Orthopaedics & Traumatology: Surgery & Research (2012) 98S, S112S119

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ORIGINAL ARTICLE

Kyphoplasty versus vertebroplasty in osteoporotic

thoracolumbar spine fractures. Short-term
retrospective review of a multicentre cohort of 127
consecutive patients
L. Garnier a,, J. Tonetti a, A. Bodin a, H. Vouaillat a, P. Merloz a, R. Assaker b,
C. Court c , the French Society for Spine Surgery1

a
Academic Orthopaedics and Trauma Surgery Unit, Michallon Hospital, 38043 Grenoble Cedex 09, France
b
Neurosurgical Academic Unit, Salengro Hospital, boulevard Professeur-Emile-Leyne, 59037 Lille, France
c
Orthopaedic and Traumatology Academic Department, Bictre Hospital, rue du General-Leclerc, 94275 Le Kremlin Bictre,
France

Accepted: 28 March 2012

KEYWORDS Summary
Spine fractures; Background: Osteoporotic spine fractures induce a heavy burden in terms of both general health
Osteoporosis; and healthcare costs. The objective of this multicentre study by the French Society for Spine
Vertebroplasty; Surgery (SFCR) was to compare outcomes after vertebroplasty and kyphoplasty in the treatment
Kyphoplasty of osteoporotic thoracolumbar vertebral fractures.
Hypothesis: We hypothesised that differences existed between vertebroplasty and kyphoplasty,
notably regarding operative time and reduction efcacy, from which criteria for patient selec-
tion might be inferred.
Material and methods: We conducted a retrospective multicentre review of 127 patients with
Magerl Type A low-energy fractures after a fall from standing height between 2007 and 2010; 85
were managed with vertebroplasty and 42 with kyphoplasty. Age was not a selection criterion.
We recorded pain intensity, time to management, operative time, kyphosis angle, wedge angle,
cement leakage rate, and degree of cement lling.
Results: Operative time was 43 minutes with kyphoplasty and 24 minutes with vertebroplasty
(P = 0.0002). Both techniques relieved pain, with no signicant difference. Kyphoplasty signi-
cantly improved the wedge angle, by +6 , versus +2 with vertebroplasty (P = 0.002). With
kyphoplasty, the volume injected was larger and cement distribution was less favourable.
Leakage rates were similar.

Corresponding author.
E-mail address: LGarnier1@chu-grenoble.fr (L. Garnier).
1 94, rue Bobillot, 75013 Paris.

1877-0568/$ see front matter 2012 Published by Elsevier Masson SAS.

doi:10.1016/j.otsr.2012.03.018
Kyphoplasty vs. Vertebroplasty in Osteoporotic Spinal Fractures S113

Discussion: Despite the heterogeneity of our study, our data conrm the effectiveness of kypho-
plasty in alleviating pain and decreasing deformities due to osteoporotic vertebral fractures.
Vertebroplasty is a faster and less costly procedure that remains useful; no detectable clinical
complications occur with vertebroplasty, which ensures better anchoring of the cement in the
cancellous bone.
Level of evidence: Level 4, retrospective cohort study.
2012 Published by Elsevier Masson SAS.

Introduction
45
40
Over 100 million individuals are at risk for new osteoporotic
35
spinal fractures worldwide [1,2]. Osteoporotic vertebral
30
fractures may occur in 20% of individuals older than 70 years
25
of age and 16% of postmenopausal women [3]. The main
20
manifestations are pain and a kyphotic deformity of the
15
spine. Kyphosis negatively impacts lung vital capacity, bowel
transit, quality of life, self-sufciency, and mood, ultimately 10

resulting in a signicant decrease in life expectancy [410]. 5

Recent data indicate that spinal deformities due to osteo- 0

porotic vertebral fractures are associated with increases
in 5-year mortality of 23% to 34%, similar to femoral neck
fractures [1114]. The inconsistent effectiveness of non-
operative management has led to the development of
several surgical methods for treating osteoporotic vertebral
fractures [15].
Vertebroplasty, which consists in injecting cement into
the fractured vertebra, is used to relieve persistent pain
at least 6 weeks after the fracture [1618]. Balloon tamps
for kyphoplasty were developed to improve the safety of
cement injection by decreasing the risk of leakage while
allowing correction of the kyphotic deformity [19].
We used the multicentre data from the French Society
for Spine Surgery (Socit Francaise de Chirurgie de Rachis,
SFCR) presented at the 2011 meeting on vertebral augmen-
tation to compare the short-term clinical and radiological
outcomes after vertebroplasty and kyphoplasty used to treat
osteoporotic fractures of the thoracic and lumbar spine.
Materials and methods
Study population
We included 127 patients who received treatment at 138 ver-
tebral levels between December 2007 and December 2010.
Patients were eligible if they had Magerl A1, A2, or A3 frac-
tures without fragments in the spinal canal [20] and without
neurological abnormalities. The diagnosis of osteoporotic
fracture relied on the low-energy nature of the trauma,
which could be either a fall from standing height or a fall
from a chair. Age was not a selection criterion. Exclusion cri-
teria were as follows: Magerl B and C fractures with disk and
ligament instability, fractures requiring internal xation,
fractures related to tumours, neurological abnormalities,
skin infection along the trocar track, and vertebra plana.
The patients were separated into two groups based
on whether they underwent vertebroplasty or kyphoplasty
(Table 1). The vertebroplasty group had 85 patients with
95 treated levels and the kyphoplasty group 42 patients
A1 A2 A3
group V group K
Magerl A1 V versus K: Chi 2, p=0.13
Magerl A2 V versus K: Chi 2, p=0.09
Magerl A3 V versus K: Chi 2, p=0.04
V, vertebroplasty group ; K, kyphoplasty group
Figure 1 Fracture distribution according to the Magerl clas-
sication scheme.
with 43 treated levels (Figs. 1 and 2). The vertebroplas-
ties were performed by four surgeons in a single centre
(Grenoble) and the kyphoplasties by 11 surgeons in ve cen-
tres (Strasbourg, Lille, Poitiers, Grenoble, and Marseille).
Mean patient age was signicantly higher in the verte-
broplasty group (71 years) than in the kyphoplasty group
(59 years) (P = 0.00001). The proportion of women was higher
in the vertebroplasty group (P = 0.0131) and the propor-
tion of Magerl A3 fractures was higher in the kyphoplasty
group (P = 0.04). The groups were comparable in terms
of topographic fracture distribution and time to opera-
tive management. Mean time to operative management
was 15 days (range, 0120) in the vertebroplasty group and
10 days (range, 042 days) in the kyphoplasty group.
Surgical techniques
Vertebroplasty was done under general anaesthesia with the
patient in the prone position supported by rolled sheets
under the thorax and hips to cause lordosis, thereby facili-
tating reduction of the fracture responsible for the kyphotic
deformity. The trocars were inserted through the pedicles
at the lumbar spine and between the ribs and transverse
processes at the thoracic spine. TVTTM trocars (Thiebaud,
Thonon, France) with an outer diameter of 4 mm were
used. After trocar placement into the anterior vertebral
body, cement (Biomet VTM , Biomet, Valence, France) at the
viscous phase was injected under lateral then anteroposte-
S114
Table 1 Main features in the vertebroplasty and kyphoplasty groups.
Vertebroplasty
Number of patients 85
Number of treated levels 95
Mean age, years (range) 71 (4392)
Women (%) 74
Magerl A1 fracture 44
Magerl A2 fracture 17
Magerl A3 fracture 34
Figure 2 Distribution of the fractured levels.
rior uoroscopic guidance. The injection was stopped when
lling was considered sufcient or cement leaked outside
the vertebral body.
Kyphoplasty was also performed under general anaesthe-
sia. The patient was in the prone position. No particular
position for the supports was specied. The trocars were
inserted through the pedicles at the lumbar spine and
between the ribs and transverse processes at the thoracic
spine. KyphonTM device (Medtronic, Boulogne-Billancourt,
France) and introducer system were used. Under uoro-
scopic guidance, two balloons placed within the vertebral
body were lled with saline containing injectable contrast
material. Balloon lling and fracture reduction were mon-
itored by lateral uoroscopy. The cavity left after balloon
removal was lled with cement to stabilise the reduction.
The cement used was either KYPH X HV-RTM (Medtronic) or
a similar high-viscosity radio-opaque cement.
With both techniques, cement injection was preceded
by a manual check of viscosity, 4 minutes on average after
mixing started. The volume injected was recorded. After
the procedure, early sitting was allowed as possible without
pain, and ambulation was started on day 1. Braces were
not used.
Follow-up
Baseline data recorded for the study were pain intensity on a
010 visual analogue scale (VAS), time to management, and
deformity in the sagittal plane on a lateral radiograph cen-
tred on the fracture. The baseline wedge angle (bWA) was
the angle between the lines drawn along the upper and lower
endplates of the fractured vertebra. The baseline kyphosis
L. Garnier et al.
Kyphoplasty P value
42
43
59 (3294) P = 0.00001
46 P = 0.0131
14 P = 0.129
3 P = 0.091
24 P = 0.045
angle (bKA) was the angle between the lines along the upper
endplate of the suprajacent vertebra and the lower endplate
of the infrajacent vertebra. Angles indicating kyphosis were
positive and those indicating lordosis were negative.
The following perioperative data were recorded: time to
operative management in days, volume of cement injected
in millilitres, operative time in minutes, and hospital stay
length in days. A neurological evaluation was performed
and the VAS pain score was determined immediately after
the procedure, before patient discharge. Anteroposterior
and lateral radiographs were obtained to measure the post-
operative wedge angle (poWA) and postoperative kyphosis
angle (poKA) and to evaluate the degree of cement lling
(Fig. 3). The volume injected is not sufcient to evaluate
the technical quality of the procedure and we therefore
recorded the sites of cement leakage (Fig. 4). When leakage
was detected, computed tomography (CT) was performed to
determine the exact location of the leak.
Patients were seen 3 months after the procedure for
a physical evaluation, VAS pain score determination, and
anteroposterior and lateral radiographs centred on the frac-
ture for measurement of the 3-month wedge angle (m3WA)
and 3-month kyphosis angle (m3KA). Wedge reduction was
computed as the difference between the baseline and post-
operative wedge angles (bWApoWA) and kyphosis reduction
as the difference between the baseline and postoperative
Figure 3 Method used to analyse lling by the cement.
Kyphoplasty vs. Vertebroplasty in Osteoporotic Spinal Fractures
Figure 4 Topographic distribution of the leaks.
kyphosis angles (bKApoKA). After 3 months, loss of wedge
reduction was computed as the difference between the post-
operative and 3-month wedge angles (poWAm3WA) and loss
of kyphosis reduction as the difference between the post-
operative and 3-month kyphosis angles (poKAm3KA).
Statistical analysis
Students test was used to compare quantitative data and
the Chi2 test to compare qualitative data. Values of P smaller
than 0.05 were considered signicant. Pearsons correlation
coefcients were computed to assess the inuence of sev-
eral quantitative variables on WA and KA reduction and loss
of reduction.
Results
Mean follow-up was shorter in the vertebroplasty group
than in the kyphoplasty group (4 months vs. 6 months,
P = 0.00003) and the proportion of patients lost to follow-
up was 29% after vertebroplasty and 5% after kyphoplasty
(P = 0.0014). Patients who were lost to follow-up were
included in the analysis on an intent-to-treat basis.
Table 2 reports the main follow-up data. No signicant
differences were found regarding pain intensity immedi-
ately after surgery and after 3 months (3-points VAS score
improvement) (Fig. 5), proportion of patients with sat-
isfactory lling (78%), cement leakage rate (61% in the
vertebroplasty group and 51% in the kyphoplasty group), or
7
6 14
5 12
4 10
3 8
2 6
1 4
0 2
VAS 1 VAS 2 VAS 3
group V group K
Figure 5 Pain severity scores determined using a visual ana-
logue self-assessment scale before surgery (VAS 1), immediately
after surgery (VAS 2), and 3 months after surgery (VAS 3).
S115
hospital stay length (8 days after vertebroplasty and 6 days
after kyphoplasty). Signicant differences were found for
operative time, which was twice as long in the kypho-
plasty as in the vertebroplasty group, and for the volume
injected, which was 5 mL for vertebroplasty and 7 mL for
kyphoplasty.
Table 2 and Figs. 6 and 7 describe the deformities and
their outcomes. The postoperative measurements showed
signicant WA improvements in the vertebroplasty group
(mean, 2 ; range, 0 to 35 ; P = 5 109 ) and in the kypho-
plasty group (mean, 6 ; range, 16 to 2 ). The WA
improvement was signicantly greater after kyphoplasty
than after vertebroplasty (P = 0.002). In both groups, the
WA improved more in patients with A3 fractures than in
patients with A1 fractures (P = 0.03). None of the Magerl
groups responded signicantly better to one method than
to the other. The loss of WA reduction after 3 months was
not signicant in either group.
The postoperative KA improvement was not signicant
in either group (P = 0.12 for vertebroplasty and P = 0.35 for
kyphoplasty). Postoperative KA reduction was not signicant
with either method (P = 0.16). The loss of KA reduction after
3 months was not signicant (P = 0.21 for vertebroplasty and
P = 0.37 for kyphoplasty). However, loss of KA reduction was
greater for A2 fractures than for A1 fractures (P = 0.05),
whereas no signicant difference was seen between A1 and
A3 fractures (P = 0.41).
Table 3 reports the data on vertebral lling. Z3 lling,
dened as uniform cement distribution within the verte-
bral body (Fig. 3), was more common after vertebroplasty
than after kyphoplasty (P = 0.03). Table 4 shows the occur-
rence and location of leaks. Leaks in the anterior direction
16
14
12
10
8
6
4
2
0
WA 1 WA 2 WA 3
Group V Group K
Figure 6 Wedge angle at baseline (WA 1), immediately after
surgery (WA 2), and at last follow-up (WA 3).
0
KA 1 KA 2 KA 3
group V group K
Figure 7 Kyphosis angle at baseline (KA 1), immediately after
surgery (KA 2), and at last follow-up (KA 3).
S116 L. Garnier et al.

Table 2 Outcomes after vertebroplasty and kyphoplasty.

Vertebroplasty Kyphoplasty P value

1-10 VAS scale 6 (3) 6 (3) 0.26

VAS score improvement (VAS1VAS2) 3 (4) 3 (3) 0.22
Time to surgery (days) 15 (23) 10 (10) 0.11
Volume injected (mL) 5 (2) 7 (2) 0.00007
n with satisfactory lling: Y3, Z2, Z3 78% 78% 0.98
n with leaks 61% 51% 0.26
Operative time (minutes) 24 (25) 43 (24) 0.0002
Hospital stay (days) 8 (12) 6 (6) 0.19
Last follow-up (months) 4 (2) 6 (4) 0.00003
Baseline WA (degrees) 12 (7) 14 (4) 0.06
Postoperative wedge angle (degrees) 10 (6) 7 (5) 0.01
3-month wedge angle (degrees) 11 (5) 9 (6) 0.07
Baseline kyphosis angle (degrees) 12 (14) 10 (13) 0.22
Postoperative kyphosis angle (degrees) 11 (16) 6 (14) 0.05
3-month kyphosis angle (degrees) 13 (18) 7 (15) 0.04
Wedge reduction (degrees) 2 (7) 6 (7) 0.002
Loss of wedge reduction (degrees) 1 (8) 2 (3) 0.02
Kyphosis reduction (degrees) 2 (9) 3 (7) 0.16
Loss of kyphosis reduction (degrees) 0 (10) 1 (5) 0.21
The values in parentheses are the standard deviations. VAS: visual analogue scale.

Table 3 Quality of cement lling.

Overall V K P value (Chi2 )

n 118 86 32
X1 2 2 0 NS
Y1 0 0 0 NS
Z1 5 3 2 NS
Grade 1 7 5 2 NS
X2 2 2 0 NS
Y2 16 12 4 NS
X3 1 0 1 NS
Grade 2 19 14 5 NS
Y3 6 3 3 NS
Z2 12 5 7 NS
Z3 74 59 15 0.03
Grade 3 92 67 25 0.98
X1, X2, X3, Y1, Y2, Y3, Z1, Z2, Z3: see Fig. 3. NS: not signicant.

(type 3, Fig. 4) were more common after vertebroplasty,

although the difference was not statistically signicant
(P = 0.07).
Table 4 Cement leaks. In the correlation analysis, the postoperative WA
improvement in the vertebroplasty group showed a weak
V K P value (Chi2 ) negative correlation with time to surgery (correlation coef-
cient, 0.23) and a weak positive correlation with age
n 93 43
(correlation coefcient, 0.39).
Leak at any site 57 (61%) 22 (51%) 0.26
No deaths directly related to the procedures were
Posterior leaks (1) 9 3 0.61
reported. There were no systemic complications due to
Cranial leaks (2) 17 6 0.53
the cement. No neurological complications occurred, and
Anterior leaks (3) 11 1 0.07
there were no new fractures of the treated or adjacent
Caudal leaks (4) 4 3 0.51
vertebrae. In the vertebroplasty group, 1 patient required
Lateral leaks (5) 16 9 0.6
two further surgical procedures to treat an early infec-
See Fig. 4 for details on leak sites. tion.
Kyphoplasty vs. Vertebroplasty in Osteoporotic Spinal Fractures
Discussion
Study limitations
Our study has multiple biases related to the retrospective
multicentre design. In addition, the kyphoplasty patients
were recruited at several centres, whereas nearly all the
vertebroplasty patients came from a single centre. Mean
age was older in the vertebroplasty than in the kyphoplasty
group, despite the use of low-energy trauma as an inclusion
criterion. The practice habits in each centre seem to play
a major role. Early vertebroplasty or kyphoplasty, as per-
formed in this case-series, was not considered in patients
older than 80 years. However, in neither group did we nd a
correlation between age and WA improvement. The choice
between cement injection and initial bracing was at the dis-
cretion of each centre instead of being based on specic
criteria, given the absence of published recommendations.
Thus, in some centres cement injection was performed only
in patients with persistent pain despite bracing. Further-
more, each centre used its own denition of low-energy
trauma, which may explain the age difference and broad
indications for kyphoplasty in some centres.
The lack of accuracy inherent in manual measurement
of angles and heights is another limitation of our study. In
addition, the double concavity of the upper endplate may
impair the ability to accurately position the upper endplate.
The analysis of impaction and reduction at the centre of the
endplate, which is the only means of effectively improv-
ing mechanical support to the intervertebral disc, would be
more accurate if performed on routine computed tomog-
raphy images. Finally, the clinical evaluation in our study
patients was limited to the VAS pain score. Determining a
functional score is difcult in the oldest patients. We there-
fore focused on short-term structural improvements and
pain relief.
Outcomes
Vertebroplasty and kyphoplasty produced similar outcomes
in terms of pain, cement leaks, complications, and reduc-
tion of the deformity. Our data on pain are consistent with
earlier reports [15,2124]. We did not evaluate function
at last follow-up. The consensus at present is that early
vertebroplasty or kyphoplasty to treat vertebral fractures
improves survival and quality of life and allows an earlier
return to work [2426]. A 7% increase in survival has been
reported with kyphoplasty compared to vertebroplasty. The
better reduction achieved using kyphoplasty has not been
proven to result in short-term benets. In our study, the
leak rate and topographic distribution of the leaks (with a
predominance of lateral and cranial leaks) were comparable
in the two groups. Leaks had no adverse clinical effects in
our patients. Kyphoplasty has been reported to decrease the
number of leaks [19,2729]. The high leak rate in our study
is ascribable to injection of the cement at a low-viscosity
stage and in a large volume of 7 mL on average in the kypho-
plasty group. The current trend is to inject at a higher
viscosity stage, after a longer mixing time. Since the early
studies, in addition to changes in available cements, tech-
nical progress made by surgeons has contributed to diminish
S117
the leak rates. In our study, anterior leaks were more com-
mon with vertebroplasty, although the difference was not
statistically signicant. Complications were not signicantly
different between our two groups. In contrast, Taylor et al.
reported higher rates of pulmonary embolism and neurolog-
ical complications after vertebroplasty [21]. We recorded
no new fractures, but follow-up was brief in our study. The
treated level had no inuence on the quality of reduction in
either group. In contrast, Phillips et al. reported a mean KA
improvement of 8.8 with larger gains at the thoracic lev-
els than at the lumbar levels [30]. Finally, the WA improved
signicantly with both techniques. After 3 months, mean
KA was 12 after vertebroplasty and 14 after kyphoplasty,
with no clinical differences, suggesting that restoring a WA
greater than 10 may be benecial. However, no target
WA value has been published to date. The KA improve-
ments noted in our study were not statistically signicant
(1 on average in both groups). The correlation between the
improvements in KA and WA was weak (correlation coef-
cient, 0.39). Thus, correcting the wedge deformity does
not reduce the kyphotic deformity. It seems that the WA
improvement is consumed in the adjacent disks. Shin
et al. reported a 7 improvement in the KA immediately
after the procedure [31] and Teng et al. a KA improvement
of 4.5 to 5 [32]. The quality of reduction is consistently
better in Magerl A3 fractures. Therefore, the higher preva-
lence of these fractures in the kyphoplasty group introduced
a bias that should be taken into account when interpreting
the results. For Magerl A1 fractures, which are more dif-
cult to reduce, we found no evidence that one technique
was superior over the other.
Technique
We noted a number of technical differences between ver-
tebroplasty and kyphoplasty. With vertebroplasty, patient
positioning under general anaesthesia to increase spinal
lordosis is the main method used to reduce the defor-
mity [3234]. Carlier et al. reported better reduction in
cases with intravertebral clefts [3335]. Tropiano et al.
obtained good outcomes with closed reduction using a Cotrel
frame followed by casting [36]. In our study, hyperlordo-
sis ensured a 2 improvement in the WA immediately after
surgery. Cement injection during vertebroplasty stabilises
the fracture by lling the spaces created in the cancellous
bone during reduction. Reinforced trocars have been devel-
oped to ensure lifting of the upper endplate during cement
injection; however, no comparative studies establishing the
efcacy of this method are available. The use of balloon
tamps was suggested to better reduce the deformity by lift-
ing the upper endplate [21,24,30,3743]. Our data conrm
that kyphoplasty produces greater WA gains, although there
is no evidence that these translate into clinical benets.
Other methods for achieving reduction via intracorporeal
procedures are being developed. The Spinejack (Vexim SA,
Balma, France) is a jack-like device that is introduced via a
pedicle into the vertebral body before the cement injection.
A vertebral body stenting system has also been introduced
(VBS, Synthes, Issy-les-Moulineaux France). These promis-
ing methods need to be evaluated in clinical and economic
studies.
S118 L. Garnier et al.

Table 5 Review of the literature. Improvements in pain, angles, and vertebral heights across methods.

Authors Reduction technique WA gain KA gain Pain improvement AH gain MH gain

Our study, SFCR 2011 Vertebroplasty 2 1 3 NA/NA NA/NA

Kyphoplasty 6 2 3
Eck [22] Vertebroplasty NA NA 5.68 NA NA
Kyphoplasty 4.60
Carlier [33] Hyperlordosis + unilateral 1.9 NA NA NA NA
vertebroplasty
Chin [34] Hyperlordosis 5.4 NA NA NA NA
Teng [32] Hyperlordosis 7.4 4.5 NA 16.7% 14.5%
Li [42] Conventional surgery 11.5 /9.4 NA NA 8 mm/6.1 mm NA
Orler [43] Conventional surgery 15.2 /15 NA NA 8 mm/NA NA
Shin [31] Vertebroplasty 9.7 7 NA 7.6 mm 5.9 mm
Voggenreiter [38] Kyphoplasty 4.4 10.5 NA 36% 36%
Tropiano [36] Corset on a frame 9 2 NA NA NA
AH: anterior height of the vertebral body; MH: middle height of the vertebral body; NA: not available; NS: not signicant.
Gains in degrees are reported as the postoperative gain (postoperative value baseline value)/3-month gain (value after
3 months baseline value).

In our case-series, the differences in operative tech-
niques explain the differences in operative time, lling,
and impact of time to treatment. The operative time for
vertebroplasty was half that for kyphoplasty. This point
deserves consideration given that patients with compres-
sion fractures are often frail. Performance of the procedure
on an ambulatory basis with a brief general anaesthesia
may be possible. We found no previous data on vertebral
body lling by the cement. In our study, vertebroplasty
was associated with uniform lling (Z3, Fig. 3), both in the
cranio-caudal direction and from side to side. With kypho-
plasty, bone compression during expansion of the balloon
probably hinders the diffusion of the cement. We found a
weak correlation between time to operative management
and quality of the reduction. Similarly, Philips et al. reported
that the WA improvement was better when vertebroplasty
was performed rapidly after the accident (7.1 within the
rst week vs. 1.3 after 4 weeks, P < 0.05) [36]. With kypho-
plasty, we found no correlation. Thus, the time to operation
does not seem to inuence the reduction achieved with
kyphoplasty.
Table 5 reports the review of the literature.
Conclusion
Despite the marked heterogeneity of this case-series, the
results conrm the effectiveness of kyphoplasty in alleviat-
ing pain and reducing deformities related to osteoporotic
vertebral fractures. Vertebroplasty, which is faster and
less costly than kyphoplasty, remains useful when per-
formed early. There is no difference in the rate of clinically
detectable complications, and cement diffusion into the
cancellous bone is better than with kyphoplasty. Finally, with
both techniques, Magerl A1 fractures are more difcult to
reduce, even in patients with osteoporosis.
Disclosure of interest
L. Garnier: no nancial relationship with industy. J. Tonetti:
consultant company SPINEART. Unpaid research project with
the company THIEBAUD MDICAL. A. Bodin: no nancial
relationship with industy. H. Vouaillat: consultant com-
pany Medtronic. R. Assaker: consultant company Medtronic.
C. Court: consultant company Medtronic. P. Merloz: no con-
icts of interest concerning this article.
Acknowledgements
We are grateful to Dr T. Aubert, Dr Y.-P. Charles, Dr
P. Marinho, Dr J. Michel, Dr M. Saget, Prof. L.-E. Gayet, and
Prof P. Tropiano for contributing to collect the data for this
study.
References
[1] Farrokhi MR, Alibai E, Maghami Z. Randomized controlled
trial of percutaneous vertebroplasty versus optimal medical
management for the relief of pain and disability in acute osteo-
porotic vertebral compression fractures. J Neurosurg Spine
2011;14:5619.
[2] National osteoporosis foundation. Americas bone health: the
state of osteoporosis and low bone mass in our nation. Report
of national osteoporosis foundation. Washington, DC; 2002,
www.nof.org/advocacy/resources/prevalencereport.
[3] Riggs 3rd BL, Melton LJ. The worldwide problem of
osteoporosis: insights afforded by epidemiology. Bone
1995;17(Suppl. 5):505S11S.
[4] Schlaich C, Minne HW, Bruckner T, Wagner G, Gebest
HJ, Grunze M, et al. Reduced pulmonary function in
patients with spinal osteoporotic fractures. Osteoporos Int
1998;8(Suppl. 3):2617.
[5] Gold DT. The clinical impact of vertebral fractures: quality of
life in women with osteoporosis. Bone 1996;18:185S9S.
[6] Gold DT. Fractures: effects on quality of life in the aging skele-
ton. Clin Geriatr Med 2003;19:27180.
[7] Leidig G, Minne HW, Sauer P, Wster C, Wster J, Lojen M, et al.
A study of complaints and their relation to vertebral destruc-
tion in patients with osteoporosis. Bone Miner 1990;8:21729.
[8] Lyles KW, Gold DT, Shipp KM, Pieper CF, Martinez S, Mulhauser
PL. Association of osteoporotic vertebral compression fractures
with impaired functional status. Am J Med 1993;94:595601.
Kyphoplasty vs. Vertebroplasty in Osteoporotic Spinal Fractures
[9] Pluijm SM, Tromp AM, Smit JH, Deeg DJ, Lips P. Consequences
of vertebral deformities in older men and women. J Bone Miner
Res 2000;15:156472.
[10] Silverman SL. The clinical consequences of vertebral compres-
sion fracture. Bone 1992;13:2731.
[11] Radid.J. Recognizing and reporting vertebral fractures: redu-
cing the risk of future osteoporotic fracture. Can Assoc
2007;58:2736.
[12] Morin S. Mortality rates after incident non-traumatic fractures
in older men and women. Osteoporos Int 2011;22:243948.
[13] Borgstrom F. Costs and quality of life associated with
osteoporosis-related fractures in Sweden. Osteoporos Int
2011;17:63750.
[14] Edidin AA, Ong KL, Lau E, Kurtz MS. Mortality risk for operated
and nonoperated vertebral fracture patients in the Medicare
population. J Bone Miner Res 2011;26:161726.
[15] Diamond TH, Bryant C, Browne L, Clark WA. Clinical outcomes
after acute osteoporotic vertebral fractures: a 2-year non-
randomised trial comparing percutaneous vertebroplasty with
conservative therapy. Med J Aust 2006;6(184):1137.
[16] Galibert P, Deramond H, Rosat P, Le Gars D. Preliminary note
on the treatment of vertebral angioma by percutaneous acrylic
vertebroplasty. Neurochirurgie 1987;33:1668 [In French].
[17] Evans AJ, Jensen ME, Kip KE, DeNardo AJ, Lawler GJ, Negin
GA, et al. Vertebral compression fractures: pain reduction and
improvement in functional mobility after percutaneous poly-
methylmethacrylate vertebroplasty retrospective report of 245
cases. Radiology 2003;226:36672.
[18] Cortet B, Cotten A, Boutry N, Flipo RM, Duquesnoy B, Chastanet
P, et al. Percutaneous vertebroplasty in the treatment of osteo-
porotic vertebral compression fractures: an open prospective
study. J Rheumatol 1999;26:22228.
[19] Kasperk C, Hillmeier J, Nldge G, Grafe IA, Dafonseca K. Treat-
ment of painful vertebral fractures by kyphoplasty in patients
with primary osteoporosis: a prospective nonrandomized con-
trolled study. J Bone Miner Res 2005;20:60412.
[20] Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S. A com-
prehensive classication of thoracic and lumbar injuries. Eur
Spine J 1994;3:184201.
[21] Taylor RS, Taylor RJ, Fritzell P. Balloon kyphoplasty and
vertebroplasty for vertebral compression fractures: a com-
parative systematic review of efcacy and safety. Spine
2006;31:274755.
[22] Eck JC, Nachtigall D, Humphreys SC, Hodges SD. Comparison of
vertebroplasty and balloon kyphoplasty for treatment of verte-
bral compression fractures: a meta-analysis of the literature.
Spine J 2008;8:48897.
[23] McGirt MJ, Parker SL, Wolinsky JP, Witham TF, Bydon A,
Gokaslan ZL. Vertebroplasty and kyphoplasty for the treatment
of vertebral compression fractures: an evidenced-based review
of the literature. Spine J 2009;9:5018.
[24] Pugmacher R, Kandziora F, Schrder R, Schleicher P, Scholz
M, Schnake K, et al. Vertebroplasty and kyphoplasty in osteo-
porotic fractures of vertebral bodies a prospective 1-year
follow-up analysis. Rofo 2005;177:16706.
[25] Rllinghoff M, Zarghooni K, Schlter-Brust K, Schlegel U,
Eysel P, Delank KS. Indications and contraindications for
vertebroplasty and kyphoplasty. Arch Orthop Trauma Surg
2010;130:76574.
[26] Edidin AA, Ong KL, Lau E, Kurtz SM. Mortality risk for operated
and nonoperated vertebral fracture patients in the medicare
population. J Bone Miner Res 2011;26:161726.
S119
[27] Kim KH, Kuh SU, Chin DK, Jin BH, Kim KS, Yoon YS, et al. Kypho-
plasty versus vertebroplasty: restoration of vertebral body
height and correction of kyphotic deformity with special atten-
tion to the shape of the fractured vertebrae. J Spinal Disord
Tech 2012;25:33844.
[28] Han S. Percutaneous vertebroplasty versus balloon kyphoplasty
for treatment of osteoporotic vertebral compression fracture:
a meta-analysis of randomised and non-randomised controlled
trials. Int Orthop 2011;35:134958.
[29] Ploeg WT. Percutaneous vertebroplasty as a treatment for
osteoporotic vertebral compression fractures: a systematic
review. Eur Spine J 2006;15:174958.
[30] Phillips FM, Ho E, Campbell-Hupp M, McNally T, Todd Wetzel
F, Gupta P. Early radiographic and clinical results of bal-
loon kyphoplasty for the treatment of osteoporotic vertebral
compression fractures. Spine 2003;28:22605.
[31] Shin JJ, Chin DK, Jin BH, Kim KS, Cho YE, Park SK. Percutaneous
vertebroplasty in burst fractures of thoracolumbar spine. Spine
J 2008;6(Suppl. 5):137S8S.
[32] Teng MM, Wei CJ, Wei LC, Luo CB, Lirng JF, Chang FC,
et al. Kyphosis correction and height restoration effects
of percutaneous vertebroplasty. AJNR Am J Neuroradiol
2003;24:1893900.
[33] Carlier RY, Gordji H, Mompoint DM, Vernhet N, Feydy
A, Valle C. Osteoporotic vertebral collapse: percutaneous
vertebroplasty and local kyphosis correction. Radiology
2004;233:8918.
[34] Chin DK, Kim YS, Cho YE, Shin JJ. Efcacy of postural
reduction in osteoporotic vertebral compression fractures fol-
lowed by percutaneous vertebroplasty. Neurosurgery 2006;58:
695700.
[35] Krauss M, Hirschfelder H, Tomandl B, Lichti G, Br I. Kyphosis
reduction and the rate of cement leaks after vertebroplasty of
intravertebral clefts. Eur Radiol 2006;16:101521.
[36] Tropiano T, Huang RC, Louis CA, Poitout DG, Louis RP. Func-
tional and radiographic outcome of thoracolumbar and lumbar
burst fractures managed by closed orthopaedic reduction and
casting. Spine 2003;28:245965.
[37] Garn SR, Yuan HA, Reiley MA. New technologies in
spine: kyphoplasty and vertebroplasty for the treatment of
painful osteoporotic compression fractures. Spine 2001;26:
15115.
[38] Voggenreiter G. Balloon kyphoplasty is effective in deformity
correction of osteoporotic vertebral compression fractures.
Spine 2005;30:280612.
[39] Ledlie JT, Renfro MB. Kyphoplasty treatment of vertebral
fractures: 2-year outcomes show sustained benets. Spine
2006;31:5764 [Erratum in: Spine 2006;31(14):1635].
[40] Lieberman IH, Dudeney S, Reinhardt MK, Bell G. Initial
outcome and efcacy of kyphoplasty in the treatment of
painful osteoporotic vertebral compression fractures. Spine
2001;26:16318.
[41] Mathis JM, Ortiz AO, Zoarski GH. Vertebroplasty versus
kyphoplasty: a comparison and contrast. Am J Neuroradiol
2004;25:8405.
[42] Li KC, Li AF, Hsieh CH, Chen HH. Transpedicle body augmenter
in painful osteoporotic compression fractures. Eur Spine J
2007;16:58998.
[43] Orler R, Frauchiger LH, Heini PF. Lordoplasty: report on early
results with a new technique for the treatment of vertebral
compression fractures to restore the lordosis. Eur Spine J
2006;15:176975.