Balloon Kyphoplasty vs Vertebroplasty: A Systematic Review of Height Restoration in Osteoporotic Vertebral Compression Fractures

A novel assessment system for osteoporotic vertebral compression fractures

The objective of this study was to introduce and validate a novel developed scoring system tailored specifically for osteoporotic vertebral compression fractures (OVCFs), aiming to provide guidance for treatment selection. A retrospective analysis spanning from March 2016 to March 2021 was conducted on 208 patients diagnosed with osteoporotic vertebral compression fractures (OVCFs) who received conservative treatment. Patients were categorized into low-score (47 cases), medium-score (98 cases), and high-score (63 cases) groups based on the Novel Assessment System for OVCFs (NASOVCF) scores. Comparative analyses of radiographic and clinical data were performed, and logistic regression analysis was used to determine the risk factors for bone non-union and progressive kyphosis. The high-score group exhibited significantly inferior outcomes, characterized by higher Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) scores (P < 0.05), increased vertebral height loss, and kyphosis angle differences compared to the low and medium-score groups (P < 0.05). Notably, a bone union rate of 38.1% (24/63) was observed in the high-score group, significantly lower than that of the low-score group (97.9%, 46/47). Furthermore, the progressive kyphosis rate was 47.6% (30/63) in the high-score group, significantly higher than the 17.3% (17/98) observed in the medium-score group and the 2.2% (1/46) observed in the low-score group. In multivariate analysis, higher NASOVCF score emerged as an independent risk factor for bone non-union (OR = 1.713, 95% CI 1.458-2.013, P < 0.001). Similarly, higher NASOVCF score (OR = 1.373, 95% CI 1.203-1.568, P < 0.001), along with female gender and higher pre-treatment ODI score, were identified as independent risk factors for progressive kyphosis. The area under the curve (AUC) for bone non-union and progressive kyphosis were 0.895 and 0.835, respectively, indicating robust discriminative performances. Higher NASOVCF score was identified as a significant risk factor for non-union and progressive kyphosis following conservative treatment in OVCFs. NASOVCF score emerged as a crucial predictor for adverse outcomes in patients at high risk who underwent conservative management. Surgical interventions such as vertebral augmentation may represent a potentially superior option for individuals with high NASOVCF scores.

Prediction models for adjacent vertebral fractures after vertebral augmentation: a systematic review and meta-analysis

OBJECTIVE

To systematically review published studies on risk prediction models for adjacent vertebral fractures (AVF) after vertebral augmentation (VA), thereby providing a reference for constructing and improving such models.

METHODS

PubMed, Web of Science, The Cochrane Library, Embase, China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database (VIP), Wanfang Database, and SinoMed were searched from their inception to July 13, 2024. The Prediction Model Risk of Bias Assessment Tool (PROBAST) was used to assess the risk of bias and applicability of the prediction model studies; STATA 15.0 software was used to perform a meta-analysis on the area under the curve (AUC) values of the model validation and the common predictors used in model construction.

RESULTS

A total of 13 studies were included, establishing 13 risk prediction models, with a total sample size of 3,083 patients. The AUC values of the included models ranged from 0.72 to 0.988. Of the included studies, 11 conducted internal validation, while two performed external validation. According to the PROBAST evaluation, all 13 studies exhibited a high risk of bias, yet demonstrated good applicability. The results of meta-analysis showed that the combined AUC value for the 5 validation models was 0.86 (95% CI: 0.76, 0.97). Notably, bone cement leakage (OR = 5.75, 95% CI: 3.43 ~ 9.60), age (OR = 1.20, 95% CI: 1.05 ~ 1.36), and a history of vertebral fractures (OR = 2.60, 95% CI: 1.64 ~ 4.13) were identified as significant high-risk factors for AVF after VA.

CONCLUSION

The risk prediction models for AVF after VA performed well, but exhibited a high risk of bias. It is recommended that future studies should consider selecting more appropriate machine learning algorithms and conducting large-sample, multicenter studies. Meanwhile, healthcare providers should focus on patients with bone cement leakage, advanced age, and a previous history of vertebral fractures, remaining vigilant for the potential occurrence of AVF.

Re-evaluating vertebral height restoration assessment in osteoporotic compression fractures: a systematic review and meta-analysis

PURPOSE

Vertebral compression fractures (VCFs) are common among the elderly, causing significant morbidity, pain, and disability. This study quantitatively analyzes the vertebral height restoration via Kyphoplasty (KP) and Vertebroplasty (VP), along with the cement volume used and leakage percentage. Our meta-analysis of 14 randomized controlled trials (RCTs) compares these objective outcomes, considering cement volume and leakage in both procedures.

METHODS

Databases searched included Medline, PubMed, and Web of Science using MeSH keywords: 'Kyphoplasty,' 'Vertebroplasty,' 'Vertebral height restoration,' 'Bone cement volume,' and 'Vertebral compression fractures.' Fourteen RCTs were selected, focusing on outcomes such as anterior and central vertebral body height, kyphotic angle, cement volume, and leakage. Data analysis included mean values, standard deviations, ranges, Cohen's d-effect sizes, and standard errors, summarized in a forest plotQuery.

RESULTS

The review included 1456 patients (mean age 71.11 years). Follow-up ranged from 1 to 48 months (mean 15 months). KP showed a greater effect size in restoring anterior and central vertebral body height and kyphotic angle. Combined data from KP and VP showed increases of 3.48 mm (19.14%) in anterior vertebral heights, 4.38 mm in central vertebral heights, and a 2.85-degree correction in kyphotic angle.

CONCLUSIONS

Both KP and VP effectively restore vertebral height in VCF patients. KP is superior in restoring anterior and central vertebral body height and correcting kyphotic angle. VP, particularly unilateral, shows higher central vertebral height restoration but higher cement leakage. Standardized reporting and patient-specific volumetric assessments are crucial for optimizing vertebral augmentation procedures.

Safety and Efficacy of Balloon-Assisted Kyphoplasty Followed by Stereotactic Body Radiation Therapy for Pathological Fractures

BACKGROUND AND OBJECTIVES

In patients experiencing pain secondary to pathological compression fractures, balloon-assisted kyphoplasty and subsequent stereotactic body radiation therapy (SBRT) may allow for restoration of vertebral height and irradiation of the underlying malignancy to control local disease progression. The aim of this study was to evaluate the safety and efficacy of kyphoplasty treatment before SBRT in patients with spinal metastases and benign tumors.

METHODS

An analysis of a prospectively collected database of 70 patients and 75 metastatic and benign spinal lesions that underwent kyphoplasty before SBRT at a single institution (2002-2023) was conducted. Patient characteristics were recorded, including treatment history, dosimetry and fractionation schedule, pain outcomes, local control (LC), and overall survival. The Bilsky score and Spinal Instability Neoplastic Score were calculated to assess epidural involvement and spinal stability, respectively.

RESULTS

The median time from kyphoplasty to SBRT was 29 days (range: 2-159). Seventy-two lesions (96%) were managed with single-fraction SBRT and 3 lesions (4%) with a multifraction regimen. The median single-fraction prescription dose was 20 Gy (range: 12-25) delivered to a median tumor volume of 35.1 cc (range: 2.2-160). After a median follow-up period of 9 months (range: 1-201), 6 lesions (8%) locally progressed. Pain was reported to improve or remain stable for most patients (88%). The LC rate was 88% at 6 months, 1 year, and 2 years. No prognostic factors were significantly associated with LC. The median overall survival was 11 months (range: 1-201) after radiosurgery. There were no reports of cement extravasation or radiation-induced neurological deficit. Two acute pain flares (3%) were reported 1 and 3 months after radiosurgery.

CONCLUSION

The combined kyphoplasty and SBRT treatment paradigm can be used to treat patients with painful pathological compression fractures. Long-term LC and patient-reported improvement in pain were observed without the morbidity associated with open surgery.

Association between vertebral bone quality score and residual back pain following percutaneous vertebroplasty for osteoporotic vertebral compression fractures

BACKGROUND

Residual back pain (RBP) is one of the complications following percutaneous vertebroplasty (PVP) in older people with osteoporotic vertebral compression fractures (OVCFs). The vertebral bone quality (VBQ) score obtained from magnetic resonance imaging (MRI) can be used to evaluate bone quality. The objective of this study aimed to explore the potential relationship between the VBQ score and RBP after PVP.

METHODS

From January 2018 to January 2022, patients with OVCFs who underwent PVP in our hospital were retrospectively reviewed. Each patient's lumbar VBQ score was recorded. The RBP was defined as a visual analog scale (VAS) score ≥ 4 for back pain postoperatively. Other variables included demographic, clinical, radiological, and surgical data. The univariate and multivariate logistic regression analyses were used to determine the independent risk factors.

RESULTS

The incidence of RBP was 8.0% among 598 patients. The results of the multivariate regression analysis showed that preoperative VBQ score (OR 3.295, P < 0.001), BMD (OR 0.545, P = 0.007), lumbodorsal fascia contusion (OR 4.297, P = 0.034), and cement distribution (OR 4.556, P = 0.006) were risk factors associated with RBP after PVP.

CONCLUSIONS

The preoperative high VBQ score was an independent risk factor associated with RBP after PVP. Moreover, other risk factors included low BMD, lumbodorsal fascia contusion, and cement distribution. The MRI-VBQ score may serve as a useful tool for assisting in evaluating patients at risk of RBP following PVP.

A relevant investigation of the degree of cement diffusion after robot-assisted percutaneous vertebroplasty

The aim of this research was to conduct randomized trials assessing the extent of cement diffusion following robot-assisted percutaneous vertebroplasty (R-PVP) for osteoporotic vertebral compression fractures (OVCF). A total of 96 OVCF patients meeting the inclusion criteria and admitted between January 2023 and November 2023 were included in the study. Among them, 48 patients were assigned to the robotic-assisted PVP group (R-PVP group) and 48 patients were assigned to the traditional PVP group (PVP group). The study examined the differences in age, sex, BMD T-value, fracture segment, preoperative, postoperative, and 3-month postoperative visual analogue scale (VAS) and Oswestry disability index (ODI) pain scores, fluoroscopic dose, frequency of fluoroscopy, volume of bone cement injected, angle of puncture abduction, degree of cement diffusion, and bone cement spillage among the two patient groups. A logistic regression model was employed to analyze the factors influencing the extent of postoperative bone cement diffusion. The findings indicated that the R-PVP group exhibited a significantly larger puncture abduction angle, improved postoperative cement dispersion, increased cement injection volume, and decreased incidence of cement spillage compared to the PVP group. Furthermore, the R-PVP group demonstrated superior outcomes in these aspects, as well as lower intraoperative fluoroscopic frequency and radiation exposure. Additionally, bone density, puncture abduction angle, cement injection volume, and surgical approach were identified as independent factors associated with the extent of postoperative cement dispersion.

Analysis of injected cement volume and clinical outcomes following balloon-assisted kyphoplasty in a series of 368 patients

OBJECTIVE

Balloon-assisted kyphoplasty (BAK) is a modified vertebroplasty technique developed to treat vertebral compression fractures (VCFs) secondary to osteoporosis. This study investigates the association between injected cement volume and the development of subsequent VCFs after BAK.

METHODS

A retrospective analysis of 368 patients who underwent BAK at a single institution was performed from 2001 to 2021. Inclusion was defined by at least 2 years of follow-up. Clinical characteristics and outcomes following BAK, including subsequent fractures at adjacent and remote levels, were identified. Patients that underwent a thoracic BAK were stratified by injected cement volume: below or equal to the median (≤ 6.0 mL, 265 vertebrae) or above the median (> 6.0 mL, 144 vertebrae). Patients that underwent a lumbar BAK were similarly stratified: below or equal to the median (≤ 8.0 mL, 233 vertebrae) or above the median (>8.0 mL, 160 vertebrae).

RESULTS

A total of 802 vertebrae were treated. The average volume of cement was recorded in the thoracic (6.2 ± 1.9 mL) and lumbar (7.8 ± 1.8 mL) vertebrae. In the thoracic spine, vertebrae that were injected with > 6.0 mL of cement underwent a greater change in local kyphotic angle (P = 0.0001) and were more likely to develop adjacent-level VCFs (P = 0.032) after kyphoplasty. Univariate analysis did not elucidate any additional risk factors. There were no statistical differences in clinical outcomes between the three groups of lumbar vertebrae.

CONCLUSIONS

Larger volumes of injected cement were associated with a greater change in local kyphosis and subsequent adjacent-level fractures after BAK in the thoracic spine. This association was not found in the lumbar spine. Close attention to injected cement volumes must be made in the thoracic spine and patients who undergo significant kyphotic correction should be carefully observed postoperatively.

Comparison of the clinical effect of unilateral transverse process extrapedicular and bilateral transpedicular percutaneous kyphoplasty for thoracolumbar osteoporotic vertebral compression fracture

Background

Osteoporosis vertebral compression fractures (OVCF) are common with the aging process. This study aimed to compare the effects of unilateral transverse process extrapedicular (UEPKP) and bilateral transpedicular percutaneous kyphoplasty (BTPKP) for patients with thoracolumbar OVCF.

Methods

Data from 136 patients with OVCF treated with single-level PKP in our hospital between May 2019 and April 2021 were studied. Patients were grouped based on surgical procedure: there were 62 patients in the UEPKP group and 74 in the BTPKP group. All clinical and radiological data were collected from medical records. Clinical outcomes, including visual analog scale (VAS), Oswestry Disability Index (ODI), and Japanese Orthopaedic Association (JOA) scores of the lumbar spine, were evaluated preoperatively, postoperatively, and at the follow-up visit. The radiological evaluations (anterior vertebral height rate and local kyphosis angle) and complications were also collected.

Results

All patients had successfully improved after surgery. In the UEPKP group, patients showed a significantly shorter operating time and lower fluoroscopy frequency than patients in the BTPKP group (p < 0.05). However, a significantly better distribution score and cement volume were found in the BTPKP group (p < 0.05). The UEPKP group achieved a significantly better VAS score (0.6 ± 0.5 vs. 0.9 ± 0.8) and ODI (24.7 ± 3.1 vs. 27.5 ± 1.8) at the final follow-up visit than the BTPKP group (p < 0.05). The UEPKP group showed significantly worse radiological outcomes (anterior height rate and local kyphosis angle) at the 6- and 12-month follow-ups (p < 0.05). As for complications, the UEPKP group showed significantly fewer facet joint violations and intraspinal leakages (p < 0.05).

Conclusion

UEPKP could be a safe and effective alternative procedure for patients with thoracolumbar osteoporotic vertebral compression fracture, which possesses an apparent advantage in reducing intraspinal leakage and facet joint violation over BTPKP.

Clinical efficacy of percutaneous vertebroplasty versus percutaneous kyphoplasty treating osteoporotic vertebral compression fractures with kyphosis

PURPOSE

This study aimed to investigate the clinical efficacy of percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) in treating osteoporotic vertebral compression fractures (OVCFs) with kyphosis.

METHODS

The clinical data included 63 patients in the PVP group and 70 in the PKP group. The study assessed the pain visual analog scale (VAS), Oswestry Disability Index (ODI), wedge angle (WA), local kyphotic angle (LKA), and vertebral height.

RESULTS

The operative time was significantly less in the PVP group (p < 0.05). Meanwhile, more bone cement was injected into the PKP group (p < 0.05), with significantly higher surgical costs (p > 0.05). Post-operative VAS, ODI, WA, LKA, and vertebral height were significantly improved in PVP and PKP groups compared with pre-operative measurements (p < 0.05). The results revealed insignificant VAS and ODI improvement differences between the two groups at each follow-up time (p > 0.05). Vertebral height, WA, and LKA improved more significantly in the PKP group at day 1 and 3 months post-operatively (p < 0.05), with insignificant group differences at subsequent time points (p > 0.05). The improvements in VAS were unrelated to those in WA, LKA, or vertebral height in either group (p > 0.05). The improvement in VAS was unrelated to the amount of bone cement injected (p > 0.05); the PKP group demonstrated a lower incidence of cement leakage (12.9%; p < 0.05).

CONCLUSION

PVP and PKP can restore partial vertebral height and improve kyphosis with similar clinical outcomes. PVP has a shorter operating time, is more economical, and can represent a therapeutic choice.

Health Care Fraud and Abuse: Lessons From One of the Largest Scandals of the 21st Century in the Field of Spine Surgery

Up to hundreds of billions of dollars are annually lost to fraud and abuse in the US health care, making it a significant burden on the system. This study investigates a specific instance of health care fraud in spine surgery, in which a medical device company ended up paying $75 million to settle violations of the False Claims Act. We review the surgical background regarding the kyphoplasty procedure, as well as its billing and reimbursement details. We also explore the official legal complaint brought by the US Department of Justice to tell the story of how one of the most significant medical innovations in spine surgery in the 21st century turned into a widespread fraudulent marketing scheme. In the sequence, we provide a detailed root cause analysis of this scandal and propose some proactive measures that can be taken to avoid such type of unfortunate events. Ultimately, this historical health care scandal constitutes a valuable lesson to surgeons, health care administrators, medical device companies, and policymakers on how misaligned incentives and subsequent unscrupulous practices can transform a medical innovation into an unfortunate tale of fraud and deceit.

Kyphoplasty is associated with reduced mortality risk for osteoporotic vertebral compression fractures: a systematic review and meta-analysis

BACKGROUND

Vertebral augmentation, such as vertebroplasty (VP) or kyphoplasty (KP), has been utilized for decades to treat OVCFs; however, the precise impact of this procedure on reducing mortality risk remains a topic of controversy. This study aimed to explore the potential protective effects of vertebral augmentation on mortality in patients with osteoporotic vertebral compression fractures (OVCFs) using a large-scale meta-analysis.

MATERIALS AND METHODS

Cochrane Library, Embase, MEDLINE, PubMed and Web of Science databases were employed for literature exploration until May 2023. The hazard ratios (HRs) and 95% confidence intervals (CIs) were utilized as a summary statistic via random-effect models. Statistical analysis was executed using Review Manager 5.3 software.

RESULTS

After rigorous screening, a total of five studies with substantial sample sizes were included in the quantitative meta-analysis. The total number of participants included in the study was an 2,421,178, comprising of 42,934 cases of vertebral augmentation and 1,991,244 instances of non-operative management. The surgical intervention was found to be significantly associated with an 18% reduction in the risk of mortality (HR 0.82; 95% CI 0.78, 0.85). Subgroup analysis revealed a remarkable 71% reduction in mortality risk following surgical intervention during short-term follow-up (HR 0.29; 95% CI 0.26, 0.32). Furthermore, KP exhibited a superior and more credible decrease in the risk of mortality when compared to VP treatment.

CONCLUSIONS

Based on a comprehensive analysis of large samples, vertebral augmentation has been shown to significantly reduce the mortality risk associated with OVCFs, particularly in the early stages following fractures. Furthermore, it has been demonstrated that KP is more reliable and effective than VP in terms of mitigating mortality risk.

Clinical significance of cement leakage in kyphoplasty and vertebroplasty: a systematic review

BACKGROUND

Osteoporotic vertebral compression fractures affect a large number of elderly people and cause significant issues with pain and mobility. Percutaneous vertebroplasty (PVP) and kyphoplasty (PKP) are employed to treat those who remain symptomatic, with comparable clinical outcomes. Although PVP is faster and less expensive, concerns around cement-leakage complications make PKP perceptively safer.

METHODS

By means of systematic review, we sought to ascertain whether PVP did carry a higher risk of cement-leakage and associated symptomatic complications (neural compromise, pulmonary embolism and need for emergency decompression surgery).

RESULTS

Our search of 138 articles returned six studies after shortlisting and manual review: three randomised-controlled trials, and three retrospective comparative studies which met our criteria and directly compared cement-leakage rates and complications between the two treatments. 532 PVPs and 493 PKPs recorded 213 (39.3%) and 143 (28.9%) leaks, respectively (p < 0.0005). Of these, no leaks resulted in any of the aforementioned leak-related complications. No meta-analysis was performed due to heterogeneity of the data.

CONCLUSIONS

We therefore concluded that whilst PVP does result in more cement leaks, this does not appear to be clinically significant. Further studies would add weight to this conclusion, and cost-effectiveness should be assessed to restore confidence in PVP.

LEVEL OF EVIDENCE

Level III Evidence.

Retrospective Cohort Study of Early versus Delayed Ballon Kyphoplasty Intervention for Osteoporotic Vertebral Fracture Treatment

Objectives: To investigate the outcomes of early balloon kyphoplasty (BKP) intervention compared with late intervention for osteoporotic vertebral fracture (OVF). Background: Osteoporotic vertebral fracture can lead to kyphotic deformity, severe back pain, depression, and disturbances in activities of daily living (ADL). Balloon kyphoplasty has been widely utilized to treat symptomatic OVFs and has proven to be a very effective surgical option for this condition. Furthermore, BKP is relatively a safe and effective method due to its reduced acrylic cement leakage and greater kyphosis correction. Materials and Methods: A retrospective cohort study was conducted at our hospital for patients who underwent BKP for osteoporotic vertebral fractures in the time frame between January 2020 and December 2022. Ninety-nine patients were included in this study, and they were classified into two groups: in total, 36 patients underwent early BKP intervention (EI) at <4 weeks, and 63 patients underwent late BKP intervention (LI) at ≥4 weeks. We performed a clinical, radiological and statistical comparative evaluation for the both groups with a mean follow-up of one year. Results: Adjacent segmental fractures were more frequently observed in the LI group compared to the EI group (33.3% vs. 13.9%, p = 0.034). There was a significant improvement in postoperative vertebral angles in both groups (p = 0.036). The cement volume injected was 7.42 mL in the EI, compared with 6.3 mL in the LI (p = 0.007). The mean surgery time was shorter in the EI, at 30.2 min, compared with 37.1 min for the LI, presenting a significant difference (p = 0.0004). There was no statistical difference in the pain visual analog scale (VAS) between the two groups (p = 0.711), and there was no statistical difference in cement leakage (p = 0.192). Conclusions/Level of Evidence: Early BKP for OVF treatment may achieve better outcomes and fewer adjacent segmental fractures than delayed intervention.

Treatment for Osteoporotic Vertebral Fracture - A Short Review of Orthosis and Percutaneous Vertebroplasty and Balloon Kyphoplasty

The management of osteoporotic vertebral fractures (OVFs) in the elderly includes nonoperative treatment and vertebroplasty, but has not been established due to the diversity of patient backgrounds. The purpose of this study was to compare the impact of 3 treatment modalities for the management of OVF: orthotic treatment, percutaneous vertebroplasty (PVP), and balloon kyphoplasty (BKP). The method was based on an analysis of the latest RCTs, meta-analyses, and systematic reviews on these topics. No study showed a benefit of bracing with high level of evidence. Trials were found that showed comparable outcomes without orthotic treatment. Only 1 randomized controlled trial (RCT) showed an improvement in pain relief up to 6 months compared with no orthosis. Rigid and nonrigid orthoses were equally effective. Four of 5 RCTs comparing vertebroplasty and sham surgery were equally effective, and one RCT showed superior pain relief with vertebroplasty within 3 weeks of onset. In open trials comparing vertebroplasty with nonoperative management, vertebroplasty was superior. PVP and BKP were comparable in terms of pain relief, improvement in quality of life, and adjacent vertebral fractures. BKP does not affect global sagittal alignment, although BKP may restore vertebral body height. An RCT was published showing that PVP was effective in chronic cases without pain relief. Vertebroplasty improved life expectancy by 22% at 10 years. The superiority of orthotic therapy for OVF was seen only in short-term pain relief. Soft orthoses proved to be a viable alternative to rigid orthoses. Vertebroplasty within 3 weeks may be useful. There is no significant difference in clinical efficacy between PVP and BKP. Vertebroplasty improves life expectancy.

Augmented Reality in Neurosurgery: A New Paradigm for Training

Augmented reality (AR) involves the overlay of computer-generated images onto the user's real-world visual field to modify or enhance the user's visual experience. With respect to neurosurgery, AR integrates preoperative and intraoperative imaging data to create an enriched surgical experience that has been shown to improve surgical planning, refine neuronavigation, and reduce operation time. In addition, AR has the potential to serve as a valuable training tool for neurosurgeons in a way that minimizes patient risk while facilitating comprehensive training opportunities. The increased use of AR in neurosurgery over the past decade has led to innovative research endeavors aiming to develop novel, more efficient AR systems while also improving and refining present ones. In this review, we provide a concise overview of AR, detail current and emerging uses of AR in neurosurgery and neurosurgical training, discuss the limitations of AR, and provide future research directions. Following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), 386 articles were initially identified. Two independent reviewers (GH and AC) assessed article eligibility for inclusion, and 31 articles are included in this review. The literature search included original (retrospective and prospective) articles and case reports published in English between 2013 and 2023. AR assistance has shown promise within neuro-oncology, spinal neurosurgery, neurovascular surgery, skull-base surgery, and pediatric neurosurgery. Intraoperative use of AR was found to primarily assist with surgical planning and neuronavigation. Similarly, AR assistance for neurosurgical training focused primarily on surgical planning and neuronavigation. However, studies included in this review utilize small sample sizes and remain largely in the preliminary phase. Thus, future research must be conducted to further refine AR systems before widespread intraoperative and educational use.

Early experience with percutaneous balloon kyphoplasty for treatment of osteoporotic vertebral compression fracture in Nepal: A case report

Key Clinical Message

Balloon kyphoplasty is a promising treatment option for osteoporotic vertebral compression fractures with posterior cortical defect, offering pain relief, vertebral height restoration, and low risk of cement leakage.

Abstract

Millions of people worldwide suffer from osteoporotic vertebral compression fractures (OVCFs) annually, which cause pain and functional limitations, particularly in the elderly. Conservative treatments such as pain management, rest, and medication are frequently used, while surgical options such as vertebroplasty and kyphoplasty are considered. We present a case of 68-year-old female with vertebral compression fracture of L1 vertebra with posterior cortical defect and posterior wall retropulsion. She was treated successfully with balloon kyphoplasty. Kyphoplasty appears to be a better option than vertebroplasty in cases with posterior cortical defect due to lower chance of cement leakage.

Comparison Between the Clinical Effect of Percutaneous Kyphoplasty for Osteoporosis Vertebral Compression Fracture Patient with or Without Sarcopenia: A Retrospective Cohort Study

Background

Sarcopenia and osteoporosis vertebral compression fractures (OVCF) are common diseases that increase with age. This study aimed to investigate the effects of sarcopenia on OVCF patients after percutaneous kyphoplasty (PKP).

Methods

Data of 101 patients who were treated with single-level PKP between January 2021 and March 2022 at Ningbo No.6 Hospital were enrolled. Forty-five OVCF patients with sarcopenia who met our inclusion criteria were included in the Sarcopenia-PKP group (SPKP group), and 56 patients in the Normal-PKP group (NPKP group). All clinical and radiological data were collected from medical records. Baseline characteristics, operation-related parameters (operation time, time to ambulation, hospital stay, surgery segment), clinical outcomes (visual analog score [VAS], Oswestry Disability Index [ODI], Japanese Orthopaedic Association Scores [JOA] of lumber), radiological outcomes (vertebral anterior height rate and local kyphosis angle), Macnab score, and complications were evaluated and compared.

Results

There were no significant differences in age, sex, surgical segment preoperative VAS score, ODI, or JOA between the two groups (P > 0.05). The SPKP group had a significantly lower body mass index (BMI), bone mineral density (BMD), and smooth muscle index (SMI) than the NPKP group (P < 0.05). Significantly longer hospital stays and time to ambulation in SPKP group than NPKP group (3.7±0.8 vs 3.4±0.5 and 2.0±0.8 vs 1.6±0.5, P < 0.05). In SPKP group, significantly better clinical outcomes at 6- and 12-months follow-up were observed in NPKP group than SPKP group (P < 0.05), and NPKP group showed significantly better in vertebral anterior height rates than SPKP group after 6-month follow-up (P < 0.05). Moreover, there were significantly more cases of complications in the SPKP group (P < 0.05).

Conclusion

Sarcopenia could reduce the clinical effect of percutaneous kyphoplasty, and furthermore. Related studies are needed to verify the effect of sarcopenia on OVCF patients.

Bioactive mineralized small intestinal submucosa acellular matrix/PMMA bone cement for vertebral bone regeneration

Polymethylmethacrylate (PMMA) bone cement extensively utilized for the treatment of osteoporotic vertebral compression fractures due to its exceptional handleability and mechanical properties. Nevertheless, the clinical application of PMMA bone cement is restricted by its poor bioactivity and excessively high modulus of elasticity. Herein, mineralized small intestinal submucosa (mSIS) was incorporated into PMMA to prepare a partially degradable bone cement (mSIS-PMMA) that provided suitable compressive strength and reduced elastic modulus compared to pure PMMA. The ability of mSIS-PMMA bone cement to promote the attachment, proliferation and osteogenic differentiation of bone marrow mesenchymal stem cells was shown through cellular experiments carried out in vitro, and an animal osteoporosis model validated its potential to improve osseointegration. Considering these benefits, mSIS-PMMA bone cement shows promising potential as an injectable biomaterial for orthopedic procedures that require bone augmentation.

Intraoperative analgesic effect of intravertebral lidocaine injection during percutaneous kyphoplasty in the treatment of thoracolumbar compression fractures in elderly patients

BACKGROUND

In recent years, percutaneous kyphoplasty (PKP) has been increasingly used in clinical settings.

OBJECTIVE

In this study, we aimed to determine the analgesic effect of intravertebral lidocaine injections in PKP.

METHODS

A total of 60 patients who were treated with PKP were enrolled in this study. Lidocaine hydrochloride was chosen as the medication for the experimental group. Patients were randomly assigned into three groups using a double-blind study design: In group A (20 cases), no drugs were injected into the vertebral body during surgery; group B (20 cases) received intravertebral injection of normal saline; and in group C (20 cases), lidocaine hydrochloride was administered into the vertebral body during surgery. The age of patients, operation time, balloon dilatation pressure, balloon dilatation volume, and amount of bone cement injected were compared across the three groups. A pain visual analog scale (VAS) was used to assess pain suffered by the patients before, during, and 24 hours after the surgery.

RESULTS

Age, operation time, balloon dilatation pressure, balloon dilatation volume, and amount of bone cement injected did not differ significantly among the three groups (P> 0.05). The differences in VAS scores 24 hours before and after surgery were not statistically significant (P> 0.05). Group C had lower intraoperative VAS scores than groups A and B, and the difference was statistically significant (P< 0.01). There was no statistically significant difference between group A and group B (P> 0.05).

CONCLUSION

Intravertebral injections of lidocaine during PKP can successfully reduce intraoperative pain.

Novel Polyethylene Terephthalate Screw Sleeve Implant: Salvage Treatment in a Case of Spine Instability after Vertebroplasty Failure

INTRODUCTION

The management of osteoporotic fractures is sometimes rather challenging for spinal surgeons, and considering the longer life expectancy induced by improved living conditions, their prevalence is expected to increase. At present, the approaches to osteoporotic fractures differ depending on their severity, location, and the patient's age. State-of-the-art treatments range from vertebroplasty/kyphoplasty to hardware-based spinal stabilization in which screw augmentation with cement is the gold standard.

CASE PRESENTATION

We describe the case of a 74-year-old man with an L5 osteoporotic fracture. The patient underwent a vertebroplasty (VP) procedure, which was complicated by a symptomatic cement leakage in the right L4-L5 neuroforamen. We urgently decompressed the affected pedicle via hemilaminectomy. At that point, the column required stability. The extravasation of cement had ruled out the use of cement-augmented pedicle screws but leaving the pedicular screws alone was not considered sufficient to achieve stability. We decided to cover the screws with a polyethylene terephthalate sleeve (OGmend^®) to avoid additional cement leakage and to reinforce the screw strength required by the poor bone quality.

CONCLUSION

In the evolving technologies used for spinal surgery, screws sleeve implants such as OGmend^® are a useful addition to the surgeon's armamentarium when an increased pull-out strength is required and other options are not available.

[Effectiveness of modified orthopedic robot-assisted percutaneous kyphoplasty in treatment of osteoporotic vertebral compression fracture]

Objective

To evaluate the effectiveness of orthopedic robot with modified tracer fixation (short for modified orthopedic robot) assisted percutaneous kyphoplasty (PKP) in treatment of single-segment osteoporotic vertebral compression fracture (OVCF).

Methods

The clinical data of 155 patients with single-segment OVCF who were admitted between December 2017 and January 2021 and met the selection criteria was retrospectively analyzed. According to the operation methods, the patients were divided into robot group (87 cases, PKP assisted by modified orthopedic robot) and C-arm group (68 cases, PKP assisted by C-arm X-ray fluoroscopy). There was no significant difference in gender, age, body mass index, T value of bone mineral density, therapeutic segment, grade of vertebral compression fracture, and preoperative visual analogue scale (VAS) score, midline vertebral height, and Cobb angle between the two groups (P>0.05). The effectiveness evaluation indexes of the two groups were collected and compared. The clinical evaluation indexes included the establishment time of working channel, dose of intraoperative fluoroscopy, the amount of injected cement, VAS score before and after operation, and the occurrence of complications. The imaging evaluation indexes included the degree of puncture deviation, the degree of bone cement diffusion, the leakage of bone cement, the midline vertebral height and the Cobb angle before and after operation.

Results

The establishment time of working channel in robot group was significantly shorter than that in C-arm group, and the dose of intraoperative fluoroscopy was significantly larger than that in C-arm group (P<0.001). There was no significant difference in the amount of injected cement between the two groups (t=1.149, P=0.252). The patients in two groups were followed up 10-14 months (mean, 12 months). Except that the intraoperative VAS score of the robot group was significantly better than that of the C-arm group (P<0.05), there was no significant difference between the two groups at other time points (P>0.05). No severe complication such as infection, spinal cord or nerve injury, and pulmonary embolism occurred in the two groups. Five cases (5.7%) in robot group and 7 cases (10.2%) in C-arm group had adjacent segment fracture, and the difference in incidence of adjacent segment fracture between the two groups was not significant (χ2=1.105, P=0.293). Compared with C-arm group, the deviation of puncture and the diffusion of bone cement at 1 day after operation, the midline vertebral height and Cobb angle at 1 month after operation and last follow-up were significantly better in robot group (P<0.05). Eight cases (9.1%) in the robot group and 16 cases (23.5%) in the C-arm group had cement leakage, and the incidence of cement leakage in the robot group was significantly lower than that in the C-arm group (χ2=5.993, P=0.014). There was no intraspinal leakage in the two groups.

Conclusion

Compared with traditional PKP assisted by C-arm X-ray fluoroscopy, modified orthopedic robot-assisted PKP in the treatment of single-segment OVCF can significantly reduce intraoperative pain, shorten the establishment time of working channel, and improve the satisfaction of patients with operation. It has great advantages in reducing the deviation of puncture and improving the diffusion of bone cement.

Chronic Proton-Pump Inhibitor Therapy and Fracture Risk in Women Aged Between 50 and 65 years: A Retrospective Case-Control Study

Introduction

Chronic proton-pump inhibitor (PPI) prescription is on the rise in the last decade with an increased prevalence in the elderly population. For most patients, this class of drugs is the primary treatment for various diseases. Even though PPIs are generally safe, long-term use has been associated with multiple adverse effects like bone fractures. The extent of the association between PPI and fracture is still unclear in women aged between 50 and 65 years. Besides, many other variables and risk factors must be accounted for in the analysis of this relation.

Methods

This is a retrospective case-control study looking at women 50-65 years of age who presented to Genesys Health for a low-impact fall. Data were extracted from electronic medical records and fracture outcomes; PPI therapy exposure and duration were determined. Chi-square analysis was performed to determine the association between chronic PPI therapy and fracture outcome and independently analyzed for major risk factors of osteoporosis, including smoking, low body mass index, and cancer.

Results

Patients in the chronic PPI therapy group were found to have a decreased fracture outcome overall in each subcategory of risk factors. When adjusting for all risk factors, there was a significant but weak association between chronic PPI therapy and increased fracture outcome.

Conclusion

With different results from previous studies, this study sheds new light on this debate. More studies need to be carried out to determine the association between chronic PPI therapy and fracture outcomes in postmenopausal women.