High- versus low-viscosity cement vertebroplasty and kyphoplasty for osteoporotic vertebral compression fracture: a meta-analysis

[Current surgical treatment concepts for traumatic fractures of the thoracic and lumbar spine with osteoporotic bone substance]

Osteoporosis-related vertebral fractures are among the most frequent fracture entities in geriatric patients. They are associated with far-reaching individual and socioeconomic consequences. Adequate diagnostics and treatment are therefore essential. The osteoporotic fracture (OF) score is a central element in determining the right treatment. Although the majority of fractures can be healed with conservative treatment, a change of treatment should be considered in good time in cases of failure. Isolated cement augmentation procedures are particularly suitable for reducing pain in primarily stable osteoporotic vertebral fractures with a preserved framework structure (OF types 1-3) and a largely intact posterior edge. Dorsal cement-augmented stabilization with cementing of the fractured vertebral body leads to good results in unstable OF types 3 and 4 fractures. Dorsoventral procedures with cement-augmented internal fixator from the dorsal side and vertebral body replacement from the ventral side play a more subordinate role. Purely ventral procedures should be avoided in this patient group.

Risk factor analysis of adjacent vertebral compression fracture following the surgery of percutaneous kyphoplasty in postmenopausal women

To evaluate the risk factors for adjacent vertebral compression fracture(AVCF) following the surgery of percutaneous kyphoplasty (PKP) in postmenopausal women. Two hundred and ninety-seven postmenopausal female patients had been reviewed, underwent PKP surgery between January 2016 and December 2020, were divided into two groups according to whether or not AVCF. Receiver operating characteristic (ROC) curves were generated to analyze the sensitivity and specificity of the relative risk factors in the identification of AVCF. In this study of 297 postmenopausal women who underwent PKP, 67 developed AVCF during follow-up. There were no significant differences in BMI, surgical method, or cement leakage between the groups. The AVCF group was older, had lower BMD, less bone cement volume per section, higher VHA, and larger VKAC. The non-fracture group had lower postoperative VAS and fewer surgical vertebrae. The model showed good discrimination with age, BMD, postoperative VAS, VHR, and VKAC. ROC analysis indicated that a postoperative with high VHR, high VKAC or VAS score > 2.5 was highly predictive of AVCF in postmenopausal women after PKP. In the context of PKP for OVCF in postmenopausal women, it is crucial to avoid excessive VHR and VKAC. Postoperatively, clinicians should prioritize pain management strategies to ensure optimal patient outcomes.

Effect of Robot-Assisted Surgery on Clinical Outcomes in Patients with Osteoporotic Vertebral Compression Fractures after Percutaneous Vertebral Augmentation: a Meta-Analysis and a Validation Cohort

Background

The objective of this study was to investigate the impact of robot-assisted surgery (RA) on the risk of new vertebral compression fracture (NVCF) and bone cement leakage in patients with osteoporotic vertebral compression fractures (OVCF) after percutaneous vertebral augmentation (PVA), including percutaneous kyphoplasty (PKP) and percutaneous vertebroplasty (PVP).

Methods

A meta-analysis was performed to evaluate the clinical outcomes and adverse effects of RA-PVA versus fluoroscopy-assisted (FA)-PVA in patients with OVCF. A validation cohort of 385 patients who underwent PVP or PKP was retrospectively analyzed. In addition, we attempted to create well-calibrated nomograms to estimate the risk of NVCF and bone cement leakage.

Results

The meta-analysis revealed that the incidence of NVCF and bone cement leakage was significantly lower in RA-PVA than in FA-PVA. The validation cohort confirmed that RA-PVA provided better results than FA-PVA in terms of NVCF and bone cement leakage.

Conclusions

The meta-analysis and the validation cohort suggest that RA reduced the risk of NVCF and bone cement leakage in patients with OVCF after PVA. The nomograms are accurate and easy-to-implement methods for clinicians to estimate the risk of NVCF and bone cement leakage after PVA.

Percutaneous Vertebroplasty versus Nonoperative Treatment of Osteoporotic Vertebral Fractures: A Meta-Analysis of Randomized Controlled Trials

Osteoporotic vertebral fractures frequently result in pain and decreased quality of life (QoL). The management of these fractures remains a topic of debate. Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we analyzed randomized controlled trials comparing percutaneous vertebroplasty (PV) with non-operative treatment (non-OT). The outcomes of interest included pain, QoL, cement leakage, and new osteoporotic vertebral fractures after 1 year. Compared to non-OT regarding pain relief, PV yielded significant improvement at 1-2 weeks, 1 month, 6 months (standard mean difference [SMD] = -0.67 (6/14; 95% confidence interval [CI]: -1.29 to -0.06; I2 = 92%, random effects) and 1 year (mean difference = -1.07 (4/14; 95% CI: -1.97 to -0.18; I2 = 97%, random effects). For QoL, notable improvements were observed at 1 week (standard mean difference = -2.10 (5/14; 95% CI: -3.77 to -0.42; I2 = 98%, random effects) and 3 months (mean difference = -1.58 (4/14; 95% CI: -3.07 to -0.09; I2 = 96%, random effects), with 1 month, 6 months and 1 year being inconclusive. A cement leakage rate of 42% (10/14; 95% CI: 25% to 59%; I2 = 99%, random effects) was found. Further, PV did not significantly heighten the risk of new fractures within a year (odds ratio = 1.26 (6/14; 95% CI: 0.63 to 2.53; I2 = 74%, random effects). PV emerges as a promising intervention for specific time intervals regarding pain relief, especially in the extended-term analysis, and QoL, especially in the short-term analysis, compared to non-OT. However, clinicians must consider cement leakage risks. Heterogeneity among studies underscores careful patient selection.

Tips and tricks for using cement augmentation of pedicle screws and vertebral body replacements-A literature review supported by two case reports

BACKGROUND

The prevalence of osteoporosis is escalating alongside an aging global population, increasing the demand for spinal surgeries, including those necessitating cement augmentation for enhanced construct stability.

OBJECTIVE

This article delves into the nuanced application of cement augmentation techniques for pedicle screws and vertebral body replacements (VBR), aimed at optimizing surgical outcomes in osteoporotic spines.

METHOD

Drawing from a comprehensive literature review according to important clinical and biomechanical studies and the authors' clinical experiences, we elucidate strategies to mitigate complications and improve surgical efficacy.

RESULTS

Cement augmentation has shown promise in managing vertebral fractures and in securing pedicle screws within osteoporotic vertebrae, with the advent of polymethylmethacrylate (PMMA) bone cement marking a pivotal advancement in spinal surgery. We highlight intraoperative measures like the choice between pre-injecting cement and utilizing cannulated or fenestrated screws, emphasizing the importance of controlling cement viscosity to prevent leakage and embolism. Through two case reports, we demonstrate the practical application of endplate cementation following VBR.

CONCLUSION

While the use of cement augmentation poses certain risks, its judicious application-supported by evidence-based guidelines and surgical expertise-can substantially enhance the stability of spinal constructs in osteoporotic patients. This allows a reduction in instrumentation length by enhancing biomechanical stability concerning pullout, bending, and rotational forces. Furthermore, the incidence of endplate sintering following VBF can be significantly reduced. Future research, particularly on antibiotic-loaded PMMA, may further expand its utility and optimize its safety profile.

Tips and tricks for using cement augmentation of pedicle screws and vertebral body replacements-A literature review supported by two case reports

BACKGROUND

The prevalence of osteoporosis is escalating alongside an aging global population, increasing the demand for spinal surgeries, including those necessitating cement augmentation for enhanced construct stability.

OBJECTIVE

This article delves into the nuanced application of cement augmentation techniques for pedicle screws and vertebral body replacements (VBR), aimed at optimizing surgical outcomes in osteoporotic spines.

METHOD

Drawing from a comprehensive literature review according to important clinical and biomechanical studies and the authors' clinical experiences, we elucidate strategies to mitigate complications and improve surgical efficacy.

RESULTS

Cement augmentation has shown promise in managing vertebral fractures and in securing pedicle screws within osteoporotic vertebrae, with the advent of polymethylmethacrylate (PMMA) bone cement marking a pivotal advancement in spinal surgery. We highlight intraoperative measures like the choice between pre-injecting cement and utilizing cannulated or fenestrated screws, emphasizing the importance of controlling cement viscosity to prevent leakage and embolism. Through two case reports, we demonstrate the practical application of endplate cementation following VBR.

CONCLUSION

While the use of cement augmentation poses certain risks, its judicious application-supported by evidence-based guidelines and surgical expertise-can substantially enhance the stability of spinal constructs in osteoporotic patients. This allows a reduction in instrumentation length by enhancing biomechanical stability concerning pullout, bending, and rotational forces. Furthermore, the incidence of endplate sintering following VBF can be significantly reduced. Future research, particularly on antibiotic-loaded PMMA, may further expand its utility and optimize its safety profile.

Efficacy and Safety of High-Viscosity Bone Cement in Percutaneous Vertebroplasty for Kummell's Disease

Background

To analyze and evaluate the clinical outcomes of using high-viscosity bone cement compared to low-viscosity bone cement in percutaneous vertebroplasty (PVP) for treatment of Kummell's disease.

Methods

From July 2017 to July 2019, 68 Kummell's disease patients who underwent PVP were chosen and separated into 2 groups: H group (n = 34), were treated with high-viscosity bone cement and L group (n = 34), treated with low-viscosity bone cement during treatment. The operation time, number of fluoroscopy tests done, and amount of bone cement perfusion were recorded for both groups. Clinical outcomes were compared, by measuring their Visual Analog Scale (VAS), Oswestry Disability Index (ODI), Kyphosis Cobb's angle, vertebral height compression rate, and other complications.

Results

High-viscosity group showed less operation time and reduced number of fluoroscopy tests than the low-viscosity group (P < 0.05). When compared to preoperative period, both groups' VAS and ODI scores were significantly reduced at 1 day and 1 year postoperatively (P < 0.05). The vertebral height compression rate and Cobb's angle were significantly lower (P < 0.05) in both groups after surgery compared with those before surgery (P < 0.05). The cement leakage rate in group H was 26.5%, which was significantly lower than that in group L, which was 61.8% (P < 0.05).

Conclusions

High-viscosity and low-viscosity bone cement in PVP have similar clinical efficacy in reducing pain in patients during the treatment, but in contrast, high-viscosity bone cement shortens the operative time, reduces number of fluoroscopy views and vertebral cement leakage and improves surgical safety.

Advances in materials used for minimally invasive treatment of vertebral compression fractures

Vertebral compression fractures are becoming increasingly common with aging of the population; minimally invasive materials play an essential role in treating these fractures. However, the unacceptable processing-performance relationships of materials and their poor osteoinductive performance have limited their clinical application. In this review, we describe the advances in materials used for minimally invasive treatment of vertebral compression fractures and enumerate the types of bone cement commonly used in current practice. We also discuss the limitations of the materials themselves, and summarize the approaches for improving the characteristics of bone cement. Finally, we review the types and clinical efficacy of new vertebral implants. This review may provide valuable insights into newer strategies and methods for future research; it may also improve understanding on the application of minimally invasive materials for the treatment of vertebral compression fractures.

[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.

Case report: Inspiration from a rare fatal heart perforation after percutaneous vertebroplasty

The principal benefit of employing percutaneous vertebroplasty (PVP) for managing osteoporotic vertebral compression fractures lies in its capacity to facilitate early mobilization in elderly patients, thereby effectively avoiding the potential catastrophic complications associated with prolonged bedridden states. However, bone cement leakage, as the most common complication of PVP, may have fatal consequences. Here, we report a case involving an 85-year-old male patient with L1 vertebral compression fracture who underwent PVP at our hospital and was discharged on the same day of the surgical intervention. Subsequently, the patient experienced symptoms of chest tightness and palpitations. Cardiac ultrasound examination revealed pericardial effusion, while pulmonary computed tomographic angiography (CTA) demonstrated a strip high-density shadow in the right ventricular area. Finally, it was determined that the perforation of the right ventricular wall was caused by bone cement embolism. Through this comprehensive case report, we aim to deepen the understanding of orthopedic doctors on the importance of preventing bone cement leakage.

Analysis of optimal volume fraction percentage and influencing factors of bone cement distribution in vertebroplasty using digital techniques

Purpose

To explore the optimal volume fraction percentage (VF%) and influencing factors of bone cement distribution in percutaneous vertebroplasty (PVP) for osteoporotic vertebral compression fractures (OVCF) using digital techniques.

Patients and methods

From January 2019 to February 2021, 150 patients with 0VCF who underwent PVP surgery in our hospital were analyzed. Based on postoperative X-ray and CT, the spatial distribution score of the intravertebral cement was calculated and the patients were divided into two groups: 0–7 were divided into group A; 8–10 were divided into group B. The general data of the two groups of patients were compared, and Mimics three-dimensional reconstruction images were used to measure the cement dispersion volume (CDV), vertebral body volume (VBV), and VF%. Factors affecting bone cement distribution were included in a multifactorial logistic regression analysis to construct a receiver operating characteristic (ROC) curve, calculate a cut-off value for the extensive distribution of bone cement, and analyze the correlation between bone cement distribution scores and VF%.

Results

There were 60 patients in group A and 90 patients in group B. Univariate analysis showed that bone mineral density (BMD), cement leakage, CDV, and VF% were significantly lower in group A than in group B (p < 0.05). Multivariate logistic regression analysis showed that BMD and VF% were independent influencing factors on bone cement distribution. The area under the curve (AUC) of VF% was 84.7%, and the cut-off value for extensive distribution of bone cement was 28.58%, which corresponded to a sensitivity and specificity of 72.2% and 91.7%, respectively. There was a strong correlation between the cement distribution score and VF% (r = 0.895, p < 0.001).

Conclusion

BMD and VF% were important independent influencing factors of bone cement distribution. Extensive bone cement distribution can be achieved when the VF% reaches 28.58%.

Advances in materials-based therapeutic strategies against osteoporosis

Osteoporosis is caused by the disruption in homeostasis between bone formation and bone resorption. Conventional management of osteoporosis involves systematic drug administration and hormonal therapy. These treatment strategies have limited curative efficacy and multiple adverse effects. Biomaterials-based therapeutic strategies have recently emerged as promising alternatives for the treatment of osteoporosis. The present review summarizes the current status of biomaterials designed for managing osteoporosis. The advantages of biomaterials-based strategies over conventional systematic drug treatment are presented. Different anti-osteoporotic delivery systems are concisely addressed. These materials include injectable hydrogels and nanoparticles, as well as anti-osteoporotic bone tissue engineering materials. Fabrication techniques such as 3D printing, electrostatic spinning and artificial intelligence are appraised in the context of how the use of these adjunctive techniques may improve treatment efficacy. The limitations of existing biomaterials are critically analyzed, together with deliberation of the future directions in biomaterials-based therapies. The latter include discussion on the use of combination strategies to enhance therapeutic efficacy in the osteoporosis niche.

Acute abdomen after vertebroplasty-A rare complication

Introduction

In recent years, as the concept of minimally invasive treatment has been accepted by the majority of patients, the application of percutaneous vertebroplasty in osteoporotic vertebral compression fractures has gradually increased, and research on the adverse complications of bone cement leakage has gradually deepened.

Case

Here, we report a rare case of acute pancreatitis after vertebroplasty. The patient had no previous history of pancreatitis and presented with obvious abdominal pain after vertebroplasty. Abdominal CT examination revealed that the leaking bone cement penetrated the anterior wall of the L1 vertebral body into the diaphragm, and the heat released by the polymerization reaction caused inflammation and damage to the adjacent pancreas, resulting in poor blood flow to the pancreatic tissue and leading to acute pancreatitis. Early postoperative symptomatic treatment was given to the patient, and the corresponding symptoms were gradually relieved. During postoperative follow-up, the leaking cement did not degrade, but the patient had no symptoms.

Conclusion

Lesions of adjacent organs caused by bone cement leakage are rare, and clinicians often ignore the association between such complications and vertebroplasty. This case report will provide guidance and a reference for clinicians.

Robot Versus Fluoroscopy-Assisted Vertebroplasty and Kyphoplasty for Osteoporotic Vertebral Compression Fractures: A Systematic Review and Meta-analysis

OBJECTIVE

This study aimed to conduct a systematic review and meta-analysis to compare the clinical results and complications of robot-assisted (RA) versus fluoroscopy-assisted (FA) percutaneous vertebral augmentation (PVA) in the treatment of osteoporotic vertebral compression fractures (OVCFs).

METHODS

A comprehensive search of online databases including PubMed, Embase, Cochrane Library, web of science, and core journals of China National Knowledge Infrastructure were performed to identify related studies reporting the clinical results and complications of RA versus FA-assisted PVA in the treatment of OVCFs. The rate of bone cement leakage was used to assess the complications. After the surgery, the clinical findings were analyzed using the Visual Analog Scale scores and the Oswestry Disability Index scores. The surgical time, intraoperative fluoroscopy frequency, and x-ray exposure duration were used to evaluate the perioperative results. Forest plots were constructed to investigate the results.

RESULTS

RA-PVA had a significantly lower bone cement leakage rate, shorter fluoroscopy frequency, and shorter radiation exposure time of doctors compared with FA-PVA. However, no significant differences were found between RA-PVA and FA-PVA in operative time and radiation exposure time of patients. Furthermore, no statistically differences were found between the 2 groups in Visual Analog Scale and Oswestry Disability Index scores after surgery.

CONCLUSIONS

This meta-analysis showed that RA-PVA can reduce bone cement leakage rate, fluoroscopy frequency, and doctors' radiation exposure time. With the advancement of RA technology, we anticipate more high-quality randomized controlled trials of RA versus FA-PVA in the future to validate and update the results of this analysis.