Balloon kyphoplasty for vertebral compression fractures in solid organ transplant recipients: results of treatment and comparison with primary osteoporotic vertebral compression fractures

Clinical Considerations and Outcomes for Spine Surgery Patients with a History of Transplant: A Systematic Scoping Review

OBJECTIVE

The objective of this study was to investigate the perioperative management and outcomes of patients with a prior history of successful transplantation undergoing spine surgery.

METHODS

We searched Medline, Embase, and Cochrane Central Register of Controlled Trials for matching reports in July 2021. We included case reports, cohort studies, and retrospective analyses, including terms for various transplant types and an exhaustive list of key words for various forms of spine surgery.

RESULTS

We included 45 studies consisting of 34 case reports (published 1982-2021), 3 cohort analyses (published 2005-2006), and 8 retrospective analyses (published 2006-2020). The total number of patients included in the case reports, cohort studies, and retrospective analysis was 35, 48, and 9695, respectively. The mean 1-year mortality rate from retrospective analyses was 4.6% ± 1.93%, while the prevalence of perioperative complications was 24%. Cohort studies demonstrated an 8.5% ± 12.03% 30-day readmission rate. The most common procedure performed was laminectomy (38.9%) among the case reports. Mortality after spine surgery was noted for 4 of 35 case report patients (11.4%).

CONCLUSIONS

This is the first systematic scoping review examining the population of transplant patients with subsequent unrelated spine surgery. There is significant heterogeneity in the outcomes of post-transplant spine surgery patients. Given the inherent complexity of managing this group and elevated mortality and complications compared to the general spine surgery population, further investigation into their clinical care is warranted.

Percutaneous vertebroplasty of the entire thoracic and lumbar vertebrae for vertebral compression fractures related to chronic glucocorticosteriod use: case report and review of literature

Glucocorticosteroid-induced osteoporosis is the most frequent of all secondary types of osteoporosis, and can increase the risk of vertebral compression fractures (VCFs). There are promising additions to current medical treatment for appropriately selected osteoporotic patients. Few studies have reported on the efficiency of percutaneous vertebroplasty (PVP) or kyphoplasty for whole thoracic and lumbar glucocorticosteroid-induced osteoporotic vertebral compression fractures. We report a case of a 67-year-old man with intractable pain caused by successional VCFs treated by PVP.

Cluster phenomenon of vertebral refractures after percutaneous vertebroplasty in a patient with glucocorticosteroid-induced osteoporosis: case report and review of the literature

STUDY DESIGN

A case report and literature review.

OBJECTIVE

To describe a rare cluster phenomenon of spontaneous vertebral refractures in a patient with glucocorticosteroid-induced osteoporosis (GIOP) subsequent to percutaneous vertebroplasty (PVP) for the management of initial vertebral compression fractures (VCFs).

SUMMARY OF BACKGROUND DATA

PVP has become the popular strategy for stabilizing osteoporotic VCFs and obtaining rapid pain alleviation and earlier restoration of mobility in both patients with primary osteoporosis and patients with glucocorticosteroid-induced osteoporosis. However, current data are insufficient to recommend routine use of PVP for VCFs caused by GIOP as recent retrospective studies indicate that the risk of vertebral refractures is much higher in patients with GIOP than those with primary osteoporosis.

METHODS

We reported a 63-year-old Chinese female with GIOP as well as pulmonary infection who underwent PVP for the management of initial VCFs, experienced the cluster phenomenon of spontaneous vertebral refractures.

RESULTS

Within a 4-month period, she underwent a total of 6 PVP operations with 13 cement-augmented vertebral bodies from T5-L5. Eleven refractures after the initial PVP procedures included 3 remote-level fractures, 4 adjacent-level fractures, 1 pincher body fracture, and 3 fractures in previously augmented bodies. The average interval between each PVP operation was 23.6 days.

CONCLUSION

The use of PVP as a therapeutic alternative for the treatment of VCFs in patients with GIOP is still controversial. As seen in our case, even when the management decisions were made in consideration of the patient's pulmonary infection, the outcome was disastrous with the cluster phenomenon of vertebral refractures. Current findings suggest a compelling need for high-quality studies investigating cement augmentation procedures in patients with VCF with GIOP.

Hypovitaminosis D as a risk factor of subsequent vertebral fractures after kyphoplasty

BACKGROUND CONTEXT

Over the past 20 years, methods of minimally invasive surgery have been developed for the treatment of vertebral compression fractures. Balloon kyphoplasty and vertebroplasty are associated with a recurrent fracture risk in the adjacent levels after the surgical procedure. In certain patient categories with impaired bone metabolism, the risk of subsequent fractures after kyphoplasty is increased.

PURPOSE

To determine the incidence of recurrent fractures after kyphoplasty and explore whether the status of bone metabolism and 25-hydroxyvitamin D (25(OH)D) levels affect the occurrence of these fractures.

STUDY DESIGN

Prospective longitudinal clinical study.

PATIENT SAMPLE

Forty female postmenopausal women with primary osteoporosis and acute symptomatic vertebral compression fractures.

OUTCOME MEASURES

Identification of new vertebral fractures and documentation of indicators of bone metabolism.

METHODS

A total of ninety-eight kyphoplasties were performed in 40 female patients. Balloon kyphoplasty was performed on all symptomatic acute vertebral compression fractures. Age, body mass index, history of tobacco use, number of initial vertebral fractures, intradiscal cement leakage, history of nonspinal fractures, use of antiosteoporotic medications, bone mineral density, bone turnover markers, and 25(OH)D levels were assessed. All participants were evaluated clinically and/or radiographically. Follow-up period was 18 months.

RESULTS

The mean population age was 70.6 years (range, 40-83 years). After initial kyphoplasty procedure, nine patients (11 levels) (22.5% of patients; 11.2% of levels) developed a postkyphoplasty vertebral compression fracture. Cement leakage was identified in seven patients (17.5%). The patients without recurrent fractures after kyphoplasty demonstrated higher levels of 25(OH)D (22.6±5.51 vs. 14.39±7.47; p=.001) and lower N-terminal cross-linked telopeptide values (17.11±10.20 vs. 12.90±4.05; p=.067) compared with the patients with recurrent fractures.

CONCLUSIONS

Bone metabolism and 25(OH)D levels seem to play a role in the occurrence of postkyphoplasty recurrent vertebral compression fractures.

Balloon kyphoplasty and vertebroplasty in the management of vertebral compression fractures

Vertebral compression fractures (VCFs) are the most prevalent fractures in osteoporotic patients. The classical conservative management of these fractures is through rest, pain medication, bracing and muscle relaxants. The aim of this paper is to review prospective controlled studies comparing the efficacy and safety of minimally invasive techniques for vertebral augmentation, vertebroplasty (VP) and balloon kyphoplasty (BKP), versus non-surgical management (NSM). The Fracture Working Group of the International Osteoporosis Foundation conducted a literature search and developed a review paper on VP and BKP. The results presented for the direct management of osteoporotic VCFs focused on clinical outcomes of these three different procedures, including reduction in pain, improvement of function and mobility, vertebral height restoration and decrease in spinal curvature (kyphosis). Overall, VP and BKP are generally safe procedures that provide quicker pain relief, mobility recovery and in some cases vertebral height restoration than conventional conservative medical treatment, at least in the short term. However, the long-term benefits and safety in terms of risk of subsequent vertebral fractures have not been clearly demonstrated and further prospective randomized studies are needed with standards for reporting. Referral physicians should be aware of VP/BKP and their potential to reduce the health impairment of patients with VCFs. However, VP and BKP are not substitutes for appropriate evaluation and treatment of osteoporosis to reduce the risk of future fractures.

Balloon kyphoplasty treatment for a spontaneous vertebral fracture in renal osteodystrophy

Renal osteodystrophy is a spectrum of musculoskeletal abnormalities. Bony fractures can occur spontaneously or with minor trauma in this condition. The authors report the first case of balloon kyphoplasty treatment for painful renal osteodystrophy vertebral body collapse secondary to end-stage renal failure on dialysis. The authors have demonstrated that kyphoplasty is a safe procedure for pain management in severe dystrophic patients. In addition, pain treatment with kyphoplasty can be achieved without anatomical restoration of vertebral body height.

Teriparatide and raloxifene reduce the risk of new adjacent vertebral fractures in postmenopausal women with osteoporosis. Results from two randomized controlled trials

BACKGROUND

Vertebral fractures increase the risk of new vertebral fractures; however, we are not aware of any study addressing the risk of new vertebral fractures adjacent to existing vertebral fractures. Therefore, we sought to determine the influence of the number and severity of prevalent (preexisting) vertebral fractures on the risk of new adjacent vertebral fractures and to determine whether teriparatide (rhPTH [recombinant human parathyroid hormone] [1-34]) or raloxifene treatment reduces the incidence of adjacent vertebral fractures in postmenopausal women with osteoporosis.

METHODS

Data from the Fracture Prevention Trial and the Multiple Outcomes of Raloxifene Evaluation trial were analyzed to determine the incidences of new adjacent and new nonadjacent vertebral fractures in the placebo groups and the effect of treatment with raloxifene and teriparatide on the incidence of new adjacent vertebral fractures as compared with that of new nonadjacent vertebral fractures.

RESULTS

Of 1226 untreated postmenopausal women with one or more prevalent vertebral fractures at baseline, 196 (16.0%) had a total of 292 new vertebral fractures during the two-year follow-up period, with 108 (8.8%) of the 1226 women having at least one new fracture adjacent to a prevalent fracture. Of the 292 new vertebral fractures, 136 (47%) were adjacent to a previously existing vertebral fracture. The risk of a new adjacent vertebral fracture was 2.5-fold higher than the risk of a new nonadjacent vertebral fracture (4.03% compared with 1.59%). The incidence of new adjacent vertebral fractures increased with both the number and the severity of prevalent vertebral fractures. Teriparatide reduced the risk of any new, new adjacent, and new nonadjacent vertebral fractures by 72%, 75%, and 70%, respectively, compared with the rates in the placebo group. Similarly, compared with the placebo, raloxifene treatment reduced the risk of any new vertebral fracture, new adjacent vertebral fracture, and new nonadjacent vertebral fracture by 54%, 54%, and 53%, respectively.

CONCLUSIONS

In untreated postmenopausal women with osteoporosis, nearly half of the incident vertebral fractures occur adjacent to an existing vertebral fracture. Both teriparatide and raloxifene can significantly reduce the occurrence of new adjacent and nonadjacent vertebral fractures.

Costs and state-specific rates of thoracic and lumbar vertebroplasty, 2001-2005

STUDY DESIGN

Sequential cross-sectional analysis.

OBJECTIVE

To document vertebroplasty rates and costs.

SUMMARY OF BACKGROUND DATA

Little is known about interstate variation in rates or about nation-wide costs associated with the growing use of percutaneous vertebroplasty.

METHODS

Using specific CPT-4 billing codes, we reviewed aggregate Medicare Part B fee-for-service claims data (cross-stratified by physician specialty and treatment setting) on thoracolumbar vertebroplasties performed from 2001-2005. Vertebroplasty rates for individual states were expressed per 100,000 Part B fee-for-service enrollees. Nation-wide facility and physician charges (combining expected contributions from all sources) allowed by Medicare for vertebroplasties and associated imaging guidance procedures were applied to observed vertebroplasty volumes. These charges (reflecting direct medical costs from an all-payer perspective) were expressed in 2005 dollars using the Producer Price Index.

RESULTS

Vertebroplasty rates for individual states rose but varied considerably, ranging from 0.0 to 515.6/100,000 Medicare Part B fee-for-service enrollees in 2001 (median state rate = 35.4), and from 9.8 to 849.5 in 2005 (median state rate = 75.0). On average, 1.3 vertebral levels were treated per procedure, varying by treatment site and physician specialty. Fluoroscopic rather than computed tomography guidance was used in 98.7% of cases. Total nation-wide inflation-adjusted charges rose from $76.0 million for 14,142 cases performed in 2001 to $152.3 million for 29,090 cases in 2005. While vertebroplasty was predominantly an outpatient procedure, inpatient cases generated most of the charges. Increasing volumes and costs were associated with cases performed in ambulatory surgery centers and physicians' offices.

CONCLUSION

Nation-wide vertebroplasty volumes and inflation-adjusted charges doubled from 2001 to 2005 in this Medicare population. Procedure rates varied considerablyby state. Almost all cases involved fluoroscopic guidance; procedures treating multiple vertebral levels were not uncommon. Procedures performed in free-standing facilities are of growing importance. Given the issues surrounding appropriate vertebroplasty use, future practice patterns and outcomes should be closely tracked.

Kyphoplasty and vertebroplasty

Percutaneous vertebroplasty is the injection of a vertebral compression fracture (VCF) with bone cement, generally polymethylmethacrylate. Percutaneous kyphoplasty is the placement of balloons into the vertebral body with an inflation/deflation sequence to create a cavity before the cement injection. These procedures are most often performed in a percutaneous fashion on an outpatient (or short stay) basis. The procedure is indicated for painful VCFs due to osteoporosis or malignancy, and painful hemangiomas. The procedure may have efficacy in painful vertebral metastasis and traumatic compression fractures. Much evidence favors the use of this procedure for pain associated with these disorders. The overall risks of the procedure are low, but serious complications (including spinal cord compression) can occur. With good patient selection and careful technique, these complications are avoidable, making the risk-to-benefit ratio highly favorable.

An update on glucocorticoid-induced osteoporosis

PURPOSE OF REVIEW

Glucocorticoids are widely used, often long term, and a major side effect is osteoporosis and increased risk of fracture. This review considers how common is the problem, the patients who are most at risk, our current understanding of mechanisms, and how to prevent and effectively treat glucocorticoid-induced osteoporosis. The actions currently being undertaken in clinical practice are reviewed.

RECENT FINDINGS

Glucocorticoid-induced osteoporosis is an increasing problem that occurs not only in those on high-dose therapy. Advances in our knowledge of the cellular and cytokine mechanisms of bone turnover and glucocorticoid mechanisms of action are leading to a better understanding of how glucocorticoids affect bone cells and novel ways of prevention. Although there are effective treatments to prevent and control glucocorticoid-induced osteoporosis as well as guidelines for their use, they are still not being applied in routine clinical practice.

SUMMARY

Glucocorticoid-induced osteoporosis is a significant problem. Although our understanding of effective prevention and treatment strategies is improving, there needs to be better implementation of these strategies.

Regional changes in spine posture at lift onset with changes in lift distance and lift style

STUDY DESIGN

Repeated measures experiment.

OBJECTIVE

To determine the effect of changes in horizontal lift distance on the amount of flexion, at lift onset, in different spine regions when using different lift styles.

SUMMARY OF BACKGROUND DATA

By approximating spine bending during lifting as a pure rotation about a single revolute joint, the differential effects of task constraints and instructions on motions of different spine levels will be obscured.

METHODS

Eight participants lifted a 10-kg crate from the floor, 10 times at each of five distances. Participants were instructed to use freestyle (a participant's preferred lift style), squat, or stoop lift styles. Kinematic data were collected from the mid thoracic spine, lower thoracic/upper lumbar spine, mid lumbar spine, and the lower lumbar spine at lift onset. A whole spine angle was also calculated.

RESULTS

Flexion of the lower lumbar spine was not affected by lift distance and style. Differences between lift styles occurred mainly in the mid thoracic and the lower thoracic/upper lumbar regions. With increasing horizontal distance, changes in lift style occurred in the upper three spine regions.

CONCLUSIONS

These results suggest that the tensile strain on tissues in the lower lumbar spine, which can be a cause of injury in lifting, was not affected by lift style or horizontal lift distance when lifting from floor level.

Kyphoplasty and vertebroplasty: How good is the evidence?

The absence of Level I evidence undermines the credibility of all clinical studies pertaining to percutaneous vertebral augmentation (ie, kyphoplasty and vertebroplasty). The powerful desire to relieve suffering in the frail elderly cannot substitute for a rigorously designed randomized controlled trial comparing vertebral augmentation with continued nonoperative care. Though the level of available evidence is currently inadequate, its quality is improving.