Failed percutaneous kyphoplasty in treatment of stage 3 Kummell disease: A case report and literature review

Semi-vertebral column resection with preservation of posterior ligament complex for Kümmell's disease: a case report

BACKGROUND

Kümmell's disease is characterized by ischemic osteonecrosis and nonunion after osteoporotic vertebral compression fractures, leading to intractable low back pain, pseudoarthrosis, kyphosis, and neurological dysfunction, which can seriously affect the quality of life and life expectancy of patients. Although many surgical methods have been reported, uniform standard procedures for Kümmell's disease are still lacking.

CASE PRESENTATION

This case described a new procedure for Kümmell's disease. A 67-year-old woman from China underwent semi-vertebral column resection through the posterior of the diseased vertebra, while the posterior ligament complex and the contralateral spinal structure were preserved. Subsequently, intervertebral titanium cage support bone graft fusion combined with posterior pedicle screw internal fixation was conducted, and the patient was followed up with for 22 months. Kyphosis Cobb angle was 20° 2 weeks post-surgery and was maintained at 20° even after 22 months. Titanium cage was in a good position 2 weeks and 22 months after surgery.

CONCLUSION

This new spine surgery could completely decompress the spinal canal and reduce the iatrogenic destruction of spinal stability, which might be helpful for the reconstruction and maintenance of spinal stability.

Clinical efficacy and biomechanical analysis of a novel hollow pedicle screw combined with kyphoplasty for the treatment of Kümmell disease

Background

Vertebral augmentation is the preferred treatment for Kümmell disease (KD), but there exists a risk of cement displacement resulting in severe back pain and exacerbation of kyphosis. The study aimed to investigate the efficacy and safety of a novel hollow pedicle screw combined with kyphoplasty (HPS-KP) for treating KD, effectively preventing postoperative bone cement displacement.

Methods

The prospective study included 50 KD patients with no neurological deficit detected during clinical and radiological evaluation who underwent HPS-KP (n = 25) and PKP (n = 25) surgeries. The visual analogue scale (VAS) score, Oswestry dysfunction index (ODI), anterior vertebral height (AVH), wedge-shape affected vertebral Cobb angle (WCA), bisegmental Cobb angle (BCA), and complications were evaluated and compared in both groups. Besides, a finite element (FE) model of T11-L2 was constructed. The stress distributions, maximum von Mises stresses of vertebrae and bone cement, and maximum displacement of bone cement were compared and analyzed.

Results

The VAS and ODI scores at 3 days, 3 and 6 months, and 1 year after surgery significantly improved in both groups (p < 0.05). The AVH, BCA, and WCA significantly improved initially after the surgery in both groups (p < 0.05). The displacement of M2 was larger than other models, especially in flexion, right bending, and left and right rotation, while that of M6 was the lowest under all conditions.

Conclusion

HPS-KP was a safe and effective treatment for KD, effectively relieving pain, restoring vertebral height, and correcting local kyphosis, and it had better biomechanical stability and safety than ordinary single PKP and PKP combined with pediculoplasty in avoiding cement loosening and displacement.

Intravertebral insertion of interbody fusion cage via transpedicular approach for the treatment of stage III Kümmell disease: a technical note and case presentation

BACKGROUND

Kümmell disease usually occurs in the elderly osteoporosis population and develops gradually into symptomatic, progressive kyphosis of the spine. However, current surgical methods to deal with stage III Kümmell disease are less satisfying. The objective of this study was to describe a less invasive technique for treating stage III Kümmell disease.

TECHNIQUE

A less invasive technique of intravertebral insertion of interbody fusion cage via transpedicular approach with posterior spine stabilization was applied to treat stage III Kümmell disease.

RESULTS

This study details a modified technique applied in a patient with stage III Kümmell disease, showing significant improvement in pain relief, anterior column height recovery, and kyphotic angle correction. And no complications were reported during our follow-up.

CONCLUSIONS

Intravertebral insertion of interbody fusion cage via transpedicular approach provides advantages of acceptable correction of kyphosis, bony fusion, minimal invasion. Thus, our method was a good alternative choice for stage III Kümmell disease.

Prevention of Bone Cement Displacement in Kümmell Disease without Neurological Deficits through Treatment with a Novel Hollow Pedicle Screw Combined with Kyphoplasty

OBJECTIVE

Displacement of bone cement following percutaneous vertebral augmentation for Kümmell disease (KD) presents a significant concern, resulting in increasing back pain and compromising daily activities. Unfortunately, current literature does not yet establish a validated and minimally invasive surgical intervention for this issue. This study aims to investigate the effects of a novel hollow pedicle screw combined with kyphoplasty (HPS-KP) in preventing bone cement displacement following simply percutaneous kyphoplasty for the management of KD.

METHODS

A total of 22 patients (six males, 16 females, averagely aged 77.18 ± 7.63 years) with KD without neurological deficits treated by HPS-KP at the hospital between March 2021 and June 2022 were hereby selected, among which, there were three stage I KD cases, 12 stage II KD cases, and seven stage III KD cases according to Li's classification. Bone mineral density (BMD), spinal X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) were examined before the operation. The operation time, intraoperative blood loss, and postoperative complications were all recorded. The follow-up focused on visual analog scale (VAS) score, Oswestry dysfunction index (ODI), anterior vertebral height (AVH), middle vertebral height (MVH), posterior vertebral height (PVH), wedge-shape affected vertebral Cobb angle (WCA), and bisegmental Cobb angle (BCA). One-way analysis of variance (ANOVA) followed by Bonferroni post-hoc test was employed for performing multiple comparisons in the present study.

RESULTS

All patients having received the operation successfully were followed up for more than 8 months (ranging from 8 to 18 months). The operation time, intraoperative blood loss, and BMD (T-score) were 39.09 ± 5.64 min, 14.09 ± 3.98 ml, and - 3.30 ± 0.90 g/cm3 , respectively. Statistically significant differences were observed in the VAS score, ODI, AVH, MVH, and WCA (All p < 0.05), but there was no statistically significant difference in PVH and BCA at different time points (All p > 0.05). During follow-up, five patients suffered from bone cement leakage, and one presented an adjacent vertebral fracture and no bone cement displacement.

CONCLUSION

HPS-KP could be safe and effective in the treatment of KD without neurological deficits, effectively relieving the symptoms of patients, restoring partial vertebral height, and preventing the occurrence of bone cement displacement.

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.

Incidence, Risk Factors, and Outcomes of Symptomatic Bone Cement Displacement following Percutaneous Kyphoplasty for Osteoporotic Vertebral Compression Fracture: A Single Center Study

STUDY DESIGN

Retrospective.

BACKGROUND

Symptomatic bone cement displacement (BCD) is a rare complication following percutaneous kyphoplasty (PKP) interventions for osteoporotic vertebral compression fracture (OVCF). This study aimed to investigate the incidence and the outcomes of symptomatic BCD comprehensively and identify its risk factors.

METHODS

The clinical data of patients treated with PKP for OVCF between January 2012 and December 2020 were extracted. Patients who developed BCD following PKP during follow-up were divided into the symptomatic and asymptomatic groups. Patients who did not develop BCD were assigned to the control group. Univariate and multiple logistic regression analyses were used to compare the three clinical groups' features to assess the independent risk factors for the symptomatic and asymptomatic groups.

RESULTS

A total of 896 patients were enrolled. Twenty-one patients (2.3%) were identified as having symptomatic BCD following PKP for OVCF, and 35 (3.9%) developed asymptomatic BCD. Compared with the control group, the symptomatic and asymptomatic groups had a higher incidence of anterior leakage, intravertebral vacuum cleft (IVC) signs, and a lower cement distribution score. The symptomatic group had a lower relative cross-sectional area (rCSA) of the paraspinal muscle (PSM), higher PSM fatty degeneration, and higher kyphotic angle (at the last follow-up) than the asymptomatic and control groups. For outcomes, the symptomatic group had a higher VAS/ODI score and a higher incidence of new vertebral fractures compared with the asymptomatic and control groups. Anterior leakage (OR: 1.737, 95% CI: 1.215-3.300), the IVC sign (OR: 3.361, 95% CI: 1.605-13.036), the cement distribution score (OR: 0.476, 95% CI: 0.225-0.904), PSM rCSA (OR: 0.953, 95% CI: 0.917-0.992), and PSM fatty degeneration (OR: 1.061, 95% CI: 1.005-1.119) were identified as independent risk factors for the symptomatic group. Anterior leakage (OR: 1.839, 95% CI: 1.206-2.803), the IVC sign (OR: 2.936, 95% CI: 1.174-9.018), and cement distribution score (OR: 0.632, 95% CI: 0.295-0.858) were independent risk factors for the asymptomatic group.

CONCLUSION

The incidence of symptomatic BCD is 2.3% in patients treated with PKP. Anterior leakage, the IVC sign, and the distribution score were independent risk factors for BCD, and paraspinal muscle degeneration was a specific risk factor for symptomatic BCD. Symptomatic BCD can lead to poor outcomes.

The Use of Three-Column Enhanced Percutaneous Vertebroplasty to Treat Kummell's Disease

Purpose

To describe the operative technique and clinical effects of three-column enhanced percutaneous vertebroplasty used to treat Kummell’s disease.

Methods

From April 2017 to April 2020, 39 patients with Kummell’s disease were treated via three-column enhanced percutaneous vertebroplasty. There were 12 males and 27 females of average age 70.23 ± 7.41 years. The operative time, volume of bone cement injected, and intraoperative cement leakage were recorded. The patients were re-examined postoperatively. The VAS was used to evaluate low back pain and the ODI score to evaluate improvement in the quality-of-life.

Results

All patients were successfully operated upon; the average operation time was 35.1±4.7 min and average volume of bone cement injected 4.5±0.92 mL. Five cases exhibited bone cement leakage during operation, two into the intervertebral disc and three into the anterior upper margin of the vertebral body. No leakage into the vertebral canal occurred. The average hospital stay was 2.50±0.86 days. The VAS score before operation was 7.47±0.24, but low back pain symptoms were significantly relieved after operation (P < 0.05). The VAS scores at 1 day and 1, 3, 6, and 12 months after operation were 2.91±0.09, 2.04±0.07, 1.59±0.05, 1.28±0.15, and 0.8±0.18, respectively. The preoperative ODI score was 72.97±1.45 and significantly decreased postoperatively (P < 0.05), being 30.08±1.79 at 1 day, and 25.35±0.94, 23.19±1.76, 20.49±0.65, and 20.05±0.58 at 1, 3, 6, and 12 months after operation respectively.

Conclusion

Three-column enhanced percutaneous vertebroplasty effectively treats Kummell’s disease. The surgical trauma is low, recovery rapid, and bone cement fixation firm, especially in patients with stage I and II disease.

The comparison of percutaneous kyphoplasty and vertebroplasty for the management of stage III Kummell disease without neurological symptoms

Purpose

To compare the clinical and radiological outcomes of percutaneous kyphoplasty (PKP) and percutaneous vertebroplasty (PVP) in the treatment of stage III Kummell disease without neurological deficit.

Methods

This retrospective study involved 41 patients with stage III Kummell disease without neurological deficit who underwent PKP or PVP from January 2018 to December 2019. Demographic data and clinical characteristics were comparable between these two groups before surgery. Operation time, volume of injected bone cement, intraoperative blood loss and time of hospital stay were analyzed. Visual analog scale (VAS) scoring and Oswestry disability index (ODI) scoring were assessed for each patient before and after operation. Radiographic follow-up was assessed by the height of anterior (Ha), the height of middle (Hm), Cobb’s angle, and Vertebral wedge ratio (VWR). The preoperative and postoperative recovery values of these data were used for comparison.

Results

The two groups showed no significant difference in demographic features (p > 0.05). What’s more, the operation time, intraoperative blood loss, and time of hospital stay revealed no sharp statistical distinctions either (p > 0.05), except PKP used more bone cement than PVP (7.4 ± 1.7 mL vs 4.7 ± 1.4 mL, p < 0.05). Radiographic data, such as the Ha improvement ratio (35.1 ± 10.2% vs 16.2 ± 9.4%), the Hm improvement ratio (41.8 ± 11.3% vs 22.4 ± 9.0%), the Cobb’s angle improvement (10.0 ± 4.3° vs 3.5 ± 2.1°) and the VWR improvement ratio (30.0 ± 10.6% vs 12.7 ± 12.0%), were all better in PKP group than that in PVP group (p < 0.05). There were no statistical differences in the improvement of VAS and ODI 1-day after the surgery between these two groups (p > 0.05). However, at the final follow-up, VAS and ODI in PKP group were better than that in PVP (p < 0.05). Cement leakage, one of the most common complications, was less common in the PKP group than that in the PVP group (14.3% vs 45.0%, p < 0.05). And there was 1 case of adjacent vertebral fractures in both PKP and PVP (4.8% vs 5.0%, p > 0.05), which showed no statistical difference, and there were no severe complications recorded.

Conclusions

For stage III Kummell disease, both PKP and PVP can relieve pain effectively. Moreover, PKP can obtain more satisfactory reduction effects and less cement leakage than PVP. We suggested that PKP was more suitable for stage III Kummell disease without neurological deficit compared to PVP from a vertebral reduction point of view.

Efficacy and Safety of Posterior Long-Segment Fixation Versus Posterior Short-Segment Fixation for Kummell Disease: A Meta-Analysis

PURPOSE

Posterior short-segment fixation (SSF) and long-segment fixation (LSF) are two methods for the treatment of Kummell disease, but the safety and effectiveness of these two surgical methods still lack adequate medical evidence. This study aimed to evaluate the two methods.

METHODS

Database searches for randomized controlled trials, case-control studies, and cohort studies of posterior SSF and posterior LSF in the treatment of Kummell disease were performed. After the document quality was evaluated with the Newcastle-Ottawa Quality Assessment Scale, a meta-analysis was carried out.

RESULTS

Meta-analysis revealed that the operation time and intraoperative blood loss in the LSF group were higher than those in the SSF group [MD = -18.17, 95% CI (-30.31, -6.03), z = 2.93, P = .003; MD = -82.07, 95% CI (-106.91, -57.24], z = 6.48, P < .00001). The postoperative last follow-up local kyphosis angle in the SSF group was greater than that in the LSF group (MD = 3.18, 95% CI [.56, 5.81], z = 2.38, P = .02), and there were no significant differences in perioperative complications, bone cement leakage rate, incidence of adverse events during follow-up, postoperative follow-up visual analog scale, postoperative Oswestry dysfunction index, and postoperative immediate local kyphosis angle between the two groups (P > .05).

CONCLUSION

SSF and LSF are effective and safe for the treatment of Kummell disease. SSF can reduce the operation time and intraoperative bleeding; LSF can better maintain the long-term stability of kyphosis. The methods should be evaluated by clinicians according to the individual situation of the patients.

Consecutive Kummell's Disease Combined with Parkinson's Disease and Experienced Internal Fixation Failure: A Case Report and Literature Review

Background

The continuous occurrence of Kummell's disease is extremely rare in clinical practice, and its treatment is difficult. The study aimed to present a rare case of consecutive Kummell's disease combined with Parkinson's disease (PD) and experienced internal fixation failure.

Case presentation

A 69‐year‐old female patient had a history of PD for 10 years, and was treated by posterior decompression, fixation, and fusion because of Kummell's disease of T12 with neurological damage. The patient's back pain and lower limb pain were significantly improved after surgery. Twenty‐two months later, the patient was rehospitalized for Kummell's disease of L4 with neuropathic pain of left lower extremity. She received almost identical surgical procedures as T12 lesion, and the difference was no L4 vertebroplasty preformed due to the fact that the L4 vertebrae collapse was not obvious, the intravertebral vacuum cleft (IVC) range was small, and the pedicle screw fixation strength was high. The pain symptoms were significantly relieved after operation. Unfortunately, there was a complication of internal fixation failure that occurred a month later, and a revision operation was carried out.

Conclusion

Osteoporosis combined with PD may lead patients to become prone to consecutive Kummell's disease, and patients are prone to experience failure of internal fixation. Bone cement filling of vertebral IVC and effective support of anterior vertebral column are very important procedures to ensure the clinical efficacy of treating Kummell's disease.

Outcome after Posterior Vertebral Column Resection in Patients with Severe Osteoporotic Fractures—A Retrospective Analysis from Two Centers

Background and Objectives: In osteoporotic fractures of the spine with resulting kyphosis and threatening compression of neural structures, therapeutic decisions are difficult. The posterior vertebral column resection (pVCR) has been described by different authors as a surgical treatment in a single-stage posterior procedure. The aim of this study is to evaluate midterm outcomes of patients treated by pVCR due to severe osteoporotic fractures. Materials and Methods: Retrospective data analysis of all the patients treated for osteoporotic fractures by pVCR from 2012–2020 at two centers was performed. Demographic data, visual analog scale (VAS), Frankel scale (FS), Karnofsky performance status (KPS), radiological result and spinal fusion rates were evaluated. Results: A total of 17 patients were included. The mean age was 70 ± 10.2 y. The mean VAS decreased significantly from 7.7 ± 2.8 preoperatively to 3.0 ± 1.6 at last follow-up (p < 0.001) and the segmental kyphosis decreased from 29.4 ± 14.1° to 7.9 ± 8.0° (p < 0.001). The neurologic function on the FS did not worsen in any and improved in four of the patients. The median KPS remained stable over the whole observation period (70% vs. 70%). Spinal fusion was observed in nine out of nine patients who received CT follow-up >120 days after index surgery. Conclusions: This study showed that pVCR is a safe surgical technique with few surgical complications and no neurological deterioration considering the cohort. The patients’ segmental kyphosis and VAS improved significantly, while the KPS remained stable.

Vertebral augmentation plus short-segment fixation versus vertebral augmentation alone in Kümmell's disease: a systematic review and meta-analysis

Osteoporotic vertebral compression fractures of the thoracolumbar spine can progress to Kümmell's disease, an avascular vertebral osteonecrosis. Vertebral augmentation (VA)-vertebroplasty and/or kyphoplasty-is the main treatment modality, but additional short-segment fixation (SSF) has been recommended concomitant to VA. The aim is to compare clinical and radiological outcomes of VA + SSF versus VA alone. Systematic review, including comparative articles in Kümmell's disease, was performed. This study assessed the following outcome measurements: visual analog scale (VAS), Oswestry Disability Index (ODI), anterior vertebral height (AVH), local kyphotic angle (LKA), operative time, blood loss, length of stay, and cement leakage. Six retrospective studies were included, with 126 patients in the VA + SSF group and 152 in VA alone. Pooled analysis showed the following: VAS, non-significant difference favoring VA + SSF: MD -0.61, 95% CI (-1.44, 0.23), I² 91%, p = 0.15; ODI, non-significant difference favoring VA + SSF: MD -9.85, 95% CI (-19.63, -0.07), I² 96%, p = 0.05; AVH, VA + SSF had a non-significant difference over VA alone: MD -3.21 mm, 95% CI (-7.55, 1.14), I² 92%, p = 0.15; LKA, non-significant difference favoring VA + SSF: MD -0.85°, 95% CI (-5.10, 3.40), I² 95%, p = 0.70. There were higher operative time, blood loss, and hospital length of stay for VA + SSF (p < 0.05), but with lower cement leakage (p < 0.05). VA + SFF and VA alone are effective treatment modalities in Kümmell's disease. VA + SSF may provide superior long-term results in clinical and radiological outcomes but required a longer length of stay.

Analysis on the Effect of Different Surgical Methods on the Treatment of Senile Osteoporotic Spinal Compression Fractures and the Influencing Factors of Complications

Osteoporotic fractures are a common type of fractures in the elderly, among which spinal compression fractures are more common. After the occurrence of fractures, due to the compression and burst of the vertebral body, this will lead to local kyphosis deformity and even affect the balance of the sagittal spine. In the past, conservative treatments were used for osteoporotic spinal compression fractures. Although it can relieve pain symptoms, it can easily lead to complications such as aggravation of osteoporosis and deep vein thrombosis of the lower extremities. At present, percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) are the main clinical surgical treatments, both of which are minimally invasive surgery, short operation time, effective pain relief, and rapid postoperative recovery. Although both of them are effective, there is still controversy over the efficacy of both in the treatment of osteoporotic spinal compression fractures. The purpose of this study was to investigate the efficacy of PVP and PKP in the treatment of elderly osteoporotic spinal compression fractures and to analyze the related factors that affect the occurrence of postoperative complications. The results show that both PVP and PKP can effectively improve the pain and dysfunction of elderly patients with osteoporotic spinal compression fracture, restoration of vertebral height, and correct kyphosis, but PKP has better effect and higher safety and is worth promoting. Postoperative complications of patients are related to their age, bone mineral density, use of hormones, and antiosteoporosis treatment.

The clinical results of treating Kummell's disease with mineralized collagen modified polymethyl methacrylate

To investigate the clinical results of treating Kummell's Disease by using mineralized collagen modified polymethyl methacrylate bone cement, 23 cases (23 vertebras) who sustained Kummell's Disease treated with mineralized collagen modified polymethyl methacrylate bone cement from July 2017 to February 2019 were reviewed retrospectively. The visual analogue scale, vertebral body height, Cobb angle, CT values pre-operation and post-operation as well as incidence of complications were observed. All the patients were successfully followed up with an average period of 11.3 months (ranging from 6 to 12 months). The patients could ambulate on the second day after the operation. The visual analogue scale scores significantly decreased from two days after the operation to the last follow-up compared with that before the operation (p < 0.05); the average vertebral height and local Cobb angle had significant recovery (p < 0.05); the CT value of the treated vertebra significantly increased compared with that before the operation (p < 0.05). Bone cement leakage occurred in one case, anterior edge leakage occurred in one case, and no clinical symptoms caused by bone cement leakage occurred. No re-fracture of the treated vertebral body or adjacent vertebral bodies were observed in the follow-ups. With good osteogenic activity and degradable absorption characteristics, mineralized collagen was compounded with the existing polymethyl methacrylate bone cement to reduce its strength in the vertebral body and enhance biocompatibility, the incidence of adjacent vertebral fractures and re-fractures within the injured vertebrae is significantly reduced, and good clinical results are obtained, which is worthy of popularization.

Percutaneous vertebroplasty versus kyphoplasty for the treatment of neurologically intact osteoporotic Kümmell's disease

BACKGROUND

Percutaneous vertebroplasty (PVP) and kyphoplasty (PKP) have been widely used to treat neurologically intact osteoporotic Kümmell's disease (KD), but it is still unclear which treatment is more advantageous. Our study aimed to compare and investigate the safety and clinical efficacy of PVP and PKP in the treatment of KD.

METHODS

The relevant data that 64 patients of neurologically intact osteoporotic KD receiving PVP (30 patients) or PKP (34 patients) were analyzed. Surgical time, operation costs, intraoperative blood loss, volume of bone cement injection, and fluoroscopy times were compared. Occurrence of cement leakage, transient fever and re-fracture were recorded. Universal indicators of visual analogue scale (VAS) and Oswestry disability index (ODI) were evaluated separately before surgery and at 1 day, 6 months, 1 year, 2 years and the final follow-up after operation. The height of anterior edge of the affected vertebra and the Cobb's angle were assessed by imaging.

RESULTS

All patients were followed up for at least 24 months. The volume of bone cement injection, intraoperative blood loss, occurrence of bone cement leakage, transient fever and re-fracture between two groups showed no significant difference. The surgical time, the operation cost and fluoroscopy times of the PKP group was significantly higher than that of the PVP group. The post-operative VAS, ODI scores, the height of the anterior edge of the injured vertebrae and kyphosis deformity were significantly improved in both groups compared with the pre-operation. The improvement of vertebral height and kyphosis deformity in PKP group was significantly better than that in the PVP group at every same time point during the follow-up periods, but the VAS and ODI scores between the two groups showed no significant difference.

CONCLUSION

PVP and PKP can both significantly alleviate the pain of patients with KD and obtain good clinical efficacy and safety. By contrast, PKP can achieve better imaging height and kyphosis correction, while PVP has the advantages of shorter operation time, less radiation volume and operation cost.

Current Concepts in the Management of Osteoporotic Vertebral Fractures: A Narrative Review

Vertebral fractures are the most common type of osteoporotic fracture and can increase morbidity and mortality. To date, the guidelines for managing osteoporotic vertebral fractures (OVFs) are limited in quantity and quality, and there is no gold standard treatment for these fractures. Conservative treatment is considered the primary treatment option for OVFs and includes pain relief through shortterm bed rest, analgesics, antiosteoporotic drugs, exercise, and braces. Studies on vertebral augmentation (VA) including vertebroplasty and kyphoplasty have been widely reported, but there is still debate and controversy regarding the effectiveness of VA when compared with conservative treatment, and the routine use of VA for OVF is not supported by current evidence. Although most OVFs heal well, approximately 15%-35% of patients with unstable fractures, chronic intractable back pain, severely collapsed vertebra (leading to neurological deficits and kyphosis), or chronic pseudarthrosis frequently require surgery. Given that there is no single technique for optimizing surgical outcomes in OVFs, tailored surgical techniques are needed. Surgeons need to pay attention to advances in osteoporotic spinal surgery and should be open to novel thoughts and techniques. Prevention and management of osteoporosis is the key element in reducing the risk of subsequent OVFs. Bisphosphonates and teriparatide are mainstay drugs for improving fracture healing in OVF. The effects of bisphosphonates on fracture healing have not been clinically evaluated. The intermittent administration of teriparatide significantly enhanced spinal fusion and fracture healing and reduced mortality risk. Based on the current literature, there is still a lack of standard management strategies for OVF. There is a need for greater efforts through multimodal approaches including conservative treatment, surgery, osteoporosis treatment, and drugs that promote fracture healing to improve the quality of the guidelines.

Different Performance of Intravertebral Vacuum Clefts in Kümmell's Disease and Relevant Treatment Strategies

Objectives

This study aimed to present the different pattern of intravertebral vacuum cleft (IVC) related to high risk of cement complications in minimally invasive treatments for Kümmell's disease (KD) and relevant treatment strategies.

Methods

A retrospective study from January 2016 to January 2018 was conducted at Wuhan Fourth Hospital and comprised 35 patients with Kümmell's disease. There were seven males and 28 females, and the mean age of the patients was 70.4 years. The patterns of IVC in KD were analyzed. These patients were divided into three groups based on the treatment method used. The treatment methods included long‐segment fixation (LSF), posterior short‐segment fixation (SSF), and percutaneous kyphoplasty (PKP). We retrospectively reviewed outcomes, including the Oswestry Disability Index (ODI), visual analog scale (VAS) score, anterior height of affected vertebrae, kyphotic Cobb angle, and complications.

Results

All patients were followed up for 12–38 months. According to their radiographic appearance we could observe two main patterns of clefts. Pattern I, clefts that were found to be near to the endplate and connected with intervertebral space, the endplate was incomplete. Pattern II, IVC traversed to anterior edge of the vertebral body affected. Both were related to high risk of cement complications in minimal invasive treatments for KD. Good results have been achieved in LSF and SSF groups, the VAS, ODI, anterior height of affected vertebrae and kyphotic Cobb angle showed statistically significant differences between pre‐ and post‐operation and between pre‐ and final follow‐up (P < 0.05). In PKP group, although the VSA and ODI showed statistically significant differences between pre‐ and post‐operation and between pre‐ and final follow‐up (P < 0.05), we could observe that the VSA and ODI rebounded a little at the final follow‐up. Cement leakage into intervertebral space occurred in four (44.45%) patients of PKP group.

Conclusions

PKP should be chosen carefully if the IVC of the patient presents to be pattern I or II. LSF and SSF are safe and effective, and can achieve satisfactory correction of kyphosis and vertebral height, with pain relief and improvement in patient's daily life, with few complications.

Percutaneous kyphoplasty: Risk Factors for Recollapse of Cemented Vertebrae

INTRODUCTION

Percutaneous kyphoplasty can offer pain relief and restoration of vertebral height immediately after the procedure; however, little is known about how many vertebrae recollapse during follow-up or why recollapse occurs. In the present study, we define recollapse of a treated vertebra, assess how common it is following percutaneous kyphoplasty, and investigate risk factors for the condition.

METHODS

In total, 203 consecutive patients who underwent percutaneous kyphoplasty were reviewed after an average 12.7 months to assess what proportion of cement-augmented vertebrae had recollapsed. Potential risk factors for recollapse included age, gender, body weight, body height, body mass index, treated level, duration of symptoms, follow-up duration, preoperative T-scores, surgical approach, the intravertebral cleft, contact of polymethyl methacrylate (PMMA) with endplates, cement volume, cement leakage, and midline vertebral body height. Stepwise multivariate linear regression was conducted to predict recollapse as quantified by midline vertebral height loss.

RESULTS

Overall, 38.9% of the augmented vertebrae recollapsed. In the recollapse group, the average midline vertebral height ratio and kyphotic angles statistically significantly changed during follow-up (P < 0.05). Pain scores decreased immediately after percutaneous kyphoplasty and generally remained low at follow-up. Significant predictors of midline vertebral height loss at follow-up included presence of an intravertebral cleft, postoperative vertebral height, and non-PMMA-endplate-contact. Together, these factors accounted for 28% of the variability in midline height loss.

CONCLUSIONS

Benefits of percutaneous kyphoplasty are partly offset by subsequent recollapse. Recollapse is greater if there is an intravertebral cleft, non-PMMA-endplate-contact and an increase in the post vertebral height.

[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.