Utilisation de vis cimentées percutanées dans la prise en charge rachidienne des patients à faible capacité osseuse

Mono-segmental percutaneous screw fixation in the management of AoSpine thoracolumbar type B fracture in patients with ankylosing spondylitis: A new treatment

PURPOSE

To assess the viability and effectiveness of mono-segmental percutaneous screw fixation in the treatment of unstable type B thoracolumbar fracture due to ankylosing spondylitis.

METHODS

We report here all 40 patients treated by mono-segmental screw fixation in this indication, between January 2018 and January 2022, with follow-up at 3 and 9 months. Study variables comprised operating time, length of stay, fusion, stabilization quality, and peri-operative morbidity and mortality.

RESULTS

One patient showed early displacement of rods caused by technical error. None of the others showed secondary displacement of rods or screws. Mean age was 73 years (range 18-93), mean hospital stay 4.8 days (range 2-15), mean operative time 52minutes (range 26-95minutes) and mean estimated blood loss 40ml. There were 2 deaths caused by intensive care unit complications. All patients except those in intensive care were verticalized within 24hours after surgery. Parker score was unchanged for each patient before and after surgery and during follow-up.

CONCLUSION

Mono-segmental percutaneous screw fixation in the treatment of unstable type B thoracolumbar fracture due to ankylosing spondylitis was safe and effective. This study showed that this surgery reduced length of hospital stay, operative time, blood loss and complications compared to open or extended percutaneous surgery, and allowed fast rehabilitation in this vulnerable population.

Percutaneous instrumentation with cement augmentation for traumatic hyperextension thoracic and lumbar fractures in ankylosing spondylitis: a single-institution experience

OBJECTIVE

The typical traumatic thoracolumbar (TL) fracture in patients with ankylosing spondylitis (AS) is a hyperextension injury involving all three spinal columns, which is associated with unfavorable outcomes. Although a consensus on the management of these highly unstable injuries is missing, minimally invasive surgery (MIS) has been progressively accepted as a treatment option, since it is related to lower morbidity and mortality rates. This study aimed to evaluate clinical and radiological outcomes after percutaneous instrumentation with cement augmentation for hyperextension TL fractures in patients with AS at a single institution.

METHODS

This cohort study was completed retrospectively. Back pain was assessed at preoperative, postoperative, and final follow-up visits using the visual analog scale (VAS). Patient-reported outcomes via the Oswestry Disability Index (ODI) and the new mobility score (NMS) were obtained to assess disability and mobility during follow-up. Radiological outcomes included the Cobb angle, sagittal index (SI), union rate, and implant failure. Intra- and postoperative complications were recorded.

RESULTS

A total of 22 patients met inclusion criteria. The mean patient age was 74.2 ± 7.3 years with a mean follow-up of 39.2 ± 17.4 months. The VAS score for back pain significantly improved over the follow-up period (from 8.4 ± 1.1 to 2.8 ± 0.8, p < 0.001). At the last follow-up, all patients had minor disability (mean ODI score 24.4 ± 6.1, p = 0.003) and self-sufficiency of mobility (mean NMS 7.5 ± 1.6, p = 0.02). The Cobb angle (5.2° ± 2.9° preoperatively to 4.4° ± 3.3° at follow-up) and SI (7.9° ± 4.2° to 8.8° ± 5.1°) were maintained at follow-up, showing no loss of segmental kyphosis. Bone union was observed in all patients. The overall complication rate was 9.1%, while the reoperation rate for implant failure was 4.5%.

CONCLUSIONS

Percutaneous instrumentation with cement augmentation for traumatic hyperextension TL fractures in AS demonstrated good clinical and radiological outcomes, along with a high bone union level and low reoperation rate. Accordingly, MIS reduced the complication rate in the management of these injuries of the ankylosed spine.

First results of multicortical screw anchoring compared with conventional bicortical screw placement in the sacrum: A biomechanical investigation of a new screw design

BACKGROUND

Bicortical screw fixation is an established technique to increase screw strength in vertebral bodies, although it is associated with several complications, for example screw-loosening. Cement augmentation can increase stability of screw-fixation but can also cause various complications, such as cement-leakage or cement embolism. In this study, we tested a new, multicortical screw fixation technique in the sacrum.

METHODS

Four fresh-frozen sacrums were used. In group 1, standard screw insertion, with sagittal parallel and axial convergent screw-drive was performed. In group 2, the screw-drive of the first screw was similar to the screw-drive in group 1. In addition, a second screw was inserted descending into the intended hole in the head of the screw and at a stable angle. Therefore, the screws of the multiloc humerus nail-system (Synthes) were used. The specimens were connected to a testing-machine and underwent cyclic axial loading with an increase in the load after each completed stage.

FINDINGS

Multicortical screw fixation leads to a significant increase in the number of completed cycles and a significantly increased load until failure.

INTERPRETATION

Multicortical screw fixation in the sacrum offers a stronger attachment of the screws. In the future, multicortical implants, which fulfil the criteria demanded in spine surgery, can offer higher stability and may decrease the loosening rates of the implanted screws.

Percutaneous Vertebral Augmentation Techniques in Osteoporotic and Traumatic Fractures

Percutaneous vertebral augmentation/consolidation techniques are varied. These are vertebroplasty, kyphoplasty, and several methods with percutaneous introduction of an implant (associated or not with cement injection). They are proposed in painful osteoporotic vertebral fractures and traumatic fractures. The objectives are to consolidate the fracture and, if possible, to restore the height of the vertebral body to reduce vertebral and regional kyphosis. Stabilization of the fracture leads to a reduction in pain and thus restores the spinal support function as quickly as possible, which is particularly important in the elderly. The effectiveness of these interventions on fracture pain was challenged once by two randomized trials comparing vertebroplasty to a sham intervention. Since then, many other randomized studies in support of vertebroplasty efficacy have been published. International recommendations reserve vertebroplasty for medical treatment failures on pain, but earlier positioning may be debatable if the objective is to limit kyphotic deformity or even reexpand the vertebral body. Recent data suggest that in osteoporotic fracture, the degree of kyphosis reduction achieved by kyphoplasty and percutaneous implant techniques, compared with vertebroplasty, is not sufficient to justify the additional cost and the use of a somewhat longer and traumatic procedure. In young patients with acute traumatic fractures and a significant kyphotic angle, kyphoplasty and percutaneous implant techniques are preferred to vertebroplasty, as in these cases a deformity reduction has a significant positive impact on the clinical outcome.

Analyses of the efficacy of percutaneous kyphoplasty and alendronate sodium on thoracolumbar vertebral fracture and the risk factors of fracture

The present study investigated the efficacy of percutaneous kyphoplasty and alendronate sodium on thoracolumbar vertebral fracture, and the risk factors leading to the recurrence of fracture. In the present study, a total of 80 patients with thoracolumbar vertebral fracture who were admitted to the Affiliated Jiangyin Hospital of Southeast University Medical College between January 2014 and March 2016 for combination treatment of percutaneous kyphoplasty and alendronate sodium were enrolled. According to the recurrence of fracture, the patients were divided into two groups, the observation group (patients with fracture recurrence, n=40) and control group (patients with no fracture recurrence, n=40). All patients participated in a 1-year follow-up. The recurrence of fracture and the site of fracture were identified through the clinical symptoms and examination of the spine using magnetic resonance imaging. In addition, comparisons of the time of alleviation in numbness of lower limb and that in pains in waist and legs were carried out. Furthermore, statistics on the adverse reactions during intervention in the two groups were also collected; changes in visual analogue scale (VAS) and Oswestry Disability Index (ODI) of pains at different time points in two groups were also observed. One-way analysis and multivariate analysis were performed to identify the relevant risk factors. Alleviation time in numbness of lower legs in patients of the control group was significantly earlier than that in the observation group (P<0.05) and the alleviation time in pains of the waist and legs of patients in the control group was also significantly earlier than that in the observation group (P<0.05). Furthermore, the incidence rates of abdominal pain, diarrhea, constipation and hypocalcemiain in the control group were also significantly lower compared with those in the observation group (P<0.05). One week, one month and one year after operation, the scores of VAS of pains and ODI in the control group were significantly lower compared with those in the observation group in the same period (P<0.05). Lower preoperative bone density and exosmosis of bone cement in treatment were the independent risk factors leading to the recurrence of fracture. For patients with thoracolumbar vertebral fracture who received the combination treatment of percutaneous kyphoplasty and alendronate sodium, there underlies an important correlation between the recurrence rate of fracture and the preoperative bone density as well as the exosmosis of bone cement in operation.

Percutaneous surgery for thoraco-lumbar fractures in ankylosing spondylitis: Study of 31 patients

BACKGROUND

The risk of vertebral fracture is increased 4-fold in patients with ankylosing spondylitis (AS). Diagnostic challenges and the vulnerability associated with AS combine to generate high morbidity and mortality rates. The objective of this study was to assess the outcome of percutaneous thoraco-lumbar fracture surgery in patients with AS, in terms of quality of life, fracture healing, and complications.

HYPOTHESIS

Percutaneous surgery used to treat thoraco-lumbar fractures in patients with AS reliably provides fracture healing, preserves self-sufficiency, and minimises post-operative complications.

METHODS

Two centres included 31 patients with AS who were managed by percutaneous surgery for thoraco-lumbar fractures in 2013-2015. The data were reviewed retrospectively, although admission data were collected prospectively. Clinical outcomes were assessed by comparing the values at baseline and last follow-up of three variables: the Parker score, the visual analogue scale (VAS) pain score, and the EuroQol five dimensions (EQ-5D) quality-of-life score. Computed tomography was performed 1 year after surgery to evaluate bone healing, screw position, and implant loosening. Intra- and post-operative complications were recorded.

RESULTS

The 31 patients had a mean age at surgery of 75.1 years, a mean follow-up of 35.6 months, and a minimum follow-up of 12 months. Three patients died during follow-up. Mean hospital stay duration was 6 days. Cemented screw fixation was used in 18 patients. At last follow-up, all patients had recovered their self-sufficiency; the mean Parker score was 7.14, compared to 6.73 at baseline, the mean VAS pain score was 1.8, and the mean EQ-5D score decrease versus baseline was 0.07 (P=0.02). Bone healing was consistently achieved. Loosening of an uncemented pedicle screw was noted in 1 patient. Of the 228 screws implanted, 6 (2.6%) were improperly positioned, including 1 within the spinal canal in a patient free of neurological manifestations. Asymptomatic cement leakage was noted in 2 patients.

DISCUSSION

Percutaneous fixation of thoraco-lumbar fractures in patients with AS is a reliable method that produces a high healing rate and allows prompt patient mobilisation with preservation of self-sufficiency. The post-operative complication rate is low.

LEVEL OF EVIDENCE

IV, retrospective observational study.