Pathological Vertebral Compression Fractures Research Articles

Osteoporotic Vertebral Compression Fractures: Medical, Social Aspects, Clinical Picture, Treatment and Medical Rehabilitation. A Review

INTRODUCTION. Osteoporosis is one of the most common metabolic skeletal diseases in the world, which is characterized by a decrease in bone tissue strength and an increased risk of fractures with minimal trauma, including pathological vertebral compression fractures (VCFs). VCFs are accompanied by a decrease in the quality of life of patients with osteoporosis due to a pronounced pain syndrome, sleep problems, decreased motor and social activity, a high risk of falls and fractures, the development of pathological spinal deformities, decreased lung capacity and increased number of comorbid diseases. In this regard, timely treatment and medical rehabilitation in patients with osteoporosis and VCFs are of particular importance to restore functionality, reduce the risk of developing new fractures, disability and death.
 MAIN CONTENT OF THE REVIEW. The literature review is the analysis of 7 domestic and 49 foreign literary sources, which was used to describe the prevalence, medical and social significance and clinical picture of osteoporotic VCFs. It provides data on modern methods of drug and non-drug treatment of patients with VCFs. The effectiveness and limitations of the use of physical therapy methods in the rehabilitation of patients with pathological spinal fractures are described in detail.
 CONCLUSION. It is concluded that VCFs pose a significant healthcare burden due to their high prevalence and negative impact on the quality of life of older patients with osteoporosis. Osteoporotic VCFs lead to the development of severe back pain, limited mobility, spinal deformities, loss of height and permanent disability. An effective strategy for the treatment and rehabilitation of patients with osteoporotic VCFs should include the use analgesics, orthotics, correction of nutritional deficiency, elimination of vitamin D and calcium deficiency, modern methods of physical therapy, fall prevention and timely prescription of effective drugs for pathogenetic therapy of osteoporosis to reduce the risk of pathological fractures in the future and ensure a high level of functioning and of the quality of life.

Impact of metastatic epidural spinal cord compression (MESCC) and pathological vertebral compression fracture (pVCF) in neurological and survival prognosis

BackgroundMetastatic epidural spinal cord compression (MESCC) and pathological vertebral compression fractures (pVCF) are the most serious debilitating morbidities of spine metastases (SpMs) causing devastating neurological damages. The respective impact of these two metastasis-spreading entities on survival and on neurological damage is debated. MethodsA French prospective cohort study collected 279 consecutive patients presenting with SpMs between January 2017 and 2021. We compared 174 patients with MESCC and 105 patients with pVCF. ResultsThe median Overall Survival (OS) for the MESCC group was 13.4 months (SD 1.5) vs 19.2 months (SD 2.3) for pVCF patients (p = 0.085). Sixty-five patients (23.3 %) were operated on: 49/65 (75.4 %) in the MESCC group and 16/65 (15.2 %) in the pVCF group, p < 0.0001. At 6 months FU, in the MESCC group, 21/44 (45.4 %) of non-ambulatory patients at onset improved to ambulatory status (Frankel D-E) vs 10/13 (76.9 %) in the pVCF group (p = 0.007). In multivariable analysis with the Cox proportional hazard model, good ECOG-PS and SINS Score 7–12 [HR: 6.755, 95 % CI 2.40–19.00; p = 0.001] were good prognostic factors for preserved ambulatory neurological status. However, SpMs diagnosed synchronously with the primary tumor [HR: 0.397, 95 % CI 0.185–0.853; p = 0.018] and MESCC [HR: 0.058, 95 % CI 0.107–0.456; p = 0.007] were independent risk factors for impaired neurological function. ConclusionContrary to pVCF, MESCC causes neurological damage. Nevertheless, neurological recovery remains possible. MESCC and pVCF have no impact on survival. The management of MESCC remains to be clarified and optimized to reduce neurological damage.

Retrospective Review of 181 Patients with Pathologic Vertebral Compression Fractures

Background: Compression fractures are often associated with lower energy trauma and may occur in the setting of abnormal bone health associated with genetic disorders and endocrine disorders, neoplastic disease, infection, and inflammatory disorders. There is no significant series in the literature describing the prevalence or etiology of pathologic pediatric compression fractures.Methods: IRB-approved retrospective study was performed at a tertiary children's hospital from 2012-2022. Patients <18 years old diagnosed with atraumatic vertebral compression fractures were included and reviewed for demographics, underlying diagnosis/comorbidity, presentation, mobility, deformities, imaging data, treatments, and outcomes.Results: 181 patients (54% Male) were included with mean age 14.17 years and follow-up of 20 months. A compression fracture was the presenting symptom of an underlying diagnosis in 32% of patients, and 21% of patients received an MRI to distinguish between metastatic disease and benign fractures. Primary osteoporosis was the cause in 15% and secondary osteoporosis was in 65% of patients; most commonly due to immunosuppressants (46%) and acute lymphoblastic leukemia (ALL) (10%). Primary lesions were the etiology in 20% of patients. There was a median of 3 fractures per patient, mostly of the midthoracic (82%) and thoracolumbar spine (51%). Radiographs revealed wedge fractures in 82%, biconcave fractures in 22%, and vertebra plana in 12%. Patients were managed with observation (46%), bracing (31%), bisphosphonates (31%), and fusions (4%). By last follow-up, there was a higher proportion of patients who developed scoliosis or became wheelchair-bound. Overall, there was a 16% mortality rate which was mostly associated with cancer.Conclusion: Overall, 32% of patients presented with a compression fracture as the presenting symptom of an underlying disease. Pathologic vertebral compression fractures in children frequently occurred due to immunosuppressants, ALL, and metastatic disease. The fractures were most often wedge morphology in the thoracolumbar and mid-thoracic regions of the spine. MRIs may be useful for distinguishing between benign fractures and malignancy.Levels of Evidence: Level IV Key Concepts•Pathologic Vertebral Compression Fractures occur commonly in children with primary or secondary osteoporosis or due to primary site lesions, such as metastases.•Patients often have multiple fractures about the thoracolumbar and mid-thoracic regions of the spine.•Wedge and biconcave fractures were the most common fracture type at presentation and indicated an underlying disease not previously known in one-third of patients.•MRI is useful for distinguishing between benign fractures and malignancy as the etiology of the fracture.

Spine-specific skeletal related events and mortality in non-small cell lung cancer patients: a single-institution analysis.

The population prevalence of non-small cell lung cancer (NSCLC) continues to increase; however, data are limited regarding the incidence rate of skeletal related events (SREs) (i.e., surgery to the spinal column, radiation to the spinal column, radiofrequency ablation, kyphoplasty/vertebroplasty, spinal cord compression, or pathological vertebral body fractures) and their impact on overall mortality. In this study, the authors sought to estimate the incidence rates of SREs in NSCLC patients and to quantify their impact on overall mortality. This was a single-institution retrospective study of patients diagnosed with NSCLC between 2002 and 2014. The incidence rates for bone metastasis and subsequent SREs (per 1000 person-years) by time since lung cancer diagnosis were calculated and analyses were stratified separately for each histological type. Incidence rates for mortality at 1, 2, and 3 years from diagnosis stratified by the presence of SREs were also calculated. Kaplan-Meier survival curves were constructed to describe crude survival ratios in patients with spine metastasis and SREs and those with spine metastasis but without SREs. These curves were used to estimate the 1- and 2-year survival rates for each cohort. We identified 320 patients with incident NSCLC (median follow-up 9.5 months). The mean ± SD age was 60.65 ± 11.26 years; 94.48% of patients were smokers and 60.12% had a family history of cancer. The majority of first-time SREs were pathological vertebral body compression fractures (77.00%), followed by radiation (35%), surgery (14%), and spinal cord compression (13.04%). Mortality rates were highest in NSCLC patients with spine metastasis who had at least 1 SRE. Stratifying by histological subtype, the incidence rate of mortality in patients with SRE was highest in the large cell cohort, 7.42 per 1000 person-years (95% CI 3.09-17.84 per 1000 person-years); followed by the squamous cell cohort, 2.49 per 1000 person-years (95% CI 1.87-3.32 per 1000 person-years); and lowest in the adenocarcinoma cohort, 1.68 per 1000 person-years (95% CI 1.46-1.94 per 1000 person-years). Surgery for decompression of neural structures and stabilization of the spinal column was required in 6% of patients. SREs in NSCLC patients with bone metastasis are associated with an increased incidence rate of mortality.

A retrospective study of the use of percutaneous vesselplasty for pathological vertebral compression fractures

To assess percutaneous vesselplasty's safety and efficacy in treating pathological vertebral compression fractures (VCFs). This retrospective review covered nine patients with an equal number of symptomatic pathological VCFs treated with vesselplasty. The study assessed the patients' pain scores, subjective conditions, imaging guidance, and incidence of procedure-related complications. The VCFs were at the T4 and L5 spine regions. The procedure success rate was 100%. In 88.89% (8/9) of the examined cases, there was a posterior vertebral body or pedicle involvement or both. Two patients with high thoracic VCFs underwent combined computed tomography and mobile C-arm fluoroscopy guidance. The other patients underwent digital subtraction angiography guidance. The average visual analog scale (VAS) score and the Oswestry Disability Index (ODI) before the treatment were 7.78 ± 0.67 standard deviation (SD) and 75.45 ± 7.55, respectively. The average VAS score and ODI 3 months after the treatment were 2.67 ± 0.50 (SD) and 32.45 ± 6.19 (P < 0.001), respectively. There were no recorded cases of symptomatic cement leakage or other operation-associated complications. Percutaneous vesselplasty appears to be a safe and effective minimally invasive local treatment for pathological VCFs. This approach may offer benefits in improving pain, mobility, and function and minimizing the bone cement leakage rate while providing a safe and effective alternative treatment for pathological VCFs.

Radiofrequency Ablation of Spine Metastases: A Clinical and Technical Approach.

Percutaneous radiofrequency ablation (RFA) is an integral component of the multidisciplinary treatment algorithm for both local tumor control and palliation of painful spine metastases. This minimally invasive therapy complements additional treatment strategies, such as pain medications, systemic chemotherapy, surgical resection, and radiotherapy. The location and size of the metastatic lesion dictate preprocedure planning and the technical approach. For example, ablation of lesions along the spinal canal, within the posterior vertebral elements, or with paraspinal soft tissue extension are associated with a higher risk of injury to adjacent spinal nerves. Additional interventions may be indicated in conjunction with RFA. For example, ablation of vertebral body lesions can precipitate new, or exacerbate existing, pathologic vertebral compression fractures that can be prevented with vertebral augmentation. This article reviews the indications, clinical work-up, and technical approach for RFA of spine metastases.

Efficacy and Safety of Balloon Kyphoplasty for Pathological Vertebral Fractures in Patients with Hematological Malignancies in Our Institution.

Objective Patients with hematological malignancies, particularly those with multiple myeloma, often suffer from pathological vertebral compression fractures (VCFs). Consequent and significant spinal pain and paralysis impair the activities of daily living and quality of life and delay subsequent chemotherapy. Balloon kyphoplasty (BKP), which is less invasive than conventional therapies, is a type of percutaneous vertebroplasty in which cement is injected into the broken vertebrae to stabilize the spinal column. The present study assessed the effect of BKP on hematological tumors. Methods We retrospectively analyzed five myeloma patients and one lymphoma patient who underwent BKP for pathological VCFs in our institution. Results The median age was 74 years old. The spinal operation level ranged from T2 to L4. BKP was performed at the diagnosis in two cases, after first-line chemotherapy in one case, and after subsequent chemotherapy in three cases. After approximately 1 month, the patients’ average Eastern Cooperative Oncology Group performance status score rapidly improved from 3.2 to 1.3. The numeric rating scale score decreased from 8.8 to 2.0, and the Karnofsky Performance Status score increased from 35 to 75. No severe complications were observed. All patients became able to walk unassisted and underwent early subsequent chemotherapy. Conclusion BKP can be a safe and effective treatment option for pathological VCFs in patients with hematological malignancies and allows for rapid induction with subsequent chemotherapy.

Turning a Challenge into an Advantage: A Technical Report on Kyphoplasty for Multiple Myeloma

Kyphoplasty, a procedure first described in 2001 for the treatment of osteoporotic Vertebral Compression Fractures (VCFs) has since been used successfully for pathological vertebral compression fractures, including those caused by multiple myeloma. Whilst the evidence base for kyphoplasty remains incomplete, there is a general consensus that it is safe and significantly reduces pain in up to 84% of patients in whom nonsurgical management has failed.

CT based quantitative measures of the stability of fractured metastatically involved vertebrae treated with spine stereotactic body radiotherapy.

Mechanical instability secondary to vertebral metastases can lead to pathologic vertebral compression fracture (VCF) mechanical pain, neurological compromise, and the need for surgical stabilization. Stereotactic body radiation therapy (SBRT) as a treatment for spinal metastases is effective for pain and local tumor control, it has been associated with an increased risk of VCF. This study quantified computed tomography (CT) based stability measures in metastatic vertebrae with VCF treated with spine SBRT. It was hypothesized that semi-automated quantification of VCF based on CT metrics would be related to clinical outcomes. 128 SBRT treated spinal metastases patients were identified from a prospective database. Of these, 18 vertebral segments were identified with a VCF post-SBRT. A semi-automated system for quantifying VCF was developed based on CT imaging before and after SBRT. The system identified and segmented SBRT treated vertebral bodies, calculated stability metrics at single time points and changes over time. In the vertebrae that developed a new (n = 7) or progressive (n = 11) VCF following SBRT, the median time to VCF/VCF progression was 1.74months (range 0.53-7.79months). Fractured thoracolumbar vertebrae that went on to be stabilized (cemented and/or instrumented), had greater fractured vertebral body volume progression over time (12%) compared to those not stabilized (0.4%, p < 0.05). Neither the spinal instability neoplastic score (SINS) or any single timepoint stability metrics in post-hoc analyses correlated with future stabilization. This pilot study presents a quantitative semi-automated method assessing fractured thoracolumbar vertebrae based on CT. Increased fractured vertebral body volume progression post-SBRT was shown to predict those patients who were subsequently stabilized, motivating study of methods that assess temporal radiological changes toward augmenting existing clinical management in the metastatic spine.

Attaches the great importance of routine biopsy in vertebral augmentation

Vertebral compression fractures(VCFs) are severe and common complications of osteoporosis. Most VCFs were caused by osteopenia or osteoporosis. Nevertheless, spinal metastases probably result in pathological fractures that easily confused with osteoporotic vertebral compression fractures(OVCFs). Using biopsy during vertebral augmentation(VA) is considered as the golden standard protocol to rule out pathological VCFs. Up to data, conventionally using biopsy during VA is suggested by more and more researchers to confirm the etiology of VCFs and to avoid missed diagnosis and misdiagnosis of spinal metastases with pathological vertebral fractures as the first manifestation. For patients with spinal metastases, histological evaluation of vertebral biopsy specimens is convenient for further treatment.

Efficacy of balloon kyphoplasty in pain management of vertebral compression fractures

Aim: Vertebral compression fractures lead to pain, significant spinal deformity and functional disability that severely limit the health-related quality of life. Although most patients respond to conservative treatment, it has been shown that more than 40% of patients do not achieve the desired reduction in pain within 1 year of onset of symptoms. Percutaneous balloon kyphoplasty is often used to relieve symptoms and accelerate the recovery of function. The aim of this study is to evaluate the pain and functional outcomes of patients treated with percutaneous balloon kyphoplasty. Material and Methods: Data of 113 patients who underwent percutaneous balloon kyphoplasty with the diagnosis of vertebra compression fracture between January 2015 and June 2019 were scanned. Preoperative and postoperative Numeric Rating Scale scores and Oswestry Disability Index (ODI) scores with complications were evaluated.Results: 113 patients with 154 vertebral fractures were treated. 86 were female and 27 were male. The mean age was 76.8 years. L1 (n=29) and Th12 (n=31) vertebral fractures were the most common. The mean duration of the procedure was 65.93 minutes, and the mean volume of cement was 5.02 ml. Cement leakage was observed at 12 cases. Permanent neuromotor deficits or mortality was not observed at any of the patients. Following percutaneous balloon kyphoplasty, the NRS and ODI scores significantly improved at the 6th month follow-up compared with preoperative scores, the NRS and ODI scores before the procedure were 8.8 and 49.2 whereas the postoperative NRS and ODI were 2.2 and 18.1, which is.Conclusion: Percutaneous balloon kyphoplasty is an effective procedure to control pain and improve health related quality of life. This method has the advantage of improving and restoring the vertebral height and kyphotic deformity in osteoporotic or pathological vertebral compression fractures.

Photodynamic Therapy for the Treatment of Vertebral Metastases: A Phase I Clinical Trial

Vertebroplasty (VP) and balloon kyphoplasty (KP) are minimally invasive stabilization procedures for pathologic vertebral compression fractures (VCF). Concurrent administration of photodynamic therapy (PDT) as a tumor-ablative modality has yet to be studied in humans as a potential complement to improved mechanical stability that is afforded by vertebral cement augmentation (VCA). This first-in-human trial used a single 6 mg/m2 dose of the clinical photosensitizer Visudyne with escalating laser light doses. Following a cohort of light-only controls (n = 6), the drug and light treatment groups (n = 6 each) were 50, 100, 150, and 200 J/cm. VCA was performed within 15 minutes following PDT. Patients were clinically reviewed at 1 and 6 weeks. The primary outcome measure was safety from a neurologic perspective. Thirty patients comprising a variety of primary tumors were treated with PDT and either KP or VP. Vertebral PDT was technically feasible and delivered in all study patients. No dose groups showed significant increases in pain as defined by the generic SF-36 as well as disease-specific EORTC-QLQ-BM22 and EORTC-QLQ-C15-PAL questionnaires. The 50 and 100 J/cm groups showed the most significant pain reduction (P < 0.05). Twelve (40%) patients experienced complications during the study including 3 patients with further vertebral fracture progression by 6 weeks despite VCA. No complications were directly attributed to PDT. Using the parameters described, vertebral PDT as an adjunct to VCA is safe from a pharmaceutical and neurologic perspective. The results of this trial motivate scale-up study evaluating potential PDT efficacy in vertebral metastatic treatment.

Stereotactic Vertebroplasty for Spinal Metastases with Multilevel Bilateral Pedicle Fractures: A Technical Note.

Vertebral compression fractures (VCFs) represent a significant cause of disability and primarily result from either underlying vertebral body neoplasms or osteoporosis. Vertebroplasty (VP) is a procedure commonly utilized to repair pathologic VCFs in order to manage pain and reinstate vertebral body height. However, there is a paucity of literature on how to manage painful multilevel VCFs with concomitant bilateral pedicle fractures. We describe a patient with a primary prostatic carcinoma and VCFs of the third and fourth lumbar vertebrae (L3 and L4, respectively) with concomitant bilateral pedicle fractures secondary to metastatic disease. Due to the degree of damage to the L3 and L4 vertebral bodies and pedicles, a VP performed via a percutaneous approach was deemed to be too high risk. VP for L3 and L4 was instead performed by utilizing stereotactic spine navigation and an intraoperative O-arm (Medtronic Corporation, Minneapolis, Minnesota). Our result indicates a potential role for stereotactic spine navigation in vertebroplasty for complex pathologic VCFs.

Change in the cross-sectional area of the thecal sac following balloon kyphoplasty for pathological vertebral compression fractures prior to spine stereotactic radiosurgery.

OBJECTIVEPercutaneous vertebral augmentation procedures such as vertebroplasty and kyphoplasty are often performed in cancer patients to relieve mechanical axial-load pain due to pathological collapse deformities. The collapsed vertebrae in these patients can be associated with varying degrees of spinal canal compromise that can be worsened by kyphoplasty. In this study the authors evaluated changes to the spinal canal, in particular the cross-sectional area of the thecal sac, following balloon kyphoplasty (BKP) prior to stereotactic radiosurgery (SRS).METHODSThe authors retrospectively reviewed the records of all patients with symptomatic vertebral compression fractures caused by metastatic disease who underwent kyphoplasty prior to single-fraction SRS. The pre-BKP cross-sectional image, usually MRI, was compared to the post-BKP CT myelogram required for radiation treatment planning. The cross-sectional area of the thecal sac was calculated pre- and postkyphoplasty, and intraprocedural CT imaging was reviewed for epidural displacement of bone fragments, tumor, or polymethylmethacrylate (PMMA) extravasation. The postkyphoplasty imaging was also evaluated for evidence of fracture progression or fracture reduction.RESULTSAmong 30 consecutive patients, 41 vertebral levels were treated with kyphoplasty, and 24% (10/41) of the augmented levels showed a decreased cross-sectional area of the thecal sac. All 10 of these vertebral levels had preexisting epidural disease and destruction of the posterior vertebral body cortex. No bone fragments were displaced posteriorly. Minor epidural PMMA extravasation occurred in 20% (8/41) of the augmented levels but was present in only 1 of the 10 vertebral segments that showed a decreased cross-sectional area of the thecal sac postkyphoplasty.CONCLUSIONSIn patients with preexisting epidural disease and destruction of the posterior vertebral body cortex who are undergoing BKP for pathological fractures, there is an increased risk of further mass effect upon the thecal sac and the potential to alter the SRS treatment planning.

Kyphoplasty with purified silicone VK100 (Elastoplasty) to treat spinal lytic lesions in cancer patients: A retrospective evaluation of 41 cases

ObjectivesBalloon Kyphoplasty (BKP) for vertebral compression fractures (VCFs) in cancer patients is more challenging than for osteoporotic ones. Cord compressions are frequent and the incidence of complications ten-fold greater. Polymethylmetacrylate (PMMA) is the gold standard material for BKP but has disadvantages: exothermic reaction, short working time, rapid solidification, absence of osteoconduction. VK100 is a mixture of Dimethyl Methylvinyl siloxane and Barium Sulphate. It is elastic, adhesive to bone, leaves 30 min before solidification without exothermic reaction, and shows a stiffness close to the intact vertebrae. The surgical procedure, called elastoplasty, is similar to a BKP. Clinical results obtained with this new silicone in pathological VCFs have been investigated. Patients and Methods41 cancer patients with symptomatic VCFs (70 vertebral bodies), underwent percutaneous and open elastoplasties. Post-operative leakages, pulmonary embolism (PE) and adjacent fractures were carefully evaluated with neuroimaging. KPS, VAS and Dennis Pain Score were calculated pre- post-operatively and at the last follow-up. ResultsThe mean volume of silicone inserted in each vertebra was 3.8 cc. Complications included seven leakages (17%), two asymptomatic PE (4.3%) and 3 post-operative adjacent fractures (7.3%). Median follow-up was 29 months. A significant improvement was observed in KPS, VAS and Dennis Pain Score (p < .0001). The 1-yr survival rate was 76.9%. ConclusionsElastoplasty appears a safe and effective palliative treatment of VCFs in oncologic patients. Useful qualities of VK100 are the lack of exothermic reaction and the wider working window. The influence of biomechanical properties of silicone on reduction of adjacent level fractures requires further investigations.

Percutaneous Balloon Kyphoplasty Vertebral Augmentation for Compression Fracture Due to Vertebral Metastasis: A 12-Month Retrospective Clinical Study in 72 Patients.

BackgroundVertebral compression fracture is common in osteoporosis, but can also occur due to bone metastases, for which current treatment options are limited and include bone-strengthening with cement and supportive care. Kyphoplasty is a surgical method of bone augmentation that can reduce pain, stabilize vertebral bone, and restore some or all of the vertebral body height. The aim of this study was to investigate the clinical results of balloon kyphoplasty in the correction of vertebral deformity due to metastatic vertebral compression fracture.Material/MethodsA retrospective clinical study included 72 patients (82 vertebral bodies) with metastases resulting in vertebral compression fracture, treated by percutaneous balloon kyphoplasty; 9 patients were found incidentally to have vertebral metastases. Bone mineral density (BMD) levels were measured. Patient responses from questionnaires, including the visual analog scale (VAS) for pain intensity, and the Oswestry Disability Index (ODI) for disability, were scored. The local kyphosis angle (KA) and the vertebral height ratio (VHR) were measured. All patients were followed up for 12 months. The initial postoperative and 12-month postoperative values, and the preoperative and postoperative values were compared.ResultsFollowing balloon kyphoplasty, the KA, VHR, VAS, and ODI scores significantly improved at the final 12-month follow-up compared with preoperative levels (p<0.05, and p<0.001). There was cement leakage in 6 procedures (8.3%) and adjacent segment fracture in 11 procedures (15.2%).ConclusionsBalloon kyphoplasty was an effective method to reduce pain, reduce disability, and improve quality of life by eliminating kyphotic deformity in pathological vertebral compression fractures due to vertebral metastases.

Incidence of unexpected positive histology in kyphoplasty.

Kyphoplasty and vertebroplasty have become one of the most frequent surgical procedures in the treatment of vertebral compression fractures. Often, the cause of compression fractures is lowered bone mineral density as in osteoporosis. In the differential workup, also pathologic vertebral compression fractures need to be ruled out. Importantly, imaging techniques alone cannot safely differentiate between invasive lymphatic and osteoporotic vertebral fracture. Our goal was to identify the degree of unexpected positive histology in kyphoplasty for presumed osteoporotic vertebral compression fracture. We retrospectively analyzed all kyphoplasties performed between 2007 and 2015 at our institution. The data were acquired by reviewing our medical documentation system. The data analysis was done using Microsoft Excel. The statistical analysis was done using the Chi-squared test. We performed 130 kyphoplasties/vertebroplasties. A biopsy was taken in 97 (74.6%) cases. In 10 (10.3%) cases, the histology revealed a pathological fracture. From these patients, only in 3 (30%) cases, a positive histology was not expected. Meaning that there was no history of cancer and the radiological findings presumed an osteoporotic fracture. Therefore, we could demonstrate that the incidence of unexpected positive histology in vertebral compression fracture treated with kyphoplasty is significant (3.1%). As a conclusion, if a kyphoplasty is performed due to assumed osteoporotic vertebral compression fracture, a biopsy should be taken to safely rule out a pathological fracture caused by lymphatic bony invasion.

Combined Vertebral Augmentation and Radiofrequency Ablation in the Management of Spinal Metastases: an Update.

Spinal metastases are the most commonly encountered tumour of the spine, occurring in up to 40% of patients with cancer. Each year, approximately 5% of cancer patients will develop spinal metastases. This number is expected to increase as the life expectancy of cancer patients increases. Patients with spinal metastases experience severe and frequently debilitating pain, which often decreases their remaining quality of life. With a median survival of less than 1year, the goals of treatment in spinal metastases are reducing pain, improving or maintaining level of function and providing mechanical stability. Currently, conventional treatment strategies involve a combination of analgesics, bisphosphonates, radiotherapy and/or relatively extensive surgery. Despite these measures, pain management in patients with spinal metastases is often suboptimal. In the last two decades, minimally invasive percutaneous interventional radiology techniques such as vertebral augmentation and radiofrequency ablation (RFA) have shown progressive success in reducing pain and improving function in many patients with symptomatic spinal metastases. Both vertebral augmentation and RFA are increasingly being recognised as excellent alternative to medical and surgical management in carefully selected patients with spinal metastases, namely those with severe refractory pain limiting daily activities and stable pathological vertebral compression fractures. In addition, for more complicated lesions such as spinal metastasis with soft tissue extension, combined treatments such as vertebral augmentation in conjunction with RFA may be helpful. While combined RFA and vertebral augmentation have theoretical benefits, comparative trials have not been performed to establish superiority of combined therapy. We believe that a multidisciplinary approach as well as careful pre-procedure evaluation and imaging will be necessary for effective and safe management of spinal metastases. RFA and vertebral augmentation should be considered during early stages of the disease so as to maintain the remaining quality of life in this patient population group.

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.

Modification of PMMA vertebroplasty cement for reduced stiffness by addition of normal saline: a material properties evaluation.

Vertebral augmentation is an established treatment for patients with pathological vertebral compression fractures. These procedures typically employ a PMMA-based bone cement, which possesses a high compressive stiffness. Because of the increased risk of subsequent fractures after vertebral augmentations, there is a desire for reducing this stiffness. The goal of our study was to examine the influence of adding isotonic saline on the biomechanical properties of PMMA vertebroplasty cement. A PMMA-based vertebroplasty cement was prepared according to the manufacturer's recommendations after which isotonic saline was mixed into the cement at 10, 20, and 30% (volume:volume). Testing bodies were cast, and compression and bending tests were performed. Fracture surfaces were studied using SEM. Measurements of injectability, setting temperature, and radioopacity were also performed. The addition of saline solution (of up to vol-30%) led to a pronounced reduction in the compression modulus of the cement from 3409±312 to 1131±127MPa. In parallel, maximal compression strength was reduced from 86±4 to 33±3MPa and bending strength from 40±4 to 24±3MPa. The differences regarding injectability, setting temperature, and radioopacity were small and probably of no clinical relevance. The compressive stiffness of PMMA-based vertebroplasty cement can be reduced to almost a third by the addition of saline. The probable explanation is an increase in microporosity. Future simulator experiments will show whether the achieved reduction in stiffness is large enough to reduce the rate of subsequent vertebral fractures.