Osteoporotic vertebral fractures without compression: key factors of diagnosis and initial outcome of treatment with cement augmentation

Introduction

Because of the nonspecific symptoms and unapparent radiographic findings, occult osteoporotic vertebral fractures (VFs) have a high rate of missed diagnosis, and the treatment of these fractures has rarely been discussed in the literature. We investigated diagnostic key factors of such occult VFs and evaluated the effects of cement augmentation in these patients.

Methods

A total of 225 patients with VFs treated with vertebroplasty (VP) or kyphoplasty (KP) were retrospectively analyzed. All patients have taken preoperatively magnetic resonance imaging (MRI) including T1/T2-weighted images and short tau inversion recovery (STIR) sequences, and 45 patients met the inclusion criteria. Clinical outcomes were evaluated by comparing visual analog scale (VAS) and Oswestry disability index (ODI) values preoperatively, postoperatively, and at the final follow-up.

Results

MRI (T1 and STIR sequences) showed bone marrow edema in all fresh fractures including occult VFs and concomitant VFs; five patients showed no abnormality signal in their T2-weighted sequences of occult VFs. While 40 patients underwent KP, and five patients underwent VP. We did not find delayed collapsed fractures in the augmented occult VFs in both groups after operation. Both groups had significant improvement in pain and functional activity after the intervention (p<0.01).

Conclusion

The presence of previous or concomitant VFs leads to further imaging examination, which helps identify the occult VFs. Preoperative MRI examination especially T1 and STIR sequences plays a vital role in the early diagnosis of occult VFs. Except for significant pain relief and functional improvement, VP and KP can effectively prevent delayed vertebral collapse of occult VFs comparing to previous reported data.     

Vertebroplasty in patients with severe vertebral compression fractures: a technical report

Vertebroplasty is a procedure in which polymethlymethacrylate (PMMA) is injected into a vertebral body compression fracture. It has been suggested that fractues greater than 65% to 70% of the original vertebral body height are too compressed to be treated successfully with this procedure. We describe six patients with severe compression fractures that were successfully treated with vertebroplasty in which the trocar was inserted in the far lateral aspect of the vertebral body, because of the typical morphology of severe compression fractures.     

Osteoporotic compression fractures: outcomes after single- versus multiple-level percutaneous vertebroplasty

PURPOSE: To compare single- and multiple-level percutaneous vertebroplasty (PV) in terms of pain relief, activity level, and analgesic use in patients with osteoporotic vertebral compression fractures (VCFs). MATERIALS AND METHODS: Institutional review board approval and informed consent were obtained, and the study was HIPAA compliant. One hundred seventy-three patients (mean age at treatment, 73.8 years +/- 11.9 [standard deviation]) with 422 symptomatic osteoporotic VCFs underwent 204 treatment sessions for over 4 years. Pain immediately before and after PV was measured by using a visual analogue scale (VAS). Pain degree, activity level, and analgesic use were assessed at 2 weeks and 1, 3, 6, 12, and 24 months after PV by using telephone interview questionnaires. Data were analyzed by using a combination of paired t tests, analysis of variance, contingency tables, and chi2 tests. RESULTS: Findings of 172 PV treatment sessions for 149 patients (mean age at treatment, 73.4 years +/- 12), 110 (74%) of whom were women, were assessed; 32 treatment cases were lost to follow-up or lost owing to death. A single fracture level was treated at 65 sessions; two fracture levels, at 52 sessions; and three or more fracture levels, at 55 sessions. The mean VAS pain score decreased significantly (P < .001), from 76 +/- 21 before to 19 +/- 27 immediately after PV. Of the outcomes reported at 24 months, 82% (64 of 78 treatment sessions) were marked to complete resolution of the initial pain, 51% were complete cessation of analgesic use, and 51% were increased activity levels. These results did not differ greatly over time or when stratified into groups according to the number of fracture levels treated. CONCLUSION: PV performed at a single fracture level and that performed at multiple fracture levels were equally effective in facilitating long-term pain relief, increased activity level, and decreased analgesic use in patients with osteoporotic VCFs.     

Latent mobility of osteoporotic vertebral compression fractures

PURPOSE: To describe the property of latent mobility in osteoporotic vertebral compression fractures (VCFs) and discuss its clinical significance. MATERIALS AND METHODS: This was a retrospective case series of 14 patients with 14 painful osteoporotic VCFs who were comfortably confined to the supine position overnight for the purpose of vertebral height restoration. There was sufficient additional vertebral height restoration the following morning to allow percutaneous vertebroplasty (PV) in some patients when this had initially been deemed unsafe or technically impossible. Anterior vertebral height of the index VCF was measured from the preoperative standing lateral, immediate cross-table supine lateral, and postconfinement cross-table supine lateral radiographs as well as the first postoperative standing lateral radiograph. Dynamic mobility was defined as the difference in anterior vertebral height between preoperative standing lateral and immediate cross-table supine lateral radiographs. Latent mobility was defined as difference in anterior vertebral height between immediate cross-table supine lateral and postconfinement cross-table supine lateral radiographs. Postoperative vertebral height restoration was defined as the difference in anterior vertebral height between preoperative and first postoperative standing lateral radiographs. Mean patient age was 81.0 years, and mean fracture age was 83.6 days. RESULTS: Dynamic mobility averaged +4.7 mm (range, -2.1 to +12.6 mm; P = .001). Latent mobility averaged +2.7 mm (range, -1.9 to +15.5; P < .02). The average sum of preoperative dynamic and latent mobility (+7.4 mm; range -1.0 to +17.0; P < .001) was not different from final postoperative vertebral height restoration (P > .4). PV was successfully accomplished in all cases. CONCLUSIONS: Latent mobility occurs in some VCFs and contributes to vertebral height restoration. Recognition of latent mobility may permit vertebroplasty in some patients in whom the procedure had otherwise been deemed unsafe. Reports of vertebral height restoration following vertebral augmentation should account for that proportion resulting from dynamic and latent mobility.     

Treatment of painful compression vertebral fractures with vertebroplasty: results and complications

AIM: The aim of this paper is to assess the effectiveness and safety of percutaneous vertebroplasty in patients with focal pain caused by compression vertebral body fractures. MATERIALS AND METHODS: Over an eleven-month period 49 patients underwent percutaneous vertebroplasty, of which seven were retreated, for a total of 56 operations on 108 vertebrae. The patients were affected by osteoporotic compression fractures (n=28) or by benign and malignant infiltrative processes (n=21). All of the patients were examined at discharge and later at one week, and one, three, six and nine months after surgery to ascertain the development of the pain and possible changes in the quality of life. The mean length of follow-up was 3.8 months. RESULTS: One week after treatment all patients reported complete disappearance or significant alleviation of the pain. In 8 out of 49 patients (16.3%) there was a reoccurrence of pain; 7 of these patients underwent further treatment at another level with immediate pain relief. After surgery only three patients (6.1%) continued to take non-steroidal anti-inflammatory drugs (NSAIDs), whereas prior to surgery all patients were taking pain medication. We also observed an important benefit in the quality of life, in that after treatment all patients reported an improvement in functional abilities, and only three (6.1%) still had to wear a back brace (against 15 in the preoperative period). We only had one serious complication (1.7%) which involved the formation of a subcutaneous paravertebral haematoma, which was resolved in about a week. Eight patients (16.3%) developed transient pain at the site of the puncture or radiculopathy in the days following the operation. In 63 out of 108 of the treated vertebrae (58) there were small asymptomatic leakages of cement outside the vertebral body and in two asymptomatic patients (3.5%) the chest radiograph revealed a small pulmonary embolism of cement. DISCUSSION: Our experience confirms the effectiveness of vertebroplasty in the treatment of pain caused by vertebral fractures. If the indications are respected the improvement of symptoms is often immediate, such as the return of mobility, and patient satisfaction with surgery is higher. The use of appropriate guiding systems limits the number of complications.     

脊柱良恶性压缩骨折的MR波谱分析

目的探讨骨质疏松和恶性肿瘤所致脊柱良恶性压缩骨折的MR氢质子波谱(1HMRS)特征。方法对37例骨质疏松和21例恶性肿瘤所致椎体压缩性骨折病例进行1H MRS采集,同时以30例健康志愿者L2椎体的1H MRS作对照,定量分析感兴趣椎体的脂肪百分含量(FF%)及脂与水的比率(LWR)。结果对照组L2椎体平均脂肪含量为(45.0±20.2)%,平均LWR为0.76;骨质疏松组病变椎体的平均脂肪含量(67.0±14.3)%,平均LWR为1.75;恶性肿瘤组病变椎体平均脂肪含量(1.8±1.2)%;平均LWR为0.1。骨质疏松组FF%和LWR明显高于恶性肿瘤组(t=2.87,P<0.01),亦较高于正常对照组(t=2.06,P<0.05);恶性肿瘤组FF%和LWR明显低于正常对照组(t=2.75,P<0.01)。结论1H MRS能无创性检测脊柱椎体的脂肪含量及LWR,脊柱良恶性压缩椎体的脂肪含量及LWR差异有统计学意义,有助于骨质疏松和恶性肿瘤所致椎体压缩性骨折的鉴别诊断。     

Treatment of severe vertebral body compression fractures with percutaneous vertebroplasty

Objective  

Evaluate the efficacy of percutaneous vertebroplasty for severe vertebral body compression fractures.     

Treatment of chronic symptomatic vertebral compression fractures with percutaneous vertebroplasty

OBJECTIVE: Most fractures treated with percutaneous vertebroplasty are subacute and less than 1 year old. We report our experience treating chronic vertebral fractures with vertebroplasty. MATERIALS AND METHODS: Our database identified 41 patients with symptomatic fractures more than 1 year old. These patients were categorized into subgroups determined by fracture age: 12 months 1 day-24 months (n = 16) or more than 24 months 1 day (n = 25). Changes in pain and mobility for the study group were compared with those in 49 patients with fractures less than 1 year old. RESULTS: Thirty-three (80%) of the 41 patients in the study group had improvement in pain-seven (17%) had complete and 26 (63%) had partial relief. Forty-five (92%) of the 49 control group patients had improvement in pain-24 (49%) had complete and 21 (43%) had partial relief. The number of patients achieving partial or complete relief of pain was not statistically different between groups (p > 0.05), although complete relief was significantly more frequent in the control group (p = 0.002). Twenty patients (49%) in the study group versus 34 patients (69%) in the control group had improved mobility after vertebroplasty (p = 0.047). Patients with fractures 12 months 1 day-24 months old had improvement in mobility similar to that in patients in the control group (p = 0.962). Fractures more than 24 months 1 day old were associated with significantly less improvement in mobility (p = 0.006). CONCLUSION: Most patients with fractures more than 1 year old will experience clinical benefit from vertebroplasty. Complete relief of pain is more likely when less mature fractures are treated.     

Malrotation of the midgut: a rare complication in an adult patient

Complications caused by a congenital anomaly of the midgut usually occur in the first 4 weeks of life; later such complications are rare. We present an adult patient with extrinsic duodenal compression caused by malrotation. The embryology, symptoms and complications in the adult and the radiological diagnosis are discussed. The literature on this subject is reviewed.     

Percutaneous vertebroplasty in the therapy of osteoporotic vertebral compression fractures: a critical review

Percutaneous vertebroplasty has become an efficient technique for the treatment of painful vertebral fractures. Osteoporotic vertebral compression fractures are characterized by severe back pain and immobilization causing other complications like thrombosis or pneumonia. Vertebral cement augmentation provides increased strength of the vertebral body and an obvious pain relief. Between 1989 and 2004, 30 studies and a total of 2,086 treated patients have been published in literature. A review of these studies has been performed. The number and age of the patients, number of treated vertebrae, pre- and postoperative outcome of pain and complications of the different studies were assessed and analyzed. Percutaneous vertebroplasty is an efficient technique with low complication rates and a significant reduction in pain. It rapidly improves the mobility and quality of life of patients with vertebral compression fractures. With an increasing number of treated patients, experience with this interventional technique has become excellent. But still there are no randomized controlled trials available, showing that percutaneous vertebroplasty has a significantly better outcome than other treatment options, especially after a long-term follow-up. K. Hochmuth and D. Proschek contributed equally to this work.     

Percutaneous vertebroplasty: treatment of painful vertebral compression fractures with intraosseous vacuum phenomena

OBJECTIVE: This study was undertaken to determine the efficacy of percutaneous vertebroplasty in treating patients with painful compression fractures of the thoracic and lumbar vertebrae that contain intraosseous vacuum phenomena. MATERIALS AND METHODS: Nineteen cases of painful vertebral compression fractures with intraosseous phenomena occurring in 18 patients (six men, 12 women; age range, 59-88 years; mean age, 75.5 years) were identified from 393 percutaneous vertebroplasties performed in 199 patients during 32 and a half months. All patients had osteoporosis, with severe vertebral compression to less than one third of the vertebral body height in 13 of 19 cases. Affected levels were T6 (n = 1), T8 (n = 2), T9 (n = 1), T11 (n = 1), T12 (n = 4), L1 (n = 5), L2 (n = 2), L3 (n = 1), L4 (n = 1), and L5 (n = 1). All cases had the typical intravertebral body vacuum cleft appearance on radiographs. Imaging and clinical features were analyzed. RESULTS: The mean volume of polymethyl methacrylate injected was 7.43 mL (range, 4.0-15.0 mL). Typically, the polymethyl methacrylate filled the intravertebral vacuum cleft. Complications during radiography consisted of minimal polymethyl methacrylate leakage into the adjacent disk (15/19 cases) and the paravertebral soft tissues (8/19 cases). No complications required surgical intervention. At clinical follow-up, pain relief was complete in eight patients (44.4%), partial in six patients (33.3%), and unchanged in four patients (22.2%). CONCLUSION: Percutaneous vertebroplasty is effective in the treatment of patients with painful vertebral compression fractures with intraosseous vacuum phenomena.     

经皮椎体成形术治疗骨质疏松性椎体骨折疗效观察

目的探讨经皮椎体成形术治疗骨质疏松性椎体压缩性骨折的临床疗效及应用价值。方法36例骨质疏松性压缩性骨折患者45个椎体，在C型臂X线透视下，取俯卧位，经皮穿刺，在病椎注入聚甲基丙烯酸甲酯。术前及术后3d进行疼痛视觉类比评分（VAS评分），并进行统计学分析。结果治疗后36例患者疼痛较治疗前有明显好转，VAS评分差异有统计学意义（P〈0．001）；活动能力也有不同程度改善；部分椎体的前缘和椎体中部高度有一定恢复。结论经皮椎体成形术治疗骨质疏松性椎体压缩骨折止痛效果明显，能很快改善患者的活动能力，早期下床活动。该手术属微创手术，在骨科临床有一定的应用前景。     

经皮椎体成形术治疗骨质疏松性椎体压缩性骨折的MRI评价

目的:探讨MRI对经皮椎体成形术治疗骨质疏松性椎体压缩性骨折(osteoporotic vertebral compression fractures,OVCF)的评价作用。方法:收集130例确诊为OVCF患者,分为对照组和实验组各65例,分别采用保守治疗和中医分期辨证治疗辅助的经皮椎体成形术治疗,治疗效果采用VAS评分,并行X线及MRI检查,测量MRI信号强度,计算信号强度比,分析其与治疗效果的关系。结果:对照组和实验组VAS评分、椎体高度恢复率及后凸Cobb角3个评价指标在治疗后均较治疗前有明显改善,差异均有统计学意义(均P0.05),且实验组改善程度较对照组更明显(P0.05)。采用MRI评价结果与前两者的评价结果一致(P0.05)。结论:MRI能准确评价经皮椎体成形术治疗OVCF的疗效。