Comparative Study of Modified Posterior Operation to Treat Kümmell's Disease

Biomechanical analysis of a novel bone cement bridging screw system combined with percutaneous vertebroplasty for treating Kummell's disease

Kummell's Disease (KD) was originally proposed by Dr. Hermann Kummell in 1891 as a type of delayed posttraumatic vertebral collapse, which is a clinical phenomenon. The purpose of this experiment is to compare the strength of bone cement and the novel bone cement bridging screw in the treatment of thoracolumbar Kummell disease (KD) with other treatment methods. Thirty sheep spine specimens were selected. T12 to L2 segments were selected, and a KD intravertebral vacuum cleft model was made at the L1 segment. According to the ways of cement filling, the specimens were divided into percutaneous vertebroplasty (PVP), PVP combined with unilateral percutaneous pediculoplasty (PPP), PVP combined with bilateral PPP, unilateral novel bone cement bridging screw system combined with PVP, and bilateral cement bridging screw system combined with PVP groups. There were two experiments: three-dimensional biomechanical strength test and axial compression test. In the three-dimensional biomechanical strength test, we measured the strength of bone cement in specimens under six motion states, including flexion, extension, left bending, right bending, and left and right axial rotations. In the axial compression test, we detected the maximum axial pressure that the bone cement could withstand when it was under pressure until the bone cement was displaced. The unilateral or bilateral novel bone cement bridging screw with PVP groups had the best strength under flexion, extension, left bending, right bending, and had better biomechanical strength, with a significant difference from the other three groups (p < 0.05). There was no significant difference between the unilateral or bilateral novel bone cement bridging screw with PVP groups (p > 0.05). Unilateral and bilateral novel bone cement bridging screw could achieve similar bone cement strength. Compared with the other three groups, the unilateral or bilateral novel bone cement bridging screw with PVP groups are higher 136.35%, 152.43%; 41.93%, 51.58%; 34.37%, 43.50% respectively. The bilateral novel bone cement bridging screw with PVP could bear the largest pressure under vertical force. To conclude, the novel bone cement bridging screw can increase the strength of bone cement and avoid the loosening and displacement of bone cement in the treatment of KD of the thoracolumbar spine.

Biomechanical analysis of a novel bone cement bridging screw system for the treatment of Kummell disease: a finite element analysis

When bone cement is used to strengthen the vertebrae in patients with Kummell disease (KD), loosening and displacement of cement are common complications that can cause poor results. We developed a bone cement bridging screw system to avoid this complication. This three-dimensional finite element study aims to analyze the biomechanical properties of the novel bridging screw system and compare it to single vertebroplasty and vertebroplasty combined with pediculoplasty. After the effective establishment of a KD three-dimensional finite element model, the stability of the bone cement in the five treatment methods was analyzed and compared on four aspects. According to the calculation results of the maximum von Mises stress of bone cement and the relative displacement ratio of bone cement, it was determined that the stability of the bone cement was significantly improved when combined with the bridging screw system or pediculoplasty. In addition, according to the calculation results of the maximum von Mises stress of the inferior endplate of T12 and the displacement load ratio of the bone cement, we further found that after using the bridging screw system, the bone cement in the vertebral body has the best stability, and the risk of bone cement loosening or displacement is the lowest. In conclusion, for treating KD with bone cement augmentation, the bone cement bridging screw system combined with vertebroplasty has better stability and safety than ordinary single vertebroplasty and vertebroplasty combined with pediculoplasty. This treatment approach has the most robust ability to avoid loosening and displacement of bone cement.

A comparative study of PSPVP and PSIBG in the treatment of stage II–III Kummell’s disease

BACKGROUND: Percutaneous kyphoplasty (PKP) or percutaneous vertebroplasty (PVP) are commonly employed for Kummell’s disease in stages II–III; however, these techniques produce some complications. OBJECTIVE: To compare the clinical efficacy and imaging results of percutaneous vertebroplasty + bone cement-augmented short-segment pedicle screw fixation (PSPVP) versus transpedicular intracorporeal bone grafting + pedicle screw fixation (PSIBG) in the treatment of stage II–III Kummell’s disease. METHODS: A total of 69 patients admitted between November 2017 and March 2021 were included in this study; 36 of these were treated with PSPVP, and 33 were treated with PSIBG. Patients in the two groups were compared in terms of perioperative, follow-up, and imaging data. RESULTS: No statistically significant differences were found between the two groups in terms of operation duration (P > 0.05). However, the PSPVP group was superior to the PSIBG group in terms of incision length, intraoperative blood loss, and length of stay (P < 0.05). All patients were followed up for more than 12 months. The VAS score, height of anterior vertebral margin, kyphosis Cobb angle, wedge angle of the affected vertebra at seven days after surgery and last follow-up, and the ODI index at the last follow-up of the two groups were significantly improved compared with figures before surgery (P < 0.05). Compared with values before surgery, no statistically significant differences were found in the height of the posterior vertebral margin in the PSPVP group at seven days after surgery and at the last follow-up (P > 0.05). There were also no statistically significant differences in the VAS score, ODI index, kyphosis Cobb angle, and wedge angle of the affected vertebra between the two groups at corresponding time points (P > 0.05). The heights of the anterior and posterior vertebral margins in the PSIBG group were better than those in the PSPVP group after surgery and at the last follow-up (P < 0.05). In the PSPVP group, a pedicle screw fracture occurred in one patient two months after surgery, while an upper adjacent vertebral fracture occurred in one patient eight months after surgery. CONCLUSION: Both PSPVP and PSIBG can achieve good early clinical efficacy in the treatment of stage II–III Kummell’s disease, with PSPVP being relatively less invasive while producing a poorer orthopedic effect and more complications than PSIBG.

Strategies in the Management of Osteoporotic Kummell's Disease

Introduction

Kummell disease is a condition characterized by severe pain, progressing kyphosis with or without neurological deficit following a trivial trauma in the old age osteoporotic population. It is an osteoporotic vertebral fracture due to avascular necrosis of the vertebra, having an asymptomatic period initially followed by progressive pain, kyphosis, and neurologic deficit. Although various management options are available for Kummell's disease, a dilemma occurs in selecting an optimal modality in each case.

Case Report

A 65-year-old female presented with complaints of low back pain for 4 weeks. She developed progressive weakness and bowel bladder disturbance. Radiographs showed a D12 vertebral compression fracture with an intravertebral vacuum cleft sign. Magnetic resonance imaging showed intravertebral fluid and significant compression of the cord. We performed posterior decompression, stabilization, and transpedicular bone grafting at the D12 level. Histopathology confirmed Kummell's disease. The patient recovered with restored power and bladder control and resumed independent ambulation.

Conclusion

Osteoporotic compression fractures are more prone to pseudoarthrosis due to poor vascular and mechanical support, they need adequate immobilization and bracing. Transpedicular bone grafting for kummels disease seems to be a good surgical option due to its short operating time, less bleeding, less invasive approach, and early recovery. However, a treatment-oriented classification is needed to treat this clinical entity on a case-by-case basis.

Radiographic and clinical outcomes of surgical treatment of Kümmell's disease with thoracolumbar kyphosis: a minimal two-year follow-up

BACKGROUND

Up to now in the surgical treatment of Kümmell's disease combined with thoracolumbar kyphosis, little research has focused on the evaluation of the imaging and clinical outcomes of restoring the normal alignment and sagittal balance of the spine. This study aimed to evaluate the short to mid-term radiographic and clinical outcomes in the treatment of Kümmell's disease with thoracolumbar kyphosis.

METHODS

From February 2016 to May 2018, 30 cases of Kümmell's disease with thoracolumbar kyphosis were divided into group A and B according to whether the kyphosis was combined with neurological deficits. All of the cases underwent surgical treatment to regain the normal spinal alignment and sagittal balance. The radiographic outcomes and clinical outcomes of the cases were retrospectively evaluated. The sagittal imaging parameters including sagittal vertebral axis (SVA),thoracic kyphosis (TK),thoracolumbar kyphosis (TLK),lumbar lordosis (LL),pelvic incidence (PI),pelvic tilt (PT),and sacral slope (SS) before operation,immediately after operation,and the last follow-up of each case were measured and evaluated. The clinical results included the Oswestry Disability Index (ODI) and the Numerical Rating Scale (NRS) of the two groups. Statistical software SPSS21.0 was used to analyze the data.

RESULTS

In group A: Mean SVA before operation was 75 mm and 26.7 mm at the final postoperative evaluation (P = 0.000); Mean TLK before operation was 39°, and 7.1° at the final postoperative evaluation (P = 0.000); Mean NRS before operation was 4.7, compared with 0.9 at the final postoperative evaluation (P = 0.000). In group B: Mean preoperative SVA was 62.5 mm and decreases to 30.7 mm at the final postoperative evaluation (P = 0.000); Mean TLK before operation was 33°, and 9.7° 2 years post-operation (P = 0.000); Mean NRS prior to surgery was 4.0, and 0.8 at the last follow-up evaluation (P = 0.000). The improvement of the NRS scores of groups A and B was related to the improvement of the cobb angle (P = 0.020); (P = 0.009) respectively.

CONCLUSION

In the treatment of Kümmell's disease with thoracolumbar kyphosis,to restore the normal alignment and sagittal balance can obtain a satisfactory radiographic and clinical short and medium-term effects.

[Effectiveness of posterior short-segmental fixation with bone cement augmentation for stage Kümmell's disease with spinal canal stenosis]

OBJECTIVE

To investigate the effectiveness of posterior short-segmental fixation with bone cement augmentation in treatment of stage Ⅲ Kümmell's disease with spinal canal stenosis.

METHODS

Between June 2012 and January 2017, 36 patients with stage Ⅲ Kümmell's disease and spinal canal stenosis were treated by posterior short-segmental fixation and bone cement augmentation. There were 12 males and 24 females, aged 55-83 years (mean, 73.5 years). The disease duration ranged from 2 to 8 months, with an average of 4.6 months. Preoperative bone mineral density examination showed that all patients had different degrees of osteoporosis in the spines. The lesion segments included T 10 in 4 cases, T 11 in 7 cases, T 12 in 8 cases, L 1 in 9 cases, and L 2 in 8 cases. The preoperative neural function was classified as grade B in 4 cases, grade C in 12 cases, grade D in 13 cases, and grade E in 7 cases according to Frankle classification. The operation time, intraoperative blood loss, and the volume of injected bone cement, and hospital stay were recorded. The visual analogue scale (VAS) score, Oswestry Disability Index (ODI), kyphotic Cobb angle, and the height of anterior edge of injured vertebra were recorded before operation, at 1 week after operation, and at last follow-up; and the leakage of bone cement was observed.

RESULTS

All operations were completed successfully. The operation time was 90-145 minutes (mean, 110.6 minutes); the intraoperative blood loss was 198-302 mL (mean, 242.5 mL); the volume of injected bone cement was 8.3-10.5 mL (mean, 9.2 mL); the hospital stays were 7-12 days (mean, 8.3 days). All patients were followed up 12-26 months (mean, 24.5 months). At 1 week after operation, the neural function was classified as grade B in 2 cases, grade C in 8 cases, grade D in 12 cases, and grade E in 14 cases, which was significantly improved when compared with that before operation ( Z=2.000, P=0.047). The VAS score, ODI, the height of anterior edge of injured vertebra, and Cobb angle were significantly improved at 1 week and last follow-up when compared with preoperative values ( P<0.05); but there was no significant difference between 1 week and last follow-up ( P>0.05). Two cases had asymptomatic cement leakage to the intervertebral disc at 1 week after operation; and 1 case had adjacent vertebral fracture at 8 months after operation. No complication such as loosening or breaking of internal fixator occurred during the follow-up.

CONCLUSION

Posterior short-segmental fixation with bone cement augmentation is a safe and effective surgical scheme for stage Ⅲ Kümmell's disease combined with spinal canal stenosis, which can avoid the aggravation of nerve injury and complications related to staying in bed.

Surgical Treatment of Osteoporotic Vertebral Fracture with Neurological Deficit-A Nationwide Multicenter Study in Japan

Introduction

The prevalence of patients with osteoporosis continues to increase in aging societies, including Japan. The first choice for managing osteoporotic vertebral compression fracture (OVF) is conservative treatment. Failure in conservative treatment for OVF may lead to non-union or vertebral collapse, resulting in neurological deficit and subsequently requiring surgical intervention. This multicenter nationwide study in Japan was conducted to comprehensively understand the outcomes of surgical treatments for OVF non-union.

Methods

This multicenter, retrospective study included 403 patients (89 males, 314 females, mean age 73.8 ± 7.8 years, mean follow-up 3.9 ± 1.7 years) with neurological deficit due to vertebral collapse or non-union after OVF at T10-L5 who underwent fusion surgery with a minimum 1-year follow-up. Radiological and clinical outcomes at baseline and at the final follow-up (FU) were evaluated.

Results

OVF was present at a thoracolumbar junction such as T12 (124 patients) and L1 (117 patients). A majority of OVF occurred after a minor trauma, such as falling down (55.3%) or lifting objects (8.4%). Short segment fusion, including affected vertebra, was conducted (mean 4.0 ± 2.0 vertebrae) with 256.8 minutes of surgery and 676.1 g of blood loss. A posterior approach was employed in 86.6% of the patients, followed by a combined anterior and posterior (8.7%), and an anterior (4.7%) approach. Perioperative complications and implant failures were observed in 18.1% and 41.2%, respectively. VAS scores of low back pain (74.7 to 30.8 mm) and leg pain (56.8 to 20.7 mm) improved significantly at FU. Preoperatively, 52.6% of the patients were unable to walk and the rate of non-ambulatory patients decreased to 7.5% at FU.

Conclusions

This study demonstrated that substantial improvement in activity of daily living (ADL) was achieved by fusion surgery. Although there was a considerable rate of complications, fusion surgery is beneficial for elderly OVF patients with non-union.

Titanium mesh bone grafting combined with pedicle screw internal fixation for treatment of Ku[Combining Diaeresis]mmell disease with cord compression: A case report and literature review

RATIONALE

In 1891, Dr. Hermann Kümmell, a German surgeon, described a clinical entity characterized by the development of progressive painful kyphosis following an asymptomatic period of months or years after a minor spinal trauma, leading to a gradual collapse of the vertebra and dynamic instability, ultimately progressing to kyphosis with prolonged back pain and/or paraparesis. To date, the main pathologic eliciting event remains unclear, and no standard treatment or single effective treatment are available for Kümmell disease.

PATIENT CONCERNS

A 74-year-old woman presented with severe back pain and numbness of both legs for approximately 2 months.

DIAGNOSES

According to the clinical symptoms and imaging examinations, the patient was diagnosed with stage III Kümmell disease.

INTERVENTIONS

The patient underwent titanium mesh bone grafting combined with pedicle screw internal fixation.

OUTCOMES

Postoperative kyphosis was corrected, and the vertebra was reconstructed.

LESSONS

Kümmell disease is not a rare complication of osteoporotic vertebral compression fractures, and treatment of each patient must be individualized. The application of titanium mesh bone grafting combined with pedicle screw internal fixation is an effective treatment option for stage III Kümmell disease.

Anterior reconstruction versus posterior osteotomy in treating Kümmell's disease with neurological deficits: A systematic review

OBJECTIVE

This study aimed to conduct a systematic review of literature comparing the clinical effectiveness and safety between anterior reconstruction (AR) and posterior osteotomy (PO) in the treatment of Kümmell's disease with neurological deficits.

METHODS

We systematically reviewed the literature in PubMed, EMBASE, Cochrane Database of Systematic Reviews, and the Web of Science for "spin*," "surg*," "Kümmell's disease," "Kummell's disease," "Kummell disease," "vertebral osteonecrosis," "vertebral pseudarthrosis," "intravertebral vacuum cleft," "delayed vertebral collapse," and "compression fracture nonunion". Quality was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation method.

RESULTS

A total of 10 publications involving 268 Kümmell's disease patients with neurological deficits were included in this review, with 7 studies of low- or very low-quality. There were 37.7% and 62.3% of patients receiving AR and PO, respectively. For clinical outcomes, AR group showed no significant differences in pain, neurological dysfunction, and imaging outcome improvements compared with patients who underwent PO. However, the incidence of implant-related complications including loose screw, screw fracture, screw disconnection, and plate dislodgment, was higher in AR group compared with PO group (21.6% vs. 14.3%). As another major complication, AR group more often required a second surgery.

CONCLUSION

This systematic review demonstrated that both AR and PO could improve pain, neurological dysfunction and imaging outcomes. However, serious comorbidities, multilevel corpectomies and/or severe osteoporosis highly required PO. Design discrepancies were found in the current studies, further higher-quality studies are warranted.

LEVEL OF EVIDENCE

Level III, therapeutic study.

What is the Current Evidence on Vertebral Body Osteonecrosis?: A Systematic Review of the Literature

Osteonecrosis (ON) is a clinical entity characterized by a pattern of cell death and complex process of bone resorption and formation. Studies related to ON have largely focused on certain anatomical sites; however, the evidence on vertebral body ON (VBON) is largely inconsistent and fragmented. The aim of this study was to clarify the pathophysiology, risk factors, imaging findings, and available treatment modalities for VBON. A systematic review of the relevant articles published in English was performed using PubMed, Embase, Medline, Google Scholar, Cochrane Central Register of Controlled Trials (CENTRAL), and CINAHL databases. A total of 81 articles were included in this study. Three main topics about VBON were identified: (1) pathophysiology and risk factors, (2) diagnosis, and (3) treatment. Forty-five studies were based on the pathophysiology, 52 on diagnosis, and 38 on the treatment options for VBON. The literature on VBON was limited and mainly focused on post-traumatic cases with a considerable overlap with nonunion and pseudoarthrosis.

Comparison of Percutaneous Kyphoplasty and Bone Cement-Augmented Short-Segment Pedicle Screw Fixation for Management of Kümmell Disease

BACKGROUND The purpose of this study was to compare the efficacy of percutaneous kyphoplasty (PKP) and bone cement-augmented short segmental fixation (BCA+SSF) for treating Kümmell disease. MATERIAL AND METHODS Between June 2013 and December 2015, 60 patients were treated with PKP or BCA+SSF. All patients were followed up for 12-36 months. We retrospectively reviewed outcomes, including Oswestry Disability Index (ODI), visual analogue scale (VAS), and kyphotic Cobb angle. RESULTS VAS, ODI, and Cobb angle, measured postoperatively and at the final follow-up, were lower than those measured preoperatively in both groups (P<0.05). VAS, ODI, and Cobb angle measured postoperatively demonstrated no significant differences when compared with those measured at the final follow-up in the PKP group (P>0.05). In the BCA+SSF group, VAS and ODI at the final follow-up were lower than those measured postoperatively (P<0.05), but no significant difference was found in the Cobb angle (P>0.05). The PKP group had better VAS and ODI than the BCA+SSF group, postoperatively (P<0.05). No significant difference was found in VAS and ODI at the final follow-up (P>0.05) or the Cobb angle measured postoperatively and at the final follow-up (P>0.05) between the 2 groups. Operative time, blood loss, and hospital stay in the PKP group were lower than those in the BCA+SSF group (P<0.05). No significant difference was found in complications (P>0.05). CONCLUSIONS PKP patients had better early clinical outcomes, shorter operation times and hospital admission times, and decreased blood loss, but had similar complications, radiographic results, and long-term clinical outcomes compared with BCA+SSF patients.

Bone Cement-Augmented Short-Segment Pedicle Screw Fixation for Kümmell Disease with Spinal Canal Stenosis

Background

This study aimed to explore the feasibility and efficacy of bone cement-augmented short-segmental pedicle screw fixation in treating Kümmell disease.

Material/Methods

From June 2012 to June 2015, 18 patients with Kümmell disease with spinal canal stenosis were enrolled in this study. Each patient was treated with bone cement-augmented short-segment fixation and posterolateral bone grafting, and posterior decompression was performed when needed. All patients were followed up for 12–36 months. We retrospectively reviewed outcomes, including the Oswestry disability index (ODI), visual analog scale (VAS) score, anterior and posterior heights of fractured vertebrae, kyphotic Cobb angle, and neurological function by Frankel classification.

Results

The VAS grades, ODI scores, anterior heights of affected vertebrae, and kyphotic Cobb angles showed statistically significant differences between pre- and postoperative and between preoperative and final follow-up values (P<0.05), whereas the differences between postoperative and final follow-up values were not statistically significant (P>0.05). The differences between posterior vertebral heights at each time point were not statistically significant (P>0.05). Improved neurological function was observed in 12 cases at final follow-up. Three cases had complications, including asymptomatic cement leakage in 2 patients and delayed wound infection in 1 patient.

Conclusions

Bone cement-augmented short-segment pedicle screw fixation is safe and effective for treating Kümmell disease, and can achieve satisfactory correction of kyphosis and vertebral height, with pain relief and improvement in neurological function, with few complications.

Posttraumatic Delayed Vertebral Collapse : Kummell's Disease

Posttraumatic delayed vertebral collapse, known as Kummell’s disease, is increasing in number of patients. This disease is already progressive kyphosis due to vertebral collapse at the time of diagnosis and it causes intractable pain or neurologic deficit due to intravertebral instability. Treatment is very difficult after progression of the disease, and the range of treatment, in hospital day, and cost of treatment are both increased. Clinical features, pathogenesis and radiologic findings of these disease groups were reviewed to determine risk factors for delayed vertebral collapse. The purpose of this article is to suggest appropriate treatment before vertebral collapse for patients with osteoporotic vertebral compression fracture who have risk factors for posttraumatic delayed vertebral collapse.

Short-segment fixation with a cement-augmented pedicle screw for Kummell disease: Case report

RATIONALE

Kummell disease is described as avascular necrosis of a vertebral body that occurred in a delayed fashion after a minor trauma. Anterior, posterior, and anterior-posterior approaches have been reported. Nevertheless, there is no standard treatment for patients with Kummell disease.

PATIENT CONCERNS

We reported a successful cement-augmented pedicle screw placement in a patient with Kummell disease. A 63-year-old woman with serious osteoporosis complained persistent back pain with progressive lower extremities weakness for almost 2 years.

DIAGNOSES

The diagnosis of Kummell disease was mainly depended on clinical symptoms and imaging examinations.

INTERVENTIONS

The application of a cement-augmented pedicle screw was designed to treat this illness.

OUTCOMES

The operation was successful without any complications. The patient stated that symptoms were obviously improved in 1 week after operation.

LESSONS

The application of a cement-augmented pedicle screw is an effective treatment option for Kummell disease.

Modified posterior vertebral column resection for Kümmell disease: Case report

RATIONALE

Kümmell's disease is defined as delayed traumatic vertebral collapse disease in which patients develop a kyphosis after asymptomatic minor spinal trauma. Both anterior approach and posterior approach have been reported, however, there is no standard treatment for Kümmell's disease.

PATIENT CONCERNS

We described a successful modified posterior vertebral column resection in a patient with Kümmell's disease. A 65-year-old woman reported persistent back pain for almost three months.

DIAGNOSES

Kümmell's disease was diagnosed based on computer tomography (CT) and magnetic resonance imaging (MRI).

INTERVENTIONS

Modified posterior vertebral column resection combined with short-segment fixation was designed to treat this disease.

OUTCOMES

The procedure was successful without any complications. Patient reported that symptoms were obviously improved in one week after operation.

LESSONS

Modified posterior vertebral column resection combined with short-segment fixation is an effective treatment option for Kümmell's disease.