Combined open decompressive laminectomy and vertebroplasty for treatment of thoracolumbar fractures retrospective review of 41 cases

Background

Vertebral compression fractures are common, and can occur concomitantly in patients with symptomatic degenerative stenosis. Less commonly, complicated vertebral body fractures may involve retropulsion of bone into the spinal canal, resulting in stenosis with myelopathy and/or radiculopathy. Decompression of the neural elements can lead to destabilization and progressive kyphotic deformity. Laminectomy combined with open vertebroplasty provides a way to decompress the neural elements and stabilize the anterior columns in patients who cannot tolerate extended surgical time or complications associated with instrumentation and fusion. The authors describe the combination of decompressive laminectomy and open transpedicular vertebroplasty as a means to decompress neural elements and simultaneously stabilize the anterior vertebral column.

Methods

Forty-one patients with a total of 51 thoracolumbar fractures were included in this retrospective case review. A decompressive laminectomy was performed first, followed by vertebroplasty using an open transpedicular approach. For subjective assessment of outcome, the patients were assessed using the Oswestry Low Back Disability Questionnaire and additional questions pertaining to the patient's condition.

Results

Out of 51 fractures, there were 15 burst fractures and 36 compression fractures. Fracture levels ranged from T12 to S1. The average follow-up period was 27 months (range, 0.5–60 months). The mean post-operative Oswestry score was 16 (range, 0–39), and all patients except for one were subjectively pleased with the results of the procedure and said they would recommend it to others. All patients were able to return to all routine activities of daily living.

Conclusions

The authors’ cases indicate combining open decompressive laminectomies with vertebroplasty can be an effective treatment for patients with complicated thoracic and lumbar fractures without involving bone fusion or spinal instrumentation and with good long-term outcomes.     

Bone Cement-Augmented Short Segment Fixation with Percutaneous Screws for Thoracolumbar Burst Fractures Accompanied by Severe Osteoporosis

Objective

The purpose of this study was to determine the efficacy of bone cement-augmented short segment fixation using percutaneous screws for thoracolumbar burst fractures in a background of severe osteoporosis.

Methods

Sixteen patients with a single-level thoracolumbar burst fracture (T11-L2) accompanying severe osteoporosis treated from January 2008 to November 2009 were prospectively analyzed. Surgical procedures included postural reduction for 3 days and bone cement augmented percutaneous screw fixation at the fracture level and at adjacent levels without bone fusion. Due to the possibility of implant failure, patients underwent implant removal 12 months after screw fixation. Imaging and clinical findings, including involved vertebral levels, local kyphosis, canal encroachment, and complications were analyzed.

Results

Prior to surgery, mean pain score (visual analogue scale) was 8.2 and this decreased to a mean of 2.2 at 12 months after screw fixation. None of the patients complained of pain worsening during the 6 months following implant removal. The percentage of canal compromise at the fractured level improved from a mean of 41.0% to 18.4% at 12 months after surgery. Mean kyphotic angle was improved significantly from 19.8° before surgery to 7.8 at 12 months after screw fixation. Canal compromise and kyphotic angle improvements were maintained at 6 months after implant removal. No significant neurological deterioration or complications occurred after screw removal in any patient.

Conclusion

Bone cement augmented short segment fixation using a percutaneous system can be an alternative to the traditional open technique for the management of selected thoracolumbar burst fractures accompanied by severe osteoporosis.     

Bone Cement Augmentation of Short Segment Fixation for Unstable Burst Fracture in Severe Osteoporosis

Objective

The purpose of this study was to determine the efficacy of short segment fixation following postural reduction for the re-expansion and stabilization of unstable burst fractures in patients with osteoporosis.

Methods

Twenty patients underwent short segment fixation following postural reduction using a soft roll at the involved vertebra in cases of severely collapsed vertebrae of more than half their original height. All patients had unstable burst fracture with canal compromise, but their motor power was intact. The surgical procedure included postural reduction for 2 days and bone cement-augmented pedicle screw fixations at one level above, one level below and the fractured level itself. Imaging and clinical findings, including the level of the vertebra involved, vertebral height restoration, injected cement volume, local kyphosis, clinical outcome and complications were analyzed.

Results

The mean follow-up period was 15 months. The mean pain score (visual analogue scale) prior to surgery was 8.1, which decreased to 2.8 at 7 days after surgery. The kyphotic angle improved significantly from 21.6±5.8° before surgery to 5.2±3.7° after surgery. The fraction of the height of the vertebra increased from 35% and 40% to 70% in the anterior and middle portion. There were no signs of hardware pull-out, cement leakage into the spinal canal or aggravation of kyphotic deformities.

Conclusion

In the management of unstable burst fracture in patients with severe osteoporosis, short segment pedicle screw fixation with bone cement augmentation following postural reduction can be used to reduce the total levels of pedicle screw fixation and to correct kyphotic deformities.     

Implant Removal after Percutaneous Short Segment Fixation for Thoracolumbar Burst Fracture : Does It Preserve Motion?

Objective

The purpose of this study was to evaluate the efficacy of implant removal of percutaneous short segment fixation after vertebral fracture consolidation in terms of motion preservation.

Methods

Between May 2007 and January 2011, 44 patients underwent percutaneous short segment screw fixation due to a thoracolumbar burst fracture. Sixteen of these patients, who underwent implant removal 12 months after screw fixation, were enrolled in this study. Motor power was intact in all patients, despite significant vertebral height loss and canal compromise. The patients were divided into two groups by degree of osteoporosis : Group A (n=8), the non-osteoporotic group, and Group B (n=8), the osteoporotic group. Imaging and clinical findings including vertebral height loss, kyphotic angle, range of motion (ROM), and complications were analyzed.

Results

Significant pain relief was achieved in both groups at final follow-up versus preoperative values. In terms of vertebral height loss, both groups showed significant improvement at 12 months after screw fixation and restored vertebral height was maintained to final follow-up in spite of some correction loss. ROM (measured using Cobb''s method) in flexion and extension in Group A was 10.5° (19.5/9.0°) at last follow-up, and in Group B was 10.2° (18.8/8.6°) at last follow-up. Both groups showed marked improvement in ROM as compared with the screw fixation state, which was considered motionless.

Conclusion

Removal of percutaneous implants after vertebral fracture consolidation can be an effective treatment to preserve motion regardless of osteoporosis for thoracolumbar burst fractures.     

The Role of Bone Cement Augmentation in the Treatment of Chronic Symptomatic Osteoporotic Compression Fracture

Objective

Bone cement augmentation procedures such as percutaneous vertebroplasty and balloon kyphoplasty have been shown to be effective treatment for acute or subacute osteoporotic vertebral compression fractures. The purpose of this study was to determine the efficacy of bone cement augmentation procedures for long standing osteoporotic vertebral compression fracture with late vertebral collapse and persistent back pain.

Methods

Among 278 single level osteoporotic vertebral compression fractures that were treated by vertebral augmentation procedures at our institute, 18 consecutive patients were included in this study. Study inclusion was limited to initially, minimal compression fractures, but showing a poor prognosis due to late vertebral collapse, intravertebral vacuum clefts and continuous back pain despite conservative treatment for more than one year. The subjects included three men and 15 women. The mean age was 70.7 with a range from 64 to 85 years of age. After postural reduction for two days, bone cement augmentation procedures following intraoperative pressure reduction were performed. Imaging and clinical findings, including the level of the vertebra involved, vertebral height restoration, injected cement volume, local kyphosis, clinical outcome and complications were analyzed.

Results

The mean follow-up period after bone cement augmentation procedures was 14.3 months (range 12-27 months). The mean injected cement volume was 4.1 mL (range 2.4-5.9 mL). The unipedicular approach was possible in 15 patients. The mean pain score (visual analogue scale) prior to surgery was 7.1, which decreased to 3.1 at 7 days after the procedure. The pain relief was maintained at the final follow up. The kyphotic angle improved significantly from 21.2 ± 4.9° before surgery to 10.4 ± 3.8° after surgery. The fraction of vertebral height increased from 30% to 60% after bone cement augmentation, and the restored vertebral height was maintained at the final follow up. There were no serious complications related to cement leakage.

Conclusion

In the management of even long-standing osteoporotic vertebral compression fracture for over one year, bone cement augmentation procedures following postural reduction were considered safe and effective treatment in cases of non-healing evidence.     

Short Segment Screw Fixation without Fusion for Unstable Thoracolumbar and Lumbar Burst Fracture : A Prospective Study on Selective Consecutive Patients

Objective

The purpose of this prospective study was to evaluate the efficacy and safety of screw fixation without bone fusion for unstable thoracolumbar and lumbar burst fracture.

Methods

Nine patients younger than 40 years underwent screw fixation without bone fusion, following postural reduction using a soft roll at the involved vertebra, in cases of burst fracture. Their motor power was intact in spite of severe canal compromise. The surgical procedure included postural reduction for 3 days and screw fixations at one level above, one level below and at the fractured level itself. The patients underwent removal of implants 12 months after the initial operation, due to possibility of implant failure. Imaging and clinical findings, including canal encroachment, vertebral height, clinical outcome, and complications were analyzed.

Results

Prior to surgery, the mean pain score (visual analogue scale) was 8.2, which decreased to 2.2 at 12 months after screw fixation. None of the patients complained of worsening of pain during 6 months after implant removal. All patients were graded as having excellent or good outcomes at 6 months after implant removal. The proportion of canal compromise at the fractured level improved from 55% to 35% at 12 months after surgery. The mean preoperative vertebral height loss was 45.3%, which improved to 20.6% at 6 months after implant removal. There were no neurological deficits related to neural injury. The improved vertebral height and canal compromise were maintained at 6 months after implant removal.

Conclusion

Short segment pedicle screw fixation, including fractured level itself, without bone fusion following postural reduction can be an effective and safe operative technique in the management of selected young patients suffering from unstable burst fracture.     

Short Segment Fixation for Thoracolumbar Burst Fracture Accompanying Osteopenia : A Comparative Study

Objective

The purpose of this study was to compare the results of three types of short segment screw fixation for thoracolumbar burst fracture accompanying osteopenia.

Methods

The records of 70 patients who underwent short segment screw fixation for a thoracolumbar burst fracture accompanying osteopenia (-2.5< mean T score by bone mineral densitometry <-1.0) from January 2005 to January 2008 were reviewed. Patients were divided into three groups based on whether or not bone fusion and bone cement augmentation procedure 1) Group I (n=26) : short segment fixation with posterolateral bone fusion; 2) Group II (n=23) : bone cement augmented short segment fixation with posterolateral bone fusion; 3) Group III (n=21) : bone cement augmented, short segment percutaneous screw fixation without bone fusion. Clinical outcomes were assessed using a visual analogue scale and modified MacNab''s criteria. Radiological findings, including kyphotic angle and vertebral height, and procedure-related complications, such as screw loosening or pull-out, were analyzed.

Results

No significant difference in radiographic or clinical outcomes was noted between patients managed using the three different techniques at last follow up. However, Group I showed more correction loss of kyphotic deformities and vertebral height loss at final follow-up, and Group I had higher screw loosening and implant failure rates than Group II or III.

Conclusion

Bone cement augmented procedure can be an efficient and safe surgical techniques in terms of achieving better outcomes with minimal complications for thoracolumbar burst fracture accompanying osteopenia.     

Analysis of Results Using Percutaneous Vertebroplasty for the Treatment of Avascular Necrosis of the Vertebral Body

Objective

Avascular necrosis (AVN) of the vertebral body is known as a relatively uncommon phenomenon in a vertebral compression fracture (VCF). The outstanding radiologic findings of AVN are intravertebral vacuum phenomenon with or without fluid collection. Several reports revealed that PVP or balloon kyphoplasty might be the effective treatment modalities for AVN. We also experienced excellent results when using PVP for the treatment of AVN of the vertebral body, and intend to describe the treatment''s efficacy in this report.

Methods

Thirty-two patients diagnosed with AVN of the vertebral body were treated with PVP. We measured the pre- and post-operative anterior body height and kyphotic angulation. The visual analogue scale (VAS) was used to determine the relief of back pain.

Results

The anterior body height (pre-operative : 1.49 cm, post-operative : 2.22 cm) and kyphotic angulation (pre-operative : 14.47 degrees, post-operative : 6.57 degrees) were significantly restored (p<0.001). VAS was improved from 8.9 to 3.7. Pseudoarthrosis was corrected in all cases, which was confirmed by dynamic radiographs. Fluid collection was found in sixteen cases and was aspirated with serous nature. No organism and tumor cell were noted.

Conclusion

PVP proved to be an effective procedure for the treatment of AVN of the vertebral body, which corrected dynamic instability and significantly restored the anterior body height and kyphotic angulation.     

Predictable Factors for Dural Tears in Lumbar Burst Fractures with Vertical Laminar Fractures

Objective

The purpose of the present study was to determine the incidence of dural tears and predictable factors suggesting dural tears in patients who had lumbar burst fractures with vertical laminar fractures.

Methods

A retrospective review was done on thirty-one patients who underwent operative treatment for lumbar burst fractures with vertical laminar fractures between January 2003 and December 2008. All patients were divided into two groups according to existence of dural tears, which were surgically confirmed; 21 patients with dural tears and 10 patients without dural tears. Clinical and radiographic findings were analyzed for their association with dural tears.

Results

Among a total of 31 patients, dural tears were detected in 21 (67%) patients. A preoperative neurological deficits and mean separation distances of the edges in laminar fractures were found to be the reliable factors of dural tears (p=0.001 and 0.002, respectively). Decreased ratio of the central canal diameter and interpedicular distance were also the reliable factors suggesting dural tears (p=0.006 and 0.015, respectively). However, dural tears showed no significant association with age, sex, level of injury, absence of a posterior fat pad signal, the angle of retropulsed segment, or site of laminar fracture.

Conclusion

Our study of lumbar burst fracture combined laminar fracture revealed that dural tears should be ruled out in cases of a preoperative neurological deficits, wide separation of the laminar fracture, severe canal encroachment, and wider interpedicular distance.     

The Prognostic Factors Influencing on the Therapeutic Effect of Percutaneous Vertebroplasty in Treating Osteoporotic Vertebral Compression Fractures

Objective

This retrospective study of 215 patients with 383 symptomatic osteoporotic vertebral compression fractures (VCFs) treated by percutaneous vertebroplasty (PVP), was performed to evaluate the clinical outcomes, and to analyze the various clinical factors affecting these results.

Methods

The authors assessed the clinical outcome under the criteria such as the pain improvement, activity, requirement of analgesics, and the patient''s satisfaction, and determined the relation to various peri- and intra-operative factors, and postoperative imaging findings.

Results

The outcome was determined as 84.2% in relief of pain, 72.0% in change in activity, 65.7% in analgesics use, and 84.7% of satisfaction rate. More severe focal back pain, high uptake bone scan, and the lower mean T-score were related to the better pain relief following PVP. The longer the duration between fracture and PVP, the less severe focal back pain, low uptake bone scan, and leakage of PMMA into the paravertebral space were related to the less improvement in activity. Female and low uptake bone scan showed a correlation with more analgesic use. The longer the duration between fracture and PVP, low uptake bone scan, and the higher the mean T-score were correlated with the less the patients satisfaction.

Conclusion

Our study suggests that PVP may be more effective in the acute phase of VCFs, more severe focal pain, and far advanced osteoporosis on BMD. Leakage of PMMA into the paravertebral spcae also could be affecting the surgical results.     

Clinical Analysis of Acute Radiculopathy after Osteoporotic Lumbar Compression Fracture

Objective

The purpose of this study was to analyze the relationship between fracture pattern and the development of acute radiculopathy after osteoporotic lumbar compression fracture.

Methods

This study included 59 patients who underwent bone cement augmentation for osteoporotic compression fracture below the L2 level, which can lead to radiculopathic radiating pain. The patients were divided into two groups according to the presence of radiculopathy (group A : back pain only; group B : back pain with newly developed radiating pain). We categorized compression fractures into three types by the position of the fracture line. The incidence of newly developed radiculopathy was examined retrospectively for each compression fracture type.

Results

The overall incidence of newly developed leg pain (group B) was 25%, and the frequency increased with descending spinal levels (L2 : 0%, L3 : 22%, L4 : 43%, and L5 : 63%). The back pain-only group (group A) had mostly superior-type fractures. On the other hand, the back pain with radiculopathy group (group B) had mostly inferior-type fractures. Most patients in group B showed significant relief of leg pain as well as back pain after bone cement augmentation.

Conclusion

The incidence of a newly developed, radiating pain after osteoporotic compression fractures increased gradually from the L3 to L5 levels. Most of these fractures were of the inferior type, and the bone cement augmentation procedures seemed to be sufficient for relief of both back and radiating pain.     

The Proper Volume and Distribution of Cement Augmentation on Percutaneous Vertebroplasty

Objective

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.

Methods

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.

Results

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.

Conclusion

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.     

Clinical Outcomes after Percutaneous Vertebroplasty for Pathologic Compression Fractures in Osteolytic Metastatic Spinal Disease

Objective

Percutaneous vertebroplasty (VP) can provide immediate stabilization in pathologic fractures of spinal tumors. However, long term follow-up data in cases of pathologic fractures are lacking. The authors report follow-up results of VP in 185 pathologic fractures of 102 spinal tumor patients.

Methods

Percutaneous VP was performed at 185 vertebral bodies of 102 patients from 2001 to 2007. Retrospective analysis was done with medical records and radiological data. The change of visual analogue score (VAS), vertebral body (VB) height and kyphotic angle were measured preoperatively and on postoperative one day and at 3, 6, and 12 months.

Results

The patients were composed of metastatic spine tumors (81%) and multiple myeloma (19%). Involved spinal segments were between T6 and L5. Mean follow-up period was 12.2 months. VAS for back pain was 8.24 preoperatively, 3.59 (postoperative one day), 4.08 (three months) and 5.22 (one year). VB compression ratio changed from 21.33% preoperatively to 13.82% (postoperative one day), 14.36% (three month), and 16.04% (one year). Kyphotic angle changed from 15.35° preoperatively to 12.03° (postoperative one day), 13.64° (three month), and 15.61° (one year).

Conclusion

Immediate pain relief was definite after VP in pathologic compression fracture of osteolytic spinal disease. Although VAS was slightly increased on one year follow-up, VP effect was maintained without significant change. These results indicate that VP could be a safe and effective procedure as a palliative treatment of the spinal tumor patients.     

The Patterns of Intraosseous Venography before Percutaneous Vertebroplasty for Osteoporotic Compression Fractures

Objective

Bone cement leakage is a well-known potential complication of percutaneous vertebroplasty (PVP) in patients with osteoporotic compression fracture. Even though there has been a controversy in the efficacy of antecedent venography to prevent this complication, many authors have performed intraosseous venography before bone cement injection. The goal of this study was to classify the venous drainage patterns of spine before PVP, and compare their patterns at different vertebral levels.

Methods

The authors retrospectively reviewed 1,042 intraosseous venographic patterns in 321 patients with 574 osteoporotic compression fractures during six-year period in one institution. To classify venogram patterns, we selected simple lateral X-ray of spine taken immediately after injection of the contrast dye. We classified the venography patterns according to contrast leakage pattern and leakage direction as follows; trabecular (TR), trabecular anterior (TA), trabecular posterior (TP), trabecular anterior-posterior (TAP), trabecular lateral (TL), venous anterior(VA), venous posterior (VP), venous anterior-posterior (VAP), soft tissue (ST). Also, we compared venogram patterns according to different spinal levels.

Results

In overall, the most common pattern was TP type accounting for 37.4% (390/1042) of all intraosseous venograms. This is followed by TAP in 21.5%, TR 17.4%, TA 11.6%, TL 5.8%, ST 4.1%, VA 1.2%, VP 0.6%, and VAP 0.4% in descending order of frequency. According to the spinal level, TR and TAP types were most common in thoracic spine (T6-T10), TP type was most common in thoraco-lumbar spine (T11-L2), and TP and TAP types were most common in lumbo-sacral spine (L3-S1). Contrast dye leakage to soft tissue such as psoas muscle or disc were detected in 43 (4.1%) venograms. Direct venous drainage without staining of vertebral body was found in 23 (2.2%) venograms. The 8.3% of thoracic venogram showed direct venous drainage. Thoracic level showed a more tendency of direct venous drainage than other spine levels (p<0.01).

Conclusion

The authors propose a new classification system of intraosseous venography during PVP. The trabecular-posterior (TP) type is most common through all spine, and venous-filling (V) type was most frequent in thoracic spine. Further study would be necessary to elucidate the efficacy of this classification system to prevent bone cement leakage during PVP.     

The Analysis of Patterns and Risk Factors of Newly Developed Vertebral Compression Fractures after Percutaneous Vertebroplasty

Objective

The purpose of this study was to investigate the patterns and the risk factors of newly developed vertebral compression fractures (VCFs) after percutaneous vertebroplasty (PVP).

Methods

We performed a retrospective review of the 244 patients treated with PVP from September 2006 to February 2011. Among these patients, we selected 49 patients with newly developed VCFs following PVP as the new VCFs group, and the remaining 195 patients as the no VCFs group. The new VCFs group was further divided into 2 groups : an adjacent fractures group and a nonadjacent fractures group. The following data were collected from the groups : age, gender, body weight/height, body mass index (BMI), bone mineral density (BMD) score of the spine and femur, level of initial fracture, restoration rate of anterior/middle vertebral height, and intradiscal cement leakage, volume of polymethylmethacrylate (PMMA).

Results

Age, gender, mean body height/weight, mean BMI and volume of PMMA of each of the group are not statistically significantly associated with fractures. In comparison between the new VCFs group and the no VCFs group, lower BMD, intradiscal cement leakage and anterior vertebral height restoration were the significant predictive factors of the fracture. In addition, new VCFs occurrence at the adjacent spines was statistically significant, when the initial fracture levels were confined to the thoracolumbar junction, among the subgroups of new VCFs.

Conclusion

Lower spinal BMD, the greater anterior vertebral height restoration rate and intradiscal cement leakage were confirmed as risk factors for newly formed VCFs after PVP.     

Early Vertebroplasty versus Delayed Vertebroplasty for Acute Osteoporotic Compression Fracture : Are the Results of the Two Surgical Strategies the Same?

Objective

In Korea, early vertebroplasty (EVP) or delayed vertebroplasty (DVP, which is performed at least 2 weeks after diagnosis) were performed for the treatment of acute osteoporotic compression fracture (OCF) of the spine. The present study compared the outcomes of two surgical strategies for the treatment of single-level acute OCF in the thoracolumbar junction (T12-L2).

Methods

From 2004 to 2010, 23 patients were allocated to the EVP group (EVPG) and 27 patients to the DVP group (DVPG). Overall mean age was 68.3±7.9 and minimum follow-up period was 1.0 year. Retrospective study of clinical and radiological results was conducted.

Results

No significant differences in baseline characteristics were observed between the two groups. As expected, mean duration from onset to vertebroplasty and mean duration of hospital stay were significantly longer in the DVPG (17.1±2.1 and 17.5±4.2) than in the EVPG (3.8±3.3 and 10.8±5.1, p=0.001). Final clinical outcome including visual analogue scale (VAS), Oswestry Disability Index, and Odom''s criteria did not differ between the two groups. However, immediate improvement of the VAS after vertebroplasty was greater in the EVPG (5.1±1.3) than in the DVPG (4.0±1.0, p=0.002). The proportion of cement leakage was lower in the EVPG (30.4%) than in the DVPG (59.3%, p=0.039). In addition, semiquantitative grade of cement interdigitation was significantly more favorable in the EVPG than in the DVPG (p=0.003). Final vertebral body collapse and segmental kyphosis did not differ significantly between the two groups.

Conclusion

Our findings suggest that EVP achieves a better immediate surgical effect with more favorable cost-effectiveness.     

Classification of symptomatic osteoporotic compression fractures of the thoracic and lumbar spine.

The pathophysiology of osteoporotic compression fractures is different from those occurring secondary to traumatic spinal injury, and currently, there is no classification suitable for symptomatic osteoporotic compression fractures treated by percutaneous vertebroplasty. We propose a new classification based on the radiological appearance in the subacute or chronic stage of the clinical presentation of these fractures. They are classified by the authors based on observations and measurements from preoperative and postoperative dynamic lateral radiographs. Compression fractures are divided into two types. Type I is a compression fracture involving the anterior column only. Type II is a fracture involving both the anterior and middle column. Each type is divided into two groups: fractures with union and those with non-union. Type II compression fractures have a higher incidence of non-union than type I (p<0.05). In both type I and II non-union groups, fractures achieve greater increase in vertebral body height after vertebroplasty than both type I and type II union group fractures (p<0.05). In both non-union groups, fractures achieved a greater reduction of kyphotic angle post-vertebroplasty than type I and II union group fractures (p<0.05). Further clinical follow-up of these patients will confirm and extend this classification.     

Minimally Invasive Option Using Percutaneous Pedicle Screw for Instability of Metastasis Involving Thoracolumbar and Lumbar Spine : A Case Series in a Single Center

Objective

To report a minimally invasive treatment option using percutaneous pedicle screw fixation with adjuvant treatment for metastatic thoraco-lumbar and lumbar spinal tumors.

Methods

This is a retrospective study of charts of patients with spinal metastases. All were older than 18 years of age and were considered to have more than 3 months of life expectancy. The patients had single or two level lesions, and compression fracture or impending fracture. Exclusion criterion was metastasis showing severe epidural compression with definite neurological symptoms. Usually spinal segments from one level above to below pathology were stabilized. Visual analog scale (VAS) score for pain assessment and Frankel scale for neurological deficit were used, while pre- and post-operative performance status was evaluated using the Eastern Cooperative Oncology Group (ECOG).

Results

Twelve patients (nine men, three women; median age 54.29 years) underwent surgery. All patients presented with back pain with/without radicular pain. There were no early complications and perioperative mortalities. Following surgery, a significant difference between average pre- and post-operative VAS scores was found (p=0.003). Overall, 91.8% of patients (11/12) experienced improvement in their ECOG score post-operatively. The mean ambulation time was 196.9 days [95% confidence interval (CI), 86.2-307.6 days; median, 97 days]. During follow-up, nine patients died and the mean overall survival time in enrolled twelve patients was 249.9 days (95% CI, 145.3-354.4 days; median, 176 days).

Conclusion

Minimally invasive treatment using percutaneous pedicle screw fixation with adjuvant treatment is a good alternative treatment option for potential instability of the thoraco-lumbar and lumbar spinal metastasis.     

Clinical and radiological factors affecting progressive collapse of acute osteoporotic compression spinal fractures

Osteoporotic compression spine fractures have a different clinical course and outcomes when compared to spinal fractures occurring in the younger population. Only a few studies have investigated the risk factors for progressive osteoporotic compression spine fractures. The purpose of this study was to investigate clinical and radiological factors related to progressive collapse following acute osteoporotic compression spine fractures. We retrospectively identified all patients treated for thoracolumbar fractures in our institution between January 2008 and July 2013. Included cases were examined by plain radiographs and CT scans. For each patient we classified the fracture according to the AOSpine Thoracolumbar Spine Injury Classification System. The difference between initial and final height loss and initial and final local kyphosis was documented as height loss difference and kyphotic angle difference. The presence of old fractures and intravertebral cleft were also documented. The study included 153 patients, comprising 102 women and 51 men. The mean patient age was 68.9 years. The mean length of follow up was 15 months. A statistically significant correlation was found between patient age, final height loss, height loss difference and kyphotic angle difference. Height loss difference and kyphotic angle difference were significantly correlated to type of fracture according to the AO classification system. The height loss difference was 18.1% in A1 type fractures, 27.1% in A2 type fractures, 24.2% in A3 type fractures and 25.7% in A4 type fractures. During a minimum 3-month follow up of conservative treatment for acute osteoporotic vertebral compression fractures, age and the AOSpine Thoracolumbar Spine Injury Classification System were predictive factors for progressive collapse.     

Short-segment Pedicle Instrumentation of Thoracolumbar Burst-compression Fractures; Short Term Follow-up Results

Objective

The current literature implies that the use of short-segment pedicle screw fixation for spinal fractures is dangerous and inappropriate because of its high failure rate, but favorable results have been reported. The purpose of this study is to report the short term results of thoracolumbar burst and compression fractures treated with short-segment pedicle instrumentation.

Methods

A retrospective review of all surgically managed thoracolumbar fractures during six years were performed. The 19 surgically managed patients were instrumented by the short-segment technique. Patients'' charts, operation notes, preoperative and postoperative radiographs (sagittal index, sagittal plane kyphosis, anterior body compression, vertebral kyphosis, regional kyphosis), computed tomography scans, neurological findings (Frankel functional classification), and follow-up records up to 12-month follow-up were reviewed.

Results

No patients showed an increase in neurological deficit. A statistically significant difference existed between the patients preoperative, postoperative and follow-up sagittal index, sagittal plane kyphosis, anterior body compression, vertebral kyphosis and regional kyphosis. One screw pullout resulted in kyphotic angulation, one screw was misplaced and one patient suffered angulation of the proximal segment on follow-up, but these findings were not related to the radiographic findings. Significant bending of screws or hardware breakage were not encountered.

Conclusion

Although long term follow-up evaluation needs to verified, the short term follow-up results suggest a favorable outcome for short-segment instrumentation. When applied to patients with isolated spinal fractures who were cooperative with 3-4 months of spinal bracing, short-segment pedicle screw fixation using the posterior approach seems to provide satisfactory result.