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Posterior instrumentation after a failed balloon kyphoplasty in the thoracolumbar junction: a case report
© Cumming et al.; licensee BioMed Central Ltd. 2014
Received: 13 January 2014
Accepted: 24 March 2014
Published: 13 June 2014
Balloon kyphoplasty provides symptomatic relief of vertebral compression fractures in elderly patients. Peri-operative complications are rare; however, they can potentially be devastating. To the best of our knowledge, complications during balloon kyphoplasty have not been described previously in published case reports.
A 66-year-old man who was a farmer of Caucasian origin presented with a 6-month history of back pain after a fall. We discovered a significant T12 wedge compression fracture, so we performed a T12 balloon kyphoplasty. Approximately 2 weeks after being discharged from our hospital, the patient presented with increasing back pain. He presented for a second time with excruciating pain on the left side of his thoracolumbar region, so he was admitted to our ward. X-rays did not show any further fractures or compromise, but magnetic resonance imaging showed extensive edema in the T11 and L1 vertebral bodies as well as fluid tracking from the T11-T12 disc into the vertebral body. Nine days after being discharged, the patient presented to the outpatient clinic with severe back pain. Magnetic resonance imaging at that visit showed edema at the levels above and below the T11/T12 disc. He was put into a brace and given 300mg of morphine, which did not provide any pain resolution. Posterior instrumentation from T9 to L2 (pedicle fixation of T9-T10 as well as L1-L2, rods in between and a crosslink above T11-T12) was performed as the final treatment, and the patient was discharged uneventfully.
Patients presenting with residual pain over a previous balloon kyphoplasty level should raise high suspicion for a fracture or complication involving the levels above and/or below the balloon kyphoplasty. The best way to treat fractures that develop after a failed balloon kyphoplasty is to instrument and fuse posteriorly. Our present case report shows that a high level of suspicion for possible new fractures should be maintained for all similar cases.
Balloon kyphoplasty (BKP) has been shown to provide symptomatic relief of vertebral compression fractures in elderly patients refractory to conservative medical therapy[1–3]. Brace treatment and open surgical intervention are less desirable treatments in this population because of the associated medical comorbidities. As such, BKP has been advocated as a minimally invasive treatment option for symptomatic compression fractures. BKP involves the inflation of a balloon to create a cavity and restore vertebral height. This procedure is followed by injection of cement into the fractured vertebra. Peri-operative complications related to the treatment of vertebral compression fractures are rare; however, when they occur, they can potentially be devastating[4–7]. The use of cement extravasation has been reported. Other procedural complications of vertebral augmentation that have been described include fractured transverse processes or ribs, dural tears, discitis and subcutaneous hematomas. In general, complications during BKP have been published in case reports[8, 9].
Twenty days after the procedure the patient was re-reviewed and found to be pain-free while his pain medication had been reduced. The results of the biopsy showed a possible diagnosis of osteoporosis, but nothing else of note. The patient was reviewed 3 months after surgery, at which time his condition had improved significantly.
Complications of BKP are usually poorly reported. In general, vertebral compression fractures occur in elderly patients with multiple medical comorbidities. The reporting of medical complications may be subject to bias because BKP is often an outpatient procedure and thus complications may not be reported during the hospitalization. We wish to emphasize the poor overall condition of patients who typically experience compression fractures, whether osteoporotic or pathologic. The incidence of procedure-related complications appears to be higher for vertebroplasty (VP) than for BKP in all studies and prospective studies. This trend may be explained in part by historical context. VP was developed before BKP. The two procedures share the same approach, but complications encountered in earlier VP procedures may not be encountered in BKP because of the increased technical experience gained over time. VP is associated with a higher rate of cement leakage, both symptomatic and asymptomatic, in patients with osteoporotic and/or pathologic conditions. Furthermore, VP in pathologic fractures is associated with a higher cement leak rate than VP in osteoporotic fractures. It appears that VP may be associated with an increased new fracture rate compared to BKP. This result should be interpreted cautiously because the occurrence of new fractures at previously unaffected spine levels may be multi-factorial. Variability in fracture reporting can confound these results because only symptomatic fractures are likely to be reported.
Patients presenting with residual spinal pain over a previous BKP site should raise high suspicion for a fracture or complication involving the levels above and/or below the VP site. The best way to treat fractures that develop after a failed VP is to perform instrumentation and fusion posteriorly.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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