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Kyphoplasty offers advantages over vertebroplasty: reduces angle of deformity. (Clinical Rounds).

CHICAGO -- Kyphoplasty offers advantages over vertebroplasty as the first-line surgical treatment for patients who have failed medical management for osteoporotic vertebral compression fractures, Dr. Frank Phillips said at a meeting sponsored by the American College of Rheumatology.

While both procedures relieve pain and improve mobility, vertebroplasty has no effect on the fracture deformity. Kyphoplasty can restore some of the height lost as a result of the fracture and can reduce the angle of deformity, which is associated with disability.

Dr. Phillips, professor of orthopedics at Rush-Presbyterian-St. Luke's Medical Center in Chicago, said he no longer performs vertebroplasty because it freezes the deformity and increases the risk of leakage outside the vertebra.

In his metaanalysis of 31 published studies involving about 1,300 patients who underwent vertebroplasty, Dr. Phillips found that 82% of these individuals reported reduced pain; there was also a low incidence of clinically relevant complications. However, 38% had cement leaks, a complication that can involve spillage into the spinal canal, venous system, and pulmonary circulation.

In vertebroplasty, a thin, liquid cement is injected under high pressure to fill the vertebral body. During kyphoplasty, an instrument called a bone tamp is inflated inside the fractured vertebral body to elevate the endplates and create a cavity. A thick, methylmethacrylate cement is then injected under low pressure into the cavity.

In a study of 40 consecutively treated osteoporosis patients, 64 vertebral compression fractures from level T6 to level L5 were treated with kyphoplasty at the University of Chicago Spine Center. The mean duration of symptoms was 3.8 months prior to surgery.

Cement leaks occurred in 9.8% of the study participants. The leaks were confined to soft tissue or disks, and did not enter the spinal canal or vascular areas. There were no neurologic events.

On average, thoracic kyphosis was 38 degrees preoperatively and 29 degrees postoperatively, while lumbar lordosis was 10 degrees preoperatively and 17 degrees postoperatively The mean improvement in kyphosis was 14 degrees in two-thirds of the fractures that were repairable by kyphoplasty.

Virtually all patients reported immediate pain relief. Visual analogue scale pain ratings dropped from 8.6 preoperatively to 2.5 at 1 week after the procedure, an improvement that was sustained at 1-year follow-up.

In a multicenter trial conducted by Dr. Phillips and his colleagues, 2,000 vertebral compression fractures were treated with kyphoplasty between 1999 and 2001. More than 90% of patients had osteoporosis-related vertebral fractures, and the remainder had fractures related to multiple myeloma. All had failed medical management. Most of the fractures were at the thoracolumbar junction.

The procedure was generally well tolerated, and 90% of patients reported pain relief and the ability to return to normal activities of daily living. There were four neurologic events due to a variety of causes; all occurred in the first 50 patients treated with kyphoplasty in the United States.

Kyphoplasty is indicated for patients with acute, painful vertebral compression fractures that have not responded to nonsurgical treatment, and fractures associated with or at risk for significant or progressive deformity. Dr. Phillips added that he would perform the procedure on patients with even a minimal angular compression.

While most kyphoplasty patients have primary or secondary osteoporosis, a growing number of patients with fractures associated with multiple myeloma are undergoing the procedure.

The jury is still out on whether kyphoplasty should be performed prophylactically. However, recent study findings reported at the 2002 meeting of the North American Spine Society indicate that adjacent vertebrae aren't at higher risk for fracture following kyphoplasty.

Dr. Phillips recommended treating no more than three vertebral levels at one time because of concerns about the effect of high doses of cement on the cardiopulmonary system.

A single case of pulmonary embolism believed to be associated with kyphoplasty has been reported. All patients undergoing the procedure should be hospitalized overnight for observation.

For now, the use of kyphoplasty is restricted because only one company Kyphon Inc. of Sunnyvale, Calif., produces the Kyph X Xpander inflatable bone tamp. Kyphon requires all physicians to take a 1-day hands-on course before they may obtain the instruments.

More than 2,700 physicians who specialize in spine surgery in the United States, Europe, and Korea have been trained to use the Kyph X instruments, according to the company.

Dr. Phillips noted that limits on who performs kyphoplasty "will change over time," and he cautioned against kyphoplasty going the route of vertebroplasty in terms of the ease with which a physician can begin performing the procedure. Both kyphoplasty and vertebroplasty are technically demanding procedures, yet "with vertebroplasty the only equipment you need is an x-ray, a needle, and cement."

Radiologists perform most vertebroplasties, whereas kyphoplasty is predominantly performed by neurosurgeons and orthopedic surgeons.

Some patients and insurance carriers may be discouraged by the cost of kyphoplasty, which is three times that of vertebroplasty, on average. Medicare is now reimbursing hospitals for the procedure at $6,000-$ 10,000, depending on the patient's comorbidities, said David Schummers, director of investor relations at Kyphon.

Dr. Phillips is a consultant for Kyphon. His study was not sponsored by the company.
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Title Annotation:osteoporotic vertebral compression fracture treatment
Author:Norton, Patrice G.W.
Publication:Family Practice News
Geographic Code:1USA
Date:Jun 1, 2003
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