Osteoporotic vertebral compression fractures are a leading cause of disability and morbidity in the elderly. The consequences of these fractures include pain, progressive vertebral collapse with resultant spinal kyphosis, and systemic manifestations. Nonsurgical measures have proved unsuccessful in a portion of this population and for this group, minimally invasive vertebral augmentation can be beneficial. Vertebroplasty is designed to address vertebral fracture pain. It involves percutaneous injection of polymethylmethacrylate (PMMA) directly into a fractured vertebral body with the goals of pain relief and prevention of further collapse of the fractured vertebra. Kyphoplasty is designed to address the kyphotic deformity as well as the fracture pain. It involves the percutaneous insertion of an inflatable bone tamp into a fractured vertebral body. Bone tamp inflation works to elevate the end plates and create a cavity to be filled with PMMA with the goals of pain relief, restoration of vertebral body height, and reduced kyphotic deformity. Optimizing surgical technique can improve outcomes and decrease complication rates, and decrease radiation exposure to the patient and surgical team. Obtaining a biopsy prior to cement injection has proved efficacious and may result in the diagnosis of occult pathology underlying a seemingly routine vertebral fracture. As competence and surgical success are acquired, the indications will continue to expand to encompass more challenging pathologies. Recently, vertebral augmentation during spinal decompression and instrumented fusion for burst fracture with neurologic insult has been reported to be successful.
"However, these techniques carry substantial risks of major complications in elderly and osteoporotic patients who have undergone long-segment fixation. Long-segment fixation may also fail when the bone involved is fragile
[12,13]. Recently, the I-VEP had been effective in restoring the body height of the compressed vertebra and providing proper stiffness for the collapsed vertebra in an osteoporotic patient in vitro biomechanical study
[Show abstract][Hide abstract] ABSTRACT: Background
Osteoporotic vertebral compression fracture is the leading cause of disability and morbidity in elderly people. Treatment of this condition remains a challenge. Osteoporotic vertebral compression fractures can be managed with various approaches, but each has limitations. In this study, we compared the clinical outcomes obtained using short-segment fixation with intravertebral expandable pillars (I-VEP) to those obtained with percutaneous kyphoplasty in patients who had suffered vertebral compression fractures.
The study included 46 patients with single-level osteoporotic thoracolumbar fractures. Twenty-two patients in Group I underwent short-segment fixation with I-VEP and 24 patients in Group II underwent kyphoplasty. All patients were evaluated pre- and postoperatively using a visual analogue scale, anterior height of the fractured vertebra, and kyphotic angle of the fractured vertebra. The latter 2 radiological parameters were measured at the adjacent segments as well.
There was no significant difference between the groups in terms of gender or fracture level, but the mean age was greater in Group II patients (p = 0.008). At the 1-year follow-up, there were no significant differences in the visual analogue scale scores, anterior height of the fractured vertebra, or the value representing anterior height above the fractured vertebra and kyphotic angle below the fractured vertebra, after adjusting for the patients’ gender, fracture level, and age. When considered separately, the anterior height below the fractured vertebra was significantly higher and the kyphotic angle above the fractured vertebra was significantly smaller in Group I than in Group II (p = 0.029 and p = 0.008, respectively). The kyphotic angle of the fractured vertebra was significantly smaller in Group II than in Group I (p < 0.001).
In older individuals with vertebral compression fractures, kyphoplasty restored and maintained the collapsed vertebral body with less kyphotic deformity than that induced by short-segment fixation with I-VEP. Short-segment fixation with I-VEP was more effective in maintaining the integrity of adjacent segments, which prevented the domino effect often observed in patients with osteoporotic kyphotic spines.
"This tamp both increases vertebral height and provides a cavity for the subsequent installation of cement. The balloon is inflated; volume and pressure are monitored using digital manometer controls until the maximum pressure or volume of the balloon is reached or contact occurs with a cortical wall (Manson & Phillips, 2006). The balloon is then deflated and removed . "
[Show abstract][Hide abstract] ABSTRACT: To determine the efficacy of percutaneous vertebroplasty in treating severe vertebral body compression fractures, or vertebra plana, in patients with osteoporosis.
In 155 patients, 310 percutaneous vertebroplasties were performed during 25 months and 15 days. Of these, 37 patients (27 women, 10 men; mean age, 73.6 years) underwent 48 vertebroplasties for severe osteoporotic vertebral body compression fractures. The fractures were defined as vertebrae that have collapsed to less than one-third of their original height. Imaging and clinical features were analyzed, including the extent of vertebral collapse, location of the involved vertebra, pattern of vertebral compression, volume of polymethylmethacrylate injected, vertebroplasty complications, and clinical outcome.
Vertebral body collapse averaged 23% (range, 4.5%-33.0%) of the original height. Involved vertebrae were located from levels T5 to L5, with one-half affected at the thoracolumbar junction. Patterns of vertebral compression were divided into gibbus (31 of 48 or 65%), plana (13 of 48 or 27%), and H shape (four of 48 or 8%). The mean volume of the cement injected was 6.0 mL (range, 1.5-12.5 mL). Complications observed on radiographs included cement leakage to the adjacent disc (17 of 48 or 35%) and the paravertebral soft tissues (four of 48 or 8%). There were no major complications. At clinical follow-up (mean duration, 11 months and 3 days; range, 3-24 months), pain relief was complete in 14 (47%) of 30 patients, partial in 15 (50%), and unchanged in one (3%). No patient required surgery.
Percutaneous vertebroplasty for severe osteoporotic vertebral body compression fractures is safe and effective and should not be withheld in this group of patients.
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