Vertebral Height Restoration Research Articles

Uniextrapedicular Kyphoplasty for the Treatment of Thoracic Osteoporotic Vertebral Fractures

Osteoporotic vertebral compression fractures are common and cause pain and disability. Most osteoporotic vertebral compression fractures occur in the lower thoracic and thoracolumbar spine. Percutaneous balloon kyphoplasty through a transpedicular approach is a classic procedure performed to treat osteoporotic vertebral compression fractures. However, due to the slender morphology of the pedicles, small pedicle size, and the angular severity of thoracic kyphosis, performing kyphoplasty in middle and high thoracic levels is technically challenging. The purpose of this retrospective study was to evaluate the clinical outcomes of single-balloon kyphoplasty for the treatment of thoracic osteoporotic vertebral compression fractures via an extrapedicular approach. Between July 2004 and May 2008, thirty-eight patients with thoracic osteoporotic vertebral compression fractures underwent percutaneous kyphoplasty via a unilateral extrapedicular approach. Average patient age was 60.3 years. Symptomatic levels ranged from T4 to T12. All affected vertebrae were identified via physical examination, magnetic resonance imaging, and radiographs. Pain relief, vertebral height restoration, and kyphosis correction were compared pre- and postoperatively using the visual analog scale and radiographs. The operation was successful in all patients. Average injected bone cement volume was 3.2±1.4 mL. Mean follow-up was 9.5 months. Visual analog scale pain score improved in 36 of 38 patients postoperatively. Mean visual analog scale pain score was 8.92±0.682 preoperatively and 2.40±0.31 postoperatively and remained at 2.80±0.34 until last follow-up. Mean middle body height correction ratio was 50.9%±34.6%. No lateral wedging was found in the coronal alignment of the treated vertebrae. Three (7.9%) patients sustained cement extravasation with no adverse events. Kyphoplasty through a unilateral extrapedicular approach can achieve convergent and proper cement filling in the affected vertebrae to effectively restore stiffness, relieve pain, and correct kyphosis in fractured vertebrae.

Vertebral Augmentation with Nitinol Endoprosthesis: Clinical Experience in 40 Patients with 1-Year Follow-up

This study was designed to assess the clinical outcomes of patients treated by vertebral augmentation with nitinol endoprosthesis (VNE) to treat painful vertebral compression fractures. Forty patients with one or more painful osteoporotic VCF, confirmed by MRI and accompanied by back-pain unresponsive to a minimum 2 months of conservative medical treatment, underwent VNE at 42 levels. Preoperative and postoperative pain measured with Visual Analog Scale (VAS), disability measured by Oswestry Disability Index (ODI), and vertebral height restoration (measured with 2-dimensional reconstruction CT) were compared at last follow-up (average follow-up 15 months). Cement extravasation, subsequent fractures, and implant migration were recorded. Long-term follow-up was obtained in 38 of 40 patients. Both VAS and ODI significantly improved from a median of 8.0 (range 5-10) and 66 % (range 44-88 %) to 0.5 (range 0-8) and 6 % (range 6-66 %), respectively, at 1 year (p < 0.0001). Vertebral height measurements comparing time points increased in a statistically significant manner (ANOVA, p < 0.001). Overall cement extravasation rate was 9.5 %. Discal and venous leakage rates were 7.1 and 0 % respectively. No symptomatic extravasations occurred. Five of 38 (13.1 %) patients experienced new spontaneous, osteoporotic fractures. No device change or migration was observed. VNE is a safe and effective procedure that is able to provide long-lasting pain relief and durable vertebral height gain with a low rate of new fractures and cement leakages.

Risk Factors for New Vertebral Compression Fractures After Percutaneous Vertebroplasty

Methodological systematic review. To identify the risk factors for new vertebral compression fractures (VCFs) in patients after percutaneous vertebroplasty (PVP) and to grade the evidence according to the quality of included studies. PVP is an effective procedure for the treatment of VCFs. A major concern after PVP in patients with osteoporosis is the occurrence of new VCFs in the untreated vertebrae. The risk factors for new VCFs after PVP reported thus far remain controversial. These risk factors have neither been well identified or summarized. This systematic review was performed to identify the risk factors for new VCFs after PVP. Noninterventional studies evaluating the risk factors for new VCFs of patients with osteoporosis after PVP were searched in MEDLINE, EMBASE, ScienceDirect, and OVID databases (all up to November 2012). Only observational studies with eligible data were included. Quality of included studies was assessed by a modified quality assessment tool, which was previously designed for observational study. The effects of studies were combined with the study quality score using a model of best-evidence synthesis. Twenty-four observational studies involving 3789 patients were included. These articles were published between 2004 and 2012. According to the quality assessment criteria for included studies, 8 studies were deemed as high-quality studies, 6 as moderate-quality studies, and 10 as low-quality studies. There were strong evidences of 3 risk factors, including lower bone mineral density, lower body mass index, intradiscal cement leakage, and vertebral height restoration. We also identified 6 moderate-evidence factors including lower body mass index, number of pre-existing vertebral fractures, thoracolumbar junction in initial VCFs, cement distraction, older age, and number of treated vertebrae. Thirteen factors were classified into the limited-evidence risk factors. Although there is no conclusive evidence for new VCFs of patients with osteoporosis after PVP procedure, these data provide evidence to guide the surgeon and develop optimal preventions for new VCFs after PVP. Special attention should be paid to the 3 strong-evidence risk factors. Further studies were still required to evaluate the effects of the earlier mentioned risk factors. 2.

Surgical approaches and their outcome in treatment of fracture and dislocation of the lower cervical spine

Objective To investigate surgical approaches and their effects in treating fracture and dislocation of the lower cervical spine.Methods A retrospective study was performed on data of 68 patients with fracture and dislocation of the lower cervical spine admitted to our hospital in recent years.All patients received CT,MRI and X-ray examination before and after admission.Among them,54patients were treated with anterior surgical approach,10 with posterior surgical approach and four with combined anterior and posterior surgical approach.Neurologic function recovery,dislocation correction,vertebral height restoration and fusion of bone graft were detected postoperatively so as to evaluate surgical outcome.Results None of the patients had aggravation of the neurologic function in follow-up for 6-36 months (average 21 months).All the patients had 1-2 level improvement according to American Spinal Injury Association (ASIA) classification,except for five patients with ASIA grade A injury.Restorations of dislocation and vertebral height were obtained in all patients.Interbody fusion was achieved in average 12 weeks.Postoperative X-ray films showed satisfactory fixation without loosening or fall of screws,and loosening or protrusion of bone grafts.Conclusions Determination of surgical approaches should be based on the fracture types and dislocation of the lower cervical spine,as well as sites and degree of spinal cord compression.In comparison with posterior surgical approach or combined anterior and posterior surgical approach,the anterior surgical approach has advantages of wider indications,shorter operation time and less bleeding,and can more effectively facilitate neural decompression,cervical physiological curvature recovery,cervical spine stabilization and early rehabilitation exercise.Therefore,anterior surgical approach should be the optimal choice in treatment of fracture and dislocation of the lower cervical spine. Key words: Spinal fractures; Cervical vertebrae; Fracture fixation; Surgical approach

Ist eine Höhenrekonstruktion mit vergleichsweise wenig Zement für die Radiofrequenz-Kyphoplastie über einen monopedikulären Zugang möglich?

Percutaneous cement augmentation systems have been proven to be an effective treatment for vertebral compression fractures in the last 10 years. A special form available since 2009 is the radiofrequency kyphoplasty (RF) in which the applied energy raises the viscosity of the cement. The aim of this study is to find out if a smaller cement amount in radiofrequency kyphoplasty can also restore vertebral body height in osteoporotic vertebral compression fractures. The treatment was minimally invasive using the StabiliT® vertebral augmentation system by DFine. In a retrospective study from 2011 to January 2012, 35 patients underwent RF kyphoplasty for 49 fresh osteoporotic vertebral compression fractures. From the clinical side the parameters, demographics and pain relief using a visual analogue scale (VAS: 0 to 100 mm) were collected. For the radiological outcome the vertebral body height (anterior, mean and posterior vertebral body height with kyphosis angle) after surgery and after three months was measured and compared to the cement volume. All patients still had permanent pain on the fractured level after conservative treatment. The time from initial painful fracture to treatment was 3.0 weeks ± 1.3. Average visual analogue scale results decreased significantly from 71 ± 9.2 preoperatively to 35 ± 6.2 postoperatively (p < 0.001) and to 30 ± 5.7 (p < 0.001) after three months. With a mean cement volume in the thoracic spine of 2.9 ± 0.7 ml (1.8-4.1) and lumbar spine of 3.0 ± 0.7 ml (2.0-5.0) we had a significant vertebral body height restoration. Anterior and mean vertebral body heights significantly increased by an average of 2.3 and 3.1 mm, kyphosis angle significantly decreased with an average of 2.1° at three-month follow-up (p < 0.05). In two vertebrae (4.1 %) a minimal asymptomatic cement leakage occurred into the upper disc. In two patients (5.7 %) we had new fractures in the directly adjacent segment that were also successfully treated with radiofrequency kyphoplasty. With a mean cement volume of 3.0 ml radiofrequency kyphoplasty achieves rapid and short-term improvements of clinical symptoms with a significant restoration of vertebral body height. There was no correlation between restoration of vertebral body height and pain relief. With a cement leakage of 4.1 % RF kyphoplasty is a safe and effective minimally invasive percutaneous cement augmentation procedure. Our data confirm the higher safety described in literature for kyphoplasty in contrast to vertebroplasty.

In Not Only Vertebroplasty but Also Kyphoplasty, the Resolution of Vertebral Deformities Depends on Vertebral Mobility

It has not been clarified whether the postoperative resolution of vertebral deformities achieved by KP are superior to those achieved by VP. We compared the outcomes of KP and VP, taking into account the presence of vertebral mobility, to determine whether the balloon inflation in KP may contribute to postoperative resolution of the vertebral deformities in patients with VCFs. The subjects had 34 vertebral bodies treated by VP, and 43 vertebral bodies treated by KP. In all patients, preoperative dynamic imaging was performed to assess the presence of vertebral mobility. First, the vertebral height restoration and kyphotic change were compared between the VP and KP groups. Then, the patients were further divided into 2 groups on the basis of the presence of vertebral mobility, and they were compared within and between the VP and KP groups in relation to the presence of vertebral mobility. Overall, no significant differences were observed in either the vertebral height restoration or kyphotic change between the VP and KP groups (P > .20). Preoperative dynamic imaging identified 19 vertebral bodies each with vertebral mobility in the VP (56%) and KP groups (44%) (P = .21). Within the VP and KP groups, the vertebral height restoration and kyphotic changes were significantly better in patients with vertebral mobility than in those without (P < .01). There were no significant differences between the 2 treatment groups after adjustment for the presence of vertebral mobility (P > .30). In both the VP and KP groups, the vertebral height restoration and kyphotic change largely depended on the preoperative vertebral mobility. The use of the balloon itself contributed little to resolution of the vertebral deformities.

Balloon Kyphoplasty Versus KIVA Vertebral Augmentation—Comparison of 2 Techniques for Osteoporotic Vertebral Body Fractures

Prospective, parallel-group, controlled comparative randomized study. This study compares the efficacy in sagittal vertebral height and wedge deformity restoration, polymethylmethacrylate cement leakage safety, and functional outcome of balloon kyphoplasty (BK) versus KIVA (a novel vertebral augmentation technique) implant for the augmentation of fresh osteoporotic vertebral body fractures. Minimally invasive vertebral augmentation procedures have been widely used to treat vertebral compression fractures caused by osteoporosis. The results of these trials are encouraging in augmenting the vertebra and reducing the wedge deformity. However, after BK, polymethylmethacrylate leakage remains common after A3.1 AO type fractures, with a frequency per vertebra into the epidural space up to 9.8% but less common (0.03%-5.6%) in A1.1 AO type fracture. KIVA is a novel percutaneous uniportal vertebral augmentation device that is designed to restore the vertebral body and reduce polymethylmethacrylate leakage. From a total 190 patients with osteoporotic fractures who were initially enrolled in this prospective randomized study, 10 patients were excluded (5 met exclusion criteria, 5 with evidence of metastasis). This study examined 82 patients (69 ± 11 yr) with 133 fractures who received KIVA and 86 patients (72 ± 9 yr) with 122 fractures that were reinforced with BK. Anterior (anterior vertebral body height ratio [AVBHr]), midline (midline vertebral body height ratio [MVBHr]), and posterior (posterior vertebral body height ratio [PVBHr]) vertebral body height ratio and Gardner segmental vertebral wedge deformity were measured preoperatively to postoperatively. New fractures were recorded at the final observation. The baseline anthropometric and roentgenographic parameters did not differ between the 2 groups. Any cement leakage was examined on plain roentgenograms and computed tomographic scan. All patients were followed for an average of 14 months (range, 13-15 mo) postoperatively. RESULTS.: At the final observation, both KIVA and BK restored significantly AVBHr, PVBHr, and MVBHr. However, only KIVA device reduced significantly the Gardner angle (P = 0.002). Residual kyphosis of more than 5° was measured significantly more (P < 0.001) in the BK than in KIVA spines. KIVA showed significantly lower (3%, χ2, P ≤ 0.05) leakage) [corrected] (paravertebral, intradiscal) rate per vertebra than BK (0.098%) in which because of intracanal leakage 2 patients developed acute paraplegia and were reoperated in emergency. New fracture rate was similar in both groups. Back pain scores (visual analogue scale), 36-Item Short Form Health Survey (Physical Function and Mental Health domains), and Oswestry Disability Index scores improved significantly in the patients of both groups. Both KIVA and BK restored in short-term similarly vertebral body height, but only KIVA restored vertebral body wedge deformity. KIVA was followed by significantly lower and harmless always extracanal leakage rate than BK. Longer observation is needed to show whether these radiological changes have any functional impact.

Current concepts of percutaneous balloon kyphoplasty for the treatment of osteoporotic vertebral compression fractures: Evidence-based review

Vertebral compression fractures constitute a major health care problem, not only because of their high incidence but also due to both direct and indirect consequences on health-related quality of life and health care expenditures. The mainstay of management for symptomatic vertebral compression fractures is targeted medical therapy, including analgesics, bed rest, external fixation, and rehabilitation. However, anti-inflammatory drugs and certain types of analgesics can be poorly tolerated by elderly patients, and surgical fixation often fails due to the poor quality of osteoporotic bone. Balloon kyphoplasty and vertebroplasty are two minimally invasive percutaneous surgical approaches that have recently been developed for the management of symptomatic vertebral compression fractures. The purpose of this study was to perform a comprehensive review of the literature and conduct a meta-analysis to compare clinical outcomes of pain relief and function, radiographic outcomes of the restoration of anterior vertebral height and kyphotic angles, and subsequent complications associated with these two techniques.

Adjacent Vertebral Compression Fracture after Percutaneous Vertebroplasty

Summary of Literature Review: Percutaneous vertebroplasty is regarded as more effective treatment than conservative care, but additional fracture could cause complications during follow up. Materials and Methods: We analyzed 43 patients who had only one vertebral compression fracture after one vertebroplasty. The number of patients who had additional compression fracture within one level from the operated vertebra were 23 cases (Group I); beyond two levels from the operated vertebra were 20 cases (Group II). We compared the onset period of additional compression fracture, the degree of osteoporosis, age, level, restoration of vertebral body height and kyphosis between the two groups. Results: The onset period of additional compression fracture was 18.7±28.1 months in Group I and 42.7±39.4 months in Group II, showing significant difference between the two groups. Group I had more cases of previous vertebroplasty on thoraco-lumbar vertebra than Group II. The restoration rate of vertebral body height of Group I was 42.3±40.9% and that of Group II was 22.8±21.6%, which shows significant difference between the two. Conclusion: Adjacent vertebral compression fracture after vertebroplasty can occur earlier than non adjacent one. We need to pay attention to the patients who had higher restoration rate of vertebral body height after vertebroplsty as they are more prone to having additional adjacent compression fracture.

A Randomized Trial Comparing 2 Techniques of Balloon Kyphoplasty and Curette Use for Obtaining Vertebral Body Height Restoration and Angular-Deformity Correction in Vertebral Compression Fractures due to Osteoporosis

Vertebral compression fractures often result in pain and vertebral deformity. We compared 2 different balloon kyphoplasty techniques both using intraoperative curettage. Adults 50 years of age or older with osteoporosis and 1 acute VCF were randomized to undergo bilateral BKP in which the curette was used first (n = 57) followed by inflatable bone tamps or in which IBTs were used first, followed by curettage and a second IBT inflation (n = 55). Mean procedure duration was 33.5 and 36.8 minutes, and fluoroscopy duration was 3.8 and 3.7 minutes for the CF and IBTF groups, respectively. Two-thirds of VCFs were wedge-shaped, and one-half had dynamic mobility. Anterior height restored postoperatively was 2.28 mm (95% CI, 1.49-3.08 mm; P < .001) and 2.78 mm (95% CI, 1.89-3.66 mm; P < .001) for CF and IBTF groups, representing ∼35% and 39% of lost height restored, but group differences were not significant (P = .4). Intraoperative anterior height gain attributed to dynamic mobility was 2.96 mm (95% CI, 1.92-4.00 mm; P < .001) and 3.05 mm (95% CI, 2.10-4.00 mm; P < .001); additional height attributed to IBT inflation was 1.09 mm (95% CI, 0.77-1.41 mm; P < .001) and 1.25 mm (95% CI, 0.68-1.82 mm; P < .001), representing a 37% and 41% increase. There was no significant height loss on IBT removal and cementation. Both groups had improved pain and ambulation. Asymptomatic leakage occurred in 15% of VCFs. There was 1 nonserious device-related hematoma (IBTF group). One new clinical VCF occurred in each group, but they were not device-related. Both techniques resulted in significant vertebral body height and pain improvement. Procedure and adverse event data demonstrated safe curette use in conjunction with balloon kyphoplasty procedures.

A Randomized Trial Comparing Two Techniques of Balloon Kyphoplasty and Curette Use for Obtaining Vertebral Body Height Restoration and Angular Deformity Correction

A Randomized Trial Comparing Two Techniques of Balloon Kyphoplasty and Curette Use for Obtaining Vertebral Body Height Restoration and Angular Deformity Correction

Simultaneous Posterior and Anterior Approaches With Posterior Vertebral Wall Preserved for Rigid Post-Traumatic Kyphosis in Thoracolumbar Spine

A retrospective study. To evaluate the radiological and clinical results of simultaneous surgery with preservation of the posterior vertebral wall for rigid post-traumatic kyphosis in the thoracolumbar spine. Management of rigid post-traumatic kyphosis has been a challenge for surgeons. Current widely used posterior osteotomy procedures have the disadvantages of significant invasiveness, spinal column shortening, and instrumentation-related complications. From 2004 to 2009, 21 patients with rigid post-traumatic kyphosis in the thoracolumbar spine (T11-L2) were managed in our hospital. Average kyphotic angle was 45.2° ± 11.2° (range, 31°-67°). The surgical technique used was posterior and anterior circumferential release and anterior corpectomy with posterior vertebral wall preservation and short segmental instrumentation. Preoperative and postoperative kyphotic angle was measured to assess the degree of kyphosis correction and maintenance. Changes in low back pain were assessed by Japanese Orthopaedic Association scores. All patients were successfully managed with this procedure without major complications. Most patients (19 of 21) were instrumented with anterior-only fixation, while posterior interspinal wire was added in 2 patients with osteoporosis. The mean blood loss was 470 mL (range, 300-700 mL). Patients were followed for an average of 32 months (range, 6-70 mo) postoperatively. Back pain was relieved to some degree in all patients and the improvement in Japanese Orthopaedic Association scores was 76.9% ± 7.9. Average kyphotic angle was 6.0° ± 5.7° (range, -2 to 17) immediately after surgery and 7.2° ± 5.8° (range, -3 to 17) at final follow-up. Average of 1° of correction loss was documented and all patients obtained solid fusion uneventfully. This technique is indicated for most patients with rigid post-traumatic kyphosis in the thoracolumbar spine and can yield satisfactory clinical results not only in terms of pain relief, kyphosis correction, vertebral height restoration, and spinal canal integrity preservation, but also in reducing the risk of excessive bleeding and spinal cord injury.

Comparison of a Paraspinal Approach with a Percutaneous Approach in the Treatment of Thoracolumbar Burst Fractures with Posterior Ligamentous Complex Injury: A Prospective Randomized Controlled Trial

This prospective randomized controlled study compared the efficacy and safety of two paraspinal muscle-sparing surgical approaches for the management of neurologically intact patients with thoracolumbar burst fractures and posterior ligamentous complex injuries. Patients were randomized to undergo either percutaneous (n=31) or paraspinal (n=30) fluoroscopically-guided pedicle screw-rod fixation, and were followed for ≥3 years. Preoperative postural reduction was attempted in all patients. The percutaneous approach was associated with significantly less intraoperative blood loss and shorter duration of surgery and hospitalization, as well as less pain and better functional recovery at 3 months after surgery compared with the paraspinal approach. Paraspinal surgery resulted in significantly better correction of kyphosis and restoration of vertebral height compared with percutaneous surgery. There were no differences in long-term clinical outcomes between the two groups. The minimally invasive percutaneous approach appears to be better in cases of successful postural reduction. The paraspinal approach results in better surgical correction and is, therefore, recommended for patients without successful postural reduction.

Early or delayed operation, which is more optimal for kyphoplasty? A retrospective study on cement leakage during kyphoplasty

PurposeTo retrospectively assess the optimal operating time for kyphoplasty as far as the cement leakage during kyphoplasty is concerned. Materials and methodsOne hundred and six patients with a total of 117 osteoporotic vertebral compression fractures (VCFs) were enrolled in our study. According to the time of kyphoplasty, they were divided into two groups: group 1 (early operation group, who received the operation within 14 days after fracture, n=46) and group 2 (delayed operation group, who received the operation between 15 and 28 days after fracture, n=71). Preoperative and postoperative visual analogue scale (VAS) and Oswestry Disability Index (ODI) scores were compared 3 days after surgery within each group and between the two groups. The radiographic outcomes were evaluated by the restoration rate (RR) of the treated vertebrae. The outcome of cement leakage was assessed after surgery using X-ray and computed tomography (CT) scans. Leaks of cement were classified into three types: those via the basivertebral vein (type B), via the segmental vein (type S) and through a cortical defect (type C). ResultsThe mean VAS and ODI scores decreased significantly from pre-surgery to post-surgery in each group, as did the RR (p>0.05). There was no significant difference postoperatively on VAS and ODI scores (p>0.05) between the two groups. However, significant differences were observed postoperatively on RR (p=0.045) and vertebrae with leakage (p=0.038). In addition, there was a significant difference on leakage site of type C between the two groups (p=0.032). ConclusionBoth early and delayed operations of kyphoplasty can achieve satisfactory clinical and radiographic outcomes for osteoporotic VCFs. The risk of cement leakage during kyphoplasty will decrease obviously in delayed operation; so delayed operation, perhaps 2 weeks after fracture, is more safe and optimal than early operation as far as cement leakage is concerned, especially for vertebrae with cortical defects. But early operation of kyphoplasty is more effective in vertebral height restoration.

Is there a stable vertebral height restoration with the new radiofrequency kyphoplasty? A clinical and radiological study

The aim of this study is to evaluate whether radiofrequency kyphoplasty can restore vertebral body height in osteoporotic vertebral fractures and whether restoration of vertebral height correlates with decreased pain. In a prospective study from December 2010 to October 2011, 25 patients underwent RF kyphoplasty for 30 fresh osteoporotic vertebral fractures. The parameter demographics, pain relief, restoration of vertebral body height (mean vertebral body height, kyphosis angle, anterior/posterior edge height) and all complications were recorded. Mean age of patients was 73.8 ± 9.6 (range, 55-83); time from initial painful fracture to treatment was 3.0 weeks ± 1.2; average operative time was 23.5 min (range, 15-41). Average pain index score decreased significantly from 69 ± 8.5 preoperatively to 34.4 ± 5.9 postoperatively (p < 0.001), and to 30 ± 6.3 (p < 0.001) after 3 months. Mean vertebral body height, anterior edge height and kyphosis angle showed significant increases postoperatively and at 3-month follow-up (p < 0.05). In two vertebrae (6.6 %), minimal, asymptomatic cement leakage occurred in the upper disc. After 2 months, one new fracture (3.3 %) was identified in the directly adjacent segment that was also successfully treated with radiofrequency kyphoplasty. There was a preliminary correlation between mean vertebral body height elevation and cement volume (r = 0.533). Radiofrequency kyphoplasty achieves rapid and lasting improvement in clinical symptoms. There was stable restoration of vertebral body height with a mean cement volume of 3.0 ml ± 0.6. There was no correlation between restoration of vertebral body height and pain relief.

Comparison of Kyphoplasty and Vertebroplasty for Treatment of Painful Osteoporotic Vertebral Compression Fractures

A prospective nonrandomized comparative study. To compare the efficacy and safety of kyphoplasty and vertebroplasty for treatment of painful osteoporotic vertebral compression fractures (VCFs) with respect to pain, functional outcome, radiomorphology, cement leakage, and incidence of new adjacent vertebral fracture. Kyphoplasty and vertebroplasty have become common treatments for painful osteoporotic VCFs. Although the benefits of either kyphoplasty or vertebroplasty compared with conservative treatment have been frequently discussed, few clinical studies are available that directly compare the 2 procedures. Ninety-six patients with painful osteoporotic VCFs less than 4 weeks old were included and nonrandomly assigned to undergo kyphoplasty or vertebroplasty treatment. Clinical outcomes were assessed using the visual analog scale and the Oswestry Disability Index. Plain radiographs were analyzed to quantify spinal deformity correction (vertebral body height and kyphotic angle), and evaluate cement leakage and new adjacent vertebral fractures. The follow-up time was 12 months. The baseline clinical and radiological characteristics of both groups were comparable. There were no significant differences between the 2 groups with regard to improvement in pain and functional scores at all postoperative intervals. Vertebral height restoration and kyphotic angle reduction were achieved in both groups, but the correction of spinal deformity was more significant in the kyphoplasty group. Asymptomatic cement leakage occurred in 9.1% and 34.6% of treated vertebrae for the kyphoplasty and vertebroplasty groups, respectively. Three adjacent fractures in the kyphoplasty group and 2 in the vertebroplasty group were identified during the follow-up time, and no major adverse events were observed. Kyphoplasty and vertebroplasty demonstrated similar good clinical outcomes during the 12-month follow-up. Kyphoplasty offers a higher degree of spinal deformity correction and results in less cement leakage than vertebroplasty. The benefits of these relative merits need to be ascertained in future long-term studies.

Minimally invasive treatments for osteoporotic vertebral compression fracture: Current concepts and state-of-the-art technologies

Osteoporotic vertebral compression fractures (VCFs) are common in the elderly and can result in debilitating pain, loss of function, kyphosis with resulting height loss, and reductions in quality of life. Conservative treatment of VCFs is considered the gold standard but has limited effectiveness after the initial 2‐3-week period when the majority of uncomplicated VCFs resolve. Surgical intervention is invasive and associated with morbidity, particularly in the elderly patient with poor bone quality. Percutaneous techniques such as vertebroplasty and vertebral augmentation have revolutionized the treatment of VCFs by filling the treatment gap between conservative care and surgery. A robust series of randomized controlled trials and case series have demonstrated effective pain reduction, function improvement, and acceptable safety with these procedures. However, limitations still exist with these techniques including the need for bipedicular access, inadequate vertebral height restoration, trabecular destruction with balloon-based techniques, inability to precisely control cement delivery, and significant radiation exposure to patients and physicians. New technologies are emerging that retain the clinical advantages of traditional percutaneous vertebroplasty and vertebral augmentation while minimizing these limitations. This review article discusses the history of minimally invasive VCF treatment, summarizes clinical evidence with these therapies, and highlights the most innovative experimental and commercial technologies available today.

CT fluoroscopy-guided vertebral augmentation with a radiofrequency-induced, high-viscosity bone cement (StabiliT®): technical results and polymethylmethacrylate leakages in 25 patients

To assess the technical results of CT fluoroscopy-guided, radiofrequency-induced vertebral augmentation (StabiliT®) in terms of vertebral height restoration and polymethylmethacrylate (PMMA) leakages, occurring in 25 individual patients with vertebral compression fractures and osteolysis. From 07/2010 to 08/2011, 25 patients (16 women, nine men; age 71 ± 14; range 41-89) with painful vertebral compression fractures due to osteoporosis (n = 19), metastases (n = 2) or multiple myeloma (n = 4) underwent vertebral augmentation with a radiofrequency-activated, high-viscosity polymethylmethacrylate (PMMA) bone cement (StabiliT® Vertebral Augmentation system; DFINE Europe GmbH, Mannheim) under local anesthesia. Thirty-four vertebrae (Th5-L5) were treated in 27 sessions under CT fluoroscopy guidance (128-row CT, Somatom Definition AS, Siemens, Erlangen) using a unilateral access and a cavity-creating osteotome prior to remote-controlled, hydraulically driven cement injection. 1/2/3 levels were treated in 21/5/1 session(s). Vertebral height change in the midsagittal plane (anterior, midvertebral, posterior endplate distance) and PMMA leaks were retrospectively evaluated using the postinterventional CT. All patients were successfully treated in the first session. Mean (MV ± SD) procedure time and amount of injected PMMA were 56 ± 14 min and 4.5 ± 1.4 ml, respectively. Mean anterior/midvertebral/posterior height gain was +7.1/+9.7/+0.4%. Small local vertebral leaks were observed in 18/34 vertebrae (53%) without any clinical sequelae. No major complications occurred. CT fluoroscopy-guided, RF-induced vertebral augmentation with a high-viscosity bone cement (StabiliT®) was safe and technically successful in all patients. Using a hydraulic cement injection technique, a moderate restoration of anterior and midvertebral height was seen while the system was not markedly superior to standard vertebroplasty regarding the frequency of minor asymptomatic PMMA leaks.

Comparison of unilateral versus bilateral balloon kyphoplasty for the treatment of osteoporotic vertebral compression fractures

Thirty-one patients with osteoporotic vertebral compression fractures (OVCF) were treated with unilateral balloon kyphoplasty (BKP), and 31 patients were treated with bilateral BKP. The efficacy of unilateral and bilateral BKP was assessed by comparing operation time, X-ray exposure times, incidence of complications, vertebral height restoration, and improvement of the visual analogue scale (VAS) scores. The mean operative time and the exposure time to X-rays in the unilateral BKP group was less than that of the bilateral BKP group (p<0.05). No statistically significant differences were observed in the cement leakage rate, VAS score, or vertebral height restoration between the two groups (p>0.05). Unilateral and bilateral BKP are safe and effective treatments for OVCF. Compared with bilateral BKP, patients undergoing unilateral BKP have shorter operations and receive lower X-ray radiation doses.

Modification of percutaneous vertebroplasty for painful old osteoporotic vertebral compression fracture in the elderly: Preliminary report

ObjectiveTo study the clinical efficacy of modified percutaneous vertebroplasty (PVP) in the treatment of painful old osteoporosis vertebral compression fractures (OVCF). MethodsFrom April 2007 to October 2009, 16 cases (23 vertebrae) of symptomic old OVCF were treated with a modified PVP. Before operation, all the patients were examined by standing anteroposterior and lateral X-Ray and MRI. The pain level of each patient was assessed before operation and 1 week, 6, 12 months after the operation using visual analogue scale (VAS) and Oswestry disability index (ODI). The middle line vertebral body height and local sagittal Cobb's angle were also measured. ResultsPostoperative average VAS, Oswestry disability index (ODI), the local sagittal Cobb's angle decreased from 7.8, 72.3%, and 38.2° to 3.1, 26.8%, and 21.5° respectively before and after surgery (p<0.05). The mean midline vertebral height increased from 13.8mm to 26.6mm before and after surgery (p<0.05). There was no infection, nerve injury, pulmonary embolism, or death after operation. ConclusionsThe modified PVP can increase the space for bone cement filling and is good for the restoration of vertebral body height. It is an optimal procedure for the treatment of painful old OVCF.