Vertebroplasty and epiduroscopy as seen by interventional radiologist

Two minimally-invasive techniques in the spinal region are introduced: vertebroplasty and epiduroscopy. Vertebroplasty is mostly used in the treatment of osteoporotic vertebral body fractures, as well as in the palliative treatment of spinal metastases or symptomatic hemangiomas. It is usually performed under fluoroscopic, and often also CT control under analgesic sedation. If correctly indicated an analgesic effect occurs in roughly 90 % of patients. Epiduroscopy is a new technique, which is promising especially in patients with failed back surgery syndrome; patients with clinically-symptomatic fibrous adhesions, generally after repeated surgery. If correctly indicated a positive effect occurs in roughly one third to one half of patients.

Efficacy of percutaneous vertebroplasty treatment of spinal tumors: A meta-analysis

OBJECTIVE

To evaluate the function of percutaneous vertebroplasty (PVP) treatment to pain relief and life quality for patients with spinal tumors.

METHODS

Articles about the researches on the treatment of spinal tumors by PVP in PubMed, Embase, and the Chinese Biomedical Literature database from January 1, 2015 to December 31, 2013. The keywords "spinal tumors," "efficacy," and "vertebroplasty" were firstly scanned to exclude all irrelevant articles. Then, the final inclusion of studies was determined by reading the full text of the remaining articles. The citation lists of all retrieved articles were scanned to identify other potentially relevant reports. RevMan5.2 was used to analyze pain intensity visual analog scale (VAS) and Karnofsky performance scores (KPS) within each research. Combined HRs (hazard ratio) were calculated using fixed- or random- effects models according to the heterogeneity.

RESULTS

Twenty-six studies involving 1351 patients met our selection criteria. Meta-analysis results among 10 case-control studies showed that the combined HR was -2.83 [95% confidence interval (CI) -2.92, -2.73; P < .0001], indicating a 2.83-fold decrease of pain in PVP group. For 12 single-arm studies, a significantly decrease of pain after PVP treatment (HR = -4.79, 95% CI -5.00, -4.57, P < .0001) was also found in PVP group. In addition, for KPS analysis, the combined HR was 16.31 (95% CI 14.31, 18.31; P < .0001), which indicated that PVP treatment was associated with a 16.31-fold increase of KPS. The combined HR was 0.58 (95% CI 0.35, 0.96; P = .04) for complication analysis.

CONCLUSIONS

PVP treatment of spinal tumor is significantly associated with better pain relief and life quality, which could improve the outcome in metastatic spinal tumor patients.

Synthesis and Characterization of an Injectable and Hydrophilous Expandable Bone Cement Based on Poly(methyl methacrylate)

Poly(methyl methacrylate) (PMMA), the most common bone cement, has been used as a graft substitute in orthopedic surgeries such as vertebroplasty. However, an undesirable minor crack in the bone-cement interface provoked by shrinkage during polymerization and high elastic modulus of conventional PMMA bone cement dramatically increases the risk of vertebral body refracture postsurgery. Thus, herein, a hydrophilous expandable bone cement was synthesized based on a PMMA commercial cement (Mendec Spine Resin), acrylic acid (AA), and styrene (St). The two synthesized cements (PMMA-PAA, PMMA-PAA-PSt) showed excellent volumetric swelling in vitro and cohesive bone-cement contact in rabbit femur cavity defect. The elastic modulus and compressive strength of the new cements were lower than PMMA. Furthermore, the in vitro analysis indicated that the new cements had lower cytotoxicity than PMMA, including superior proliferation and lower apoptotic rates of Sprague-Dawly rat-derived osteoblasts. Western blotting for protein expression and RT-PCR analysis of osteogenesis-specific genes were conducted on SD rat-derived osteoblasts from both PMMA and new cements films; the results showed that new cements enhanced the expression of osteogenesis-specific genes. Scanning electron microscopy demonstrated improved morphology and attachment of osteoblast on new cement discs compared to the PMMA discs. Additionally, the histological morphologies of the bone-cement interface from the rabbit medial femoral condyle cavity defect model revealed direct and cohesive contact with the bone in the new cement groups in contrast to a minor crack in the PMMA cement group. The sign of a new bone growing into the cement has been found in the new cements after 12 weeks, thereby indicating the osteogenic capacity in vivo. In conclusion, the synthesized hydrophilous expandable bone cements based on PMMA and poly(acrylic acid) (PAA) are promising candidates for vertebroplasty.

Open C2 Vertebroplasty: Case Report, Technique, and Review of Literature

Osteolytic lesions of C2 are challenging pathologies to manage. Vertebroplasty, a minimally invasive technique has been widely used in lytic lesions of thoracic and lumbar spine. However, there has been limited experience with percutaneous vertebroplasty at C2, and the procedure is technically difficult. We describe a safer alternative technique of open vertebroplasty for lytic lesions involving the axis. Methods: The procedure was performed in a 49-year-old male with a metastatic lytic lesion involving the body and dens of C2 using an anterior cervical approach. The patient had an immediate reduction in pain with complete pain relief at 2 weeks and good stability at 3-month follow-up. The patient did not have any perioperative or postoperative complications. The anterior cervical approach open C2 vertebroplasty is a safe and effective option in the management of C2 osteolytic lesions.

Biomechanical behavior of novel composite PMMA-CaP bone cements in an anatomically accurate cadaveric vertebroplasty model

Vertebral compression fractures are caused by many factors including trauma and osteoporosis. Osteoporosis induced fractures are a result of loss in bone mass and quality that weaken the vertebral body. Vertebroplasty and kyphoplasty, involving cement augmentation of fractured vertebrae, show promise in restoring vertebral mechanical properties. Some complications however, are reported due to the performance characteristics of commercially available bone cements. In this study, the biomechanical performance characteristics of two novel composite (PMMA-CaP) bone cements were studied using an anatomically accurate human cadaveric vertebroplasty model. The study involves mechanical testing on two functional cadaveric spinal unit (2FSU) segments which include monotonic compression and cyclical fatigue tests, treatment by direct cement injection, and microscopic visualization of sectioned vertebrae. The 2FSU segments were fractured, treated, and mechanically tested to investigate the stability provided by two novel bone cements; using readily available commercial acrylic cement as a control. Segment height and stiffness were tracked during the study to establish biomechanical performance. The 2FSU segments were successfully stabilized with all three cement groups. Stiffness values were restored to initial levels following fatigue loading. Cement interdigitation was observed with all cement groups. This study demonstrates efficient reinforcement of the fractured vertebrae through stiffness restoration. The pre-mixed composite cements were comparable to the commercial cement in their performance and interdigitative ability, thus holding promise for future clinical use. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2067-2074, 2017.

Percutaneous cement augmentation for osteoporotic vertebral fractures

Thoracolumbar vertebral fracture incidents usually occur secondary to a high velocity trauma in young patients and to minor trauma or spontaneously in older people.

Osteoporotic vertebral fractures are the most common osteoporotic fractures and affect one-fifth of the osteoporotic population.

Percutaneous fixation by ‘vertebroplasty’ is a tempting alternative for open surgical management of these fractures.

Despite discouraging initial results of early trials for vertebroplasty, cement augmentation proved its superiority for the treatment of symptomatic osteoporotic vertebral fracture when compared with optimal medical treatment.

Early intervention is also gaining ground recently.

Kyphoplasty has the advantage over vertebroplasty of reducing kyphosis and cement leak.

Stentoplasty, a new variant of cement augmentation, is also showing promising outcomes.

In this review, we describe the additional techniques of cement augmentation, stressing the important aspects for success, and recommend a thorough evaluation of thoracolumbar fractures in osteoporotic patients to select eligible patients that will benefit the most from percutaneous augmentation. A detailed treatment algorithm is then proposed.

Cite this article: EFORT Open Rev 2017;2:293–299. DOI: 10.1302/2058-5241.2.160057

Vertebroplasty for vertebral compression fractures: Placebo or effective?

Vertebral compression fractures (VCFs) are a major cause of pain and disability. Here, we reviewed six randomized control trials (RCTs) focusing on the efficacy vs. placebo effect of vertebroplasty (VP) for symptomatic VCF. Four RCTs involved a nonsurgically treated control group. Two RCTs compared the use of VP vs. a sham surgery control group. Notably, RCTs comparing nonsurgically treated patients as a control group vs. those undergoing VP uniformly reported that VP contributed to improved pain relief. In contrast, RCTs comparing sham surgery vs. VP uniformly reported no significant differences between the two groups.

Preparation and characterization of injectable PMMA-strontium-substituted bioactive glass bone cement composites

In most minimally-invasive procedures used to address severe pain arising from compression fractures of the vertebral bodies, such as percutaneous vertebroplasty (PVP), a poly(methyl methacrylate) (PMMA) bone cement is used. Shortcomings of this type of cement, such as high exotherm temperature and lack of bioactivity, are well known. We prepared different formulations of a composite bone cement, whose solid constituents consisted of PMMA beads and particles of a bioactive glass (BG), where 0-20%(w/w) of the calcium component was substituted by strontium. The difference between the formulations was in the relative amounts of the solid phase constituents and in the Sr-content of BG. We determined the influence of the mixture of solid phase constituents of the cement formulation on a collection of properties, such as maximum exotherm temperature (T_max ), setting time (t_set ), and injectability (I). The selection of the PMMA beads was crucial to obtain cement composite formulations capable to be efficiently injected. Results allowed to select nine solid phase mixtures to be further tested. Then, we determined the influence of the composition of these composite bone cements on T_max , t_set , I, and cell proliferation. The results showed that the performance of various of the selected composite cements was better than that of PMMA cement reference, with lower T_max , lower t_set , and higher I. We found that incorporation of Sr-substituted BGs into these materials bestows bioactivity properties associated with the role of Sr in bone formation, leading to some composite cement formulations that may be suitable for use in PVP. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 1245-1257, 2018.

Decision Making: Osteoplasty, Ablation, or Combined Therapy for Spinal Metastases

Metastatic disease involving the spine and pelvis is common, often resulting in significant pain and disability. Several percutaneous interventions have been described, including osteoplasty, ablation, and screw fixation, that when used alone or in combination can significantly reduce pain and disability from metastatic bone disease. Although it is possible to make a significant impact in patient care with basic principles and techniques, certain advanced techniques can extend the application of percutaneous interventions while minimizing morbidity.

Comparison of the efficacy and safety of 3 treatments for patients with osteoporotic vertebral compression fractures: A network meta-analysis

BACKGROUND

Osteoporotic vertebral compression fractures (OVCFs) constitute an age-related health problem that affects approximately 200 million people worldwide. Currently, various treatments are performed with the goal of reducing pain, stabilizing the vertebrate, and restoring mobility. In this study, we aimed to assess the efficacy and safety of vertebroplasty (VP), kyphoplasty (KP), and conservative treatment (CT) for the treatment of OVCFs.

METHODS

We performed a network meta-analysis. PubMed and Embase databases were searched to identify randomized controlled trials (RCTs) that contained at least one of the following outcomes: visual analog scale (VAS), Roland-Morris Disability Questionnaire (RDQ), European Quality of Life-5 Dimensions (EQ-5D), and new fractures. Odds ratios with 95% confidence intervals (CIs) were used to calculate the risk of new fractures, and mean differences (MDs) with 95% CIs were utilized to express RDQ, EQ-5D, and VAS outcomes.

RESULTS

Sixteen RCTs with 2046 participants were included in this meta-analysis. Compared with CT, patients treated with VP had improved pain relief, daily function, and quality of life; however, no significant differences were found between VP and KP for these 3 outcomes. All treatment options were associated with comparable risk of new fractures. When the rank probability was assessed to distinguish subtle differences between the treatments, VP was the most effective treatment for pain relief, followed by KP and CT; conversely, KP was the most effective in improving daily function and quality of life and decreasing the incidence of new fractures, followed by VP and CT.

CONCLUSION

VP might be the best option when pain relief is the principle aim of therapy, but KP was associated with the lowest risk of new fractures and might offer better outcomes in terms of daily function and quality of life.

Clinical management of osteoporotic vertebral fracture treated with percutaneous vertebroplasty

Our study demonstrated percutaneous vertebroplasty (PVP) is an effective procedure to rapidly reduce back pain in patients affected by acute osteoporotic vertebral compression fractures (OVCFs) assessed by MRI. We confirmed in our sample, femoral bone density impacts more deeply than vertebral T-score and/or BMD on bone strenght, as it is less affected by any interferences. We interestingly found the presence of previous osteoporotic fragility fractures and chronic glucocorticoids therapy should especially negatively influence bone health of our patients. On the other hand, even if both FRAX scores for major osteoporotic fractures and for femoral fractures seemed to globally define a population at major risk for fragility fractures, our analysis is retrospectively done. We choose and suggest a multidisciplinary medical management of these patients, considering OP is a multifactorial disease and OVCFs usually produce lots of different important consequences on general health.

Treating osteoporotic vertebral compression fractures with intraosseous vacuum phenomena using high-viscosity bone cement via bilateral percutaneous vertebroplasty

Osteoporotic vertebral compression fractures with intraosseous vacuum phenomena could cause persistent back pains in patients, even after receiving conservative treatment. The aim of this study was to evaluate the efficacy of using high-viscosity bone cement via bilateral percutaneous vertebroplasty in treating patients who have osteoporotic vertebral compression fractures with intraosseous vacuum phenomena.Twenty osteoporotic vertebral compression fracture patients with intraosseous vacuum phenomena, who received at least 2 months of conservative treatment, were further treated by injecting high-viscosity bone cement via bilateral percutaneous vertebroplasty due to failure of conservative treatment. Treatment efficacy was evaluated by determining the anterior vertebral compression rates, visual analog scale (VAS) scores, and Oswestry disability index (ODI) scores at 1 day before the operation, on the first day of postoperation, at 1-month postoperation, and at 1-year postoperation.Three of 20 patients had asymptomatic bone cement leakage when treated via percutaneous vertebroplasty; however, no serious complications related to these treatments were observed during the 1-year follow-up period. A statistically significant improvement on the anterior vertebral compression rates, VAS scores, and ODI scores were achieved after percutaneous vertebroplasty. However, differences in the anterior vertebral compression rate, VAS score, and ODI score in the different time points during the 1-year follow-up period was not statistically significant (P > 0.05).Within the limitations of this study, the injection of high-viscosity bone cement via bilateral percutaneous vertebroplasty for patients who have osteoporotic vertebral compression fractures with intraosseous vacuum phenomena significantly relieved their back pains and improved their daily life activities shortly after the operation, thereby improving their life quality. In this study, the use of high-viscosity bone cement reduced the leakage rate and contributed to their successful treatment, as observed in patients during the 1-year follow-up period.

Minimally Invasive Surgical Techniques for Management of Painful Metastatic and Primary Spinal Tumors

Patients with metastatic spinal disease are affected by disabling pain. The treatment of spinal metastases is focused on pain reduction and improvement in quality of life. Until recently, many patients with metastatic spinal disease did not qualify as surgical candidates due to the risks of surgery and length of recovery period. However, recent advances in minimally invasive surgery such as kyphoplasty and vertebroplasty allow patients to safely undergo surgery for pain relief with a short recovery period.

The studies reviewed here suggest that vertebral augmentation is successful in reducing pain and disability scores in patients with painful metastases and multiple myeloma and are a safe modality to provide lasting pain relief. As the use of kyphoplasty and vertebroplasty for treatment of vertebral metastases is becoming more common, new combinations of cement augmentation with other techniques such as percutaneous pedicle screws and radiofrequency ablation are being explored. The implementation of kyphoplasty and vertebroplasty, in conjunction with other minimally invasive surgical techniques as well as nonsurgical modalities, may lead to the best palliative management of cancer patients with spinal metastases and help them ultimately achieve a better quality of life.

Quality of Life in Patients Following Vertebroplasty

AIM

To examine the quality of life in patients who underwent vertebroplasty treatment and compare it to the preoperative quality of life.

STUDY DESIGN

The Cross-sectional study conducted at the Department of Orthopaedics, Clinical Hospital Centre Osijek.

PATIENTS AND METHODS

The research included 50 patients under stationary treatment in hospital at the Department of Orthopaedics. The research instruments include a questionnaire containing demographic data and the standardised EuroQuol Research Foundation Questionnaire (EQ-5D-5L) consisting of five dimensions which include mobility, self-care, usual activities, pain level and anxiety.

RESULTS

The average score of the current health status before surgery was 67.5 whereas post-operative health was rated 80 (p < 0.001). After the procedure, a significantly higher number of respondents reported greater mobility levels, and lower pain intensity; fewer respondents reported feeling anxious or depressed (p < 0.001), more respondents rated their self-care abilities higher (p = 0.003), and felt improvements when performing usual activities (p = 0.031).

CONCLUSION

After the vertebroplasty, a significantly higher number of respondents reported higher levels of mobility, lower pain or discomfort levels, and a smaller number of respondents felt anxious or depressed, more respondents felt they can take better care of themselves, and are better at performing usual activities when compared to the preoperative status.

Evaluation and Interventional Management of Pain After Vertebral Augmentation Procedures

Introduction

A small subset of patients who underwent successful vertebral compression fracture (VCF) augmentation procedures may develop subsequent pain requiring spinal injections. In a retrospective analysis, we determined whether the pain was related to the original fracture site or to another area within the lumbar or thoracic spine. The pain occurred either at the same/adjacent level and/or non-adjacent level as the VCF. Interventional treatments primarily targeted the facet joints, specifically in the form of facet joint blocks and/or radiofrequency ablation to the medial branches. The pattern of facet injections relative to the original fracture level was studied. Additionally, the elapsed time between the vertebral augmentation and the subsequent interventional blocks was also evaluated.

Methods

A total of 56 patients sustained VCFs. 12 of these patients underwent interventional procedures after vertebral augmentation procedures. The level(s) of same/adjacent level and non-adjacent level pain were determined via physical examination and/or imaging studies. These levels were subsequently treated with interventional procedures primarily focused on the facet joints. The time period of the injections varied from two weeks status post-vertebral augmentation to as late as 304 weeks (5.8 years) status post-vertebral augmentation.

Results

We performed 25 vertebral augmentation procedures on these 12 patients. 15 lumbar, eight lower thoracic, and two mid-thoracic VCFs were augmented. 9/14 cases of blocks included those performed at non-adjacent levels, whereas 5/14 cases of blocks were performed only at the same and/or adjacent levels as the VCF. For the events in which thoracic VCFs were augmented, 6/7 (or 86%) had developed non-adjacent level pain in areas of the lumbar spine. 

The time from vertebral augmentation procedure to subsequent pain procedure ranged from two weeks to five plus years. The average time elapsed was 83 weeks. Only one case required blocks performed within the first six weeks after vertebral augmentation. In this case, the blocks included those at non-adjacent levels. A total of 4/12 cases (33%) had a block within 12 weeks of the original vertebral augmentation procedure.

Lumbar spine imaging showed that at least 9/12 patients had pre-existing significant lumbar pathology at the time of fracture treatment. This may have contributed to the later development of pain.

Conclusion

Pain after a successful vertebral augmentation is typically non-acute (i.e., beyond six weeks). Mechanisms other than the primary VCF are usually responsible for non-adjacent level pain, which are present a majority of the time on reviewing the patients' diagnostic studies. These mechanisms usually take many weeks to develop and subsequently elicit pain that requires additional interventional pain procedures. In our study, the pain is usually related to the pre-existing degenerative spondylosis and stenosis rather than the fracture site. This study shows that the facet joints in closely related lumbar degenerative changes are the cause of pain in this patient group. These procedures should be explored with pain after vertebral augmentation, especially in those patients with known or suspected spinal degeneration and/or poor biomechanics.

Low Volume Vertebral Augmentation with Cortoss® Cement for Treatment of High Degree Vertebral Compression Fractures and Vertebra Plana

This is a retrospective analysis of a consecutive series of patients undergoing vertebroplasty and vertebral augmentation in an outpatient setting for high degree osteoporotic vertebral fractures or vertebra plana using consistently low volumes (less than 3 cc) of Cortoss® cement, rather than polymethylmethacrylate (PMMA). The results in these patients demonstrate that it is both technically feasible to do vertebroplasty on these patients and using a low volume hydrophilic silica-based cement is effective in providing diffuse vertebral body fill with minimal complications. There was no increased risk of complications, such as cement leakage, displacement of bone fragments, or progression of the angulation. Specifically, with over a 24-month follow-up, the preoperative collapse or angulation did not worsen and none of the patients developed adjacent level fractures or required further surgery at the involved vertebral level.

[Effectiveness comparison between two operations in treatment of unstable type Kümmell's disease]

Objective

To compare the effectiveness between short segmental fixation combined with vertebroplasty (SSF+VP) and short segmental pedicle screw fixation combined with bone graft (SSF+BG) in the treatment of unstable type Kümmell's disease so as to provide a reference for the selection of the surgical method.

Methods

Between March 2013 and February 2015, 48 patients with unstable type Kümmell's disease who were in accordance with the inclusive criteria were included in the study. SSF+VP were used in 25 cases (SSF+VP group) and SSF+BG in 23 cases (SSF+BG group). There was no significant difference in gender, age, disease duration, bone mineral density, fracture segment, and preoperative visual analogue scale (VAS), Oswestry disability index (ODI), and kyphotic Cobb angle between 2 groups ( P>0.05). The operation time and complications related to operation were recorded; the effectiveness was evaluated by VAS, ODI, and kyphotic Cobb angle.

Results

The operation time was (107.7±18.8) minutes in SSF+VP group and was (113.7±22.4) minutes in SSF+BG group, showing no significant difference between 2 groups ( t=-1.045, P=0.302). Bone cement leakage occurred in 6 cases of SSF+VP group, and incision delayed healing occurred in 1 case of SSF+BG group. All patients achieved bone graft fusion on X-ray films. The bone graft fusion time was (15.1±1.3) weeks in SSF+VP group and (15.7±1.8) weeks in SSF+BG group, showing no significant difference between 2 groups ( t=-1.361, P=0.180). The VAS, ODI, and kyphotic Cobb angle at immediate after operation and at last follow-up were significantly lower than preoperative ones ( P<0.05). The VAS, ODI, and kyphotic Cobb angle had no significant difference between at immediate and at last follow-up in SSF+VP group ( P>0.05). In SSF+BG group, VAS at last follow-up was significantly lower than that at immediate after operation ( P<0.05), but no significant difference was found in kyphotic Cobb angle and ODI ( P>0.05). SSF+VP group was significantly better than SSF+BG group in VAS at immediate after operation ( P<0.05), but SSF+BG group was significantly better than SSF+VP group at last follow-up ( P<0.05). There was no significant difference in kyphotic Cobb angle and ODI between 2 groups at immediate after operation and at last follow-up ( P>0.05).

Conclusion

SSF+BG can achieve satisfactory effectiveness in the treatment of unstable type Kümmell's disease, and it has the advantages of good bony healing, obvious improvement of pain, and low complication incidence when compared with SSF+VP.

Sacral Insufficiency Fractures: Recognition and Treatment in Patients with Concurrent Lumbar Vertebral Compression Fractures

INTRODUCTION

In reviewing a larger group of osteoporotic vertebral compression fractures (VCFs), we found that the overall incidence of sacral insufficiency fractures (SIFs) is higher than commonly reported values. This is especially seen in patients with previous or concurrent lumbar VCFs and also in a subgroup that had lumbar stenosis or hip arthroplasty. The altered biomechanics due to associated lumbar stenosis or hip arthroplasty lead to increased mechanical stress on already weakened and deficient sacral alae, which are more vulnerable to osteoporotic weakening than other parts of the sacrum.

MATERIALS & METHODS

We studied an overall population of patients with VCF seen clinically and separated the patients into the following groups: patients not previously treated, patients treated with vertebroplasty or kyphoplasty at one or more levels, and patients diagnosed with sacral fractures and treated with vertebroplasty or kyphoplasty. We wanted to see if a pattern existed among the patients who had sacral symptoms, were diagnosed with sacral insufficiency fractures, and subsequently underwent sacroplasty.

RESULTS

In a review of 79 consecutive patients, over a 24-month period, with VCF who underwent surgical treatment, there were 10 patients who also had sacral insufficiency fractures. Four of the patients had sacral insufficiency fractures without VCF. None of the patients with sacral insufficiency fractures were on treatment for osteoporosis at the time of diagnosis. The following symptoms indicated SIF: lower sacral pain (n = 10), buttock pain (n = 7), lateral hip pain (n = 5), and groin pain radiating to the thigh (n = 4). The average time to diagnose SIF was two months after the onset of pain.

CONCLUSIONS

Sacral insufficiency fractures are a frequent cause of both acute and chronic pain; however, they are often missed by the majority of physicians. The frequency of undetected sacral fractures is high. This is due to a number of potential pitfalls, which include both subjective and objective reasons: the patient presenting with vague symptoms, the physician only performing a physical examination of the lumbar spine, and the physician ordering the inadequate standard lumbosacral radiographs, computed tomography (CT), or magnetic resonance imaging (MRI), as well as automatically relating the pain and other symptoms to preexisting MRI findings that are very commonly found in the elderly population. All of these pitfalls lead to SIFs being overlooked.

Spinal Compression Fracture Management: A Review of Current Treatment Strategies and Possible Future Avenues

STUDY DESIGN

Narrative review.

OBJECTIVE

Despite the numerous treatment options for vertebral compression fractures, a consensus opinion for the management of patients with these factures has not been established. This review is meant to provide an up-to-date overview of the most common treatment strategies for compression fractures and to suggest possible routes for the development of clearer treatment guidelines.

METHODS

A comprehensive database search of PubMed was performed. All results from the past 30 years were obtained and evaluated based on title and abstract. The full length of relevant studies was analyzed for level of evidence, and the strongest studies were used in this review.

RESULTS

The major treatment strategies for patients with compression fractures are conservative pain management and vertebral augmentation. Despite potential adverse effects, medical management, including nonsteroidal anti-inflammatory drugs, calcitonin, teriparatide, and bisphosphonates, remains the first-line therapy for patients. Evidence suggests that vertebral augmentation, especially some of the newer procedures, have the potential to dramatically reduce pain and improve quality of life. At this time, balloon-assisted kyphoplasty is the procedure with the most evidence of support.

CONCLUSIONS

Based on current literature, it is evident that there is a lack of standard of care for patients with vertebral compression fractures, which is either due to lack of evidence that a procedure is successful or due to serious adverse effects encountered with prolonged treatment. For a consensus to be reached, prospective clinical trials need to be formulated with potential new biomarkers to assess efficacy of treatment strategies.

Image-guided minimally invasive percutaneous treatment of spinal metastasis

In order to provide effective options for minimally invasive treatment of spinal metastases, the present study retrospectively evaluated the efficacy and safety of image-guided minimally invasive percutaneous treatment of spinal metastases. Image-guided percutaneous vertebral body enhancement, radiofrequency ablation (RFA) and tumor debulking combined with other methods to strengthen the vertebrae were applied dependent on the indications. Percutaneous vertebroplasty (PVP) was used when vertebral body destruction was simple. In addition, RFA was used in cases where pure spinal epidural soft tissue mass or accessories (spinous process, vertebral plate and vertebral pedicle) were destroyed, but vertebral integrity and stability existed. Tumor debulking (also known as limited RFA) combined with vertebral augmentation were used in cases presenting destruction of the epidural soft tissue mass and accessories, and pathological vertebral fractures. A comprehensive assessment was performed through a standardized questionnaire and indicators including biomechanical stability of the spine, quality of life, neurological status and tumor progression status were assessed during the 6 weeks-6 months follow-up following surgery. After the most suitable treatment was used, the biomechanical stability of the spine was increased, the pain caused by spinal metastases within 6 weeks was significantly reduced, while the daily activities and quality of life were improved. The mean progression-free survival of tumors was 330±54 days, and no associated complications occurred. Therefore, the use of a combination of image-guided PVP, RFA and other methods is safe and effective for the treatment of spinal metastases.

Surgical treatment of secondary fractures after percutaneous vertebroplasty: A retrospective study

BACKGROUND

Percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) are effective procedures for the treatment of vertebral compression fractures (VCFs). However, recent studies have reported that secondary VCFs develop in patients after PVP or PKP treatment. This study aimed to investigate the clinical characteristics and management of secondary fractures after PVP or PKP.

MATERIALS AND METHODS

599 cases who had vertebral compression fracture and underwent PVP or PKP between September 2008 and June 2014 were enrolled, including 121 males and 478 females. Secondary fractures were observed in 52 cases, including 3 males and 49 females, who were treated by re-operation with PVP or PKP.

RESULTS

The ratio of secondary fracture after PVP or PKP was 8.68% in all cases. The age ranged from 59 to 92 years (74.41 ± 6.83 average). A composition of 44.44% of the secondary fracture occurred near the initial fracture vertebrae. After re-operation with PVP or PKP, visual analog scale score significantly decreased to 2.72 ± 0.88 or 2.52 ± 1.12, respectively, anterior height of vertebral bodies increased to 24.69 ± 4.59 or 24.54 ± 5.97 mm, respectively, and middle height of vertebral bodies increased to 20.90 ± 3.72 or 20.36 ± 6.33 mm, respectively.

CONCLUSIONS

There is a high chance of secondary fracture near the initially operated vertebrae after PVP or PKP. Re-operation with PVP or PKP achieves satisfactory outcomes in these patients such as pain relief and the recovery of the vertebrae height.

Small cavity creation in the vertebral body reduces the rate of cement leakage during vertebroplasty

Cement leakage is the most common complication during vertebroplasty and may result in serious morbidity. Measures to reduce the rate of cement leakage are valuable ways to improve vertebroplasty safety. The present study aimed to evaluate whether creating a small cavity in the vertebral body prior to cement injection would reduce the rate of cement leakage during vertebroplasty. The study included 36 consecutive patients with 42 painful osteoporotic vertebral body compression fractures that were classified as A1 fractures according to AO classification. Patients were randomly assigned to receive either treatment with vertebroplasty (control) or with a procedure termed cavuplasty, in which a small cavity was created in the vertebral body prior to cement injection. CT scanning was performed to detect cement leakage. Cement leakage was observed in 14 (66.6%) of the 21 vertebral bodies treated with vertebroplasty and 5 (23.8%) of the 21 vertebral bodies treated with cavuplasty (p = 0.012). These results suggest that the creation of a small cavity in the vertebral body prior to cement injection is an effective way to reduce cement leakage during vertebroplasty. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:154-159, 2017.

Analysis of the spinal nerve roots in relation to the adjacent vertebral bodies with respect to a posterolateral vertebral body replacement procedure

OBJECTIVE

This study aims to improve the understanding of the anatomic variations along the thoracic and lumbar spine encountered during an all-posterior vertebrectomy, and reconstruction procedure. This information will help improve our understanding of human spine anatomy and will allow better planning for a vertebral body replacement (VBR) through either a transpedicular or costotransversectomy approach.

SUMMARY OF BACKGROUND DATA

The major challenge to a total posterior approach vertebrectomy and VBR in the thoracolumbar spine lies in the preservation of important neural structures.

METHODS

This was a retrospective analysis. Hundred normal magnetic resonance imaging (MRI) spinal studies (T1-L5) on sagittal T2-weighted MRI images were studied to quantify: (1) mid-sagittal vertebral body (VB) dimensions (anterior, midline, and posterior VB height), (2) midline VB and associated intervertebral discs height, (3) mean distance between adjacent spinal nerve roots (DNN) and mean distance between the inferior endplate of the superior vertebrae to its respective spinal nerve root (DNE), and (4) posterior approach expansion ratio (PAER).

RESULTS

(1) The mean anterior VB height gradually increased craniocaudally from T1 to L5. The mean midline and posterior VB height showed a similar pattern up to L2. Mean posterior VB height was larger than the mean anterior VB height from T1 to L2, consistent with anterior wedging, and then measured less than the mean anterior VB height, indicating posterior wedging. (2) Midline VB and intervertebral disc height gradually increased from T1 to L4. (3) DNN and DNE were similar, whereby they gradually increased from T1 to L3. (5) Mean PAER varied between 1.69 (T12) and 2.27 (L5) depending on anatomic level.

CONCLUSIONS

The dimensions of the thoracic and lumbar vertebrae and discs vary greatly. Thus, any attempt at carrying out a VBR from a posterior approach should take into account the specifications at each spinal level.

Biomechanical Analysis of Range of Motion and Failure Characteristics of Osteoporotic Spinal Compression Fractures in Human Cadaver

BACKGROUND

Vertebroplasty is a treatment for osteoporotic vertebral compression fractures. The optimal location of needle placement for cement injection remains a topic of debate. As such, the authors assessed the effects of location of two types of cement instillations. In addition, the motion and failure modes at the index and adjacent segments were measured.

MATERIALS AND METHODS

Seven human osteoporotic cadaver spines (T1-L4), cut into four consecutive vertebral segments, were utilized. Of these, following the exclusion of four specimens not suitable to utilize for analysis, a total of 24 specimens were evaluable. Segments were randomly assigned into four treatment groups: unipedicular and bipedicular injections into the superior quartile or the anatomic center of the vertebra using confidence (Confidence Spinal Cement System^®, DePuy Spine, Raynham, MA, USA) or polymethyl methacrylate. The specimens were subjected to nondestructive pure moments of 5 Nm, in 2.5 Nm increments, using pulleys and weights to simulate six degrees of physiological motion. A follower preload of 200 N was applied in flexion extension. Testing sequence: range of motion (ROM) of intact specimen, fracture creation, cement injection, ROM after cement, and compression testing until failure. Nonconstrained motion was measured at the index and adjacent levels.

RESULTS

At the index level, no significant differences were observed in ROM in all treatment groups (P > 0.05). There was a significant increase in adjacent level motion only for the treatment group that received a unipedicular cement injection at the anatomic center.

CONCLUSION

The location of the needle (superior or central) and treatment type (unipedicular or bipedicular) had no significant effect on the ROM at the index site. At the adjacent levels, a significant increase occurred with therapy through a unipedicular approach into the centrum of the vertebra at the treated segment.

Prophylactic vertebroplasty procedure applied with a resorbable bone cement can decrease the fracture risk of sandwich vertebrae: long-term evaluation of clinical outcomes

A sandwich vertebra is formed after multiple osteoporotic vertebral fractures treated by percutaneous vertebroplasty, which has a risk of developing new fractures. The purpose of our study was to (i) investigate the occurrence of new fractures in sandwich vertebra after cement augmentation procedures and to (ii) evaluate the clinical outcomes after prophylactic vertebral reinforcement applied with resorbable bone cement.

From June 2011 to 2014, we analysed 55 patients with at least one sandwich vertebrae and treated with percutaneous vertebroplasty. Eighteen patients were treated by prophylactic vertebroplasty with a resorbable bone cement to strengthen the sandwich vertebrae as the prevention group. The others were the non-prevention group. All patients were examined by spinal radiographs within 1 day, 6 months, 12 months, 24 months and thereafter.

The incidence of sandwich vertebra is 8.25% (55/667) in our study. Most sandwich vertebrae (69.01%, 49/71) are distributed in the thoracic–lumbar junction. There are 24 sandwich vertebrae (18 patients) and 47 sandwich vertebrae (37 patients) in either prevention group or non-prevention group, respectively. No significant difference is found between age, sex, body mass index, bone mineral density, cement disk leakage, sandwich vertebrae distribution or Cobb angle in the two groups. In the follow-up, 8 out of 37 (21.6%) patients (with eight sandwich vertebrae) developed new fractures in non-prevention’ group, whereas no new fractures were detected in the prevention group. Neither Cobb angle nor vertebral compression rate showed significant change in the prevention group during the follow-up. However, in the non-prevention group, we found that Cobb angle increased and vertebral height lost significantly (P < 0.05).

Prophylactic vertebroplasty procedure applied with resorbable bone cement could decrease the rate of new fractures of sandwich vertebrae.

Is There a Dose-Response Relationship of Cement Volume With Cement Leakage and Pain Relief After Vertebroplasty?

The aim of this study was to determine if there were dose–response relationships of cement volume with cement leakage and pain relief after percutaneous vertebroplasty (PVP) for osteoporosis vertebral compression fractures (OVCFs). We collected the patient and procedural characteristics on 108 patients with OVCFs in our hospital who received PVP. Univariate and multivariate analyses were performed to explore the relationships between these potential influential variables and cement leakage and pain relief at 1 month postoperatively. Multivariate linear and logistic regression analyses were conducted with the pain score reduction and the bone cement leakage as dependent variables and the potential risk factors as independent variables, respectively. The results showed that the independent risk factors for the pain relief were the cement volume injected and fracture age, and for bone cement leakage were the cement volume injected and low-viscosity cement. In conclusion, the present study indicated that there were positive dose–response correlation relationships of cement volume with the incidence of cement leakage and the degree of pain relief after PVP, respectively. Thus, the cement should be injected into the vertebrae as much as possible during the PVP procedure.

The effect of oligo(trimethylene carbonate) addition on the stiffness of acrylic bone cement

With the increasing elderly population an increase in the number of bony fractures associated to age-related diseases such as osteoporosis also follows. The relatively high stiffness of the acrylic bone cements used in these patients has been suggested to give raise to a suboptimal load distribution surrounding the cement in vivo, and hence contribute to clinical complications, such as additional fractures. The aim of this study was to develop a low-modulus bone cement, based on currently used, commercially available poly(methyl methacrylate) (PMMA) cements for vertebroplasty. To this end, acrylate end-functionalized oligo(trimethylene carbonate) (oTMC) was incorporated into the cements, and the resulting compressive mechanical properties were evaluated, as well as the cytotoxic and handling properties of selected formulations. Sixteen wt%oTMC was needed in the vertebroplastic cement Osteopal V to achieve an elastic modulus of 1063 MPa (SD 74), which gave a corresponding compressive strength of 46.1 MPa (SD 1.9). Cement extracts taken at 1 and 12 hours gave a reduced MG-63 cell viability in most cases, while extracts taken at 24 hours had no significant effect on cell behavior. The modification also gave an increase in setting time, from 14.7 min (SD 1.7) to 18.0 min (SD 0.9), and a decrease in maximum polymerization temperature, from 41.5°C (SD 3.4) to 30.7°C (SD 1.4). While further evaluation of other relevant properties, such as injectability and in vivo biocompatibility, remains to be done, the results presented herein are promising in terms of approaching clinically applicable bone cements with a lower stiffness.

Bone cement allocation analysis in artificial cancellous bone structures

Background

One of the most serious adverse events potentially occurring during vertebroplasty is cement leakage. Associated risks for the patient could be reduced if cement filling is preoperatively planned. This requires a better understanding of cement flow behaviour. Therefore, the aim of the present study was to investigate bone cement distribution in artificial inhomogeneous cancellous bone structures during a simulated stepwise injection procedure.

Methods

Four differently coloured 1-mL cement portions were injected stepwise into six open-porous aluminum foam models with simulated leakage paths. Each model was subsequently cross-sectioned and high-resolution pictures were taken, followed by anatomical site allocation based on the assumption about a posterior insertion of the cannula. A radial grid consisting of 36 equidistant beams (0°–350°) was applied to evaluate the cement flow along each beam by measuring the radial length of each cement portion (total length) and of all four portions together (distance to border). Independently from the injection measurements, the viscosity of 20 cement portions was measured at time points corresponding to the start of the first and the end of the last injection.

Results

Despite some diffuse colour transitions at the borderlines, no interfusion between the differently coloured cement portions was observed. The two highest values for total length of each of the first three injected cement portions and for distance to border were indicated in directions anterior bilateral to the cannula along the 120°, 240° and 250° beams and posterolateral along the 60° beam. The two highest total lengths for the fourth cement portion were registered in the direction of the cannula along the 170° and 180° beams. Standard deviations of total length for each of the last three injected portions and for distance to border were with two highest values in directions anterior bilateral to the cannula along the 120°, 150°, 240° and 250° beams and opposite to the direction of the cannula along the 10° beam. The two highest values for the first cement portion were registered posterior bilateral to the cannula along the 70° and 350° beams. The values for averaged standard deviations of the total length of the fourth cement portion and the distance to border were significantly higher in comparison to the first cement portion (p ≤ 0.020). Dynamic viscosity at the start of the first injection was 343 ± 108 Pa∙s and increased to 659 ± 208 Pa∙s at the end of the fourth injection.

Conclusion

The simulated leakage path seemed to be the most important adverse injection factor influencing the uniformity of cement distribution. Another adverse factor causing dispersion of this distribution was represented by the simulated bone marrow. However, the rather uniform distribution of the totally injected cement amount, considered as one unit, could be ascribed to the medium viscosity of the used cement. Finally, with its short waiting time of 45 s, the stepwise injection procedure was shown to be ineffective in preventing cement leakage.

Effects of cement augmentation on the mechanical stability of multilevel spine after vertebral compression fracture

BACKGROUND

Studies on the effects of cement augmentation or vertebroplasty on multi-level spine after vertebral compression fractures are lacking. This paper seeks to establish a 3-vertebrae ovine model to determine the impact of compression fracture on spine biomechanics, and to discover if cement augmentation can restore mechanical stability to fractured spine.

METHODS

Five lumbar spine segments (L1-L3) were obtained from 5-year-old female Merino sheep. Standardized wedge-compression fractures were generated in each L2 vertebra, and then augmented with polymethyl methacrylate (PMMA) cement mixed with 30% barium sulphate powder. Biomechanical pure moment testing in axial rotation (AR), flexion/extension (FE) and lateral bending (LB) was carried out in the intact, fractured and repaired states. Range of motion (ROM) and neutral zone (NZ) parameters were compared, and plain radiographs taken at every stage.

RESULTS

Except for a significant increase in ROM between the intact and fractured states in AR between L1 and L2 (P<0.05), there were no other significant differences in ROM or NZ between the other groups. There was a trend towards an increase in ROM and NZ in all directions after fracture, but this did not reach significance. Normal biomechanics was only minimally restored after augmentation.

CONCLUSIONS

Results suggest that cement augmentation could not restore mechanical stability of fractured spine. Model-specific factors may have had a role in these findings. Caution should be exercised when applying these results to humans.

Vertebral augmentation by kyphoplasty and vertebroplasty: 8 years experience outcomes and complications

Background and Context:

Minimally invasive percutaneous vertebral augmentation techniques; vertebroplasty, and kyphoplasty have been treatment choices for vertebral compression fractures (VCFs). The purpose of this study is to evaluate the outcomes of the patients who underwent vertebroplasty or kyphoplasty regarding complications, correction of vertebral body height, kyphosis angle and pain relief assessment using visual analog score (VAS) for pain.

Materials and Methods:

A retrospective review of the hospital records for 100 consecutive patients treated with kyphoplasty or vertebroplasty in our department database. Patients with osteoporotic compression fractures, traumatic compressions, and osteolytic vertebral lesions, including metastases, hemangiomas, and multiple myeloma, were included in the study. Preoperative and postoperative VAS pain scores, percentages of vertebral compression and kyphotic angles were measured and compared as well as demographic characteristics and postoperative complications. Mobilization and length of stay (LOS) were recorded.

Results:

One hundred patients were treated by 110 procedures. 64 patients were operated on due to osteoporosis (72 procedures). Twelve patients were operated on because of metastasis (13 procedures), 8 patients were operated on because of multiple myeloma (9 procedures). Five patients had two surgeries, 1 patient had 3 surgeries, and 1 patient had 5 surgeries. The mean preoperative VAS was 74.05 ± 9.8. In total, 175 levels were treated, 46 levels by kyphoplasty and 129 by vertebroplasty. The mean postoperative VAS was 20.94 ± 11.8. Most of the patients were mobilized in the same day they of surgery. Mean LOS was 1.83 days. Six patients had nonsymptomatic leakage of polymethlymethacrylate, and patient had epidural hematoma, which was operated on performing hemi-laminectomy.

Conclusions:

Percutaneous vertebroplasty and balloon kyphoplasty are both effective and safe minimally invasive procedures for the stabilization of VCFs. However, complications should be kept in mind during decision making.

Surgeon Specialty Influences Referral Rate for Osteoporosis Management following Vertebral Compression Fractures

STUDY DESIGN

Retrospective chart review.

OBJECTIVE

To evaluate the referral rate for long-term osteoporosis management following vertebral compression fracture treated by different specialties at a single academic institution.

METHODS

Patients undergoing vertebral cement augmentation for painful osteoporotic compression fractures from 2009 to 2014 were identified. Medical records were reviewed to determine if the treating surgeon discussed and/or referred the patient for long-term osteoporosis management. Any referral for or mention of medical long-term osteoporosis management was counted as a positive response. Results were statistically analyzed with chi-square test.

RESULTS

Two hundred fourteen patients underwent vertebral cement augmentation; 150 met inclusion criteria. Orthopedic surgeons treated 88 patients, neurosurgeons treated 39, and interventional radiology or pain management physicians treated 23. Orthopedic surgeons referred 82% of patients for osteoporosis management, neurosurgeons referred 36%, and interventional radiology/pain management referred 17%. The referral rate was significantly higher for orthopedic surgeons compared with either of the other two groups; there was no significant difference between neurosurgery and interventional radiology/pain management.

CONCLUSIONS

Among physicians who treat osteoporotic vertebral compression fractures, orthopedic surgeons more frequently address osteoporosis or refer patients for osteoporosis management compared with neurosurgeons and interventional radiologists or pain management physicians. The results of this study shed light on the disparity in how different specialties approach treatment of osteoporosis in patients with fractures painful enough to require surgery and highlight potential areas for improvement in osteoporosis awareness training.

Life-threatening paraspinal muscle hematoma after percutaneous vertebroplasty

Bleeding and hematoma formation is rarely reported in percutaneous vertebroplasty procedure. An 84 year old male presented with a large paraspinal muscle hematoma after a percutaneous vertebroplasty. The patient had neither any prior bleeding disorder nor any anticoagulant treatment. Vital signs of the patient were unstable, and his hemoglobin level decreased daily. After a month of conservative treatment, including transfusion, cryotherapy, pain control and bed rest, his hemoglobin level remained stable and he showed relief from pain. Four months later, hematoma resolved spontaneously and he could walk without back pain.

Vertebroplasty and balloon kyphoplasty versus conservative treatment for osteoporotic vertebral compression fractures: A meta-analysis

OBJECTIVE

Although the majority of available evidence suggests that vertebroplasty and kyphoplasty can relieve pain associated with vertebral compression fractures (VCFs) and improve function, some studies have suggested results are similar to those of placebo. The purpose of this meta-analysis was to compare the outcomes of vertebroplasty and kyphoplasty with conservative treatment in patients with osteoporotic VCFs.

METHODS

Medline, Cochrane, and Embase databases were searched until January 31, 2015 using the keywords: vertebroplasty, kyphoplasty, compression fracture, osteoporotic, and osteoporosis. Inclusion criteria were randomized controlled trials (RCTs) in which patients with osteoporosis, and VCFs were treated with vertebroplasty/kyphoplasty or conservative management. Outcome measures were pain, function, and quality of life. Standardized differences in means were calculated as a measure of effect size.

MAIN RESULTS

Ten RCTs were included. The total number of patients in the treatment and control groups was 626 and 628, respectively, the mean patient age ranged from 64 to 80 years, and the majority was female. Vertebroplasty/kyphoplasty was associated with greater pain relief (pooled standardized difference in means = 0.82, 95% confidence interval [CI]: 0.374-1.266, P < 0.001) and a significant improvement in daily function (pooled standardized difference in means = 1.273, 95% CI: 1.028-1.518, P < 0.001) as compared with conservative treatment. The pooled estimate indicated vertebroplasty/kyphoplasty was associated with higher quality of life (pooled standardized difference in means = 1.545, 95% CI: 1.293-1.798, P < 0.001). Subgroup analysis of 8 vertebroplasty studies and 2 kyphoplasty studies that reported pain data, however, indicated that vertebroplasty provided greater pain relief than conservative treatment but kyphoplasty did not.

CONCLUSION

Vertebroplasty may provide better pain relief than balloon kyphoplasty in patients with osteoporotic VCFs, both may improve function, and their effect on quality of life is less clear.

A Systematic Review of Clinical Outcomes and Prognostic Factors for Patients Undergoing Surgery for Spinal Metastases Secondary to Breast Cancer

STUDY DESIGN

Review of the literature.

OBJECTIVE

Surgery and cement augmentation procedures are effective palliative treatment of symptomatic spinal metastases. Our objective is to systematically review the literature to describe the survival, prognostic factors, and clinical outcomes of surgery and cement augmentation procedures for breast cancer metastases to the spine.

METHODS

We performed a literature review using PubMed to identify articles that reported outcomes and/or prognostic factors of the breast cancer patient population with spinal metastases treated with any surgical technique since 1990.

RESULTS

The median postoperative survival for metastatic breast cancer was 21.7 months (8.2 to 36 months), the mean rate of any pain improvement was 92.9% (76 to 100%), the mean rate of neurologic improvement was 63.8% (53 to 100%), the mean rate of neurologic decline was 4.1% (0 to 8%), and the local tumor control rate was 92.6% (89 to 100%). Kyphoplasty studies reported a high rate of pain control in selected patients. Negative prognostic variables included hormonal (estrogen and progesterone) and human epidermal growth factor receptor 2 (HER2) receptor refractory tumor status, high degree of axillary lymph node involvement, and short disease-free interval (DFI). All other clinical or prognostic parameters were of low or insufficient strength.

CONCLUSION

With respect to clinical outcomes, surgery consistently yielded neurologic improvements in patients presenting with a deficit with a minimal risk of worsening; however, negative prognostic factors associated with shorter survival following surgery include estrogen receptor/progesterone receptor negativity, HER2 negativity, and a short DFI.

The role of intraoperative scrape cytology in vertebroplasty

Aims:

To assess the adequacy of intraoperative scrape cytology during percutaneous vertebroplasty by correlating results with corresponding histopathology.

Settings and Design:

Vertebroplasty is a procedure increasingly used to treat painful vertebral compression fractures. The history and presentation of osteoporotic fractures are straightforward, but difficulty arises in differentiating infective from neoplastic lesions, especially in cases where the magnetic resonance imaging is equivocal. The procedure involves injection of polymethyl methacrylate (bone cement) into the pathological vertebral body and gives dramatic pain relief. It is indicated in osteoporotic and neoplastic lesions but contraindicated in infections. Hence, intraoperative evaluation of a specimen is essential to aid in the decision of performing vertebroplasty.

Subjects and Methods:

A total of 128 patients with vertebral lesions underwent core biopsy and scrape cytology from June 2006 to June 2015. Based on the findings of cytological examination, malignant lesions were subjected to vertebroplasty. In lesions with infective etiology, vertebroplasty was abandoned and antibiotic or antituberculous therapy started.

Results:

The overall diagnostic accuracy of scrape cytology was excellent with 97.58% cases correlating with the final histopathological diagnosis. Specificity was 100%, positive predictive value was 100% and negative predictive value was 33.33%.

Conclusion:

Scrape cytology is a simple, rapid, accurate cytodiagnostic technique and should be routinely utilized in vertebral lesions for intraoperative consultation and decision making during vertebroplasty.

Cone-Beam CT-Guided Vertebroplasty in a Patient With Vertebra Plana

OBJECTIVE

Vertebra plana has been considered a contraindication for vertebroplasty for various reasons including difficulty in needle placement. Recently, vertebroplasty under conventional fluoroscopic guidance has been shown to be feasible in patients with vertebra plana.

CONCLUSION

Cone-beam CT with a navigation guidance system can be used during vertebroplasty in patients with severe vertebra plana to allow safe needle trajectory and placement.

Transdiscal mid- and upper thoracic vertebroplasty: first description of 2 exemplary cases

Kyphoplasty and vertebroplasty are established treatment methods to reinforce fractured vertebral bodies. In cases of previous pedicle screw instrumentation, vertebral body cannulation may be challenging. The authors describe, for the first time, an approach through the adjacent inferior vertebra and disc space in the thoracic spine for cement augmentation. A 78-year-old woman underwent posterior fusion with pedicle screws after vertebrectomy and reconstruction with cement and Steinmann pins for a pathological T-7 fracture. Two months later she developed a compression fracture of the vertebral body at the lower part of the construct, and a vertebroplasty was performed. Because a standard transpedicular route was not available, an inferior transdiscal trajectory was used for the cement injection. A 73-year-old man with a history of rheumatoid arthritis underwent cervicothoracic fusion posteriorly for subluxation. He developed pain in the upper thoracic area, and the authors performed a transdiscal vertebroplasty at T-2. The standard transpedicular route was not possible. The vertebral body was satisfactorily filled up with cement. Clinically both patients benefited significantly in terms of back pain and showed an uneventful follow-up of 3 months. Transdiscal vertebroplasty can achieve good results in the mid- and upper thoracic spine when a standard transpedicular trajectory is not possible, and can therefore be a good alternative in select cases.

Vertebroplasty and kyphoplasty for cervical spine metastases: a systematic review and meta-analysis

BACKGROUND

Vertebroplasty (VP) and kyphoplasty (KP) are two minimally invasive techniques used to relieve pain and restore stability in metastatic spinal disease. However, most of these procedures are performed in the thoracolumbar spine, and there is limited data on outcomes after VP/KP for cervical metastases. The purpose of this article is to evaluate the safety and efficacy of VP and KP for treating pain in patients with cervical spine metastases.

METHODS

A systematic review of the literature was conducted using the PubMed and Medline databases. Only studies that reported five or more patients treated with VP/KP in the cervical spine were included. Levels of evidence and grades of recommendation were established based on the Oxford Centre for Evidence-Based Medicine guidelines. Data was pooled to perform a meta-analysis for pain relief and complication rates.

RESULTS

Six studies (all level 4 studies) met the inclusion criteria, representing 120 patients undergoing VP/KP at 135 vertebrae; the most common addressed level was C2 in 83 cases. The average volume of injected cement was 2.5 ± 0.5 milliliters at each vertebra. There were 22 asymptomatic cement leaks (16%; 95% CI, 9.8% - 22.2%) most commonly occurring in the paraspinal soft tissue. There were 5 complications (4%; 95% CI, 0.5% - 7.5%): 3 cases of mild odynophagia, 1 case of occipital neuralgia secondary to leak, and 1 case of stroke secondary to cement embolism. Pain relief was achieved in 89% of cases (range: 80 - 100%). The calculated average pain score decreased significantly from 7.6 ± 0.9 before surgery to 1.9 ± 0.8 at last evaluation (p=0.006).

CONCLUSION

Although the calculated complication rate after VP/KP in the cervical spine is low (4%) and the reported pain relief rate is approximately 89%, there is lack of high-quality evidence supporting this. Future randomized controlled trials are needed.

Percutaneous pedicle screw placement into a spinal segment previously treated with vertebroplasty: technical note

Vertebral augmentation with cement has become a common procedure for the treatment of compression fractures, leading to a growing population who have had this procedure and are now in need of another spinal surgery. This technical note reports an undescribed method for placing pedicle screws through a previously cemented level.

Risk factors for new vertebral compression fractures after vertebroplasty: a meta-analysis

BACKGROUND

The risk factors for new vertebral compression fractures (VCFs) after vertebroplasty are unclear. The aim of this meta-analysis was to identify potential risk factors.

METHODS

A systematic electronic literature search was performed using the following databases: PubMed, Embase and Cochrane Library; the databases were searched from the earliest available records in 1966 to May 2015. Pooled odds ratios (ORs) or standardized mean differences (SMDs) with 95% confidence intervals (CIs) were calculated using random- or fixed-effects models. The Newcastle-Ottawa scale was used to evaluate the methodological quality of the studies, and Stata 11.0 was used to analyse the data.

RESULTS

The primary factors that were associated with new fractures after vertebroplasty were low bone mineral density (SMD -0.375; 95% CI -0.579 to -0.171), steroid usage (OR 2.632; 95% CI 1.399 to 4.950) and the presence of multiple treated vertebrae (OR 2.027; 95% CI 1.442 to 2.851). The data did not support that age, sex, body mass index, non-steroidal anti-inflammatory drug usage, vacuum cleft, thoracolumbar junction, cement volume, kyphosis correction, or intradiscal cement leakage could lead to infection after vertebroplasty.

CONCLUSIONS

The present analysis demonstrated that low bone mineral density, the presence of multiple treated vertebrae and a history of steroid usage were associated with the new VCFs after vertebroplasty. Patients with these factors should be informed of the potential increased risk.

[Recovery form of the vertebral body in a transpedicular fixation at spine fractures associated with osteoporosis]

We analyzed the correction indexes of posttraumatic deformation in 27 patients aged 61-76 years (62,9±1,4 years), when using an osteoplasty and transpedicular of fixation in respect of fractures of bodies vertebras of the thoracic and lumbar localization, associated with osteoporosis. Indicators of posttraumatic deformation the wedging index (WI) and the segmental kyphosis (SK) decreased at all patients. At the same time the minimally invasive (transcutaneous) operation allowed to achieve recovery of the lost anatomy and does not concede to results of open intervention. In group of patients with compression fractures decreased WI and SK, and in group with burst nature of damage only WI authentically decreased. Both indicators of deformation decreased at patients with T-criterion more than -3 SD, and only WI authentically decreased at patients with more expressed decrease in mineral density (T-criterion >-3). The received results show recovery of the lost anatomy, at the same time extent of correction depends on character fractures and the number of bone masses.

Pulmonary cement embolization after vertebroplasty, an uncommon presentation of pulmonary embolism: A case report and literature review

Pulmonary Cement Embolization (PCE) is a rare complication of vertebroplasty surgery. There is no clear guideline for management of this entity. There is no definite protocol for anticoagulation in PCE. This is a case report of our patient who was diagnosed to have Pulmonary Cement Embolization, which was quite significant involving both lungs. She was successfully managed without long term anticoagulation.

Computational modelling of bone augmentation in the spine

Computational models are gaining importance not only for basic science, but also for the analysis of clinical interventions and to support clinicians prior to intervention. Vertebroplasty has been used to stabilise compression fractures in the spine for years, yet there are still diverging ideas on the ideal deposition location, volume, and augmentation material. In particular, little is known about the long-term effects of the intervention on the surrounding biological tissue. This review aims to investigate computational efforts made in the field of vertebroplasty, from the augmentation procedure to strength prediction and long-term in silico bone biology in augmented human vertebrae. While there is ample work on simulating the augmentation procedure and strength prediction, simulations predicting long-term effects are lacking. Recent developments in bone remodelling simulations have the potential to show adaptation to cement augmentation and, thus, close this gap.

Acute Spinal Subdural Hematoma after Vertebroplasty: A Case Report Emphasizing the Possible Etiologic Role of Venous Congestion

Study Design Case report and literature review. Objective Spinal subdural hematomas are rare events that often progress with severe neurologic deficits. Although there have been several case reports in the literature of spontaneous spinal subdural hematomas in the setting of anticoagulation, antiplatelet therapy, or coagulation disorders, the exact pathophysiology of such phenomena remains obscure. Methods We present the first report of a subdural hematoma after a percutaneous vertebroplasty and provide a comprehensive review on the anatomy of venous drainage of the vertebral bodies with emphasis on the possible effects of venous congestion caused by cement obstruction. Results Because the subdural hematoma occurred in the absence of major cement extravasation to the spinal canal and two levels above the site of the vertebroplasty, we discuss the possible role of venous congestion as the main etiologic factor leading to rupture of the fragile, valveless radiculomedullary veins into the subdural space. Conclusions The reported case supports a possible new pathophysiological scheme for the development of spinal subdural hematoma in which venous congestion plays a pivotal etiologic role. The reported findings suggests that future anatomical and histologic studies investigating the response of the radiculomedullary veins to congestive venous hypertension may shed new light into the pathophysiology of spinal subdural hematomas.

Intravertebral clefts in osteoporotic compression fractures of the spine: incidence, characteristics, and therapeutic efficacy

OBJECTIVE

To determine the pathogenesis and characteristics and to assess the long-term effectiveness of polymethylmethacry late (PMMA) vertebroplasty treatment in patients with intravertebral cleft (IVC) in osteoporotic compression fractures.

METHODS

A retrospective analysis of radiological and clinical parameters was performed on 388 patients who underwent percutaneous vertebroplasty or kyphoplasty to treat osteoporotic compression fractures from January 2010 to October 2012. IVC sign was observed in the MRI of 47 patients. Postoperative follow-ups were conducted for at least 2 years after surgery.

RESULTS

IVC incidence was associated with older age and lower bone mineral density. Other baseline measurements, such as preoperative visual analogue scale and Oswestry Disability Index (ODI), showed no significant difference between IVC and non-IVC fracture patients. Vertebral height and kyphotic angle were corrected after percutaneous vertebroplasty or kyphoplasty with no significant difference in outcome between the two procedures. Restored vertebral height collapsed and the kyphotic angle became aggravated during the 2 years following surgery in patients with IVC. Similarly, initial improvements in visual analogue scale and ODI decreased over time. Non-IVC patients' had a slight recurrence of compression and kyphosis that began to normalize after 1 year. Visual analogue scale and ODI at 2 years' post-surgery was also significantly lower in non-IVC than IVC patients.

CONCLUSION

Polymethylmethacrylate vertebroplasty treatment of osteoporotic compression fractures is initially effective for patients with signs of IVC, but compression and kyphosis gradually reoccur. Therefore, we strongly recommend strict observation and follow-up after vertebroplasty.

Effects of handholding and providing information on anxiety in patients undergoing percutaneous vertebroplasty

AIMS AND OBJECTIVES

This study evaluated the effects of handholding and spoken information provided on the anxiety of patients undergoing percutaneous vertebroplasty under local anaesthesia.

BACKGROUND

A surgical intervention usually entails physical discomfort and psychological burden. Furthermore, patients under local anaesthesia are conscious during the surgical intervention, which leads to more anxiety, as patients are aware of their surroundings in the operating theatre.

DESIGN

A quasi-experimental design with a nonequivalent control group was utilised.

METHODS

Amsterdam preoperative anxiety scale assessed psychological anxiety, while blood pressure and pulse were measured to evaluate physiological anxiety. Participants were 94 patients undergoing percutaneous vertebroplasty in a spine hospital in Gwangju Metropolitan City, South Korea. Thirty patients were assigned to Experimental Group I, 34 to the Experimental Group II and 30 to the control group. During a surgical intervention, nurses held the hands of those in Experimental Group I and provided them with spoken information. Patients in Experimental Group II experienced only handholding.

RESULTS

Psychological anxiety in Experimental Group I was low compared to those in Experimental Group II and the control group. In addition, there were significant decreases in systolic blood pressure in both Experimental Groups compared to the control group.

CONCLUSIONS

Handholding and spoken information provided during a surgical intervention to mitigate psychological anxiety, and handholding to mitigate physiological anxiety can be used in nursing interventions with patients undergoing percutaneous vertebroplasty.

RELEVANCE TO CLINICAL PRACTICE

Handholding and providing nursing information are possibly very useful interventions that are easily implemented by circulating nurses during a surgical intervention. In particular, handholding is a simple, economical and appropriate way to help patient in the operating theatre.

Does Balloon Kyphoplasty Deliver More Cement Safely into Osteoporotic Vertebrae with Compression Fractures Compared with Vertebroplasty? A Study in Vertebral Analogues

Study Design A biomechanical and radiographic study using vertebral analogues. Objectives Kyphoplasty and vertebroplasty are widely used techniques to alleviate pain in fractures secondary to osteoporosis. However, cement leakage toward vital structures like the spinal cord can be a major source of morbidity and even mortality. We define safe cement injection as the volume of the cement injected into a vertebra before the cement leakage occurs. Our objective is to compare the amount of cement that can be safely injected into an osteoporotic vertebra with simulated compression fracture using either vertebroplasty or balloon kyphoplasty techniques. Methods Forty artificial vertebral analogues made of polyurethane with osteoporotic cancellous matrix representing the L3 vertebrae were used for this study and were divided into four groups of 10 vertebrae each. The four groups tested were: low-viscosity cement injected using vertebroplasty, high-viscosity cement injected using vertebroplasty, low-viscosity cement injected using balloon kyphoplasty, and high-viscosity cement injected using balloon kyphoplasty. The procedures were performed under fluoroscopic guidance. The injection was stopped when the cement started protruding from the created vascular channel in the osteoporotic vertebral fracture model. The main outcome measured was the volume of the cement injected safely into a vertebra before leakage through the posterior vascular channel. Results The highest volume of the cement injected was in the vertebroplasty group using high-viscosity cement, which was almost twice the injected volume in the other three groups. One-way analysis of variance comparing the four groups showed a statistically significant difference (p < 0.005). Conclusions High-viscosity cement injected using vertebroplasty delivers more cement volume before cement leakage and fills the vertebral body more uniformly when compared with balloon kyphoplasty in osteoporotic vertebrae with compression fractures.

Current trends in mini-invasive management of spine metastases

The spine is a frequent localization of primary tumours or metastasis involving posterior arch, pedicles and vertebra body, and often causing unsustainable pain. The management of spinal metastasis remains complex, including medical therapy (corticosteroids, chemotherapy), radiotherapy and surgical treatment, or the recent percutaneous mini-invasive approach. The target of all these treatments is to improve the quality of life of patients affected by this type of lesion. Diagnosis of spinal metastasis and then its treatment should be based on the combination of different elements: clinical evaluation, CT, MRI and nuclear medicine patterns, considering the age of the patient, known primary tumour, location of the lesions, single/multiple lesions, pattern of morphology (border, matrix, expansile character, soft tissue extension), density or signal intensity, oncologic instability and expectancy of life. The percutaneous mini-invasive approach for patients affected by secondary lesions involving the spine has as treatment goal of: (1) pain relief improving the quality of life; (2) stability treatment re-establishing the spinal biomechanics, alterated by bone destruction or deformity, preventing pathological fracture; and (3) an anti-neoplastic effect. The aim of this paper is to provide a comprehensive diagnostic and percutaneous approach to the bone metastatic spine lesions, identifying which metamer should be treated to improve patient quality of life, showing the importance of a multi-disciplinary approach to this problem.

[Interventional neuroradiology: current options]

Modern interventional neuroradiology has a leading role in the treatment of ischemic and hemorrhagic stroke, and it provides more and more important treatment options for degenerative diseases of the vertebral column and the management of correlated pain. During the last decades interventional neuroradiology has played a primary role in the treatment of intracranial berry aneurysms due to the continuous technical improvements. Ongoing studies proved superiority of mechanical stent-thrombectomy in acute proximal occlusion of cerebral arteries. Less invasive neurointerventional methods, such as vertebroplasty, are widely used in osteoporotic and neoplastic pathologic fractures of the vertebral bodies. These treatments should be performed in a specialized center by well trained physicians.

Long-term follow-up study of osteoporotic vertebral compression fracture treated using balloon kyphoplasty and vertebroplasty

OBJECT

Long-term follow-up study is required for verifying whether the clinical outcomes of kyphoplasty and vertebroplasty are altered. The authors' findings showed only subtle differences between these operations within a 5-year period. However, they still suggest the use of vertebroplasty over kyphoplasty in view of the treatment costs. In their previous study, the authors performed a short-term prospective comparison between vertebroplasty and kyphoplasty. Vertebroplasty was recommended instead of kyphoplasty for the treatment of vertebral compression fractures (VCFs) because of the subtle differences between this procedure and kyphoplasty and the treatment costs. To determine whether these clinical outcomes persist in the long term, they continued to observe the patients from their short-term study over a longer-term period. METHODS :One hundred cases of VCF were assigned randomly to either the kyphoplasty or the vertebroplasty group. In cement augmentation, the authors used polymethylmethacrylate as bone filler. Pain was assessed by using a visual analog scale (VAS). For each patient, vertebral body height and wedge angle were measured from reconstructed CT images.

RESULTS

The duration of the follow-up period was 5 years. Vertebral body height, kyphotic wedge angle, and VAS score were not evidently altered. Eight patients in the kyphoplasty group had an adjacent fracture after the procedure, whereas 7 patients in the vertebroplasty group had an adjacent fracture after the procedure. These adjacent fractures occurred within 1 year of surgery in both treatment groups except in 1 kyphoplasty-treated patient in whom the adjacent fracture was noted 16 months after treatment. Three patients in the vertebroplasty group had a nonadjacent fracture, and 4 patients in the kyphoplasty group had a nonadjacent fracture. The link between angular correction and the occurrence of adjacent fracture was statistically significant in the vertebroplasty group.

CONCLUSIONS

Excessive angular correction is a critical concern in the risk of adjacent fracture after vertebroplasty. Given the subtle differences between vertebroplasty and kyphoplasty observed over the course of 5 years, vertebroplasty remains the preferred option in view of the costs.