In a kyphoplasty, a fractured vertebral body is stabilised from the inside. Through a hollow needle a small balloon is guided into the vertebral body and expanded, in order to raise the collapsed bone as far as possible; the cavity created in this way is filled with bone cement, which hardens within minutes. The typical occasion is a vertebral fracture in osteoporosis that hurts so much despite painkillers that getting up and walking are not possible. We perform this procedure.
Most vertebral fractures in osteoporosis heal without a procedure. Kyphoplasty is intended for the cases in which the pain cannot be controlled despite treatment — and it never replaces the treatment of the osteoporosis itself.
Who is kyphoplasty suitable for?
A fracture of a vertebral body in osteoporosis often arises without any notable accident — when lifting, coughing or stumbling, or without any recognisable occasion — and causes a deep, movement-dependent pain in the thoracic or lumbar spine. As a rule the pain improves markedly within four to six weeks; it takes about three months until the fracture has healed. Treatment therefore almost always begins without a procedure. A kyphoplasty is considered when that treatment does not carry far enough:
- Fresh fracture with severe pain — the osteoporosis guideline names fractures that are between two and six weeks old, with moderate to severe pain that does not respond sufficiently to painkillers, where opioids through the vein are necessary or where admission to hospital because of the pain takes place. The guideline on osteoporotic vertebral fracture regards the early procedure within the first month as effective when treatment without an operation does not bring sufficient improvement.
- Stable fracture — the cement filling on its own is suitable for fractures in which the posterior wall of the vertebral body and its outer framework are preserved. If the vertebra is so destroyed that it is unstable, or if bone is pressing on nerves, a different procedure is necessary, for instance a stabilisation with screws and rods.
- Inability to be mobilised — when those affected cannot get up despite pain treatment. For older people, lying still is itself a risk: loss of muscle, thrombosis, pneumonia, confusion.
- Older fracture with persistent pain — after more than six weeks only if the pain has barely improved despite adequate treatment; after more than three months only if the MRI still shows bone marrow oedema in the affected vertebra and other causes of pain have been ruled out.
To classify the form of the fracture and the symptoms, the German guideline uses a classification (OF 1 to 5) and a score, into which the form of the fracture, bone density, further collapse, pain, nerve deficits, ability to be mobilised and general condition are entered; below six points, treatment is without an operation. A kyphoplasty to prevent fractures at vertebrae that are not broken does not make sense.
A vertebral fracture after a fall in later life should be assessed by a doctor promptly, even if the fall seemed harmless. New weakness in the legs, numbness or a disturbance of bladder or bowel after a fracture are emergencies — more on this on the page Warning signs. And a fracture without a sufficient cause always needs the cause to be clarified: usually osteoporosis, rarely something else that is treated differently.
What happens exactly?
- PreparationX-rays taken standing show the shape of the fracture and, over the course of time, whether the vertebra is collapsing further. The MRI shows whether the fracture is fresh — bone marrow oedema is the sign of that, explained on the page on the MRI report — and whether further vertebrae are affected; a computed tomography scan clarifies the posterior wall where this is needed. Added to that are an anaesthetic consultation, blood values, your list of medication and the question of blood thinners. The osteoporosis work-up, with bone density measurement, is part of it from the start.
- The procedureLying on your front, as a rule under general anaesthetic — the procedure is also possible under local or regional anaesthesia, but according to the guideline the general anaesthetic achieves the best pain relief without more complications. Under X-ray guidance, a hollow needle is advanced through a small skin incision through the pedicle into the vertebral body, usually from both sides. The balloon is introduced and carefully expanded until the vertebral body straightens up, as far as the bone allows. The balloon is then removed and the viscous cement is filled into the cavity under X-ray vision — not more than about 30 per cent of the volume of the vertebral body, so that the vertebra does not become too stiff. The cement hardens within a few minutes. The skin is sutured and covered with a sterile dressing.
- AfterwardsGetting up on the day of the procedure or the day after. X-ray check, wound check, testing of strength and sensation. The procedure can be carried out as a day case or in the course of a hospital stay; that depends on your general condition and on your situation at home.
What kyphoplasty can achieve — and what it cannot
The evidence is contradictory, and we do not want to smooth it over. For the simple cement filling without a balloon, vertebroplasty, there are studies with a sham procedure: a Cochrane analysis of five such studies with 541 participants found no meaningful advantage after one month — the pain lay on average 0.6 points on a scale from 0 to 10 below that of those given the sham treatment. Two studies from the year 2009 with 78 and 131 participants and a Dutch study from the year 2018 with 180 participants with fresh fractures likewise found no difference from the sham treatment. An Australian study with 120 participants whose fractures were less than six weeks old and whose pain was very severe did, by contrast, find an advantage: after two weeks, 44 out of 100 had only mild pain after the procedure, compared with 21 out of 100 after the sham procedure.
For kyphoplasty itself there is no study with a sham procedure. In the largest comparative study, with 300 participants with fresh fractures, physical quality of life after one month was improved more markedly with kyphoplasty than without a procedure — by 7.2 compared with 2.0 points on a scale from 0 to 100; this study could not blind out whether those treated knew which treatment they were receiving. Seven studies that compared kyphoplasty and vertebroplasty directly found no differences in pain. The German guideline draws from this: the early procedure within the first few weeks can relieve pain effectively and make mobilisation possible; in fractures with loss of height or with kyphosis, kyphoplasty is to be preferred to vertebroplasty. IQWiG draws from this: most people do not benefit from a cement procedure; where the pain is very severe and the fracture fresh, it can sometimes relieve the symptoms somewhat faster; long-term advantages are not established.
What kyphoplasty does not achieve: it restores the original height of the vertebra only in part, it does not remedy a rounded back that was already present beforehand, and it changes nothing about the osteoporosis — further fractures remain possible. That is why after every vertebral fracture, whether with or without a procedure, the recommendation applies to begin a treatment of the osteoporosis or to review an existing one.
Risks and side effects
The procedure is small, its complications are rare, but they can be serious. The most frequent is the escape of cement out of the vertebral body — into vessels, into the disc or towards the spinal canal. In an analysis of 22 studies with 2,872 people treated, cement leakage occurred in about 18 out of 100 kyphoplasties, compared with about 55 out of 100 vertebroplasties; the balloon creates a protected cavity, and viscous cement lowers the risk further. The great majority of cement leaks remain without symptoms. If cement reaches the spinal canal and presses on the spinal cord or on nerves, an emergency operation can become necessary; if it reaches the bloodstream, it can block vessels in the lung — usually unnoticed, in rare cases life-threatening.
Serious complications overall — wound infection, a repeat procedure, heart or lung problems — occurred in an analysis of 26 studies in 2 out of 100 kyphoplasties and in just under 4 out of 100 vertebroplasties. Added to that are bruising and pain at the puncture site, the risks of the anaesthetic and, very rarely, an injury to the pedicle or to a nerve. A particular topic is fractures of the neighbouring vertebrae: after a cement filling they occur in 12 to 24 out of 100 cases, most often in the vertebra directly above. Whether the procedure encourages them is not established — in several studies the risk was no higher than without a procedure, and the osteoporosis itself is the main cause; a leak of cement into the disc does, however, raise the risk. Which of these is to the fore in your situation is something we discuss before the procedure.
Before and after
Before the procedure: the first weeks after a vertebral fracture belong to pain treatment and to the attempt to stay in movement. Bed rest should be as short as possible, because it weakens muscles, circulation and independence. A back brace can relieve for a short time; its benefit is not well established, and worn permanently it weakens the trunk muscles. To begin with you should avoid lifting and carrying more than about five kilograms. If in spite of everything the pain prevents you from getting up, that is the moment to talk about the procedure — not only after months.
After the procedure: getting up as early as possible, walking from the start. Physiotherapy with strengthening of the back muscles and balance exercises: according to the guideline’s assessment, exercise programmes lower the risk of a further fall and, in observational studies, also the risk of further vertebral fractures. A brace after the procedure only if there is an individual reason for it. And above all: treat the osteoporosis — bone density measurement, vitamin D and calcium as needed, a bone-active medication, and fall prevention at home. That is usually taken on by the general practitioner, where appropriate by a practice specialising in bone disease; we set it in motion. A follow-up check with us is part of it.
Alternatives
Treatment without a procedure is the rule and for most of those affected the right choice: painkillers, where the pain is severe temporarily stronger ones as well, early mobilisation, physiotherapy, a brace for a short period, and the treatment of the osteoporosis. Vertebroplasty, the cement filling without a balloon, can come into consideration; in fractures with loss of height, kyphoplasty is preferred. Procedures with a metal stent in the vertebral body should, according to the guideline, not be used routinely for lack of evidence. If the vertebra is unstable or if bone is pressing on nerves, a stabilisation with screws and rods comes into consideration, where appropriate combined with a cement filling. IQWiG expressly advises obtaining a second medical opinion before a cement procedure if you are unsure.
Frequently asked questions
How quickly does the pain ease?
If the procedure works, then quickly — in the studies the difference showed itself after as little as two weeks to one month. Some of those treated feel no clear difference; that is not a sign that something has gone wrong, but corresponds to the evidence.
Does the cement stay in the vertebra for ever?
Yes. The hardened cement is not broken down and does not have to be removed. It supports the vertebral body permanently; the bone around it heals as usual.
Will I be straight again?
The balloon raises a fresh fracture in part, an old one hardly at all. A rounded back that has developed over years through several fractures cannot be corrected with a kyphoplasty. The aim of the procedure is the pain, not the posture.
Can the vertebra next to it break as well?
Yes, that occurs in 12 to 24 out of 100 — with and without a procedure, because the osteoporosis is the cause. That is why the treatment of the osteoporosis, strengthening and fall prevention after a vertebral fracture are as important as the procedure itself.
How long may one wait after the fracture?
The studies with an advantage for the procedure concerned fresh fractures — in the Australian study less than six weeks old — and the German guideline names the first month. After more than six weeks the benefit is uncertain, after more than three months it is present only in special cases. So do not leave a fracture that stops you getting up unattended for weeks.
Do I have to take osteoporosis medication afterwards?
The osteoporosis guideline recommends, with the strongest grade of recommendation, beginning a specific treatment after every osteoporotic vertebral fracture or reviewing an existing one — regardless of whether an operation was carried out. Which medication is suitable is decided according to bone density, previous illnesses and your wishes.
If a kyphoplasty or vertebroplasty has been recommended to you elsewhere and you are unsure, you can obtain a second opinion from us. We look at your images, examine you and tell you frankly whether we consider the procedure sensible in your situation — or whether treatment without a procedure is the better way. What you should bring to the first appointment is on the page Your first appointment.