Fluoroscopy

  • MIS retractors

Medications None None
Anatomical considerations Never roots, spinal canal, great vessels, bowel, kidneys Vascular anatomy, diaphragm insertion
Complications feared with approach chosen Bow injury, injury to great vessels, nerve root injury, pseudoarthrosis, spinal instrumentation failure, adjacent level kyphosis Inferior vena cava injury
Intraoperative
Anesthesia General General
Exposure

  • Stage 1: T10-L3

  • Stage 2: T12-L2

T12-L2
Levels decompressed

  • Stage 1: None

  • Stage 2: T12-L2

L1–2
Levels fused

  • Stage 1: T10-L3

  • Stage 2: T12-L2

T12-L2
Surgical narrative

  • Position prone, midline posterior incision, expose bone, place pedicle screws from T10-L3 using anatomy, place cement through pedicles at T10 and T11 using x-rays, determine whether alignment proper, determine Smith-Peterson osteotomies as needed, remove inferior facets with osteotome and ligamentum flavum with Leksell rongeur, remove superior facets to complete osteotomy, place rods with appropriate lordosis, place locking caps, layered closure with drains

  • Possible stage 2 (2–3 days later) standing x-rays show more anterior support is needed, position right lateral decubitus, identify 12th rib, incise skin and dissect to rib tip, bluntly dissect through lateral abdominal musculature, enter into retroperitoneal space, sweep retroperitoneal tissue anteriorly and identify psoas muscle with fingertip, palpate bulging discs beneath psoas, retract psoas muscle posterior and incise T12-L1 and L1–2 discs back to posterior annulus, place two PEEK cages or L1 corpectomy with expandable cage with 1/3 ilium to fit defect, layered closure

Lateral position similar to an OLIF, psoas muscle identification after peritoneum retraction, corridor between peritoneum and psoas enlarged with dissection and vascular retraction until L1 vertebral body well defined, sometimes diaphragm pillar needs to be cut for the T12-L1 disc to be exposed, ligate lumbar artery at L1 level, place MIS retractor, L1 corpectomy and removal of cement, care with thecal sac, preparation of the T12 and L2 end plates for mesh, lace mesh filled with allograft bone, bone material send for pathological analysis, closure of muscle layers without drain, percutaneous posterior T10-L2 fusion
Complication avoidance Support top of construct with cement, determine Smith-Peterson osteotomies as needed based on positioning in Jackson table, staged procedure if more anterior support needed based on standing x-rays, palpate bulging discs beneath psoas Lateral approach, care with thecal sac, percutaneous posterior fusion to supplement, concern for breast cancer metastasis
Postoperative
Admission Floor ICU
Postoperative complications feared Adjacent vertebral fracture, loss of fixation, proximal or distal junction kyphosis Deep vein thrombosis, hardware pull out, adjacent fracture
Anticipated length of stay 3 days
Follow-up testing

  • Thoracolumbar x-rays in 4 weeks in brace

  • CT thoracolumbar spine 3 and 6 months

Standing x-rays 3 weeks after surgery Thoracolumbar x-rays in 2–4 weeks

  • Physical therapy

  • Thoracolumbar x-rays after surgery, 2 weeks, monthly for 6 months after surgery

Bracing TLSO brace for 6 months TLSO brace for 6 weeks Jewett brace for 4 weeks None
Follow-up visits 4 weeks, 3 months, 6 months 3 weeks after surgery 2–4 weeks 2 weeks, monthly for 6 months after surgery
BMP , Bone morphogenic protein; CRP , C-reactive protein; CT , computed tomography; DEXA , dual-energy x-ray absorptiometry; ESR , erythrocyte sedimentation rates; ICU , intensive care unit; IOM , intraoperative monitoring; MAP , mean arterial pressure; MEP , motor evoked potentials; MIS , minimally invasive surgery; MRI , magnetic resonance imaging; PEEK , polyether ether ketone; SSEP , somatosensory evoked potentials; SVA , sagittal vertical axis; TLSO , thoracic lumbar sacral orthosis.

Differential diagnosis

  • ▪

    Osteoporotic fracture

  • ▪

    Metastatic lesion

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