Compression fractures in the spine — signs of osteoporosis — are often painful, but people may not always realize when they have occurred. Compression fractures often cause the loss of height and rounding of the upper back that are typical of old age.
In fact, fractures in vertebrae are the most common clinical manifestation of osteoporosis, occurring in about 550,000 people in the United States annually. More than 150,000 people are hospitalized each year due to vertebral fractures. Risk factors include advanced age, lower bone mineral density, falls, smoking, and inadequate calcium intake.
“An extremely important point for patients and clinicians is that a vertebral fracture is a very strong predictor of subsequent fractures, both vertebral and nonvertebral,” according to a 2013 paper published in the journal JAMA Internal Medicine.
While medications are often prescribed to treat the pain of vertebral fractures, another option is a surgical procedure called kyphoplasty or vertebral augmentation. In the hour-long procedure, a surgeon injects medical cement into the fractured vertebrae to restore it to a solid state. In many cases, patients who had been confined to bed, a wheelchair, or a walker due to debilitating pain can walk out of the hospital shortly after the procedure.
We spoke with Joshua Tepper, M.D. (pictured above), a diagnostic radiologist with Presence St. Joseph Medical Center in Joliet, Illinois, about kyphoplasty. He specializes in vascular and interventional radiology and performs multiple vertebral augmentations each week.
Most of his patients have osteoporosis and are over age 65. “They have bone weakening, which makes them more susceptible to having a compression fracture, and what that means is that the bones are not strong enough to tolerate a normal spread that other people may be able to tolerate,” he says. “I had a patient who fractured her back when she tried to push a refrigerator, or even coughing can cause a fracture. The bone is not strong enough to deal with the stress that’s put on it and that results in a collapse of the bone.”
The pain is often debilitating, he says, noting that it can reach 8, 9, or 10 out of 10 on the pain scale. “For older patients, that can result in significant morbidity, because they’re not taking deep breaths, making them prone to pneumonia,” Tepper adds. “They’re not moving around doing their normal activities, making them susceptible to a blood clot. These are life-threatening issues for an older person. For someone who is living on their own and taking care of themselves, it can be a pretty severe event. Some patients in their mid-60s can say, ‘Well, I can deal with this pain,’ but as you get older and are more acutely affected by pain, the morbidity also rises significantly.”
People who are candidates for kyphoplasty either have X-rays or an MRI that shows one or more compression fractures. A bone scan may also be performed.
“The majority of the patient’s pain is when they’re standing and walking,” Tepper says. “The micromotion on the bone is rubbing, and the bone is not allowed to heal because it’s always in constant motion. If either test plus a physical exam correlates with the site of their pain, we will offer the kyphoplasty.”
In the surgical room, the patient lies face down and is sedated through a vein. “There’s no incision, just tiny nicks that allow us to access the bone, and we put in a balloon that restores some of the height that has been lost,” Tepper says. “We take the balloon out and fill it with cement. It goes in like toothpaste, and then it hardens within about 10 minutes. So that acts as an internal cast on that bone.”
About 80 percent of the people who rated their pain at eight or higher often report it’s down to three after the procedure. The pain relief usually goes into effect about 24-48 hours after the procedure. “Another 10 percent of the time, patients will feel perfect right after the procedure,” Tepper says. “It’s not common, but it does happen.”
Tepper notes that about 10 percent of patients don’t experience much pain relief after a kyphoplasty. Although the procedure addresses the compression fracture, in those patients, it may unmask other pain, such as a nerve that’s being squashed or a significant spinal muscle injury.
The risks are minimal, he adds. “We give pre-op antibiotics to reduce the risk of infection. The risk of having cement come out of the vertebral body is real, but as long as you go to a center that does a lot of procedures, the chances are small.”
Kyphoplasty is also available for younger patients, including people who suffer major traumas, such as car crashes. Tepper notes that doctors are cautious about the procedure in middle-age patients who have long lives ahead of them. “Even though kyphoplasty has been around for about 20 years, leaving something behind in a patient for 40 or 50 years isn’t something we take lightly,” he says.
Kyphoplasty is covered by insurance, given proper documentation of the person’s medical history. Tepper has been performing the surgery for 15 years and says very few patients have been denied the procedure by insurers.
Doctors who perform the surgery are usually interventional radiologists, orthopedic spine surgeons, and pain doctors.
“You want to make sure you go to a center that has a high turnover of patients and has experience with managing them,” he advises. “That means you get the full benefit of the procedure.”