Height restoration and wedge angle correction effects of percutaneous vertebroplasty: association with intraosseous clefts

The surgical strategy selection and clinical efficacy analysis of Kummell's disease

PURPOSE

To evaluate the clinical efficacy of surgery in Kummell's disease (KD) to help us select the optimum surgical strategy.

METHODS

We included 67 KD patients who underwent Percutaneous vertebral plasty (PVP), Percutaneous kyphosis plasty (PKP), Percutaneous pedicle screw fixation (PPSF) or Posterior decompression osteotomy fixation (PDOF). The differences in imaging parameters and prognosis changes of pre-operation, post-operative and follow-up endpoint were analyzed.

RESULTS

The incidence rate of KD was 10.02% (67/668) in vertebral compressibility fracture. 80.60% of patients underwent PVP/PKP, 14.93% underwent PPSF, and 4.47% underwent PDOF. The significant differences between the actual used surgical methods and the classification recommended surgical strategies could be found. In I type, there was no significant difference in total improvement of the radiography data and clinical efficacy between PVP and PKP. In II type, there was a significant correlation between opening and closing sign (OCS) and surgical choice. Compared with PPSF, the positive OCS patients who underwent PVP/PKP suffered a poor prognosis. PDOF is an effective surgical method for type III, but PVP could also achieve a good prognosis for patients with poor condition.

CONCLUSION

The mainstream KD classification system has shortcomings, and completely following its treatment strategy may lead to poor prognosis. Compared to PKP, PVP is a better choice for type I patients. OCS is one of the important factors in surgical selection for type II patients. The Li's type III is mainly treated with PDOF but the overall condition of the body needs to be evaluated.

Clinical efficacy of percutaneous vertebroplasty versus percutaneous kyphoplasty treating osteoporotic vertebral compression fractures with kyphosis

PURPOSE

This study aimed to investigate the clinical efficacy of percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) in treating osteoporotic vertebral compression fractures (OVCFs) with kyphosis.

METHODS

The clinical data included 63 patients in the PVP group and 70 in the PKP group. The study assessed the pain visual analog scale (VAS), Oswestry Disability Index (ODI), wedge angle (WA), local kyphotic angle (LKA), and vertebral height.

RESULTS

The operative time was significantly less in the PVP group (p < 0.05). Meanwhile, more bone cement was injected into the PKP group (p < 0.05), with significantly higher surgical costs (p > 0.05). Post-operative VAS, ODI, WA, LKA, and vertebral height were significantly improved in PVP and PKP groups compared with pre-operative measurements (p < 0.05). The results revealed insignificant VAS and ODI improvement differences between the two groups at each follow-up time (p > 0.05). Vertebral height, WA, and LKA improved more significantly in the PKP group at day 1 and 3 months post-operatively (p < 0.05), with insignificant group differences at subsequent time points (p > 0.05). The improvements in VAS were unrelated to those in WA, LKA, or vertebral height in either group (p > 0.05). The improvement in VAS was unrelated to the amount of bone cement injected (p > 0.05); the PKP group demonstrated a lower incidence of cement leakage (12.9%; p < 0.05).

CONCLUSION

PVP and PKP can restore partial vertebral height and improve kyphosis with similar clinical outcomes. PVP has a shorter operating time, is more economical, and can represent a therapeutic choice.

The Effectiveness of Vertebral Height Restoration Based on the Vertebroplasty Procedure Used to Treat Osteoporotic Vertebral Fractures

OBJECTIVE

Whether the use of a balloon or stent in vertebroplasty for vertebral fractures, such as balloon kyphoplasty (BKP) or vertebral body stenting (VBS), actually contributes to the restoration of postoperative vertebral height is unclear. The aim of the current study was to compare the effectiveness of percutaneous vertebroplasty (PVP), BKP, and VBS in the correction of collapsed vertebrae in patients with painful vertebral fractures.

METHODS

The cases studied involved 34 vertebrae in 28 patients treated with PVP, 43 vertebrae in 38 patients treated with BKP, and 20 vertebrae in 20 patients treated with VBS at Izinkai Takeda General Hospital. Changes in the vertebral height and local kyphosis angle were measured based on standing lumbar radiographs before and after surgery and were compared among the treatment groups.

RESULTS

There were no differences in changes in the height of the anterior wall, middle body, or posterior wall of the treated vertebrae among the 3 treatment groups. The same was true for changes in the local kyphosis angle. The effectiveness of vertebral height restoration depended heavily upon preoperative vertebral instability in all the treatment groups. Correction loss due to balloon deflation effect or balloon sinking was noted with VBS or BKP.

CONCLUSION

BKP and VBS have the advantage of reducing the risk of extravertebral leakage of injected bone cement, but they have a disadvantage in that they are no more effective than PVP in restoring collapsed vertebrae despite the use of a balloon or metal stent.

Percutaneous Functional Spinal Unit Cementoplasty versus Posterior Spinal Fixation with Vertebroplasty for Symptomatic Chronic Osteoporotic Vertebral Fractures: A Retrospective Study with a 2-Year Follow up

PURPOSE

To compare the clinical efficacy of percutaneous functional spinal unit cementoplasty (PFSUP) and posterior spinal fixation combined with vertebroplasty (PSF + VP) for the treatment of symptomatic chronic osteoporotic vertebral fractures (SCOVFs).

METHOD

Thirty-one patients with SCOVFs were included in this retrospective study and divided into PFSUP (n = 14) and PSF + VP (n = 17) groups. Visual analog scores (VAS) and Oswestry Disability Index (ODI) were recorded before and after surgery and at the last follow-up. Besides, the local kyphosis angle (LKA) and sagittal vertical axis (SVA) were measured. The operation duration, number of X-ray exposures, amount of blood loss, bed rest duration, hospitalization duration, and presence of complications were recorded.

RESULT

The VAS, ODI, LKA, and SVA after surgery and at the last follow-up were significantly improved in both groups compared to preoperative measurements. The PFSUP group experienced shorter operation duration (78.2 ± 13.1 vs. 124.7 ± 14.7, p < 0.001), less blood loss (31.1 ± 8.1 vs. 334.7 ± 70.9, p < 0.001), more X-ray exposures (92.1 ± 14.3 vs. 29.4 ± 5.5, p < 0.001), shorter bed rest duration (12.4 ± 3.8 vs. 43.4 ± 10.0, p < 0.001), shorter hospitalization (6.6 ± 2.4 vs. 10.9 ± 2.7, p < 0.001), lower complication rate (28.5% vs. 64.7%, p < 0.05), and higher cement leakage rate (42.9% vs. 5.8%, p < 0.05) than the PSF + VP group.

CONCLUSION

During the treatment of SCOVFs, the combination of PFSUP and PSF + VP can restore spinal stability, improve kyphosis, and relieve pain. PFSUP can reduce blood loss and complications, early mobilization, and shorten the hospital stay, but it is associated with a higher cement leakage rate and more radiation exposure.

Comparison of Unipedicular and Bipedicular Percutaneous Kyphoplasty for Kummell's Disease

Objective

To compare the clinical efficacy of unipedicular and bipedicular percutaneous kyphoplasty (PKP) for Kummell's disease.

Methods

A retrospective study was performed to review 40 patients with stage I and II Kummell's disease who underwent PKP in our hospital from January 2015 to June 2018. Based on the transpedicular approach of PKP, those patients were randomly divided into unipedicular group (n = 19) and bipedicular group (n = 21). Operative time, bone cement injection volume and cement leakage rate were compared in the two groups. Pre- and post-operative visual analogue score (VAS), local kyphotic angle and average vertebral height were also evaluated.

Results

All patients underwent surgery successfully. Compared with preoperative condition, VAS was significantly decreased at 1 day after operation and the last follow-up in both groups (P < .05), and local kyphotic angle and average vertebral height were restored markedly (P < .05). Operative time of both groups had no significant difference (P > .05). Bone cement injection volume was larger in bipedicular group (P < .05). At 1 day after operation and the last follow-up, the local kyphotic angle and average vertebral height in bipedicular group were restored better than those in unipedicular group (P < .05). There were 4 cases of cement leakage in both groups, with leakage rates of 21.1% and 19.0%, respectively, and the difference was not significant (P > .05).

Conclusion

Both unipedicular and bipedicular PKP are effective for treating patients with stage I and II Kummell's disease, while postoperative pain relief and imaging results in bipedicular group were better than those in unipedicular group.

Outcomes of Augmentation in Osteoporotic Vertebral Compression Fractures Showing a Cleft Sign on MRI

INTRODUCTION

Intravertebral clefts (IVCs) typically occur in association with osteoporotic vertebral compression fractures (OVCFs) and can be characterized based on magnetic resonance imaging (MRI). This study aimed to identify the clinical characteristics of IVCs with different MRI signals and assess their influence on outcomes of vertebral augmentation.

MATERIALS AND METHODS

We retrospectively recruited patients with OVCFs and associated IVCs who underwent vertebral augmentation. Patients were stratified into two groups based on whether the IVCs were full of liquid or gas, as determined by MRI signals. Patients were also stratified based on whether vertebral augmentation involved percutaneous kyphoplasty (PKP) or vertebroplasty (PVP). Pre- and postprocedural parameters were compared between groups.

RESULTS

A total of 194 fractured vertebrae (86 liquid-filled, 108 gas-filled) were examined. Scores for bone cement distribution were significantly higher in the gas group than in the liquid group, indicating broader cement distribution in the gas group. In both groups, intervention significantly improved pain and mobility scores. Among patients with gas-filled IVCs, the incidence of bone cement leakage and recollapse of treated vertebrae were significantly higher after PKP than after PVP. In the liquid group, incidence of bone cement leakage and recollapse of treated vertebrae did not differ significantly between patients who received PKP or PVP.

CONCLUSION

Vertebral augmentation is effective for treating OVCFs with gas- or liquid-filled IVCs. However, in patients with gas-filled IVCs, PKP may be associated with higher incidence of cement leakage and recollapse of treated vertebrae than PVP. Liquid-filled IVCs may not promote bone cement distribution.

Vertebral augmentation

Vertebral augmentation, including vertebroplasty and kyphoplasty, is a minimally invasive, image-guided procedure in which cement (typically polymethylmethacrylate (PMMA)) is injected into a vertebral body to treat painful fractures. The majority of vertebroplasty and kyphoplasty procedures are performed to treat symptomatic osteoporotic compression fractures refractory to conservative medical therapy; however, there is also evidence to suggest the benefits of augmentation in patients with refractory pain in the acute compression setting. The primary goal of augmentation is decreasing pain and improving a patient's functional status. The secondary goal of augmentation is vertebral body stabilization. This chapter outlines the indications, contraindications, techniques, and literature behind vertebral augmentation.

Creation of a planned or central-clefted puncture combined with a second puncture during vertebroplasty to treat osteoporotic vertebral compression fractures with large clefts

BACKGROUND

Cemented vertebrae frequently re-fracture after vertebroplasty to treat osteoporotic vertebral compression fractures (OVCFs) with large clefts. We compared the efficacy of planned and central-clefted puncture, both followed by a second puncture, as treatments for OVCFs with large clefts.

METHODS

We retrospectively studied 38 patients. 18 of whom underwent planned puncture (group A) and 20 central-clefted puncture (group B). A second puncture was performed when the initially injected cement was restricted to the cleft. We recorded a visual analog scale (VAS) pain scores, vertebral kyphotic angles (KAs), and compression ratios (CRs) preoperatively and at 2 days and 6 months postoperatively. We recorded the cement dispersion patterns and complications.

RESULTS

Second punctures succeeded in 15/18 and 7/20 patients of groups A and B, respectively. At 2 days postoperatively, the VAS score, KA, and CR were significantly better than the preoperative values (P < 0.01); no significant difference was found between the two groups (P > 0.05). At the 6-month follow-up, all scores were poorer than at 2 days postoperatively (all P < 0.05), significantly more so in group B than group A (P < 0.05). Significant differences in terms of the cement dispersion patterns, and the cemented vertebral re-fracture and cement leakage rates, were observed between the two groups (all P < 0.05).

CONCLUSION

The two-puncture techniques were initially effective when treating large-clefted OVCFs. However, compared to the central-clefted puncture, the planned puncture improved the success rate of the second puncture, allowed better cement dispersion, and reduced the incidence of vertebral re-fracture during follow-up.

Short-term outcomes of percutaneous pedicle screw fixation combined with vertebroplasty: A minimally invasive treatment for Kümmell's disease with intravertebral instability

OBJECTIVE

The aim of this study was to present early clinical and radiological outcomes of percutaneous pedicle screw fixation (PPSF) combined with vertebroplasty (VP) in the treatment of Kümmell's disease with intravertebral instability.

METHODS

In this study, 21 consecutive patients (4 male and 17 female; mean age = 75.6 years; age range=65-86 years) who suffered from stage II and III Kümmell's disease with intravertebral instability were prospectively recruited from 2012 to 2016 and treated with PPSF combined with VP. The Cobb angle (CA) or wedge angle (WA) in both flexion and extension positions was measured using lateral radiographs, computed tomography, or magnetic resonance imaging. In addition to these radiological parameters, clinical outcome measures, including the visual analog scale (VAS) and the Oswestry Disability Index (ODI) were collected preoperatively; 1 week and 1, 3, 6, and 12 months postoperatively; and then annually. Complications were also recorded.

RESULTS

The mean follow-up was 19.3 (range=12-36) months. The mean operating time was 135.4 (range, 110-175) min, and the mean estimated blood loss was 106.9 (range, 50-165) mL. The mean VAS score and ODI significantly decreased from 7.7±1.1 and 65.3%±7.7% preoperatively to 3.4±0.6 and 30.0%±7.6% postoperatively, respectively (p<0.05). At the final follow-up, the mean VAS score and ODI were 2.5±0.8 and 21.5%±8.8%, respectively (p>0.05). CA and WA significantly decreased from 26.9°±9.7° and 21.3°±6.0° preoperatively to 12.7°±7.2° to 8.6°±4.5° postoperatively, respectively (p<0.05). At the final follow-up, CA was 4.2°±2.0°, and WA was 4.7°±1.8° (p>0.05). No major complications were encountered during the follow-up period.

CONCLUSION

PPSF combined with VP seems to be an effective surgical option for the treatment of Kümmell's disease with intravertebral instability.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

Intravertebral cleft in pathological vertebral fracture resulting from spinal tuberculosis: a case report and literature review

Background

Among common findings in osteoporotic vertebral compression fractures (OVCFs), the intravertebral cleft (IVC) is usually considered a benign lesion. The current study was aimed to present a rare case of vertebral fracture caused by IVC-related spinal tuberculosis.

Case presentation

A 73-year-old female complained of back pain and weakness in lower limbs for 2 weeks. 3 months ago, after a minor trauma, she got back pain without weakness in lower limbs. Initially, she was diagnosed with a L1 compression fracture and accepted conservative treatment. After an asymptomatic period, she complained progressive pain at the fracture position with weakness of both lower limbs and was referred to our hospital with suspicion of Kümmell’s disease. The patient underwent posterior debridement and internal fixation for decompression and stabilization of the spine. Pathological examinations revealed the patient with spinal tuberculosis.

Conclusions

Although IVC is common in patients with OCVFs, there are some cases believed to be found in patients with spinal tuberculosis or infection. Further test, like CT-guided puncture biopsy, may be required before decisive treatment when an IVC is observed.

Percutaneous vertebral augmentation using drill rotation for osteoporotic vertebral compression fractures with intravertebral vacuum cleft

OBJECTIVE

To evaluate the efficacy of a new technique of percutaneous vertebral augmentation (PVA): drill rotation-cement injected under vacuum aspiration (DR-CIVAS) for vertebral compression fractures (OVCFs) with intravertebral vacuum cleft (IVC) sign.

MATERIALS AND METHODS

A retrospective study was conducted in 46 consecutive patients with OVCFs and IVC signs, who underwent PVA using DR-CIVAS (n = 22, DR-CIVAS group) or traditional technique without DR-CIVAS (n = 24, control group). The pre- and postoperative vertebral height and wedge angle change and visual analog scale (VAS), the volume of cement injected, incidences of cement leakage, and subsequent new vertebral compression fractures were evaluated between the two groups.

RESULTS

No significant difference was found in cement leakage incidences, pre- and postoperative VAS scores, vertebral height, and wedge angle change between the two groups. The mean cement volume was significantly higher (P < 0.001) in DR-CIVAS group (4.87 mL) than in the control group (3.58 mL). Of the 22 patients in DR-CIVAS group, the subsequent fractures occurred in 2 cases (9.1%) located in the nonadjacent levels. In the control group, the subsequent fractures occurred in 6 cases (25.0%) located in the adjacent level (n = 1) and the augmented levels (n = 5). Although DR-CIVAS group did not demonstrate a statistical reduction of the incidence of subsequent fractures (P = 0.25), the subgroup analysis revealed that subsequent fractures frequently involved the augmented level in the control group (P = 0.04).

CONCLUSIONS

PVA with DR-CIVAS technique is effective for OVCFs with IVC sign, with lower incidences of subsequent new vertebral compression fractures in the augmented vertebra.

Safety and Efficacy Studies of Vertebroplasty with Dual Injections for the Treatment of Osteoporotic Vertebral Compression Fractures: Preliminary Report

PURPOSE

To evaluate the clinical safety and efficacies of percutaneous vertebroplasty (PVP), percutaneous vertebroplasty with dual injections (PVPDI), and percutaneous kyphoplasty (PKP) for the treatment of osteoporotic vertebral compression fractures (OVCFs), a retrospective study of 90 patients with OVCFs who had been treated by PVP (n = 30), PVPDI (n = 30), and PKP (n = 30) was conducted in this work.

METHODS

The clinical efficacies of these three treatments were evaluated by comparing their PMMA cement leakages, cement patterns, height restoration percentages, wedge angles, visual analogue scales, and Oswestry disability index (ODI) at the pre- and postoperative time points.

RESULTS

Ten percent, 6.7%, and 0% of patients had PMMA leakage in PVP, PVPDI, and PKP groups, respectively. Three (solid, trabecular, and mixed patterns), two (trabecular and mixed patterns), and two (solid and mixed patterns) types of cement patterns were observed in PVP, PVPDI, and PKP groups, respectively. PVP and PVPDI treatments had similar and less height restoration ability than PKP treatment. All the PVP, PVPDI, and PKP treatments had significant and similar ability in pain relief and functional recovery ability for the treatment of OVCFs. Microfractures after the surgery occurred after PVP and PKP treatments.

CONCLUSION

These results indicate minimally invasive techniques were effective methods for the treatment of OVCFs. Moreover, these initial outcomes suggest PVPDI treatment has great value and is worth promoting vigorously in orthopedics clinics.

Efficacy analysis of percutaneous pedicle screw fixation combined with percutaneous vertebroplasty in the treatment of osteoporotic vertebral compression fractures with kyphosis

BACKGROUND

To investigate the clinical effect of percutaneous pedicle screw fixation (PPSF) combined with percutaneous vertebroplasty (PVP) in the treatment of osteoporotic compression vertebral fracture (OVCF) of the thoracolumbar vertebra with kyphosis.

METHODS

One hundred sixty-six patients before June 2017 were retrospectively analyzed, and patients were divided into PPSF + PVP group A and PVP group B. Operative time, bone mineral density, postoperative bed time, high compression ratio, bone cement leakage rate, and bone cement dose were recorded. Comparison of vertebral anterior edge height, Cobb angle, visual analogue score (VAS), and low back pain dysfunction index (ODI) between the two groups in preoperative, postoperative 3 days, postoperative 6 months, postoperative 12 months, and postoperative 24 months, postoperative complications were observed in the two groups.

RESULTS

The operation time of group A was longer than that of group B (59.0 ± 8.6 min, 26.6 ± 5.2 min), longer postoperative bed rest time (3.3 ± 0.7 days, 1.2 ± 0.5 days), the differences were statistically significant (P < 0.01), there was no difference in the amount of bone cement between the two groups (5.4 ± 0.6 ml, 5.3 ± 0.8 ml) (P > 0.05). The height of the anterior edge and Cobb angle of the two groups recovered significantly in postoperative 3 days. The height of anterior edge (2.7 ± 0.3 cm, 2.6 ± 0.2 cm, 2.5 ± 0.7 cm; 2.3 ± 0.6 cm, 1.7 ± 0.5 cm, 1.6 ± 0.3 cm) and Cobb angle (4.9 ± 2.2, 5.5 ± 2.3, 5.7 ± 2.3; 12.4 ± 3.2, 17.2 ± 2.5, 13.2 ± 2.3) was statistically significant in postoperative 6 months, postoperative 12 months, and postoperative 24 months (P < 0.01). VAS and ODI scores of postoperative 6 months and 12 months were significantly different between the two groups (P < 0.05). Postoperative complications in group B were much higher than those in group A.

CONCLUSION

The efficacy of PVP alone was not satisfactory, and the rate of complications was high for OVCF patients with severe anterior edge compression with kyphosis. PPSF combined with PVP is recommended, the vertebral height loss was not obvious, the satisfaction was good, and the complication rate was lower during 2 years follow-up.

Influence of the distribution of bone cement along the fracture line on the curative effect of vertebral augmentation

Objective

The present study was performed to evaluate the effect of different bone cement distributions along the fracture line on clinical and imaging outcomes of vertebral augmentation.

Methods

In total, 84 patients who underwent vertebral augmentation for a single osteoporotic vertebral compression fracture from January 2016 to August 2018 were retrospectively reviewed. These patients were divided into two groups according to the relationship between the bone cement distribution and the fracture line: the unilateral group (n = 23) and the bilateral group (n = 61). Postoperative clinical and imaging parameters were compared between the two groups.

Results

Statistical analyses showed no significant difference in postoperative pain relief, bone cement leakage, nerve injury, or new vertebral fracture between the two groups. Significant recovery from vertebral compression was observed in the bilateral group after surgery, but there was no significant difference in vertebral compression after surgery in the unilateral group.

Conclusions

Pain relief was similar for different types of cement distributions along the fracture line, but a bilateral cement distribution exhibited better recovery from vertebral compression and did not increase bone cement leakage in the vertebral augmentation procedure.

Clinical comparison between a percutaneous hydraulic pressure delivery system and balloon tamp system using high-viscosity cement for the treatment of osteoporotic vertebral compression fractures

OBJECTIVES

Osteoporotic vertebral compression fractures (OVCFs) affect the elderly population, especially postmenopausal women. Percutaneous kyphoplasty is designed to treat painful vertebral compression fractures for which conservative therapy has been unsuccessful. High-viscosity cement can be injected by either a hydraulic pressure delivery system (HPDS) or a balloon tamp system (BTS). Therefore, the purpose of this study was to compare the safety and clinical outcomes of these two systems.

METHODS

A random, multicenter, prospective study was performed. Clinical and radiological assessments were carried out, including assessments of general surgery information, visual analog scale, quality of life, cement leakage, and height and angle restoration.

RESULTS

Using either the HPDS or BTS to inject high-viscosity cement effectively relieved pain and improved the patients' quality of life immediately, and these effects lasted at least two years. The HPDS using high-viscosity cement reduced cost, surgery time, and radiation exposure and showed similar clinical results to those of the BTS. In addition, the leakage rate and the incidence of adjacent vertebral fractures after the HPDS treatment were reduced compared with those after treatment using the classic vertebroplasty devices. However, the BTS had better height and angle restoration abilities.

CONCLUSIONS

The percutaneous HPDS with high-viscosity cement has similar clinical outcomes to those of traditional procedures in the treatment of vertebral fractures in the elderly. The HPDS with high-viscosity cement is better than the BTS in the treatment of mild and moderate OVCFs and could be an alternative method for the treatment of severe OVCFs.

Morphological changes of vertebral compression fracture with intra-vertebral cleft treated with percutaneous vertebroplasty

BACKGROUND

Vertebroplasty represents an established treatment option for osteoporotic vertebral compression fracture (OVCF), but its radiographic and clinical outcomes have not been clearly described in patients with intra-vertebral cleft (IVC). The aim of this study was to assess vertebral height restoration, recollapse and change of back pain in OVCF patients with or without IVC.

METHODS

The records of 108 patients with IVC (group I) and 233 patients without IVC (group II) were included in our analysis between March 2001 and February 2014. The heights of the anterior, middle, and posterior columns, as well as the wedge angle (WA) of the fractured vertebral body were measured. For each vertebral column, the mean height of the superior and inferior vertebral body served as reference. Pre-operative, postoperative, and final compression rates (CR), as well as restoration and recollapse rates were calculated for each column. Subjective back pain was assessed as the numeric rating scale (NRS) score.

RESULTS

The overall incidence of IVC in OVCF patients who underwent vertebroplasty was 20.8% (127/611 patients). Group I showed significantly higher CR over the entire follow-up period, with the exception of CR for the anterior column at final follow-up, and CR for the posterior column throughout the follow-up. The mean restoration rates at the anterior and middle column immediately after vertebroplasty were also significantly larger in group I. Recollapse rate in all columns was similar for groups I and II. The mean wedge angle was significantly larger in group I over the entire follow-up period. The groups did not differ in terms of NRS score at final follow-up.

CONCLUSIONS

Vertebroplasty restores vertebral body heights and WA more effectively in OVCF patients with IVC, and provides satisfactory radiographic and clinical outcomes regardless of the presence of IVC.

Percutaneous Kyphoplasty for the Treatment of Osteoporotic Vertebral Fractures With Intravertebral Fluid or Air: A Comparative Study

STUDY DESIGN

A retrospective comparative study.

OBJECTIVE

To compare the characteristics of osteoporotic vertebral fractures (OVFs) with intravertebral fluid (IVF) and those with intravertebral air (IVA), and the efficacy of percutaneous balloon kyphoplasty (PKP) in treating OVFs with these 2 different intravertebral components.

SUMMARY OF BACKGROUND DATA

Previous studies have focused on the efficacy of percutaneous vertebroplasty (PVP) and PKP in treating OVFs with intravertebral cleft. However, no prior studies investigated the impact of the different components of cleft on the therapeutic effect of PVP or PKP.

METHODS

On the basis of the presence of IVF or IVA signal on preoperative MR images, 22 patients were classified into IVF group and 13 patients into IVA group. The characteristics of patients with IVF and those with IVA were compared. The anterior and middle heights of the involved vertebrae, the kyphotic angles, the Visual Analogue Scale (VAS), and Oswestry Disability Index (ODI) scores were recorded preoperatively, 1 day after surgery, and at last follow-up.

RESULTS

Severe collapse of involved vertebrae (P=0.024) and the gap appearance of clefts (P=0.004) were significantly more common in IVA group than in IVF group. The vertebral heights, the local kyphotic angles, the VAS, and ODI scores were all significantly improved after PKP in both groups. However, the vertebral height restoration and kyphotic deformity correction were more significant in IVF group than in IVA group (P<0.001). No significant differences regarding VAS and ODI scores were detected between the 2 groups at each follow-up time.

CONCLUSIONS

PKP is an effective treatment strategy for both OVFs with IVF and with IVA, whereas vertebral height restoration and kyphotic deformity correction are much more significant in vertebrae with IVF. Presence of IVA without fluid filling-in on MR images may indicate an advanced stage of intravertebral osteonecrosis.

Clinical management of osteoporotic vertebral fracture treated with percutaneous vertebroplasty

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

Clinical Experience Using a Remote Control Injection System in Vertebroplasty: Feasibility, Safety, and Cement Leakage of Osteoporotic and Malignant Compression Fractures

STUDY DESIGN

A retrospective study.

SUMMARY OF BACKGROUND DATA

Cement leakage is a frequent occurrence in vertebroplasty and is also the main source of complications. Continuous radiographic evaluation is mandatory to detect cement leakage during injecting cement into the vertebral body, while the operator is subjected to x-ray radiation exposure.

OBJECTIVE

The aim of this study was to evaluate the feasibility and safety of vertebroplasty performed on patients and operators for the treatment of osteoporotic and malignant vertebral compression fractures using a remote control injection system.

MATERIALS AND METHODS

Institutional review board approval was obtained for this retrospective study. Clinical charts and postoperative radiographs were obtained for 74 patients (114 levels) who underwent vertebroplasty. The study group included 46 cases (71 levels) of benign osteoporotic fractures and 28 cases (43 levels) of different malignant metastatic lesions. Under fluoroscopic guidance, cement was injected using a remote control injection system, while the operator was standing outside the radiation field. The location and degree of leakage at each treated level were recorded.

RESULTS

Cement leakage rate reached 47.4% across all treated levels. No severe leakage in any location was observed. A total of 35 leakages were detected in 71 levels and 24 leakages were detected in 43 levels in the benign and malignant fracture group, respectively. The overall rate of cement leakages and the location of the leakages were not statistically different between the benign and malignant fracture group (P=0.60, P=0.45). With the operator standing outside the radiation field to inject cement, the radiation dose to operators was avoided during cement injection.

CONCLUSIONS

Vertebroplasty using a remote control injection system was feasible and safe in treatment of osteoporotic and malignant compression fractures. The cement injection system had potential benefits to decrease the leakage rate in treating malignant fractures and eliminate injection dose to operators under lateral fluoroscopic monitoring.

The therapeutic effect of intravertebral vacuum cleft with osteoporotic vertebral compression fractures: A systematic review and meta-analysis

BACKGROUND

To date, there has been ongoing debate over whether intravertebral vacuum cleft (IVC) has the effect of therapeutic efficacy in percutaneous vertebral augmentation (PVA) for the treatment of osteoporotic vertebral compression fractures (OVCFs).

OBJECTIVE

The aim of this meta-analysis was to calculate a pooled estimate of the IVCs on the effect of therapeutic efficacy of PVA for the treatment of OVCFs.

METHODS

A systematic electronic literature search was performed using the following databases: PubMed, Embase and Cochrane Library; the databases were searched from the earliest available records up to June 2016. Pooled risk ratio (RR) or a mean difference (MD) with 95% confidence interval (CI) was calculated using random- or fixed-effects models. The RevMan 5.2 was used to analyze the data.

RESULTS

In the immediate postoperative period, pooled results showed that vertebral height and VAS scores of the IVC patients were significantly lower than those of the non-IVC patients. However, pooled results showed there was no significant difference in kyphotic angle and ODI indices between the two groups. At final follow-up period, significant difference was observed in all the radiological and clinical parameters for the IVC patients with compared to the non-IVC patients in our pooled results. Pooled results showed significant difference with respect to the rate of cement leakage between the two groups.

CONCLUSION

The IVCs had an important effect of therapeutic efficacy in PVA for the treatment OVCFs. Therefore, we strongly recommend its strict observation and follow-up for the IVCs patients.

Repeat Percutaneous Vertebroplasty for Recurrent Pain Arising From Previously Treated Vertebrae in Patients With Osteoporotic Vertebral Compression Fractures

STUDY DESIGN

A retrospective study.

SUMMARY OF BACKGROUND DATA

Percutaneous vertebroplasty (PV) changes mechanical stress of vertebral column and can cause recurrent pain at the treated level. However, there were a few reports on the therapeutic effects of the repeat PV for patients with recurrent pain at the treated level.

OBJECTIVE

To evaluate the therapeutic effects of repeat PV at previously treated vertebral level for patients with osteoporotic vertebral compression fractures (OVCFs) having recurrent pain after initial PV.

METHODS

Institutional review board approval was obtained for this retrospective study. Patients with OVCFs who underwent repeat PV for recurrent pain at previously treated vertebral levels were identified and included in this study. Correlative parameters were analyzed that included pain score before and after repeat PV, amount of bone cement injected, and presence of cleft sign in the vertebral body on pre-PV and post-PV medical imaging tests.

RESULTS

Nine of consecutive 827 patients met the selection criteria. Cleft sign was identified in 5 patients before or during initial PV, whereas it was present in all 9 patients on prerepeat PV images. A reduction of 4.3±0.5 points of pain scale and 2.1±0.6 points of mobility rate at 1 week after the repeat PV was reported in all 9 patients. The mean pain scale and mobility rate score were 2.8±0.45 points and 0.3±0.5 at the 3-month follow-up, respectively. The mean volume of injected cement (6.8±1.92 mL) in repeat PV was larger than that in initial PV (4.2±0.84 mL). There was statistically significant difference (P=0.033).

CONCLUSIONS

Repeat PV is an effective option for patients having OVCFs with recurrent pain at the previously treated level. There was a correlation between therapeutic benefits of repeat PV and the cleft sign disappearance in patients at the previously treated vertebral level.

Safety and Efficacy Studies of Vertebroplasty, Kyphoplasty, and Mesh-Container-Plasty for the Treatment of Vertebral Compression Fractures: Preliminary Report

To evaluate the clinical safety and efficacies of percutaneous vertebroplasty (PVP), percutaneous kyphoplasty (PKP), and percutaneous mesh-container-plasty (PMCP) for the treatment of vertebral compression fractures (VCFs), a retrospective study of 90 patients with VCFs who had been treated by PVP (n = 30), PKP (n = 30), and PMCP (n = 30) was conducted. The clinical efficacies of these three treatments were evaluated by comparing their PMMA cement leakages, cement patterns, height restoration percentages, wedge angles, visual analogue scales (VAS), and oswestry disability index (ODI) at the pre- and post-operative time points. 6.67%, 3.33%, and 0% of patients had PMMA leakage in PVP, PKP, and PMCP groups, respectively. Three (solid, trabecular, and mixed patterns), two (solid and mixed patterns), and one (mixed patterns) types of cement patterns were observed in PVP, PKP, and PMCP groups, respectively. PKP and PMCP treatments had better height restoration ability than PVP treatment. PVP, PKP, and PMCP treatments had significant and similar ability in pain relief and functional recovery ability for the treatment of VCFs. These results indicate minimally invasive techniques were effective methods for the treatment of VCFs. Moreover, these initial outcomes suggest PMCP treatment may be better than both PVP treatment and PKP treatment.

Clinical effect evaluation of percutaneous vertebroplasty combined with the spinal external fixator for the treatment of osteoporotic compressive fractures with posterior vertebral defect

PURPOSE

The purpose of this study is to report a new technique and assess clinical outcome of compressive fractures with posterior vertebral defect treated by percutaneous vertebroplasty combined with the spinal external fixator.

METHOD

80 patients (32 males and 48 females), ranging from 62 to 88 years old with the mean age of 71.5 years, underwent surgery for the compressive fractures with posterior vertebral defect by percutaneous vertebroplasty combined with the spinal external fixator. All patients were diagnosed to have fresh compressive fractures with osteoporosis and posterior vertebral defect shown on roentgenograms, computed tomography scans or magnetic resonance imaging preoperatively. They underwent spinal external fixation firstly to be fixed and restored, then to be carried out percutaneous vertebroplasty. The mean follow-up was 24 months (16-42 months). Spinal canal encroachment, spinal cobb angle and vertebral body height loss were measured to assess clinical outcome before and after surgery, at the final follow-up. The Visual Analogue Scale and Oswestry Disability Index were used for pain and functional assessment. In all cases, preoperative and postoperative radiographs and magnetic resonance imaging were obtained.

RESULTS

The average time of surgery was 88 min (75-115 min). The mean blood loss was 10 ml (6-12 ml) during surgery. The anterior height loss of vertebral body decreased significantly from 79.3 ± 11% before surgery to 8.0 ± 5.2% after surgery, and 7.6 ± 6.0% at the final follow-up. The spinal canal encroachment significantly reduced from 19.9 ± 2.6 % preoperatively to 4.0 ± 0.7% postoperatively, 4.1 ± 0.7% at the final follow-up. The Cobb angle was corrected from 25.8 ± 7.9° primarily to 8.2 ± 4.1° postoperatively, 7.8 ± 3.1° at the final follow-up. There were significant differences (p < 0.05) among them before and after the surgery. Postoperative VAS and Oswestry scores were both significantly different from the preoperative and follow-up (p < 0.05).

CONCLUSION

The preliminary results are encouraging, showing that the spinal external fixator combined with percutaneous vertebroplasty was a safe and effective method to treat the osteoporotic compressive fractures with posterior vertebral defect.

ACR appropriateness criteria management of vertebral compression fractures

This is an updated review of management of vertebral compression fracture for both benign osteoporotic and malignant causes. Vertebral compression fracture radiologic imaging evaluation is discussed. A literature review is provided of current indications for vertebral augmentation with percutaneous vertebroplasty and kyphoplasty as well as medical management. Limitations and potential benefits of these procedures are discussed. Variant tables describing various clinical situations are also provided to assist in determining appropriate use of these treatments for patient care. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to formulate recommendations for imaging or treatment.

Analysis of risk factors of subsequent fractures after vertebroplasty

PURPOSE

The purpose of this study is to identify risk factors related to the development of subsequent fractures after vertebroplasty.

METHOD

A retrospective study was conducted to review 175 patients with a 1-year follow-up who underwent vertebroplasty for first-time and single-level osteoporotic vertebral fractures. Subsequent fractures were diagnosed as recurrent intractable back pain, post-operatively correlated with MR image. Clinical parameters, such as age, gender, baseline VAS-score, lumbar bone mineral density (BMD) T-score, history of use of steroids, bisphosphonate therapy, symptom-free interval, the amount of bone cement injected, vacuum clefts, leakage of cement into the disk space, treated level and the changes of spinal geometry were recorded.

RESULTS

During the follow-up period, subsequent fractures developed in 37 (21.1 %) of 175 patients. Significant differences (P < 0.05) were found between the patients with subsequent fractures and the patients without subsequent fractures in regard to their BMD T-score, and treated vertebrae location. Average BMD T-score was -3.4 ± 1.5 in patients with subsequent fractures and -2.9 ± 1.6 in patients without subsequent fractures. The percentage of subsequent fractures was 13.9 % (10 of 72) for treated vertebrae located in non-thoracolumbar junction, and 26.2 % (27 of 103) in the thoracolumbar junction.

CONCLUSION

The most important risk factors affecting subsequent fractures after vertebroplasty were osteoporosis and treated level at the thoracolumbar junction.

In not only vertebroplasty but also kyphoplasty, the resolution of vertebral deformities depends on vertebral mobility

BACKGROUND AND PURPOSE

It has not been clarified whether the postoperative resolution of vertebral deformities achieved by KP are superior to those achieved by VP. We compared the outcomes of KP and VP, taking into account the presence of vertebral mobility, to determine whether the balloon inflation in KP may contribute to postoperative resolution of the vertebral deformities in patients with VCFs.

MATERIALS AND METHODS

The subjects had 34 vertebral bodies treated by VP, and 43 vertebral bodies treated by KP. In all patients, preoperative dynamic imaging was performed to assess the presence of vertebral mobility. First, the vertebral height restoration and kyphotic change were compared between the VP and KP groups. Then, the patients were further divided into 2 groups on the basis of the presence of vertebral mobility, and they were compared within and between the VP and KP groups in relation to the presence of vertebral mobility.

RESULTS

Overall, no significant differences were observed in either the vertebral height restoration or kyphotic change between the VP and KP groups (P > .20). Preoperative dynamic imaging identified 19 vertebral bodies each with vertebral mobility in the VP (56%) and KP groups (44%) (P = .21). Within the VP and KP groups, the vertebral height restoration and kyphotic changes were significantly better in patients with vertebral mobility than in those without (P < .01). There were no significant differences between the 2 treatment groups after adjustment for the presence of vertebral mobility (P > .30).

CONCLUSIONS

In both the VP and KP groups, the vertebral height restoration and kyphotic change largely depended on the preoperative vertebral mobility. The use of the balloon itself contributed little to resolution of the vertebral deformities.

Vertebral compression fracture with intravertebral vacuum cleft sign: pathogenesis, image, and surgical intervention

The intravertebral vacuum cleft (IVC) sign in vertebral compression fracture patients has obtained much attention. The pathogenesis, image character and efficacy of surgical intervention were disputed. Many pathogenesis theories were proposed, and its image characters are distinct from malignancy and infection. Percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP) have been the main therapeutic methods for these patients in recent years. Avascular necrosis theory is the most supported; PVP could relieve back pain, restore vertebral body height and correct the kyphotic angulation (KA), and is recommended for these patients. PKP seems to be more effective for the correction of KA and lower cement leakage. The Kümmell's disease with IVC sign reported by modern authors was incomplete consistent with syndrome reported by Dr. Hermann Kümmell.

High precision semi-automated vertebral height measurement using computed tomography: A phantom study

The measurement of vertebral heights is necessary for the evaluation of many disorders affecting the spine. High precision is particularly important for longitudinal studies where subtle changes are to be detected. Computed tomography (CT) is the modality of choice for high precision studies. Radiography and dual emission X-ray absorptiometry (DXA) use 2D images to assess 3D structures, which can result in poor visualization due to the superimposition of extraneous anatomical objects on the same 2D space. We present a semi-automated computer algorithm to measure vertebral heights in the 3D space of a CT scan. The algorithm segments the vertebral bodies, extracts their end plates and computes vertebral heights as the mean distance between end plates. We evaluated the precision of our algorithm using repeat scans of an anthropomorphic vertebral phantom. Our method has high precision, with a coefficient of variation of only 0.197% and Bland-Altmann 95% limits of agreement of [-0.11, 0.13] mm. For local heights (anterior, middle, posterior) the algorithm was up to 4.2 times more precise than a manual mid-sagittal plane method.

High precision semiautomated computed tomography measurement of lumbar disk and vertebral heights

PURPOSE

Evaluation of treatments of many spine disorders requires precise measurement of the heights of vertebral bodies and disk spaces. The authors present a semiautomated computer algorithm measuring those heights from spine computed tomography (CT) scans and evaluate its precision.

METHODS

Eight patients underwent two spine CT scans in the same day. In each scan, five thoracolumbar vertebral heights and four disk heights were estimated using the algorithm. To assess precision, the authors computed the differences between the height measurements in the two scans, coefficients of variation (CV), and 95% limits of agreement. Intraoperator and interoperator precisions were evaluated. For local vertebral and disk height measurement (anterior, middle, posterior) the algorithm was compared to a manual mid-sagittal plane method.

RESULTS

The mean (standard deviation) interscan difference was as low as 0.043 (0.031) mm for disk heights and 0.044 (0.043) mm for vertebral heights. The corresponding 95% limits of agreement were [-0.085, 0.11] and [-0.10, 0.12] mm, respectively. Intraoperator and interoperator precision was high, with a maximal CV of 0.30%. For local vertebral and disk heights, the algorithm improved upon the precision of the manual mid-sagittal plane measurement by as much as a factor of 6 and 4, respectively.

CONCLUSIONS

The authors evaluated the precision of a novel computer algorithm for measuring vertebral body heights and disk heights using short term repeat CT scans of patients. The 95% limits of agreement indicate that the algorithm can detect small height changes of the order of 0.1 mm.

Is there really no benefit of vertebroplasty for osteoporotic vertebral fractures? A meta-analysis

BACKGROUND

Osteoporotic vertebral compressed fractures (VCFs) are the most common osteoporotic fractures. Although percutaneous vertebroplasty (PVP) reportedly relieves pain and improves function, a recent pooled analysis from two multicenter randomized controlled trials concluded the improvement in pain and disability treated with PVP was similar to those with sham surgery.

QUESTIONS/PURPOSE

Using meta-analysis we therefore asked whether compared with either nonoperative therapy or a sham injection for patients with VCF, PVP would (1) better relieve pain, (2) provide greater improvement in pain-related disability, and (3) increase the recurrence of vertebral fractures.

METHODS

We searched PubMed, EMBASE, Medline, and the Cochrane library using the keywords "vertebroplasty AND osteoporosis OR fracture". We included nine of the 469 articles identified. Using a random effects model, we calculated the weighted mean differences to evaluate the pain reduction at different times as the primary outcome. Pain-related disability was assessed by a quality of life (QOL) measure. Improvement of QOL and recurrence of vertebral fractures were the secondary outcomes. We used subgroup analysis to reinvestigate pain relief and function improvement of PVP based on two different controls: nonoperative therapy and sham injection. The total number of patients was 886.

RESULTS

Pain scoring was similar between the PVP group and the sham injection group at 1 to 29 days and 90 days. However, compared with nonoperative therapy, PVP reduced pain at all times studied. QOL in the PVP group was improved or tended to be improved compared with QOL for both control groups. The risk of new fractures was similar between the PVP groups and both control groups.

CONCLUSIONS

Different control groups may have accounted for the different conclusions in the literature regarding the ability of PVP to relieve pain and restore function recovery. Compared with nonoperative treatment PVP relieved pain better and improved QOL. PVP did not increase the risk of new fractures.

LEVEL OF EVIDENCE

Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.