[A case of neurosarcoidosis initially diagnosed as cervical spondylotic myelopathy, leading to diagnosis by gadolinium contrast-enhanced MRI]

A 70-year-old female presented with bilateral numbness in her upper limbs. She was diagnosed with cervical spondylotic myelopathy and underwent cervical laminoplasty. However, there was no significant improvement in sensory disturbance, and at 6 months after surgery, she developed subacute motor and gait disturbance in four extremities. Spinal MRI revealed a long lesion of the spinal cord with edema, and a part of the lesion showed gadolinium contrast enhancement. Bronchoscopy revealed an elevated CD4/8 ratio, and gallium scintigraphy demonstrated an accumulation in the hilar lymph nodes, leading to a diagnosis of neurosarcoidosis. In case of rapid deterioration during the course of cervical spondylotic myelopathy, neurosarcoidosis should be considered as a differential diagnosis, which can be assessed by contrast-enhanced MRI.

Outcomes of percutaneous vertebroplasty in multiple myeloma: a tertiary neurosciences experience with long-term follow-up

Background

Multiple myeloma is diagnosed in 5,800 people in the United Kingdom (UK) each year with up to 64% having vertebral compression fractures at the time of diagnosis. Painful vertebral compression fractures can be of significant detriment to patients' quality of life. Percutaneous vertebroplasty aims to provide long-term pain relief and stabilize fractured vertebrae.

Methods and materials

Data was collected from all cases of percutaneous vertebroplasty performed on patients with multiple myeloma from November 2017 to January 2019. Pain scores were measured using the Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) pre-procedure, 2 months post procedure and 4 years post-procedure. Procedure related complications and analgesia use were also documented.

Results

22 patients were included with a total of 119 vertebrae treated. Patients reported a significant improvement in overall pain score with a median pre-procedure VAS of 8 and a median post-procedure VAS of 3.5 (p<0.0001). There was a median pre-procedure ODI score of 60% and a median post-procedure ODI score of 36% (p<0000.1). There was improvement across all ODI domains and a 77% reduction in analgesic requirement. There were small cement leaks into paravertebral veins or endplates at 15 levels (12%) which were asymptomatic. There were 8 responders to the long-term follow-up questionnaire at 4 years. This demonstrated an overall stable degree of pain relief in responders with a median VAS of 3.5 and median ODI of 30%.

Conclusion

At this center, vertebroplasty has been shown to reduce both VAS and ODI pain scores and reduce analgesia requirements in patients with VCFs secondary to multiple myeloma with long lasting relief at 4 years post-procedure.

Preclinical Evaluation of Bioactive Small Intestinal Submucosa-PMMA Bone Cement for Vertebral Augmentation

In vertebroplasty and kyphoplasty, bioinert poly(methyl methacrylate) (PMMA) bone cement is a conventional filler employed for quick stabilization of osteoporotic vertebral compression fractures (OVCFs). However, because of the poor osteointegration, excessive stiffness, and high curing temperature of PMMA, the implant loosens, the adjacent vertebrae refracture, and thermal necrosis of the surrounding tissue occurs frequently. This investigation addressed these issues by incorporating the small intestinal submucosa (SIS) into PMMA (SIS-PMMA). In vitro analyses revealed that this new SIS-PMMA bone cement had improved porous structure, as well as reduced compressive modulus and polymerization temperature compared with the original PMMA. Furthermore, the handling properties of SIS-PMMA bone cement were not significantly different from PMMA. The in vitro effect of PMMA and SIS-PMMA was investigated on MC3T3-E1 cells via the Transwell insert model to mimic the clinical condition or directly by culturing cells on the bone cement samples. The results indicated that SIS addition substantially enhanced the proliferation and osteogenic differentiation of MC3T3-E1 cells. Additionally, the bone cement's biomechanical properties were also assessed in a decalcified goat vertebrae model with a compression fracture, which indicated the SIS-PMMA had markedly increased compressive strength than PMMA. Furthermore, it was proved that the novel bone cement had good biosafety and efficacy based on the International Standards and guidelines. After 12 weeks of implantation, SIS-PMMA indicated significantly more osteointegration and new bone formation ability than PMMA. In addition, vertebral bodies with cement were also extracted for the uniaxial compression test, and it was revealed that compared with the PMMA-implanted vertebrae, the SIS-PMMA-implanted vertebrae had greatly enhanced maximum strength. Overall, these findings indicate the potential of SIS to induce efficient fixation between the modified cement surface and the host bone, thereby providing evidence that the SIS-PMMA bone cement is a promising filler for clinical vertebral augmentation.

Bone Cements Used in Vertebral Augmentation: A State-of-the-art Narrative Review

Vertebral compression fractures (VCFs) are common in osteoporotic patients, with a frequency projected to increase alongside a growing geriatric population. VCFs often result in debilitating back pain and decreased mobility. Cement augmentation, a minimally invasive surgical technique, is widely used to stabilize fractures and restore vertebral height. Acrylic-based cements and calcium phosphate cements are currently the two primary fill materials utilized for these procedures. Despite their effectiveness, acrylic bone cements and calcium phosphate cements have been associated with various intraoperative and postoperative incidents impacting VCF treatment. Over the past decade, discoveries in the field of biomedical engineering and material science have shown advancements toward addressing these limitations. This narrative review aims to assess the potential pitfalls and barriers of the various types of bone cements.

A retrospective cohort study on the efficacy and safety of percutaneous vertebroplasty combined with bone-filling mesh container in vertebral metastases with posterior wall defect

Background

To evaluate the clinical safety and efficacy of percutaneous vertebroplasty (PVP) combined with bone-filling mesh containers (BFMCs) for vertebral metastases with posterior wall defect.

Methods

From January 2019 to December 2021, patients with vertebral metastases and posterior wall defect who received BFMCs combined with PVP were included. The visual analog scale (VAS) scores and Oswestry disability index (ODI) scores were evaluated before and 72 hours after the operation, respectively. Post-operational X-ray and computed tomography (CT) scans were conducted to observe bone cement leakage, and complications were recorded. Follow-up CT and magnetic resonance imaging (MRI) were conducted to evaluate the condition of the operated vertebrae and the recurrence or progression of other bone metastases.

Results

A total of 43 patients with 44 operated vertebrae were included. All patients successfully completed the surgery. The average VAS score decreased from 7.35 ± 0.78 to 1.63 ± 0.93 (p < 0.05), and the ODI score decreased from 80.06 ± 8.91 to 32.5 ± 4.87 (p < 0.05). Bone cement leakage was observed in 18 operated vertebrae, which were all asymptomatic. No intraspinal leakage, post-operative spinal nerve compression, pulmonary embolism, or other serious complications were recorded. A total of 21 patients had a follow-up of more than 1 year, with no operated vertebral progression, 13 target vertebrae showed obvious sclerosis and necrosis, and no adjacent pathological fracture occurred. Of these patients, 16 had different degrees of bone metastasis of other sites other than the operated vertebrae.

Conclusion

For spinal metastases with posterior wall defect, PVP combined with BFMCs was highly safe and can effectively relieve pain for patients. A 1-year follow-up showed a local antitumor effect.

Assessment of Cement Leakage in Decompressed Percutaneous Kyphoplasty

Symptomatic osteoporotic compression fractures are commonly addressed through vertebroplasty and kyphoplasty. However, cement leakage poses a significant risk of neurological damage. We introduced "aspiration percutaneous kyphoplasty", also known as "decompressed kyphoplasty", as a method to mitigate cement leakage and conducted a comparative analysis with high viscosity cement vertebroplasty. We conducted a retrospective study that included 136 patients with single-level osteoporotic compression fractures. Among them, 70 patients underwent high viscosity cement vertebroplasty, while 66 patients received decompressed percutaneous kyphoplasty with low-viscosity cement. Comparison parameters included cement leakage rates, kyphotic angle alterations, and the occurrence of adjacent segment fractures. The overall cement leakage rate favored the decompressed kyphoplasty group (9.1% vs. 18.6%), although statistical significance was not achieved (p = 0.111). Nonetheless, the risk of intradiscal leakage significantly reduced in the decompressed kyphoplasty cohort (p = 0.011), which was particularly evident in cases lacking the preoperative cleft sign on X-rays. Kyphotic angle changes and the risk of adjacent segment collapse exhibited similar outcomes (p = 0.739 and 0.522, respectively). We concluded that decompressed kyphoplasty demonstrates efficacy in reducing intradiscal cement leakage, particularly benefiting patients without the preoperative cleft sign on X-rays by preventing intradiscal leakage.

Finite element analysis of vertebroplasty in the osteoporotic T11-L1 vertebral body: Effects of bone cement formulation

Vertebral compression fractures are one of the most severe clinical consequences of osteoporosis and the most common fragility fracture afflicting 570 and 1070 out of 100,000 men and women worldwide, respectively. Vertebroplasty (VP), a minimally invasive surgical procedure that involves the percutaneous injection of bone cement, is one of the most efficacious methods to stabilise osteoporotic vertebral compression fractures. However, postoperative fracture has been observed in up to 30% of patients following VP. Therefore, this study aims to investigate the effect of different injectable bone cement formulations on the stress distribution within the vertebrae and intervertebral discs due to VP and consequently recommend the optimal cement formulation. To achieve this, a 3D finite element (FE) model of the T11-L1 vertebral body was developed from computed tomography scan data of the spine. Osteoporotic bone was modeled by reducing the Young's modulus by 20% in the cortical bone and 74% in cancellous bone. The FE model was subjected to different physiological movements, such as extension, flexion, bending, and compression. The osteoporotic model caused a reduction in the average von Mises stress compared with the normal model in the T12 cancellous bone and an increment in the average von Mises stress value at the T12 cortical bone. The effects of VP using different formulations of a novel injectable bone cement were modeled by replacing a region of T12 cancellous bone with the materials. Due to the injection of the bone cement at the T12 vertebra, the average von Mises stresses on cancellous bone increased and slightly decreased on the cortical bone under all loading conditions. The novel class of bone cements investigated herein demonstrated an effective restoration of stress distribution to physiological levels within treated vertebrae, which could offer a potential superior alternative for VP surgery as their anti-osteoclastogenic properties could further enhance the appeal of their fracture treatment and may contribute to improved patient recovery and long-term well-being.

The effect of exercise post vertebral augmentation in osteoporotic patients: A systematic review and meta-analysis

This meta-analysis investigated the effects of exercise on Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) scores following vertebroplasty or kyphoplasty in osteoporotic fractures. A literature search of PubMed, EMBASE (Elsevier), CiNAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Scopus, and Web of Science was conducted from database inception to October 6, 2022. Eligible studies reported osteoporosis patients over 18 years of age with a diagnosis of at least one vertebral fracture via radiography or clinical assessment. This review was registered in PROSPERO (ID: CRD42022340791). Ten studies met the eligibility criteria (n = 889). VAS scores at baseline were 7.75 (95% CI: 7.54, 7.97, I2  = 76.11%). Following initiation of exercise, VAS scores at the endpoint of 12 months were 1.91 (95% CI: 1.53, 2.29, I2  = 92.69%). ODI scores at baseline were 68.66 (95% CI: 56.19, 81.13, I2  = 85%). Following initiation of exercise, ODI scores at the endpoint of 12 months were 21.20 (95% CI: 14.52, 27.87, I2  = 99.30). A two-arm analysis demonstrated improved VAS and ODI for the exercise group compared to non-exercise control at 6 months (MD = -0.70, 95% CI: -1.08, -0.32, I2  = 87% and MD = -6.48, 95% CI: -7.52, -5.44, I2  = 46%, respectively) and 12 months (MD = -0.88, 95% CI: -1.27, -0.49, I2  = 85% and MD = -9.62, 95% CI: -13.24, -5.99, I2  = 93%). Refracture was the only adverse event reported and occurred almost twice as frequently in the non-exercise group than in the exercise group. Exercise rehabilitation post vertebral augmentation is associated with improved pain and functionality, particularly after 6 months of exposure, and may reduce refracture rate.

Risk factors for new vertebral compression fracture after vertebroplasty and efficacy of osteoporosis treatment: A STROBE-compliant retrospective study

Vertebroplasty (VP) effectively treats vertebral compression fractures (VCFs). However, the issue of secondary new VCFs (SNVCFs) after VP is yet to be addressed. Therefore, identification of risk factors for SNVCFs after VP may aid the development of strategies to minimize SNVCF risk. This study aimed to retrospectively evaluate risk factors for SNVCFs after VP, including those associated with the type of anti-osteoporotic treatment administered after VP. Data from 128 patients who underwent single-level VP were collected and reviewed. Patients were divided into 2 groups: those with (n = 28) and without (n = 100) SNVCF within 1 year of VP. We collected the following patient data: age, sex, site of compression fracture, medical history, bone mineral density (BMD), history of long-term steroid use, history of osteoporosis drug use, duration between fracture and VP, VP implementation method (unilateral or bilateral), cement usage in VP, cement leakage into the disc, compression ratio before VP, pre- and postoperative recovery ratio of the lowest vertebral body height, and kyphotic angle of fractured vertebrae. These data were analyzed to identify factors associated with SNVCFs after VP and to investigate the effects of the type of anti-osteoporotic treatment administered for SNVCFs. SNVCFs occurred in 28 patients (21.9%) within 1 year of VP. Logistic regression analysis identified BMD, cement leakage into the disc, and long-term steroid use to be significantly associated with the occurrence of SNVCFs. The group treated with zoledronate after VP had a significantly reduced SNVCF incidence compared with the group treated with calcium (P < .001). In addition, the zoledronate group had a lower SNVCF incidence compared with the groups treated with alendronate (P = .05), selective estrogen receptor modulators (P = .26), or risedronate (P = .22). This study showed that low BMD, presence of an intradiscal cement leak, and long-term steroid use were risk factors for developing SNVCFs following VP. Additionally, among osteoporosis treatments prescribed for VP, zoledronate may be the preferred choice to reduce the risk of SNVCFs.

The risk of new vertebral fracture after percutaneous vertebral augmentation in patients suffering from single-level osteoporotic vertebral compression fractures: A meta-analysis and systematic review

BACKGROUND

To investigate the effect of Vertebral augmentation (VA) in the treatment of single-level osteoporotic vertebral compression fractures (OVCFs) on new vertebral fractures.

METHODS

Electronic databases Pubmed, Embase, and the Cochrane Central Register of Controlled Trials were searched from database creation to 5 September 2022. Eligible studies had to use VA as an intervention and conservative treatment as a control group. Studies had to explicitly report whether new vertebral fractures occurred during follow-up. Data were extracted by multiple investigators. Data were pooled using random or fixed effects models depending on the degree of heterogeneity.

RESULTS

Of the 682 articles screened, 7 met the inclusion criteria and were included in the analysis, giving a total of 1240 patients. Meta-analysis showed that VA (OR = 2.10, 95% CI: 1.35-3.28, P = .001) increased the risk of new postoperative vertebral fractures compared with conservative treatment. Subgroup analyses showed that the risk was greater in the group with a follow-up time greater than 1 year (OR = 2.57, 95% CI: 1.06-6.26, P = .001). Compared with conservative treatment, VA (OR = 2.17, 95% CI: 1.23-3.82, P = .007) increased the risk of postoperative adjacent vertebral fracture.

CONCLUSION SUBSECTIONS

VA is associated with an increased risk of new vertebral fractures and adjacent vertebral fractures following single-level OVCFs. With longer follow-ups, new vertebral fractures may be more significant. Clinical surgeons should pay attention to long-term postoperative complications and choose treatment carefully.

Minimally Invasive Surgery Strategies to Prevent Proximal Junctional Kyphosis

Proximal junctional kyphosis (PJK) is a common complication following long-segment thoracolumbar fusions for patients with adult spinal deformities. PJK is described as a progressive kyphosis at the upper instrumented vertebra or 1 or 2 segments adjacent to the instrumented vertebra. This condition can lead to proximal junction failure, which results in vertebral body fractures, screw pullouts, and neurological deficits. Revision surgery is necessary to address symptomatic PJK. Research efforts have been dedicated to elucidating risk factors and prevention strategies. It has been postulated that minimally invasive surgery (MIS) techniques may help prevent PJK because these techniques aim to preserve the soft tissue integrity at the top of the construct and maintain posterior element support. In this article, the authors define PJK, describe MIS strategies to prevent PJK, and compare PJK rates after MIS with PJK rates after open approaches for long-segment thoracolumbar fusion.

Effect of vertebroplasty with bone cement on osteoporotic compression fractures in elderly patients

OBJECTIVE

To explore the effect of vertebroplasty with bone cement on elderly patients with osteoporotic compression fractures.

METHODS

A retrospective study was conducted on 130 patients with osteoporotic compression fractures treated at the Second Hospital of Hebei Medical University from January 2018 to January 2022. According to different treatment methods, 50 patients who underwent conservative treatment were included in a control group (CG), and 80 patients who underwent vertebroplasty were included in a research group (RG). The anterior vertebral height, kyphotic Cobb angle, and Oswestry Disability Index (ODI) score in both groups were observed before and after treatment. The Visual Analogue Scale (VAS) scores were compared between the two groups before and after treatment. The quality of life and efficacy were evaluated in both groups.

RESULTS

After treatment, the anterior vertebral height in the RG exhibited a significant increase compared to that before treatment, and both groups showed a significant decrease in the Cobb angle and ODI (P<0.05). Furthermore, the RG exhibited notably higher anterior vertebral height, and significantly lower Cobb angle and ODI than the CG after treatment (P<0.05). The post-treatment VAS score decreased significantly in both groups (P<0.05), and was lower in the RG than that in CG (P<0.05). After treatment, the quality of life scores improved significantly in both groups (P<0.05), but the RG demonstrated significantly higher scores in the role-emotional, physical functioning, social functioning, and general health (GH) dimensions compared to the CG (P<0.05). The total response rate in the CG was significantly lower than that in the RG (P<0.05). Age, course of disease, underlying disease, distribution of bone cement, and leakage of bone cement were found to be risk factors affecting the prognosis of patients. Logistic regression analysis showed that course of disease, distribution of bone cement, and leakage of bone cement were independent risk factors affecting prognosis.

CONCLUSIONS

Vertebroplasty with bone cement is an effective treatment for elderly patients suffering from osteoporotic compression fractures. This intervention can improve anterior vertebral height, kyphotic Cobb angle, and ODI, while alleviating pain and enhancing the quality of life. Given its promising clinical outcomes, this treatment is highly recommended.

Effectiveness of unilateral percutaneous vertebroplasty for acute traumatic non-osteoporotic compression vertebral fractures

Although vertebroplasty is a well-known treatment for osteoporotic and neoplastic compression fractures, there is limited evidence to support its use in traumatic compression fractures without osteoporotic degeneration. The purpose of this study was to evaluate the correlation of kyphosis and wedge angles with pain relief and functional outcome after percutaneous vertebroplasty. 38 patients who harbored acute traumatic non-osteoporotic compression vertebral fractures without neurological complications refractory to at least 5 days of conservative treatment were included in this study. Follow-up evaluations included pain (assessed with the visual analog scale) and medication use. Functional outcome was measured using Oswestry low back pain disability questionnaire. Cobb angles, Gardner angles and kyphotic angles were measured on the full-spine radiographs preoperatively and postoperatively. The axial pain visual analog scale score (8.05 ± 1.23 pre-op vs 1.18 ± 1.09 post-op, P < .05) and The Oswestry low back pain disability questionnaire score (33.45 ± 6.97 pre-op vs 4.47 ± 2.41 post-op, P < .05). The Cobb's angle (19.66° ± 8.68° pre-op vs 15.08° ± 7.51° post-op, P < .05), the Gardner's angle (17.72° ± 6.52° pre-op vs 14.13° ± 7.13° post-op, P < .05) and the kyphotic angle (17.51° ± 5.8° pre-op vs 8.81° ± 4.14°post-op, P < .05) were significantly reduced postoperatively therefore, local kyphosis was markedly restored after vertebroplasty. Our findings show that vertebroplasty for patients with traumatic spinal compression fractures reduces pain, improves mobility, reduces the need for painkillers, and significantly affects kyphotic angles.

Effect of bone cement distribution on adjacent disc degeneration after vertebral augmentation for osteoporotic vertebral compression fractures in aging patients

Background

The influence of vertebral augmentation on adjacent intervertebral discs remains controversial. The purpose of this study is to evaluate the effect of bone cement distribution on adjacent disc degeneration after vertebral augmentation for osteoporotic vertebral compression fractures (OVCFs).

Methods

Patients with single level OVCF and upper endplate injury who underwent vertebral augmentation were enrolled. The patients were divided into four groups: Group A: bone cement contacted both the cranial and the distal endplates; Group B: bone cement only contacted the cranial endplate; Group C: bone cement only contacted the distal endplate; and Group D: bone cement contacted neither the cranial nor the distal endplates. The cranial discs of the fractured vertebrae were defined as adjacent discs and the upper discs proximally to the adjacent discs were defined as control discs. Degenerative disc change (DDC) was defined as a deteriorated postoperative Pfirrmann score compared with the preoperative score on MR images. The number of DDC cases and the disc heights were analyzed among the groups.

Results

A total of 184 patients with an average follow-up time of 28.6 months were included. The number of DDC cases in the adjacent discs was significantly higher than in the control discs in groups A (p < 0.001), B (p = 0.002), and D (p = 0.028), whereas the difference in group C was not statistically significant (p = 0.237). The incidence of adjacent disc degeneration was significantly higher in group A than that in group C (p = 0.06). The adjacent disc heights decreased significantly in groups A, B, and D (p < 0.001, p < 0.001, and p = 0.012, respectively), but did not decrease significantly in group C (p = 0.079). However, no statistical differences were detected among the four groups with respect to the preoperative adjacent disc height, follow-up adjacent disc height, preoperative control disc height, or follow-up control disc height.

Conclusion

Bone cement distribution influences adjacent disc degeneration after vertebral augmentation in OVCFs. Cement distribution proximal to the injured endplate can accelerate adjacent disc degeneration, and cement in contact with both the cranial and distal endplates can induce a higher incidence of adjacent disc degeneration.

Complications of Percutaneous Vertebroplasty: A Pictorial Review

Percutaneous vertebroplasty is a minimally invasive treatment technique for vertebral body compression fractures. The complications associated with this technique can be categorized into mild, moderate, and severe. Among these, the most prevalent complication is cement leakage, which may insert into the epidural, intradiscal, foraminal, and paravertebral regions, and even the venous system. The occurrence of a postprocedural infection carries a notable risk which is inherent to any percutaneous procedure. While the majority of these complications manifest without symptoms, they can potentially lead to severe outcomes. This review aims to consolidate the various complications linked to vertebroplasty, drawing from the experiences of a single medical center.

Significant Reduction of Radiation Exposure Using Specific Settings of the O-Arm for Percutaneous Cementoplasty in Accordance With the ALARA Principle

BACKGROUND

Three-dimensional (3D) navigation has become routinely used in spine surgery, allowing more accurate and safe procedures. However, radiation exposure related to the use of imaging is an unresolved issue, and information about it is relatively scarce. The "as low as reasonably achievable" (ALARA) principle aims to reduce the radiation exposure for the patients as low as possible. The objective of this study was to compare the effective dose related to the use of the O-arm in standard settings with adapted features for dose reduction during percutaneous cementoplasty.

METHODS

From March 2021 to October 2022, all consecutive patients who underwent navigated percutaneous cementoplasty with the use of the O-arm were prospectively included. Demographic, operative, irradiation, and radiological data were collected. The main outcome was the effective dose (E) in millisievert (mSv). Secondary outcomes were the absolute risk of cancer (AR) in percent equivalent to a whole-body exposition, operative time, and radiological results according to Garnier. In group A, patients were operated on with standard settings of the O-arm, whereas in group B, navigation on the field of view, collimation, and low-dose settings were used.

RESULTS

A total of 70 patients were included in the study: 43 in group A and 27 in group B. Also, 109 vertebrae were operated: 59 in group A and 50 in group B. Mean E was significantly higher in group A than in group B (9.94 and 4.34 mSv, respectively; P < 0.01). The 3D-related E followed the same trend (7.82 and 3.97 mSv, respectively), as did 2-dimensional-related E (2.12 and 0.37 mSv, respectively; P < 0.01). Average AR was also significantly higher in group A than in group B (5.10-4% and 2.10-4% respectively; P < 0.01). Operative time was similar in both groups, but the rate of satisfactory radiological results was higher in group A than in group B (95% and 84%, respectively; P = 0.11), and we found similar rates of cement leakage (22% and 24%, respectively; P = 0.71).

CONCLUSIONS

The application of settings of the O-arm in accordance with the ALARA principle helped to significantly reduce the radiation exposure and should be routinely used for O-arm-assisted cementoplasty procedures.

CLINICAL RELEVANCE

This study details technical aspects and settings that may help users of the O-arm to decrease radiation exposure to patients and surgeons alike, especially in cementoplasty procedures, as well as in other procedures performed under O-arm guidance.

LEVEL OF EVIDENCE: 2

Enhanced Risk Stratification for Short-Term Complications Following Vertebral Augmentation for Osteoporotic Vertebral Compression Fractures

BACKGROUND

For patients with back pain from osteoporotic vertebral compression fractures (VCFs), vertebral augmentation remains the most utilized surgical intervention. Previous studies report 30-day readmission and mortality rates of up to 10% and 2%, respectively. These studies, however, have included patients with pathologic fractures and combined patients in different admission settings. We undertook the current study to address such shortcomings, which make risk stratification and appropriate counseling difficult.

METHODS

Four consecutive years of the National Surgical Quality Improvement Program database were queried. Patients who underwent vertebral augmentation for osteoporotic VCFs were divided into 3 groups: (1) outpatient group (defined as patients with same-day discharge), (2) inpatient group (defined as those who were admitted postoperatively), and (3) preprocedure hospitalized group (defined as those who were already inpatient or were at acute/intermediate care facilities and transferred). Postoperative 30-day complications and readmission rates were compared between different groups and examined using multivariate analyses.

RESULTS

A total of 1023 patients underwent outpatient surgery; 503 were admitted on the day of surgery; and 149 patients were already in-hospital or were transferred from other facility. Mortality rates were 0.68%, 0.60%, and 2.68%, and readmission rates were 6.26%, 6.76%, and 12.8%, for outpatient, inpatient, and preprocedure hospitalization cohorts, respectively. Multivariate analyses identified preprocedure hospitalization as an independent risk factor for urinary tract infection (UTI; OR = 3.98, 95% CI = 1.41-11.20, P = 0.028), pneumonia (OR = 19.69, 95% CI = 3.81-101.65, P < 0.001), readmission (OR = 1.86, 95% CI = 1.06-3.26, P = 0.032), and mortality (OR = 4.49, 95% CI = 1.22-16.53, P = 0.024).

CONCLUSION

Our findings suggest that published rates of complications and mortality are substantially impacted by the cohort of patients who are already hospitalized or transferred from other facilities. Such patients are at a higher risk of UTI, pneumonia, readmission, and mortality. Conversely, we show that a relatively healthy patient being offered outpatient same-day augmentation has a readmission risk 40% lower and a mortality risk 3 times lower than previously reported.

LEVEL OF EVIDENCE: 3

The role of Vertebral Augmentation Procedures in the management of vertebral compression fractures secondary to multiple myeloma

Multiple myeloma (MM) is a systemic disorder characterised by proliferation of B-lymphocytes and plasma cells in the bone marrow. The primary aims of the management of spinal lesions in MM are pain control and fracture stabilisation. Vertebral augmentation procedures (VAP) can be subdivided into percutaneous vertebroplasty (VP) and balloon kyphoplasty (BKP). BKP involves the placement of orthopaedic balloons into the fractured vertebral body, creating a void into which polymethylmethacrylate bone cement is injected. This review outlines the management of spinal lesions in patients with MM, with a focus on the comparative risks and efficacy of vertebroplasty (VP) and balloon kyphoplasty (BKP). Soft tissue masses in MM are highly radiosensitive. Bisphosphonates and newer oncological therapies have decreased the indications for palliative radiotherapy, while spinal bracing can be utilised in selected cases to provide stability. BKP and VP provide equivalent long term pain control after MM vertebral compression fractures (VCF). BKP is superior to non-operative management and VP for restoration of vertebral body height and prevention of segmental kyphosis. Current evidence suggests a greater degree of correction of kyphotic deformity and restoration of mid vertebral height (MVH) with BKP when compared with VP. The literature supports the use of BKP even in the presence of posterior vertebral body wall (PVBW) fractures, a group previously considered a contraindication to VAP. Superior functional outcomes have been reported in patients undergoing early versus delayed BKP (<6-8 weeks). Current evidence supports a lower risk of cement extrusion with BKP than with VP, but serious complications following VAP are rare. MM spinal pathology should be managed in a multidisciplinary setting. Surgical decompression and instrumentation are rarely indicated, due to the radio-sensitivity of soft tissue lesions in MM. BKP is a safe and effective procedure for VCF secondary to MM.

Finite element analysis of biomechanical effects of mineralized collagen modified bone cement on adjacent vertebral body after vertebroplasty

Objective: To investigate whether mineralized collagen modified polymethyl methacrylate (MC-PMMA) bone cement impacts the implanted vertebral body and adjacent segments and the feasibility of biomechanical properties compared with common bone cement in the treatment of osteoporotic vertebral compression fractures (OVCF). Methods: A healthy volunteer was selected to perform a three-dimensional reconstruction of the T11-L1 vertebral body to establish the corresponding finite element model of the spine, and the changes in the stress distribution of different types of cement were biomechanically analyzed in groups by applying quantitative loads. Results: The stress distribution of the T11-L1 vertebral body was similar between the two bone types of cement under various stress conditions. Conclusion: Mineralized collagen modified bone cement had the advantages of promoting bone regeneration, good biocompatibility, good transformability, and coupling, and had support strength not inferior to common PMMA bone cement, indicating it has good development prospects and potential.

The Impact of Implementing a Radiation-Sparing Protocol for Percutaneous Kyphoplasty-A Prospective Dosemetric Study

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

The purpose of this prospective study was to evaluate a protocol for radiation-sparing kyphoplasty by assessing dosemetrically recorded radiation exposures to both patient and surgeon.

METHODS

This prospective clinical study examines the radiation exposure to patient and surgeon during single-level kyphoplasty in 32 thoracolumbar osteoporotic vertebral body fractures (12 OF 2, 9 OF 3, 11 OF 4 types) using a radiation aware surgical protocol between May 2017 and November 2019. The radiation exposure was measured at different locations using film, eye lens and ring dosemeters. Dose values are reported under consideration of lower detection limits of each dosemeter type.

RESULTS

A high proportion of dosemeter readings was below the lower detection limits, especially for the surgeon (>90%). Radiation exposure to the surgeon was highest at the unprotected thyroid gland (0.053 ± 0.047 mSv), however only slightly above the lower detection limit of dosemeters (0.044 mSv). Radiation exposure to the patient was highest at the chest (0.349 ± 0.414 mSv) and the gonad (0.186 ± 0.262 mSv). Fluoroscopy time, dose area product and number of fluoroscopic images were 46.0 ± 17.9 sec, 124 ± 109 cGy×cm2, and 35 ± 13 per kyphoplasty, respectively. Back pain significantly improved from 6.8 ± 1.6 to 2.5 ± 1.7 on the numeric rating scale on the first postoperative day (P < 0.0001).

CONCLUSIONS

The implementation of a strict intraoperative radiation protection protocol allows for safely performed kyphoplasty with ultra-low radiation exposure for the patient and surgeon without exceeding the annual occupational dose limits.

TRIAL REGISTRATION

The study was registered in the German Clinical Trials Register (DRKS00011908, registration date 16/05/2017).

Case report: Basivertebral nerve block during vertebral augmentation: an alternative approach to intraprocedural pain management

Osteoporotic compression fractures can be treated with vertebral augmentation. Since intraprocedural pain is common during vertebral body endplate manipulation, these procedures are often performed with conscious sedation or general anesthesia. Research has shown that vertebral endplates are innervated by the basivertebral nerve (BVN), which has been successfully targeted via radiofrequency ablation to treat chronic vertebrogenic lower back pain. With this physiology in mind, we evaluated if temporary BVN block would provide sufficient analgesia so that patients could forego sedation during percutaneous vertebral augmentation. Ten patients with single-level vertebral compression fractures were selected. Prior to balloon augmentation, temporary intraosseous BVN block was achieved using 2% lidocaine injection. All ten patients successfully completed their procedure without intraprocedural sedative or narcotic medications, and without significant deviation from baseline vital signs. Temporary BVN block can be used as intraprocedural anesthesia in select patients who may be poor candidates for general anesthesia or conscious sedation.

Adjacent Fracture Rates Following Balloon Kyphoplasty in Osteoporotic Vertebral Compression Fractures: A Case Series

Background Osteoporotic vertebral compression fractures (OVCF) represent a substantial concern, as they are associated with significant increases in morbidity and mortality. One option for the management of these patients is balloon kyphoplasty, in which a balloon is inflated within the collapsed vertebral body. Following this, the cavity is filled with polymethyl methacrylate (PMMA) cement to restore height and strength. Although this procedure has been shown to have great effectiveness, one complication that has been documented is an adjacent level refracture. This is thought to be due to the increased relative strength of the repaired vertebral body. Our study aims to quantify the rates of adjacent level refracture following balloon kyphoplasty as well as identify factors that may be associated with this event. Methods  We reviewed the electronic medical records (EMR) of patients that underwent balloon kyphoplasty between January 1, 2017 and August 1, 2020. A single surgeon performed all procedures. Only adult patients who received a diagnosis of osteoporosis based on a history of fragility fracture or bone mineral density measurement were included. Patients with additional or confounding bone conditions, such as malignancy or other lytic lesions, were excluded. Data were analyzed in SPSS (IBM Corp., Armonk, NY, United States). Results We included 89 patients in our study. We observed an adjacent level refracture prevalence of 13.5% (n=12). We observed a significant increase in refracture rates among patients with unsatisfactory resolution of symptoms following initial balloon kyphoplasty, from 8.2% for satisfactory resolution of symptoms to 43.8% for those with unsatisfactory resolution. (p-value 0.011). Additionally, all 12 patients with adjacent level refractures occurred among patients with complex, multiple-level initial fracture patterns. Conclusions The treatment of OVCF with balloon kyphoplasty is a well-documented and effective method. The prevalence of adjacent-level refracture may be linked to several variables such as the initial fracture pattern. More research is needed to better predict refracture and improve patient outcomes.

Re-expansion of vertebral compression fractures in patients with multiple myeloma with percutaneous vertebroplasty using spinejack implants: a preliminary and retrospective study

Objective

To retrospectively evaluate the feasibility and effectiveness of vertebroplasty using Spinejack implantation for the treatment and stabilization of painful vertebral compression fractures, in patients diagnosed with Multiple Myeloma (MM), to allow both an effective pain reduction and a global structural spine stabilization.

Materials and Methods

From July 2017 and May 2022 thirty-nine patients diagnosed MM, with forty-nine vertebral compression fractures underwent percutaneous Vertebroplasty using Spinejack Implants. We analyzed the feasibility and complications of the procedure, the decrease in pain using visual analogue scale (VAS) and Functional Mobility Scale (FMS).

Results

The technical success rate was 100%. No procedure-related major complications or death occurred. In the 6-month follow-up, the mean VAS score decreased from 5.4 ± 1.0 to 0.2 ± 0.5 with a mean reduction of 96.3%. FMS decreased from 2.3 ± 0.5 vs. 1.2 ± 0.4 with a mean reduction of -47.8%. There were no major complications related to incorrect positioning of the Expandable Titanium SpineJack Implants. In five patients, a cement leak was observed with no associated clinical manifestations. The average length of hospital stay was 6-8 Hours6.6 ± 1.2 h. No new bone fractures or local disease recurrence occurred during a median contrast-enhanced CT follow-up of 6 months.

Conclusions

Our results suggest that vertebroplasty, using Spinejack implantation for the treatment and stabilization of painful vertebral compression fractures, secondary to Multiple Myeloma is a safe and effective procedure with long - term pain relief and restoration of vertebral height.

Comparison of Wiltse Approach of Pedicle Screw Fixation With or Without Vertebroplasty in the Treatment of Genant III Degree Osteoporotic Thoracolumbar Fractures: Analysis of Clinical Findings, Radiographic Parameters, and Follow-Up Complications

STUDY DESIGN

A retrospective case-control study.

OBJECTIVE

This study aimed to compare the effects of the Wiltse approach of pedicle screw fixation (PSF) either in combination with or without vertebroplasty (VP) in the treatment of Genant III degree osteoporotic thoracolumbar fractures (Genant III-OTLFs).

METHODS

A retrospective study of Genant III-OTLFs was performed from January 2018 to December 2019, including 54 cases of PSF + VP and 56 cases of PSF. Clinical indicators [visual analog scale (VAS) score, Oswestry disability index (ODI)], radiographic parameters [local kyphosis angle (LKA), percentage of anterior, central, and posterior vertebral heights (AVH%, CVH%, and PVH%, respectively)] and follow-up complications [adjacent vertebral fracture (AVF), residual pain (RP), vertebral height loss (VHL), and internal fixation failure (IFF)] were compared between the 2 groups.

RESULTS

No differences in surgical outcomes, clinical indicators, and radiographic parameters were observed between the 2 groups during the preoperation period and 7 days post-operatively (P > .05). However, the VAS score [2.0 (.6), 1.9 (.5)], ODI [23.7 (4.0), 22.6 (3.0)], LKA [9.5 (1.8), 10.6 (3.0)], AVH% [90.1 (2.7), 87.7 (6.0)], CVH% [92.5 (2.6), 91.3 (3.7)], and PVH% [93.4 (2.0), 92.7 (2.4)] at 1 year post-operatively and last follow-up of the PSF + VP group were better than those of the PSF group [2.5 (.8), 3.1 (1.1), 26.6 (3.8), 29.6 (4.6), 12.2 (1.6), 16.6 (3.2), 84.9 (4.0), 69.9 (6.6), 88.1 (3.1), 78.2 (5.1), 89.7 (2.3), 84.8 (4.6)], respectively (P < .001). During follow-up, the incidence of AVF had no difference (P > .05), while that of RP (32.1 vs 14.8%), VHL (33.9 vs 9.3%) and IFF (17.9 vs 5.6%) had statistical differences between them (P < .05).

CONCLUSION

The Wiltse approach of PSF combined with VP for Genant III-OTLFs can not only effectively relieve pain, restore vertebral height, and correcte kyphosis, but also better maintain vertebral height, delay kyphosis progression, and reduce complications during follow-up.

Right atrial and pulmonary cement embolization following vertebral laminectomy: An incidental finding

Right heart cement embolization is a rare but potentially life-threatening complication of vertebroplasty surgeries. Transthoracic echocardiography is the first-line imaging modality for detecting cement particles in cardiac chambers. Anticoagulation treatments or surgical interventions are necessary, depending on the patient's condition.

Radiofrequency Ablation in Vertebral Body Metastasis with and without Percutaneous Cement Augmentation: A Systematic Review Addressing the Need for SPINE Stability Evaluation

Vertebral body metastases (VBM) are one of the most frequent sites of bone metastasis, and their adequate therapeutic management still represents an insidious challenge for both oncologists and surgeons. A possible alternative treatment for VBM is radiofrequency ablation (RFA), a percutaneous technique in which an alternating current is delivered to the tumor lesion producing local heating and consequent necrosis. However, RFA alone could alter the biomechanics and microanatomy of the vertebral body, thus increasing the risk of post-procedure vertebral fractures and spine instability, and indeed the aim of the present study is to investigate the effects of RFA on spine stability. A systematic review according to PRISMA-P guidelines was performed, and 17 papers were selected for the systematic review. The results show how RFA is an effective, safe, and feasible alternative to conventional radiotherapy for the treatment of VBM without indication for surgery, but spine stability is a major issue in this context. Although exerting undeniable benefits on pain control and local tumor recurrence, RFA alone increases the risk of spine instability and consequent vertebral body fractures and collapses. Concomitant safe and feasible therapeutic strategies such as percutaneous vertebroplasty and kyphoplasty have shown synergic positive effects on back pain and improvement in spine stability.

Outcomes of Treatment of Spinal Fractures with the SpineJack System

BACKGROUND

The use of "SpineJack" implants in patients with stable spinal fractures and without neurological deficits enables restoration of the shape of the fractured vertebra and significantly accelerates restoration of normal function. In unstable spinal fractures, additional posterior fixation is recommended. This is not recommended in patients with traumatic spinal stenosis. The aim of the study was to evaluate the surgical and functional outcomes of treatment of patients with the SpineJack implant.

MATERIAL AND METHODS

The objectives of this paper were accomplished on the basis of an evaluation of the outcomes of treatment of 39 patients operated on at the Orthopaedic Oncology Department in Brzozów and the Department of Orthopaedics and Traumatology in the District Hospital in Stalowa Wola in the years 2020-2021. 71% of patients were men; the mean age of women was 54 years and the mean age of men was 41 years. A total of 30 patients suffered traumatic fractures, while 9 patients suffered non-traumatic (pathological) fractures. Fractures were most often located in the lower parts of the thoracic and upper lumbar spine. Patient radiographs taken on the day before, the first day after and 3 months following the surgery were evaluated to assess the correction of vertebral wedging and cement leakage. Functional status was assessed using ODI, the quality of life was assessed with the EQ-VAS and the severity of pain was measured with a VAS.

RESULTS

Pain intensity, measured with a VAS scale after the surgery, significantly decreased from the mean preoperative 6.9 to 2.4 three months post-op. The mean functional status of patients (ODI) before surgery was 74.4, compared to 14.8 at 3 months post-op. Mean Quality of life (EQ-VAS) was 56.4 before the surgery and 72.4 at 3 months post-op. The vertebral wedge angle decreased after surgical treatment, from a mean value of 15.8 degrees before surgery to 8.8 degrees after surgical treatment. At three months following the surgery, the mean loss of correction was 2.2 degrees and occurred in 4 patients. The most frequent complication was cement leakage into the disc and into the spinal canal, occurring in 4 and 2 patients, respectively.

CONCLUSIONS

1. The use of "SpineJack" implants in the treatment of stable vertebral fractures enables the restoration of the shape and reduction of the vertebral wedge angle. 2. The quality of life of patients after vertebral fracture treatment with "SpineJack" implants assessed using the EQ-VAS improved significantly. The severity of pain assessed on a VAS scale decreased significantly and the patients' functional status improved according to the ODI. 3.Complications observed during treatment with "SpineJack" implants include fractures of the vertebral endplate and cement leakage, mostly asymptomatic.

Cement leakage during vertebroplasty: comparison between intact and wall disruption in spinal metastases

BACKGROUND

Percutaneous vertebroplasty (PVP) is an effective measure for painful metastases or impending pathological fractures of the spine with cement leakages being the most frequent complication. Posterior extrusion of cement into the spinal canal may result in neurological symptoms and deficits.

PURPOSE

To compare the occurrence of intraspinal canal cement leakage between vertebrae with posterior wall disruption and vertebrae without posterior wall disruption.

MATERIAL AND METHODS

A single-center retrospective study was conducted of all PVP for spine metastases between June 2020 and November 2021. All leaks were analyzed by a postprocedural computed tomography scan or cone-beam computed tomography.

RESULTS

A total of 77 patients with 143 vertebrae treated by PVP were included. Posterior wall disruption was observed in 64 (44.8%) vertebrae while 79 (55.2%) had a complete posterior wall. Spinal canal cement leakage occurred in 36 (25.2%) vertebrae and was comparable in both groups, occurring in 16 (25.0%) vertebrae with posterior wall disruption and 20 (25.3%) vertebrae without posterior wall disruption (P = 1). No risk factors for spinal canal leakage were found in the univariate and multivariate analyses. One spinal leak was symptomatic with intercostal neuralgia.

CONCLUSION

Our results suggest that an incomplete vertebral posterior wall does not increase the rate of spinal canal cement leakage during PVP.

Percutaneous CT-Guided Microwave Ablation Combined with Pedicle Screw Fixation Followed by Vertebroplasty (MASFVA): Initial Experience of a Minimally Invasive Treatment of Vertebral Metastases with Extension to the Vertebral Pedicle

(1) Background: The aim of this study was to retrospectively evaluate the safety and efficacy of a combined CT-guided percutaneous microwave ablation (MWA) and pedicle screw fixation followed by vertebroplasty (MASFVA) for the treatment and stabilization of painful vertebral metastases with vertebral pedicle involvement. (2) Methods: from January 2013 to January 2017 11 patients with 16 vertebral metastatic lesions (7 men and 5 women; mean age, 65 ± 11 years) with vertebral metastases underwent CT-guided microwave ablation and screw fixation followed by vertebroplasty (MASFVA). Technical success, complication rate, pain evaluation using a visual analogue scale (VAS), Oswestry Disability Index (ODI) and local tumor control were examined. (3) Results: Technical success rate was 100%. No procedure-related major complications occurred. VAS score decreased from 6.8 ± 0.7 to 0.6 ± 0.6. ODI score decreased from 3.1 ± 0.7 to 1.2 ± 0.4. All patients could walk independently without neurological complication after one week from the procedure. No new bone fractures or local disease recurrence occurred during a median follow-up of 12 months. (4) Conclusions: Our results suggest that MWA and percutaneous pedicle screw fixation followed by vertebroplasty for the treatment of painful vertebral metastases is a safe and effective procedure for painful vertebral metastases with vertebral pedicle involvement, allowing pain relief and local tumor control.

Multilevel unilateral versus bilateral pedicular percutaneous vertebroplasty for osteoporotic vertebral compression fractures

Study design

Retrospective study.

Objective

Controversy exists over the need for unilateral vs. bilateral pedicular percutaneous vertebroplasty (PVP) for patients with osteoporotic vertebral compression fractures (OVCFs). Clinical research is scarce comparing two approaches for multi-level PVP. This study aimed at evaluating the clinical and radiographic outcomes of multi-level PVP using two approaches for OVCFs.

Methods

Seventy-eight patients with OVCFs undergoing multi-level PVP were enrolled including 36 patients undergoing unilateral PVP and 42 undergoing bilateral PVP. The clinical and radiological assessments including the Visual Analogue Scale (VAS), sagittal and coronal segmental Cobb, vertebral compression ratio (VCR), and vertebral sides ratio (VSR) were evaluated preoperatively and postoperatively.

Results

All patients achieved a minimum 2-year follow-up. A total of 164 fractured vertebrae were enrolled. Regarding clinical efficacy, the VAS score improved in both groups after surgery, but the two groups did not differ significantly. The changes tendency in Sagittal Segmental Cobb, VSR, and VCR were similar postoperatively, and no statistically significant difference between groups. As for the Coronal Segmental Cobb angle, patients in unilateral and bilateral groups were shown to have 5.0° ± 4.0° and 2.6° ± 2.2° degrees loss of correction at a minimum 2-years follow-up duration, respectively. The loss of correction in the Coronal Segmental Cobb of unilateral group was significantly greater than that of bilateral group.

Conclusion

Both multi-level unilateral and bilateral pedicular PVP achieved significant pain reduction and vertebral height restoration. Moreover, the bilateral PVP has shown advantages in stabilizing Coronal Cobb angle in patients with OVCFs.

Acute abdomen after vertebroplasty-A rare complication

Introduction

In recent years, as the concept of minimally invasive treatment has been accepted by the majority of patients, the application of percutaneous vertebroplasty in osteoporotic vertebral compression fractures has gradually increased, and research on the adverse complications of bone cement leakage has gradually deepened.

Case

Here, we report a rare case of acute pancreatitis after vertebroplasty. The patient had no previous history of pancreatitis and presented with obvious abdominal pain after vertebroplasty. Abdominal CT examination revealed that the leaking bone cement penetrated the anterior wall of the L1 vertebral body into the diaphragm, and the heat released by the polymerization reaction caused inflammation and damage to the adjacent pancreas, resulting in poor blood flow to the pancreatic tissue and leading to acute pancreatitis. Early postoperative symptomatic treatment was given to the patient, and the corresponding symptoms were gradually relieved. During postoperative follow-up, the leaking cement did not degrade, but the patient had no symptoms.

Conclusion

Lesions of adjacent organs caused by bone cement leakage are rare, and clinicians often ignore the association between such complications and vertebroplasty. This case report will provide guidance and a reference for clinicians.

Porous titanium microsphere kyphoplasty for augmentation treatment of osteoporotic vertebral fractures: Technical report and case series

Background

Vertebral augmentation procedures (VAPs) are used in cases of persistent and unresponsive pain in patients with vertebral compression fractures (VCFs). Although VAPs are considered a safe procedure providing quick pain relief and improved physical function, some postoperative complications can occur, for example, bone cement leakage. The material used in this procedure is almost exclusively polymethyl methacrylate (PMMA), which appears to lack biological activity and osteointegration capabilities. In this study, we introduce a new filling system consisting of cannulas preloaded with titanium microspheres, which stabilizes and consolidates the structure of the vertebral body in treating VCFs after the performance of the kyphoplasty procedure.

Methods

We report a retrospective case series of six patients affected by osteoporotic vertebral fractures with worsening back pain, neurologic impairment, and failed conservative treatment who underwent the VAP at our institute, for which the SPHEROPLAST [MT ORTHO s.r.l., Aci Sant'Antonio (CT), Italy] system was used.

Results

The patients had failed an average conservative trial of 3.9 weeks before they presented to us with neurodeficit. There were two men and four women with a mean age of 74.5 years. The average hospital stay was 2 days. There were no reported perioperative complications related to cement injection, such as intraoperative hypoxia, hypotension, pulmonary embolization, myocardial infarction, neurovascular or viscera injury, or death. The VAS score significantly decreased from a mean preoperative of 7.5 (range 6-19) to 3.8 (range 3-5) immediately after surgery and 1.8 (range 1-3).

Conclusion

We report the first clinical results in a series of six patients treated for VCF using the microsphere system after analyzing the clinical results produced by, and the complications that arose from, this new device. In patients with VCF, the VAP using titanium microspheres appears to be a feasible and safe procedure with a low risk of material leakage.

Clinical Outcome and Histological Findings After Induced Leakage of PMMA Loaded With Methotrexate and Cisplatin During Vertebroplasty: Experimental Model in Pigs

STUDY DESIGN

Animal experimental model.

OBJECTIVE

To study the clinical behavior and histological changes in the spinal cord, nerve roots and perivertebral muscles of the spine after induced leakage of polymethylmethacrylate (PMMA) loaded with antiblastic drugs during vertebroplasty in an animal model of pigs.

METHODS

We performed vertebroplasty on 25 pigs. The animals were divided into 3 groups: vertebroplasty with PMMA alone (control group), vertebroplasty with PMMA loaded with methotrexate (MTX) and vertebroplasty with PMMA loaded with cisplatin (CYS). At 2 vertebral levels, epidural and prevertebral, massive cement leaks were induced. Animals were evaluated daily. Two weeks later, the pigs were sacrificed, and the tissues that came in contact with the cement were analyzed.

RESULTS

The clinical results for each of the groups were reported. The control group had no clinical alterations. In the MTX group, 2 pigs died before 1 week due to pneumonitis. In the CYS group, 4 animals had motor impairment, and 3 of the 4 had paraplegia. The histological results were as follows: the control and MTX groups showed synovial metaplasia, inflammatory reaction, crystal deposits, and giant cell reaction in the dura mater and muscle and all the animals in the CYS group had spinal cord and muscular necrosis.

CONCLUSIONS

Massive cement leak after vertebroplasty with PMMA loaded with cisplatin is extremely toxic to the spinal cord and muscles around the spine. Therefore, its use cannot be recommended for the treatment of vertebral metastases. Using PMMA loaded with methotrexate seems to be a safe procedure, but further research is needed.

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

INTRODUCTION

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

CASE PRESENTATION

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

CONCLUSION

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

Trends in Hospitalization and Economic Impact of Percutaneous Kyphoplasty in Italy

Vertebral Fractures (VFs) caused by osteoporosis are the most typical reason for performing Percutaneous Kyphoplasty (PK). Globally, VF prevalence is not well described in the literature. In Europe, only Sweden has an accurate record of the incidence of this type of fracture. Moreover, the exact incidence of the PK procedure is not reported. Therefore, the annual patterns and financial burden of PK in Europe is not well known, and it could be may better understood by examining national registers. For surgeons, lawmakers, hospital administrators, and the healthcare system, determining the annual national costs of this treatment is helpful. The National Hospital Discharge Reports (SDOs) submitted to the Italian Ministry of Health during the years covered by this study (2009-2015) were used. A total of 13,113 kyphoplasties were performed in Italy, with a prevalence of 3.6 procedures for every 100,000 Italian inhabitants over 15 years. The average age of patients was 68.28 (±12.9). Females represented the majority of patients undergoing PK procedures (68.6%). The median length of hospital stay was 5.33 days. The prevalence of PK procedures increased from 2009 to 2015, while the average days of hospitalization decreased. Older patients were most at risk in undergoing PK procedures. Reporting the national data on PK in Italy could also help compare the findings across nations. The current study aims to determine the trends of PK hospitalisation and patient features in Italy.

Vertebral Body Height Changes in Acute Symptomatic Osteoporotic Vertebral Compression Fractures Treated with Vertebral Cement Augmentation-Which Factors Affect Vertebral Body Height during Follow-up? A Multiple Linear Regression Study

Changes in vertebral body height depend on various factors which were analyzed in isolation and not as a whole. The aim of this study is to analyze what factors might influence the restoration of the vertebral body height after vertebral augmentation. We analyzed 48 patients (108 vertebrae) with osteoporotic vertebral fractures who underwent vertebral augmentation when a conservative treatment proved to be unsatisfactory. The analyses were carried out at the time of the fracture, during surgery (pre-cementation and post-cementation), at the first medical check-up (6 weeks post-surgery) and at the last medical check-up. The average vertebral height was measured, and the differences from the preoperative values were calculated at each timepoint. A Pearson correlation coefficient and a linear multivariable regression were carried out at different timepoints. The time since the vertebral fracture was 60.4 ± 41.7 days. The patients' average age was 73.8 ± 7 years. The total follow-up period was 1.43 ± 1 year. After vertebral cementation, there was an increase in the vertebral body height of +0.3 cm (13.6%). During the post-operative follow-up, there was a progressive collapse of the vertebral body, and the pre-surgical height was reached. The factors that most influenced the vertebral height restoration were: a grade III collapse, an intervertebral-vacuum-cleft (IVVC) and the use of a flexible trocar before cement augmentation. The factor that negatively influenced the vertebral body height restoration was the location of the thoracolumbar spine.

Risk factors for new vertebral compression fracture after kyphoplasty and efficacy of osteoporosis treatment: A STROBE-compliant retrospective study

Kyphoplasty (KP) has been widely used to treat vertebral compression fractures (VCFs). However, the issue of new VCFs after KP remains controversial. Identification of risk factors for new VCF after KP may help prevent their occurrence in patients. This study aimed to retrospectively determine the major risk factors for new VCF after KP, including those associated with osteoporosis drugs used after kyphoplasty. We reviewed 117 patients who underwent single-level KP. During the follow-up period of 1 year after KP, the demographic data of these patients were compared by dividing them into two groups: those with new fractures (n = 19) and those without new fractures (n = 98). We investigated the age, sex, fracture location, medical history, steroid use history, bone mineral density (BMD), type of osteoporosis treatment, period from fracture to KP, KP method (unilateral or bilateral), bone cement dose, intradiscal cement leakage, preoperative and postoperative compression ratio, kyphotic angle (KA), and lowest vertebral body height in the fractured vertebrae. Based on these data, the factors related to new VCFs after KP were investigated using univariate and multivariate logistic regression analyses. We also investigated whether there were differences in new VCFs according to the type of osteoporosis treatment. During the 1-year follow-up period after KP, the rate of new VCFs was 16.2%. Factors related to new VCFs were BMD, intradiscal cement leakage, KA recovery rate after 1 day, and baseline height in the univariate and multivariate logistic regression analyses. The group treated with zoledronate after KP tended to show a lower frequency of developing new VCFs than the groups treated with alendronate (P = .07), calcium (P = .05), selective estrogen receptor modulator (SERM) (P = .15), and risendronate (P = .02). This study showed that for patients with new VCFs after KP, lower BMD, greater intradiscal cement leakage, greater KA recovery rate, and lower baseline vertebral height were likely risk factors for the development of new VCFs. Additionally, among the drugs used for the treatment of osteoporosis after KP, zoledronate tends to reduce the development of new VCFs compared with other bisphosphonates, SERMs, or calcium.

Thoracic Percutaneous Vertebroplasty for the Treatment of Vertebral Hemangioma in a Patient With Forestier's Disease: A Case Report

Percutaneous vertebroplasty consists of an injection of polymethylmethacrylate in the vertebral body, with the aim of reinforcing the bone structure, preventing vertebral collapse, and achieving analgesic and antitumor effects. It is used in the treatment of patients with aggressive vertebral hemangiomas, as well as compression fractures of traumatic etiology and pathological fractures. Forestier's disease is also known as senile ankylosing hyperostosis of the spine. It is characterized by hypertrophy of the anterior longitudinal ligament. Depending on the most prominent place of ossification of this ligament, its clinical symptoms vary, with intense pain being the most relevant. Here, we present the case of a 73-year-old female with complaints of intense, constant pain that did not improve with conservative treatment, located at the level of the Th4Th10 vertebrae, radiating along the intercostal spaces, with eight months of evolution with muscular hypertonism. Magnetic resonance imaging of the thoracic spine showed osteochondritis of the thoracic spine and right-sided scoliosis. For hemangioma of the Th6 vertebral body, the patient was referred to the vertebrology department, where she was admitted to undergo percutaneous vertebroplasty of the affected level under fluoroscopic control. In this study, we report the use of percutaneous vertebroplasty as a minimally invasive treatment in a patient with Forestier's disease, obtaining excellent results, rapid recovery, and minimal hospitalization time, without having to subject the patient to major surgery.

Biological Fixation of Bioactive Bone Cement in Vertebroplasty: The First Clinical Investigation of Borosilicate Glass (BSG) Reinforced PMMA Bone Cement

PMMA bone cement has been clinically used for decades in vertebroplasty due to its high mechanical strength and satisfactory injectability. However, the interface between bone and PMMA is fragile and more prone to refracture in situ because PMMA lacks a proper biological response from the host bone with minimal bone integration and dense fibrous tissue formation. Here, we modified PMMA by incoporating borosilicate glass (BSG) with a dual glass network of [BO₃] and [SiO₄], which spontaneously modulates immunity and osteogenesis. In particular, the BSG modified PMMA bone cement (abbreviated as BSG/PMMA cement) provided an alkaline microenvironment that spontaneously balanced the activities between osteoclasts and osteoblasts. Furthermore, the trace elements released from the BSGs enhanced the osteogenesis to strengthen the interface between the host bone and the implant. This study shows the first clinical case after implantation of BSG/PMMA for three months using the dual-energy CT, which found apatite nucleation around PMMA instead of fibrous tissues, indicating the biological interface was formed. Therefore, BSG/PMMA is promising as a biomaterial in vertebroplasty, overcoming the drawback of PMMA by improving the biological response from the host bone.

Pre-operative anemia was associated with all-cause mortality in patients with vertebral fracture who underwent percutaneous vertebroplasty

PURPOSE

We investigated the association between pre-operative anemia and long-term all-cause mortality in patients with vertebral fracture who underwent a vertebroplasty.

MATERIALS AND METHODS

We retrospectively selected patients who were admitted for vertebroplasty for vertebral compression fracture between 2013 and 2020. Patients who had pathologic fractures or had no assessment of bone mineral density were excluded. Relevant information was collected from electronic medical records. Patients' survival status was confirmed at the end of March 2021. Cox-proportional hazard models were conducted to examine the effects of anemia (<12 g/dL vs. ≥12 g/dL) and pre-operative hemoglobin levels (as a continuous variable) on all-cause mortality with multivariate adjustments.

RESULTS

A total of 167 patients were analyzed (mean age 75.8 ± 9.3 years, male 25.7%). After a median follow-up duration of 2.1 years, pre-operative anemia (hemoglobin <12 g/dL vs. ≥12 g/dL) was independently associated with a higher risk of all-cause mortality (hazard ratio 2.762, 95% CI 1.184 to 6.442, p = 0.019). An increase in pre-operative hemoglobin was associated with a lower risk of all-cause mortality after multivariate adjustment (hazard ratio 0.775, 95% CI 0.606 to 0.991, p = 0.042).

CONCLUSION

Pre-operative anemia (<12 g/dL) was independently associated with survival outcome among patients with vertebral compression fractures who underwent vertebroplasty. Our findings highlight anemia as a risk factor of long-term mortality in this elderly surgical population.

Association of Body Mass Index with Long-Term All-Cause Mortality in Patients Who Had Undergone a Vertebroplasty for a Vertebral Compression Fracture

We aimed to investigate the association between preoperative body mass index (BMI) and postoperative long-term mortality in patients who underwent a vertebroplasty. We retrospectively enrolled patients with a vertebral compression fracture who underwent a vertebroplasty between May 2013 and June 2020 in a medical center in Taiwan. The survival status of the study sample was confirmed by the end of March 2021. Cox-proportional hazard models were conducted to examine the effects of being overweight/obese (≥25 kg/m2 vs. <25 kg/m2) and BMI (as a continuous variable) on all-cause mortality after adjusting for age, sex, history of smoking, diabetes, hypertension, chronic kidney disease, and osteoporosis. A total of 164 patients were analyzed (mean age 75.8 ± 9.3 years, male 25.6%, mean BMI 24.0 ± 4.1 kg/m2) after a median follow-up of 785 days. Compared with a BMI < 25 kg/m2, a BMI ≥ 25 kg/m2 was associated with a significantly lower risk of all-cause mortality (HR 0.297, 95% CI 0.101 to 0.878, p = 0.028). These findings were consistent when BMI was examined as a continuous variable (HR 0.874, 95% CI 0.773 to 0.988, p = 0.031). A low BMI (<22 kg/m2) should be considered as a risk factor for postoperative long-term mortality in this ageing population.

Management of Aggressive Vertebral Haemangioma and Assessment of Differentiating Pointers Between Aggressive Vertebral Haemangioma and Metastases - A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

Vertebral haemangioma has been classified into typical and aggressive vertebral haemangioma (AVH). Management options for AVH are many and the clinician has decision dilemma in choosing the right one. Metastases mimic AVH in clinical and radiological presentation. Differentiating pointers between them has not been clearly delineated in literature. Aim of our review is to identify treatment options; to formulate a management algorithm for AVH based on clinical presentation and to identify radiological differentiating pointers between them.

METHODS

Systematic review was conducted according to PRISMA guidelines. We systematically reviewed all available literature from the year 2001 to 2020. Relevant articles were identified as per laid down criteria from the medical databases. After inclusion, first and second authors went through full text of each included article.

RESULTS

Of 139 studies reviewed, eight met our criteria for review of management and three separate studies for radiological differentiating pointers. 99 patients with 88 AVH had undergone treatment. Back pain with myelopathy is the presenting symptom in majority of patients. Patients with backpain - myelopathic symptoms had improved following surgery; patients with back pain alone had improved with either percutaneous vertebroplasty or CT guided alcohol ablation. Dynamic contrast MRI, Diffusion weighted MRI and ratio of signal intensity between T1w and fat suppression T1w MR help the clinician in differentiating them.

CONCLUSION

Management of AVH can be based on the patient's clinical presentation. Patients presenting with AVH and back pain can be managed with either Percutaneous vertebroplasty or CT guided alcohol ablation. Patients presenting with AVH and neurological symptoms could be managed with surgery. Dynamic contrast enhanced MR, Diffusion weighted MR, ratio of signal intensity between T1w and Fat suppression T1w MR imaging could help the clinician in differentiating the two before contemplating biopsy.

GRADE PRACTICE RECOMMENDATION

C.

Biomechanical analysis of a novel bone cement bridging screw system for the treatment of Kummell disease: a finite element analysis

When bone cement is used to strengthen the vertebrae in patients with Kummell disease (KD), loosening and displacement of cement are common complications that can cause poor results. We developed a bone cement bridging screw system to avoid this complication. This three-dimensional finite element study aims to analyze the biomechanical properties of the novel bridging screw system and compare it to single vertebroplasty and vertebroplasty combined with pediculoplasty. After the effective establishment of a KD three-dimensional finite element model, the stability of the bone cement in the five treatment methods was analyzed and compared on four aspects. According to the calculation results of the maximum von Mises stress of bone cement and the relative displacement ratio of bone cement, it was determined that the stability of the bone cement was significantly improved when combined with the bridging screw system or pediculoplasty. In addition, according to the calculation results of the maximum von Mises stress of the inferior endplate of T12 and the displacement load ratio of the bone cement, we further found that after using the bridging screw system, the bone cement in the vertebral body has the best stability, and the risk of bone cement loosening or displacement is the lowest. In conclusion, for treating KD with bone cement augmentation, the bone cement bridging screw system combined with vertebroplasty has better stability and safety than ordinary single vertebroplasty and vertebroplasty combined with pediculoplasty. This treatment approach has the most robust ability to avoid loosening and displacement of bone cement.

Finite element analysis of the indirect reduction of posterior pedicle screw fixation for a thoracolumbar burst fracture

Because burst fractures often involve damage to the column and posterior structures of the spine, the fracture block may invade the spinal canal and compress the spinal cord or the cauda equina, causing corresponding neurological dysfunction. When a thoracolumbar burst fracture is accompanied by the presence of bone in the spinal canal, whether posterior surgery requires spinal canal incision decompression is still controversial. Computed tomography images of the thoracolumbar spine of a 31-year-old male with an L1 burst fracture and Mimics 10.0 were used to establish a three-dimensional fracture model for simulating the indirect reduction process. The model was imported into Ansys 10.0 (ANSYS, Inc., Canonsburg, PA), and a 1 to 10 mm displacement was loaded 10° behind the Z-axis on the upper endplate of the L1 vertebral body to simulate position reduction and open reduction. The displacement and stress changes in the intervertebral disc, fractured vertebral body and posterior longitudinal ligament were observed during reduction. Under a displacement loaded 10° behind the Z-axis, the maximum stress in the vertebral body was concentrated on the upper disc of the injured vertebrae. The maximum displacement was in the anterior edge of the vertebral body of the injured vertebrae, and the vertebral body height and the anterior lobes were essentially restored. When the displacement load was applied in the positive Z-axis direction, the maximum displacement was in the posterior longitudinal ligament behind the injured vertebrae. Under a 6 mm load, the posterior longitudinal ligament displacement was 11.3 mm. Under an 8 mm load, this displacement significantly increased to 15.0 mm, and the vertebral stress was not concentrated on the intervertebral disc. A reduction in the thoracolumbar burst fractures by positioning and distraction allowed the injured vertebrae to be restored to normal height and kyphosis. The reduction in the posterior longitudinal ligament can push the bone block in the spinal canal into the reset space and achieve a good reset.

The Use of Three-Column Enhanced Percutaneous Vertebroplasty to Treat Kummell's Disease

Purpose

To describe the operative technique and clinical effects of three-column enhanced percutaneous vertebroplasty used to treat Kummell’s disease.

Methods

From April 2017 to April 2020, 39 patients with Kummell’s disease were treated via three-column enhanced percutaneous vertebroplasty. There were 12 males and 27 females of average age 70.23 ± 7.41 years. The operative time, volume of bone cement injected, and intraoperative cement leakage were recorded. The patients were re-examined postoperatively. The VAS was used to evaluate low back pain and the ODI score to evaluate improvement in the quality-of-life.

Results

All patients were successfully operated upon; the average operation time was 35.1±4.7 min and average volume of bone cement injected 4.5±0.92 mL. Five cases exhibited bone cement leakage during operation, two into the intervertebral disc and three into the anterior upper margin of the vertebral body. No leakage into the vertebral canal occurred. The average hospital stay was 2.50±0.86 days. The VAS score before operation was 7.47±0.24, but low back pain symptoms were significantly relieved after operation (P < 0.05). The VAS scores at 1 day and 1, 3, 6, and 12 months after operation were 2.91±0.09, 2.04±0.07, 1.59±0.05, 1.28±0.15, and 0.8±0.18, respectively. The preoperative ODI score was 72.97±1.45 and significantly decreased postoperatively (P < 0.05), being 30.08±1.79 at 1 day, and 25.35±0.94, 23.19±1.76, 20.49±0.65, and 20.05±0.58 at 1, 3, 6, and 12 months after operation respectively.

Conclusion

Three-column enhanced percutaneous vertebroplasty effectively treats Kummell’s disease. The surgical trauma is low, recovery rapid, and bone cement fixation firm, especially in patients with stage I and II disease.

Mechanical and Geometric Analysis of Fenestration Design for Polymethylmethacrylate-Augmented Pedicle Screw Fixation

BACKGROUND

The practice of cement augmentation in pedicle screw fixation is well established. However, there is a lack of consensus regarding the optimal screw design or cement type. This remains a clinically important question given the incidence of cement augmentation-associated complications. While fenestrated screws have become widely used in clinical practice, the relationship between fenestration placement along the screw axis and cement plume geometry and pullout strength have yet to be clarified. This study was designed to evaluate the mechanical and geometric properties of different fenestrated screw designs and cement viscosities in pedicle screw fixation.

METHODS

Three different screw fenestration configurations and 2 different cement viscosities were examined in this study. Axial pullout tests were conducted in both foam blocks and cadaveric vertebrae. All vertebral specimens underwent tests of bone mineral density. In the foam blocks, 6 tests were conducted for each augmentation combination and also for nonaugmented controls. In the cadaveric testing, 36 lumbar vertebrae were instrumented with a cemented and uncemented control screw to compare features of fixation. Computed tomography (CT) images were taken to assess the geometric profile of the cement plumes in both the foam blocks and the cadaveric vertebrae.

RESULTS

In both foam blocks and vertebral specimens, cementation was shown to confer a significant increase in pullout strength. Significant correlations existed between the anterior-posterior and lateral cement plume diameters and pullout strength in cadaveric vertebra and foam blocks, respectively. Within instrumented vertebra, variables such as the width of the vertebral body and screw insertion were found to significantly correlate with enhanced fixation. CT analysis of the instrumented vertebra demonstrated that a centrally distributed pattern of fenestrations was found to result in a cement plume with consistently predictable distribution within the vertebral body, without evidence of leak.

CONCLUSION

Cementation of fenestrated pedicle screws increases overall pullout forces; however, there is an unclear relationship between the geometric properties of the cement plume and the overall strength of the screw-bone interface. This study demonstrates that the plume diameter, vertebral body width, and angle of screw insertion are correlated with enhanced pullout strength. Furthermore, varying the fenestration design of injectable screws resulted in a set of predictable plume patterns, which may be associated with fewer complications. Further investigation is required to clarify the optimal geometric and biomechanical properties of injectable pedicle screws and their role in establishing the cement-bone interface.

CLINICAL RELEVANCE

This study is relevant to currently practicing spinal surgeons and biomechanical engineers.

LEVEL OF EVIDENCE: 5

Analysis of the most influential publications on vertebral augmentation for treating osteoporotic vertebral compression fracture: A review

This study aimed to analyze the most influential publications on vertebral augmentation for treating osteoporotic vertebral compression fracture. The Web of Science database was searched using the key words "percutaneous vertebroplasty," "percutaneous kyphoplasty," "balloon kyphoplasty," "vertebroplasty," "kyphoplasty," and "vertebral augmentation." The top 100 publications were arranged by citations per year and descriptively and visually analyzed. The top 100 publications were cited 25,482 times, with an average of 14.4 citations per paper per year. The corresponding authors of the publications represented 17 nations, with most authors being American (46 authors). Thirty-two journals were involved, with SPINE issuing the most publications (24 papers of the 100). Clinical research (73 of the 100 papers) outnumbered basic studies (14 papers) and systematic reviews (13 papers), and the most publications were published between 2000 and 2004. Co-citation analysis of the key words indicated that the top 5 focus areas were "complication," "balloon kyphoplasty," "vertebral compression fracture," "biomechanics," and "calcium phosphate cement." The top 3 keywords with the strongest citation bursts were "compression fracture," "cement," and "balloon kyphoplasty." The keywords with persistent strong citation bursts are "balloon kyphoplasty" and "augmentation." There are still contrary opinions about vertebral augmentation; new research should be conducted with more deliberate design and longer follow-up.

Vertebroplasty with high-viscosity cement versus conventional kyphoplasty for osteoporotic vertebral compression fractures: a meta-analysis

BACKGROUND

To evaluate outcomes following percutaneous vertebroplasty with high viscosity cement (PVP-HVC) and percutaneous kyphoplasty (PKP) with normal-viscosity cement in patients with osteoporotic vertebral compression fractures (OVCFs).

METHODS

Pertinent studies were retrieved by searching five electronic databases up to July 2021. Additional records were identified via hand-searching of related references. Risk ratio (RR) and weighted mean difference (WMD), with their 95% confidence intervals (CIs), were calculated. A trial sequential analysis (TSA) was done for cement leakage.

RESULTS

Twelve studies, embracing 1050 patients with OVCFs, were included. PVP-HVC was superior to PKP with normal-viscosity cement regarding risk of cement leakage (RR: 0.67, 95% CI: 0.54-0.83, I² : 45.1%) and operation time (WMD: -11.26, 95% CI: -14.78 to -8.34, I² : 88.8%). However, TSA revealed that a sufficient level of evidence for leakage reduction may have yet to be reached. PKP groups had a significant decrease in Cobb's angles postoperatively (within 1 month, WMD: 2.68, 95% CI: 1.85-3.48, I² : 0%; after 1 year, WMD: 2.68, 95% CI: 1.35-4.01, I² : 0%). There are no significant differences between the two procedures pertaining to injected cement volume, Visual Analogue Scale (VAS), Oswestry Disability Index (ODI) and risk of adjacent vertebral fractures.

CONCLUSION

PVP-HVC and PKP with normal-viscosity cement are safe and effective treatments for the management of OVCF, but the former is superior to the latter in terms of procedure time. The potential of PVP-HVC in reducing cement leaks remains to be validated by more well-designed studies.

Incidence and Risk Factors for Complications and Mortality After Vertebroplasty or Kyphoplasty in the Osteoporotic Vertebral Compression Fracture-Analysis of 1,932 Cases From the American College of Surgeons National Surgical Quality Improvement

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

The purpose was to investigate the incidence of and risk factors for complications associated with vertebroplasty (VP) or kyphoplasty (KP) for osteoporotic vertebral compression fracture (OVCF) using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.

METHODS

A cohort of patients undergoing VP/KP was constructed from the 2011-2013 ACS-NSQIP dataset using Current Procedural Terminology (CPT) codes. The incidences of minor complications (i.e. urinary tract infection, pneumonia, renal insufficiency, superficial infection, wound dehiscence), major complications (i.e. reoperation, deep vein thrombosis, pulmonary embolism, sepsis, dialysis, cardiac arrest, deep infection, stroke), and mortality within 30 days post-surgery were investigated, and their risk factors were assessed using logistic regression modeling.

RESULTS

Of 1932 patients undergoing VP/KP, 166 (8.6%) experienced a complication, including minor complications in 53 (2.7%), major complications in 95 (4.9%), and death in 40 (2.1%). Multivariate logistic regression analysis indicated that the adjusted odds ratios (95% confidence interval [CI]) of mortality was significantly associated with ASA 4: 16.604 (1.956-140.959) and increased creatinine (≥ 1.3 mg/dL): 3.494 (1.128-10.823). History of chronic obstructive pulmonary disease was associated with minor complications. Increased WBC count and hypoalbuminemia (<3.0 g/dL) were also associated with major complications.

CONCLUSIONS

The major complication and mortality rates associated with VP/KP were 4.9% and 2.1% respectively, higher than previous reports. Increased creatinine and ASA 4 were independently associated with mortality after VP/KP. Therefore, cautious monitoring and counseling is needed for elderly, patients with preexisting kidney disease or ASA 4 undergoing VP/KP.