Kyphoplasty for the treatment of vertebral compression fractures with anterior vertebral wall destruction: how can we do it better?

It was with great interest that we read the article by Lim et al, “Kyphoplasty for the Treatment of Vertebral Compression Fractures in a Cancer Patient with Neurological Deficits and Anterior Vertebral Wall Destruction,” published in the 2011 November/December issue of Pain Physician (1). This is a well-prepared case report which introduces a new cement injection technique used in kyphoplasty for the treatment of vertebral compression fractures with anterior vertebral wall destruction. The technique mentioned in the article is a slow injection of highly viscous bone cement posterior to the anterior vertebral defect to build a barrier, followed by a second injection 10 minutes later to allow the previously injected cement to harden. It is emphasized that the first injected bone cement used as a barrier should be thicker than usual to minimize the risk of accidental leakage. The viewpoint of the author is right, but we have some disagreement on the amount of bone cement used as a barrier and delayed time between the 2 injections. We suggest using a smaller amount of bone cement to protect against anterior leakage (2-4). The reason is that if the cement used as a barrier, as mentioned in the article, is too thick, then the second injected cement could become separated from the first after the operation, especially when the time between injections is too long (Fig. 1). In the article a second injection is given 10 minutes later to allow the previously injected cement to harden. Ten minutes is a really long time. As senior orthopedic surgeons, my co-authors and I are well aware that just after the first filling has solidified (usually no more than 3 minutes), late-stage bone cement in the paste phase should be applied to allow the filling to diffuse evenly, and then the second injection and “barrier” could be integrated together as one part (Fig. 2). In summary, to patients with vertebral compression fractures with anterior vertebral wall destruction, we also advise the “barrier technique” to minimize anterior leakage of the cement. However, the amount of