Treatment of severe vertebral body compression fractures with percutaneous vertebroplasty

Comparison between Percutaneous Kyphoplasty and Posterior Fixation Combined with Vertebroplasty in the Treatment of Stage III Kümmell’s Disease without Neurological Deficit

Objective. To evaluate the clinical and radiological outcomes of percutaneous kyphoplasty (PKP) versus posterior fixation combined with vertebroplasty PF+VP for treating stage III Kümmell’s disease (KD) patients without neurological deficits. Methods. From April 2016 to February 2020, a total of 88 patients with single-level stage III KD without neurological deficits, including 45 patients treated by PKP and 43 patients who underwent posterior fixation combined with vertebroplasty PF+VP, were retrospectively studied. The outcome parameters, including blood loss, operative time, kyphotic Cobb angle, height of vertebrae, Oswestry Disability Index (ODI), and visual analog scale (VAS) score, were compared between the PKP group and the PF+VP group. Results. The mean follow-up time was $29.3\pm 7.0$ months, ranging from 24 to 48 months. The kyphotic angle and vertebral height in both groups were significantly improved compared with those before surgery at three days, 3 months and the final follow-up. The estimated blood loss, operative time, and length of stay were significantly lower in the PKP group than in the PF+VP group ( $P<0.001$ ). The FP+VP group showed better results in kyphotic angle correction than the PKP group ( $P=0.024$ ). In the short-term follow-up (up to 3 months), the PKP group had lower VAS and ODI scores than the PF+VP group. In contrast, there were no significant differences between the two groups ( $P>0.05$ ) at the final follow-up. The average cost of PKP was lower than that of PF+VP. Conclusion. The results of our study showed that both PKP and PF+VP were safe and effective for stage III KD patients without neurological deficits. Although PF+VP presents better performance in kyphotic angle correction, PKP was associated with less surgical trauma, quicker pain relief, and lower expense than PF+VP. Therefore, it can be considered an alternative option for patients with advanced KD.

Minimally Invasive Stent Screw-Assisted Internal Fixation Technique Corrects Kyphosis in Osteoporotic Vertebral Fractures with Severe Collapse: A Pilot "Vertebra Plana" Series

BACKGROUND AND PURPOSE

Fractures with "vertebra plana" morphology are characterized by severe vertebral body collapse and segmental kyphosis; there is no established treatment standard for these fractures. Vertebroplasty and balloon kyphoplasty might represent an undertreatment, but surgical stabilization is challenging in an often elderly osteoporotic population. This study assessed the feasibility, clinical outcome, and radiologic outcome of the stent screw-assisted internal fixation technique using a percutaneous implant of vertebral body stents and cement-augmented pedicle screws in patients with non-neoplastic vertebra plana fractures.

MATERIALS AND METHODS

Thirty-seven consecutive patients with vertebra plana fractures were treated with the stent screw-assisted internal fixation technique. Vertebral body height, local and vertebral kyphotic angles, outcome scales (numeric rating scale and the Patient's Global Impression of Change), and complications were assessed. Imaging and clinical follow-up were obtained at 1 and 6 months postprocedure.

RESULTS

Median vertebral body height restoration was 7 mm (+74%), 9 mm (+150%), and 3 mm (+17%) at the anterior wall, middle body, and posterior wall, respectively. Median local and vertebral kyphotic angles correction was 8° and 10° and was maintained through the 6-month follow-up. The median numeric rating scale score improved from 8/10 preprocedure to 3/10 at 1 and 6 months (P < .001). No procedural complications occurred.

CONCLUSIONS

The stent screw-assisted internal fixation technique was effective in obtaining height restoration, kyphosis correction, and pain relief in patients with severe vertebral collapse.

Percutaneous Cement-Augmented Screws Short Fixation for the treatment of Severe Osteoporotic Vertebral Burst Fractures

OBJECTIVE (BACKGROUND)

This study aims to evaluate the therapeutic reliability of posterior percutaneous cement-augmented screws short fixation(PASF) in patients with severe osteoporotic vertebral burst fractures(OVBFs).

METHODS

Single-level OVBFs with an anterior vertebral body height(VBH) reduction equal or superior to 60% were included. A frailty index was employed for preoperative frailty assessment. Back pain and related disability were assessed through the VAS scale and Oswestry low-back pain disability index(ODI), being administered at injury time, preoperative, postoperative, twelfth-month and last patient follow-up evaluations. The main radiological outcomes were represented by Cobb angle(CA) and anterior vertebral body compression percentage(AVBC%), being measured at injury time, preoperative, postoperative and twelfth-month examinations. Among the others, the incidence of cement leakages and hardware failures was assessed.

RESULTS

Thirty-three patients met the inclusion criteria. All patients resulted frail(76%) or semi-frail(24%). Significant VBH restoration and segmental kyphosis improvement after PASF was documented (AVBC%:-40(-43;-37) VS -67(-70;-65), P = 0.0001; CA: 10(8-12) VS 24(23-26), P = 0.0001). The mean VAS and ODI scores documented optimal and long-enduring pain relief and related disability reduction after PASF (VAS: 2(2-3) VS 8(7-8), P = 0.0001; ODI: 22(17-26) VS 64(60-69), P = 0.0001). Only one cement leakage (3%), asymptomatic, occurred. After a mean follow-up of 33 months, no early/late hardware failures were reported.

CONCLUSIONS

The clinical and radiological results of this study suggest that PASF could be a safe and effective treatment option for severe OVBFs when conservative treatments failed.

Risk factors of postoperative bone cement leakage on osteoporotic vertebral compression fracture: a retrospective study

Purpose

To investigate risk factors of bone cement leakage in percutaneous vertebroplasty(PVP)for osteoporotic vertebral compression fracture (OVCF).

Methods

A total of 236 patients (344 vertebrae) who underwent PVP between November 2016 and June 2020 were enrolled in the study. Clinical and radiological characteristics, including age, gender, course of disease, trauma, type of vertebral fracture, cortical continuity of vertebral body, intervertebral vacuum cleft (IVC), fracture severity, fracture level, basivertebral foramen, bone cement dispersion types, the cement injection volume, the type of cement leakage, puncture approach, and intrusion of the posterior wall, were considered as potential risk factors. Three types of leakage (type-B, type-C, and type-S) were defined and risk factors for each type were analyzed. Logistic analysis was used to study the relationship between each factor and the type of cement leakage.

Results

The incidences of the three types of leakage were 28.5%, 24.4%, and 34.3%. The multinomial logistic analysis revealed that the factors of type-B leakage were the shape of cement and basivertebral foramen. One significant factor related to type-C leakage was cortical disruption, and the factors of type-S leakage were bone cement dispersion types, basivertebral foramen, cleft, fracture severity, an intrusion of the posterior wall, and gender.

Conclusion

Different types of cement leakage have their own risk factors, and the analysis of risk factors of these might be helpful in reducing the rate of cement leakage.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02337-1.

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.

Floating Vertebral Body Cement Ball After High-Viscosity-Cement Vertebroplasty for Lytic Defect: Report of 2 Cases

BACKGROUND

Percutaneous vertebroplasty (PVP) is an effective procedure for painful pathological vertebral fractures. High-viscosity cement is the preferred choice for vertebroplasty given its low risk of extravasation. We describe here 2 cases of high-viscosity cement vertebroplasty in large lytic defects and associated complications.

CASE DESCRIPTION

Case 1 describes PVP in an 89-year-old male patient with L1 pathological fracture from prostrate metastasis. Case 2 describes PVP in a 68-year-old male with T7 and T8 vertebral fractures from multiple myeloma. In both cases, high-viscosity cement was used to fill large lytic cavities. This resulted in poor interdigitation of the cement with the trabeculae forming an unstable floating cement ball and dangerous retrieval of the cement trocar needle. The implications of this occurrence have been described.

CONCLUSIONS

High-viscosity-cement vertebroplasty in large lytic defects needs to be done with caution. The potential occurrence of poor cement interdigitation and the following complications can be catastrophic, and caution must be used.

Percutaneous kyphoplasty for the treatment of very severe osteoporotic vertebral compression fractures with spinal canal compromise

Background

Very severe osteoporotic vertebral compression fractures (vsOVCFs) are osteoporotic vertebral compression fractures with vertebral body collapse to less than one third of their original height. Few data are available about the use of percutaneous kyphoplasty (PKP) in treating vsOVCFs with spinal canal compromise. The aim of this study was to evaluate the safety and efficacy of percutaneous kyphoplasty (PKP) for the treatment of vsOVCFs with spinal canal compromise.

Methods

Thirty-five patients who suffered vsOVCFs with spinal canal compromise but without neurological deficits were treated by PKP between January 2009 and October 2014. The vertebral height, local kyphotic angle (LKA), visual analogue scale (VAS) and Oswestry Disability Index (ODI) values were assessed before the operation, 1 day after the operation and at the final follow-up.

Results

Significant improvements on the VAS and ODI were noted 1 day post-operatively (p < 0.01), and these results were preserved at the final follow-up. The vertebral height was restored and the LKA was improved after surgery (p < 0.01). No neurological deterioration was found. Five of 35 vertebrae (14.3%) of cement leakages were all asymptomatic. Four new OVCFs in three patients were identified.

Conclusion

PKP is a safe and effective procedure for the treatment of vsOVCFs with spinal canal compromise, achieving significant vertebral height restoration and kyphotic angle reduction and leading to a significant pain relief and improvement in function.

Comparison the clinical outcomes and complications of high-viscosity versus low-viscosity in osteoporotic vertebral compression fractures

To compare the clinical outcomes and complications of high viscosity and low viscosity bone cement percutaneous vertebroplasty (PVP) for osteoporotic vertebral compression fractures (OVCF).From September 2009 to September 2015, 100 patients with OVCF were randomly divided into 2 groups: group H, using high viscosity cement (n = 50) or group L, using low viscosity cement (n = 50). The clinical outcomes were assessed by the visual analog scale (VAS), Oswestry Disability Index (ODI), kyphosis Cobb angle, vertebral height, and complications.Significant improvements in the VAS, ODI, kyphosis Cobb angle, and vertebral height were noted in both groups, and the VAS score in the H group showed greater benefit than in the L group. Cement leakage was observed less in group H. Postoperative assessment using computed tomography identified cement leakage in 27 of 98 (27.6%) vertebrae in group H and in 63 of 86 (73.3%) vertebrae in group L (P = .025).Compared with PVP using low viscosity bone cement, PVP using high viscosity bone cement can provide the same clinical outcomes with fewer complications and is recommended for routine clinical use.

A comparative study of high-viscosity cement percutaneous vertebroplasty vs. low-viscosity cement percutaneous kyphoplasty for treatment of osteoporotic vertebral compression fractures

The clinical effects of two different methods-high-viscosity cement percutaneous vertebroplasty (PVP) and low-viscosity cement percutaneous kyphoplasty (PKP) in the treatment of osteoporotic vertebral compression fractures (OVCFs) were investigated. From June 2010 to August 2013, 98 cases of OVCFs were included in our study. Forty-six patients underwent high-viscosity PVP and 52 patients underwent low-viscosity PKP. The occurrence of cement leakage was observed. Pain relief and functional activity were evaluated using the Visual Analog Scale (VAS) and Oswestry Disability Index (ODI), respectively. Restoration of the vertebral body height and angle of kyphosis were assessed by comparing preoperative and postoperative measurements of the anterior heights, middle heights and the kyphotic angle of the fractured vertebra. Nine out of the 54 vertebra bodies and 11 out of the 60 vertebra bodies were observed to have cement leakage in the high-viscosity PVP and low-viscosity PKP groups, respectively. The rate of cement leakage, correction of anterior vertebral height and kyphotic angles showed no significant differences between the two groups (P>0.05). Low-viscosity PKP had significant advantage in terms of the restoration of middle vertebral height as compared with the high-viscosity PVP (P<0.05). Both groups showed significant improvements in pain relief and functional capacity status after surgery (P<0.05). It was concluded that high-viscosity PVP and low-viscosity PKP have similar clinical effects in terms of the rate of cement leakage, restoration of the anterior vertebral body height, changes of kyphotic angles, functional activity, and pain relief. Low-viscosity PKP is better than high-viscosity PVP in restoring the height of the middle vertebra.

Severe pathological fractures caused by vertebral hemangiomas with posterior decompression, bone cement augmentation and internal fixation

AIM

To evaluate the treatment strategy for pathological fractures caused by vertebral hemangiomas (VHs) using large case series.

METHODS

From January 2008 to January 2014, 28 patients suffering from severe pathological fractures (more than 2/3 loss of original vertebral height) due to thoracic or lumbar VHs were randomized to an experimental (the posterior decompression, bone cement augmentation and internal fixation, n=14) or control (only the posterior decompression combined with internal fixation, n=14) group. The anterior, middle vertebral body height, kyphosis angle and the cement leakage were measured on radiography. Visual analogue scale (VAS), 36-item short form (SF-36) and Oswestry disability index (ODI) were recorded to assess the pain relief, life quality and function improvement.

RESULTS

Compared with the preoperation, the anterior, middle vertebral body height and kyphosis angle were significantly improved after two procedures, but the improvement efficacy seemed to be more significant in the experimental group, with no significant loss of correction effect at final follow-up. The VAS, SF-36 and ODI scores were all significantly improved postoperatively, especially at final follow-up in two groups. The neurological situation was improved in patients at least 1 grade in Frankel scale. After mean follow-up of 24 months, no operative complications (internal fixation loosening, breakage, spinal nerve damage or pneumothorax) were observed, except bone cement leakage occurred in two cases in experimental group.

CONCLUSION

Posterior decompression, bone cement augmentation and internal fixation seems to be effective and safe for pathological fractures caused by VHs, with better outcomes and few complications.

Cone-Beam CT-Guided Vertebroplasty in a Patient With Vertebra Plana

OBJECTIVE

Vertebra plana has been considered a contraindication for vertebroplasty for various reasons including difficulty in needle placement. Recently, vertebroplasty under conventional fluoroscopic guidance has been shown to be feasible in patients with vertebra plana.

CONCLUSION

Cone-beam CT with a navigation guidance system can be used during vertebroplasty in patients with severe vertebra plana to allow safe needle trajectory and placement.

A comparison of high viscosity bone cement and low viscosity bone cement vertebroplasty for severe osteoporotic vertebral compression fractures

OBJECTIVE

To compare the clinical outcome and complications of high viscosity and low viscosity poly-methyl methacrylate bone cement PVP for severe OVCFs.

METHODS

From December 2010 to December 2012, 32 patients with severe OVCFs were randomly assigned to either group H using high viscosity cement (n=14) or group L using low viscosity cement (n=18). The clinical outcomes were assessed by the Visual Analog Scale (VAS), Oswestry Disability Index (ODI), Short Form-36 General Health Survey (SF-36), kyphosis Cobb's angle, vertebral height, and complications.

RESULTS

Significant improvement in the VAS, ODI, SF-36 scores, kyphosis Cobb's angle, and vertebral height were noted in both the groups, and there were no significant differences between the two groups. Cement leakage was seen less in group H. Postoperative assessment using computed tomography identified cement leakage in 5 of 17 (29.4%) vertebrae in group H and in 15 of 22 (68.2%) vertebrae in group L (P=0.025).

CONCLUSIONS

The PVP using high viscosity bone cement can provide the same clinical outcome and fewer complications compared with PVP using low viscosity bone cement.

Vertebra plana: reappraisal of a contraindication to percutaneous vertebroplasty

PURPOSE

We evaluated the efficacy of percutaneous vertebroplasty (PVP) in treating symptomatic vertebra plana, which is considered a relative contraindication to the procedure.

METHODS

Out of 540 levels treated in 260 patients, we treated 40 patients (mean age: 74 years) with vertebra plana between T6 and L3 (37 osteoporotic and 3 metastatic levels). In most cases, the vertebra was accessed with fluoroscopic guidance from a single, transpedicular approach. All patients underwent a preliminary MRI examination, an immediate, post-procedure radiological examination, and a follow-up examination (mean duration, 6 months).

RESULTS

Both immediate and follow-up examinations showed that the mean pain and physical disability scores were significantly reduced compared to the scores before treatment (p ≤ 0.001). No complications occurred during the procedures. In 23/40 cases, asymptomatic intradiscal cement leakage occurred. Posterior or perivertebral leakage never occurred. In most cases, an intravertebral cleft was present, and we filled it with polymethylmethacrylate, which healed the pseudarthrosis. Partial vertebral height was restored in 7 cases. In 6 cases, a new fracture occurred between 1 and 3 months at a different level from the treated level.

CONCLUSION

Our preliminary results showed that PVP was a safe, effective treatment for symptomatic vertebra plana; thus, it should not be discounted for this group of patients. In most cases, the procedure was favored by the presence of an intravertebral cleft that appeared to contribute to minimizing the risk of posterior cement leakage. Filling the cleft with polymethylmethacrylate allowed intravertebral stabilization.

An overview of vertebroplasty: current status, controversies, and future directions

Vertebroplasty is a cost-effective procedure for the relief of pain in appropriately selected patients when performed by a skilled practitioner. The currently accepted indications and contraindications for vertebroplasty are reviewed. The techniques routinely used by the authors are presented, including a discussion of recognized complications. Recent controversy has highlighted weaknesses in the practice of technology evaluation, and more robust studies will be required to address these issues across the board in the future more scientifically than has been done in the past.

Investigation of polymethylmethacrylate pulmonary embolus in a patient ten years following vertebroplasty

Percutaneous vertebroplasty (PV) is a procedure commonly used for the treatment of vertebral compression fractures, and the number of procedures has been steadily increasing over the past decade. We report a case of an 81 year old female with a history of breast cancer that developed two vertebral body compression fractures and was subsequently treated with PV. The patient developed a subsegmental pulmonary polymethylmethacrylate (PMMA) embolus as a complication of the procedure. Ten years following the procedure, she remained asymptomatic with the PMMA embolus being discovered incidentally during workup for a suspected chronic obstructive pulmonary disease (COPD) exacerbation. In reviewing the case, we describe the typical presentation of a pulmonary PMMA embolus and consider methods to decrease the incidence of this complication.