Spinal surgeon Sotiris Papastefanou is one of a handful of UK specialists to use kyphoplasty. So far the Middlesbrough-based surgeon has treated four patients with serious spinal fractures at James Cook University Hospital in this way.

Although the procedure is still experimental and carries some risk of paralysis, patients have been willing to have the operation. If it succeeds, it can bring virtually full mobility back to patients whose bodies have been immobilized by serious spinal fractures caused by the brittle bone disease osteoporosis.

Unlike conventional operations, it involves injecting cement the consistency of toothpaste into the decayed vertebrae.

The aim is to stabilize the spine and remove the source of pain.

Unlike a similar operation called vertebroplasty, which squirts cement into a fracture under pressure, kyphoplasty utilizes a tiny balloon.

Guided by X-rays, the surgeon makes a tiny hole in the patient's back and pushes a thin tube, or cannula, into the fracture. Then a miniature, deflated balloon is fed into the tube and pushed into the vertebrae. As it is slowly inflated, it pushes aside weak, damaged bone which helps to prevent any leaks.

Once the surgeon is satisfied the vertebrae is ready, the balloon is withdrawn and cement is fed down the cannula and into the void created by the balloon.

Amazing Progress

Patient David Coverdale from Redcar underwent kyphoplasty at James Cook hospital earlier this year after suffering a recurrence of a spinal problem.

"I was working in the garden and when I bent down, I suddenly heard a cracking sound and was in terrific pain, " says Mr Coverdale, 54, a retired army officer.

He was taken to James Cook hospital by ambulance and seen by Mr. Papastefanou, who diagnosed a fractured vertebrae, caused by an underlying weakness in his bones.

It was during that first meeting that Mr. Papastefanou told Mr. Coverdale that a procedure which was in its infancy might help him.

Warned that it could be dangerous, Mr. Coverdale decided to give it a go: The alternative was to spend the rest of his life in great pain and virtual immobility.

"I could hardly move at all, and I was on lots of painkillers. I thought, why not give it a go?" he says.

After an MRI scan, the surgeon recommended that Mr. Coverdale should undergo kyphoplasty. Performed under a general anesthetic, the procedure went well.

"For about three days, I took pain killers. Then I was told I could stop, " said Mr. Coverdale.

After a few days bed rest, Mr. Coverdale was amazed to find that he was virtually back to the way he was before his fracture. "I was up and about and walking again. I couldn't believe the improvement, " he says.

Within a fortnight of the operation, Mr. Coverdale felt well enough to go on holiday with his wife Jane Anne and 18-yearold son to Turkey and, months after the operation, he is still much better, although he has developed an unrelated problem with his hip. "I feel about a thousand times better than I did. Before the operation, I could only walk about 30 yards. Within a day or two, I could walk the mile from our house into town."

Risky Procedure

Mr. Papastefanou is delighted at the progress of Mr. Coverdale but cautions that kyphoplasty is only suitable for a very small number of specially selected patients with spinal problems.

"We consider people with a history of previous compression fractures caused by osteoporosis, those with pain which is not amenable to treatment and where MRI scans suggest that they may be suitable, " says Mr. Papastefanou.

He always goes out of his way to explain to patients that there is a risk associated with the operation. It is possible that cement might escape through tiny splits in the vertabrae which are too small to be seen on an MRI monitor. If this happens it can interfere the patient's spinal cord, causing varying degrees of paralysis.

Mr. Papastefanou has performed about ten vertebroplasty procedures compared to four kyphoplasty operations. From his experience, he believes there is less chance of leakage onto the spinal cord from the procedure involving a balloon.

Both procedures are carried out in America and Europe, but Mr. Papastefanou is not convinced that they should be offered to large numbers of patients with spinal fractures.

"The Americans are saying that everyone should have an injection of cement but this has not been our impression, " he says. "We believe we need to be much more selective and try medication, a brace or pain control before considering these procedures."

Kyphoplasty costs the NHS around 5,500 a time and vertebroplasty costs around 3,000 but Mr. Papastefanou argues that this cost should be set against the high cost of 24 hour care for spinal patients who become completely incapacitated by their condition.

"In extreme cases the alternative might be to completely sedate someone and look after them around the clock, which would cost the NHS thousands of pounds a week. We could also implant a device which breaks pain pathways to brain but that would cost 20,000 just for the equipment, " he says.

The use of cement in the treatment of spinal patients began in France in the 1980s when surgeons tried to counteract the effect of spinal cancer by injecting stabilizing man-made materials into vertebrae.

Mr. Papastefanou frequently operates on patients where cancer has spread to the spine and is considering whether injections of a material which stimulates the growth of new bone, rather than cement, could have a role to play.

"At the moment we are talking about major surgery, which can last eight to 12 hours, to remove tumors, " he adds.

Bright Future for Spinal Surgery

The popular Greek surgeon is very keen to stress that he is just part of a team at James Cook. But he is also ambitious for the future.

"In the wider context, we are moving forward towards creating unified spinal surgery services in this trust. It will mean there will be an array of people dedicated to spine surgery, using the newest, most up-to-date techniques, " he says.

The range of serious spinal conditions referred to him from all over the NorthEast and North Yorkshire is daunting.

Apart from patients with crumbling vertebrae, he also sees children and adults with deformed backs and necks and other patients with spinal tumors. But he is optimistic about the future, and confident that services for spinal patients will improve.

"This is a very good time to be a spinal surgeon, " he says. "It is a very exciting area to be in and a lot of progress is being made."

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