Hybrid stabilization of unstable osteoporotic thoracolumbar vertebral body fractures: clinical and radiological outcome after a mean of 4 years

Percutaneous kyphoplasty combined with pediculoplasty for the surgical treatment of osteoporotic thoracolumbar burst fractures

OBJECTIVE

This study introduces a minimally invasive technique for efficient three-column reconstruction, augmentation, and stabilization of osteoporotic thoracolumbar burst fractures (OTLBFs).

METHODS

Sixty-eight patients with OTLBFs and no neurological deficits were included from July 2019 to September 2020. The patients were divided into two groups: the simple percutaneous kyphoplasty (PKP) group (n = 32) and the percutaneous kyphoplasty combined with pediculoplasty (PKCPP) group (n = 36). The clinical and radiological outcomes were assessed during a minimum 1-year follow-up period. Clinical outcomes were assessed via the visual analog scale (VAS) and modified MacNab grading criteria. The radiological outcomes included the Cobb angle (CA), anterior wall height (AWH), and posterior wall height (PWH). The surgery duration, postoperative analgesic dosage, length of hospital stay, and complications were recorded.

RESULTS

Surgery duration was not significantly different between the two groups (P > 0.05). The PKCPP group had a lower analgesic dosage and shorter hospital stay (P < 0.05). Postoperatively, the PKCPP group exhibited better VAS scores and modified MacNab scale scores (P < 0.05), but the differences at the last follow-up assessment were not significant (P > 0.05). Postoperative CA, AWH, and PWH correction were not significantly different on the first postoperative day (P > 0.05). However, the PKCPP group had significantly less CA and PWH loss of correction at the last follow-up visit (P < 0.05). The PKCPP group had significantly fewer complications (P < 0.05).

CONCLUSIONS

The PKCPP technique complements simple PKP for OTLBFs. It quickly relieves pain, maintains the vertebral body height and Cobb angle, ensures cement stabilization, and offers more stable three-column support.

[Osteoporotic vertebral body fractures]

The number of osteoporotic fractures of the spine is increasing. These fractures are associated with elevated morbidity and mortality. This article provides an overview of the special features of these fractures, the diagnostic procedure, their classification, and the conservative and surgical treatment options. For the mostly elderly patients, it is important to treat the underlying disease and to address associated problems such as frailty and sarcopenia. To meet this growing medical and socio-economic challenge, a holistic interdisciplinary and interprofessional treatment approach is required.

Georg Schmorl prize of the German spine society (DWG) 2022: current treatment for inpatients with osteoporotic thoracolumbar fractures-results of the EOFTT study

AIM

Osteoporotic thoracolumbar fractures are of increasing importance. To identify the optimal treatment strategy this multicentre prospective cohort study was performed.

PURPOSE

Patients suffering from osteoporotic thoracolumbar fractures were included. Excluded were tumour diseases, infections and limb fractures. Age, sex, trauma mechanism, OF classification, OF-score, treatment strategy, pain condition and mobilization were analysed.

METHODS

A total of 518 patients' aged 75 ± 10 (41-97) years were included in 17 centre. A total of 174 patients were treated conservatively, and 344 were treated surgically, of whom 310 (90%) received minimally invasive treatment. An increase in the OF classification was associated with an increase in both the likelihood of surgery and the surgical invasiveness.

RESULTS

Five (3%) complications occurred during conservative treatment, and 46 (13%) occurred in the surgically treated patients. 4 surgical site infections and 2 mechanical failures requested revision surgery. At discharge pain improved significantly from a visual analogue scale score of 7.7 (surgical) and 6.0 (conservative) to a score of 4 in both groups (p < 0.001). Over the course of treatment, mobility improved significantly (p = 0.001), with a significantly stronger (p = 0.007) improvement in the surgically treated patients.

CONCLUSION

Fracture severity according to the OF classification is significantly correlated with higher surgery rates and higher invasiveness of surgery. The most commonly used surgical strategy was minimally invasive short-segmental hybrid stabilization followed by kyphoplasty/vertebroplasty. Despite the worse clinical conditions of the surgically treated patients both conservative and surgical treatment led to an improved pain situation and mobility during the inpatient stay to nearly the same level for both treatments.

Treatment and Outcome of Osteoporotic Thoracolumbar Vertebral Body Fractures With Deformation of Both Endplates With or Without Posterior Wall Involvement (OF 4): Short-Term Results from the Prospective EOFTT Multicenter Study

STUDY DESIGN

Multicenter prospective cohort study.

OBJECTIVE

To analyse therapeutical strategies applied to osteoporotic thoracolumbar OF 4 injuries, to assess related complications and clinical outcome.

METHODS

A multicenter prospective cohort study (EOFTT) including 518 consecutive patients who were treated for an Osteoporotic vertebral compression fracture (OVCF). For the present study, only patients with OF 4 fractures were analysed. Outcome parameters were complications, Visual Analogue Scale, Oswestry Disability Questionnaire, Timed Up & Go test, EQ-5D 5L, and Barthel Index after a minimum follow-up of 6 weeks.

RESULTS

A total of 152 (29%) patients presented with OF 4 fractures with a mean age of 76 years (range 41-97). The most common treatment was short-segment posterior stabilization (51%; hybrid stabilization in 36%). Mean follow up was 208 days (±131 days), mean ODI was 30 ± 21. Dorsoventral stabilized patients were younger compared to the other groups (P < .001) and had significant better TuG compared to hybrid stabilization (P = .049). The other clinical outcomes did not differ in the therapy strategies (VAS pain: P = 1.000, ODI: P > .602, Barthel: P > .252, EQ-5D 5L index value: P > .610, VAS-EQ-5D 5L: P = 1.000). The inpatient complication rate was 8% after conservative and 16% after surgical treatment. During follow-up period 14% of conservatively treated patients and 3% of surgical treated patients experienced neurological deficits.

CONCLUSIONS

Conservative therapy of OF 4 injuries seems to be viable option in patients with only moderate symptoms. Hybrid stabilization was the dominant treatment strategy leading to promising clinical short-term results. Stand-alone cement augmentation seems to be a valid alternative in selected cases.

Treatment and Outcome of Osteoporotic Thoracolumbar Vertebral Fractures With Anterior or Posterior Tension Band Failure (OF 5): Short-Term Results From the Prospective EOFTT Multicenter Study

STUDY DESIGN

Subgroup analysis of a multicenter prospective cohort study.

OBJECTIVE

To analyse surgical strategies applied to osteoporotic thoracolumbar osteoporotic fracture (OF) 5 injuries with anterior or posterior tension band failure and to assess related complications and clinical outcome.

METHODS

A multicenter prospective cohort study (EOFTT) was conducted at 17 spine centers including 518 consecutive patients who were treated for an osteoporotic vertebral fracture (OVF). For the present study, only patients with OF 5 fractures were analysed. Outcome parameters were complications, Visual Analogue Scale (VAS), Oswestry Disability Questionnaire (ODI), Timed Up & Go test (TUG), EQ-5D 5L, and Barthel Index.

RESULTS

In total, 19 patients (78 ± 7 years, 13 female) were analysed. Operative treatment consisted of long-segment posterior instrumentation in 9 cases and short-segment posterior instrumentation in 10 cases. Pedicle screws were augmented in 68 %, augmentation of the fractured vertebra was performed in 42%, and additional anterior reconstruction was done in 21 %. Two patients (11 %) received short-segment posterior instrumentation without either anterior reconstruction or cement-augmentation of the fractured vertebra. No surgical or major complications occurred, but general postoperative complications were observed in 45%. At a follow-up of mean 20 ± 10 weeks (range, 12 to 48 weeks), patients showed significant improvements in all functional outcome parameters.

CONCLUSIONS

In this analysis of patients with type OF 5 fractures, surgical stabilization was the treatment of choice and lead to significant short-term improvement in terms of functional outcome and quality of life despite a high general complication rate.

Comparative analysis of hybrid stabilization methods in the treatment of burst fractures of the vertebral bodies associated with osteoporosis

Objective. To perform comparative analysis of posterior stabilization methods combined with cement vertebroplasty and osteoplasty with deproteinized bone allograft in the treatment of uncomplicated burst fractures of the vertebral bodies associated with osteoporosis.Material and Methods. The study was a retrospective analysis. Two groups of patients were formed, inclusion and exclusion criteria were determined. The follow-up period was 12 months. The magnitude of kyphosis correction according to the Cobb method, the magnitude of residual postoperative kyphotic deformity, its recurrence in the long term postoperative period, and the length of transpedicular fixationwere assessed. Sagittal balance parameters and subjective assessments of the patient’s condition were not evaluated.Results. With a statistically significant difference, it can be said that the main predictors of recurrence of local kyphosis, incomplete correction of deformity and increased pain syndrome are the level of injury (T12 vertebra), the degree of initial kyphotic deformity, incomplete achievement of its correction after surgery (>10°), and the value of T-criterion according to densitometry. The length of fixation does notaffect the loss of correction and recurrence of kyphosis, however it may correlate with the severity of osteoporosis.Conclusions. When comparing posterior stabilization methods in combination with cement vertebroplasty or osteoplasty, there was no statistical difference in clinical and radiological outcomes.

Effect of subsequent vertebral body fractures on the outcome after posterior stabilization of unstable geriatric fractures of the thoracolumbar spine

PURPOSE

The purpose of this study was analyzing the effect of subsequent vertebral body fractures on the clinical outcome in geriatric patients with thoracolumbar fractures treated operatively.

METHODS

Retrospectively, all patients aged ≥ 60 with a fracture of the thoracolumbar spine included. Further inclusion parameters were acute and unstable fractures that were treated by posterior stabilization with a low to moderate loss of reduction of less than 10°. The minimal follow-up period was 18 months. Demographic data including the trauma mechanism, ASA score, and the treatment strategy were recorded. The following outcome parameters were analyzed: the ODI score, pain level, satisfaction level, SF 36 score as well as the radiologic outcome parameters.

RESULTS

Altogether, 73 patients were included (mean age: 72 years; 45 women). The majority of fractures consisted of incomplete or complete burst fractures (OF 3 + 4). The mean follow-up period was 46.6 months. Fourteen patients suffered from subsequent vertebral body fractures (19.2%). No trauma was recordable in 5 out of 6 patients; 42.8% of patients experienced a low-energy trauma (significant association: p < 0.01). There was a significant correlation between subsequent vertebral body fracture and female gender (p = 0.01) as well as the amount of loss of reduction (p = 0.02). Thereby, patients with subsequent vertebral fractures had significant worse clinical outcomes (ODI: 49.8 vs 16.6, p < 0.01; VAS pain: 5.0 vs 2.6, p < 0.01).

CONCLUSION

Patient with subsequent vertebral body fractures had significantly inferior clinical midterm outcome. The trauma mechanism correlated significantly with both the rate of subsequent vertebral body fractures and the outcome. Another risk factor is female gender.

Impact of Multifidus Muscle Atrophy on the Occurrence of Secondary Symptomatic Adjacent Osteoporotic Vertebral Compression Fractures

To assess the potential influence of multifidus atrophy and fatty degeneration on the incidence of adjacent vertebral compression fractures within one year after the index fracture. In a retrospective cohort study, patients who underwent surgery for an OVCF were identified and baseline characteristics, fracture patterns and the occurrence of secondary adjacent fractures within one year were obtained by chart review. Multifidus muscle atrophy and fatty degeneration were determined on preoperative MRI or CT scans. In this analysis of 191 patients (mean age 77 years, SD 8, 116 female), OF type 3 was the most common type of OVCF (49.2%). Symptomatic adjacent OVCFs within one year after index fracture were observed in 23/191 patients (12%) at mean 12, SD 12 weeks (range 1-42 weeks) postoperatively. The mean multifidus muscle area was 264, SD 53 mm² in patients with an adjacent vertebral fracture and 271, SD 92 mm² in patients without a secondary fracture (p = 0.755). Mean multifidus fatty infiltration was graded Goutallier 2.2, SD 0.6 in patients with an adjacent fracture and Goutallier 2.2, SD 0.7 in patients without an adjacent fracture (p = 0.694). Pre-existing medication with corticosteroids was associated with the occurrence of an adjacent fracture (p = 0.006). Multifidus area and multifidus fatty infiltration had no significant effect on the occurrence of adjacent vertebral fractures within one year after the index fracture. Patients with a pre-existing medication with corticosteroids were more likely to sustain an adjacent fracture.

Dorsal instrumentation with and without vertebral body replacement in patients with thoracolumbar osteoporotic fractures shows comparable outcome measures

PURPOSE

In the surgical treatment of osteoporotic spine fractures, there is no clear recommendation, which treatment is best for the individual patient with vertebra plana and/or neurological deficit requiring instrumentation. The aim of this study was to evaluate clinical and radiological outcomes after dorsal or 360° instrumentation of osteoporotic fractures of the thoracolumbar spine in a cohort of patients representing clinical reality.

METHODS

A total of 116 consecutive patients were operated on between 2008 and 2020. Inclusion criteria were osteoporotic fracture, thoracolumbar location, and dorsal instrumentation. In 79 cases, vertebral body replacement (VBR) was performed additionally. Patient outcomes including complications, EQ-5D at follow-up, and sagittal correction were analyzed.

RESULTS

Medical and surgical complications occurred in 59.5% of patients with 360° instrumentation compared to 64.9% of patients with dorsal instrumentation only (p = 0.684). Dorsal instrumentation plus VBR resulted in a sagittal correction of 9.3 ± 7.4° (0.1-31.6°) compared to 6.0 ± 5.6° (0.2-22.8°) after dorsal instrumentation only, respectively (p = 0.0065). EQ-5D was completed by 79 patients after 4.00 ± 2.88 years (0.1-11.8 years) and was 0.56 ± 0.32 (- 0.21-1.00) for VBR compared to 0.56 ± 0.34 (- 0.08-1.00) without VBR after dorsal instrumentation (p = 0.994).

CONCLUSION

360° instrumentation represents a legitimate surgical technique with no additional morbidity even for the elderly and multimorbid osteoporotic population. Particularly, if sufficient long-term construct stability is in doubt or ventral stenosis is present, there is no need to abstain from additional ventral reinforcement and decompression.

Multicenter evaluation of therapeutic strategies of inpatients with osteoporotic vertebral fractures in Germany

PURPOSE

The aim of this study was to assess therapeutic strategies of inpatients with osteoporotic thoracolumbar fractures (OTF) in Germany.

METHODS

Prospective multi-center study including 16 German-speaking trauma centers over a period of 7 months. All inpatients with OTF were included. Radiological and clinical data on admission and treatment modalities were assessed.

RESULTS

Seven hundred and seven (99.3%) out of 712 included patients (73.3% female) could be evaluated. Mean age was 75 years (30-103). 51.3% could not remember any traumatic incident. Fracture distribution was from T2 to L5 with L1 (19%) most commonly affected. According to the Magerl classification type A1 (52.1%) and A3 (42.7%) were most common. B and C type injuries (2.6%) and neurological deficits (3.1%) were rare. Previous progression of vertebral deformation was evident in 34.4% of patients and related to t score below - 3 (Odds ratio 1.9661). Patients presented with anticoagulation medication (15.4%), dementia (13%), and ASA score > 3 (12.4%) frequently. 82.3% of patients complained of pain > 4 on VAS, 37% could not be mobilized despite pain medication according to grade II WHO pain ladder. 81.6% received operative treatment. Kyphoplasty (63.8%) and hybrid stabilization including kyphoplasty with (14.4%) or without screw augmentation (7.6%) were the techniques most frequently used. Invasiveness of treatment increased with degree of instability.

CONCLUSIONS

OTF are mostly type A compression fractures. Patients suffer from severe pain and immobilization frequently. Progression of deformity is correlated to t score below - 3. Treatment of inpatients is mainly surgical, with kyphoplasty followed by hybrid stabilization as commonly used techniques.

Midterm outcome after posterior stabilization of unstable Midthoracic spine fractures in the elderly

Background

The evidence for the treatment of midthoracic fractures in elderly patients is weak. The aim of this study was to evaluate midterm results after posterior stabilization of unstable midthoracic fractures in the elderly.

Methods

Retrospectively, all patients aged ≥65 suffering from an acute unstable midthoracic fracture treated with posterior stabilization were included. Trauma mechanism, ASA score, concomitant injuries, ODI score and radiographic loss of reduction were evaluated. Posterior stabilization strategy was divided into short-segmental stabilization and long-segmental stabilization.

Results

Fifty-nine patients (76.9 ± 6.3 years; 51% female) were included. The fracture was caused by a low-energy trauma mechanism in 22 patients (35.6%). Twenty-one patients died during the follow-up period (35.6%). Remaining patients (n = 38) were followed up after a mean of 60 months. Patients who died were significantly older (p = 0.01) and had significantly higher ASA scores (p = 0.02). Adjacent thoracic cage fractures had no effect on mortality or outcome scores. A total of 12 sequential vertebral fractures occurred (35.3%). The mean ODI at the latest follow up was 31.3 ± 24.7, the mean regional sagittal loss of reduction was 5.1° (± 4.0). Patients treated with long segmental stabilization had a significantly lower rate of sequential vertebral fractures during follow-up (p = 0.03).

Conclusion

Unstable fractures of the midthoracic spine are associated with high rates of thoracic cage injuries. The mortality rate was rather high. The majority of the survivors had minimal to moderate disabilities. Thereby, patients treated with long segmental stabilization had a significantly lower rate of sequential vertebral body fractures during follow-up.

[Minimally invasive stabilization of thoracolumbar osteoporotic fractures]

BACKGROUND

Minimally invasive stabilization of thoracolumbar osteoporotic fractures (OF) in neurologically intact patients is well established. Various posterior and anterior surgical techniques are available. The OF classification and OF score are helpful for defining the indications and choice of operative technique.

OBJECTIVE

This article gives an overview of the minimally invasive stabilization techniques, typical complications and outcome.

MATERIAL AND METHODS

Selective literature search and description of surgical techniques and outcome.

RESULTS

Vertebral body augmentation alone can be indicated in painful but stable fractures of types OF 1 and OF 2 and to some extent for type OF 3. Kyphoplasty has proven to be an effective and safe procedure with a favorable clinical outcome. Unstable fractures and kyphotic deformities (types OF 3-5) should be percutaneously stabilized from posterior. The length of the pedicle screw construct depends on the extent of instability and deformity. Bone cement augmentation of the pedicle screws is indicated in severe osteoporosis but increases the complication rate. Restoration of stability of the anterior column can be achieved through additional vertebral body augmentation or rarely by anterior stabilization. Clinical and radiological short and mid-term results of the stabilization techniques are promising; however, the more invasive the surgery, the more complications occur.

CONCLUSION

Minimally invasive stabilization techniques are safe and effective. The specific indications for the individual procedures are guided by the OF classification and the individual clinical situation of the patient.

Posterior short segment fixation including the fractured vertebra combined with kyphoplasty for unstable thoracolumbar osteoporotic burst fracture

BACKGROUND

Various studies have described the efficacy and safety of the treatment for unstable thoracolumbar osteoporotic burst fracture, however, there is still no consensus on the optimal treatment regimen. The aim of this study was to evaluate the clinical and radiographic results of posterior short segment fixation including the fractured vertebra (PSFFV) combined with kyphoplasty (KP) for unstable thoracolumbar osteoporotic burst fracture.

METHODS

Forty-three patients with unstable thoracolumbar osteoporotic burst fracture underwent PSFFV combined with KP from January 2015 to December 2017 were analyzed retrospectively. Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) was used to evaluate the clinical outcome, radiological parametres including local kyphotic Cobb angle, percentage of the anterior, middle and posterior height of the fractured vertebra were measured and compared pre-operation, post-operation and at final follow-up.

RESULTS

All patients underwent surgery successfully and with an average follow-up of 19.2 ± 6.7 months (rang 15-32). The VAS decreased from 7.1 ± 2.3 pre-operation to 1.6 ± 0.4 at the final follow-up (p < 0.05). The ODI decreased from 83.1 ± 10.5 pre-operation to 19.2 ± 7.3 (P < 0.05) at the final follow-up. The correction of local kyphotic angle was 16.9° ± 5.3° (p < 0.05), and the loss of correction was 3.3° ± 2.6° (p > 0.05), the correction of anterior vertebral height was 30.8% ± 8.6% (p < 0.05), and the loss of correction was 4.5% ± 3.9% (p > 0.05), the correction of middle vertebral height was 26.4% ± 5.8% (p < 0.05), and the loss of correction was 2.0% ± 1.6% (p > 0.05), the correction of posterior vertebral height was 9.4% ± 6.9% (p < 0.05), and the loss of correction was 1.6% ± 1.3% (p > 0.05). Two cases of screw pullout and 8 cases of cement leakage were observed, but without clinical consequence.

CONCLUSIONS

PSFFV combined with KP is a reliable and safe procedure with satisfactory clinical and radiological results for the treatment of unstable thoracolumbar osteoporotic burst fracture.

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.