[Balloon kyphoplasty in the treatment of back pain]

[Atraumatic fractures of the spine : Current strategies for diagnosis and treatment]

Atraumatic fractures of the spine are a common orthopedic disease condition that can be asymptomatic or associated with complaints of varying intensity and quality. The risk factors for such fracture forms are often metabolic and genetic diseases, which have a direct or indirect effect on bone metabolism and therefore secondarily affect the stability of the spinal vertebrae. Furthermore, benign and malignant tumors as well as infectious diseases can also be causative for atraumatic spinal fractures; however, those factors that are attributable to lifestyle habits should also not be underestimated. The treatment of affected patients is complex and nearly always interdisciplinary. In addition to purely symptom-oriented treatment concepts, orthoses in particular and when indicated surgical treatment procedures can be implemented. This article summarizes the important clinical, diagnostic and therapeutic aspects of atraumatic spinal fractures.

A modification and validation of quantitative morphometry classification system for osteoporotic vertebral compressive fractures in mainland Chinese

This study described a modified quantitative morphometry (mQM) system adapted to specific reference values for Mainland Chinese population. The mQM system is validated using the Genant Semiquantative system and is sensitive for detecting vertebral height changes and predicting cement leakage after percutaneous kyphoplasty (PKP) in patients with osteoporotic vertebral compressive fracture (OVCF).

INTRODUCTION

OVCF is a manifestation of osteoporosis. To improve clinical management of osteoporosis, the quantitative morphometry (QM) system has been widely used for the early diagnosis and precise classification of OVCF in developed countries. Here, we present an mQM system and validated its use in detecting OVCF in Mainland Chinese.

METHODS

Using our mQM system, the pre- and post-operative values of vertebral heights were measured and evaluated in 309 Mainland Chinese who received percutaneous kyphoplasty (PKP) as OVCF treatment. Measurements and classification of fractures from the mQM system were validated by comparing to values obtained by the Genant semiquantative (SQ) method. Moreover, we evaluated the sensitivity of the mQM system by its ability to detect restoration of vertebral heights and predict cement leakage after PKP.

RESULTS

The five classification of fractures, No deformity (ND), anterior wedge (AW), posterior wedge (PW), biconcavity (BC), and compression (CP), evaluated by the mQM method shared similar distribution characteristics compared to those obtained by the SQ method. In addition, mQM evaluation showed that the vertebra height of all fracture types showed significant restoration after PKP. The incidence of cement leakage was most common in CP (37.5%), followed by AW (31.6%), BC (26.5%), ND (23.7%), and PW (0.0%).

CONCLUSIONS

Our mQM system is suitable for classification of fractures, detection of vertebral height restoration, and correlation of cement leakage after PKP in Mainland Chinese population.

Analysis of Pre- and Postoperative Pain Variation in Osteoporotic Vertebral Compression Fracture Patients Undergoing Kyphoplasty

Background

Balloon kyphoplasty (KP) has been widely applied in the treatment of elderly patients with osteoporosis vertebral compression fracture (OVCF), but there has been little research on the pain relief effect. Therefore, we performed this study of patients who received KP. The study included a set of fluoroscopy tests and follow-up evaluation, which aimed to verify the effectiveness of kyphoplasty in controlling back pain associated with OVCFs.

Material/Methods

Forty-three OVCF patients underwent kyphoplasty: 21 were allocated to an intervention group and 22 were allocated to a control group, and the 2 groups received treatment with different KP instruments. The variation of vertebral height was measured on X-ray and change of signal of MRI was recorded. The pain was assessed by VAS score and diagram, and physical function was evaluated by ODI. The complications after surgery were recorded and collated during 2 years of follow-up.

Results

The intervention group showed no significant difference on the VAS and ODI compared to the control group (p>0.05). There was no difference in the VAS with different degrees of radiological change (p>0.05). Signal change on MRI imaging was rare.

Conclusions

Kyphoplasty is a positive way to alleviate early-onset OVCF pain. The change of BME extent in the treated level is unrelated to the relief of back pain after KP.

Kyphoplasty in osteoporotic vertebral compression fractures--guidelines and technical considerations

Osteoporotic vertebral compression fractures are a menace to the elderly generation causing diminished quality of life due to pain and deformity. At first, conservative treatment still is the method of choice. In case of resulting deformity, sintering and persistent pain vertebral cement augmentation techniques today are widely used. Open correction of resulting deformity by different types of osteotomies addresses sagittal balance, but has comparably high morbidity.

Besides conventional vertebral cement augmentation techniques balloon kyphoplasty has become a popular tool to address painful thoracic and lumbar compression fractures. It showed improved pain reduction and lower complication rates compared to standard vertebroplasty. Interestingly the results of two placebo-controlled vertebroplasty studies question the value of cement augmentation, if compared to a sham operation. Even though there exists now favourable data for kyphoplasty from one randomised controlled trial, the absence of a sham group leaves the placebo effect unaddressed. Technically kyphoplasty can be performed with a transpedicular or extrapedicular access. Polymethyl methacrylate (PMMA)-cement should be favoured, since calcium phosphate cement showed inferior biomechanical properties and less effect on pain reduction especially in less stable burst fractures. Common complications of kyphoplasty are cement leakage and adjacent segment fractures. Rare complications are toxic PMMA-monomer reactions, cement embolisation, and infection.

[Kyphoplasty in osteoporotic spinal fractures]

Kyphoplasty has been the standard procedure for osteoporotic fractures for more than 5 years but the material costs are still very high. The aim of this study was to clarify whether pain reduction could be achieved without increasing the rate of new fractures and also in what areas costs could possibly be reduced. From 15.01.2007 until 15.01.2008, a total of 100 patients with 126 recent osteoporotic spinal fractures were treated by kyphoplasty with an average operation time of 38 min and follow-up times up to 12 months. During this follow-up period 15 lateral and 2 dorsal cement leakages remained asymptomatic and 1 dorsal leakage caused an incomplete paraparesis, which was finally cured completely. All patients were very content and pain measured on the visual analogous scale could be lowered from 8.0 before the operation to 2.7 points after the operation. With material costs of 3,056 Euro, there were additional operation costs of 247 Euro per case. The average effective weight was 2.84. On average 7,810 Euro returns could be achieved, deducting material and operation costs left 4,507 Euro per case. More than 40% of gains were reinvested in operation and material costs. Within 12 months 6 new fractures occurred despite medicinal prophylactic treatment which could also be successfully treated by kyphoplasty. The average visual analogous scale after 12 months was 2.1 points.Kyphoplasty still causes financial deficits due to high material costs, however, patients benefit from a reduction of pain.

Indications and contraindications for vertebroplasty and kyphoplasty

INTRODUCTION

Vertebral fractures (VF) are a leading cause of morbidity in the elderly. In the past decade, minimally invasive bone augmentation techniques for VF, such as percutaneous vertebroplasty (VP) and kyphoplasty (KP) have become more widespread. According to the literature, both techniques provide significant pain relief. However, KP is more expensive and technically more demanding than VP. The current study surveyed German surgeons who practice percutaneous augmentation to evaluate and compare decisions regarding the implementation of these techniques. Is there a difference in the indications and contraindications of VP and KP compared with the interdisciplinary consensus paper on VP and KP of the German medical association in the treatment of VF?

METHODS

A multiple choice questionnaire was designed with questions regarding diagnostic procedures, clinical and radiologic (AO classification) indications, as well as contraindications for both VP and KP. A panel of five experts refined the initial questionnaire. The final version was then sent to 580 clinics registered to practice KP in Germany. The statistical analysis was done by two authors, who collected the questionnaire data and Wilcoxon's signed ranks test was performed for non-parametric variables with SPSS.

RESULTS

327 of 580 questionnaires (56.4%) were completed and returned. 151 (46.2%) of participants were performing both procedures, and 176 (53.8%) performed KP only. Median duration from onset of acute pain to intervention was 3 weeks. For most participants (95.4%), consistent back pain at the fracture level with a visual analog scale score over 5 was the main clinical indication for VP and KP. A1 and A3.1 fractures from osteoporosis and metastasis were considered indications for KP. Osteoporotic A1.1 fractures were an indication for VP. Traumatic A3.2 fractures were not an indication for either procedure. Major contraindications to both procedures were active infection (94.7%), cement allergy (86.8%), and coagulation disorders (80.3%).

CONCLUSION

Vertebroplasty and kyphoplasty both have roles in the treatment of vertebral fractures. However, we could see differences in the indications for the two percutaneous techniques. Participants of this study found more indications for KP versus VP in cases of painful A1.2 and A3.1 fractures due to osteoporosis, metastasis, and trauma. About half of the respondents reported that VP is indicated for osteoporotic and pathologic A1.1 fractures. This study offers only limited conclusions. Open questionnaires and prospective data from all clinicians performing these procedures should be analyzed to offer more specific information.

Management of pulmonary cement embolism after percutaneous vertebroplasty and kyphoplasty: a systematic review of the literature

Balloon kyphoplasty and percutaneous vertebroplasty are relatively recent procedures in the treatment of painful vertebral fractures. There are, however, still some uncertainties about the incidence and treatment strategies of pulmonary cement embolisms (PCE). In order to work out a treatment strategy for the management of this complication, we performed a review of the literature. The results show that there is no clear diagnostic or treatment standard for PCE. The literature research revealed that the risk of a pulmonary embolism ranges from 3.5 to 23% for osteoporotic fractures. In cases of asymptomatic patients with peripheral PCE we recommend no treatment besides clinical follow-up; in cases of symptomatic or central embolisms, however, we recommend to proceed according to the guidelines regarding the treatment of thrombotic pulmonary embolisms, which includes initial heparinization and a following 6-month coumarin therapy. In order to avoid any types of embolisms, both procedures should only be performed by experienced surgeons after critical determination of the indications.

Complications and safety aspects of kyphoplasty for osteoporotic vertebral fractures: a prospective follow-up study in 102 consecutive patients

Background

Kyphoplasty represents an established minimal-invasive method for correction and augmentation of osteoporotic vertebral fractures. Reliable data on perioperative and postoperative complications are lacking in the literature. The present study was designed to evaluate the incidence and patterns of perioperative complications in order to determine the safety of this procedure for patients undergoing kyphoplasty.

Patients and Methods

We prospectively enrolled 102 consecutive patients (82 women and 20 men; mean age 69) with 135 operatively treated fractured vertebrae who underwent a kyphoplasty between January 2004 to June 2006. Clinical and radiological follow-up was performed for up 6 months after surgery.

Results

Preoperative pain levels, as determined by the visual analogous scale (VAS) were 7.5 +/- 1.3. Postoperative pain levels were significantly reduced at day 1 after surgery (VAS 2.3 +/- 2.2) and at 6-month follow-up (VAS 1.4 +/- 0.9). Fresh vertebral fractures at adjacent levels were detected radiographically in 8 patients within 6 months. Two patients had a loss of reduction with subsequent sintering of the operated vertebrae and secondary spinal stenosis. Accidental cement extravasation was detected in 7 patients in the intraoperative radiographs. One patient developed a postoperative infected spondylitis at the operated level, which was treated by anterior corporectomy and 360 degrees fusion. Another patient developed a superficial wound infection which required surgical revision. Postoperative bleeding resulting in a subcutaneous haematoma evacuation was seen in one patient.

Conclusion

The data from the present study imply that percutaneous kyphoplasty can be associated with severe intra- and postoperative complications. This minimal-invasive surgical procedure should therefore be performed exclusively by spine surgeons who have the capability of managing perioperative complications.