Surgical techniques and clinical evidence of vertebroplasty and kyphoplasty for osteoporotic vertebral fractures

Injecting a ventricular tachycardia into the heart-Α unique case report

INTRODUCTION

A 52-year-old woman presented with a complex ventricular arrhythmia in an intraoperative context, during kyphoplasty for an osteoporotic fracture of a lumbar vertebra. The subject showed no indications of a previous cardiovascular condition.

METHODS AND RESULTS

Causes of arrhythmias associated with the procedure were excluded. Due to her positive family history for dilated cardiomyopathy, upcoming thoughts were made for unmasking a previous asymptomatic cardiomyopathy. Nevertheless, an intracardiac cement embolism was diagnosed and, finally, the patient underwent an open-heart surgery with successful removal of the cardiac cement. Νo new arrhythmia recorded during follow up.

CONCLUSION

To the best of our knowledge, this is the first reported case of ventricular arrhythmogenic presentation of a cardiac cement embolus after a KP procedure.

Infrapedicular approach to CT-guided thermal ablation in the thoracic spine

OBJECTIVES

The aim of this study is to introduce the infrapedicular approach to CT-guided spine interventions, a specialized technique that can safely expand the scope of spine lesions amenable to treatment, and to document the feasibility in a variety of procedural scenarios to the extent possible with a retrospective case series.

METHODS

Data from 24 cases performed at a single institution over a 10-year period were retrospectively reviewed to assess the technical feasibility and safety profile of the technique.

RESULTS

The infrapedicular approach enabled a technically satisfactory procedural result in 24 cases (mean age 63.9 years, range 35-83 years). Two peri-procedural complications occurred, including a small pneumothorax and a cerebrospinal fluid leak, both of which resolved with conservative treatment. No lasting injurious effects or additional complications were identified. The infrapedicular approach was found to be particularly useful in multiple technically challenging scenarios: it facilitates access to lesions in the inferior vertebral body, allows biopsy, cement augmentation, or ablation of high thoracic lesions difficult to treat due to limitations of steep angulation of fluoroscopy and CT scanners, and enables treatment of large lesions by using multiple overlapping probes.

An anatomical study of transpedicular vs. extrapedicular approach for kyphoplasty and vertebroplasty in the thoracic spine

INTRODUCTION

Percutaneous vertebral augmentation is a common therapeutic approach for osteoporotic or osteolytic vertebral fractures. Due to the variable pedicle anatomy two different approaches, the transpedicular and the extrapedicular approach have been established. In particular, in the middle and upper thoracic spine, percutaneous procedures are challenging because of difficult visualisation of anatomical landmarks and a more unfavourable anatomy with smaller and differently orientated pedicles.

MATERIAL AND METHODS

In our cadaveric study we compared the transpedicular and the extrapedicular approach to the thoracic spine. In 26 cadaveric spine specimes, embalmed using Thiel's method, we placed a total of 486 trans- and extrapedicular K-wires through Jamshidi needles in the vertebral bodies T4 - T12 under fluoroscopy. A CT scan was then performed to verify the actual position of the K-wire. Malpositioning was defined as deviation from the planned approach or placement of the K-wire in the spinal canal or outside the vertebral body. Number and direction of malpositionings was recorded.

RESULTS

Malpositioning occurred in 68 of 468 K-wires. It was more frequent in the transpedicular (54) than in the extrapedicular (14) approach. Intraspinal malposition was seen more often in the transpedicular approach (n=36) especially in the upper and middle thoracic spine.

CONCLUSION

In summary both approaches are relatively safe but in the upper and middle thoracic spine the risk of intraspinal malpositioning seems to be lower when using the extrapedicular approach.

Fracture behavior of cancellous bone and cancellous bone-PMMA bone cement interface: An experimental study using an integrated methodology (wedge splitting test and Heaviside-based digital image correlation)

Minimally invasive methods, such as balloon kyphoplasty (BKP) and percutaneous sacroplasty (PS), which are now widely used for the surgical treatment of compression fractures, involve injection of a bolus of poly (methyl methacrylate) bone cement (hereafter, "bone cement") into the fractured tissue. Many of the common complications following these surgeries, such as cement leakage and adjacent-level fractures (in the case of BKP), have been postulated to be related to the quality of the cancellous bone-bone cement interface, which, in turn, is a function of its fracture resistance. It is common to use bovine cancellous bone or polyurethane foam (PF) as a substitute for human cancellous bone in biomechanical studies of these surgical methods. The literature is lacking in studies of determination of fracture properties of human cancellous bone-bone cement interface, bovine cancellous bone-bone cement interface, and PF-bone cement interface. In the present work, an integrated methodology (combination of wedge splitting test and Heaviside-based digital image correlation) was used to make these determinations as well as those for the bone cement, bones and the PF alone. The fracture properties determined were maximum fracture load (F_max), fracture toughness (K_c), and specific fracture energy (G_f). For example, G_f values for human cancellous bone and human cancellous bone-bone interface were 0.48±0.14 N/mm and 0.38±0.05 N/mm, respectively, whereas in the case of bovine cancellous bone and bovine cancellous bone-bone cement interface, they were 1.08±0.11 N/mm and 0.22±0.05 N/mm, respectively, and for PF (Grades 12.5 and 15.0) and PF-bone cement interface, they were 0.81±0.12 and 0.55±0.06 N/mm, respectively. The same trends were seen in the F_max and K_c results. These results suggest that it may not be justified to use either bovine cancellous bone or either of the PF grades as a substitute for human cadaveric cancellous bone in biomechanical studies of BKP, PS, and similar surgical methods.

"How to measure the outcome in the surgical treatment of vertebral compression fractures? A systematic literature review of highly cited level-I studies"

Background

The economic burden of vertebral compression fractures (VCF) caused by osteoporosis was estimated at 37 billion euros in the European Union in 2010. In addition, the incidence is expected to increase by 25% in 2025. The recommendations for the therapy of VCFs (conservative treatment versus cement augmentation procedures) are controversial, what could be partly explained by the lack of standardized outcomes for measuring the success of both treatments. Consensus on outcome parameters may improve the relevance of a study and for further comparisons in meta-analyses. The aim of this study was to analyze outcome measures from frequently cited randomized controlled trials (RCTs) about VCF treatments in order to provide guidance for future studies.

Material and methods

We carried out a systematic search of all implemented databases from 1973 to 2019 using the Web of Science database. The terms “spine” and “random” were used for the search. We included: Level I RCTs, conservative treatment or cement augmentation of osteoporotic vertebral fractures, cited ≥50 times. The outcome parameters of each study were extracted and sorted according to the frequency of use.

Results

Nine studies met the inclusion criteria. In total, 23 different outcome parameters were used in the nine analyzed studies. Overall, the five most frequently used outcome parameters (≥ 4 times used) were the visual analogue scale (VAS) for pain (n = 9), European Quality of Life–5 Dimensions (EQ-5D; n = 4) and Roland–Morris Disability Questionnaire (RMDQ, n = 4).

Conclusion

With our study, we demonstrated that a large inconsistency exists between outcome measures in highly cited Level I studies of VCF treatment. Pain (VAS), followed by HrQoL (EQ-5D) and disability and function (RMDQ), opioid use, and radiological outcome (kyphotic angle, VBH, and new VCFs) were the most commonly used outcome parameters.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04305-6.

EFFECT OF PKP ON SERUM SOST IN PATIENTS WITH VERTEaBRAL COMPRESSION FRACTURES

Objective:

This study sought to determine serum sclerostin (SOST) expression in patients with osteoporotic thoracolumbar vertebral compression fractures before and after percutaneous kyphoplasty (PKP).

Methods:

Serum SOST levels were quantified with a sandwich enzyme-linked immunosorbent assay (ELISA) preoperatively and six months postoperatively. Anterior vertebral height, kyphotic angles, and Visual Analogue Scale (VAS) scores were also recorded.

Results:

Serum SOST was highly expressed in patients and remained negatively correlated with bone mineral density (BMD). Vertebral heights, local kyphotic angles, and VAS scores were all significantly improved after PKP. However, serum SOST was positively correlated with BMD six months after surgery.

Conclusion:

PKP was an effective treatment strategy for osteoporotic thoracolumbar vertebral compression fractures, improving BMD and decreasing serum SOST levels. Level of Evidence II, Prospective comparative study.

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

BACKGROUND

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

CASE PRESENTATION

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

CONCLUSIONS

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