Comparing complications of vertebroplasty and kyphoplasty for treating osteoporotic vertebral compression fractures: a meta-analysis of the randomized and non-randomized controlled studies

Percutaneous vertebroplasty versus percutaneous kyphoplasty for osteoporotic vertebral compression fractures: an umbrella review protocol of systematic reviews and meta-analyses

INTRODUCTION

Several systematic reviews and meta-analyses have confirmed that percutaneous vertebroplasty and percutaneous kyphoplasty showed safety and beneficial efficacy in patients with osteoporotic vertebral compression fractures. Whereas, there is wide variation among results, which are not conducive to the evaluation and use of clinicians. This study will investigate the efficacy and safety of percutaneous vertebroplasty and percutaneous kyphoplasty for the treatment of osteoporotic vertebral compression fractures, aiming to provide a more reliable evidence base for clinical practice in treating osteoporotic vertebral compression fractures.

METHODS AND ANALYSIS

We will retrieve the relevant articles using the five databases(PubMed, Scopus, EMBASE, Cochrane Library and Web of Science) from inception to March 2023 for systematic review and meta-analysis comparing the overall safety and efficacy of percutaneous vertebroplasty and percutaneous kyphoplasty in patients with osteoporotic vertebral compression fractures. Three reviewers will screen citation titles, abstracts and evaluate the full text of each relevant citation based on prespecified eligibility criteria. Any discrepancies in decisions between reviewers will be resolved through discussion. We will assess the methodological quality of the included studies according to A MeaSurement Tool to Assess systematic Reviews 2 checklist.

ETHICS AND DISSEMINATION

This umbrella review will inform clinical and policy decisions regarding the benefits and harms of percutaneous vertebroplasty versus percutaneous kyphoplasty for osteoporotic vertebral compression fractures. Neither primary data nor individual patient information will be collected, thus ethics approval is not required. Findings will be reported through a peer-reviewed publication, conference presentations and the popular press.

PROSPERO REGISTRATION NUMBER

CRD42021268141.

Interventional Pain Procedures: A Narrative Review Focusing On Safety and Complications. PART 2 Interventional Procedures For Back Pain

In patients where conservative approaches have failed to relieve from chronic pain, interventional procedures may be an option in well selected patients. In recent years there has been an increase in the use and development of invasive procedures. Concomitantly, there has also been an increase in the complications associated with these procedures. Taken this into consideration, it is important for healthcare providers to take a cautious and vigilant approach, with a focus on patient safety, in order to minimize the risk of adverse events and ensure the best possible outcome for the patient. This may include careful selection of patients for procedures, use of proper techniques and equipment, and close monitoring and follow-up after the procedure. The aim of this narrative review is to summarize the primary complications associated with commonly performed image-guided (fluoroscopy or ultrasound-guided) interventional procedures and provide strategies to reduce the risk of these complications. We conclude that although complications from interventional pain procedures can be mitigated to a certain degree, they cannot be eliminated altogether. In order to avoid adverse events, patient safety should be given considerable attention and physicians should be constantly aware of the possibility of developing complications.

The American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain

Introduction

Painful lumbar spinal disorders represent a leading cause of disability in the US and worldwide. Interventional treatments for lumbar disorders are an effective treatment for the pain and disability from low back pain. Although many established and emerging interventional procedures are currently available, there exists a need for a defined guideline for their appropriateness, effectiveness, and safety.

Objective

The ASPN Back Guideline was developed to provide clinicians the most comprehensive review of interventional treatments for lower back disorders. Clinicians should utilize the ASPN Back Guideline to evaluate the quality of the literature, safety, and efficacy of interventional treatments for lower back disorders.

Methods

The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations. Experts from the fields of Anesthesiology, Physiatry, Neurology, Neurosurgery, Radiology, and Pain Psychology developed the ASPN Back Guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Scopus, and meeting abstracts to identify and compile the evidence (per section) for back-related pain. Search words were selected based upon the section represented. Identified peer-reviewed literature was critiqued using United States Preventive Services Task Force (USPSTF) criteria and consensus points are presented.

Results

After a comprehensive review and analysis of the available evidence, the ASPN Back Guideline group was able to rate the literature and provide therapy grades to each of the most commonly available interventional treatments for low back pain.

Conclusion

The ASPN Back Guideline represents the first comprehensive analysis and grading of the existing and emerging interventional treatments available for low back pain. This will be a living document which will be periodically updated to the current standard of care based on the available evidence within peer-reviewed literature.

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 Covid 19 Pandemic Effect on the Epidemiology of Thoracolumbar Fractures Presenting to the Emergency Department in Patients Above 65 years Old

Introduction

Studies investigating the Covid-19 Pandemic’s orthopedic aspects are accumulating, including reports on a 10-33% decrease in hip fracture incidence alongside shorter times to surgery. Osteoporotic vertebral compression fractures (VCF) have not yet been discussed. This study evaluated the effect of the Covid-19 pandemic’s first wave on VCF in the elderly.

Method

A retrospective cohort of elderly patients diagnosed with VCF between 2018-19 (Pre-Covid-19 pandemic) to 2020.

Results

The cohort included 172 patients above 65 years with VCF during 2018-2020. Patients’ age and gender were similar between the two study groups. We found a higher proportion of high-energy VCF during 2020 (10.5% vs 6.7%). Incidence of recurrent fractures was 7.5 times higher during 2020 (5.3% vs .7%, P =.06), and significantly higher rates of Ankylosing Spondylitis or Diffuse Idiopathic Skeletal Hyperostosis in 2020 (7.9% vs 1.5%, P=.04). VCF ED admission rates were similar, with 60% treated conservatively. Admitted patients underwent more surgeries in 2020 (66.7% vs 60%, P =.71) and a tendency towards Precoutaneus Balloon Kyphoplasty (BKP) + fixation compared with BKP alone (15.8% in 2020 vs 7.5% in 2018-19, P =.29). RR for BKP + fixation vs BKP alone was 1.95, suggesting higher odds for a more complex surgery during the Covid-19 pandemic. The complication rate was significantly higher during 2020 (18.4% vs 3.7%, P <.001). Admission length was slightly longer during 2020 (12.2 days vs 9.9 days, P = .27), and time to surgery was marginally longer, 6.25 vs 5.3 days (P = .55). Many patients chose home over institutional rehabilitation during the Covid-19 pandemic (72.2% vs 58.8%).

Conclusion

The Covid-19 pandemic did not alter VCF incidence, but patients’ characteristics changed, affecting admissions, institutional rehabilitation, and a tendency towards complex surgery rather than BKP alone. It is still unclear if Covid-19 will remain an issue in the upcoming years, but its impact and lessons are still worthwhile.

KYPHOPLASTY VERSUS VERTEBROPLASTY IN VERTEBRAL COMPRESSION FRACTURES: A META-ANALYSIS

ABSTRACT Introduction: Vertebral fracture is the main complication of osteoporosis and is common among the elderly. Conservative treatment is the first choice for osteoporotic vertebral compression fractures (OVCF) but for persistent painful cases, percutaneous vertebral cement augmentation techniques, such as vertebroplasty and kyphoplasty, are indicated. We performed a systematic review to compare clinical and radiological outcomes of both methods. Methods: A systematic review was performed according to the PRISMA and Cochrane Handbook for Systematic Reviews of Interventions. The PICO search strategy consisted of the following terms: Population- Patients with OVCFs; Intervention- Kyphoplasty; Control- Vertebroplasty; Outcomes- Pain, Cement Leakage, Vertebral Body Height, Adjacent level fractures, Oswestry (ODI) and SF36. Results: Seven articles were included in the qualitative analysis, selecting only randomized controlled trials. Four hundred and fifty patients were treated with vertebroplasty (VP) and 469 with kyphoplasty (KP). The leakage rate of the VP group was 63% versus 14% for the KP group. However, these results were without statistical significance. The Visual Analogue Scale (VAS), ODI and SF-36 outcomes were evaluated based on the 6-month and 1-year follow-up results, and we were unable to find any significant differences between treatments. For restoration of vertebral height, the values of the KP group were, on average, 0.71 cm higher than those of the VP group, with 95% CI. Conclusion: Based on this systematic review, kyphoplasty is superior to vertebroplasty for achieving gains in vertebral body height. As regards cement leakage and other clinical outcomes, neither method showed statistically significant superiority. Level of Evidence I; Systematic review.

Outcomes of different minimally invasive surgical treatments for vertebral compression fractures: An observational study

BACKGROUND

Osteoporosis with vertebral compression fractures is increasingly common in the elderly population. Cement augmentation is one of the effective surgical treatments for these patients. Currently, there are several different types of cement augmentation treatments. No studies have compared the safety and efficacy of different cement augmentation types for the treatment of such fractures; thus, we retrospectively compared vertebroplasty, balloon kyphoplasty, and kyphoplasty with SpineJack or an intravertebral expandable pillar.

AIM

To compare the postoperative safety and efficacy of each surgical intervention in treating vertebral compression fractures.

METHODS

We retrospectively analyzed 354 patients with acute vertebral compression fractures, defined as signal changes in the T1 weighted magnetic resonance imaging, and randomly divided the patients into five groups. Their visual analog scale scores for pain, kyphotic angle, average body height, rate of cement leakage, and occurrence of adjacent vertebral compression fractures were followed for 1 year. One-way analysis of variance, the post hoc Bonferroni test, and Fisher exact probability test were used for statistical analyses.

RESULTS

All pain scores significantly improved 12 mo postoperatively; however, there was no significant difference between the groups (P = 0.325). Kyphoplasty with SpineJack significantly reduced the kyphotic angle (P = 0.028) and restored the height of the vertebral body (P = 0.02). The rate of adjacent compression fractures was the highest in the vertebroplasty group, with a statistically significant difference according to the Fisher exact probability test (P = 0.02). The treatment with the lowest cement leakage rate cannot be identified because of the small sample size; however, kyphoplasty with SpineJack, an IVEP, and vesselplasty resulted in lower rates of cement leakage than balloon kyphoplasty and vertebroplasty.

CONCLUSION

Kyphoplasty with SpineJack has good outcomes in kyphotic angle reduction and body height restoration. Vertebroplasty has the highest cement leakage rate and adjacent compression fracture occurrence.

The Early Results of Vertebral Pathological Compression Fracture of Extra- nodal Lymphoma with HIV-positive Patients Treated by Percutaneous Kyphoplasty

BACKGROUND

Vertebral pathological compression fracture involving extra-nodal lymphoma impacts negatively on the quality of life of HIV-positive patients. The choice of a safe and effective approach to palliative care in this condition remains a challenge.

OBJECTIVE

The purpose of this study was to investigate the safety and efficacy of percutaneous kyphoplasty (PKP) in the treatment of vertebral pathological compression fracture of extra-nodal lymphoma in HIV-positive patients.

METHODS

A retrospective analysis, from January 2016 to August 2019, was performed on 7 HIVpositive patients, 3 males and 4 females, with extra-nodal lymphoma with a vertebral pathological compression fracture. The patients were treated using percutaneous kyphoplasty in our hospital. Preoperative assessment of the patients was conducted regarding their hematological profile, biochemical indicators, liver and kidney function, blood coagulation function, CD4+T lymphocyte count and viral load. Subsequently, the patients were placed on highly active antiretroviral therapy (HAART) and rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (RCHOP) regimen. Besides, antibiotics, nutritional support and immune-modulating drugs were also administered, rationally. Postoperatively, the height of the anterior edge of the injured vertebrae, Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) values were evaluated. Patients were also monitored for any complications related to the operation.

RESULTS

The average CD4+T cell count for the patients was 164 (range 114 ~247 / ul), while the viral load was 26,269 (range 5,765 ~82,321 copies/ul). All patients received nutritional and immune support and registered significant improvements in the levels of ALB and Hb (P<0.05). In all cases, the operation was uneventful with neither cement leakage nor toxic reactions observed. Similarly, no opportunistic infections, other complications or deaths were reported. The height of the anterior vertebral body and the ODI score of the injured vertebrae were significantly improved immediately after surgery (P<0.05). Compared to the preoperative VAS (7.71±1.11), postoperative values were significantly reduced immediately after surgery (3.85±0.90) and at 2 weeks, 1 month and 6 months post-surgery: 2.71±0.76, 3.29±1.11, and 4.00±0.82, respectively (P<0.01).

CONCLUSION

Supported with appropriate perioperative treatment measures, PKP is safe and effective in the treatment of pathological vertebral compression fracture due to extra-nodal lymphoma in HIV-positive patients.

Exploration of percutaneous vertebroplasty in the treatment of osteoporotic vertebral compression fracture as day surgery: a retrospective study

BACKGROUND

The purpose of this retrospective study was to evaluate and compare the clinical outcomes of patients underwent PVP for OVCF as day surgery with the outcomes of patients managed as traditional inpatients.

METHODS

According to the selection criteria, patients who underwent PVP for single-segment thoracolumbar OVCF were included retrospectively in the day surgery procedure (DSP) group and the traditional inpatient procedure (TIP) group between April 2018 and September 2019. The visual analog scale score (VAS) and Oswestry Disability Index (ODI) score were recorded preoperatively and 1 day, 1 week, 1 month, 3 months, 6 months, and 12 months after surgery. Duration of hospital stay, preoperative waiting time, hospital cost, and postoperative complications were recorded and analyzed.

RESULTS

A total of 335 patients (53 in DSP group; 282 in TIP group) were enrolled and completed 12-month follow-up. The mean duration of hospital stay, the mean preoperative waiting time, and the mean hospital costs were significant lower in the DSP group. The postoperative VAS and ODI scores in both groups were significantly improved after surgery. Moreover, both VAS and ODI scores at each follow-up stage were also significantly lower than the previous follow-up stage. However, the ODI score in the DSP group was significantly lower at 1-day, 1-week, 1-month, and 3-month follow-up, respectively. For cement leakage and secondary vertebral compression fractures, there was no statistical difference between the two groups.

CONCLUSIONS

We suggest that PVP for OVCFs in day surgery procedure is worthy of wide application.

Role of percutaneous vertebroplasty with high-viscosity cement in the treatment of severe osteoporotic vertebral compression fractures

Severe osteoporotic vertebral compression fractures (OVCFs) were considered as relative or even absolute contraindication for vertebroplasty and kyphoplasty and these relevant reports are very limited. This study aimed to evaluate and compare the efficacy of vertebroplasty with high-viscosity cement and conventional kyphoplasty in managing severe OVCFs. 37 patients of severe OVCFs experiencing vertebroplasty or kyphoplasty were reviewed and divided into two groups, according to the procedural technique, 18 in high-viscosity cement percutaneous vertebroplasty (hPVP) group and 19 in conventional percutaneous kyphoplasty (cPKP) group. The operative time, and injected bone cement volume were recorded. Anterior vertebral height (AVH), Cobb angle and cement leakage were also evaluated in the radiograph. The rate of cement leakage was lower in hPVP group, compared with cPKP group (16.7% vs 47.4%, P = 0.046). The patients in cPKP group achieved more improvement in AVH and Cobb angle than those in hPVP group postoperatively (37.2 ± 7.9% vs 43.0 ± 8.9% for AVH, P = 0.044; 15.5 ± 4.7 vs 12.7 ± 3.3, for Cobb angle, P = 0.042). At one year postoperatively, there was difference observed in AVH between two groups (34.1 ± 7.4 vs 40.5 ± 8.7 for hPVP and cPKP groups, P = 0.021), but no difference was found in Cobb angle (16.6 ± 5.0 vs 13.8 ± 3.8, P = 0.068). Similar cement volume was injected in two groups (2.9 ± 0.5 ml vs 2.8 ± 0.6 ml, P = 0.511). However, the operative time was 37.8 ± 6.8 min in the hPVP group, which was shorter than that in the cPKP group (43.8 ± 8.2 min, P = 0.021). In conclusion, conventional PKP achieved better in restoring anterior vertebral height and improving kyphotic angle, but PVP with high-viscosity cement had lower rate of cement leakage and shorter operative time with similar volume of injected cement.

Full-endoscopic spine surgery for radiculopathy after osteoporotic vertebral compression fractures: a case report

Full-endoscopic spine surgery (FESS) is a suitable treatment for lumbar disc herniation (LDH) and foraminal stenosis. Here, we describe the usefulness of FESS for treating radiculopathy after osteoporotic vertebral compression fractures (OVCFs). Between October 2018 and April 2019, three female patients (mean age, 81.7 years) with radiculopathy after OVCFs underwent FESS. Decompression of the corresponding nerve root was achieved using several FESS techniques, including foraminoplasty, discectomy, and removal of osteophyte or cement leakage. The mean operative time was 60.7 min. Preoperative and postoperative statuses were evaluated using numerical rating scale (NRS) scores. The mean pre- and postoperative NRS scores were 9 and 2.3, respectively. We observed no postoperative complications. Our results demonstrate that FESS is a safe and effective minimally invasive treatment for radiculopathy after OVCFs, with the potential to be an alternative to vertebroplasty, balloon kyphoplasty (BKP), or lumbar interbody fusion.

Current Concepts in the Management of Vertebral Compression Fractures

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

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

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

Therapeutic effect of kyphoplasty and balloon vertebroplasty on osteoporotic vertebral compression fracture: A systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

This study aimed to assess the treatment effects of kyphoplasty (KP) compared with percutaneous vertebroplasty (VP) in patients with osteoporotic vertebral compression fracture, based on evidence from randomized controlled trials (RCTs).

METHODS

The electronic databases PubMed (from 1966), EmBase (from 1974), and Cochrane Library (including Cochrane Central Register of Controlled Trials and Cochrane Reviews) were searched systematically to identify relevant studies published up to August 31, 2019. Meta-analyses were conducted for subjective pain as measured using visual analogue scale (VAS), disability function as measured by Oswestry disability index (ODI), and cement leakage. For VAS and ODI, mean change from the baseline and standard deviation were used; for cement leakage, numbers of events and patients in each group were used. The random-effects model was applied to summarize the effects across trials.

RESULTS

Previous reviews and meta-analysis included non-RCTs, which brought (for those studies) a higher risk of bias. Therefore, 6 RCTs involving 1077 patients were included in the meta-analysis. No between-group difference was found. The weighted mean difference was -0.19 (95% confidence interval [CI], -0.39-0.01; P = .057) for VAS and -3.51 (95% CI, -8.70-1.67; P = .184) for ODI. However, KP had numerically lower rates of cement leakage across trials in a consistent fashion (relative risk, 0.83; 95% CI, 0.74-0.94; P = .004).

CONCLUSIONS

Both KP and VP had clinically meaningful beneficial effects on pain and disability, and the effects were stable and similar. KP had significantly fewer cement leakages.

Vertebroplasty for acute painful osteoporotic vertebral compression fractures: An update

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

Prophylactic vertebroplasty versus kyphoplasty in osteoporosis: A comprehensive biomechanical matched-pair study by in vitro compressive testing

Vertebroplasty and kyphoplasty are alternative augmentation techniques of osteoporotic vertebral compression fractures. However, shortly after augmentation, new vertebral compression fractures may occur, mostly in the adjacent vertebrae. To prevent this, prophylactic cement injection can be applied to the neighboring vertebral bodies. Although there are many evidence-based clinical studies on the potential hazards of vertebroplasty and kyphoplasty, there are only few studies comparing the prophylactic potential of the two treatments. In this matched-pair experimental biomechanical study, the two treatments were compared via destructive compressive testing of 76 non-fractured osteoporotic human lumbar vertebral bodies from 24 cadavers, augmented pair-wise with vertebroplasty or kyphoplasty. Strength, stiffness and deformability were analyzed in terms of donor age, CT-based bone density, vertebral morphometry, and cement-endplate contacts. These were investigated in a paired analysis and also in terms of the number of cement-endplate contacts. Vertebroplasty resulted in significantly, but only 19% larger stiffness, approximately equal failure load and smaller failure displacement compared to kyphoplasty. Cement-endplate contacts affect augmentation differently for the two techniques, namely, strength significantly increased with increasing number of contacts in vertebroplasty, but decreased in kyphoplasty. The reasons for these contrasting behavior included the fundamentally different augmentation method, the resulting different construction and location of cement clouds and the different form and location of failure. These results indicate that both prophylactic vertebroplasty and kyphoplasty of non-fractured adjacent vertebrae may be advantageous to avoid subsequent fractures after post-fracture vertebroplasty and kyphoplasty, respectively. However, cement bridging in vertebroplasty and central cement placement in kyphoplasty are advantageous in prevention.

Percutaneous Balloon Kyphoplasty Vertebral Augmentation for Compression Fracture Due to Vertebral Metastasis: A 12-Month Retrospective Clinical Study in 72 Patients

Background

Vertebral compression fracture is common in osteoporosis, but can also occur due to bone metastases, for which current treatment options are limited and include bone-strengthening with cement and supportive care. Kyphoplasty is a surgical method of bone augmentation that can reduce pain, stabilize vertebral bone, and restore some or all of the vertebral body height. The aim of this study was to investigate the clinical results of balloon kyphoplasty in the correction of vertebral deformity due to metastatic vertebral compression fracture.

Material/Methods

A retrospective clinical study included 72 patients (82 vertebral bodies) with metastases resulting in vertebral compression fracture, treated by percutaneous balloon kyphoplasty; 9 patients were found incidentally to have vertebral metastases. Bone mineral density (BMD) levels were measured. Patient responses from questionnaires, including the visual analog scale (VAS) for pain intensity, and the Oswestry Disability Index (ODI) for disability, were scored. The local kyphosis angle (KA) and the vertebral height ratio (VHR) were measured. All patients were followed up for 12 months. The initial postoperative and 12-month postoperative values, and the preoperative and postoperative values were compared.

Results

Following balloon kyphoplasty, the KA, VHR, VAS, and ODI scores significantly improved at the final 12-month follow-up compared with preoperative levels (p<0.05, and p<0.001). There was cement leakage in 6 procedures (8.3%) and adjacent segment fracture in 11 procedures (15.2%).

Conclusions

Balloon kyphoplasty was an effective method to reduce pain, reduce disability, and improve quality of life by eliminating kyphotic deformity in pathological vertebral compression fractures due to vertebral metastases.

Percutaneous cement augmentation for osteoporotic vertebral fractures

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

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

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

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

Early intervention is also gaining ground recently.

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

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

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Percutaneous vertebral augmentation in fragility fractures-indications and limitations

INTRODUCTION

There is still no general consensus about the management of osteoporotic vertebral fractures. Recommendations depend on type of fracture, grade of instability, bone quality, and general conditions of the patient. Spontaneous fractures may be considered to be treated different compared to cases with high-velocity trauma.

METHODS

According to the DVO, patients without trauma should first be treated conservatively. However, there is no more strict time protocol of 3 or 6 week conservative treatment before operations may be indicated. Surgical criteria are not yet distinctly defined. For highly unstable fractures (type B and C according to the AO Spine Classification), posterior instrumentation with cement augmented screws and as long construct, respectively, is adequate. Current literature has been analysed for diagnostic and therapeutic protocols.

RESULTS

There is no clear operative concept for burst fractures and classic osteoporotic fractures with dynamic ongoing sintering. Percutaneous vertebral augmentation showed to prevent the fractures from ongoing kyphotic deformity and the patients from painful immobilization. Indications and results of classical vertebroplasty and kyphoplasty have been discussed intensively in the literature. Further development included special injection techniques, cements with different viscosities and stenting systems to reach more stable constructs and avoid typical complications, such as cement extrusion.

CONCLUSIONS

This review reports upon indications and limitations of percutaneous vertebral augmentation and the potential development of classifications and therapeutic algorithms.

Comparing Percutaneous Vertebroplasty and Conservative Therapy for Treating Osteoporotic Compression Fractures in the Thoracic and Lumbar Spine: A Systematic Review and Meta-Analysis

BACKGROUND

Vertebral compression fractures are a common complication of osteoporosis and are often treated by percutaneous vertebroplasty (PVP). The ability of this procedure to relieve pain better than conservative treatment is still debated. The purpose of this study was to compare the degree and duration of pain relief following PVP with that following conservative treatment for osteoporotic compression fractures by means of meta-analysis of randomized controlled trials.

METHODS

The CENTRAL (Cochrane Central Register of Controlled Trials), MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Web of Science databases were queried for randomized controlled trials comparing PVP with conservative treatment or placebo/sham. The methodological quality was assessed according to the Cochrane Collaboration's domain-based evaluation framework. Random-effects meta-analysis of the raw mean difference between groups in change in pain level was performed, with sensitivity analyses and the Egger test for potential publication bias.

RESULTS

Of 209 records found, 11 were considered relevant, involving 1,048 participants. The risk of bias was considered low in 10 studies and high in 1. The 531 patients treated with PVP had a significantly lower pain level compared with the control group at 1 to 2 weeks, 2 to 3 months, and 12 months. The 95% CI (confidence interval) of the pooled effect size at every time interval included the score of 1.5, considered to be the minimal clinically important difference. The largest pooled effect size of -1.4 (95% CI, -2.3 to -0.5) was found during the first 1 to 2 weeks. The heterogeneity was high at all 3 time points (I(2), 71% to 96%). No significant publication bias was detected.

CONCLUSIONS

Up to 1 year postoperatively, the effect of PVP exceeded the effect of conservative therapy with respect to pain relief in patients with osteoporotic compression fractures. The effect size was significant and close to the minimal clinically important difference.

Risk factors of recompression of cemented vertebrae after kyphoplasty for osteoporotic vertebral compression fractures

PURPOSE

To evaluate the risk factors correlated with loss of cemented vertebral body height after kyphoplasty in patients with osteoporotic vertebral compression fractures.

METHODS

Thirty-four consecutive patients with single-level osteoporotic vertebral compression fractures who underwent kyphoplasty in the Affiliated Hospital of Jiangsu University between January 2012 and August 2014 were retrospectively analysed. Eight independent variables (age, gender, body mass index, pre-operative T-score in bone mineral density, the volume of polymethylmethacrylate injected, pre-operatively vertebral body height, the restoration of body height and the distance between polymethylmethacrylate and endplate) were assessed. The recompression of body height was the dependent variable. Multivariate linear regression analyses were used to determine the factors associated with recompression of body height.

RESULTS

Multiple linear regression analyses indicated that the recompression of cemented vertebral body height was correlated with the distance between polymethylmethacrylate and endplate (P = 0.008, b' = 0.489). The final multiple linear regression model, which included only the distance between polymethylmethacrylate and endplate, resulted in a formula that accounted for 41.02 % of the recompression of body height.

CONCLUSIONS

The distance between polymethylmethacrylate and endplate is an important risk factor of recompression of cemented vertebrae after kyphoplasty for patients with osteoporotic vertebral compression fractures.

Vertebral Augmentation: State of the Art

Osteoporotic vertebral compression fractures (OVF) are an increasing public health problem. Cement augmentation (vertebroplasty of kyphoplasty) helps stabilize painful OVF refractory to medical treatment. This stabilization is thought to improve pain and functional outcome. Vertebroplasty consists of injecting cement into a fractured vertebra using a percutaneous transpedicular approach. Balloon kyphoplasty uses an inflatable balloon prior to injecting the cement. Although kyphoplasty is associated with significant improvement of local kyphosis and less cement leakage, this does not result in long-term clinical and functional improvement. Moreover, vertebroplasty is favored by some due to the high cost of kyphoplasty. The injection of cement increases the stiffness of the fracture vertebrae. This can lead, in theory, to adjacent OVF. However, many studies found no increase of subsequent fracture when comparing medical treatment to cement augmentation. Kyphoplasty can have a protective effect due to restoration of sagittal balance.

Percutaneous kyphoplasty with or without temporary unipedicle screw reduction : A retrospective comparative study of osteoporotic vertebral fractures

Background

Temporary unipedicle screw reduction with percutaneous kyphoplasty (TUSR-PKP) is a relatively new method for managing osteoporotic vertebral compression fractures (OVCFs). A clinical retrospective comparative study was conducted to verify whether TUSR-PKP was noninferior to simple PKP regarding the management of OVCFs.

Methods

A total of 38 consecutive patients who sustained OVCFs without neurological deficits and had undergone surgeries in our hospital from June 2012 to January 2014 were included in the study: 24 patients underwent simple PKP (control group) and the other 14 patients underwent TUSR-PKP (treatment group). All 38 patients were asked to participate in a long-term (>1 year) follow-up. Visual analog scale (VAS) pain scores and Oswestry Disability Index (ODI) were recorded, and the Cobb angles and the vertebral body heights were measured on the lateral radiographs before surgery and on day 1, as well as 1, 3, 6, and 12 months after surgery.

Results

The patients in the treatment group had better vertebral height gain and greater improvement on ODI compared with the control group (p < 0.05). The VAS scores of the two groups were similar at all points until the end of the 1‑year follow-up period. Two patients from the treatment group and 5 patients from the control group had cement leakage. In the control group, 3 patients suffered adjacent or nonadjacent vertebra fractures.

Conclusion

TUSR-PKP is a safe and effective surgical option for OVCFs. Compared with simple PKP, TUSR-PKP provided at least equal results for OVCFs. Moreover, during the postsurgery observations, TUSR-PKP showed potential advantages including vertebral height gain, ODI improvement, and fewer subsequent refractures.

Cement Calcaneoplasty: An Innovative Method for Treating Nonunion in Calcaneal Insufficiency Fracture

Insufficiency type stress fractures are common in older patients with osteoporosis. Persistent pain after nonunion of these fractures can be disabling, with the management options often limited. We aimed to assess the suitability of fluoroscopic-guided injection of bone cement into a persistently symptomatic nonuniting calcaneal insufficiency fracture. To the best of our knowledge, this technique has not previously been described in the published data. After local subcutaneous anesthesia, the midpoint of the fracture site was accessed by trocar insertion under radiographic guidance, and bone cement was injected directly into the site. A preprocedure visual analog scale pain score of 90 of 100 was recorded. This had improved to 0 of 100 at the 12-month follow-up point after the procedure. The aim of the present case report was to raise awareness of percutaneous calcaneoplasty, which we believe to be a safe and well-tolerated technique for the management of osteoporotic insufficiency fracture of the calcaneus. We propose that this technique be considered when conservative methods aimed at promoting fracture healing have failed.