Percutaneous vertebroplasty for osteoporotic vertebral compression fracture

Manifestations of radiation toxicity in the head, neck, and spine: An image-based review

BACKGROUND AND PURPOSE

Radiation therapy is an important component of treatment in patients with malignancies of the head, neck, and spine. However, radiation to these regions has well-known potential side effects, many of which can be encountered on imaging. In this manuscript, we review selected radiographic manifestations of therapeutic radiation to the head, neck, and spine that may be encountered in the practice of radiology.

METHODS

We conducted an extensive literature review of known complications of radiation therapy in the head, neck, and spine. We excluded intracranial and pulmonary radiation effects from our search. We selected complications that had salient, recognizable imaging findings. We searched our imaging database for illustrative examples of these complications.

RESULTS

Based on our initial literature search and imaging database review, we selected cases of radiation-induced tumors, radiation tissue necrosis (osteoradionecrosis and soft tissue necrosis), carotid stenosis and blowout secondary to radiation, enlarging thyroglossal duct cysts, radiation myelopathy, and radiation-induced vertebral compression fractures.

CONCLUSIONS

We describe the clinical and imaging features of selected sequelae of radiation therapy to the head, neck, and spine, with a focus on those with characteristic imaging findings that can be instrumental in helping to make the diagnosis. Knowledge of these entities and their imaging findings is crucial for accurate diagnosis. Not only do radiologists play a key role in early detection of these entities, but many of these entities can be misinterpreted if one is not familiar with them.

An observational study of vertebroplasty and kyphoplasty for osteoporotic spinal fractures: utilisation and outcomes in England using an administrative dataset

We reviewed outcomes for vertebroplasty and balloon kyphoplasty for the surgical treatment of osteoporotic spinal fracture. Our study of 5792 vertebroplasty and 3136 balloon kyphoplasty procedures conducted in England over a 7-year period found no evidence that the patient outcomes studied were poorer for vertebroplasty than for balloon kyphoplasty.

PURPOSE

To investigate use, safety and functional outcomes of vertebroplasty (VP) and balloon kyphoplasty (BKP) techniques for osteoporotic spinal fracture for patients operated on within the National Health Service in England.

METHODS

This was an observational analysis of administrative data. Data were extracted from the Hospital Episodes Statistics database for the period 1^st April 2011 to 31^st March 2018 for all VP and BKP procedures. Patients aged < 19 years, with metastatic carcinoma and undergoing other decompression procedures, were excluded. The primary outcome was repeat spinal surgery within 1 year. Secondary outcomes were 30-day emergency readmission, death within 1 year, extended hospital stay, post-procedural pain within 30 days and post-procedural haemorrhage or infection within 30 days. Multilevel, multivariable logistic regression was used to adjust for covariates.

RESULTS

Data were available for 5792 VP and 3136 BKP patients operated on at 96 hospital trusts. In the 63 trusts that conducted more than 20 procedures during the study period, the proportion of procedures conducted as BKP varied from 0 to 100%. There was no difference in any of the outcomes between VP and BKP patients or between trusts performing ≥ 70% and ≤ 30% of procedures as BKP.

CONCLUSIONS

With regard to the outcomes studied, there is no evidence that VP is associated with poorer outcomes than BKP.

Risk factors for bone cement displacement after percutaneous vertebral augmentation for osteoporotic vertebral compression fractures

Purpose

To explore the risk factors of bone cement displacement after percutaneous vertebral augmentation (PVA) in patients with osteoporotic vertebral compression fracture (OVCF).

Methods

We retrospectively reviewed the records of 1,538 patients with OVCF treated with percutaneous vertebroplasty (PVP) or percutaneous vertebroplasty (PKP) from January 2016 to June 2021. Patients were divided into bone cement displacement group (n = 78) and bone cement non-displacement group (n = 1,460) according to the radiographic images. Possible risk factors for bone cement displacement were noted, including age, gender, body mass index (BMI), bone mineral density (BMD), underlying disease, number of fractured vertebrae, involved vertebral segment, surgical method, surgical approach, vertebral height, Cobb angle, cement leakage, the viscosity of bone cement, bone cement diffuse ratio, degree of bone cement interweaving, sagittal bone cement placement, targeted location of bone cement, the distance between the bone cement and the upper and lower endplates, the time of wearing brace and postoperative osteoporosis treatment. Risk factors were identified with univariate and multivariate logistic regressions and the discrimination ability of the predictive indicators was evaluated using area under the curve (AUC) of the receiver operating characteristic (ROC).

Results

In multivariate regression, independent risk factors for bone cement displacement included: high restoration of Cobb angle (OR = 2.019, 95%[CI] 1.545–4.852, P < 0.001), cement leakage (anterior edge) (OR = 1.727, 95%[CI] 1.05–2.20, P < 0.001), small degree of bone cement interweaving (OR = 1.917, 95%[CI] 1.129–2.747, P < 0.001), non-targeted location of bone cement (OR = 2.323, 95%[CI] 1.645–4.134, P < 0.001), short duration of brace wearing (OR = 3.207, 95%[CI] 2.036–4.348, P < 0.001) and postoperative osteoporosis treatment (OR = 0.422, 95% CI = 0.323–0.547, P < 0.001). The AUCs for the high restoration of Cobb angle, cement leakage (anterior edge), small degree of bone cement interweaving, non-targeted location of bone cement, short duration of brace wearing and non-postoperative osteoporosis treatment were 0.784 (95% CI, 0.747–0.821), 0.811 (95% CI 0.764–0.859), 0.917 (95%CI 0.864–0.970), 0.610 (95%CI 0.552–0.669), 0.854 (95%CI 0.816–0.892) and 0.756 (95% CI, 0.712–0.800), respectively.

Conclusion

High restoration of Cobb angle, cement leakage (anterior edge), small degree of bone cement interweaving, non-targeted location of bone cement, short duration of brace wearing and non-postoperative osteoporosis treatment were the independent risk factors of bone cement displacement after PVA.

The Acute VertEbRal AugmentaTion (AVERT) study: protocol for a randomised controlled, feasibility trial of spinal medial branch nerve block in hospitalised older patients with vertebral fragility fractures

INTRODUCTION

Vertebral fragility fractures (VFFs) are the most common type of osteoporotic fracture found in older people, resulting in increasing morbidity and excess mortality. These fractures can cause significant pain, requiring admission to hospital. Vertebroplasty (VP) is effective in reducing pain and allowing early mobilisation in hospitalised patients. However, it may be associated with complications such as cement leakage, infection, bleeding at the injection site and fracture of adjacent vertebrae. It is also costly and not readily accessible in many UK hospitals.A recent retrospective study reported that spinal medial branch nerve block (MBNB), typically used to treat facet arthropathy, had similar efficacy in terms of pain relief compared with VP for the treatment of painful VFF. However, to date, no study has prospectively compared MBNB to VP. We therefore propose a prospective feasibility randomised controlled trial (RCT) to compare the role of MBNB to VP, in hospitalised older patients.

METHOD

A parallel, two-arm RCT with participants allocated on a 1:1 ratio to either standard care-VP or MBNB in hospitalised patients aged over 70 with acute osteoporotic vertebral fractures. Follow-up will be at weeks 1, 4 and 8 post intervention. The primary objective is to determine the feasibility and design of a future trial, including specific outcomes of recruitment, adherence to randomisation and safety. Embedded within the trial will be a health economic evaluation to understand resource utilisation and implications of the intervention and a qualitative study of the experiences and insights of trial participants and clinicians. Secondary outcomes will include pain scores, analgesia requirements, resource use and quality of life data.

ETHICS AND DISSEMINATION

Ethical approval was granted by the Yorkshire & the Humber Research Ethics Committee (reference 21/YH/0065). AVERT (Acute VertEbRal AugmentaTion) has received approval by the Health Research Authority (reference IRAS 293210) and is sponsored by Nottingham University Hospitals NHS Trust (reference 21HC001). Recruitment is ongoing. Results will be presented at relevant conferences and submitted to appropriate journals for publication on completion.

TRIAL REGISTRATION NUMBER

ISRCTN18334053.

Efficacy and complications of different surgical modalities of treating osteoporotic spinal compression fracture in the elderly

PURPOSE

To explore the efficacy and complications of different surgical modalities in the treatment of osteoporotic spinal compression fractures (OSCFs) in the elderly.

METHODS

This retrospective study included 98 elderly patients with OSCFs who received surgical treatment in the Changsha Hospital of Traditional Chinese Medicine from March 2018 to July 2020. Based on different surgical treatments, the patients were divided into a percutaneous kyphoplasty (PKP) group (n=51) and a percutaneous vertebroplasty (PVP) group (n=47). The intraoperative blood loss, operation time, the amount of bone cement per vertebral body, length of hospitalization, and fracture healing time were recorded and compared between the two groups. The original anterior wall height and middle height of the compressed fractured vertebra were then evaluated and compared at 3 time points, namely before operation, 2 days after operation, and 6 months after operation. Pain, spinal function improvement and Cobb's angle were evaluated and compared between the two cohorts of patients before operation and 3 months after operation. Adverse reactions and bone cement permeability were recorded and compared between the two groups. Patients' quality of life quality was evaluated using the 36-Item Short-Form Health Survey (SF-36) before treatment and 12 months after treatment. Treatment satisfaction was evaluated.

RESULTS

Intraoperative blood loss, the average use of bone cement per vertebral body and length of hospitalization were similar between the groups (P>0.05). However, the PKP group had significantly longer operation time and fracture healing time than the PVP group (P<0.05). Vertebral 3D volume, as well as anterior wall and middle vertebra heights increased significantly at 6 months after surgery in both groups (all P<0.05). In addition, anterior wall and middle vertebra heights increased more in the PVP group than in the PKP group. The Visual Analogue Scale (VAS) and Oswesrty Disability Index (ODI) scores, as well as Cobb's angle decreased in both groups at 3 months after treatment (all P<0.05). The Cobb's angle and VAS score of the PVP group showed more significant reductions (all P<0.05). The PKP group had a higher incidence of adverse reactions and bone cement leakage rate than the PVP group (all P<0.05). However, no distinct difference was determined between the two groups in terms of patients' quality of life at 12 months after surgery. Treatment satisfaction was significantly higher in the PVP group than the PKP group.

CONCLUSION

For the treatment of senile OSCFs, both PVP and PKP have the advantages of little trauma and quick recovery. PVP has an edge over PKP with significantly shorter operation time, lower possibility of bone cement venous leakage and adjacent cone fracture, and higher surgical safety.

Trends and regional variation in vertebroplasty and kyphoplasty in Switzerland: a population-based small area analysis

Regional variation in procedure use often reflects the uncertainty about the risks and benefit of procedures. In Switzerland, regional variation in vertebroplasty and balloon kyphoplasty rates was high, although the variation declined between 2013 and 2018. Substantial parts of the variation remained unexplained, and likely signal unequal access and differing physician opinion.

PURPOSE

To assess trends and regional variation in percutaneous vertebroplasty (VP) and balloon kyphoplasty (BKP) use across Switzerland.

METHODS

We conducted a population-based analysis using patient discharge data from all Swiss acute care hospitals for 2013-2018. We calculated age/sex-standardized mean procedure rates and measures of variation across VP/BKP-specific hospital areas (HSAs). We assessed the influence of potential determinants of variation using multilevel regression models with incremental adjustment for demographics, cultural/socioeconomic, health, and supply factors.

RESULTS

We analyzed 7855 discharges with VP/BKP from 31 HSAs. The mean age/sex-standardized procedure rate increased from 16 to 20/100,000 persons from 2013 to 2018. While the variation in procedure rates across HSAs declined, the overall variation remained high (systematic component of variation from 56.8 to 6.9 from 2013 to 2018). Determinants explained 52% of the variation.

CONCLUSIONS

VP/BKP procedure rates increased and regional variation across Switzerland declined but remained at a high level. A substantial part of the regional variation remained unexplained by potential determinants of variation.

Advances in the application of mesenchymal stem cells, exosomes, biomimetic materials, and 3D printing in osteoporosis treatment

Owing to an increase in the aging population, osteoporosis has become a severe public health concern, with a high prevalence among the elderly and postmenopausal adults. Osteoporosis-related fracture is a major cause of morbidity and mortality in elderly and postmenopausal adults, posing a considerable socioeconomic burden. However, existing treatments can only slow down the process of osteoporosis, reduce the risk of fractures, and repair fractures locally. Therefore, emerging methods for treating osteoporosis, such as mesenchymal stem cell transplantation, exosome-driving drug delivery systems, biomimetic materials, and 3D printing technology, have received increasing research attention, with significant progress. Mesenchymal stem cells (MSCs) are pluripotent stem cells that can differentiate into different types of functional cells. Exosomes play a key role in regulating cell microenvironments through paracrine mechanisms. Bionic materials and 3D printed scaffolds are beneficial for the reconstruction and repair of osteoporotic bones and osteoporosis-related fractures. Stem cells, exosomes, and biomimetic materials represent emerging technologies for osteoporosis treatment. This review summarizes the latest developments in these three aspects.

Percutaneous vertebroplasty versus conservative treatment and placebo in osteoporotic vertebral fractures: meta-analysis and critical review of the literature

OBJECTIVES

To assess the current evidence regarding the efficacy of percutaneous vertebroplasty (PVP) over conservative treatment (CT) and placebo in osteoporotic vertebral fractures (OVFs) by performing a meta-analysis of randomized controlled trials (RCTs).

MATERIALS AND METHODS

A systematic search was conducted on PubMed, EMBASE, and Cochrane databases. The main outcomes were pain relief, improvement of functional disability, and quality of life at different time points: short-term (1-2 weeks), medium-term (1-3 months), and long-term (≥ 6 months). Subgroup analyses based on time from fracture onset and sham procedure were also performed.

RESULTS

A total of 14 RCTs were included in the meta-analysis. PVP showed significant benefits over CT in all outcomes, but slight-to-none clear differences over placebo. Subgroup analyses revealed that PVP performed in fractures < 6 weeks provided superior short-term pain relief than the control group (p = .02), and better quality of life in the medium-term (p = .03) and long-term (p = .006). Placebo based on infiltrating the skin alone was significantly inferior to PVP at most time points in all outcomes, but no significant differences between PVP and placebo were found when the sham procedure consisted of infiltrating both the skin and periosteum.

CONCLUSIONS

PVP showed significant advantages over CT in terms of efficacy, but benefits were more limited when compared to placebo. In addition, benefits of PVP are more prominent in recent OVFs. Differences in the sham procedure or criteria regarding patient's selection/allocation seem to be the main causes of disparity in previous RCTs.

KEY POINTS

• Previous RCTs showed significant advantages of PVP over CT in terms of efficacy, but benefits were more limited when compared to placebo. • Differences in patient allocation or in the sham procedure might explain the lack of benefits of PVP versus placebo found in previous RCTs. • Despite controversial opinions, PVP should be offered to patients with OVFs as an alternative option to conservative treatment.

Vertebroplasty in patients with multiple myeloma with vertebral compression fractures: protocol for a single-blind randomised controlled trial

INTRODUCTION

Multiple myeloma (MM) is a plasma cell cancer where about 1/3 of the patients present with pathological fractures at the time of diagnosis. Despite treatment, the majority of the patients will develop additional fractures. Because survival and prognosis has improved significantly over the last two decades for patients with MM, there is an increased need to focus on optimal fracture treatment. Traditionally, fracture pain is treated conservatively with opioids, bisphosphonates, bracing and radiation therapy. Vertebral augmentation has been used for the last three decades as a minimally invasive treatment option for vertebral compression fractures, but the evidence base for the efficacy is weak. We describe a trial assessing the impact of vertebroplasty on clinical outcome in the treatment of patients with MM with painful vertebral fractures.

METHODS

100 patients with MM with painful vertebral fractures will be randomised in a prospective, single-blinded, multicentre, clinical trial where patients are randomised to either usual care or usual care supplemented with vertebroplasty with a possibility of crossover 4 weeks after randomisation. The primary outcome will be change in Oswestry Disability Index at 4 weeks.

ANALYSIS

Primary and secondary outcomes are assessed at baseline and at 4, 8, 26 and 52 weeks. Categorical data will be presented by means of frequencies and related percentages; continuous data will be displayed by means of descriptive statistics.

ETHICS AND DISSEMINATION

The study has been evaluated by the Regional Committees on Health Research for Southern Denmark (S-20200075) and notified and approved by the Region of Southern Denmark and listed in the internal record, journal no. 20/22355. All participants provide consent. The protocol will follow the SPIRIT (Standard Protocol Items for Randomized Trials) statement. The Danish Myeloma Patient Organization supports the study. Findings will be disseminated in peer-reviewed publications and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

NCT04533217.

Vertebroplasty for osteoporotic vertebral fracture

Appropriate care of patients with a recent painful osteoporotic vertebral fracture (VF) requires immobilisation, analgesics and spinal orthoses. Some VFs are however responsible for disabling pain and prolonged bed rest. In this context, vertebroplasty techniques have been proposed with a large benefit in case series and open-label randomised studies, but lack efficacy in three among four double-blind randomised studies. The objectives of the treatment of a recent painful VF are to relieve pain and to preserve mechanical conditions. With this in mind, we report an experts’ opinion paper on the indications for vertebroplasty and research agenda for clinical studies.

A retrospective comparison of organ dose and effective dose in percutaneous vertebroplasty performed under CT guidance or using a fixed C-arm with a flat-panel detector

PURPOSE

To compare the organ-dose and effective-dose (E) delivered to the patient during percutaneous vertebroplasty (PVP) of one thoracic or lumbar vertebra performed under CT guidance or using a fixed C-arm.

METHODS

Consecutive adult patients undergoing PVP of one vertebra under CT-guidance, with optimized protocol and training of physicians, or using a fixed C-arm were retrospectively included from January 2016 to June 2017. Organ-doses were computed on 16 organs using CT Expo 2.4 software for the CT procedures and PCXMC 2.0 for the fixed C-arm procedures. E was also computed with both software. Dosimetric values per anatomic locations for all procedures were compared using the paired Mann-Whitney-Wilcoxon test.

RESULTS

In total, 73 patients were analysed (27 men and 46 women, mean age 78 ± 10 years) among whom 35 (48%) underwent PVP under CT guidance and 38 (52%) PVP using a fixed C-arm. The median E was 11.31 [6.54; 15.82] mSv for all PVPs performed under CT guidance and 5.58 [3.33; 8.71] mSv for fixed C-arm and the differences was significant (p<0.001). For lumbar PVP, the organ doses of stomach, liver and colon were significantly higher with CT-scan than with the fixed C-arm: 97% (p=0.02); 21% (p=0.099) and 375% (p=0.002), respectively. For thoracic PVP, the lung organ dose was significantly higher with CT-scan than with the fixed C-arm (127%; p<0.001) and the oesophagus organ doses were not significantly different (p = 0.626).

CONCLUSION

This study showed that the E and the organ dose on directly exposed organs were both higher for PVP performed under CT-guidance than with the fixed C-arm.

A randomized trial comparing the clinical efficacy and safety of a novel steerable percutaneous kyphoplasty with traditional PKP in osteoporotic vertebral fractures

Background

Percutaneous kyphoplasty (PKP) is a highly practical technology to treat osteoporotic vertebral compression fractures (OVCFs). However, the operation time and radiation exposure remain problematic. This study explored the differences in surgical effects and safety between a novel steerable percutaneous kyphoplasty (S-PKP) and traditional PKP in order to achieve better clinical outcomes for OVCF patients. It is also exploring whether the new technology could reduce the radiation exposure.

Methods

This study recruited 72 patients (between March 2019 and January 2020) with OVCFs (single vertebra). The patients were semi-randomly divided these patients into two groups according to ID numbers: a S-PKP group (33 cases) and a PKP group (39 cases). We evaluated the clinical efficacy using the kyphotic Cobb angle, Oswestry disability index (ODI), visual analogue scale (VAS) score, injected cement volume, operation time, intraoperative radiation times, bone cement leakage, and postoperative complications. Patients were followed up once preoperatively, and at 1 day, 6 months, and 1 year postoperatively.

Results

There were no cases of cement leakage or postoperative complications. There were no significant differences in gender, age, Bone mineral density T-score (BMD T) value, Cobb angle between the two groups (P>0.05). Intraoperative bone cement injection was approximately 5.25±1.37 and 5.32±1.29 mL in the PKP and S-PKP groups respectively. The postoperative VAS score and ODI of the two groups at 1 day, 6 months, and 1 year were markedly lower than before (P<0.05). There was a considerable improvement in the Cobb angle postoperatively (P<0.05). However, as the follow-up time extended, the Cobb Angle increased. The operation time and X-ray exposure times of patients in the PKP group were notably higher than those in the S-PKP group. The operation time was 51.59±9.14 min in the PKP group and 30.76±4.82 min in the S-PKP group. The frequency of intraoperative radiation was 105.9±31.93 times in the PKP group and 47.42±11.88 times in the S-PKP group.

Conclusions

Early results showed that S-PKP is a safe and efficient method for the treatment of OVCFs. S-PKP can reduce the operation time and radiation exposure.

Trial registration

Chinese Clinical Trial Registry ChiCTR2100046727

Refracture of the cemented vertebrae after percutaneous vertebroplasty: risk factors and imaging findings

BACKGROUND

To determine the related imaging findings and risk factors to refracture of the cemented vertebrae after percutaneous vertebroplasty (PVP) treatment.

METHODS

Patients who were treated with PVP for single vertebral compression fractures (VCFs) and met this study's inclusion criteria were retrospectively reviewed from January 2012 to January 2019. The follow-up period was at least 2 years. Forty-eight patients with refracture of the cemented vertebrae and 45 non-refractured patients were included. The following variates were reviewed: age, sex, fracture location, bone mineral density (BMD), intravertebral cleft (IVC), kyphotic angle (KA), wedge angle, endplate cortical disruption, cement volume, surgical approach, non-PMMA-endplate-contact (NPEC), cement leakage, other vertebral fractures, reduction rate (RR), and reduction angle (RA). Multiple logistic regression modeling was used to identify the independent risk factors of refracture.

RESULTS

Refracture was found in 48 (51.6%) patients. Four risk factors, including IVC (P = 0.005), endplate cortical disruption (P = 0.037), larger RR (P = 0.007), and NPEC (P = 0.006) were found to be significant independent risk factors for refracture.

CONCLUSIONS

Patients with IVC or larger RR, NPEC, or endplate cortical disruption have a high risk of refracture in the cemented vertebrae after PVP.

Predictive risk factors for recollapse of cemented vertebrae after percutaneous vertebroplasty: A meta-analysis

BACKGROUND

As one of the most common complications of osteoporosis, osteoporotic vertebral compression fracture (OVCF) increases the risk of disability and mortality in elderly patients. Percutaneous vertebroplasty (PVP) is considered to be an effective, safe, and minimally invasive treatment for OVCFs. The recollapse of cemented vertebrae is one of the serious complications of PVP. However, the risk factors associated with recollapse after PVP remain controversial.

AIM

To identify risk factors for the recollapse of cemented vertebrae after PVP in patients with OVCFs.

METHODS

A systematic search in EMBASE, MEDLINE, the Cochrane Library, and PubMed was conducted for relevant studies from inception until March 2020. Studies investigating risk factors for the recollapse of cemented vertebrae after PVP without additional trauma were selected for analysis. Odds ratios (ORs) or standardized mean differences with 95% confidence interval (CI) were calculated and heterogeneity was assessed by both the chi-squared test and the I-squared test. The methodological quality of the included studies was assessed according to the Newcastle-Ottawa Scale.

RESULTS

A total of nine case-control studies were included in our meta-analysis comprising 300 cases and 2674 controls. The significant risk factors for the recollapse of cemented vertebrae after PVP in OVCF patients were fractures located at the thoracolumbar junction (OR = 2.09; 95%CI: 1.30 to 3.38; P = 0.002), preoperative intravertebral cleft (OR = 2.97; 95%CI: 1.93 to 4.57; P < 0.00001), and solid lump distribution pattern of the cement (OR = 3.11; 95%CI: 1.91 to 5.07; P < 0.00001). The analysis did not support that age, gender, lumbar bone mineral density, preoperative visual analogue scale score, injected cement volume, intradiscal cement leakage, or vertebral height restoration could increase the risk for cemented vertebra recollapse after PVP in OVCFs.

CONCLUSION

This meta-analysis suggests that thoracolumbar junction fractures, preoperative intravertebral cleft, and solid lump cement distribution pattern are associated with the recollapse of cemented vertebrae after PVP in OVCF patients.

Midterm outcome after posterior stabilization of unstable Midthoracic spine fractures in the elderly

Background

The evidence for the treatment of midthoracic fractures in elderly patients is weak. The aim of this study was to evaluate midterm results after posterior stabilization of unstable midthoracic fractures in the elderly.

Methods

Retrospectively, all patients aged ≥65 suffering from an acute unstable midthoracic fracture treated with posterior stabilization were included. Trauma mechanism, ASA score, concomitant injuries, ODI score and radiographic loss of reduction were evaluated. Posterior stabilization strategy was divided into short-segmental stabilization and long-segmental stabilization.

Results

Fifty-nine patients (76.9 ± 6.3 years; 51% female) were included. The fracture was caused by a low-energy trauma mechanism in 22 patients (35.6%). Twenty-one patients died during the follow-up period (35.6%). Remaining patients (n = 38) were followed up after a mean of 60 months. Patients who died were significantly older (p = 0.01) and had significantly higher ASA scores (p = 0.02). Adjacent thoracic cage fractures had no effect on mortality or outcome scores. A total of 12 sequential vertebral fractures occurred (35.3%). The mean ODI at the latest follow up was 31.3 ± 24.7, the mean regional sagittal loss of reduction was 5.1° (± 4.0). Patients treated with long segmental stabilization had a significantly lower rate of sequential vertebral fractures during follow-up (p = 0.03).

Conclusion

Unstable fractures of the midthoracic spine are associated with high rates of thoracic cage injuries. The mortality rate was rather high. The majority of the survivors had minimal to moderate disabilities. Thereby, patients treated with long segmental stabilization had a significantly lower rate of sequential vertebral body fractures during follow-up.

Effectiveness of Tirobot-assisted vertebroplasty in treating thoracolumbar osteoporotic compression fracture

Background

Percutaneous kyphoplasty is the main method in the treatment of thoracolumbar osteoporotic compression fractures. However, much radiation exposure during the operation harms the health of surgeons and patients. In addition, the accuracy of this surgery still needs to be improved. This study aimed to assess the radiation exposure and clinical efficacy of Tirobot-assisted vertebroplasty in treating thoracolumbar osteoporotic compression fracture.

Methods

Included in this retrospective cohort study were 60 patients (60–90 years) who had undergone unilateral vertebroplasty for thoracolumbar osteoporotic compression fracture at our hospital between June 2019 and June 2020. All showed no systemic diseases and were assigned to Tirobot group (treated with Tirobot-assisted approach) and control group (treated with traditional approach). Fluoroscopic frequency, operative duration, length of stay (LOS), post-operative complications (cement leakage, infection, and thrombosis), and pre-operative and pre-discharge indexes (VAS score, JOA score, and Cobb’s angle) were compared.

Results

The fluoroscopic frequency (P < 0.001) and post-operative complications (P = 0.035) in Tirobot group were significantly lower than those in control group. The operative duration and LOS in the Tirobot group were shorter than those in the control group, but the differences were not statistically significant (P = 0.183). Pre-discharge VAS score and Cobb’s angle decreased, and JOA increased after surgeries in both groups. These three indexes showed a significant difference after surgery in each group (P < 0.001), but not between groups (P_VAS = 0.175, P_Cobb’s = 0.585, P_JOA = 0.448).

Conclusion

The Tirobot-assisted vertebroplasty can reduce surgery-related trauma, post-operative complications, and patients’ and operators’ exposure to radiation. As a safe and effective strategy, this surgery can realize the quick recovery from thoracolumbar osteoporotic compression fracture.

Comorbid pain in axial spondyloarthritis, including fibromyalgia

The main symptom in patients with axial spondyloarthritis (axSpA) is inflammatory back pain, caused principally by inflammation of the sacroiliac joints and the spine. However, not all back pain in patients with axSpA is related to active inflammation: other types of pain can occur in these patients, and may be related to structural damage (e.g. ankylosis), degenerative changes, vertebral fractures or comorbid fibromyalgia, which are not uncommon in these patients. Structural damage and ankylosis may lead to a biomechanical stress, which can lead to chronic mechanical pain; and degenerative changes of the spine may also exist in patients with axSpA also leading to mechanical pain. Osteoporosis is more prevalent in axSpA patients than in the general population, and vertebral fractures may result in acute bone pain, which can persist for several months. Fibromyalgia, which is also more prevalent in patients with chronic inflammatory diseases (including axSpA), presents with widespread pain which can mimic entheseal pain. A correct diagnosis of the origin of the pain is crucial, since treatments and management may differ considerably. Recognizing these causes of pain may be a challenge in clinical practice, especially for fibromyalgia, which can coexist with axSpA and may have a significant impact on biologic drug response.

In this review, we provide an update of the most common causes of pain other than inflammatory back pain in axSpA patients, and we discuss the latest management options for such causes.

Vertebral fragility fractures: clinical and radiological results of augmentation and fixation-a systematic review of randomized controlled clinical trials

AIM

To assess the outcome of augmentation techniques, i.e., percutaneous vertebroplasty (PVP), balloon kyphoplasty (BKP), vertebral body stenting (VBS) and fixation techniques in the management of vertebral fragility fractures (VFFs).

METHODS

OVID-MEDLINE®, EMBASE, Cochrane Library, SCOPUS, Springer Link, Web of Science, Google Scholar and PubMed were searched from January 2009 to February 2019 to identify relevant studies. The methodological qualities of the studies were evaluated and relevant data were extracted.

RESULTS

Thirteen randomized controlled trials, recruiting 1963 patients, were included. PVP, compared with conservative management (CM), showed a greater pain relief and an improved vertebral body height (VBH) restoration. Moreover, PVP revealed superior to a sham procedure for pain relief in acute VFFs. BKP, compared with CM, rapidly reduces pain and improves quality of life without increasing the risk of additional VFFs. BKP, compared with PVP, has fewer cement leakage rates and is more effective in VBH restoration. BKP should also be preferred to VBS, since it is associated with less material-related complications. Pedicle screw fixation associated with PVP, compared with PVP alone, revealed effective in preventing secondary VFFs.

CONCLUSIONS

BKP showed better clinical and radiological outcomes compared with CM and PVP. BKP revealed as effective as VBS in VBH restoration with less material-related complications.

Cochrane vertebroplasty review misrepresented evidence for vertebroplasty with early intervention in severely affected patients

The Cochrane vertebroplasty review of April 2018 was replaced with an updated version in November 2018 to address complaints of errors in analysis. The updated version continues to misrepresent the evidence supporting early intervention with vertebroplasty for patients with uncontrolled, severe pain and fracture duration <6 weeks. The VAPOUR trial is the only blinded trial of vertebroplasty restricted to this patient group. It showed the benefit of vertebroplasty over placebo, particularly when the intervention occurred within 3 weeks of fracture. The Cochrane vertebroplasty review has ignored the positive outcomes in the VAPOUR trial. Open randomised trials of fractures <6-week duration support the positive findings of the VAPOUR trial. This is not described in the Cochrane review. The VAPOUR trial is clinically heterogeneous from other blinded trials. Cochrane protocol stipulates that clinically heterogeneous trials be described separately, as independent evidence, and not combined in analysis with dissimilar trials. Failure to observe this represents a serious protocol breach in the Cochrane review.

Thorned heart. Description of a near-fatal cardiac embolism after percutaneous Vertebroplasty

Cement extravasation is a rather common complication of vertebroplasty, which can be observed in up to 30-40% of patients undergoing this procedure, further associated with venous leakage occurring in up to 24% of cases. Pulmonary embolism may eventually develop once the cement migrates within the pulmonary artery, and is the most common complication of cement extravasation (involving ~4.6% of patients). Intra-cardiac cement embolism is considerably less frequent, but is a potentially fatal complication, mostly managed with cardiac surgery. We describe here a rare case of near-fatal cardiac cement embolism, with a large fragment perforating the right ventricle and reaching the pericardium, who presented to the Emergency Department (ED) for syncope. The patient, who displayed this severe complication after a vertebroplasty procedure performed for osteoporotic compression fracture, needed cardiac surgery.

Safety of vertebral augmentation with cranio-caudal expansion implants in vertebral compression fractures with posterior wall protrusion

OBJECTIVES

Vertebral augmentation (VA) has become routinely used in vertebral compression fractures (VCFs). VCFs are often associated with posterior wall protrusions (PWPs), which theoretically contraindicates vertebroplasty due to a higher risk of neurological complications. The latest generation of VA devices uses intravertebral cranio-caudal expandable implants to improve the correction of structural deformities but could also be used to prevent further PWP during cement injection. The aim of this study was to evaluate the safety of VA with expandable implant for VCFs with PWP.

METHODS

All consecutive patients treated with expandable implants were considered eligible for inclusion if they met the following criteria: (1) non-neurological VCF, (2) considered unstable (A3-A4 in AOSpine classification), (3) significant PWP (> 2 mm), (4) back pain with a visual analogue scale (VAS) ≥ 4. PWPs were independently measured by two investigators; Pearson's statistics were used for interobserver reproducibility.

RESULTS

Fifty-one consecutive patients, with a mean age of 75 ± 8.3 years (range, 50-92), were included. There was a slight decrease between mean preoperative (6.7 mm ± 2.2 mm) and postoperative (6.5 mm ± 2.2 mm) PWP (p = 0.02), with an excellent interobserver reproducibility (Pearson correlation coefficient = 0.92). A mean kyphosis reduction of 34.9% (± 28.4) was observed (p < 0.001). Forty-two patients (82.4%) had significant pain improvements (mean preoperative VAS = 6.9 [± 1.7] versus 3.1 [± 2.0] postoperatively [p < 0.001]). Secondary adjacent level fractures were noted in 16 patients (31.4%), with a reduction of that risk down to 18.8% if a preventive adjacent vertebroplasty was performed, without reaching the significance threshold (p = 0.14).

CONCLUSIONS

VA with expandable implants appeared safe for non-neurological VCFs with PWP, while allowing satisfactory pain relief.

KEY POINTS

• Vertebral augmentation with cranio-caudal expandable implants is safe for non-neurological vertebral compression fractures with posterior wall protrusions. • Vertebral augmentation with cranio-caudal expandable implants might increase the occurrence of secondary adjacent level fractures. • Adjacent level vertebroplasty might be helpful to prevent secondary adjacent level fractures.

Current Concepts in the Management of Vertebral Compression Fractures

PURPOSE OF REVIEW

This comprehensive review of current concepts in the management of vertebral compression fractures is a manuscript of vertebral augmentation literature of risk factors, clinical presentation, and management. The objective of this review is to compare outcomes between multiple augmentation techniques and ongoing discussions of effectiveness of vertebral augmentation procedures.

RECENT FINDINGS

Vertebral compression fractures (VCFs) are a prevalent disease affecting approximately 1.5 million US adults annually. VCFs can cause severe physical limitations, including back pain, functional disability, and progressive kyphosis of the thoracic spine that ultimately results in decreased appetite, poor nutrition, impaired pulmonary function, and spinal cord compression with motor and sensory deficits. The deconditioning that affects patients with vertebral compression fractures leads to mortality at a far higher rate than age-matched controls. The management of vertebral compression fractures has been extensively discussed with opponents arguing in favor or restricting conservative management and against augmentation, while proponents argue in favor of augmentation. The literature is well established in reference to the effects on mortality when patients undergo treatment with vertebral augmentation; in over a million patients with vertebral compression fractures treated with vertebral augmentation as compared with patients treated with non-surgical management, the patients receiving augmentation performed well with a decrease in morbidity and mortality. Summary of the literature review shows that understanding the risk factors, appropriate clinical evaluation, and management strategies are crucial. Analysis of the evidence shows, based on level I and II studies, balloon kyphoplasty had significantly better and vertebroplasty tended to have better pain reduction compared with non-surgical management. In addition, balloon kyphoplasty tended to have better height restoration than vertebroplasty.

Management of glucocorticoid-related osteoporotic vertebral fracture

The vertebral column is the most common site of osteoporotic fractures in long-term users of glucocorticoids. Vertebral fracture leads to significant morbidities such as unrelenting pain, spinal deformities and reduced mobility, leading to diminished quality of life. Epidemiological data on the prevalence of glucocorticoid-induced vertebral fractures are limited. As vertebral fracture is a strong risk factor for further fragility fractures and mortality, it should be treated appropriately. This article reviews recent data on the prevalence of vertebral fractures in glucocorticoid users, fracture risk stratification, and evidence-based treatment options. The risk of osteoporotic fractures estimated by FRAX should be adjusted for glucocorticoid users. The first-line treatment of glucocorticoid-induced osteoporosis remains the bisphosphonates. Teriparatide and denosumab are alternative options. Percutaneous vertebroplasty and kyphoplasty may be considered for symptomatic control of acute vertebral fracture-related pain when conservative measures fail.

The clinical efficacy and experience of bipedicular percutaneous vertebroplasty combined with postural reduction in the treatment of Kümmell's disease

Background

Kümmell’s disease is a special type of osteoporotic vertebral fracture that causes chronic low back pain and deformity, which seriously affects the living quality of patients. PVP is commonly used to treat osteoporotic vertebral fractures and can quickly relieve low back pain. So, the objective of this study was to analyze the clinical efficacy and experience of bipedicular percutaneous vertebroplasty combined with postural reduction for the treatment of Kümmell’s disease.

Methods

A retrospective analysis of patients with Kümmell’s disease who underwent bipedicular percutaneous vertebroplasty was conducted from February 2016 to May 2018. Operative time, VAS, bone cement injection volume, cement leakage rate, compression improvement of vertebral front edge and vertebral center, and correction degree of kyphosis were collected and analyzed meticulously.

Results

The operative time was 45.33 ± 7.64 min. The volume of bone cement injected was 5.38 ± 1.33 ml. The compression improvement of vertebral front edge was 7.31 ± 1.21%. The compression improvement of vertebral center was 10.34 ± 1.15% and the correction degree of kyphosis was − 2.73 ± 0.31゜. Bone cement leakage occurred in 6 of 39 patients (15.38%), but no clinical symptoms were observed. The VAS scores were significantly lower at 1 day after the surgery, 6 months and at the last follow-up than before the surgery (P = 0.000, respectively). The VAS score was lower at the last follow-up than at 1 day after the surgery (P = 0.001).

Conclusion

Bipedicular percutaneous vertebroplasty combined with postural reduction could achieve satisfactory analgesic effect in the treatment of Kümmell’s disease, and restore the height of the vertebral body and improve kyphosis to some extent.

[Vertebroplasty and kyphoplasty : A critical statement]

BACKGROUND

Despite optimal drug-conservative therapy, a relevant percentage of patients with vertebral compression fractures (WKF) do not experience any relevant improvement in their pain symptoms. Vertebroplasty (VP) and kyphoplasty (KP) are described in the literature as percutaneous interventional procedures for the treatment of WKF.

OBJECTIVE

Assessment of the effectiveness of the VP and KP in the treatment of WKF and discussion of the procedures in the context of the current literature.

MATERIAL AND METHODS

Presentation of the fundamentals of VP and KP and their further developments. Description of indications and contraindications. Discussion of the current literature and recommendations of the individual professional associations.

RESULTS

In patients with vertebral compression fractures, VP or KP of the affected vertebral body leads to a pain reduction in more than 90% of cases. Clinically relevant complications occur in less than 1% of interventions.

CONCLUSION

VP and KP are a safe and effective method for treating painful WKF. Optimal patient selection improves the clinical outcome.

Which anatomic structures are responsible for the reduction loss after hybrid stabilization of osteoporotic fractures of the thoracolumbar spine?

Introduction

Hybrid stabilization is an accepted therapy strategy for unstable osteoporotic thoracolumbar fractures. However, a moderate reduction loss has been reported and it remains unclear which anatomic structure is responsible for the reduction loss.

Methods

This retrospective study was performed at a level I trauma center. Patients aged 61 and older were stabilized using hybrid stabilization after suffering acute and unstable osteoporotic vertebral body fractures at the thoracolumbar spine. Posterior stabilization was done short-segmental and minimal invasive with cement-augmentation of all pedicle screws. The minimum follow-up has been 2 years. The outcome parameters were the reduction loss and the relative loss of height of both intervertebral discs adjacent to the fractured vertebral body, the fractured vertebral body and a reference disc (intervertebral disc superior of the stabilization) between the postoperative and latest lateral radiographs. Additionally, implant positioning and loosening was analyzed.

Results

29 mainly female (72%) patients (73.3 ± 6.0 years) were included. Fractures consisted of 26 incomplete burst fractures and 3 complete burst fractures of the thoracolumbar junction (Th11 – L2: 86%) and the midlumbar spine. The mean follow-up time was 36 months (range: 24–58 months). The mean reduction loss was 7.7° (range: 1–25). The relative loss of heights of both intervertebral discs adjacent to the fractured vertebral body, the reference disc, and the central vertebral body were significant. Thereby, the relative loss of the superior disc height was significant higher compared to the reference disc. Additionally, only the relative loss of central vertebral body height and reduction loss correlated significantly. There were no signs of implant loosening in any patient.

Conclusions

The mean reduction loss was moderate 3 years after hybrid stabilization of unstable osteoporotic vertebral fractures of the thoracolumbar spine. A significant loss of both adjacent disc heights and the central vertebral body was seen, with the highest loss in the superior adjacent disc significantly outranging the reference disc. The superior adjacent intervertebral disc and the central part of the fractured vertebral body seem to be responsible for the majority of reduction loss.

Therapeutic effect of percutaneous kyphoplasty combined with anti-osteoporosis drug on postmenopausal women with osteoporotic vertebral compression fracture and analysis of postoperative bone cement leakage risk factors: a retrospective cohort study

Background

The purpose of this study is to explore the therapeutic effect of percutaneous kyphoplasty (PKP) combined with anti-osteoporosis drug, zoledronic acid, on postmenopausal women with osteoporotic vertebral compression fracture (OVCF) and to perform an analysis of postoperative bone cement leakage risk factors.

Methods

A total of 112 OVCF patients, according to therapeutic regimens, were divided into control group (n = 52, treated with PKP) and observation group (n = 60, treated with PKP and zoledronic acid injection).

Results

Postoperative tumor necrosis factor-α and interleukin-6 levels were significantly decreased in the two groups, compared with those before treatment (both P < 0.05); bone mineral density (BMD), serum bone gla protein (BGP), and vertebral height ratio of injured vertebrae were significantly increased, and procollagen type I N-terminal propeptide (PINP), Cobb angle, visual analogue scale/score (VAS), and Oswestry disability index (ODI) were significantly decreased compared with those before treatment (all P < 0.05). There were significantly higher changes in difference value of BMD, PINP, BGP, vertebral height ratio of injured vertebrae, Cobb angle, VAS, and ODI levels and significantly better therapeutic effect in the observation group than those in the control group (all P < 0.05). Multivariate logistic regression analysis showed that the use of zoledronic acid, vertebral height ratio of injured vertebrae, and ODI were independent factors affecting the therapeutic effect, and that the dosage of bone cement, and peripheral vertebrae wall damage were independent risk factors causing postoperative bone cement leakage. There were no significant differences in postoperative bone cement leakage rate between the two groups.

Conclusions

Peripheral vertebrae wall damage and the dosage of bone cement are independent risk factors causing bone cement leakage in OVCF patients treated with PKP. PKP combined with zoledronic acid has an improvement effect on the condition of postmenopausal women with OVCF and reduces the inflammation and pain in patients, which is beneficial to clinical treatment.

The association between sarcopenia and osteoporotic vertebral compression refractures

Sarcopenia was reported to be significantly associated with osteoporosis. In this study, we reported for the first time that sarcopenia was an independent risk predictor of osteoporotic vertebral compression refractures (OVCRFs). Other risk factors of OVCRFs are low bone mass density T-scores, female sex, and advanced age.

INTRODUCTION

The purpose of this study was to investigate the association between osteoporotic vertebral compression refractures (OVCRFs) and sarcopenia, and to identify other risk factors of OVCRFs.

METHODS

We evaluated 237 patients with osteoporotic vertebral compression fracture who underwent percutaneous kyphoplasty (PKP) in our hospital from August 2016 to December 2017. To diagnose sarcopenia, a cross-sectional computed tomography (CT) image at the inferior aspect of the third lumbar vertebra (L3) was selected for estimating muscle mass. Grip strength was used to assess muscle strength. Possible risk factors, such as age, sex, body mass index (BMI), bone mineral density (BMD), location of the treated vertebra, anterior-posterior ratio (AP ratio) of the fractured vertebra, cement leakage, and vacuum clefts, were assessed. The multivariable analysis was used to determine the risk factors of OVCRFs.

RESULTS

During the follow-up period, OVCRFs occurred in 64 (27.0%) patients. Sarcopenia was present in 48 patients (20.3%), including 21 OVCRFs and 27 non-OVCRFs patients. Sarcopenia was significantly correlated with advanced age, lower BMI, lower BMD, and hypoalbuminemia. Compared with non-sarcopenic patients, sarcopenic patients had higher OVCRFs risk. In univariate analysis, sarcopenia (p = 0.003), female (p = 0.024), advanced age (≥ 75 years; p < 0.001), lower BMD (p < 0.001), lower BMI (p = 0.01), TL junction (vertebral levels at the thoracolumbar junction) (p = 0.01), cardiopulmonary comorbidity (p = 0.042), and hypoalbuminemia (p = 0.003) were associated with OVCRFs. Multivariable analysis revealed that sarcopenia (OR 2.271; 95% CI 1.069-4.824, p = 0.033), lower BMD (OR 1.968; 95% CI 1.350-2.868, p < 0.001), advanced age (≥ 75 years; OR 2.431; 95% CI 1.246-4.744, p = 0.009), and female sex (OR 4.666; 95% CI 1.400-15.552, p = 0.012) were independent risk predictors of OVCRFs.

CONCLUSIONS

Sarcopenia is an independent risk predictor of osteoporotic vertebral compression refractures. Other factors affecting OVCRFs are low BMD T-scores, female sex, and advanced age.

Polymethylmethacrylate Pulmonary Embolism Following Kyphoplasty

We report a case of polymethylmethacrylate cement pulmonary embolism (PE) that occurred two days following a minimally invasive kyphoplasty procedure. Our patient developed non-specific rib pain postoperatively followed by dyspnea, prompting presentation to the emergency department. The polymethylmetacrylate cement was visualized on initial chest radiograph and further characterized using computed tomography. The patient was admitted and anticoagulation started, later having an uncomplicated hospital course. The polymethylmethacrylate cement has a well-documented history of leakage and other postoperative complications. Cement PE, while rare, can present similarly to a thrombotic PE and requires adequate long-term anticoagulation with close follow-up.

Vertebroplasty for acute painful osteoporotic vertebral compression fractures: An update

Vertebral compression fractures (VCFs) are a common cause of back pain and disability and are usually osteoporotic in nature. Therapy aims to adequately control pain and allow early mobilisation and return of function while preventing additional fractures. A proportion of patients do not achieve adequate pain relief using conservative measures alone. Unwanted adverse effects from medications may also ensue. Vertebroplasty represents an alternative treatment option for VCFs. Patients with acute VCFs (≤6 weeks old) may gain the most benefit from vertebroplasty as healed fractures are not as amenable to cement injection. High-quality studies have reported conflicting results regarding the use of vertebroplasty in the treatment of acute VCFs. Despite high-quality evidence, varying study designs and heterogenous patient cohorts make interpretation of this data difficult. Only one sham-controlled randomised controlled trial (RCT) has evaluated vertebroplasty exclusively in patients with acute VCFs, reporting favourable results. Pooled data from RCTs also suggest vertebroplasty to be safe. This article provides a concise and critical review of the current literature regarding vertebroplasty for the treatment of acute VCFs.

Hybrid stabilization of unstable osteoporotic thoracolumbar vertebral body fractures: clinical and radiological outcome after a mean of 4 years

PURPOSE

The aim of this study was to evaluate midterm results after hybrid stabilization of unstable osteoporotic fractures of the thoracolumbar junction.

METHODS

This retrospective study was performed at a level I trauma center. A total of 113 patients aged 61 and older were stabilized using hybrid stabilization consisting of short-segmental posterior instrumentation and augmentation of the fractured vertebral body after suffering an unstable osteoporotic vertebral body fracture at the thoracolumbar spine. All patients were treated by hybrid stabilization. The primary outcome parameters were the ODI score and loss of reduction. Secondary radiological outcome parameters were the sagittal alignment parameters.

RESULTS

Seventy-two women and 41 men (74.6 ± 6.8 years) were included. Sixty-nine patients (61%) were re-evaluated after a mean of 48 months. Seventeen patients have died during the follow-up period (15%). A total of five in-patient complications were documented (4.4%). Additionally, 12 patients (17.4%) suffered from further osteoporotic vertebral body fractures affecting vertebral bodies of different levels. The average ODI score at the final follow-up was 29.9 (± 22.0). Thereby, 66.6% of all patients had low to moderate limitations. The average regional sagittal loss of reduction was 7.4% (± 5.6%). Loss of reduction was below 10° in 78% of the patients. There were statistically significant correlations between the loss of reduction and the ODI score, pelvic incidence and latest Cobb angle, and between the ODI scores and the lumbar lordosis.

CONCLUSIONS

The majority of patients had low or moderate limitations and low to moderate reduction loss. Thereby, high loss of reduction correlated directly with inferior outcomes. These slides can be retrieved under Electronic Supplementary Material.

Unilateral versus bilateral percutaneous vertebroplasty for osteoporotic vertebral compression fractures in elderly patients: A meta-analysis

OBJECTIVE

To contrast the effects and complications in unilateral and bilateral percutaneous vertebroplasty (PVP) for osteoporotic vertebral compression fractures in elderly patients.

METHODS

Multiple databases were adopted to search relevant studies, and the articles eventually satisfied the criteria were included. All the meta-analyses were conducted with the Review Manager 5.2. To estimate the quality of each article, risk of bias table was performed.

RESULTS

Finally, 627 patients were enrolled in 9 studies and ultimately met the eligibility criteria. The unilateral and bilateral surgical samples were 314 and 313, respectively. The meta-analysis showed no significant difference in Visual Analog Scale/Score (VAS) (MD = -0.05, 95% confidence interval [CI] [-0.24, 0.13], P = .57), Oswestry Disability Index (ODI) score (MD = 0.03, 95% CI [-0.57, 0.62], P = .93) and cement leakage (OR = 1.00, 95% CI [0.67, 1.50], P = 1.00) between unilateral group and bilateral group. The surgery time of unilateral PVP is much less than that of bilateral PVP (MD = -8.42, 95% CI [-13.17, -3.66], P = .0005). Patients with bilateral PVP surgery have been injected more cement than patients with a unilateral surgery (MD = -2.56, 95% CI [-2.79, -2.33], P <.00001).

CONCLUSION

This study demonstrated unipedicular approach is the preferred surgical technique for treatment of osteoporotic vertebral fracture (OVF) compared with bilateral PVP since unipedicular approach injects less cement and cost less surgery time.

Unwarranted regional variation in vertebroplasty and kyphoplasty in Switzerland: A population-based small area variation analysis

Background

Percutaneous vertebroplasty (VP) and balloon kyphoplasty (BKP) for treating painful osteoporotic vertebral fractures are controversial.

Objective

We assessed the regional variation in the use of VP/BKP in Switzerland.

Methods

We conducted a population-based small area variation analysis using patient discharge data for VP/BKP from all Swiss hospitals and Swiss census data for calendar years 2012/13. We derived hospital service areas (HSAs) by analyzing patient flows, assigning regions from which most residents were discharged to the same VP/BKP specific HSA. We calculated age-/sex-standardized mean VP/BKP-rates and measures of regional variation (extremal quotient [EQ], systematic component of variation [SCV]). We estimated the reduction in variation of VP/BKP rates using negative binomial regression, with adjustment for patient demographic and regional socioeconomic factors (socioeconomic status, urbanization, and language region). We considered the residual, unexplained variation most likely to be unwarranted.

Results

Overall, 4955 VP/BKPs were performed in Switzerland in 2012/13. The age-/sex-standardized mean VP/BKP rate was 4.6/10,000 persons and ranged from 1.0 to 10.1 across 26 HSAs. The EQ was 10.2 and the SCV 57.6, indicating a large variation across VP/BKP specific HSAs. After adjustment for demographic and socioeconomic factors, the total reduction in variance was 32.2% only, with the larger part of the variation remaining unexplained.

Conclusions

We found a 10-fold variation in VP/BKP rates across Swiss VP/BKP specific HSAs. As only one third of the variation was explained by differences in patient demographics and regional socioeconomic factors, VP/BKP in the highest-use areas may, at least partially, represent overtreatment.

A Colombian experience involving SpineJack®, a consecutive series of patients experiencing spinal fractures, percutaneous approach and anatomical restoration 2016-2017

Background

Spinal fractures are becoming more frequent and should be handled as a severe and endemic pathology that requires timely diagnosis and adequate treatment. The classification of the AOSpine is currently the classification used for this type of fractures, not only for its approach, but to predict surgical management.

Methods

These patients had spinal fracture reduction procedures done through percutaneous way with expander endovertebral implants, and intraosseous fixation using SpineJack^® intravertebral implants plus Cohesion^® cement. Within the follow-up scheme, subsequent measurements were taken after a week, a month after surgery, 3 months after the procedure and after 6 months of follow-up. STATA^® (Statistical Analysis System, version 12.1, SAS Institute Inc., Cary, NC, USA) was used for all analyzes. The Wilcoxon or Student's t-test was used for comparisons in pairs depending on the normality of the distribution.

Results

A clinical follow-up is performed to 20 consecutive patients experiencing spinal compression fractures (SCF) who received percutaneous treatment involving SpineJack^® and Cohesion^® cement, resulting in a statistically significant decrease of both pain and pain-related disability. No complications arose from the procedure.

Conclusions

According to the observations, which reflect what is found in the world literature, this is an effective and safe way of handling SCF.

Radiologic Evaluation of Chronic Vertebral Compression Fractures and Role of Vertebral Augmentation

The literature has classified chronic vertebral compression fractures (VCF) as those still "symptomatic" four or more months after onset. Pain is regarded as the predominant chronic symptom; however, radiologic changes are important in evaluating fracture progression. This review examines a series of patients with chronic fractures and both persistence of spinal pain combined with radiologic changes, such as worsening collapse, spinal angulation, the development of vertebral edema and clefts, as well as the development of new fractures at adjacent spinal levels. In patients with clear progressive radiologic changes in addition to pain, vertebral augmentation on an average of 9.3 months after injury was effective in reducing the pain and stabilizing these more chronic osteoporotic fractures. A comparison of the pre- and post-procedure visual analog scale score (VAS) indicated an average of 66% reduction in pain. There are several reasons for the development of chronic symptomatic fractures. Most commonly, interventional treatment is delayed in a patient already diagnosed with VCF after a long period of conservative treatment, yet pain persists, or the initial clinical and radiologic evaluation misses the fracture, leading to a delay in diagnosis and treatment. In this report, management in these patients and the role of late vertebral augmentation for chronic symptomatic fractures is clarified based on the findings of various radiologic changes seen on both initial and follow-up radiologic studies.