Kyphoplasty: stopping a broken vertebra from getting worse

The problem

What a vertebral compression fracture is

A vertebral compression fracture is a collapse of the front part of a spine bone. Most begin with osteoporosis: bone density has thinned to the point that ordinary daily loading — standing up, bending, a minor stumble, sometimes nothing identifiable at all — is enough to crush the front of the vertebra like an aluminum can. The vertebra does not shatter and displace; it compresses and wedges, which is why these fractures rarely injure the spinal cord directly, but they are still a structural failure of the bone.

Untreated, a compressed vertebra tends to keep settling under load. Each fracture increases the mechanical stress on the vertebrae immediately above and below it, which is part of why one compression fracture significantly raises the risk of another. Multiple fractures accumulate into the forward-stooped posture (kyphosis) sometimes called a dowager's hump, along with loss of height, and in more advanced cases, compression of the chest and abdomen that affects breathing and digestion.

The procedure

What kyphoplasty does

Kyphoplasty is done through the skin — there is no open incision, no muscle stripped off the spine, and no hardware left behind. Working under live X-ray guidance, a narrow needle is passed down the pedicle, the bony tunnel that connects the back of the vertebra to its body, and into the fractured bone. With the system currently used, one pedicle is enough: a single access point reaches across the vertebral body, so there is one small incision rather than two. A balloon is inflated inside the collapsed bone to lift the endplate and create a cavity. The balloon comes out, and that cavity is filled with acrylic bone cement, which hardens in minutes into an internal cast.

That cavity is the difference between kyphoplasty and plain vertebroplasty. Making a space first means the cement can be placed as a thick paste at low pressure, rather than injected as a thin liquid into porous bone — which is why cement leaks outside the vertebra are less frequent with kyphoplasty.

Indications

Who kyphoplasty helps

Kyphoplasty works when it is aimed at the right fracture. The single most important question is not whether a fracture is visible on imaging — old, healed fractures are visible for life — but whether this fracture is the one generating this pain, right now.

• A painful vertebral compression fracture that is still biologically active, confirmed by marrow edema on MRI (STIR sequence) or uptake on a bone scan when MRI cannot be done.
• Pain that matches the level. Tenderness on examination at the fractured segment, not diffusely across the back.
• Pain severe enough to matter — limiting walking, sleep, or the ability to care for oneself, typically 5 or higher out of 10.
• A recent fracture. Most often within the past several weeks to a few months. Earlier treatment generally restores more height.
• Inadequate relief from conservative care — rest, bracing, and analgesics — or pain so severe from the outset that weeks of waiting is not a reasonable plan, particularly in an older adult for whom bed rest itself carries risk.
• Fractures from cancer or myeloma, where the bone will not heal on its own and waiting has no upside.

On the evidence: early sham-controlled trials of vertebral augmentation enrolled patients with fractures of any age and any pain severity, and found little benefit. Later trials that selected for acute, severely painful fractures — VAPOUR, VERTOS IV, and the FREE trial of balloon kyphoplasty — found clear advantages in pain and function. The lesson of that literature is not that the procedure works or does not work; it is that patient selection is the procedure.

Contraindications

When it is the wrong operation

Part of doing a high volume of these is turning them down. Kyphoplasty is not appropriate when:

• The fracture is old and healed, or found incidentally without matching pain.
• It is a burst fracture with bone displaced backward into the spinal canal.
• There is spinal cord compression, myelopathy, or a progressive neurological deficit — these need a surgical decompression, not cement.
• There is active infection: spinal osteomyelitis, discitis, or bacteremia.
• Bleeding cannot be safely controlled, or there is a known allergy to the cement components.
• The back pain is coming from something else — spinal stenosis, facet arthritis, or a disc — which is more common than patients expect and is why the MRI matters.

Seek care immediately, not an appointment, if back pain comes with new leg weakness, numbness in the groin or inner thighs, or loss of bladder or bowel control. That combination suggests pressure on the spinal cord or nerve roots and is treated as an emergency.

Spinal tumors

Fractures caused by cancer

Not every collapsed vertebra is osteoporotic. Multiple myeloma and metastatic disease — most often from breast, lung, prostate, kidney, or thyroid primaries — destroy the vertebral body from within, and those fractures do not heal with time and a brace. They tend to be relentlessly painful.

For these patients kyphoplasty is frequently combined with radiofrequency ablation. A small probe is placed into the tumor through the same access, and controlled heat is used to destroy tumor tissue within the bone; cement is then injected to restore structural support. The two work together: ablation addresses the tumor and the pain fibers, and the cement addresses the mechanical failure. Radiation therapy takes weeks to relieve pain and does nothing for the bone's strength, so ablation and augmentation are often used alongside it rather than instead of it.

This work is coordinated with medical and radiation oncology, and it can usually be done between systemic therapy cycles without interrupting cancer treatment.

What to expect

The day itself, and the days after

Risks, stated plainly. The most common finding is cement extending slightly beyond the vertebral body, which is usually seen on imaging and causes no symptoms. Less common are infection, bleeding, nerve irritation, and a new fracture at an adjacent level. Rare but serious complications include cement entering a vein and travelling to the lungs, and injury to nerve tissue. Vertebral augmentation is a well-established procedure with a low complication rate in experienced hands, but it is not a zero-risk one.

Experience

Why experience matters here

Kyphoplasty looks simple on a diagram and is not simple in practice. The judgment sits in the parts a diagram cannot show: reading which level on the MRI is actually generating the pain when three vertebrae look abnormal; choosing a needle trajectory in a pedicle that osteoporosis has left narrow and soft; knowing when the cement is at the right viscosity to advance and when to stop; and recognizing the case that should be sent to a spine surgeon instead.

Questions patients ask

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