Adjacent Vertebral Body Fracture Research Articles

Preoperative Scoring System for Prediction of Early Adjacent Vertebral Body Fracture After Balloon Kyphoplasty Using X-Rays Taken in a Non-Weight-Bearing Position

Prevention of adjacent vertebral body fracture (AVF) following balloon kyphoplasty (BKP) is a key challenge. The objective of this study was to develop a scoring system that could be more extensively and effectively used to determine the surgical indications for BKP. The study involved 101 patients aged 60 years or older who had undergone BKP. Logistic regression analysis was used to identify risk factors for early AVF within 2 months following BKP. Scoring was based on the odds ratio for risk factors, and cut-off values were determined from the receiver operating characteristics curve. The correlation between the total scores and the incidence of early AVF, and the area under the curve (AUC) for the logistic regression model predicting early AVF using the scoring system were investigated. 29 cases (28.7%) experienced early AVF after BKP. The scoring system was created as follows: ① Age (<75 years: 0 points (P), ≥75 years: 1P), ② Number of previous vertebral fractures (0: 0P, 1 or more: 2P), and ③ Local kyphosis (<7°: 0P, ≥7°: 1P). The total scores were found to be positively correlated with the incidence of early AVF (r=0.976, P=0.004). The AUC of the scoring system for predicting early AVF was 0.796. The incidence of early AVF was 4.2% at ≤1P and 44.3% at ≥2P (P<0.001). A scoring system which can be applied to a broader patient population was developed. In cases where the total score is 2P or more, alternatives to BKP should be considered.

Effect of cement distribution type on clinical outcome after percutaneous vertebroplasty for osteoporotic vertebral compression fractures in the aging population.

ObjectiveThe study aimed to investigate the effect of the type of bone cement distribution on clinical outcomes following percutaneous vertebroplasty (PVP) for osteoporotic vertebral compression fractures (OVCF) in the elderly.MethodsRetrospective analysis of 160 patients diagnosed with OVCF who underwent PVP treatment from March 2018 to December 2020. Based on the kind of postoperative bone cement distribution, bone cement was classified as types I, II, III, IV, and V. Visual Analog Scale (VAS), Oswestry Disability Index (ODI), Cobb angle, anterior vertebral height ratio, refracture rate of injured vertebrae, and incidence of adjacent vertebral fractures were compared for the five types before and after three days, and one year of operation.ResultsVAS and ODI at three days and one year postoperative were significantly lower than those preoperative (P < 0.05) for all five distribution types. VAS and ODI for types I, II, and III were lower at one year postoperatively than for types IV and V (P < 0.05). There was no significant difference in Cobb angle and anterior vertebral body height ratio between preoperative and three days postoperative groups (P < 0.05); however, there were significant differences between three days and one-year postoperative and preoperative groups (P < 0.05). Following one year of surgery, the Cobb angle and the anterior vertebral height ratio of types IV and V were significantly different from those of types I, II, and III (P < 0.05), and there was a statistically significant difference between types IV and V (P < 0.05). In terms of the incidence of injured vertebral refractures and adjacent vertebral fractures, the evenly distributed types I, II, and III were significantly lower than the unevenly distributed types IV and V, and the incidence of type V was higher (P < 0.05).ConclusionsThe clinical efficacy of cement distribution following PVP of types I, II, and III is better than that of types IV and V, which can better relieve pain with long-lasting efficacy and minimize the occurrence of refractures of injured vertebrae and adjacent vertebral body fractures.

Is Vertebroplasty Truly Associated with the Occurrence of Adjacent Vertebral Body Fractures?

Is Vertebroplasty Truly Associated with the Occurrence of Adjacent Vertebral Body Fractures?

Osteoporotic Thoracolumbar Vertebral Fractures With Neurological Deficit Treated by Balloon Kyphoplasty Augmented with Newly Developed Minimally Invasive Posterior Hook Stabilization.

Most osteoporotic vertebral fractures (OVFs) are treated conservatively, but surgery is often indicated for residual pain, neuropathy, or severe deformity. OVFs tend to develop in elderly patients, so less invasive surgery is desirable. Surgery is mainly performed to stabilize the fractured vertebral body. Percutaneous cement augmentation, such as via balloon kyphoplasty (BKP), has produced satisfactory results as a surgical method for managing OVFs. Posterior fixation with implants is often performed with or without cement augmentation when stronger fixation is considered necessary for OVFs with local kyphosis and angular instability. Pedicle screws (PSs) are widely used as an implant for posterior fixation, but given the risk of backing out in bones with severe osteoporosis, several measures have been taken to increase the strength such as by adding hooks. In cases of osteoporosis, hooks that can use cortical bone as an anchor are considered more useful than PS but are rarely used in minimally invasive surgery. We developed a minimally invasive posterior hook stabilization approach to directly stabilize the posterior spinal components as a new augmentation method for BKP and applied it to four cases of thoracolumbar OVF with neurological symptoms. The operation time was about 60 minutes, including BKP, and the estimated blood loss was about 10 ml. No postoperative implant problems occurred, and in all cases, neurological symptoms, such as buttocks and leg pain, were alleviated at an early stage after surgery. One patient had a postoperative adjacent vertebral body fracture that was conservatively treatable. Minimally invasive posterior hook stabilization, which we developed as a way of augmenting BKP, was considered useful for managing vertebral body fractures of the thoracolumbar spine with local kyphosis and angular instability.

Use of Parathyroid Hormone and Rehabilitation Reduces Subsequent Vertebral Body Fractures after Balloon Kyphoplasty.

Study DesignRetrospective cohort study.PurposeTo evaluate the efficacy of our current prophylactic strategy by investigating the incidence of subsequent vertebral body fractures (SVBFs) following balloon kyphoplasty (BKP).Overview of LiteratureAlthough extensive studies have investigated the risk factors for SVBFs after BKP, few have reported on postoperative therapies to prevent SVBFs and have evaluated their effectiveness.MethodsThis study enrolled 273 patients who underwent an initial BKP. To treat osteoporosis, parathyroid hormone (PTH) administration was started 1–2 weeks before BKP and continued for at least 6 months postoperatively. Corsets were applied for 3 months after the procedure. Rehabilitative interventions, including hip range-of-motion training, muscle strengthening exercises, and motion/posture instruction, were started from the preoperative assessment time point and resumed 3 hours postoperatively. Corsets were used in all patients. Therefore, no grouping based on corset use was performed. PTH was used in 180 patients, and they were divided into the following two groups: PTH user group and PTH nonuser group. Rehabilitative interventions were provided to all patients for a median duration of 17 days. Patients who underwent rehabilitative intervention for <17 and ≥17 days were included in the short-term and long-term intervention groups, respectively. The incidences of SVBFs for these four groups were compared.ResultsSVBF occurred in 29 patients (10.6%). The SVBF incidence among patients who were prescribed all three prophylactic measures was 6.2%. The PTH user group had a significantly lower incidence of distant vertebral body fractures as compared to the PTH nonuser group. The long-term rehabilitation group had a significantly lower incidence of SVBFs and adjacent vertebral body fractures within 50 postoperative days than the short-term group.ConclusionsA 17-day or longer rehabilitative intervention may lower the risk of early adjacent vertebral body fractures, and the use of PTH may reduce the risk of distant vertebral body fractures.

Intra-spinal epidural leakage of bone cement during vertebroplasty of an osteoporotic vertebral fracture: case report and review of literature

&lt;p class="abstract"&gt;Vertebral fractures are one of the most common complications of osteoporosis. Prolonged and intractable pain leads to immobilization and significant morbidity. Vertebroplasty is designed primarily to relieve pain, and the procedure is considered when osteoporotic vertebral fracture does not respond to a reasonable period of conservative care. Vertebroplasty has a low complication rate with most common complication being adjacent vertebral body fracture and rare complication due to extra-vertebral cement leakage causing nerve root compression or pulmonary embolism. We report a case of 55 year old lady with osteoporotic D12 wedge compression fracture subjected to vertebroplasty resulting in intraspinal cement leakage noticed intra-operatively. Patient underwent immediate decompression, cement extraction and posterior instrumentation. Postoperative course was uneventful.&lt;/p&gt;

The Radiologic and Clinical Outcomes of Oblique Lateral Interbody Fusion for Correction of Adult Degenerative Lumbar Deformity

Background:Osteotomies aimed at correcting adult spinal deformity are associated with higher complications and perioperative morbidity. Recently, oblique lumbar interbody fusion (OLIF) was introduced for degenerative lumbar diseases. The aim of our study is to demonstrate the effectiveness of OLIF on the management of adult degenerative lumbar deformity (ADLD).Materials and Methods:Patients with ADLD who underwent deformity correction and decompression using OLIF and posterior instrumentation were enrolled. For radiologic evaluation, Cobb's angle (CA), sagittal vertical axis (SVA), lumbar lordosis (LL), thoracic kyphosis (TK), pelvic tilt (PT), sacral slope (SS), and pelvic incidence (PI) were evaluated. Visual analog scale (VAS), Oswestry disability index (ODI), and perioperative parameters were recorded for clinical evaluation.Results:Fifteen patients with a mean age of 67 years (63–74 years) were enrolled prospectively and an average of 3 OLIFs (range 1–4) was performed. Posterior instrumentations were done at average of six levels (range 4–8). The mean operative blood loss was 863 ml (range 500–1400 ml) with a mean surgical duration of 7 h (range 3–11 h). SVA, TK, LL, CA, PT, and SS showed significant correction (P < 0.05) in immediate postoperative period and all parameters except TK were maintained at final followup. At the end of 24 months of average followup, 86% (13/15) showed fusion. VAS (leg pain), VAS (back pain), and ODI improved by 74% (range 40–100), 58% (range 20%–80%), and 69.5% (range 4%–90%), respectively. There were two major complications requiring revision (1 infection and 1 adjacent vertebral body fracture). Transient hip weakness present in two patients (13%) recovered within 6 weeks.Conclusions:OLIF gives favorable short term clinical and radiological outcomes in patients of ADLD. It could potentially reduce the need for morbid pelvic fixation and posterior osteotomies in patients with degenerative lumbar deformity.

Glass -polyalkenoate cement: An alternative material for kyphoplasty in osteoporotic vertebral compression fractures - An ex vivo study.

Adjacent vertebral body fracture is described as a risk after vertebroplasty and kyphoplasty. It may be true that this phenomenon is caused precisely because of the frequently used polymethylmethacrylate cement (PMMA), which shows a higher level of stiffness than bone material and may ultimately lead to shifting stress levels within the entire spine. The goal of the present study was to evaluate and compare the pressure distribution in the endplate of human vertebrae after kyphoplasty with PMMA and aluminum-free glass-polyalkenoate cement (gpc). For the present study, 8 fresh frozen human cadaveric vertebral bodies from the thoracolumbar junction were used. All vertebrae were augmented transpedicularly on one side with gpc and on the other side with PMMA. A loading of 600 N, 800 N and 1000 N was applied. In the data processing an individual region of interest (roi) was generated for each vertebra. The following parameters were determined for each roi: maximum force [N], maximum pressure [kPa], mean pressure [kPa], roi area [cm2]. We found significantly higher mean pressure values in the areas of the vertebrae augmented with PMMA, compared to the ones after augmentation with gpc (p = 0.012) when applying 1000 N. In the groups with lower forces there were no statistical relevant differences. The pressure distribution shows an advantage for gpc. A material, which does not create load concentration onto the cranial and caudal vertebral surface, could have major advantages concerning the risk of adjacent vertebral fractures. Thus the results of the 1000 N loading protocol suggest gpc being a possible alternative to ordinary PMMA cement, regarding its influence on stiffness in kyphoplasty. These and other general aspects like incorporation should be addressed and elaborated more detailed in further studies.

BIOMECHANICAL EVALUATION OF LOW-MODULUS BONE CEMENT FOR ENHANCING APPLICABILITY IN VERTEBROPLASTY — AN EXPERIMENTAL STUDY IN PORCINE MODEL

Polymethylmethacrylate (PMMA) bone cement has been widely used in vertebroplasty to treat osteoporotic vertebral compression fracture. However, the high compression stiffness of PMMA is suspected to induce adjacent vertebral fracture following vertebroplasty. In the current study, modified low-modulus cement was prepared by combining PMMA with castor oil to solve this problem. The percentage of height recovery and compression stiffness of vertebral bodies was compared after injection of standard PMMA or low-modulus cement. This study aims to investigate whether low-modulus cement is as effective as standard PMMA for storing the initial vertebral height; while lowering the compression stiffness in treatment of osteoporotic vertebral compression fractures. A total of 20 fresh porcine lumbar vertebrae were assigned into two groups (10 per group): standard and low-modulus. All specimens received a four-week decalcification to mimic human osteoporotic vertebrae. The standard and low-modulus groups received a simulated compression fracture followed by treatment of standard and low-modulus cement augmentation, respectively. The low-modulus cement was prepared by combining standard PMMA with 15% weight fractions of castor oil. For all the 20 specimens, vertebral compression fracture was created by reducing the vertebral height of 25% using a material testing machine. The compression stiffness determined from the creation of compression fracture was defined as the intact group (20 specimens). The fractured vertebrae were then treated with standard and low-modulus cement augmentation. The vertebral height was measured pre- and post-treatment, and the percentage of vertebral height recovery was compared between two cementing groups. Following cement augmentation, axial compression test was conducted to compare compression stiffness among three groups. The results indicated that there is no significant difference in percentage of vertebral height between standard (83.42[Formula: see text][Formula: see text][Formula: see text]11.60%) and low-modulus (88.50[Formula: see text][Formula: see text][Formula: see text]6.15%) groups ([Formula: see text]). Moreover, the compression stiffnesses were 1166.49[Formula: see text][Formula: see text][Formula: see text]392.91 N/mm, 1795.85[Formula: see text][Formula: see text][Formula: see text]247.45[Formula: see text]N/mm and 1362.57[Formula: see text][Formula: see text][Formula: see text]236.92[Formula: see text]N/mm for intact, standard and low-modulus groups, respectively. There is significant difference among three groups ([Formula: see text]). We concluded that the modified low-modulus cement is as effective as standard PMMA for storing the initial vertebral height while lowering the compression stiffness in treatment of osteoporotic vertebral compression fractures. These reduce the risks of adjacent vertebral body fracture following vertebroplasty.

Clinical outcome and subsequent sequelae of cement extravasation after percutaneous kyphoplasty and vertebroplasty: a comparative review.

Background Injection of cement during vertebroplasty and kyphoplasty can leak into surrounding structures and could be symptomatic. Purpose To identify the sites and incidence of cement extravasation after kyphoplasty and vertebroplasty, and to evaluate their impacts on clinical outcomes. Material and Methods A retrospective review of 316 patients treated with kyphoplasty and vertebroplasty; 411 cases were included (223 kyphoplasty and 188 vertebroplasty). Cement extravasation was evaluated postoperatively by computed tomography (CT) scan of the spine. Clinical outcomes were assessed by visual analog scale (VAS) and Oswestry Disability Index (ODI). Results There was a statistically significant difference in the incidence rate of cement extravasation between vertebroplasty and kyphoplasty groups ( P < 0.04). The most common site of cement extravasation was in paravertebral soft tissues for vertebroplasty (n = 33, 40.7%) and for kyphoplasty (n = 30, 30%). In the subgroup where cement leaked into the intradiscal space, adjacent vertebral body fractures occurred in 3/26 vertebrae (11.5%) in the vertebroplasty group and in 2/18 vertebrae (11.1%) in the kyphoplasty group. Both groups showed a statistically significant decrease in both VAS ( P < 0.001) and ODI scores ( P < 0.001). There was no significantly difference in patient satisfaction between those who had cement extravasation and those who did not, in both groups. Conclusion Kyphoplasty has an advantage in terms of less risk of cement extravasation. However, this factor did not reflect on subsequent sequelae or final clinical outcomes. This study did not find a distinct correlation between intradiscal cement extravasation and increased risk of adjacent vertebral fractures.

Experimental study of adjacent vertebral refracture after vertebroplasty on embalmed specimens

Objective To study the causes of fractures in untreated adjacent vertebraes after vertebroplasty. Methods Twelve spinal segements (four T9-T10, four T12-L2, and four L3-L5) from four embalmed human cadavers were divided into groups A and B (n=6/group). In group A, experimental vertebral compression fractures were created at middle vertebraes (T10, L1, L4), and these middle vertebraes were augmented with polymethymethacryclate. Then all spinal segements were compressed until a new fracture occured at any vertebrae, and the location of fractured vertebrae, maximum veritical load, and stiffness were investigated. Results There was statistically significant difference in the maximum vertical load between groups A and B (t=-2.267, P=0.047). The maximum veritical load in group A was, on average, 15% lower than that in group B [(3 048±403), (3 586±418) N, respectively]. There was no significant difference in stiffness between the two groups (t=-0.542, P=0.600). In the group A, new fractures following percutaneous verteoplasty (PVP) occurred at T9 in 2 specimens, T12 in 2, and L3 in 2. All new fractures occurred in the superior vertebrae in the group A. In the group B, the fractures occurred at T9 in 1 specimen, T10 in 1, T12 in 1, L1 in 1, and L3 in 2. Conclusion The failure strength of spinal segments can be decreased by vertebroplasty, which will increase the risk of adjacent vertebral body fracture, especially the superior vertebrae. Key words: Vertebroplasty; Adjacent vertebral body refracture; Bone cement; Maximum veritical load; Stiffness

Effect of Augmentation Material Stiffness on Adjacent Vertebrae after Osteoporotic Vertebroplasty Using Finite Element Analysis with Different Loading Methods

Background: Vertebroplasty is an effective treatment for osteoporotic vertebral fractures, which are one of the most common fractures associated with osteoporosis. However, clinical observation has shown that the risk of adjacent vertebral body fractures may increase after vertebroplasty. The mechanism underlying adjacent vertebral body fracture after vertebroplasty is not clear; excessive stiffness resulting from polymethyl methacrylate has been suspected as an important mechanism. Objectives: The aim of our study was to compare the effects of bone cement stiffness on adjacent vertebrae after osteoporotic vertebroplasty under load-controlled versus displacementcontrolled conditions. Study Design: An experimental computer study using a finite element analysis. Setting: Medical research institute, university hospital, Korea. Methods: A three-dimensional digital anatomic model of L1/2 bone structure was reconstructed from human computed tomographic images. The reconstructed three-dimensional geometry was processed for finite element analysis such as meshing elements and applying material properties. Two boundary conditions, load-controlled and displacement-controlled methods, were applied to each of 5 deformation modes: compression, flexion, extension, lateral bending, and torsion. Results: The adjacent L1 vertebra, irrespective of augmentation, revealed nearly similar maximum von Mises stresses under the load-controlled condition. However, for the displacementcontrolled condition, the maximum von Mises stresses in the cortical bone and inferior endplate of the adjacent L1 vertebra increased significantly after cement augmentation. This increase was more significant than that with stiffer bone cement under all modes, except the torsion mode. Limitations: The finite element model was simplified, excluding muscular forces and incorporating a large volume of bone cement, to more clearly demonstrate effects of bone cement stiffness on adjacent vertebrae after vertebroplasty. Conclusion: Excessive stiffness of augmented bone cement increases the risk of adjacent vertebral fractures after vertebroplasty in an osteoporotic finite element model. This result was most prominently observed using the displacement-controlled method. Key words: Bone cements, displacement-controlled method, finite element analysis, loadcontrolled method, osteoporosis, osteoporotic fracture, polymethyl methacrylate, vertebroplasty

MRI evaluation of lumbar endplate and facet erosion in rheumatoid arthritis.

A cross-sectional study. This study was aimed to quantify the extent of lumbar endplate and facet joint erosion in patients with rheumatoid arthritis (RA) using magnetic resonance imaging, to calculate the prevalence of erosion, and sought correlated factors. Few studies have examined the lumbar spine in RA, especially the relationship between endplate and facet joint erosions and lumbar lesions induced by RA. A total of 201 patients with RA were enrolled. Lumbar endplate and facet joint erosion were defined as irregularities and low-intensity change on magnetic resonance imaging, and graded utilizing the Rheumatoid Arthritis Magnetic Resonance Imaging Score. Lumbar lesions were defined as scoliosis, spondylolisthesis, and vertebral fracture on plain x-ray. Multivariable logistic regression analysis was used to seek correlations between the erosion and spinal level, RA-related factors and x-ray findings. Lumbar endplate and facet erosion were detected in 70.6% and 76.6% of individuals, respectively, and at 33.8% and 38.7% of lumbar intervertebral levels, respectively. The severity of erosion in individual patients correlated with lumbar lesions. Endplate and facet erosion at each level correlated with high disease activity, and were most common at mid-lumbar and lower-lumbar levels. Strong correlations were observed between endplate erosion and adjacent vertebral body fracture or disk degeneration, and between facet erosion and spondylolisthesis. Lumbar endplate and facet erosion are common in RA, and are observed more frequently at mid-low levels and when RA is poorly controlled. This pattern of erosion may play a crucial role in the generation of lumbar lesions in RA.

Thoraco-lumbar traumatic vertebral fractures augmentation by osteo-conductive and osteo-inductive bone substitute containing strontium–hydroxyapatite: our experience

The aim of our study was to evaluate the effectiveness of osteointegrable strontium-hydroxyapatite (Sr-HA) bone cement in the treatment of thoracolumbar traumatic vertebral fractures by percutaneous vertebroplasty (VTP). We treated 35 patients [29 (82.85 %) men, 6 (17.14 %) women, mean age 34.05 ± 8.36 years (range 21-54 years)] with single type A1.1 and A1.2 thoracolumbar traumatic vertebral fracture without endospecal bone fragments. Pain intensity was evaluated before and at 1 day; 1 week; and 1, 6, and 12 months after VTP by a 10-point visual analog scale (VAS) score (0 = no pain, 10 = unbearable pain). Physical status and quality of life were evaluated by Oswestry Disability Index (ODI) questionnaire before and 1, 6, and 12 months after VTP. Procedural technical success was achieved in all patients with no deaths observed during follow-up. In three patients (8.57 %), postprocedural CT showed cement leakages: one intradiscal and two in venous plexus. No adjacent vertebral body fractures nor intrasomatic recollapse was detected. The VAS and ODI scores showed a statistically significant reduction 1 week after procedure (P value <0.0001) with a progressive statistically significant reduction during follow-up (P value <0.0001). Twenty-three patients (65.71 %) assigned a value of 0 to the VAS scale at 1 year after treatment. Strontium-hydroxyapatite bone cement is an effective and safe bone filler in percutaneous vertebroplasty with low leakage rate and absence of major complications when performed by a skilled equipe. It allows an immediate and long-lasting stabilization with a significant pain reduction and quality of life improvement.

Long Term Results of Vertebroplasty in the Treatment of Osteoporotic Compression Fracture

Study Design: A retrospective study. Objectives: The purpose of this study was to assess the clinical efficacy and long term results of patients undergoing percutaneous vertebroplasty, with bone cement, for osteoporotic compression fractures. Summary of Literature Review: Percutaneous vertebroplasty is an effective surgical method for the treatment of osteoporotic compression fracture. Materials and Methods: Among 82 patients who underwent percutaneous vertebroplasty, with bone cement, between February 2005 and February 2008, 54 patients who were followed-up for more than 4 years were selected. We compared the postoperative clinical and radiological findings immediately and at 1, 2, and 4 year follow-up. Clinical findings were evaluated using the Visual analogue scale (VAS) score. Radiologically, height of the vertebral body and adjacent vertebral body fracture were also assessed. Results: Clinical outcome by mean VAS score revealed a change from 5.9 to 3.8 points preoperatively. The mean VAS scores were 3.4, 3.5 and 3.7 at 1, 2, 4 year follow-up, retrospectively. The compression rate of the vertebral body on plain radiographs was 30.8% preoperatively, 22.4% immediately after the operation, 23.2% at 1 year follow-up, 26.9% at 2 year follow-up, and 29.7% at 4 year follow-up. A new adjacent vertebral body fracture was noted in 7 patients at 1 year follow-up and 3 patients at 2 and 4 year follow-up, respectively. Conclusions: Percutaneous vertebroplasty is a valuable method for the treatment of osteoporotic compression fractures, providing immediate pain relief as well as long term pain relief. However, percutaneous vertebroplasty gave unsatisfactory report about height of the vertebral body and adjacent vertebral body fracture.

Role of major revision spine surgery in recurrent adjacent segment osteoporotic vertebral body fracture: a case report

Case report. To report the beneficial effects of kyphoplasty, cement augmentation and extension of posterior instrumentation in a patient with recurrent adjacent segment osteoporotic vertebral body fracture. A 72-year-old lady underwent multiple revision spine surgeries for recurrent adjacent segment osteoporotic vertebral body fracture. The patient underwent four surgeries in 6years: (1) in 2005, posterior lumbar interbody fusion with stabilization (L4-S1) was done; (2) in August 2010, implants from L4-S1 were removed and revised, transforaminal lumbar interbody fusion was done at L2/L3 and L3/L4 along with pedicle screw stabilization from T12-S1; (3) in September 2011, revision surgery was attempted, wherein a kyphoplasty was done at T12 and the stabilization was extended to T4; (4) again in October 2011, a revision surgery was attempted, wherein a kyphoplasty was done at T5 along with stabilization using pedicular screws in the T2 and T3 vertebrae and lateral mass screws in the C6 vertebra. To current date, the patient is stable with good sagittal and coronal balance and walking pain free without support. The current case demonstrates the need for posterior spinal reconstruction in osteoporotic vertebral collapse. Cement augmentation and extension of posterior instrumentation are both viable techniques that could be used to improve stabilization in the elderly spine.

Adjacent Vertebral Body Fracture Following Vertebroplasty With Polymethylmethacrylate or Calcium Phosphate Cement

A biomechanical study using human cadaveric thoracolumbar spinal columns. To compare the effect of treatment by vertebroplasty (VP) with polymethylmethacrylate cement and VP with calcium phosphate cement on the creation of adjacent vertebral body fracture following VP. Adjacent vertebral body fractures have been reported as a complication following VP. Twenty-four spinal columns (T10-L2) from human cadavers were subjected to dual energy radiograph absorptiometry to assess bone mineral density. They were divided into the P group and C group, and experimental vertebral compression fractures were created at T12 vertebrae. T12 vertebrae were augmented with polymethylmethacrylate and calcium phosphate cement in the P group and C group, respectively. Each spinal column was compressed until a new fracture occurred at any vertebra, and the location of newly fractured vertebra and failure load was investigated. There was no significant difference in bone mineral density at each level within each group. In the P group, a new fracture occurred at T10 in 2 specimens, T11 in 8, and L1 in 2. In the C group, it occurred at T10 in 1 specimen, T11 in 2, L1 in 1, and T12 (treated vertebra) in 8. The failure loads of the spinal column were 1774.8+/-672.3 N and 1501.2+/-556.5 N in the P group and C group, respectively. There was no significant difference in the failure load of the spinal column between each group. New vertebral fractures occurred at the vertebra adjacent to augmented vertebrae in the P group and in the augmented vertebrae in the C group. The difference in the fractured site may be because of the difference in strength between the 2 bone filler materials. Therefore, the strength of bone filler materials is considered a risk factor in developing adjacent vertebral body fractures after VP.

Altered disc pressure profile after an osteoporotic vertebral fracture is a risk factor for adjacent vertebral body fracture

This study investigated the effect of endplate deformity after an osteoporotic vertebral fracture in increasing the risk for adjacent vertebral fractures. Eight human lower thoracic or thoracolumbar specimens, each consisting of five vertebrae were used. To selectively fracture one of the endplates of the middle VB of each specimen a void was created under the target endplate and the specimen was flexed and compressed until failure. The fractured vertebra was subjected to spinal extension under 150 N preload that restored the anterior wall height and vertebral kyphosis, while the fractured endplate remained significantly depressed. The VB was filled with cement to stabilize the fracture, after complete evacuation of its trabecular content to ensure similar cement distribution under both the endplates. Specimens were tested in flexion-extension under 400 N preload while pressure in the discs and strain at the anterior wall of the adjacent vertebrae were recorded. Disc pressure in the intact specimens increased during flexion by 26 +/- 14%. After cementation, disc pressure increased during flexion by 15 +/- 11% in the discs with un-fractured endplates, while decreased by 19 +/- 26.7% in the discs with the fractured endplates. During flexion, the compressive strain at the anterior wall of the vertebra next to the fractured endplate increased by 94 +/- 23% compared to intact status (p < 0.05), while it did not significantly change at the vertebra next to the un-fractured endplate (18.2 +/- 7.1%, p > 0.05). Subsequent flexion with compression to failure resulted in adjacent fracture close to the fractured endplate in six specimens and in a non-adjacent fracture in one specimen, while one specimen had no adjacent fractures. Depression of the fractured endplate alters the pressure profile of the damaged disc resulting in increased compressive loading of the anterior wall of adjacent vertebra that predisposes it to wedge fracture. This data suggests that correction of endplate deformity may play a role in reducing the risk of adjacent fractures.

Incidence of fracture in adjacent levels in patients treated with balloon kyphoplasty: a review of the literature

The available evidence suggests that the treatment of painful vertebral compression fractures (VCFs) secondary to osteoporosis or multiple myeloma, by cement augmentation with balloon kyphoplasty (BK), is both safe and effective. However, there is uncertainty in the literature concerning the potential of the procedure to influence the risk for adjacent segment fracture. The aim of this article is to review the available peer-reviewed literature, regarding adjacent vertebral body fractures after kyphoplasty augmentation.

Recurrent fracture after vertebral kyphoplasty

Background context Osteoporotic compression fractures cause great morbidity to the aging population. Various percutaneous methods have been developed to aid in treatment, including vertebral kyphoplasty. Biomechanical studies and recent published data relate concerns about adjacent fracture. Purpose This study investigated the incidence of recurrent fracture after the kyphoplasty procedure. Study design/setting Retrospective review of kyphoplasty procedures preformed by a single surgeon. Patient sample A total of 109 procedures in 94 patients were reviewed. Outcome measures Patient medical records were reviewed as well as the radiology database at two major regional hospitals. Methods Patient records were reviewed for fracture recurrence. Results Confounding factors of age at procedure, sex, and chronic steroid use were also considered and found to have no statistically significant difference between those with fracture recurrence and those without fracture recurrence (p=.1979, p=.2058, p=.4684, respectively). Eleven kyphoplasty procedures resulted in a recurrent fracture after kyphoplasty within the first 90 days (34±19). After the first 90 days, five recurrent fractures occurred (459±101). The number of vertebral levels treated was found to be related to incidence of recurrent fracture with a p value of .0005 via chi-square testing. Patients who sustained a recurrent fracture tended to have a higher number of vertebral levels treated. There was no statistically significant difference between the survival time of kyphoplasty procedures that resulted in recurrent adjacent versus distant vertebral body fracture (survival time 112±145 vs. 237±268, p value .2362). Conclusions The incidence of recurrent fracture after kyphoplasty is substantial at 10% within the first 90 days. It is difficult to determine if this fracture rate is the result of surgical intervention or the natural history of the patient's osteoporosis.