Presentation Power Point

1. Kyphoplasty In AcuteKyphoplasty In Acute
Osteoporotic DorsolumbarOsteoporotic Dorsolumbar
FracturesFractures

2. ByBy
Elsayed MahgoubElsayed Mahgoub
SupervisorsSupervisors
 Prof. Dr. Hassan Mustafa ElgamalProf. Dr. Hassan Mustafa Elgamal
 Prof. Dr. Wael Mohammed TawfiekProf. Dr. Wael Mohammed Tawfiek
KobtanKobtan
 Dr. Mohamed Ayman ElroubyDr. Mohamed Ayman Elrouby

3.  First, I would like to express my deepest thanks to "ALLAH", theFirst, I would like to express my deepest thanks to "ALLAH", the
most merciful. This would not be achieved without "ALLAH" willingmost merciful. This would not be achieved without "ALLAH" willing
and support.and support.
 I would like to express my deep appreciation and gratitude to Prof.I would like to express my deep appreciation and gratitude to Prof.
Dr.Dr. Hassan Mustafa Elgamal,Hassan Mustafa Elgamal, Professor of OrthopedicsProfessor of Orthopedics
Surgery, Faculty of Medicine, Cairo University.Surgery, Faculty of Medicine, Cairo University.
 I would like to welcome and thank Prof. Dr.I would like to welcome and thank Prof. Dr. Mohamed wafa,Mohamed wafa,
Professor of Orthopaedic Surgery, Faculty of Medicine, Ain ShamsProfessor of Orthopaedic Surgery, Faculty of Medicine, Ain Shams
University.University.
 I would like to express my deep appreciation and gratitude to Prof.I would like to express my deep appreciation and gratitude to Prof.
Dr.Dr. Hazem Elsebaey,Hazem Elsebaey, Professor of Orthopaedic Surgery, FacultyProfessor of Orthopaedic Surgery, Faculty
of Medicine, Cairo University,of Medicine, Cairo University,

4.  Purpose of this study: -Purpose of this study: -
 To study the role of kyphoplasty in management ofTo study the role of kyphoplasty in management of
osteoporotic dorsolumbar fractures, analyzing theosteoporotic dorsolumbar fractures, analyzing the
clinical and radiographic outcomes. We willclinical and radiographic outcomes. We will
evaluate the efficacy and safety of kyphoplasty forevaluate the efficacy and safety of kyphoplasty for
the treatment of acute vertebral osteoporoticthe treatment of acute vertebral osteoporotic
compression fractures, to test the hypothesis thatcompression fractures, to test the hypothesis that
kyphoplasty will result in diminishing Pain, disabilitykyphoplasty will result in diminishing Pain, disability
and improving the quality of life.and improving the quality of life.

5. Vertebral CompressionVertebral Compression
FracturesFractures
 The most common complication of osteoporosisThe most common complication of osteoporosis
 The National Osteoporosis Foundation has estimatedThe National Osteoporosis Foundation has estimated
that more than 100 million people worldwide are at a riskthat more than 100 million people worldwide are at a risk
for the development of fractures secondary tofor the development of fractures secondary to
osteoporosis.osteoporosis.
 Can result in spinal deformity: kyphosis/lordosisCan result in spinal deformity: kyphosis/lordosis
 Cause acute and chronic pain leading to disabilityCause acute and chronic pain leading to disability
 Cause of reduced vital capacityCause of reduced vital capacity

6. ComplicationsComplications
 OsteoporosisOsteoporosis
 VCFsVCFs
 Spinal DeformitySpinal Deformity
 Decreased lungDecreased lung
capacitycapacity
 Decreased physicalDecreased physical
functionfunction
 Early SatietyEarly Satiety
 Sleep problemsSleep problems
 Decreased activityDecreased activity
 More bone lossMore bone loss
 Increased fractureIncreased fracture
riskrisk
 Decreased pulmonaryDecreased pulmonary
functionfunction
 Increased mortalityIncreased mortality

7. PreventionPrevention
 Bone Density Testing in women > 65 years, menBone Density Testing in women > 65 years, men
> 70 years> 70 years
 Adequate intake of calcium, vitamin D, andAdequate intake of calcium, vitamin D, and
regular weight bearing exerciseregular weight bearing exercise
 Pharmacology: e.g.(bisphosphonates andPharmacology: e.g.(bisphosphonates and
calcitonin).calcitonin).
 Reduce the risk of fallingReduce the risk of falling

8. Signs and SymptomsSigns and Symptoms
 Consider VCF in any patient > 50 years if theyConsider VCF in any patient > 50 years if they
complain of acute or chronic back paincomplain of acute or chronic back pain
 Get AP and lateral x-ray of the spineGet AP and lateral x-ray of the spine
 Look for wedge shaped vertebral bodiesLook for wedge shaped vertebral bodies
 MRI with T2 sequence shows state of fractureMRI with T2 sequence shows state of fracture
healinghealing

9. Compression fracture in L2 (white arrow).

10. Tc-99m–bone scan image, posteriorTc-99m–bone scan image, posterior
view, demonstrating increased uptakeview, demonstrating increased uptake
at the level of a sub acute L2 VCFat the level of a sub acute L2 VCF
(White Arrow)(White Arrow)
Thin-section axial CT (a) and sagittalThin-section axial CT (a) and sagittal
reformatted CT images(b) demonstratingreformatted CT images(b) demonstrating
severe compression fracture of T12severe compression fracture of T12

11. (a) (Sagittal T1-weighted MR image) demonstrating VCFs at T9,(a) (Sagittal T1-weighted MR image) demonstrating VCFs at T9,
T11, T12, and L1. The acutely compressed T9 and T11 vertebraeT11, T12, and L1. The acutely compressed T9 and T11 vertebrae
demonstrate hypointense marrow signal. Old fractures of T12 anddemonstrate hypointense marrow signal. Old fractures of T12 and
L1 demonstrate normal marrow signal indicating healing). (b) T2-L1 demonstrate normal marrow signal indicating healing). (b) T2-
weighted MRI demonstrates heterogeneously increased signal inweighted MRI demonstrates heterogeneously increased signal in
the T9 and T11 vertebral bodies, and L1 demonstrate normalthe T9 and T11 vertebral bodies, and L1 demonstrate normal
marrow signal. (c) Sagittal STIR MR image demonstrates edema inmarrow signal. (c) Sagittal STIR MR image demonstrates edema in
T9 and T11.T9 and T11.

12. Conservative TherapyConservative Therapy
 NSAIDSNSAIDS
 Muscle relaxantsMuscle relaxants
 Bed restBed rest
 Orthotic bracingOrthotic bracing
 VCF healing should occur in 6-12 weeksVCF healing should occur in 6-12 weeks

13. KyphoplastyKyphoplasty
 Minimally-invasiveMinimally-invasive
 PercutaneousPercutaneous
 Can restore lost vertebral heightCan restore lost vertebral height
 Immediate pain reductionImmediate pain reduction
 Fewer complications compared to vertebroplastyFewer complications compared to vertebroplasty
 Kyphoplasty was initially developed in the lateKyphoplasty was initially developed in the late
1990s as a modification of the vertebroplasty1990s as a modification of the vertebroplasty
procedure.procedure.

14. Indications for KyphoplastyIndications for Kyphoplasty
 Acute to subacute (usually <3 months old)Acute to subacute (usually <3 months old)
painful vertebral compression fractures frompainful vertebral compression fractures from
osteoporosis, osteolysis or invasion of benign orosteoporosis, osteolysis or invasion of benign or
malignant tumorsmalignant tumors
 Kyphoplasty is second line approach consideredKyphoplasty is second line approach considered
when the patient has failed standard medicalwhen the patient has failed standard medical
therapy. (after at least 4 weeks).therapy. (after at least 4 weeks).
 However, some operators will intervene moreHowever, some operators will intervene more
acutely.acutely.

15. The contraindication forThe contraindication for
KyphoplastyKyphoplasty
 Absolute contraindicationsAbsolute contraindications
 Asymptomatic vertebral compression fracturesAsymptomatic vertebral compression fractures
 Ongoing local or systemic infectionOngoing local or systemic infection
 Uncorrectable coagulopathy the goal INR shouldUncorrectable coagulopathy the goal INR should
be ≤1.4 and the platelet count should bebe ≤1.4 and the platelet count should be
≥50,000.≥50,000.
 Improving pain on medical therapyImproving pain on medical therapy
 Fractures of the posterior elements (withoutFractures of the posterior elements (without
vertebral body fracture)vertebral body fracture)..

16.  Relative contraindicationsRelative contraindications
 Retropulsed osseous fragment or intracanalicularRetropulsed osseous fragment or intracanalicular
tumor extension with greater than one-third spinaltumor extension with greater than one-third spinal
canal.canal.
 Burst fractures compromise (high incidence ofBurst fractures compromise (high incidence of
cement leakage).cement leakage).
 Malignant osteolytic lesions with posterior corticalMalignant osteolytic lesions with posterior cortical
destruction.destruction.
 Loss of greater than two thirds of the vertebral bodyLoss of greater than two thirds of the vertebral body
height increases the technical difficulty ofheight increases the technical difficulty of
kyphoplasty.kyphoplasty.

17. ComplicationsComplications
 Nontarget PMMA EmbolizationNontarget PMMA Embolization
 Intradiscal cement leakage.(increase incidenceIntradiscal cement leakage.(increase incidence
of adjacent level fracture).of adjacent level fracture).
 Anterior and posterior vertebral body margins.Anterior and posterior vertebral body margins.
 Posterior epidural passage of cement.(IntraduralPosterior epidural passage of cement.(Intradural
cement leakage has been rarely reported).cement leakage has been rarely reported).
 Cement extravasation is usually asymptomaticCement extravasation is usually asymptomatic
(96% of vertebroplasty and 89% of kyphoplasty(96% of vertebroplasty and 89% of kyphoplasty
cases)cases)
 Embolization of PMMA material into paraspinalEmbolization of PMMA material into paraspinal
veins(common in vertebroplasty).veins(common in vertebroplasty).

18.  Adjacent Vertebral Body or Rib Fractures.Adjacent Vertebral Body or Rib Fractures.
 InfectionInfection
 Rupture of the inflatable balloon tamp.Rupture of the inflatable balloon tamp.
 Noncement pulmonary emboli are rare butNoncement pulmonary emboli are rare but
can be secondary to bone marrow or fatcan be secondary to bone marrow or fat
particles displaced from the vertebral bodyparticles displaced from the vertebral body
into the venous circulation.into the venous circulation.
 There is also a small risk of epiduralThere is also a small risk of epidural
hematoma with both vertebral augmentationhematoma with both vertebral augmentation
procedure.procedure.

19. Materials & MethodsMaterials & Methods
 We performed a prospective analysis ofWe performed a prospective analysis of
30 patients treated with Kyphoplasty. They30 patients treated with Kyphoplasty. They
had VCFs at levels T7 to L4 due tohad VCFs at levels T7 to L4 due to
osteoporosis arising from primary andosteoporosis arising from primary and
secondary osteoporosis. There were 41secondary osteoporosis. There were 41
VCFs in these 30 patients.VCFs in these 30 patients.

20. Radiographic evaluation:-Radiographic evaluation:-
 Standing films were used to measure kyphosisStanding films were used to measure kyphosis
of the fracture vertebral body. In some patients,of the fracture vertebral body. In some patients,
pre-op standing films could not be obtained duepre-op standing films could not be obtained due
to their pain. In these cases measurements wereto their pain. In these cases measurements were
taken from the available supine films.taken from the available supine films.
 Not all patients underwent magneticNot all patients underwent magnetic
resonance imaging due to financial issuesresonance imaging due to financial issues
 Computed tomography scans were done as aComputed tomography scans were done as a
study in patients we thought that they couldstudy in patients we thought that they could
have posterior wall fracture.have posterior wall fracture.

21.  Kyphotic angles across the fractured levelKyphotic angles across the fractured level
were calculated using the Cobb technique.were calculated using the Cobb technique.
 The operation was considered to be indicated in theThe operation was considered to be indicated in the
presence of painful thoracic or lumbar osteoporoticpresence of painful thoracic or lumbar osteoporotic
fractures without the involvement of the posteriorfractures without the involvement of the posterior
vertebral edge, classified after the AO classification;vertebral edge, classified after the AO classification;
 A1.1 Endplate impactionA1.1 Endplate impaction
 A1.2 Wedge impaction fractureA1.2 Wedge impaction fracture
 A1.3 Vertebral body collapseA1.3 Vertebral body collapse
 A3.1 Incomplete burst fracture (depending on the degreeA3.1 Incomplete burst fracture (depending on the degree
of the posterior wall involvement)of the posterior wall involvement)

23. Device design:-Device design:-
The kyphoplasty system consists of a balloon, of
which one or two each are inserted bilaterally into
the vertebral body.

27.  Surgical technique:-Surgical technique:-
 A radiolucent table and 2 C-arm fluoroscopyA radiolucent table and 2 C-arm fluoroscopy
machines Mobile Digital C-Arm weremachines Mobile Digital C-Arm were
requested for every kyphoplasty procedure atrequested for every kyphoplasty procedure at
our institute. The 2 fluoroscopy machinesour institute. The 2 fluoroscopy machines
placed orthogonally across the radiolucentplaced orthogonally across the radiolucent
table allowed simultaneous viewing oftable allowed simultaneous viewing of
anteroposterior and lateral projections of theanteroposterior and lateral projections of the
fractured level.fractured level.

29.  General anesthesia was used in 17 proceduresGeneral anesthesia was used in 17 procedures
and local anesthesia with heavy sedation in 13and local anesthesia with heavy sedation in 13
interventions.interventions.
 The patient was carefully turned prone and allThe patient was carefully turned prone and all
bony prominences were protected to preventbony prominences were protected to prevent
infection, a preoperative single shot I.V dose of ainfection, a preoperative single shot I.V dose of a
third generation cephalosporin wasthird generation cephalosporin was
administered.administered.
 Two fluoroscopy machines were then wheeledTwo fluoroscopy machines were then wheeled
into position, and the fractured level was centeredinto position, and the fractured level was centered
in both the anteroposterior and lateral projections.in both the anteroposterior and lateral projections.

30. ApproachApproach
 The access instruments can be insertedThe access instruments can be inserted
through either a transpedicular orthrough either a transpedicular or
extrapedicular approach. Identify theextrapedicular approach. Identify the
anatomical landmarks of the affectedanatomical landmarks of the affected
segment(s) under imaging.segment(s) under imaging.
 Option A: TranspedicularOption A: Transpedicular
 The incision should facilitate insertion directlyThe incision should facilitate insertion directly
through the pedicle. Do not breach the pediclethrough the pedicle. Do not breach the pedicle
wall or anterior cortical wall of the vertebral bodywall or anterior cortical wall of the vertebral body
during the approach.during the approach.

31.  Option B: ExtrapedicularOption B: Extrapedicular
 The trocar assembly should enter theThe trocar assembly should enter the
vertebral body lateral to the pedicle.vertebral body lateral to the pedicle.
 Insert the tip of the access instrumentationInsert the tip of the access instrumentation
through the incision until it contacts thethrough the incision until it contacts the
posterolateral border of the vertebralposterolateral border of the vertebral
body.body.

33. Determine access pathDetermine access path
 Access options include trocar or guideAccess options include trocar or guide
wire access. The trocar option allowswire access. The trocar option allows
access in a single step. The guide wireaccess in a single step. The guide wire
access can be used to create a path foraccess can be used to create a path for
the access instruments.the access instruments.

36.  Prepare the inflation systemPrepare the inflation system
 Attach the stopcock to the inflation systemAttach the stopcock to the inflation system
 Fill the inflation systemFill the inflation system
 Connect a balloon catheter to the inflation systemConnect a balloon catheter to the inflation system
and create a vacuumand create a vacuum
 Inflate Vertebral Body balloons withInflate Vertebral Body balloons with
fluidfluid
 Inflate the balloon, slowly rotate the handle of theInflate the balloon, slowly rotate the handle of the
inflation system clockwise while monitoring theinflation system clockwise while monitoring the
pressure and volume. Proceed with inflationpressure and volume. Proceed with inflation
slowly, stopping every few seconds to allow theslowly, stopping every few seconds to allow the
bone to adjust to the pressure/volume changes.bone to adjust to the pressure/volume changes.
Use fluoroscopy to monitor balloon inflation.Use fluoroscopy to monitor balloon inflation.

37.  Stop increasing pressure when anyStop increasing pressure when any
of the following happens:of the following happens:
 The desired clinical outcome is reachedThe desired clinical outcome is reached
 The pressure reaches 30 atm (440 psi)The pressure reaches 30 atm (440 psi)
 The maximum volume is achievedThe maximum volume is achieved
 4.0 ml for the small balloon4.0 ml for the small balloon
 4.5 ml for the medium balloon4.5 ml for the medium balloon
 5.0 ml for the large balloon5.0 ml for the large balloon

39.  Deflate and Remove Vertebral BodyDeflate and Remove Vertebral Body
BalloonsBalloons
 Gradually decrease the pressure by turning the handleGradually decrease the pressure by turning the handle
of the inflation system counterclockwise, until theof the inflation system counterclockwise, until the
manometer indicates approximately 10 atm (150 psi).manometer indicates approximately 10 atm (150 psi).
Slide the wings forward while pulling the handle all theSlide the wings forward while pulling the handle all the
way back slowly, to fully collapse the balloon and drawway back slowly, to fully collapse the balloon and draw
a vacuum. Release the wings with the handle pulleda vacuum. Release the wings with the handle pulled
all the way back, to seal the vacuum.all the way back, to seal the vacuum.
 Hold the working sleeves in place and remove theHold the working sleeves in place and remove the
catheters to retrieve the balloons.catheters to retrieve the balloons.

40. Inject PMMA Bone CementInject PMMA Bone Cement
 Under lateral fluoroscopy, inject PMMAUnder lateral fluoroscopy, inject PMMA
cement. The direction of the PMMA flowcement. The direction of the PMMA flow
can be changed by orienting the handle ofcan be changed by orienting the handle of
the side-opening cannula. The arrow onthe side-opening cannula. The arrow on
the handle of the side opening needlethe handle of the side opening needle
corresponds to the side of the opening.corresponds to the side of the opening.
The PMMA should be contained within theThe PMMA should be contained within the
vertebral body.vertebral body.

42. Postoperative scar.
Diagram showing steps of balloon kyphoplasty.

43. Maximal fracture reduction technique for a
patient with L1 vertebral fracture due to
osteoporosis.

44. Clinical OutcomeClinical Outcome
measurements:-measurements:-
 VASVAS
 Patients were asked to mark their pain on a scale of 0.0 to 10.0 cmPatients were asked to mark their pain on a scale of 0.0 to 10.0 cm
where 0.0 cm being no pain at all and 10.0 cm is the worst painwhere 0.0 cm being no pain at all and 10.0 cm is the worst pain
imaginable. VAS scores were assessed before the procedure, andimaginable. VAS scores were assessed before the procedure, and
at 1, 4, 12 and 24 weeks after the procedure.at 1, 4, 12 and 24 weeks after the procedure.

45.  ODIODI
 The ODI is a low back pain specific questionnaire thatThe ODI is a low back pain specific questionnaire that
assesses the ability of the patient to perform variousassesses the ability of the patient to perform various
activities of daily living. The ODI has been shown toactivities of daily living. The ODI has been shown to
have high test-retest reliability and is the most commonlyhave high test-retest reliability and is the most commonly
recommended condition-specific outcome measure inrecommended condition-specific outcome measure in
patients with chronic low back pain.patients with chronic low back pain.
SCORE INTERPRETATION OF THE OSWESTRY LBP DISABILITY
QUESTIONNAIRE
0-20% Minimal disability
20-40% Moderate disability
40-60% Severe disability
60-80% Crippled Back pain
80-100% These patients are either bed-bound or exaggerating their symptoms.
Data compiled from Fairbanks et al, 1980.

46. Study populationStudy population
 A total of 30 patients with 41 VCFsA total of 30 patients with 41 VCFs
underwent kyphoplasty at our institutionunderwent kyphoplasty at our institution
from Feb 2011 to Jun 2013. The studyfrom Feb 2011 to Jun 2013. The study
population included (10) male (33.3%) andpopulation included (10) male (33.3%) and
(20) female (66.6%). The median age of(20) female (66.6%). The median age of
the patients was 69 years (range 53–87the patients was 69 years (range 53–87
years). The follow up period was 24years). The follow up period was 24
weeks.weeks.

47.  The causes of injury were either simple fallThe causes of injury were either simple fall
on the ground in (14) patients(46.7%)on the ground in (14) patients(46.7%)
 RTA in (6) patients (20%),RTA in (6) patients (20%),
 (4) patients(13.3%) gave a history of lifting(4) patients(13.3%) gave a history of lifting
heavy object preceding their feeling ofheavy object preceding their feeling of
pain andpain and
 (6) patients (20%) developed sudden(6) patients (20%) developed sudden
onset of pain without precipitating incidentonset of pain without precipitating incident

48. Age of fracturesAge of fractures
 15 patients (50%) presented with a history15 patients (50%) presented with a history
of fracture of less than 10 days whereasof fracture of less than 10 days whereas
(11) patients (36.7%) gave a history of(11) patients (36.7%) gave a history of
fracture from 10-30 days. 2 Patientsfracture from 10-30 days. 2 Patients
(6.7%) presented with a history of fracture(6.7%) presented with a history of fracture
from 30-40 days. Note that in 2 patientsfrom 30-40 days. Note that in 2 patients
(6.7%), the exact age of fracture couldn't(6.7%), the exact age of fracture couldn't
be estimatedbe estimated

49. Level of fractureLevel of fracture

50. The clinical outcomes:-The clinical outcomes:-
 Change in spinal sagittal alignmentChange in spinal sagittal alignment
 The median kyphosis angle was 21.8The median kyphosis angle was 21.8
degrees before the procedure anddegrees before the procedure and
decreased by a median of 6.7 degreesdecreased by a median of 6.7 degrees
after the operation. 60% of patientsafter the operation. 60% of patients
experienced a reduction in kyphosis ofexperienced a reduction in kyphosis of
more than 5 degreesmore than 5 degrees

51. Improvement in Spinal Sagittal Alignment
Changes in kyphotic angle

52.  The median VAS scores. went from 8.7The median VAS scores. went from 8.7
preoperatively to 3.5 at one weekpreoperatively to 3.5 at one week
postoperatively , to 1.7 at 12 weekspostoperatively , to 1.7 at 12 weeks
following the procedure and to 1.5 at 24following the procedure and to 1.5 at 24
weeks and last follow up.weeks and last follow up.

53.  The mean preoperative ODI score was 80,The mean preoperative ODI score was 80,
decreasing to 32 at 1 month post-op, anddecreasing to 32 at 1 month post-op, and
improving to 21 and 17 at 3-month andimproving to 21 and 17 at 3-month and
last follow- up, respectively.last follow- up, respectively.

54.  The median preoperative ODI score wasThe median preoperative ODI score was
85.00, improving to 32.6 at 1 month85.00, improving to 32.6 at 1 month
postoperatively, and decreasing 22 and 18postoperatively, and decreasing 22 and 18
at 3-month and last follow-up, respectivelyat 3-month and last follow-up, respectively

55. Complications:-Complications:-
 Cement leakage:-Cement leakage:-

56.  Location of cement leakage:-Location of cement leakage:-
Location of leakage Number Percentage Complications
Adjacent intervertebral disc 3 27% No
Anterior to vertebral body 4 36% No
Lateral to vertebral body 3 27% No
In the spinal canal 1 9% No
Total 11 100% No

57.  Failure of balloon distension:-Failure of balloon distension:-
 We treated 41 fractures with BKP. FailureWe treated 41 fractures with BKP. Failure
of balloon distension occurred in 6of balloon distension occurred in 6
fractures (14%), so we managed thesefractures (14%), so we managed these
fractures with conventional vertebroplastyfractures with conventional vertebroplasty
 Fracture of bone filler:Fracture of bone filler:
 We treated 41 fractures with BKP.We treated 41 fractures with BKP.
Fracture of bone filler occurred only in oneFracture of bone filler occurred only in one
patientpatient

58. Case presentationCase presentation
 CASE 1CASE 1
 Name: MA Age: 76. Number:1Name: MA Age: 76. Number:1
 Age of fracture: 13 days.Age of fracture: 13 days.
 M.O.I: did not recall specific injury.M.O.I: did not recall specific injury.
 Medical history of D.M, H.T.N, Old CVA & RenalMedical history of D.M, H.T.N, Old CVA & Renal
impairment.impairment.
 X-ray: Osteoporotic Compression fractures T12.X-ray: Osteoporotic Compression fractures T12.
 Operated with : BKP (T12). But, there wasOperated with : BKP (T12). But, there was
cement leakage towards inter vertebral disc andcement leakage towards inter vertebral disc and
the patient presented without neurologicalthe patient presented without neurological
manifestation.manifestation.

62.  Case 2Case 2
 Name: A.H Age: 84 Number: 6Name: A.H Age: 84 Number: 6
 Age of fracture: 3 days.Age of fracture: 3 days.
 M.O.I.: No obvious cause.M.O.I.: No obvious cause.
 Medical history of D.M, H.T.N & CardiacMedical history of D.M, H.T.N & Cardiac
problems.problems.
 X-ray: Osteoporotic CompressionX-ray: Osteoporotic Compression
fractures L2, 3.fractures L2, 3.
 Operated with : BKP pain improved afterOperated with : BKP pain improved after
surgery. Patient started assisted weightsurgery. Patient started assisted weight
bearing 48hrs after surgery.bearing 48hrs after surgery.

66.  CASE 3CASE 3
 Name: M.S Age: 65. Number: 26Name: M.S Age: 65. Number: 26
 Age of fracture: 10 days.Age of fracture: 10 days.
 M.O.I: Simple fall on the ground.M.O.I: Simple fall on the ground.
 Medical history; D.M, HTN.Medical history; D.M, HTN.
 X-ray: Osteoporotic Compression fracturesX-ray: Osteoporotic Compression fractures
L1.L1.
 Operated with: BKP pain dramaticallyOperated with: BKP pain dramatically
improved after surgery. Patient startedimproved after surgery. Patient started
assisted weight bearing 48hrs afterassisted weight bearing 48hrs after
surgery.surgery.

71. DiscussionDiscussion
 The first experience with the use ofThe first experience with the use of
kyphoplasty was published bykyphoplasty was published by Wong et al.Wong et al. inin
the Journal of Women’s Imaging in 2000.the Journal of Women’s Imaging in 2000.
They report on the experience of 85 patients.They report on the experience of 85 patients.
Over 90% of patients report good or excellentOver 90% of patients report good or excellent
pain relief. The height restoration was 62%.pain relief. The height restoration was 62%.
Lieberman et alLieberman et al. presents a prospective. presents a prospective
clinical investigation the treatment of 30clinical investigation the treatment of 30
patients with 70 kyphoplasty procedurespatients with 70 kyphoplasty procedures
performed. Local cement leakage wasperformed. Local cement leakage was
observed in 8.6%observed in 8.6%

72.  Theodorou et alTheodorou et al. reports on the treatment of 15. reports on the treatment of 15
patients with 24 BKP. Height restoration waspatients with 24 BKP. Height restoration was
best in the mid- vertebral body with 65%.best in the mid- vertebral body with 65%.
Kyphosis correction was 9.5° in average or byKyphosis correction was 9.5° in average or by
62%. Pain was improved in all patients at a62%. Pain was improved in all patients at a
follow-up of 6– 8 months.follow-up of 6– 8 months.
 Coumans et al.Coumans et al. presents a prospective studypresents a prospective study
with kyphoplasty with a minimal follow-up of 1with kyphoplasty with a minimal follow-up of 1
year. Of 78 patients with 188 kyphoplastyyear. Of 78 patients with 188 kyphoplasty
procedures, 62% were available for a follow-upprocedures, 62% were available for a follow-up
evaluation. They report five cases ofevaluation. They report five cases of
asymptomatic extravasation. Oswestry scoreasymptomatic extravasation. Oswestry score
and pain (VAS) improved immediatelyand pain (VAS) improved immediately
postoperatively with lasting effect at FU. Thepostoperatively with lasting effect at FU. The
kyphosis correction is not mentionedkyphosis correction is not mentioned

73.  In our study, we found that the median kyphosisIn our study, we found that the median kyphosis
angle was 21.8 degrees before the procedureangle was 21.8 degrees before the procedure
and decreased by a median of 6.7 degrees afterand decreased by a median of 6.7 degrees after
the operation. 60% of patients experienced athe operation. 60% of patients experienced a
reduction in kyphosis of more than 5 degreesreduction in kyphosis of more than 5 degrees
(Interquartile range 10 degrees). In an analysis(Interquartile range 10 degrees). In an analysis
of this subgroup of patients, faster pain reliefof this subgroup of patients, faster pain relief
was achieved compared with patients whowas achieved compared with patients who
showed minimal to no reduction in Kyphoticshowed minimal to no reduction in Kyphotic
angle.angle.
 The VCFs were then analyzed by spinal regionThe VCFs were then analyzed by spinal region
(thoracic or lumbar).(thoracic or lumbar).

74.  Long-term follow-up will be required toLong-term follow-up will be required to
determine whether the improvement in spinaldetermine whether the improvement in spinal
kyphosis will reduce the disability, morbidity, orkyphosis will reduce the disability, morbidity, or
risk of subsequent VCFs associated withrisk of subsequent VCFs associated with
kyphotic deformity from osteoporotic vertebralkyphotic deformity from osteoporotic vertebral
fractures. The clinical and radiographic resultsfractures. The clinical and radiographic results
showed that the effects of BKP are immediateshowed that the effects of BKP are immediate
and dramatic, and showed no evidence ofand dramatic, and showed no evidence of
deteriorating with time. Alleviation of pain,deteriorating with time. Alleviation of pain,
reduction in the use of pain medications, andreduction in the use of pain medications, and
improved mobility occurred within the first fewimproved mobility occurred within the first few
postoperative days to weeks and remainedpostoperative days to weeks and remained
stable for the entire length of study.stable for the entire length of study.

75.  Pain relief after BKP was rapid and evidentPain relief after BKP was rapid and evident
within the first week after the procedure. Thewithin the first week after the procedure. The
pain relief was sustained for up to 6 monthspain relief was sustained for up to 6 months
after the procedure. The majority of patientsafter the procedure. The majority of patients
also reported a return to pre-fracture functionalalso reported a return to pre-fracture functional
levels. This effect was shown by at least a 4-levels. This effect was shown by at least a 4-
point decrease in the VAS pain score and ODIpoint decrease in the VAS pain score and ODI
score.score.

76.  In our study, Evaluation of intraoperativeIn our study, Evaluation of intraoperative
and postoperative radiographs revealedand postoperative radiographs revealed
extra vertebral cement leaks in 11 levelsextra vertebral cement leaks in 11 levels
(27%) of 41 vertebral fractures treated.(27%) of 41 vertebral fractures treated.
from our experience, it seems that thefrom our experience, it seems that the
using of BKP limit the occurrence ofusing of BKP limit the occurrence of
extravasation. As our results aboutextravasation. As our results about
extravasation are decreased than thoseextravasation are decreased than those
reported from conventional vertebroplasty.reported from conventional vertebroplasty.

77. Conclusion:-Conclusion:-
The important thing that has to be in mind is that theThe important thing that has to be in mind is that the
device is expensive an issue that needs to bedevice is expensive an issue that needs to be
considered in times of cost problems in nearly everyconsidered in times of cost problems in nearly every
health care system; therefore, the use of thesehealth care system; therefore, the use of these
techniques appears restricted to selected cases. Thetechniques appears restricted to selected cases. The
BKP system is designed to treat painful vertebral bodyBKP system is designed to treat painful vertebral body
compression fractures, ideally after failed period ofcompression fractures, ideally after failed period of
conservative treatment for 4 weeks which includes shortconservative treatment for 4 weeks which includes short
periods of bed rest, followed by gradual increase inperiods of bed rest, followed by gradual increase in
mobilization, braces, analgesics, narcotics and physicalmobilization, braces, analgesics, narcotics and physical
therapy. This failure is manifested by progressivetherapy. This failure is manifested by progressive
increase in deformity and persistent of the same painincrease in deformity and persistent of the same pain
intensity.intensity.

78. Thank You!Thank You!