Subsequent Vertebral Compression Fractures Research Articles

Impact of Nonoperative Treatment, Vertebroplasty, and Kyphoplasty on Survival and Morbidity After Vertebral Compression Fracture in the Medicare Population

The treatment of vertebral compression fractures with vertebral augmentation procedures is associated with acute pain relief and improved mobility, but direct comparisons of treatments are limited. Our goal was to compare the survival rates, complications, lengths of hospital stay, hospital charges, discharge locations, readmissions, and repeat procedures for Medicare patients with new vertebral compression fractures that had been acutely treated with vertebroplasty, kyphoplasty, or nonoperative modalities. The 2006 Medicare Provider Analysis and Review File database was used to identify 72,693 patients with a vertebral compression fracture. Patients with a previous vertebral compression fracture, those who had had a vertebral augmentation procedure in the previous year, those with a diagnosis of malignant neoplasm, and those who had died were excluded, leaving 68,752 patients. The patients were stratified into nonoperative treatment (55.6%), vertebroplasty (11.2%), and kyphoplasty (33.2%) cohorts. Survival rates were compared with use of Kaplan-Meier analysis and Cox regression. Results were adjusted for potential confounding variables. Secondary parameters of interest were analyzed with the chi-square test (categorical variables) and one-way analysis of variance (continuous variables), with the level of significance set at p < 0.05. The estimated three-year survival rates were 42.3%, 49.7%, and 59.9% for the nonoperative treatment, vertebroplasty, and kyphoplasty groups, respectively. The adjusted risk of death was 20.0% lower for the kyphoplasty group than for the vertebroplasty group (hazard ratio = 0.80, 95% confidence interval, 0.77 to 0.84). Patients in the kyphoplasty group had the shortest hospital stay and the highest hospital charges and were the least likely to have had pneumonia and decubitus ulcers during the index hospitalization and at six months postoperatively. However, kyphoplasty was more likely to result in a subsequent augmentation procedure than was vertebroplasty (9.41% compared with 7.89%; p < 0.001). Vertebral augmentation procedures appear to be associated with longer patient survival than nonoperative treatment does. Kyphoplasty tends to have a more striking association with survival than vertebroplasty does, but it is costly and may have a higher rate of subsequent vertebral compression fracture. These provocative findings may reflect selection bias and should be addressed in a prospective, direct comparison of methods to treat vertebral compression fractures. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The vertebral biomechanic previous and after kyphoplasty

The biomechanical understanding of increasing anterior column load with progressing kyphosis leading to subsequent vertebral compression fracture (VCF) established the basic rationale for kyphoplasty. The lumbar spine can support an effort of 500 kg in the axis of the vertebral body, and a bending moment of 20 Nm in flexion. Consequently, if this effort is forward deviated of only 10 cm, the acceptable effort will be reduced to 20 kg so it is important to restore the vertebral anterior wall after a VCF: the authors describe the biomechanical modifications in the spine after kyphoplasty.

Comparison of the Therapeutic Effect of Teriparatide With That of Combined Vertebroplasty With Antiresorptive Agents for the Treatment of New-onset Adjacent Vertebral Compression Fracture After Percutaneous Vertebroplasty

Comparing a prospective group of 32 patients, who underwent percutaneous vertebroplasty (PVP) and who were treated with teriparatide for at least 18 months after a new-onset adjacent vertebral compression fracture (VCF), and compared it with a retrospective group of 33 patients, who received antiresorptive agents combined with repeated PVPs for post-PVP new-onset adjacent VCFs. This comparative study aimed to assess the immediate and mid-term efficacy and safety of teriparatide for treating new adjacent VCFs after vertebroplasty. Vertebroplasty may provoke fractures in adjacent, nonaugmented vertebrae. Subsequent VCFs can occur much sooner and more frequently after PVPs. Antiresorptive agents do not effectively prevent new-onset VCFs or prompt pain relief. Treatment with teriparatide is effective and rapid in increasing spinal bone mineral density (BMD) and in decreasing vertebral fracture risk in patients with osteoporosis. Relevant clinical data were compared between a prospective group of patients who received teriparatide and a retrospective group of patients who received antiresorptive agents and repeated PVPs for new-onset adjacent VCFs after PVP. Data in prospective group, including visual analogue scale scores and BMD were compared with those in a retrospective group. In group A, only 1 new-onset VCF occurred during the mean follow-up period of 22.56 months. In group B, 5 patients (6 vertebrae) developed new-onset VCFs after the second PVP, and 2 of these 5 patients had additional new VCFs after the third PVP. Teriparatide significantly reduced the risk of new VCFs after vertebroplasty (odds ratio=0.18; 95% confidence interval, 0.02-1.64). The increase of lumbar spine BMD was 26.32% after 18 months of treatment with teriparatide and 4.62% after 18 months of treatment with antiresorptive agents. In addition, at the 18-month follow-up, mean visual analogue scale scores had decreased from 8.03±1.97-1.37±0.52 in the teriparatide group and from 7.91±1.95-4.23±1.21 in the antiresorptive group. For the treatment of new-onset adjacent VCF after PVPs, the therapeutic effects of teriparatide is better than that of the combined vertebroplasty and an antiresorptive agent in fracture prevention, BMD change, and sustained pain relief.

Clinical Features of Percutaneous Hemivertebroplasty in Patients with Osteoporotic Vertebral Compression Fractures

Objective: Unilateral percutaneous vertebroplasty is a widely accepted treatment for osteoporotic vertebral compression fractures (VCFs). However, bone cement may fail to fill both hemivertebra from the single needle. We assessed the radiographic and clinical outcome of hemivertebroplasty (HVP) and evaluated the factors that affect subsequent VCFs after HVP. Methods: Fifty two patients who underwent HVP were reviewed. VCFs were identified based on clinical and radiological findings. The patients were grouped into two groups : 1) no subsequent VCFs, 2) subsequent VCFs. We evaluated the association between age, sex, body mass index (BMI) and bone mineral density (BMD) and subsequent VCFs. We also assessed the impact of location, type and grade of fracture, endplate fracture, burst fracture, bone cement volume on subsequent VCFs. We analyzed the compression ratio, wedge angle, kyphotic angle, and visual analogue scale (VAS) score in both groups. Results: There were no significant differences in age, gender, BMI, and BMD between two groups. No significant differ ence was also found in pre-existing VCF, location, type and grading of fracture, endplate fracture, burst fracture, amount of bone cement, and radiological findings such as compression ratio, wedge angle, and kyphotic angle between two groups. The final mean VAS scores of patients with or without subsequent VCFs were 3.11 and 4.02, respectively. Conclusion: No major risk factors for the subsequent VCFs after HVP were found. However, we identified adjacent frac tures, refractures, and remote fractures after HVP in chronological order. Therefore, long-term follow-up is necessary to evaluate the effectiveness of HVP to osteoporotic VCFs. (Korean J Neurotrauma 2013;9:17-22)

Risk Factors of Subsequent Vertebral Compression Fractures After Vertebroplasty

To elucidate the risk factors for a subsequent vertebral compression fracture following percutaneous vertebroplasty, we analyzed the potential predictors of vertebral compression fractures adjacent to or remote from fractures previously treated with percutaneous vertebroplasty. This is a retrospective cohort study. A major concern after percutaneous vertebroplasty in patients with osteoporosis is the occurrence of subsequent vertebral compression fractures in the untreated vertebral bodies. The risk factors for the development of subsequent vertebral compression fractures after percutaneous vertebroplasty are unclear. Two hundred four consecutive patients underwent percutaneous vertebroplasty for acute vertebral compression fractures between January 2007 and December 2008. Forty-nine patients were excluded. Subsequent vertebral compression fractures were diagnosed by bone edema changes on magnetic resonance imaging. Patient's demographic data were used for univariate and multivariable binary logistic regression analyses. Forty-three (27.7%) of the 155 patients had subsequent vertebral compression fractures within 2 years of percutaneous vertebroplasty, with 21 (48.8%) of these patients having fractures detected within 3 months. Adjacent vertebral compression fractures tended to occur sooner, although not significantly (log-rank test, P = 0.112). On multivariate analyses, only the T-score of bone mineral density was significantly associated with subsequent vertebral compression fractures (P < 0.0001; odds ratio = 0.27; 95% confidence interval, 0.15-0.49). The only risk factor significantly associated with subsequent vertebral compression fractures following percutaneous vertebroplasty was a low bone mineral density T-score. Patients with lower bone mineral density have a higher incidence of vertebral compression fractures and thus need more intensive clinical and radiological follow-up.

Does alendronate disturb the healing process of posterior lumbar interbody fusion? A prospective randomized trial

Bisphosphonate medications are widely used for the treatment of osteoporosis, but they might disturb the healing process of spinal fusion. The object of this prospective randomized controlled study was to evaluate the effect of bisphosphonate medication on spinal fusion through radiographic, clinical, and biological assessments. A total of 40 patients with osteoporosis who were candidates for single-level posterior lumbar interbody fusion were randomly assigned to the alendronate group (alendronate sodium 35 mg/week) or the control group (vitamin D, alfacalcidol 1 μg/day). Pedicle screw fixation and carbon polyetheretherketone cages were used for all the patients. Bone graft material was prepared as a mixture of local bone and β-tricalcium phosphate in a ratio of 2:1. Functional radiography and CT scans were used to evaluate fusion status and cage subsidence. The incidence of vertebral compression fractures (VCFs) occurring after surgery (subsequent VCFs) was assessed by means of MR imaging. Bridging bone formation was graded into 3 categories: Grade A (bridging bone through bilateral cages), Grade B (bridging bone through a unilateral cage), or Grade C (incomplete bony bridging). A solid fusion was defined as less than 5° of angular motion in flexion-extension radiographs and the presence of bridging bone through the cage (Grade A or B). Clinical outcome was evaluated by means of the Oswestry Disability Index. Bone metabolic markers (serum bone alkaline phosphatase, serum and urine Type I collagen cross-linked N-telopeptides) were measured to investigate the biological effects of alendronate on spinal fusion. Bridging bone formation (Grade A or B) was more frequently observed in the alendronate group at all postoperative assessment periods. At 1-year postoperative follow-up, a solid fusion was achieved in 95% of the patients in the alendronate group and 65% of those in the control group. Cage subsidence (> 2 mm) was observed in 5% of the alendronate group and 29% of the control group. No vertebral fractures were observed in the alendronate group, whereas 24% of patients in the control group showed subsequent VCFs. There was no statistically significant between-groups difference in clinical outcomes, but poor clinical results in the control group were associated with pseudarthrosis and subsequent VCFs. Biochemical analysis of bone turnover demonstrated that alendronate inhibited bone resorption from the early phase of the fusion process and also suppressed bone formation after 6 months postoperatively. Favorable mechanical circumstances provided by alendronate overcame its detrimental biological effect on the healing process of spinal fusion. The authors recommend that osteoporosis patients undergoing spinal fusion take bisphosphonates throughout the postoperative period.

Recompression of vertebral body after balloon kyphoplasty for osteoporotic vertebral compression fracture

The purpose of this retrospective clinical study was to evaluate the factors that affect recompression of operated vertebrae after percutaneous balloon kyphoplasty (PKP) for osteoporotic vertebral compression fractures (VCFs) and assess their clinical importance. PKP has been used for VCFs with satisfactory results. Several studies about subsequent VCFs adjacent to cemented vertebrae have been reported after PKP. However, the presence and significance of recompression of operated vertebrae have not been adequately described. In total, 80 patients treated with PKP for single thoracolumbar VCFs were reviewed. The follow-up period was at least 1 year. Patients were divided into those without recompression (maintained group, n = 70) and those with recompression (recompressed group, n = 10). Plain roentgenography (preoperative, operative, and last), preoperative BMD, and preoperative MRI were checked. Age, gender, T-score in BMD, duration of symptom, compression rate (CR) of VCF, reduction rate, kyphotic angle (KA), reduction angle, intervertebral cleft (IVC), and non-PMMA-endplate-contact (NPEC) were evaluated. To evaluate the clinical results, we checked the VAS score at each follow-up period. All data were analyzed statistically. The CR for the recompressed group increased significantly after surgery and decreased at the last follow-up (p < 0.05). The last CR was not significantly different from the preoperative CR. The KA showed the same pattern. The preoperative, postoperative, and last VAS scores were significantly different from one another in both groups (p < 0.05). Between the groups, preoperative KA, postoperative KA, last KA, IVC, and NPEC were significantly different (p < 0.05). In particular, last KA, IVC, and NPEC showed highly significant differences (p < 0.001). In a correlation test for the evaluated factors, IVC (r = 0.557) and NPEC (r = 0.496) were the most significant. The presence of IVC and NPEC may play an important role in inducing recompression of treated vertebrae after PKP. Careful observation of patients with these conditions is necessary to prevent deterioration of their clinical course.

Heterotopic ossifications after vertebroplasty using calcium phosphate in osteoporotic vertebral compression fractures: Report of 2 cases

Background Recently, calcium phosphate (CaP) cement, instead of polymethylmethacrylate, has been injected into the compressed vertebral body. Calcium phosphate may have the potential for ectopic or heterotopic ossification and, thus, injected CaP cement can induce unwanted heterotopic ossifications in the human body. Case Description The authors describe 2 cases of heterotopic ossifications after vertebroplasty using CaP in osteoporotic vertebral compression fractures. We performed percutaneous vertebroplasty using CaP cement in a 69-year-old woman with L2 compression fracture and an 80-year-old man with L1 compression fracture. Follow-up radiologic studies for both cases showed that heterotopic ossifications had developed around the CaP-augmented vertebral bodies and that the cemented vertebral bodies had recollapsed. Also, subsequent vertebral compression fractures had occurred. Conclusions We suggest that heterotopic ossification may be complications of vertebroplasty with CaP. Therefore, we strongly recommended that the patients who undergo a vertebroplasty with CaP need strict observation.

One-stage posterior instrumentation surgery for the treatment of osteoporotic vertebral collapse with neurological deficits

The number of reports describing osteoporotic vertebral fracture has increased as the number of elderly people has grown. Anterior decompression and fusion alone for the treatment of vertebral collapse is not easy for patients with comorbid medical problems and severe bone fragility. The purpose of the present study was to evaluate the efficacy of one-stage posterior instrumentation surgery for the treatment of osteoporotic vertebral collapse with neurological deficits. A consecutive series of 21 patients who sustained osteoporotic vertebral collapse with neurological deficits were managed with posterior decompression and short-segmental pedicle screw instrumentation augmented with ultra-high molecular weight polyethylene (UHMWP) cables with or without vertebroplasty using calcium phosphate cement. The mean follow-up was 42 months. All patients showed neurologic recovery. Segmental kyphotic angle at the instrumented level was significantly improved from an average preoperative kyphosis of 22.8-14.7 at a final follow-up. Spinal canal occupation was significantly reduced from an average before surgery of 40.4-19.1% at the final follow-up. Two patients experienced loosening of pedicle screws and three patients developed subsequent vertebral compression fractures within adjacent segments. However, these patients were effectively treated in a conservative fashion without any additional surgery. Our results indicated that one-stage posterior instrumentation surgery augmented with UHMWP cables could provide significant neurological improvement in the treatment of osteoporotic vertebral collapse.

The Proper Volume and Distribution of Cement Augmentation on Percutaneous Vertebroplasty

The purpose of this study was to determine the optimal volume of injected cement and its distribution when used to treat vertebral compression fractures, and to identify factors related to subsequent vertebral fractures. A retrospective analysis of newly developing vertebral fractures after percutaneous vertebroplasty was done. The inclusion criteria were that the fracture was a single first onset fracture with exclusion of pathologic fractures. Forty-three patients were included in the study with a minimum follow up period of six months. Patients were dichotomized for the analysis by volume of cement, initial vertebral height loss, bone marrow density, and endplate-to-endplate cement augmentation. None of the four study variables was found to be significantly associated with the occurrence of a subsequent vertebral compression fracture. In particular, and injected cement volume of more or less that 3.5 cc was not associated with occurrence (p = 0.2523). No relation was observed between initial vertebral height loss and bone marrow density (p = 0.1652, 0.2064). Furthermore, endplate-to-endplate cement augmentation was also not found to be significantly associated with a subsequent fracture (p = 0.2860) by Fisher's exact test. Neither volume of cement, initial vertebral height loss, bone marrow density, or endplate-to-endplate cement augmentation was found to be significantly related to the occurrence of a subsequent vertebral compression fracture. Our findings suggest that as much cement as possible without causing leakage should be used.

Vertebroplasty and kyphoplasty: complementary techniques for the treatment of painful osteoporotic vertebral compression fractures. A prospective non-randomised study on 154 patients

In a prospective study, we aimed to evaluate the potential use of kyphoplasty (KP) and vertebroplasty (VP) as complementary techniques in the treatment of painful osteoporotic vertebral compression fractures (VCFs). After 1 month of conservative treatment for VCFs, patients with intractable pain were offered treatment with KP or VP according to a treatment algorithm that considers time from fracture (Delta t) and amount of vertebral body collapse. Bone biopsy was obtained intra-operatively to exclude patients affected by malignancy or osteomalacia. 164 patients were included according to the above criteria. Mean age was 67.6 years. Mean follow-up was 33 months. 10 patients (6.1%) were lost to follow-up and 154 reached the minimum 2-year follow-up. 118 (69.5%) underwent VP and 36 (30.5%) underwent KP. Complications affected five patients treated with VP, whose one suffered a transient intercostal neuropathy and four a subsequent VCF (two at adjacent level). Results in terms of visual analogue scale and Oswestry scores were not different among treatment groups. In conclusion, at an average follow-up of almost 3 years from surgical treatment of osteoporotic VCFs, VP and KP show similar good clinical outcomes and appear to be complementary techniques with specific different indications.

Vertebroplasty and kyphoplasty: complementary tecniques for the treatment of painful osteoporotic vertebral compression fractures

OBJECTIVE: in a prospective study, we aimed to evaluate the potential use of kyphoplasty (KP) and vertebroplasty (VP) as complementary techniques in the treatment of painful osteoporotic vertebral compression fractures (VCFs). METHODS: after one month of conservative treatment for VCFs, patients with intractable pain were offered treatment with KP or VP according to a treatment algorithm that considers time from fracture (Ät) and amount of Vertebral Body Collapse (VBC). Bone biopsy was obtained intraoperatively to exclude patients affected by malignancy or osteomalacia. RESULTS: hundred and sixty-four patients were included according to the above criteria. Mean age was 67.6 years. Mean followup was 33 months. Ten patients (6.1%) were lost to follow-up and 154 reached the minimum two years follow-up. 118 (69.5%) underwent VP and 36 (30.5%) underwent KP. Complications affected five patients treated with VP, whose one suffered a transient intercostal neuropathy and four a subsequent VCF (two at adjacent level). Results in terms of VAS and Oswestry scores were not different among treatment groups. CONCLUSION: in conclusion, at an average follow-up of almost 3 years from surgical treatment of osteoporotic VCFs, VP and KP show similar good clinical outcomes and appear to be complementary techniques with specific different indications.

Vertebroplasty and kyphoplasty are associated with an increased risk of secondary vertebral compression fractures: a population-based cohort study

To better understand the risk of secondary vertebral compression fracture (VCF) following a vertebroplasty or kyphoplasty, we compared patients treated with those procedures to patients with a previous VCF. The risk of subsequent fracture was significantly greater among treatment patients, especially within 90 days of the procedure. Predominantly uncontrolled studies suggest a greater risk of subsequent vertebral compression fractures (VCFs) associated with vertebroplasty/kyphoplasty. To further understand this risk, we conducted a population-based retrospective cohort study using data from a large regional health insurer. Administrative claims procedure codes were used to identify patients receiving either a vertebroplasty or kyphoplasty (treatment group) and a comparison group of patients with a primary diagnosis of VCF who did not receive treatment during the same time period. The main outcomes of interest, validated by two independent medical record reviewers, were any new VCFs within (1) 90 days, (2) 360 days, and (3) at adjacent vertebral levels. Multivariable logistic regression examined the association of vertebroplasty/kyphoplasty with new VCFs. Among 48 treatment (51% vertebroplasty, 49% kyphoplasty) and 164 comparison patients, treated patients had a significantly greater risk of secondary VCFs than comparison patients for fractures within 90 days of the procedure or comparison group time point [adjusted odds ratio (OR) = 6.8; 95% confidence interval (CI) 1.7-26.9] and within 360 days (adjusted OR = 2.9; 95% CI 1.1-7.9). Patients who had undergone vertebroplasty/kyphoplasty had a greater risk of new VCFs compared to patients with prior VCFs who did not undergo either procedure.

The recognition and treatment of vertebral fractures in males with chronic obstructive pulmonary disease

Males with chronic obstructive pulmonary disease (COPD) are at increased risk for developing osteoporosis (OP) with subsequent vertebral compression fractures. Such fractures with resultant increased thoracic kyphotic angle (TKA) may interfere with these patients' already compromised pulmonary function. A retrospective cross-sectional study was performed to evaluate the recognition and treatment of vertebral fractures in male patients with COPD. The study population included male patients with COPD aged 55 years and older who had a lateral chest X-ray (index film) performed between January 1, 2001 and July 5, 2005. Vertebral fractures and the TKA were determined independently by two different radiologists. One radiologist (reviewer #1) used direct measurement including quantitative morphometric analysis to determine fractures and the TKA, whereas the second radiologist (reviewer #2) used visual inspection only. Inter-reader agreement for vertebral fractures and TKA was assessed. The computerized charts were reviewed to determine the initial recognition of vertebral fractures and the subsequent therapy. Logistic regression was employed to determine significant risk factors for vertebral fractures in this male population. Three hundred and fifty male study subjects and their index lateral chest X-rays were reviewed. Ages ranged from 52 to 90 and 9/350 (2.6%) of the study subjects had vertebral fractures identified on the initial radiology report. None of these nine patients were subsequently treated with anti-osteoporotic agents other than calcium and vitamin D, and two of them had a follow-up central bone density. Reviewer #1 measured 361 fractures in 181 subjects and determined the mean TKA to be 31.43 (+/-8.62) degrees. Reviewer #2 identified 27 fractures in 19 subjects and with an estimated mean TKA of 24.84 (+/-8.53) degrees. There was little inter-observer agreement with vertebral fractures (kappa=0.07), but there was a strong positive correlation with the TKA (r=0.79). There was a weak to moderate correlation with the TKA and the presence of vertebral fractures (r=0.26). Significant risk factors for vertebral fractures included smoking status (odds ratio 1.84 [1.08-3.15]) and age (odds ratio 1.06 [1.03-1.09] for each year increase in age). A large number of vertebral fractures in males with COPD goes undiagnosed. In those patients with diagnosed vertebral fractures, follow-up therapy is under-utilized. When analyzing lateral chest X-rays for vertebral fractures, visual inspection alone without direct measurement may not be an adequate technique for identifying fractures.

13. The Natural History of Subsequent Adjacent Level Vertebral Compression Fractures

BACKGROUND CONTEXT: Osteoporotic vertebral compression fractures (VCF) are routinely treated with the vertebral augmentation procedures (VAP), vertebroplasty and kyphoplasty. Both are reported to be an effective means of pain relief; however, there may be an increased risk of developing subsequent VCFs after such procedures. The risk of subsequent VCF after 1 fracture is reported to be 19.2% at one year, and is widely reported as the benchmark figure to define the expected natural history of subsequent fractures in patients after VAPs.

Patients with Osteoporosis on Steroid Medication Tend to Sustain Subsequent Fractures

Repeat fractures after percutaneous vertebroplasty can be seen in patients with osteoporotic compression fractures. The purpose of this study was to identify characteristics of patients with new fractures after vertebroplasty. Fifty-five consecutive patients were treated with vertebroplasty for painful osteoporotic compression fractures at our institution. The charts and radiographic studies of all patients were retrospectively reviewed. Special attention was paid to patient age and sex, imaging studies, long-term use of steroid medication, and treatment for osteoporosis. We used logistic regression analysis and the Fisher exact test for statistical evaluation. Thirty-five patients were treated with vertebroplasty at one time and did not develop new fractures, whereas 20 patients returned with new fractures. Sixteen of 55 patients had been on steroid medication. The incidence of subsequent vertebral compression fractures after vertebroplasty in patients on long-term steroid therapy was 69% (11/16), compared with 23% (9/39) in those with primary osteoporosis (ie, those who were not on steroid therapy). There was a statistically significant association between use of steroids and new fractures (P<.01). No statistically significant difference was noted in patient age, sex, and medication for osteoporosis. Patients who are on long-term steroid medication have an elevated risk of developing new fractures after vertebroplasty.

Percutaneous vertebral augmentation: an elevation in adjacent-level fracture risk in kyphoplasty as compared with vertebroplasty

Background context Osteoporotic vertebral compression fractures (VCFs) are being increasingly treated with minimally invasive bone augmentation techniques such as kyphoplasty and vertebroplasty. Both are reported to be an effective means of pain relief; however, there may be an increased risk of developing subsequent VCFs after such procedures. Purpose The purpose of this study was to compare the effectiveness and complication profile of kyphoplasty and vertebroplasty in a single patient series. Study design/setting A clinical series of 36 patients with VCFs treated by vertebral augmentation procedures was retrospectively analyzed for surgical approach, volume of cement injected, cement extravasation (symptomatic and asymptomatic), the occurrence of subsequent adjacent level fracture, and pain relief. Patient sample Thirty-six patients with 46 VCFs underwent either kyphoplasty or vertebroplasty after failing conservative therapy. The mean patient age was not significantly different between the kyphoplasty group (70; range, 46–83) and vertebroplasty group (72; range, 38–90) (p=.438). Outcome measures Outcomes were assessed by using self-report measures (a comparative pain rating scale) and physiologic measures (pre- and postoperative radiographs). Methods Thirty-six patients with VCFs underwent 46 augmentation procedures (17 patients had 20 fractures treated via kyphoplasty, and 19 patients had 26 fractures treated via vertebroplasty). Seventeen patients in this series underwent kyphoplasty using standard techniques involving bone void creation with balloon tamps, followed by cement injection. Nineteen patients underwent a percutaneous vertebroplasty procedure using a novel cannulated, fenestrated bone tap developed to direct cement anteriorly into the vertebral body to avoid backflow of cement onto neural elements. Results Pain improvement was seen in >90% of patients in both groups. Mean cement injection per vertebral body was 4.65 mL and 3.78 mL for the kyphoplasty and vertebroplasty groups, respectively (p=.014). Ninety-five percent of the kyphoplasty procedures were performed bilaterally, whereas only 19% of the vertebroplasty procedures required bilateral augmentation (p<.001). There was no cement extravasation resulting in radiculopathy, or myelopathy in either group. Asymptomatic cement extravasation was seen in 5 of 46 (11%) of the total series (3/20 [15%] and 2/26 [7.7%] of kyphoplasty and vertebroplasty, respectively) (p=.696). Within a 3-month period, there were 5 new adjacent level fractures seen in 3 patients who underwent a kyphoplasty procedure (5/20 [25%]) and none in the vertebroplasty group (p<.05). Conclusions Vertebroplasty appears to offer a comparable rate of postoperative pain relief as kyphoplasty while using less bone cement more often via a unilateral approach and without the attendant risk of adjacent level fracture.

Adjacent Level Load Transfer Following Vertebral Augmentation in the Cadaveric Spine

In vitro biomechanics. To determine if osteoporotic vertebral compression fracture (VCF) augmentation increases adjacent level load transfer. Osteoporotic VCF subsequent to augmentation may result from disease progression or increased adjacent level load transfer, or both. There were 11 T3-T7 and 10 T8-T12 divided by lumbar bone mineral density into a normal group (No. 1; n = 11) and an osteoporotic group (No. 2; n = 10). Strain and centrum stress were measured on T4 and T6 (T3-T7), and T9 and T11 (T8-T12) during tests in the intact state, following a centrum defect, during and after an augmented VCF at T5 or T10, and during a subsequent VCF. Stiffness and strength were compared: between groups 1 and 2; among intact, defect, and augmented VCF states; and between the initial and subsequent VCF. Group 1 was stiffer than 2 in compression (P = 0.01) and flexion (P = 0.07), with no difference in adjacent level load transfer (strain P = 0.72, centrum stress P = 0.36) or strength (P = 0.07). The centrum defect reduced compressive stiffness from the intact (P = 0.001), which was partially restored following VCF augmentation (P = 0.006). There were no differences in flexion stiffness (P > or = 0.14). Adjacent level load transfer in flexion exceeded that in compression (strain P = 0.001, centrum stress P = 0.19). Initial and subsequent VCF occurred at similar forces (P = 0.26) with higher adjacent level load at subsequent (strain and centrum stress P = 0.04). Augmentation of multilevel spinal segments with VCF produced by combined compression, flexion, and a centrum defect normalizes adjacent level load transfer at physiologic loads. In both normal and osteoporotic spinal segments, as loads approach those of the initial VCF, protection from augmentation is lost, and subsequent adjacent level VCFs occur from extreme loading, and not the augmentation process.

3:40 82. Percutaneous Vertebral Augmentation: An Elevation in Adjacent-Level Fracture Risk in Kyphoplasty as Compared With Vertebroplasty

BACKGROUND CONTEXT: Osteoporotic vertebral compression fractures (VCF) are being more aggressively treated with the minimally invasive bone augmentation techniques, kyphoplasty and vertebroplasty. Both are reported to be an effective means of pain relief; however, there may be an increased risk of developing subsequent VCFs after such procedures.

Primary and secondary osteoporosis' incidence of subsequent vertebral compression fractures after kyphoplasty.

Retrospective review of prospective database. Define the incidence of adjacent and remote fractures after kyphoplasty vertebral augmentation, and identify vulnerable subpopulations at increased risks. Painful osteoporotic compression fractures can be effectively treated with methyl methacrylate vertebral augmentation, but the effect of intervention on the generation of future remote and adjacent fractures has not been identified. No paper has analyzed the association of long-term steroid use to subsequent compression fractures. A total of 175 patients were treated for compression fractures, from October 1999 to November 2001, 60 patients were excluded due to insufficient follow-up (less than 3 months) or malignancy related fracture. The remaining 115 patients' charts and radiographs were then individually analyzed. New fractures were identified based on changes from baseline imaging studies (). Demographic information, vertebral levels treated, adjacent fractures, and remote fractures underwent statistical analyzed (P < 0.05). A total of 225 vertebral bodies were treated in 115 patients using the kyphoplasty technique; of those, 26 patients developed 34 subsequent compression fractures. The mean follow-up was 11 months (range, 3-33 months). The incidence of subsequent fracture per procedure per kyphoplasty was 15.1% (34 of 225), overall incidence per patient was 22.6% (26 of 115). There were 80 patients with primary osteoporosis and 35 patients with secondary steroid-induced osteoporosis. These populations were similar in terms of demographics, single or multiple sites, along with two or three adjacent levels treated. Seventeen of the 26 (65%) patients with subsequent fracture had secondary steroid-induced osteoporosis, while only 9 of the 26 (35%) patients had primary osteoporosis. Therefore, the incidence of post-kyphoplasty VCF in the primary osteoporotic patient was 11.25% (9 of 80) and the incidence in the steroid-induced osteoporotic patient was 48.6% (17 of 35). This increased fracture rate in the steroid-dependent patients was significant (P < 0.0001), along with adjacent fractures (12 of 19 on steroids, P = 0.0009), and remote fractures (7 of 9 on steroids, P = 0.027). Steroid-induced compression fractures appear to have an increased incidence of subsequent fractures after the kyphoplasty procedure. The kyphoplasty protocol with concurrent medical osteoporotic regimen does not appear to increase, and may serve to reduce, the incidence of remote and adjacent fractures for primary osteoporotic fractures.