Posttraumatic Vertebral Collapse Research Articles

Biomechanical analysis of a novel bone cement bridging screw system combined with percutaneous vertebroplasty for treating Kummell's disease.

Kummell's Disease (KD) was originally proposed by Dr. Hermann Kummell in 1891 as a type of delayed posttraumatic vertebral collapse, which is a clinical phenomenon. The purpose of this experiment is to compare the strength of bone cement and the novel bone cement bridging screw in the treatment of thoracolumbar Kummell disease (KD) with other treatment methods. Thirty sheep spine specimens were selected. T12 to L2 segments were selected, and a KD intravertebral vacuum cleft model was made at the L1 segment. According to the ways of cement filling, the specimens were divided into percutaneous vertebroplasty (PVP), PVP combined with unilateral percutaneous pediculoplasty (PPP), PVP combined with bilateral PPP, unilateral novel bone cement bridging screw system combined with PVP, and bilateral cement bridging screw system combined with PVP groups. There were two experiments: three-dimensional biomechanical strength test and axial compression test. In the three-dimensional biomechanical strength test, we measured the strength of bone cement in specimens under six motion states, including flexion, extension, left bending, right bending, and left and right axial rotations. In the axial compression test, we detected the maximum axial pressure that the bone cement could withstand when it was under pressure until the bone cement was displaced. The unilateral or bilateral novel bone cement bridging screw with PVP groups had the best strength under flexion, extension, left bending, right bending, and had better biomechanical strength, with a significant difference from the other three groups (p < 0.05). There was no significant difference between the unilateral or bilateral novel bone cement bridging screw with PVP groups (p > 0.05). Unilateral and bilateral novel bone cement bridging screw could achieve similar bone cement strength. Compared with the other three groups, the unilateral or bilateral novel bone cement bridging screw with PVP groups are higher 136.35%, 152.43%; 41.93%, 51.58%; 34.37%, 43.50% respectively. The bilateral novel bone cement bridging screw with PVP could bear the largest pressure under vertical force. To conclude, the novel bone cement bridging screw can increase the strength of bone cement and avoid the loosening and displacement of bone cement in the treatment of KD of the thoracolumbar spine.

Kummell's Disease is Becoming Increasingly Important in an Aging Society: A Review.

Kummell's disease (KD) is referred to as delayed posttraumatic vertebral collapse, avascular necrosis of vertebrae, or ischemic vertebral collapse. KD is no longer rare in an aging society. It is mainly caused by minor trauma, and nonunion occurs secondary to avascular necrosis at the vertebral body fracture site, which can lead to vertebral kyphosis or intravertebral instability. Clinical symptoms of KD range from no symptoms to severe paralysis due to nerve injury. KD is considered a complication of osteoporotic vertebral compression fractures, and conservative treatment, including osteoporosis treatment, is important. Timely interventions such as vertebral augmentation or surgery, with active regular follow-up are necessary before the onset of neurological deficits due to osteonecrotic collapse in patients with suspected KD. In this study, we summarize the pathogenesis, diagnosis, and treatment of KD, which is showing increasing prevalence in an aging society. We have presented a literature review and discussed clinical guidelines and therapeutic strategies to reduce the morbidity and mortality associated with KD.

Delayed posttraumatic vertebral body collapse “Kummell disease”

Abstract Introduction: Kummell disease(KD) is a relatively rare condition, which refers to a lack of blood supply to the bone leading to collapse. It typically presents in the thoracic vertebrae of elderly patients, as a compressive deformation of the vertebral body and its osteonecrosis. It appears as a result of minor trauma experienced weeks to months before the onset of the disease. Osteoporosis tends to be the biggest risk factor for KD, hence its high frequency in the affected patient population. Patients concerns: A 67-year-old female patient presented to the hospital with a back pain deteriorating since 1 year, limiting her daily activities. Over the time it progressed to involve extremities and caused hypersensitivity of the skin at the level of the affected thoracic region. She had a history of osteoporotic vertebral compression fracture 2 years earlier after a fall. It was treated by conservative methods. Diagnosis: Computed tomography procedure revealed a compression fracture at the level of Th11. Further investigation and collection of the past medical history showed a delayed nonunion of the vertebral fracture and intravertebral vacuum cleft. The final diagnosis was KD. Conservative treatment of the patient's condition in another hospital resulted in non-healing. Interventions: As there is no specific treatment for patients suffering from delayed posttraumatic vertebral body collapse, an attempt of the most promising surgical combination of methods was performed. SpineJack system procedure resulted in satisfactory vertebral height improvement. This included vertebroplasty and minimally invasive percutaneous transpedicular fixation using bone-cement screw augmentation, providing stabilization and kyphotic angle correction. All these procedures facilitated pain relief and alleviation of spinal symptoms. Outcomes: The radiological outcomes of the patient's condition showed improvement after the surgery. Patient reported subjective improvement in daily life functioning. Follow up period at 6 and 9 months postoperatively showed stable condition and a satisfactory feedback from the patient. Conclusion: The conservative treatment in this patient, provoked an occurrence of markedly diminished vertebral height, debilitating back pain and neurological symptoms. These features caused a significantly lower quality of life. An accurate diagnosis of KD requires a detailed medical history and awareness of this rare condition and its irreversible complications. The treatment chosen for specific cases should primarily involve a meticulous observation of the efficacy of conservative methods. Furthermore, after the appearance of any deterioration of vertebral fracture, surgical method should be planned in order to avoid undesirable effects.

Percutaneous vertebroplasty versus percutaneous kyphoplasty for the treatment of delayed post-traumatic vertebral body collapse (Kümmell’s disease) in Chinese patients: a systematic review and meta-analysis

Abstract Objective To compare the clinical efficacy between percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) in the treatment of Kümmell’s disease in Chinese patients. Methods The studies using randomized controlled trials to compare clinical efficacy between PVP and PKP in the treatment of Kümmell’s disease in Chinese patients were retrieved from Embase, Pubmed, Central, Cinahl, PQDT, CNKI, CQVIP, Wanfang Data, and CBM (from September 2008 to September 2018). Keywords for both Chinese and English search were: percutaneous vertebroplasty, PVP, percutaneous kyphoplasty, PKP, and Kümmell’s disease. A total of 132 articles were retrieved based on the search strategy through online database searching and manual searching. Finally, one foreign report and seven Chinese reports were included. After extracting the data, statistical software Review Manager 5.3 was used for data analysis. Results Through comparison, Cobb angle (95% CI [0.54, 4.42), P = 0.01] and Oswestry Dysfunction Index (ODI) (95% CI [0.21, 2.15], P= 0.02) of PKP group was smaller than that of PVP group. Postoperative anterior vertebral body height of the PKP group was better than PVP group (95% CI [−1.27, −0.66], P &lt; 0.001]. However, the PVP group had shorter operation time than PKP group (95% CI [−13.48, −7.43), P = 0.001]. In the other outcome measures, including Visual Analogue Scale (VAS) score (95% CI [−0.04, 0.27), P = 0.15), cement volume (95% CI [−0.82, 0.32], P = 0.39) and cement leakage (95% CI [0.90, 2.76], P = 0.11), there was no significant differences between the two procedures. Conclusions At this stage, there is sufficient evidence to support that PKP is better than PVP in the treatment of Kümmell’s disease in Chinese patients. Although PVP surgery requires much less operation time, PKP has better postoperative radiological results and lower ODI. Moreover, both of them had similar clinical results (e.g., analgesic effects, cement dosage, and leakage rate). Further evidence is dependent on the emergence of randomized controlled trials with higher quality and larger sample sizes in the future.

Pathomechanism of intravertebral clefts in osteoporotic compression fractures of the spine

Background contextIntravertebral cleft (IVC) associated with vertebral collapse is not uncommon in osteoporotic compression fracture. However, the pathomechanism of IVC is poorly understood. Bone ischemia is indicated in the current hypothesis. PurposeTo clarify the pathomechanism of IVC in delayed posttraumatic vertebral collapse, referred to as Kummell's disease. Study designMagnetic resonance (MR) angiography and histology of segmental arteries and vertebral bodies in delayed posttraumatic vertebral collapse were investigated. Patient sampleAll elderly patients admitted to the authors' spine clinic of tertiary referral center for a 105-month period. Outcome measuresAll imaging tests including plain radiographs, computed tomography, and MR angiography were reviewed by authors using a double-blind method. All operations were performed by one experienced surgeon. The statistical data were analyzed using SPSS program. MethodsEvaluations using MR angiography and computed tomography were performed in 22 patients. Twelve of the 22 patients underwent corpectomy and anterior interbody fusion. At operation, segmental artery and bone surrounding IVC were harvested and microscopically evaluated. ResultsMagnetic resonance angiography showed occlusions of bilateral segmental arteries in nine of 22 patients. Seven patients had unilateral occlusion. In six patients, no occlusion was seen. Microscopically, the left segmental arteries of three patients were completely obstructed by thrombosis. Histologic examination of necrotic bone showed fragile trabecular bone and sparse osteocytes. ConclusionsThe findings of thrombosis of the segmental arteries of the vertebral body with IVC could suggest a mechanism by which IVC is formed, and the progressive collapse may develop following osteoporotic spinal fracture.

Kummell’s disease: delayed post-traumatic osteonecrosis of the vertebral body

Delayed post-traumatic osteonecrosis, also known by its eponym Kummell's disease, is a rarely reported clinical entity that likely occurs with higher frequency than recognized. We highlight a case of a 75-year-old female household ambulator who presented with significant thoracolumbar pain and delayed T12 collapse after a ground-level fall. The patient had sustained a trivial fall at home 4 months prior to this presentation and had been hospitalized in our institution at that time for a general medical workup. Dedicated spine radiographs were not obtained during this visit. However, lateral chest radiograph demonstrated an intact T12 vertebral body. The patient was able to mobilize successfully with therapy and was discharged home. During the interim between the initial fall and subsequent presentation, she resumed physical activity including ambulating independently and performing various housework. Approximately 4 months following her initial injury, the patient returned to a local emergency department with vague complaints of abdominal pain without any history of recent fall or injury. After an unremarkable workup, the patient was sent home. Ten days later, she represented to our institution's emergency room with worsening pain. Radiographs and CT scan demonstrated interval collapse of the T12 vertebral body. A linear vacuum cleft was noted on X-rays and CT. An extensive workup to exclude other processes such as malignancy or infection, which was negative, ensued. Delayed post-traumatic vertebral collapse was diagnosed. A trial of medical management and therapy was attempted, but she continued to experience significant pain. A T12 vertebroplasty was therefore offered and performed to stabilize the injury and to relieve the pain. She was subsequently able to be discharged from the hospital and transitioned back to home life. At approximately 2 years following her injury, the patient was noted to be able to ambulate with a walking aid. Her final radiograph after her surgery demonstrated that the T12 vertebroplasty had maintained its height and sagittal alignment. This Grand Round case highlights the clinical presentation of Kummell's disease. Aspects of the clinical entity that will be discussed include a historical review of the disease, hallmark radiographic findings and treatment options.

Catastrophic intramedullary hematoma following Kümmell's disease with large intravertebral cleft

Background context Kümmell's disease is defined as avascular osteonecrosis and occurs after delayed posttraumatic vertebral collapse. Devastating cord injury with Kümmell's disease is rare except in advanced cases with kyphosis and posterior cortex breakage. Purpose The authors report unique experience with patients who presented with a catastrophic intramedullary hematoma after early stage Kümmell's disease without kyphosis. Study design Case report with analysis of the literature. Methods A 72-year-old woman with osteoporotic vertebral fractures of T12 visited the emergency room complaining of persistent back pain and paraparesis. The plain radiographic examination revealed mild osteoporotic wedge compression fractures. The magnetic resonance images revealed the fracture cavity as a discrete area of abnormal low and high signal, which is consistent with vertebral osteonecrosis with evidence of Kümmell's disease on T12, and conus showing an extensive hematoma with mixed signal changes. Results The authors performed laminectomy and the removal of the intramedullary hematoma, followed by vertebroplasty on T12. The spinal column was reduced and fixed posteriorly with a pedicle screw system using a one-stage procedure. Conclusions An increasing awareness of the delayed vertebral collapse with cord injury attached to an osteoporotic spine fracture, as well as a periodic follow-up and treatment are essential for preventing catastrophic neurological impairment.

Delayed Post-traumatic Vertebral Collapse: MR Categorization and MR-Pathology Correlation

Study DesignA retrospective study.PurposeTo categorize the MR appearance of ischemic vertebral collapse and to correlate surgical and histologic findings.Overview of LiteratureX-ray and MRI findings of delayed posttraumatic vertebral collapse shows several patterns. Histopathologic signs of osteonecrosis were present only in minor portion of cases sampled for biopsy of delayed post-traumatic vertebral collapse in the literature.MethodsTwenty-one patients (22 vertebral bodies), with surgically and histopathologically proven ischemic vertebral collapse were included. The patients were examined with a 1.5 T MR imager. Spin echo T1- and T2-weighted images were obtained in axial and sagittal planes. Two experienced musculoskeletal radiologists, who reached consensus, evaluated the MR images. Then, MR-pathology correlations were made.ResultsFour different MR patterns were identified. Fluid patterns, were seen in 14% (3/22) of the affected vertebral bodies, and were characterized by hypo-intense signals on T1-weighted images, and hyper-intense signals, similar to water, on T2-weighted images. Extensive bone necrosis was predominant. Compression pattern, the most common pattern, found in 41% (9/22 vertebral bodies), was characterized by a marked decrease of anterior column height. Bone necrosis, granulation tissue, marrow fibrosis, and reactive new bone formation were found in relatively equal proportion. Granulation pattern, seen in 27% (6/22 vertebral bodies), was characterized by hypo-intense signals on T1-weighted images, and intermediate signals on T2-weighted images. Extensive granulation tissue was predominant. Mixed patterns were present in 18% (4/22), of the vertebral bodies.ConclusionsAwareness of histopathologic correlation of MR patterns in patients with delayed post-traumatic vertebral collapse may facilitate effective interpretation of clinical MR images of the spine.

Air in bone: intraosseous pneumatocyst in a child

Intraosseous pneumatocyst [1] is an uncommon benign condition in which gas collects in bone. The imaging features are of a localized collection of gas in the bone, usually adjacent to a joint, a thin sclerotic rim, no bony destruction, no soft-tissue mass and no other medullary abnormalities. The differential diagnosis for this incidental finding includes osteonecrosis, osteomyelitis, neoplastic or post-traumatic vertebral collapse, and postoperative changes. There may be progression to a fluid-filled cyst. The axial and sagittal CT images (Fig. 1) are of a 9-yearold boy with abdominal pain due to blunt trauma showing well-defined intraosseous air (−940 HU) with a sclerotic margin in the left ilium adjacent to the sacroiliac joint. No fractures or joint abnormality was noted and the appearances are consistent with an intraosseous pneumatocyst. This is a distinct but benign entity [2] and has to be kept in mind, particularly in patients with a history of trauma to avoid unnecessary investigations.

Comparison of the Results of Percutaneous Vertebroplasty for Treating Osteoporotic Vertebral Compression Fracture and Posttraumatic Vertebral Collapse (Kummell's disease)

Comparison of the Results of Percutaneous Vertebroplasty for Treating Osteoporotic Vertebral Compression Fracture and Posttraumatic Vertebral Collapse (Kummell's disease)

STAGING OF KÜMMELL'S DISEASE

Kümmell's disease is defined as delayed post-traumatic vertebral collapse, common in osteoporotic people with/without a trauma history. Its clinical course is progressive, and treatment modalities have to be tailored to the patient. In the literature, no staging system has been reported. Based on clinical symptomatology, radiographic and MRI imaging, a staging system for Kümmell's disease was developed. This study involved 129 Kümmell's disease patients with 348 compression fractures involving 136 vertebrae. The mean age was 72.5 ± 6.6 years, with a female to male ratio of 103 to 26. Osteoporosis is a common risk factor. Minor trauma can be traced in some of the patients. A three-stage system was proposed. Stage I: Intact or minor compression on plain X-ray films with signs of osteonecrosis on the MRI. Stage II: Body collapse with dynamic mobility, but with intact posterior body wall. Stage III: Collapse of posterior body wall with resultant cord compression. There were 19, 90 and 33 vertebrae respectively classified in Stages I, II and III. Kümmell's disease is most common threat to the thoracolumbar junction. Treatments based on clinical symptomatology and radiographic findings were well correlated with the staging system. The present staging system therefore seems appropriate to describe the natural course of Kümmell's disease and to guide management policy.

Delayed posttraumatic vertebral collapse with intravertebral vacuum cleft

Objective: To discuss the case of a 79-year-old man who had a delayed posttraumatic vertebral collapse and an intravertebral vacuum cleft. The patient had been on long-term corticosteroid therapy. A discussion of Kummell's diseaseand the controversy surrounding the etiology of the condition is also presented. Clinical Features: Six weeks before coming to the clinic, the patient remembered twisting, hearing a pop, and having severe low back pain. Two weeks after the incident, while hospitalized for bacterial cellulitis, he underwent lumbar spine radiography. The radiographs showed degenerative changes and remote (healed) compression fractures but did not demonstrate any deformity of L2. Four weeks later, he sought care for persistent low back pain. Radiographs revealed marked compression of the L2 vertebral body with an intravertebral vacuum phenomenon. Intervention and Outcome: The patient was referred to his geriatrician for evaluation as a candidate for vertebroplasty or other stabilization procedures. He required a moderately high dose (60 mg) of prednisone daily to combat the symptoms of myasthenia gravis; therefore, the prognosis appears unfavorable for this patient. Conclusion: Clinical research is needed to determine the definitive etiology and pathophysiology of Kummell's disease. This case demonstrates that the intravertebral vacuum is a dynamic entity, subject to changes in size and shape. Previous case reports have suggested that Kummell's disease only presents as a linear, horizontal cleft. This disease needs further investigation to determine the true correlation between radiographic signs and the underlying pathophysiology. (J Manipulative Physiol Ther 2002;25:270-275)

Kummell's Disease Managed by Percutaneous Vertebroplasty

Study Design : Prospective study about fourteen consecutive patients with Kummell’s disease who were treated by percutaneous vertebroplasty with bone cement. Objectives : To evaluate the results of percutaneous vertebroplasty using bone cement in the treatment of Kummell’s disease. Summary of Literature Review : Kummell’s disease is a rarely reported, poorly documented, and poorly understood phenomenon. It is associated with intravertebral vacuum phenomenon and clinically manifested by painful kyphosis. The treatment of the disease had been conservative or surgical reconstruction, but both conservative and operative treatment were not satisfactory in some patients. Materials and Methods : A review was conducted of 14 patients with 18 vertebrae treated with percutaneous vertebroplasty from June 1999 to May 2000. They had posttraumatic vertebral collapse or Kummell’s disease and had failed medical therapy. Immediate and long-term pain response and complications of percutaneous vertebroplasty with bone cement were evaluated. R e s u l t s : All patients reported complete relief of pain within the first 24 hours. Ten(71.5%) were evaluated as excellent; three(21.4%), good; one(7.1%), fair until 3 months postoperatively. Eight(57.2%) were evaluated as excellent; four(28.6%), good; fair(7.1%), one; poor(7.1%), one at final follow-up. Five(35.7%) patients had cement extrusion into the disc, paravertebral vessels and epidural space without significant systemic symptoms. C o n c l u s i o n : For patients with posttraumatic vertebral collapse or Kummell’s disease, percutaneous vertebroplasty technique using bone cement would be a minimally invasive treatment option to achieve immediate relief of pain and stabilization without significant side effects.

Delayed Post-traumatic Vertebral Collapse (Kummellʼs Disease)

A case of delayed posttraumatic vertebral collapse (Kummell's disease) is described and documented with serial radiographs, computed tomographic scans, and bone scans. The bone scan was normal before the back injury occurred and showed increased radionuclide uptake 3 weeks after injury and before vertebral collapse. Plain radiographs and computed tomographic scans taken during the interval between injury and collapse revealed no evidence of fracture or bone destruction. The authors believe this represents the first example of Kummell's phenomenon documented with serial computed tomographic and bone scans, and provides further support to the ischemic necrosis theory as the underlying process.

Spondylitis Traumatica Tarda (Kummell's Disease)

THE name “Kummell's disease” has been given to a specific X-ray and symptom complex first described by Kummell in 1891 (1). Other terms include appropriate and descriptive phrases which indicate the pathologic change, the causative factor, and the characteristic delay of symptoms, namely, “post-traumatic spondylitis,” “spondylitis traumatica tarda,” and “posttraumatic vertebral collapse.” Attention is being directed to this peculiar condition by medical writers and investigators with increasing frequency in Germany, France, and in America, which may be construed as evidence that the lesion is not so rare as some surgeons and roentgenologists believe it to be. However, it is safe to say that it is an uncommon condition and that it occurs so seldom that many busy roentgenologists have never encountered a typical case, or, at least, never have been confronted with the chain of events which characterize Kummell's disease. An X-ray study of this condition reveals varying degrees of loss of bone substance of a ...