Comparison of kyphoplasty and vertebroplasty for treatment of painful osteoporotic vertebral compression fractures: twelve-month follow-up in a prospective nonrandomized comparative study

[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.

Effect of percutaneous vertebroplasty versus percutaneous kyphoplasty on post-operative wound pain in patients with osteoporotic vertebral compression fractures

This research is intended to evaluate the efficacy of percutaneous vertebroplasty (PVP) versus percutaneous kyphoplasty (PKP) in osteoporotic vertebral compression fracture (OVCF), which is associated with post-operative pain. Eligible studies were screened by searching multiple databases and sources such as PubMed, Cochrane and EMBASE for search terms updated to October 2023, and relevant literature sources were searched. Randomized, controlled, prospective or retrospective, and cohort studies were eligible. For the analysis of the primary results, an analysis of the data was carried out, such as mean difference (MD) or odds ratio (OR), and 95% confidence interval (CI). In the present research, 1933 research was screened in 4 databases, and 30 articles were chosen to be examined under strict exclusion criteria. No statistical significance was found in the use of bone cement in the PVP group and PKP (MD, -0.60; 95% CI, -1.40, 0.21, p = 0.15); PKP was associated with a reduced risk of cement leak compared with PVP group (OR, 2.18; 95% CI, 1.38, 3.46, p = 0.0009); no statistical significance was found in the wound VAS score in PVP operation compared with that of PKP (MD, 0.16; 95% CI, -0.07, 0.40, p = 0.17); no statistical significance was found between the time of PVP operation and the time of PKP operation (MD, -2.65; 95% CI, -8.91, 3.60, p = 0.41). Compared with PVP technology, the PKP treatment of osteoporotic vertebral compression fractures reduces post-operative cement leakage, but there is no significant difference in the number of operative cement and wound VAS after operation. Nor did there appear to be a statistically significant difference in time between the two operations.

Re-expansion of vertebral compression fractures in patients with multiple myeloma with percutaneous vertebroplasty using spinejack implants: a preliminary and retrospective study

Objective

To retrospectively evaluate the feasibility and effectiveness of vertebroplasty using Spinejack implantation for the treatment and stabilization of painful vertebral compression fractures, in patients diagnosed with Multiple Myeloma (MM), to allow both an effective pain reduction and a global structural spine stabilization.

Materials and Methods

From July 2017 and May 2022 thirty-nine patients diagnosed MM, with forty-nine vertebral compression fractures underwent percutaneous Vertebroplasty using Spinejack Implants. We analyzed the feasibility and complications of the procedure, the decrease in pain using visual analogue scale (VAS) and Functional Mobility Scale (FMS).

Results

The technical success rate was 100%. No procedure-related major complications or death occurred. In the 6-month follow-up, the mean VAS score decreased from 5.4 ± 1.0 to 0.2 ± 0.5 with a mean reduction of 96.3%. FMS decreased from 2.3 ± 0.5 vs. 1.2 ± 0.4 with a mean reduction of -47.8%. There were no major complications related to incorrect positioning of the Expandable Titanium SpineJack Implants. In five patients, a cement leak was observed with no associated clinical manifestations. The average length of hospital stay was 6-8 Hours6.6 ± 1.2 h. No new bone fractures or local disease recurrence occurred during a median contrast-enhanced CT follow-up of 6 months.

Conclusions

Our results suggest that vertebroplasty, using Spinejack implantation for the treatment and stabilization of painful vertebral compression fractures, secondary to Multiple Myeloma is a safe and effective procedure with long - term pain relief and restoration of vertebral height.

Posterior Midline Interspinal Fixation (PMIF) to Treat Persistent Severe Pain Due to Severe Compression Fracture of Thoracic Vertebral Body: A Case Report

Generally, severe persistent pain due to compression fractures of the lumbar and thoracic vertebral bodies in the elderly, that fail conservative measures are treated with vertebroplasty or kyphoplasty. However, in the case reported in this paper, the compression fracture was so severe, that accurate bone needle placement into the vertebral body was felt to be difficult. In addition, there was a high risk of extravasation of the cement into the surrounding structures or blow-up of the lateral wall of the vertebral body. Therefore, a simple operation of posterior midline interspinal fixation (PMIF) was performed. The patient was a 91-year-old lady with severe pain in the mid-thoracic spine due to a severe compression fracture of the seventh thoracic vertebral body that was totally flattened in its anterior part. The patient was neurologically intact. However, she had difficulty walking, because the pain was very severe in an upright position. She was treated with a back brace and oxycodone for six weeks without any benefit. Because she was a poor candidate for vertebroplasty or kyphoplasty, a PMIF system was implanted. Postoperatively, within two weeks, her pain score dropped from 9/10 to 0/10; and from two months onwards she was completely free of pain medications until her death from an unrelated cause, 18 months after the operation. This is the first reported case of PMIF for the treatment of pain due to vertebral body compression fracture in the elderly. PMIF is a simple minimally invasive procedure without compromising the facet or any bony structure. The risk of severe complications, therefore, is remote. The success in this single case, therefore, begs for further exploration of this method in the treatment of compression fractures in the elderly.

Biomechanical evaluation of a novel tri-blade titanium implantable vertebral augmentation device

BACKGROUND CONTEXT

Titanium implantable vertebral augmentation device (TIVAD) are regarded as having potential in the treatment of vertebral compression fractures (VCFs). However, improper design in current TIVADs results in the inability to effectively restore VCF height and maintain stability. There is still an unmet clinical need for improvement.

PURPOSE

The authors tested a newly developed a TIVAD (Tri-blade fixed system) that can provide enough endplate collapse support to restore the vertebral body height in a safe retraction mechanism for VCFs using minimally invasive surgery (MIS).

STUDY DESIGN

The performed biomechanical tests included blade expansion force, lifetime of cement embedded and vertebral height restoration efficiency of porcine osteoporosis VCFs for its feasibility.

METHODS

A cylinder with 3 surface cuts that form blades that can be expanded into a conical space was designed (Tri-blade fixed system). The 3 blades can be expanded outward with angles between blades as 105°/ 105°/150° for lower left/lower right/upper arms, respectively that reach 15mm in height and 14.8 mm in width. A frame was specifically designed to measure the contact force using force sensing resistors during blade expansion. The Tri-blade fixed system was embedded into a cement block to perform fatigue testing under 2000N pressure (5*10⁶ cycles) for understanding the device lifetime limitation. The Tri-blade system was then inserted into porcine osteoporosis VCFs to examine the vertebral height restoration efficiency.

RESULTS

The average maximum contact force for the top, bottom left and right blades were 299.0N, 283.5N and 279.3N, respectively with uniformly outward expansion forces. The fatigue test found that there were no obvious cracks or damage to the cement block. The porcine osteoporosis vertebral body at the anterior, middle, and posterior heights can be restored to 21.9%, 12.6% and 6.4%, respectively.

CONCLUSIONS

This study developed a novel TIVAD with conical shape that can provide a more stable structure with sufficient/uniform expansion force, passing the fatigue test with bone cement and high effective in vertebral height restoration tests for porcine osteoporosis VCFs.

CLINICAL SIGNIFICANCE

The new 3D Tri-blade TIVAD may offer a new treatment option for VCFs.

Comparison of Efficacy of Percutaneous Vertebroplasty versus Percutaneous Kyphoplasty in the Treatment of Osteoporotic Vertebral Asymmetric Compression Fracture

BACKGROUND

This study aims to compare the clinical efficacy of percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) in the treatment of osteoporotic vertebral asymmetric compression fracture (OVACF).

METHODS

This study retrospectively reviewed the patients who were diagnosed with OVACF between September 2015 and July 2019. Forty-one patients received PVP surgery (group A), and 44 patients received PKP surgery (group B). The visual analog scale, Oswestry Disability Index, scoliosis angle (SA), height of long side, height of short side (HS), and lateral height difference (LHD) before operation and 3 days and 1 year after operation were compared between both groups. The operation time, fluoroscopic time, hospital stay, cement volume, and complications were also compared between both groups.

RESULTS

The visual analog scale and Oswestry Disability Index differed significantly between the groups 1 year after operation (P < 0.05). Compared with the preoperative results, there were significant differences in SA, height of long side, HS, and LHD 3 days and 1 year after operation (P < 0.05). Compared with group A, group B showed significantly better in SA, HS, and LHD in group B 3 days and 1 year after operation (P < 0.05). More patients in group A suffered cement leakage and scoliosis than group B after operation (P < 0.05).

CONCLUSIONS

In our study, PVP and PKP are both effective in the treatment of OVACF, but PKP surgery had better long-term clinical efficacy.

A predictive nomogram for intradiscal cement leakage in percutaneous kyphoplasty for osteoporotic vertebral compression fractures combined with intravertebral cleft

BACKGROUND

For patients with osteoporotic vertebral compression fractures (OVCFs) treated with percutaneous kyphoplasty (PKP), the occurrence and risk factors of intradiscal cement leakage should be characteristic of the presence of intravertebral cleft (IVC). This study aimed to identify risk factors for intradiscal leakage in individuals with OVCFs combined with IVC treated with PKP and build a powered and well-calibrated predictive nomogram.

METHODS

This study retrospectively reviewed consecutive patients who underwent PKP at our center between January 2016 and May 2021. Patients diagnosed with OVCFs combined with IVC were identified, and the incidence of different types of bone cement leakage was recorded. Risk factors for intradiscal leakage among the demographic, perioperative baseline, and radiologic data were identified, following which a nomogram was developed and verified.

RESULTS

A total of 109 eligible patients were included, and the intradiscal leakage rate was 32.1%. Compression rate (odds ratio [OR] 0.025; 95% confidence interval [CI] 0.002-0.264; P = 0.002) and cemented vertebral body fraction (OR 44.122; 95% CI 2.790-697.740; P = 0.007) were identified as independent risk factors. A predictive nomogram with good predictive power (C-statistic = 0.786) and fitness of data (Hosmer-Lemeshow goodness-of-fit test, P = 0.092) was established to build a quantitative relationship between the risk factors and intradiscal leakage.

CONCLUSION

The incidence rate of intradiscal leakage in PKP for OVCFs combined with IVC was 32.1%. Compression rate and cemented vertebral body fraction were identified as independent risk factors. A powered and well-calibrated nomogram was established to accurately predict the probability of intradiscal leakage. Further prospective and multicenter studies are required to verify and calibrate our findings.

Managements of osteoporotic vertebral compression fractures: A narrative review

Osteoporotic vertebral compression fractures (OVCFs) are the most common fragility fracture and significantly influence the quality of life in the elderly. Currently, the literature lacks a comprehensive narrative review of the management of OVCFs. The purpose of this study is to review background information, diagnosis, and surgical and non-surgical management of the OVCFs. A comprehensive search of PubMed and Google Scholar for articles in the English language between 1980 and 2021 was performed. Combinations of the following terms were used: compression fractures, vertebral compression fractures, osteoporosis, osteoporotic compression fractures, vertebroplasty, kyphoplasty, bisphosphonates, calcitonin, and osteoporosis treatments. Additional articles were also included by examining the reference list of articles found in the search. OVCFs, especially those that occur over long periods, can be asymptomatic. Symptoms of acute OVCFs include pain localized to the mid-line spine, a loss in height, and decreased mobility. The primary treatment regimens are pain control, medication management, vertebral augmentation, and anterior or posterior decompression and reconstructions. Pain control can be achieved with acetaminophen or nonsteroidal anti-inflammatory drugs for mild pain or opioids and/or calcitonin for moderate to severe pain. Bisphosphonates and denosumab are the first-line treatments for osteoporosis. Vertebroplasty and kyphoplasty are reserved for patients who have not found symptomatic relief through conservative methods and are effective in achieving pain relief. Vertebroplasty is less technical and cheaper than kyphoplasty but could have more complications. Calcium and vitamin D supplementation can have a protective and therapeutic effect. Management of OVCFs must be combined with multiple approaches. Appropriate exercises and activity modification are important in fracture prevention. Medication with different mechanisms of action is a critical long-term causal treatment strategy. The minimally invasive surgical interventions such as vertebroplasty and kyphoplasty are reserved for patients not responsive to conservative therapy and are recognized as efficient stopgap treatment methods. Posterior decompression and fixation or Anterior decompression and reconstruction may be required if neurological deficits are present. The detailed pathogenesis and related targeted treatment options still need to be developed for better clinical outcomes.

OSTEOPOROTIC SPINE FRACTURES TREATED WITH KYPHOPLASTY OR VERTEBROPLASTY: A META-ANALYSIS

ABSTRACT Kyphoplasty (KP) and vertebroplasty (VP) are both widely adopted treatments for patients with osteoporotic vertebral fractures (OVF), however, which of these techniques is more effective has not yet been established. We performed a systematic review of articles, followed by meta-analysis, in an attempt to establish the differences between KP and VP. Initially, 187 articles were obtained, 20 of which were systematically reviewed and submitted to meta-analysis. Thus, 2,226 patients comprised the universe of the present article, 1202 of whom underwent KP and 1024 of whom underwent VP. The statistically significant results observed included lower mean bone cement leakage (ml) in the group submitted to kyphoplasty, with OR: 1.50 [CI95%: 1.16 - 1.95], p <0.05; shorter mean surgical time (minutes), 0.45 [CI90% 0.08 - 0.82], p <0.1, for the group submitted to VP as compared to the KP group; and a lower mean postoperative Oswestry Disability Index score in the KP group, OR: −0.14 [CI95%: −0.28 - 0.01], p <0.05. KP was more effective in improving physical function and had a lower frequency of cement leakage when compared to VP, although it requires longer surgical time. Level of evidence III; Systematic review of level III studies.

Advances in Vertebral Augmentation Systems for Osteoporotic Vertebral Compression Fractures

Osteoporotic vertebral compression fracture (OVCF) is a common cause of pain and disability and is steadily increasing due to the growth of the elderly population. To date, percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) are almost universally accepted as appropriate vertebral augmentation procedures for OVCFs. There are many advantages of vertebral augmentation, such as short surgical time, performance under local anaesthesia, and rapid pain relief. However, there are certain issues regarding the utilization of these vertebral augmentations, such as loss of vertebral height, cement leakage, and adjacent vertebral refracture. Hence, the treatment for OVCF has changed in recent years. Satisfactory clinical results have been obtained worldwide after application of the OsseoFix System, the SpineJack System, radiofrequency kyphoplasty of the vertebral body, and the Kiva VCF treatment system. The following review discusses the development of the current techniques used for vertebral augmentation.

Mechanical Cavity Creation with Curettage and Vacuum Suction (Q-VAC) in Lytic Vertebral Body Lesions with Posterior Wall Dehiscence and Epidural Mass before Cement Augmentation

Background and Objectives: We describe a novel technique for percutaneous tumor debulking and cavity creation in patients with extensive lytic lesions of the vertebral body including posterior wall dehiscence prior to vertebral augmentation (VA) procedures. The mechanical cavity is created with a combination of curettage and vacuum suction (Q-VAC). Balloon kyphoplasty and vertebral body stenting are used to treat neoplastic vertebral lesions and might reduce the rate of cement leakage, especially in presence of posterior wall dehiscence. However, these techniques could theoretically lead to increased intravertebral pressure during balloon inflation with possible mobilization of soft tissue tumor through the posterior wall, aggravation of spinal stenosis, and resultant complications. Creation of a void or cavity prior to balloon expansion and/or cement injection would potentially reduce these risks. Materials and Methods: A curette is coaxially inserted in the vertebral body via transpedicular access trocars. The intravertebral neoplastic soft tissue is fragmented by multiple rotational and translational movements. Subsequently, vacuum aspiration is applied via one of two 10 G cannulas that had been introduced directly into the fragmented lesion, while saline is passively flushed via the contralateral cannula, with lavage of the fragmented solid and fluid-necrotic tumor parts. Results: We applied the Q-VAC technique to 35 cases of thoracic and lumbar extreme osteolysis with epidural mass before vertebral body stenting (VBS) cement augmentation. We observed extravertebral cement leakage on postoperative CT in 34% of cases, but with no clinical consequences. No patients experienced periprocedural respiratory problems or new or worsening neurological deficit. Conclusion: The Q-VAC technique, combining mechanical curettage and vacuum suction, is a safe, inexpensive, and reliable method for percutaneous intravertebral tumor debulking and cavitation prior to VA. We propose the Q-VAC technique for cases with extensive neoplastic osteolysis, especially if cortical boundaries of the posterior wall are dehiscent and an epidural soft tissue mass is present.

Percutaneous vertebral augmentation in special Genant IV osteoporotic vertebral compression fractures

Background

Percutaneous vertebral augmentation is widely used for treating osteoporotic vertebral compression fractures (OVCFs). Bony encroachment in the spinal canal can be detected in some severe cases, increasing the difficulty of operation and risks of perioperative complications.

Purpose

A special type of OVCF has been introduced, and the clinical efficacy of vertebral augmentation has been evaluated in treating this special OVCF.

Materials and methods

The medical history of patients with OVCF treated with vertebral augmentation was reviewed. The vertebral body height and local kyphotic angle were measured and calculated on the lateral plain radiographs. The visual analogue scale and Oswestry Disability Index were assessed preoperatively, two days after operation, and at final follow-up periods. Complications such as cement leakage and recurrent vertebral fractures were also recorded and followed up.

Results

Twenty-nine patients with special Genant IV OVCF accepted vertebral augmentation, and 28 of them were followed up. The mean follow-up duration was 21.9 months, ranging from 17 to 34 months. The lateral plain radiographs revealed significant restoration of vertebral body height and local kyphotic angle. Both visual analogue scale and Oswestry Disability Index scores showed improvement 2 days after surgery and at final follow-up. Four patients experienced asymptomatic cement leakage, and 6 patients suffered OVCF recurrence in other segments.

Conclusion

Despite a great challenge, vertebral augmentation can be considered as a safe and effective option for treating special the Genant IV OVCF, showing significant restoration of vertebral body height, local kyphotic angle, and daily life function.

The translational potential of this article

Vertebral augmentation has been proven a safe and effect surgery method for special Genant IV OVCF. While surgery complications related to the commercially available filling material – polymethyl methacrylate (PMMA) is common and inevitable. Hence, this article is aimed to provide practical surgical techniques and suggestions to the modification of PMMA and fabrication of newly developed bone cements.

Percutaneous kyphoplasty: Risk Factors for Recollapse of Cemented Vertebrae

INTRODUCTION

Percutaneous kyphoplasty can offer pain relief and restoration of vertebral height immediately after the procedure; however, little is known about how many vertebrae recollapse during follow-up or why recollapse occurs. In the present study, we define recollapse of a treated vertebra, assess how common it is following percutaneous kyphoplasty, and investigate risk factors for the condition.

METHODS

In total, 203 consecutive patients who underwent percutaneous kyphoplasty were reviewed after an average 12.7 months to assess what proportion of cement-augmented vertebrae had recollapsed. Potential risk factors for recollapse included age, gender, body weight, body height, body mass index, treated level, duration of symptoms, follow-up duration, preoperative T-scores, surgical approach, the intravertebral cleft, contact of polymethyl methacrylate (PMMA) with endplates, cement volume, cement leakage, and midline vertebral body height. Stepwise multivariate linear regression was conducted to predict recollapse as quantified by midline vertebral height loss.

RESULTS

Overall, 38.9% of the augmented vertebrae recollapsed. In the recollapse group, the average midline vertebral height ratio and kyphotic angles statistically significantly changed during follow-up (P < 0.05). Pain scores decreased immediately after percutaneous kyphoplasty and generally remained low at follow-up. Significant predictors of midline vertebral height loss at follow-up included presence of an intravertebral cleft, postoperative vertebral height, and non-PMMA-endplate-contact. Together, these factors accounted for 28% of the variability in midline height loss.

CONCLUSIONS

Benefits of percutaneous kyphoplasty are partly offset by subsequent recollapse. Recollapse is greater if there is an intravertebral cleft, non-PMMA-endplate-contact and an increase in the post vertebral height.

Treatment of a High-risk Thoracolumbar Compression Fracture Using Bilateral Expandable Titanium SpineJack Implants

In this case, an 80-year-old active patient developed an acute osteoporotic fracture after a fall at L1 above a previous interlaminar implant at L4-5 for stenosis with neurogenic claudication. Radiologic studies found both intra-discal and intra-vertebral vacuum clefts that are highly correlated with instability and progressive kyphosis. Long-term experience with kyphoplasty has shown that acute and subacute fractures can often be re-expanded; however, over three months to one year, the correction is frequently lost and the vertebral height continues to decrease leading to increased risk of both continued deformity and especially adjacent level fractures. The use of newly available titanium intra-vertebral implants combined with bone cement restores and maintains vertebral height and correction of deformities. Long-term studies also demonstrate a reduced risk of adjacent level fractures compared to balloon kyphoplasty. Using vertebral body implants that remain in place within the fractured vertebral body the initial height correction can be better maintained leading to less adjacent level fractures.

Re-expansion of Osteoporotic Compression Fractures Using Bilateral SpineJack Implants: Early Clinical Experience and Biomechanical Considerations

Thoraco-lumbar osteoporotic compression fractures have a higher incidence of continued collapse with development of deformity and progression to vertebra plana when untreated and even after vertebral augmentation (VA) or balloon kyphoplasty (BKP). Even when there is the restoration of height and improvement in angulation, multiple long-term follow-up series have repeatedly documented that over time, many patients lose the initial height correction and in a smaller group the vertebral body re-collapses leading to the development of progressive deformity with an increased risk for adjacent level fractures. At first, larger balloons and more cement were used to try and avoid these problems, but it did not reduce the risk of adjacent fractures. Several procedures were developed to place various types of intervertebral implants combined with bone cement to maintain the initial height correction. Initial studies with these implants showed a reduction in adjacent level fractures but the systems did not proceed to market. The SpineJack^R (SJ) system (Stryker Corp, Kalamazoo, MI), consisting of bilateral expandable titanium implants supplemented with bone cement, was first used approximately 10 years ago in Europe and recently gained FDA approval in the United States. This system provides more symmetric and balanced lateral and anterior support and is effective with lesser amounts of bone cement compared to BKP. Follow-up studies have documented that there is equal or better pain control, with better long-term results based both on maintaining vertebral height restoration and deformity correction. Most importantly, statistically it clearly reduces the risk of adjacent level fractures by at least 60%. The biomechanical effects of intravertebral implants for osteoporotic fractures in regard to the risk of adjacent level fractures and preliminary experience with the use of the SJ is reviewed.

Review of Vertebral Augmentation: An Updated Meta-analysis of the Effectiveness

Background

To update vertebral augmentation literature by comparing outcomes between vertebroplasty (VP), balloon kyphoplasty (BKP), vertebral augmentation with implant (VAI), and nonsurgical management (NSM) for treating vertebral compression fractures (VCFs).

Methods

A PubMed literature search was conducted with keywords kyphoplasty, vertebroplasty, vertebral body stent, and vertebral augmentation AND implant for English-language articles from February 1, 2011, to November 22, 2016. Among the results, 25 met the inclusion criteria for the meta-analysis. Inclusion criteria were prospective comparative studies for mid-/lower-thoracic and lumbar VCFs enrolling at least 20 patients. Exclusion criteria included studies that were single arm, systematic reviews and meta-analyses, traumatic nonosteoporotic or cancer-related fractures, lack of clinical outcomes, or non-Level I and non-Level II studies. Standardized mean difference between baseline and end point for each outcome was calculated, and treatment groups were pooled using random effects meta-analysis.

Results

Visual analog scale pain reduction for BKP and VP was -4.05 and -3.88, respectively. VP was better than but not significantly different from NSM (-2.66), yet BKP showed significant improvement from both NSM and VAI (-2.77). The Oswestry Disability Index reduction for BKP showed a significant improvement over VAI (P < .001). There was no significant difference in changes between BKP and VP for anterior (P = .226) and posterior (P = .293) vertebral height restoration. There was no significant difference in subsequent fractures following BKP (32.7%; 95% confidence interval [CI]: 8.8%-56.6%) or VP (28.3%; 95% CI: 7.0%-49.7%) compared with NSM (15.9%; 95% CI: 5.2%-26.6%).

Conclusions/Level of Evidence

Based on Level I and II studies, BKP had significantly better and VP tended to have better pain reduction compared with NSM. BKP tended to have better height restoration than VP. Additionally, BKP had significant improvements in pain reduction and disability score as compared with VAI.

Clinical Relevance

This meta-analysis serves to further define and support the safety and efficacy of vertebral augmentation.

Nonfusion Intracorporeal Enhancement System for the Treatment of Osteoporotic Vertebral Compression Fractures-Preliminary Clinical Result of a Novel Technique

OBJECTIVE

This study sought to determine whether implantation of a newly designed nonfusion intracorporeal enhancement (NICE) system is an effective and safe way to treat osteoporotic vertebral compression fracture (OVCF).

METHODS

Thirteen patients with OVCF (10 women, 3 men; mean age 69 years, T11-L4) were included. From June 2014 to June 2016, all patients were treated with the NICE system. The clinical and radiologic results were evaluated preoperatively, postoperatively, and at 24 months follow-up based on the visual analog scale and the Oswestry Disability Index, radiography, magnetic resonance imaging, and computed tomography (height of fractured body and kyphosis Cobb angle).

RESULTS

There was a significant improvement in pain intensity (visual analog scale score decreased from 8.3 preoperatively to 2.2 postoperatively, and decreased to 1.5 twenty-four months postoperatively). Also, a significant reduction was observed in that the mean Oswestry Disability Index decreased from 71.9% preoperatively to 17.6% after 24 months. The mean Cobb angle had a significant improvement, which decreased from 6.6° preoperatively to 1.3° postoperatively and then decreased to 1.2° after 24 months. Height of fractured body improved significantly from 66.4% to 86.5% and slightly decreased to 82.4% after 24 months. No specific complications were identified to be associated with this technique.

CONCLUSIONS

With a low complication rate, the clinical midterm results are satisfactory. The treatment of symptomatic OVCF with the NICE system is a safe and effective procedure.

Refracture of osteoporotic vertebral body after treatment by balloon kyphoplasty: Three cases report

RATIONALE

Balloon kyphoplasty is a widely accepted treatment of osteoporotic vertebral compression fractures (OVCFs) with good results and a low risk for complications. A refracture of previously treated vertebra is a relatively rare condition.

PATIENT CONCERNS

We reported our 3 cases and reviewed all relevant literatures of 11 cases with refracture of osteoporotic vertebral body after kyphoplasty.

DIAGNOSES

Follow-up radiographs or magnetic resonance imaging examination confirmed refractures of previously treated vertebrae after kyphoplasty.

INTERVENTIONS

One patient with 1 refracture of osteoporotic vertebral body after kyphoplasty was treated conservatively, but the other 2 patients were treated surgically because of multiple vertebral fractures or neurological deficits.

OUTCOMES

The average age of the patients was 76.8 years (range, 63-86 years). All the patients had severe osteoporosis with a mean T-score of -3.46 (range -5.0 to -3.0). The sites of refractures are in the lumbar and thoracolumbar regions. Severe osteoporosis, the presence of intravertebral cleft, and a solid lump injection pattern of polymethylmethacrylate would result in insufficient strengthening effects of cement augmentation and therefore increased the likelihood of refractures of the kyphoplasty vertibrae.

LESSONS

Patients with OVCFs and intravertebral cleft who did not obtain complete pain-relief at the treated vertebral level after kyphoplasty should be strictly followed up. Early finding of this condition and rapid intervention might contribute to avoiding the occurrence of the cemented vertebral refracture after kyphoplasty. Conservative treatments such as back brace and antiosteoporotic medications were strongly recommended.

Preoperative prone position exercises: a simple and novel method to improve tolerance to kyphoplasty for treatment of single level osteoporotic vertebral compression fractures

Background

The proper choice of anesthesia for kyphoplasty remains controversy. There are only a few clinical studies specially focusing on and giving detailed information about this treatment under local anesthesia with or without conscious sedation. To evaluate the effect of preoperative prone position exercises on patient tolerance to percutaneous kyphoplasty under local anesthesia.

Methods

Eighty-three patients with single level osteoporotic vertebral compression fractures were nonrandomly assigned to undergo percutaneous kyphoplasty under local anesthesia with preoperative prone position exercises or without. The number of procedure with or without a pause, need for intravenous sedation, and patient satisfactory were recorded and analyzed. Clinical outcomes were assessed using the visual analog scale and the Oswestry Disability Index. The follow-up time was 6 months.

Results

The baseline characteristics of both groups were comparable. The number of procedure without a pause in the exercises group was more than the control group (30/42 patients and 10/41 patients, respectively, P < 0.001), and fewer patients required intravenous sedation in the exercises group (7/42 and 28/41, respectively, P < 0.001). Patients in the exercises group were more satisfied compared to the control group (41/42 and 32/41, respectively, P < 0.01). There were no significant differences between the two groups with regard to improvement in pain and functional scores at all postoperative intervals.

Conclusions

Prone position exercises may improve patient tolerance and satisfaction and reduce the need for intravenous sedation for those with single level vertebral compression fracture undergoing kyphoplasty under local anesthesia. We expect large sample size and multi-center randomized controlled trial studies to be conducted.

Comparing pain reduction following kyphoplasty and vertebroplasty : A meta-analysis of randomized and non-randomized controlled trials

PURPOSE

The aim of the study was to compare the extent of pain reduction with kyphoplasty (KP) and vertebroplasty (VP) in the treatment of osteoporotic vertebral compression fractures (OVCF) using a visual analog scale (VAS).

METHODS

A computerized database search was performed to compare pain relief from VP and KP in OVCF. The available literature was analysed to quantify the amount of pain reduction using VAS as the primary outcome.

RESULTS

A total of 10 studies encompassing 902 patients met the inclusion criteria. Subgroup meta-analyses were performed according to the study design. VAS for the KP group was not significant compared with the VP group at 1 week, 1 month, and 6 months. Pain relief in the KP group was greater than that in the VP group at 12 months and 2 years.

CONCLUSION

KP is superior to VP in patients requiring pain relief. More large-scale, double-blinded controlled trials are necessary in order to quantify the pain relief afforded by VP more precisely.

Postoperative Functional Evaluation of Percutaneous Vertebroplasty Compared With Percutaneous Kyphoplasty for Vertebral Compression Fractures

Both percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) have shown their superiorities in the treatment of vertebral compression fractures (VCFs), yet, few studies have compared their postoperative functional outcomes in patients with VCFs; the authors therefore conducted this meta-analysis to explore the postoperative functional recovery efficacies of PVP and PKP in the treatment of VCFs. Computerized bibliographic databases were applied to identify relevant articles comparing the therapeutic effect of PVP and PKP in the treatment of VCFs. Standardized mean difference and its 95% confidence interval were calculated. Statistical analyses were conducted with the STATA statistical software. Postoperative Oswestry Disability Index investigation outcomes revealed a significant difference between the PVP group and PKP group. Subgroup analysis by the 8 dimensions of the SF-36 health survey presented a statistical significance in general health between the PVP group and PKP group. The application of PKP has the superiority in postoperative functional recovery of VCFs as compared with PVP, especially in efficaciously extending kyphosis angle, improving vertebral body height and decreasing complication rate.

Percutaneous Kyphoplasty in the Treatment of Osteoblastic-related Spinal Metastases

STUDY DESIGN

A retrospective study.

OBJECTIVE

To evaluate the feasibility, efficacy, and safety of percutaneous kyphoplasty (PKP) for the treatment of painful osteoblastic-related spinal metastases unresponsive to conservative treatments.

SUMMARY OF BACKGROUND DATA

PKP represents a powerful tool in the management of oncology patients who suffer from painful osteolytic spinal lesions. However, to our knowledge, there have been no reports on the role of PKP in the treatment of osteoblastic metastatic spinal lesions. In this study, we evaluate the potential efficacy of kyphoplasty for the treatment of painful osteoblastic spinal metastases unresponsive to conservative treatments.

METHODS

A retrospective study was performed on 13 patients managed with PKP for painful osteoblastic-related spinal metastases. Visual analog scale pain score and Oswestry disability index questionnaire were used to assess back pain and functional status, respectively.

RESULTS

The average visual analog scale pain score before the treatment was 8.5±0.5 compared with 2.0±0.8 at 3 days after the procedure (P<0.001), and remained largely unchanged from 1.6±0.5 at 1 month, 1.5±0.5 at 3 months to 2.2±0.7 at the last follow-up. The Oswestry disability index scores decreased from 77.2±8.2 before the surgery to 34.6±7.4 at 3 days after the operation (P<0.001), 32.2±6.1 at 1 month, 30.2±5.9 at 3 months, and 34.5±6.7 at the last follow-up. No symptomatic cement leakage and PKP-related complications were found after operation.

CONCLUSIONS

PKP is an effective, safe, and minimally invasive procedure to treat painful osteoblastic spinal metastases, leading to a significant reduction of pain and improvement of functional status.

Bone scintigraphy for the diagnosis of the responsible level of osteoporotic vertebral compression fractures in percutaneous balloon kyphoplasty

OBJECTIVES

This study was to investigate the efficacy of bone scintigraphy in order to diagnose the correct level of vertebral compression fractures (VCF) for the severe back pain before balloon kyphoplasty (BKP) was performed.

PATIENTS AND METHODS

A total of 30 consecutive patients were treated with BKP for 38 times since May 2012. Eleven patients had acute multi-level VCFs. Bone scintigraphy was performed preoperatively except for the first case and the case with a chronic course and the level responsible for the pain was defined with bone scintigraphy. The responsible level of acute single level VCF was easily diagnosed with T1, T2, and fat sat T2 but the responsible level of acute multi-level VCFs was not easily determined. BKP was performed at the most accumulated level on bone scintigraphy and the preoperative and postoperative Visual analogue score (VAS) scores were researched with questionnaire postoperatively.

RESULTS

BKP was effective in relief of pain at the most accumulated level on bone scintigraphy. Preoperative VAS score (average 8.6) was significantly improved at post-ope day1 (average 3.9), at discharge (average 2.4) and at 1 month after discharge (average 2.1). New symptomatic VCFs after the first treatment occurred in 5 patients at an adjacent level in 3 and twice in 2 of 5 and additional BKP was effective in each patient.

CONCLUSIONS

The correct level of symptomatic VCF in the patients with acute multi-level VCFs should be diagnosed to achieve good clinical results. In this study, we showed that bone scintigraphy is very useful in diagnosing the proper level for BKP in addition to CT and MRI.

Review of Percutaneous Kyphoplasty in China

STUDY DESIGN

Review article.

OBJECTIVE

The article mainly reviewed the development and current situation of percutaneous kyphoplasty (PKP) in China, aiming to introduce native efforts and progress for PKP procedure on the exploring road.

SUMMARY OF BACKGROUND DATA

Since PKP was first reported in China in 2002, Chinese orthopedic researchers have performed lots of clinical applications and studies on the treatment of osteoporotic vertebral compression fracture, spinal metastatic tumor, hemangioma, myeloma, vertebral nonunion, and so on.

METHODS

We reviewed the papers on PKP published by native researchers in English and Chinese via Pubmed, EMBASE, the Scopus database, and a series of Chinese databases including Wanfang Data, China National Knowledge Infrastructure (CNKI), and the China Science and Technology Journal Database. The large sample capacity researches, convictive systematic analysis, and overviews were mainly elected as convictive evidence to describe the overall situation of clinical outcomes, complications, and the various technical aspects used to improve conventional surgical management and clinical applications of PKP in China.

RESULTS

Until October 2015, 211 articles in English and 2352 studies in Chinese about PKP were reported by 1443 Chinese institutions from 22 provinces around China. More than 50976 patients reported through published articles have received the treatment of PKP. With the technique gradually improved, including puncture, bone cement infusion, vertebral expander instruments, diagnosis, and treatment of special type of vertebral fractures, PKP is performed with the better efficacy and less complication.

CONCLUSION

With the progression of minimally invasive spinal surgery around the world, PKP in China has been performed with a trend towards a rapid, safe, and effective treatment. Digital, real-time and artificial intelligence are the directions of future development of PKP.

LEVEL OF EVIDENCE

4.

Balloon kyphoplasty or percutaneous vertebroplasty for osteoporotic vertebral compression fracture? An updated systematic review and meta-analysis

BACKGROUND

Both kyphoplasty (KP) and vertebroplasty (VP) are effective for patients with osteoporotic vertebral compression fracture (OVCF), but which approach might be more effective remains unclear, so we decided to update earlier systematic reviews.

OBJECTIVE

Review and analyze studies published as of August 2015 that compared clinical outcomes and complications of KP versus VP.

DESIGN

Systematic review and meta-analysis.

SEARCH METHOD

Published reports up to August 2015 were found in PubMed, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL).

SELECTION CRITERIA

Randomized controlled trials (RCTs) and prospective and retrospective cohort stud.ies comparing KP and VP in patients with OVCF.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the studies and extracted data.

RESULTS

Thirty-two studies involving 3274 patients fulfilled the inclusion criteria. There were significant differences between the two groups in short- and long-term postoperative changes in measures of pain intensity and dysfunction (P < .01), in anterior and middle height (P < .01), kyphotic angle (P < .01), and time to injury, but not in posterior height (P=.178). There were no significant differences in the rate of postoperative fractures including adjacent and total fractures, but cement leakage to the intraspinal space was greater in the VP group (P=.035). KP surgery took longer and required a greater volume of injected cement.

CONCLUSIONS

KR resulted in better pain relief, improvements in Oswestry dysfunction and radiographic outcomes with less cement leakage, but further RCTs are needed to verify this conclusion.

LIMITATIONS

Only four RCTs with a certain of risk of bias. Most studies were observational.

Percutaneous kyphoplasty with or without temporary unipedicle screw reduction : A retrospective comparative study of osteoporotic vertebral fractures

Background

Temporary unipedicle screw reduction with percutaneous kyphoplasty (TUSR-PKP) is a relatively new method for managing osteoporotic vertebral compression fractures (OVCFs). A clinical retrospective comparative study was conducted to verify whether TUSR-PKP was noninferior to simple PKP regarding the management of OVCFs.

Methods

A total of 38 consecutive patients who sustained OVCFs without neurological deficits and had undergone surgeries in our hospital from June 2012 to January 2014 were included in the study: 24 patients underwent simple PKP (control group) and the other 14 patients underwent TUSR-PKP (treatment group). All 38 patients were asked to participate in a long-term (>1 year) follow-up. Visual analog scale (VAS) pain scores and Oswestry Disability Index (ODI) were recorded, and the Cobb angles and the vertebral body heights were measured on the lateral radiographs before surgery and on day 1, as well as 1, 3, 6, and 12 months after surgery.

Results

The patients in the treatment group had better vertebral height gain and greater improvement on ODI compared with the control group (p < 0.05). The VAS scores of the two groups were similar at all points until the end of the 1‑year follow-up period. Two patients from the treatment group and 5 patients from the control group had cement leakage. In the control group, 3 patients suffered adjacent or nonadjacent vertebra fractures.

Conclusion

TUSR-PKP is a safe and effective surgical option for OVCFs. Compared with simple PKP, TUSR-PKP provided at least equal results for OVCFs. Moreover, during the postsurgery observations, TUSR-PKP showed potential advantages including vertebral height gain, ODI improvement, and fewer subsequent refractures.

Percutaneous vertebroplasty for patients with metastatic compression fractures of the thoracolumbar spine: clinical and radiological factors affecting functional outcomes

BACKGROUND CONTEXT

Vertebroplasty (VP), including balloon kyphoplasty (BKP), has long been accepted as a minimally invasive surgical intervention for the stabilization of painful vertebral compression fractures. In metastatic compression fracture (MCF), cancer often invades the paravertebral structure and involves the posterior column of the vertebrae.

PURPOSE

In the present study, we first analyzed how clinical features of MCF affect functional outcomes after VP. Second, we evaluated whether BKP is more beneficial than simple VP (SVP) in MCF.

STUDY DESIGN/SETTING

This is a retrospective observational study.

PATIENT SAMPLE

Three hundred forty-two patients who underwent VP for painful MCF from solid cancer were included. We excluded MCF from hematopoietic cancer, such as leukemia or multiple myeloma.

OUTCOME MEASURES

Pain improvement was evaluated using the visual analog scale (VAS; range: 0-10), and if the VAS score decreased by at least three points the treatment was considered effective. Postoperative change in Karnofsky performance status (KPS) and drug requirement for pain control were also measured as functional outcomes.

METHODS

An institutional database at the National Cancer Center of Korea was searched to identify all patients who underwent VP for painful MCF between March 2002 and September 2013. Demographic data, as well as preoperative and postoperative clinical factors, were collected from patients' medical records. Radiological features, including paravertebral extension of tumors and the extent of three-column involvement, were reviewed from pretreatment magnetic resonance imaging (MRIs). These clinical and radiological factors were then analyzed for their influence on functional outcomes.

RESULTS

The mean preoperative VAS score was 5.8; this improved to a mean of 2.7 after VP. Effective improvement in VAS score (≥3) was achieved in 206 patients (60%). Patients with radiculopathy, as well as those with involvement of (1) the posterior column or (2) more than four out of six columns, presented with significantly higher pretreatment VAS scores and experienced more effective improvement after treatment (p<.05). Two hundred thirty-eight patients (70%) underwent SVP, whereas the remaining 104 patients underwent BKP. The pretreatment degree of compression was significantly higher in BKP (mean: 47%) than in SVP patients (mean: 30%) (p<.001). However, preoperative VAS scores were not significantly different between the two groups, and the resultant VAS score improvement was also not significantly different. Although BKP patients reported to have a greater chance of more than 3 mL of cement injection (p=.01), the mean amount of cement injected was not different between the two groups. Patients with other bone metastases showed a significantly poorer KPS improvement rate (p=.015). Patients having moderately or slowly growing cancer according to the Tomita classification had a greater chance of reduced drug requirements 1 month after the procedure (p=.004).

CONCLUSIONS

Paravertebral extension and posterior column involvement of MCF did not preclude pain improvement after VP. Balloon kyphoplasty for MCF failed to show enhanced pain improvement relative to SVP. Metastatic compression fracture patients with other bone metastases or rapidly growing tumors had a lower chance of performance improvement and reduced drug requirements, respectively.

The standardized creation of a lumbar spine vertebral compression fracture in a sheep osteoporosis model induced by ovariectomy, corticosteroid therapy and calcium/phosphorus/vitamin D-deficient diet

INTRODUCTION

Vertebral compression fractures (VCFs) are one of the most common injuries in the aging population presenting with an annual incidence of 1.4 million new cases in Europe. Current treatment strategies focus on cement-associated solutions (kyphoplasty/vertebroplasty techniques). Specific cement-associated problems as leakage, embolism and the adjacent fracture disease are reported adding to open questions like general fracture healing properties of the osteoporotic spine. In order to analyze those queries animal models are of great interest; however, both technical difficulties in the induction of experimental osteoporosis in animal as well as the lack of a standardized fracture model impede current and future in vivo studies. This study introduces a standardized animal model of an osteoporotic VCF type A3.1 that may enable further in-depth analysis of the afore mentioned topics.

MATERIAL AND METHODS

Twenty-four 5-year-old female Merino sheep (mean body weight: 67 kg; range 57-79) were ovariectomized (OP1) and underwent 5.5 months of weekly corticosteroid injections (dexamethasone and dexamethasone-sodium-phosphate), adding to a calcium/phosphorus/vitamin D-deficient diet. Osteoporosis induction was documented by pQCT and micro-CT BMD (bone mineral density) as well as 3D histomorphometric analysis postoperatively of the sheep distal radius and spine. Non osteoporotic sheep served as controls. Induction of a VCF of the second lumbar vertebra was performed via a mini-lumbotomy surgical approach with a standardized manual compression mode (OP2).

RESULTS

PQCT analysis revealed osteoporosis of the distal radius with significantly reduced BMD values (0.19 g/cm(3), range 0.13-0.22 vs. 0.27 g/cm(3), range 0.23-0.32). Micro-CT documented significant lowering of BMD values for the second lumbar vertebrae (0.11 g/cm(3), range 0.10-0.12) in comparison to the control group (0.14 g/cm(3), range 0.12-0.17). An incomplete burst fracture type A3.1 was achieved in all cases and resulted in a significant decrease in body angle and vertebral height (KA 4.9°, range: 2-12; SI 4.5%, range: 2-12). With OP1, one minor complication (lesion of small bowel) occurred, while no complications occurred with OP2.

CONCLUSIONS

A suitable spinal fracture model for creation of VCFs in osteoporotic sheep was developed. The technique may promote the development of improved surgical solutions for VCF treatment in the experimental and clinical setting.

Does Balloon Kyphoplasty Deliver More Cement Safely into Osteoporotic Vertebrae with Compression Fractures Compared with Vertebroplasty? A Study in Vertebral Analogues

Study Design A biomechanical and radiographic study using vertebral analogues. Objectives Kyphoplasty and vertebroplasty are widely used techniques to alleviate pain in fractures secondary to osteoporosis. However, cement leakage toward vital structures like the spinal cord can be a major source of morbidity and even mortality. We define safe cement injection as the volume of the cement injected into a vertebra before the cement leakage occurs. Our objective is to compare the amount of cement that can be safely injected into an osteoporotic vertebra with simulated compression fracture using either vertebroplasty or balloon kyphoplasty techniques. Methods Forty artificial vertebral analogues made of polyurethane with osteoporotic cancellous matrix representing the L3 vertebrae were used for this study and were divided into four groups of 10 vertebrae each. The four groups tested were: low-viscosity cement injected using vertebroplasty, high-viscosity cement injected using vertebroplasty, low-viscosity cement injected using balloon kyphoplasty, and high-viscosity cement injected using balloon kyphoplasty. The procedures were performed under fluoroscopic guidance. The injection was stopped when the cement started protruding from the created vascular channel in the osteoporotic vertebral fracture model. The main outcome measured was the volume of the cement injected safely into a vertebra before leakage through the posterior vascular channel. Results The highest volume of the cement injected was in the vertebroplasty group using high-viscosity cement, which was almost twice the injected volume in the other three groups. One-way analysis of variance comparing the four groups showed a statistically significant difference (p < 0.005). Conclusions High-viscosity cement injected using vertebroplasty delivers more cement volume before cement leakage and fills the vertebral body more uniformly when compared with balloon kyphoplasty in osteoporotic vertebrae with compression fractures.

KAST Study: The Kiva System As a Vertebral Augmentation Treatment-A Safety and Effectiveness Trial: A Randomized, Noninferiority Trial Comparing the Kiva System With Balloon Kyphoplasty in Treatment of Osteoporotic Vertebral Compression Fractures

STUDY DESIGN

The KAST (Kiva Safety and Effectiveness Trial) study was a pivotal, multicenter, randomized control trial for evaluation of safety and effectiveness in the treatment of patients with painful, osteoporotic vertebral compression fractures (VCFs).

OBJECTIVE

The objective was to demonstrate noninferiority of the Kiva system to balloon kyphoplasty (BK) with respect to the composite primary endpoint.

SUMMARY OF BACKGROUND DATA

Annual incidence of osteoporotic VCFs is prevalent. Optimal treatment of VCFs should address pain, function, and deformity. Kiva is a novel implant for vertebral augmentation in the treatment of VCFs.

METHODS

A total of 300 subjects with 1 or 2 painful osteoporotic VCFs were randomized to blindly receive Kiva (n = 153) or BK (n = 147). Subjects were followed through 12 months. The primary endpoint was a composite at 12 months defined as a reduction in fracture pain by at least 15 mm on the visual analogue scale, maintenance or improvement in function on the Oswestry Disability Index, and absence of device-related serious adverse events. Secondary endpoints included cement usage, extravasation, and adjacent level fracture.

RESULTS

A mean improvement of 70.8 and 71.8 points in the visual analogue scale score and 38.1 and 42.2 points in the Oswestry Disability Index was noted in Kiva and BK, respectively. No device-related serious adverse events occurred. Despite significant differences in risk factors favoring the control group at baseline, the primary endpoint demonstrated noninferiority of Kiva to BK. Analysis of secondary endpoints revealed superiority with respect to cement use and site-reported extravasation and a positive trend in adjacent level fracture warranting further study.

CONCLUSION

The KAST study successfully established that the Kiva system is noninferior to BK based on a composite primary endpoint assessment incorporating pain-, function-, and device-related serious adverse events for the treatment of VCFs due to osteoporosis. Kiva was shown to be noninferior to BK and revealed a positive trend in several secondary endpoints.

LEVEL OF EVIDENCE

1.

Does balloon kyphoplasty improve the global spinal alignment in osteoporotic vertebral fracture?

PURPOSE

Balloon kyphoplasty (BKP) has been a well-accepted procedure in the treatment of osteoporotic vertebral compression fracture (OVCF), whereas it remains unclear whether or not this procedure has an impact on the global spinal alignment. The purpose of this study is to evaluate the effect of BKP on the global spinal alignment in OVCF.

METHODS

Fifty-six consecutive patients who had undergone BKP for symptomatic OVCF were retrospectively reviewed with a mean follow-up of 32 months. They were seven males and 49 females with a mean age of 75 years. Radiographic assessment was performed using upright whole spine radiographs. The parameters included vertebral kyphosis, mid-vertebral body height and global sagittal spinal alignment (C7 plumb line deviation). Clinical outcomes were evaluated using visual analog scale of back pain.

RESULTS

Fifty-one of 56 patients (91.1 %) achieved immediate pain relief. Vertebral kyphosis significantly decreased from 18 to 14 degrees, but 43 patients (76.8 %) still had more than 10 degrees of local kyphosis. Subsequent vertebral compression fractures were observed in seven patients (12.5 %). Anterior deviation of a C7 plumb line (C7PL) was 3.1 cm pre-operatively, 3.1 cm postoperatively, and significantly increased to 5.9 cm at the final follow-up. Consistent results were obtained in those with pre-operative sagittal imbalance (>5 cm anterior deviation of C7PL) and with pre-existing OVCFs.

CONCLUSIONS

BKP contributed to immediate pain relief, but did not improve the global sagittal spinal alignment after OVCF. This procedure should be solely indicated for painful OVCF or non-union, and could not be expected to restore the global sagittal alignment.

Bony healing of unstable thoracolumbar burst fractures in the elderly using percutaneously applied titanium mesh cages and a transpedicular fixation system with expandable screws

INTRODUCTION

There is a high incidence of vertebral burst fractures following low velocity trauma in the elderly. Treatment of unstable vertebral burst fractures using the same principles like in stable vertebral burst fractures may show less favourable results in terms of fracture reduction, maintenance of reduction and cement leakage. In order to address these shortcomings this study introduces cementless fixation of unstable vertebral burst fractures using internal fixators and expandable intravertebral titanium mesh cages in a one-stage procedure via minimum-invasive techniques.

MATERIAL AND METHODS

A total of 16 consecutive patients (median age 76 years, range 58-94) with unstable thoracolumbar burst fractures and concomitant osteoporosis were treated by an internal fixator inserted via minimum invasive technique one level above and below the fractured vertebra. Fracture reduction was achieved and maintained by transpedicular placement of two titanium mesh cages into the fractured vertebral body during the same procedure. Intra- and postoperative safety of the procedure as well as analysis of reduction quality was analysed by 3D C-arm imaging or CT, respectively. Clinical and radiographic follow-up averaged 10.4 months (range 4.5-24.5).

RESULTS

Stabilization of the collapsed vertebral body was achieved in all 16 cases without any intraoperative complication. Surgical time averaged 102 ± 6.6 minutes (71-194). The postoperative kyphotic angle (KA) and Cobb angle revealed significant improvements (KA 13.7° to 7.4°, p < 0.001; Cobb 9.6° to 6.0°, p < 0.002) with partial loss of reduction at final follow-up (KA 8.3°, Cobb 8.7°). VAS (Visual Analogue Scale) improved from 7.6 to 2.6 (p < 0.001). Adjacent fractures were not observed. One minor (malposition of pedicle screw) complication was encountered.

CONCLUSION

Cementless fixation of osteoporotic burst fractures revealed substantial pain relief, adequate maintenance of reduction and a low complication rate. Bony healing after unstable osteoporotic burst fractures is possible.

TRIAL REGISTRATION

www.germanctr.de DRKS00005657.

A randomized trial comparing balloon kyphoplasty and vertebroplasty for vertebral compression fractures due to osteoporosis

BACKGROUND AND PURPOSE

Several trials have compared vertebral augmentation with nonsurgical treatment for vertebral compression fractures. This trial compares the efficacy and safety of balloon kyphoplasty and vertebroplasty.

MATERIALS AND METHODS

Patients with osteoporosis with 1-3 acute fractures (T5-L5) were randomized and treated with kyphoplasty (n = 191) or vertebroplasty (n = 190) and were not blinded to the treatment assignment. Twelve- and 24-month subsequent radiographic fracture incidence was the primary end point. Due to low enrollment and early withdrawals, the study was terminated with 404/1234 (32.7%) patients enrolled.

RESULTS

The average age of patients was 75.6 years (77.4% female). Mean procedure duration was longer for kyphoplasty (40.0 versus 31.8 minutes, P < .001). At 12 months, 7.8% fewer patients with kyphoplasty (50/140 versus 57/131) had subsequent radiographic fracture, and there were 8.6% fewer at 24 months (54/110 versus 64/111). The results were not statistically significant (P > .21). When we used time to event for new clinical fractures, kyphoplasty approached statistical significance in longer fracture-free survival (Wilcoxon, P = .0596). Similar pain and function improvements were observed. CT demonstrated lower cement extravasation for kyphoplasty (157/214 versus 164/201 levels treated, P = .047). For kyphoplasty versus vertebroplasty, common adverse events within 30 postoperative days were procedural pain (12/191, 9/190), back pain (14/191, 28/190), and new vertebral fractures (9/191, 17/190); similar 2-year occurrence of device-related cement embolism (1/191, 1/190), procedural pain (3/191, 3/190), back pain (2/191, 3/190), and new vertebral fracture (2/191, 2/190) was observed.

CONCLUSIONS

Kyphoplasty and vertebroplasty had similar long-term improvement in pain and disability with similar safety profiles and few device-related complications. Procedure duration was shorter with vertebroplasty. Kyphoplasty had fewer cement leakages and a trend toward longer fracture-free survival.

Is balloon kyphoplasty better than percutaneous vertebroplasty for osteoporotic vertebral biconcave-shaped fractures?

BACKGROUND

Osteoporotic vertebral biconcave-shaped fractures are not commonly seen in clinical practice. Some articles have been published showing the outcome of vertebroplasty (PV) and balloon kyphoplasty (BKP), but few comparative studies have been performed.

PURPOSE

To compare the effect and safety of PV and BKP in treating osteoporotic vertebral biconcave-shaped fractures.

MATERIAL AND METHODS

In this retrospective comparative study, 38 patients with osteoporotic vertebral biconcave-shaped fractures were treated by PV, and 41 patients were treated by BKP from May 2005 to July 2011. The heights of the compromised vertebral body and the kyphotic angles were measured. Visual analogue scale (VAS) and Oswestry Disability Index (ODI) were used to evaluate pain and functional activity, respectively. The occurrence of refracture and cement leakage were determined, and the costs were recorded.

RESULTS

The mean VAS and ODI scores significantly improved for both procedures at postsurgical measurements (P < 0.05), and the improvement sustained at the final follow-up. In both groups, there were no significant differences in terms of restoration of the anterior vertebral height and correction of the kyphotic deformity. However, BKP was more effective in restoring the middle vertebral height than PV. Cement leakages were observed in nine (23.7%) treated vertebral bodies in PV group and in three (7.4%) treated vertebral bodies in BKP group, which was a statistically significant difference (P < 0.05). There were four new osteoporotic vertebral fractures in the PV group and two in the BKP group during the follow-up period. The mean cost in the BKP group (6200 ± 122.1 USD) was higher than the PV group (2100 ± 112.5 USD) (P < 0.05).

CONCLUSION

Both PV and BKP achieved similar improvements in pain and functional outcomes for the treatment of osteoporotic vertebral biconcave-shaped fractures. BKP had a significant advantage over PV in terms of the restoration of the middle vertebral height and fewer cement leakages than PV.

Cement augmentation in a thoracolumbar fracture model: reduction and stability after balloon kyphoplasty versus vertebral body stenting

STUDY DESIGN

In vitro biomechanical investigation.

OBJECTIVE

To assess differences in kyphosis after balloon kyphoplasty (BKP) or vertebral body stenting (VBS).

SUMMARY OF BACKGROUND DATA

Cement augmentation techniques allow early mobilization in patients with osteoporotic thoracolumbar fractures. Biomechanically, the grade of reduction and preservation are as important as in nonosteoporotic fractures. With BKP, negative effects of balloon deflation on the reduction and whether specific combinations of materials may preserve the reduction are as yet unclear.

METHODS

Twelve bisegmental human thoracolumbar specimens (6×T12-L2, 6×L3-L5; age at death, 76.3 yr; range, 63-89 yr; female:male ratio, 3:3; bone mineral density, 68.1 g/cm; mean, 12.9 g/cm) were tested in a spine simulator with pure moments of 7.5 Nm to assess primary and secondary stability. After flexibility testing of the intact specimens, an eccentric compression force induced standardized fractures, which were reduced using either BKP or VBS against a flexional moment of 2.5 Nm. Primary and secondary stability were assessed using range of motion in a spine tester. The specimens were tested after each of 3 periods of cyclic flexion loading. The kyphotic angle of the index vertebra was measured radiographically.

RESULTS

The 2 techniques achieved comparable reduction against a relatively high bending moment in this model. Neither technique restored the stability of the intact state; with increasing loads, the range of motion continuously increased to the level of fractured specimen to the level of the fractured specimen. Although the deflation effect on the kyphotic angle was lower with VBS (P≤0.05), there were no significant differences between the techniques relative to angle restoration.

CONCLUSION

Both augmentation techniques are able to restore vertebral body height after thoracolumbar fractures. The deflation effect on the kyphotic angle was less with VBS than with BKP. High flexion moments during implantation limit the effectiveness of reduction using cement augmentation methods.

LEVEL OF EVIDENCE

N/A.

Prospective quantitative assessment of spinal range of motion before and after minimally invasive surgical treatment of vertebral body fractures

INTRODUCTION

Randomized clinical trials have generated doubts regarding the therapeutic effectiveness of spinal kyphoplasty to reduce pain and improve quality of life in patients with vertebral fractures. There is a paucity of data on the influence of kyphoplasty on spinal range of motion. To quantify early postoperative changes following kyphoplasty in spinal motion, a noninvasive, radiation-free measurement method was used and results related to clinical and radiological parameters.

METHODS

The study group included 30 patients with an overall number of 54 symptomatic pathological vertebral compression fractures. All patients were treated with balloon kyphoplasty. Clinical results were recorded using the visual analog scale, SF 36, Roland Morris Score and the Oswestry Disability Index, at three time points; preoperative, 2 days postoperative, and at 12 weeks postoperative. The kyphosis angle/sagittal index were determined with biplanar X-rays. Amplitude/velocity of motion in extension/flexion was measured at each time point by use of the EpionicsSPINE(©) system (Epionics Medical GmbH; Potsdam, Germany) using two external sensor strips.

RESULTS

Preoperative magnetic resonance imaging scans showed bone marrow edema in all vertebral bodies indicative of a recent, non-consolidated fracture. Pain and quality of life was significantly improved by kyphoplasty, both for the immediate postoperative period, as well as at 12 weeks postoperative. Radiological parameters also showed significant improvement following surgery. Total ROM did not significantly change 2 days after kyphoplasty, but amplitude and velocity were found to be increased 12 weeks postoperatively. Significant positive correlations were observed between increased range of motion and improved clinical/radiological scores.

CONCLUSION

Significant clinical and radiological improvement following kyphoplasty supports the rational for cement augmentation in patients with pathological vertebral body fractures. To the knowledge of the authors, no prior study has assessed the influence of preservation and improvement of spinal range of motion on clinical outcome following kyphoplasty.

Identification of Risk Factors for the Occurrence of Cement Leakage During Percutaneous Vertebroplasty for Painful Osteoporotic or Malignant Vertebral Fracture

STUDY DESIGN

Retrospective study.

OBJECTIVE

To identify fracture morphology-dependent risk factors for the occurrence of cement leakage during percutaneous vertebroplasty.

SUMMARY OF BACKGROUND DATA

Extravertebral cement leakage is the most frequently reported complication and represents a major risk after vertebroplasty and balloon kyphoplasty. Despite the frequent occurrence of cement leakage and potentially dangerous complications and sequelae, there are few reports that examine its predictors.

METHODS

Retrospective review of 194 consecutive patients who underwent percutaneous vertebroplasty for painful osteoporotic or malignant vertebral fracture. The influences of several parameters that might affect the occurrence of cement leakage were assessed using univariate and multivariate analyses. Cement leakage was assessed using computed tomography scanning and classified into 4 different types with different potential sequelae: through the basivertebral vein, through the segmental vein, through a cortical defect, and intradiscal leakage.

RESULTS

Leakage of cement was detected in 209 of the 272 treated vertebrae (76.83%). The most common types of leakage detected were through the basivertebral vein (43.38%) and the segmental vein (42.27%). None of the evaluated variables showed a statistically significant effect. Only the absence of Kummell disease (P = 0.063) and a lower severity grade of collapse (P = 0.068) approached statistical significance. For basivertebral vein leakages, the location at the thoracolumbar level and the absence of Kummell disease (P < 0.05) were strong predictive factors for cement leakages. For segmental vein leakages, the odds decreased as the severity grade of collapse increased (P = 0.008).

CONCLUSION

Each different vertebral fracture pattern has its own risk factors for cement leakage. For certain types of leakage, Kummell avascular necrosis as a protective factor and fracture severity grade with paradoxical effect have each demonstrated influence in the occurrence of cement leakage.

LEVEL OF EVIDENCE

4.

Refracture of osteoporotic vertebral body concurrent with cement fragmentation at the previously treated vertebral level after balloon kyphoplasty: a case report

Kyphoplasty has been shown to provide symptomatic relief of vertebral compression fractures refractory to medical therapy. However, few reports have focused on refracture of cemented vertebrae after kyphoplasty. The presence of cemented vertebrae refracture concurrent with cement fragmentation is an extremely rare condition. We reported an 86-year-old man with a T12 osteoporotic compression fracture undergoing the kyphoplasty treatment. The patient postoperatively continued to have back pain at the same level. The solid lumped polymethylmethacrylate (PMMA) mass and inadequate use and insufficient filling of PMMA cement were observed in postoperative radiographs and magnetic resonance image (MRI) examination. He refused to receive the surgical intervention, but had not strict compliance with oral anti-osteoporotic medications. Ten months postoperatively, refracture of osteoporotic vertebral body concurrent with cement fragmentation occurred at the previously kyphoplasty-treated vertebral level. Bone mineral analysis showed severe osteoporosis with a T-score of -4.0. The patient finally obtained therapeutic benefit of pain relief and bony union of T12 vertebral body by consistently adhering to anti-osteoporotic medication treatment. This case illustrated that patients who underwent kyphoplasty to treat osteoporotic vertebral compression fractures with intravertebral fracture should be strictly followed up and supervised in their anti-osteoporotic medication treatment. The interdigitation injection pattern of PMMA and sufficient PMMA filling with trabeculae in the kyphoplasty procedure also might prevent refracture of the cemented vertebrae concurrent with PMMA fragmentation.

Controversial issues in kyphoplasty and vertebroplasty in osteoporotic vertebral fractures

Kyphoplasty (KP) and vertebroplasty (VP) have been successfully employed for many years for the treatment of osteoporotic vertebral fractures. The purpose of this review is to resolve the controversial issues raised by the two randomized trials that claimed no difference between VP and SHAM procedure. In particular we compare nonsurgical management (NSM) and KP and VP, in terms of clinical parameters (pain, disability, quality of life, and new fractures), cost-effectiveness, radiological variables (kyphosis correction and vertebral height restoration), and VP versus KP for cement extravasation and complications profile. Cement types and optimal filling are analyzed and technological innovations are presented. Finally unipedicular/bipedicular techniques are compared. Conclusion. VP and KP are superior to NSM in clinical and radiological parameters and probably more cost-effective. KP is superior to VP in sagittal balance improvement and cement leaking. Complications are rare but serious adverse events have been described, so caution should be exerted. Unilateral procedures should be pursued whenever feasible. Upcoming randomized trials (CEEP, OSTEO-6, STIC-2, and VERTOS IV) will provide the missing link.

Usefulness of prone cross-table lateral radiographs in vertebral compression fractures

Background

Dynamic radiographs are recommended to investigate non-healing evidence such as the dynamic mobility or intravertebral clefts in osteoporotic vertebral compression fractures (VCFs). However, it is difficult to examine standing flexion and extension lateral radiographs due to severe pain. The use of prone cross-table lateral radiographs (PrLRs) as a diagnostic tool has never been proposed to our knowledge. The purpose of this study is to clarify the usefulness of PrLRs in diagnosis and treatment of VCFs.

Methods

We reviewed 62 VCF patients examined with PrLRs between January 1, 2008 and June 30, 2011. To compare the degree of pain provoked between standing extension lateral radiographs (StLRs) and PrLRs, numeric rating scale (NRS) scores were assessed and compared by a paired t-test. Vertebroplasty was done for 40 patients and kyphoplasty was done for 9 patients with routine manners. To assess the degree of postural reduction, vertebral wedge angles (VWA) and vertebral height ratios (VHR) were calculated by using preoperative StLRs, PrLRs, and postoperative lateral radiographs. Two variables derived from changes in VWA and VHR between preoperative and postoperative radiographs were compared by a paired t-test.

Results

The average NRS scores were 6.23 ± 1.67 in StLRs and 5.18 ± 1.47 in PrLRs. The degree of pain provocation was lower in using PrLRs than StLRs (p < 0.001). The average changes of VWA between preoperative and postoperative status were 5.24° ± 6.16° with PrLRs and 3.46° ± 3.47° with StLRs. The average changes of VHR were 0.248 ± 0.178 with PrLRs and 0.148 ± 0.161 with StLRs. The comparisons by two variables showed significant differences for both parameters (p = 0.021 and p < 0.001, respectively). The postoperative radiological status was reflected more precisely when using PrLRs than StLRs.

Conclusions

In comparison with StLR, the PrLR was more accurate in predicting the degree of restoration of postoperative vertebral heights and wedge angles, and provoked less pain during examination. The PrLR could be a useful diagnostic tool to detect intravertebral cleft or intravertebral dynamic instability.

Risk factors for the development of vertebral fractures after percutaneous vertebroplasty

We have recently observed an increased risk for vertebral fractures (VF) in a randomized controlled trial comparing the analgesic effect of vertebroplasty (VP) versus conservative treatment in symptomatic VF. The aim of the present study was to evaluate the risk factors related to the development of VF after VP in these patients. We evaluated risk factors including age, gender, bone mineral density, the number, type, and severity of vertebral deformities at baseline, the number of vertebral bodies treated, the presence and location of disk cement leakage, bone remodeling (determining bone turnover markers) and 25 hydroxyvitamin D [25(OH)D] levels at baseline in all patients. Twenty-nine radiologically new VF were observed in 17 of 57 patients undergoing VP, 72% adjacent to the VP. Patients developing VF after VP showed an increased prevalence of 25(OH)D deficiency (<20 ng/mL) and higher P1NP values. The principal factor related to the development of VF after VP in multivariate analysis was 25(OH)D levels < 20 ng/mL (RR, 15.47; 95% CI, 2.99-79.86, p < 0.0001), whereas age >80 years (RR, 3.20; 95% CI, 1.70-6.03, p = 0.0007) and glucocorticoid therapy (RR, 3.64; 95% CI, 1.61-8.26, p = 0.0055) constituted the principal factors in the overall study population. Increased risk of VF after VP was also associated with cement leakage into the inferior disk (RR, 6.14; 95% CI, 1.65-22.78, p = 0.044) and more than one vertebral body treated during VP (RR, 4.19; 95% CI, 1.03-34.3, p = 0.044). In conclusion, nearly 30% of patients with osteoporotic VF treated with VP had a new VF after the procedure. Age, especially >80 years, the presence of inferior disk cement leakage after the procedure, the number of cemented vertebrae, and low 25(OH)D serum levels were related to the development of new VF in these patients, with the latter indicating the need to correct vitamin D deficiency prior to performing VP.

In not only vertebroplasty but also kyphoplasty, the resolution of vertebral deformities depends on vertebral mobility

BACKGROUND AND PURPOSE

It has not been clarified whether the postoperative resolution of vertebral deformities achieved by KP are superior to those achieved by VP. We compared the outcomes of KP and VP, taking into account the presence of vertebral mobility, to determine whether the balloon inflation in KP may contribute to postoperative resolution of the vertebral deformities in patients with VCFs.

MATERIALS AND METHODS

The subjects had 34 vertebral bodies treated by VP, and 43 vertebral bodies treated by KP. In all patients, preoperative dynamic imaging was performed to assess the presence of vertebral mobility. First, the vertebral height restoration and kyphotic change were compared between the VP and KP groups. Then, the patients were further divided into 2 groups on the basis of the presence of vertebral mobility, and they were compared within and between the VP and KP groups in relation to the presence of vertebral mobility.

RESULTS

Overall, no significant differences were observed in either the vertebral height restoration or kyphotic change between the VP and KP groups (P > .20). Preoperative dynamic imaging identified 19 vertebral bodies each with vertebral mobility in the VP (56%) and KP groups (44%) (P = .21). Within the VP and KP groups, the vertebral height restoration and kyphotic changes were significantly better in patients with vertebral mobility than in those without (P < .01). There were no significant differences between the 2 treatment groups after adjustment for the presence of vertebral mobility (P > .30).

CONCLUSIONS

In both the VP and KP groups, the vertebral height restoration and kyphotic change largely depended on the preoperative vertebral mobility. The use of the balloon itself contributed little to resolution of the vertebral deformities.

Percutaneous Stabilization System Osseofix® for Treatment of Osteoporotic Vertebral Compression Fractures - Clinical and Radiological Results after 12 Months

Study Design

A prospective consecutive cohort study (follow-up study).

Objective

Our study investigated whether implantation of an expandable titanium mesh cage (Osseofix®) is a successful and safe minimally invasive therapy for osteoporotic vertebral compression fractures (VCF). Our experiences, clinical and radiological findings after 12 months follow-up are presented. Kypho- and vertebroplasty are well-established minimally invasive procedures for the treatment of osteoporotic VCF. The main complications associated with both procedures are uncontrolled bone cement leakage. Therefore a suitable alternative has been investigated.

Methods

During June 2010 to May 2011 24 patients were included with 32 osteoporotic VCF (T6 to L4). All of them were stabilized with the Osseofix® system. Preinterventionally we performed X-ray, MRI, and bone density measurements (DXA). Clinical and radiological results were evaluated preop., postop. and after 12 months postop. based on the Oswestry Disability Index (ODI) and the Visual Analogue Scale (VAS), X-ray (Beck Index, Cobb-angle) and CT.

Results

There was a significant improvement in the mean ODI (70,6% to 30,1%) as well as a significant reduction in pain intensity (VAS) (7,7 to 1,4) after 12 month. The mean kyphotic angle according to Cobb showed significant improvements (11,7° to 10,4°) after 12 months. Postinterventional imaging showed only one case of loss of height in a stabilized vertebral body (3.1%). We saw no changes in posterior vertebral wall or adjacent fractures. Except for one pronounced postoperative hematoma we saw no surgical complications including no cement leakage.

Conclusions

Stabilization of symptomatic osteoporotic VCF with Osseofix® system is a safe and effective procedure, even in fractures with posterior wall involvement. The clinical mid-term results are good at a very low complication rate. The Osseofix® system is an interesting alternative to the established procedures of cement augmentation.