Vertebral infection after kyphoplasty: distinguishing misdiagnosis from true postoperative infection and implications for management.

BACKGROUND

Spinal infection following percutaneous kyphoplasty (PKP) is rare but clinically devastating. However, its true incidence, diagnostic challenges, and optimal revision strategies remain poorly defined, particularly in referral-based cohorts.

METHODS

We conducted a retrospective study comprising two components: (1) an institutional incidence analysis of 6,328 PKP procedures performed between 2015 and 2025, and (2) a pooled clinical cohort of 39 patients treated for post-PKP spinal infection, including 3 hospital-acquired cases and 36 referred cases. Patients were managed with either surgical (n = 27) or conservative (n = 12) strategies. Within the surgical group, a selective cement management approach (complete removal vs. partial retention) was applied based on intraoperative assessment. Clinical, microbiological, and radiographic data were analyzed descriptively. Functional outcomes were assessed using the Oswestry Disability Index (ODI).

RESULTS

The institutional incidence of post-PKP infection was 0.05% (3/6328). In the pooled cohort (n = 39), the median age was 72 years, all patients presented with back pain, and fever was present in 20 patients. Potential etiologies included hematogenous spread, preoperative misdiagnosis, and iatrogenic factors. Eight cases of spinal tuberculosis were initially misdiagnosed as osteoporotic fractures. Microbiological confirmation was limited, with low culture positivity. Surgical management was associated with lower ODI scores at final follow-up compared to conservative treatment; however, interpretation is limited by baseline imbalance and selection bias. Among surgically treated survivors, infection control and radiographic fusion were observed at final follow-up. No recurrence was recorded in 8 carefully selected patients managed with partial cement retention; however, this observation remains limited by the small subgroup size and the absence of matched controls.

CONCLUSIONS

Post-PKP vertebral infection is uncommon but clinically challenging and often complicated by diagnostic uncertainty. Surgical debridement and stabilization may be useful in selected patients. Partial cement retention can be considered only in selected situations, and its wider use requires further validation.