Does balloon kyphoplasty improve the global spinal alignment in osteoporotic vertebral fracture?

Vertebral Augmentation plus Pedicle Screw Fixation versus Vertebral Augmentation Alone in the Treatment of Osteoporotic Thoracolumbar Fractures: A Meta-Analysis

BACKGROUND

This meta-analysis was conducted to compare the efficacy and safety of vertebral augmentation (VA) plus pedicle screw fixation (PSF) with VA for treating osteoporotic thoracolumbar fractures (OTLFs).

METHODS

A comprehensive search was conducted in PubMed, Embase, Cochrane Library, and CNKI (China National Knowledge Infrastructure) to identify studies comparing PSF + VA with VA for treating OTLF. The primary outcomes were operation time, blood loss, length of stay, visual analog scale (VAS) score, Oswestry Disability Index (ODI), Cobb angle, anterior vertebral height (AVH), bone cement leakage, secondary fracture, and other adverse events. Standardized mean deviation (SMD) and risk ratio with 95% confidence interval (CI) were calculated.

RESULTS

Fourteen studies met the entire inclusion criteria for our meta-analysis. The PSF + VA group was associated with significantly more operation time (SMD, 4.41; 95% CI, 3.32-5.51), blood loss (SMD, 6.72; 95% CI, 4.50-8.95), and length of stay (SMD, 2.05; 95% CI, 1.02-3.07). There was no significant VAS score or ODI difference at early follow-up. No significant difference was found in AVH between the 2 groups before 2 years. The remaining outcomes (VAS at 6 months and 2 years; ODI at 6 months and 1 year; Cobb angle at all follow-up periods; AVH at 2 years; bone cement leakage and secondary fracture) favored the PSF + VA group.

CONCLUSIONS

PSF + VA was superior to VA for the VAS score, ODI, Cobb angle, AVH, and complications, especially in the long-term follow-up. However, more operation time, blood loss, and length of stay were the disadvantages for PSF + VA.

The impact of different courses of osteoporotic vertebral compression fracture on the early efficacy of percutaneous vertebroplasty: a retrospective study

INTRODUCTION

Percutaneous vertebroplasty (PVP) is a frequently employed technique for treating osteoporotic vertebral compression fracture (OVCF). However, there is still controversy regarding whether PVP with different courses affects clinical efficacy. Therefore, this study aims to investigate the impact of different courses of OVCF on early clinical and radiological outcomes after PVP.

HYPOTHESIS

OVCF with shorter course can obtain more satisfactory clinical efficacy and radiological results after PVP.

MATERIALS AND METHODS

A retrospective analysis was conducted on the clinical data of 100 patients undergoing PVP for OVCF. Patients were categorized into early group (n = 37, <2 weeks), intermediate group (n = 35, 2-4 weeks), and late group (n = 28, 4-6 weeks) according to the time from the occurrence of OVCF to undergoing PVP. The visual analogue scale (VAS) and oswestry disability index (ODI) were used to evaluate the clinical effect before, 1 day, and 12 months after surgery. Anterior vertebral height ratio (AVHR) and local kyphosis angle (LKA) were measured on plain radiographs to evaluate the radiographic changes. The cement volume, cement leakage, hospitalization time, new fractures, and outdoor activity (ODA) were compared among the three groups.

RESULTS

Compared with preoperative, VAS and ODI of the three groups were significantly improved (p < 0.05). There was no difference in VAS at 1 day and 12 months after surgery among the three groups (3.3 vs. 3.2 vs. 3.2, 1.7 vs. 2.0 vs. 2.0, respectively). ODI was significantly better in the early and intermediate groups at 1 day and 12 months after surgery (33.49% vs. 32.37% vs. 35.24%, 31.86% vs. 30.73% vs. 34.56%, all p < 0.05), and without inter-group differences. Postoperative AVHR and LKA were improved in all three groups (p < 0.05). The improvement of AVHR and LKA at 1 day and 12 months after surgery was more significant in the early and intermediate groups (AVHR: 21.00% vs. 18.52% vs. 26.31%, 21.82% vs. 20.03% vs. 27.75%, LKA: 17.82º vs. 17.61º vs. 20.49º, 19.07º vs. 19.10º vs. 20.80º, all p < 0.05), and without inter-group differences. The cement volume in the late group was less (4.3 ml vs. 4.3 ml vs. 3.2 ml, p < 0.05), but there were no differences in cement leakage and new fractures. Patients in the late group had a longer hospitalization time (5.1d vs. 5.0d vs. 6.4d, p < 0.05) and poorer ODA (5/15/17 vs. 4/17/14 vs. 11/11/6, p < 0.05).

CONCLUSION

OVCF with a course of less than 4 weeks can recover partial vertebral height and improve local kyphosis after PVP. The clinical and radiological outcomes are better than course of more than 4 weeks. We recommend performing PVP within 4 weeks of the occurrence of OVCF.

LEVEL OF EVIDENCE

III; retrospective comparative study.

Predictive Factors for Health-Related Quality of Life Post-Balloon Kyphoplasty in Patients with Osteoporotic Vertebral Compression Fractures

Study Design

Retrospective cohort study.

Purpose

Balloon kyphoplasty (BKP) is a minimally invasive surgical treatment for osteoporotic vertebral compression fractures (OVCFs), with good clinical outcomes reported in short-term investigations. However, the impact of BKP on health-related QOL in the long term remains unclear. This study aimed to evaluate the effects of BKP on global sagittal balance and alignment and to determine the association between predictive factors before BKP and health-related QOL in the long term.

Methods

A longitudinal cohort study was conducted on 62 patients (13 men and 49 women) diagnosed with OVCF who underwent BKP and were followed up for more than 12 months. Spinopelvic parameters, including sagittal vertical axis (SVA), thoracic kyphosis (TK), pelvic incidence (PI) minus lumbar lordosis (LL), and low back pain (LBP) severity, were measured preoperatively, at 3 months post-BKP, and at final follow-up. Multivariate logistic regression analysis was performed to identify predictive factors for unhealthy condition after BKP, with adjustment for age, sex, and duration from onset of back pain to BKP.

Results

The mean follow-up duration was 20.7 months. The mean SVA values were 7.42 cm preoperatively, 7.62 cm at 3 months post-BKP, and 8.01 cm at final follow-up. The mean self-reported numerical rating scale scores for LBP were 8.4 preoperatively, 0.4 post-BKP, 0.6 at 3 months post-BKP, and 1.0 at final follow-up. Imbalanced spine (SVA ≥5.0 cm) and PI-LL mismatch (PI-LL ≥20°) before BKP were significantly associated with unhealthy condition (EuroQol 5 dimensions 5-level <0.65) (odds ratio and 95% confidence intervals: imbalanced spine, 4.76 and 1.32-17.2; PI-LL mismatch, 3.78 and 1.18-12.1, respectively).

Conclusion

BKP did not improve global spinopelvic parameters or health-related QOL in imbalanced patients. Higher SVA measurements and PI-LL mismatch before BKP were associated with lower health-related QOL after BKP.

Lateral Lumbar Interbody Fusion within Three-level for Patients with Neurological Symptoms due to Vertebral Fragility Fractures in the Lumbar Spine

There is a lack of agreement on whether minimally invasive lateral lumbar intervertebral fusion (LLIF) is a suitable treatment option for vertebral fragility fractures (VFFs). Hence, we sought to evaluate the efficacy and safety of LLIF in the management of VFF with neurological deficits in the lumbar spine. Between April 2015 and March 2020, we conducted a retrospective observational study of patients with VFF treated with three-level or less LLIF. The participants had previously received conservative treatment but had not been able to control their neurological symptoms. To assess the outcomes of the LLIF procedures, the patients were followed up for a minimum of 1 year. Clinical and radiological results, which include the timing and location of the bony fusion, were analyzed. The study involved 19 patients with 23 vertebral fracture levels. The residual height of the fractured vertebra was found to be 57.0 ± 12.3% of the height of the adjacent level. The mean Japanese Orthopedic Association score significantly improved postoperatively. Postoperative radiological parameters were significantly maintained at 1 year, and lumbar lordosis was maintained at the last follow-up (45.0 ± 26.7). In total 31 LLIF levels, bone fusion was observed in four levels at 6 months postoperatively, in 16 levels at 1 year, and in 23 levels at the last follow-up. The facet joint had the highest bony fusion location. LLIF within three levels can be safely performed in certain VFF cases with sufficient residual vertebral height.

ACR Appropriateness Criteria® Management of Vertebral Compression Fractures: 2022 Update

Vertebral compression fractures (VCFs) can have a variety of etiologies, including trauma, osteoporosis, or neoplastic infiltration. Osteoporosis related fractures are the most common cause of VCFs and have a high prevalence among all postmenopausal women with increasing incidence in similarly aged men. Trauma is the most common etiology in those >50 years of age. However, many cancers, such as breast, prostate, thyroid, and lung, have a propensity to metastasize to bone, which can lead to malignant VCFs. Indeed, the spine is third most common site of metastases after lung and liver. In addition, primary tumors of bone and lymphoproliferative diseases such as lymphoma and multiple myeloma can be the cause of malignant VCFs. Although patient clinical history could help raising suspicion for a particular disorder, the characterization of VCFs is usually referred to diagnostic imaging. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Effect of cement distribution type on clinical outcome after percutaneous vertebroplasty for osteoporotic vertebral compression fractures in the aging population

Objective

The study aimed to investigate the effect of the type of bone cement distribution on clinical outcomes following percutaneous vertebroplasty (PVP) for osteoporotic vertebral compression fractures (OVCF) in the elderly.

Methods

Retrospective analysis of 160 patients diagnosed with OVCF who underwent PVP treatment from March 2018 to December 2020. Based on the kind of postoperative bone cement distribution, bone cement was classified as types I, II, III, IV, and V. Visual Analog Scale (VAS), Oswestry Disability Index (ODI), Cobb angle, anterior vertebral height ratio, refracture rate of injured vertebrae, and incidence of adjacent vertebral fractures were compared for the five types before and after three days, and one year of operation.

Results

VAS and ODI at three days and one year postoperative were significantly lower than those preoperative (P < 0.05) for all five distribution types. VAS and ODI for types I, II, and III were lower at one year postoperatively than for types IV and V (P < 0.05). There was no significant difference in Cobb angle and anterior vertebral body height ratio between preoperative and three days postoperative groups (P < 0.05); however, there were significant differences between three days and one-year postoperative and preoperative groups (P < 0.05). Following one year of surgery, the Cobb angle and the anterior vertebral height ratio of types IV and V were significantly different from those of types I, II, and III (P < 0.05), and there was a statistically significant difference between types IV and V (P < 0.05). In terms of the incidence of injured vertebral refractures and adjacent vertebral fractures, the evenly distributed types I, II, and III were significantly lower than the unevenly distributed types IV and V, and the incidence of type V was higher (P < 0.05).

Conclusions

The clinical efficacy of cement distribution following PVP of types I, II, and III is better than that of types IV and V, which can better relieve pain with long-lasting efficacy and minimize the occurrence of refractures of injured vertebrae and adjacent vertebral body fractures.

Comparison of Percutaneous Kyphoplasty With or Without Posterior Pedicle Screw Fixation on Spinal Sagittal Balance in Elderly Patients With Severe Osteoporotic Vertebral Compression Fracture: A Retrospective Study

Objective

To compare the effects of percutaneous kyphoplasty (PKP) with or without posterior pedicle screw fixation (PPSF) on spinal sagittal balance in elderly patients with severe osteoporotic vertebral compression fracture (sOVCF).

Methods

From January 2016 to December 2018, 102 elderly patients with single-level thoracolumbar sOVCF were enrolled. Among them, 78 cases underwent PKP (Group A), and 24 cases underwent PPSF+KP (Group B). Clinical evaluation included perioperative parameters, Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) for back pain; Radiographic evaluation included anterior vertebral height (AVH) and rate (AVHr), local kyphotic angle (LKA), and spino-pelvic sagittal balance parameters.

Results

Perioperative parameters including operation time, blood loss, fluoroscopic time and hospital stay in Group A were less than those in Group B (p &lt; 0.05). Compared with the pre-operative results, the ODI and VAS scores of both groups decreased significantly in the three follow-ups after surgery (p &lt; 0.05). The post-operative ODI and VAS scores of Group A were significantly better than those of Group B, but the results were opposite at the final follow-up (p &lt; 0.05). Compared with the pre-operative values, except that there was no significant difference in pelvic incidence (PI) (p &gt; 0.05), other radiographic parameters of both groups were improved significantly in the three follow-ups after surgery (p &lt; 0.05). The AVH, AVHr, LKA and lumbar lordosis (LL) in Group B were better than those in Group A in the three follow-ups after surgery (p &lt; 0.05). At the final follow-up, the sacral slope (SS) and pelvic tilt (PT) differed significantly between the two groups (p &lt; 0.05).

Conclusions

Both PPSF+KP and PKP can achieve favorable clinical outcomes and maintain the spinal sagittal balance. Compared with PPSF+KP, PKP showed more significant advantages in the early post-operative period. However, in the long-term follow-up, PPSF+KP showed better clinical outcomes and may be better than PKP in maintaining spinal sagittal balance.

Influence of Different Surgical Timing after Percutaneous Kyphoplasty for Osteoporotic Vertebral Compression Fractures: A Retrospective Study

BACKGROUND

A large number of people suffer from osteoporotic vertebral compression fractures (OVCFs) worldwide. Percutaneous kyphoplasty (PKP), considered a minimally invasive surgery, has been widely used to treat OVCFs and achieves satisfactory outcomes. However, the surgical timing of PKP is still under discussion.

METHODS

A total of 149 patients were enrolled in the study and were divided into 3 groups according to different surgical timing. Group A (n = 52) included patients who required emergency surgery. Group B (n = 50) included patients who required surgery around a week after injury. Group C (n = 47) included patients who required surgery a month or more after injury. Characteristics of patients and radiological images were recorded. The Visual Analog Scale (VAS) scores and the Oswestry Disability Index (ODI) scores were analyzed before, 1 day, 1 month, and 6 months after surgery. In addition, compression rates of anterior vertebral height (AVH) were calculated and the kyphosis Cobb angle was measured before and after surgery.

RESULTS

There was a significant difference in the VAS and ODI scores between the three groups at 1 day, 1 month, and 6 months after PKP. The VAS and ODI scores of Group C were higher than those of Groups A and B. The AVH compression rates of Group C were significantly higher than those of Groups A and B postoperatively 1 day, 1 month, and 6 months. The kyphosis Cobb angles in Group C was significantly larger than those in Groups A and B at 1 day and 1 month after PKP.

CONCLUSIONS

Emergency PKP showed more advantages in both clinical and radiological outcomes. We recommend early PKP for the treatment of OVCFs.

Safety and efficacy studies of kyphoplasty, mesh-container-plasty, and pedicle screw fixation plus vertebroplasty for thoracolumbar osteoporotic vertebral burst fractures

Background

Percutaneous kyphoplasty (PKP), percutaneous mesh-container-plasty (PMCP), and pedicle screw fixation plus vertebroplasty (PSFV) were three methods for osteoporotic vertebral burst fractures (OVBF). The purpose of the current study was to evaluate the clinical safety and efficacy of PKP, PMCP, and PSFV for OVBFs.

Methods

This retrospective study included 338 consecutive patients with thoracolumbar OVBFs who underwent PKP (n = 111), PMCP (n = 109), or PSFV (n = 118) and compared their epidemiological data, surgical outcomes, and clinical and radiological features. Clinical evaluations of VAS and ODI and radiological evaluations of height restoration, deformity correction, cement leakage, and canal compromise were calculated preoperatively, postoperatively, and 2 years postoperatively.

Results

Cement leakage (31/111 vs. 13/109 and 16/118, P < 0.05) was significantly higher in group PKP than in groups PSFV and PMCP. VAS and ODI scores improved postoperatively from 7.04 ± 1.15 and 67.11 ± 13.49 to 2.27 ± 1.04 and 22.00 ± 11.20, respectively, in group PKP (P < 0.05); from 7.04 ± 1.29 and 67.26 ± 12.79 to 2.17 ± 0.98 and 21.01 ± 7.90, respectively, in group PMCP (P < 0.05); and from 7.10 ± 1.37 and 67.36 ± 13.11 to 3.19 ± 1.06 and 33.81 ± 8.81, respectively, in the PSFV group (P < 0.05). Moreover, postoperative VAS and ODI scores were significantly higher in group PSFV than in groups PKP and PMCP (P < 0.05). However, VAS scores were not significantly different in the three groups 2 years postoperatively (P > 0.05). Postoperative anterior (81.04 ± 10.18% and 87.51 ± 8.94% vs. 93.46 ± 6.42%, P < 0.05) and middle vertebral body height ratio (83.01 ± 10.16% and 87.79 ± 11.62% vs. 92.38 ± 6.00%, P < 0.05) were significantly higher in group PSFV than in groups PMCP and PKP. Postoperatively, Cobb angle (10.04 ± 4.26° and 8.16 ± 5.76° vs. 4.97 ± 4.60°, P < 0.05) and canal compromise (20.76 ± 6.32 and 19.85 ± 6.18 vs. 10.18 ± 6.99, P < 0.05) were significantly lower in group PSFV than in groups PMCP and PKP.

Conclusion

Despite relatively worse radiological results, PMCP is a safe and minimally invasive surgical method that can obtain better short-term clinical results than PKP and PSFV for OVBFs.

Finite element analysis of wedge and biconcave deformity in four different height restoration after augmentation of osteoporotic vertebral compression fractures

Purpose

Biomechanical comparison of wedge and biconcave deformity of different height restoration after augmentation of osteoporotic vertebral compression fractures was analyzed by three-dimensional finite element analysis (FEA).

Methods

Three-dimensional finite element model (FEM) of T11-L2 segment was constructed from CT scan of elderly osteoporosis patient. The von Mises stresses of vertebrae, intervertebral disc, facet joints, displacement, and range of motion (ROM) of wedge and biconcave deformity were compared at four different heights (Genant 0–3 grade) after T12 vertebral augmentation.

Results

In wedge deformity, the stress of T12 decreased as the vertebral height in neutral position, flexion, extension, and left axial rotation, whereas increased sharply in bending at Genant 0; L1 and L2 decreased in all positions excluding flexion of L2, and T11 increased in neutral position, flexion, extension, and right axial rotation at Genant 0. No significant changes in biconcave deformity. The stress of T11-T12, T12-L1, and L1-L2 intervertebral disc gradually increased or decreased under other positions in wedge fracture, whereas L1-L2 no significant change in biconcave fracture. The utmost overall facet joint stress is at Genant 3, whereas there is no significant change under the same position in biconcave fracture. The displacement and ROM of the wedge fracture had ups and downs, while a decline in all positions excluding extension in biconcave fracture.

Conclusions

The vertebral restoration height after augmentation to Genant 0 affects the von Mises stress, displacement, and ROM in wedge deformity, which may increase the risk of fracture, whereas restored or not in biconcave deformity.

Percutaneous mesh-container-plasty for osteoporotic thoracolumbar burst fractures: A prospective, nonrandomized comparative study

OBJECTIVE

This study aimed to compare the clinical and radiological results of percutaneous mesh-container-plasty (PMCP) versus percutaneous kyphoplasty (PKP) in the treatment of osteoporotic thoracolumbar burst fractures.

METHODS

A prospective study of 122 patients with osteoporotic thoracolumbar burst fractures was conducted. The patients were nonrandomly assigned to receive PKP (62; 16 men, 46 women) and PMCP (60; 14 men, 46 women). The epidemiological data, surgical outcomes, and clinical and radiological features were compared between the 2 groups. Cement leakage, height restoration, deformity correction, canal compromise, and cement distribution were calculated from the radiographs. Visual pain analog scale (VAS), the Oswestry disability index (ODI), and short-form 36 health survey domains role physical (SF-36 rp) and bodily pain (SF-36 bp) were calculated before surgery and immediately and 2 years after surgery.

RESULTS

Although VAS, ODI, SF-36 bp, and SF-36 rp scores improved from 7 (6-9), 71.28±16.38, 22 (0-32), and 25 (0-50) preoperatively to 2 (1-3), 20.02±8.97, 84 (84-84), and 75 (75-100) immediately postoperatively in the PMCP group (p<0.05) and from 7 (6-8), 71.40±13.52, 22 (10.5-31.75), and 25 (0-50) preoperatively to 2 (1-3), 21.78±11.21, 84 (84-84), and 75 (75-100) immediately postoperatively in the PKP group (p<0.05), there was no difference between the 2 groups. The mean cost in the PKP group was less than that in the PMCP group ($5109±231 vs. $6699±201, p<0.05). Anterior, middle, and posterior vertebral body height ratios in the PMCP group were greater than those in the PKP group postoperatively (88.44%±3.76% vs. 81.10%±11.78%, 86.15%±3.50% vs. 82.30%±11.02%, and 93.91%±3.01% vs. 91.43%±6.71%, respectively, p<0.05). The Cobb angle in the PMCP group was lower than that in the PKP group postoperatively (6.67°±4.39° vs. 8.99°±4.06°, p<0.05). Cement distribution in the PMCP group was higher than that in the PKP group (30.48%±5.62% vs. 27.18%±4.87%, p<0.05). Cement leakage was observed to be lesser in the PMCP group (2/60) than in the PKP group (10 vs. 62, p<0.05).

CONCLUSION

Both PKP and PMCP treatments seem to have significant ability in pain relief and functional recovery. Despite its higher cost, PMCP treatment may have a better inhibition ability of cement leakage, cement distribution, height restoration, and improvement in segmental kyphosis than PKP treatment for osteoporotic thoracolumbar burst fractures.

LEVEL OF EVIDENCE

Level II, Therapeutic Study.

Characteristics of Osteoporotic Low Lumbar Vertebral Fracture and Related Lumbosacral Sagittal Imbalance

Osteoporotic vertebral fracture (OVF) usually occurs in the thoracolumbar region and rarely affects the low lumbar region. The characteristics of osteoporotic low lumbar fracture (OLLF) have not been reported. Lumbosacral sagittal balance plays an important role in preserving the normal physiologic function of the spine. However, it is unknown how lumbosacral parameters vary in patients with OLLF. The authors retrospectively analyzed the clinical and radiologic characteristics of patients with OLLF and osteoporotic thoracolumbar vertebral fracture (OTVF) who were treated at their institution. Vertebral height, local deformity angle, and visual analog scale and Oswestry Disability Index scores were assessed preoperatively and postoperatively for both groups. The changes in lumbosacral parameters were measured for patients with OLLF. The results showed that OLLF was more likely to occur at L3 (53.66%) and that the prevalence of severe trauma (29.27%) was higher among patients with OLLF (P<.05). The most common morphologic type of the vertebrae affected by OLLF was biconcave (58.54%, P<.05). Patients who had OLLF showed an apparent increase in pelvic tilt and a decrease in local lordosis and sacral slope. Postoperatively, vertebral height, local deformity angle, and visual analog scale and Oswestry Disability Index scores were significantly improved compared with preoperative values (P<.05). Among patients with OLLF, local lordosis and sacral slope increased significantly, whereas pelvic tilt decreased significantly after percutaneous kyphoplasty. Restoration of local lordosis had a mean value of 6.29°±4.80°. These results indicate that OLLF has unique characteristics compared with OTVF and that it results in lumbosacral sagittal imbalance. Percutaneous kyphoplasty is effective and safe for the treatment of OLLF and plays an important role in postoperative improvement of sagittal imbalance. [Orthopedics. 2021;44(1):e7-e12.].

Presence or absence of adjacent vertebral fractures has no effect on long-term global alignment and quality of life in patients with osteoporotic vertebral fractures treated with balloon kyphoplasty

BACKGROUND

Global sagittal malalignment after osteoporotic vertebral fracture is correlated with decreased quality of life. Balloon kyphoplasty promotes short-term global alignment, but long-term correction is difficult in patients with such fractures. Adjacent vertebral fracture is one of the major complications of balloon kyphoplasty. We investigated the correlation of the incidence of adjacent vertebral fracture with the loss of global alignment correction after balloon kyphoplasty.

METHODS

Forty patients were enrolled in this retrospective study. Adjacent vertebral fracture occurred in 17 patients. Sagittal vertical axis, the angle between the two vertebrae above and below the balloon kyphoplasty site (local alignment angle), and the vertebral kyphotic angle at the kyphoplasty site were measured pre- and post-operatively. Clinical results were assessed.

RESULTS

There were no significant differences between the sagittal vertical axis before and after balloon kyphoplasty in groups with (+) or without (-) adjacent vertebral fracture. Local alignment angles decreased soon after balloon kyphoplasty, but increased during follow-up in both groups. Vertebral kyphotic angles decreased significantly soon after balloon kyphoplasty in both groups; although this increased significantly in the adjacent vertebral fracture (-) group, but not in the adjacent vertebral fracture (+) group, during follow-up. Correction loss of alignment was found in both adjacent vertebral fracture (+) and (-) groups, attributed to adjacent vertebral fracture in the former and re-collapse of the balloon kyphoplasty site in the latter. No significant differences in clinical results were observed between the groups, although these were strongly correlated with sagittal vertical axis before balloon kyphoplasty.

CONCLUSIONS

The adjacent vertebral fracture (+) and (-) groups exhibited similar correction loss of alignment and improved quality of life. The presence or absence of adjacent vertebral fractures had no effect on long-term global alignment and patient quality of life.

Kyphoplasty Restores the Global Sagittal Balance of the Spine Independently from Pain Reduction

Kyphoplasty is the standard surgical treatment of vertebral compression fractures. We aimed to clarify the influence of kyphoplasty on the sagittal profile as well as the relation between posture improvement and pain relief. For this purpose, we evaluated various radiological parameters of the sagittal profile on whole spine standing radiographs of 73 Patients with a single vertebral fracture treated by kyphoplasty. The key outcome was the postoperative change of the sagittal vertical axis (SVA). Additionally, clinical parameters including pain scores on visual analogue scale (VAS) and use of analgesics were obtained from medical records. Pre- and postoperative radiological as well as clinical parameters were compared. Additionally, the correlation between changes of SVA and changes of local kyphotic angle (LKA) or VAS was examined. The clinical parameters as well as various radiographic parameters (SVA, LKA, Gardner, Cobb) improved significantly postoperatively. The improvement of SVA correlated significantly with the correction of the LKA but not with postoperative pain relief. We conclude that kyphoplasty helps to restore the global sagittal balance of the spine after vertebral fractures. The correction of the sagittal profile seems to depend on the correction of the local kyphotic angle but does not correlate with postoperative pain relief.

Modified kyphoplasty with controllable balloon dilatation for treatment of thoracolumbar osteoporotic vertebral compression fractures

PURPOSE

To investigate the surgical effects of modified kyphoplasty with controllable balloon dilatation for treatment of thoracolumbar osteoporotic vertebral compression fractures (OVCF).

METHODS

From April 2013 to October 2017, a total of 53 patients with thoracolumbar OVCF were treated with controllable balloon percutaneous kyphoplasty (C-PKP). Peri-operative parameters including days from injury to operation, operation time, injected cement volume, cement leakage and complications were collected. Visual analogue scale (VAS) and Cobb angle before and after operation were applied to evaluate surgical effects. Moreover, a total of 53 cases treated with traditional balloon of percutaneous kyphoplasty were retrospectively analyzed and compared with C-PKP in above parameters.

RESULTS

C-PKP achieved significant fewer events of cement leakage (type C) than that of traditional PKP (5/53 vs 13/53, p < 0.01). The patients were followed up for 10.8 ± 4.2 months; VAS and Cobb angle of the injured vertebra in both two groups at three days and final follow-up were significantly improved compared with that before surgery (p < 0.05), while there were no significant differences between the two groups regarding the VAS and Cobb angle at corresponding time points (p > 0.05).

CONCLUSIONS

C-PKP technology is a safe and efficient way for the treatment of thoracolumbar OVCF, and it can reduce cement leakage.

Percutaneous kyphoplasty for osteoporotic vertebral compression fractures improves spino-pelvic alignment and global sagittal balance maximally in the thoracolumbar region

Background

Osteoporotic vertebral compression fractures (OVCFs) often cause local kyphosis. Percutaneous kyphoplasty (PKP) is a common method for the treatment of local kyphosis. However, the influence of kyphoplasty on spino-pelvic alignment and global sagittal balance when performed at specific treatment sites in the spine remains unclear.

The purpose of the study is to investigate the influence of different fracture sites and PKP treatment on the spino-pelvic alignment and global sagittal balance in patients with OVCFs.

Methods

90 patients with OVCF who underwent PKP were included in the retrospective study. According to the site of the fractured vertebrae, all the cases were divided into 3 groups: Main thoracic (MT) group (T1 to T9), Thoracolumbar (TL) group (T10 to L2) and Lumbar (LU) group (L3 to L5). 26 healthy elderly volunteers (aged over 59) were enrolled as the control group. Sagittal spino-pelvic parameters were measured on the full-spine radiographs preoperatively and postoperatively. Information of sagittal spino-pelvic parameters and global sagittal balance was gathered.

Results

Compared with the Control group, TL group showed significant differences in almost all parameters, except pelvic incidence (PI) and lumbar lordosis (LL). While only local sagittal parameters (Thoracic kyphosis (TK), Thoracolumbar kyphosis (TLK), LL) were significantly different in MT group. There was no significant difference in almost all of the parameters except for PT and TPA in LU group.

Correspondingly, the sagittal parameters of TL group improved best after PKP, except for thoracic kyphosis (TK) and sagittal vertical axis (SVA). In MT group, only TLK was significantly decreased, while in LU group, only local kyphosis Cobb angle and SSA were improved.

Conclusions

OVCF mainly occurs in the thoracolumbar region. Compared with MT group and LU group, OVCF occurred in the thoracolumbar region had greater influence on the spino-pelvic alignment and global sagittal balance. When PKP was performed, the improvement of sagittal balance parameters of TL group was the best in the three groups.

Kyphosis Progression after Balloon Kyphoplasty Compared with Conservative Treatment

Study Design

Retrospective cohort study (level of evidence: 4).

Purpose

To demonstrate the effects of balloon kyphoplasty (BKP) on prevention of kyphosis progression.

Overview of Literature

Kyphoplasty can correct local kyphosis (fractured vertebra), but its efficacy is attenuated by adjacent fracture and/or disc height reduction with endplate damage. With these attenuating factors incorporated, a comparison between BKP and conservative treatment is necessary to verify the effect of BKP on kyphosis correction.

Methods

This study retrospectively analyzed 129 patients treated conservatively and 95 treated with BKP in our institution. The rate of new adjacent fracture occurrence was determined using Kaplan–Meier analysis. We examined the progression of local kyphosis in patients who underwent lateral X-ray after 1 year. Local kyphosis was measured as an angle between higher end plate of the vertebra above and lower end plate of the vertebra below the fractured vertebra. The comparison included 45 patients treated conservatively and 58 treated with BKP.

Results

The incidence of new adjacent fracture at 1 year was 7.3% in the conservative treatment group and 23.2% in the BKP group (p<0.001), while the progression of local kyphosis at 1 year was 5.7°±4.7° and 3.2°±4.6°, respectively (p=0.01). Relative to conservative treatment, local kyphosis did not progress after BKP, despite the higher incidence of adjacent fracture. Local kyphosis progressed in cases with adjacent fracture compared with those without adjacent fracture (6.0°±4.3° vs. 2.1°±4.3°, p=0.003), and fractured vertebral instability was found to be a risk factor for adjacent fracture in BKP.

Conclusions

Compared with the conservative treatment, BKP suppressed the progression of local kyphosis. However, an adjacent fracture attenuated the BKP correction and was more frequently seen in patients with unstable vertebral fractures.

ACR Appropriateness Criteria® Management of Vertebral Compression Fractures

Vertebral compression fractures (VCFs) have various causes, including osteoporosis, neoplasms, and acute trauma. As painful VCFs may contribute to general physical deconditioning, management of painful VCFs has the potential for improving quality of life and preventing superimposed medical complications. Various imaging modalities can be used to evaluate a VCF to help determine the etiology and guide intervention. The first-line treatment of painful VCFs has been nonoperative or conservative management as most VCFs show gradual improvement in pain over 2 to 12 weeks, with variable return of function. There is evidence that vertebral augmentation (VA) is associated with better pain relief and improved functional outcomes compared to conservative therapy for osteoporotic VCFs. A multidisciplinary approach is necessary for the management of painful pathologic VCFs, with management strategies including medications to affect bone turnover, radiation therapy, and interventions such as VA and percutaneous thermal ablation to alleviate symptoms. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Early versus late percutaneous kyphoplasty for treating osteoporotic vertebral compression fracture: A retrospective study

OBJECTIVE

Osteoporotic vertebral compression fracture (OVCF) is a common disease in the aged population that can greatly affect the quality of life. Percutaneous kyphoplasty (PKP) has become a mainstream approach for treating OVCF, but the optimal surgical timing for treating OVCF with PKP remains controversial. In the current study, we retrospectively studied patients with OVCF that underwent PKP, and aimed to find out whether surgical timing could affect the clinical and radiological outcomes.

PATIENTS AND METHODS

We retrospectively studied 62 patients who underwent PKP for OVCF. Patients were divided into 2 groups based on the timing of PKP: operation within 4 weeks (group A) and operation later than 4 weeks (group B). VAS, ODI, height of fracture vertebra, restored height rate, local kyphosis angle and complications were assessed preoperatively and throughout the follow-up.

RESULTS

There were 36 cases (58 fracture vertebra) in the group A and 26 cases (40 fracture vertebra) in the group B. There was no significant difference between the two groups regarding to the demographic data before surgery. In terms of the VAS and ODI, no statistical difference was observed before operation, after operation and at the 6th month follow-up between the two groups. The HRR after operation and at the 6^th month follow-up in the group A was 17.5 ± 5.3% and 10.5 ± 3.7%, and that in the group B was 7.2 ± 3.2% and 3.6 ± 1.1%, and there is significant difference between the two groups (p < 0.05). The LKA (preoperatively / post-operatively / 6th month follow-up) was -12.7°, -7.3°, -11.4° in the group A and -17.6°, -14.4°, -16.1° in the group B. There was significant difference between the two groups at all the time points for local kyphosis angle (p < 0.01), with a lower rate of subsequent vertebral fracture in the group A (p < 0.05).

CONCLUSION

Both surgical timings of PKP showed similar outcomes in terms of the VAS and ODI. Early PKP could result in better restoration of vertebral body height and reduced rate of subsequent fracture compared to late PKP.

Analysis of correlation between degeneration of lower lumbar paraspinal muscles and spinopelvic alignment in patients with osteoporotic vertebral compression fracture

BACKGROUND

A few studies have pointed that trunk extensors may affect the spinopelvic alignment; however, little is known about the exact association between degeneration of lower lumbar paraspinal muscles and spinopelvic parameters.

OBJECTIVE

The study aimed to analyze the relationship between degeneration of lower lumbar paraspinal muscles and spinopelvic alignment in patients with osteoporotic vertebral compression fracture (OVCF).

METHODS

Thirty-nine OVCF patients were involved in this study. All patients underwent a standing lateral radiographs of the entire spine and pelvis 6 months after kyphoplasty. Pelvic incidence, pelvic tilt, lower lumbar lordosis (LLL) were measured. On the MRI images, the cross-sectional areas of the erector spinae (ES), multifidus (MF), vertebral body and the signal intensity of ES, MF, subcutaneous fat were measured. Pearson's correlation coefficients was applied to analyze the correlation between the muscular degeneration degree (muscular atrophy and fatty infiltration) and spinopelvic parameters.

RESULTS

The fatty change degree of ES at L4 inferior endplate level was positively correlated with pelvis retroversion (r= 0.480, p< 0.05). The grade of fat infiltration of ES plus MF at L5 level was negatively related to LLL (r=-0.446, p< 0.05). The fatty change of ES at L5 level, atrophy of ES at L4 and L5 level did not correlate with pelvis back tilt. The fat infiltration of ES plus MF at L4 level, the atrophy degree of ES plus MF at L4 and L5 level had no correlation with LLL.

CONCLUSIONS

With the increase of fatty infiltration of the erector spinae, the degree of pelvis retroversion increases; the lower lumbar lordosis decreases with the increase of intramuscular adipose tissue of the erector spinae plus multifidus. The atrophy degree of the erector spinae and multifidus is not correlated with pelvis back tilt and lower lumbar lordosis.

Risk factors of recompression of cemented vertebrae after kyphoplasty for osteoporotic vertebral compression fractures

PURPOSE

To evaluate the risk factors correlated with loss of cemented vertebral body height after kyphoplasty in patients with osteoporotic vertebral compression fractures.

METHODS

Thirty-four consecutive patients with single-level osteoporotic vertebral compression fractures who underwent kyphoplasty in the Affiliated Hospital of Jiangsu University between January 2012 and August 2014 were retrospectively analysed. Eight independent variables (age, gender, body mass index, pre-operative T-score in bone mineral density, the volume of polymethylmethacrylate injected, pre-operatively vertebral body height, the restoration of body height and the distance between polymethylmethacrylate and endplate) were assessed. The recompression of body height was the dependent variable. Multivariate linear regression analyses were used to determine the factors associated with recompression of body height.

RESULTS

Multiple linear regression analyses indicated that the recompression of cemented vertebral body height was correlated with the distance between polymethylmethacrylate and endplate (P = 0.008, b' = 0.489). The final multiple linear regression model, which included only the distance between polymethylmethacrylate and endplate, resulted in a formula that accounted for 41.02 % of the recompression of body height.

CONCLUSIONS

The distance between polymethylmethacrylate and endplate is an important risk factor of recompression of cemented vertebrae after kyphoplasty for patients with osteoporotic vertebral compression fractures.