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Is additional balloon Kyphoplasty safe and effective for acute thoracolumbar burst fracture?
© The Author(s). 2017
Received: 12 January 2017
Accepted: 5 September 2017
Published: 11 September 2017
Burst fracture is a common thoracolumbar injury that is treated using posterior pedicle instrumentation and fusion combined with transpedicular intracorporeal grafting after reduction. In this study, we compared the outcome of these two techniques by using radiologic imaging and functional outcome.
Sixty-one patients with acute thoracolumbar burst fracture were operated with kyphoplasty (n = 31) or vertebroplasty (n = 30) and retrospectively reviewed in our institution between 2011 and 2014. All 61 patients underwent surgery within 5 days after admission to the hospital and then followed-up for 12 to 24 months after surgery.
Significant improvement was found in the anterior vertebral height (92 ± 8.9% in the kyphoplasty group, 85.6 ± 7.2% in the vertebroplasty group, p < 0.01) at 1 month post-operatively and (89 ± 7.9% in the kyphoplasty group, 78 ± 6.9% in the vertebroplasty group, p < 0.01) at the 24-month follow-up. Significant improvement was also observed in the kyphotic angle (1.2 ± 0.5° in the kyphoplasty group, 10.5 ± 1.2° in the vertebroplasty group, p < 0.01) at 1 month post-operatively and (5.4 ± 1.2° in the kyphoplasty group, 11.5 ± 8.5° in the vertebroplasty group, p < 0.01) at the 24-month follow-up. Both operations led to significant improvement of the patients’ pain and the Oswestry disability index (p < 0.01). Cement leakage was noted in 29% of patients after kyphoplasty and 77% of patients after vertebroplasty (p < 0.01). Only one implant failure (3.3%), which required further surgical intervention, was reported in the vertebroplasty group.
Reduction with additional balloon at the fractured site is better than indirect reduction only by posterior instrumentation. The better reduction of kyphotic angle and the lower cement leakage rate in the kyphoplasty group indicate that additional balloon kyphoplasty is safe and effective for acute thoracolumbar burst fracture.
Burst fracture is a common thoracolumbar injury that occurs because of failure of the anterior and middle columns due to axial loading . When anterior vertebral body height loss exceeds 50%, when the spinal canal is compromised by more than 50%, or when angulation is greater than 20° , surgical intervention should be considered. Recently, Thoracolumbar Injury Classification and Severity Score (TLICSS), which included fracture morphology, neurological injury and the integrity status of posterior ligamentous complex to determine stability and to decide operative or nonoperative treatment . According to this classification, operative treatment is recommended for a score ≥ 5 points, and conservative nonoperative treatment for a score ≤ 3 points [2, 3].
Posterior pedicle instrumentation and fusion combined with transpedicular intracorporeal grafting after reduction is a well-known surgical technique [4, 5]. Several different types of grafts exist, including autogenous bone grafts, allogenous bone grafts, and artificial bone grafts; these bone grafts are composed of polymethylmethacrylate (PMMA) or calcium sulfate, and calcium phosphate, among others [6–8]. Because of the complications at the donor site with autogenous bone grafts  and the risk of infection with allogenous bone grafts, artificial bone grafts are now more widely used. In addition, studies have shown that artificial bone grafts are as efficient as autogenous bone grafts .
Balloon kyphoplasty is a relatively effective technique to reduce the fracture site [11–14]. Reduction by balloon is speculated to effectively correct vertebral body height and angle. Another advantage of balloon kyphoplasty is decreased cement leakage, which is often a problem with vertebroplasty. Few researches  have compared the effects of balloon kyphoplasty with traditional vertebroplasty in acute thoracolumbar burst fracture. Our study aimed to compare the radiologic and functional outcomes of these two techniques.
Patient demographics data
Number of patients
35.5 ± 6.5
41.2 ± 6.8
Gender: female (%)
Location of fractured vertebrae
Neurological status (ASIA + )
12.5 ± 2.55
13 ± 3
Operation was indicated when the patient had a thoracolumbar injury classification and severity score  greater than 5. Additional balloon kyphoplasty was favored in the presence of kyphotic vertebrae and disruption of the posterior vertebral cortex, where higher-viscosity cement can be injected. All 61 patients underwent surgery within 5 days after admission to the hospital and were followed up for at least 24 months after surgery. Each patient underwent neurologic assessment by using a rating scale based on the American Spine Injury Association (ASIA) impairment scale . The treatment outcomes were assessed with special reference to the anterior vertebral height (AVH), kyphotic angle, degree of back pain (visual analog scale or VAS), the Oswestry disability index (ODI) at pre-operative and post-operative follow-up after 1, 3, 6, 12, and 24 months. Complications including cement leakage and implant failure were also assessed. Beginning on the day after surgery and continuing for 3 months, patients were encouraged to ambulation while wearing a Taylor’s brace. Unrestricted activity was permitted after considering the individual patient’s neurologic situation.
Short (1 above and 1 below fractured vertebra)
Long (2 above and 2 below fractured vertebra)
Blood loss (ml)
265 ± 25
215 ± 85
Operative time (minutes)
125 ± 26
115 ± 14
29.5 ± 5.5
28.5 ± 4.5
Volume injected (ml)
12 ± 2.5
6.5 ± 1.5
Data from both groups were analyzed with SPSS statistical software package (SPSS Inc., Chicago, IL, USA). Tests of hypotheses between both groups were conducted using a Student t-test for numerical data (including age, follow-up period, operation time, estimated blood loss, AVH, kyphotic angle, presence of back pain [VAS], and the ODI). P-values <0.05 were defined as statistically significant.
No significant difference was observed in age, gender, location of fractured vertebrae, neurological status, and hospital stay in both groups (Table 1). According to the ASIA neurologic grading scale, 7 patients had grade A, 2 patients had grade B, 4 patients had grade C, 3 patients had grade D, and 45 patients had grade E. All 9 patients with incomplete neurologic deficit had at least 1 ASIA grade neurologic improvement at the 24-month follow-up.
The mean operative time in the kyphoplasty group was 125 min (range, 99–151 min) and 115 min in the vertebroplasty group (range, 101–129 min) which was not statistically significant difference(p = 0.25). The total volume of blood loss was 265 ml in the kyphoplasty group (range, 240–290 ml) and 215 ml in the vertebroplasty group (range, 130–300); the difference was also not statistically significant (p = 0.058). All patients were observed in an average follow-up of 29 months (range, 24–36 months). The volume of cement injected in the kyphoplasty group was 12 ml (range, 9.5–14.5 ml) and 6.5 ml in the vertebroplasty group (range, 5–8 ml); the difference was statistically significant (p < 0.01) (Table 2).
In this study, long instrumentation were performed in T11-L1 fractured vertebrae. 9 patients with T11-L1 fractured vertebrae in kyphoplasty group and 5 patients in vertebroplasty group were performed short instrumentation because of strong bone screw purchase. However, the results of many studies [10, 23–25] showed that lack of anterior support may lead to a high percentage of early implant failure. A large cavity in fractured vertebrae is created during posterior instrumented construct after application of a distraction force, and thus may lead to reduction site collapse and worsened clinical outcomes. The materials used for anterior reconstruction includes autogenous and artificial bone grafts. The results of several studies have shown that artificial bone grafts produce similar success rates to autogenous bone grafts. In addition, the use of artificial bone grafts may lead to shorter operation time and less blood loss .
Many techniques have been used to establish anterior vertebral support. Vertebroplasty, which was first used in 1987 , became an efficient method for treating compression fractures . Balloon-assisted kyphoplasty is a developed technique [19, 28, 29] to restore the vertebral body height and to treat local kyphosis which also contributes to anterior column stability. In the present study, posterior screw fixation combined with kyphoplasty for anterior support produced significantly better kyphosis angle correction and better vertebral body height, as shown during the 24-month follow-up. Using posterior distraction, reduction of fractured vertebrae is improved indirectly by ligamentotaxis but distraction force also increases kyphotic angle. The distraction force applied in the kyphoplasty patients may be lower in the vertebroplasty patients, and thus post-operative lordotic angle may be better in the kyphoplasty group. The reported kyphotic angle correction with transpedicular bone grafting and short pedicle fixation techniques ranges from 64% to 105% [18, 30–33]. The average corrections of 92% in the kyphoplasty group and 85.6% in vertebroplasty group are within the previous reported range. The average loss of correction after posterior short segment instrumentation plus transpedicular augmentation with biodegradable bone cement is not significantly different from that following traditional anterior and posterior spinal operations [18, 30, 34], with the loss of correction ranging from 1° to 4.2°.
Posterior instrumentation is speculated to fail due to the large bone defect created inside the fractured vertebra after indirect height restoration through distraction and ligamentotaxis force applied during surgery . Because the majority of patients with burst fractures in our series were aged between 29 and 48 years, the use of a more biocompatible bone cements (e.g.,calcium phosphate and hydroxyapatite) is preferred [30, 36, 37]. Self-hardening calcium sulfate/phosphate bone cements have been developed as alternatives to avoid long-term side effects of PMMA [38–40] because of the biocompatibility, no local heat or toxic effect on surrounding bone tissues [41, 42] and can stimulate bone formation at the bone–cement interface . Korovessis P.  reported an improvement of kyphotic angle from preoperative 16° to postoperative 1° at final follow-up and the AVH ratio from 0.6 to 0.9 in 29 thoracolumbar burst fracture patients using kyphoplasty with calcium phosphate cement and pedicle screws instrumentation and reported a similar result in 18 thoracolumbar burst fracture patients  using balloon kyphoplasty with calcium phosphate cement combined with posterior short segmental fixation. In both of their study, they didn’t use vertebroplasty as a control group which is difficult to make a conclusion that the reduction using balloon at the site of the fractured vertebra is better than the indirect reduction by means of distraction provided only by instrumentation. We also doubt this similar data [44, 45] because of the distraction force applied in open surgery should be larger than minimal invasive method so that radiological result in open surgery should be better.
The reason why significant improvements were noted in kyphotic angle and AVH at post-operative one month, but decreased in the 24-month follow-up in our study, because of the calcium sulfate/phosphate cement was partial resorption.
In this study, the volume injected in the kyphoplasty group was significantly higher than that in the vertebroplasty group (12 ± 2.5 cm3 vs. 6.5 ± 1.5 cm3, p < 0.01) because the void space in fractured vertebrae was created by balloon kyphoplasty, and thus, the vertebral height and kyphotic angle will be better and maintained in the 24-month follow-up in the kyphoplasty group.
In our series, a larger amount of cement was injected into the vertebrae of the kyphoplasty group; this group exhibited better eventual stability than the vertebroplasty group. The authors believe that the reduction with additional balloon at the fractured site is better than the indirect reduction through distraction force provided by posterior instrumentation. Additional balloon kyphoplasty is safe and effective for acute thoracolumbar burst fracture.
There are several limitations in this study. 1) This is a retrospective study and mean follow-up was 29 months. The long-term effectiveness of this technique still needs to be evaluated. 2) The surgical indication is different in kyphoplasty group and vertebroplasty group. 3) The numbers of the patients in both groups were limited.
Balloon kyphoplasty and vertebroplasty with injection of calcium sulfate/phosphate cement combined with posterior fixation for acute thoracolumbar burst fractures both provided immediate stability and reduction of post-traumatic segmental kyphosis. In addition, the use of additional balloon kyphoplasty led to better reduction of fractured vertebrae, less cement leakage, and better stability than in patients who only received vertebroplasty.
We thank the Department of Orthopaedic Surgery for their contribution to the study.
This work was supported by Chang Gung Memorial Hospital (grant No. CMRPG3F2051).
Availability of data and materials
The data that support the findings of this study are available from Chang Gung Memorial Hospital but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of Chang Gung Memorial Hospital.
P-JT, K-FF and M-KH participated in the study design, in collecting the data, the statistically analyses and drafting of the manuscript. L-HC, C-CN, P-LL, W-JC, T-TT and C-WY participated in the study design. M-KH advised and assisted drafting of the manuscript. All authors read and approved the final manuscript.
Ethics approval and consent to participate
The Chang Gung Medical Foundation Institutional Review Board approved this study (103-3387B) and waived the requirement for informed consent due to the retrospective nature of the study.
Consent for publication
TT-T is a member of the Editorial Board of BMC Musculoskeletal Disorders. The remaining authors have no competing interests.
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