Early experience with percutaneous balloon kyphoplasty for treatment of osteoporotic vertebral compression fracture in Nepal: A case report (2024)

Associated Data

Data Availability Statement

Abstract

Keywords: balloon kyphoplasty, compression fracture, osteoporosis, posterior cortical defect, vertebra

1. INTRODUCTION

Osteoporotic vertebral compression fracture (OVCF) is a common and serious consequence of osteoporosis, impacting individuals aged ≥50 years, with an estimated prevalence ranging from 30% to 50%.1 Despite the prevalence of OVCFs, there is currently no accepted treatment plan for patients who suffer from this condition. An acute OVCF is typically treated with a combination of pain management, activity modification, patient education, and osteoporosis treatment. Conservative treatment options include things like rest and/or medication, while surgical ones like vertebroplasty and kyphoplasty may also be taken into account.2 Conservative treatment for vertebral compression fractures typically involves immobilization with a back brace, patient‐specific analgesia, and medication for osteoporosis. The back brace provides stability and reduces the need for surgery, but may not be well tolerated by older patients. Regular radiological monitoring is necessary to detect any worsening of displacement, malunion, or nonunion that may cause persistent pain. This approach can be indicated for fractures with less than 20° kyphosis and 25% loss in height.3 But in elderly patients, prolonged bed rest and lack of physical activity can elevate risks of pneumonia, pressure ulcers (decubitus ulcers), venous thromboembolism, and mortality.4 Percutaneous vertebroplasty (PVP) and percutaneous balloon kyphoplasty (BK) have been developed to alleviate pain associated with fractures and restoring vertebral height. These procedures have demonstrated effectiveness in providing short‐term pain relief.5 Of these interventional treatments, vertebroplasty is generally considered a simpler procedure as it involves a direct injection of cement into the fractured vertebra. Kyphoplasty, with the additional step of balloon inflation, may require more technical expertise and specialized equipment and is costlier. However, vertebroplasty, has the significant risk of cement leakage, with one of the potential complications being leakage into the spinal canal. Kyphoplasty, a minimally invasive procedure for neurologically intact patients, has demonstrated effectiveness in numerous cases, and can offer rapid pain relief and less cement leakage. Kyphoplasty may be preferred when there is a significant vertebral collapse or deformity or cortical defect. We present here the pioneering example of interventional radiology performing percutaneous balloon kyphoplasty on a patient with OVCF in Nepal.

2. CASE PRESENTATION

A 68‐year‐old female, presented to the emergency room with 6 weeks history of increasing back pain, limiting her ability to sit and stand for the last 30 days. The pain was constant at rest and increased with activities such as sitting, standing, or using the bathroom.

Her medical history was notable for chronic obstructive pulmonary disease (COPD) for 12 years, hypothyroidism for 5 years, hypertension (HTN) for 3 years, and diabetes mellitus (DM) for 1 year. She was receiving medical management for all her comorbidities.

Tenderness was noted in the L1 region of her back. There was no step‐up deformity or swelling. Lower limb examination showed normal tone, bulk, power, reflexes, and sensation bilaterally. Radiological findings from computed tomography (CT) scan of the lumbar‐sacral spine revealed diffuse osteoporosis of the dorso‐lumbar vertebra and central wedging compression fracture at the L1 vertebra and mild retropulsion of the posterior wall, leading to a mild narrowing of the central spinal canal. Additionally, there were cortical defects in the posterior aspect (Figure1). The L4 vertebra also showed anterior wedging with an irregular superior subchondral surface.

Based on the clinical presentation, examination findings, and imaging results, she was diagnosed with an osteoporotic L1 fracture (ASIA impairment scale E). She was scheduled for kyphoplasty rather than vertebroplasty, as there was a posterior cortical defect.

The procedure, performed under fluoroscopic guidance, involved accessing the L1 vertebra through the pedicles from both sides. Since there were few cortical defects in the posterior aspect balloon was inflated to create a cavity, and approximately 5 mL polymethylmethacrylate cement was injected slowly (Figure2). There was not any cement leakage or clinical complications.

Post‐operative imaging confirmed the presence of a good amount of cement in the affected vertebra. One day after the procedure, she reported significant pain relief and was able to sit in bed. By postoperative day two, she began mobilizing with support and reported reduced pain. Her vital signs remained stable throughout her hospital stay. No complications were seen.

Given her improved condition and stable neurology, she was discharged from the hospital. She was advised to take paracetamol tablets (1 gm) thrice daily for 3 days, followed by as‐needed (SOS) for pain relief. Additionally, she was prescribed gabapentin capsules (100 mg) orally twice daily for a duration of 1 month to manage neuropathic pain. Her medications for the comorbid diseases were continued. She was instructed to take a weekly dose of vitamin D (60,000 IU) for 4 weeks. At the time of discharge, her condition remained stable, and she was able to ambulate with support. On follow‐up at 2 months, she was pain‐free and ambulating without difficulty.

3. DISCUSSION

Osteoporotic vertebral fractures can result in height loss, spinal deformities, pain, restricted mobility, and disability. Pain associated with acute fractures is attributed to instability at the fracture site and is typically less pronounced at rest but exacerbated during physical activity.6

Diagnosis of a vertebral fracture can be established by imaging, but one must consider the patient's medical history and conduct a physical examination, which may include assessing tenderness over the vertebrae and performing a neurological assessment. Imaging techniques such as magnetic resonance imaging (MRI) and computed tomography (CT) scans are commonly employed to evaluate the timing, extent, and involvement of soft tissues or the spinal cord in the fracture. These imaging modalities provide detailed information about the fracture, aiding in the diagnosis and determining the appropriate treatment approach.7

The comprehensive management of osteoporotic vertebral compression fractures (OVCFs) involves various components, including pain alleviation, administration of anti‐osteoporosis medication, and surgical interventions like percutaneous vertebroplasty (PVP) and percutaneous balloon kyphoplasty (BK). These procedures aim to augment the affected vertebrae, provide decompression, and enable structural reconstruction.8 In the short term, VP and balloon BK costs are higher compared to conservative medical management (CMM). However, the analgesic effect is quickly and significantly achieved because the cement stabilization stabilizes the vertebral body upon polymerization. This enables the patient to mobilize rapidly without the requirement of a back brace. Model results indicate that interventional treatments are cost‐effective, particularly among patients who meet the criteria for surgery.9

Balloon kyphoplasty (BK), a minimally invasive technique used to treat osteoporotic vertebral compression fractures, has shown promising results in terms of rapid pain relief and low complication rates. Several studies have found encouraging results in support of this procedure.10 During BK, a balloon is inflated within the affected bone, creating a cavity, which is subsequently filled with cement through an injection. This technique provides the benefit of performing cement augmentation in a controlled and low‐pressure environment, thereby reducing the risk of cement leakage. As a result, it allows for the restoration of vertebral body height and potentially decreases the occurrence of complications related to cement extravasation.11, 12 Perez et al.13 provide support for the safety and efficacy of BK in managing benign vertebral compression fractures even in the presence of a posterior wall defect. While posterior wall defects were previously considered contraindications to BK, carefully selected patients can still experience favorable clinical outcomes and safety with BK in this frequently encountered clinical situation.

PVP was introduced as a minimally invasive treatment option for thoracolumbar burst fractures in patients with preserved neurological function. Nevertheless, the utilization of vertebroplasty in these cases remains a topic of debate. Retropulsed fragments and enhancements in the central spinal canal have been identified as contraindications for vertebroplasty according to certain studies. This is because there is a potential risk of causing further damage to the spinal canal during the procedure.4 The risk of cement leakage in percutaneous vertebroplasty for osteoporotic vertebral compression fractures is influenced by two factors: the volume ratio of intravertebral bone cement to the vertebral body and the competence of the vertebral body wall. Cement leakage is more likely to occur when there is vertebral body wall incompetence and a high volume ratio of intravertebral bone cement to the vertebral body.14 According to a systematic review by Zhan et al.15 the incidence of cement leakage in percutaneous vertebroplasty (PVP) that could potentially result in severe complications is significant. However, by implementing rigorous patient selection criteria and adopting individually tailored therapeutic strategies, the occurrence of cement leakage can be reduced.

Comparison studies were searched regarding BK and PVP in OVCF. Patel et al.16 concluded that both BK and PVP are effective treatments for vertebral compression fractures. Their review suggests that balloon kyphoplasty may be preferred for restoring vertebral height. Similarly, Wang et al. concluded kyphoplasty had specific advantages over vertebroplasty, including reducing the kyphotic wedge angle and the risk of cement leakage, as well as increasing vertebral body height. However, they noted that the radiographic differences did not significantly impact the clinical outcomes. There were no significant differences observed in visual analog scale (VAS) scores and Oswestry Disability Index (ODI) scores between the two treatment groups. Therefore, both BK and PVP were deemed equally effective in terms of clinical outcomes for osteoporotic vertebral compression fractures (OVCF) in their review. However, comparison studies of these two methods in OVCF with posterior wall defects were not found in the literature.

In a study by Venier et al.8 involving 43 patients with traumatic, osteoporotic, and neoplastic burst fractures, the outcomes of armed kyphoplasty using vertebral body stents or SpineJack were assessed. They concluded that in selected cases, armed kyphoplasty could be a suitable minimally invasive treatment option, either as a stand‐alone procedure or in combination with posterior stabilization.

Cement leakage is recognized as a significant complication of BK, and it is believed that the presence of a posterior vertebral body wall (PVBW) defect increases the risk. In a prospective study of 82 patients by Abdelgawaad et al.,17 it was observed that 22.5% of patients with traumatic vertebral compression fractures and PVBW defects experienced asymptomatic leakage of cement, which could be cortical, discal, or vascular. However, it is noteworthy that no cases of cement leakage into the spinal canal were reported. Furthermore, it is also important to know that the occurrence of intraoperative cement extravasation during the procedure can potentially result in severe neurological injury or pulmonary cement embolism. Although there have been only a limited number of case reports documenting neurological injuries, the estimated incidence of pulmonary cement embolism ranges between 3% and 23%, with the majority of cases having no clinical significance.18, 19 In rare cases, postoperative symptomatic cement leakage may occur, leading to significant neurological complications such as worsening pain, radiculopathy, spinal cord compression, or cauda equina compression.20, 21 Zhang et al.22 analysis found no increased risk of vertebral body fractures, including those adjacent to the treated vertebrae, with minimally invasive surgery compared to conservative treatment.

The successful introduction of kyphoplasty in Nepal marks a significant milestone for the healthcare system in the country. It showcases the dedication of interventional radiologists and the medical community to enhancing treatment options and delivering optimal care to patients with osteoporotic vertebral compression fractures. This pioneering experience in Nepal not only showcases the achievements thus far but also creates opportunities for further research, collaboration, and training, aiming to extend the benefits of this advanced intervention to a larger number of patients in the future. We aim to showcase our ability to effectively manage chronic pain and prevent further fractures in osteoporotic bones. This report serves as a symbolic and informative document.

Due to being a tertiary hospital and referral center, our facility encounters a substantial number of osteoporotic fracture cases on a daily basis. In collaboration with our competent neurosurgeons, we have developed a coordinated approach to treating these cases. Our treatment plan involves kyphoplasty for fractures with posterior cortical defects and vertebroplasty for the remaining cases.

In our setting, it is unfortunate that insurance policies do not cover the cost of the procedure for treating vertebral fractures. This poses a challenge as a significant portion of our population is uninsured and individuals must bear the expenses out of their own pockets. However, it is worth noting that the charges for the procedure are at around 150 USD, which is relatively low compared to US.23 However, making it available to local level is still challenging.

4. CONCLUSION

Percutaneous balloon kyphoplasty demonstrates promising outcomes in the management of osteoporotic vertebral compression fractures with posterior cortical defect. It provides pain relief, restores vertebral body height, and has a low risk of cement leakage. Collaboration among various specialties, including orthopedics, radiology, and anesthesia, was critical in achieving the best results. Kyphoplasty should be regarded as a viable option for treating osteoporotic compression fractures, providing significant advantages to patients with pain and restricted mobility as a result of vertebral fractures.

AUTHOR CONTRIBUTIONS

Paras Thapa: Conceptualization; writing – original draft; writing – review and editing. Madhur Bhattarai: Writing – original draft; writing – review and editing. Basanta Sharma Paudel: Writing – original draft; writing – review and editing. Prakash Sharma: Writing – review and editing. Pratiksha Kunwar: Writing – review and editing. Sushil Poudel: Writing – review and editing. Saru Koirala: Writing – review and editing. Amit Pradhanang: Supervision; writing – review and editing. Brendan J. Klein: Supervision; writing – review and editing. Farrokh Farrokhi: Supervision; writing – review and editing.

FUNDING INFORMATION

None.

CONFLICT OF INTEREST STATEMENT

The authors have no conflict of interest to declare.

CONSENT

Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.

Notes

Thapa P, Bhattarai M, Sharma Paudel B, et al. Early experience with percutaneous balloon kyphoplasty for treatment of osteoporotic vertebral compression fracture in Nepal: A case report. Clin Case Rep. 2023;11:e7852. doi: 10.1002/ccr3.7852 [CrossRef] [Google Scholar]

DATA AVAILABILITY STATEMENT

All the required information is available in the manuscript itself.

REFERENCES