Painful Vertebral Compression Fractures Research Articles

Rate of Unsuspected Malignancy in Patients With Vertebral Compression Fracture Undergoing Percutaneous Vertebroplasty.

Retrospective study. To determine the malignancy rate and histology in bone biopsies obtained during PVP for VCF. Osteoporotic vertebral compression fractures (VCF) affect approximately 20% of postmenopausal women and can lead to long-term disability. Percutaneous vertebroplasty (PVP) is a minimally invasive procedure, primarily used in patients with severe pain after VCF. Even with a thorough clinical examination, magnetic resonance imaging (MRI) scans, and blood samples, some fractures maybe caused by an underlying malignant disease. 144 consecutive patients underwent PVP for painful VCF, at the Center for Spine Surgery and Research, Middelfart Hospital. All patients had bone biopsies obtained during the PVP, and these biopsies were sent to the Department for Pathology at Vejle Sygehus for histologic diagnosis. About 144 patients were included in this study. The majority of the biopsy specimens (137, 95.1%) were acceptable for histological diagnosis. One hundred and twenty nine (89.6%) biopsies showed no signs of malignancy. Seven (4.9 %) were positive for malignancy. One biopsy was positive for MGUS. Seven (4.9 %) of the biopsies were unsuitable for histologic diagnosis. Our study shows an incidence of unsuspected malignancy in biopsies during PVP of 4.9%. Conservative treatment with analgesics and brace can potentially delay diagnosis and treatment of underlying malignant disease. We recommend biopsy during PVP as a standard procedure, to insure not to overlook any underlying malignancy despite the MRI-scan, blood analysis, and clinical examination being inconspicuous.

Safety and efficacy of vertebroplasty in the treatment of osteoporotic vertebral compression fractures: a prospective multicenter international randomized controlled study.

Vertebral compression fractures (VCFs) treated non-operatively can diminish function and quality of life, and lead to chronic health effects. The short-term safety and effectiveness of vertebroplasty for symptomatic VCFs are well-documented, but long-term follow-up is needed. The aim of this paper was to analyse a multicenter international experience of 200 compression fractures treated with percutaneous vertebroplasty (VP) and compare the results of this procedure with the result of 200 patients treated conservatively. To estimate cost-effectiveness of VP compared to conservative care in terms of: pain reduction, quality of life, complications, secondary fractures and mortality. 400 patients have been enrolled in a prospective randomized controlled study with painful VCFs with bone edema on MR imaging, local back pain for 6 weeks or less, osteoporosis and aged 55 years or older; after obtaining informed consent patients are included and randomized for VP or conservative care. Before treatment and at follow-up with regular intervals during 1-year period were administered to patients standard questionnaires addressing: clinical symptoms, pain medication, Visual Analogue Scale (VAS) score for pain, Oswestry Disability Index (ODI) score to evaluate functional activity. 200 patients treated with PV compared with 200 patients treated conservatively had significantly better VAS and used less analgesics 1 day after treatment. Twenty-four hours after VP, there was a reduction in pain scores and an improvement in physical functions, whereas remain unchanged in the patients treated conservatively. Pain relief and improvement of mobility and function after PV is immediate and significantly better in the short term compared with non-surgical care treatment.

Vertebral Bone Drilling (Puncture) Attenuates the Intractable Pain Due to Vertebral Fractures without Collapse

Purpose: Osteoporotic vertebral fractures with no sign of vertebral collapse on initial radiographs, which is so-called occult vertebral fractures (VFs), exist. Occult VFs have a high rate of missed diagnosis, and the treatment of these fractures has rarely been discussed in the literature. We evaluated the effects of vertebral bone drilling for the pain due to occults VFs. Materials and Methods: Eighteen patients with painful osteoporotic occult VFs underwent the vertebral bone drilling. We evaluated the clinical outcome by comparing numerical rating scale (NRS) and activity of daily life (ADL) values between before and after the vertebral bone drilling. Comparisons were made by using Wilcoxon signed rank test. Results: The mean baseline NRS and ADL score, and the mean NRS and ALD score after the bone drilling were 8.4 ± 0.8, 2.2 ± 0.6, 2.4 ± 1.0, 4.6 ± 0.5, respectively. Among the patients, we detected significant improvements in NRS pain score and ADL score after the drilling compared with baseline score (p < 0.0002). Conclusion: Vertebral bone drilling at the site of painful vertebral compression fractures alleviated the intractable pain due to osteoporotic occult VFs.

Percutaneous vertebroplasty for patients with metastatic compression fractures of the thoracolumbar spine: clinical and radiological factors affecting functional outcomes

Background ContextVertebroplasty (VP), including balloon kyphoplasty (BKP), has long been accepted as a minimally invasive surgical intervention for the stabilization of painful vertebral compression fractures. In metastatic compression fracture (MCF), cancer often invades the paravertebral structure and involves the posterior column of the vertebrae. PurposeIn the present study, we first analyzed how clinical features of MCF affect functional outcomes after VP. Second, we evaluated whether BKP is more beneficial than simple VP (SVP) in MCF. Study Design/SettingThis is a retrospective observational study. Patient SampleThree hundred forty-two patients who underwent VP for painful MCF from solid cancer were included. We excluded MCF from hematopoietic cancer, such as leukemia or multiple myeloma. Outcome MeasuresPain improvement was evaluated using the visual analog scale (VAS; range: 0–10), and if the VAS score decreased by at least three points the treatment was considered effective. Postoperative change in Karnofsky performance status (KPS) and drug requirement for pain control were also measured as functional outcomes. MethodsAn institutional database at the National Cancer Center of Korea was searched to identify all patients who underwent VP for painful MCF between March 2002 and September 2013. Demographic data, as well as preoperative and postoperative clinical factors, were collected from patients' medical records. Radiological features, including paravertebral extension of tumors and the extent of three-column involvement, were reviewed from pretreatment magnetic resonance imaging (MRIs). These clinical and radiological factors were then analyzed for their influence on functional outcomes. ResultsThe mean preoperative VAS score was 5.8; this improved to a mean of 2.7 after VP. Effective improvement in VAS score (≥3) was achieved in 206 patients (60%). Patients with radiculopathy, as well as those with involvement of (1) the posterior column or (2) more than four out of six columns, presented with significantly higher pretreatment VAS scores and experienced more effective improvement after treatment (p<.05). Two hundred thirty-eight patients (70%) underwent SVP, whereas the remaining 104 patients underwent BKP. The pretreatment degree of compression was significantly higher in BKP (mean: 47%) than in SVP patients (mean: 30%) (p<.001). However, preoperative VAS scores were not significantly different between the two groups, and the resultant VAS score improvement was also not significantly different. Although BKP patients reported to have a greater chance of more than 3 mL of cement injection (p=.01), the mean amount ofcement injected was not different between the two groups. Patients with other bone metastases showed a significantly poorer KPS improvement rate (p=.015). Patients having moderately or slowly growing cancer according to the Tomita classification had a greater chance of reduced drug requirements 1 month after the procedure (p=.004). ConclusionsParavertebral extension and posterior column involvement of MCF did not preclude pain improvement after VP. Balloon kyphoplasty for MCF failed to show enhanced pain improvement relative to SVP. Metastatic compression fracture patients with other bone metastases or rapidly growing tumors had a lower chance of performance improvement and reduced drug requirements, respectively.

Kyphoplasty-Vertebroplasty. A critical assessment

Painful vertebral compression fractures. Analgesia. Osteoplastic procedures, such as kyphoplasty and vertebroplasty. Anamnestic and radiological associations of clinical complaints with the radiomorphological findings of vertebral compression fractures are required for an adequate consideration to assess whether an osteoplastic procedure should be carried out. A computed tomography (CT) scan allows a reliable judgement whether an osteoplastic procedure is technically feasible and promising to improve the local vertebral fracture-associated pain. Prospective controlled trials have demonstrated a satisfactory improvement of back pain associated with vertebral fractures and parameters of quality of life by osteoplastic interventions. No prospective, truly sham-controlled blind trials are currently available which demonstrate an advantage of osteoplastic interventions compared to standard pain treatment; however, the currently published prospective controlled trials show a satisfactory pain reduction by osteoplastic interventions, such as kyphoplasty and vertebroplasty. Painful vertebral fractures and progressive loss of vertebral height of compression fractures should be evaluated in an interdisciplinary team consisting of radiologists, spinal surgeons and internists to assess whether an osteoplastic procedure is technically feasible and promising to improve local pain and immobility associated with vertebral fractures.

A Novel Composite PMMA-based Bone Cement with Reduced Potential for Thermal Necrosis.

Percutaneous vertebroplasty (VP) and balloon kyphoplasty (BKP) are now widely used to treat patients who suffer painful vertebral compression fractures. In each of these treatments, a bone cement paste is injected into the fractured vertebral body/bodies, and the cement of choice is a poly(methyl methacrylate) (PMMA) bone cement. One drawback of this cement is the very high exothermic temperature, which, it has been suggested, causes thermal necrosis of surrounding tissue. In the present work, we prepared novel composite PMMA bone cement where microcapsules containing a phase change material (paraffin) (PCMc) were mixed with the powder of the cement. A PCM absorbs generated heat and, as such, its presence in the cement may lead to reduction in thermal necrosis. We determined a number of properties of the composite cement. Compared to the values for a control cement (a commercially available PMMA cement used in VP and BKP), each composite cement was found to have significantly lower maximum exothermic temperature, increased setting time, significantly lower compressive strength, significantly lower compressive modulus, comparable biocompatibility, and significantly smaller thermal necrosis zone. Composite cement containing 20% PCMc may be suitable for use in VP and BKP and thus deserves further evaluation.

Vertebral Body Lavage before Vertebra/Kyphoplasty Significantly Reduces Cement Leakage in a Clinical Setting

Introduction Vertebra/kyphoplasty is an established treatment option for painful vertebral compression fractures. Cement leakage is the most frequent adverse event for this procedure that can result in serious, sometimes fatal, complications. We have shown in an experimental cadaveric as well as in a large animal model that lavage of the vertebral body before cement injection can remove bone marrow and significantly reduced injection pressure, cement leakage, and pulmonary fat embolism.1,2,3 In this study, we examined the effects of a simplified lavage technique in a clinical setting. Methods Retrospective radiological analysis of cement leakage and distribution of a cohort that underwent lavage before vertebral augmentation; cases without lavage were used as control group. Lavage was performed by rinsing the vertebrae with 100 mL Ringer solution, which was alternatingly injected through one filling cannula while aspirating the bone marrow via the contralateral cannula. For all augmentations, the same cement and filling cannulas were used under identical external conditions. Filling pattern, occurrence of cement leakage as well as type (venous, cortical defect, disc) and extend of the leakage was assessed from biplanar radiographs. Results In a 1-year period (2012–2013) the lavage technique was applied in 138 vertebrae. The control group consisted of 105 vertebrae; patient's characteristics, fracture types, and locations were comparable to the treatment group. The lavage group showed significantly lower leakage rates for the venous and disc type as compared with the standard technique group (venous 12.3 vs. 30.5%, disc 15.9 vs. 60% [both p &lt; 0.001]; cortical defect 10.1 vs. 15.2% [ p = 0.23]). Venous cement extrusions were, in general, shorter after lavage ( p = 0.08) and extrusions larger than 10 mm were only observed in the control group (0 vs. 12.5%). Cement filling pattern (aiming for end plate-to-end plate filling) was significant better in the lavage group ( p = 0.001). According to the multivariate analysis, nonlavaged vertebra have a 3.57 times higher likelihood for a venous leakage than a lavaged one ( p = 0.0009). Discussion The results of this retrospective data analysis show clearly that lavage before vertebra/kyphoplasty can reduce occurrence and severity of cement leakage under clinical condition. The technique is simple and the increase in OR time (range, 10–30 seconds) and costs (&lt; 1$) are insignificant. References Benneker LM, Heini PF, Suhm N, Gisep A. The effect of pulsed jet lavage in vertebroplasty on injection forces of polymethylmethacrylate bone cement, material distribution, and potential fat embolism: a cadaver study. Spine (Phila Pa 1976) 2008;33(23) E906-E910 Boger A, Benneker LM, Krebs J, Boner V, Heini PF, Gisep A. The effect of pulsed jet lavage in vertebroplasty on injection forces of PMMA bone cement: an animal study. Eur Spine J 2009;18(12) 1957-1962 Benneker LM, Krebs J, Boner V, Boger A, Hoerstrup S, Heini PF, Gisep A. Cardiovascular changes after PMMA vertebroplasty in sheep: the effect of bone marrow removal using pulsed jet-lavage. Eur Spine J 2010;19(11) 1913-1920. P070.

Kyphoplasty versus Conservative Treatment: A Case–Control Study in 110 Postmenopausal Women Population. Is Kyphoplasty Better than Conservative Treatment?

Introduction Osteoporosis is a highly prevalent and one of the most debilitating and costly chronic diseases worldwide and it is also responsible for approximately 1.5 million vertebral fragility fractures (VCFs) a year.1,2,3 Most of the patients experiencing an osteoporotic VCFs remain asymptomatic or minimally symptomatic; however, a large part of these patients do experience significant pain, resulting in decreased quality of life and disability and mortality too.4 The consequences of these fractures include pain and, in many cases, progressive vertebral collapse with resultant spinal kyphosis. Minimally invasive procedures, namely, kyphoplasty and vertebroplasty, represent a recent advance to the treatment of osteoporotic VCFs.5,6,7 The aim of this study is to compare effects in terms of recovery and quality of life and to compare deformity prevention efficacy of kyphoplasty and conservative treatment in postmenopausal women with an osteoporotic VCF. The aim of this study is to provide an efficacy assessment of kyphoplasty as compared with standard conservative treatment in postmenopausal women (bracing immobilization).8,9,10 Patients and Methods We designed a retrospective case–control study on 110 postmenopausal women. Included in this study were patients who were diagnosed with postmenopausal osteoporosis according to National Osteoporosis Foundation (NOF) guidelines, with a recent (&lt; 2 weeks) symptomatic osteoporotic vertebral compression fracture (VCF), no more than two (if any) old VCFs with no resultant kyphotic deformity, and whose treatment starts no later than 15 days from the VCF time. Study population was split in a surgery cohort and a conservative cohort according to the provided treatment. All patients were asked to fill in VAS, SF-12, and Eq. 5D questionnaires at different time points up to 12 months after treatment. Segmental kyphosis at fracture level was also measured for our analysis. Results Kyphoplasty-treated patients had lower back pain VAS scores at 1 month as compared with conservatively treated patients ( p &lt; 0.05). Eq. 5D questionnaire also showed a better quality of life at 1 month for surgically treated patients ( p &lt; 0.05). As for the SF-12 no significant difference was observed. At 12 months, scores from all scales were not statistically different between the two cohorts, although surgically treated patients showed better trends than conservatively treated patients in pain and quality of life. Kyphoplasty was able to restore more than 55% of the original segmental kyphosis, whereas patients in conservative cohort lost 6.67% of the original segmental kyphosis on average. Conclusion Kyphoplasty seems to be a safe and effective procedure in reducing back pain due to painful VCF. The kyphosis restoring effect is also extremely interesting and can be achieved only in the first days after fracture time. In conclusion, kyphoplasty is a procedure that offers a fast recovery and a better quality of life at 1 month after treatment, helping restoring segmental kyphosis after VCFs.11,12,13 Acknowledgments There was no external funding source and no funding source played a role in the investigation. References Who are candidates for prevention and treatment for osteoporosis? Osteoporos Int 1997;7(1):1–6 Johnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int 2006;17(12):1726–1733 Iqbal MM, Sobhan T. Osteoporosis: a review. Mo Med 2002;99(1):19–24 Gold DT. The clinical impact of vertebral fractures: quality of life in women with osteoporosis. Bone 1996;18(3, Suppl):185S–189S Jarvik JG, Kallmes DF. Point of view. Efficacy of vertebroplasty and kyphoplasty. Spine 2009;34(6):613–614 Kallmes DF, Comstock BA, Heagerty PJ, et al. A randomized trial of vertebroplasty for osteoporotic spinal fractures. N Engl J Med 2009;361(6):569–579 Weinstein JN. Balancing science and informed choice in decisions about vertebroplasty. N Engl J Med 2009;361(6):619–621 Lyritis GP, Mayasis B, Tsakalakos N, et al. The natural history of the osteoporotic vertebral fracture. Clin Rheumatol 1989;8(2, Suppl 2):66–69 Prather H, Watson JO, Gilula LA. Nonoperative management of osteoporotic vertebral compression fractures. Injury 2007;38(3, Suppl 3):S40–S48 Garfin SR, Yuan HA, Reiley MA. New technologies in spine: kyphoplasty and vertebroplasty for the treatment of painful osteoporotic compression fractures. Spine 2001;26(14):1511–1515 Ledlie JT, Renfro M. Balloon kyphoplasty: one-year outcomes in vertebral body height restoration, chronic pain, and activity levels. J Neurosurg 2003;98(1, Suppl):36–42 Voggenreiter G. Balloon kyphoplasty is effective in deformity correction of osteoporotic vertebral compression fractures. Spine 2005;30(24):2806–2812 Pradhan BB, Bae HW, Kropf MA, Patel VV, Delamarter RB. Kyphoplasty reduction of osteoporotic vertebral compression fractures: correction of local kyphosis versus overall sagittal alignment. Spine 2006;31(4):435–441

The relationship between the spinopelvic balance and the incidence of adjacent vertebral fractures following percutaneous vertebroplasty.

We evaluated the relationship between sagittal spinopelvic parameters and the occurrence of adjacent vertebral fractures (AVF) and determined the possible risk factor. The most important factors for AVFs are the degree of osteoporosis and altered biomechanics due to the spinopelvic imbalance in the fractured area of the spine. We intend to evaluate the relationship between sagittal spinopelvic parameters and the occurrence of adjacent vertebral fractures following the initial compression fracture and to determine the possible dominant risk factor associated with new compression fractures. From March 2010 to May 2012, 240 consecutive patients with painful vertebral compression fractures (VCFs) were enrolled in a retrospective study. Ninety-one patients with VCFs underwent percutaneous vertebroplasty (VP) at 112 levels. The sagittal vertical axis (SVA), thoracic kyphosis (TK), lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), and segmental kyphotic angle on sagittal standing radiographs were used to evaluate radiologic outcomes. In 2 years, 15 out of 134 patients (11.1%) treated with conservative treatment, and 12 out of 91 patients (13.1%) treated with VP sustained adjacent level fracture. More patients with the BMD higher or equal to 3.0 experienced a new fracture than those with a BMD less than 3.0 (p = 0.019), and the risk for adjacent level fractures decreased significantly when segmental kyphotic angle was less than 11° (p = 0.001), SVA was less than 6 cm (p = 0.001), SS was higher or equal to 25° (p = 0.004), and LL was higher or equal to 25° (p = 0.020). The most important factors for new VCFs after the initial compression fractures are the degree of osteoporosis and altered biomechanics due to the spinopelvic imbalance in the fractured area of the spine. Regarding the spinopelvic alignment to investigate the relationship with a subsequent AVF, segmental kyphotic angle, SS, LL, and SVA may be a potential predictor.

Comparison of Vertebroplasty Versus Vertebral Perforation for the Treatment of Acute Vertebral Compression Fractures.

The efficacy of vertebroplasty on acute vertebral compression fractures (VCFs) has not yet been established. This study, focusing on patients with acute VCFs, aims to compare therapeutic effects between vertebroplasty and vertebral perforation without cement injection. Fifty-five patients with single painful VCFs were assigned to undergo vertebroplasty (Vertebroplasty group; 28 patients) or vertebral perforation (Perforation group; 27 patients). Analgesic effects before and after surgery were compared between 2 groups. Furthermore, the frequency of new VCFs during the follow-up period was compared. In both groups, the visual analog scale (VAS) scores markedly decreased immediately after surgery and remained low until 90 days after surgery (p < 0.05). However, in the Perforation group, the analgesic effect from postoperative day 7 to 90 was significantly lower in patients with vertebral mobility before surgery than those without mobility (p < 0.05). New fractures after surgery occurred in 12 (42.9%) of the 28 patients in the Vertebroplasty group and 8 (29.6%) of the 27 patients in the Perforation group (p =0.054). In acute VCFs, vertebroplasty exerts a marked analgesic effect, which does not differ much from that of vertebral perforation without cement injection. Considering the risk of new postoperative fractures, the application of bone cement infusion should be carefully considered in patients with acute VCF.

Percutaneous balloon kyphoplasty in the treatment of painful vertebral compression fractures: Effect on local kyphosis and one-year outcomes in pain and disability

Background and purposeThe aim of the study was to determine the effectiveness of percutaneous balloon kyphoplasty for treatment of compressive vertebral fractures. Materials and methodsA retrospective analysis was conducted on 24 patients with 58 symptomatic vertebral fractures treated by balloon kyphoplasty. Visual Analogue Pain Scale (VAS) and Oswestry Disability Index (ODI) were used to assess fracture-related pain and patient's disability: preoperatively and within 12-months follow-up. Following the procedures to evaluate the change of vertebral deformity, the angle of local kyphosis was measured. ResultsPreoperative VAS score was 6.54, at discharge it significantly regressed in 95.8% of patients. The overall VAS score at discharge was 1.25 and within 12 months decreased to 0.26. Preoperative ODI score was 50%, at follows-up in all patients it decreased, ranging from 21% to 10%. Reduction of local kyphosis was achieved in 30 (51.7%) vertebrae by average 4.3°. In 9 (37.5%) patients kyphosis of all augmented vertebrae was reduced, in 7 (29.2%) patients procedures reduced kyphosis in part of augmented vertebrae and in 8 patients (33.3%) kyphosis remained unchanged. Asymptomatic complications included cement leak in 10 (17%) vertebrae and intraoperative rupture of 4 (4%) balloons. ConclusionsRapid significant pain relief after kyphoplasty followed by long-term pain release and disability reduction obtained in all patients was most probably the result of vertebral augmentation. The correction of local kyphosis had no influence on the outcome.

Critique of the analysis of UpToDate.com on the treatment of painful vertebral compression fractures: time to update UpToDate.

The treatment of painful vertebral compression fractures has changed substantially since the introduction of vertebroplasty in the mid-1980s and balloon kyphoplasty in the late 1990s. Both procedures were widely accepted with the vertebral fractures treated reaching 150,000 per annum in 2009 prior to the publication of 2 randomized controlled trials comparing vertebroplasty with a sham treatment published in the New England Journal of Medicine in August 2009. Since then, there has been a flood of information on vertebral augmentation and balloon kyphoplasty. It is worth evaluating this information especially because it relates to current recommendations that are often followed blindly by medical and administrative groups unfamiliar with either the procedure or the high level of evidence surrounding vertebral augmentation. To streamline the evaluation of some current recommendations, we limited the analysis to the recommendations found on UpToDate.com. This Web site is an evidence-based, peer-reviewed source of information available for patients, doctors, health insurance companies, and population-based medical decision-making.

Postoperative change in sagittal balance after Kyphoplasty for the treatment of osteoporotic vertebral compression fracture.

The influence of vertebral cement augmentation on spinal sagittal balance is unknown. The present study aimed to analyze the changes in total spinal alignment after Kyphoplasty in VCF patients. The study involved 21 VCF patients who underwent Kyphoplasty. In all patients, lateral radiographs of the entire spine were taken preoperatively and 1 month after surgery, to measure the pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT), lumbar lordosis (LL), sagittal vertical axis (SVA), and spinosacral angle (SSA). These parameters were compared between VCF patients and 30 healthy volunteers. In VCF patients, the parameters were compared before and after Kyphoplasty. In VCF patients, preoperative SVA was 7.00 ± 3.9 cm, showing a significant shift to anterior sagittal balance as compared to the healthy group (1.45 ± 2.7 cm) (P < 0.0001). Preoperative SS was smaller and PT was larger in VCF group than in the healthy group (P < 0.05). After Kyphoplasty, SVA decreased to 5.02 ± 2.91 (P = 0.0007) and LL and SSA increased (LL P = 0.028; SSA P = 0.0031). Postoperative decrease of SVA was correlated with the kyphotic change of treated vertebra (r = 0.792, P < 0.01). VAS score decreased from 7.98 ± 1.8 before Kyphoplasty to 2.38 ± 2.3 postoperatively (P < 0.0001). Total spinal alignment is shifted to anterior sagittal balance in VCF patients. Kyphoplasty plays a role not only in reducing pain associated with fractures but also in improving sagittal imbalance in the treatment of painful vertebral compression fracture.

A Comparison between Unilateral Transverse Process-Pedicle and Bilateral Puncture Techniques in Percutaneous Kyphoplasty

Percutaneous kyphoplasty (PKP) is a widely used vertebral augmentation procedure for treating painful vertebral compression fractures. A percutaneous bilateral approach is typically used to access the vertebral body. Many previous studies have reported excellent clinical results with PKP. In contrast, numerous complications and problems have also been reported, such as puncture difficulty, cement leakage, adjacent vertebral fracture.

Efficacy and safety of vertebral stenting for painful vertebral compression fractures in patients with metastatic disease

Background and Purpose:Painful vertebral compression fractures in cancer patients reduce quality of life and may limit survival. We assessed pain relief, vertebral height restoration, and kyphosis correction following vertebral augmentation using a novel expandable titanium stent implant in cancer patients with painful vertebral compression fractures.Materials and Methods:Patients >18 years of age with metastatic disease who presented symptomatic compression fractures of vertebral bodies T5–L5, with or without a history of osteoporosis, were included in the study. Back pain at presentation, immediately after vertebral stenting, and at 1-, 3-, 6-, and 12-month follow-up was estimated using the visual analog scale (VAS). Vertebral height and local kyphotic angle (alpha angle) were measured on lateral standing X-ray before and 1–3 months after stenting.Results:Forty-one cancer patients with painful vertebral compression fractures underwent vertebral stenting procedures at 55 levels. There was no perioperative mortality and no significant complication. Median preoperative VAS was 8·0 (range 8–10), falling to 2·0 immediately postop (range 1–6, P = 0·000) and 0 at all subsequent follow-up (P ≤ 0·012). Mean preoperative vertical height loss was 25·8% (range 0–84·0%) versus a postoperative mean of 18·0% (range 0–66·0%, P = 0·000). Median pre- and postoperative kyphotic angle improved from 8·3° (range 0·2°–54·0°) to 7·1° (range 0·2°–25·0°, P = 0·000). Wilcoxon signed rank test or student's t-test was used for comparisons.Conclusions:Vertebral augmentation using a novel vertebral stenting system provided immediate and enduring pain relief and improved vertebral height loss and kyphotic angle.

Penetration Approach for Repeat Vertebroplasty Through the Previously Impacted Bone Cement

Dear Editor, Vertebroplasty (VP) and kyphoplasty (KP) are effective treatments for painful vertebral compression fractures (VCFs) [1,2]. Although not common, subsequent refracture in the previously augmented vertebra causes persistent or recurrent pain [3]. Some reports have shown that repeat VP can control pain caused by refractures [3–5]. However, repeat VP is challenging because the previously impacted bone cement blocks the fluoroscopic views and access of procedure needles. A 57-year-old woman presented with severe pain (visual analog scale [VAS] 8/10) in her lower back and both thighs, which left her unable to sit or walk. She had a history of rectal cancer that had metastasized to the liver and lungs. Six months previously, metastasis to the fourth lumbar vertebra was detected and KP was performed (Figure ⇓). After the procedure, her pain reduced from VAS 8 to 2, but it recurred a week before her visit to our clinic. Magnetic resonance imaging (MRI) revealed further metastatic progression in the L4 vertebral body, and bone cement was located in front of the left pedicle (Figure ⇓). After the failure of conservative treatments, we undertook repeat VP with a …

Kyphoplasty versus vertebroplasty for the treatment of malignant vertebral compression fractures caused by metastases: a retrospective study

Background There are few comparative studies regarding kyphoplasty (KP) and vertebroplasty (VP) for the treatment of painful vertebral compression fractures (VCF) in patients with cancer. The purpose of this study is to retrospectively compare KP with VP in pain improvement, cement leakage incidence, and the cost of treatment of malignant VCF. Methods We performed a retrospective study of clinical data for 80 patients with multiple spinal metastases, treated with KP in 42 cases and VP in 38. Visual analog scale (VAS) scores were collected pre-operatively, post-operatively, at 1 month, 6 months, and 1 year after treatment. Cement leakage was identified using fluoroscopy and CT scan. Total cost per patient was also collected. Results There was a significant difference between the pre- and post-operative VAS scores (7.4±2.0 to 3.8±1.6, P &lt; 0.001 in the KP group; 6.7±2.4 to 3.7±1.4, P &lt;0.001 in the VP group), and was maintained at 1-year follow-up (3.2±1.4 in the KP group, 3.1±1.3 in the VP group). However, the difference in VAS score between these two groups was insignificant at baseline and every follow-up assessment post-operatively (P &gt;0.05). The incidence of cement leakage in the KP group was lower than that of the VP group (16.9% (14/83) vs 30.3% (23/76), P&lt;0.05). However, none of the patients developed any symptoms. The length of postoperative hospital stay in the VP group was shorter than that of the KP group ((2.4±1.3) vs (5.3±1.9) days, P&lt;0.05). Total hospital cost in the KP group was much higher than that of the VP group (RMB Yuan 8 492±3 332 vs RMB Yuan 3 173±1 341, P &lt;0.01). Conclusions VP and KP are both effective in providing pain relief for patients with cancer-related VCF. KP provides no greater degree of pain improvement. KP is associated with a lower rate of cement leakage compared with VP. VP is associated with lower cost and shorter postoperative hospital stay in China.

Anterior Spinal Artery Syndrome: Reversible Paraplegia after Minimally Invasive Spine Surgery

Background Context. Percutaneous balloon kyphoplasty is an established minimally invasive technique to treat painful vertebral compression fractures, especially in the context of osteoporosis with a minor complication rate. Purpose. To describe the heparin anticoagulation treatment of paraplegia following balloon kyphoplasty. Study Design. We report the first case of an anterior spinal artery syndrome with a postoperative reversible paraplegia following a minimally invasive spine surgery (balloon kyphoplasty) without cement leakage. Methods. A 75-year-old female patient underwent balloon kyphoplasty for a fresh fracture of the first vertebra. Results. Postoperatively, the patient developed an acute anterior spinal artery syndrome with motor paraplegia of the lower extremities as well as loss of pain and temperature sensation with retained proprioception and vibratory sensation. Complete recovery occurred six hours after bolus therapy with 15.000 IU low-molecular heparin. Conclusion. Spine surgeons should consider vascular complications in patients with incomplete spinal cord syndromes after balloon kyphoplasty, not only after more invasive spine surgery. High-dose low-molecular heparin might help to reperfuse the Adamkiewicz artery.

Vertebroplasty

Percutaneous vertebroplasty has become widely accepted as a safe and effective minimally invasive procedure for the treatment of painful vertebral body compression fractures refractory to medical therapy. In this article, the authors review the indications and contraindications for vertebroplasty, principles of appropriate patient selection, useful techniques to achieve optimal outcomes, and the potential risks and complications of the procedure.

Safety and therapeutic efficacy of the second treatment for new fractures developed after initial vertebroplasty performed for painful vertebral compression fractures

Objectives: There is no report on the safety and therapeutic efficacy of the second treatment for new vertebral fractures developed after vertebroplasty. This study aims to examine the therapeutic effects and clinical characteristics in patients undergoing a second vertebroplasty for these new fractures.Methods: The initial treatment group included 182 patients (276 vertebrae) who underwent vertebroplasty. Among 182 patients, the second treatment group included 34 patients (36 vertebrae) who developed new fractures postoperatively, which were retreated. Analgesic effects on the day following surgery, frequency of new fractures during the 12 month period after surgery, and other clinical characteristics were compared between the initial and second treatment groups. Furthermore, similar comparisons were performed between patients with adjacent and non-adjacent vertebral fractures in the second treatment group.Results: The improvement rates in visual analogue scale (VAS) scores before and after surgery were 83·4% in the initial treatment group and 85·6% in the second treatment group (P = 0·27). The frequencies of new fractures occurring within 12 months after surgery were 20·9% and 20·6%, respectively.Within the second treatment group, the VAS improvement rates were 76·7% in the adjacent and 88·2% in the non-adjacent vertebral fracture groups (P = 0·83). However, the frequencies of subsequent new fractures after the second treatment were 31·6% and 5·9%, respectively, being significantly higher in the adjacent vertebral fracture group (P < 0·05).Conclusions: Additional vertebroplasty for new fractures exerts analgesic effects similar to those of the initial procedure. However, we must note that the second treatment for new adjacent vertebral fractures frequently causes more subsequent new fractures in comparison with non-adjacent fractures.