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F. Pellise
´Reviewer’s comment on: Balloon kyphoplasty
for the treatment of pathological vertebral
compressive fractures (I.N. Gaitanis et al.)
Published online: 17 September 2004
ÓSpringer-Verlag 2004
The authors (I.N. Gaitanis et al. [7])
describe a small, heterogeneous ser-
ies of patients in whom balloon
kyphoplasty was performed. Twen-
ty-seven had osteoporotic vertebra
compression fractures (OVCF), and
five had vertebral metastases.
Although many goals of the study
have been previously analysed in
larger series of patients [3], the paper
introduces some issues of interest.
Findings from imaging tech-
niques may have prognostic value
and be useful for predicting clinical
and radiological outcome after ver-
tebral cement augmentation. The
authors suggest that MRI short time
inversion recovery (STIR) images
depicting oedema may be more
accurate than bone scan to predict
the final outcome and that, there-
fore, these could become the gold
standard imaging technique for
kyphoplasty. Four patients with
OVCF included in this series had
negative bone scans. Two of them
with acute pain (less than 4 weeks)
and a hyperintense MRI STIR
signal had better clinical and radio-
logical outcome than the two with
chronic pain (more than 14 months)
and normal STIR MRI. Two addi-
tional patients with positive bone
scans but no hyperintense STIR
MRI signal also had unsatisfactory
results. The current data do not
allow reaching firm conclusions.
However, the procedure is not
exempt from complications and
some patients may have residual
pain after kyphoplasty. Further-
more, the device is very expensive.
Consequently, any effort to identify
characteristics that may be related to
outcome—such as vertebral STIR
MRI signal intensity—should be
advocated. Assessing and comparing
the clinical performance of the
various diagnostic tools available to
determine their accuracy and
predictive value should also be
encouraged.
Aggravation of a pre-existing
spinal canal stenosis by an
osteoporotic vertebral fracture is
another interesting point to study.
The authors evaluated three
patients with pre-existing symptoms
of spinal stenosis that remained
unchanged after balloon kyphopl-
asty. There is no data on the loca-
tion of the fracture or the level of
spinal stenosis. If spinal stenosis
and OVCF occurred at different
spinal segments, one might expect
no aggravation of pre-existing
radicular symptoms with OVCF
and no change after kyphoplasty.
The combination of an OVCF with
a pre-existing stenosis at the same
spinal segment is a more challeng-
ing clinical scenario, in which
posterior decompression would in-
crease traumatic instability and ce-
ment augmentation might trigger
radicular symptoms if some degree
of intracanal cement leak occurred.
However, Chung et al. described
Eur Spine J (2005) 14: 261–262
DOI 10.1007/s00586-004-0790-5 REVIEWER’S COMMENT
F. Pellise
´
Unitat de Cirurgia del Raquis,
Hospital de Traumatologia Vall d’Hebron,
08035 Barcelona, Spain
E-mail: 24361fpu@comb.es
seven patients in whom root com-
pression resulted from combined
OVCF and pre-existing stenosis of
the intervertebral foramen [1].
After injection of polymethylmeth-
acrylate into the compressed ver-
tebral body through the pedicle of
the symptomatic side, all seven
patients experienced pain relief that
lasted until last follow-up. The
authors concluded that vertebropl-
asty might be an effective way of
relieving radicular pain caused by
osteoporotic compression fractures
combined with foraminal stenosis.
Percutaneous transpedicular
biopsy of deep vertebral body le-
sions can be performed safely and
effectively under computed tomog-
raphy or fluoroscopy guidance
using needles ranging 14–17-gauge
[4,5]. Kyphoplasty has the
advantage of allowing biopsy
through a 2.5-mm needle. The au-
thors performed biopsies in 15
patients, but an adequate tissue
specimen was obtained in only
67% of cases. The low success rate
reported should be further investi-
gated. Technical issues or fracture
characteristics could be the origin
of the problem. The need for
routine performance of vertebral
biopsy through the vertebroplasty
or kyphoplasty needle before ce-
ment injection has been stressed
several times [2,6]. The existence
of unmineralised bone, secondary
osteoporosis or even occult malig-
nancies in so-called OVCF is more
frequent than suspected. Discus-
sion is required to establish a
conscientious approach for
obtaining adequate biopsy tissue
specimens and optimising diagnos-
tic accuracy (tetracycline labelling),
while performing vertebral cement
augmentation.
References
1. Chung SK, Lee SH, Kim DY, Lee HY
(2002) Treatment of lower lumbar radi-
culopathy caused by osteoporotic com-
pression fracture: the role of
vertebroplasty. J Spinal Disord Tech
15:461–468
2. Hammond A, Riley LH, Gailloud P,
Nussbaum DA, Watkins M, Murphy KJ
(2004) Treatment considerations for ver-
tebroplasty in men. Am J Neuroradiol
25:639–641
3. Heini PF, Orler R (2004) Kyphoplasty
for treatment of osteoporotic vertebral
fractures. Review. Eur Spine J 13:184–
192
4. Jelinek JS, Kransdorf MJ, Gray R, Ab-
oulafia AJ, Malawer MM (1996) Percu-
taneous transpedicular biopsy of
vertebral body lesions. Spine 21:2,035–
2,040
5. Strimgham DR, Hadjipavlou A, Dzioba
RB, Lander P (1994) Percutaneous tran-
spedicular biopsy of the spine. Spine
19:1,985–1,991
6. Togawa D, Bauer TW, Lieberman IH,
Reinhardt MK (2003) Occult osteoma-
lacia and myeloma in patients with
osteoporotic compression fractures. Eur
Spine J 12 [Suppl 1]:S3
7. Gaitanis IN et al (2004) Balloon kyp-
hoplasty for the treatment of pathologi-
cal vertebral compressive fractures. Eur
Spine J (DOI http://dx.doi.org/10.1007/
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