Posterior short segment fixation including the fractured vertebra combined with kyphoplasty for unstable thoracolumbar osteoporotic burst fracture

Influence of Screw Length and Cement Position Within the Injured Vertebra on Fixation Strength in Short-Segment Fixation of Osteoporotic Thoracolumbar Burst Fractures

OBJECTIVE

The prevalence of osteoporotic vertebral fractures has increased with aging populations, necessitating effective treatments such as percutaneous kyphoplasty combined with posterior screw fixation. However, biomechanical research on the effects of using short screws on fixation stability and bone stress or on the impact of bone cement bonding to screws on structural strength is lacking. This study aimed to optimize short-segment fixation strategies for osteoporotic thoracolumbar burst fractures by analyzing the biomechanical effects of pedicle screw length and bone-cement augmentation.

METHODS

Four models of the thoracolumbar spine were established using computed tomography data of a female volunteer: 1) short screws in the injured vertebra without contact with the bone cement, 2) long screws without contact with the bone cement, 3) long screws in contact with the bone cement, and 4) long screws without the bone cement. The 4 fixation models were simulated under physiological loads. The range of motion, implant stress, and segmental stability were assessed.

RESULTS

The 3 groups containing the bone cement exhibited similar performances in terms of stability and stress distribution, whereas the group without the bone cement exhibited a poorer biomechanical performance. Incorporation of the bone cement enhanced the biomechanical properties of the structure, and short screws in the injured vertebra without contact with the bone cement did not significantly compromise the biomechanical performance.

CONCLUSIONS

Short screws in injured vertebrae without contact with the bone cement can achieve satisfactory stability and stress distribution. It is feasible to implant short screws in the injured vertebrae, reduce the number of bilaterally injured vertebrae, and inject bone cement through the non-pedicle approach during the surgical procedure, which simplifies the surgical process.

Short Fixation Using Upward/Downward Penetrating Endplate Screws and Percutaneous Vertebral Augmentation for Unstable Osteoporotic Vertebral Fractures

Introduction

Percutaneous vertebral augmentation techniques, such as balloon kyphoplasty (BKP) and vertebral body stenting (VBS), are commonly used for surgical intervention in osteoporotic vertebral fractures (OVFs). However, markedly unstable OVF cases require additional fixation procedures, prompting the exploration of combined percutaneous vertebral augmentation and posterior fixation. A novel surgical approach involving percutaneous vertebral augmentation with upward penetrating endplate screws (PES) and downward PES, complemented by a short fusion of one above one below, was developed. This study aimed to introduce and report the preliminary outcomes of this technique based on a retrospective analysis of 20 consecutive cases in the short and medium term.

Methods

Surgical indications are a vertebral wedge angle difference of 10° or more, vertebral pedicle fractures, posterior wall fractures, and diffuse low-signal changes exceeding 50% on T1-weighted magnetic resonance imaging. The procedure is reserved for highly unstable cases following a comprehensive health assessment. The surgical technique involves prone positioning, fluoroscopy-guided percutaneous vertebral augmentation, and the use of downward PES in the cranial vertebral body and upward PES for the caudal vertebral body by percutaneous technique. The fixation range is one above and one below.

Results

The case series of 20 patients, with an average follow-up period of 146.9 days, demonstrates a mean surgical time of 57 min and minimal complications. The advantages of the technique are as follows: ease of performance, minimal fixation range, and time efficiency. Risks, such as potential screw loosening and the need for prolonged follow-up, are acknowledged.

Discussion

The technique represents a promising surgical approach that balances the requirements of minimally invasive intervention and relatively robust initial fixation for elderly osteoporotic patients with unstable OVFs. While short- and medium-term results are favorable, long-term observations are needed to further assess its efficacy. This novel technique has a potential to be a valuable surgical option for unstable OVFs.

Satisfactory 2-year outcome of minimal invasive hybrid stabilization with double treated screws for unstable osteoporotic spinal fractures

PURPOSE

This study evaluates whether the fracture level alters the outcomes of minimally invasive hybrid stabilization (MIHS) with double-threaded, uncemented polyaxial screws for unstable osteoporotic vertebral fractures.

METHODS

This prospective cohort study included 73 patients (71.23% females, mean age: 79.9 ± 8.8 years) with unstable OF 3-4 fractures treated by MIHS between Nov 2015-Jan 2018. Patient characteristics, operative data, clinical outcomes, complications, radiological outcomes, and midterm (24-month) follow-up regarding functionality, pain, and quality of life were analyzed.

RESULTS

Patients had thoracolumbar (71.23%), thoracic (10.97%), and lumbar (17.8%) fractures. Operative time was < 120 min in 73.97% of patients, with blood loss < 500 ml in 97.25% of cases. No in-hospital mortality was recorded. Spine-associated complications occurred in 15.07% of patients, while 36.98% of patients had urinary tract infections (n = 12), pneumonia (n = 5), and electrolyte disturbances (n = 9). The mean length of hospital stay was 13.38 ± 7.20 days. Clinically-relevant screw loosening occurred in 1.7% of screws, and secondary adjacent fractures were diagnosed in 5.48% of patients. The alpha-angle improved significantly postoperatively (mean change: 5.4°) and remained stable for 24 months. The beta-angle improved significantly from 16.3° ± 7.5 to 10.8° ± 5.6 postoperatively but increased slightly to 14.1° ± 6.2 at midterm follow-up. Although no differences were seen regarding baseline data, clinical outcomes, and complications, fracture level significantly altered the COMI score at 24 months with no effect on pain score or quality-of-life.

CONCLUSION

MIHS using polyaxial screws is a safe treatment for single-level osteoporotic spinal fractures. Fracture level did not alter radiological reduction loss; however, it significantly altered patients' function at 24 months.

Comparison between percutaneous short-segment fixation and percutaneous vertebroplasty in treating Kummell's disease: A minimum 2-year follow-up retrospective study

BACKGROUND

Percutaneous kyphoplasty (PKP) or percutaneous short-segment fixation (PSSF) is often used to treat Kummell's disease. However, it is not clear which treatment is better for patients.

OBJECTIVE

To retrospectively compare the clinical efficacy of PVP and PSSF for the treatment of Kummell's disease.

METHOD

60 patients were involved in this research and the period of follow-up was at least 2 years. 27 of them were treated with PVP (Group I) and the rest who received PSSF (Group II). The visual analog scale (VAS) and radiographic indexes of each participant had been measured preoperatively as well as 1 week, 3 months, and 2 years postoperatively. Additionally, the Oswestry Disability Index (ODI) scores were assessed at the last time point.

RESULTS

Comparing the two groups, no statistical significance was found among all parameters preoperatively. The time of operations and blood loss is less in Group I. At each time point after operation, the imaging indices in Group II are lower (P< 0.05). One week after treatments, the VAS scores are lower in Group I, and similarly, 3 months are the same (P< 0.05), while VAS are similar at the last time point. In the aspect of ODI scores, they are lower in Group II during long-term follow-up.

CONCLUSION

For the treatment of Kummell's disease, both PVP and PSSF have been found to be effective. PVP can provide rapid pain relief with a shorter operation time. However, in cases with severe kyphosis deformity, PSSF should be given priority.

Effectiveness of the Endplate Reduction Technique Combined With Bone Grafting for the Treatment of Thoracolumbar Fractures by Using Posterior Short-Segment Fixation

Objective: This study aimed to examine the effect of the endplate reduction (EPR) technique combined with bone grafting for treating thoracolumbar burst fractures using posterior short-segmental fixation.Methods: Patients with thoracolumbar fractures admitted between January 2018 and October 2021 were retrospectively analyzed, and those meeting the criteria were assigned to the EPR group and the intermediate screws (IS) group. The vertebral wedge angle (VWA), Cobb angle (CA), anterior vertebral body height (AVBH), middle vertebral body height (MVBH), upper endplate line (UEPL), upper intervertebral angle (UIVA), and upper intervertebral disc height (UIDH) indices were examined and compared preoperatively, first day postoperatively, as well as at 12 months postoperatively.Results: The result indicated that the EPR group achieved better MVBH reduction (p < 0.001), UEPL reduction (p < 0.001), vertebral body fracture healing (p = 0.006), as well as implant breakage (p = 0.04) than the IS group; VWA (p < 0.001), CA (p = 0.005), AVBH (p < 0.001), MVBH (p < 0.001), UEPL (p < 0.001), and UIDH (p < 0.001) were lost after reduction less than those in the IS group. There was no significant difference in operative time (p = 0.315) and intraoperative bleeding (p = 0.274) between the 2 groups.Conclusion: The EPR group achieved better results in repositioning and maintaining MVBH and endplate morphology, with less correction loss after the reduction of the VWA, CA, AVBH, and endplate morphology. The EPR group exhibited a better healing pattern after vertebral fracture and disc degeneration was better relieved.

Vertebral Augmentation for Painful Type 4 Osteoporotic Compression Fractures: A Comparative Study

BACKGROUND

Type 4 osteoporotic fracture (OF4), according to the classification system of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU), is unstable and requires fixation as per the guidelines of the same group. We evaluated the use of stand-alone vertebral body augmentation (VBA) in pain control of OF4.

METHODS

This is a single-centre, in two hospitals, comparative study to evaluate the effectiveness of percutaneous vertebroplasty (PVP) and kyphoplasty (KP) in pain control of OF4. OF4 patients treated with VBA were compared to a conservatively treated control group. The two groups of OF4 were then compared to similar cohort of OF2 and OF3 patients who were treated by either VBA or expectantly.

RESULTS

A total of 78 cases were studied. VBA of OF4 showed a statistically significant better pain control than conservative treatment. The response of this group of fractures to VBA was similar to that of OF2 and 3.

CONCLUSION

VBA can provide satisfactory pain control for OF4 patients.

Time to revisit contraindications of vertebroplasty- A retrospective study of osteoporotic burst fracture operated with vertebroplasty and short segment fixation

Background

Methods

Results

Conclusions

Percutaneous Cement-Augmented Screws Short Fixation for the treatment of Severe Osteoporotic Vertebral Burst Fractures

OBJECTIVE (BACKGROUND)

This study aims to evaluate the therapeutic reliability of posterior percutaneous cement-augmented screws short fixation(PASF) in patients with severe osteoporotic vertebral burst fractures(OVBFs).

METHODS

Single-level OVBFs with an anterior vertebral body height(VBH) reduction equal or superior to 60% were included. A frailty index was employed for preoperative frailty assessment. Back pain and related disability were assessed through the VAS scale and Oswestry low-back pain disability index(ODI), being administered at injury time, preoperative, postoperative, twelfth-month and last patient follow-up evaluations. The main radiological outcomes were represented by Cobb angle(CA) and anterior vertebral body compression percentage(AVBC%), being measured at injury time, preoperative, postoperative and twelfth-month examinations. Among the others, the incidence of cement leakages and hardware failures was assessed.

RESULTS

Thirty-three patients met the inclusion criteria. All patients resulted frail(76%) or semi-frail(24%). Significant VBH restoration and segmental kyphosis improvement after PASF was documented (AVBC%:-40(-43;-37) VS -67(-70;-65), P = 0.0001; CA: 10(8-12) VS 24(23-26), P = 0.0001). The mean VAS and ODI scores documented optimal and long-enduring pain relief and related disability reduction after PASF (VAS: 2(2-3) VS 8(7-8), P = 0.0001; ODI: 22(17-26) VS 64(60-69), P = 0.0001). Only one cement leakage (3%), asymptomatic, occurred. After a mean follow-up of 33 months, no early/late hardware failures were reported.

CONCLUSIONS

The clinical and radiological results of this study suggest that PASF could be a safe and effective treatment option for severe OVBFs when conservative treatments failed.

Long-segment fixation VS short-segment fixation combined with kyphoplasty for osteoporotic thoracolumbar burst fracture

Background

To retrospectively compare clinical and radiological results of long-segment fixation (LF) and six-screw short-segment fixation combined with kyphoplasty (SSFK) for osteoporotic thoracolumbar burst fracture (OTBF).

Methods

Forty patients affected by OTBF with mean age of 61.85 years were included in this study. The mean follow-up period was 13.63 months. Twenty-four patients were treated by SSFK, and 16 patients were treated by LF. Clinical outcomes, radiological parameters and complications were assessed and compared.

Results

The mean operative time and blood loss were 89.71 ± 7.62 min and 143.75 ± 42.51 ml for SSFK group, respectively; 111.69 ± 12.25 min (P < 0.01) and 259.38 ± 49.05 ml (P < 0.01) for LF group, respectively. The two groups were similar in terms of preoperative radiological and clinical results. Compared with preoperative values, both groups achieved significant improvement in terms of VAS, ODI, Cobb angle and anterior vertebral body height (AVH) ratio at final follow-up. However, during the follow-up period, significant loss of Cobb angle and AVH ratio were observed for both groups. Five cases (20.83%) of asymptomatic cement leakage were observed in SSFK group. One case of implant failure and two cases of adjacent or non-adjacent vertebral fractures were observed in LF group.

Conclusions

Both SSFK and LF are safe and effective for treatment of OTBF. Comparatively, SSFK is less invasive and can preserve more motion segments, which may be a more valuable surgical option in some elderly patients. A high-quality randomized controlled study is required to confirm our finding in the future.