Intravertebral Cleft Research Articles

Recent advances in Vertebral Augmentation for the treatment of Vertebral body compression fractures

Osteoporotic and pathologic vertebral compression fractures (VCFs) result in significant pain, reduced quality of life, and patient morbidity. Vertebral augmentation procedures (VAPs), which include vertebroplasty and kyphoplasty, have been extensively studied. Here, we review the evidence for the effectiveness of these techniques with an emphasis on recent clinical trials. There has been controversy regarding the effectiveness of VAPs in the treatment of painful VCFs. Recent high-quality clinical trials have demonstrated that with proper patient selection, which includes identification of (1) pain referable to a fracture, (2) acute or subacute fracture (less than 6 weeks), and (3) evidence of bone edema or intravertebral clefts on magnetic resonance imaging or high radiotracer uptake on bone scintigraphy, patients are highly likely to achieve significant improvements in long-term pain control and reduced pain-related disability with low procedural risk. Both vertebroplasty and kyphoplasty are effective VAPs, and no high-quality, recent study has found a substantial difference in the relative effectiveness of these techniques. VAPs are safe and effective in the management of acute, painful osteoporotic, and pathologic VCFs given appropriate clinical and imaging-based patient selection. Developing evidence suggests a role for VAPs in the management of painful chronic osteoporotic fractures, and as part of a multimodal approach toward both pain and local tumor control in patients with pathologic VCFs.

Analysis of risk factors causing short-term cement leakages and long-term complications after percutaneous kyphoplasty for osteoporotic vertebral compression fractures

Background Percutaneous kyphoplasty (PKP) is a common treatment modality for painful osteoporotic vertebral compression fractures (OVCFs). Pre- and postoperative identification of risk factors for cement leakage and follow-up complications would therefore be helpful but has not been systematically investigated. Purpose To evaluate pre- and postoperative risk factors for the occurrence of short-term cement leakages and long-term complications after PKP for OVCFs. Material and Methods A total of 283 vertebrae with PKP in 239 patients were investigated. Possible risk factors causing cement leakage and complications during follow-up periods were retrospectively assessed using multivariate analysis. Cement leakage in general, three fundamental leakage types, and complications during follow-up period were directly identified through postoperative computed tomography (CT). Results Generally, the presence of cortical disruption ( P = 0.001), large volume of cement ( P = 0.012), and low bone mineral density (BMD) ( P = 0.002) were three strong predictors for cement leakage. While the presence of intravertebral cleft and Schmorl nodes ( P = 0.045 and 0.025, respectively) were respectively identified as additional risk factors for paravertebral and intradiscal subtype of cortical (C-type) leakages. In terms of follow-up complications, occurrence of cortical leakage was a strong risk factor both for new VCFs ( P = 0.043) and for recompression ( P = 0.004). Conclusion The presence of cortical disruption, large volume of cement, and low BMD of treated level are general but strong predictors for cement leakage. The presence of intravertebral cleft and Schmorl nodes are additional risk factors for cortical leakage. During follow-up, the occurrence of C-type leakage is a strong risk factor, for both new VCFs and recompression.

Posterior Vertebrectomy and Circumferential Fusion for the Treatment of Advanced Thoracolumbar Kümmell Disease with Neurologic Deficit.

Study DesignSingle-center, retrospective case series.PurposeTo investigate the effectiveness of posterior vertebrectomy and circumferential fusion in patients with advanced Kümmell disease with neurologic deficit.Overview of LiteratureVarious surgical options exist for the treatment of Kümmell disease, and determination of the appropriate treatment is based on the clinical and radiologic status of the patient. However, surgical intervention is required for patients with advanced Kümmell disease accompanied by neurologic deficit.MethodsWe retrospectively analyzed 22 neurologically compromised patients with advanced Kümmell disease who were treated surgically at Ewha Womans Hospital between January 2011 and January 2014. The surgical approach used by us was a posterior vertebrectomy with mesh cage insertion and segmental cement-augmented pedicle screw fixation. The tissue from the corpectomy was histopathologically examined. Anterior vertebral height, kyphotic angle, visual analog scale (VAS) score, and the Frankel classification were used to evaluate the efficacy of the procedure.ResultsThe mean follow-up period was 26 months (range, 13–40 months). VAS score, anterior vertebral height, kyphotic angle, and neurologic state were significantly improved immediately postoperatively and at the last follow-up compared with preoperatively (p<0.05). Most patients exhibited intravertebral clefts on imaging, and postoperative pathology revealed bone necrosis.ConclusionsPosterior vertebrectomy with mesh cage insertion and segmental cement-augmented pedicle screw fixation is an effective approach for treating patients with advanced Kümmell disease with neurologic deficit.

Corpectomy and circumferential fusion for advanced thoracolumbar Kümmell's disease.

The aim of this study was to investigate the surgical treatment of neurologically compromised advanced Kümmell's disease. The surgical treatment of Kümmell's disease has various options according to clinical and radiologic status. Far collapsed Kümmell's disease patients with neurological deficit need to be treated surgically. We retrospectively analyzed 22 patients operated to our hospital with neurologically compromised Kümmell's disease between January 2011 and January 2014. Surgical approach was vertebrectomy, mesh cage insertion and segmental cement-augmented pedicle screw fixation. Corpectomy tissue was examined histopathologically. Anterior vertebral heights, kyphotic angle, the visual analog scale (VAS) and the Frankel classification were used to evaluate the effects of the surgery. The mean time of follow-up was 26months (range, 13-40months). The VAS, anterior vertebral heights, kyphotic angle and neurological state were improved significantly immediate postoperatively and at the last follow-up compared with the preoperative examinations (P<0.05). Most of the patients in this study exhibited intravertebral clefts, and postoperative pathology revealed bone necrosis. Posterior vertebrectomy with mesh cage insertion and segmental cement-augmented pedicle screw fixation is an effective option for advanced Kümmell's disease with neurological deficits.

Factors Affecting Delayed Union of Vertebral Fractures Following Percutaneous Kyphoplasty

Background: Although percutaneous kyphoplasty (PKP) could achieve rapid pain relief for the elderly with osteoporotic vertebral compression fracture (OVCF), some patients still had risks of suffering vertebrae delayed union which led to persisting pain and vertebral collapse. Preventing the delayed vertebral union could reduce the further morbidities and medical costs for patients with OVCF after PKP. Objectives: To explore the factors involved in delayed vertebral union after PKP in patients with OVCF. Study Design: Retrospective analysis. Setting: All data were from Hong-Hui hospital in Xi’an. Methods: There were 580 patients treated using single-segment PKP between January 2011 and January 2012. Demographics, clinical data, types of vertebral fracture, and surgical data were collected to analyze the factors associated with delayed vertebral union after PKP. Results: Twenty-nine patients (5%) experienced delayed vertebral union. Univariate analyses showed that preoperative bone mineral density (BMD), cement consumption, intravertebral cleft, restoration rate of vertebral height, and improvement in kyphotic angle were associated with delayed union of vertebrae after PKP (P &lt; 0.05). Multivariate analysis revealed that preoperative BMD (odds ratio (OR) = 0.452, 95% confidence interval (CI): 0.207 – 0.987, P = 0.046), intravertebral cleft (OR = 9.156, 95% CI: 3.712 – 22.585, P &lt; 0.001), and restoration rate of vertebral height (OR = 2.731, 95% CI: 1.622 – 4.599, P &lt; 0.001) were independently associated with delayed union of vertebrae. Limitation: A multi-center study is recommended to confirm our findings and explore the factors related to vertebrae delayed union. Conclusions: Preoperative BMD, intravertebral cleft, and restoration rate of vertebral height could be factors independently associated with delayed union of vertebrae after PKP in patients with OVCF. Key words: Percutaneous kyphoplasty, delayed union, osteoporotic vertebral compression fracture

Risk Factors for Cement Leakage After Vertebroplasty or Kyphoplasty: A Meta-Analysis of Published Evidence.

Cement leakage is the most common complication of vertebroplasty and kyphoplasty. So far, the reported risk factors remain conflicting because of limited data and lack of uniform measurement and evaluation. Here, we performed a systematic review and meta-analysis of potential risk factors for cement leakage after vertebroplasty or kyphoplasty. Relevant literature was retrieved using PubMed, EMBASE, Cochrane Controlled Trial Register, and MEDLINE with no language restriction, supplemented by a hand search of the reference lists of selected articles. A fixed-effects model was used if homogeneity existed among included studies; otherwise, a random-effects model was used. The results were presented with weighted mean difference for continuous outcomes and odds ratio (OR) for dichotomous outcomes with a 95% confidence interval (CI). Twenty-two studies consisting of 2872 patients with 4187 vertebrae were included in the meta-analysis. The incidences of cement leakage for percutaneous vertebroplasty and percutaneous balloon kyphoplasty were 54.7% and 18.4%, respectively. The significant risk factors for new vertebral compression fractures were intravertebral cleft (OR, 1.40; 95% CI, 1.09-1.78; P < 0.01), cortical disruption (OR, 5.56; 95% CI, 1.84-16.81; P < 0.01), cement viscosity (OR, 3.32; 95% CI, 1.36-8.07; P < 0.01) and injected cement volume (weighted mean difference, 0.59; 95% CI, 0.02-1.17; P < 0.05). Age, sex and fracture type, operation level, and surgical approach were not significant risk factors. The results of this meta-analysis suggest that patients with intravertebral cleft, cortical disruption, low cement viscosity, and high volume of injected cement may be at high risk for cement leakage after vertebroplasty or kyphoplasty. Rigorous patient selection and individual therapeutic strategy irrespective of age, sex and fracture type, operation level, and surgical approach may reduce the occurrence of cement leakage. Given the inherent limitation of the meta-analysis, more large sample-sized randomized controlled trials are needed to further validate the present findings.

Relationship between clinical symptoms of osteoporotic vertebral fracture with intravertebral cleft and radiographic findings.

With aging of the population, the numbers of osteoporotic vertebral fractures with intravertebral cleft have been increasing. However, the details of clinical symptoms of osteoporotic vertebral fractures with intravertebral cleft are poorly understood. The purpose of this study was to evaluate the relationship between clinical symptoms of osteoporotic vertebral fractures with intravertebral cleft and radiographic findings. Two hundred seventeen patients with single-level osteoporotic vertebral fractures with intravertebral cleft were examined. Clinical symptoms were evaluated using Numerical Rating Scale for back pain and the Oswestry Disability Index for physical disability. The presence of delayed neurologic deficit was also detected. Radiography and computed tomography were used to measure local kyphotic angle and vertebral instability and to detect the presence of posterior wall fracture of the vertebral body. Correlations between clinical symptoms of osteoporotic vertebral fractures with intravertebral cleft and radiographic findings were investigated. Mean Numerical Rating Scale and Oswestry Disability Index were 7.4 and 58.0%, respectively. Delayed neurologic deficit occurred in 41 patients (19%). The mean local kyphotic angle, vertebral instability, and rate of posterior wall fracture of the vertebral body were 19.4°, 7.3°, and 91%, respectively. Numerical Rating Scale and Oswestry Disability Index were statistically correlated with vertebral instability but not with local kyphotic angle and presence of posterior wall fracture. In the patients with delayed neurologic deficit, vertebral instability was significantly higher and posterior wall fractures were significantly more frequent than in the patients without delayed neurologic deficit. Local kyphotic angle was not correlated with delayed neurologic deficit. Vertebral instability is a factor causing symptoms of osteoporotic vertebral fractures with intravertebral cleft. In addition, vertebral instability may be the predominant cause of delayed neurologic deficit. To manage osteoporotic vertebral fractures with intravertebral cleft and delayed neurologic deficit efficiently, it may be important to control vertebral instability of osteoporotic vertebral fractures.

Acute traumatic intraosseous fluid sign predisposes to dynamic fracture mobility.

The intraosseous fluid sign (IFS) in chronic osteoporotic vertebral fractures is attributed to fluid accumulation within non-healing intervertebral clefts. IFS can also be seen in acute traumatic fractures, not previously described. We hypothesize a pathophysiological mechanism for the acute traumatic intraosseous fluid sign (ATIFS) and its predisposition to dynamic fracture mobility with axial loading on upright radiographs. Retrospective analysis was performed of 41 acute thoracic and lumbar compression or stable burst fractures with both supine CT and upright plain films completed within 1week of each other. The presence of an intravertebral cleft with fluid attenuation and vertebral body height loss was assessed on CT scans. Changes in the fractured vertebral body height and angulation were measured on upright radiographs. The ATIFS was identified in 18 (44%) of the 41 acute fractures. Mean kyphotic angle increase was significantly greater (p=0.000) for ATIFS fractures (8.2°, SD ±4.2) than fractures without ATIFS (1.6°, SD ±3.4). There was significantly greater mean anterior (p=0.0009) and central (p=0.026) height loss in ATIFS fractures (4.3mm, SD ±3.76 and 1.89mm, SD ±4.44, respectively) compared to fractures without ATIFS (0.59mm, SD ±2.24 and -0.52mm, SD ±2.01, respectively). The IFS can be seen in acute traumatic vertebral fractures and show dynamic mobility. These ATIFS fractures show statistically significant greater mean height loss ratio differences and have significantly greater changes in kyphotic angulation on upright imaging when compared to fractures without ATIFS.

Efficacy and safety of the target puncture technique for treatment of osteoporotic vertebral compression fractures with intravertebral clefts

ObjectiveTo compare the efficacy and safety of our target puncture technique with the traditional technique during percutaneous kyphoplasty (PKP) for osteoporotic vertebral compression fractures (OVCFs) with intravertebral clefts (IVCs).Methods104 patients...

Clinical and radiological factors affecting progressive collapse of acute osteoporotic compression spinal fractures

Osteoporotic compression spine fractures have a different clinical course and outcomes when compared to spinal fractures occurring in the younger population. Only a few studies have investigated the risk factors for progressive osteoporotic compression spine fractures. The purpose of this study was to investigate clinical and radiological factors related to progressive collapse following acute osteoporotic compression spine fractures. We retrospectively identified all patients treated for thoracolumbar fractures in our institution between January 2008 and July 2013. Included cases were examined by plain radiographs and CT scans. For each patient we classified the fracture according to the AOSpine Thoracolumbar Spine Injury Classification System. The difference between initial and final height loss and initial and final local kyphosis was documented as height loss difference and kyphotic angle difference. The presence of old fractures and intravertebral cleft were also documented. The study included 153 patients, comprising 102 women and 51 men. The mean patient age was 68.9years. The mean length of follow up was 15months. A statistically significant correlation was found between patient age, final height loss, height loss difference and kyphotic angle difference. Height loss difference and kyphotic angle difference were significantly correlated to type of fracture according to the AO classification system. The height loss difference was 18.1% in A1 type fractures, 27.1% in A2 type fractures, 24.2% in A3 type fractures and 25.7% in A4 type fractures. During a minimum 3-month follow up of conservative treatment for acute osteoporotic vertebral compression fractures, age and the AOSpine Thoracolumbar Spine Injury Classification System were predictive factors for progressive collapse.

Cognizance on the re-fracture of the operated vertebra with cemented augmentation in osteoporotic vertebral compression fractures

One option with minimally invasive surgery for treatment of painful osteoporotic vertebral compression fracture is percutaneous vertebroplasty or percutaneous kyphoplasty via an inflatable balloon tamp followed by stabilization with polymethylmethacrylate cement. The vertebral height is restored and the decreased loading ability of the fractured vertebral body is restrengthened with pain relief. The effect of the method is widely demonstrated in those conditions. At the same time, the relative problems, such as the complications are being lucubrated and discussed. The reports on the re-fracture or height loss of the operated vertebrae with cemented augmentation are becoming more. By now, there are some unclear aspects on the problem: the definition of the re-fracture of the augmented vertebra is still unclear and not ascertained and the clinical manifestations are various. The mechanisms and correlative factors are still not clear-cut either. The rate of subsequent re-fractures after cemented augmentation from literature is fargoing, with a rate of 0% to 63%. The correlative factors on the re-fracture of the operated vertebrae chiefly include: osteoporosis, bone necrosis caused by the heat injury from cement solidification, failure to achieve endplate-to-endplate cement augmentation, intravertebral cleft or avascular bone necrosis, premature mobilization or excessive movement, overfull reduction of the vertebral height, the biological character of the spine column, and so on. Great controversy still exists on the correlation between those possible factors and the re-fractures. More attention should be paid to this problem to explore the true risk factors and mechanism, decrease the re-fracutre rate, and elevate the clinical outcome in osteoporotic compression fractures.

Computed Tomography and Magnetic Resonance Imaging in the Differentiation of Osteoporotic Fractures From Neoplastic Metastatic Fractures

Determining whether a low-intensity vertebral fracture in an older person, particularly one with a history of cancer, is due to osteoporosis (OP) or is the result of a metastasis, is a not infrequent clinical problem that has important prognostic and therapeutic implications. The 2 types of fracture are usually indistinguishable on plain radiographs and require higher order imaging for diagnosis. Magnetic resonance imaging is the modality of choice because of its unique ability to depict the bone marrow, which becomes transiently edematous in an acute OP fracture. Preservation of at least part of the normal marrow signal, the visualization of a fracture line parallel to the end plates, the presence of an intravertebral cleft, lack of pedicle involvement, and no extra-osseous mass all favor a benign OP fracture. Absence of the preceding signs, particularly if there is complete replacement of the normal bone marrow and a convex posterior contour of the vertebral body, favors a fracture of malignant origin. Non-routine magnetic resonance sequences using diffusion-weighted imaging and/or chemical shift imaging may be helpful in difficult cases.

Intervertebral bridging ossifications increase the risk of intravertebral cleft formation following a vertebral compression fracture.

To determine whether the presence of intervertebral bridging ossifications is associated with intravertebral cleft (IVC) formation following a vertebral compression fracture (VCF). Patients with a VCF who received conservative treatment for a minimum of 3months were recruited over a 3-year period. Baseline radiographs obtained within a month of onset were compared between 50 patients who developed an IVC at 3-month follow-up (IVC group) and 100 patients without an IVC (control group). Intervertebral bridging ossification was defined as complete bridging of the intervertebral space by ossification. The presence of bridging ossification was assessed at each intervertebral level from T9/10 to L5/S. In addition to the absolute levels of bridging ossifications, the level relative to a fresh VCF was recorded. The incidence of bridging ossification at levels T9/10 and T10/11 was significantly higher in the IVC group than in the control group. IVC group patients showed a significantly higher incidence of bridging ossification at the second proximal intervertebral segment than those in the control group. IVC group patients also had a significantly greater sagittal wedge angle and a greater local kyphosis angle than control group patients. A fresh VCF with bridging ossification at the second proximal intervertebral level is associated with increased risk of IVC formation. Careful observation and strict conservative treatment are recommended in such cases.

Efficacy of Percutaneous Vertebroplasty in the Treatment of Osteoporotic Vertebral Compression Fractures with Intravertebral Cleft.

Intravertebral cleft (IVC) is frequently observed in patients with painful osteoporotic vertebral compression fracture (OVCF). Some studies reported the usefulness of percutaneous vertebroplasty (PVP) for treating OVCF with IVC. However, systematic studies are scarce, and their results are conflicting. The purpose of this study was to evaluate the clinical and radiographic results of PVP in the treatment of painful OVCF with IVC. Two hundred ninety-one patients with OVCF with IVC underwent PVP. Back pain was measured using a visual analog scale (VAS), and physical disability was assessed using the Oswestry Disability Index (ODI). Three radiological parameters were assessed: the local kyphotic angle, percentage spinal canal cross-sectional area of compromise, and intravertebral instability of the affected vertebra. The mean follow-up period was 28 months. The mean values for the VAS and ODI were 8.4 and 60.0%, respectively, before PVP, versus 3.9 and 35.4%, respectively, at the final follow-up. The average local kyphotic angle, percentage spinal canal cross-sectional area of compromise, and intravertebral instability were 10.5°, 17.9% and 6.1°, respectively, before PVP and 8.1°, 15.2%, and 0.8°, respectively, at the final follow-up. There were no neurological or systemic complications due to cement leakage. PVP is an effective and safe intervention for treating OVCF with IVC.

The Radiographical Feature of Osteoporotic Verbal Fracture Nonunion in Extended CT Reconstruction Images

Introduction This study is to summarize the main radiographical feature of osteoporotic vertebral fracture nonunion (VFNU) in extended CT reconstruction images, and to evaluate reducibility and stability of the vertebrae. Patients and Methods All of the senior patients suffered from thoracolumbar spine fracture (December 2009 to March 2013) were retrospectively reviewed, 36 cases of VFNU with 39 level of vertebrae were included in this study according to inclusion criteria. The main radiographical features of 39 level of VFNU vertebrae were analyzed, including the specific segment, the type of substance in the intravertebral cleft, the starting points and terminals of intervertebral cleft, to explore the different radiographic feature of various type of VFNU. Results According to the over extension CT, new classification criteria are reported in the literature, all of VFNU patients were divided into the following three subgroups: reducible type (type A), unstable but can be reset type (type B), and loss of reducibility type (type C). Overall, 39 level of VFNU vertebrae in 36 patients were located in the region of T9 to L4, in which the thoracolumbar segments were compromised frequently, and 16 level of VFNU existed in L1. According to extended CT reconstruction images, 25 level of type A, 7 level of type B, and 7 level of type C VFNU were identified with the radiographic analysis, the starting points of intervertebral cleft located in the anterior edge of vertebral body (18 levels) or disc plate (21 levels), the terminals of cleft located in the intersecting point of pedicle and posterior–inferior edge of vertebral body (18 level) or superior disc plate (14 levels), the fracture line could be displayed clearly in the all coronal CT reconstruction images, however, terminals of intravertebral cleft in type C VFNU located in the trabecular bone region in the middle one-third part of vertebral body(4 level), and the middle one-third part of superior disc plate, even though there were significant collapse or intracranial retropulsion of posterior one-third part of vertebral body, fracture line could rarely be shown except for one patient, the fracture lines lateral cortex united in three patients, or just be shown in anterior–middle part of vertebral body in three patients according to the coronal CT reconstruction images. Conclusion Thoracolumbar segments are the most common region compromised by VFNU. There is a difference between the terminals of intravertebral cleft of types A, B, and C VFNU, and existence of fracture lines from the anterior edge to the posterior cortex might explain the mechanism of reducibility of types A and B.

Nonsurgical Corrective Union of Osteoporotic Vertebral Fracture with Once-Weekly Teriparatide.

Osteoporotic vertebral fractures usually heal with kyphotic deformities with subsidence of the vertebral body when treated conservatively. Corrective vertebral union using only antiosteoporotic pharmacotherapy without surgical intervention has not been reported previously. An 81-year-old female with osteoporosis presented with symptomatic fresh L1 vertebral fracture with intravertebral cleft. Segmental vertebral kyphosis angle (VKA) at L1 was 20° at diagnosis. Once-weekly teriparatide administration, hospitalized rest, and application of a thoracolumbosacral orthosis alleviated symptoms within 2 months. Corrective union of the affected vertebra was obtained with these treatments. VKA at 2 months after injury was 8° (correction, 12°) and was maintained as of the latest follow-up at 7 months. Teriparatide has potent bone-forming effects and has thus been expected to enhance fracture healing. Based on the clinical experience of this case, teriparatide may have the potential to allow correction of unstable vertebral fractures without surgical intervention.

Adjacent-level symptomatic fracture after percutaneous vertebral augmentation of osteoporotic vertebral compression fracture: a retrospective analysis

Vertebral augmentation is an effective and minimally invasive procedure that is used extensively worldwide for the treatment of osteoporosis vertebral compression fractures (OVCFs). New pain from adjacent vertebra fracture (AVF) after initial cement augmentation has gradually been given attention, but the exact causes of AVF are still controversial. The purpose of this study was to analyze the associated incidence, risk factors, and possible causative mechanism of symptomatic AVF, and to evaluate the intrinsic relationship between cement leakage into the disk and AVF. Three hundred and fifty-eight patients (271 women, 87 men; mean age 70.5 ± 9.1 years; range 42-91 years) undergoing vertebral augmentation for their single level of OVCFs were enrolled in the study. Patients were divided into AVF (n = 26) and AVF-free (n = 332) groups, and the groups were compared with respect to preoperative and perioperative parameters, as well as postoperative results. Potential risk factors were evaluated using logistic regression analysis. The rate of symptomatic AVF was 7.3%. The majority of symptomatic AVF, 57.7% of which developed 6 months after the procedures, were located mainly in the thoraco-lumbar vertebra. Significant differences were found between the AVF and AVF-free groups with regard to age, bone mineral density (BMD), and intravertebral clefts (p < 0.05). AVF occurred in six of 28 patients with intravertebral clefts, and five of them developed AVF within 6 months after the procedure. No statistically significant association was observed in the correlation between intradiscal cement leakage and the incidence of symptomatic AVF (p = 0.390). Older age, lower BMD, and intravertebral clefts are the main risk factors for symptomatic AVF after vertebral augmentation, but intradiscal cement leakage does not increase the risk of AVF. AVF occurs because of the natural progression of osteoporosis. Even distribution of bone cement in the vertebral body is important in OVCF patients with intravertebral clefts.

Percutaneous Vertebroplasty versus Balloon Kyphoplasty for Osteoporotic Vertebral Fracture with Intravertebral Cleft

Percutaneous Vertebroplasty versus Balloon Kyphoplasty for Osteoporotic Vertebral Fracture with Intravertebral Cleft

The Existence of Intravertebral Cleft Impact on Outcomes of Nonacute Osteoporotic Vertebral Compression Fractures Patients Treated by Percutaneous Kyphoplasty

A retrospective comparative study. The purpose of this study is to assess radiologic features of intravertebral cleft (IVC) in nonacute osteoporotic vertebral compression fractures (OVCFs) patients, and analyze the existence of IVC impact on outcomes of percutaneous kyphoplasty (PKP). The IVC sign is regarded as vertebral instability and the cause of persisting pain. It is more likely to happen at nonacute OVCFs patients. Patients with IVC sign have different outcomes from these without IVC treated by percutaneous vertebroplasty. There were rare reports about the outcomes of patients with IVC sign treated by PKP. We divided 92 nonacute OVCFs patients (total of 113 vertebrae) into 2 groups according to the existence of IVC. Preoperative and postoperative Visual Analogue Scales, Oswestry Disability Index, kyphotic angulation (KA), and anterior vertebral height were recorded; the incidence and radiologic features of IVC were analyzed. The diagnostic sensitivity of IVC on plain radiograph, computed tomography, and magnetic resonance imaging were 35.4%, 89.3%, and 83.3%, respectively. The IVC group had an average correction KA of 9.14 degrees and reduction of ratio of compression of 20.09%, and the non-IVC group was 8.76 degrees and 20.23%, respectively. Cleft pattern of cement accounted for 64.6% in IVC group and 27.7% in non-IVC group. Five/7 of cement leakage in IVC group was intradiscal leakage, whereas 7/9 of cement leakage in non-IVC group was perivertebral leakage. Computed tomography and magnetic resonance imaging were more sensitivity to diagnose IVC sign than X-ray. PKP could improve pain, functional activity, KA, and anterior height of both IVC and non-IVC groups, however, there was more cleft pattern of cement and higher intradiscal cement leakage in the IVC group.

The connection between the basivertebral foramen and the intravertebral cleft could be a related factor of cement leakage after percutaneous kyphoplasty

Objective To assess incidence rate of different types of cement leakage in percutaneous kyphoplasty (PKP) with or without intravertebral clefts and to determine whether basivertebral foramen could be connected with intravertebral cleft.Methods 270 vertebrae in 224 consecutive patients who underwent percutaneous kyphoplasty for treatment of osteoporotic vertebral compression fractures were classified into two groups on preoperative radiographs,computed tomography scans,and/or magnetic resonance images of the treated levels:Cleft group with an intravertebral cleft in vertebral body and trabecular group without intravertebral clefts.On direct postoperative images,the patterns of cement leakage were classified as 5 types:through a cortical defect into paraspinal soft tissues (type A),through the basivertebral foramen (type B),via the needle channel (type C),through a cortical defect into the disc space (type D),via the paravertebral vein (type E).The incidence of different types of cement leakage between two groups was analyzed.Results In 72 of 270 vertebrae,an intravertebral cleft was confirmed on preoperative images.Leaks through basivertebral foramen as type B (42,15.5％) and through cortical defects into the disc space as type D leaks (21,7.8％) were more common than other types.The incidence of type B leakage in the cleft group (23.6％) was higher than the incidence in the trabecular group (12.6％),which made a statistical significance (P=0.028).There was no statistical difference between the trabecular pattern and the cleft pattern on other types of leaks.Conclusion Type B leaks were more common in vertebrae with the presence of an intravertebral cleft,which support the presence of the connection between an intravertebral cleft and the basivertebral foramen.Thus,care must be taken when PKP was performed in these patients to avoid cement leakage into spinal canal through basivertebral foramen directly. Key words: Kyphoplasty; Osteoporotic fractures; Fractures, compression