A Longitudinal Cohort Investigation of the
Development of Symptomatic Adjacent Level
Compression Fractures Following Balloonassisted Kyphoplasty in a Series of 726 Patients
Authors: Gerszten Peter C. 
Published: February 2021

Background: Balloon-assisted kyphoplasty (BAK) is a well-accepted treatment for symptomatic
vertebral compression fractures (VCF) secondary to osteoporosis. Some have raised a concern of
an increased incidence of adjacent fractures due to alterations in spine biomechanics after cement
augmentation. The incidence of subsequent VCFs following BAK is poorly understood. The aim of
this study was to investigate the timing, location, and incidence of new VCFs following BAK and to
identify risk factors associated specifically with the occurrence of new adjacent level fractures.
Objectives: The study was performed to determine the incidence of symptomatic subsequent
adjacent and remote level compression fractures in a cohort of patients undergoing BAK.
Study Design: Longitudinal cohort investigation at an academic medical center and a central
referral center for VCFs.
Setting: A consecutive single surgeon series of 726 patients with osteoporotic compression fractures.
Methods: A prospectively collected cohort of 726 patients who underwent BAK between 2001 and
2014 for osteoporotic VCFs was evaluated. Seventy-seven patients were identified who underwent
a second BAK for a new compression fracture and were include in the present series. The indication
for BAK treatment was pain unresponsive to non-surgical management for all cases. Variables were
recorded for each patient, including the time between index and subsequent fracture, fracture level, and
number of initial fractures as well as with tobacco use, body mass index (BMI), and chronic steroid use.
Results: Seventy-seven of 726 patients (10.6%) underwent a second BAK procedure on average
350 days following the initial procedure (range 21 to 2,691 days). Third and fourth procedures were
less common, treated in 11 and 3 patients, respectively. Forty-eight of 77 patients (62%) suffered a
fracture at a level immediately adjacent to the index level at mean time of 256 days. Remote level
fractures were treated at a mean time of 489 days, but no statistical difference was noted. There was
no statistically significant difference between tobacco use, BMI, and chronic steroid use between
patients suffering from remote and adjacent level VCFs.
Limitations: This was not a population based study, and the true incidence of subsequent fractures
after BAK might be underestimated by this analysis.
Conclusions: Symptomatic compression fractures after BAK are relatively uncommon and may occur
long after the initial kyphoplasty procedure. Only half of subsequent fractures occur immediately adjacent
to the initially treated level; the others occur remotely. Patients with a single symptomatic thoracic or
lumbar fracture suffered from remote and adjacent level fractures equally. In contrast, all patients who
suffered both a thoracic and lumbar fracture at the same time had a second fracture at an adjacent level.
Specific risk factors for remote versus adjacent level fractures could not be determined.
Key words: Balloon kyphoplasty, cement augmentation, osteoporosis, vertebral compression
fracture, adjacent level fracture, vertebroplasty