Zusammenfassung
Bei der Ballonkyphoplastie handelt es sich um ein inzwischen hoch standardisiertes
und weit verbreitetes minimalinvasives Verfahren zur Stabilisierung und Wiederaufrichtung
insbesondere schmerzhafter osteoporotischer Wirbelkörperfrakturen. Im Rahmen der flächendeckenden
Anwendung mehren sich jedoch auch die Berichte über stattgehabte Komplikationen. Außerdem
gelten zahlreiche unterschiedliche Standards bezüglich der Indikation zu diesem Eingriff.
Der folgende Artikel soll neben einem Überblick über die Technik des Verfahrens die
Indikationen aufzeigen und die möglichen Komplikationen dieses vermeintlichen Routineeingriffs
anhand einiger Beispiele aus der täglichen Praxis beleuchten.
Abstract
Background: Considering the demographic changes in the populations of Germany and Europe as a
whole, the field of geriatric traumatology is gaining more and more importance within
the specialty of orthopedic and trauma surgery. The high prevalence of osteoporosis
in this specific group of patients poses a special challenge, with vertebral compression
fractures being the by far most common osteoporosis-related fractures. These fractures
present with acute as well as chronic back pain leading to severe consequences for
the affected patients. Mobility and quality of life are often heavily impaired. Furthermore,
higher morbidity and mortality as well as higher risk for further fractures have been
proven in these patients. Method: Balloon kyphoplasty has become a more frequently used therapy and is now offered
broadly. This treatment addresses stable fractures not involving the posterior margin
of the vertebrae. With increasing application of this surgical procedure the number
of complication reports is also rising. The following article gives an overview of
the technique, indications and the possible complications by giving several examples
from the daily practice and reviewing the relevant literature. Results: Cement leakage of the treated vertebrae is the most common complication associated
with balloon kyphoplasty. In almost all cases this occurs due to too early application
of the cement, not having reached its optimum in viscosity. Literature research shows
a percentage rate of about 9 % for cement leakage. Thus, balloon kyphoplasty provides
more safety for the patient than vertebroplasty, for which cement leakage rates of
up to 41 % are reported. Other studies report cement leakage ratios of 4–10 % for
kyphoplasty versus 20–70 % for vertebroplasty. Overall the percentage of cement leakage
is clearly increased in osteoporotic fractures compared to non-osteoporotic fractures,
with the cement leaking mainly into the spinal disc space. So far, valid data in order
to further explore the consequences of intradiscal cements are lacking. Most relevant
for everyday practice are cement leakages that have become symptomatic. Depending
on the localisation they present with dysaesthesia culminating in radicular pain or
even paraplegia. Cement leakage into vessels can, depending on the amount of cement,
lead to embolism of pulmonary arteries. Complications due to the surgical technique,
postoperative infections, bleeding or cardiovascular complications are rare with less
than 1 %. The probability for symptomatic cement leakage averages about 1.3 % for
balloon kyphoplasty. Another discussion, for which at present there is no evidence-based
verification, is concerned with the higher risk for adjacent vertebral fractures after
cement augmentation of an osteoporotic vertebral compression fracture. At present
the degree of osteoporosis and more important the number of osteoporosis-related fractures
must be the relevant predictor for adjacent fractures of neighbouring vertebrae. Conclusion: Balloon kyphoplasty is a highly standardised and widely used minimally invasive procedure
for stabilising and augmenting painful osteoporotic fractures of the vertebral body.
When surgery is indicated carefully and is carried out subtly, the risk of complications
is reasonable and the outcome is promising. Viscosity of the used cement has to be
adequate and it must not be inserted with too high a pressure. A causal connection
between cement viscosity and risk of cement leakage has been proven in experimental
studies. During application of PMMA cement a thorough fluoroscopic monitoring must
take place in order to detect cement leakage at an early stage and if necessary stop
application. These procedures should be reserved for clinical centres and surgeons
who are able to surgically handle possible complications such as compression of the
spinal cord. On the basis of our own experience we also recommend treatment in a hospital
with an integrated osteoporosis centre and consecutive treatment in specialised outpatient
care. Standards in primary care as well as after treatment can be introduced thereby.
Also communication with practitioner concerned with outpatient care is simplified,
which leads to enduring therapeutic outcome.
Schlüsselwörter
Ballonkyphoplastie - Wirbelkörperfraktur - Osteoporose - Komplikationen - Zementaustritt
Key words
balloon kyphoplasty - vertebral body fracture - osteoporosis - complications - cement
leakage
Literatur
bula-ph@khdf.de
