The two most common treatment methods for osteoporotic burst fractures are conservative treatment and posterior instrumentation and fusion. Conservative treatment can be performed in senile patients with medical comorbidities; however, conservative treatment may lead to cardiovascular complications, as well as decreased correction rate for kyphotic deformities. Posterior instrumentation and fusion provides solid stability; however, posterior instrumentation and fusion is not a viable surgical option for patients who lack sufficient bone mass from osteoporotic burst fractures. Age and comorbid medical conditions may further contribute to the impracticality of posterior instrumentation and fusion as a treatment for osteoporotic burst fractures.
KP, as well as vertebroplasty, offers significant pain relief and fracture stabilization. The application of percutaneous vertebroplasty as a minimally invasive procedure is popular and pervasive. Nevertheless, the danger of cement leakage into the posterior spinal canal has precluded percutaneous vertebroplasty as a treatment for burst fractures. In 2004, however, Chen and Lee1
, reported a clinically satisfactory result by performing percutaneous vertebroplasty in six stable burst fractures without osteoporosis. Although cement leakage into the adjacent intervertebral disc space occurred in four instances (66.7%), it did not cause the neurological symptoms associated with cement leakage into the posterior spinal canal. Despite its evident benefits with regard to pain relief and vertebral stabilization, vertebroplasty is not as effective in correcting kyphotic deformities. Balloon KP was developed in order to compensate for vertebroplasty's disadvantages in correcting kyphotic deformities. Balloon KP minimizes the possibility of cement leakage. Hence, we performed balloon KP for the treatment of osteoporotic burst fractures.
Balloon KP was developed by applying Dr. Mark Reiley's balloon tamp in percutaneous vertebroplasty2,3
. The balloon tamp was developed by Reiley in 1997, with the goal of restoring vertebral body height and reducing kyphosis. KP involves the inflation of a balloon tamp before injection of bone cement in the compressed vertebral body, in an effort to reduce kyphotic deformity. Shindle et al.4
, reported that balloon KP enhances the height reduction >4.5-fold over the positioning maneuver alone and accounts for over 80% of the ultimate reduction. Because KP enables the injection of bone cement at low pressure, the procedure minimizes the possibility of cement leakage5-7
Reportedly, the complication rate following balloon KP is similar to that seen in vertebroplasty. Complications deriving from vertebroplasty as a treatment for osteoporotic burst fracture occur in less than 1% of patients when the procedure is performed by an experienced surgeon. The complication rate stemming from vertebral pathologic compression fractures is 5~10%. Although complications occur slightly more frequently in KP than in vertebroplasty, we believe that such results derive from KP's relative dearth of recognition. However, according to Orlando, the complication rate with respect to symptomatic cement extravasation may be lower in KP than in vertebroplasty2
. We observed only one instance of cement leakage in this study. We attribute our success to 4 weeks of conservative treatment prior to the procedure and our decision to perform KP in stable burst fractures. Hulme et al.8
, reported the following distribution of cement extravasation in vertebroplasty: epidural, 32%; paraspinal, 32.5%; intradiscal, 30.5%; pulmonary, 1.7%; and foraminal, 3.3%. He further reported the following distribution of cement extravasation in KP: epidural, 11%; paraspinal, 48%; intradiscal, 38%; pulmonary, 1.5%; and foraminal, 1.5%. In most cases (vertebroplasty, 96%; KP, 89%), symptoms do not accompany cement extravasation. Intradiscal cement leakage, which occurs relatively frequently, may cause mechanical overload to the disc and/or to the adjacent vertebrae. Lin et al.9
, reported that 58% of vertebral bodies adjacent to a disc with cement leakage fractured during the follow-up period, compared with 12% of vertebral bodies adjacent to a disc without cement leakage after vertebroplasty. We only observed complications accompanying cement leakage in a single case.
Frail older patients have poor tolerance for the bed rest required in non-operative management and the physiologic stress engendered by an open stabilization procedure10
. Indications for open surgery are rare and include major neurologic injury and mechanical instability. Anterior decompression is an effective method; however, the morbidity rate and the risk of spinal deterioration in instrumentation and fusion are very high in senile patients. Posterior decompression and stabilization are perhaps better tolerated by older patients. The pedicles remain stronger than the vertebral bodies, but implant loosening remains a problem10
We did not observe any major complications when we performed KP as a treatment for stable burst fractures. The clinical and radiological results of KP were superior to those of conservative treatment. Lyritis et al.11
showed that pain decreased by 33% at day 14 in vertebral compression fracture patients treated with the conservative method, and Gennari et al.12
, noted that pain decreased by 40% at day 30. However, Silverman13
noted the long-term sequelae associated with vertebral compression fractures: chronic back pain, muscle fatigue, reduced exercise tolerance, early satiety, insomnia, fibromyalgia, and low self-esteem. Therefore, vertebral fractures must be treated aggressively. The results of conservative treatment seen in this study were inferior to those seen in previous studies. However, the previous studies addressed compression fractures, while we assessed burst fractures. We attained very satisfactory results with KP, in comparison to those attained with posterior instrumentation and fusion. The limitation of our study lies in the insufficient number of cases and short follow-up duration. Future studies are recommended.