Kyphoplasty

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Original Editor - Margaret Chislett Top Contributors - Margaret Chislett, Kim Jackson, Admin, Khloud Shreif, 127.0.0.1 and WikiSysop  

Introduction

Kyphoplasty is a relatively new procedure that was first performed in California in 1998. It is a minimally invasive percutaneous procedure that involves the percutaneous insertion of an inflatable bone tamp into the fractured vertebral body under fluoroscopic guidance. The bone tamp is then inflated, elevating the endplates and restoring the vertebral body toward its original height. The procedure has been shown to speed up the treatment and recovery period of vertebral compression fractures. It has the added benefit of addressing kyphotic deformity as well as pain, unlike vertebroplasty that only addresses pain. Indications for kyphoplasty include painful or progressive osteoporotic and osteolytic vertebral compression fractures that do not compromise the spinal canal. The indication for this procedure is pain and the percentage of vertebral collapse. If a patient rates his/her pain as being greater than 4 out of 10 (when 10 equals worst pain imaginable and 0 equals no pain) or the vertebral bodies are collapsed more than 40%, then kyphoplasty or vertebroplasty is indicated as an initial intervention. Conservative treatment has been questioned as it can take months to resolve and requires an extended period of rest which can lead to a further decrease in bone density. In most cases kyphoplasty can eliminate the need for complex surgical fixation, especially where the bones are osteoporotic. However, if there is compromise neurological compromise kyphoplasty is not indicated.

Procedure

Unlike vertebroplasty a balloon is inserted percutaneously into the vertebral body and inflated before the thick polymethylmethacrylate (PMMA) is injected in a under low pressure into the cavity of the body. The bone tamp is then deflated and removed. Kyphoplasty has been shown to provide significant pain relief as well as substantial improvement in the height of the collapsed vertebral body and has been found to reduce the spinal kyphosis.

Clinical Presentation

The onset of sudden, severe back pain, that worsens on standing or walking but relieves when lying down can often be mistaken for muscle strain but if there is loss of movement and pain when bending or twisting couple with loss of height, deformity of the spine - "hunchback" shape then a fracture may be suspected. In most cases the mechanism of injury is the same as a back strain and can be caused doing every day tasks such as lifting, bending to pick something up from the floor or a simple slip or missing a step. Another warning sign that it could be something more serious is the age of the client, people over the age of 50 and in particular women are at risk of osteoporosis and therefore more susceptible to a serious injury like a fracture.

Diagnostic Tests

It is important to correctly assess a patient who presents with spinal pain of traumatic or atraumatic origin that is not responding to conservative treatment, particularly if the patient falls under the risk category for osteoporisis. The most common tests are:

• Radiography - X-rays are usually the first diagnostic test performed as they are inexpensive. A lateral X-ray of the thoracic or lumbar spine can often identify a fracture and reveal any loss of height or misalignment of the spine.
• Computed Tomography (CT) scan - provides greater detail of bony anatomy and can reveal loss of height, fragment retropulsion, and any compromise of the spinal
• Magnetic Resonance Imaging (MRI) - This is more expensive but can reveal whether the fracture is acute (by the presence of bony oedema) and also if there is compromise of the neurological system.
• Bone Scintigraphy - a nuclear medicine imaging technique of the bone that is used to diagnose bone conditions and disorders such as fracture, infection and cancer

Physiotherapy Management

Physical therapy, analgesic medication, heat, massage and rest can all provide temporary relief of back pain, however, attention should be focused on preventing secondary complications such as progressive immobility and weakness. Pt's should avoid flexion exercises such as crunches and situps. Axial back extension strengthening exercises should be intiated within the patient's pain tolerance. Weight bearing exercises should be the hallmark of any program which attempts to minimize the affects of ostoeporosis, however, aquatic exercises and balance training are also beneficial.  

Any patient with diagnosed osteopenia or osteoporosis should be on anti-osteoporotic medications, including second-generation bisphosphonates, as well as (daily) with 1500 mg of elemental calcium and 400 IU of vitamin D.

Most Kyphoplasty procedures are performed on an outpatient basis unless the patient has comorbidities requiring a short inpatient stay. Post-op treatment should be geared towards home safety training if the patient is at high risk for fall (Berg Balance Scale>40), pain management, and transfer training. Once the patient has recovered a program mentioned in the pre-op/non-op section should be initiated.

• Strengthening Exercises
• Stretching
• Pain Management
• Advice and transfer practice
• Manual handling training and activities of daily living
• Balance and Proprioception Training
• Posture Re-education

Outcome Measures

Case Studies

http://web.ebscohost.com.dml.regis.edu/ehost/pdf?vid=4&hid=103&sid=bc9cf379-25b6-487a-be82-e0f59aade795%40sessionmgr112

References

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