Presentation
Lower back pain. MRI reveals an acute osteoporotic L1 vertebral body compression fracture. Original kyphoplasty was performed one month earlier. Redo kyphoplasty to fix the new fracture was performed on 12 days after the diagnostic MRI.
Patient Data
First image is the post-procedure lateral view of the spine obtained after the initial L1 kyphoplasty. Second image is the post-procedure lateral view of the spine obtained after the redo kyphoplasty.
After discussing potential risks with the patient, a redo kyphoplasty to repair the L1 fracture was performed 12 days after the new diagnostic MRI. The L1 vertebral body was localized fluoroscopically in two different planes (AP and lateral). Using fluoroscopic guidance, a trochar needle was inserted and advanced into the right and left posterolateral aspects of the vertebral body. A hand drill was used to create a track for the insertion of a balloon. Two balloons were positioned within the vertebra and inflated. The balloons were then removed and liquid polymethylmethacrylate bone cement was injected into the vertebral body. The trocar needles were then pulled back and removed. The patient showed no signs of post-procedural complications.
Four days later, a call to the patient showed that no back pain was present.
Case Discussion
A redo kyphoplasty is a viable option after having one performed, especially if the initial kyphoplasty did not inject enough cement to stabilize the vertebral body which is what we suspect in this case. Therefore we filled her vertebral body with an additional 8 mL of cement which resolved her pain.
Osteoporosis is a disease in which the bones lose density making someone more prone to fractures. According to the U.S. National Library of Medicine, "as a result of osteoporosis about half of all women over 50 will experience a fracture of the hip, wrist, or vertebra."
This patient was a female 75-year-old so she already had a predisposition to having a fracture like this occur. According to the Hartford HealthCare Medical Group, osteoporosis affects about 30 million Americans and 700,000 individuals experience vertebral fractures each year. Although the levels of severity can differ and are treated differently, about 260,000 of these cases are vertebral compression fractures. However, a lot of these vertebral compression fractures are not treated, misdiagnosed or never diagnosed.
After a patient has already received a kyphoplasty, there is an 8% chance of having a cement leakage. There is a <1% chance of having a repeat fracture in the previously treated vertebra and a 9% chance in the adjacent vertebrae. There is a 0.17% chance of having a PCE (pulmonary cement embolism). Spinal stenosis resulting in compression of the spinal cord occurred in 0.16% of the cases 2.
Vertebral compression fractures (VCF) are most commonly caused by osteoporosis. In patients with osteoporosis, the forces encountered in daily life are enough to cause fractures. They also occur in patients on "long-term steroid therapy" or in patients suffering from cancers that have metastasized to the spine. These fractures occur when the vertebral cortex collapses which reduces the overall structure of the vertebra causing excruciating pain. About an equal number of fractures occur acutely, as occur chronically.
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