Vertebra plana: reappraisal of a contraindication to percutaneous vertebroplasty

Early Balloon Kyphoplasty Treatment for Osteoporotic Vertebral Fracture Reduces Adjacent Vertebral Fractures

Background and Objectives: This study retrospectively examined whether the incidence rates of adjacent vertebral fractures (AVFs) can be reduced through balloon kyphoplasty (BKP) for osteoporotic vertebral fractures (OVFs) in the early stages, when there is little vertebral height variation. Materials and Methods: A total of 95 patients (22 males, 73 females, mean age: 80.7 years) who had undergone BKP were divided into two groups: the Early group (underwent BKP within 2 weeks after injury, n = 62), and the Non-early group (underwent BKP > 2 weeks after injury, n = 33). The following data were analyzed: patient characteristics; fracture level; the presence of old vertebral fractures, posterior wall injury, and intravertebral cleft; duration of surgery; duration of hospitalization; cement volume; the occurrence of AVF; the timing of AVF occurrence; Numerical Rating Scale (NRS) scores at the preoperative, postoperative, and final follow-up assessments; posterior vertebral kyphosis angle of the affected vertebra on plain lateral X-ray; vertebral wedge ratio; local kyphotic angle; and changes in posterior vertebral kyphosis angle, vertebral wedge ratio, and local kyphotic angle between preoperative and postoperative assessments. The patients were divided based on the occurrence or non-occurrence of AVF after BKP: the Non-AVF group, in which AVF did not occur, and the AVF group, in which AVF occurred. Results: The incidence of AVF was 15.8% (15/95 patients), with a notably lower incidence rate in the Early group at 6.5% (4/62 patients) compared to the Non-early group at 33.3% (11/33 patients). NRS scores significantly improved in both groups at the postoperative assessment and final follow-up. The changes in posterior vertebral kyphosis angle and vertebral wedge ratio were significantly lower in the Early group. In the Non-AVF group, the time from injury to surgery was significantly shorter. Conclusions: The Early group had a significantly lower incidence of AVF. The time from injury to surgery was a risk factor for AVF occurrence, suggesting that early BKP is recommended.

Vertebra Plana: A Narrative Clinical and Imaging Overview among Possible Differential Diagnoses

Vertebra plana is a rare radiologic condition characterized by a uniform loss of height of a vertebral body that represents a diagnostic challenge for surgeons. The purpose of this study was to review all possible differential diagnoses that may present with a vertebra plana (VP) described in the current literature. For that purpose, we performed a narrative literature review in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, analyzing 602 articles. Patient demographics, clinical presentation, imaging characteristics and diagnoses were investigated. VP is not a pathognomonic feature of Langerhans cell histiocytosis, but other oncologic and non-oncologic conditions should be considered. The list of differential diagnoses, based on our literature review, can be recalled with the mnemonic HEIGHT OF HOMO: H-Histiocytosis; E-Ewing's sarcoma; I-Infection; G-Giant cell tumor; H-Hematologic neoplasms; T-Tuberculosis; O-Osteogenesis imperfecta; F-Fracture; H-Hemangioma; O-Osteoblastoma; M-Metastasis; O-Osteomyelitis, chronic.

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.

Vertebral Augmentation Compared to Conservative Treatment of Vertebra Plana and High-Degree Osteoporotic Vertebral Fractures: A Review of 110 Fractures in 100 Patients

This is a retrospective study that evaluated surgical versus non-surgical treatment of 100 patients followed for up to six years diagnosed with severe osteoporotic vertebral compression fractures (VCF). Fractures were classified by percent collapse of vertebral body height as "high-degree fractures" (HDF) (>50%) or vertebra plana (VP) (>70%). A total of 310 patients with VCF were reviewed, identifying 110 severe fractures in 100 patients. The HDF group was composed of 47 patients with a total of 50 fractures. The VP group was composed of 53 patients with a total of 60 fractures. Surgical intervention was performed in 59 patients, comprised entirely of percutaneous vertebral cement augmentation procedures, including vertebroplasty, balloon kyphoplasty, or cement with expandable titanium implants. The remaining 41 patients only underwent conservative treatment that is the basis of the comparison study. All procedures were performed as an outpatient under local anesthesia with minimal sedation and there were no procedural complications. The initial or pre-procedural visual analog scale (VAS) score averaged 8.4 in all patients, with surgical patients having the most marked drop in VAS, averaging four points. This efficacy was achieved to a greater degree in surgically treated VP fractures compared to HDF. Non-surgical patients persisted with the most pain in both short- and long-term follow-up. This large series, with follow-up up to six years, demonstrated that the more severe fractures respond well to different percutaneous cement augmentation procedures with reduction of pain without increased complications in a comparison to conservatively treated patients. 

Re-expansion and Stabilization of Vertebra Plana Fractures Using Bilateral SpineJack® Implants

The surgical treatment of osteoporotic vertebral fractures with greater than 70% collapse, known as "Vertebra Plana (VP)" has been controversial. Originally VP was a considered a contraindication to vertebroplasty or kyphoplasty because of presumed difficulty of entering the collapsed vertebra as well as obtaining significant re-expansion or correct associated sagittal kyphosis. In some cases, multilevel pedicle screw fixation with or without attempts to correct the collapse is still performed to correct the kyphosis or prevent progression. With experience it was clear that the pedicle could be accessed and VP could be treated without added risk of epidural leak of cement or epidural extravasation. Now, with the introduction of newer third-generation intraspinal expansion devices that are larger and need to be placed bilaterally, their use in cases of VP was again an issue since VP cases were excluded from the original multicenter studies used for worldwide approval. This report reviews six cases of VP treated with bilateral SpineJack® implants (Stryker Corp, Kalamazoo, Michigan, USA) demonstrating it is not only feasible to place these larger size implants but achieve significant reconstitution of vertebral height as well as correction of the kyphotic deformity.

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.

Update of vertebral cementoplasty in porotic patients

Vertebroplasty (VP) is a percutaneous mini-invasive technique developed in the late 1980s as antalgic and stabilizing treatment in patients affected by symptomatic vertebral fracture due to porotic disease, traumatic injury and primary or secondary vertebral spine tumors. The technique consists of a simple metameric injection of an inert cement (poly-methyl-methacrylate, PMMA), through a needle by trans-peduncular, parapeduncular or trans-somatic approach obtaining a vertebral augmentation and stabilization effect associated with pain relief. The technique is simple and fast, and should be performed under fluoroscopy or CT guidance in order to obtain a good result with low complication rate. The aim of this paper is to illustrate the utility of VP, the indications-contraindications criteria, how to technically perform the technique using imaging guidance, and the results and complications of this treatment in patients affected by symptomatic vertebral compression fracture.

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.