Unipedicular versus bipedicular percutaneous vertebroplasty for osteoporotic vertebral compression fractures: a prospective randomized study

Percutaneous Kyphoplasty via Transverse Process-Rib-Pedicle Approach for Upper and Middle Thoracic Osteoporosis Fracture with Pedicle Stenosis

OBJECTIVE

To explore the clinical effect of percutaneous kyphoplasty (PKP) via process-rib-pedicle approach for upper and middle thoracic osteoporosis fractures with pedicle stenosis.

METHODS

This study is a retrospective observational study. In this study, we retrospectively analyzed the data of 62 patients with upper thoracic vertebral bone loss compression fracture treated via the process-rib-pedicle pathway PKP at the First Affiliated Hospital of Soochow University from January 2020 to December 2022. The patients were divided into group A (unilateral PKP, 38 cases) and group B (bilateral PKP, 24 cases). The aspects of surgical safety, clinical efficacy, and radiological outcome were investigated.

RESULTS

All 62 patients successfully completed the surgery without any spinal cord, nerve, or vascular injury, and there were no complications such as infection and vascular embolism. The differences in visual analog scale scores（P < 0.05）, Oswestry disability index functional index（P < 0.05）, and Cobb angle（P < 0.05） were significant when comparing preoperative and postoperative periods, and the differences were not significant when comparing the postoperative periods (P > 0.05). There were no statistically significant differences in days of hospital stay (P = 0.653) and the rate of bone cement leakage (P = 0.537) between the 2 groups.

CONCLUSIONS

For upper middle osteoporotic thoracic vertebral fractures with pedicle stenosis, puncture via the process-rib-pedicle path is a safe and reliable puncture route, and more than 2.5 ml of cement can achieve good clinical outcomes, regardless of bilateral or unilateral PKP.

Comparison of the efficacy and safety of vertebroplasty with different pedicle approaches for osteoporotic vertebral

OBJECTIVE

To compare the efficacy and safety of vertebroplasty through different pedicle approaches in the treatment of osteoporotic vertebral compression fracture osteoporotic vertebral compression fractures (OVCF) by network meta-analysis.

METHODS

Pubmed, Embase, Cochrane Library, Web of Science. Database for literature retrieval, retrieval time from the establishment of the database to April 2023, the randomized controlled trials of unilateral vertebroplasty (UVP), bilateral vertebroplasty (BVP), unilateral kyphoplasty (UKP), bilateral kyphoplasty (BKP), curved vertebroplasty (CVP) and curved kyphoplasty (CKP) were screened, evaluated and the data were extracted and included in the analysis. STATA 15.0 and ReMan 5.3 were used for data analysis. This study was registered in the National Institute for Health Research (NIHR) with the registration number CRD42023405181.

RESULTS

This study included 16 articles with a total of 1712 patients. The order of visual analogue scale (VAS) improvement from good to bad is CVP > BVP > UVP > CKP > BKP > UKP. The order of kyphotic angles improvement from good to bad is CKP > UKP > UKP > UVP > BVP > CVP. The order of bone cement injection from less to more is UVP > CVP > UKP > CKP > BVP > BKP. The order of bone cement leakage rate from less to more is CKP > CVP > UKP > BKP > UVP > BVP. The order of X-ray exposure time from less to more is CKP > CVP > UVP > BVP > UKP > BKP. The order of operation time from less to more is CVP > UVP > UKP > CKP > BVP > BKP.

CONCLUSION

For patients with kyphotic angles, kyphoplasty has unique advantages in improving kyphotic angles. But generally speaking, curved approach can optimize the distribution of bone cement through unilateral approach to achieve the orthopedic effect of bilateral approach, which is a minimally invasive technique with better curative effect and higher safety in the treatment of OVCF.

Effect of cement volume on biomechanical response of a spine segment treated with a PEEK polymer implant: a finite element comparative study with vertebroplasty

In the current study, a 3D finite element study was performed to investigate the biomechanical response of an osteoporotic spine segment treated with a novel transpedicular implant (V-STRUT©, Hyprevention, France) made of PEEK (polyetheretherketone) material combined with either injections of 2, 3, 4, 5 and 6 cc of cement. The objective was to assess numerically the biomechanical performance of the implant in combination with different doses of the injected bone cement and to compare its performance with the gold standard vertebroplasty (VP) technique. A female (69 yo) was selected and a 3D finite element model of an osteoporotic spine segment was built based on a Computed Tomography (CT) scan performed from T12 to L2 with corresponding intervertebral discs and ligaments. A heterogeneous distribution of bone material properties was assigned to the bone using grey scale levels. Bilateral ellipsoid geometries of the inserted cement were retained for the V-STRUT and VP models based on experimental observation performed on different patients treated with the V-STRUT device. The current study demonstrated an optimal dose of 4 cc of bilaterally injected cement for the V-STRUT and VP techniques to restore the treated segment and confirmed that the V-STRUT device in combination with bone cement is superior to VP alone in establishing the normal stiffness and in reducing the applied stress to the immediately adjacent vertebral levels.

Clinical efficacy of percutaneous vertebroplasty versus percutaneous kyphoplasty treating osteoporotic vertebral compression fractures with kyphosis

PURPOSE

This study aimed to investigate the clinical efficacy of percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) in treating osteoporotic vertebral compression fractures (OVCFs) with kyphosis.

METHODS

The clinical data included 63 patients in the PVP group and 70 in the PKP group. The study assessed the pain visual analog scale (VAS), Oswestry Disability Index (ODI), wedge angle (WA), local kyphotic angle (LKA), and vertebral height.

RESULTS

The operative time was significantly less in the PVP group (p < 0.05). Meanwhile, more bone cement was injected into the PKP group (p < 0.05), with significantly higher surgical costs (p > 0.05). Post-operative VAS, ODI, WA, LKA, and vertebral height were significantly improved in PVP and PKP groups compared with pre-operative measurements (p < 0.05). The results revealed insignificant VAS and ODI improvement differences between the two groups at each follow-up time (p > 0.05). Vertebral height, WA, and LKA improved more significantly in the PKP group at day 1 and 3 months post-operatively (p < 0.05), with insignificant group differences at subsequent time points (p > 0.05). The improvements in VAS were unrelated to those in WA, LKA, or vertebral height in either group (p > 0.05). The improvement in VAS was unrelated to the amount of bone cement injected (p > 0.05); the PKP group demonstrated a lower incidence of cement leakage (12.9%; p < 0.05).

CONCLUSION

PVP and PKP can restore partial vertebral height and improve kyphosis with similar clinical outcomes. PVP has a shorter operating time, is more economical, and can represent a therapeutic choice.

Risk of adjacent level fracture after percutaneous vertebroplasty and kyphoplasty vs natural history for the management of osteoporotic vertebral compression fractures: a network meta-analysis of randomized controlled trials

OBJECTIVES

Percutaneous vertebroplasty and kyphoplasty are common interventions for osteoporotic vertebral compression fractures. However, there is concern about an increased risk of adjacent-level fractures after treatment. This study aimed to compare the risk of adjacent-level fractures after vertebroplasty and kyphoplasty with the natural history after osteoporotic vertebral compression fractures.

MATERIALS AND METHODS

A network meta-analysis of randomized controlled trials (RCTs) was conducted to evaluate the risk of adjacent-level fractures after vertebroplasty and kyphoplasty compared to the natural history after osteoporotic vertebral compression fractures. Frequentist network meta-analysis was conducted using the "netmeta" package, and heterogeneity was assessed using Q statistics. The pooled risk ratio (RR) and 95% confidence intervals (CI) were calculated using random effects.

RESULTS

Twenty-three RCTs with a total of 2838 patients were included in the analysis. The network meta-analysis showed comparable risks of adjacent-level fractures between vertebroplasty, kyphoplasty, and natural history after osteoporotic vertebral compression fractures with a mean follow-up of 21.2 (range: 3-49.4 months). The pooled RR for adjacent-level fractures after kyphoplasty compared to natural history was 1.35 (95% CI, 0.78-2.34, p = 0.23) and for vertebroplasty compared to natural history was 1.16 (95% CI, 0.62-2.14) p = 0.51. The risk of bias assessment showed a low to moderate risk of bias among included RCTs.

CONCLUSION

There was no difference in the risk of adjacent-level fractures after vertebroplasty and kyphoplasty compared to natural history after osteoporotic vertebral compression fractures. The inclusion of a large patient number and network meta-analysis of RCTs serve evidence-based clinical practice.

CLINICAL RELEVANCE STATEMENT

The risk of adjacent-level fracture following percutaneous vertebroplasty or kyphoplasty is similar to that observed in the natural history after osteoporotic vertebral compression fractures.

KEY POINTS

RCTs have examined the risk of adjacent-level fracture after intervention for osteoporotic vertebral compression fractures. There was no difference between vertebroplasty and kyphoplasty patients compared to the natural disease history for adjacent compression fractures. This is strong evidence that interventional treatments for these fractures do not increase the risk of adjacent fractures.

Advantages of unilateral percutaneous kyphoplasty for osteoporotic vertebral compression fractures-a systematic review and meta-analysis

Data from English randomized controlled trials comparing unilateral versus bilateral PKP for the treatment of OVCFs were retrieved and analyzed, and the results showed that unilateral PKP is a better choice for the treatment of patients with OVCFs, which will provide a reliable clinical rationale for the treatment of OVCFs.

PURPOSE

To investigate the advantages of unilateral percutaneous kyphoplasty (PKP) for the treatment of osteoporotic vertebral compression fractures(OVCFs).

METHODS

The systematic evaluation program met all program requirements (CRD 42023422383) by successfully passing the PROSPERO International Prospective Systematic Evaluation Registry. Researchers searched the references of English-language randomized controlled trials comparing unilateral and bilateral PKP for the treatment of osteoporotic vertebral compression fractures published between 2010 and 2023 and manually searched for known primary and review articles. The study statistically analyzed data from all the included literature, which primarily included time to surgery, visual pain score(VAS) and Oswestry disability index(ODI) at postoperative follow-up time points, polymethylmethacrylate (PMMA, bone cement) injection dose, cement leakage, radiation dose, and improvement in kyphotic angle.

RESULTS

This meta-analysis searched 416 articles published from 2010 to 2023 based on keywords, and 18 articles were finally included in this study. The results of the forest plot showed that unilateral PKP operative time, amount of bone cement used, and radiation dose to the patient were significantly reduced (p < 0.01, p < 0.01, and p < 0.01, respectively), and unilateral and bilateral PKP had comparable cement leakage (p = 0.49, 95% CI = 0.58-1.30), and there was no significant difference in the kyphotic angle between unilateral and bilateral PKP (p = 0.42, 95% CI =  - 2.29-0.96). During follow-up, there was no significant difference in pain relief between unilateral and bilateral PKP (p = 0.70, 95% CI =  - 0.09-0.06), nor was there a significant difference in ODI (p = 0.27, 95% CI =  - 0.35-1.24).

CONCLUSIONS

There is no difference in clinical efficacy between unilateral PKP and bilateral PKP, but unilateral PKP has a shorter operative time, a lower incidence of cement leakage, a lower amount of cement, and a lower radiation dose to the patient and operator. Unilateral PKP is a better option for patients with OVCFs.

Percutaneous Curved Vertebroplasty Decrease the Risk of Cemented Vertebra Refracture Compared with Bilateral Percutaneous Kyphoplasty in the Treatment of Osteoporotic Vertebral Compression Fractures

Purpose

The purpose of this study is to compare the refracture rate of the cemented vertebral body of percutaneous curved vertebroplasty (PCVP) and bilateral percutaneous kyphoplasty (PKP) in the treatment of osteoporotic vertebral compression fractures (OVCF).

Methods

Ninety-four patients with single segment thoracolumbar OVCF were randomly divided into two groups (47 patients in each) and underwent PCVP or bilateral PKP surgery, respectively. Refracture of cemented vertebral body, bone cement injection volume and cement pattern, cement leakage rate, total surgical time, intraoperative fluoroscopy time, preoperative and postoperative Cobb angles and anterior vertebral height, Oswestry disability index questionnaire (ODI) and visual analog scales (VAS) were recorded.

Results

The PCVP group had significantly lower refracture incidence of the cemented vertebral than the bilateral PKP group (p<0.05). There was a significant postoperative improvement in the VAS score and ODI in both group (p<0.01), and no significant difference was found between two groups. The operation time and intraoperative fluoroscopy times were significantly less in the PCVP group than in the bilateral PKP group (p<0.01). The mean kyphosis angle correction and vertebral height restoration in the PCVP group was significantly less than that in the bilateral PKP group (p<0.01).

Conclusion

Both PCVP and PKP were safe and effective treatments for OVCF. The PCVP had lower refracture rate of the cemented vertebral than the bilateral PKP group, and PCVP entailed less exposure to fluoroscopy and shorter operation time than bilateral PKP.

Comparative Efficacy of Surgical Interventions for Osteoporotic Vertebral Compression Fractures: A Systematic Review and Network Meta-analysis

OBJECTIVE

We aimed to comprehensively compare surgical methods for osteoporotic vertebral compression fracture (OVCF) using systematic review and network meta-analysis to understand their effectiveness and outcomes, as current research provides limited overviews.

METHODS

We followed PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines, preregistering our protocol with PROSPERO. We analyzed Englishpublished randomized controlled trials (RCTs) on adults with OVCFs that evaluated pain intensity or functionality using tools like visual analogue scale (VAS) or Oswestry Disability Index (ODI). Exclusions included non-RCTs, malignancy-related fractures, and certain interventions. Using the RoB 2 tool, we assessed bias and visualized results with Robvis. Our primary outcome was pain intensity, with secondary outcomes including disability, new fractures, and cement leakage. Results were synthesized using Stata/MP.

RESULTS

Thirty-four RCTs from 10 countries, totaling 4,384 patients, were analyzed. Shortterm VAS indicated kyphoplasty with facet joint injection (KIJ) as the top treatment at 87.7%, while unipedicular kyphoplasty (UKP) led to long-term at 74.9%. Short-term ODI favored vertebroplasty with facet joint injection (VIJ) at 98.4%, with kyphoplasty (KP) leading longterm at 66.0%. All surgical techniques were superior to conservative treatment. Vertebral augmentation devices reported the fewest new fractures and curved vertebroplasty had the least cement leakage. SUCRA (surface under the cumulative ranking) analyses suggested UKP and VIJ as top choices for postoperative pain relief, with VIJ excelling in postoperative disability improvement.

CONCLUSION

Our analysis evaluates 12 OVCF interventions, underscoring KIJ for short-term pain relief and VIJ and UKP for long-term efficacy. Notably, VIJ stands out in disability outcomes, emphasizing the need for comprehensive OVCF management.

Percutaneous Curved Vertebroplasty and Bilateral-Pedicle-Approach Percutaneous Vertebroplasty in the Treatment of Osteoporotic Vertebral Compression Fracture: A Meta-Analysis

Introduction

The aim of this study was to evaluate the use of percutaneous curved vertebroplasty procedure (PCVP) and bilateral-pedicle-approach percutaneous vertebroplasty (bPVP) for the treatment of osteoporotic vertebral compression fractures (OVCFs) through a systematic review and meta-analysis of the scientific literature.

Methods

A systematic review of the scientific literature in PubMed, China National Knowledge Infrastructure (CNKI), Wanfang and other databases was conducted in conjunction with different keywords. Nine studies were included; all but 3 were randomised controlled studies and all were prospective or retrospective cohort studies.

Results

We observed statistically significant differences between the PCVP group and the bPCVP group in terms of postoperative visual analogue scale (VAS) scores (mean difference [MD]: -.08; 95% confidence intervals [CI]: -.15 to .00), bone cement leakage rates (OR = .33; 95%CI: .20 to .54), bone cement injection (MD: -1.52; 95%CI: -1.58 to 1.45), operative times (MD: -16.69; 95%CI: -17.40 to -15.99) and intraoperative fluoroscopies (MD: -8.16; 95%CI: -9.56 to -6.67), with the PCVP group being more dominant. There were no statistical differences in postoperative Oswestry Disability Index (ODI) scores (MD: -.72; 95%CI: -2.11 to .67) and overall bone cement distribution rates (MD: 2.14; 95%CI: .99 to 4.65) between the 2 groups.

Conclusions

Meta-analysis showed more favourable outcomes in the PCVP group compared to the bPVP group. PCVP might be effective and safe in the treatment of OVCFs because it relieves postoperative patient pain, reduces operative time and cement injection, and decreases the risk of cement leakage and radiation exposure to the surgeon and patient.

Comparison of unipedicular and bipedicular kyphoplasty for treating acute osteoporotic vertebral compression fractures in the lower lumbar spine: a retrospective study

BACKGROUND

Unipedicular and bipedicular approaches for percutaneous kyphoplasty are reportedly both effective in treating osteoporotic vertebral compression fractures (OVCFs). However, most studies have reported thoracolumbar fractures, with few reports describing the treatment of the lower lumbar spine. Here, we compared the clinical and radiological results of unipedicular and bipedicular approaches for percutaneous kyphoplasty for treating osteoporotic vertebral compression fractures.

METHODS

We retrospectively reviewed the records of 160 patients who underwent percutaneous kyphoplasty for lower lumbar (L3-L5) osteoporotic vertebral compression fractures between January 2016 and January 2020. Patient characteristics, surgical outcomes, operation time, blood loss, clinical and radiological features, and complications were compared between two groups. Cement leakage, height restoration, and cement distribution were calculated from the radiographs. Visual pain analog scale (VAS) and Oswestry Disability Index (ODI) were calculated before surgery, immediately post-surgery, and 2 years after surgery.

RESULTS

The mean age, sex, body mass index, injury time, segmental distribution, and morphological classification of fractures before surgery did not differ significantly between the groups. The results showed significant improvements in the VAS score, ODI score, and vertebral height restoration in each group (p < 0.05), with no significant differences between the two groups (p > 0.05). The mean operation time and extent of blood loss were lower in the unipedicular group than those in the bipedicular group (p < 0.05). Different types of bone cement leakage were observed in both groups. Leakage rate was higher in the bipedicular group than in the unipedicular group. Patients in the bipedicular group showed greater improvement in bone cement distribution than those in the unipedicular group (p < 0.05).

CONCLUSIONS

The clinical and radiological results of unipedicular percutaneous kyphoplasty for treating osteoporotic vertebral compression fractures in the lower lumbar region were similar to those of bipedicular percutaneous kyphoplasty. However, the unipedicular approach resulted in shorter surgical time, less blood loss, and less bone cement leakage. Thus, the unipedicular approach may be preferable owing to its several advantages.

ACR Appropriateness Criteria® Management of Vertebral Compression Fractures: 2022 Update

Vertebral compression fractures (VCFs) can have a variety of etiologies, including trauma, osteoporosis, or neoplastic infiltration. Osteoporosis related fractures are the most common cause of VCFs and have a high prevalence among all postmenopausal women with increasing incidence in similarly aged men. Trauma is the most common etiology in those >50 years of age. However, many cancers, such as breast, prostate, thyroid, and lung, have a propensity to metastasize to bone, which can lead to malignant VCFs. Indeed, the spine is third most common site of metastases after lung and liver. In addition, primary tumors of bone and lymphoproliferative diseases such as lymphoma and multiple myeloma can be the cause of malignant VCFs. Although patient clinical history could help raising suspicion for a particular disorder, the characterization of VCFs is usually referred to diagnostic imaging. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Analysis of the Curative Effect of Curved Angle Vertebroplasty in the Treatment of Osteoporotic Vertebral Compression Fracture

Objective

To evaluate the clinical efficacy of Percutaneous curved vertebroplasty (PCVP) for osteoporotic vertebral compression fracture of the thoracolumbar spine.

Methods

Retrospective analysis of 113 patients with osteoporotic vertebral compressive fractures (OVCFs) in our hospital from January 2017 to January 2020, a total of 120 diseased vertebrae, were divided into PCVP group (35 cases, 37 sections) and bilateral PVP(BVP) group (78 cases, 83 sections). To compare the distribution of baseline clinical data, pain relief (Visual Analog Scale, VAS), ODI (Oswestry Dability Index, ODI), operation time, intraoperative fluoroscopy, postoperative vertebral body re-fracture, and comparison of bone, and to compare the volume of cement penetration and the leakage rate of bone cement, etc.

Results

There was no significant difference in VAS and ODI before operation between the two groups (P > 0.05), and the VAS score and ODI after operation were significantly improved (P < 0.001). Compared with the bilateral PVP group, the operation time, the number of fluoroscopy, and the leakage rate of each layer of bone cement in the PCVP group were significantly reduced (P < 0.05); however, the amount of cement used in the two groups was similar (P > 0.05). There were no serious complications in both groups. In the bilateral PVP group, a total of seven patients had adjacent vertebral fractures or re-fractures of the original vertebral body. However, no patients in the PCVP group had re-fractures in any vertebral body segment.

Conclusion

Both PCVP and bilateral PVP are safe and effective methods for the treatment of osteoporotic vertebral compression fractures, but PCVP has a short operation time, fewer fluoroscopy times, and a low bone cement leakage rate.

High-viscosity versus low-viscosity cement for the treatment of vertebral compression fractures: A meta-analysis of randomized controlled trials

BACKGROUND

High viscosity cement (HVC) and low viscosity cement (LVC) have been used to treat osteoporotic vertebral compression fractures (OVCFs). Our study was to assess the safety and efficacy of HVC and LVC in treating OVCFs.

METHODS

We searched the electronic database for randomized controlled trials of HVC and LVC to treat OVCFs. Random-effects model was performed to pool the outcomes about operation time, visual analogue scale (VAS), bone cement injection volume, oswestry disability index (ODI), bone cement leakage and adjacent vertebral fractures.

RESULTS

Twelve randomized trials were included in the meta-analysis. The 2 groups had similar changes in terms of bone cement injection volume, ODI and adjacent vertebral fractures. The HVC group showed shorter operation time and better VAS score improvement. The bone cement leakage rate of the HVC group was significantly better than LVC group (P < .00001).According to the location of bone cement leakage, in the leakages of the veins (P < .00001), the intervertebral disc (P < .00001), the paravertebral area (P = .003) and the intraspinal space (P = .03), the HVC group were significantly better than the LVC group.

CONCLUSIONS

In terms of bone cement injection volume, ODI and adjacent vertebral fractures, the 2 group are equivalent. HVC had a shorter operation time, lower bone cement leakage rate and better VAS score improvement, compared with LVC.

Effect of cement distribution type on clinical outcome after percutaneous vertebroplasty for osteoporotic vertebral compression fractures in the aging population

Objective

The study aimed to investigate the effect of the type of bone cement distribution on clinical outcomes following percutaneous vertebroplasty (PVP) for osteoporotic vertebral compression fractures (OVCF) in the elderly.

Methods

Retrospective analysis of 160 patients diagnosed with OVCF who underwent PVP treatment from March 2018 to December 2020. Based on the kind of postoperative bone cement distribution, bone cement was classified as types I, II, III, IV, and V. Visual Analog Scale (VAS), Oswestry Disability Index (ODI), Cobb angle, anterior vertebral height ratio, refracture rate of injured vertebrae, and incidence of adjacent vertebral fractures were compared for the five types before and after three days, and one year of operation.

Results

VAS and ODI at three days and one year postoperative were significantly lower than those preoperative (P < 0.05) for all five distribution types. VAS and ODI for types I, II, and III were lower at one year postoperatively than for types IV and V (P < 0.05). There was no significant difference in Cobb angle and anterior vertebral body height ratio between preoperative and three days postoperative groups (P < 0.05); however, there were significant differences between three days and one-year postoperative and preoperative groups (P < 0.05). Following one year of surgery, the Cobb angle and the anterior vertebral height ratio of types IV and V were significantly different from those of types I, II, and III (P < 0.05), and there was a statistically significant difference between types IV and V (P < 0.05). In terms of the incidence of injured vertebral refractures and adjacent vertebral fractures, the evenly distributed types I, II, and III were significantly lower than the unevenly distributed types IV and V, and the incidence of type V was higher (P < 0.05).

Conclusions

The clinical efficacy of cement distribution following PVP of types I, II, and III is better than that of types IV and V, which can better relieve pain with long-lasting efficacy and minimize the occurrence of refractures of injured vertebrae and adjacent vertebral body fractures.

Balloon Kyphoplasty vs Vertebroplasty: A Systematic Review of Height Restoration in Osteoporotic Vertebral Compression Fractures

Purpose of Review

This systematic review comprehensively compared balloon kyphoplasty and vertebroplasty with respect to height restoration and pain relief.

Recent Findings

PRISMA guidelines were utilized to compare balloon kyphoplasty and vertebroplasty, focusing on the primary outcome of height restoration and the secondary outcomes of pain relief and functionality. A total of 33 randomized controlled trials were included; 20 reviewed balloon kyphoplasty, 7 reviewed vertebroplasty, and 6 compared vertebroplasty to balloon kyphoplasty. Both treatments restored some vertebral body height and showed benefits in pain reduction and improved patient-reported functionality.

Summary

Balloon kyphoplasty and vertebroplasty are effective treatments for vertebral compression fractures and this review suggests that balloon kyphoplasty may be favored for vertebral height restoration. Further studies are needed to conclude whether balloon kyphoplasty or vertebroplasty is superior for alleviating pain.

Percutaneous Vertebroplasty: Efficacy of Unipedicular Vertebroplasty as Compared to Bipedicular Vertebroplasty

Introduction  Percutaneous vertebroplasty has been used for treatment of intractable painful fractures of vertebral bodies. With the help of refined procedures and standard techniques, the interventional radiologist can now offer help to orthopedics and neurosurgeons in these cases, which include treatment of vertebral compression fracture. Vertebroplasty is aimed at reducing the pain induced by collapse. Vertebroplasty is the standard mode of treatment for vertebral collapse, and in our study, bipedicular vertebroplasty was compared with unipedicular approach as bipedicular vertebroplasty is the routinely used approach.

Aim  To compare efficacy of unipedicular percutaneous vertebroplasty with that of bipedicular percutaneous vertebroplasty.

Material and Methods  A total of 52 vertebroplasties were done over a period of 2 years. Out of 52 patients, 28 patients underwent unipedicular vertebroplasty and 24 patients underwent bipedicular vertebroplasty. Visual analogue scale (VAS) scores were used to assess the pain prior to vertebroplasty and after vertebroplasty. Efficacy of the two procedures were assessed by comparing VAS scores.

Results  There was no statistically significant difference observed in the preprocedure and postprocedure VAS scores ( p -value < 0.0001, < 0.0001, respectively). The mean procedure time was lesser in unipedicular vertebroplasty (41.9 ± 3.90) than bipedicular vertebroplasty (54.5 ± 3.4).

Conclusion  Unipedicular vertebroplasty is as effective as bipedicular vertebroplasty, as there is insignificant difference in postprocedure VAS scores between the unipedicular and bipedicular vertebroplasty.

Insufficient Augmentation of Bone Cement Causes Recompression of Augmented Vertebra after Balloon Kyphoplasty

Introduction

Balloon kyphoplasty (BKP) is one of the most frequently used clinical methods to relieve pain caused by osteoporotic vertebral compression fracture (OVCF); it can effectively improve the body height of the vertebra. However, recompression of the augmented vertebra (RAV) is often observed after BKP. This study aimed to report factors that are associated with RAV in terms of cement augmentation.

Methods

A total of 78 patients (women, 60; men, 18) were included in this study. RAV was defined as anterior vertebral height loss (VHL), between immediate postoperation and 3 or 6 months after BKP, of more than 5.0 mm. Cement augmentation ratio (CAR) was calculated as the ratio of the maximal height of polymethylmethacrylate (PMMA) to the maximal distance between both end plates. Age, gender, fracture age, CAR, presence of medication for osteoporosis, intervertebral cleft (IVC), and cement leakage were evaluated using Fisher's exact test or Mann-Whitney U test to compare between RAV and non-RAV groups. Aforementioned variables were also analyzed using multiple logistic regression test. A P<0.05 was considered statistically significant.

Results

The incidence rates for RAV at 3 and 6 months were 35.9% (28/78) and 38.5% (30/78), respectively. Age (80.1 vs 74.7) was significantly higher in the RAV group, whereas CAR (69.4% vs 77.6%) was lower in the non-RAV group. A multivariate regression analysis revealed that age (odds ratio (OR)=1.12, P=0.001) and CAR (OR=0.91, P=0.001) were independently associated with RAV.

Conclusions

RAV was observed in 38.5% of patients in this study. Older age and low CAR were independently associated with RAV. To prevent RAV, especially in the elderly, augmented PMMA should come in contact with both end plates.

Comparison of the effectiveness and safety of unilateral and bilateral percutaneous vertebroplasty for osteoporotic vertebral compression fractures: A protocol for systematic review and meta-analysis

BACKGROUND

The objective of this study was to compare the efficacy of lateral and bilateral percutaneous vertebroplasty (PVP) in treating osteoporotic vertebral compression fractures (OVCFs).

METHODS

A comprehensive literature search was performed using PubMed, Cochrane Library, EMBASE, CMB, CNKI, Wanfang, and VIP databases between January 2014 and December 2020. The clinical efficacy of the 2 approaches was evaluated by comparing perioperative outcomes (operation time, X-ray exposure time, volume of injected cement), clinical outcomes (degree of vertebral height restoration, improvement of Cobb angle, visual analogue scale score, and Oswestry Disability Index scores), and operation-related complications (rate of cement leakage, adjacent vertebral fracture rate, and nerve root stimulation). Data were analyzed using RevMan 5.3.3 and Stata 15.1.

RESULTS

A total of 237 related articles were retrieved, and 17 randomized controlled trials were included. Meta-analysis results showed that compared to bilateral PVP, unilateral PVP led to decreased operation times (mean difference [MD] = -15.24, 95% confidence interval [CI]: [-17.77, -12.70], P < .05), decreased X-ray exposure time (MD-8.94, 95% CI[-12.08,-5.80]; P < .01), decreased volumes of injected cement (MD-1.57, 95% CI[-2.00,-1.14]; P < .05), and lower incidence of cement leakage (risk ratio [RR] = 0.6,95% CL[0.48,0.77], P < .01). Patients that underwent unilateral PVP experienced more effective pain relief at the last follow-up (MD-0.09, 95% CI [-0.15,-0.03];P=.006 < .05) and had a low degree of vertebral height restoration (MD-0.38, 95% CL [-0.71, -0.06]; P=.02 < .05). However, no differences in adjacent vertebral fractures (RR 1.19, 95% CI [0.78,1.82]; P = .41 > .01), nerve root stimulation (RR 1.98, 95% CI [0.22, 17.90]; P = .54 > .01), improvement of Cobb angle (MD = -0.18, 95% CI [-0.49, 0.13], P = .26 > .01), and improvement of ODI score (MD = 0.22, 95% CI[-0.37, 0.80], P > .05) were found between the 2 approaches.

CONCLUSIONS

Although both unilateral and bilateral PVP can improve the quality of life of this patient population by managing pain effectively, unilateral PVP offers more benefits, including shorter operation time and less fluoroscopy, and should be recommended in clinical practice for OVCFs.

A Modified Transverse Process-Pedicle Approach Applied to Unilateral Extrapedicular Percutaneous Vertebroplasty

Objective

To introduce a modified transverse process-pedicle puncture technique applied to unilateral extrapedicular percutaneous vertebroplasty (PVP) for the treatment of osteoporotic lumbar vertebral compression fractures.

Methods

A retrospective study was performed on 91 patients with osteoporotic vertebral compression fractures (OVCFs) who underwent unilateral extrapedicular PVP from June 2016 to September 2018. Lumbar and back pain was assessed through the visual analogue scale (VAS). Function recovery was assessed through the Oswestry disability index (ODI). Radiologic outcomes were assessed mainly on the basis of bone cement distribution and anterior vertebral height.

Results

A total of 101 fractured vertebrae were successfully treated using the extrapedicular technique without any recognized clinical complications. The postoperative VAS and ODI values were significantly lower than the corresponding preoperative values (P < 0.01). Radiologic outcomes in all fractured vertebrae showed that the diffusion of bone cement could exceed the midline of the vertebral body. There was no significant difference between preoperative and postoperative anterior vertebral heights (P < 0.05).

Conclusion

The modified transverse process-pedicle approach applied to unilateral extrapedicular percutaneous vertebroplasty is a simple, safe, and effective surgical method.

Logistic regression analysis on risk factors of augmented vertebra recompression after percutaneous vertebral augmentation

Objective

To explore the high-risk factors of augmented vertebra recompression after percutaneous vertebral augmentation (PVA) in the treatment of osteoporotic vertebral compression fracture (OVCF) and analyze the correlation between these factors and augmented vertebra recompression after PVA.

Methods

A retrospective analysis was conducted on 353 patients who received PVA for a single-segment osteoporotic vertebral compression fracture from January 2017 to December 2018 in our department according to the inclusion criteria. All cases meeting the inclusion and exclusion criteria were divided into two groups: 82 patients in the recompression group and 175 patients in the non-compression group. The following covariates were reviewed: age, gender, body mass index (BMI), injured vertebral segment, bone mineral density (BMD) during follow-up, intravertebral cleft (IVC) before operation, selection of surgical methods, unilateral or bilateral puncture, volume of bone cement injected, postoperative leakage of bone cement, distribution of bone cement, contact between the bone cement and the upper or lower endplates, and anterior height of injured vertebrae before operation, after surgery, and at the last follow-up. Univariate analysis was performed on these factors, and the statistically significant factors were substituted into the logistic regression model to analyze their correlation with the augmented vertebra recompression after PVA.

Results

A total of 257 patients from 353 patients were included in this study. The follow-up time was 12–24 months, with an average of 13.5 ± 0.9 months. All the operations were successfully completed, and the pain of patients was relieved obviously after PVA. Univariate analysis showed that in the early stage after PVA, the augmented vertebra recompression was correlated with BMD, surgical methods, volume of bone cement injected, preoperative IVC, contact between bone cement and the upper or lower endplates, and recovery of anterior column height. The difference was statistically significant (P < 0.05). Among them, multiple factors logistic regression elucidated that more injected cement (P < 0.001, OR = 0.558) and high BMD (P = 0.028, OR = 0.583) were negatively correlated with the augmented vertebra recompression after PVA, which meant protective factors (B < 0). Preoperative IVC (P < 0.001, OR = 3.252) and bone cement not in contact with upper or lower endplates (P = 0.006, OR = 2.504) were risk factors for the augmented vertebra recompression after PVA. The augmented vertebra recompression after PVP was significantly less than that of PKP (P = 0.007, OR = 0.337).

Conclusions

The augmented vertebra recompression after PVA is due to the interaction of various factors, such as surgical methods, volume of bone cement injected, osteoporosis, preoperative IVC, and whether the bone cement is in contact with the upper or lower endplates.

Perioperative Hidden Blood Loss in Elderly Osteoporotic Vertebral Compression Fracture Patients With Percutaneous Vertebroplasty and Influencing Factors

Introduction

To analyze perioperative hidden blood loss (HBL) and its influencing factors in elderly patients with osteoporotic vertebral compression fracture (OVCF) treated with percutaneous vertebroplasty (PVP).

Materials and Methods

From January 2016 to December 2018, 103 elderly patients with OVCF (age > 85 years) treated with PVP were selected. The patient's height, weight, duration of symptoms, previous medical history and other basic information were recorded. The hemoglobin (Hb) and hematocrit (Hct) immediately after admission and the next day postoperative were recorded. The operation time, surgical bleeding, Kummell's disease, vertebral height preoperative and postoperative, and bone cement leakage was recorded. The total blood loss (TBL) was calculated according to Gross's formula, and HBL was calculated based on the TBL and surgical bleeding. The influential factors were analyzed by multivariate linear regression analysis and single factor correlation analysis.

Results

The mean surgical bleeding was 11.83 ± 5.37 mL, and HBL was 306.19 ± 185.92 mL, with a statistically significant difference (P = 0.000). According to the multiple linear regression analysis, the duration of symptoms (P = 0.030), number of fracture segments (P = 0.016), operation time (P = 0.004), loss of vertebral height (P = 0.026), recovery of vertebral height (P = 0.004), Kummell's disease (P = 0.040) and cement leakage (P = 0.004) were correlated with an increased amount of HBL. Sex (P = 0.077), body mass index (BMI) (P = 0.486), hypertension (P = 0.734), diabetes (P = 0.769), fracture level (P = 0.518) and surgical bleeding (P = 0.821) had no correlation with the amount of HBL.

Conclusions

There was obvious HBL during the perioperative period of PVP in elderly patients with OVCF. A fresh fracture, multi-segment vertebral fracture, longer operation time, presence of Kummell's disease, loss of vertebral height, recovery of vertebral height and cement leakage the increased perioperative HBL during PVP.

Short-term Efficacy of the Percutaneous Vertebroplasty Using a Curved Versus Straight Vertebroplasty Needle in Osteoporotic Vertebral Compression Fractures

The purpose of this study was to compare the efficacy of the curved puncture approach with 2 conventional approaches in percutaneous vertebroplasty (PVP) for the treatment of single-level osteoporotic vertebral compression fractures. Ninety-six patients with a single-level thoracolumbar vertebral fracture were surgically treated in the authors' department from February 2016 to February 2018. Patients were randomly divided into 3 groups, including 25 patients who had PVP punctured with a curved vertebroplasty needle (group C), 40 patients with unipedicular PVP with a straight vertebroplasty needle (group U), and 31 patients with bipedicular PVP with a straight vertebroplasty needle (group B). The short-term efficacies of PVP using different vertebroplasty needles were compared. Significant differences were tested preoperatively and postoperatively in vertebral body height variation, visual analog scale score, and Oswestry Disability Index in each of the 3 groups (P<.05). There was no significant difference among the groups in terms of Cobb angle correction and bone cement leakage. Group C and group U were superior to group B in terms of operative time and injected cement volume (P<.05). Twenty-four (96.0%) patients in group C and 29 (93.5%) patients in group B had centered cement distribution without significant differences (P>.05), which was superior to group U (P<.05). Curved puncture PVP achieved a satisfactory clinical outcome for osteoporotic vertebral compression fractures, with the advantages of less operative time, less injected cement volume, and more reasonable cement distribution for stabilization of the affected vertebrae. [Orthopedics. 2021;44(1):e131-e138.].

Advances in Vertebral Augmentation Systems for Osteoporotic Vertebral Compression Fractures

Osteoporotic vertebral compression fracture (OVCF) is a common cause of pain and disability and is steadily increasing due to the growth of the elderly population. To date, percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) are almost universally accepted as appropriate vertebral augmentation procedures for OVCFs. There are many advantages of vertebral augmentation, such as short surgical time, performance under local anaesthesia, and rapid pain relief. However, there are certain issues regarding the utilization of these vertebral augmentations, such as loss of vertebral height, cement leakage, and adjacent vertebral refracture. Hence, the treatment for OVCF has changed in recent years. Satisfactory clinical results have been obtained worldwide after application of the OsseoFix System, the SpineJack System, radiofrequency kyphoplasty of the vertebral body, and the Kiva VCF treatment system. The following review discusses the development of the current techniques used for vertebral augmentation.

Modified percutaneous Kyphoplasty technique in the treatment of osteoporotic thoracolumbar burst fractures: could it reduce the odds of cement leakage?

Background

Osteoporotic thoracolumbar burst fracture (OTLBF) is common in seniors. Due to the fracture of the posterior vertebra and spinal canal occupancy, the risk of cement leakage and spine injury is high in OTLBF patients, thus the application of vertebroplasty and kyphoplasty is limited in these patients. This study aims to investigate the efficacy and safety of the modified percutaneous kyphoplasty (MPKP) in the treatment of OTLBF.

Methods

Clinical data of the OTLBF patients treated with MPKP and the osteoporotic thoracolumbar compression fracture (OTLCF) patients undergone PKP from January 2014 to June 2016 were collected. The key procedure of the MPKP was to fill the bone cavity with gel-foam by the first balloon inflation and to press the gel-foam by a second balloon inflation. Pain intensity, Oswestry disability index (ODI), and bone cement leakage of the patients in the two groups were analyzed.

Results

In the burst fracture group, the overall spinal canal occupancy was relatively low, and the maximum occupancy was 1/3 of the sagittal diameter of the spinal canal. The surgical duration was longer in the burst fracture group (39.0 ± 5.0 min with 95% CI: 37.7, 40.3) than in the compression fracture group (31.7 ± 4.3 min with 95% CI: 31.1, 32.3), and the difference between the two groups was statistically significant (Z = -8.668 and P = 0.000). Both the Oswestry disability index (ODI) and the visual analog scales (VAS) were apparently improved, but there was no significant difference between the two groups. Cement leakage occurred in 13 out of the 53 cases (24.5%) in the burst fracture group and 35 out of the 193 cases (18.1%) in the compression fracture group, and there was no significant difference between the two groups (Z = − 1.038 and P = 0.299). Neither group had consequential symptoms, such as spinal cord lesion, pain, and numbness of the peripheral nerve.

Conclusion

Similar to the efficacy of PKP in the treatment of OTLCF, MPKP efficiently reduced the cement leakage rate and improved the safety of the surgery, although it prolonged the surgical duration and introduced more surgical steps.

Unilateral percutaneous kyphoplasty for lumbar spine: A comparative study between transverse process-pedicle approach and conventional transpedicular approach

Anatomical differences of unilateral percutaneous kyphoplasty (PKP) between transverse process-pedicle approach (TPPA) and conventional transpedicular approach (CTPA) are not well discussed. To investigate the anatomical distinctions of unilateral PKP between TPPA and CTPA, we have discussed the unilateral PKP through a 3-dimensional-computed tomography database.Five hundred lumbar spines from 100 patients have been retrospectively collected and unilateral CTPA and TPPA were simulated. Distance between the entry point and the midline of the vertebral body (DEM), the puncture inclination angle (PIA), and the success rate (SR) of puncture were measured and compared.The male presented with significantly larger DEM than the female. The TPPA group presented with larger DEM than the CTPA group according to different level, the difference was 1.5 ± 1.1 mm to 3.8 ± 2.3 mm. The PIAs in the TPPA group were larger than that in the CTPA group. The SR including 1 side SR and bilateral SR was 72.0% in the CTPA group and 98.0% in the TPPA group. Compared with CTPA group, the SR in TPPA group was significantly higher for L1 to L4 no matter in the left, right side and female patients.The TPPA group presented with more lateral entry point, larger PIAs and higher SRs than that in the CTPA group. PKP surgery through a TPPA was safer and could provide a more symmetrical distribution of bone cement than the CTPA group.

Unilateral curved versus bipedicular vertebroplasty in the treatment of osteoporotic vertebral compression fractures

Background

Vertebral compression fracture is one of the most common complications of osteoporosis. In this study an unilateral curved vertebroplasty device was developed, and the safety, effectiveness, and surgical parameters of curved vertebroplasty (CVP) in the treatment of painful osteoporotic vertebral compression fractures was investigated and compared with traditional bipedicular vertebroplasty (BVP).

Methods

We investigated 104 vertebral augmentation procedures performed over 36 months. CVP and BVP procedures were compared for baseline clinical variables, pain relief (Visual Analog Scale, VAS), disability improvement (Oswestry Disability Index, ODI), operation time, number of fluoroscopic images, volume of cement per level, and cement leakage rate for each level treated. Complications and refracture incidence were also recorded in the two groups.

Results

The VAS and ODI in both group had no significant difference preoperative (P > 0.05), and a significant postoperative improvement in the VAS scores and ODI was found in both group (P < 0.001). However, the CVP group had significantly lower operation time, number of fluoroscopic images, and cement leakage rate per level than the BVP group (P < 0.05); however, the volumes of cement per level were similar in the two groups (P > 0.05). Neither group had any serious complications. Five and two patients in the BVP group developed refractures at non-adjacent and adjacent levels, respectively, with one patient developing refractures twice; however, none of the patients in the CVP group developed refractures at any level.

Conclusions

Our findings revealed that both CVP and BVP were safe and effective treatments for osteoporotic vertebral compression fractures, and CVP entails a shorter operation time, less exposure to fluoroscopy, and lower rate of cement leakage.

Kambin triangle approach in percutaneous vertebroplasty for the treatment of osteoporotic vertebral compression fractures

The aim of this study was to evaluate the safety and efficacy of percutaneous vertebroplasty (PVP) in Kambin triangle approach for the treatment of osteoporotic vertebral compression fractures (OVCFs).Between November 2017 and September 2018, 109 patients (144 vertebral bodies) with OVCFs, with a mean age of 76.7 ± 9.9 years (55-96 years), underwent PVP in Kambin triangle approach. The time of operation, the volume of bone cement, the incidence of complication, the Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) score, the position of puncture needles, and the spread of polymethylmethacrylate (PMMA) in vertebral body (VB) were recorded.All patients had been completed the operation successfully and were followed up 9.1 ± 2.9 months. The average operation time of each VB was 24.0 ± 3.5 minutes. The average volume of cement was 4.8 ± 0.6 ml. The mean VAS scores were 8.4 ± 0.7 preoperatively, 1.6 ± 0.6 at the first day postoperatively, and 1.2 ± 0.6 at the last follow-up. The mean ODI scores were 70.97 ± 7.73 preoperatively, 27.99 ± 4.12 at the first day postoperatively, and 19.65 ± 3.49 at the last follow-up. The position of puncture needles in the VB was: 119 vertebral puncture needles reached the midline, 15 were close to the midline, and 10 exceeded the midline. The spread of PMMA in the VB was: type 1 in 81 levels (56.3%), type 2 in 37 (25.7%), type 3 in 18 (12.5%), type 5 in 8 (5.5%), and no case in type 4. One case developed pneumothorax after operation. No other complications (hematoma, cement embolism, spinal cord, and nerve injury) occurred.Kambin triangle approach in PVP, which can deliver the puncture needle to the midline of VB easily and with excellent cement distribution, is a safe and effective method.

Can an unipedicular approach replace bipedicular percutaneous vertebroplasty for osteoporotic vertebral compression fracture?

OBJECTIVE

To compare outcomes of unipedicular versus bipedicular approach for percutaneous vertebroplasty for the treatment of thoracolumbar acute osteoporotic vertebral compression fracture (AOVCF).

METHOD

From November 2014 to September 2015, 382 patients with AOVCF were randomly assigned to the unipedicular and bipedicular groups. Clinical outcomes and complications were compared.

RESULTS

Both groups were comparable with respect to bone cement leakage and adjacent vertebral fractures (P> 0.05). Although the bipedicular approach was found to be superior in terms of reduction of kyphosis and loss of reduction, frequency of x-ray fluoroscopy, VAS and ODI scores, the volume of cement injected and operating time, the between-group differences were not statistically significant (P> 0.05). Nerve root stimulation was more frequent in the unipedicular group (P< 0.05).

CONCLUSIONS

The clinical and radiological outcomes of both procedures were comparable. The unipedicular approach was associated with more nerve root stimulation.

ACR Appropriateness Criteria® Management of Vertebral Compression Fractures

Vertebral compression fractures (VCFs) have various causes, including osteoporosis, neoplasms, and acute trauma. As painful VCFs may contribute to general physical deconditioning, management of painful VCFs has the potential for improving quality of life and preventing superimposed medical complications. Various imaging modalities can be used to evaluate a VCF to help determine the etiology and guide intervention. The first-line treatment of painful VCFs has been nonoperative or conservative management as most VCFs show gradual improvement in pain over 2 to 12 weeks, with variable return of function. There is evidence that vertebral augmentation (VA) is associated with better pain relief and improved functional outcomes compared to conservative therapy for osteoporotic VCFs. A multidisciplinary approach is necessary for the management of painful pathologic VCFs, with management strategies including medications to affect bone turnover, radiation therapy, and interventions such as VA and percutaneous thermal ablation to alleviate symptoms. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Analysis of the Causes on Poor Clinical Efficacy of Kyphoplasty Performed in Unilateral Transpedicular Puncture for the Treatment of Senile Osteoporotic Vertebral Compression Fractures

This study intends to analyze the causes on poor clinical efficacy of kyphoplasty performed in unilateral transpedicular puncture for the treatment of senile osteoporotic vertebral compression fractures. A retrospective study was conducted on a consecutive series of 70 patients who had underwent kyphoplasty performed in unilateral transpedicular puncture for the treatment of senile osteoporotic vertebral compression fractures between March 2016 to March 2017. These patients were compared for clinical data to investigate the causes on poor clinical efficacy of kyphoplasty performed in unilateral transpedicular puncture for the treatment of senile osteoporotic vertebral compression fractures. Comparison result of the indices between these patients showed that the differences in body weight, fracture type and bone cement dispersion were statistically significant. Logistic multivariate regression analysis showed body weight (OR = 0.892, p = 0.042), fracture type 2 (OR = 0.089, p = 0.020) and bone cement dispersion (OR = 4.773, p = 0.025) are risk factors for poor clinical efficacy. The results of corresponding analysis on VAS (Visual Analogue Scale), vertebral height and Cobb angle in patients with poor clinical efficacy showed that there is a correlation between them. We believe that patients' weight, dispersion degree of bone cement and fracture type of injured vertebra are the risk factors of kyphoplasty with poor clinical efficacy.

Percutaneous vertebroplasty for osteoporotic vertebral compression fracture

BACKGROUND

Percutaneous vertebroplasty remains widely used to treat osteoporotic vertebral fractures although our 2015 Cochrane review did not support its role in routine practice.

OBJECTIVES

To update the available evidence of the benefits and harms of vertebroplasty for treatment of osteoporotic vertebral fractures.

SEARCH METHODS

We updated the search of CENTRAL, MEDLINE and Embase and trial registries to 15 November 2017.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials (RCTs) of adults with painful osteoporotic vertebral fractures, comparing vertebroplasty with placebo (sham), usual care, or another intervention. As it is least prone to bias, vertebroplasty compared with placebo was the primary comparison. Major outcomes were mean overall pain, disability, disease-specific and overall health-related quality of life, patient-reported treatment success, new symptomatic vertebral fractures and number of other serious adverse events.

DATA COLLECTION AND ANALYSIS

We used standard methodologic procedures expected by Cochrane.

MAIN RESULTS

Twenty-one trials were included: five compared vertebroplasty with placebo (541 randomised participants), eight with usual care (1136 randomised participants), seven with kyphoplasty (968 randomised participants) and one compared vertebroplasty with facet joint glucocorticoid injection (217 randomised participants). Trial size varied from 46 to 404 participants, most participants were female, mean age ranged between 62.6 and 81 years, and mean symptom duration varied from a week to more than six months.Four placebo-controlled trials were at low risk of bias and one was possibly susceptible to performance and detection bias. Other trials were at risk of bias for several criteria, most notably due to lack of participant and personnel blinding.Compared with placebo, high- to moderate-quality evidence from five trials indicates that vertebroplasty provides no clinically important benefits with respect to pain, disability, disease-specific or overall quality of life or treatment success at one month. Evidence for quality of life and treatment success was downgraded due to possible imprecision. Evidence was not downgraded for potential publication bias as only one placebo-controlled trial remains unreported. Mean pain (on a scale zero to 10, higher scores indicate more pain) was five points with placebo and 0.7 points better (0.3 better to 1.2 better) with vertebroplasty, an absolute pain reduction of 7% (3% better to 12% better, minimal clinical important difference is 15%) and relative reduction of 10% (4% better to 17% better) (five trials, 535 participants). Mean disability measured by the Roland-Morris Disability Questionnaire (scale range zero to 23, higher scores indicate worse disability) was 14.2 points in the placebo group and 1.5 points better (0.4 better to 2.6 better) in the vertebroplasty group, absolute improvement 7% (2% to 11% better), relative improvement 9% better (2% to 15% better) (four trials, 472 participants).Disease-specific quality of life measured by the Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO) (scale zero to 100, higher scores indicating worse quality of life) was 62 points in the placebo group and 2.3 points better (1.4 points worse to 6.7 points better), an absolute imrovement of 2% (1% worse to 6% better); relative improvement 4% better (2% worse to 10% better) (three trials, 351 participants). Overall quality of life (European Quality of Life (EQ5D), zero = death to 1 = perfect health, higher scores indicate greater quality of life) was 0.38 points in the placebo group and 0.05 points better (0.01 better to 0.09 better) in the vertebroplasty group, absolute improvement: 5% (1% to 9% better), relative improvement: 18% (4% to 32% better) (three trials, 285 participants). In one trial (78 participants), 9/40 (or 225 per 1000) people perceived that treatment was successful in the placebo group compared with 12/38 (or 315 per 1000; 95% CI 150 to 664) in the vertebroplasty group, RR 1.40 (95% CI 0.67 to 2.95), absolute difference: 9% more reported success (11% fewer to 29% more); relative change: 40% more reported success (33% fewer to 195% more).Low-quality evidence (downgraded due to imprecision and potential for bias from the usual-care controlled trials) indicates uncertainty around the risk estimates of harms with vertebroplasty. The incidence of new symptomatic vertebral fractures (from six trials) was 48/418 (95 per 1000; range 34 to 264)) in the vertebroplasty group compared with 31/422 (73 per 1000) in the control group; RR 1.29 (95% CI 0.46 to 3.62)). The incidence of other serious adverse events (five trials) was 16/408 (34 per 1000, range 18 to 62) in the vertebroplasty group compared with 23/413 (56 per 1000) in the control group; RR 0.61 (95% CI 0.33 to 1.10). Notably, serious adverse events reported with vertebroplasty included osteomyelitis, cord compression, thecal sac injury and respiratory failure.Our subgroup analyses indicate that the effects did not differ according to duration of pain (acute versus subacute). Including data from the eight trials that compared vertebroplasty with usual care in a sensitivity analyses altered the primary results, with all combined analyses displaying considerable heterogeneity.

AUTHORS' CONCLUSIONS

We found high- to moderate-quality evidence that vertebroplasty has no important benefit in terms of pain, disability, quality of life or treatment success in the treatment of acute or subacute osteoporotic vertebral fractures in routine practice when compared with a sham procedure. Results were consistent across the studies irrespective of the average duration of pain.Sensitivity analyses confirmed that open trials comparing vertebroplasty with usual care are likely to have overestimated any benefit of vertebroplasty. Correcting for these biases would likely drive any benefits observed with vertebroplasty towards the null, in keeping with findings from the placebo-controlled trials.Numerous serious adverse events have been observed following vertebroplasty. However due to the small number of events, we cannot be certain about whether or not vertebroplasty results in a clinically important increased risk of new symptomatic vertebral fractures and/or other serious adverse events. Patients should be informed about both the high- to moderate-quality evidence that shows no important benefit of vertebroplasty and its potential for harm.

An innovative technique for osteoporotic vertebral compression fractures - vertebral osteotome with side-opening cannula

Objective

This study is to assess an innovative technique - a vertebral osteotome (VO) combined with side-opening injection cannula for percutaneous vertebroplasty (PVP).

Methods

A retrospective study by propensity score matching. From January 2016 to April 2016, 63 patients who were diagnosed with monosegmental osteoporotic vertebral compression fracture received the innovative technique. The epidemiologic data, surgical indexes, and recovery outcomes were collected in the follow-up period. Propensity score matching identified 63 pairs form historical controls by traditional unilateral PVP approach in 2015 using six independent variables: age, sex, preoperative visual analog score (VAS), Oswestry Disability Index (ODI), body mass index, and bone mineral density.

Results

The surgical duration and cement distribution were longer and larger in patients by VO method. Besides, postoperative VAS and ODI in the VO group were lower than those in the control group. However, there were no differences in radiation exposure times, improvement of Cobb angle, cement leakage, or adjacent vertebral fracture between two groups. Cement volume in the VO group was less than that in the control group.

Conclusion

This new innovative technique makes PVP safe and effective. Although it lasts longer, the restoration rate of vertebral height and cement distribution can be improved, which contributes to a better pain relief.

Anatomical feasibility study of unilateral percutaneous kyphoplasty for lumbar through the conventional transpedicular approach: An observational study using 3D CT analysis

The aim of the study was to discuss the significance of sex, level, age, and side in relation to the anatomical distinctions of unilateral percutaneous kyphoplasty (PKP) for lumbar osteoporotic vertebral compression fractures (OVCFs) through the conventional transpedicle approach (CTPA).We have retrospectively collected lumbar spines (L1-L5) of 200 patients and simulated PKP on the 3D CT scans through unilateral CTPA. We have measured the distance between the entry point and the midline of the vertebral body (DEM), the puncture inclination angle (PIA), safe range of the inner inclination angles (SRA), and the success rate (SR) of puncture.Significant differences (P < .05) between the male and female for L1 to L5, left and right side for L1 to L3 in the mean DEM were shown. The DEM from L1 to L5 was significantly increased (P < .05) from (20.6 ± 2.0) mm to (29.8 ± 2.9) mm. For L1 to L5, the right maximum PIA was significantly larger than the left. The maximum PIA and SRA in the male was significantly larger than that in the female. The SRA from L1 to L5 was significantly increased (P < .05) from (19.5 ± 5.9)° to (48.9 ± 8.1)°. The SR in male was significantly higher than that in female for L1 to L4. There were no significant differences in the SR between different age groups except for L4. The SR from L1 to L5 was significantly increased (P < .05) from 26.3% to 99.0%.DEM was 20.6 to 29.8 mm according to different levels. The value of DEM, PIA, SRA, and SR was significantly increased from L1 to L5. No significant differences in the SR between right and left for L1 to L5, different age groups except for L4 were observed.

Clinical efficacy of PVP and PKP in the treatment of OVCFs after bilateral resection of ovarian cancer

The clinical efficacy of percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) in the treatment of osteoporotic vertebral compression fractures after bilateral resection of ovarian cancer was investigated. Eighty-six patients with osteoporotic vertebral compression fractures after bilateral resection of ovarian cancer admitted to the Second People's Hospital of Hefei from September, 2015 to August, 2016 were selected and randomly divided into control group (n=43) and observation group (n=43). The control group was treated with PVP, while the observation group received PKP. The operation time, fluoroscopy times, bone cement volume and leakage rate of patients in the two groups were recorded; the postoperative pain of patients was compared using Short-form McGill Pain Questionnaire; the changes in height of injured vertebra and Cobb angle of patients in two groups were compared; the efficacy of patients in the two groups was compared in accordance with Oswestry dysfunction index (ODI) and Japanese Orthopedic Association (JOA) low back pain scoring; and the quality of life was compared. The fluoroscopy times and bone cement leakage were significantly less in observation group than those in control group (P<0.05). After operation, the scores of ODI, MPQ and JOA in the two groups were significantly improved (P<0.05). The postoperative height of injured vertebra and the Cobb angle of patients in two groups were significantly different than those before the operation (P<0.05). The quality of life of patients in the observation group was higher than that in the control group one year after operation (P<0.05). In conclusion, PKP and PVP are effective in the treatment of osteoporotic vertebral compression fractures after bilateral resection of ovarian cancer; however, PKP is more conducive to lumbar stability and maintenance of intervertebral height thus greatly correcting the kyphosis, which is beneficial to improving the quality of life of patients.

Percutaneous vertebroplasty for osteoporotic vertebral compression fracture

BACKGROUND

Percutaneous vertebroplasty remains widely used to treat osteoporotic vertebral fractures although our 2015 Cochrane review did not support its role in routine practice.

OBJECTIVES

To update the available evidence of the benefits and harms of vertebroplasty for treatment of osteoporotic vertebral fractures.

SEARCH METHODS

We updated the search of CENTRAL, MEDLINE and Embase and trial registries to 15 November 2017.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials (RCTs) of adults with painful osteoporotic vertebral fractures, comparing vertebroplasty with placebo (sham), usual care, or another intervention. As it is least prone to bias, vertebroplasty compared with placebo was the primary comparison. Major outcomes were mean overall pain, disability, disease-specific and overall health-related quality of life, patient-reported treatment success, new symptomatic vertebral fractures and number of other serious adverse events.

DATA COLLECTION AND ANALYSIS

We used standard methodologic procedures expected by Cochrane.

MAIN RESULTS

Twenty-one trials were included: five compared vertebroplasty with placebo (541 randomised participants), eight with usual care (1136 randomised participants), seven with kyphoplasty (968 randomised participants) and one compared vertebroplasty with facet joint glucocorticoid injection (217 randomised participants). Trial size varied from 46 to 404 participants, most participants were female, mean age ranged between 62.6 and 81 years, and mean symptom duration varied from a week to more than six months.Three placebo-controlled trials were at low risk of bias and two were possibly susceptible to performance and detection bias. Other trials were at risk of bias for several criteria, most notably due to lack of participant and personnel blinding.Compared with placebo, high- to moderate-quality evidence from five trials (one with incomplete data reported) indicates that vertebroplasty provides no clinically important benefits with respect to pain, disability, disease-specific or overall quality of life or treatment success at one month. Evidence for quality of life and treatment success was downgraded due to possible imprecision. Evidence was not downgraded for potential publication bias as only one placebo-controlled trial remains unreported. Mean pain (on a scale zero to 10, higher scores indicate more pain) was five points with placebo and 0.6 points better (0.2 better to 1 better) with vertebroplasty, an absolute pain reduction of 6% (2% better to 10% better, minimal clinical important difference is 15%) and relative reduction of 9% (3% better to14% better) (five trials, 535 participants). Mean disability measured by the Roland-Morris Disability Questionnaire (scale range zero to 23, higher scores indicate worse disability) was 14.2 points in the placebo group and 1.7 points better (0.3 better to 3.1 better) in the vertebroplasty group, absolute improvement 7% (1% to 14% better), relative improvement 10% better (3% to 18% better) (three trials, 296 participants).Disease-specific quality of life measured by the Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO) (scale zero to 100, higher scores indicating worse quality of life) was 62 points in the placebo group and 2.75 points (3.53 worse to 9.02 better) in the vertebroplasty group, absolute change: 3% better (4% worse to 9% better), relative change: 5% better (6% worse to 15% better (two trials, 175 participants). Overall quality of life (European Quality of Life (EQ5D), zero = death to 1 = perfect health, higher scores indicate greater quality of life) was 0.38 points in the placebo group and 0.05 points better (0.01 better to 0.09 better) in the vertebroplasty group, absolute improvement: 5% (1% to 9% better), relative improvement: 18% (4% to 32% better) (three trials, 285 participants). In one trial (78 participants), 9/40 (or 225 per 1000) people perceived that treatment was successful in the placebo group compared with 12/38 (or 315 per 1000; 95% CI 150 to 664) in the vertebroplasty group, RR 1.40 (95% CI 0.67 to 2.95), absolute difference: 9% more reported success (11% fewer to 29% more); relative change: 40% more reported success (33% fewer to 195% more).Moderate-quality evidence (low number of events) from seven trials (four placebo, three usual care, 1020 participants), up to 24 months follow-up, indicates we are uncertain whether vertebroplasty increases the risk of new symptomatic vertebral fractures (70/509 (or 130 per 1000; range 60 to 247) observed in the vertebroplasty group compared with 59/511 (120 per 1000) in the control group; RR 1.08 (95% CI 0.62 to 1.87)).Similarly, moderate-quality evidence (low number of events) from five trials (three placebo, two usual care, 821 participants), indicates uncertainty around the risk of other serious adverse events (18/408 or 76 per 1000, range 6 to 156) in the vertebroplasty group compared with 26/413 (or 106 per 1000) in the control group; RR 0.64 (95% CI 0.36 to 1.12). Notably, serious adverse events reported with vertebroplasty included osteomyelitis, cord compression, thecal sac injury and respiratory failure.Our subgroup analyses indicate that the effects did not differ according to duration of pain ≤ 6 weeks versus > 6 weeks. Including data from the eight trials that compared vertebroplasty with usual care in a sensitivity analyses altered the primary results, with all combined analyses displaying considerable heterogeneity.

AUTHORS' CONCLUSIONS

Based upon high- to moderate-quality evidence, our updated review does not support a role for vertebroplasty for treating acute or subacute osteoporotic vertebral fractures in routine practice. We found no demonstrable clinically important benefits compared with placebo (sham procedure) and subgroup analyses indicated that the results did not differ according to duration of pain ≤ 6 weeks versus > 6 weeks.Sensitivity analyses confirmed that open trials comparing vertebroplasty with usual care are likely to have overestimated any benefit of vertebroplasty. Correcting for these biases would likely drive any benefits observed with vertebroplasty towards the null, in keeping with findings from the placebo-controlled trials.Numerous serious adverse events have been observed following vertebroplasty. However due to the small number of events, we cannot be certain about whether or not vertebroplasty results in a clinically important increased risk of new symptomatic vertebral fractures and/or other serious adverse events. Patients should be informed about both the high- to moderate-quality evidence that shows no important benefit of vertebroplasty and its potential for harm.

Comparison of unilateral and bilateral percutaneous vertebroplasty for osteoporotic vertebral compression fractures: a systematic review and meta-analysis

Background

The aim of this meta-analysis is to examine the safety and effectiveness of unilateral percutaneous vertebroplasty (PVP) for treatment of osteoporotic vertebral compression fractures (OVCFs) compared with that of bilateral treatment.

Methods

The multiple databases including PubMed, Springer, EMBASE, OVID, and China Journal Full-text Database were adopted to search for relevant studies in English or Chinese, and full-text articles involving comparison of unilateral and bilateral PVP surgery were reviewed. Review Manager 5.0 was adopted to estimate the effects of the results among selected articles. Forest plots, sensitivity analysis, and bias analysis for the articles included were also conducted.

Results

Finally, 1043 patients were included in the 14 studies, which eventually satisfied the eligibility criteria, and unilateral and bilateral surgeries were 550 and 493, respectively. The meta-analysis suggested that there was no significant difference of VAS score, ODI score, and cement leakage rate (MD = 0.12, 95%CI [−0.03, 0.26], P = 0.11; MD = −1.28, 95%CI [−3.59, 1.04], P = 0.28; RR = 0.89, 95%CI [0.61, 1.29], P = 0.52). The surgery time of unilateral PVP is much less than that of bilateral PVP (MD = −16.67, 95%CI [−19.22, −14.12], P < 0.00001). Patients with bilateral PVP surgery have been injected more cement than patients with unilateral PVP surgery (MD = −1.55, 95%CI [−1.94, −1.16], P < 0.00001).

Conclusions

Both punctures provide excellent pain relief and improvement of life quality. We still encourage the use of the unipedicular approach as the preferred surgical technique for treatment of OVCFs due to less operation time, limited X-ray exposure, and minimal cement introduction and extravasation.

Extrapedicular Infiltration Anesthesia as an Improved Method of Local Anesthesia for Unipedicular Percutaneous Vertebroplasty or Percutaneous Kyphoplasty

Aim. This report introduces extrapedicular infiltration anesthesia as an improved method of local anesthesia for unipedicular percutaneous vertebroplasty or percutaneous kyphoplasty. Method. From March 2015 to March 2016, 44 patients (11 males and 33 females) with osteoporotic vertebral compression fractures with a mean age of 71.4 ± 8.8 years (range: 60 to 89) received percutaneous vertebroplasty or percutaneous kyphoplasty. 24 patients were managed with conventional local infiltration anesthesia (CLIA) and 20 patients with both CLIA and extrapedicular infiltration anesthesia (EPIA). Patients evaluated intraoperative pain by means of the visual analogue score and were monitored during the procedure for additional sedative analgesia needs and for adverse nerve root effects. Results. VAS of CLIA + EPIA and CLIA group was 2.5 ± 0.7 and 4.3 ± 1.0, respectively, and there was significant difference (P = 0.001). In CLIA group, 1 patient required additional sedative analgesia, but in CLIA + EPIA group, no patients required that. In the two groups, no adverse nerve root effects were noted. Summary. Extrapedicular infiltration anesthesia provided good local anesthetic effects without significant complications. This method deserves further consideration for use in unipedicular percutaneous vertebroplasty and percutaneous kyphoplasty.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Tuberculous Spondylitis Following Kyphoplasty: A Case Report and Review of the Literature

Tuberculous spondylitis of the augmented vertebral column following percutaneous vertebroplasty or kyphoplasty has rarely been described. We report an unusual case of tuberculous spondylitis diagnosed after percutaneous kyphoplasty (PKP). A 61-year-old woman presented to our institution complaining of back pain following a fall 7 days before. Radiologic studies revealed an acute osteoporotic compression L1 fracture. The patient denied history of pulmonary tuberculosis (TB) and there were no signs of infection. The patient was discharged from hospital 4 days after undergoing L1 PKP with a dramatic improvement in her back pain. Two years later, the patient was readmitted with a 1 year history of recurrent back pain. Imaging examinations demonstrated long segmental bony destruction involving L1 vertebra with massive paravertebral abscess formation. The tentative diagnosis of tuberculous spondylitis was made, after a serum T-SPOT. The TB test was found to be positive. Anterior debridement, L1 corpectomy, decompression, and autologous rib graft interposition, and posterior T8-L4 instrumentation were performed. The histologic examination of the resected tissue results confirmed the diagnosis of spinal TB. Anti-TB medications were administered for 12 months and the patient recovered without sequelae. Spinal TB and osteoporotic vertebral compression fractures are similar clinically and radiologically. Spinal surgeons should consider this disease entity to avoid misdiagnosis or complications. Early surgical intervention and anti-TB treatment should be instituted as soon as the diagnosis of spinal TB after vertebral augmentation is made.

Extrapedicular Infiltration Anesthesia as an Improved Method of Local Anesthesia for Unipedicular Percutaneous Vertebroplasty or Percutaneous Kyphoplasty

Aim.This report introduces extrapedicular infiltration anesthesia as an improved method of local anesthesia for unipedicular percutaneous vertebroplasty or percutaneous kyphoplasty.Method.From March 2015 to March 2016, 44 patients (11 males and 33 females) with osteoporotic vertebral compression fractures with a mean age of71.4±8.8years (range: 60 to 89) received percutaneous vertebroplasty or percutaneous kyphoplasty. 24 patients were managed with conventional local infiltration anesthesia (CLIA) and 20 patients with both CLIA and extrapedicular infiltration anesthesia (EPIA). Patients evaluated intraoperative pain by means of the visual analogue score and were monitored during the procedure for additional sedative analgesia needs and for adverse nerve root effects.Results.VAS of CLIA + EPIA and CLIA group was2.5±0.7and4.3±1.0,respectively, and there was significant difference (P=0.001). In CLIA group, 1 patient required additional sedative analgesia, but in CLIA + EPIA group, no patients required that. In the two groups, no adverse nerve root effects were noted.Summary.Extrapedicular infiltration anesthesia provided good local anesthetic effects without significant complications. This method deserves further consideration for use in unipedicular percutaneous vertebroplasty and percutaneous kyphoplasty.

Extrapedicular Infiltration Anesthesia as an Improved Method of Local Anesthesia for Unipedicular Percutaneous Vertebroplasty or Percutaneous Kyphoplasty

Aim. This report introduces extrapedicular infiltration anesthesia as an improved method of local anesthesia for unipedicular percutaneous vertebroplasty or percutaneous kyphoplasty. Method. From March 2015 to March 2016, 44 patients (11 males and 33 females) with osteoporotic vertebral compression fractures with a mean age of 71.4 ± 8.8 years (range: 60 to 89) received percutaneous vertebroplasty or percutaneous kyphoplasty. 24 patients were managed with conventional local infiltration anesthesia (CLIA) and 20 patients with both CLIA and extrapedicular infiltration anesthesia (EPIA). Patients evaluated intraoperative pain by means of the visual analogue score and were monitored during the procedure for additional sedative analgesia needs and for adverse nerve root effects. Results. VAS of CLIA + EPIA and CLIA group was 2.5 ± 0.7 and 4.3 ± 1.0, respectively, and there was significant difference (P = 0.001). In CLIA group, 1 patient required additional sedative analgesia, but in CLIA + EPIA group, no patients required that. In the two groups, no adverse nerve root effects were noted. Summary. Extrapedicular infiltration anesthesia provided good local anesthetic effects without significant complications. This method deserves further consideration for use in unipedicular percutaneous vertebroplasty and percutaneous kyphoplasty.