Surgical Intervention for Osteoporotic Vertebral Burst Fractures in Middle-low Lumbar Spine with Special Reference to Postoperative Complications Affecting Surgical Outcomes

The incidence and outcomes of traumatic cauda equina syndrome in Victoria, Australia

Background

Little is known about the incidence, management or long-term outcomes of traumatic cauda equina syndrome (CES), with few cohort studies. The purpose of this study is to establish the incidence and long-term outcomes of traumatic CES in Victoria, Australia. This study is a registry-based cohort study, and people with a diagnosis of traumatic CES from 2010 to 2022 were recruited from the Victorian State Trauma Registry.

Methods

An incidence rate was calculated by dividing the amount of new cases each year by the estimated population in Victoria. Demographic, injury and hospital admission details were extracted from the Victorian State Trauma Registry. Routine follow-up occurred at 6, 12- and 24- months postinjury, with a focus on health-related quality of life outcomes using the EuroQol EQ-5D scale, level of disability using the World Health Organization Disability Assessment Schedule (WHODAS) score and return to work outcomes. An additional telephone interview undertaken at a median 6.8 years postinjury collected the EQ-5D, bowel and bladder outcomes. Descriptive statistics were used to analyse data. Mixed effects regression modelling was used to model change in EQ-5D outcomes over time.

Results

Of the 94 participants, most were men (67%), the median age at injury was 41 years, and the most common cause was road trauma (35%). The incidence rate ranged from 0.56 to 2.51 per million per year. Most people reported problems on the EQ-5D at all 4 follow-up time points, with no clear improvement over time. 47% of people had not returned to work 24 months after injury. Of the survivors who completed the additional follow-up, 41% of people experienced constipation and 51% reported almost losing bladder continence at least once per week.

Conclusions

While the incidence rate of traumatic CES was low, most people experienced long-term sequelae, highlighting the impact of this injury on peoples' lives. Multijurisdictional studies may be needed to comprehensively measure the impacts of this injury.

Operative results of AO A3 and A4 traumatic injuries in the thoracic and lumbar spine. A multicenter surveillance study of 4230 patients from the German Spine Registry (DWG-Register)

BACKGROUND

The diagnosis, classification and treatment of thoracolumbar burst fractures, continue to be controversial. Surgery is generally the preferred treatment for unstable fractures while stable fractures are managed conservatively. This study aims to describe surgical procedures, outcomes, complications, demography, clinical features and differences between A3 and A4 fractures (AO classification) of the thoracolumbar region. A subgroup of patients <91 years with osteoporotic fractures is included and analyzed.

METHODS

Analysis of data from the DWG-Register German spine registry on operative treatment for thoracolumbar AO A3 and A4 fractures out of 170 departments from January 2017 to May 2021. The evaluated variables included age, gender, surgical approach (posterior, anterior combined), and re-operation.

RESULTS

In total, 4230 AO A3 and A4 thoracolumbar fractures were identified in the registry; 2898 A3 (group 1) and 1332 A4 (group 2). The preoperative ASIA-impairment scale score in group 1 was significantly different compared with group 2 (P=0.02). Surgical procedures such as decompression/stabilization with rod-screw system cemented/non-cemented, as well as an anterior approach, were statistically significant between the groups. Odds ratio was calculated for variables that could be influenced for the type of fracture (A3 or A4): decompression 4.89, OR time >2 hours 48.22, osteoporosis 6.46 and posterior access 9.85.

CONCLUSIONS

This study provides multicenter results from a huge number of surgically treated AO A3 and A4 fractures. Anterior approaches are more often used in A4 type fractures, probably because of its inherent instability related to burst fractures, surprisingly, not associated with the occurrence of added perioperative complications. Nevertheless, A3 type fractures are presented with worse ASIA Impairment-Scale at admission, in comparison with A4 type fractures of the thoracolumbar region.

Geriatric spine fractures - Demography, changing trends, challenges and special considerations: A narrative review

The aim of this manuscript was to summarize the demography and changing trends of geriatric spinal injuries and to enumerate the challenges and special considerations in the care of geriatric spinal injuries. PubMed, Scopus and Embase databases were searched for literature on geriatric spine fractures using MeSH terms 'aged', 'aged, 80 and over', 'elderly', 'spinal fracture/epidemiology', spinal fracture/therapy∗' and keywords pertaining to the same. The search results were screened for appropriate articles and reviewed. There is a high community prevalence of elderly vertebral fractures ranging from 18% to as high as 51%. The proportion of older patients among the spinal injured is rising as well. There is a higher chance of missing spinal injuries in the elderly and clinical guidelines may not be applicable to this patient group. Classification and surgical treatment are different from younger adult counterparts as the elderly osteoporotic spine behaves differently biomechanically. There is a high incidence of respiratory complications both for surgically and conservatively managed groups. Older age generally is associated with a higher complication rate including mortality.

Clinical Features and Surgical Outcomes of Lower Lumbar Osteoporotic Vertebral Collapse with Symptomatic Stenosis: A Surgical Strategy from a Multicenter Case Series

STUDY DESIGN

A retrospective multicenter case series was conducted.

PURPOSE

This study was designed to investigate the clinical features and surgical outcomes of lower lumbar osteoporotic vertebral collapse (LL-OVC) with symptomatic stenosis based on various surgical procedures and classify them using the newly developed collapse severity criteria.

OVERVIEW OF LITERATURE

The surgical outcomes of LL-OVC with symptomatic stenosis remain unclear.

METHODS

We investigated patients who underwent surgical intervention for LL-OVC (L3, L4, and/or L5) with symptomatic foraminal and/or central stenosis from eight spine centers. Only patients with a minimum follow-up duration of 1 year were included. We developed new criteria to grade vertebral collapse severity (grade 1, 0%-25%; grade 2, 25%-50%; grade 3, 50%-75%; and grade 4, 75%-100%). The clinical features and outcomes were compared based on the collapse grade and surgical procedures performed (i.e., decompression alone, posterior lateral fusion [PLF], lateral interbody fusion [LIF], posterior/transforaminal interbody fusion [PLIF/TLIF], or vertebral column resection [VCR]).

RESULTS

In this study, 59 patients (average age, 77.4 years) were included. The average follow-up period was 24.6 months. The clinical outcome score (Japanese Orthopaedic Association score) was more favorable in the LIF and PLIF/TLIF groups than in the decompression alone, PLF, and VCR groups. The use of VCR was associated with a high rate of revision surgery (57.1%). No significant difference in clinical outcomes was observed between the collapse grades; however, grade 4 collapse was associated with a high rate of revision surgery (40.0%).

CONCLUSIONS

When treating LL-OVC, appropriate instrumented reconstruction with rigid intervertebral stability is necessary. According to our newly developed criteria, LIF may be a surgical option for any collapse grade. The use of VCR for grade 4 collapse is associated with a high rate of revision.

Finite element analysis of dynamic changes in spinal mechanics of osteoporotic lumbar fracture

Aim

This study aims to explore the effects of finite element biomechanical properties of different methods in the treatment of osteoporotic thoracolumbar fractures.

Methods

Based on the ultra-thin computed tomography scan data of a volunteer’s thoracolumbar spine, the finite element method was used to simulate the treatment of osteoporotic thoracolumbar fracture. Spiral computed tomography scanning was used to obtain images of the thoracolumbar region, which was then imported into Mimics software to obtain the three-dimensional geometric model. The finite element model of normal T₁₁ – L₂ segment was established by finite element software Abaqus and the validity of the model loading was verified. The finite element model of T₁₁ vertebral compression fracture was established based on normal raw data. The clinical overextension reduction manipulation was simulated by different treatment methods and the changes in stress and displacement in different parts of injured vertebrae were analyzed.

Results

An effective finite element model of T₁₁–L₂ segment was established. The maximum stress, axial compression strength, axial compression stiffness, and transverse shear stiffness were significantly better in the percutaneous kyphoplasty and percutaneous vertebroplasty treatment group than in the conservative treatment group and open treatment group (P < 0.05). Additionally, there was no significant difference between the open treatment group and conservative treatment group, or between the PKP and PVP treatment group.

Conclusion

Percutaneous vertebroplasty and percutaneous kyphoplasty not only met the requirements of normal functional kinematics of thoracolumbar spine, but also restored the stability of thoracolumbar spine. They had good biomechanical properties and remarkable application effects. The application of finite element analysis can help select a scientific, reasonable, and effective treatment scheme for the clinical diagnosis and treatment of osteoporotic thoracolumbar fractures.

Biomechanical Analysis of the External Fixation in a Lumbar Fracture Model: A Finite Element Study

Purpose

This study aimed to investigate the biomechanical characteristics of the external spinal fixation for treating lumbar fracture through finite element analysis (FEA) and provide a theoretical basis for its further application.

Methods

Two different models of L3 fracture fixed with the external spinal fixation and the internal fixation system respectively were constructed. The ROM, maximum stresses at L3, and the screws of the two models were measured under load control. Subsequently, the applied torque, the maximum stressed at L3, L1/2, L2/3, L3/4, L4/5 discs and the screws were analyzed under displacement control.

Results

Under load control, the external fixation model reserved more ROM than the internal fixation model (40.4–48.0% vs 30.5–41.0%). Compared to the internal fixation model, the maximum stresses at L3 and screws in the external fixation model were increased. Under displacement control, the external fixation model required fewer moments (N·mm) than the internal fixation model (flexion: 7500 vs 12,294; extension: 7500 vs 9027). Further, the maximum stresses at L3 and the screws in the external fixation model were greater than those of the internal fixation model, while the maximum stresses at the upper and lower adjacent discs of fixed segments were less than the internal fixation model.

Conclusion

Compared to the internal fixation system, the external fixation has a better stress distribution with the greater overall mobility. It theoretically reduces the stress concentration of the adjacent discs and the stress shielding of the fractured vertebral body.

Lateral Lumbar Interbody Fusion Using Bone Graft Substitute for Lumbar Vertebral Fracture Associated Radiculopathy

This study aims to present our surgical technique of lateral lumbar interbody fusion (LLIF) without corpectomy for lumbar vertebral fracture (LVF) associated radiculopathy. This study includes three patients treated with LLIF (mean age of 77.3 years, Group L) and three patients treated with PLIF (mean age of 75.7 years, Group P) to compare the surgical outcomes. The cartilage on the fractured vertebrae was aggressively resected with attention to avoid injury to the ring apophysis. The central cavity of the fractured endplate was filled with a bone graft substitute made of hydroxyapatite and collagen composite, followed by interbody fusion achieved by utilizing of a cage with sufficient length spanning the bilateral edges of the fractured vertebra. PLIF was performed with a standard technique using two interbody cages, and vertebroplasty was combined in one patient. Comparing to PLIF, LLIF could be performed with less estimated blood loss in shorter surgical time. Local kyphotic angle improved in all cases of Group L immediately after the surgery, but correction loss was observed at the final examination. The lordotic angle was lost in Group P postoperatively. Arthrodesis was achieved in all the cases. The mean VAS score for leg pain was 85.3 mm in Group L and 82.0 mm in Group P at preoperation and decreased to 8.7 mm and 11.3 mm, respectively, at postoperation. LLIF is an effective surgical option that enables stabilization of the fractured vertebra and reduces radicular pain by indirect neural decompression.

Decompression and fusion surgery for osteoporotic vertebral fractures: WFNS Spine Committee Recommendations

INTODUCTION

Osteoporotic vertebral fractures (OVF) are common due to aging populations. Their clinical management remains controversial. Although conservative approaches are sufficient in most cases, there are certain conditions where decompression or fusion surgery are necessary. This manuscript aims to clarify the indications and types of surgeries for OVF.

EVIDENCE ACQUISITION

A Medline and Pubmed search spanning the period between 2010 and 2020 was performed using the keywords "osteoporotic vertebral fractures and decompression surgery" and "osteoporotic vertebral fractures and fusion surgery". In addition, we reviewed up-to-date information on decompression and fusion in osteoporotic vertebral fracture (OVF) to reach an agreement in two consensus meetings of the World Federation of Neurosurgical Societies (WFNS) Spine Committee that was held in January and February 2021. The Delphi method was utilized to improve the validity of the questionnaire.

EVIDENCE SYNTHESIS

A total of 19 studies examining decompression and fusion surgery in OVF were reviewed. Literature supports the statement that decompression and fusion surgery are necessary for progressive neurological deficits after OVF. The Spine Section of the German Society for Orthopedics and Trauma (DGOU) classification revealed that it might help make surgical decisions. We also noted that in patients planning to undergo surgery to correct significant kyphosis after OVF, several techniques, including multilevel fixation, cement augmentation, preservation of sagittal balance, and avoiding termination at the apex of kyphosis are necessary to prevent complications. Additionally, it became clear that there is no consensus to choose the type of open surgery (anterior, posterior, combined, using cement or bone or vertebral body cage, the levels, and kind of instrumentation). The current literature indicated that implant failure in the osteoporotic spine is a common complication, and many techniques have been described to prevent implant failure in the osteoporotic spine. However, the superiority of one method over another is unclear.

CONCLUSIONS

Open surgery for osteoporotic vertebral fractures should be considered if neurologic deficits and significant painful kyphosis. The apparent indications of surgery and most ideal surgical technique for OVF remain unclear in the literature; therefore, the decision must be individualized.

A Pilot Study of Radiculopathy Following Osteoporotic Vertebral Fracture in Elderly Patients: An Algorithmic Approach to Surgical Management

Background: Osteoporotic vertebral compression fractures (OVCF) due to severe and refractory back pain or neurological complications require surgical treatment. In this study, patients with radiculopathy due to foraminal stenosis following OVCF were surgically managed by performing transforaminal full-endoscopic lumbar foraminoplasty and/or discectomy (FELFD). Methods: From May 2015 to November 2019, fifteen patients underwent transforaminal FELFD. Patient data, Charlson comorbidity index (CCI), and American Society of Anesthesiologists (ASA) score were collected. Clinical outcomes, including pre- and postoperative Visual Analog Scale (VAS) scores for back and leg pain, Oswestry Disability Index (ODI), and MacNab criteria of response to surgical treatment, were evaluated. Results: Mean of age, bone mineral density (T-score), CCI, ASA, and follow-up duration were 69.5 ± 6.6 years, −2.6 ± 0.8, 5.2 ± 2.3, 2.4 ± 0.5, and 24.5 ± 8.8 months, respectively. Mean VAS for leg pain significantly decreased from 6.9 ± 0.8 preoperatively to 2.9 ± 1.1 (P < .05). Mean ODI decreased from 39.9 ± 3.2 preoperatively to 19.3 ± 4.6 postoperatively (P < .05). The satisfaction rate is 86.7% (based on Macnab criteria), showed six patients had excellent outcomes and seven had good outcomes. Conclusions: Transforaminal FELFD is an effective treatment option for patients with radiculopathy due to lumbar OVCF, including those with severe osteoporosis and elderly patients.

Surgical treatment of complete fifth lumbar osteoporotic vertebral burst fracture: A retrospective case report of three patients

Background:

Due to its rarity, surgical treatments for a complete fifth lumbar osteoporotic vertebral burst fracture (L5 OVBF) have yet to be well documented as compared to that for osteoporotic vertebral fractures of the thoracolumbar spine. The current case report discusses details of the surgical outcomes following posterior decompression and fusion for a complete L5 OVBF.

Case Description:

Three women, ranging in age from 69 years to 82 years, were surgically treated for a complete L5 OVBF. Two of these patients were being treated for rheumatoid arthritis. Surgery was performed using the L5 shortening osteotomy or vertebroplasty, with one- or two-level posterior lumbar interbody fusion, and posterior spinal fixation for the L2 or L3 to the pelvis. Although the spinal alignment parameters, which included lumbar lordosis (LL), pelvic incidence-lumbar lordosis, T1 pelvic angle, and sagittal vertical axis, were better as compared to that observed before the surgery, these worsened at the final follow-up due to clinical fractures that occurred at the adjacent vertebral body and proximal junctional kyphosis. Compared to preoperative Japanese Orthopaedic Association (JOA) scores, postoperative JOA scores were improved and maintained at the final follow-up.

Conclusion:

Posterior surgery of a complete L5 OVBF led to improvement of both the JOA score and spinal alignment after the surgery. Despite a worsening of the spinal alignment parameters, the JOA score was maintained at the final follow-up.

Long versus Short Segment Instrumentation in Osteoporotic Thoracolumbar Vertebral Fracture

Study Design

Retrospective comparative study.

Purpose

This study aimed to compare clinical and radiological data and rate of mechanical complications in elderly patients treated with short segment (SSS) or long segment stabilization (LSS) for thoracolumbar junction osteoporotic vertebral fractures (OVFs).

Overview of Literature

A fervent debate is now focused on the treatment of OVF using SSS or LSS. High rate of complications is associated with pedicle screw fixation because of poor bone quality.

Methods

Patients over 65 years old with a T-score of <−2.5, affected by (T10–L2) vertebral fracture treated with LSS or SSS pedicle screw fixation, with at least 24 months of follow-up were evaluated. All patients were analyzed with conventional X-ray to evaluate bisegmental kyphotic angle (BKA) and clinically with Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and rate of mechanical complications at 2, 6, 12, and 24 months. Data were expressed as mean±standard deviation. Student t-test was used to compare clinical scores between populations. Mann-Whitney U-test was used to analyze clinical and radiological variable, whereas Fisher’s exact test was used to identify differences in the rate of complications between groups.

Results

A total of 37 patients met the inclusion criteria. Mean follow-up was 33.97±9.26 months. For both groups, ODI and VAS significantly decreased over time with good results (p<0.00001). At the final follow-up, no significant differences were found in terms of ODI and VAS. There was no difference in correction of BKA between groups; however, a significant difference was found in LSS group between pre- and postoperative BKA (p=0.046), whereas no difference was found in SSS group. A significant difference in the rate of mechanical complications was found between groups (p=0.011).

Conclusions

Both treatments showed good clinical and radiological results; however, LSS group showed better BKA correction and lower mechanical complications than SSS group.

Effect of bisphosphonates or teriparatide on mechanical complications after posterior instrumented fusion for osteoporotic vertebral fracture: a multi-center retrospective study

Background

The optimal treatment of osteoporosis after reconstruction surgery for osteoporotic vertebral fractures (OVF) remains unclear. In this multicentre retrospective study, we investigated the effects of typically used agents for osteoporosis, namely, bisphosphonates (BP) and teriparatide (TP), on surgical results in patients with osteoporotic vertebral fractures.

Methods

Retrospectively registered data were collected from 27 universities and affiliated hospitals in Japan. We compared the effects of BP vs TP on postoperative mechanical complication rates, implant-related reoperation rates, and clinical outcomes in patients who underwent posterior instrumented fusion for OVF. Data were analysed according to whether the osteoporosis was primary or glucocorticoid-induced.

Results

A total of 159 patients who underwent posterior instrumented fusion for OVF were included. The overall mechanical complication rate was significantly lower in the TP group than in the BP group (BP vs TP: 73.1% vs 58.2%, p = 0.045). The screw backout rate was significantly lower and the rates of new vertebral fractures and pseudoarthrosis tended to be lower in the TP group than in the BP group. However, there were no significant differences in lumbar functional scores and visual analogue scale pain scores or in implant-related reoperation rates between the two groups. The incidence of pseudoarthrosis was significantly higher in patients with glucocorticoid-induced osteoporosis (GIOP) than in those with primary osteoporosis; however, the pseudoarthrosis rate was reduced by using TP. The use of TP also tended to reduce the overall mechanical complication rate in both primary osteoporosis and GIOP.

Conclusions

The overall mechanical complication rate was lower in patients who received TP than in those who received a BP postoperatively, regardless of type of osteoporosis. The incidence of pseudoarthrosis was significantly higher in patients with GIOP, but the use of TP reduced the rate of pseudoarthrosis in GIOP patients. The use of TP was effective to reduce postoperative complications for OVF patients treated with posterior fusion.

Impact of Osteoporosis on Different Type of Short-Segment Posterior Instrumentation for Thoracolumbar Burst Fracture-A Finite Element Analysis

OBJECTIVE

In Taiwan (my country), the proportion of people 65 years or older was over 14% in 2018, which is known as entering "aged society." More and more thoracolumbar burst fractures in the setting of osteoporosis happen nowadays. In this study, a finite element model on thoracolumbar burst fracture was established and 4 types of posterior short-segment fixations were tested under normal bone quality and osteoporotic conditions.

METHODS

The intact T11-L1 spine finite element model was created, and one-half of the spongy bone of the T12 vertebra was removed to simulate burst fracture. Four fixation models with posterior fusion devices were established: 1) a link (S-L); 2) intermediate bilateral screws (S-I); 3) a link and calcium sulfate cement (S-L-C); and 4) intermediate bilateral screws and calcium sulfate cement (S-I-C). The Young modulus of the osteoporotic cancellous bone was set at 70 MPa. Range of motion, as well as the maximum value and distribution of the implant stress on T11 and L1, were compared between normal bone and osteoporotic status.

RESULTS

The strongest construct was the S-I-C group of both normal bone and osteoporosis condition. In osteoporotic status, the range of motion of construct in 4 types would be increased when comparing with normal bone. The stress on pedicle screws at the T11 and L1 level would also be increased in osteoporosis. The value of the maximal von Mises stress on the superior vertebral body (T11) for all loading conditions was larger than that on the inferior vertebral body (L1) in both normal bone and osteoporosis.

CONCLUSIONS

The S-I-C provided the strongest construct even in osteoporosis status. But osteoporosis would result in weakness for spinal construct, which might lead to implant failure.