Redo lumbar spine kyphoplasty

Case contributed by Vikram Shaw

Presentation

Patient presenting with back pain. MRI performed on July 3rd reveals an acute osteoporotic L1 vertebral body compression fracture. Original kyphoplasty was performed on June 4th. Second kyphoplasty to fix the new fracture was performed on July 16th.

Patient Data

Age: 74
Gender: Female
X-ray

Lumbar Spine X-Ray

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 was performed.

A 74-year-old women presented with back pain to an imaging center.  An MRI taken July 3rd showed an acute L1 vertebral body compression fracture.  After discussing potential risks with the patient, a redo kyphoplasty to repair the L1 fracture was scheduled for July 16th.  The L1 vertebral body was localized fluoroscopically in two different planes (AP and lateral).  With fluoroscopic guidance, a trochar needle was inserted and advanced into the right and left posterior-lateral aspect 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 trochar 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.

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." 

 The patient was a female 74-year-old so she already had a pre-disposition to having a fracture like this occur.  According to 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 undiagnosed.  

After a patient has already received a kyphoplasty, there is an 8% chance of having a cement leakage . There is a less than 1% chance of having a repeat fracture in the previously treated vertebra and a 9% chance in the adjacent vertebra.  There is a 0.17% chance of having a PCE (pulmonary cement embolism.)  Spinal stenosis that resulted in compression of the spinal cord occurred in 0.16% of the cases.  (Information about complications performed by Yohan Robinson, Sven Kevin Tschöke and Christoph E Heyde)

Vertebral compression fractures (VCF) are 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 even number of fractures occur acutely as opposed to chronic fractures that develop over time.  

Case Discussion

A redo kyphoplasty is a viable option after having one performed especially if the inital kyphoplasty did not fill enough cement to stabilize the vertebral body which is what we suspect in this case.  Therefore we refilled her vertebral body with an additional 8cc's of cement which resolved her pain.

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Case information

rID: 24232
Case created: 2nd Aug 2013
Last edited: 4th May 2017
Inclusion in quiz mode: Included

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