Anterior decompression and strut graft versus posterior decompression and pedicle screw fixation with vertebroplasty for osteoporotic thoracolumbar vertebral collapse with neurologic deficits

Background contextWith the increase of the elderly population, osteoporotic vertebral fractures have been frequently reported. Surgical intervention is usually recommended in osteoporotic vertebral collapse with neurologic deficits. However, very few reports on surgical interventions exist.PurposeTo compare surgical results of anterior and posterior procedures for treating osteoporotic thoracolumbar vertebral collapse with sustained neurologic deficits.Study designRetrospective comparative study.Patient sampleFifty patients who sustained osteoporotic thoracolumbar vertebral collapse with neurologic deficits were treated either by anterior decompression and strut graft (n=32) or by posterior decompression and pedicle screw fixation with vertebroplasty (n=18).Outcome measuresIncidence of complications, sagittal Cobb angle, spinal canal encroachment, and Japanese Orthopedic Association score.MethodsThe authors retrospectively reviewed the results of a consecutive series of patients undergoing anterior decompression and strut graft or posterior decompression and pedicle screw fixation with vertebroplasty for osteoporotic thoracolumbar vertebral collapse with neurologic deficits. Operative notes, clinical charts, and radiographs were analyzed.ResultsOperative time was similar between the groups, but intraoperative blood loss was significantly lower in the posterior group. All patients showed neurologic recovery. No significant difference was observed in the neurologic improvement, kyphosis correction angle, and loss of correction. Perioperative respiratory complications were found in 11 patients (34%) in the anterior group. In the anterior group, early posterior reinforcement was required in patients with very low bone density below 0.60 g/cm² and/or in those with three segments of instrumentation for two vertebral collapses. Posterior group patients did not undergo additional surgery.ConclusionsAnterior reconstruction for osteoporotic vertebral collapse is significant because anterior elements, particularly those at the thoracolumbar junction, play a major role in load bearing. However, difficulties arise when anterior reconstruction is performed in cases with very low bone density and in those with multiple vertebral collapse.     

Surgical treatment of post-traumatic kyphosis in the thoracolumbar spine: indications and technical aspects

Previous reports have emphasized the importance of neural decompression through either an anterior or posterior approach when reconstruction surgery is performed for neurological deficits following vertebral collapse in the osteoporotic thoracolumbar spine. However, the contribution of these decompression procedures to neurological recovery has not been fully established. In the present study, we investigated 14 consecutive patients who had incomplete neurological deficits following vertebral collapse in the osteoporotic thoracolumbar spine and underwent posterior instrumented fusion without neural decompression. They were radiographically and neurologically assessed during an average follow-up period of 25 months. The mean local kyphosis angle was 14.6° at flexion and 4.1° at extension preoperatively, indicating marked instability at the collapsed vertebrae. The mean spinal canal occupation by bone fragments was 21%. After surgery, solid bony fusion was obtained in all patients. The mean local kyphosis angle became 5.8° immediately after surgery and 9.9° at the final follow-up. There was no implant dislodgement, and no additional surgery was required. In all patients, back pain was relieved, and neurological improvement was obtained by at least one modified Frankel grade. The present series demonstrate that the posterior instrumented fusion without neural decompression for incomplete neurological deficits following vertebral collapse in the osteoporotic thoracolumbar spine can provide neurological improvement and relief of back pain without major complications. We suggest that neural decompression is not essential for the treatment of neurological impairment due to osteoporotic vertebral collapse with dynamic mobility.     

Preventive effects of conservative treatment with short-term teriparatide on the progression of vertebral body collapse after osteoporotic vertebral compression fracture

Summary

The progression of fractured vertebral collapse is not rare after a conservative treatment of vertebral compression fracture (VCF). Teriparatide has been shown to directly stimulate bone formation and improve bone density, but there is a lack of evidence regarding its use in fracture management. Conservative treatment with short-term teriparatide is effective for decreasing the progression of fractured vertebral body collapse.

Introduction

Few studies have reported on the prevention of collapsed vertebral body progression after osteoporotic VCF. Teriparatide rapidly enhances bone formation and increases bone strength. This study evaluated preventive effects of short-term teriparatide on the progression of vertebral body collapse after osteoporotic VCF.

Methods

Radiographs of 68 women with single-level osteoporotic VCF at thoracolumbar junction (T11–L2) were reviewed. Among them, 32 patients were treated conservatively with teriparatide (minimum 3 months) (group I), and 36 were treated with antiresorptive (group II). We measured kyphosis and wedge angle of the fractured vertebral body, and ratios of anterior, middle, and posterior heights of the collapsed body to posterior height of a normal upper vertebra were determined. The degree of collapse progression was compared between two groups.

Results

The progression of fractured vertebral body collapse was shown in both groups, but the degree of progression was significantly lower in group I than in group II. At the last follow-up, mean increments of kyphosis and wedge angle were significantly lower in group I (4.0°?±?4.2° and 3.6°?±?3.6°) than in group II (6.8°?±?4.1° and 5.8°?±?3.5°) (p?=?0.032 and p?=?0.037). Decrement percentages of anterior and middle border height were significantly lower in group I (9.6?±?10.3 and 7.4?±?7.5 %) than in group II (18.1?±?9.7 and 13.8?±?12.2 %) (p?=?0.001 and p?=?0.025), but not in posterior height (p?=?0.086).

Conclusions

In female patients with single-level osteoporotic VCF at the thoracolumbar junction, short-term teriparatide treatment did not prevent but did decrease the progression of fractured vertebral body collapse.     

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.     

Treatment of acute thoracolumbar burst fractures with kyphoplasty and short pedicle screw fixation: Transpedicular intracorporeal grafting with calcium phosphate: A prospective study

Background:

In the surgical treatment of thoracolumbar fractures, the major problem after posterior correction and transpedicular instrumentation is failure to support the anterior spinal column, leading to loss of correction and instrumentation failure with associated complaints. We conducted this prospective study to evaluate the outcome of the treatment of acute thoracolumbar burst fractures by transpedicular balloon kyphoplasty, grafting with calcium phosphate cement and short pedicle screw fixation plus fusion.

Materials and Methods:

Twenty-three consecutive patients of thoracolumbar (T₉ to L₄) burst fracture with or without neurologic deficit with an average age of 43 years, were included in this prospective study. Twenty-one from the 23 patients had single burst fracture while the remaining two patients had a burst fracture and additionally an adjacent A1-type fracture. On admission six (26%) out of 23 patients had neurological deficit (five incomplete, one complete). Bilateral transpedicular balloon kyphoplasty with liquid calcium phosphate to reduce segmental kyphosis and restore vertebral body height and short (three vertebrae) pedicle screw instrumentation with posterolateral fusion was performed. Gardner kyphosis angle, anterior and posterior vertebral body height ratio and spinal canal encroachment were calculated pre- to postoperatively.

Results:

All 23 patients were operated within two days after admission and were followed for at least 12 months after index surgery. Operating time and blood loss averaged 45 min and 60 cc respectively. The five patients with incomplete neurological lesions improved by at least one ASIA grade, while no neurological deterioration was observed in any case. The VAS and SF-36 (Role physical and Bodily pain domains) were significantly improved postoperatively. Overall sagittal alignment was improved from an average preoperative 16° to one degree kyphosis at final followup observation. The anterior vertebral body height ratio improved from 0.6 preoperatively to 0.9 (P<0.001) postoperatively, while posterior vertebral body height improved from 0.95 to 1 (P<0.01). Spinal canal encroachment was reduced from an average 32% preoperatively to 20% postoperatively. Cement leakage was observed in four cases (three anterior to vertebral body and one into the disc without sequalae). In the last CT evaluation, there was a continuity between calcium phosphate and cancellous vertebral body bone. Posterolateral radiological fusion was achieved within six months after index operation. There was no instrumentation failure or measurable loss of sagittal curve and vertebral height correction in any group of patients.

Conclusions:

Balloon kyphoplasty with calcium phosphate cement secured with posterior short fixation in the thoracolumbar spine provided excellent immediate reduction of posttraumatic segmental kyphosis and significant spinal canal clearance and restored vertebral body height in the fracture level.     

Posterior approach in thoracolumbar tuberculosis: a clinical and radiological review of 67 operated cases

(1) To present the indications of single stage all posterior surgery in thoracic and lumbar tuberculosis. (2) To evaluate the results of single stage all posterior surgery. We analysed 67 patients who underwent single stage all posterior surgery with follow-up of 31.37 months. We performed the following operative procedures depending upon level and case requirements. (Group A) Instrumentation alone for instability. (Group B) Transpedicular decompression and instrumentation for neurological compression in thoracic and thoracolumbar spine. (Group C) Transforaminal approach for access to anterior column in lumbar spine in addition to posterior instrumentation. (Group D) Pedicle subtraction osteotomy and instrumentation for deformity correction. (Group E) Posterior decompression alone for isolated posterior epidural compression. (Group F) Reconstruction of anterior column by all posterior approach. Thirty-eight had neurological deficit whereas 29 were Frankel E. In 12 cases, anterior reconstruction was done. In the remaining 55 cases, we relied on vertebral reconstitution under chemotherapy. Operative time was 150.5 min and blood loss was 514.18 ml. Of 38 patients with deficit, 34 improved. There was radiological fusion in all patients. Pre- and post-operative Cobb’s measurements were 9.95 and 8.1, respectively, in thoracic and thoracolumbar spine and ?9.39 and ?11.42, respectively, in lumbar spine. Of 55 cases where anterior reconstruction was not done, only 3 had progression of Cobb’s >10°. Posterior approach can achieve adequate decompression of offending middle column and if required, even anterior reconstruction. Posterior approach is versatile, with many surgical options depending on the level and case requirements.     

Percutaneous vertebroplasty for the treatment of osteoporotic burst fractures

Background  Vertebroplasty is a minimally invasive surgical procedure which involves injecting polymethylmethacrylate into the compressed vertebral body. At present the indications include the treatment of osteoporotic compression fractures, vertebral myeloma, and metastases. The value of vertebroplasty in osteoporotic compression fracture has been discussed comprehensively. The surgical operation for burst fractures without neurological deficit remains controversial. Some authors have asserted that vertebroplasty is contraindicated in patients with burst fracture. However, we performed the procedure, after considering the patents general condition, to reduce surgical risks and the duration of immobilisation. The purpose of this study is to investigate clinical outcomes, kyphosis correction, wedge angle, and height restoration of thoraco-lumbar osteoporotic burst fractures treated by percutaneous vertebroplasty. Materials and methods  Twenty-five patients with osteoporotic burst fracture were treated with postural reduction followed by vertebroplasty. We measured the kyphosis, wedge angle, spinal canal compromise and the height of the fractured vertebral body initially, after postural reduction, and after vertebroplasty. Findings  The average height of the collapsed vertebral bodies was 24.8% of the original height. Average kyphosis angle was 19.4° and average wedge angle was 19.8° at first. Mean canal encroachment was initially 25.1%. Kyphosis angle, wedge angle, and anterior, middle, and posterior height improved significantly after the procedure. The mean amelioration of the spinal canal encroachment after vertebroplasty was 23.3%. The average increase in anterior vertebral body height was 7.5 mm, central was 5.8 mm, and posterior was 0.9 mm. The mean reduction in kyphosis angle was 6.8° and the mean reduction in wedge angle was 9.7°. Conclusion  Although vertebroplasty has been considered as contraindicated in thoraco-lumbar burst fractures, we successfully used the procedure as a safe treatment in patients with osteoporotic burst fracture without neurologic deficit. This method could eliminate the need for and risks of major spinal surgery. We would like to offer it as a relatively safe and effective methods of management in thoraco-lumbar burst fractures.     

前路与后路减压治疗胸腰段骨折合并脊髓损伤疗效的Meta分析

目的:系统评价前路减压(anterior decompression)与后路减压(posterior decompression)治疗胸腰段骨折合并脊髓损伤的疗效与安全性,为胸腰段骨折合并脊髓损伤的疗效提供更好的科学依据。方法:检索并收集前路减压与后路减压治疗胸腰段骨折合并脊髓损伤的比较性研究。通过计算机检索下列数据库:Pubmed、Embase、Cochrane图书馆、CNKI、CBM、万方医学网。人工检索期刊Spine、European Spine Journal、The Journal of Bone and Joint Surgery。2名脊柱外科专业人员按照既定的纳入与排除标准,独立筛选文献,并对各纳入的研究进行质量评价。使用Review Manager5.3软件对数据进行Meta分析,观察指标包括手术时间、术中出血量、术后触觉评分、术后运动评分、术后伤椎高度、住院时间、神经功能恢复、治疗有效率及术后并发症。结果:最终纳入15项随机对照试验(randomized controlled trail,RCT),共1360例患者,其中前路减压术680例,后路减压术680例。Meta分析结果示,与后路减压组相比,前路减压组手术时间长[MD=80.09,95%CI(36.83,123.34),P=0.0003],术中出血量多[MD=225.21,95%CI(171.07,279.35),P0.00001],住院时间长[MD=2.31,95%CI(0.32,4.31),P=0.02],术后触觉评分高[MD=13.39,95%CI(9.86,16.92),P0.00001],术后运动评分高[MD=13.15,95%CI(7.02,19.29),P0.0001],伤椎高度高[MD=1.36,95%CI(0.79,1.92),P0.00001],而两者在治疗有效率[OR=1.14,95%CI(0.56,2.31),P=0.72]、神经功能恢复[OR=0.87,95%CI(0.57,1.33),P=0.52]方面,差异均无统计学意义。结论:前路减压与后路减压相比,手术时间长,术中出血量多,住院时间长,术后触觉评分高,术后运动评分高,伤椎高度高,但是两者在治疗有效率、神经功能恢复方面差异无统计学意义。     

A comparative study of two reconstruction procedures for osteoporotic vertebral fracture with lumbar spinal stenosis: Posterior lumbar interbody fusion versus posterior and anterior and combined surgery

BackgroundOptimal treatment of lumbar spinal stenosis (LSS) with neurological deficit due to osteoporotic vertebral fractures (OVFs) has been controversial. We assessed the usefulness, safety, and efficacy of posterior lumbar interbody fusion (PLIF) for LSS with neurological deficit due to OVFs and compared this procedure to posterior/anterior combined surgery (PACS).MethodsOf 36 consecutive patients with LSS with neurological deficit due to OVFs, 15 underwent PLIF (6 males, 9 females; mean age, 74 years), and 21 underwent PACS (4 males, 17 females; mean age, 70 years). Surgical complications, clinical outcomes (operative time, blood loss, American Spinal Injury Association Impairment Scale [AIS], activities of daily living [ADLs]), and sagittal alignment were investigated. Bony fusion was assessed using plain and functional X-rays and computed tomography scans.ResultsThere were no significant differences in age, sex, or disease or follow-up duration between the groups. Operative time was significantly shorter and intraoperative blood loss significantly less in the PLIF than in the PACS groups. AIS and ADL improved significantly postoperatively in both groups. No significant difference was observed in neurological improvement, correction angle, loss of correction, and surgical complications. No pseudarthrosis occurred, and no patient required additional surgery in the PLIF group.ConclusionsPLIF for LSS with neurological deficit due to OVFs achieves posterior rigid fixation with instrumentation, anterior column reconstruction by interbody fusion, and adequate decompression using a single posterior approach. This less invasive procedure is a useful reconstructive surgery option.     

两种不同入路治疗无神经症状胸腰椎骨折的病例对照研究

目的:探讨两种不同手术入路治疗无神经症状胸腰椎骨折的临床疗效。方法:自2008年1月至2009年12月,对采用经后正中入路(A组,20例)和椎旁肌间隙入路(B组,20例)治疗的无神经损伤的胸腰椎骨折40例进行回顾性分析,男13例,女27例,年龄26～61岁,平均46岁。所有患者均接受相同的脊柱后路内固定系统(Basis TM)。40例患者平均随访16个月(10～27个月)。分析内容包括手术时间、术中出血量、术后引流量、术后卧床时间、术后24 h及72 h疼痛视觉模拟评分(VAS)、术后Cobb角纠正率、椎体塌陷纠正率。结果:术后患者均无明显并发症,两组患者术后Cobb角纠正率,椎体塌陷纠正率比较无统计学差异;经椎旁肌间隙入路组在手术时间、术中出血量、术后引流量、术后卧床时间、术后24 h及72 h的VAS等方面均优于后正中入路组。结论:经椎旁肌间隙入路治疗无神经症状胸腰椎骨折具有创伤小、出血少、术后恢复快等优点,但有神经症状或椎管内占位超过1/3者慎用此入路。