Radiological evaluation of kyphoplasty with an intravertebral expander after osteoporotic vertebral fracture

Appropriate Use Criteria for Osteoporotic Compression Fractures

BACKGROUND CONTEXT

There is a lack of consensus regarding optimal indications for treatment of patients with osteoporotic vertebral fractures. An opportunity exists to improve outcomes if these indications can be clarified.

PURPOSE

The purpose of the North American Spine Society (NASS) Appropriate Use Criteria (AUC) was to determine the appropriate (i.e. reasonable) multidisciplinary treatment recommendations for patients with osteoporotic vertebral fractures across a spectrum of more common clinical scenarios.

STUDY DESIGN

A Modified Delphi process.

PATIENT SAMPLE

Modified consensus based guideline OUTCOME MEASURES: Final rating for treatment recommendations as either "Appropriate", "Uncertain", or "Rarely Appropriate" based on the median final rating among the raters.

METHODS

The methodology was based on the AUC development process established by the Research AND Development (RAND) Corporation. The topic of osteoporotic vertebral compression fracture was selected by NASS for its Clinical Practice Guideline development (CPG). In conjunction, the AUC committee determined key modifiers and adapted the standard definitions developed by the CPG with minimal modifications. A literature search and evidence analysis performed by the CPG were reviewed by the AUC work group. A separate multidisciplinary rating group was assembled. Clinical scenarios were generated based on a matrix of the modifiers, to rate the appropriateness of medical management, cement augmentation, or surgery. Based on the literature, provider experience, and group discussion, each scenario was scored on a nine-point scale on two separate occasions: once without discussion and again following discussion of the initial responses. The median rating for each scenario and level of agreement was then used to determine final indications as rarely appropriate with agreement (1 - 3), uncertain or disagreement (4-6), or appropriate with agreement (7-9). Consensus was not mandatory.

RESULTS

Medical management was appropriate across all scenarios. Cement augmentation was rarely appropriate in 60% of scenarios and uncertain or disagreement in 35% of scenarios. In the 5% of scenarios rated as appropriate with agreement for cement augmentation, high pain scores, acute duration, and simple fracture pattern were always present. Surgery was appropriate in 35% of scenarios and strongly influenced by instability and stenosis with neurological findings. Surgery was rarely appropriate in 18%, and uncertain or disagreement in 47% of scenarios.

CONCLUSIONS

Multidisciplinary appropriate treatment criteria for osteoporotic vertebral fractures were generated based on the RAND methodology. This document provides comprehensive evidence-based recommendations for evaluation and treatment of osteoporotic vertebral fractures. The document in its entirety will be found on the NASS website (https://www.spine.org/Research-Clinical-Care/Quality-Improvement/Appropriate-Use-Criteria).

Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of adults with osteoporotic vertebral compression fractures

BACKGROUND CONTEXT

The North American Spine Society's (NASS) Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Adults with Osteoporotic Vertebral Compression Fractures features evidence-based recommendations for diagnosing and treating adult patients with osteoporotic vertebral compression fractures. The guideline is intended to reflect contemporary treatment concepts for osteoporotic vertebral compression fractures as reflected in the highest quality clinical literature available on this subject as of September 2020.

PURPOSE

The purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with osteoporotic vertebral compression fractures. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition.

STUDY DESIGN

This is a guideline summary review.

METHODS

This guideline is the product of NASS' Clinical Practice Guidelines Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with a medical librarian. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guideline was submitted to an internal and external peer review process and ultimately approved by the NASS Board of Directors.

RESULTS

Twenty-nine clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature.

CONCLUSIONS

The evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with osteoporotic vertebral compression fractures. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at http://www.spine.org/guidelines.

Vesselplasty for the treatment of osteoporotic vertebral compression fractures with peripheral wall damage: a retrospective study

STUDY DESIGN

A retrospective study.

OBJECTIVE

The clinical efficacy of vertebroplasty and kyphoplasty treating osteoporotic vertebral compression fractures (OVCF) has been widely recognized in recent years. However, there are also disadvantages of bone cement leakage (BCL), limited correction of kyphosis and recovery of vertebral height. Nowadays, in view of these shortcomings, vesselplasty has been widely used in clinical practice. The objective of this study is to assess its clinical effect and application value for the treatment of OVCF with peripheral wall damage.

METHODS

62 patients (70 vertebrae) treated for OVCF with peripheral wall damage using vesselplasty retrospectively reviewed. The data collection included operation time, volume of bone cement, relevant surgical complications, visual analog scale (VAS), Oswestry disability index (ODI), vertebral body height and kyphosis Cobb angle.

RESULTS

The volume of bone cement was 3-8 (5.3 ± 1.3) ml. There were 3 vertebrae of BCL (4.3%). VAS and ODI at different time points after operation were decreased compared with before operation (all p < 0.05). There were no statistical differences between VAS or ODI at different postoperative time points (p > 0.05). Vertebral body height and Cobb angle at different time points after operation were improved compared with before operation (all p < 0.05). There were no statistical differences between vertebral body height or Cobb angle at different postoperative time points (all p > 0.05).

CONCLUSIONS

Vesselplasty may reduce the risk of BCL and better control the dispersion of bone cement in the treatment of OVCF. It relieves pain, restores vertebral body height and corrects kyphosis, especially in OVCF with peripheral wall damage. Therefore, vesselplasty is safe and worthy of clinical application.

Bipedicular percutaneous kyphoplasty versus unipedicular percutaneous kyphoplasty in the treatment of asymmetric osteoporotic vertebral compression fractures: a case control study

BACKGROUND

Bipedicular/unipedicular percutaneous kyphoplasty are common treatments for OVCF, and there are no studies to show which is more beneficial for AVCF. The purpose of this study was to investigate the clinical efficacy of BPKP or UPKP in the treatment of AVCF.

METHODS

The clinical data of AVCF patients treated by PKP were retrospectively analyzed. They were divided into two groups according to the surgical approach. General demographic data, perioperative complications, and general information related to surgery were recorded for both groups. The preoperative and postoperative vertebral height difference, vertebral local Cobb angle, lumbar pain VAS score and lumbar JOA score were counted for both groups. The above data were compared preoperatively, postoperatively and between the two groups.

RESULTS

25 patients with AVCF were successfully included and all were followed up for at least 12 months, with no complications during the follow-up period. 10 patients in the BPKP group and 15 patients in the UPKP group, with no statistically significant differences in general information between the two groups. The VAS scores of patients in the BPKP group were lower than those in the UPKP group at 12 months after surgery, and the differences were statistically significant, and there were no statistically significant differences between the two groups at other follow-up time points. In the BPKP group, 80% of patients had symmetrical and more homogeneous bone cement dispersion. 50% of patients in the UPKP group had a lateral distribution of bone cement and uneven bone cement distribution, and the difference in bone cement distribution between the two groups was statistically significant.

CONCLUSION

For the treatment of AVCF, the clinical efficacy of both surgical approaches is basically the same. The distribution of cement is more symmetrical and uniformly diffused in the BPKP group, and the clinical efficacy VAS score is lower in the long-term follow-up. Bipedicular percutaneous kyphoplasty is recommended for the treatment of AVCF.

THE ETHICAL REVIEW BATCH NUMBER

XZXY-LJ-20161208-047.

Height restoration and sustainability using bilateral vertebral augmentation systems for vertebral compression fractures: a cadaveric study

BACKGROUND CONTEXT

The treatment of vertebral compression fractures using percutaneous augmentation is an effective method to reduce pain and decrease mortality rates. Surgical methods include vertebroplasty, kyphoplasty, and vertebral augmentation with implants. A previous study suggested that a titanium implantable vertebral augmentation device (TIVAD) produced superior height restoration compared to balloon kyphoplasty (BKP) but was based on a less clinically relevant biomechanical model. Moreover, the introduction of high pressure balloons and directional instruments may further aid in restoring height.

PURPOSE

The objective was to evaluate three procedures (BKP, BKP w/ Kyphon Assist (KA; directional instruments), and TIVAD) used for percutaneous augmentation of vertebral fractures with respect to height restoration and sustainability post-operatively.

STUDY DESIGN/SETTING

This is an in vitro cadaver study performed in a laboratory setting.

METHODS

Five osteoporotic female human cadaver thoracolumbar spines (age: 63-77 years, T-score: -2.5 to -3.5, levels: T7-S1) were scanned using computed tomography and dissected into 30 two-functional spine units (2FSUs). Vertebral wedge compression fractures were created by reducing the anterior height of the vertebrae by 25% and holding the maximum displacement for 15 minutes. Post-fracture, surgery was performed on each 2FSU with a constant 100 N load. Surgeries included BKP, BKP w/ KA, or TIVAD (n=10 per treatment group). Post-surgery, cyclic loading was performed on each 2FSU for 10,000 cycles at 600 N (walking), followed by 5,000 cycles at 850 N (standing up/sitting down), and 5,000 cycles at 1250 N (lifting a 5-10kg weight from the floor). Fluoroscopic images were taken and analyzed at the initial, post-fracture, post-surgery, and post-loading timepoints. Anterior, central, and posterior heights, Beck Index, and angle between endplates were assessed.

RESULTS

No difference in height restoration was observed among treatment groups (p=.72). Compared to the initial height, post-surgery anterior height was 96.3±8.7% for BKP, 94.0±10.0% for BKP w/ KA, and 95.3±5.8% for TIVAD. No difference in height sustainability in response to 600 N (p=.76) and 850 N (p=.20) load levels was observed among treatment groups. However, after 1250 N loading, anterior height decreased to 93.8±6.8% of the post-surgery height for BKP, 95.9±6.4% for BKP w/ KA, and 86.0±6.6% for TIVAD (p=.02). Specifically, the mean anterior height reduction between post-surgery and post-1250 N loading timepoints was lower for BKP w/ KA compared to TIVAD (p=.02), but not when comparing BKP to TIVAD (p=.07). No difference in Beck Index or angle between endplates was observed at any timepoint among the treatment groups.

CONCLUSIONS

The present study, utilizing a clinically relevant biomechanical model, demonstrated equivalent height restoration post-surgery and at relatively lower-level cyclic loading using BKP, BKP w/ KA, and TIVAD, contrary to results from a previous study. Less anterior height reduction in response to high-level cyclic loading was observed in the BKP w/ KA group compared to TIVAD.

CLINICAL SIGNIFICANCE

All three treatments can restore height similarly after a vertebral compression fracture, which may lead to pain reduction and decreased mortality. BKP w/ KA may exhibit less height loss in higher-demand patients who engage in physical activities that involve increased weight resistance.

Effect of Artificial Tiger Bone Powder (Jintiange Capsule®) on Vertebral Height Ratio, Cobb's Angle, Bone Mineral Density, and Visual Analog Score

OBJECTIVES

To investigate the effect of Jintiange capsule on acute bone atrophy (vertebral height, Cobb's angle, bone mineral density, and visual analog score (VAS) in patients with osteoporotic vertebral compression fracture.

METHODS

A total of 106 patients with osteoporotic vertebral compression fractures were selected and randomly divided into study and control group. Vertebral height ratio (VHR), Cobb's angle, bone mineral density (BMD), and VAS analyses were performed as study indexes. The study was performed from January 2019 to December 2019 as a double-blind, randomized, controlled trial and all the participants were blinded throughout the study. There were 24 males and 29 females in the study group, with 14 cases of thoracic fractures and 39 cases of lumbar fractures. The age was 61-75 years, with an average of 67.5 ± 2.7 years, and the course of disease was 1-9 days, with an average of 2.7 ± 0.5 days. There were 22 males and 31 females in the control group, with 17 cases of thoracic fractures and 36 cases of lumbar fractures. Patients in the control group received conventional postoperative treatment, while patients in the study group were treated with Jintiange capsule. The treatment continued for 3 months. The ages of the participants were from 60 to 70 years, while the average ages of both groups were 67 ± 2.8 years and the study recruited participants of both sexes.

RESULTS

The clinical efficacy, vertebral imaging indexes before and after treatment, as well as pain and daily activity dysfunction scores were compared. The effect of the Jintiange capsule was followed for 3 months and both the groups were compared. The total effective score of the study group was significantly increased (90.6%) in contrast to the control group (67.9) and the P value was less than the 0.5. The vertebral height and bone mineral density of the study group was significantly improved compared to the control group (P < 0.034) using t-test. However, the Cobb's angle of the study group was significantly (P < 0.047) lower than the control group using t-test after the treatment. On the other hand, the VAS score and Oswestry score of the study group were significantly lower than control group at 1 month and 3 months after treatment (P < 0.05). There was no significance difference (all P > 0.05) in term of gender and ages in both the recruited groups.

CONCLUSION

It can be concluded that Jintiange capsule can significantly improve the clinical efficacy rate, vertebral height, Cobb's angle, and bone mineral density, pain relief, and daily activity function.

An independent inter- and intra-observer agreement assessment of Yeom classification for bone cement leakage following vertebroplasty/kyphoplasty

STUDY DESIGN

An inter- and intra-observer agreement study.

BACKGROUND

In recent years, vertebroplasty and kyphoplasty have been widely used in treating osteoporotic vertebral compression fractures (OVCF) though the clinical efficacy of them is still controversial. However, there are also inevitable complications, first and foremost is bone cement leakage (BCL). Yeom classification is commonly used to evaluate BCL. The objective of this study is to assess its reliability and reproducibility, and to explore its clinical application value.

METHODS

All 58 patients with BCL following vertebroplasty/kyphoplasty were involved. Six spine surgeons were selected to be evaluators as they were unaware of the identity of the patients and the treatment they received. They classified BCL according to Yeom system, we used kappa (K) to assess the inter- and intra-observer agreement. After 12 weeks, we repeated the analysis.

RESULTS

The inter-observer reliability of Yeom classification was substantial with K value of 0.71 (1st assessment) and 0.73 (2nd assessment). The intra-observer reproducibility of Yeom classification was near perfect with K value of 0.88.

CONCLUSION

Yeom classification system has substantial inter-observer reliability and near perfect intra-observer reproducibility in BCL following vertebroplasty/kyphoplasty, which can be widely used in clinical care as an appropriate instrument for early observation, mechanism and severity cognition, and prognosis predicting of BCL. Besides, the adding of type M (the mixed type) may improve the classification.

Which anatomic structures are responsible for the reduction loss after hybrid stabilization of osteoporotic fractures of the thoracolumbar spine?

Introduction

Hybrid stabilization is an accepted therapy strategy for unstable osteoporotic thoracolumbar fractures. However, a moderate reduction loss has been reported and it remains unclear which anatomic structure is responsible for the reduction loss.

Methods

This retrospective study was performed at a level I trauma center. Patients aged 61 and older were stabilized using hybrid stabilization after suffering acute and unstable osteoporotic vertebral body fractures at the thoracolumbar spine. Posterior stabilization was done short-segmental and minimal invasive with cement-augmentation of all pedicle screws. The minimum follow-up has been 2 years. The outcome parameters were the reduction loss and the relative loss of height of both intervertebral discs adjacent to the fractured vertebral body, the fractured vertebral body and a reference disc (intervertebral disc superior of the stabilization) between the postoperative and latest lateral radiographs. Additionally, implant positioning and loosening was analyzed.

Results

29 mainly female (72%) patients (73.3 ± 6.0 years) were included. Fractures consisted of 26 incomplete burst fractures and 3 complete burst fractures of the thoracolumbar junction (Th11 – L2: 86%) and the midlumbar spine. The mean follow-up time was 36 months (range: 24–58 months). The mean reduction loss was 7.7° (range: 1–25). The relative loss of heights of both intervertebral discs adjacent to the fractured vertebral body, the reference disc, and the central vertebral body were significant. Thereby, the relative loss of the superior disc height was significant higher compared to the reference disc. Additionally, only the relative loss of central vertebral body height and reduction loss correlated significantly. There were no signs of implant loosening in any patient.

Conclusions

The mean reduction loss was moderate 3 years after hybrid stabilization of unstable osteoporotic vertebral fractures of the thoracolumbar spine. A significant loss of both adjacent disc heights and the central vertebral body was seen, with the highest loss in the superior adjacent disc significantly outranging the reference disc. The superior adjacent intervertebral disc and the central part of the fractured vertebral body seem to be responsible for the majority of reduction loss.

The effect of bone cement distribution on clinical efficacy after percutaneous kyphoplasty for osteoporotic vertebral compression fractures

To evaluate the influence of various distributions of bone cement on the clinical efficacy of percutaneous kyphoplasty (PKP) in treating osteoporotic vertebrae compression fractures.A total of 201 OVCF patients (30 males and 171 females) who received PKP treatment in our hospital were enrolled in this study. According to the characteristic of cement distribution, patients were divided into 2 groups: group A ("H" shaped group), the filling pattern in vertebral body were 2 briquettes and connected with / without cement bridge; and group B ("O" shaped group), the filling pattern in vertebral body was a complete crumb and without any separation. Bone mineral density, volume of injected cement, radiographic parameters, and VAS scores were recorded and analyzed between the 2 groups.All patients finished at least a 1-year follow-up and both groups had significant improvement in radiographic parameters and clinical results. No significant differences in BMD, operation time, bleeding volume, or leakage of cement were observed between the 2 groups. Compared with group B, group A had a larger use of bone cement, lower proportion of unipedicular approach, and better VAS scores at 1 year after surgery.Both "H" and "O" shaped distribution pattern can improve radiographic data and clinical outcomes effectively. However, "H" shaped distribution can achieve better clinical recovery at short-term follow-up.