Comparison of percutaneous vertebroplasty and percutaneous kyphoplasty for the management of Kümmell's disease: A retrospective study

Efficacy and Safety of High-Viscosity Bone Cement in Percutaneous Vertebroplasty for Kummell's Disease

Background

To analyze and evaluate the clinical outcomes of using high-viscosity bone cement compared to low-viscosity bone cement in percutaneous vertebroplasty (PVP) for treatment of Kummell's disease.

Methods

From July 2017 to July 2019, 68 Kummell's disease patients who underwent PVP were chosen and separated into 2 groups: H group (n = 34), were treated with high-viscosity bone cement and L group (n = 34), treated with low-viscosity bone cement during treatment. The operation time, number of fluoroscopy tests done, and amount of bone cement perfusion were recorded for both groups. Clinical outcomes were compared, by measuring their Visual Analog Scale (VAS), Oswestry Disability Index (ODI), Kyphosis Cobb's angle, vertebral height compression rate, and other complications.

Results

High-viscosity group showed less operation time and reduced number of fluoroscopy tests than the low-viscosity group (P < 0.05). When compared to preoperative period, both groups' VAS and ODI scores were significantly reduced at 1 day and 1 year postoperatively (P < 0.05). The vertebral height compression rate and Cobb's angle were significantly lower (P < 0.05) in both groups after surgery compared with those before surgery (P < 0.05). The cement leakage rate in group H was 26.5%, which was significantly lower than that in group L, which was 61.8% (P < 0.05).

Conclusions

High-viscosity and low-viscosity bone cement in PVP have similar clinical efficacy in reducing pain in patients during the treatment, but in contrast, high-viscosity bone cement shortens the operative time, reduces number of fluoroscopy views and vertebral cement leakage and improves surgical safety.

Intravertebral insertion of interbody fusion cage via transpedicular approach for the treatment of stage III Kümmell disease: a technical note and case presentation

BACKGROUND

Kümmell disease usually occurs in the elderly osteoporosis population and develops gradually into symptomatic, progressive kyphosis of the spine. However, current surgical methods to deal with stage III Kümmell disease are less satisfying. The objective of this study was to describe a less invasive technique for treating stage III Kümmell disease.

TECHNIQUE

A less invasive technique of intravertebral insertion of interbody fusion cage via transpedicular approach with posterior spine stabilization was applied to treat stage III Kümmell disease.

RESULTS

This study details a modified technique applied in a patient with stage III Kümmell disease, showing significant improvement in pain relief, anterior column height recovery, and kyphotic angle correction. And no complications were reported during our follow-up.

CONCLUSIONS

Intravertebral insertion of interbody fusion cage via transpedicular approach provides advantages of acceptable correction of kyphosis, bony fusion, minimal invasion. Thus, our method was a good alternative choice for stage III Kümmell disease.

Prevention of Bone Cement Displacement in Kümmell Disease without Neurological Deficits through Treatment with a Novel Hollow Pedicle Screw Combined with Kyphoplasty

OBJECTIVE

Displacement of bone cement following percutaneous vertebral augmentation for Kümmell disease (KD) presents a significant concern, resulting in increasing back pain and compromising daily activities. Unfortunately, current literature does not yet establish a validated and minimally invasive surgical intervention for this issue. This study aims to investigate the effects of a novel hollow pedicle screw combined with kyphoplasty (HPS-KP) in preventing bone cement displacement following simply percutaneous kyphoplasty for the management of KD.

METHODS

A total of 22 patients (six males, 16 females, averagely aged 77.18 ± 7.63 years) with KD without neurological deficits treated by HPS-KP at the hospital between March 2021 and June 2022 were hereby selected, among which, there were three stage I KD cases, 12 stage II KD cases, and seven stage III KD cases according to Li's classification. Bone mineral density (BMD), spinal X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) were examined before the operation. The operation time, intraoperative blood loss, and postoperative complications were all recorded. The follow-up focused on visual analog scale (VAS) score, Oswestry dysfunction index (ODI), anterior vertebral height (AVH), middle vertebral height (MVH), posterior vertebral height (PVH), wedge-shape affected vertebral Cobb angle (WCA), and bisegmental Cobb angle (BCA). One-way analysis of variance (ANOVA) followed by Bonferroni post-hoc test was employed for performing multiple comparisons in the present study.

RESULTS

All patients having received the operation successfully were followed up for more than 8 months (ranging from 8 to 18 months). The operation time, intraoperative blood loss, and BMD (T-score) were 39.09 ± 5.64 min, 14.09 ± 3.98 ml, and - 3.30 ± 0.90 g/cm3 , respectively. Statistically significant differences were observed in the VAS score, ODI, AVH, MVH, and WCA (All p < 0.05), but there was no statistically significant difference in PVH and BCA at different time points (All p > 0.05). During follow-up, five patients suffered from bone cement leakage, and one presented an adjacent vertebral fracture and no bone cement displacement.

CONCLUSION

HPS-KP could be safe and effective in the treatment of KD without neurological deficits, effectively relieving the symptoms of patients, restoring partial vertebral height, and preventing the occurrence of bone cement displacement.

Double Vertebrae Kümmell Disease: Five Cases Report and Literature Review

Kümmell disease (KD) is a complication of osteoporotic vertebral compression fractures. There is a lot of literature on KD, but the reported cases are all single vertebrae. This study reports five double vertebrae KD cases (10 levels) and discusses the possible underlying mechanisms with a literature review. One hundred and thirty vertebrae KD were diagnosed from 2074 osteoporotic vertebral compression fractures patients treated in our hospital between 2015 and 2019. These vertebrae KD were divided into two groups, one-level vertebrae KD (n = 125) and double-level KD (n = 5). The diagnosis of KD is mainly based on the signs of intravertebral vacuum cleft on X-ray or CT scan. Double vertebrae KD cases were classified by using the KD staging system. The analysis was performed on KD to compare age, gender, femoral neck bone mineral density of femoral neck (BMD), vertebrae distribution, Cobb angle, and visual analog scale (VAS) between one-level KD and double-level by t-tests, Welch's t-test, or hypothesis testing. The mean age of the participants in the one-level KD group was 78.69 years, while the mean age in the double-level KD group was 82.4 years. The difference was statistically significant (t = 3.66, p = 0.0004). There were 89 females and 36 males in the one-level KD group, while the double-level KD group had five females and no males. The femoral neck BMD was significantly different between the two groups, with the one-level KD group having a mean BMD of -2.75 and the double-level KD group having a mean BMD of -4.2 (t = 2.99, p= 0.0061). The vertebrae distribution was different between the groups, with the one-level KD group having vertebrae from T7 to L4 and the double-level KD group having vertebrae from T11 to L1. The Cobb angle was also significantly different between the groups, with the one-level KD group having a mean angle of 20.58 and the double-level KD group having a mean angle of 31.54 (t = 6.22, p = 0.0001). Finally, the VAS scores were similar between the two groups, with the one-level KD group having a mean score of 8.63 and the double-level KD group having a mean score of 8.8 (t = 1.35, p = 0.1790). It is concluded that double vertebrae Kümmell disease has special clinical significance due to its potential to cause greater spinal instability and deformity, increased risk of neurological symptoms, more complex surgical management, and greater risk of complications.

Comparison of Outcomes Between Percutaneous Vertebroplasty and Percutaneous Kyphoplasty for the Treatment of Kümmell's Disease: A Meta-Analysis

STUDY DESIGN

A meta-analysis.

OBJECTIVE

The aim is to compare the efficacy of percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) in treating Kümmell's disease (KD) without neurological deficits.

SUMMARY OF BACKGROUND DATA

PVP and PKP are routine methods for the treatment of KD without neurological deficits; however, whether PVP or PKP is superior is a matter of debate.

MATERIALS AND METHODS

According to the Cochrane Handbook for Systematic Reviews of Interventions, PubMed, Embase, the Cochrane Library, and Web of Knowledge were searched for eligible randomized controlled trials or cohort studies. Two authors independently collected data and assessed the methodologic quality of the included studies. Intraoperative and postoperative clinical outcomes, cement leakage, refracture rate, and the costs during hospitalization were evaluated.

RESULTS

Five observational studies comparing 119 PVP and 128 PKP patients were included in qualitative and quantitative reviews. All of the included s studies had evidence of good quality, as assessed by the Newcastle-Ottawa scale. On the basis of meta-analysis the operation time [weighted mean difference: -10.65; 95% confidence interval (95% CI): -11.94 to -9.35; P <0.00001] and hospitalization cost (weighted mean difference: -2.38; 95% CI: -2.87 to -1.89; P <0.00001) were less for PVP, while the cement leakage rate was lower for PKP (odds ratio: 3.03; 95% CI: 1.58-5.82; P <0.001). Together, the data indicated that the differences in cement volume, visual analog scale score, Oswestry disability index score, Cobb angle, anterior vertebral height, and refracture rate were not significantly different.

CONCLUSION

The findings of this study suggest that PVP and PKP are safe and effective for the treatment of KD. PVP required less operative time and was more affordable, but PKP was superior given the lower cement leakage rate. Additional high-quality randomized controlled trials designed to support these findings are warranted.

Comparative Efficacy of Three Minimally Invasive Procedures for Kümmell's Disease: A Systematic Review and Network Meta-Analysis

Background

Percutaneous vertebroplasty (PVP), percutaneous kyphoplasty (PKP), and bone-filling mesh containers(BFC) are three viable minimally invasive techniques that have been used to treat Kümmell's disease(KD). However, there is still debate as to which is safer and more effective. This study summarized the pros and cons of the three techniques in the treatment of KD through network meta-analysis(NMA).

Methods

All eligible published clinical control studies comparing PVP, PKP, and BFC for KD up to December 2021 were collected by online search of Cochrane Library, PubMed, Embase, CNKI, Wanfang Database, and Chinese biomedical literature database. Data were extracted after screening, and Stata 16.0 software was used to perform the network meta-analysis.

Results

Four randomized controlled trials (RCTs) and 16 retrospective case-control studies (CCTs) with a total of 1114 patients were included. The NMA results showed no statistical difference between the 3 procedures in terms of improving patients' clinical symptoms. PKP was most likely to be the most effective in correcting kyphosis, while BFC was likely to be the most effective in managing the occurrence of cement leakage. No statistical differences were found in the incidence of new vertebral fractures in adjacent segments.

Conclusions

Ranking analysis showed that BFC has the highest likelihood of being the optimal procedure for the treatment of KD, based on a combined assessment of effectiveness in improving patients' symptoms and safety in the occurrence of adverse events.

Comparison of high- and low-viscosity cement percutaneous vertebroplasty with manipulative reduction for the treatment of Kümmell's disease: A retrospective cohort study

OBJECTIVE

To compare the clinical outcomes and cement leakage rate between high-viscosity and low-viscosity cement percutaneous vertebroplasty (PVP) with manipulative reduction in the treatment of Kümmell's disease (KD).

METHOD

PVP using high-viscosity cement (Group H) or low-viscosity cement (Group L) with manipulative reduction was compared in 86 KD patients. Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), vertebral height, kyphosis angle and complications were evaluated and compared preoperative, one day postoperative, and at final follow-up.

RESULTS

The VAS score, ODI score, mean anterior and middle vertebral height variation significantly improved in both groups postoperatively. However, there was no significant difference between the two groups considering the above results preoperative and postoperative. Significantly less cement leakage (13.6%) and shorter operative time (35.6 ± 5.1 min) were observed in Group H when compared with Group L (45.2% and 41.1 ± 5.3 min) (p< 0.05).

CONCLUSION

The clinical outcomes and radiologic findings of PVP with manipulative reduction was not influenced by cement viscosity. However, high cement viscosity PVP was found to be significant less cement leakage and shorter operative time.

Percutaneous Kyphoplasty Versus Percutaneous Vertebroplasty for Neurologically Intact Osteoporotic Kümmell's Disease: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

Percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) are minimally invasive techniques widely used for the treatment of neurologically intact osteoporotic Kümmell's disease (KD), but which treatment is preferable remains controversial. Therefore, this study aimed to shed light on this issue.

METHODS

Six databases were searched for all relevant studies based on the PRISMA guidelines. Two investigators independently conducted a quality assessment, extracted the data and performed all statistical analyses.

RESULTS

Eight studies encompassing 438 neurologically intact osteoporotic KD patients met the inclusion criteria. Compared to PVP, PKP was associated with greater improvement in the short- and long-term Cobb angle [SMD = -0.37, P = 0.007; SMD = -0.34, P = 0.012], short-term anterior vertebral height [SMD = 0.43, P = 0.003] and long-term middle vertebral height [SMD = 0.57, P = 0.012] and a lower cement leakage rate [SMD = 0.50, P = 0.003] but produced more consumption (cement injection volume, operative time, fluoroscopy times, intraoperative blood loss and operation cost). However, there were no differences between the 2 procedures in the short- and long-term VAS and ODI scores, long-term anterior vertebral height, overall complications or new vertebral fractures.

CONCLUSIONS

Both procedures are equally effective for neurologically intact KD in terms of the clinical outcomes, with the exception of a lower cement leakage risk and better radiographic improvement for PKP but greater resource consumption. Based on the evidence available, good clinical judgment should be exercised in the selection of patients for these procedures.

Percutaneous Kyphoplasty for Osteoporotic Vertebral Compression Fractures Associated with Spinal Canal Encroachment without Neurological Symptoms

Background

Percutaneous kyphoplasty (PKP) has been widely used for osteoporotic vertebral compression fractures (OVCFs). However, whether this approach is suitable for osteoporotic vertebral fractures with spinal canal encroachment remains controversial.

Material/Methods

Of 526 patients who underwent PKP at our hospital, 40 had conditions associated with spinal canal encroachment, and were enrolled in the study. Detailed physical, neurological, and radiological examinations were performed on each patient before and after surgery and at the followup. A visual analog scale (VAS) and the Oswestry Disability Index (ODI) were used for the clinical assessment. The vertebral body height, the local kyphosis, and the spinal canal width were used for the radiological evaluation.

Results

There were 11 male and 29 female patients, with a mean age of 71±8 years. The VAS score decreased from 6.4±0.7 preoperatively to 1.6±0.7 postoperatively and to 2.3±1.5 at the last followup visit. The ODI score was 78±9.5 before surgery, declined to 24±11.3 after surgery, and was 27.6±12.5 at the last followup visit. The vertebral body height increased from 11.7±4.3 mm to 14.6±4.4 mm. The local kyphosis decreased from 15.0±10.7 degrees preoperatively to 8.5±11.3 degrees postoperatively. The spinal canal width remained stable, at 8.5±2.0 mm before PKP and 8.7±1.9 after PKP.

Conclusions

PKP effectively relieved back pain in OVCF patients with spinal canal encroachment. Their social function improved as well.

Percutaneous vertebroplasty versus kyphoplasty for the treatment of neurologically intact osteoporotic Kümmell's disease

BACKGROUND

Percutaneous vertebroplasty (PVP) and kyphoplasty (PKP) have been widely used to treat neurologically intact osteoporotic Kümmell's disease (KD), but it is still unclear which treatment is more advantageous. Our study aimed to compare and investigate the safety and clinical efficacy of PVP and PKP in the treatment of KD.

METHODS

The relevant data that 64 patients of neurologically intact osteoporotic KD receiving PVP (30 patients) or PKP (34 patients) were analyzed. Surgical time, operation costs, intraoperative blood loss, volume of bone cement injection, and fluoroscopy times were compared. Occurrence of cement leakage, transient fever and re-fracture were recorded. Universal indicators of visual analogue scale (VAS) and Oswestry disability index (ODI) were evaluated separately before surgery and at 1 day, 6 months, 1 year, 2 years and the final follow-up after operation. The height of anterior edge of the affected vertebra and the Cobb's angle were assessed by imaging.

RESULTS

All patients were followed up for at least 24 months. The volume of bone cement injection, intraoperative blood loss, occurrence of bone cement leakage, transient fever and re-fracture between two groups showed no significant difference. The surgical time, the operation cost and fluoroscopy times of the PKP group was significantly higher than that of the PVP group. The post-operative VAS, ODI scores, the height of the anterior edge of the injured vertebrae and kyphosis deformity were significantly improved in both groups compared with the pre-operation. The improvement of vertebral height and kyphosis deformity in PKP group was significantly better than that in the PVP group at every same time point during the follow-up periods, but the VAS and ODI scores between the two groups showed no significant difference.

CONCLUSION

PVP and PKP can both significantly alleviate the pain of patients with KD and obtain good clinical efficacy and safety. By contrast, PKP can achieve better imaging height and kyphosis correction, while PVP has the advantages of shorter operation time, less radiation volume and operation cost.

Modified poly(methyl methacrylate) bone cement in the treatment of Kümmell disease

Kümmell disease (KD) causes serious vertebral body collapse in patients. However, only a few case reports have been conducted and the number of patients with KD investigated was limited. Additionally, the frequently used poly(methyl methacrylate) (PMMA) bone cement for KD is limited by excessive modulus and poor biocompatibility. Herein, we aimed to modify PMMA bone cement with mineralized collagen (MC), and compare the clinical effects, image performance and finite element analysis between the modified bone cement and PMMA bone cement for the treatment of phase I and II KD. Thirty-nine KD patients treated with PMMA bone cement and 40 KD patients treated with MC-modified PMMA bone cement from June 2015 to March 2017 were retrospectively analyzed. The surgical procedure, intraoperative blood loss, hospital stay and complications were compared between different groups. Visual analog scale, Oswestry disability index, anterior vertebral height, posterior vertebral height, computed tomography value, adjacent vertebral re-fracture, Cobb angle and wedge-shaped correction angle were evaluated. Additionally, the representative sample was selected for finite element analysis. We found that the MC-modified PMMA bone cement could achieve the same effect as that of PMMA bone cement and was associated with better vertebral height restoration in the long term.

Analysis of two minimally invasive procedures for osteoporotic vertebral compression fractures with intravertebral cleft: a systematic review and meta-analysis

Background

A systematic review and meta-analysis to assess the pros and cons of percutaneous vertebroplasty (PVP) versus kyphoplasty (PKP) for osteoporotic vertebral compression fractures (OVCFs) with intravertebral cleft (IVC) including all available evidence from controlled trials.

Methods

Databases including Pubmed, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), and Wanfang Data were searched to identify relevant studies comparing PVP and PKP for OVCFs with IVC. The outcomes mainly included visual analog scale (VAS), Oswestry Disability Index (ODI), local kyphotic angle (LKA), rate of vertebral height (VH%), and adverse events.

Results

Nine studies enrolling 688 patients were eligible for meta-analysis. The results indicated no significant differences between the two groups in the short-and long-term VAS, ODI, LKA, or VH% (P > 0.05). Compared with PVP, PKP was associated with significantly longer operation time (P < 0.05), higher cost (P > 0.05), and more injected cement volume (P < 0.05). In terms of adverse events, PKP has a lower risk of cement leakage (P < 0.05), while with no significant difference in adjacent-level fracture rates (P > 0.05).

Conclusion

The two procedures have similar short- and long-term pain relief, functional recovery, local kyphosis correction, and vertebral height maintenance in OVCFs with IVC. PKP is superior to PVP for the injected cement volume, and lower cement leakage rate, however, with longer operation time, more fluoroscopy times, and higher cost. Further randomized controlled trials (RCTs) should be conducted to confirm these results.

The clinical efficacy and experience of bipedicular percutaneous vertebroplasty combined with postural reduction in the treatment of Kümmell's disease

Background

Kümmell’s disease is a special type of osteoporotic vertebral fracture that causes chronic low back pain and deformity, which seriously affects the living quality of patients. PVP is commonly used to treat osteoporotic vertebral fractures and can quickly relieve low back pain. So, the objective of this study was to analyze the clinical efficacy and experience of bipedicular percutaneous vertebroplasty combined with postural reduction for the treatment of Kümmell’s disease.

Methods

A retrospective analysis of patients with Kümmell’s disease who underwent bipedicular percutaneous vertebroplasty was conducted from February 2016 to May 2018. Operative time, VAS, bone cement injection volume, cement leakage rate, compression improvement of vertebral front edge and vertebral center, and correction degree of kyphosis were collected and analyzed meticulously.

Results

The operative time was 45.33 ± 7.64 min. The volume of bone cement injected was 5.38 ± 1.33 ml. The compression improvement of vertebral front edge was 7.31 ± 1.21%. The compression improvement of vertebral center was 10.34 ± 1.15% and the correction degree of kyphosis was − 2.73 ± 0.31゜. Bone cement leakage occurred in 6 of 39 patients (15.38%), but no clinical symptoms were observed. The VAS scores were significantly lower at 1 day after the surgery, 6 months and at the last follow-up than before the surgery (P = 0.000, respectively). The VAS score was lower at the last follow-up than at 1 day after the surgery (P = 0.001).

Conclusion

Bipedicular percutaneous vertebroplasty combined with postural reduction could achieve satisfactory analgesic effect in the treatment of Kümmell’s disease, and restore the height of the vertebral body and improve kyphosis to some extent.

Percutaneous vertebroplasty versus percutaneous kyphoplasty for the treatment of delayed post-traumatic vertebral body collapse (Kümmell’s disease) in Chinese patients: a systematic review and meta-analysis

Objective

To compare the clinical efficacy between percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) in the treatment of Kümmell’s disease in Chinese patients.

Methods

The studies using randomized controlled trials to compare clinical efficacy between PVP and PKP in the treatment of Kümmell’s disease in Chinese patients were retrieved from Embase, Pubmed, Central, Cinahl, PQDT, CNKI, CQVIP, Wanfang Data, and CBM (from September 2008 to September 2018). Keywords for both Chinese and English search were: percutaneous vertebroplasty, PVP, percutaneous kyphoplasty, PKP, and Kümmell’s disease. A total of 132 articles were retrieved based on the search strategy through online database searching and manual searching. Finally, one foreign report and seven Chinese reports were included. After extracting the data, statistical software Review Manager 5.3 was used for data analysis.

Results

Through comparison, Cobb angle (95% CI [0.54, 4.42), P = 0.01] and Oswestry Dysfunction Index (ODI) (95% CI [0.21, 2.15], P= 0.02) of PKP group was smaller than that of PVP group. Postoperative anterior vertebral body height of the PKP group was better than PVP group (95% CI [−1.27, −0.66], P < 0.001]. However, the PVP group had shorter operation time than PKP group (95% CI [−13.48, −7.43), P = 0.001]. In the other outcome measures, including Visual Analogue Scale (VAS) score (95% CI [−0.04, 0.27), P = 0.15), cement volume (95% CI [−0.82, 0.32], P = 0.39) and cement leakage (95% CI [0.90, 2.76], P = 0.11), there was no significant differences between the two procedures.

Conclusions

At this stage, there is sufficient evidence to support that PKP is better than PVP in the treatment of Kümmell’s disease in Chinese patients. Although PVP surgery requires much less operation time, PKP has better postoperative radiological results and lower ODI. Moreover, both of them had similar clinical results (e.g., analgesic effects, cement dosage, and leakage rate). Further evidence is dependent on the emergence of randomized controlled trials with higher quality and larger sample sizes in the future.

Bone-filling mesh container versus percutaneous kyphoplasty in treating Kümmell's disease

Kümmell's disease (eponymous name for osteonecrosis and collapse of a vertebral body due to ischemia and non-union of anterior vertebral body wedge fractures after major trauma) cannot heal spontaneously. Bone-filling mesh container (BFMC) can significantly relieve pain, help the correction of kyphosis, and may prevent cement leakage. This pilot study may provide the basis for the design of future studies.

PURPOSE

To compare the effectiveness and safety of BFMC and percutaneous kyphoplasty (PKP) for treatment of Kümmell's disease.

METHODS

From August 2016 to May 2018, 40 patients with Kümmell's disease were admitted to Guizhou Provincial People's Hospital. Among them, 20 patients (20 vertebral bodies) received PKP (PKP group) and the other 20 received BFMC (BFMC group). Operation time, Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), Cobb's angle changes, and related complications were recorded.

RESULTS

All patients underwent operations successfully. VAS scores and ODI of both groups at each postoperative time point were lower than preoperatively, with statistically significant difference (p < 0.05). Postoperative Cobb's angle of both groups postoperatively was lower than preoperatively (p < 0.05). Cement leakage occurred in eight vertebrae (8/20) in the PKP group and in one vertebra (1/20) in the BFMC group. No complications such as pulmonary embolism, paraplegia, or perioperative death occurred during operation in both groups. Adjacent vertebral refractures occurred in five patients (5/20) in the PKP group and in four patients (4/20) in the BFMC group, with no significant difference in the incidence rate of refractures in both groups but the material is too small to verify statistically.

CONCLUSIONS

Both PKP and BFMC technologies can significantly relieve pain and help the correction of kyphosis while treating Kümmell's disease. Moreover, the BMFC may prevent cement leakage.

Cement Distribution Patterns in Osteoporotic Vertebral Compression Fractures with Intravertebral Cleft: Effect on Therapeutic Efficacy

OBJECTIVE

To determine cement distribution patterns on therapeutic efficacy after percutaneous vertebroplasty treatment of osteoporotic vertebral compression fractures (OVCFs) with intravertebral cleft (IVC).

METHODS

Patients who were treated with percutaneous vertebroplasty for single OVCFs with IVC and met this study's inclusion criteria were retrospectively reviewed. The follow-up period was at least 2 years. Distribution patterns of cement in the IVC area were respectively specified into 2 groups: group 1: solid lump distribution pattern (n = 22); group 2: the comparatively diffused pattern (n = 90). Radiologic and clinical parameters were analyzed and compared. Then, associations of recollapse with covariates and a risk score were further analyzed and developed to predict recollapse of the augmented vertebrae.

RESULTS

At the immediate postoperative period, all patients benefited from significant improvement in vertebrae height and kyphotic angle correction. However, significant recollapse was observed at the 2 years postoperative follow-up for the patients in group 1. Furthermore, we found that preoperative severe kyphotic deformity (a cutoff value of 12.5°), solid lump cement distribution pattern, and larger reduction angle (a cutoff value of 8.3°) was significantly associated with increased risk for recollapse. A risk score was developed based on the number of risk factors present in each patient and the receiver operating characteristic curve of the risk score generated an area under the curve of 0.788 (95% confidence interval 0.702-0.873, P = 0.000).

CONCLUSIONS

The comparatively diffused pattern shows better long-term radiologic and clinical outcomes for the treatment for OVCFs with IVC. A risk score can be used to predict the incidence of recollapse.

Percutaneous kyphoplasty treatment evaluation for patients with Kümmell disease based on a two-year follow-up

Percutaneous kyphoplasty (PKP) has been used in Kümmell disease treatment for years. The objective of the current study was to evaluate the efficacy and safety of PKP in the treatment of patients with Kümmell disease and to explore the association between cement injection volume and pain relief. A total of 50 patients were enrolled in the present study and follow-up was 2 years. Efficacy was evaluated using the Visual Analog Scale (VAS), the Oswestry Disability Index (ODI) and the kyphotic angle (Cobb's angle). VAS and ODI were determined at the initial evaluation (prior to surgery), at 3 days, 3 months, and 1 and 2 years post surgery. Cobb's angle was measured prior to and 3 months, 1 year and 2 years following surgery. PKP safety was assessed by evaluating complications, including cement leakage and spinal cord compression. In the follow-ups, VAS significantly decreased from 7.00±0.78 pre-PKP to 3.14±0.67 at 2 years post-PKP (P<0.05). ODI significantly decreased from 73.88±8.60 prior to surgery to 22.84±8.85 at 1 year following surgery (P<0.05) and did not significantly change at the following 2-year measurement (26.44±8.63). The Cobb's angle, measured at 17.73±2.43° preoperatively, significantly decreased to 8.32±2.21° at 3 months following surgery (P<0.05). On subsequent follow-ups at 1 and 2 years, the Cobb's angle increased to 9.55±2.82 and 10.27±3.22°, respectively. A total of 8 patients exhibited signs of cement leakage during the PKP procedure. No patients experienced severe neurological deficits or complications. Spearman analysis demonstrated a positive correlation between cement injection volume and pain relief. The current study indicated that PKP was a safe and effective treatment for patients with Kümmell disease and that there was a positive correlation between cement injection volume and pain relief. The current study may be used a reference in cement dosing for the treatment of PKP.

What is the Current Evidence on Vertebral Body Osteonecrosis?: A Systematic Review of the Literature

Osteonecrosis (ON) is a clinical entity characterized by a pattern of cell death and complex process of bone resorption and formation. Studies related to ON have largely focused on certain anatomical sites; however, the evidence on vertebral body ON (VBON) is largely inconsistent and fragmented. The aim of this study was to clarify the pathophysiology, risk factors, imaging findings, and available treatment modalities for VBON. A systematic review of the relevant articles published in English was performed using PubMed, Embase, Medline, Google Scholar, Cochrane Central Register of Controlled Trials (CENTRAL), and CINAHL databases. A total of 81 articles were included in this study. Three main topics about VBON were identified: (1) pathophysiology and risk factors, (2) diagnosis, and (3) treatment. Forty-five studies were based on the pathophysiology, 52 on diagnosis, and 38 on the treatment options for VBON. The literature on VBON was limited and mainly focused on post-traumatic cases with a considerable overlap with nonunion and pseudoarthrosis.

Clinical efficacy of PVP and PKP in the treatment of OVCFs after bilateral resection of ovarian cancer

The clinical efficacy of percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) in the treatment of osteoporotic vertebral compression fractures after bilateral resection of ovarian cancer was investigated. Eighty-six patients with osteoporotic vertebral compression fractures after bilateral resection of ovarian cancer admitted to the Second People's Hospital of Hefei from September, 2015 to August, 2016 were selected and randomly divided into control group (n=43) and observation group (n=43). The control group was treated with PVP, while the observation group received PKP. The operation time, fluoroscopy times, bone cement volume and leakage rate of patients in the two groups were recorded; the postoperative pain of patients was compared using Short-form McGill Pain Questionnaire; the changes in height of injured vertebra and Cobb angle of patients in two groups were compared; the efficacy of patients in the two groups was compared in accordance with Oswestry dysfunction index (ODI) and Japanese Orthopedic Association (JOA) low back pain scoring; and the quality of life was compared. The fluoroscopy times and bone cement leakage were significantly less in observation group than those in control group (P<0.05). After operation, the scores of ODI, MPQ and JOA in the two groups were significantly improved (P<0.05). The postoperative height of injured vertebra and the Cobb angle of patients in two groups were significantly different than those before the operation (P<0.05). The quality of life of patients in the observation group was higher than that in the control group one year after operation (P<0.05). In conclusion, PKP and PVP are effective in the treatment of osteoporotic vertebral compression fractures after bilateral resection of ovarian cancer; however, PKP is more conducive to lumbar stability and maintenance of intervertebral height thus greatly correcting the kyphosis, which is beneficial to improving the quality of life of patients.

Vertebral body osteonecrosis: proposal of a treatment-oriented classification system

PURPOSE

To present a classification system for vertebral body osteonecrosis (VBON) based on imaging findings and sagittal alignment and consequently to propose treatment guidelines.

METHODS

Chart review and classification of imaging and clinical findings. An analysis of literature about VBON has been evaluated to conceive the classification. The current data allows to correlate radiological findings with different stages of the pathophysiological process and consequently to propose a patient-tailored treatment plan.

RESULTS

The classification identifies 4 stages: stage 0 (theoretical phase), stage 1 (early phase), stage 2 (instability phase) and stage 3 (fixed deformity phase). Local (angular kyphosis expressed as anterior-posterior wall height ratio) and global (sagittal vertical axis and pelvic tilt) sagittal alignment are considered as complementary modifiers to tailor the most suitable treatment. Stage 1 is generally managed conservatively. Stage 2 and 3 often require different surgical approaches according to local and global sagittal alignment.

CONCLUSIONS

The classification allows a systematic staging of this disease and can help establish a proper and patient-oriented treatment plan. Further researches are advocated to fully validate the proposed classification system. These slides can be retrieved under Electronic Supplementary Material.

Clinical outcomes of percutaneous vertebroplasty for selective single segment dorsolumbar vertebral compression fractures

OVERVIEW OF LITERATURE

Elderly patients sustaining a trivial fall may develop vertebral compression fractures if they are predisposed to any factor that leads to decreased bone mineral density. Such patients suffer with severe pain and disability during the early healing stages. Percutaneous Vertebroplasty is mainly done to provide immediate pain relief and also believed to offer stability to the compressed vertebra by preventing further collapse.

METHODS

Selected patients [n = 20; Age = 57.9 ± 7.9 years] with osteoporotic vertebral compression fracture of a single dorsolumbar vertebra were treated with percutaneous vertebroplasty after 2-3 weeks of conservative trail. Their Pain score was noted using numeric rating scale (NRS) before and after the procedure. Functional outcomes were analysed using Roland Morris Disability Questionnaire (RMDQ) score.

RESULTS

NRS pain score before procedure was 8.3 ± 0.6. RMDQ score before procedure was 21.6 ± 0.5. Third post procedural day NRS pain score was 4.7 ± 1.2 (p < 0.0001), denoting significant decrease in pain. Functional outcome analysis using RMDQ score showed an average of 87 ± 6.1 percent improvement (p < 0.0001), by 6 weeks following procedure. Considering pre-injury status all patients were in their best possible functional state by 6 weeks.

CONCLUSIONS

Percutaneous Vertebroplasty serves its purpose adequately and economically. Under controlled circumstances, it offers immediate pain relief and stability, leading to early recovery in selective patients. Yet, underlying poor bone mineral density status needs to be treated.

STUDY DESIGN

Observational Case Series (Level 4).

Posterior Vertebral Column Resection Through Unilateral Osteotomy Approach for Old Lumbar Fracture Combined with Kummell Disease

BACKGROUND

Kummell disease is a clinical syndrome characterized by minor spinal trauma with a symptom-free period from months to years, followed by progressive painful kyphosis. Many surgical options for Kummell disease have been reported in the previous literature; however, no study has mentioned the surgical strategy for patients whose fractured vertebrae were severely compressed and only a slice of superior and inferior end plate was left.

CASE DESCRIPTION

Here we report the case of a 69-year-old woman who suffered persistent severe back pain since she slipped and fell 1 year before medical consult. The patient presented with constrained body posture and pressure pain on the thoracolumbar region. Visual analog scale pain under weight bearing was 90/100, and her Oswestry Disability Index score was 74%. Kummell disease was diagnosed on the basis of clinical presentation, trauma history, radiograph, computed tomography, and magnetic resonance imaging. We performed the posterior vertebral column resection through the unilateral osteotomy approach for the patient, and the clinical outcome and radiologic restoration were recorded. One year after the surgery, outpatient follow-up review revealed that the visual analog scale reduced to 10/100 and Oswestry Disability Index reduced to 13%. The posteroanterior and lateral radiograph in the standing position showed bony fusion was achieved at the osteotomy site. No pseudarthrosis or instrumentation-related failure occurred.

CONCLUSION

Posterior vertebral column resection through unilateral osteotomy approach is an effective method for patients with Kummell disease, especially when the fractured vertebrae compressed severely and only a slice of superior and inferior end plate was left.

Percutaneous Balloon Kyphoplasty in Treatment of Painful Osteoporotic Occult Vertebral Fracture: A Retrospective Study of 89 Cases

BACKGROUND The definition of a vertebral fracture is usually based on the presence of a deformation of the vertebral body and this can be misleading in the presence of a fracture without radiologic collapse with the definition of occult osteoporotic vertebral fractures (OOVFs). STIR sequence of MRI images showing hyperintensity signal was the most confirmative screening examination used to determine the presence of painful OOVFs. To date, clinical management of OOVFs has been rarely discussed. MATERIAL AND METHODS Between 2011 and 2013, 89 patients suffering from painful OOVFs underwent 142 percutaneous balloon kyphoplasty (PKP) procedures. Outcome data (mean variation of anterior and middle vertebral body height, visual analog scale [VAS] scores, Oswestry Disability Index [ODI] scores, and SF-36 scores) were recorded preoperatively, postoperatively, and at 1 month, 6 months, and 2 year after treatment, to evaluate the results. RESULTS We successfully treated 89 patients (142 vertebral bodies) with PKP. Cement leakages were observed in 12 (8.45%) treated vertebral bodies and there were 5 new adjacent vertebral fractures during the follow-up period. The mean variation of anterior and middle vertebral body height changed from 96.5±3.4% preoperatively to 97.2±2.5% postoperatively (p>0.05) and from 96.3±2.8% preoperatively to 97.9±3.1% postoperatively (p>0.05), respectively. The mean VAS scores were reduced significantly from pre-surgery to post-surgery (8.3±1.2 to 2.9±0.7; p<0.05), as was the ODI score (76.4±12.5 to 26.7±5.6; p<0.05). The SF-36 scores, including Bodily Pain (BF), Vitality (VT), Physical Function (PF), and Social Functioning (SF), all showed notable improvement (P<0.05). These variations were maintained during the 2-year follow-up period. CONCLUSIONS PKP is a safe and effective method in the treatment of painful OOVFs.