Percutaneous Vertebroplasty and Kyphoplasty: Current Status, New Developments and Old Controversies

Satisfactory 2-year outcome of minimal invasive hybrid stabilization with double treated screws for unstable osteoporotic spinal fractures

PURPOSE

This study evaluates whether the fracture level alters the outcomes of minimally invasive hybrid stabilization (MIHS) with double-threaded, uncemented polyaxial screws for unstable osteoporotic vertebral fractures.

METHODS

This prospective cohort study included 73 patients (71.23% females, mean age: 79.9 ± 8.8 years) with unstable OF 3-4 fractures treated by MIHS between Nov 2015-Jan 2018. Patient characteristics, operative data, clinical outcomes, complications, radiological outcomes, and midterm (24-month) follow-up regarding functionality, pain, and quality of life were analyzed.

RESULTS

Patients had thoracolumbar (71.23%), thoracic (10.97%), and lumbar (17.8%) fractures. Operative time was < 120 min in 73.97% of patients, with blood loss < 500 ml in 97.25% of cases. No in-hospital mortality was recorded. Spine-associated complications occurred in 15.07% of patients, while 36.98% of patients had urinary tract infections (n = 12), pneumonia (n = 5), and electrolyte disturbances (n = 9). The mean length of hospital stay was 13.38 ± 7.20 days. Clinically-relevant screw loosening occurred in 1.7% of screws, and secondary adjacent fractures were diagnosed in 5.48% of patients. The alpha-angle improved significantly postoperatively (mean change: 5.4°) and remained stable for 24 months. The beta-angle improved significantly from 16.3° ± 7.5 to 10.8° ± 5.6 postoperatively but increased slightly to 14.1° ± 6.2 at midterm follow-up. Although no differences were seen regarding baseline data, clinical outcomes, and complications, fracture level significantly altered the COMI score at 24 months with no effect on pain score or quality-of-life.

CONCLUSION

MIHS using polyaxial screws is a safe treatment for single-level osteoporotic spinal fractures. Fracture level did not alter radiological reduction loss; however, it significantly altered patients' function at 24 months.

[Translated article] Truths and myths about augmentation techniques in the treatment of fragility fractures

The main event of osteoporosis is fragility fractures. Vertebral compression fractures are the most commonly fragility fracture related to osteoporosis. Our goal is to review the available literature to confirm or deny concepts learned about spinal cementation and adapt our clinical practice according to scientific evidence. In the complex world of spine surgery, constant innovations seek to improve the quality of life of patients. Among these, vertebral augmentation has emerged as an increasingly popular technique, but often shrouded in myths and misunderstandings. In this systematic review, we will thoroughly explore the truths behind vertebral augmentation, unravelling common myths and providing a clear insight into this technique. As specialists in the field, it is crucial to understand the reality surrounding these interventions to offer our patients the best possible information and make informed decisions.

Factors influencing further vertebral height loss following percutaneous vertebroplasty in osteoporotic vertebral compression fractures: A 1-year follow-up study

BACKGROUND

Osteoporotic vertebral compression fractures (OVCFs) contribute to back pain and functional limitations in older individuals, with percutaneous vertebroplasty (PVP) emerging as a minimally invasive treatment. However, further height loss post-PVP prompts investigation into contributing factors.

AIM

To investigate the factors associated with further height loss following PVP with cement augmentation in OVCF patients.

METHODS

A total of 200 OVCF patients who underwent successful PVP between January 2021 and December 2022 were included in this study. "Further height loss" during 1 year of follow-up in OVCF patients with bone edema was defined as a vertical height loss of ≥ 4 mm. The study population was divided into two groups for analysis: The "No Further Height Loss group (n = 179)" and the "Further Height Loss group (n = 21)."

RESULTS

In comparing two distinct groups of patients, significant differences existed in bone mineral density (BMD), vertebral compression degree, prevalence of intravertebral cleft (IVF), type of bone cement used, and cement distribution patterns. Results from binary univariate regression analysis revealed that lower BMD, the presence of IVF, cleft distribution of bone cement, and higher vertebral compression degree were all significantly associated with further height loss. Notably, the use of mineralized collagen modified-poly(methyl methacrylate) bone cement was associated with a significant reduction in the risk of further height loss. In multivariate regression analysis, lower BMD and the presence of IVF remained significantly associated with further height loss.

CONCLUSION

Further height loss following PVP in OVCF patients is influenced by a complex interplay of factors, especially lower BMD and the presence of IVF. These findings underscore the importance of assessing and managing these factors when addressing height loss following PVP in OVCF patients.

Augmented Central Pain Processing Occurs after Osteoporotic Vertebral Compression Fractures and Is Associated with Residual Back Pain after Percutaneous Vertebroplasty

STUDY DESIGN

A retrospective analysis.

PURPOSE

To investigate the occurrence of central sensitization (CS) in patients with osteoporotic vertebral compression fractures (OVCFs) and identify the association between CS and residual back pain (RBP).

OVERVIEW OF LITERATURE

RBP is a vexing complication that affects 6.3%-17.0% of patients with OVCFs who underwent percutaneous vertebroplasty (PVP). Given the negative effect of RBP on patients' psychological and physiological statuses, efforts to preoperatively select patients who are at risk for RBP development have a high priority to offer additional treatment and minimize this complication.

METHODS

Preoperatively, all 160 patients with OVCFs underwent pressure-pain threshold (PPT), temporal summation (TS), conditioned pain modulation (CPM), and imaging assessments. Pain intensity and pain-related disability were evaluated before and after PVP.

RESULTS

Preoperatively, patients with OVCFs had lower PPTs in both local pain and pain-free areas and lower CPM and higher TS in pain-free areas than healthy participants (p<0.05). Unlike patients with acute fractures, patients with subacute/chronic OVCFs showed higher TS with or without lower CPM in the pain-free area compared with healthy participants (p<0.05). Postoperatively, RBP occurred in 17 of 160 patients (10.6%). All preoperative covariates with significant differences between the RBP and non-RBP groups were subjected to multivariate logistic regression, showing that intravertebral vacuum cleft, posterior fascia edema, numeric rating pain scale scores for low back pain at rest, and TS were independently associated with RBP (p<0.05).

CONCLUSIONS

Augmented central pain processing may occur in patients with OVCFs, even in the subacute stage, and this preexisting CS may be associated with RBP. Preoperative assessment of TS in pain-free areas may provide additional information for identifying patients who may be at risk of RBP development, which may be beneficial for preventing this complication.

Advantages of unilateral percutaneous kyphoplasty for osteoporotic vertebral compression fractures-a systematic review and meta-analysis

Data from English randomized controlled trials comparing unilateral versus bilateral PKP for the treatment of OVCFs were retrieved and analyzed, and the results showed that unilateral PKP is a better choice for the treatment of patients with OVCFs, which will provide a reliable clinical rationale for the treatment of OVCFs.

PURPOSE

To investigate the advantages of unilateral percutaneous kyphoplasty (PKP) for the treatment of osteoporotic vertebral compression fractures(OVCFs).

METHODS

The systematic evaluation program met all program requirements (CRD 42023422383) by successfully passing the PROSPERO International Prospective Systematic Evaluation Registry. Researchers searched the references of English-language randomized controlled trials comparing unilateral and bilateral PKP for the treatment of osteoporotic vertebral compression fractures published between 2010 and 2023 and manually searched for known primary and review articles. The study statistically analyzed data from all the included literature, which primarily included time to surgery, visual pain score(VAS) and Oswestry disability index(ODI) at postoperative follow-up time points, polymethylmethacrylate (PMMA, bone cement) injection dose, cement leakage, radiation dose, and improvement in kyphotic angle.

RESULTS

This meta-analysis searched 416 articles published from 2010 to 2023 based on keywords, and 18 articles were finally included in this study. The results of the forest plot showed that unilateral PKP operative time, amount of bone cement used, and radiation dose to the patient were significantly reduced (p < 0.01, p < 0.01, and p < 0.01, respectively), and unilateral and bilateral PKP had comparable cement leakage (p = 0.49, 95% CI = 0.58-1.30), and there was no significant difference in the kyphotic angle between unilateral and bilateral PKP (p = 0.42, 95% CI =  - 2.29-0.96). During follow-up, there was no significant difference in pain relief between unilateral and bilateral PKP (p = 0.70, 95% CI =  - 0.09-0.06), nor was there a significant difference in ODI (p = 0.27, 95% CI =  - 0.35-1.24).

CONCLUSIONS

There is no difference in clinical efficacy between unilateral PKP and bilateral PKP, but unilateral PKP has a shorter operative time, a lower incidence of cement leakage, a lower amount of cement, and a lower radiation dose to the patient and operator. Unilateral PKP is a better option for patients with OVCFs.

Predicting osteoporotic fractures post-vertebroplasty: a machine learning approach with a web-based calculator

PURPOSE

The aim of this study was to develop and validate a machine learning (ML) model for predicting the risk of new osteoporotic vertebral compression fracture (OVCF) in patients who underwent percutaneous vertebroplasty (PVP) and to create a user-friendly web-based calculator for clinical use.

METHODS

A retrospective analysis of patients undergoing percutaneous vertebroplasty: A retrospective analysis of patients treated with PVP between June 2016 and June 2018 at Liuzhou People's Hospital was performed. The independent variables of the model were screened using Boruta and modelled using 9 algorithms. Model performance was assessed using the area under the receiver operating characteristic curve (ROC_AUC), and clinical utility was assessed by clinical decision curve analysis (DCA). The best models were analysed for interpretability using SHapley Additive exPlanations (SHAP) and the models were deployed visually using a web calculator.

RESULTS

Training and test groups were split using time. The SVM model performed best in both the training group tenfold cross-validation (CV) and validation group AUC, with an AUC of 0.77. DCA showed that the model was beneficial to patients in both the training and test sets. A network calculator developed based on the SHAP-based SVM model can be used for clinical risk assessment ( https://nicolazhang.shinyapps.io/refracture_shap/ ).

CONCLUSIONS

The SVM-based ML model was effective in predicting the risk of new-onset OVCF after PVP, and the network calculator provides a practical tool for clinical decision-making. This study contributes to personalised care in spinal surgery.

Truths and myths about augmentation techniques in the treatment of fragility fractures

The main event of osteoporosis is fragility fractures. Vertebral compression fractures are the most commonly fragility fracture related to osteoporosis. Our goal is to review the available literature to confirm or deny concepts learned about spinal cementation and adapt our clinical practice according to scientific evidence. In the complex world of spine surgery, constant innovations seek to improve the quality of life of patients. Among these, vertebral augmentation has emerged as an increasingly popular technique, but often shrouded in myths and misunderstandings. In this systematic review, we will thoroughly explore the truths behind vertebral augmentation, unraveling common myths and providing a clear insight into this technique. As specialists in the field, it is crucial to understand the reality surrounding these interventions to offer our patients the best possible information and make informed decisions.

Unilateral percutaneous vertebroplasty in osteoporotic vertebral compression fractures: A clinical efficacy evaluation

Osteoporotic vertebral compression fractures, often resulting from low-energy trauma, markedly impair the quality of life of elderly individuals. The present retrospective study focused on the clinical efficacy of unilateral percutaneous vertebroplasty (PVP) in the treatment of osteoporotic compression fractures. A total of 68 patients, representing 92 vertebral bodies, who underwent the unilateral PVP technique from March 2020 to January 2023 were evaluated. Key parameters such as visual analogue scale (VAS) values, Oswestry disability index (ODI) scores, Cobb angle measurements, and anterior vertebral height (AVH) were documented pre- and post-surgery. The mean follow-up period was 15.41±3.74 months. The mean pre-operative VAS score was 8.08±0.79, which was significantly reduced to 2.25±0.71 by 24 h post-surgery and stabilized at 1.58±0.51 by the final follow-up. The ODI showed a significant improvement from a pre-operative average of 67.75±7.91 to 19.74±2.90 post-surgery, and was maintained at a low level of 28.00±4.89 at the last assessment. Radiological evaluations revealed significant alterations in Cobb angle and AVH post-operation. Notably, during the follow-up, eight patients developed new compression fractures in different vertebral segments. In conclusion, the unilateral PVP method is safe and efficient for the management of osteoporotic vertebral compression fractures.

Efficacy and Complication Rates of Percutaneous Vertebroplasty and Kyphoplasty in the Treatment of Vertebral Compression Fractures: A Retrospective Analysis of 280 Patients

Background: Percutaneous vertebroplasty (PVP) and kyphoplasty (PKP) are established methods in the treatment of vertebral compression fractures (VCFs). In our manuscript, the target was to evaluate the efficacy of PVPs/PKPs and to determine the implications of potential periprocedural complications. Methods: 280 patients, specifically 194 women (69.3%) and 86 men (30.7%), were enrolled. We used the AO spine fractures classification and the Yeom classification to determine the subtype of cement leakage. Only single-level VCFs of the thoracic or lumbar spine were included. Visual analogue scale (VAS) was assessed preoperatively and regularly after the surgery. Vertebral compression ratio (VBCR) was used to determine postoperative vertebral body collapse. Results: We recorded 54 cases (19.3%) of cement leakage. There was a significant decrease in mean VAS scores (6.82-0.76 in PVPs, 7.15-0.81 in PKPs). The decrease in VBCR was greater in the VP group (4.39%; 84.21-79.82) compared to the KP group (1.95%; 74.36-72.41). Conclusions: No significant difference in the risk of cement leakage when comparing KPs and VPs was found. VPs and KPs provide rapid and significant pain relief in patients with VCFs. Clinically relevant complications of VPs and KPs are rare. Kyphoplasties prevent further vertebral body collapse more effectively compared to vertebroplasties.

A Toolbox of Bone Consolidation for the Interventional Radiologist

Bone consolidation is increasingly used in the treatment of both benign and malignant bone conditions. Percutaneous vertebroplasty, for example, has been shown to be useful in vertebral compression fractures in the VAPOUR trial which showed its superiority to placebo for pain reduction in the treatment of acute vertebral compressive fractures. Further tools have since been developed, such as kyphoplasty, spinal implants, and even developments in bone cements itself in attempt to improve outcome, such as chemotherapy-loaded cement or cement replacements such as radio-opaque silicon polymer. More importantly, bone fixation and its combination with cement have been increasingly performed to improve outcome. Interventional radiologists must first know the tools available, before they can best plan for their patients. This review article will focus on the tool box available for the modern interventional radiologist.

Advancements in poly(methyl Methacrylate) bone cement for enhanced osteoconductivity and mechanical properties in vertebroplasty: A comprehensive review

The evolution of polymethyl methacrylate (PMMA) based bone cement (BC) from plexiglass to a biomaterial has revolutionized the joint and vertebral arthroplasties field. This widely used grouting material possesses exceptional properties for medical applications, including excellent biocompatibility, impressive mechanical strength, and favorable handling characteristics. PMMA-based BC is preferred in challenging conditions such as osteoporotic vertebral compression fractures, scoliosis, vertebral hemangiomas, spinal metastases, and myelomas, where it is crucial in withstanding stress. This review aims to comprehensively analyze the available reports and guide further research toward enhanced formulations of vertebral BC, focusing on its osteoconductive and mechanical properties. Furthermore, the review emphasizes the significant impact of BC's mechanical properties and osteoconductivity on the success and longevity of vertebroplasty procedures.

Therapeutic Efficacy and Safety of Percutaneous Curved Vertebroplasty in Osteoporotic Vertebral Compression Fractures: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis is aimed to provide higher quality evidence regarding the efficacy and safety between PCVP and PVP/KP in OVCFs. We searched the Cochrane Library, PubMed, Web of Science, and Embase databases for all randomized controlled trials (RCTs) and observational studies (cohort or case-control studies) that compare PCVP to PVP/KP for OVCFs. The Cochrane Collaboration's Risk of Bias Tool and Newcastle-Ottawa Scale (NOS) were used to evaluate the quality of the RCTs and non-RCTs, respectively. Meta-analysis was performed using RevMan 5.4 software. A total of seven articles consisting of 562 patients with 593 diseased vertebral bodies were included. Statistically significant differences were found in the postoperative visual analog scale (VAS) at 1 day (MD = -0.11; 95% CI: [-0.21 to -0.01], p = 0.03), but not at 3 months (MD = -0.21; 95% CI: [-0.41-0.00], p = 0.05) or 6 months (MD = 0.03; 95% CI: [-0.13-0.20], p = 0.70). There was no statistically significant difference in postoperative Oswestry disability index (ODI) at 1 day (MD = -0.28; 95% CI: [-0.62-0.05], p = 0.10), 3 months (MD = -1.52; 95% CI: [-3.11-0.07], p = 0.06), or 6 months (MD = 0.18; 95% CI: [-0.13-0.48], p = 0.25). Additionally, there were no statistically significant differences in Cobb angle (MD = 0.30; 95% CI: [-1.69-2.30], p = 0.77) or anterior vertebral body height (SMD = -0.01; 95% CI: [-0.26-0.23], p = 0.92) after surgery. Statistically significant differences were found in surgical time (MD = -8.60; 95% CI: [-13.75 to -3.45], p = 0.001), cement infusion volume (MD = -0.82; 95% CI: [-1.50 to -0.14], P = 0.02), and dose of fluoroscopy (SMD = -1.22; 95% CI: [-1.84 to -0.60], p = 0.0001) between curved and noncurved techniques, especially compared to bilateral PVP. Moreover, cement leakage showed statistically significant difference (OR = 0.40; 95% CI: [0.27-0.60], p < 0.0001). Compared with PVP/KP, PCVP is superior for pain relief at short-term follow-up. Additionally, PCVP has the advantages of significantly lower surgical time, radiation exposure, bone cement infusion volume, and cement leakage incidence compared to bilateral PVP, while no statistically significant difference is found when compared with unilateral PVP or PKP. In terms of quality of life and radiologic outcomes, the effects of PCVP and PVP/KP are not significantly different. Overall, this meta-analysis reveals that PCVP was an effective and safe therapy for patients with OVCFs.

New Research Progress of Modified Bone Cement Applied to Vertebroplasty

Percutaneous vertebroplasty and percutaneous kyphoplasty are effective methods to treat acute osteoporotic vertebral compression fractures that can quickly provide patients with pain relief, prevent further height loss of the vertebral body, and help correct kyphosis. Many clinical studies have investigated the characteristics of bone cement. Bone cement is a biomaterial injected into the vertebral body that must have good biocompatibility and biosafety. The optimization of the characteristics of bone cement has become of great interest. Bone cement can be mainly divided into 3 types: polymethyl methacrylate, calcium phosphate cement, and calcium sulfate cement. Each type of cement has its own advantages and disadvantages. In the past 10 years, the performance of bone cement has been greatly improved via different methods. The aim of our review is to provide an overview of the current progress in the types of modified bone cement and summarize the key clinical findings.

A novel device with pedicular anchorage provides better biomechanical properties than balloon kyphoplasty for the treatment of vertebral compression fractures

PURPOSE

To compare the biomechanical behavior of vertebrae with vertebral compression fractures (VCF) treated by a novel system with pedicular anchorage (dowelplasty) versus balloon kyphoplasty.

METHODS

Four cadaveric spines (T12-L5) were harvested, cleaned from soft tissues, and separated into vertebrae. Axial compressive loads were applied to each vertebra until a VCF was generated. Half of the vertebrae (n = 11) were instrumented using the "dowelplasty" system, consisting of a hollow titanium dowel anchored into the pedicle, through which a cannulated titanium nail is inserted and locked and through which cement is injected. The other half (n = 11) were instrumented using balloon kyphoplasty. Axial compressive loads were re-applied to each vertebra until fracture. Fracture load and fracture energy were calculated from load-displacement data for the pre- and post-treatment states.

RESULTS

Compared to balloon kyphoplasty, dowelplasty granted greater net change in fracture load (373N; 95%CI,-331-1076N) and fracture energy (755Nmm; 95%CI,-563-2072Nmm). A sensitivity analysis was performed without L4 and L5 vertebrae from the dowelplasty group, since the length of the cannulated nails was too short for these vertebrae: compared to balloon kyphoplasty, dowelplasty granted an even greater net change in fracture load (680N; 95%CI,-96-1457N) and fracture energy (1274Nmm; 95%CI,-233-2781Nmm).

CONCLUSION

Treating VCFs with dowelplasty grants increased fracture load and fracture energy compared to the pre-treatment state. Furthermore, dowelplasty grants greater improvement in fracture load and fracture energy compared to balloon kyphoplasty, which suggests that dowelplasty may be a good alternative for the treatment of VCF.

LEVEL OF EVIDENCE

level IV.

Case report: Shock after percutaneous vertebroplasty of the 5th thoracic vertebra

Background

Percutaneous vertebroplasty (PVP) is a common treatment for osteoporotic vertebral compression fracture (OVCF). Perioperative bleeding is usually rare, so there are few reports of shock. However, we developed shock after treating a case of OVCF of the 5th thoracic vertebra with PVP.

Case presentation

An 80 years old female patient received PVP due to OVCF of the 5th thoracic vertebra. The operation was successfully completed and the patient returned to the ward safely after the operation. At 90 min after operation, she developed shock, which was induced by subcutaneous hemorrhage up to 1500 ml at the puncture site. Before using vascular embolization, transfusion and blood transfusion were used to maintain blood pressure, and local ice bag compression was used to reduce swelling and stop bleeding, which achieved successful hemostasis. She recovered and discharged after 15 days, with the hematoma having absorbed. There was no recurrence during the 17-month follow-up.

Conclusion

Although PVP is considered to be a safe and effective method to treat OVCF, the possible hemorrhagic shock still needs to arouse the vigilance of surgeons.

Percutaneous vertebral augmentation for acute traumatic vertebral Fractures: A TQIP database study

Patients with vertebral fractures may be treated with percutaneous vertebroplasty (VP) and kyphoplasty (KP) for pain relief. Few studies examine the use of VP and KP in the setting of an acute trauma. In this study, we describe the current use of VP/KP in patients with acute traumatic vertebral fractures. All patients in the ACS Trauma Quality Improvement Program (TQIP) 2016 National Trauma Databank with severe spine injury (spine AIS ≥ 3) met inclusion criteria, including patients who underwent PVA. Logistic regression was used to assess patient and hospital factors associated with PVA; odds ratios and 95 % confidence intervals are reported. 20,769 patients met inclusion criteria and 406 patients received PVA. Patients aged 50 or older were up to 6.73 (2.45 - 27.88) times more likely to receive PVA compared to younger age groups and women compared to men (1.55 [1.23-1.95]). Hospitals with a Level II trauma center and with 401-600 beds were more likely to perform PVA (2.07 [1.51-2.83]) and (1.82 [1.04-3.34]) respectively. African American patients (0.41 [0.19-0.77]), isolated trauma (0.64 [0.42-0.96]), neurosurgeon group size > 6 (0.47 [0.30-0.74]), orthopedic group size > 10, and hospitals in the Northeastern and Western regions of the U.S. (0.33 [0.21-0.51] and 0.46 [0.32-0.64]) were less likely to be associated with PVA. Vertebroplasty and kyphoplasty use for acute traumatic vertebral fractures significantly varied across major trauma centers in the United States by multiple patient, hospital, and surgeon demographics. Regional and institutional practice patterns play an important role in the use of these procedures.

Role of interventional radiology in pain management in oncology patients

This article reviews the current evidence of interventional radiology procedures for patients suffering with debilitating cancer pain, refractory to conventional therapies. Cancer pain is notoriously difficult to treat. Up to 90% of cancer patients experience pain with 56-82% of cancer pain controlled inadequately. Cancer pain influences a patient's ability to perform normal daily activities, causes higher risk of depression, and reduces quality of life. Pain-free status has been universally voted as a "good death". Alternative minimally invasive options include nerve blocks, neurolysis, bone ablation, spine and peripheral musculoskeletal augmentation techniques, embolisation, and cordotomy with evidence highlighting improved pain control, reduced analgesic requirements, and improved quality of life. Unfortunately, awareness and availability of these procedures is limited, potentially leaving patients suffering during their remaining life. The purpose of this review is to describe the basic concepts of interventional radiology techniques for pain palliation in oncology patients. In addition, emphasis will be given upon the need for an individually tailored approach aiming to augment efficacy and safety.

Effect of Percutaneous Kyphoplasty on the progression of intervertebral disc degeneration: a retrospective cohort study

BACKGROUND

The effect of percutaneous kyphoplasty (PKP) or rather polymethylmethacrylate (PMMA) on adjacent intervertebral discs is still controversial. The evidence from experimental study to clinical study presents bipolar conclusions. In this study, we investigated the effect of PKP on adjacent intervertebral disc degeneration (IDD).

METHODS

The experimental group included adjacent intervertebral discs of vertebrae treated with the PKP procedure, and the control group included adjacent intervertebral discs of non-traumatized vertebrae. All measurements were taken by magnetic resonance imaging or X-ray. The intervertebral disc height, the modified Pfirrmann grading system (MPGS), and its differences with Klezl Z and Patel S (ZK and SP) classifications were compared.

RESULTS

A total of 264 intervertebral discs from 66 individuals were selected for the study. The comparison of intervertebral disc height between the two groups pre and post-operatively resulted in a p-value of > 0.05. No significant change was observed in the adjacent discs in the control groups post-operatively. Post-operatively, the mean Ridit increased significantly from 0.413 to 0.587 in the upper disc and from 0.404 to 0.595 in the lower disc in the experimental group. The comparison of MPGS differences showed that the predominant value was 0 in the Low-grade leaks group and 1 in the Medium and high-grade leaks group.

CONCLUSIONS

The PKP procedure can accelerate adjacent IDD, but it does not cause disc height changes in the early stage. The quantity of cement leaking into the disc space positively correlated with the rate of disc degeneration progression.

Osteoporotic vertebral compression fractures caused by Cushing's syndrome in young women: case report and literature review

BACKGROUND

Cushing's syndrome is known as an important cause of secondary osteoporosis, characterized by reduction of bone mineral density and potential occurrence of fragility fractures before diagnosis in young population. Therefore, for young patients with fragility fractures, especially in young women, more attention should be paid on glucocorticoid excess caused by Cushing's syndrome, due to relatively higher rate of misdiagnosis, distinct pathological characteristics and different treatment strategies compared with violent fractures and primary osteoporosis related fractures.

CASE PRESENTATION

We presented an unusual case of a 26-year-old woman with multiple vertebral compression fractures and pelvis fractures, subsequently diagnosed as Cushing's syndrome. On admission, the radiographic results showed fresh second lumbar vertebra fracture, and old fourth lumbar vertebra and pelvic fractures. The dual energy X-ray absorptiometry of lumbar spine revealed marked osteoporosis, and her plasm cortisol was extremely high. Then, Cushing's syndrome, caused by left adrenal adenoma, was diagnosed by further endocrinological and radiographic examinations. After receiving left adrenalectomy, her plasma ACTH and cortisol values returned to normal level. In term of OVCF, we adopted conservative treatments, including pain management, brace treatment, and anti-osteoporosis measures. Three months after discharge, the patient's low back pain was in complete remission without new onset of pain, and returned to normal life and work. Furthermore, we reviewed the literatures on advancements in the treatment of OVCF caused by Cushing's syndrome, and based on our experiences, proposed some additional perspectives to guide treatment.

CONCLUSION

In term of OVCF secondary to Cushing's syndrome without neurological damage, we prefer systematic conservative treatments, including pain management, brace treatment, and anti-osteoporosis measures, to surgical treatment. Among them, anti-osteoporosis treatment has the highest priority because of the reversibility of osteoporosis caused by Cushing's syndrome.

Multimodal locoregional procedures for cancer pain management: a literature review

Pain is the most common and fearsome symptom in cancer patients, particularly in the advanced stage of disease. In cancer pain management, the first option is represented by analgesic drugs, whereas surgery is rarely used. Prior to considering surgical intervention, less invasive locoregional procedures are available from the wide pain management arsenal. In this review article, comprehensive information about the most commonly used locoregional options available for treating cancer pain focusing on interventional radiology (neurolysis, augmentation techniques, and embolization) and interventional radiotherapy were provided, also highlighting the potential ways to increase the effectiveness of treatments.

Intraoperative analgesic effect of intravertebral lidocaine injection during percutaneous kyphoplasty in the treatment of thoracolumbar compression fractures in elderly patients

BACKGROUND

In recent years, percutaneous kyphoplasty (PKP) has been increasingly used in clinical settings.

OBJECTIVE

In this study, we aimed to determine the analgesic effect of intravertebral lidocaine injections in PKP.

METHODS

A total of 60 patients who were treated with PKP were enrolled in this study. Lidocaine hydrochloride was chosen as the medication for the experimental group. Patients were randomly assigned into three groups using a double-blind study design: In group A (20 cases), no drugs were injected into the vertebral body during surgery; group B (20 cases) received intravertebral injection of normal saline; and in group C (20 cases), lidocaine hydrochloride was administered into the vertebral body during surgery. The age of patients, operation time, balloon dilatation pressure, balloon dilatation volume, and amount of bone cement injected were compared across the three groups. A pain visual analog scale (VAS) was used to assess pain suffered by the patients before, during, and 24 hours after the surgery.

RESULTS

Age, operation time, balloon dilatation pressure, balloon dilatation volume, and amount of bone cement injected did not differ significantly among the three groups (P> 0.05). The differences in VAS scores 24 hours before and after surgery were not statistically significant (P> 0.05). Group C had lower intraoperative VAS scores than groups A and B, and the difference was statistically significant (P< 0.01). There was no statistically significant difference between group A and group B (P> 0.05).

CONCLUSION

Intravertebral injections of lidocaine during PKP can successfully reduce intraoperative pain.

Trends in Hospitalization and Economic Impact of Percutaneous Kyphoplasty in Italy

Vertebral Fractures (VFs) caused by osteoporosis are the most typical reason for performing Percutaneous Kyphoplasty (PK). Globally, VF prevalence is not well described in the literature. In Europe, only Sweden has an accurate record of the incidence of this type of fracture. Moreover, the exact incidence of the PK procedure is not reported. Therefore, the annual patterns and financial burden of PK in Europe is not well known, and it could be may better understood by examining national registers. For surgeons, lawmakers, hospital administrators, and the healthcare system, determining the annual national costs of this treatment is helpful. The National Hospital Discharge Reports (SDOs) submitted to the Italian Ministry of Health during the years covered by this study (2009-2015) were used. A total of 13,113 kyphoplasties were performed in Italy, with a prevalence of 3.6 procedures for every 100,000 Italian inhabitants over 15 years. The average age of patients was 68.28 (±12.9). Females represented the majority of patients undergoing PK procedures (68.6%). The median length of hospital stay was 5.33 days. The prevalence of PK procedures increased from 2009 to 2015, while the average days of hospitalization decreased. Older patients were most at risk in undergoing PK procedures. Reporting the national data on PK in Italy could also help compare the findings across nations. The current study aims to determine the trends of PK hospitalisation and patient features in Italy.

Vertebral Augmentation: Is It Time to Get Past the Pain? A Consensus Statement from the Sardinia Spine and Stroke Congress

Vertebral augmentation has been used to treat painful vertebral compression fractures and metastatic lesions in millions of patients around the world. An international group of subject matter experts have considered the evidence, including but not limited to mortality. These considerations led them to ask whether it is appropriate to allow the subjective measure of pain to so dominate the clinical decision of whether to proceed with augmentation. The discussions that ensued are related below.

The Value of Dynamic Fracture Mobility in Determining the Optimum Operation Choice for Acute Osteoporotic Vertebral Compression Fracture

Purpose

This retrospective study aimed to verify whether the use of a balloon in balloon kyphoplasty (BKP) could offer a higher degree of vertebral height restoration and deformity correction than percutaneous vertebroplasty (PVP) after adjustment for preoperative dynamic fracture mobility. We expect that this research will help surgeons to determine the optimum operation choice (PVP or BKP) for treating osteoporotic vertebral compression fractures (OVCFs).

Patients and Methods

We evaluated retrospectively 262 patients who were treated by PVP or BKP for acute, single-level OVCF at our institution from July 2015 to July 2019. According to the presence or absence of dynamic fracture mobility, the patients were divided into two groups: mobile group and fixed group. We compared the changes in the vertebral height and kyphotic angle for PVP and BKP, respectively, within each group.

Results

In the mobile group, the anterior vertebral height restoration (BKP group, 8.73±5.27%; PVP group, 2.96±1.59%), middle vertebral height restoration (BKP group, 7.58±5.18%; PVP group, 2.74±1.24%) and kyphotic angle correction (BKP group, 4.41±4.46°; PVP group, 1.38±1.60°) due to percutaneous vertebral augmentation technique itself were more obvious in BKP group compared with PVP group (P < 0.05). The BKP group has lower incidence of bone cement leakage (BKP group, 10.17%; PVP group, 25.53%, P < 0.05). In the fixed group, differences from comparison of changes were not statistically significant between PVP and BKP (P > 0.05).

Conclusion

The use of a balloon in BKP could offer greater kyphosis correction, higher vertebral body height restoration, and lower cement leakage rate than PVP if a fractured vertebral body existed dynamic mobility. However, all these advantages of BKP over PVP are not obvious and could be overrated for a fixed fracture exhibited no mobility. BKP is recommended for a fractured vertebral body with dynamic mobility. PVP is suggested for a fixed fractured vertebral body with no mobility as it produces similar capability of vertebral height restoration, kyphosis correction, and cement leakage as BKP.

Update on Interventional Radiology of the Spine

Interventional radiologists now perform spinal interventions routinely for diagnostic and therapeutic purposes. New technologies for the management of spine pathologies have emerged with promising results in terms of safety and efficacy. Interventional radiology techniques in the spine include percutaneous biopsy and therapies for intervertebral disk herniation or spinal stenosis, facet and sacroiliac joint pathologies, vertebral and sacral fractures, and metastases. These techniques can also be easily combined one with the other or to further therapeutic approaches including systemic therapies, surgical approaches, and radiotherapy. This review provides a comprehensive overview of current percutaneous imaging-guided interventional radiology techniques in the spine. It will help readers become familiar with the most common indications, learn about different technical considerations during performance, and review the available evidence. Controversies concerning new products and technical approaches are also addressed.

Vertebroplasty with high-viscosity cement versus conventional kyphoplasty for osteoporotic vertebral compression fractures: a meta-analysis

BACKGROUND

To evaluate outcomes following percutaneous vertebroplasty with high viscosity cement (PVP-HVC) and percutaneous kyphoplasty (PKP) with normal-viscosity cement in patients with osteoporotic vertebral compression fractures (OVCFs).

METHODS

Pertinent studies were retrieved by searching five electronic databases up to July 2021. Additional records were identified via hand-searching of related references. Risk ratio (RR) and weighted mean difference (WMD), with their 95% confidence intervals (CIs), were calculated. A trial sequential analysis (TSA) was done for cement leakage.

RESULTS

Twelve studies, embracing 1050 patients with OVCFs, were included. PVP-HVC was superior to PKP with normal-viscosity cement regarding risk of cement leakage (RR: 0.67, 95% CI: 0.54-0.83, I² : 45.1%) and operation time (WMD: -11.26, 95% CI: -14.78 to -8.34, I² : 88.8%). However, TSA revealed that a sufficient level of evidence for leakage reduction may have yet to be reached. PKP groups had a significant decrease in Cobb's angles postoperatively (within 1 month, WMD: 2.68, 95% CI: 1.85-3.48, I² : 0%; after 1 year, WMD: 2.68, 95% CI: 1.35-4.01, I² : 0%). There are no significant differences between the two procedures pertaining to injected cement volume, Visual Analogue Scale (VAS), Oswestry Disability Index (ODI) and risk of adjacent vertebral fractures.

CONCLUSION

PVP-HVC and PKP with normal-viscosity cement are safe and effective treatments for the management of OVCF, but the former is superior to the latter in terms of procedure time. The potential of PVP-HVC in reducing cement leaks remains to be validated by more well-designed studies.

Lumbar Spine Posttherapeutic Imaging

Management of patients after lumbar spine surgery or interventional radiology can be complex, and postoperative imaging patterns are often poorly understood by nonspecialized radiologists. This article focuses on postoperative imaging features of the lumbar spine in five clinical settings (with corresponding interventions): vertebral osteoporotic fractures (percutaneous vertebroplasty and vertebral augmentation), lumbar disk herniation (surgical diskectomy and percutaneous interventional radiology), lumbar spinal stenosis (surgical decompression), lumbar spondylolisthesis (surgical decompression and fusion), and degenerative scoliosis (techniques of osteotomies).For each intervention, we discuss imaging indications, depending if the patient is asymptomatic or if there are suspected complications, describe normal and pathologic imaging features, and present key points.

Management of vertebral compression fractures: the role of dual-energy CT in clinical practice

PURPOSE

To evaluate the role of dual-energy computed tomography (DECT) in the management of vertebral compression fractures in clinical practice.

MATERIALS AND METHODS

This retrospective IRB-approved study included 497 consecutive patients with suspected acute vertebral fractures, imaged either by DECT (group 1) or MRI (group 2) before vertebroplasty. The site, number and type of fractures at imaging findings, and clinical outcome based on any change in pain (DELTA-VAS), before (VAS-pre) and after treatment (VAS-post), were determined and compared. Two radiologists evaluated DECT and MRI images (15 and 5 years of experience, respectively), and inter-observer and intra-observer agreement were calculated using k statistics.

RESULTS

Both in the control group (n = 124) and in the group of patients treated by vertebroplasty (n = 373), the clinical outcome was not influenced by the imaging approach adopted, with a DELTA-VAS of 5.45 and 6.42 in the DECT group and 5.12 and 6.65 in the MRI group (p = 0.326; p = 0.44). In the group of treated patients, sex, age, lumbar fractures, multiple fractures, previous fractures, Genant grade, involvement of anterior apex or superior endplates, and increased spinal curvatures were similar (p = ns); however, dorsal fractures were more prevalent in group 1 (p = 0.0197). Before treatment, the mean VAS-pre was 8.74 in group 1 (DECT) and 8.65 in group 2 (MRI) (p = 0.301), whereas after treatment, the mean VAS-post value was 2.32 in group 1 (p = 0.0001), and 2.00 in group 2 (p = 0.0001). The DELTA-VAS was 6.42 in the group of patients imaged using DECT and 6.65 in the group imaged using MRI (p = 0.326). Inter-observer and intra-observer agreement were 0.85 and 0.89 for DECT, and 0.88 and 0.91 for MRI, respectively.

CONCLUSION

The outcome of vertebral compression fracture management was no different between the two groups of patients studied.

Changes in T2 Relaxation Time Mapping of Intervertebral Discs Adjacent to Vertebrae after Kyphoplasty Correlate with the Physical Clinical Outcome of Patients

(1) Background: To assess whether clinical outcomes correlate with tissue changes in the intervertebral discs (IVDs) after kyphoplasty as treatment for vertebral fractures, quantitative MRI was applied. (2) Methods: Quantitative T2 mapping acquired in a 3 T MRI scanner of the thoracolumbar spine was performed in 20 patients two years after kyphoplasty. The IVDs adjacent and nonadjacent to the treated vertebrae were divided into six regions of interest (ROI), which were further categorised into inner (ROI 2–5) and outer (ROI 1 and 6) parts of the IVDs, and the T2 values were analysed. T2 values of adjacent discs were correlated with the items of questionnaires evaluating the clinical outcome (i.e., 36-Item Short Form Survey). (3) Results: Lower T2 values in adjacent IVDs correlated with poorer physical outcome two years after kyphoplasty. The inner part of the IVDs adjacent to treated vertebrae showed statistically significant lower T2 values in segments L2/L3 and L3/L4 compared to nonadjacent ones. Patients with lower T2 values showed more pain and physical limitations in everyday life. (4) Conclusions: Quantitative T2 mapping can detect IVD degeneration in patients after kyphoplasty and correlates with the physical outcome. This technique could help to gain better insights into alterations in tissue composition following kyphoplasty and the consequences for the patients’ quality of life.

Establishment and validation of a nomogram and web calculator for the risk of new vertebral compression fractures and cement leakage after percutaneous vertebroplasty in patients with osteoporotic vertebral compression fractures

PURPOSE

The aim of this work was to investigate the risk factors for cement leakage and new-onset OVCF after Percutaneous vertebroplasty (PVP) and to develop and validate a clinical prediction model (Nomogram).

METHODS

Patients with Osteoporotic VCF (OVCF) treated with PVP at Liuzhou People's Hospital from June 2016 to June 2018 were reviewed and met the inclusion criteria. Relevant data affecting bone cement leakage and new onset of OVCF were collected. Predictors were screened using univariate and multi-factor logistic analysis to construct Nomogram and web calculators. The consistency of the prediction models was assessed using calibration plots, and their predictive power was assessed by tenfold cross-validation. Clinical value was assessed using Decision curve analysis (DCA) and clinical impact plots.

RESULTS

Higher BMI was associated with lower bone mineral density (BMD). Higher BMI, lower BMD, multiple vertebral fractures, no previous anti-osteoporosis treatment, and steroid use were independent risk factors for new vertebral fractures. Cement injection volume, time to surgery, and multiple vertebral fractures were risk factors for cement leakage after PVP. The development and validation of the Nomogram also demonstrated the predictive ability and clinical value of the model.

CONCLUSIONS

The established Nomogram and web calculator (https://dr-lee.shinyapps.io/RefractureApp/) (https://dr-lee.shinyapps.io/LeakageApp/) can effectively predict the occurrence of cement leakage and new OVCF after PVP.

Percutaneous Kyphoplasty for Osteoporotic Vertebral Compression Fractures Associated with Spinal Canal Encroachment without Neurological Symptoms

Background

Percutaneous kyphoplasty (PKP) has been widely used for osteoporotic vertebral compression fractures (OVCFs). However, whether this approach is suitable for osteoporotic vertebral fractures with spinal canal encroachment remains controversial.

Material/Methods

Of 526 patients who underwent PKP at our hospital, 40 had conditions associated with spinal canal encroachment, and were enrolled in the study. Detailed physical, neurological, and radiological examinations were performed on each patient before and after surgery and at the followup. A visual analog scale (VAS) and the Oswestry Disability Index (ODI) were used for the clinical assessment. The vertebral body height, the local kyphosis, and the spinal canal width were used for the radiological evaluation.

Results

There were 11 male and 29 female patients, with a mean age of 71±8 years. The VAS score decreased from 6.4±0.7 preoperatively to 1.6±0.7 postoperatively and to 2.3±1.5 at the last followup visit. The ODI score was 78±9.5 before surgery, declined to 24±11.3 after surgery, and was 27.6±12.5 at the last followup visit. The vertebral body height increased from 11.7±4.3 mm to 14.6±4.4 mm. The local kyphosis decreased from 15.0±10.7 degrees preoperatively to 8.5±11.3 degrees postoperatively. The spinal canal width remained stable, at 8.5±2.0 mm before PKP and 8.7±1.9 after PKP.

Conclusions

PKP effectively relieved back pain in OVCF patients with spinal canal encroachment. Their social function improved as well.

Revision surgery after cement augmentation for osteoporotic vertebral fracture

INTRODUCTION

Cement augmentation has been proven to be a safe procedure for the treatment of osteoporotic vertebral fracture, and the overall result is encouraging. However, failures caused by different complications are not uncommon, and a few patients even need revision surgery. This retrospective study aimed to investigate the primary causes of revision surgery after cement augmentation for osteoporotic vertebral fracture and how to prevent them, and the second objective was to evaluate the clinical results of revision surgery.

HYPOTHESIS

The main hypothesis is that infection and neurological dysfunction are the prime causes of revision surgery after cement augmentation for osteoporotic vertebral fracture, and the second hypothesis is that revision surgery is effective to improve the quality of daily life.

MATERIALS AND METHODS

Twenty-one patients who underwent unplanned revision surgery after cement augmentation were retrospectively analyzed. The initial radiographic and medical records were reviewed to re-evaluate whether the initial diagnosis and surgical procedure were correct and suitable. The primary causes of revision surgery and the details were recorded. The visual analog scale (VAS) and Oswestry Disability Index (ODI) were used to evaluate the efficacy of the revision surgery, and patients with neurological dysfunction were evaluated with the American Spinal Injury Association (ASIA).

RESULTS

A total of 47.6% (10/21) of patients were misdiagnosed initially or had an incorrect indication for cement augmentation surgery, including 3 pre-existing spondylitis cases that were misdiagnosed as osteoporotic vertebral fracture and 7 cases of three column fractures that were treated with cement augmentation. The primary causes and details of the revision surgeries were as follows: 7 patients with infection underwent anterior and/or posterior debridement and fixation; 9 patients with progressive kyphosis underwent posterior osteotomy and fixation; and 5 patients with neurological dysfunction underwent posterior decompression and fixation. The mean follow-up time was 30.6±8.7 months, the VAS score decreased from 7.3±1.1 preoperatively to 2.3±0.3 (p<0.05) at the last follow-up, the ODI decreased from 61.1%±16.3% preoperatively to 20.6%±6.2% (p<0.05) at the last follow-up, and 5 patients with neurological dysfunction improved by at least one grade.

CONCLUSION

Infection, progressive kyphosis and neurological dysfunction are the primary causes of revision surgery after cement augmentation for osteoporotic vertebral fracture. Avoiding misdiagnosis and ensuring suitable indications might be the key points to decreasing unplanned revision surgery for cement augmentation for osteoporotic vertebral fracture. The quality of daily life and neurological function can be improved through revision surgery.

Analysis on the Effect of Different Surgical Methods on the Treatment of Senile Osteoporotic Spinal Compression Fractures and the Influencing Factors of Complications

Osteoporotic fractures are a common type of fractures in the elderly, among which spinal compression fractures are more common. After the occurrence of fractures, due to the compression and burst of the vertebral body, this will lead to local kyphosis deformity and even affect the balance of the sagittal spine. In the past, conservative treatments were used for osteoporotic spinal compression fractures. Although it can relieve pain symptoms, it can easily lead to complications such as aggravation of osteoporosis and deep vein thrombosis of the lower extremities. At present, percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) are the main clinical surgical treatments, both of which are minimally invasive surgery, short operation time, effective pain relief, and rapid postoperative recovery. Although both of them are effective, there is still controversy over the efficacy of both in the treatment of osteoporotic spinal compression fractures. The purpose of this study was to investigate the efficacy of PVP and PKP in the treatment of elderly osteoporotic spinal compression fractures and to analyze the related factors that affect the occurrence of postoperative complications. The results show that both PVP and PKP can effectively improve the pain and dysfunction of elderly patients with osteoporotic spinal compression fracture, restoration of vertebral height, and correct kyphosis, but PKP has better effect and higher safety and is worth promoting. Postoperative complications of patients are related to their age, bone mineral density, use of hormones, and antiosteoporosis treatment.

When to perform vertebroplasty? A retrospective analysis from a single center and a review of the literature

BACKGROUND AND AIM

To establish an optimal timing for vertebroplasty in order to obtain a clinically important pain reduction and improving quality of live in patients with osteoporotic or traumatic vertebral fractures.

METHODS

This study includes 22 vertebroplasty procedures performed from October 2018 to July 2020 in 21 patients with traumatic or osteoporotic vertebral fractures (19 female, two men; age between 53 and 89 years). All treatments were executed under fluoroscopic guidance using 11 or 13 G needle through transpedicular or costovertebral unilateral approach. Each patient underwent conscious sedation, continuously monitored by an anesthesiologist. Preoperative MRI images, obtained by 3T or 1.5T MRI scanner, always showed bone marrow edema. The VAS scale and Roland Morris disability questionnaire (RMdq) were administered to patients before and after the treatment to evaluate pain and life quality.

RESULTS

7 patients were treated in the first month after the injury, one was treated twice; 8 patients in the second month, 6 in the third. We observed a reduction of: 5.5 points in the vas scale, 10.3 in the RMdq in the first month; 5.6 points vas, 11.6 points RMdq in the second month; 4 points vas and 9.75 points RMdq in the third month.

CONCLUSIONS

This study demostrated that, in our preliminary experience, vertebroplasty has the best outcome if performed at 2 months from injury.

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.

Cluster phenomenon of vertebral refractures after posterior pedicle screw fixation in a patient with glucocorticosteroid-induced Kümmell's disease: a treatment dilemma

INTRODUCTION

Surgical treatments are usually preferred in patients with Kümmell's disease since it represents a failure of conservative treatment for osteoporotic vertebral compression fracture without evidence of spontaneous healing. However, the risk of postoperative refractures is much higher in patients with glucocorticosteroid-induced osteoporosis (GIOP) than in those with primary osteoporosis, possessing a therapeutic challenge and dilemma to orthopaedic surgeons.

CASE REPORT

We described a rare cluster phenomenon of vertebral refractures in a patient with GIOP subsequent to segmental internal fixation for the initial management of glucocorticosteroid-induced Kümmell's disease, and a review of the literature.

CONCLUSION

Our patient illustrates that clinicians should be aware of the significant management dilemma and possible disastrous outcome after surgical interventions for glucocorticosteroid-induced Kümmell's disease and, thus, pay much more attention to comprehensive perioperative antiosteoporotic medications for patients with GIOP in current medical treatment.

Sacroplasty Augmentation of Instrumented Pelvic Reconstruction After High Sacrectomy: A Technical Case Report

BACKGROUND AND IMPORTANCE

En bloc resection of sacral tumors is the most effective treatment to help prevent recurrence. Sacrectomy, however, can be destabilizing, depending on the extent of resection. Various surgical techniques for improving stability and enabling early ambulation have been proposed.

CLINICAL PRESENTATION

Here, we report a case in which we use PMMA (poly[methyl methacrylate]) to augment pelvic instrumentation to improve mechanical stability after sacrectomy for en bloc resection of a solitary fibrous tumor.

CONCLUSION

We highlight the use of sacroplasty augmentation of pelvic ring reconstruction to provide biomechanical stability without the need for fusion of any mobile spine segments, which allowed for early patient ambulation and no appreciable loss of range of motion or mobility.

Long-term mechanical properties of a novel low-modulus bone cement for the treatment of osteoporotic vertebral compression fractures

In spite of the success of vertebroplasty (VP) and balloon kyphoplasty (BKP), which are widely used for stabilizing painful vertebral compression fractures, concerns have been raised about use of poly(methyl methacrylate) (PMMA) bone cements for these procedures since the high compressive modulus of elasticity (E) of the cement is thought to be one of the causes of the higher number of adjacent-level vertebral fractures. Therefore, bone cements with E comparable to that of cancellous bone have been proposed. While the quasi-static compressive properties of these so-called "low-modulus" cements have been widely studied, their fatigue performance remains underassessed. The purpose of the present study was to critically compare a commercial bone cement (control cement) and its low-modulus counterpart on the basis of quasi-static compressive strength (CS), E, fatigue limit under compression-compression loading, and release of methyl methacrylate (MMA). At 24 h, mean CS and E of the low-modulus material were 72% and 77% lower than those of the control cement, whereas, at 4 weeks, mean CS and E were 60% and 54% lower, respectively. The fatigue limit of the control cement was estimated to be 43-45 MPa compared to 3-5 MPa for the low-modulus cement. The low-modulus cement showed an initial burst release of MMA after 24 h followed by a plateau, similar to many other commercially available cements, whereas the control cement showed a much lower, stable release from day 1 and up to 1 week. The low-modulus cement may be a promising alternative to currently available PMMA bone cements, with the potential for reducing the incidence of adjacent fractures following VP/BKP.

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.

Advances in Vertebral Augmentation Systems for Osteoporotic Vertebral Compression Fractures

Osteoporotic vertebral compression fracture (OVCF) is a common cause of pain and disability and is steadily increasing due to the growth of the elderly population. To date, percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) are almost universally accepted as appropriate vertebral augmentation procedures for OVCFs. There are many advantages of vertebral augmentation, such as short surgical time, performance under local anaesthesia, and rapid pain relief. However, there are certain issues regarding the utilization of these vertebral augmentations, such as loss of vertebral height, cement leakage, and adjacent vertebral refracture. Hence, the treatment for OVCF has changed in recent years. Satisfactory clinical results have been obtained worldwide after application of the OsseoFix System, the SpineJack System, radiofrequency kyphoplasty of the vertebral body, and the Kiva VCF treatment system. The following review discusses the development of the current techniques used for vertebral augmentation.

Cement leakage following percutaneous kyphoplasty in a patient after a posterior lumbar fusion: a case report

BACKGROUND

Percutaneous kyphoplasty (PKP) has become an important minimally invasive surgical technique for fracture stabilization and pain relief in patients with vertebral compression fractures. However, intraspinal cement leakage following PKP is a serious postoperative complication that can lead to morbidity and mortality.

CASE PRESENTATION

We describe an uncommon case of epidural leakage of bone cement in an 81-year-old woman who underwent posterior lumbar decompression and fusion from L3-5 4 years prior and had an unremarkable postoperative course. The patient was admitted to Peking Union Medical College Hospital with complaints of muscle weakness and severe low back pain radiating to the left thigh 1 week after PKP of L5 due to an acute osteoporotic compression fracture. Computed tomographic imaging revealed massive leakage of cement into the spinal canal at L5-S1, and therefore, surgical decompression and removal of epidural cement were performed carefully without causing a dural tear. She improved remarkably and no neurologic deterioration was observed in the postoperative period during the one-year follow-up.

CONCLUSIONS

We present the rare reported case, to our knowledge, of epidural cement leakage after PKP at the segment of internal fixation and discuss the most likely etiologies and preventive measures for this condition.

[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.

Percutaneous vertebroplasty versus percutaneous kyphoplasty for the treatment of delayed post-traumatic vertebral body collapse (Kümmell’s disease) in Chinese patients: a systematic review and meta-analysis

Objective

To compare the clinical efficacy between percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) in the treatment of Kümmell’s disease in Chinese patients.

Methods

The studies using randomized controlled trials to compare clinical efficacy between PVP and PKP in the treatment of Kümmell’s disease in Chinese patients were retrieved from Embase, Pubmed, Central, Cinahl, PQDT, CNKI, CQVIP, Wanfang Data, and CBM (from September 2008 to September 2018). Keywords for both Chinese and English search were: percutaneous vertebroplasty, PVP, percutaneous kyphoplasty, PKP, and Kümmell’s disease. A total of 132 articles were retrieved based on the search strategy through online database searching and manual searching. Finally, one foreign report and seven Chinese reports were included. After extracting the data, statistical software Review Manager 5.3 was used for data analysis.

Results

Through comparison, Cobb angle (95% CI [0.54, 4.42), P = 0.01] and Oswestry Dysfunction Index (ODI) (95% CI [0.21, 2.15], P= 0.02) of PKP group was smaller than that of PVP group. Postoperative anterior vertebral body height of the PKP group was better than PVP group (95% CI [−1.27, −0.66], P < 0.001]. However, the PVP group had shorter operation time than PKP group (95% CI [−13.48, −7.43), P = 0.001]. In the other outcome measures, including Visual Analogue Scale (VAS) score (95% CI [−0.04, 0.27), P = 0.15), cement volume (95% CI [−0.82, 0.32], P = 0.39) and cement leakage (95% CI [0.90, 2.76], P = 0.11), there was no significant differences between the two procedures.

Conclusions

At this stage, there is sufficient evidence to support that PKP is better than PVP in the treatment of Kümmell’s disease in Chinese patients. Although PVP surgery requires much less operation time, PKP has better postoperative radiological results and lower ODI. Moreover, both of them had similar clinical results (e.g., analgesic effects, cement dosage, and leakage rate). Further evidence is dependent on the emergence of randomized controlled trials with higher quality and larger sample sizes in the future.

[Minimally invasive spinal surgery: stages of development]

In recent decades, spinal surgery has changed significantly. The active use of modern knowledge of anatomy, various diagnostic modules, specialized surgical equipment and high-tech tools has made it possible to transform classical surgical techniques into a new area of spinal neurosurgery - minimally invasive spine surgery (MISS). Its main goals are to reduce damage to the skin and adjacent tissues, significantly reduce the level of pain, reduce the duration of inpatient treatment and fully restore functional status in the shortest possible time. This article reflects the main criteria for MISS compliance and types of surgical interventions, provides information on the advantages of minimally invasive surgical technologies and their possible disadvantages. Currently, the use of MISS is observed in all areas of vertebrology - for degenerative diseases, tumors, inflammatory and traumatic lesions of the spine. At the same time, minimizing surgical aggression while maximizing the achievement of goal becomes the main rule of modern spinal surgery.