LUMBAR KYPHOPLASTYLUMBAR KYPHOPLASTY
Lumbar Spine Kyphoplasty Balloon Vertebroplasty pain management animations
Kyphoplasty is a procedure that is used to manage unremitting pain from an osteoporotic wedge fracture of a vertebral body. It involves the inflation of the collapsed vertebral body with a balloon, then the stabilization of the fracture with synthetic material. Kyphoplasty does not restore the lost height of the compressed vertebra. The procedure is mildly painful, and most people experience immediate pain reduction afterwards.
Kyphoplasty is used when severe pain and immobility are caused by a collapsed vertebral body. A Kyphoplasty can only be performed on fractures due to osteoporosis or trauma, and sometimes cancer. It is not recommended for fractures caused by infection, vascular lesions or where there is compression of the spinal nerves or spinal cord. The best result is achieved when the Kyphoplasty is performed within eight weeks of the fracture occurring.
The alternative treatments for vertebral fractures are
- bed rest
- pain relief
- high dose vitamin D, calcium and parathyroid hormone therapy
- hospitalization for pain management
- back braces
- or spinal fusion surgery with rods and screws.
It is your right to delay or refuse the recommended treatment for your condition. However, this delay or refusal may lead to the worsening of your symptoms, such as increased back pain. You should ask your doctor what might happen should you choose not to undertake the recommended treatment. Lumbar Spine Kyphoplasty Balloon Vertebroplasty pain management animations.
Before the kyphoplasty
- cease blood thinners as instructed ie coumadin/warfarin, plavix, heparin, aspirin
- let your doctor know all the medications you are taking including herbal medications that can increase bleeding risk ie vitamin E, glucosamine, chamomile, danshen, garlic, gingko, devil’s claw, ginseng, fish oil, willow bark, feverfew, and goji berries
- don't eat or drink for a few hours before the procedure.
- wear loose-fitting clothes that are easy to take off and put on. Do not wear any jewelry.
- before the procedure, the skin on your back will be cleaned and you will be given a general health check.
- an intra-venous line may be placed in to a vein in your arm to administer fluid and medications
- let your doctor know if you develop a fever, cold or flu symptoms before your scheduled procedure.
The goals of a kyphoplasty are to expand and stabilize a collapsed fractured vertebral body at the original vertebral height, and to eliminate the fracture pain. Lumbar Spine Kyphoplasty Balloon Vertebroplasty pain management animations.
You may be lying on your front for up to two hours during the preparation phase. An intravenous line is used for partial sedation and pain control. The skin on your back will be cleaned. A small needle will be used to inject some local anesthetic under the skin over the fracture site. This will sting for a few seconds before causing numbness. The kyphoplasty needle is inserted from behind and slightly to one side into the fractured vertebra, using X-rays to assist correct placement. Contrast material may be injected to check the positioning of the needle. A balloon is inserted into the vertebral body, and inflated to attempt to regain some of the lost vertebral height. The balloon is removed and a small amount of synthetic material is then injected into the cavity to immobilize the bone fragments. Then the needle is removed. Occasionally material will need to be injected from the opposite side as well. The synthetic material is injected as a liquid, and hardens over 10-20 minutes. You may feel some warmth as the material hardens. The entire procedure takes about 60 minutes per vertebra treated. A band-aid is usually all that is needed on the skin.
Smoking damages every part of your body and decreases the chance of a successful procedure. If you smoke, you should stop now.
Seventy-five to ninety percent of patients receive substantial pain relief and increased mobility from a Kyphoplasty, within 48 hours. Most of them will return to their previous activity levels.
Normalizing the height of the fractured vertebra reduces the locally exaggerated curve of the spine. This results in an aesthetic improvement, improved posture, and a reduced risk of fracture of the adjacent vertebra as a result of abnormal load bearing.
Kyphoplasty does not correct the spinal curvature caused by an established spinal deformity nor does it prevent compression fractures in other vertebra.
There may be a dull ache at the skin puncture site for the first day. Follow-up care is usually done by your family doctor. Lumbar Spine Kyphoplasty Balloon Vertebroplasty pain management animations.
Your rehabilitation will require the following
- you will spend 30 to 60 minutes under observation.
- you will then be taken back to your ward on your bed. You may be offered some physical therapy or short-term back bracing.
- you will usually be able to walk around and go home the same day. If it is a long trip home, you should stay for the first night in the hospital or a hotel.
– check your wound twice a day. If you notice any redness, swelling, green or yellow discharge, or opening of the wound, see your family doctor immediately and call your surgeon
– you may have small bandages called steri-strips on your incision. Keep these dry. These can be removed when they begin to peel off by themselves or after one week.
- you can usually return to your normal daily activities, although strenuous exertion, such as heavy lifting, should be avoided for at least six weeks.
- if you have osteoporosis, you should see your physician to begin or review your treatment plan, including medications to prevent further bone loss.
You have a weak spot in your back, and surgery can never return it to full strength. You will need to engage in lifelong back care to reduce the risk of further neck problems. You should always maintain correct posture, lose any excess body fat, continue your daily exercise program and avoid unnecessary stresses on your back.
Lumbar Spine Kyphoplasty Balloon Vertebroplasty pain management animations.
POTENTIAL COMPLICATIONS OF A LUMBAR KYPHOPLASTY
ACCIDENTAL SPINAL CANAL INJECTION
Accidental injection of medication into the spinal canal can cause an unexpected decrease in nerve function. The effect varies, depending on the type and amount of medication, and its location in the spinal canal. The effect will eventually wear off. If the effect is in the upper neck, it can interfere with breathing and may require breathing assistance.
Adhesive arachnoiditis is a rare complication of lumbar surgery. It starts as an inflammation of the arachnoid membrane surrounding the spinal cord and nerve roots. It can be triggered by surgery, trauma such as a dural tear (membrane around spinal cord), chemical irritants such as radiographic contrast dye (mainly older ones), infection or hemorrhage. The inflammation can lead to scar tissue and adhesions that stick the nerve roots together. This tension on the nerve roots interferes with local blood flow and nerve function, leading to back or leg pain, numbness, cramps and stiffness. Arachnoiditis often develops gradually, over one to six or more months. There is no cure. The treatment is physical therapy and pain management medications and techniques.
ALLERGIC REACTION TO MEDICATION
An allergic reaction to the medications used can occur. This can cause a rash, swelling of the eyelids, hands, joints and throat, difficulty breathing, low blood pressure and death. These reactions are easily controlled with the right equipment and medications.
Arteries are large blood vessels that can carry blood under pressure throughout the body. Your doctor will be very careful to avoid injuring arteries near your operation site. An artery perforation can result in significant bleeding and blood loss. This is very uncommon. If an artery is perforated, the artery can usually be repaired and the lost blood can be replaced by a blood transfusion. A specialist vascular surgeon is often asked to repair arteries. Late consequences of artery injury include fistula, hemorrhage, pseudo-aneurysm, thrombosis and emboli.
Back pain after the procedure is to be expected. This may be similar or different to the original back pain. It is usually temporary. Sometimes the original back pain can persist, or it can be worse.
There is the potential for problems to occur as a result of the cement used to immobilize a fractured vertebral body during a vertebropasty or a kyphoplasty. These include
– heat generated as cement hardens can injure adjacent tissues
– extruded cement compresses adjacent spinal cord, nerves, discs
– extruded cement particles block adjacent blood vessels, or travel to the lung, forming pulmonary emboli
– extruded fat particles become pulmonary emboli
stiff cement transmits more load to the adjacent vertebrae, increasing the vertebrae's risk of fracture. Lumbar Spine Kyphoplasty Balloon Vertebroplasty pain management animations.
A tear in the dura, which contains the spinal cord and the cerebrospinal fluid, can allow cerebrospinal fluid to leak out through the wound, and onto the skin. This is called a cerebrospinal fistula. It may cause headache when standing, back or limb pain, nausea, vomiting, dizziness, ringing in the ears or eye pain from bright light. There is a risk of infection and meningitis. The dural tear may reseal spontaneously, or it may require bed rest, a blood patch procedure, drainage, or surgery to repair.
No physician can guarantee a risk-free procedure. All operations and procedure have some risks. Some risks are minor inconveniences, while some are major disabilities. The risks increase with repeat operations on the same area of your body. Your entire medical staff will do their best to eliminate all risks to you, before, during and after your surgery. However sometimes, even after the surgery goes well, serious problems can arise that can result in death. These include pneumonia, pulmonary emboli, heart attack and stroke. You should discuss these risks with your Physician and your Anesthesiologist.
Discitis is an infection of the intervertebral disc. It can occur spontaneously, without any surgical procedure. Post-operative discitis can occur up to six weeks after a kyphoplasty, and most commonly causes worsening pain after an initial period of relief. Risk factors include age, smoking, obesity, diabetes, malignancy, chemotherapy, immune suppression, malnutrition, indwelling venous catheters, concurrent infections and extended hospitalization. Discitis is treated with antibiotics. Often a prolonged (months) course of antibiotics is required. Discitis with infection of the adjacent bone, or osteomyelitis, can be very difficult to cure, even with antibiotics. Discitis can lead to an epidural abscess that can cause spinal cord compression or cauda equina syndrome, and may require an operation to cure.
The dura is a thin layer of tissue that forms a sac containing the brain, spinal cord and nerve roots. The sac is filled with cerebrospinal fluid or CSF. The dura can be torn during spinal surgery leading to a leak of the fluid from the sac. This complication is more difficult to avoid during repeat surgery at the same location, or when operating on severe spinal narrowing or a large disc herniation. A dural tear with the leakage of cerebrospinal fluid, can cause a headache when standing, back or limb pain, nausea, vomiting, dizziness, ringing in the ears or eye pain from bright light. A continuing leak can lead to a cerebrospinal fluid cyst under the skin, or a leakage of fluid from the wound. Dural tears can reseal spontaneously, or it may require bed rest, a blood patch procedure, drainage, or an additional operation to repair.
An embolus is any particle that travels in the blood stream. It may be air, insoluble medication, solid material or body tissue. If it becomes stuck in a small blood vessel and blocks the flow of blood past that point, an embolism has occurred. This leads to inadequate blood flow to the tissues supplied by that blood vessel, an event known as ischemia. Tissue death can then occur, known as infarction. If the blockage is quickly removed, the ischemic tissues can make a full recovery. If the blockage persists, the infarcted tissues are permanently damaged. Emboli released by medical procedures can cause infarction in any tissue, but they can be particularly disabling in the brain, heart and lungs. Your surgical team will take steps to minimize the risk of embolism.
Epidural abscess is a collection of pus that has formed in the epidural space of the spinal canal due to a bacterial infection. It can occur spontaneously, or occur one to two days after a spine procedure. As well as the usual signs of infection, the abscess can place pressure on the spinal cord and block its blood supply. Antibiotics may resolve the infection. If not, aspiration with a needle or a surgical drainage procedure may be required.
Spine surgery can lead to the formation of excessive amounts of scar tissue in the epidural space that can compress or tether adjacent tissues. This can cause pain and nerve irritation symptoms. Prevention involves post-operative physical therapy. Treatment may require physical therapy, pain medications, pain management techniques or further surgery. Lumbar Spine Kyphoplasty Balloon Vertebroplasty pain management animations.
If bleeding occurs into the epidural space around the spinal cord, it may form a collection of blood, called an epidural hematoma. If the hematoma is large, it can compress the spinal cord and nerve roots leading to pain, weakness, numbness and bowel and bladder problems. A surgical procedure may be required to stop the bleeding and remove the hematoma.
Fluoroscopy uses X-rays to obtain instant pictures of the inside of a patient during a surgical procedure. This is very useful when needle tips or devices need to be accurately positioned. X-rays are a form of ionising radiation. They can potentially cause cancer, reproductive abnormalities, cataracts and radiation dermatitis. Any effect depends on the amount and duration of exposure to the X-rays. During surgical procedures, the exposure is usually not significant. Your doctors will minimize the radiation dose to yourself and themselves by minimising the intensity and duration of exposure and by using lead shields. Pregnant women can wear extra shielding. By way of comparison, a pelvic (AP) x-ray gives a radiation dose of 0.7 mSv, and a pelvic CT gives 10.0 mSv. The world average background radiation level is 2.4 mSv per year.
FRACTURE - ADJACENT
The injection of cement into a fragile fractured vertebra during a kyphoplasty decreases the elasticity of that vertebra. This stiffer vertebra is less able to absorb force, and will therefore transmit more force to the adjacent vertebrae. If these vertebrae are also fragile, as in osteoporosis, they are at risk of fracturing.
During any surgery, some blood vessels will be cut. Your surgeon will stop all significant bleeding before suturing the wound shut. Sometimes bleeding recommences after the operation, forming a collection of blood in the tissues, called a hematoma. The hematoma can cause pain, pressure on adjacent tissues or become infected. It may need to be removed by inserting a drainage tube or performing a surgical operation.
During surgery, blood vessels must be cut to access the desired location in your spine. Your surgeon will plan the surgical route to avoid large blood vessels, and will ensure bleeding has stopped before finishing the operation. Sometimes, one of these cut blood vessels begins re-bleeding after the operation. If the amount or location of the bleeding is causing you a problem, your surgeon may need to perform a further procedure to stop the bleeding and remove the accumulated blood.
Infections occur in less than one percent of spinal operations. If the wound becomes more painful or tender, red, hot or swollen, oozes a clear or yellow fluid and doesn’t heal, or if you have fever or chills, the wound may be infected. Your Surgical Team will use sterile instruments, aseptic techniques, antibiotics and regular wound care to minimize this risk. Infections can be :
superficial, involving the skin. These infections usually respond to oral antibiotics and washing the site. Sometimes the wound needs cleaning and re-suturing in the operating theatre.
deep, involving the vertebrae or spinal cord. This is more serious and may require intravenous antibiotics, and further operations to drain the infection. Rarely, infected bone graft or hardware may need to be removed.
Wound infections are more likely if you smoke, have diabetes, are overweight, or if the wound took a while to heal or there was a hematoma.
If you have any concerns, you should contact your doctor immediately.
INJECTION SITE PAIN
Pain at the injection site usually settles quickly.
LOCAL ANESTHETIC TOXICITY
If the medication is accidentally injected into one of the blood vessels around the spine, it can enter the general circulation. Depending on your sensitivity, low levels of local anesthetic in the blood can cause dizziness, ringing in the ears, headache, anxiety, nausea and increased heart rate, blood pressure and breathing rate. More severe reactions include muscle twitching, seizures, loss of consciousness, and low heart rate, breathing rate and blood pressure. This is a very rare complication.
Rarely the synthetic material used during a kyphoplasty leaks out of the vertebral body and compresses surrounding tissues or enters a vein and embolises to the lungs. If the compression causes symptoms, further surgery may be required to remove the excess material.
Osteomyelitis is a bacterial infection of bone or the bone marrow. It can occur as a result of surgery, especially after the placement of foreign material in the bone, or as a result of an adjacent infection. It can take up to four weeks after the surgery to cause symptoms, and most commonly causes worsening pain after an initial period of relief. Risk factors include age, smoking, obesity, diabetes, malignancy, chemotherapy, immune suppression, malnutrition, indwelling venous catheters, concurrent infections and extended hospitalization. It is difficult to treat, often requiring weeks or months of intravenous antibiotics. A surgical procedure to clean the area may also be required. Lumbar Spine Kyphoplasty Balloon Vertebroplasty pain management animations.
There are a number of important structures next to your operation site. These include the spinal cord and nerves and their cover – the dura, and arteries and veins. Depending upon the site of your surgery, they also include the intestine in the abdomen, the lungs in the chest, and the esophagus and trachea in the neck. Your doctor will take every care to protect these structures, but they can be accidentally perforated during the procedure. If they are injured, they will be repaired as best as possible.
Less than 5% of people experience a worsening of their back pain after a kyphoplasty. Severely osteoporotic people may suffer a rib or pedicle fracture from the procedure.
Sometimes a persistent leak of cerebrospinal fluid from the spinal canal can occur after the operation, through a tear in the dura. This fluid can collect under the skin and form a pseudomeningocele. Most pseudomeningoceles do not cause any symptoms. Some cause headache when standing, back or limb pain, nausea, vomiting, dizziness, ringing in the ears or eye pain from bright light. They may also compress adjacent structures causing further symptoms. The pseudomeningocele may take days to years to appear, then may resolve spontaneously, or require bed rest, a blood patch procedure, drainage, or a surgical repair.
Sometimes, during or after the procedure, patients can experience a temporary nervous fluctuation called a vaso-vagal reaction. This produces lightheadedness, a ringing in your ears, sweating, increased heart rate, lower blood pressure and fainting. This is easily treated and usually improves rapidly.
Lumbar Spine Kyphoplasty Balloon Vertebroplasty pain management animations
This article was written with the assistance of the following surgeons.
Dr Paul Licina. Dr Licina is spinal orthopedic surgeon, and co-founder of Brisbane Orthopaedic Specialist Services in Brisbane, Queensland, Australia. www.brisbaneorthopaedics.com.au/paul_licina.html
Dr Matthew McDonald. Dr McDonald is a spinal neurosurgeon based at Wakefield Hospital, Adelaide, South Australia, Australia. www.wakefieldneurosurgery.com.au
Dr Richard Parkinson. Dr Parkinson is a spinal neurosurgeon based at St Vincent's Clinic, Sydney, New South Wales, Australia. www.svph.com.au/index.php?option=com_content&task=view&id=145&Itemid=178
Dr Lali Sekhon. Dr Sekhon is a spinal neurosurgeon, and founder of Nevada Neurosurgery in Reno / Carson City, Nevada, USA. www.nevadaneurosurgery.com