Vertebroplasty & Kyphoplasty

Vertebroplasty and kyphoplasty are minimally invasive procedures used to treat osteoporotic vertebral fractures, which are commonly caused by conditions like osteoporosis and spinal metastases. These procedures aim to stabilize the vertebrae and reduce pain, helping patients maintain or improve their quality of life. While vertebroplasty was initially designed for treating vertebral body hemangiomas, both techniques are now widely used for managing osteoporotic compression fractures and metastatic lesions in the spine.

How Common It Is and Who Gets It? (Epidemiology)

Osteoporotic vertebral fractures are widespread, particularly among the elderly. With millions of Americans affected by osteoporosis, the incidence of vertebral compression fractures (VCFs) continues to rise as the population ages. Women, especially postmenopausal women, are more susceptible to these fractures, but men also experience a higher risk in their 80s. The global prevalence of osteoporosis has significant economic impacts, and as the population continues to age, the burden of vertebral fractures will only increase.

Why It Happens – Causes (Etiology and Pathophysiology)

Osteoporotic vertebral fractures occur when bones lose density and become fragile, typically due to osteoporosis. As the vertebral bones weaken, they are more prone to collapse, leading to compression fractures. These fractures are associated with pain, deformity (kyphosis), and, in some cases, neurological impairment. The risk factors for these fractures include aging, hormonal changes (like menopause), immobilization, steroid use, and other medical conditions that weaken bone structure.

How the Body Part Normally Works? (Relevant Anatomy)

The spine is made up of vertebrae, which are separated by intervertebral discs that act as shock absorbers. The vertebral bodies are stacked to form the spine and protect the spinal cord. In healthy bones, the vertebrae are strong and able to support the body’s weight. In osteoporotic bones, the vertebrae become brittle and more susceptible to fractures, leading to compression and, if left untreated, deformity.

What You Might Feel – Symptoms (Clinical Presentation)

Patients with osteoporotic vertebral fractures often experience sudden onset back pain, which may be sharp or aching. Over time, the pain may become chronic, and a deformity called kyphosis (forward curvature of the spine) may develop. Compression of the spinal cord and nerve roots can cause symptoms such as numbness, tingling, and weakness in the arms and legs. Additionally, patients may notice difficulty with breathing, digestive issues, and impaired mobility due to the deformity.

How Doctors Find the Problem? (Diagnosis and Imaging)

Diagnosis of osteoporotic vertebral fractures typically involves a physical examination followed by imaging studies like X-rays, CT scans, and MRI scans. These imaging techniques help assess the severity of the fractures, the presence of deformities, and the degree of spinal cord compression. In some cases, fluoroscopy is used during procedures like vertebroplasty or kyphoplasty to guide the surgical instruments accurately.

Classification

Vertebral fractures are often classified based on their severity, ranging from mild compression fractures to more severe wedge fractures and complete collapses. The degree of kyphosis or spinal curvature caused by these fractures is also a key factor in classifying the condition. The classification helps determine the best course of treatment, whether conservative or surgical.

Other Problems That Can Feel Similar (Differential Diagnosis)

Other spinal conditions, such as herniated discs, spinal stenosis, or degenerative disc disease, can present with similar symptoms to osteoporotic vertebral fractures. It’s important for healthcare providers to differentiate between these conditions through clinical evaluation and imaging to ensure the correct diagnosis and treatment plan.

Treatment Options

Non-Surgical Care:
Initial treatment for osteoporotic vertebral fractures may involve pain medications, physical therapy, and bracing to stabilize the spine. These methods may provide some relief but are less effective for long-term recovery in severe cases.

Surgical Care:
Surgical options like vertebroplasty and kyphoplasty are recommended when conservative treatments fail or when there is significant pain or deformity. Both procedures are minimally invasive and aim to stabilize the fractured vertebrae, relieve pain, and improve quality of life.

Vertebroplasty Technique

Once medical clearance and informed consent are obtained, the patient is transported to the interventional radiology suite. Typically, a surgeon and a radiologist are present during the procedure, although some centers may have a single operator.

The patient is positioned in a prone position with comfortable padding and their arms elevated above the head. Mild sedation and pain relief may be administered, and vital signs are continuously monitored. To minimize the risk of infection, the targeted area is meticulously prepared and draped in a sterile manner.

After positioning the patient, the fracture site is identified using biplanar fluoroscopy. CT guidance is seldom necessary, unless there are unique anatomical limitations that make needle placement difficult. A mark is placed on the skin over the designated pedicle, and the area is infiltrated with a buffered anesthetic solution that reaches down to the periosteum.

A variety of needles and cement options are available for percutaneous vertebroplasty, and there is no standardized technique for needle placement. The preferred approach is the parapedicular approach, but the transpedicular approach is also used. Biplanar fluoroscopy confirms the correct trajectory. A small incision is made, and a Jamshidi needle is inserted.

In the transpedicular approach, the needle is advanced to the pedicle, preferably targeting the upper and outer quadrant to avoid nerve root complications. Fluoroscopy guides the needle placement into the vertebral body. The procedure is then repeated for the opposite pedicle.

Using the parapedicular approach in vertebroplasty eliminates the need for bilateral cannulization, thanks to the lateral positioning that enables more precise needle direction. The Jamshidi needle is inserted onto the transverse process and advanced downward, with entry points determined by fluoroscopic images.

Biplanar fluoroscopy ensures accurate needle alignment with the vertebral body. While the parapedicular approach carries a theoretical risk of pneumothorax and bleeding, our experience suggests that complication rates are comparable to those of the transpedicular approach.

Regardless of the approach employed, it is essential to position the needle tip in the anterior half of the vertebral body on lateral views and in the medial third on AP views. To reduce radiation exposure to the operator’s hand, a clamp can be utilized to stabilize the needle during imaging. When treating multiple vertebral levels, it is preferable to cannulate all the levels before initiating cement injection.

Although some centers previously recommended intraosseous venography, it has been determined that it does not provide additional safety benefits during cement injection. Consequently, we have discontinued the routine use of venography before the procedure. To prevent the introduction of air, the needle is filled with sterile saline once proper placement has been confirmed.

A variety of cement products are available for vertebroplasty, and the selection depends on the practitioner’s expertise. Polymethylmethacrylate (PMMA) is a commonly used cement that combines a powder and liquid to form a solid compound.

The injection is performed when the PMMA reaches a toothpaste-like consistency. Radiopaque markers are used to assist with visualization during the injection process. Typically, 5 to 10 cc of PMMA is injected into each treated vertebral body. If cement leakage occurs, the injection should be halted.

The optimal volume of cement needed for pain relief and the exact mechanism behind its effectiveness are still not fully understood, but it is believed to involve mechanical stabilization and neural thermal necrosis.

After completing the injection, the needle is removed and minor bleeding is controlled. Patients rest for 2 hours before sitting and walking with assistance. A postoperative CT scan is obtained to assess vertebral body filling and rule out spinal cord compression. Patients are discharged on the same day with NSAIDs and muscle relaxants, encouraged to be active in daily life.

Kyphoplasty Technique

Kyphoplasty involves the use of an inflatable bone tamp or balloon to restore the height of the vertebral body, creating a cavity that can be filled with cement. However, it is important to note that restoring vertebral body height does not necessarily result in pain relief or improved quality of life. Radiographic images are used with contrast medium to confirm the expansion of the vertebral body.

In kyphoplasty, a bone tamp is inserted using either a transpedicular or parapedicular approach. The tamp is inflated to create a cavity, and then PMMA cement is injected into the cavity until it reaches two-thirds of the way to the posterior cortex of the vertebral body.

Recovery and What to Expect After Treatment

Post-surgery, most patients experience immediate pain relief, often within hours of the procedure. Recovery typically includes short hospital stays, with patients being encouraged to engage in light activities soon after the procedure. Physical therapy is usually recommended to restore strength and flexibility in the spine. Most patients can return to normal activities within a few weeks, depending on their recovery progress.

Possible Risks or Side Effects (Complications)

As with any surgery, vertebroplasty and kyphoplasty carry potential risks such as infection, bleeding, cement leakage, nerve injury, and adjacent fractures. However, these complications are rare, particularly when the procedure is performed by experienced surgeons. The risk of complications can be minimized with proper patient selection and technique.

Long-Term Outlook (Prognosis)

Both vertebroplasty and kyphoplasty are effective in providing long-term relief from pain and improving spinal function. Kyphoplasty, in particular, helps to restore vertebral height and reduce spinal deformities, which can lead to better long-term outcomes. However, patients should be monitored over time to assess for new fractures or other complications.

Out-of-Pocket Costs

Medicare

CPT Code 22510 – Vertebroplasty: $401.05
CPT Code 22513 – Kyphoplasty: $1,249.27

Under Medicare, 80% of the approved amount for these procedures is covered once the annual deductible has been met. The remaining 20% is typically the patient’s responsibility. Supplemental insurance plans—such as Medigap, AARP, or Blue Cross Blue Shield—generally cover this 20%, leaving most patients with little to no out-of-pocket expenses for Medicare-approved vertebroplasty and kyphoplasty surgeries. These supplemental plans work directly with Medicare to provide comprehensive coverage for vertebral stabilization procedures.

If you have secondary insurance—such as Employer-Based coverage, TRICARE, or Veterans Health Administration (VHA)—it functions as a secondary payer once Medicare processes the claim. After your deductible is satisfied, the secondary plan can cover the remaining balance, including coinsurance or any uncovered charges. Most secondary insurance plans typically have a small deductible, ranging from $100 to $300, depending on the policy and provider network.

Workers’ Compensation
If your vertebral compression fracture requiring vertebroplasty or kyphoplasty resulted from a workplace injury, Workers’ Compensation will pay for all medical and surgical costs. You will have no out-of-pocket expenses under an accepted Workers’ Compensation claim.

No-Fault Insurance
If your vertebral fracture or spinal condition requiring these procedures is a result of a motor vehicle accident, No-Fault Insurance will cover all related surgical and hospital expenses, including vertebroplasty and kyphoplasty. The only potential out-of-pocket expense would be a small deductible depending on your individual policy terms.

Example
Linda, a 62-year-old patient with a compression fracture in her spine, underwent vertebroplasty (CPT 22510) to stabilize the vertebra and alleviate her pain. Her estimated Medicare out-of-pocket cost was $401.05. Since Linda had supplemental insurance through Blue Cross Blue Shield, the 20% that Medicare did not cover was fully paid by her plan, leaving her with no out-of-pocket expense for the vertebroplasty procedure.

Frequently Asked Questions (FAQ)

Q. What is the difference between vertebroplasty and kyphoplasty?
A. Kyphoplasty involves the use of a balloon to restore vertebral height before injecting cement, whereas vertebroplasty only involves cement injection.

Q. How effective are vertebroplasty and kyphoplasty for pain relief?
A. Both procedures are highly effective, with patients experiencing significant pain relief, improved mobility, and better quality of life.

Q. How long does it take to recover after vertebroplasty or kyphoplasty?
A. Most patients can return to normal activities within a few weeks after the procedure, although recovery times can vary depending on the patient’s condition.

Summary and Takeaway

Vertebroplasty and kyphoplasty are minimally invasive surgical techniques that offer significant pain relief and spinal stabilization for patients with osteoporotic vertebral fractures. These procedures are effective in treating fractures, reducing deformities, and improving overall quality of life. With appropriate patient selection and skilled surgical techniques, vertebroplasty and kyphoplasty provide long-term benefits and fast recovery times.

Clinical Insight & Recent Findings

A recent study systematically reviewed infections following vertebroplasty (VP) and kyphoplasty (KP), two common procedures for treating osteoporotic vertebral compression fractures (OVCF). The analysis included 102 patients from eight studies and found that infections following these procedures, though rare, can be serious, with Mycobacterium tuberculosis identified as the most common pathogen (35.3%).

While the infection rate was low, the study revealed that surgical interventions were needed in 93% of cases, with a mortality rate of 12.3%. Additionally, preoperative neurological status was a significant predictor of post-treatment mobility, with patients who had no neurological deficits before surgery having a better chance of achieving normal mobility post-surgery.

The study emphasized the importance of early diagnosis, individualized treatment strategies, and careful surgical decision-making to manage these complications. (“Study of infections following VP and KP – See PubMed.“)

Who Performs This Treatment? (Specialists and Team Involved)

The procedures are typically performed by orthopedic spine surgeons or neurosurgeons specializing in spinal interventions. The surgical team may also include interventional radiologists and anesthesiologists.

When to See a Specialist?

You should see a spine specialist if you have persistent back pain, difficulty moving, or deformities such as a hunched back. A specialist can help determine if vertebroplasty or kyphoplasty is right for you.

When to Go to the Emergency Room?

Seek emergency care if you experience severe pain, sudden weakness, or loss of bladder or bowel control due to a spinal fracture.

What Recovery Really Looks Like?

After vertebroplasty or kyphoplasty, most patients experience rapid pain relief and are encouraged to engage in light activities and physical therapy to improve strength and mobility. Full recovery typically takes a few weeks.

What Happens If You Ignore It?

If left untreated, osteoporotic vertebral fractures can lead to chronic pain, worsening deformities, and further fractures. Early intervention through vertebroplasty or kyphoplasty can prevent these complications.

How to Prevent It?

Maintaining bone health through weight-bearing exercises, a calcium-rich diet, and medications for osteoporosis can help prevent vertebral fractures.

Nutrition and Bone or Joint Health

A diet rich in calcium and vitamin D is essential for strong bones. Weight-bearing exercises and avoiding smoking and excessive alcohol can also help maintain bone density and prevent fractures.

Activity and Lifestyle Modifications

Patients recovering from vertebroplasty or kyphoplasty should avoid heavy lifting and strenuous activities during the initial recovery period. Regular exercise, especially those focusing on core strength and flexibility, can help maintain spine health.

Do you have more questions?