The major complications of transpedicular vertebroplasty

Long-term follow-up after vertebroplasty - A mean 10-years follow-up control study

Objectives

To evaluate the clinical 10 year outcome of patients treated with percutaneous vertebroplasty for vertebral compression fractures and to determine the incidence of new fractures in this time interval, as well as the mortality of the patients who underwent this procedure.

Methods

All patients undergoing vertebroplasty for vertebral compression fractures between May 2007 until July 2008 were prospectively followed up at 10 years postoperatively. Patients were assessed for radiologic outcome and self-reported outcome parameters (PROs). Gathered parameters remained unmodified to the initial ones analyzing QoL improvement (EQ5D 3L and NASS score) and pain alleviation (VAS, NRS). Mortality was defined as an additional endpoint. Exclusion criteria include additional instrumentation, use of additional devices such as kyphoplasty balloons/stentoplasty, cognitive impairment, insufficient radiological documentation or absent re-consent.

Results

Of 280 patients who underwent vertebroplasty, 49 (17.5%) were available for re-assessment with a mean follow-up of 10.5 years (9.9-11.1). Thirty patients (10.7%) were assessed clinically and radiologically, 16 (5.7%) in written form and three (1.1%) by phone only. A total of 186 (66.4%) died during the follow up period. Out of the remaining 45 patients, 27 patients declined participation, eight couldn't participate due to cognitive impairment, four had insufficient radiologic documentation. Six patients were lost to follow-up. At 10 years, patients reported a consistently improved quality of life (EQ-5D; p < 0.01) and global satisfaction. Vertebroplasty demonstrated a substantial and enduring effect on alleviating back pain over 10 years (p < 0.001). 26 (53%) patients experienced a new fracture since the initial procedure.

Conclusion

A decade following vertebroplasty, patients continue to demonstrate a quality of life and pain level comparable to short and medium-term assessments, with a significant difference from baseline measurements. More than half (53%) of the patients participating at last follow-up experienced new fractures during this interim period. The cohort as a whole has been impacted by an elevated mortality rate over the time period.

Open Surgery for Osteoporotic Compression Fracture Within One Month of Single Level Balloon Kyphoplasty

Objective

This study aimed to analyze the reasons for open surgery performed within one month of balloon kyphoplasty (BKP) for osteoporotic compression fractures.

Methods

This study included 15 patients treated with open surgery within one month of BKP in our institution from 2013 to 2020. Among them, 10 patients underwent BKP in our institution and 5 patients were transferred because of adverse events after undergoing BKP at another hospital. Clinical findings including main indications, neurological deficits, and clinical course were analyzed.

Results

All patients were followed up for at least 12 months after surgery (average time 15.5 months, range 12-39 months). Their mean age was 73.7 years and the mean T-score of the spine on bone densitometry was -3.35. The main reasons for open surgery included dislodgement of the cement mass or spinal instability (7 cases, 47%), neural injury due to cement leakage (3 cases, 20%), and spinal cord injury caused by a puncture mistake (3 cases, 20%). Two patients developed acute spinal subdural hematoma, and spinal epidural fluid was pushed out at the back edge of the vertebral body following BKP without signs of major cement leakage into the spinal canal. At the final follow-up, 7 patients with cement mass dislodgement showed complete improvement of related symptoms after posterior fusion with screw fixation. Among the 8 patients with neural injury, 6 improved; however, 2 remained at the same American Spinal Injury Association level.

Conclusion

The main reasons for open surgery were cement mass dislodgement and neural injury caused by puncture errors or cement leakage into the spinal canal. It should be noted that proper selection of cases, detailed imaging evaluation, and optimal surgical techniques are key to reducing open surgery after BKP.

Current status and challenges of percutaneous vertebroplasty (PVP)

A narrative review regarding percutaneous vertebroplasty (PVP) for osteoporotic vertebral fracture (OVF) is provided herein, addressing the epidemic of OVF in Japan, the latest response to the criticism of PVP for OVFs, the indications and potential risks of PVP for OVFs, and a future perspective for PVP. Each year in Japan, approximately 32,000 patients aged 55 years or older suffer from chronic low back pain for several months to several years due to a compression fracture. PVP is one of the surgical treatments for an OVF, and it is less invasive compared to the traditional open surgery. PVP is suitable for OVF patients who have difficulty walking as assessed by the modified Yokoyama's activities of daily living (ADL) scoring system, and for patients with Kummell's disease diagnosed by CT and MRI examinations. Serious adverse events related to PVP occur in 1.1-3.3% of the cases, but direct deaths from PVP are extremely rare at less than 1%. Recent studies demonstrated that OVF patients treated with PVP are less likely to die after the treatment than non-surgically treated patients, which conflicts with the Cochran reviews' conclusion not supporting PVP for OVFs. Novel robotic systems and procedure-support devices are being developed, providing a next step toward fully automated PVP procedures.

Artery of Adamkiewicz

This article reviews the case of a 65-year-old patient with unstable L1 fracture after trauma. The fracture was treated via balloon kyphoplasty, shortly after which the patient developed shortness of breath and severe headache. Subsequent computed tomography (CT) of the head revealed subarachnoid hemorrhage. CT angiography did not reveal any intracranial aneurysms or arteriovenous malformations. A massive spinal subdural hematoma, which caused the patient to develop right leg paresis and hip joint weakness with grade 2-3, was found during magnetic resonance imaging (MRI). The hematoma was removed using multi-stage laminectomy Th5-L3. A follow-up MRI showed no pathological findings. Due to the unusual findings, spinal angiography was performed, revealing the artery of Adamkiewicz (A. radicularis magna, AKA) on the L1 level on the right side. Control CT showed a suboptimal insertion of the needle into the right pedicle, which caused the injury of the artery. AKA is present in the majority of the population, and surgical attention should be paid to avoid injury. Surgeons operating on the thoracolumbar spinal cord should have a thorough understanding of the anatomical features and surgical implications of this artery.

Delayed complications of intradural cement leakage after percutaneous vertebroplasty: A case report

BACKGROUND

Intradural cement leakage following percutaneous vertebroplasty is a rare but acute and devastating complication that usually requires emergent treatment. Here, we report a delayed complication of intradural leakage after percutaneous vertebroplasty.

CASE SUMMARY

A 71-year-old female patient with an L1 osteoporotic compression fracture underwent percutaneous vertebroplasty in 2014. She was referred to our hospital 5 years later due to complaints of progressive weakness and numbness in both legs combined with urinary incontinence and constipation. Initially, she was suspected to have a spinal meningioma at the level of L1 according to imaging examinations. Postoperative pathological tests confirmed that cement had leaked into the dura during the first percutaneous vertebroplasty.

CONCLUSION

Guideline adherence is essential to prevent cement from leaking into the spinal canal or even the dura. Once leakage occurs, urgent evaluation and decompression surgery are necessary to prevent further neurological damage.

A Comparison between Accurate Unilateral Puncture Paths Planned by Preoperative and Conventional Unilateral Puncture Techniques in Percutaneous Vertebroplasty

Objective. Comparison of the clinical and radiological effects of precise unilateral puncture pathway prepared by preoperative CT data and traditional unilateral puncture pathway in PVP administration for the treatment of osteoporotic vertebral compression fractures. Summary of background data. PVP is a commonly used vertebral augmentation operation for the treatment of painful spinal compression fractures. A percutaneous unilateral approach is routinely used to get access to the vertebral body. PVP has had positive clinical results in a number of prior investigations. Numerous difficulties and issues, including puncture difficulty, radiation exposure, cement leakage, spinal cord or nerve damage, and intraspinal hematoma, have been described in contrast. Methods. This prospective study included 300 patients with single-level lumbar osteoporotic vertebral compression fractures, 180 females and 120 males, with an average age of 71.5 years. PVP was performed on randomized subjects using two distinct puncture procedures. The patients were separated into two groups: Preoperative planning, in which a precise unilateral puncture path was established using preoperative CT data, and Conventional planning, in which multiple puncture procedures were used. The participants were followed up on after surgery and mostly assessed on clinical and radiological results. The visual analogue scale for pain and the 36-item Short Form Health Survey (SF-36) questionnaire for health status were used to assess clinical outcomes. Radiation dosage, bone cement distribution, vertebral body height, and kyphotic angle were used to evaluate radiological results. Results. Participants remained monitored for 12 to 28 months on average. 151 individuals were treated with accurate unilateral puncture paths planned by preoperative CT data percutaneous vertebroplasty and 149 patients were treated with conventional unilateral paths percutaneous vertebroplasty. The Preoperative planning group’s operation time and radiation dose were significantly lower than the Conventional group’s; nevertheless, the volume of injected cement was significantly higher in the Preoperative steering committee than in the Conventional group. All patients in both groups had much less pain after the operations when compared to their preoperative suffering. There were no statistically significant variations between groups when the visual analogue scale and the 36-Item Short Form Health Survey were compared. Neither group showed a substantial decrease in the kyphotic angle during the follow-ups. In the Preoperative planning group, the kyphotic angle improved much more than in the Conventional group. At 1 month postoperatively, 16 patients in the Conventional group experienced apparent discomfort in the puncture sites because to facet joint violation. At the latest follow-up, all of the patients’ discomfort had vanished after receiving local block therapy. Conclusion. Both preoperatively designed precise unilateral puncture pathways and traditional unilateral puncture procedures PVP are reasonably safe and effective for individuals with painful osteoporotic spinal compression fractures. Unilateral puncture courses planned via preoperative PVP, on the other hand, absorbed less radiation and operation time, as well as a good level of deformity correction and amount of injected cement, and caused less complications than traditional unilateral PVP.

Spinal subdural hematoma from a ventral dural puncture after percutaneous vertebroplasty: illustrative case

BACKGROUND

Percutaneous vertebroplasty (PVP) is a common procedure, but cement leaks are not uncommon. Leakages do not always have consequences, but rarely complications do occur. Spinal subdural hematomas (sSDHs) are rare and even rarer presented as a complication after PVP. The best management for sSDH is, therefore, difficult to decide.

OBSERVATIONS

The patient first received PVP for acute low back pain after falling. Cement leakages were noted after the procedure, but a sudden new-onset leg weakness only developed later. An emergency lumbar computed tomography scan showed cement leakages anterior to the dural sac; lumbar magnetic resonance imaging revealed a subdural spinal hematoma, and a decompressive laminectomy was performed. During the operation, a small cement mass in the shape of a horn was seen and was believed to have caused the sSDH. Postoperatively, the patient recovered to leg strength 5/5.

LESSONS

PVP is considered a low-risk procedure, and cement leaks rarely give rise to complications. However, when leakages present anterior to the dural sac, they may cause dural tear and possible sSDH, regardless of size. This possibility draws attention to keeping awareness of such rare but possible complications after routine PVP procedures. Timely intervention for sSDH is necessary to ensure meaningful recovery.

Delayed neurological deficits caused by cement extravasation following vertebroplasty: a case report

Delayed neurological deficits secondary to percutaneous vertebroplasty caused by cement leakage is a rare condition. Although cement extravasation during percutaneous vertebroplasty is not uncommon, most cases are clinically asymptomatic, and symptomatic cement extravasation that requires surgical excision is rarely reported. Herein, a case of L4 radiculopathy secondary to cement leakage is reported that involved the delayed onset of neurological symptoms. The patient was treated using a minimally invasive transforaminal endoscopic approach. The clinical and imaging findings and treatment methods are discussed.

Role of percutaneous vertebroplasty with high-viscosity cement in the treatment of severe osteoporotic vertebral compression fractures

Severe osteoporotic vertebral compression fractures (OVCFs) were considered as relative or even absolute contraindication for vertebroplasty and kyphoplasty and these relevant reports are very limited. This study aimed to evaluate and compare the efficacy of vertebroplasty with high-viscosity cement and conventional kyphoplasty in managing severe OVCFs. 37 patients of severe OVCFs experiencing vertebroplasty or kyphoplasty were reviewed and divided into two groups, according to the procedural technique, 18 in high-viscosity cement percutaneous vertebroplasty (hPVP) group and 19 in conventional percutaneous kyphoplasty (cPKP) group. The operative time, and injected bone cement volume were recorded. Anterior vertebral height (AVH), Cobb angle and cement leakage were also evaluated in the radiograph. The rate of cement leakage was lower in hPVP group, compared with cPKP group (16.7% vs 47.4%, P = 0.046). The patients in cPKP group achieved more improvement in AVH and Cobb angle than those in hPVP group postoperatively (37.2 ± 7.9% vs 43.0 ± 8.9% for AVH, P = 0.044; 15.5 ± 4.7 vs 12.7 ± 3.3, for Cobb angle, P = 0.042). At one year postoperatively, there was difference observed in AVH between two groups (34.1 ± 7.4 vs 40.5 ± 8.7 for hPVP and cPKP groups, P = 0.021), but no difference was found in Cobb angle (16.6 ± 5.0 vs 13.8 ± 3.8, P = 0.068). Similar cement volume was injected in two groups (2.9 ± 0.5 ml vs 2.8 ± 0.6 ml, P = 0.511). However, the operative time was 37.8 ± 6.8 min in the hPVP group, which was shorter than that in the cPKP group (43.8 ± 8.2 min, P = 0.021). In conclusion, conventional PKP achieved better in restoring anterior vertebral height and improving kyphotic angle, but PVP with high-viscosity cement had lower rate of cement leakage and shorter operative time with similar volume of injected cement.

Spinal Epidural Hematoma After Percutaneous Kyphoplasty: Case Report and Literature Review

Objective

To present the case of a patient on long-term anticoagulants who developed acute spinal epidural hematoma (SEH) after percutaneous kyphoplasty (PKP) without signs of major cement extravasation to the spinal canal.

Methods

A 64-year-old woman with long-term oral antiplatelet drugs underwent the L1 PKP. Immediately after the operation, the back pain improved significantly without neurological deficit. However, 12 hours later, she developed progressive weakness of the bilateral lower limbs. No intraspinal cement leakage was obvious on the postoperative lumbar radiograph and computed tomography.

Results

An emergency MRI examination revealed a high signal aggregation in front of the spinal cord from T12 to L1, indicating spinal cord compression. The SEH was verified and removed during the laminectomy from T12-L1. Following the decompression surgery, the neurological deficit of the lower limbs improved. On follow-up after 6 months, the muscle strength of the bilateral lower limbs had returned to normal.

Conclusion

For the patient with long-term oral antiplatelet drugs or coagulation malfunction, the transpedicle approach or that via the costovertebral joint with a smaller abduction angle is recommended to reduce the risk of injury to the inner wall of the pedicle. For progressive aggravation of neurological dysfunction after surgery, SEH formation should be suspected despite the absence of intraspinal bone cement leakage. Secondary emergency decompression should be considered to avoid permanent damage to spinal cord nerve function caused by continuous compression.

Cement Leakage in Percutaneous Vertebroplasty for Multiple Osteoporotic Vertebral Compression Fractures: A Prospective Cohort Study

Purpose

This study аims to explore cement leаkаge аs а complication of percutаneous vertebroplаsty (PVP) in the treаtment of multiple osteoporotic vertebrаl compression frаctures (MOVF).

Patients and Methods

This prospective study wаs cаrried out on 32 consecutive pаtients with osteoporotic frаctures of аt leаst two vertebrаe (VB). Аll pаtients were over 50 yeаrs old аnd women аccounted for 29 out of the 32 pаtients (90.6%). PVP wаs performed under digitаl subtrаction аngiogrаphy (DSА) of аt leаst three VB, аnd 97 collаpsed VB аnd 105 VB were exаmined by PVP. Аll pаtients hаd postoperаtive computerized tomogrаphy (CT) to diаgnose аnd clаssify the complicаtions.

Results

One hundred аnd five vertebrаe were exаmined with PVP, аnd 36/105 (34.3%) exhibited complicаtions of cement leаkаge. Type B cement leаkаge wаs the most common complicаtion, with 19/105 (18.1%) cаses; type C аccounted for 8/105 (7.6%) cаses; аnd type S аccounted for 9/105 (8.6%) cаses. There wаs only one (0.95%) cаse of cement leаkаge moving to the pulmonаry аrtery. Аll complicаtions hаd no clinicаl symptoms аnd did not require treаtment.

Conclusion

Cement leаkаge is quite а common complicаtion, but it usuаlly hаs no clinicаl symptoms аnd does not require treаtment. Therefore, PVP is а sаfe аnd successful technique for the treаtment of multiple osteoporotic vertebrаl compression frаctures.

Bisegmental posterior stabilisation of thoracolumbar fractures with polyaxial pedicle screws: Does additional balloon kyphoplasty retain vertebral height?

We retrospectively evaluated single-level compression fractures (T12-L3) scheduled for a short-segment POS (posterior-only stabilization) using polyaxial screws. Patients averaged 55.7 years (range, 19–65). Patients received either POS or, concomitantly, BK (balloon kyphoplasty) of the fractured vertebrae as well. Primary endpoint was the radiological outcome at the last radiographic follow-up prior to implant removal. POS together with BK of the fractured vertebrae resulted in a significant improvement of the local kyphosis angle and vertebral body compression rates immediately post-OP. During the further course of FU, a considerable loss of correction was observed post-OP in both groups. (Local KA: pre-OP/ post-OP/ FU: 12.6±4.8/ 3.35±4.8/ 11.6±6.0; anterior vertebral body compression%: pre-OP/post-OP/ FU: 71.94±12.3/ 94.78±19.95/ 78.17±14.74). VAS was significantly improved from 7.2±1.3 pre-OP to 2.7±1.3 (P<0.001) at FU. We found a significant restoration of the vertebral body height by BK. Nevertheless, follow-up revealed a noticeable loss of reduction. Given the fact that BK used together with polyaxial screws did not maintain intra-operative reduction, our data do not support this additional maneuver when used together with bi-segmental polyaxial pedicle screw fixation.

Safety of vertebral augmentation with cranio-caudal expansion implants in vertebral compression fractures with posterior wall protrusion

OBJECTIVES

Vertebral augmentation (VA) has become routinely used in vertebral compression fractures (VCFs). VCFs are often associated with posterior wall protrusions (PWPs), which theoretically contraindicates vertebroplasty due to a higher risk of neurological complications. The latest generation of VA devices uses intravertebral cranio-caudal expandable implants to improve the correction of structural deformities but could also be used to prevent further PWP during cement injection. The aim of this study was to evaluate the safety of VA with expandable implant for VCFs with PWP.

METHODS

All consecutive patients treated with expandable implants were considered eligible for inclusion if they met the following criteria: (1) non-neurological VCF, (2) considered unstable (A3-A4 in AOSpine classification), (3) significant PWP (> 2 mm), (4) back pain with a visual analogue scale (VAS) ≥ 4. PWPs were independently measured by two investigators; Pearson's statistics were used for interobserver reproducibility.

RESULTS

Fifty-one consecutive patients, with a mean age of 75 ± 8.3 years (range, 50-92), were included. There was a slight decrease between mean preoperative (6.7 mm ± 2.2 mm) and postoperative (6.5 mm ± 2.2 mm) PWP (p = 0.02), with an excellent interobserver reproducibility (Pearson correlation coefficient = 0.92). A mean kyphosis reduction of 34.9% (± 28.4) was observed (p < 0.001). Forty-two patients (82.4%) had significant pain improvements (mean preoperative VAS = 6.9 [± 1.7] versus 3.1 [± 2.0] postoperatively [p < 0.001]). Secondary adjacent level fractures were noted in 16 patients (31.4%), with a reduction of that risk down to 18.8% if a preventive adjacent vertebroplasty was performed, without reaching the significance threshold (p = 0.14).

CONCLUSIONS

VA with expandable implants appeared safe for non-neurological VCFs with PWP, while allowing satisfactory pain relief.

KEY POINTS

• Vertebral augmentation with cranio-caudal expandable implants is safe for non-neurological vertebral compression fractures with posterior wall protrusions. • Vertebral augmentation with cranio-caudal expandable implants might increase the occurrence of secondary adjacent level fractures. • Adjacent level vertebroplasty might be helpful to prevent secondary adjacent level fractures.

Effects of teriparatide versus percutaneous vertebroplasty on pain relief, quality of life and cost-effectiveness in postmenopausal females with acute osteoporotic vertebral compression fracture: A prospective cohort study

BACKGROUND

Osteoporotic vertebral compression fracture (OVCF) is a common disease in senior patients. Conservative treatments (usual care) and percutaneous vertebroplasty (PVP) are typically applied to treat OVCFs; however, their efficacies are not fully satisfactory. While Teriparatide (TPTD) is effective in both anti-osteoporosis and bone healing, whether TPTD could be applied as a conservative treatment for acute OVCFs remains unclear.

METHODS

This investigation represents a real-world prospective cohort study, where 60 postmenopausal women (≥55 years old) with acute OVCFs were equally assigned to a TPTD conservative group or PVP (plus alendronate) group based on the patient's choice. TPTD (20 μg, s.c., once daily) or alendronate (70 mg, p.o., once weekly) were administrated together with 0.6 mg Caltrate and 500 iu Vitamin D3 per day. A health survey (SF-36) was conducted at 0-, 1- and 3-months post-treatment. Back pain and the Oswestry Disability Index (ODI) were measured at 0-week, 1-week, 1-month and 3-months after treatment, while the direct medical cost was analyzed at the end of the third month.

RESULTS

Both treatments with TPTD and PVP significantly and similarly improved the patients' health quality, with reduced visual analogue and ODI scores at the end of the first and third months. PVP was more effective in reducing pain at the early time point (1 week, p < 0.05). 24 of 27 patients who were rescanned with magnetic resonance imaging in the TPTD group showed bone healing. The mid-vertebral height was increased by PVP (p < 0.05) but not by TPTD. The cost of TPTD treatment was 21,868.61 ± 167.05 RMB per capita, while the cost for PVP treatment was 33,265.95 ± 1491.11 RMB per capita (p < 0.05).

CONCLUSION

TPTD conservative treatment obtained similar therapeutic effects but cost less than PVP in terms of treating acute OVCF.

Non-iatrogenic spontaneous acute spinal subdural haematoma after transforaminal lumbar interbody fusion

Purpose: Reporting a rare case of a non-iatrogenic spontaneously resolved spinal subdural haematoma (SSDH) following revision of transforaminal lumbar interbody fusion (TLIF) and its possible explanation.Methods: Case report of a 40-year-old man with a history of persistent lower back and left lower extremity radicular pain, secondary to recurrent disc prolapse, lumbar spondylosis with foraminal stenosis. He underwent an L5/S1 transforaminal interbody fusion via a right sided approach (through previous lumbar microdiscectomy incision). On post-operative day two, the patient developed headache and photophobia that were discovered to be secondary to an acute thoracolumbar subdural haematoma with no objective neurological deficit.Results: After close observation of his neurological status and conservative management of the subdural haematoma, the patient fully recovered from his symptoms and remained problem-free at 2-year follow-up.Conclusions: Although the occurrence of acute spinal subdural haematoma after spinal surgery is a rare complication following spinal surgery, its appropriate management relies on early recognition if significant morbidity is to be avoided.

Is it necessary to approach the compressed vertebra bilaterally during the process of PKP?

OBJECTIVE

To assess the clinical and radiological outcomes following unilateral or bilateral approach in percutaneous kyphoplasty (PKP) for treatment of osteoporotic vertebral compression fractures (OVCF).

DESIGN

Prospective comparative study.

SETTING

University affiliated hospital.

PARICIPANTS

From 2012 through 2016, those MRI-diagnosed single-level lumbar OVCF patients.

INTERVENTIONS

They were randomly assigned for treatment with unilateral or bilateral PKP.

OUTCOME MEASURES

We assessed the patient' health status with the Oswestry Disability Index (ODI) questionnaire. Anteroposterior and lateral standing radiographs were obtained to measure the vertebral height and kyphotic angle of the vertebral body in all patients.

RESULTS

Eighty-five patients were finally enrolled in this investigation, including 42 in the unilateral and 43 in the bilateral group. The operation time, PMMA volume, radiation dose was 25.6 ± 4.2 minutes, 6.2 ± 3.5 ml and 0.88 ± 0.28 mSv in the unilateral group, while 36.6 ± 8.7 minutes, 8.5 ± 2.2 ml and 1.89 ± 1.05 mSv in the bilateral group, respectively (P < 0.05). The postoperative VAS and ODI were 2.7 ± 1.2 and 19.8 ± 6.4 compared to preoperative 8.7 ± 1.6 and 35.2 ± 4.3 in unilateral group, while 2.6 ± 1.3 and 19.7 ± 2.6 compared to preoperative 8.5 ± 1.3 and 36.7 ± 3.6 in bilateral group, respectively (P > 0.05).

CONCLUSION

Both bilateral and unilateral PKP are relatively safe and provide effective treatment for patients with painful OVCF. However, unilateral PKP need less radiation dose, operation time and PMMA volume.

Spinal subdural and epidural hematomas after vertebroplasty for compression fracture: a case report

Introduction

Vertebroplasty (VP) is a well-known and effective therapeutic method for relieving the pain and improving the quality of life of patients with vertebral compression fractures. Major complications of VP are infrequent, occurring in no more than 1% of such procedures, whereas spinal subdural and epidural hematomas are extremely rare complications.

Case Presentation

We present a unique case of a spinal subdural hematoma (sSDH) (from T4 to T12) occurring immediately after VP to treat a traumatic vertebral compression fracture, followed by a spinal epidural hematoma (SEH) (from T3 to T12) after the decompressive laminectomy, occurring in a 64-year-old patient. After removing of the big spinal epidural hematoma, the patient's symptoms improved progressively and she recovered after 2 months.

Discussion

This is a rare case of sSDH and SEH occurring continuously after VP. The pathogenesis may be that the puncture damaged the abnormal blood vessel of spinal dura mater. A small-probability event is not an impossible event. We hope to bring more attention to the rare complications of VP by sharing this unusual case.

Vertebroplasty Using Allograft Bone Chips with Posterior Instrumented Fusion in the Treatment of Osteoporotic Vertebral Fractures with Neurological Deficits

Introduction

In general, osteoporotic vertebral fractures with neurological deficits require surgery. However, the ideal surgical method remains controversial. We evaluated the efficacy of combining posterior instrumented fusion and vertebroplasty using allograft bone chips.

Methods

Twelve patients (five men, seven women; age 68-84 years, mean age 75.9 years) with osteoporotic vertebral fractures with neurological deficits were reviewed retrospectively. They underwent posterior instrumented fusion and vertebroplasty, using allograft bone, at our institution between January 2007 and June 2016. We assessed the surgical results, radiologically and neurologically, after a mean follow-up of 37.3 months.

Results

The mean local kyphosis angle was 10° before surgery, −3.3° immediately after surgery, and 4.4° at follow-up. The average spinal canal compromise was 26.9% before surgery and 19.5% at follow-up. All patients achieved bony fusion and none needed additional surgery. All patients improved by at least one grade on the modified Frankel grading system.

Conclusions

Combining vertebroplasty, using allograft bone chips, and posterior instrumented fusion appears to be an effective option for osteoporotic vertebral fractures with neurological deficits.

Vertebroplasty and delayed subdural cauda equina hematoma: Review of literature and case report

Vertebroplasy is considered an alternative and effective treatment of painful oncologic spine disease. Major complications are very rare, but with high morbidity and occur in less than 1% of patients who undergo vertebroplasty. Spinal subdural hematoma (SDH) is an extremely rare complication, usual developing within 12 h to 24 h after the procedure. We report the case of a tardive SDH in an oncologic patient who underwent VP for Myxoid Liposarcoma metastasis. Trying to explain the pathogenesis, we support the hypothesis that both venous congestion of the vertebral venous plexus of the vertebral body and venous congestion due to a traumatic injury can provoke SDH. To our best knowledge, only 4 cases of spinal subdural hematoma following a transpedicular vertebroplasty have been previously described in International literature and only one of them occurred two weeks after that surgical procedures. Percutaneous verteboplasty is a well-known treatment of pain oncologic spine disease, used to provide pain relief and improvement of quality life and is considered a simple surgical procedure, involving a low risk of complications, but related to high morbidity, such as SDH. Therefore it has to be performed by experienced and skilled surgeons, that should also recognize possible risk factors, making SDH more risky.

The prospective self-controlled study of unilateral transverse process-pedicle and bilateral puncture techniques in percutaneous kyphoplasty

Many previous studies have reported excellent clinical results with percutaneous kyphoplasty (PKP). In contrast, numerous complications and problems have also been reported, such as puncture difficulty, cement leakage, and adjacent vertebral fracture.

INTRODUCTION

This study is to evaluate the application and clinical outcomes of unilateral transverse process-pedicle and bilateral PKP in the treatment of osteoporotic vertebral compression fractures (OVCF).

METHODS

A total of 56 cases with two levels thoracolumbar OVCF were randomly assigned for treatment with unilateral transverse process-pedicle and bilateral PKP. The patients were followed up postoperatively and were assessed mainly with regard to clinical and radiologic outcomes. Clinical outcomes were evaluated with mainly the use of a visual analogue scale (VAS) for pain. Radiologic outcomes were assessed mainly on the basis of radiation dose and bone cement distribution.

RESULTS

The operation was completed successfully in 56 cases. In the unilateral level, the operation time, the volume of the injected cement, and radiation dose were significantly less than bilateral level. All patients had significantly improvement on VAS score after the procedures, compared with their preoperative period. In the bilateral level, 7 patients had obvious pain in the puncture sites at 1 month postoperatively caused by facet joint violation. With local block treatment, the pain disappeared in all patients at the last follow-up.

CONCLUSION

Both bilateral and unilateral PKP are relatively safe and effective treatments for patients with painful OVCF. But unilateral PKP received less radiation dose and operation time, offered a higher degree of deformity correction, and resulted in less complication than bilateral.

Safety and Clinical Effectiveness of Percutaneous Vertebroplasty in the Elderly (≥80 years)

PURPOSE

To evaluate the safety and clinical effectiveness of percutaneous vertebroplasty (PVP) in patients aged 80 and over.

METHODS

One hundred and seventy-three patients (127 women, 46 men; mean age = 84.2y) underwent 201 PVP procedures (391 vertebrae) in our institution from June 2008 to March 2012. One hundred and twenty-six patients (73 %) had osteoporotic vertebral compression fractures (VCF), 36 (20.5 %) were treated for tumour lesions, and the remaining 11 (6.5 %) for lesions from another cause. Comorbidities and American Society of Anesthesiologists (ASA) scores were assessed before treatment. Periprocedural and delayed complications were systematically recorded. A qualitative scale was used to evaluate pain relief at 1-month follow-up, ranging from significant pain worsening to marked improvement or disappearance. New fracture occurrence was assessed on follow-up imaging.

RESULTS

Forty-five percent of patients had pretreatment ASA class scores ≥3. No major complication occurred. Pain was unchanged in 16.9 % of cases, mildly improved in 31.5 %, and disappeared in 47.8 %. We identified 27 (11 %) symptomatic new VCFs in patients with osteoporosis on follow-up imaging. The mean delay in diagnosis of new fractures was 5 ± 8.7 months.

CONCLUSIONS

Even in the elderly, PVP remains a safe and effective technique for pain relief, independently of the underlying disease.

KEY POINTS

• Post-PVP pain improvement was observed in 79.3 % of elderly patients. • PVP remains a safe technique in elderly patients. • No decompensation of comorbidity was observed in our series.

Cement augmentation in vertebral burst fractures

As a result of axial compression, traumatic vertebral burst fractures disrupt the anterior column, leading to segmental instability and cord compression. In situations with diminished anterior column support, pedicle screw fixation alone may lead to delayed kyphosis, nonunion, and hardware failure. Vertebroplasty and kyphoplasty (balloon-assisted vertebroplasty) have been used in an effort to provide anterior column support in traumatic burst fractures. Cited advantages are providing immediate stability, improving pain, and reducing hardware malfunction. When used in isolation or in combination with posterior instrumentation, these techniques theoretically allow for improved fracture reduction and maintenance of spinal alignment while avoiding the complications and morbidity of anterior approaches. Complications associated with cement use (leakage, systemic effects) are similar to those seen in the treatment of osteoporotic compression fractures; however, extreme caution must be used in fractures with a disrupted posterior wall.

A comparison between unilateral transverse process-pedicle and bilateral puncture techniques in percutaneous kyphoplasty

STUDY DESIGN

A prospective comparative study.

OBJECTIVE

To assess the clinical and radiological outcomes for the treatment of osteoporotic vertebral compression fractures using unilateral transverse process-pedicle and bilateral percutaneous kyphoplasty (PKP).

SUMMARY OF BACKGROUND DATA

PKP is a widely used vertebral augmentation procedure for treating painful vertebral compression fractures. A percutaneous bilateral approach is typically used to access the vertebral body. Many previous studies have reported excellent clinical results with PKP. In contrast, numerous complications and problems have also been reported, such as puncture difficulty, cement leakage, and adjacent vertebral fracture.

METHODS

This prospective study included 316 patients with single-level lumbar osteoporotic vertebral compression fracture, 224 females and 92 males with a mean age of 71.5 years. Randomized patients underwent PKP using 2 different puncture techniques. The patients were followed up postoperatively and were assessed mainly with regard to clinical and radiological outcomes. Clinical outcomes were evaluated mainly using the visual analogue scale for pain and 36-Item Short Form Health Survey (SF-36) questionnaire for health status. Radiological outcomes were assessed mainly on the basis of radiation dose, bone cement distribution, vertebral body height, and kyphotic angle.

RESULTS

Patients were followed up from 12 to 28 months, with an average of 16.8 months. One hundred fifty-eight patients were treated with unilateral method and 151 patients were treated with bilateral method. In the unilateral group, the volume of the injected cement and radiation dose were significantly less than that in the bilateral group. All patients in both groups had significantly less pain after the procedures, compared with their preoperative period pain. No statistically significant differences were observed when visual analogue scale and 36-Item Short Form Health Survey were compared between the groups. Both unilateral and bilateral groups showed insignificant decrease in the kyphotic angle during the follow-ups. The kyphotic angle in the unilateral group improved more significantly than in the bilateral group. In the bilateral group, 16 patients had obvious pain in the puncture sites at 1 month postoperatively caused by facet joint violation. With local block treatment, the pain disappeared in all patients at the last follow-up.

CONCLUSION

Both bilateral and unilateral PKP are relatively safe and provide effective treatment for patients with painful osteoporotic vertebral compression fracture. However, unilateral PKP received less radiation dose and operation time, it also offered a higher degree of deformity correction and resulted in less complication than bilateral PKP.

Severe kyphotic deformity resulting from collapses of cemented and adjacent vertebrae following percutaneous vertebroplasty using calcium phosphate cement. A case report

Percutaneous vertebroplasty (PVP) has been increasingly performed for the treatment of osteoporotic vertebral compression fracture. Despite its minimally invasive procedure, several complications associated with PVP have been reported, including adjacent-level vertebral fracture. Although rare, recollapse of the same vertebrae after PVP has also been reported. However, previous studies have not described a case in which collapses of both the cemented vertebrae and adjacent-level vertebrae occurred following PVP. Here, we report a rare case of severe kyphotic deformity resulting from collapses at the cemented and adjacent vertebrae after PVP using calcium phosphate cement (CPC). The patient required a highly invasive reconstruction procedure as a salvage surgery.

Treatment of multiple osteoporotic vertebral compression fractures by percutaneous cement augmentation

PURPOSE

Vertebral compression fractures cause significant pain and some patients are debilitated by the pain due to the fracture. Conventional surgery carries a high risk and has a poor outcome. Vertebroplasty is a minimally invasive surgical procedure, which in vertebral fractures restores stability and diminishes pain. The aim of the study was to analyse the effectiveness and safety of vertebroplasty in multiple vertebral compression fractures with a 24-month follow-up.

METHODS

Vertebroplasty was performed in 160 patients with multiple osteoporotic compression fractures under local anaesthesia, using a unilateral transpedicular approach. The level of pain was assessed according to a 10-cm visual analogue scale. The patients were observed for 24 months after surgery.

RESULTS

Vertebroplasty significantly diminished the level of pain in 90% of patients, and half of them were free of pain within 12 hours after surgery. Only 4% of the patients did not benefit from this type of treatment. During the 24-month follow-up these results changed only slightly, and after two years almost 80% still benefited, while the number of unsatisfactory results changed from 6 to 9%. No serious clinical complications were noted; in three patients new fractures appeared during the two year observation period.

CONCLUSIONS

Vertebroplasty should be seriously taken into account as a primary method of treatment in patients with multiple osteoporotic vertebral compression fractures.

Neurological deficit due to cement extravasation following a vertebral augmentation procedure

The authors endeavor to highlight the surgical management of severe neurological deficit resulting from cement leakage after percutaneous vertebroplasty and to systematically review the literature on the management of this complication. A patient presented after a vertebroplasty procedure for traumatic injury. A CT scan showed polymethylmethacrylate leakage into the right foramina at T-11 and L-1 and associated central stenosis at L-1. He underwent decompression and fusion for removal of cement and stabilization of the fracture segment. In the authors' systematic review, they searched Medline, Scopus, and Cochrane databases to determine the overall number of reported cases of neurological deficit after cement leakage, and they collected data on symptom onset, clinical presentation, surgical management, and outcome. After surgery, despite neurological recovery postoperatively, the patient developed pneumonia and died 16 days after surgery. The literature review showed 21 cases of cement extravasation with neurological deficit. Ultimately, 15 patients had resolution of the postoperative deficit, 5 had limited change in neurological status, and 2 had no improvement. Cement augmentation procedures are relatively safe, but certain precautions should be taken to avoid such complications including high-resolution biplanar fluoroscopy, considering the use of a local anesthetic, and controlling the location of cement spread in relationship to the posterior vertebral body. Immediate surgical intervention with removal of cement provides good results with complete recovery in most cases.

The impact of a distal expansion mechanism added to a standard pedicle screw on pullout resistance. A biomechanical study

BACKGROUND CONTEXT

Spinal deformity surgery in elderly patients is associated with an increased risk of implant loosening due to failure at the screw-bone interface. Several techniques can be used to increase the screw anchorage characteristics. Cement-augmented screw fixation was shown to be the most efficient method; however, this technique is associated with a risk of complications related to vertebral cement deposition and leakage. Hence, there is a need to further elaborate the alternative screw augmenting techniques to reduce the indications for bone cement.

PURPOSE

To analyze surgical alternatives to cement augmentation, the present study sought to quantify the impact of a distal expansion mechanism added to a standard pedicle screw on an axial pullout resistance.

STUDY DESIGN

A biomechanical laboratory study on the uniaxial pullout resistance of a standard pedicle screw versus a customized pedicle screw with a distal expansion mechanism.

METHODS

A total of 40 vertebrae from seven fresh-frozen human specimens were harvested and subjected to a computed tomography scanning and an analysis of the bone mineral density (BMD). The vertebrae were instrumented with a standard 6.0-mm pedicle screw and a modified 6.0-mm pedicle screw with a distal expansion mechanism added. The actual working length of both screws inside the vertebrae was identical. The distal expansion mechanism made up one-fifth of the shaft length. The accuracy of the screw insertion was assessed using biplanar radiographs and by inspection. Analysis of resistance to pullout was performed by a coaxial alignment of the pedicle screws and attachment to an electromechanical testing machine. The pullout rate was 5 mm/min, and the load-displacement curve was recorded until the force of the pullout resistance peaked. The peak load-to-failure was measured in Newtons and reported as the ultimate failure load. With each test, the mode of failure was noted and analyzed descriptively.

RESULTS

A total of 17 vertebrae with matched pairs of standard and expansion pedicle screws were eligible for the final statistical analysis. The BMD of the vertebrae tested was 0.67±0.19 g/cm³. The screw length was 50 mm, and the actual working length of both screws was 40.3±4.2 mm. The ultimate failure load of the standard screw was 773.8±529.4 N and that of the expansion screw was 910.3±488.3 N. Statistical analysis revealed a strong trend toward an increased failure load with the expansion screw (p=.06). The mean increase of the ultimate failure load was 136.5±350.4 N. Abrupt vertebral fracture at the vertebral body-pedicle junction and the pedicle occurred seven times with the expansion screw and only five times with the standard screw (p=.16).

CONCLUSIONS

Our study indicates that adding a distal expansion mechanism to a standard pedicle screw increases the failure load by one-fifth. Modern expansion screws might offer an intermediate solution for the augmentation of screw-rod constructs in osteoporotic bone while reducing the need for cement-augmented screws and avoiding the related risks.

Delayed onset of spinal subdural hematoma after vertebroplasty for compression fracture: a case report

Vertebroplasty (VP) is a well-known therapeutic modality used to treat pain associated with vertebral compression fractures. Major complications such as cord or root compression, epidural and subdural hematomas (SDH) and pulmonary emboli, occur in less than 1% of patients who undergo VP after compression fracture. Spinal SDH is an extremely rare complication that usually happens a few hours after the procedure. We report a case of spinal SDH that developed at two weeks after a successful VP. We also reviewed related literatures and discussed its possible pathogenesis.

Comparative clinical results of vertebroplasty using jamshidi® needle and bone void filler for acute vertebral compression fractures

OBJECTIVE

Percutaneous vertebroplasty (PVP) is an effective treatment modality for management of osteoporotic compression fracture. However physicians sometimes have problems of high pressure in cement delivery and cement leakage when using Jamshidi® needle (JN). Bone void filler (BVF) has larger lumen which may possibly diminish these problems. This study aims to compare the radiologic and clinical outcome of JN and BVF for PVP.

METHODS

One hundred twenty-eight patients were treated with PVP for osteoporotic vertebral compression fracture (VCF) where 46 patients underwent PVP with JN needle and 82 patients with BVF. Radiologic outcome such as kyphotic angle and vertebral body height (VBH) and clinical outcome such as visual analog scale (VAS) scores were measured after treatment in both groups.

RESULTS

In JN PVP group, mean of 3.26 cc of polymethylmethacrylate (PMMA) were injected and 4.07 cc in BVF PVP group (p<0.001). For radiologic outcome, no significant difference in kyphotic angle reduction was observed between two groups. Cement leakage developed in 6 patients using JN PVP group and 2 patients using BVF group (p=0.025). No significant difference in improvement of VAS score was observed between JN and BVF PVP groups (p=0.43).

CONCLUSION

For the treatment of osteoporotic VCF, usage of BVF for PVP may increase injected volume of cement, easily control the depth and direction of PMMA which may reduce cement leakage. However, improvement of VAS score did not show difference between two groups. Usage of BVF for PVP may be an alternative to JN PVP in selected cases.

Postvertebroplasty instability

Vertebroplasty provides excellent pain relief and functional restoration for osteoporotic fractures. Short-term complications such as cement leak and embolism are well described. Incident fractures are the only well-reported long-term complications. The authors describe the cases of 5 patients who presented with back pain caused by instability or worsening neurological status 13 months (range 8–17 months) after vertebroplasty. They further classify this postvertebroplasty instability into intervertebral instability and intravertebral instability, depending on the apex of abnormal mobility.

One patient presented with cement migration and progressive collapse of the augmented vertebral body. Another patient presented with an additional fracture. Both cases were classified as intravertebral instability. The cases of 3 other patients presenting with adjacent endplate erosion, vacuum disc phenomenon, and bridging osteophyte formation were classified as having intervertebral instability.

Long-term effect of cements on the augmented vertebral body and adjacent endplates and discs is a cause for concern. Vertebroplasty acts as a mechanical stabilizer and provides structural support but does not bring about union. Micromotion has been shown to persist for years after vertebroplasty. This study describes persistent instability after vertebroplasty in a series of 5 cases. The authors propose that postvertebroplasty instability occurs due to collapse of soft osteoporotic bone and endplates around cement. All 3 cases of intervertebral instability were associated with an intradiscal cement leak. With increased longevity and higher functional demands of the geriatric population, the durability of this “rock (cement) between cushions (of osteoporotic bone)” arrangement (as seen in vertebroplasty) will be increasingly challenged.

Early and long-term outcomes of vertebroplasty for single osteoporotic fractures

BACKGROUND AND PURPOSE

Percutaneous vertebroplasty (PVP) is a minimally invasive vertebral augmentation procedure for the treatment of recent, osteoporotic vertebral compression fractures. The aim of the study was to determine the early and late outcomes of PVP for osteoporotic vertebral compression fractures.

MATERIAL AND METHODS

We prospectively assessed outcomes of PVP in 200 patients with single, osteoporotic vertebral compression fracture. Follow-up assessment was made 12 hours after surgery as well as after 7 days, 30 days, 3 months, 6 months, and 1 year after surgery. A subgroup of 80 patients was evaluated also 2 years after PVP. A 100-mm visual analogue scale of pain was used for outcome measurement.

RESULTS

Twelve hours after PVP, very significant relief of pain was obtained in 85% of patients; on the 7th and 30th day a very good result of treatment was noted in 96%. The same result was noted in 92% of patients at the 6th month, and in 90% of patients at the 12th month. Among the 80 patients followed for 2 years, 3 patients reported recurrence of pain and were subsequently diagnosed with new osteoporotic fractures.

CONCLUSIONS

Percutaneous vertebroplasty is a minimally invasive method of treatment for fresh osteoporotic fractures, which provides a significant and sizeable reduction of pain in the short as well as long term after surgery. Complete relief of pain was noted 12 hours after PVP in 94% of patients, and was noted in 90% two years after treatment. Despite some literature data suggesting no beneficial effect of PVP, it can be concluded that PVP is the most effective and the safest method for fresh vertebral compression fracture treatment.

Comparative study of percutaneous vertebral body perforation and vertebroplasty for the treatment of painful vertebral compression fractures

BACKGROUND AND PURPOSE

Percutaneous vertebral body perforation is a new technique for treating painful VCFs. Herein, we compare the therapeutic effect of vertebral perforation and conventional vertebroplasty for treating VCFs.

MATERIALS AND METHODS

One hundred eight patients with single painful VCFs were assigned to undergo vertebral perforation (perforation group) or vertebroplasty (PVP group). Clinical outcomes were assessed by using the VAS. The associations of analgesic effect and clinical factors were also analyzed by multivariate regression. Plain radiographs were used to quantify the progression of vertebral body compression after surgery and to evaluate cement leakage and new vertebral fractures. The median follow-up time was 10 months.

RESULTS

Baseline characteristics were similar in the 2 groups. No factors correlated with analgesic effects in the PVP group. The analgesic effect of vertebral perforation was, however, related to the preoperative severity of vertebral compression and was low in patients with severe deformity (P < .05). Among patients with preoperative vertebral percentage of compression below 30%, there were no significant differences between the 2 groups in analgesic effect at any postoperative intervals. Progression of vertebral compression after surgery occurred in 22.2% and 16.0% of treated vertebrae in the perforation and PVP groups, respectively (P = .38). Respectively, 3.7% and 20.0% of the perforation and PVP groups had new postoperative fractures during follow-up (P < .05). There were no other complications.

CONCLUSIONS

Vertebral perforation was safe and effective for painful VCFs with slight compression. However, vertebroplasty should be considered for patients with marked vertebral body compression.

Newly developed compression fractures after percutaneous vertebroplasty: comparison with conservative treatment

PURPOSE

The aim of this study was to investigate the incidence and timing of subsequent fractures in patients treated with and without percutaneous vertebroplasty (PVP).

MATERIALS AND METHODS

We reviewed 794 patients who underwent 1500 PVPs with polymethylmethacrylate (PMMA) at our institution between January 1999 and December 2009. We also reviewed 349 patients with vertebral fractures who underwent conservative treatment without PVP between October 1999 and December 2009 and compared the incidence and timing of subsequent fractures in the two groups.

RESULTS

Among the 794 patients treated by PVP, 171 (21.5%) suffered 336 new vertebral fractures. Among the patients not treated by PVP, 82 (23.5%) presented with 154 new fractures. There was no statistically significant difference (P = 0.46). Among the PVP-treated patients, one-half of new fractures occurred at a level adjacent to the treated level, and they occurred significantly sooner than nonadjacent level fractures (log-rank test, P < 0.01).

CONCLUSION

PVP did not increase the incidence of new compression fractures compared with conservative treatment, but half of the new fractures at the adjacent vertebral bodies occurred sooner.