Joey Wahler (Host): It's an effective spinal treatment option, so we're discussing kyphoplasty. Our guest is Dr. Oren Blam. He's an orthopedic surgeon and spine specialist.

This is A Bone to Fix, a podcast from the Orthopedic Associates of Central Maryland division. Thanks so much for joining us. I'm Joey Wahler. Hi there, Dr. Blam. Welcome.

Dr. Oren Blam: Hello. Thank you so much for being with me today.

Host: Same here. Appreciate the time. So first, in a nutshell, for those unfamiliar, what exactly is kyphoplasty?

Dr. Oren Blam: Well, kyphoplasty is a procedure that we do sometimes to treat severe back pain from spinal fractures, especially for folks who are up in years may have developed osteoporosis, a disease of thinning of the bones with age, that can predispose a person to getting a fracture of the spine. And we have this minimally invasive procedure essentially allowing us to inject bone cement into a broken vertebra to stiffen up the vertebra and take a person's pain away immediately.

Host: Bone cement. So, what exactly is that?

Dr. Oren Blam: Well, this was invented years ago. We use it to support joint replacements. We've been doing it for many years. It's called polymethyl methacrylate. That's the scientific name for it. But basically, it's just a bone void filler and cement that can stiffen up thin bones. It's permanent. Once we inject it, it doesn't degrade over time. But it sort of holds a fractured bone together from the inside.

Host: Pretty amazing, right?

Dr. Oren Blam: It is. Especially since it can be placed with just a needle, we consider it truly minimally invasive because it's placed with a needle. And it provides immediate relief.

Host: Yeah. Unbelievable. Okay. So, how does kyphoplasty differ from other treatments for spinal fractures?

Dr. Oren Blam: Well, years ago, before they developed this type of cement injection procedure, the only treatments were non-operative, keeping a patient on bed rest for weeks and weeks, which itself leads to bad outcomes or, on the opposite side, there were these big massive spinal fusions one can do to put in either screws and rods or, even years earlier, hooks, and other types of spinal fixation devices requiring big surgeries to open a person up to hold the spine together from the inside. That is a huge procedure with a lot of morbidity, especially for folks who are older. And, of course, these types of fractures generally occur in older individuals, with the exception some other less common issues, fractures from cancers or other problems. So, either non-operative care or big massive surgeries were the alternatives until this came along.

If someone does research about this, they may come across the word vertebroplasty, which is very similar to kyphoplasty. Both vertebroplasty and kyphoplasty involve injecting cement into the broken vertebra. The difference is vertebroplasty involves just putting the needle in and injecting the cement and then being done. Whereas kyphoplasty has another step where we put the needle in. And before we put in the cement, we first put in a balloon inside the bone, the broken bone, inflate the balloon, and then remove the balloon, finally putting the cement subsequently.

This intermediate step with kyphoplasty utilizing the balloons provides a measure of safety to create an empty space inside the vertebra, so that when we inject the cement, it sort of can dribble in slowly under low pressure as opposed to being injected into the tight crevices within the bone and may have a bit of a risk of the cement squirting into places we don't want it to. So, the kyphoplasty has been shown in studies to be a little bit safer, lower complication rate. And so, most of the time, we'll do kyphoplasties nowadays instead of vertebroplasties.

Host: Gotcha. So, who's typically the ideal candidate for this? And are there patients, on the other hand, that it's not recommended for?

Dr. Oren Blam: Well, firstly, we want to make sure the procedure's needed. So obviously, a broken vertebra hurts. A person with osteoporosis can get a vertebral fracture just from sitting down hard on a chair or coughing hard, or minor trauma. But if this person's back pain from the fracture rapidly improves in the first week or two, then they may not need the procedure. The procedure's done just for pain. It's not to treat any fracture that's already healing on its own. So, we usually give a person a couple of weeks to see how they're feeling with conservative care. But if a person with one of these fractures is not getting better, then a kyphoplasty becomes a really good option.

The appearance of the fracture on imaging sometimes affects our decision-making. If someone has a particular kind of fracture where there are cracks extending through the vertebra and exposing the spinal canal. We'd have to be a little bit more careful when we inject cement to make sure cement doesn't leak into the spinal canal where the nerves are. So, that can affect our decision-making.

Another type of person who might do really well with this procedure is someone who has a vertebral fracture from cancer. That's much less common than these osteoporotic fractures or fractures due to weak bones from age, age-related thinning of the bones. But cancer can also lead to bone thinning and fractures. And so, this procedure can be really good for that kind of fracture as well. We always have to make sure someone's health status is good enough to withstand the twilight anesthesia we do for this procedure. But most folks are okay with that, as long as we get a medical evaluation ahead of time.

Host: Okay. So, why might you recommend kyphoplasty instead of more conservative treatments like bracing, physical therapy, or pain management? Is it just a matter of the level of pain?

Dr. Oren Blam: It's mainly the matter of level of pain and a person's activity level. If someone has a fracture and they're having what we call the downward spiral of pain leading to reduced activity, reduced activity can lead to poor appetite, which can lead to malnutrition, which can lead to more risk for fractures, difficulty breathing sometimes if a fracture is high up in the thoracic spine.

If someone's just not doing well, then kyphoplasty is a 30-minute procedure approximately that makes them better immediately as opposed to waiting four to six weeks and just getting worse and worse from the decreased activity and pain related to the fracture. Conversely, if someone's getting rapidly better, then kyphoplasty may not be needed. So, it's a judgment call the patient and the doctor make together.

Host: Right. So once it's determined this is needed, can you just, in a nutshell, please walk us through the procedure and what patients can expect on the day of?

Dr. Oren Blam: It's usually best to get this procedure done with twilight anesthesia, also called intravenous sedation. So, we have someone come in, they get an intravenous line placed. And then, we bring them to our procedure room. We lie them face down on the X-ray table, and start intravenous sedation, also called twilight anesthesia.

Basically, with twilight anesthesia, a person is still breathing on their own, no breathing tube in their mouth, but they are out of it. They become unaware of the situation around them because they're sedated. They have to be arousable. If we kind of shake their shoulder, "Are you awake? Are you awake?" Then, someone can sort of slowly say, "What? What's going on? What?" But then, we let them fall back asleep to make sure that they're not aware of the procedure, but also that they're breathing well.

So once our sedation is working, we can do the procedure. It involves X-ray guidance. It's called a fluoroscopy machine that allows us to see the spine and the details of the anatomy really well. Under X-ray guidance, we insert a needle into the broken bone. Obviously, it has to be done very carefully to avoid the nerves of the spine to avoid organs around the spine.

But with care and with X-ray guidance, it's usually a fairly straightforward procedure to put the needle into the broken bone. The patient's not aware of what's happening. But through that needle, we put in a balloon, inflate the balloon, remove the balloon and, lastly, put in the cement. This procedure is sometimes done with just one needle if we get exactly the right angle. We want to get cement to fill across the vertebra, across midline, to have support of the whole vertebral body. Sometimes we get the right angle with just one needle. Oftentimes, we'll use two needles, one on the left side, one on the right. So, we put in the needles, put in the balloons, put in the cement, and then we're done.

Usually, the little incisions needed for the needle placement are so small, I usually don't put in a stitch. Usually, just a little piece of tape. A Steri-Strip is enough to keep that closed. And then, we're done. The patient wakes up in the recovery room, hopefully, noticing pain relief immediately. This procedure can be done if there's just one vertebral fracture. Less commonly, a person can have two or three vertebral fractures, and we can do up to three levels at a time safely, as long as we inject the cement slowly and gradually. So, patients do quite well with it.

Host: And so, you started to answer my next question already, namely how quickly do patients typically experience relief? You say often immediately. What does recovery then look like?

Dr. Oren Blam: Well, as we may understand, the cement dries and solidifies immediately inside the bone. There is no fracture healing needed to occur anymore. The cement inside the broken vertebra has already solidified and is already holding the vertebra together from inside, and no new bone has to grow. The fracture is fully healed at that point.

So typically, a person's fracture pain, the severe sharp pain from the crack in the bone would go away immediately. There still may be some back pain that has to work itself out, though. If someone has been relatively inactive for two or three weeks or sometimes longer, then a person can have back pain related to muscle deconditioning and imbalance, that occurred from the fracture. And so, that kind of low back pain is usually much less severe than the fracture pain, but still may require some physical therapy in the first three or four weeks after the procedure. A person's allowed to stand and walk and be active and climb stairs and lift bags and, you know, anything immediately after the procedure, again, because we're not waiting for any bone to heal any longer.

So, there are no restrictions in activity. An important part of postoperative care is honestly treating and managing osteoporosis. The thin bones that led to the fracture in the first place would lead to a higher risk of future fractures in the spine or elsewhere. And so, getting involved in an osteoporosis management with a primary care physician or with an osteoporosis specialist is somewhat important as well.

Host: And so, naturally, as you well know, any procedure pretty much comes with some potential risks or complications. How about here?

Dr. Oren Blam: We always have to talk about risks, that's true. I think it's quite unlikely to get a complication as long as we're doing it quite carefully, without rush, with X-ray guidance. But yeah, when we inject the needle, we have to place the needle inside bone and avoid damaging any nerves or organs around the spine. That risk is quite small if we do it carefully under X-ray guidance, but I guess the risk isn't zero. Also, when we inject cement, we want the cement to be placed gently inside the fracture, inside the broken vertebra, and we don't want the cement to leak out of the vertebra to damage nerves or even embolize, that is spread through the bloodstream to the lungs, heart, or brain. A little bit of cement leakage into the disc or to the side of the spine itself is not a problem. But if cement leaks into the spinal canal where the nerves are or gets embolized to other organs far away, then we worry about those complications.

To try to reduce that risk to near zero, again, we inject the cement gradually. We're not trying to squirt it in fast. We inject the cement when it's sludgy or thick. We don't inject very thin, watery cement. We let it partially solidify outside the body before we inject it. And like I said earlier, the kyphoplasty procedure involving balloon placement first prior to the cement injection really also cuts down on the risk of cement leaking out of bone. So with those measures, the risk of cement leakage out of bone becomes very, very small.

Host: Gotcha. Couple of other questions for you. First, how about any advancements or innovations of late in kyphoplasty that have helped to improve outcomes for patients? I'm wondering for one thing, Doctor, if this is something where this cement and this type procedure can be used on other parts of the body.

Dr. Oren Blam: There's been some research in the past fifteen years trying to see if the cement injection with balloon inflation part of the cement injection, if it could be helpful for other kinds of fractures, at the knee, the tibial plateau, or elsewhere, it hasn't really gained a lot of traction in treatment for other parts of the body.

There have been some companies developing products, different kinds of cement that chemically solidify faster or flow easier. There are some companies that have cement balls on a chain. There are some companies that make a metallic implant you can put inside the bone through a needle and then put cement in. So, there are variations of this kyphoplasty procedure. No one of these procedures have been proven to be better clinically than any other. And so, it's a bit of a judgment call based on the fracture pattern, how the fracture looks on X-ray as to whether one would want to do a kyphoplasty with one of these other types of cements or implants. But it's nice to have options. Basically, as the surgeon, I can say it's nice to be able to use my judgment based on how a fracture looks as to which of these cement procedures would be best.

Host: Right. And then, in summary here, Doctor, you've done such a great job breaking down the details, what's the main takeaway you want those joining us to know about kyphoplasty?

Dr. Oren Blam: I think the main thing is back pain is horrific. And back pain from a broken bone, a fracture can be horrific. And a person doesn't have to choose to remain in pain. It's totally okay to decide to pursue non-operative treatment if pain is gradually improving. But if pain is not improving, doing a minimally invasive procedure that takes only 20 or 30 minutes to do with very, very low risk. And with immediate pain relief, such as kyphoplasty affords, it becomes a really good option.

So, I think if someone has one of these fractures, it's important to consider kyphoplasty, as a real good option for pain relief in these either osteoporotic fractures or fractures from cancer-related fracture.

Host: Absolutely. Well, folks, we trust you're now more familiar with kyphoplasty. Dr. Blam, keep up all your great work. Thanks so much again.

Dr. Oren Blam: Thank you.

Host: And for more information, please visit mdbonedocs.com. If you found this podcast helpful, please do share it on your social media. I'm Joey Wahler. And thanks so much again for being part of A Bone to Fix, a podcast from the Orthopedic Associates of Central Maryland Division.