Delayed Height Loss After Kyphoplasty in Osteoporotic Vertebral Fracture with Severe Collapse: Comparison with Vertebroplasty

Predictors for vertebral height deterioration in fractured vertebrae operated by percutaneous vertebroplasty

BACKGROUND

Vertebral height loss of fractured vertebrae treated by percutaneous vertebral augmentation (PVA) for osteoporotic vertebral compression fracture (OVCFs) during follow-up had been reported. Mostly, vertebral height loss and its relevant terms (e.g., "recompression", "recollapse" and "refracture") were defined according to immediate postoperative vertebral height as the baseline in published studies. By contrast, vertebral height deterioration (VHD) was defined according to preoperative vertebral height as the baseline in the present study. The aim of the study was to reveal predictors for VHD in fractured vertebrae operated by percutaneous vertebroplasty (PVP), with a specific focus on surgical factors.

METHODS

All patients with OVCFs treated by PVP between April 2016 and September 2018 were retrospectively reviewed. Patients were followed up for at least 12 months after procedure according to treatment protocol. VHD was defined as the presence of a decrease of vertebral height at final follow-up compared to preoperative. Clinical, radiological and surgical factors that might affect occurrence of VHD were assessed using univariate and multivariate analyses.

RESULTS

A total of 543 patients (females 80%, age 73.2 ± 8.1 years) with 681 fractured vertebrae who underwent PVP were enrolled. Mean follow-up time was 28.9 ± 13.4 months (range, 12-59 months). Incidence of VHD in fractured vertebrae was 48.9% (333/681). One clinical factor and four radiological factors, including fracture age (OR = 0.513, 95% CI 0.385-0.683, p = 0.000), fracture location (OR = 2.878, 95% CI 1.994-4.152, p = 0.000), fracture severity (OR = 0.521, 95% CI 0.386-0.703, p = 0.000), cortical defect on lateral wall (OR = 2.535, 95% CI 1.351-4.758, p = 0.004) and intravertebral cleft (OR = 2.362, 95% CI 1.488-3.750, p = 0.000), were independent predictors for VHD. However, all the surgical factors evaluated were not significant in final model analysis.

CONCLUSIONS

Surgical factors might play a negligible effect on VHD. VHD might be due to natural course of fracture/osteoporosis.

The Closer Vicinity to Treated Vertebrae in Percutaneous Vertebroplasty, the Higher Rate of New Vertebral Compression Fractures at Follow-up

OBJECTIVE

To investigate whether risk of new vertebral compression fractures (NVCFs) was associated with vicinity to treated vertebrae in percutaneous vertebroplasty (PVP) for osteoporotic vertebral compression fractures (OVCFs).

METHODS

All OVCF (T6-L5) patients treated with PVP between January 2016 and December 2020 were retrospectively reviewed. Vicinity to treated vertebrae was defined as the number of vertebrae between an untreated and its closest treated level. The closest treated level was chosen as reference vertebra. Clinical, radiologic, and surgical parameters were compared between groups of reference vertebrae for each vicinity NVCF.

RESULTS

In total, 1348 patients with 1592 fractured and 14,584 normal vertebrae were enrolled. NVCF was identified in 20.1% (271 of 1348) patients in 2.2% (319 of 14584) vertebrae in a mean follow-up time of 24.3 ± 11.9 months. Rate of NVCF in vicinity 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11 level were 4.6% (130 of 2808), 2.4% (62 of 2558), 1.8% (42 of 2365), 1.5% (31 of 2131), 1.3% (23 of 1739), 1.3% (17 of 1298), 0.8% (7 of 847), 0.9% (4 of 450), 0.8% (2 of 245), 0.9% (1 of 117), and 0% (0 of 26), respectively. Rate of NVCF in vicinity 1 level was significantly higher than that in vicinity 2, 3, 4, 5, 6, 7, 8, and 9 level, respectively. However, compared to reference vertebrae for vicinity 1 NVCF, any clinical, radiologic, or surgical parameters were not significantly different in those for vicinity 2, 3, and 4 NVCF, respectively.

CONCLUSIONS

The closer vicinity to treated vertebrae in PVP, the higher rate of NVCF at follow-up. However, any clinical, radiologic, or surgical parameters might not matter in this phenomenon of vicinity-related NVCF.

Analysis of adjacent vertebral fracture after percutaneous vertebroplasty: do radiological or surgical features matter?

PURPOSE

To report the incidence and risk factors of adjacent vertebral fracture (AVF) after percutaneous vertebroplasty (PVP) in patients with osteoporotic vertebral compression fractures (OVCFs). We focused to investigate effect of radiological or surgical features on AVF.

METHODS

All patients with OVCFs who were treated with PVP between January 2016 and December 2019 were retrospectively reviewed. Patients were followed up at least 12 months after procedure according to treatment protocol. AVF was defined as postoperatively recurrent intractable back pain and subsequently presence of fracture on magnetic resonance imaging (MRI) in adjacent levels. Clinical, radiological, and surgical factors potentially affecting occurrence of AVF were recorded and analyzed using univariate and multivariate analysis.

RESULTS

Totally, 1077 patients with 1077 fractured vertebrae who underwent PVP were enrolled in the study, after inclusion and exclusion criteria were met. Mean follow-up time was 24.3 ± 11.9 months (range, 12-59 months). AVF was identified in 98 (9.1%) patients. Univariate analysis showed that seven significant factors related to AVF were older age, non-traumatic fracture, cortical disruption on anterior wall, cortical disruption on lateral wall, basivertebral foramen, type-B leakage and type-C leakage. In multivariate analysis, two clinical factors, older age (P = 0.031) and non-traumatic fracture (P = 0.002), were significantly associated with AVF. However, any radiological or surgical factor did not reach significance in final model analysis.

CONCLUSIONS

Incidence of AVF after PVP in patients with OVCFs was 9.1% (98/1077). Older age and non-traumatic fracture were two clinical risk factors for AVF. Neither radiological nor surgical feature was significantly correlated with AVF.

Vertebral compression fractures: pain relief, progression and new fracture rate comparing vertebral augmentation with brace

BACKGROUND

Osteoporotic vertebral compression fracture (VCF) is the third most frequent fragility fracture in the world. Conservative treatment, vertebroplasty, and kyphoplasty are all recognized therapies. However, diagnostic and therapeutic recommendations must be more consistent when comparing clinical guidelines. This study aims to compare the efficacy of vertebral augmentation therapy and conservative management for treating VCFs, the risk of subsequent complications, and the length of hospital stay.

METHOD

All patients over 50 years old with a diagnosis of thoracic or lumbar VCF without underlying oncological process, treated conservatively or surgically, and consecutively attended at our department from January 2017 to June 2021 were retrospectively selected for analysis. Patients who missed follow-up or died during the first three months were excluded.

RESULTS

A total of 573 cases were selected for analysis. Most patients were treated conservatively (85.3%). Both groups were homogenous regarding epidemiological and clinical features. The median time elapsed to achieve pain relief was significantly lower in the surgical cohort (4.5 vs. 10 weeks, p < 0.001), and the proportion of patients reporting pain at the first outpatient visit was also significantly lower with a vertebral augmentation procedure (p = 0.004). The new fracture rate and the adjacent level rate did not differ significantly when comparing both treatments, whereas the progression of the diagnosed fracture was more frequent in the conservative group (4.8% vs. 29.7%; p < 0.001). The median hospital stay was significantly lower in the conservative group (3 vs. 10 days; p < 0.001).

CONCLUSION

Surgical treatment (vertebroplasty/kyphoplasty) of VCFs was associated with sooner pain relief without an increased risk of new or adjacent fractures. Moreover, the progression of treated fractures was significantly lower in the surgical cohort. The only unfavorable aspect was the more extended hospital stay compared with the conservative treatment group.

The Influence of Percutaneous Vertebral Augmentation Techniques on Recompression in Patients with Osteoporotic Vertebral Compression Fractures. Percutaneous Vertebroplasty versus Balloon Kyphoplasty

OBJECTIVE

The purpose of this study was to determine whether percutaneous vertebroplasty (PVP) and balloon kyphoplasty (BK) have any mid-term to long-term effects on the structural integrity of augmented vertebrae.

METHODS

According to our hospital records, 351 patients underwent BK and PVP as a result of osteoporotic vertebral compression fractures between 2010 and 2020. The demographic, surgical, and radiologic characteristics of the patients were analyzed retrospectively using the electronic hospital records and PACS (picture archiving and communication system). In our study, 55 patients who had a single level of PVP or BK filled with at least 6 mL og polymethylmethacrylate (PMMA) for T11-L5 levels and 3 mL of PMMA for T6-T10 levels via a bipedicular approach and who had only 1 vertebral fracture in a 10-year follow-up period were included in our study. The patients were divided into 2 groups: BK (n = 40) and PVP (n = 15). All measurements were performed on standing lateral radiographs from the postoperative first day and the last radiographs that were obtained during the follow-up. The anterior and posterior heights of the fractured vertebral body and local kyphosis angles were measured.

RESULTS

The mean follow-up time was 2.53 ± 1.78 years in the BK group and 3.07 ± 2.02 years in the PVP group. The decrease in the vertebral height and increasing kyphosis that develop from the early to late postoperative periods were found to be statistically significant in the BK group (P < 0.05). In the PVP group, vertebral height and kyphosis angle measurements did not differ significantly between the early and late postoperative periods. In addition, in terms of the percentage change, anterior parts of the vertebral bodies are more affected. However, the absolute difference for the measurement of the vertebral heights did not confirm this finding.

CONCLUSIONS

To our knowledge, our study is unique because it has the longest follow-up in the literature comparing BK and PVP in terms of recollapse of the augmented vertebrae. Our study shows that BK does not prevent height loss of the augmented vertebral bodies in the mid- to long term.

Percutaneous vertebral-disc plasty for thoracolumbar very severe osteoporotic vertebral compression fractures: A randomized controlled study

Purpose

To compare the clinical outcomes and radiological parameters of patients undergoing percutaneous vertebroplasty (PVP) versus those undergoing percutaneous vertebral-disc plasty (PVDP) for back pain, segmental instability, and kyphosis due to thoracolumbar very severe osteoporotic vertebral compression fractures (vsOVCFs).

Methods

This prospective randomized controlled study included elderly patients with thoracolumbar vsOVCFs. All the patients were randomly allocated into the PVP group (who underwent conventional PVP) and the PVDP group (who underwent PVP combined percutaneous cement discoplasty). The visual analogue scale (VAS), Oswestry Disability Index (ODI), local kyphosis angle, and disc height were recorded preoperatively and postoperatively.

Results

Significant postoperative improvements in the VAS, ODI, and the local kyphosis angle (LKA) were shown, compared with the preoperative values in both groups (p < 0.05). The average VAS, ODI, and LKA for patients in the PVP group were increased compared to those in the PVDP group observed at the last follow-up (p < 0.05). The DHA, DHP, and LKA were seen to be maintained in the PVDP group at the last follow-up (p > 0.05). The change was significantly lower in the PVDP group at the last follow-up in those parameters (p < 0.05).

Conclusion

PVDP may be a feasible and effective technique for the treatment of very severe OVCFs, that can restore intervertebral height, provide segmental stabilizing and relieve back pain in the short term.

Percutaneous Kyphoplasty Versus Percutaneous Vertebroplasty for Neurologically Intact Osteoporotic Kümmell's Disease: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

Percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) are minimally invasive techniques widely used for the treatment of neurologically intact osteoporotic Kümmell's disease (KD), but which treatment is preferable remains controversial. Therefore, this study aimed to shed light on this issue.

METHODS

Six databases were searched for all relevant studies based on the PRISMA guidelines. Two investigators independently conducted a quality assessment, extracted the data and performed all statistical analyses.

RESULTS

Eight studies encompassing 438 neurologically intact osteoporotic KD patients met the inclusion criteria. Compared to PVP, PKP was associated with greater improvement in the short- and long-term Cobb angle [SMD = -0.37, P = 0.007; SMD = -0.34, P = 0.012], short-term anterior vertebral height [SMD = 0.43, P = 0.003] and long-term middle vertebral height [SMD = 0.57, P = 0.012] and a lower cement leakage rate [SMD = 0.50, P = 0.003] but produced more consumption (cement injection volume, operative time, fluoroscopy times, intraoperative blood loss and operation cost). However, there were no differences between the 2 procedures in the short- and long-term VAS and ODI scores, long-term anterior vertebral height, overall complications or new vertebral fractures.

CONCLUSIONS

Both procedures are equally effective for neurologically intact KD in terms of the clinical outcomes, with the exception of a lower cement leakage risk and better radiographic improvement for PKP but greater resource consumption. Based on the evidence available, good clinical judgment should be exercised in the selection of patients for these procedures.

Numerical Comparison of Restored Vertebral Body Height after Incomplete Burst Fracture of the Lumbar Spine

BACKGROUND AND OBJECTIVES

Vertebral compression fracture is a major health care problem worldwide due to its direct and indirect negative influence on health-related quality of life and increased health care costs. Although a percutaneous surgical intervention with balloon kyphoplasty or metal expansion, the SpineJack, along with bone cement augmentation has been shown to efficiently restore and fix the lost vertebral height, 21-30% vertebral body height loss has been reported in the literature. Furthermore, the effect of the augmentation approaches and the loss of body height on the biomechanical responses in physiological activities remains unclear. Hence, this study aimed to compare the mechanical behavior of the fractured lumbar spine with different restored body heights, augmentation approaches, and posterior fixation after kyphoplasty using the finite element method. Furthermore, different augmentation approaches with bone cement and bone cement along with the SpineJack were also considered in the simulation.

MATERIALS AND METHODS

A numerical lumbar model with an incomplete burst fracture at L3 was used in this study. Two different degrees of restored body height, namely complete and incomplete restorations, after kyphoplasty were investigated. Furthermore, two different augmentation approaches of the fractured vertebral body with bone cement and SpineJack along with bone cement were considered. A posterior instrument (PI) was also used in this study. Physiological loadings with 400 N + 10 Nm in four directions, namely flexion, extension, lateral bending, and axial rotation, were applied to the lumbar spine with different augmentation approaches for comparison.

RESULTS

The results indicated that both the bone cement and bone cement along with the SpineJack could support the fractured vertebral body to react similarly with an intact lumbar spine under identical loadings. When the fractured body height was incompletely restored, the peak stress in the L2-L3 disk above the fractured vertebral body increased by 154% (from 0.93 to 2.37 MPa) and 116% (from 0.18 to 0.39 MPa), respectively, in the annular ground substance and nucleus when compared with the intact one. The use of the PI could reduce the range of motion and facet joint force at the implanted levels but increase the facet joint force at the upper level of the PI.

CONCLUSIONS

In the present study, complete restoration of the body height, as possible in kyphoplasty, is suggested for the management of lumbar vertebral fractures.

Comparison of Percutaneous Kyphoplasty and Pedicle Screw Fixation for Treatment of Thoracolumbar Severe Osteoporotic Vertebral Compression Fracture with Kyphosis

BACKGROUND

Pedicle screw fixation (PSF) has been considered the preferred surgery for the treatment of severe osteoporotic vertebral compression fracture (sOVCF), and sOVCF was traditionally regarded as a relative contraindication to minimally invasive percutaneous kyphoplasty (PKP). Debate has continued regarding the selection of the best surgical method for sOVCF. In the present study, we compared the efficacy and safety between PKP and PSF.

METHODS

PKP was performed in 376 patients in group 1 and PSF in 121 patients in group 2. The visual analog scale (VAS), Oswestry disability index (ODI), local kyphotic angle, fractured vertebral body height, and complications were evaluated.

RESULTS

In the immediate postoperative analysis, the mean VAS score for group 1 was 2.4, significantly lower than the VAS score of 4.7 for group 2. The mean ODI score was 44.4% for group 1, lower than the ODI score of 57.1% for group 2. In addition, group 1 had had a significantly better ODI score at 1 year of follow-up. The local kyphotic angle and fractured vertebral body height had recovered better in group 2. In group 1, 113 patients had experienced cement leakage, and 29 patients had undergone PKP for adjacent new vertebral fractures. In group 2, 2 patients had developed wound infections, 4 had developed pneumonia, 2 had developed urinary tract infection, 3 had experienced asymptomatic screw loosening, and 7 had undergone PKP to treat new vertebral fractures and 1 had undergone removal of internal fixation because of back pain.

CONCLUSIONS

The results of the clinical and radiological evaluations showed that PKP is comparable to PSF for the treatment of sOVCF with kyphosis, with PKP having the advantages of minimal invasion, quick postoperative pain relief, and functional recovery.

Efficacy analysis of percutaneous pedicle screw fixation combined with percutaneous vertebroplasty in the treatment of osteoporotic vertebral compression fractures with kyphosis

BACKGROUND

To investigate the clinical effect of percutaneous pedicle screw fixation (PPSF) combined with percutaneous vertebroplasty (PVP) in the treatment of osteoporotic compression vertebral fracture (OVCF) of the thoracolumbar vertebra with kyphosis.

METHODS

One hundred sixty-six patients before June 2017 were retrospectively analyzed, and patients were divided into PPSF + PVP group A and PVP group B. Operative time, bone mineral density, postoperative bed time, high compression ratio, bone cement leakage rate, and bone cement dose were recorded. Comparison of vertebral anterior edge height, Cobb angle, visual analogue score (VAS), and low back pain dysfunction index (ODI) between the two groups in preoperative, postoperative 3 days, postoperative 6 months, postoperative 12 months, and postoperative 24 months, postoperative complications were observed in the two groups.

RESULTS

The operation time of group A was longer than that of group B (59.0 ± 8.6 min, 26.6 ± 5.2 min), longer postoperative bed rest time (3.3 ± 0.7 days, 1.2 ± 0.5 days), the differences were statistically significant (P < 0.01), there was no difference in the amount of bone cement between the two groups (5.4 ± 0.6 ml, 5.3 ± 0.8 ml) (P > 0.05). The height of the anterior edge and Cobb angle of the two groups recovered significantly in postoperative 3 days. The height of anterior edge (2.7 ± 0.3 cm, 2.6 ± 0.2 cm, 2.5 ± 0.7 cm; 2.3 ± 0.6 cm, 1.7 ± 0.5 cm, 1.6 ± 0.3 cm) and Cobb angle (4.9 ± 2.2, 5.5 ± 2.3, 5.7 ± 2.3; 12.4 ± 3.2, 17.2 ± 2.5, 13.2 ± 2.3) was statistically significant in postoperative 6 months, postoperative 12 months, and postoperative 24 months (P < 0.01). VAS and ODI scores of postoperative 6 months and 12 months were significantly different between the two groups (P < 0.05). Postoperative complications in group B were much higher than those in group A.

CONCLUSION

The efficacy of PVP alone was not satisfactory, and the rate of complications was high for OVCF patients with severe anterior edge compression with kyphosis. PPSF combined with PVP is recommended, the vertebral height loss was not obvious, the satisfaction was good, and the complication rate was lower during 2 years follow-up.