Utilizing Left Lateral Decubitus Positioning for Transpedicular Kyphoplasty in Patient with Significant COPD & Respiratory Burden

Alexander Wellford, MD, Andrew Barker, MD, Hazem Eissa, MD, Jessin John, MD 

Background

Vertebral Compression Fractures

Vertebral compression fractures are the most common complication of osteoporosis with approximately 700,000 confirmed cases per year in the US accounting for nearly half of the 1.5 million osteoporotic fractures annually (1).

Bone mineral density begins to decline in both men and women around the 5th decade of life, however this process is markedly accelerated in postmenopausal women due to the loss of bone protective estrogens (2).

The development of osteoporosis is a multifactorial process that is influenced by genetics, age of puberty onset, sedentary lifestyle, low body mass index, insufficient dietary calcium, insufficient vitamin D status, glucocorticoid use, smoking, and alcohol abuse (1).

Vertebral Augmentation

Conservative measures are generally trialed for a 6-week period. If the patient continues to have significant pain or fracture progression on imaging, then vertebral augmentation should be considered.

Ideal candidates often have pain and tenderness around the fracture that increases with axial loading and are typically in the subacute phase before healing is complete. 

Case Report

Our patient is a 65-year-old man with history of advanced chronic obstructive pulmonary disease, congestive heart failure, and osteoporosis. The patient had initially presented to the pain clinic with approximately 4 months of midline thoracic and lumbar back pain. He states that his symptoms have been worsening and acutely worsened after picking up his dog when he felt a pop in his lower back.

Left Lateral Decubitus Kyphoplasty

The patient was initially placed in prone position in the cath lab to optimize imaging. However, due to his advanced COPD and congestive heart failure, the patient was unable to tolerate this position and had significant respiratory distress. In lieu of aborting the procedure, the decision was made to attempt left lateral decubitus positioning to improve respiratory mechanics while still optimizing patient positioning. The patient then underwent successful transpedicular kyphoplasty at L2 and T9. Much time and attention were directed toward stable positioning of the patient as he was more mobile in this position as compared to the conventional prone position. 

Discussion