Vertebroplasty and kyphoplasty

Extrapendicular Approach of Unilateral Percutaneous Vesselplasty for the Treatment of Kummell Disease

Background

Our purpose was to evaluate the efficacy of the extrapendicular approach for unilateral percutaneous vesselplasty in dealing with Kummell disease patients.

Methods

Twenty-seven patients undergoing vesselplasty at our institution were enrolled in the study. Vesselplasty was performed using percutaneous extrapendicular technique. Pain, restoration of vertebral body height, and cement leakage were evaluated in the process.

Results

Substantial pain relief was attained in all the patients. The visual analogue scale improved significantly from pre- to postoperation (P < .05), and remained unchanged at every follow-up. The anterior vertebral body heights were significantly corrected after operation (P < .05). No cement leakage was found.

Conclusion

This new technique of vesselplasty offers statistically significant benefits in Kummell disease patients. It also makes vesselplasty feasible, safe, and effective.

Comparison of effectiveness of kyphoplasty and vertebroplasty in patients with osteoporotic vertebra fractures

Objective

The aim of this study was to compare the functional and radiological outcomes of vertebroplasty and kyphoplasty in patients with osteoporotic vertebra fractures.

Methods

The files of the patients who underwent vertebroplasty or kyphoplasty for osteoporotic vertebrae fractures were retrieved from the archives. Forty-three patients with complete follow-up data were included in the study group. The patients were evaluated for radiological outcomes in terms of local kyphosis angle, wedging index, compression ratio, visual analog pain scale (VAS) and Oswestry Disability Index (ODI).

Results

In the study group, kyphoplasty was performed on 24 vertebrae of 22 patients (17 females, 5 males; mean age: 73 years) whereas vertebroplasty was applied on 24 vertebrae of 21 (16 females, 5 males; mean age: 74.7 years) patients. The mean follow-up time was 26 months. When the VAS and ODI values of the groups were analyzed, both groups showed statistically significant progress after the operation. Radiological data showed that the kyphoplasty group showed statistically significant improvement in the sagittal index values whereas the vertebroplasty group did not. The overall complication ratio was 4%.

Conclusion

Both vertebroplasty and kyphoplasty are effective treatment methods for functional recovery and pain relief in osteoporotic fractures of the vertebra. Although radiological outcomes of the kyphoplasty seem to be better, this does not have any clinical relevance. We suggest vertebroplasty over kyphoplasty since it is an easier method to manage.

Level of evidence

Level III, Therapeutic study.

Noncontiguous lumbar vertebral hemangiomas treated by posterior decompression, intraoperative kyphoplasty, and segmental fixation

Vertebral hemangiomas are benign lesions and are often asymptomatic. Most vertebral hemangiomas that cause cord compression and neurological symptoms are located in the thoracic spine and involve a single vertebra. The authors report the rare case of lumbar hemangiomas in a 60-year-old woman presenting with severe back pain and rapidly progressive neurological signs attributable to 2 noncontiguous lesions. After embolization of the feeding arteries, no improvement was noted. Thus, the authors performed open surgery using a combination of posterior decompression, intraoperative kyphoplasty, and segmental fixation. The patient experienced relief from back and leg pain immediately after surgery. At 3 months postoperatively, her symptoms and neurological deficits had improved completely. To the authors' knowledge, this is the first description of 2 noncontiguous extensive lumbar hemangiomas presenting with neurological symptoms managed by such combined treatment. The combined management seems to be an effective method for treating symptomatic vertebral hemangiomas.

[Hypobaric metameric subarachnoid anaesthesia for anaesthetic management in vertebral reinforcement techniques. Our experience in 6 cases]

Vertebral reinforcement techniques, such as percutaneous vertebroplasty and kyphoplasty, are minimally invasive procedures used in the treatment of fractured or collapsed vertebras. The anaesthetic techniques employed during these procedures are diverse and with variable results. We report 6 cases, vertebroplasty and kyphoplasty using subarachnoid metameric anaesthesia with a hypobaric technique. Haemodynamic stability and analgesia were satisfactory in all of them.

Early clinical outcome and complications related to balloon kyphoplasty

The treatment of painful osteoporotic vertebral compression fractures using transpedicular cement augmentation has grown significantly over the last two decades. The benefits of balloon kyphoplasty compared to conservative treatment remain controversial and are discussed in the literature. The complication rates of vertebroplasty and kyphoplasty are considered to be low. The focus of this study was the analysis of acute and clinically relevant complications related to this procedure. In our department, all patients treated between February 2002 and February 2011 with percutaneous cement augmentation (372 patients, 522 augmented vertebral bodies) were prospectively recorded. Demographic data, comorbidities, fracture types, intraoperative data and all complications were documented. The pre- and postoperative pain-level and neurological status (Frankel-Score) were evaluated. All patients underwent a standardized surgical procedure. Two hundred and ninety-seven patients were treated solely by balloon kyphoplasty; 216 females (72.7%) and 81 males (27.3%). Average patient age was 76.21 years (±10.71, range 35–98 years). Average American Society Anestesiologists score was 3.02. According to the Orthopedic Trauma Association classification, there were 69 A 1.1 fractures, 177 A 1.2 fractures, 178 A 3.1.1 fractures and 3 A 3.1.3 fractures. Complications were divided into preoperative, intraoperative and postoperative events. There were 4 preoperative complications: 3 patients experienced persistent pain after the procedure. In one case, the pedicles could not be visualized during the procedure and the surgery was terminated. One hundred and twenty-nine (40.06%) of the patients showed intraoperative cement leaking outside the vertebras, one severe hypotension and tachycardia as reaction to the inflation of the balloons, and there was one cardiac arrest during surgery. Postoperative subcutaneous hematomas were observed in 3 cases, 13 patients developed a urinary tract infection, and 2 patients died during hospitalization. Twenty-four patients (8.1%) returned because of new pain events and 23 patients reported a new painful fracture. Balloon kyphoplasty is a save and effective procedure to treat patients with painful vertebral compression fractures. Rapid patient mobilization after kyphoplasty, as well as a prompt reintegration into the social environment, are possible. Compared to other surgical procedures, especially in patients with an average age of 75 years, balloon kyphoplasty seems to offer some advantages. However, the procedure still has a potential for serious complications and should be performed by well trained personnel.

Cement augmentation of refractory osteoporotic vertebral compression fractures: survivorship analysis

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To compare survivorship after cement augmentation of refractory osteoporotic vertebral compression fractures (OVCFs) with traditional inpatient pain management and bracing.

SUMMARY OF BACKGROUND DATA

OVCFs can cause debilitating pain and functional decline necessitating prolonged bed rest and high-dose narcotics. Vertebroplasty and kyphoplasty are cement augmentation procedures used to control pain and restore function in patients with OVCF's that are refractory to conservative treatment. Early mobilization is associated with improved survival after other fractures in elderly patients.

METHODS

A university hospital database was used to identify all participants treated with primary diagnosis of OVCF between 1993 and 2006. Chart review and imaging studies were used to confirm demographics, comorbidities, diagnosis, and treatment. Survival time was determined using hospital data, national death indices and patient follow-up. Exact Fisher tests, Mann-Whitney tests, and proportional hazards regression models with Kaplan-Meier plots compared patients treated with cement augmentation with controls treated with inpatient pain management and bracing. Patients with high-energy trauma, tumors or age more than 60 years were excluded.

RESULTS

Within the past 12 years, 46 patients treated with cement augmentation and 129 matched controls met inclusion criteria. They did not differ with respect to age, sex, and comorbidities. A significant survival advantage was found after cement augmentation compared with controls (P < 0.001; log rank), regardless of comorbidities, age, or the number of fractures diagnosed at the start date (P = 0.565). Controlling simultaneously for covariates, the estimated hazard ratio associated with cementation was 0.10 (95% confidence interval [CI] = 0.02-0.43; P = 0.002) for year 1, 0.15 (95% CI = 0.02-1.12; P = 0.064) for year 2, and 0.95 (95% CI = 0.32-2.79; P = 0.919) for subsequent follow-up. The number of OVCFs at the start time of treatment did not affect survival benefit of cementation (P = 0.44).

CONCLUSION

Cement augmentation of refractory OVCF improves survival for up to 2 years when compared with conservative pain management with bed rest, narcotics, and extension bracing, regardless of age, sex, and number of fractures or comorbidities. Therefore, aggressive management should be considered for refractory OVCFs with intractable back pain.

[Orthopedic treatment of vertebral compression fractures in osteoporosis]

Vertebral compression fracture is the most common type of fractures in osteoporosis increasing the mortality and morbidity of the systemic disease. Adequate treatment of the vertebral compression fractures is always in the focus of the national and international spine meetings and one of the most innovative fields in the spine care is the surgical therapy of the osteoporotic spine. Here, the authors summarize the orthopedic treatment options for vertebral compression fractures based on a literature review and their own institutional experience.

A comparative analysis of the results of vertebroplasty and kyphoplasty in osteoporotic vertebral compression fractures

BACKGROUND

The most common complication of osteoporosis is vertebral fractures, which occur more frequently than all other fractures (hip, wrist, and ankle).

OBJECTIVE

To prospectively analyze vertebroplasty compared with kyphoplasty for the treatment of osteoporotic vertebral compression fractures using improvement in pain, functional capacity, and quality of life as outcome measures.

METHODS

The study population included 28 patients in the vertebroplasty group and 24 patients in the kyphoplasty group. The mean follow-up period was 42.2 weeks and 42.3 weeks in the vertebroplasty and kyphoplasty groups, respectively. Outcomes were measured pre- and postoperatively using the visual analogue scale, the Oswestry Disability Index, the EuroQol-5D questionnaire, and the Short-Form 36 Health Survey.

RESULTS

In the vertebroplasty group, visual analogue scale scores improved from a mean of 8.0 cm to 5.5 cm at last follow-up (P = .001). Preoperatively, the Oswestry Disability Index was 57.6, which improved to 38.4 (P = .006). The EuroQol-5D score preoperatively was 0.157 and improved to 0.504 (P = .001). The Short-Form 36 Health Survey showed greatest improvement in the areas of physical health, role physical, body pain, and vitality. In the kyphoplasty group, visual analogue scale scores improved from a mean of 7.5 cm preoperatively to 2.5 cm postoperatively (P = .000001). The mean Oswestry Disability Index preoperatively was 50.7 and improved to 28.8 (P = .002). The EuroQol-5D score improved from a mean of 0.234 preoperatively to 0.749 (P = .00004). The Short-Form 36 Health Survey showed greatest improvement in the areas of physical health, physical functioning, role physical, body pain, and social functioning.

CONCLUSION

Both vertebroplasty and kyphoplasty are effective at improving pain, functional disability, and quality of life; however, kyphoplasty provides better results, which are maintained over long-term follow-up.

Balloon kyphoplasty versus vertebroplasty for treatment of osteoporotic vertebral compression fracture: a prospective, comparative, and randomized clinical study

Bone pain and spinal axial deformity are major concerns in aged patients suffering from osteoporotic vertebral compression fracture (VCF). Pain can be relieved by vertebroplasty or kyphoplasty procedures, in which the compressed vertebral body is filled with substitutes. We randomly assigned 100 patients with osteoporotic compression fracture at the thoraco-lumbar (T-L) junction into two groups: vertebroplasty and kyphoplasty; we used polymethylmethacrylate (PMMA) as the bone filler. Pain before and after treatment was assessed with visual analog scale (VAS) scores and vertebral body height and kyphotic wedge angle were measured from reconstructed computed tomography images. More PMMA was used in the kyphoplasty group than in the vertebroplasty group (5.56 +/- 0.62 vs. 4.91 +/- 0.65 mL, p < 0.001). Vertebral body height and kyphotic wedge angle of the T-L spine were also improved (p < 0.001). VAS pain scores did not differ significantly between the treatment groups. The duration of follow-up was 6 months. Two patients in the kyphoplasty group had an adjacent segment fracture. In terms of clinical outcome there was little difference between the treatment groups. Thus, owing to the higher cost of the kyphotic balloon procedure, we recommend vertebroplasty over kyphoplasty for the treatment of osteoporotic VCFs.

INTRODUCTION

Spinal axial deformities are major concerns in aged patients suffering from osteoporotic vertebral compression fracture. Pain may be relieved by vertebroplasty or kyphoplasty. We investigated the radiological and clinical outcomes of these procedures.

METHODS

One hundred cases of VCF at the thoraco-lumbar junction were randomly assigned into two groups: vertebroplasty or kyphoplasty (50 cases each). We used polymethylmethacrylate as the bone filler. Pain before and after treatment was assessed with visual analog scale scores and vertebral body height and kyphotic wedge angle were measured from reconstructed computed tomography images.

RESULTS

More PMMA was used in the kyphoplasty group than in the vertebroplasty group (5.56 +/- 0.62 vs. 4.91 +/- 0.65 mL, p < 0.001). Vertebral body height and kyphotic wedge angle of the T-L spine were also improved (p < 0.001). VAS pain scores did not differ significantly between the treatment groups. The duration of follow-up was 6 months. Two patients in the kyphoplasty group had an adjacent segment fracture.

CONCLUSIONS

In terms of clinical outcome there was little difference between the treatment groups. Thus, with the higher cost of the kyphotic balloon procedure, we recommend vertebroplasty over kyphoplasty for the treatment of osteoporotic VCFs.

Influence of powder-to-liquid monomer ratio on properties of an injectable iodine-containing acrylic bone cement for vertebroplasty and balloon kyphoplasty

The interventional radiological techniques of vertebroplasty (VP) and balloon kyphoplasty (BKP) are widely used in cases where the pain secondary to compression fractures of vertebral bodies is severe, persistent, and refractory to conservative treatments. In the majority of VP and BKP cases, an injectable poly(methyl methacrylate) (PMMA) bone cement and different values of powder-to-liquid monomer ratio (PLMR) are used. A systematic study of the influence of PLMR on relevant cement properties is lacking. This was the subject of the present study, with the injectable PMMA bone cement used being an experimental one whose radiopacity is provided by an iodine-containing compound in the powder. The PLMRs used-1.54, 2.22, and 3.08 g mL(-1)-are within the range used in clinical reports on VP and BKP. One property of the curing cement, namely, the polymerization rate at 37 degrees C (k'), was estimated using nonisothermal differential scanning calorimetry results. The fatigue lives (N(f)) of cured cement specimens were obtained under axial loading corresponding to axial stresses (S) of +/-20.0, 15.0, 12.5, and 10.0 MPa, at a frequency of 2 Hz. The fatigue limit of the cement was estimated from the fit of the S - N(f) results to the Olgive equation. With increase in PLMR, k' increased significantly, but the influence of PLMR on the fatigue limit and on another property also estimated from the S - ln N(f) results is not significant.

Vesselplasty: a new technical approach to treat symptomatic vertebral compression fractures

OBJECTIVE

The objective of our study was to evaluate the effectiveness and safety of vesselplasty to treat symptomatic vertebral compression fractures (VCFs).

SUBJECTS AND METHODS

Twenty-nine patients undergoing vesselplasty at our institution between April 2006 and February 2008 were enrolled in the study. All patients had been undergoing medical therapy for one or more painful VCFs. Pain, mobility, and analgesic use scores were obtained, and restoration of vertebral body height was evaluated. A two-tailed paired Student's t test was used to compare differences in the mean scores for levels of pain, mobility, and analgesic use before and after the procedure and to evaluate changes in vertebral body height. We analyzed the influence of the age of the fracture and its cause in the variations in the pain, mobility, and analgesic use scores.

RESULTS

Seven of the 29 patients had fractures in more than one level, for a total of 37 procedures. The cause of the vertebral collapse was osteoporosis in 27 (73%), high-impact trauma in five (13.5%), myeloma in three (8%), and metastatic fracture in two (5.4%). The average pain score before treatment was 8.72 +/- 1.25 (SD), whereas the average pain score after treatment was 3.38 +/- 2.35. The average mobility score before treatment was 2.31 +/- 1.94, whereas the average mobility score after treatment was 0.59 +/- 1.05 (p < 0.001). The average analgesic use score before treatment was 3.07 +/- 1.46, whereas it was 1.86 +/- 1.90 after treatment (p < 0.001). There was no evidence of clinical complications.

CONCLUSION

Vesselplasty offers statistically significant benefits in improvements of pain, mobility, and the need for analgesia in patients with symptomatic VCFs, thus providing a safe alternative in the treatment of these fractures.

Future directions in percutaneous vertebroplasty

The first percutaneous vertebroplasty, used to treat a painful cervical haemangioma, was performed by a French team in 1984 and reported in the literature in 1987. This technique has rapidly become the standard of care for treatment of medically refractory painful vertebral compression fractures. Vertebral fractures usually become evident because of pain of varying intensity that reduces the patient's quality of life, producing functional limitations, depression, disability, height loss, spinal instability and kyphotic deformity associated with impaired lung capacity. Many diseases may underlie vertebral compression fractures, such as osteoporosis, trauma, neoplasms and haemangioma. Vertebroplasty, as derived from our experience and a review of the literature data, has more than 70%-90% effectiveness for short-term pain reduction and return to activity. The aim of this paper was to describe the state of the art of this spinal interventional radiology procedure and to examine the future directions of percutaneous vertebroplasty.

The role of bone scintigraphy in treatment planning, and predicting pain relief after kyphoplasty

BACKGROUND

The role of whole-body Tc-MDP bone scanning in the management of vertebral compression fractures with kyphoplasty has not been clearly established.

OBJECTIVE

To determine the accuracy of bone scanning in patient selection, planning treatment and predicting response to kyphoplasty.

METHODS

Retrospective chart reviews were undertaken of all kyphoplasties performed by the same orthopaedic surgeon between June 2000 and June 2004. All patients who underwent plain radiographs (X-ray) of the spine and bone scanning within 4 weeks of treatment were included. Response to treatment was assessed via a questionnaire administered to the patient 3 weeks after intervention and concomitant objective assessment. Response was graded as excellent, intermediate or poor. Each bone scan was reviewed by two nuclear physicians blinded to the initial scan results, level of treatment and therapeutic response. The readers were asked to indicate the level(s) to be treated according to the bone scan findings. Sites of chronic fractures were also recorded.

RESULTS

Sixty-six procedures on 60 patients fulfilled the selection criteria. Fifty-three patients were managed by X-ray and bone scanning (A) and seven were managed by X-ray only (B). There was a significant difference in the rates of sub-optimal results between (A) and (B) (11/53 vs. 7/7, P=0.0001). There was also a significant difference in chronic fracture rates between patients with excellent outcome and those with sub-optimal results (3/42 vs. 7/11, P=0.0002). A high rate of incorrect level selection (3/7) was found in (B). In 12 patients (20%) X-ray showed multiple fractures but the bone scanning demonstrated only one level of acute disease.

CONCLUSIONS

Bone scanning is an excellent predictor of response to kyphoplasty and decreases the number of vertebrae to be treated as suggested by X-ray. Preoperative bone scanning is recommended to avoid incorrect selection of treatment level. Even when the appropriate level has been selected an incomplete response can be expected if additional chronic fracture is seen on bone scanning. In the event of unexpected incomplete response, re-evaluation with bone scanning may demonstrate new disease amenable to therapy.

Medical management of brain tumor patients

Brain tumors can present challenging medical problems. Seizures, peritumoral edema, venous thromboembolism, fatigue, and cognitive dysfunction can complicate the treatment of patients who have primary or metastatic brain tumors. Effective medical management results in decreased morbidity and mortality and improved quality of life for affected patients.