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Lateral x-ray showing an L1 vertebral compression fracture with 50% height loss and anterior wedging in a 66-year-old man following a fall from a ladder.
A 66-year-old man presents with severe lower back pain after falling from an 8-foot ladder one week previously. He was seen in the emergency department immediately after the fall, where he was diagnosed with an L1 compression fracture. On examination, he has severe lower back pain to palpation. Motor and sensation in the lower extremities are intact. A lateral radiograph shows an L1 vertebral compression fracture with 50% height loss and anterior wedging. The posterior cortex is intact, and there is no retropulsion of bony fragments into the canal. The patient has been wearing an extension brace but continues to have pain with activities and at rest. He mentions that his friend had a kyphoplasty procedure after a spinal fracture and is wondering if this would help his pain.
This case has been brought to you in partnership with the Journal of Orthopedics for Physician Assistants.
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The American Academy of Orthopaedic Surgeons recommends against vertebroplasty for acute compression fractures because of the high complication rate with the procedure. Vertebroplasty involves the use of imaging guidance to inject cement percutaneously directly into the collapsed vertebral body.
Cement extravasation is a relatively common complication of vertebroplasty, and therefore the procedure is often avoided in favor of kyphoplasty. Vertebroplasty also fixes the vertebral body to the deformed height and does not correct the height loss or kyphosis. Kyphoplasty involves placing a percutaneous inflatable balloon into the collapsed vertebral body. The balloon is then inflated until the vertebral height and kyphosis are corrected. Cement is then injected into the space created by the balloon to maintain correction of height loss and kyphosis. Kyphoplasty has a much lower rate of cement leakage compared with vertebroplasty.1,2
The decision to move forward with vertebral kyphoplasty is made after a period of nonoperative care has failed. Nonoperative care is generally recommended for 4 to 6 weeks and includes therapy with nonsteroidal anti-inflammatory drugs and muscle relaxants, a short course of narcotic pain medication, and lumbar extension bracing. There are no accurate predictors of failure of nonoperative care, and the recommended length of time for conservative treatment is arbitrary and varies by patient presentation. Kyphoplasty can provide rapid and substantial pain relief and improvement in quality of life for those with acute lumbar compression fractures.
The potential risks and benefits of kyphoplasty should be discussed with patients who fail nonoperative treatment. In those with osteoporosis, kyphoplasty has been shown to result in a higher rate of subsequent adjacent-level vertebral fractures compared with untreated fractures. Cement augmentation places additional stress on adjacent levels, increasing the risk for subsequent fractures, which occur most often within 2 months after kyphoplasty.1,2
Surgical decompression and stabilization are rarely indicated in patients with lumbar compression fractures. Indications include progressive neurologic deficits and spinal instability.3
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
References
- Denaro D, Longo UG, Maffulli N, Denaro L. Vertebroplasty and kyphoplasty. Clin Cases Miner Bone Metab. 2009;6(2):125-130.
- McKiernan F, Faciszewski T, Jensen R. Quality of life following vertebroplasty. J Bone Joint Surg Am. 2004;86-A(12):2600-2606.
- Abbasi D, Moore D. Osteoporotic lumbar compression fractures. http://www.orthobullets.com/spine/2021/osteoporotic-vertebral-compression-fracture. Updated February 2, 2016. Accessed May 2, 2016.
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