The Surgical Outcomes of Spinal Fusion for Osteoporotic Vertebral Fractures in the Lower Lumbar Spine with a Neurological Deficit

A safe and reproducible anterior column restoration technique for Kümmell's disease: transpedicular bone packing

Background

Kümmell's disease (KD), delayed post-traumatic vertebral collapse, is diagnosed with characteristic radiologic findings such as intravertebral vacuum cleft (IVC). Because patients with KD are elderly, have many underlying diseases, poor bone quality, and relatively limited surgical outcomes compared to other spinal diseases. The aim of this study is to describe a minimally invasive surgical technique and to evaluate the clinical and radiological outcomes of this technique.

Methods

As a surgical treatment method for KD, we performed bone substitute packing via small pedicle holes with a posterior instrumented fusion. Ten consecutive patients underwent surgery for KD. Clinical outcomes and radiologic parameters were evaluated pre- and post-operatively.

Results

The average operation time was 150.5±19.64 min with a mean estimated blood loss of 252±173.32 mL. The mean Visual Analog Scale (VAS) score for back pain was reduced from preoperative 8.7±0.82 to 2.8±1.14 (P<0.001), and the mean Oswestry Disability Index (ODI) score improved from 30.6±3.2 preoperatively to 11.6±4.81 (P<0.001) at the final follow-up. The sagittal Cobb angles decreased from 23.19±9.52 degrees preoperatively to 11.59±10.06 degrees (P<0.001) immediately after surgery, and 13.31±10.43 (P=0.002) degrees at the final follow-up. Except for 1 case of minor screw migration, there were no serious perioperative complications.

Conclusions

Transpedicular bone packing does not involve technically demanding procedures such as corrective osteotomy, vertebral column resection, and insertion of large metal cage. Therefore, it may be minimally invasive and reproducible surgical option.

Appropriate Use Criteria for Osteoporotic Compression Fractures

BACKGROUND CONTEXT

There is a lack of consensus regarding optimal indications for treatment of patients with osteoporotic vertebral fractures. An opportunity exists to improve outcomes if these indications can be clarified.

PURPOSE

The purpose of the North American Spine Society (NASS) Appropriate Use Criteria (AUC) was to determine the appropriate (i.e. reasonable) multidisciplinary treatment recommendations for patients with osteoporotic vertebral fractures across a spectrum of more common clinical scenarios.

STUDY DESIGN

A Modified Delphi process.

PATIENT SAMPLE

Modified consensus based guideline OUTCOME MEASURES: Final rating for treatment recommendations as either "Appropriate", "Uncertain", or "Rarely Appropriate" based on the median final rating among the raters.

METHODS

The methodology was based on the AUC development process established by the Research AND Development (RAND) Corporation. The topic of osteoporotic vertebral compression fracture was selected by NASS for its Clinical Practice Guideline development (CPG). In conjunction, the AUC committee determined key modifiers and adapted the standard definitions developed by the CPG with minimal modifications. A literature search and evidence analysis performed by the CPG were reviewed by the AUC work group. A separate multidisciplinary rating group was assembled. Clinical scenarios were generated based on a matrix of the modifiers, to rate the appropriateness of medical management, cement augmentation, or surgery. Based on the literature, provider experience, and group discussion, each scenario was scored on a nine-point scale on two separate occasions: once without discussion and again following discussion of the initial responses. The median rating for each scenario and level of agreement was then used to determine final indications as rarely appropriate with agreement (1 - 3), uncertain or disagreement (4-6), or appropriate with agreement (7-9). Consensus was not mandatory.

RESULTS

Medical management was appropriate across all scenarios. Cement augmentation was rarely appropriate in 60% of scenarios and uncertain or disagreement in 35% of scenarios. In the 5% of scenarios rated as appropriate with agreement for cement augmentation, high pain scores, acute duration, and simple fracture pattern were always present. Surgery was appropriate in 35% of scenarios and strongly influenced by instability and stenosis with neurological findings. Surgery was rarely appropriate in 18%, and uncertain or disagreement in 47% of scenarios.

CONCLUSIONS

Multidisciplinary appropriate treatment criteria for osteoporotic vertebral fractures were generated based on the RAND methodology. This document provides comprehensive evidence-based recommendations for evaluation and treatment of osteoporotic vertebral fractures. The document in its entirety will be found on the NASS website (https://www.spine.org/Research-Clinical-Care/Quality-Improvement/Appropriate-Use-Criteria).

Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of adults with osteoporotic vertebral compression fractures

BACKGROUND CONTEXT

The North American Spine Society's (NASS) Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Adults with Osteoporotic Vertebral Compression Fractures features evidence-based recommendations for diagnosing and treating adult patients with osteoporotic vertebral compression fractures. The guideline is intended to reflect contemporary treatment concepts for osteoporotic vertebral compression fractures as reflected in the highest quality clinical literature available on this subject as of September 2020.

PURPOSE

The purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with osteoporotic vertebral compression fractures. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition.

STUDY DESIGN

This is a guideline summary review.

METHODS

This guideline is the product of NASS' Clinical Practice Guidelines Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with a medical librarian. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guideline was submitted to an internal and external peer review process and ultimately approved by the NASS Board of Directors.

RESULTS

Twenty-nine clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature.

CONCLUSIONS

The evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with osteoporotic vertebral compression fractures. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at http://www.spine.org/guidelines.

Revision Surgery Rates Following Transforaminal Lumbar Interbody Fusion in Patients with and without Osteoporosis

BACKGROUND CONTEXT

Osteoporosis is becoming increasingly prevalent in the spine surgery population and has been shown to be associated with surgical failure in spinal deformity operations. Little is known about the impact of osteoporosis on radiographic and surgical complications following degenerative fusion techniques.

PURPOSE

To compare complications and radiographic alignment in osteoporotic versus non-osteoporotic patients undergoing transforaminal lumbar interbody fusion (TLIF).

DESIGN

Retrospective cohort study.

PATIENT SAMPLE

A total of 78 patients, 39 with osteoporosis and 39 without osteoporosis, were included in this study.

OUTCOME MEASURES

The following data were observed for all cases: patient demographics, radiographic alignment, and complications.

METHODS

Adult patients with two-year follow-up who underwent transforaminal lumbar interbody fusion (TLIF) at a single academic institution were identified. Eligible patients were propensity matched by the presence of osteoporosis while accounting for age, sex, and BMI. Patient demographics, procedural characteristics, preoperative to two-year postoperative change in spinopelvic alignment, and complications were compared. Multivariate regression analyses, accounting for age, gender, and Charlson Comorbidity Index (CCI), were performed to evaluate outcomes following TLIF.

RESULTS

In total, 78 patients with complete data were included with a mean age of 63.28, 70.51% were female, mean CCI was 1.02 and mean clinical follow up was 33.3 months. At two years postoperatively, osteoporosis patients had a significantly greater increase in PI-LL from pre-operation (6.55° vs -0.02°, p=0.010). In addition, while there was no statistically significant difference in medical and surgical complication (all p>0.05), osteoporosis patients were 2.8 times more likely to develop adjacent segment diseases (p=0.05). Additionally, over 30% of patients with osteoporosis underwent revision and osteoporotic patients were 9.2 times more likely to undergo revision (p=0.008) than patients without osteoporosis, most commonly for adjacent segment disease.

CONCLUSION

In this single-center multi-surgeon study, osteoporotic patients experienced significant worsening of PI-LL mismatch postoperatively and had a higher incidence of adjacent segment disease and revision. Although TLIF remains an important procedure in osteoporotic patients, increased care should be taken to optimize bone quality in the perioperative period to avoid potential mechanical and surgical complications.

Risk Factor Analysis of Mechanical Complications in Surgical Treatment of Thoracolumbar Deformity with Osteoporotic Vertebral Fracture

Objective: Adult spinal deformity (ASD) with osteoporotic vertebral fractures (OVF) often requires vertebral body resection and replacement. However, postoperative mechanical complications (MC) have been unsolved issues. This study retrospectively investigated the risk of MC following anterior-posterior spinal fusion (APF) with vertebral body resection and replacement for OVF with ASD. Methods: Among 91 cases undergoing APF with vertebral body resection and replacement, 43 cases met the deformity criteria. The mean age was 74.2 years, and the mean number of fused segments was 5.7. Pre and postoperative spinal alignments were measured, and the risk of MC occurrence, including PJK, DJK, and cage sinking, was determined through multivariate analysis. The AUC and cutoff values were calculated through ROC analysis. Results: The incidence of MC, PJK, and DJK were 28%, 12%, and 14%, respectively. Multivariate analysis for MC revealed postoperative PI-LL and operative time (cutoff: 40.5 degrees, 238 min) as significant risk factors, while postoperative PI-LL was a significant risk factor for PJK (cutoff: 42.4 degrees). Evaluation considering only thoracolumbar level showed postoperative local kyphosis as a significant MC risk factor (cutoff: 11 degrees). There was a positive correlation between operative time and preoperative local kyphosis, with a cutoff value of 238 min being equivalent to 21 degrees. Conclusion: The postoperative mismatch over 40 degrees and preoperative local kyphosis over 21 degrees were considered as a high risk for MCs. The postoperative kyphosis of 11 degrees was the risk factor of MC in the thoracolumbar level. The meticulous preoperative assessment, including local and global alignment, and local flexibility as well as detailed surgical planning of fixation range and the requirement of osteotomy, are crucial.

Validation of thoracolumbar injury classification and Severity Score in the management of acute and subacute Osteoporotic vertebral compression fractures - A pilot study and a suggested modification

Objective

To retrospectively assess the Thoracolumbar Injury Classification and Severity Score (TLICS) in patients with osteoporotic vertebral compression fractures (OVCF) and compare the treatment given with that predicted by the TLICS score.

Methods

All medical records of patients presenting from January 2014 to November 2017 for acute atraumatic or low impact OVCF were screened, and eligible patients were retrospectively reviewed. The TLICS score was determined based upon magnetic resonance imaging (MRI) findings and clinical records. Clinical records (including pain score data), imaging data, operative procedures, and stability of neurological examination were tracked over three months for each patient.

Results

Of the 56 patients included, 36 patients had a TLICS score of 1, 18 had a TLICS score of 2, and two had a TLICS score of 4. Only one patient with a TLICS score of 4 underwent surgical stabilization, while the rest of the cohort was managed non-operatively, with or without kyphoplasty. TLICS score 1 corresponded to simple compression and TLICS score 2 corresponded to burst morphology with retropulsion and without neurological deficits. Of the patients with a TLICS score of 1 and 2 who underwent kyphoplasty, there was a statistically significant improvement in pain scores in both groups; however no significant difference was observed, between each TLICS score (i.e., 1 or 2). None of the patients developed instability or neurological decline.

Conclusion

TLICS score correctly predicted operative versus non-operative management in all patients with OVCF. TLICS may be used in making management decisions, and in the triage of these patients for operative versus non-operative evaluations. Our study suggests that patients with TLICS score of 4 or higher require surgical evaluation, while those with TLICS of 1 or 2 are likely to have satisfactory non-surgical management with augmentation or conservative care. In general, patients with OVCF typically present with low TLICS score. Kyphoplasty appears to be similarly beneficial in patients with a TLICS score of 1 or a TLICS score of 2. A modification of the TLICS score by adding TLICS Zero to include uncompressed OVCF with edema is suggested. The limitations of this study include a small size; a larger study is needed to confirm these findings.

Successful Treatment of Secondary L5 Osteoporotic Vertebral Fracture Post-balloon Kyphoplasty With Revision Balloon Kyphoplasty

Balloon kyphoplasty (BKP) is a standardized, minimally invasive procedure for treating osteoporotic vertebral fractures. However, secondary osteoporotic vertebral fractures following BKP are uncommon in clinical practice, and there is limited published experience with revision BKP for this condition. An 82-year-old man presented to our clinic with back pain after a fall. Computed tomography and magnetic resonance imaging revealed an osteoporotic L5 vertebral fracture. As conservative treatment was unsuccessful, he underwent BKP for the L5 fracture, which alleviated his pain. Twenty days post-operatively, the patient developed renewed back pain. Subsequent imaging demonstrated a secondary osteoporotic fracture within the previously treated L5 vertebra, involving both the upper and lower endplates. While posterior fixation was considered, the patient declined surgery. Therefore, we performed a revision BKP to address the secondary fracture. The postoperative course was uneventful, and 10 months later, computed tomography images showed evidence of bone healing and remodeling in the L5 vertebral body. Our case suggests that revision BKP may be an effective treatment option for secondary osteoporotic vertebral fractures. However, careful patient selection is crucial to ensure the safety and efficacy of this procedure.

The Effectiveness of Unilateral Biportal Endoscopic Decompression for Radiculopathy After Vertebral Compression Fracture: A Case Report

A 79-year-old woman was presented to our hospital with L3 radiculopathy due to excessive osteophyte formation following an osteoporotic vertebral compression fracture (OVCF). She underwent a unilateral biportal endoscopy (UBE)-assisted canal decompression via the interlaminar approach. The operation time was 101 minutes. Good results were observed at one-year postoperatively. We found that UBE may be useful to avoid the risks of facetectomy, especially when decompressing narrow interlaminar spaces after upper lumbar compression fractures. Improvement of radiculopathy after lumbar compression fractures remains challenging because the upper lumbar vertebrae are often affected by compression fractures. Even in normal cases, the interlaminar space can be narrow; furthermore, the space becomes narrower after compression fractures due to vertebral body collapse. When there is compression of the posterior wall nerve root due to thickening of the yellow ligament and posterior wall damage, decompression is needed to obtain a sufficient working space. With the UBE technique, the endoscope and portals are independent of each other, and the field of view and instrument can be moved separately. Therefore, in the upper lumbar spine with a narrow interlaminar space following OVCF, decompression can be achieved while avoiding the risk of facetectomy and is unnecessary if its purpose is to secure a field of view. This report presents a case where UBE was useful to improve the effectiveness of spinal decompression in a narrow interlaminar space to treat residual neurological symptoms.

A triple minimally invasive surgery combination for subacute osteoporotic lower lumbar vertebral collapse with neurological compromise: a potential alternative to the vertebral corpectomy/expandable cage strategy

OBJECTIVE

Acute/subacute osteoporotic vertebral collapses (OVCs) in the lower lumbar spine with neurological compromise, although far less well documented than those in the thoracolumbar junction, may often pose greater treatment challenges. The authors clarified the utility of 3 familiar combined techniques of minimally invasive surgery for this condition as an alternative to the corpectomy/expandable cage strategy.

METHODS

This report included the authors' first 5 patients with more than 2 years (range 27-48 months) of follow-up. The patients were between 68 and 91 years of age, and had subacute painful L4 OVC with neurological compromise and preexisting lumbar spinal stenosis. The authors' single-stage minimally invasive surgery combination consisted of the following: step 1, balloon kyphoplasty for the L4 OVC to restore its strength, followed by L4-percutaneous pedicle screw (PPS) placement with patients in the prone position; step 2, tubular lateral lumbar interbody fusion (LLIF) at the adjacent disc space involved with endplate injury, with patients in the lateral position; and step 3, supplemental PPS-rod fixation with patients in the prone position.

RESULTS

Estimated blood loss ranged from 20 to 72 mL. Neither balloon kyphoplasty-related nor LLIF-related potentially serious complications occurred. With CT measurements at the 9 LLIF levels, the postoperative increases averaged 3.5 mm in disc height and 3.7 mm in bilateral foraminal heights, which decreased by only 0.2 mm and 0 mm at the latest evaluation despite their low bone mineral densities, with a T-score of -3.8 to -2.6 SD. Canal compromise by fracture retropulsion decreased from 33% to 23% on average. As indicated by MRI measurements, the dural sac progressively enlarged and the ligamentum flavum increasingly shrank over time postoperatively, consistent with functional improvements assessed by the physician-based, patient-centered measures.

CONCLUSIONS

The advantages of this method over the corpectomy/expandable cage strategy include the following: 1) better anterior column stability with a segmentally placed cage, which reduces stress concentration at the cage footplate-endplate interface as an important benefit for patients with low bone mineral density; 2) indirect decompression through ligamentotaxis caused by whole-segment spine lengthening with LLIF, pushing back both the retropulsed fragments and the disc bulge anteriorly and unbuckling the ligamentum flavum to diminish its volume posteriorly; and 3) eliminating the need for segmental vessel management and easily bleeding direct decompressions. The authors' recent procedural modification eliminated step 3 by performing loose PPS-rod connections in step 1 and their tight locking after LLIF in step 2, reducing to only once the number of times the patient was repositioned.

Impact of Sarcopenia and Bone Mineral Density on Implant Failure after Dorsal Instrumentation in Patients with Osteoporotic Vertebral Fractures

Background and Objectives: Age-related loss of bone and muscle mass are signs of frailty and are associated with an increased risk of falls and consecutive vertebral fractures. Management often necessitates fusion surgery. We determined the impacts of sarcopenia and bone density on implant failures (IFs) and complications in patients with spondylodesis due to osteoporotic vertebral fractures (OVFs). Materials and Methods: Patients diagnosed with an OVF according to the osteoporotic fracture classification (OF) undergoing spinal instrumentation surgery between 2011 and 2020 were included in our study. The skeletal muscle area (SMA) was measured at the third lumbar vertebra (L3) level using axial CT images. SMA z-scores were calculated for the optimal height and body mass index (BMI) adjustment (zSMA_HT). The loss of muscle function was assessed via measurement of myosteatosis (skeletal muscle radiodensity, SMD) using axial CT scans. The bone mineral density (BMD) was determined at L3 in Hounsfield units (HU). Results: A total of 68 patients with OVFs underwent instrumentation in 244 segments (mean age 73.7 ± 7.9 years, 60.3% female). The median time of follow-up was 14.1 ± 15.5 months. Sarcopenia was detected in 28 patients (47.1%), myosteatosis in 45 patients (66.2%), and osteoporosis in 49 patients (72%). The presence of sarcopenia was independent of chronological age (p = 0.77) but correlated with BMI (p = 0.005). The zSMA_HT was significantly lower in patients suffering from an IF (p = 0.0092). Sarcopenia (OR 4.511, 95% CI 1.459–13.04, p = 0.0092) and osteoporosis (OR 9.50, 95% CI 1.497 to 104.7, p = 0.014) increased the likelihood of an IF. Using multivariate analysis revealed that the zSMA_HT (p = 0.0057) and BMD (p = 0.0041) were significantly related to IF occurrence. Conclusion: Herein, we established sarcopenic obesity as the main determinant for the occurrence of an IF after instrumentation for OVF. To a lesser degree, osteoporosis was associated with impaired implant longevity. Therefore, measuring the SMA and BMD using an axial CT of the lumbar spine might help to prevent an IF in spinal fusion surgery via early detection and treatment of sarcopenia and osteoporosis.

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.

Full-endoscopic spine surgery treatment of lumbar foraminal stenosis after osteoporotic vertebral compression fractures: A case report

BACKGROUND

Few reports have described lumbar foraminal stenosis-induced radiculopathy after treatment by full-endoscopic spine surgery (FESS) combined with percutaneous vertebroplasty (PVP) in patients with vertebral compression fractures. We herein report such a case, including the patient’s treatment process and doctor’s surgical experience.

CASE SUMMARY

A 79-year-old man presented with symptoms of radiculopathy after sustaining L4 vertebral compression fractures. Imaging and physical examination revealed L4 vertebral compression fractures combined with L3/4 Lumbar foraminal stenosis (LFS). The patient’s symptoms were low back pain with pain in the lateral left leg. Although many reports have described radiculopathy induced by osteoporotic vertebral compression fractures, the use of FESS combined with PVP has rarely been reported. This case report indicates that the combination of FESS and PVP is a safe and effective approach for the treatment of LFS-induced radiculopathy after vertebral compression fractures. This minimally invasive technique has great potential to replace traditional lumbar fixation and decompression surgery. Thus, we suggest the continued accumulation of similar cases to discuss the wider application of FESS.

CONCLUSION

For patients with osteoporotic vertebral compression fracture (OVCF) and LFS, PVP and FESS can be used to restore the vertebral height and reduce the pressure around the intervertebral foramen. Additionally, the combination of FESS and PVP can treat the pain or numbness of the low back and lower limbs and allow for recovery in a short time with excellent postoperative effects. In general, FESS is a good treatment for radiculopathy caused by foraminal stenosis after OVCF.

Clinical and imaging features of surgically treated low lumbar osteoporotic vertebral collapse in patients with Parkinson's disease

Osteoporosis and Parkinson's disease (PD) are age-related diseases, and surgery for osteoporotic vertebral collapse (OVC) in PD patients become more common. OVC commonly affects the thoracolumbar spine, but low lumbar OVC is frequent in patients with lower bone mineral density (BMD). The aim of this study was to identify differences in clinical and imaging features of low lumbar OVC with or without PD and to discuss the appropriate treatment. The subjects were 43 patients with low lumbar OVC below L3 who were treated surgically, including 11 patients with PD. The main clinical symptoms were radicular pain in non-PD cases and a cauda equina sign in PD cases. Rapid progression and destructive changes of OVC were seen in patients with PD. The morphological features of OVC were flat-type in non-PD cases with old compression fracture, and destruction-type in PD cases without old compression fracture. Progression of PD was associated with decreased lumbar lordosis, lower lumbar BMD, and severe sarcopenia. High postoperative complication rates were associated with vertebral fragility and longer fusion surgery. Progression of postural instability as a natural course of PD may lead to mechanical stress and instrumentation failure. Invasive long-fusion surgery should be avoided for single low lumbar OVC.