Balloon Kyphoplasty for Vertebral Compression Fractures

BALLOON 

KYPHOPLASTY 

A Treatment option for 

Vertebral Body 

Compression Fractures 

Brian Drew M.D.

Epidemiology 

• In the U.S., 700,000 vertebral compression fractures (VCFs) occur each 

year, more than the number of hip and wrist fractures combined. 2 

• Approximately 150,000 people in the U.S. are hospitalized due to pain and 

medical management associated with VCFs (average hospital stay of 8 

days), resulting in costs in excess of $1.6 billion annually. 2 

• Osteoporosis-related disability confines patients to more immobile days in 

bed than stroke, heart attack or breast cancer. 1 

• Estimated national direct expenditures (hospitals and nursing homes) for 

osteoporotic and associated fractures are $17 billion in 2001 ($47 million 

each day) and the cost is rising, according to the National Osteoporosis 

Foundation. 

1. National Osteoporosis Foundation 

2. Cooper C et al. J Bone Min Res. 1992;7:221–227.

ORTHOPAEDIC FRACTURE CARE 

Why have we been content 

to leave the spine in a 

physiologically and 

biomechanically 

compromised condition?

Fracture Treatment Objectives 

Four AO principles 1 

� Fracture reduction and fixation to restore anatomical 

relationships 

� Stability by fixation or splintage, as the nature of the 

fracture and the injury requires 

� Preservation of blood supply to soft tissues and bone by 

careful handling and gentle reduction techniques 

� Early and safe mobilization of the part and the patient 

*Arbeitsgemeinschaft Osteosynthesefragen 

(English translation: Association for the Study of Internal Fixation - ASIF) 

1 Ruedi & Murphy, AO Principles of Fracture Management, 

Thieme, Stuttgart, New York, 2000

Vertebral Body Compression 

Fracture (VCF) 

Wedgeshaped 

Depressed 

endplate(s) 

Normal Fractured 

Spine 

shorter, 

tilted 

forward

Deformity Progression 

16º 

kyphosis 

Aug 31, 2000 Sept 3, 2000 

Lieberman et al., Spine 2001 

25º 

kyphosis

Biomechanics of VCF 

� Center of gravity (CG) moves 

forward 

� Large bending moment created 

� Posterior muscles and 

ligaments must counterbalance 

increased bending 

� Osteoporotic anterior spine 

must resist larger compressive 

stresses 

White III and Panjabi 1990 

CG

Biomechanics of VCF 

� Knees bend, pelvis tilts 

forward to counteract 

forward bending 

� Change in balance 1 

� Decrease in gait velocity 1 

� Increased muscle fatigue 1 

� Increased risk of falls and 

additional fractures 2 

1 Gold et al., Osteoporosis 2001 

2 Ross et al., Annals Int Med 1991

Physical Impact of VCF 

Age 50 Age 75 

National Osteoporosis Foundation

Increased Fracture Risk 

� After first VCF, risk of subsequent VCF is 

increased 

– 5 fold after first VCF 

– 12 fold after 2 or more VCFs 

– 75 fold after 2 or more VCFs and low bone 

mass (below the 33rd percentile) 

Ross et al., Ann Inter Med 1991 114 (11): 919-923

Increased Mortality 

Prospective study of 9,575 women 

followed > 8 years demonstrated: 

� Patients with VCF have a 23-34% increased mortality rate 

compared to patients without VCF 

� VCF patients are 2-3xs more likely to die of pulmonary 

causes 

� Most common cause of death was pulmonary disease, 

including COPD and pneumonia 

Kado et al., Arch Intern Med 1999

Vertebral Compression Fractures 

Economic Cost 

� 161,000 PCP office visits per year 1 

� 150,000 hospitalizations per year 1 

� Mean length of stay (LOS) is 10.1 days 2 

� VCFs are among the top 3 conditions 

accounting for LOS 2 

� $12,300 average hospital charge 3 

1 Riggs and Melton, Bone 1995 

2 Papaioannou et al., Osteoporosis Int’l 2001 

3 MedPAR 1996

Vertebral Compression Fractures 

Economic Cost 

� Long-term increased morbidity and 

mortality 

� Bone loss up to 2% per week reported after 

prolonged bed rest1 1 Johnell et al., Osteoporosis Int 2000

Long-term Consequences

Possible causes of VCFs 

� Primary osteoporosis 

� Secondary osteoporosis 

– Drug-induced (corticosteroids, tobacco, 

barbituates, heparin) 

– Endocrine (hyperparathyroidism, diabetes) 

– Miscellaneous (renal failure, COPD, 

rheumatoid arthritits, hepatic disease or 

transplant) 

Merck Manual, 16 th ed., 1992

Possible causes of VCFs 

� Osteolytic lesions 

– Multiple Myeloma 

– Bone metastases 

– Paget’s disease 

• Trauma 

– ½ of all trauma cases are misclassified

• Identify painful level 

Diagnosis 

• Define fracture configuration 

• Define fracture age 

• Consider fracture etiology

Identifying Vertebral Fractures 

• Approximately two thirds of all vertebral fractures go 

undiagnosed, in part due to difficulty determining cause of 

symptoms. 

• Pain ranges from mild to severe and may be chronic, but 

may disappear over several weeks. 

• It is important to diagnose vertebral fractures, to understand 

the value of lateral spine radiographs, and to consider 

ordering additional radiographs if initial films do not show 

fracture. 

Gold et al. The Downward Spiral of Vertebral Osteoporosis, A Monograph, June 2003

Acute Event: 

Signs of VCF 

� Sudden onset of back pain 

with little or no trauma 

Chronic Manifestation(s): 

� Loss of height 

� Spinal deformity 

(“Dowager’s hump”) 

� Protuberant abdomen 

Gold et al., Osteoporosis 1996,2001

Physical Examination 

• Does direct pressure on suspect vertebral 

bodies elicit pain? 

• Palpating each spinous process to rule out disc pain as the 

underlying culprit would also be of value to help 

differentiate between back pain and vertebral compression 

fracture pain. 

• BUT the absence of tenderness does not 

indicate that the level is not painful.


• Pain findings on physical exam should be 

concordant with radiographic findings 

• Some patients will have multiple vertebral 

bodies

Radiologic Assessment 

• A lateral spine X-ray examination is a 

method that can be used to screen for the 

presence of vertebral compression fractures. 

• Older films may be useful to asses fracture 

progression 

• STIR sequence MRI can be useful to 

determine index and/or plain radiograph 

culprit.


• T1 weighted shows high intensity for fat, 

subacute hematomas and Gadolinium 

enhanced substances 

• T2 weighted shows high intensity for 

conditions that increase free water, such as 

acute fractures 

• STIR MRI sequence is most sensitive for 

water content when assessing fractures

• The age of the fracture 

may not be as important if 

MRI signal change is 

observed 

• Anecdontal reports exist 

of fractures treated 

months or years of 

symptoms with relief of 

pain 

MRI


First week post fracture 

Courtesy of B. Boszczyk & R. Bierschnieder, BG Unfallklinik, Dept. of 

Neurosurgery, Murnau, Germany 

8 weeks post fracture 

MRI: T2 Image

Vertebral Fracture Progression 

• Some fractures may collapse acutely while 

others collapse progressively over time. 

Lyritis et al. (1989) Clin Rheum Suppl 2(8):66-69

•CT Scan 

CT & Bone Scan 

– Shows structure of bone 

– Extremely high contrast between calcified 

structures(cortical & trabecular bone) and soft 

tissue 

– Assess posterior aspect of vertebral body for 

cortical breach

CT & Bone Scan 

• Use CT plus bone scan to determine 

fracture when MRI cannot be used 

– Implantable metal devices 

– other MRI contraindications

Location of Vertebral Fractures 

Nevitt MC et al. Bone. 1999;25:613–619. 

Cooper C et al. J Bone Min Res. 1992;7:221–227. 

• Are most commonly located at the 

midthoracic region (T7–T8) and the 

thoracolumbar junction (T12–L1) 1 

– Midthoracic region–thoracic kyphosis is 

most pronounced and loading (stress) 

during flexion is increased 

– Thoracolumbar junction–the relatively 

rigid thoracic spine connects to the more 

freely mobile lumbar segments 2 

• Correspond to the most mechanically 

compromised regions of the spine

Vertebral Fractures: Three types 

• Wedge fractures are most common 

Wedge Biconcave Crush 

Genant HK et al. J Bone Miner Res. 1993;8:1137–1148.

VCF Treatment Options 

Medical Management 

� Treatment Protocol 

–Bed rest 

– Narcotic analgesics 

– Braces 

� Shortcomings 

– May fail to relieve pain 

– Does not provide long-term functional improvement 

– May exacerbate bone loss 

– Does not attempt to restore the anatomy


• Best option for treatment clearly is to 

prevent the osteoporotic fracture from 

happening through prevention and treatment 

of osteoporosis 

• Once a fracture has occurred treatment of 

the underlying osteoporosis is of paramount 

importance to lessen the risk of subsequent 

fractures

Symptomatic VCFs 

� 260,000 pts/yr refractory to medical therapy 1 

� Only fracture not treated in an orthopaedic manner 

– Open surgical repair too invasive 

– Poor outcomes (osteopenic bone) 

� No orthopaedic treatment may lead to long-term 

increased morbidity, mortality 

1 Cooper et al., J Bone Min Research 1992


Open Surgical Treatment 

� Indication 

– Only if neurologic deficit (very rare, only 0.05%) 

– Instrumented fusion, anterior or posterior 


– Invasive 

– Poor outcomes in osteopenic bone

Vertebroplasty 


� Designed to stabilize painful VCFs 


– Risk of filler leaks (27-74% reported 1,2,4,5,6,7,8,9,10 ) 

– High pressure injection 

– Uncontrolled fill 

– High complication rate (1-20% reported 3,4,5 ) 

– Freezes spinal deformity 

– Does not reduce fracture or restore anatomy 

– Not designed to reposition bone 

1 Cortet et al., J Rheum 1999 5 Jensen et al., AJNR 1997 8 Grados et al., Rheumatology 2000 

2 Alvarez et al., Eurospine 2001 6 Cotten et al. Radiology 1996 9 Peh et al., Radiology 2002 

3Padovani et al., AJNR 1997 7 Gaughen et al., AJNR 2002 10 Ryu et al., J Neurosurgery 2002 

4 Weill et al., Radiology 1996

Pros & Cons Vertebroplasty 

• Efficacious in the majority of patients 

• Pain relief is expected in greater than 80% 

of patients 

• Can be performed as an outpatient 

• Rapid pain relief and earlier rehab.

Pros & Cons Vertebroplasty 

• Complications are low but but they can be severe 

• Cement is injected while it is quite liquid 

• It flow into vertebral interstices 

• Potential to enter the venous sinuses and 

embolize systemically or to leak out through the 

vertebral wall into local structures 

• Usually asymptomatic but reports of PE, 

neurologic injury and death have been reported

Why Fracture Reduction? 

• What is orthopaedic reduction? 

– The restoration, by surgical or manipulative procedures, 

of a part to its normal anatomical relation 1 

• What is the goal? 

– To produce optimal outcomes with early diagnosis and 

treatment 2 

– To accommodate the frail physical status and comorbidities 

of geriatric patients 2 

1 Stedman’s Concise Medical Dictionary. 1997. Williams and Wilkins. 

2 Brakoniecki, Anesthetic Management of the Trauma Patient with Skeletal Injuries, Skeletal 

Trauma, W.B. Saunders Company, 1998, 1:7:171-172

New VCF Treatment Option 

Minimally Invasive Fracture Reduction

Minimally Invasive Fracture Reduction 

KyphX ® Inflatable Bone Tamp has 

been developed for patients with 

symptomatic VCFs

The Procedure 

• Minimally invasive 

– Bilateral, 1cm incisions 

• Typically one hour per treated fracture 

• General or local anesthesia 

– Most are performed under general anesthesia 

– Can be performed under local anesthesia, often 

supplemented with conscious sedation. 

– Among 155 prospectively enrolled patients in Kyphon U.S. 

study, only 1 complication was related to anesthesia. 

• May require an overnight hospital stay 

Kyphon U.S. Study. Data on file at Kyphon Inc.

KyphX ® Introducer Tool Kit 

Allows precise, minimally invasive access to the 

vertebral body and provides a working channel

KyphX ® IBT Inflation 

Reduces the fracture, compacts the bone, 

and may elevate the endplates

KyphX ® IBT Removal 

Leaves a defined cavity within the 

vertebral body

Balloon Kyphoplasty 

Stabilizes the Fracture and Corrects Spinal 

Deformity caused by one or more VCFs

Minimally Invasive Fracture Reduction 

KyphX® Inflatable Bone Tamp (IBT) 

For use as a conventional bone tamp for the 

reduction of fractures and/or creation of a void 

in cancellous bone in the spine, hand, tibia, radius 

and calcaneus.

Kyphoplasty vs Vertebroplasy 

• The cement is allowed to polymerize more 

completely & is more viscous when injected 

• The cement is injected into a cavity 

• It is under less pressure 

• These factors lower the leakage rate

19 o 

Case Study 

Patient: 91 YO Female 

Diagnosis: Primary osteoporosis 

Fracture Reduced: L-1, 4 months old 

3 o 

15mm 28mm 

Courtesy of Alexander Hadjipavlou, M.D., Crete, Greece

Case Study 


Diagnosis: Primary osteoporosis 

Fracture Reduced: L-1 & L-2 6 weeks old 

Courtesy of Frank Phillips, MD, Chicago, IL 

L1-L2 Height 

Restoration 

(L3 Treated 6 

Wks Prior)

Summary 

� The general goal for fracture treatment is restoration of 

anatomy and early return to function 

� Conventional therapy not always effective 

� KyphX ® IBT is a new option for VCFs designed to: 

− reduce the fracture 

− move cancellous bone (elevate endplates) 

− create void inside vertebral body 

� As with hip fracture surgery, early diagnosis and 

intervention are important for fracture reduction

The Literature

Experience to Date 

• Over 115,000 fractures in 100,000 patients treated worldwide 

since 1998 

• Patient Outcomes include: 

� Vertebral body height restoration 

� Angular correction of deformity 

� Significant reduction in pain 

� Reduced number of days in bed 

� Improved quality of life 

� Improvement in activities of daily living 

� Improvement in mobility 

� High rate of patient satisfaction

Correction of Vertebral Body 

Deformity 

• Studies report the following radiographic 

outcomes post kyphoplasty: 

– Percent lost vertebral body height restored 

– Percent vertebral body height increased 

– Angular deformity correction

Correction of Vertebral Body 


• Three studies analyzed how many fractures in the study 

populations were “reducible” (that is, achieved a measurable 

correction). 

– In the U.S. study, “reducible” refers to measurable fractures where 

at least 15% of predicted height was lost due to fracture. 

– In Lieberman et al (2001) a fracture was reducible if at least 10% of 

lost vertebral body height was restored with balloon kyphoplasty. 

– Phillips et al. (2003) defined reducible as a decrease in local 

angulation of at least 5 degrees. 

Phillips et al (2003) Spine 28, 19: 

2260-2267 

Lieberman et al (2001) Spine 26: 2, 

1631-1638 


Percent Lost Height Restored 

• Based on the mean height 

measurement of the closest, 

unfractured vertebrae above and below 

the treated level. 

• Anterior, midline, and sometimes 

posterior measurements are taken.

Example: Percent Lost Height Restored 

Avg. 

30 mm 

20 mm 

24 mm 

% Lost Height Restored = 

(24 – 20) / (30 - 20) or 4/10 = 40%

Study 

U.S. Study 

Lieberman (2001) 

Theodorou (2002) 

Theodorou (2002) 

Percent Lost Height Restored 

Vertebral 

Body Site 

Midline 

Midline 

Midline 

Anterior 

Mean 

Fracture Age 

(mos.) 

4.3 

5.9 

3.2 

3.2 

Kyphon U.S. Study. Data on file at Kyphon Inc. 

Lieberman et al (2001) Spine 26: 2, 

Theodorou 1631-1638 et al (2002) J Clin Imaging 

26:1-5 

% 

30.2 

35 

66 

52 

% Lost vertebral Body Height Restored 

All Fractures 

N 

65 

70 

24 

24 

Reducible Fractures 

% 

58 

47 

NR 

NR 

N 

47 

49 

NR 

NR 

NR = Not Reported

Percent Vertebral Body Height Increased 

• Estimates % of total, pre-fractured vertebral body 

height 

• Percent vertebral body height is based on the mean 

measurement of the closest unfractured vertebrae 

above and below the treated level. 

• Using the same example, 30mm becomes 100% 

% Pre-KP 

% Post-KP 

20mm / 30mm 

24mm / 30mm 

66% 

80%

Percent Vertebral Body Height Increased 

Results 

Garfin (2001) 

Ledlie (2003) 

Theodorou 

(2002) 

Total Fractures 

603 treated. 

(Number of 

fractures measured 

not reported.) 

36 measured 

pre-op. 

30 measured 

post-op. 

24 treated. 

Garfin et al (2001) Spine 26:1511-1515 

Ledlie et al. (2003) J Neurosurg (Spine 1) 

98: 36-42 

Theodorou et al (2002) J Clin 

Imaging 26:1-5 

Mean 

Fracture 

Age 

Not 

reported 

2.4 mo 

3.2 mo 

Percent Predicted Vertebral Body Height 

Anterior 

Pre-op 

68% 

66% 

Midline 

Pre-op 

64% 

65% 

79% (does not specify 

measurement site) 

Anterior 

Post-op 

84% 

89% 

Midline 

Post-op 

90% 

90% 

92% (does not specify 

measurement site)

Correction of Angular Deformity 

• Measured using the Cobb Method 

• Theodorou et al. (2002) (n=24) 

– Local angular deformity decreased from 26º 26 to 16º 16 

• Phillips et al. (2003) (n=52) 

– Mean local angular deformity correction was 8.8º 8.8 (range, 0- 

29º) 

– Among reducible fractures (5º improvement), mean angular 

deformity correction was 14º 14 

Phillips et al (2003) Spine 28, 19:

Case Study: Correction of Angular 

Immediate 

post- fracture 

Kyphosis = 16º 16 

Lieberman et al. (2001) Spine 26: 2, 1631- 

1638 


Post-fracture + 

Post-kyphoplasty 

Post kyphoplasty 

4 days 

Kyphosis = 25º 25 Kyphosis = 10º 10

Balloon Kyphoplasty 

Clinical Outcomes

Clinical Outcomes 

• Studies report the following clinical 

outcomes post kyphoplasty: 

– Correction of vertebral body deformity 

– Significant reduction in pain 

– Improvement in quality of life 

– Improvement in ability to perform activities 

of daily living 

– Low complication rate

Reduction in Pain 

• Following Balloon Kyphoplasty, patients report significant pain 

reduction at short-term follow-up, sometimes within hours of the 

procedure. 

• In a retrospective analysis (Garfin et al (2001)), patients 

discontinued use of narcotics for fracture-related pain, changing 

to over-the-counter analgesics post operatively. 

• Coumans et al. (2003) prospectively followed 78 consecutive 

patients for 12 to 18 months and reported substantial 

improvement (p

Reduction in Pain 

• In the prospective multicenter U.S. study, there was an average 

of 60% reduction in pain at one week follow-up. Results 

persisted for two years (n=100). 


Quality of Life: SF-36 Survey 

• Coumans et al (2003) 

– Prospective study, 78 

pts, 188 procedures 

– Marked improvement 

in 7 domains; only 

general health did not 

improve. 

– Sustained at 18 mo f/u 

Coumans et al. (2003) J Neurosurg (Spine 1) 99:44-50

Activities of Daily Living 

• Improvements in SF-36 physical function 

scores at seen in the prospective study by 

Coumans et al. (2003) 

• Other measures in the clinical literature include 

ambulatory status, function, days of bed rest, 

and limited activity days. 


• Ledlie et al (2002) (n=79) 

Ambulatory Status 

– 80% were fully ambulatory at 

one week follow-up. 

– 27 of the pts. followed at one 

year maintained full ambulatory 

status. 

– 90% of all patients who were 

wheelchair-bound preoperatively 

were ambulatory at 

one week follow-up. 

Ledlie et al. (2003) J Neurosurg (Spine 1) 98: 36-42

Function 

• Coumans et al: 15% improvement in 

Oswestry Disability Index (ODI) at early F/U 

• Persisted at 12 and 18 month f/u 


Bed Rest and Limited Activity 

• Prospective multicenter U.S. Study 

– Measured number of days in bed during month prior to 

receiving kyphoplasty and number of days of limited 

activity due to back pain. 

• Results at f/u (statistically significant) 

– 100% reduction in median days spent in bed. Results 

maintained at two year f/u. 

– 64% reduction in median number of “days interrupted due 

to back pain” at one and three month f/u and 93% 

reduction at one and two year f/u. 


Risk of Subsequent Fracture 

• Komp et al (2004) 

– A controlled, prospective study 

– 21 patients underwent balloon kyphoplasty and 19 underwent 

conservative treatment. 

– Patient populations were similar in age, gender, fracture history, 

and other risk factors. 

– After six months, 7 out of 19 evaluable balloon kyphoplasty 

patients had new fractures (37%), whereas 11 out of 17 

conservatively-treated patients (67%) had new fractures. 

– Conclusions: 

• Incidence of adjacent and non-adjacent fracture in both arms 

corresponds to other published data. 

• A larger study is needed to assess risk of subsequent fracture. 

Komp, et al. (2004) J Miner Stoffwechs 11(Suppl 1):13-16 (German)

Procedure-Related Complication Rates 

• Literature review conducted describes the results for 

897 Balloon Kyphoplasty patients and 2408 

vertebroplasty. 

• Overall procedure-related complication rate refers to 

bone cement and non-bone cement related 

complication rates combined. 

• Results statistically significantly in favor of Balloon 

Kyphoplasty in the following areas: 

– Overall procedure-related complication rate 

– Bone cement procedure-related complication rate 

Data on file at Kyphon Inc. References listed at end of presentation.

Overall Procedure-Related 

Complication Rate 

• Overall procedure-related 

complication rate for 

balloon kyphoplastytreated 

patients was 

0.89% versus 5.44% for 

vertebroplasty (p=0.0009). 

• Statistically significant 

difference also 

demonstrated in subanalyses 

of fractures due 

to osteoporosis or cancer.

Bone Cement Procedure-Related 

Complication Rates 

• The total bone cement procedure-related 

complication rate for balloon kyphoplasty was 

0.22% versus 3.07% for vertebroplasty (p=0.0008). 

• The calculation of bone cement-related 

complications excluded asymptomatic cement 

extravasations.

Bone Cement Procedure-Related 

Complication Rates 

• The combination of compaction of cancellous bone, 

cavity creation, & controlled cement delivery 

suggests the difference in adverse events is caused 

by cement extravasation. 

• Compaction of Cancellous Bone: Balloon inflation 

compacts the cancellous bone, disrupts internal venous 

pathways and fills fracture lines, reducing leak pathways. 

• Cavity Creation and Controlled Bone Cement 

Delivery: Upon balloon removal, an intervetebral cavity 

is left behind, allowing for the delivery of a known 

volume of doughy bone cement under low pressure and 

fine manual control. 

Phillips et al. (2002) Spine 27:217 

Togawa et al. (2003) Spine 28:152

16000122-01 

Metastatic Bone Disease 

and 

Multiple Myeloma

Metastases to Bone 

Metastatic bone carcinoma 

•Originates from other cancers, such 

as breast, prostate, lung, renal cell, 

etc.. and spreads to bone 

•Metastatic cancer causes skeletal 

complications every 3-4 months 1 

1 Janjan, N. (2001). "Bone Metastases: Approaches to Management." Seminars in 

Oncology 28(4): 28-34.

Metastasis 

• Cancer typically spreads to 1: . 

– Lymphatic system 

– Lungs 

– Liver 

–Skeleton 2 

�Vertebrae 75% 

�Pelvis 40% 

�Femur 25% 

1 Levesque, J et al.. A Clinical Guide to Primary Bone Tumors. Baltimore: Williams & 

Wilkins; 1988.

Classifications 

• Osteoblastic lesions 

– Increase bone density 

– Do not change bone strength 

– Decrease bone stiffness 

– Characterized by increased bone 

formation 

• Example: 

– Metastatic osteoblastic carcinoma

Metastatic 

Osteoblastic 

Carcinoma

Classifications 

• Osteolytic lesions 

- Decrease both bone strength and stiffness 

- Characterized by increased bone resorption, 

causing swiss cheese type lesions on bone 

• Examples: 

- Multiple Myeloma 

- Metastatic osteolytic carcinoma

Metastatic 

Osteolytic 

Carcinoma

Metastases to Bone 

• Cancers that frequently metastasize to the 

skeleton include 1 : 

•Breast cancer 

– 75% of cases 

» 65% of the lesions are lytic 2 

•Lung cancer 


» 80% of the lesions are lytic 2 

•Kidney cancer 


1 Kleerekoper, M. et al (eds.) The Bone and Mineral Manual: A Practical Guide. Academic 

Press; 1999. 

2 Mirra, J. Bone Tumors: Clinical, Radiologic, and Pathologic Correlations. Philadelphia: Lea 

& Febiger; 1989.

Metastases to the Vertebrae 

• > 70% of patients who die from cancer have 

vertebral metastases 1 

• Lytic destruction of the anterior portion of the 

vertebral body 1 

• Lytic lesions are associated with higher 

fracture risk 

• Metastatic bone disease is painful 2 

– Up to 2/3 of patients experience severe pain and 

disability 

1 Harrington, K. (1986). Journal of Bone and Joint Surgery 68-A(7): 1110- 

1115. 

2 Janjan, N. (2001). Seminars in Oncology 28(4): 28-34.

Fracture Risk 

• Osteolytic lesions = higher 

fracture rate 

• Fracture probability increases 

with the duration of metastatic 

involvement1 • Certain cancers almost always 

metastasize with osteolytic 

lesions2 1 Coleman, R. (2001). Cancer Treatment Reviews 27: 165-176.

Radiation Therapy 

• May leave bone unstable 

• Radiation may increase risk of 

fracture 1 

– Up to 41% of patients who undergo 

radiation experience bone fractures 

• Cannot correct an anatomic 

abnormality such as a fracture 2 

1 Patel, B. and H. DeGroot III (2001). Orthopedics 24(6): 612-7. 

2 Janjan, N. (2001). Seminars in Oncology 28(4): 28-34.

Fracture Treatment 

• Pain is due to spinal instability 

– radiotherapy or systemic treatment will not relieve 

the pain 1 

• Stabilization is required for pain relief 1 

• Spinal cord involvement and neurologic 

deficit possible if not stabilized 2 

1 Coleman, R. (2001). Cancer Treatment Reviews 27: 165-176. 

2 Harrington, K. (1986). Journal of Bone and Joint Surgery 68-A(7): 1110-1115.

Multiple Myeloma 

Myeloma 

cells 

Picture courtesy of the International Myeloma


• Cancer of the bone marrow 

• 75,000 – 100,000 patients in the US at any 

one time 

• Over 13,500 new cases diagnosed each 

year in the US 

• Male to female ratio is 3:2 

• Trend towards patients under the age of 

55 

From “Multiple Myeloma: Cancer of the Bone Marrow.” International 

Myeloma Foundation, 2001 edition.


• Disruption of bone 

marrow function 

• Suppression of immune 

function 

• Osteoclasts activated 

• Osteoblasts inhibited 

• Hallmark is osteolytic 

lesions 

Picture courtesy of the International 

Myeloma Foundation

Common Sites for Bone Involvement 

�Skull 

�Spine 

�Pelvis 

�Long bones 

Picture courtesy of the International Myeloma 

Foundation

T-10 

fracture 

due to 

multiple 

myeloma 

Photo courtesy of Steve

T2 weighted 

MRI showing 

myeloma related 

fracture at L3 

and L4

16000121- 

02 

Case Studies

Case Study 

Patient: 55 YO Male 

Diagnosis: Secondary osteoporosis 

Fracture Reduced: L-1, 3 day old

Case Study 

Patient: 80 YO Male 

Diagnosis: Steroid-induced osteoporosis 

Fracture Reduced: T-8, 10 weeks old

Case Study 


Diagnosis: Multiple Myeloma 

Fracture Reduced: T11-L2, 1 ½ yrs old

Case Study 


Diagnosis: Primary Osteoporosis 

Fracture Reduced: L1, 6 months old

• 84 year old women 

Mrs. V.J. 

• C/o mid thoracic spine pain 

• Began 4 months ago 

• After making potato salad

PMHx 

• Previous T7 fracture treated with calcitonin 

• Bowel resection from Crohn’s disease 

• Angina 

• Severe osteoporosis 

• cholecystectomy

• Actonel 

• Atenolol 

•ASA 

•Folic acid 

• Diltiazem 

Meds


• Kyphotic spine—worsening 

• Loss of height 

• Mininal thoracic extension 

• Generalized tenderness mid thoracic spine 

• Neuro exam normal

T7, T8, T9

• Patient is booked for T9 kyphoplasty 

• In holding area patient is reviewed and 

states her pain is alittle worse

• 63 year old female 

Mrs. P.D. 

• Sudden onset of upper thoracic spine pain 

• Started insidiously 6 months ago 

• A history of a variety of aches and pains 

• Pain partially mechanical

•Breast Ca 

• Lumpectomy 

PMHx 

• Then lymph node excision 

• Osteoporosis 

• Osteoarthritis 

• hypertension 

• Ulcerative colitis 

• fibromyalgia


• Mild upper thoracic kyphosis 

• Local boney tenderness 

• Some soft tissue tenderness (mild) 

• Neurological exam normal

T4 & T6

Next step?

Bone Scan 

• Increased activity at T6 and to a lesser 

extent at T4 

• No other abnormalities other that changes 

compatible with OA

CT guided biopsy 

• Unable to perform due to technical and 

patient factors

• Prevention 



Remember 

• Treatment of osteoporosis 

• Treatment of the fracture

• History 

• Physical Exam 

Diagnostic workup 

• X-rays—Old films are helpful 

• CT—r/o cancer 

• MRI—STIR sequence if multiple fractures of 

unknown age

THANK YOU

Balloon Kyphoplasty for Vertebral Compression Fractures

Transform your PDFs into Flipbooks and boost your revenue!

Delete template?

Save as template ?