Posterior Vertebrectomy and Circumferential Fusion for the Treatment of Advanced Thoracolumbar Kümmell Disease with Neurologic Deficit

Factors influencing further vertebral height loss following percutaneous vertebroplasty in osteoporotic vertebral compression fractures: A 1-year follow-up study

BACKGROUND

Osteoporotic vertebral compression fractures (OVCFs) contribute to back pain and functional limitations in older individuals, with percutaneous vertebroplasty (PVP) emerging as a minimally invasive treatment. However, further height loss post-PVP prompts investigation into contributing factors.

AIM

To investigate the factors associated with further height loss following PVP with cement augmentation in OVCF patients.

METHODS

A total of 200 OVCF patients who underwent successful PVP between January 2021 and December 2022 were included in this study. “Further height loss” during 1 year of follow-up in OVCF patients with bone edema was defined as a vertical height loss of ≥ 4 mm. The study population was divided into two groups for analysis: The “No Further Height Loss group (n = 179)” and the “Further Height Loss group (n = 21).”

RESULTS

In comparing two distinct groups of patients, significant differences existed in bone mineral density (BMD), vertebral compression degree, prevalence of intravertebral cleft (IVF), type of bone cement used, and cement distribution patterns. Results from binary univariate regression analysis revealed that lower BMD, the presence of IVF, cleft distribution of bone cement, and higher vertebral compression degree were all significantly associated with further height loss. Notably, the use of mineralized collagen modified-poly(methyl methacrylate) bone cement was associated with a significant reduction in the risk of further height loss. In multivariate regression analysis, lower BMD and the presence of IVF remained significantly associated with further height loss.

CONCLUSION

Further height loss following PVP in OVCF patients is influenced by a complex interplay of factors, especially lower BMD and the presence of IVF. These findings underscore the importance of assessing and managing these factors when addressing height loss following PVP in OVCF patients.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

A meta-analysis of complications associated with the use of cement-augmented pedicle screws in osteoporosis of spine

PURPOSE

Our study aimed to provide updated and comprehensive evidence on the complications associated with the use of cement-augmented pedicle screws (CAPS) in osteoporosis patients undergoing spinal instrumentation.

METHODS

Databases of PubMed, Embase, Ovoid, and Google Scholar were screened from January 2000-February 2020 for studies reporting complications of CAPS in osteoporosis patients. Pooled estimates (with 95% confidence intervals) were calculated.

RESULTS

Twenty studies were included. The pooled risk of screw loosening, screw breakage and screw migration was 2.0% (0.2%-4.9%), 0.6% (0%-2.0%) and 0.2% (0%-1.2%) respectively. On pooling of data from 1277 patients, we found the risk of all cement leakage to be 21.8% (6%-43.1%). However, data from 1654 patients indicated the risk of symptomatic cement leakage was 1.2% (0.6%-1.9%). The incidence of pulmonary embolism was 3.0% (0.5%-6.8%) while the risk of symptomatic pulmonary embolism was 0.8% (0.2%-1.5%). Pooled risk of neurovascular complications was 1.6% (0.3%-3.6%), adjacent compression fracture was 3.3% (1.2%-6.2%) and infectious complications was 3.1% (1.1%-5.7%). There were high heterogeneity and variability in the study outcomes.

CONCLUSION

The incidence of screw-related complications like loosening, breakage, and migration with the use of CAPS in spinal instrumentation of osteoporotic patients is low. The risk of cement leakage is high and variable but the incidence of symptomatic cement leakage and related neurovascular or pulmonary complications is low. Further studies using homogenous methods of reporting are needed to strengthen current evidence.

LEVEL OF EVIDENCE

II, Systematic Review and Meta-analysis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Therapeutic Efficacy of Transpedicular Impaction Bone Grafting with Long Segmental Posterior Instrumentation in Stage III Kümmell Disease

STUDY DESIGN

A retrospective review of clinical and radiological parameters.

OBJECTIVE

To evaluate the therapeutic efficacy of transpedicular impaction bone grafting (TIBG) with long segmental posterior instrumentation for the treatment of stage III Kümmell disease.

SUMMARY OF BACKGROUND DATA

The optimal treatment for stage III Kümmell disease remains controversial and unclear. Theoretically, transpedicular bone grafting can reconstruct anterior column support and reduce the failure of internal fixation, which is an intuitive method for the treatment of Kümmell disease. However, the use of this technique has rarely been reported for the treatment of this disease. This study reported the clinical and radiological results of TIBG with long segmental posterior instrumentation for the treatment of stage III Kümmell disease.

METHODS

Between August 2011 and December 2017, we retrospectively analyzed 24 patients with stage III Kümmell disease who underwent TIBG with long segmental posterior instrumentation. Anterior vertebral heights, kyphotic Cobb angle, visual analog scale (VAS), Oswestry disability index (ODI), and American Spinal Injury Association (ASIA) impairment scale were used to evaluate the effects of surgery.

RESULTS

The mean time to follow-up was 38.1 ± 10.2 months. The average operative duration was 136 ± 16.5 minutes, and the average intraoperative blood loss was 293 ± 41.3 mL. The VAS, ODI, anterior vertebral heights, and kyphotic Cobb angles were improved significantly at 1 week after surgery compared the preoperative examinations, and were well maintained at the final follow-up evaluation. Fourteen patients (58%) had mild neurological impairments before surgery, with neurological function returning to normal at the final follow-up evaluation. There was no instance of instrumentation failure.

CONCLUSION

TIBG combined with long segmental posterior instrumentation is a safe and effective surgical option for stage III Kümmell disease.Level of Evidence: 4.

Is Kummell's Disease a Misdiagnosed and/or an Underreported Complication of Osteoporotic Vertebral Compression Fractures? A Pattern of the Condition and Available Treatment Modalities

This narrative review provides the outcomes of minimally invasive surgery (MIS) and describes the available conservative treatment options for patients with osteoporotic vertebral compression fractures (OVCFs) that have risk factors for Kummell's disease (KD). It aims to explore the evidence, emphasize the possible therapy complications, and aims to propose the most efficient clinical strategies for maintaining a good overall condition of individuals who may suffer from neurological deficits from a late-diagnosed OVCF complication. The secondary objective is to sum up the diagnostic particularities concerning individuals prone to OVCFs and KD, as the major risk factor for developing these severe conditions remains osteoporosis. Findings of our narrative review are based on the results found in PubMed, Embase, and Google Scholar from the beginning of their inception to December 2020, described independently by two authors. All of the studies included in the review focus on reporting the following treatment methods: conservative methods, vertebroplasty, kyphoplasty, targeted percutaneous vertebroplasty, frontal and side-opening cannula vertebroplasty, SpineJack, bone-feeling mesh container treatment, and the difference in the cement viscosity used (high vs. low) and the approach used (unilateral vs. bilateral). The comparison of randomized control trials (RCTs) as well as prospective and retrospective case series showed a comparable efficacy of kyphoplasty and vertebroplasty, and described cement-augmented screw fixation and the SpineJack system as effective and safe. Although it should be noted that several studies revealed inconsistent results in regards to the efficacy of using back braces and analgesics in patients who had vertebral fractures that were overlooked or not enrolled in any active surveillance program to track the patient's deterioration immediately. Nevertheless there are non-standardized guidelines for treating patients with OVCFs and their complications already established. Using these guidelines, a treatment plan can be planned that takes into consideration the patients' comorbidities and susceptibilities. However, the primary approach remains the management of osteoporosis and that is why prophylaxis and prevention play a crucial role. These measures reduce the risk of disease progression. Unfortunately, in the majority of cases these measures are not taken into account and KD develops.

Cluster phenomenon of vertebral refractures after posterior pedicle screw fixation in a patient with glucocorticosteroid-induced Kümmell's disease: a treatment dilemma

INTRODUCTION

Surgical treatments are usually preferred in patients with Kümmell's disease since it represents a failure of conservative treatment for osteoporotic vertebral compression fracture without evidence of spontaneous healing. However, the risk of postoperative refractures is much higher in patients with glucocorticosteroid-induced osteoporosis (GIOP) than in those with primary osteoporosis, possessing a therapeutic challenge and dilemma to orthopaedic surgeons.

CASE REPORT

We described a rare cluster phenomenon of vertebral refractures in a patient with GIOP subsequent to segmental internal fixation for the initial management of glucocorticosteroid-induced Kümmell's disease, and a review of the literature.

CONCLUSION

Our patient illustrates that clinicians should be aware of the significant management dilemma and possible disastrous outcome after surgical interventions for glucocorticosteroid-induced Kümmell's disease and, thus, pay much more attention to comprehensive perioperative antiosteoporotic medications for patients with GIOP in current medical treatment.

Application of Titanium Alloy 3D-Printed Artificial Vertebral Body for Stage III Kümmell's Disease Complicated by Neurological Deficits

Purpose

The current study aimed to compare the clinical and radiographic results of the 3D-printed artificial vertebral body (3DP-AVB) and titanium mesh cage (TMC) for the treatment of Kümmell’s disease (KD) complicated by neurological deficits.

Patients and Methods

From January 2014 to July 2018, 28 consecutive patients diagnosed with KD and nerve injuries in our department were treated by posterior vertebral column resection and internal fixation. The patients were divided into two groups (3DP-AVB group and TMC group) based on the different anterior column reconstruction implants. Clinical and radiographic parameters were used to evaluate the outcomes.

Results

The two groups achieved excellent clinical and radiographic results 1 month after surgery with no significant difference (P>0.05), while 3DP-AVB group showed better outcomes compared with TMC group during the follow-up after 6 months (P<0.05). The risk of subsidence in 3DP-AVB group was lower than that in TMC group (41.6% vs 87.5%, P<0.05), and severe subsidence (≥5 mm) was correlated with the recurrence of back pain and bad daily life function. No significant difference was found in the improvement of neurological function between the two groups (P>0.05). The blood loss and operation time in 3DP-AVB group were significantly less than both in TMC group (P<0.05).

Conclusion

The lower incidence of cage subsidence, with a better long-term efficacy in maintaining the height of the fused segment, relieving back pain, and improving daily life function indicates that the 3DP-AVB may be a superior alternative for KD with neurological deficits.

Clinical efficacy of Bone Cement-injectable Cannulated Pedicle Screw Short Segment Fixation for Lumbar Spondylolisthesis with Osteoporosise

Many clinical studies have shown a satisfactory clinical efficacy using bone cement-augmented pedicle screw in osteoporotic spine, however, few studies have involved the application of this type of screw in lumbar spondylolisthesis. This study aims to investigate the mid-term clinical outcome of bone cement-injectable cannulated pedicle screw (CICPS) in lumbar spondylolisthesis with osteoporosis. From 2011 to 2015, twenty-three patients with transforminal lumbar interbody fusion (TLIF) using CICPS for lumbar spondylolisthesis were enrolled in the study. Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS) were used to evaluate faunctional recovery and physical pain; and operation time, blood loss and hospitalization time were recorded, respectively. Radiograph and computed tomography of lumbar spine was performed to assess loss of the intervertebral disc space height, fixation loosening, and the rate of bony fusion. The average follow-up time of 23 patients was 22.5 ± 10.2 months (range, 6–36 months). According to VAS and ODI scores, postoperative pain sensation and activity function were significantly improved (p < 0.05). The height of the intervertebral disc space was reduced by 0.4 ± 1.1 mm, and the bone graft fusion rate was 100%. No cases of internal fixation loosening or screw pullout was observed. CICPS using cement augmentation may suggest as a feasible surgical technique in osteoporotic patients with lumbar spondylolisthesis.

Surgical Trend Analysis for Use of Cement Augmented Pedicle Screws in Osteoporosis of Spine: A Systematic Review (2000-2017)

STUDY DESIGN

Systematic review.

OBJECTIVES

(1) Study indications for cement-augmented pedicle screws (CAPS) in patients with osteoporosis. Have they changed over the years (2000-2017)? Are there any differences in usage of CAPS based on the geographical region? (2) What were the outcome of the studies? (3) What are the complications associated with this technique?

METHODS

Electronic database and reference list of desired articles were searched from the database (2000-2017). Articles were selected discussing indications, clinical and radiological outcomes, and complications in cases of preexistent osteoporosis treated surgically using CAPS.

RESULTS

Seventeen studies were identified; 3 were comparative studies and had a control arm (cemented vs noncemented screws). Most studies originated from Europe (10) or Asia (7). Painful vertebral fracture with or without neurological deficit, Kummell's lesion, deformity and failure to respond to conservative treatment are the common indications for cement augmentation. Visual analogue scale score was the most commonly used to assess pain and average improvement after surgery was 6.1. Average improvement in kyphosis was 13.21° and average loss of correction at the end of the study was 3°. Cement leak was the most common complication observed and pulmonary cement embolism was the most dreaded complication. Nevertheless, majority of cement leaks discussed in studies were asymptomatic.

CONCLUSION

CAPS are being increasingly used in osteoporotic spine. Pain scores, functional quality of life, and neurological function indices were studied. CAPS improved anchorage in osteoporotic vertebra and helped improve/maintain clinical and radiological improvement. Common risks of cement leak were observed.