Gradual Height Decrease of Augmented Vertebrae after Vertebroplasty at the Thoracolumbar Junction

Re-expansion of vertebral compression fractures in patients with multiple myeloma with percutaneous vertebroplasty using spinejack implants: a preliminary and retrospective study

Objective

To retrospectively evaluate the feasibility and effectiveness of vertebroplasty using Spinejack implantation for the treatment and stabilization of painful vertebral compression fractures, in patients diagnosed with Multiple Myeloma (MM), to allow both an effective pain reduction and a global structural spine stabilization.

Materials and Methods

From July 2017 and May 2022 thirty-nine patients diagnosed MM, with forty-nine vertebral compression fractures underwent percutaneous Vertebroplasty using Spinejack Implants. We analyzed the feasibility and complications of the procedure, the decrease in pain using visual analogue scale (VAS) and Functional Mobility Scale (FMS).

Results

The technical success rate was 100%. No procedure-related major complications or death occurred. In the 6-month follow-up, the mean VAS score decreased from 5.4 ± 1.0 to 0.2 ± 0.5 with a mean reduction of 96.3%. FMS decreased from 2.3 ± 0.5 vs. 1.2 ± 0.4 with a mean reduction of -47.8%. There were no major complications related to incorrect positioning of the Expandable Titanium SpineJack Implants. In five patients, a cement leak was observed with no associated clinical manifestations. The average length of hospital stay was 6-8 Hours6.6 ± 1.2 h. No new bone fractures or local disease recurrence occurred during a median contrast-enhanced CT follow-up of 6 months.

Conclusions

Our results suggest that vertebroplasty, using Spinejack implantation for the treatment and stabilization of painful vertebral compression fractures, secondary to Multiple Myeloma is a safe and effective procedure with long - term pain relief and restoration of vertebral height.

Case report: Use of peripheral nerve stimulation for treatment of pain from vertebral plana fracture

Vertebral plana fractures are a severe form of compression fractures that can cause significant morbidity due to incapacitating pain. Due to the flattening of the vertebrae in a plana fracture, accessing the vertebral body transpedicularly can be difficult, making traditional vertebral augmentation treatment dangerous. These injuries also typically occur in elderly patients with contraindications to invasive procedures. Peripheral nerve stimulation is a relatively new and minimally invasive treatment that uses electrical stimulation to inhibit pain signals from reaching the somatosensory cortex. Our case describes an 80 Year old female with multiple comorbidities and refractory pain due to a vertebral planar fracture successfully treated with a 60 day course of peripheral nerve stimulation as evidenced by over 50% reduction in symptoms and discontinuation of opioid pain medication use.

Predictive risk factors for recollapse of cemented vertebrae after percutaneous vertebroplasty: A meta-analysis

BACKGROUND

As one of the most common complications of osteoporosis, osteoporotic vertebral compression fracture (OVCF) increases the risk of disability and mortality in elderly patients. Percutaneous vertebroplasty (PVP) is considered to be an effective, safe, and minimally invasive treatment for OVCFs. The recollapse of cemented vertebrae is one of the serious complications of PVP. However, the risk factors associated with recollapse after PVP remain controversial.

AIM

To identify risk factors for the recollapse of cemented vertebrae after PVP in patients with OVCFs.

METHODS

A systematic search in EMBASE, MEDLINE, the Cochrane Library, and PubMed was conducted for relevant studies from inception until March 2020. Studies investigating risk factors for the recollapse of cemented vertebrae after PVP without additional trauma were selected for analysis. Odds ratios (ORs) or standardized mean differences with 95% confidence interval (CI) were calculated and heterogeneity was assessed by both the chi-squared test and the I-squared test. The methodological quality of the included studies was assessed according to the Newcastle-Ottawa Scale.

RESULTS

A total of nine case-control studies were included in our meta-analysis comprising 300 cases and 2674 controls. The significant risk factors for the recollapse of cemented vertebrae after PVP in OVCF patients were fractures located at the thoracolumbar junction (OR = 2.09; 95%CI: 1.30 to 3.38; P = 0.002), preoperative intravertebral cleft (OR = 2.97; 95%CI: 1.93 to 4.57; P < 0.00001), and solid lump distribution pattern of the cement (OR = 3.11; 95%CI: 1.91 to 5.07; P < 0.00001). The analysis did not support that age, gender, lumbar bone mineral density, preoperative visual analogue scale score, injected cement volume, intradiscal cement leakage, or vertebral height restoration could increase the risk for cemented vertebra recollapse after PVP in OVCFs.

CONCLUSION

This meta-analysis suggests that thoracolumbar junction fractures, preoperative intravertebral cleft, and solid lump cement distribution pattern are associated with the recollapse of cemented vertebrae after PVP in OVCF patients.

Risk factors of cemented vertebral refracture after percutaneous vertebral augmentation: a systematic review and meta-analysis

To evaluate the risk factors of cemented vertebral refracture after percutaneous vertebral augmentation (PVA) for patients with osteoporotic vertebral compression fractures (OVCFs). We performed a literature search on cemented vertebral refracture after PVA using the PubMed, EMBASE, and Cochrane Library medical databases. The clinical data, including literature information, basic patient information, observational factors, and interventional factors, were extracted by two authors. The pooled results and related heterogeneity of each factor between the refracture group and the non-refracture group were evaluated using Review Manager software 5.35. A total of 3185 patients from 10 studies were included, with 195 patients in the refracture group and 2990 patients in the non-refracture group. The mean follow-up duration was 18.9 months. According to the meta-analysis, age, low bone marrow density (BMD), intravertebral cleft (IVC), high anterior vertebral height (AVH) restoration/high Cobb angle restoration, and low cement dose were the risk factors of cemented vertebral refracture after PVA. Our results showed that age, low BMD, IVC, high AVH restoration, high Cobb angle restoration, and low cement dose were the risk factors for cemented vertebral refracture after PVA.

Changes of the adjacent discs and vertebrae in patients with osteoporotic vertebral compression fractures treated with or without bone cement augmentation

BACKGROUND CONTEXT

Although vertebral augmentation with bone cement has been commonly used to treat symptomatic osteoporotic vertebral compression fractures, relatively little is known about the impact of augmentation on the adjacent spinal components.

PURPOSE

To determine the imaging effects of vertebral augmentation on the adjacent discs, the augmented vertebra, and the involved spinal segment.

STUDY DESIGN

Retrospective radiographic study.

PATIENT SAMPLE

Patients with acute osteoporotic vertebral compression fractures who underwent vertebral augmentation or nonoperative treatments.

OUTCOME MEASURES

On baseline and follow-up mid-sagittal T2W magnetic resonance images, quantitative measurements of disc degeneration, including disc height, bulging, and signal, vertebral height, wedge angle, and segmental kyphotic angle were acquired.

METHODS

Lumbar spine magnetic resonance images of patients with acute osteoporotic vertebral compression fractures at a local hospital in Eastern China between 2010 and 2017 were reviewed. Student's t-tests and χ² tests were used to examine the differences of baseline and changes over time between vertebrae underwent vertebral augmentation and those did not. Paired t-tests were used to examine the differences between baseline and follow-up to study the changes of adjacent disc degeneration, creep deformity of the vertebra and progression of segmental kyphosis.

RESULTS

There were 112 acute vertebral compression fractures (72 treated with kyphoplasty and 40 with nonoperative treatments) in 101 subjects. At final follow-up (mean 21.5 months), the cranial disc of the augmented vertebra decreased in height (p<.001), and both cranial and caudal discs decreased in signal intensity (p≤.02). The discs in the nonoperative group did not undergo such degenerative changes. For the fractured vertebra, vertebral height significantly decreased (p<.01 for both) and vertebral wedge angle significantly increased (p≤.01 for both), regardless of augmentation treatment or not. Segmental kyphotic angle significantly increased in vertebral fractures that underwent vertebral augmentation (p<.001), but not in those underwent nonoperative treatments.

CONCLUSIONS

Patients that underwent vertebral augmentation had more advanced disc degeneration at adjacent disc levels as compared to those without augmentation. The fractured vertebral body height decreased and the wedge angle increased, regardless of vertebral augmentation treatment or not. Vertebral augmentation may be associated with increased creep deformity of the adjacent vertebra and the progression of segmental kyphosis.

Treatment of a High-risk Thoracolumbar Compression Fracture Using Bilateral Expandable Titanium SpineJack Implants

In this case, an 80-year-old active patient developed an acute osteoporotic fracture after a fall at L1 above a previous interlaminar implant at L4-5 for stenosis with neurogenic claudication. Radiologic studies found both intra-discal and intra-vertebral vacuum clefts that are highly correlated with instability and progressive kyphosis. Long-term experience with kyphoplasty has shown that acute and subacute fractures can often be re-expanded; however, over three months to one year, the correction is frequently lost and the vertebral height continues to decrease leading to increased risk of both continued deformity and especially adjacent level fractures. The use of newly available titanium intra-vertebral implants combined with bone cement restores and maintains vertebral height and correction of deformities. Long-term studies also demonstrate a reduced risk of adjacent level fractures compared to balloon kyphoplasty. Using vertebral body implants that remain in place within the fractured vertebral body the initial height correction can be better maintained leading to less adjacent level fractures.

Re-expansion of Osteoporotic Compression Fractures Using Bilateral SpineJack Implants: Early Clinical Experience and Biomechanical Considerations

Thoraco-lumbar osteoporotic compression fractures have a higher incidence of continued collapse with development of deformity and progression to vertebra plana when untreated and even after vertebral augmentation (VA) or balloon kyphoplasty (BKP). Even when there is the restoration of height and improvement in angulation, multiple long-term follow-up series have repeatedly documented that over time, many patients lose the initial height correction and in a smaller group the vertebral body re-collapses leading to the development of progressive deformity with an increased risk for adjacent level fractures. At first, larger balloons and more cement were used to try and avoid these problems, but it did not reduce the risk of adjacent fractures. Several procedures were developed to place various types of intervertebral implants combined with bone cement to maintain the initial height correction. Initial studies with these implants showed a reduction in adjacent level fractures but the systems did not proceed to market. The SpineJack^R (SJ) system (Stryker Corp, Kalamazoo, MI), consisting of bilateral expandable titanium implants supplemented with bone cement, was first used approximately 10 years ago in Europe and recently gained FDA approval in the United States. This system provides more symmetric and balanced lateral and anterior support and is effective with lesser amounts of bone cement compared to BKP. Follow-up studies have documented that there is equal or better pain control, with better long-term results based both on maintaining vertebral height restoration and deformity correction. Most importantly, statistically it clearly reduces the risk of adjacent level fractures by at least 60%. The biomechanical effects of intravertebral implants for osteoporotic fractures in regard to the risk of adjacent level fractures and preliminary experience with the use of the SJ is reviewed.

Radiologic Evaluation of Chronic Vertebral Compression Fractures and Role of Vertebral Augmentation

The literature has classified chronic vertebral compression fractures (VCF) as those still "symptomatic" four or more months after onset. Pain is regarded as the predominant chronic symptom; however, radiologic changes are important in evaluating fracture progression. This review examines a series of patients with chronic fractures and both persistence of spinal pain combined with radiologic changes, such as worsening collapse, spinal angulation, the development of vertebral edema and clefts, as well as the development of new fractures at adjacent spinal levels. In patients with clear progressive radiologic changes in addition to pain, vertebral augmentation on an average of 9.3 months after injury was effective in reducing the pain and stabilizing these more chronic osteoporotic fractures. A comparison of the pre- and post-procedure visual analog scale score (VAS) indicated an average of 66% reduction in pain. There are several reasons for the development of chronic symptomatic fractures. Most commonly, interventional treatment is delayed in a patient already diagnosed with VCF after a long period of conservative treatment, yet pain persists, or the initial clinical and radiologic evaluation misses the fracture, leading to a delay in diagnosis and treatment. In this report, management in these patients and the role of late vertebral augmentation for chronic symptomatic fractures is clarified based on the findings of various radiologic changes seen on both initial and follow-up radiologic studies.

Multilevel Contiguous Osteoporotic Lumbar Compression Fractures: The Relationship of Scoliosis to the Development of Cascading Fractures

Osteoporotic patients can present with either single or multiple fractures secondary to repeated falls and progressive osteoporosis. Multiple fractures often lead to additional spinal deformity and are a sign of more severe osteoporosis. In the thoracic spine, multiple fractures are associated with the development of gradual thoracic kyphosis but neurologic deficits are uncommon. In the lumbar spine, patients with multiple lumbar fractures have more constant lumbar pain, may have symptoms related to concurrent lumbar stenosis or degenerative scoliosis, and may present with radiculopathy, especially with fractures at L4 and L5. In a review of a series of patients with recurrent multiple lumbar fractures or 'cascading' fractures, it was found that all the patients were female, had severe osteoporosis, often untreated, had a previous history of multiple previous thoracic and lumbar fractures, and all had associated scoliotic spinal deformities ranging from 6^o to 50^o. It was found that if the curve progressed and the greater the degree of curvature, the more frequently subsequent multiple fractures developed, leading to recurrent acute episodes of pain. Forty percent also had additional sacral insufficiency fractures, an unusually high percentage. Biomechanically, the lumbar spine is both more mobile and supports a larger portion of the spinal load compared to the thoracic spine. The existence or worsening of a lumbar spinal deformity from degenerative lumbar scoliosis shifts the mechanical forces more to one side on already weakened osteoporotic lumbar vertebrae and sacrum, leading to an increased incidence of these fractures. Because of the chronic and uneven lower lumbar spinal load with severe vertebral osteoporosis in certain patients with repeat lumbar fractures and worsening degenerative lumbar scoliosis, there may be a rationale to add preventive vertebroplasty at adjacent vertebral endplates when treating acute recurrent lumbar fractures to decrease the incidence of recurrence in other vertebrae.

Risk Factors for Recollapse of the Augmented Vertebrae After Percutaneous Vertebral Augmentation: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVE

Recollapse of the augmented vertebrae after percutaneous vertebral augmentation treatment for osteoporotic vertebral compression fractures has obtained much attention. Although many potential risk factors have been proposed, they are still disputed. The aim of our study was to identify the characteristics of the augmented vertebrae that had undergone a recollapse according to a systematic review from the earliest available records up to August 2017 and then conduct a meta-analysis based on eligible studies to assess significant potential risk factors for recollapse of the augmented vertebrae.

METHODS

Fourteen studies were identified for investigating recollapse of the augmented vertebrae. Of those studies, 9 studies were eligible for meta-analysis.

RESULTS

Pooled results showed that 5 primary factors were associated with recollapse of the augmented vertebrae, including preoperative intravertebral cleft, the affected vertebrae in the thoracolumbar region, preoperative severe kyphotic deformity, solid lump cement distribution pattern, and higher vertebral height restoration. It was possibly another risk factor that the distance between PMMA and superior end plate was relatively large.

CONCLUSIONS

Careful observation of patients with these risk factors and reasonable intervention could be useful to prevent deterioration of their clinical course.

Progression of Vertebral Compression Fractures After Previous Vertebral Augmentation: Technical Reasons for Recurrent Fractures in a Previously Treated Vertebra

It is well recognized that patients can develop additional vertebral compression fractures (VCF) in an adjacent vertebra or at another vertebral level after successful vertebral augmentation. Factors such as the patient's bone mineral density, post procedure activity, and chronic corticosteroid use contribute to an increased risk of re-fracture or development of new fractures in the first three months after the initial procedure. However, there is a very small subgroup of patients that have unchanged or worse pain after the vertebral augmentation that may indicate continued progression of the treated compression fracture or a recurrent fracture at the previously treated level. This review examines the clinical findings, radiologic signs, and intraprocedural technical failures that may occur during the initial vertebral augmentation that can lead to a progressive fracture in a previously treated vertebra. Causes of failure of the initial vertebral augmentation procedure include inadequate or incomplete filling of the fracture site, the cement missing the actual fracture allowing continued osteoporotic compression, and persistent or worsened intravertebral fluid-filled clefts. The existence of an unfilled intravertebral fluid cleft on preoperative diagnostic studies is the most important indicator of risk for progression as is the later development of fluid at the bone cement interface.

Low Volume Vertebral Augmentation with Cortoss® Cement for Treatment of High Degree Vertebral Compression Fractures and Vertebra Plana

This is a retrospective analysis of a consecutive series of patients undergoing vertebroplasty and vertebral augmentation in an outpatient setting for high degree osteoporotic vertebral fractures or vertebra plana using consistently low volumes (less than 3 cc) of Cortoss® cement, rather than polymethylmethacrylate (PMMA). The results in these patients demonstrate that it is both technically feasible to do vertebroplasty on these patients and using a low volume hydrophilic silica-based cement is effective in providing diffuse vertebral body fill with minimal complications. There was no increased risk of complications, such as cement leakage, displacement of bone fragments, or progression of the angulation. Specifically, with over a 24-month follow-up, the preoperative collapse or angulation did not worsen and none of the patients developed adjacent level fractures or required further surgery at the involved vertebral level.