[Osteoporotic vertebral body fractures of the thoracolumbar spine. Diagnostics and therapeutic strategies]

Decompression and fusion surgery for osteoporotic vertebral fractures: WFNS Spine Committee Recommendations

INTODUCTION

Osteoporotic vertebral fractures (OVF) are common due to aging populations. Their clinical management remains controversial. Although conservative approaches are sufficient in most cases, there are certain conditions where decompression or fusion surgery are necessary. This manuscript aims to clarify the indications and types of surgeries for OVF.

EVIDENCE ACQUISITION

A Medline and Pubmed search spanning the period between 2010 and 2020 was performed using the keywords "osteoporotic vertebral fractures and decompression surgery" and "osteoporotic vertebral fractures and fusion surgery". In addition, we reviewed up-to-date information on decompression and fusion in osteoporotic vertebral fracture (OVF) to reach an agreement in two consensus meetings of the World Federation of Neurosurgical Societies (WFNS) Spine Committee that was held in January and February 2021. The Delphi method was utilized to improve the validity of the questionnaire.

EVIDENCE SYNTHESIS

A total of 19 studies examining decompression and fusion surgery in OVF were reviewed. Literature supports the statement that decompression and fusion surgery are necessary for progressive neurological deficits after OVF. The Spine Section of the German Society for Orthopedics and Trauma (DGOU) classification revealed that it might help make surgical decisions. We also noted that in patients planning to undergo surgery to correct significant kyphosis after OVF, several techniques, including multilevel fixation, cement augmentation, preservation of sagittal balance, and avoiding termination at the apex of kyphosis are necessary to prevent complications. Additionally, it became clear that there is no consensus to choose the type of open surgery (anterior, posterior, combined, using cement or bone or vertebral body cage, the levels, and kind of instrumentation). The current literature indicated that implant failure in the osteoporotic spine is a common complication, and many techniques have been described to prevent implant failure in the osteoporotic spine. However, the superiority of one method over another is unclear.

CONCLUSIONS

Open surgery for osteoporotic vertebral fractures should be considered if neurologic deficits and significant painful kyphosis. The apparent indications of surgery and most ideal surgical technique for OVF remain unclear in the literature; therefore, the decision must be individualized.

Comparison of Long Segmental Dorsal Stabilization with Complete Versus Restricted Pedicle Screw Cement Augmentation in Unstable Osteoporotic Midthoracic Vertebral Body Fractures: A Biomechanical Study

OBJECTIVE

To compare the construct stability of long-segmental dorsal stabilization in unstable midthoracic osteoporotic fracture situation with complete pedicle screw cement augmentation (ComPSCA) versus restricted pedicle screw cement augmentation (ResPSCA) of the most cranial and caudal pedicle screws.

METHODS

Twelve fresh frozen human cadaveric specimens (Th 4-Th 10) aged 65 years and older were tested in a biomechanical cadaver study. All specimens received a dual-energy X-ray absorption scan and computed tomography scan before testing. Standardized long segmental stabilization was performed. All specimens were matched into pairs. These pairs were randomized into the groups with ComPSCA and ResPSCA. An unstable Th7 fracture was simulated. The maximum load was tested with 6 mm/min until failure or 20 mm had been reached. After testing, a computed tomography scan was performed.

RESULTS

The mean age of the specimens was 87.8 years (range 74-101 years). The mean t score was -3.6 (range -1.2 to -5.3). The mean maximum force in the ResPSCA group was 1600 N (range 1119-1880 N) and 1941 N (1183-3761 N) in the ComPSCA group. No statistically significant differences between both study groups (P = 1.0) could be seen. No signs of screw loosening were visible.

CONCLUSIONS

No statistically significant differences in the maximum loads could be seen. No screw loosening of the non-cemented screws was visible. Thus, the construct stability of long segmental posterior stabilization of an unstable midthoracic fracture using ResPSCA seems to be comparable with ComPSCA under axial compression.

[Hybrid stabilization and geriatric complex treatment of type A spinal fractures]

Approximately 200,000 spinal fractures occur each year in Germany. The decimated stability of the vertebra often leads to type A fractures with a substantial influence by osteoporosis. A mobility preserving and gentle treatment has clear advantages compared to conservative treatment. The hybrid stabilization as a combination of minimally invasive dorsal stabilization and vertebral augmentation has become an established method. In the period from July 2014 to June 2015 a total of 205 spinal operations were documented. In the group of very old patients more than 80% were treated for a geriatric type A vertebral fracture, 24 with hybrid stabilization, 5 by percutaneous bisegmental, 22 by kyphoplasty stabilization and 13 by percutaneous polysegmental procedures. Furthermore, these 4 groups were also considered with respect to the treatment in geriatric trauma centers (GTC). The 4 forms of treatment achieved a mean remuneration of 11,238.77 €. For the individual treatment form of kyphoplasty there was an increase in the remuneration of 4276.54 €, when patients undergo geriatric complex treatment and the remuneration is according to the diagnosis-related groups (DRG) classification I34Z. In the field of operative treatment of geriatric vertebral fractures, the augmentative procedures of kyphoplasty and vertebroplasty are well-established but an injury-related involvement of adjacent spinal segments and continuity fractures are frequent occurrences so that a bisegmental hybrid stabilization is advantageous. In addition, the perioperative stress in hybrid stabilization is only negligibly longer so that hybrid stabilization and geriatric complex treatment can be recommended as the new standard in spinal surgery for the treatment of type A fractures in aged patients.

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.

[Thoracolumbar spinal fractures in the elderly : Classification and treatment]

Thoracolumbar fractures in the elderly are frequently associated with osteoporosis. Osteoporosis can cause fractures or be a significant comorbidity in traumatic fractures. The OF classification is based on conventional X‑ray, computed tomography (CT) scan and magnetic resonance imaging (MRI). It is easy to use and provides a clinically relevant classification of the fractures. Therapeutic decisions are made based on the clinical and radiological situation by using the OF score. The score takes the current clinical situation including patient-specific comorbidities into consideration. The treatment recommendations are based on an expert consensus opinion and include conservative and operative options. If surgery is indicated, vertebral body augmentation, percutaneous stabilization and even open surgery can be used.

Analysis of the Risk Factors for Unfavorable Radiologic Outcomes after Fusion Surgery in Thoracolumbar Burst Fracture : What Amount of Postoperative Thoracolumbar Kyphosis Correction is Reasonable?

Objective

The aims in the management of thoracolumbar spinal fractures are not only to restore vertebral column stability, but also to obtain acceptable alignment of the thoracolumbar junction (T-L junction) to prevent complications. However, insufficient surgical correction of the thoracolumbar spine would be likely to cause late progression of abnormal kyphosis. Therefore, we identified the surgical factors that affected unfavorable radiologic outcomes of the thoracolumbar spine after surgery.

Methods

This study was conducted in a single institution from January 2007 to December 2013. A total of 98 patients with unstable thoracolumbar spine fracture were included. In these patients, fixation was done through transpedicular screws with rods by three surgical patterns. We reviewed digital radiographs and analyzed the images preoperatively and postoperatively during follow-up visits to compare the change of the thoracolumbar Cobb angle with radiologic parameters and clinical outcomes. The unfavorable radiologic group was defined as the patients who were measured as having greater than 20 degrees of thoracolumbar Cobb angle on the last follow-up, or who underwent kyphotic progression of thoracolumbar Cobb angle greater than 10 degrees from the immediate postoperative state to final follow-up, or who had overt instrument failure with/without additional surgery. We assessed the risk factors that affected the unfavorable radiologic outcomes.

Results

We had 43 patients with unfavorable radiologic outcomes, including 35 abnormal thoracolumbar alignments and 14 instrumental failures with/without additional surgery. The multivariate logistic regression test showed that immediate postoperative T-L junction Cobb angle less than 10.5 degrees was a statistically significant risk factor, as well as the presence of osteoporosis (p=0.017 and 0.049, respectively).

Conclusion

Insufficient correction of thoracolumbar kyphosis was considered to be a major factor of an unfavorable radiological outcome. The spinal surgeon should consider that having a T-L junction Cobb angle larger than 10.5 degrees immediately after surgery could result in an unfavorable radiological outcome, which is related to a poor clinical outcome.

Correlation analysis of osteoporotic vertebral compression fractures and spinal sagittal imbalance

PURPOSE

To evaluate the correlation between osteoporotic vertebral compression fractures and spinal sagittal imbalance, in order to provide a reference for clinical treatment.

METHODS

From September 2013 to March 2015, 60 elderly patients with old osteoporotic vertebral compression factures (observation group) and 60 healthy elderly people (control group) were studied. Whole-spine anteroposterior and lateral view X‑ray photographs were taken from all participants, the number and location of fractured vertebrae were recorded, and sagittal parameters in both groups were compared. The observation group was divided into three subgroups according to the number of fractured vertebrae. The C7/sacrofemoral distance (SFD) ratio in the three subgroups was compared, and the correlation between the number of fractured vertebrae and the C7/SFD ratio was analyzed.

RESULTS

The thoracic kyphotic angle in patients in the observation group was higher than in the control group (P < 0.05), the lumbar lordotic angle in patients in the observation group was lower than in the control group (P < 0.05), the absolute value of the T1 spinopelvic inclination angle in patients in the observation group was lower than in the control group (P < 0.05), and the C7/SFD ratio of patients in the observation group was higher than in the control group (P < 0.05). C7/SFD ratios of the subgroups differed from each other, and the number of fractured vertebrae and C7/SFD ratio were positively correlated.

CONCLUSION

Osteoporotic vertebral compression fractures can change local spinal sagittal alignment, multiple vertebral compression fractures can cause spinal sagittal imbalance, and the number of fractured vertebrae and the degree of forward movement of the spine were positively correlated.

Fracture care using percutaneously applied titanium mesh cages (OsseoFix®) for unstable osteoporotic thoracolumbar burst fractures is able to reduce cement-associated complications--results after 12 months

Background

Despite the known demographic shift with expected doubled rate of vertebral body fractures by the year 2050, a standardized treatment concept for traumatic and osteoporotic incomplete burst fracture of the truncal spine does not exist. This study aims to determine whether minimally invasive fracture care for incomplete osteoporotic thoracolumbar burst fractures using intravertebral expandable titanium mesh cages is a suitable procedure and may provide improved safety in terms of cement-associated complications in comparison to kyphoplasty procedure.

Methods

In 2011/2012, 15 patients (10 women, 5 men; mean age 77) with 15 incomplete osteoporotic thoracolumbar burst fractures (T10 to L4) were stabilized using intravertebral expandable titanium mesh cages (OsseoFix®) as part of a prospective study. X-ray, MRI and bone density measurements (DXA) were performed preinterventionally. The clinical and radiological results were evaluated preoperatively, postoperatively and after 12 months according to the visual analogue scale (VAS), the Oswestry Disability Index (ODI), X-ray (Beck Index, Cobb angle) and CT analyses. Wilcoxon rank sum test, sign test and Fischer’s exact test were used for statistical evaluation.

Results

A significant reduction in pain intensity (VAS) from preoperative 8.0 to 1.6 after 12 months and significant improvement in activity level (ODI) from preoperative 79.0 to 30.5 % after 12 months were revealed. Radiologically, the mean kyphotic angle according to Cobb showed significant improvements from preoperative 9.1° to 8.0° after 12 months. A vertebral body subsidence was revealed in only one case (6.7 %). No changes in the position of the posterior wall were revealed. No cement leakage or perioperative complications were seen.

Conclusion

As a safe and effective procedure, the use of intravertebral expandable titanium mesh cages presents a valuable alternative to usual intravertebral stabilization procedures for incomplete osteoporotic burst fractures and bears the potential to reduce cement-associated complications.

Trial registration

German Clinical Trials Register (DKRS) DRKS00008833.

[Kyphoplasty combined with intraoperative radiotherapy (Kypho-IORT). Alternative therapy for patients with oligometastatic spinal metastases]

BACKGROUND

Due to a more effective systemic therapy the survival of patients suffering from malignant tumors has been significantly improved but a longer life span is often associated with a higher incidence of osseous metastases. The majority of these metastases are localized in the spine causing pain, instability and neurological impairments. The interdisciplinary management of spinal metastases previously consisted of stabilization followed by fractionated external body radiation therapy. A reduction in procedural severity and morbidity as well as consideration of self-sufficiency and hospitalization time are important target parameters for these palliative patients.

METHOD AND RESULTS

Kyphoplasty combined with intraoperative radiotherapy (Kypho-IORT) is one of several modern treatment options, which involves a minimally invasive procedure with local high-dose transpedicular irradiation of the spine with low-energy (50 kV) X-rays. Immediately following irradiation, stabilization of the spine is carried out using kyphoplasty via the same access route so that a single stage procedure with excellent pain reduction and good local tumor control can be achieved. This article presents clinical data for this procedure and the different fields of indications are critically reviewed and compared to other therapy options. Methodological improvements and options for further individualization of therapy are demonstrated.

CONCLUSION

The Kypho-IORT procedure is a safe, feasible and beneficial modern treatment option for instant stabilization and local tumor control in patients with spinal metastases. More than 100 operations have been successfully performed so that the method can be deemed suitable for inclusion in the clinical routine. A phase II dose escalation study has now been completed and submitted for publication and a 2-arm non-inferiority trial (phase III study) for comparison with conventional irradiation is in progress.

Thoracolumbar spine fractures in the geriatric fracture center: early ambulation leads to good results on short term and is a successful and safe alternative compared to immobilization in elderly patients with two-column vertebral fractures

INTRODUCTION

Thoracolumbar spine fractures are common osteoporotic fractures among elderly patients. Several studies suggest that these fractures can be treated successfully with a nonoperative management. The aim of this study is to evaluate the conservative treatment of elderly patients with a vertebral fracture.

METHODS

This study is a retrospective cohort study, which included all patients with an age of 65 years and older, who were diagnosed with a vertebral fracture and where therefore admitted to the Geriatric Fracture Center over a period of 2 years. Primary outcome was the level of functioning 6 weeks and 3 months after admission.

RESULTS

We included 106 patients with 143 vertebral fractures, of which 61 patients were evaluated after 3 months. In our population, 53% of the patients had a fracture involving both middle and anterior columns. The majority of the patients functioned sufficiently 6 weeks and 3 months after admission. Analysis showed that age <80 years is an independent predictor of a sufficient level of functioning after 6 weeks.

DISCUSSION

The nonoperative treatment of elderly patients with a vertebral fracture leads to a sufficient level of functioning 6 weeks and 3 months after admission. In our population, only age <80 years is an independent predictor for a sufficient level of functioning 6 weeks after admission. The level of functioning at 6 weeks predicts the level of functioning 3 months after admission. On comparison, the level of functioning after early ambulation is equal to the level of functioning after immobilization. Where immobilization may lead to complications, early ambulation was not associated with new complications or neurological damage. Based on these advantages, the treatment of elderly patients with a fracture involving both middle and anterior columns may be altered from immobilization to mobilization in the future.