An anatomical study on lumbar arteries related to the extrapedicular approach applied during lumbar PVP (PKP)

The new clinical classification of metastatic spinal malignancies serves as a vital reference for surgical management: a retrospective case-control study

BACKGROUND

It is commonly accepted that surgical treatment is an essential component of the comprehensive management of metastatic spinal malignancies. However, up until now, the clinical classification of metastatic spinal malignancies has not been well-structured.

METHODS

After IRB approval, 86 patients with metastatic spinal malignancies were adopted. According to the vascular distribution, stability of vertebrae, and degree of nerve compression, metastatic spinal malignancies can be classified into five types. Tumors classified as type I typically appear in the vertebral body. Type II tumors are those that develop in the transverse processes, superior and inferior articular processes, and spinal pedicles. Type III denotes malignancies that are present in the spinous process and vertebral plate. Types IVa and IVb are included in type IV. Type IVa combines type I and type II, whereas type IVb combines type II and type III. Type V tumors are those of types I, II, and III that co-occur and spread in different directions into the spinal canal. 20 of included 86 patients who did not receive segmental arterial embolization were set as the non-embolization group. The embolization group included 24 patients who received segmental arterial embolization on both sides of the diseased vertebrae. 42 patients were included in the offending embolization group after receiving responsible arterial embolization. A surgical intervention was performed within 24 h following an embolization. Surgical intervention with the purpose of removing as much of the tumor as possible and providing an effective reconstruction of the spinal column.

RESULTS

In comparison with the non-embolization group and embolization group, the offending embolization group presented unique advantages in terms of bleeding volume (p<0.001), operation time (p<0.001), and local recurrence rate within 12 months (p=0.006).

CONCLUSION

By significantly reducing surgical trauma and local recurrence rate (12 months), responsible arterial vascular embolization procedures together with associated surgical protocols developed on the basis of the clinical classification of metastatic spinal malignancies, are worthy of clinical dissemination.

A novel puncture approach via point "O" for percutaneous kyphoplasty in patients with L4 or L5 osteoporotic vertebral compression fracture

This study introduced a novel point "O" puncture approach for percutaneous kyphoplasty (PKP) in patients with L4 or L5 osteoporotic vertebral compression fracture (OVCF) and evaluated its clinical and radiographic outcomes. Between September 2019 and December 2020, we compared the clinical and radiographic outcomes in 31 cases (36 vertebrae) using the "O" entry point PKP intervention (O-PKP) and 31 cases (37 vertebrae) using transverse the process-pedicle approach PKP intervention (T-PKP). No serious postoperative complications were observed in any of the participants. Only two T-PKP patients experienced intervertebral disc space leakage. Compared with the T-PKP patients, the O-PKP patients showed shorter operative time and fluoroscopy times (P < 0.05), comparable blood loss and cement volume (P > 0.05), improved VAS and ODI scores at the final follow-up (P < 0.05), better increases in the vertebral compression ratio (P < 0.05), comparable Cobb angle (P > 0.05), comparable anteroposterior bone cement distribution, enhanced bilateral bone cement distribution (P < 0.05), and larger sagittal and transverse angles (P < 0.05). Herein, O-PKP was indicated for patients with L4 or L5 OVCF. This puncture approach showed significant advantages over T-PKP not only in terms of pain relief, surgery and fluoroscopy times but also in the puncture angle, vertebral reconstruction, and symmetrical cement distribution.

A Comparison Between Modified Unilateral Extrapedicular and Bilateral Transpedicular Percutaneous Kyphoplasty in the Treatment of Lumbar Osteoporotic Vertebral Compression Fracture

BACKGROUND

Few researchers have verified the clinical efficacy and safety of the modified unilateral extrapedicular approach (mUEP) applied to the percutaneous kyphoplasty (PKP) in comparative studies with other puncture techniques. Compared with the bilateral transpedicular approach (BTP), whether mUEP PKP is a preferred treatment for lumbar osteoporotic vertebral compression fracture (OVCF) remains unclear.

METHODS

Patients treated by PKP for single-level lumbar OVCF in our institution from September 2019 to December 2020 were retrospectively enrolled. Patients were grouped according to the puncture techniques. Clinical and radiologic outcomes were evaluated preoperatively, postoperatively, and at follow-up. The clinical evaluation was performed by using visual analog scale for pain relief and Oswestry Disability Index for health status. Radiologic measurements contained anterior vertebral height, kyphotic angle, and bone cement distribution.

RESULTS

In total, 76 patients with a mean follow-up duration of 16.6 months were enrolled, including 34 patients in the mUEP PK group and 42 patients in the BTP PKP group. In the mUEP group, operation time, fluoroscopy times, and injected cement volume were significantly less than that in the BTP group (P < 0.01). Both visual analog scale and Oswestry Disability Index scores of all patients decreased significantly after surgery (P < 0.01), with no significant differences between the 2 groups at each follow-up. Both mUEP PKP and BTP PKP showed significant anterior height restoration and kyphotic angle correction (P < 0.01), with no significant differences between the 2 groups at each follow-up. Meanwhile, the mUEP PKP reduced the incidence of intraspinal cement leakage (P < 0.05), and no facet joint violation was found in mUEP PKP.

CONCLUSIONS

mUEP PKP could be clinically and radiographically equivalent to BTP PKP. However, it has advantages in reducing operation time and fluoroscopy times, lowering the risk of intraspinal cement leakage, and preventing the presence of facet joint violation. Compared with BTP PKP, the mUEP PKP seems to be an effective and alternative puncture technique for the treatment of lumbar OVCF after appropriate patient selection.

A modified trajectory of kyphoplasty via superior pedicle notch for osteoporotic vertebral compression fractures: Technique note and clinical result

Background

Percutaneous extra-pedicular kyphoplasty can achieve better clinical results than transpedicular kyphoplasty. However, lumbar segment artery injury as a disaster complication limits its clinical application.

Objective

To describe and evaluate a modified trajectory of kyphoplasty for the treatment of osteoporotic vertebral compression fractures (OVCF).

Methods

Eighty-one patients who underwent percutaneous kyphoplasty (PKP) for lumbar OVCF at our hospital between May 2017 and May 2021 were enrolled. The patients were divided into an observation group (via the superior pedicle approach) and a control group (via the transpedicular approach) according to the surgical trajectory. The surgical procedure was described in detail, and the imaging parameters were recorded. Preoperative and postoperative clinical data were collected for statistical analysis.

Results

PKP via the superior pedicle notch approach could offer large abduction and cranial inclination angles without serious complications. The rate of paravertebral leakage was significantly lower in the observation group than in the control group. Surgery with a superior pedicle notch approach had a shorter operative time and fewer fluoroscopies.

Conclusions

PKP via the superior pedicle notch approach is a modified extra-pedicular approach for lumbar osteoporotic vertebral compression fractures. This trajectory is an easy-to-use target position because it enters the vertebral body directly. A shorter operative time and lower radiation exposure can enhance recovery after surgery.

A Study on the Anatomical Relationship of the Lumbar Extrapedicular Puncture Approach with the Spinal Nerve and its Branches

The anatomical relationship of the extrapedicular approach with the spinal nerve and its branches was researched in cadavers. Three types of extrapedicular paths were simulated: puncture inside the medial branch (MB), puncture outside the MB, and puncture outside the lateral branch (LB). At L1-L3, puncture outside the LB could avoid damage to these nerves.

Unilateral percutaneous vertebroplasty for osteoporotic lumbar compression fractures: a comparative study between transverse process root-pedicle approach and conventional transpedicular approach

Purpose

Percutaneous vertebroplasty (PVP) is a routine operation for the treatment of osteoporotic lumbar compression fractures (OLCFs). As is well known, unilateral puncture is a common method. However, with the conventional transpedicular approach (CTPA), the cement may be asymmetrically dispersed, so some surgeons use the transverse process root-pedicle approach (TPRPA). The objective of this study was to compare the clinical results and bone cement distribution of PVP for OLCF with unilateral TPRPA and CTPA to identify the advantages and disadvantages of the two surgical options.

Patients and methods

From January 2016 to June 2019, seventy-two elderly patients who underwent unilateral PVP for single-level OLCF were retrospectively reviewed. Operation time, injection amount and type of bone cement distribution, and bone cement leakage and surgical complications were recorded. The visual analog scale (VAS) scores and Oswestry disability index (ODI) scores were used to evaluate the clinical results. All patients were followed up for more than 12 months, and the assessment was based primarily on clinical and radiological outcomes.

Results

There were significant differences in the surgical time and the volume and the type of bone cement distribution and the lost of operative vertebra height between the two groups. However, there was no significant difference in bone cement leakage. Moreover, there were no significant differences in VAS and ODI between the two groups at 2 days and 12 months after the operation.

Conclusions

Unilateral TPRPA and CTPA are practical and feasible methods in PVP for the treatment of OLCF, and they have similar clinical effects. However, TPRPA has the advantages of a better distribution of bone cement and a shorter operation time and a better maintenance effect of injured vertebra height, without increasing the rate of bone cement leakage.

Modified extrapedicular kyphoplasty for the treatment of lumbar compression fracture: Case report and technical note

RATIONALE

Traditionally, transpedicular approach was used in the treatment of osteoporotic lumbar compression fracture. In order to avoid the risks of pedicle disruption and spinal canal intrusion, extrapedicular approache has been attempted. The aim of the article is to present the modified extrapedicular kyphoplasty technique for the treatment of osteoporotic lumbar compression fracture.

PATIENT CONCERNS

A 62-year-old woman suffered from severe low back pain after an accidental fall 10 days ago. Low back pain was obvious when turning over and getting out of bed. It was not relieved after bed rest and conservative treatment. Visual analog scale (VAS) of low back pain was 8 points and Oswestry disability index score was 80%.

DIAGNOSIS

Magnetic resonance imaging showed osteoporotic vertebral compression fracture of L2 and L3.

INTERVENTIONS

We performed modified extrapedicular kyphoplasty for the patient. The technique has a standardized operating procedure. The puncture point of skin is determined according to preoperative computer tomography and X-ray. The puncture point of vertebral body is located at the outer upper edge of the pedicle. The puncture direction is from the upper edge of the pedicle to the lower edge of the contralateral pedicle.

OUTCOMES

The operation time was 20 minutes. The intraoperative blood loss was 5 mL. The amount of bone cement was 4 mL in L2 and 5 mL in L3. VAS of low back pain was 2 points in 1 day after surgery. Preoperative symptoms were significantly improved.

LESSONS

Modified extrapedicular kyphoplasty is a safe and effective technique for the treatment of osteoporotic lumbar compression fracture, which should be promoted and applied.