Vertebroplasty and Kyphoplasty in Spinal Trauma

Abstract Kyphoplasty and vertebroplasty have become recognized procedures for the treatment of vertebral fractures, especially in patients with osteoporosis. In most cases of osteoporotic spinal vertebral fracture in elderly patients, polymethylmethacrylate (PMMA) cement is used to fill the defect and stabilize the vertebral body. The techniques of vertebroplasty and kyphoplasty differ in the possibility of realignment and reconstruction of the vertebral body and spinal column. Long-term results in terms of integration of the cement and bioreactivity of the vertebral body are still lacking; so, these procedures are still no options in the treatment of younger patients. Vertebroplasty and kyphoplasty show different success in the management of fresh traumatic spine fractures. The acute traumatic vertebral fracture has to be classified sensitively, to find the right indication for cement augmentation. Mild acute compression fractures can be treated by vertebroplasty or kyphoplasty, severe compression and burst fractures by combination of internal fixation and kyphoplasty. The indications for use of biological or osteoinductive cement in spinal fracture management must still be regarded as restricted owing to the lack of basic biomechanical research data. Such cement should not be used except in clinical studies.     

Minimally invasive treatment of osteoporotic vertebral body compression fractures.

BACKGROUND CONTEXT: Seven hundred thousand osteoporotic compression fractures occur yearly. Approximately 260,000 lead to severe pain, and 150,000 require hospital admissions. Associated with the fractures are increased loss of pulmonary function (90% decreased forced vital capacity per fracture level) and an increase in gastrointestinal complications (early satiety, and therefore malnutrition) and increased mortality (greater than that associated with osteoporotic hip fractures). New treatments available for these painful disorders include kyphoplasty and vertebroplasty. The injections of polymethylmethacrylate into the vertebrae (vertebroplasty technique) decrease pain and improve function. Kyphoplasty (percutaneous placement of a balloon tamp to improve height and create a void, and then the filling of this void with cement) improves function, decreases pain and helps realign the spine. PURPOSE: To compare kyphoplasty and vertebroplasty, and assess their various merits, treatment indications, and outcomes. STUDY DESIGN/SETTING: Literature review with presentation of early results of a national, clinical study. METHODS: Literature review for overview. Retrospective chart/patient review for clinical data presented on kyphoplasty. RESULTS: Ninety-five percent of individuals treated for painful osteoporotic compression fractures have significant improvement in symptoms and function after kyphoplasty or vertebroplasty. Kyphoplasty improves vertebral body height and kyphotic alignment by 50%, if performed within 3 months of the onset of the fracture collapse. CONCLUSIONS: Vertebroplasty and kyphoplasty both have roles in the treatment of painful osteoporotic compression fractures. Only kyphoplasty helps improve height and kyphosis, which should help prevent pulmonary and gastrointestinal complications.     

椎体成形术与后凸成形术治疗老年陈旧性骨质疏松椎体压缩性骨折的相关问题探讨

目的:探讨椎体成形术(PVP)与后凸成形术(PKP)治疗老年陈旧性骨质疏松椎体压缩性骨折的疗效和安全性。方法:自2004年12月至2008年6月,采用PVP治疗28例(40椎)骨质疏松性椎体压缩性骨折,其中男11例(14椎),女17例(26椎);年龄70～91岁,平均72岁。骨折部位T5-L5。采用PKP治疗31例(43椎),男13例(18椎),女18例(25椎);年龄70～92岁,平均74岁;骨折部位T4-L5。术后采用疼痛视觉模拟评分(visualanaloguescale,VAS)、Oswestry功能评分、后凸Cobb角、椎体前中柱的平均高度及骨水泥的渗漏率等指标来评估两组疗效。结果:两组术后VAS评分和Oswestry功能评分都有明显下降,与术前相比有统计学差异(P0.01);两组间VAS评分和Oswestry功能评分降低值无统计学意义(P0.05)。两组后凸Cobb角及椎体前中柱的平均高度与术前比较差异无统计学意义(P0.05)。骨水泥渗漏率,PVP组3个椎体(7.5%),PKP组2个椎体(4.7%),但均无神经症状。两组比较差异无统计学意义(P0.05)。结论:PVP和PKP均能有效缓解老年陈旧性骨质疏松性椎体压缩性骨折所引起的疼痛,改善患者的脊柱功能,并且是一种安全有效的治疗方法。     

Should we fear cement leakage during kyphoplasty in percutaneous traumatic spine surgery? A single experience with 76 consecutive cases

ObjectiveAlthough kyphoplasty is widely used to repair osteoporotic and pathologic vertebral fractures, balloon kyphoplasty and vertebral body stenting are new treatment options in cases of traumatic spinal injury. To our knowledge, there are no literature data on the incidence of cement leakage whereas these two percutaneous techniques are commonly used to repair non-pathologic fractures. The aim of this study was to evaluate and compare the clinical characteristics and the incidence of cement leakage associated with balloon kyphoplasty and vertebral body stenting in the percutaneous treatment of traumatic spinal injury.MethodsA series of 76 consecutive kyphoplasties (50 with vertebral body stenting and 26 balloon kyphoplasties) were retrospectively reviewed. Preoperative and postoperative computed tomography scans were analyzed in order to detect cement leakage and grade it as minor, moderate or major.ResultsThe overall leakage rate was 50%. None of the leakages gave rise to clinical symptoms. Although balloon kyphoplasty and vertebral body stenting did not differ in terms of the leakage rate, the latter technique was associated with a lower leakage volume. The Magerl type, fracture level and use of concomitant osteosynthesis did not appear to significantly influence the leakage rate.ConclusionVertebral body stenting can reduce the amount of cement leakage due to a better cohesion of the bone fragments after kyphosis correction and maintenance.     

An ex vivo biomechanical evaluation of an inflatable bone tamp used in the treatment of compression fracture

STUDY DESIGN: Ex vivo biomechanical study using osteoporotic cadaveric vertebral bodies. OBJECTIVES: To determine if the inflatable bone tamp (tamp) restores height to compressed vertebral bodies and to compare the biomechanical properties of isolated, fractured osteoporotic vertebral bodies treated by kyphoplasty (tamp) or vertebroplasty. SUMMARY OF BACKGROUND DATA: Previous biomechanical studies have shown that vertebroplasty increases vertebral body strength and restores vertebral body stiffness, but does not restore vertebral body height lost as a result of compression fracture. METHODS: Compression fractures were experimentally created in 16 osteoporotic VBs assigned to either the tamp or percutaneous vertebroplasty group. The tamp treatment consisted of inserting balloon-like devices into the vertebral body, inflating the bone tamp, and filling the void with Simplex P (Howmedica, Rutherford, NJ) bone cement. The percutaneous vertebroplasty treatment consisted of directly injecting Cranioplastic bone cement (CMW, Blackpool, UK) into the vertebral body. Pre- and posttreatment heights were measured, and the repaired vertebral bodies were recompressed to determine posttreatment strength and stiffness values. RESULTS: The tamp treatment resulted in significant restoration (97%) of vertebral body height lost after compression, whereas percutaneous vertebroplasty treatment resulted in a significantly lower restoration of lost height (30%) (P < 0.05). Both treatments resulted in significantly stronger vertebral bodies relative to their initial state (P < 0.05). The tamp treatment restored vertebral body stiffness to initial values, but the percutaneous vertebroplasty treatment did not (P < 0.05). CONCLUSIONS: Tamp treatment resulted in significantly greater height restoration than did percutaneous vertebroplasty, without loss of vertebral body strength or stiffness.     

单双入路后凸成形术治疗胸腰椎压缩骨折比较

目的：探讨单入路与双入路球囊扩张椎体后凸成形术治疗老年骨质疏松性胸腰椎压缩性骨折在疗效和安全性上的差异。方法：52例患者随机分为单入路组和双入路组。单入路组16例,经皮伤椎单侧入路穿刺建立工作通道,放置单枚球囊于伤椎内,行球囊扩张椎体后凸成形术 双入路组36例,经皮伤椎双侧入路穿刺建立工作通道,在双侧分别放置球囊于伤椎内,行球囊扩张椎体后凸成形术。结果：52例患者均未发现神经损伤等并发症,两组背痛缓解程度、脊柱后凸畸形矫正度、伤椎前缘高度恢复比较,差异无显著性（P〉0.05） 两组手术时间和透视次数比较,差异有显著性（P〈0.05）。结论：单入路与双入路椎体后凸成形术治疗老年骨质疏松性胸腰椎压缩性骨折疗效相似,单入路较双入路能明显减少手术时间和放射暴露。     

Efficacy of percutaneous kyphoplasty in treating osteoporotic multithoracolumbar vertebral compression fractures

Percutaneous kyphoplasty is a minimally invasive technique that has become an effective and routine alternative for managing osteoporotic vertebral compression fractures. This article reports the clinical outcome of a series of 54 cases of osteoporotic thoracolumbar vertebrae compression fractures treated by percutaneous kyphoplasty. Fifty-four patients with confirmed osteoporosis and at least 1 level of thoracolumbar vertebrae compression fracture were retrospectively selected. Pre- and postoperative and last follow-up clinical evaluation and radiological data were analyzed, including change of visual analog scale (VAS), reduced use of painkillers, locomotor activity, Cobb's angle, and average vertebral body height. Mean follow-up was 20.4 months (range, 6-36 months). In all cases, percutaneous kyphoplasty treatment was successful, significantly increasing vertebral body height, diminishing kyphosis in the fractured vertebrae, and decreasing painkiller use. In all patients, percutaneous kyphoplasty partially or completely relieved back pain. No new deformity was found within the follow-up period, nor were any other complications. The cement leakage rate was 3.86% (8 of 207 vertebrae) with percutaneous kyphoplasty, but no neurological or other complaints were received. Percutaneous kyphoplasty is a simple and safe procedure in managing osteoporotic vertebrae compression fractures. It relieves pain quickly, restores vertebral height, prevents further fracture, and improves patient quality of life.     

Kyphoplastik im konventionellen und halboffenen Verfahren

Kyphoplasty is a young method which was developed for the minimally invasive augmentation of osteoporotic vertebral fractures. In contrast to vertebroplasty, the kyphoplasty technique allows an age-dependent fracture reduction through the inflation of a special balloon in the fractured cancellous bone of the vertebral body. The cancellous bone of the fracture zone is compressed by the balloon, so that a cavity remains in the vertebral body after removing the balloon, which is filled with highly viscous augmentation material. The reduced risk of serious complications, for example epidural leakage of augmentation material, justifies progressively expanding the indications for this technique to traumatic fractures with involvement of the posterior vertebral wall and neoplastic vertebral collapse due to osteolytic metastasis. Besides the indications for the conventional percutaneous approaches, the microsurgical interlaminary approach allows the use of kyphoplasty in more complex fractures involving compression of the neural structures. Kyphoplasty induces swift pain relief and allows rapid mobilisation of patients due to the immediate stabilisation of the affected vertebral bodies. Apart from the operative intervention, the medical treatment of the primary disease and the rehabilitation of the individual patient should be optimised through an interdisciplinary approach.     

Kyphoplastie und Vertebroplastie bei Frakturen im hohen Lebensalter

Kyphoplasty and vertebroplasty are two minimally invasive percutaneous techniques used for treatment of osteoporotic vertebral compression fractures in the thoracic and lumbar spine. The injection of polymethylmetacrylate (PMMA) is often a final attempt at therapeutic treatment of complications due to such fractures. Vertebroplasty involves injection of cement via one or both pedicles under high pressure, thus filling and stabilizing the vertebra without reduction of fracture. Extravertebral cement leakage is a common complication: an intact posterior wall normally prevents cement leakage into the epidural space. Kyphoplasty involves transpedicular inflation of balloon tamps, thus creating a cavity which is then filled with PMMA under low pressure. Restoration of vertebral height is possible and the potential for extravertebral cement leakage lessened.     

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.     

骨水泥椎间渗漏与椎体成形术术后再发椎体压缩骨折相关性研究

目的 评估骨水泥椎间渗漏与椎体成形术（percutaneous vertebroplasty,PVP）术后再发椎体压缩骨折风险的相关性.方法对2009年6月～2011年6月行PVP手术治疗的153例骨质疏松性椎体压缩骨折患者进行回顾性研究,根据椎体再发骨折情况分为再发骨折组与对照组,记录2组患者骨密度、骨水泥注射量与骨水泥椎间隙渗漏情况.结果共124例患者（148个椎体）获得完整随访,平均随访18个月;24例患者（32个椎体）再发椎体压缩骨折.再发椎体压缩骨折患者骨水泥椎间渗透率为25.0%（6/24）与对照组的21.0%（21/100）差异无统计学意义（P＞0.05）.再发椎体压缩骨折患者骨密度低于对照组,差异有统计学意义（P＜0.05）.结论 骨水泥椎间渗漏并不增加PVP术后再发椎体压缩骨折风险,低骨密度是再发椎体骨折的危险因素.     

Percutaneous vertebral augmentation.

BACKGROUND CONTEXT: With the aging of the population, painful osteoporotic compression fractures are becoming more common. PURPOSE: To review the physiologic implications of these injuries as well as treatment options and outcomes, especially with reference to newer, percutaneous "augmentation" procedures, that is, vertebroplasty and kyphoplasty. STUDY DESIGN/SETTING: A literature review. METHODS: No direct, randomized studies comparing vertebroplasty, kyphoplasty and standard, nonoperative care are available. RESULTS: The growing literature suggests a role for kyphoplasty and vertebroplasty in the management of patients with intractable pain or progressive vertebral collapse after vertebral compression fracture. Both procedures likely offer similar rates of pain relief. Kyphoplasty, although more expensive, may allow fracture reduction. The void created with the balloon tamp allows a more viscous cement to be applied, thereby decreasing the risk of extravasation. CONCLUSIONS: More study is required to understand the ideal role of these new techniques in the management of spinal osteoporosis and associated fractures. However, for carefully selected cases, current data suggest that the complication rates are low and pain relief can be profound.     

Vertebroplasty and kyphoplasty for the management of osteoporotic vertebral compression fractures

Osteoporotic vertebral compression fractures have previously been treated nonoperatively given the tremendous morbidity associated with open fixation in elderly patients who often have multiple medical comorbidities. With the advent of percutaneous vertebral augmentation techniques, these fractures can now be stabilized using minimally invasive surgical techniques while maintaining a relatively safe risk profile. Vertebroplasty and kyphoplasty provide immediate pain relief in the great majority of patients who have painful, osteoporotic vertebral compression fractures. The balloon used in kyphoplasty may allow for improved height restoration, cavity creation, and decreased cement extravasation rates. The authors discuss the procedural steps, advantages and disadvantages, and results of each technique, recognizing that prospective, randomized controlled studies are necessary to objectively compare the two techniques.     

四步法单侧入路椎体成形术在胸椎骨质疏松性骨折中的应用

目的探讨四步法单侧入路的经皮椎体成形术(PVP)在胸椎骨质疏松性骨折中的应用。方法运用四步法,对胸椎骨质疏松性骨折椎体进行单侧入路的经皮椎体成形术,计录手术时间,观察骨水泥弥散分布情况,在术前、术后3 d、术后12个月随访时进行疼痛视觉类比评分(VAS)。结果18例21个椎体操作均成功,手术时间10~25 min,平均(16±2.2)min,骨水泥在椎体内弥散分布均越过椎体中线,VAS评分由术前(8.5±1.2)分降低至(2.5±1.4)分,术后效果良好。结论四步法单侧入路椎体成形术治疗胸椎骨质疏松性骨折简单快速、安全有效。     

小剂量骨水泥经皮椎体后凸成形术治疗骨质疏松性椎体压缩骨折

目的 分析小剂量骨水泥经皮椎体后凸成形术(percutaneous kyphoplasty,PKP)治疗老年骨质疏松性椎体压缩骨折(osteoporotic vertebral compression, OVCF)的临床疗效。方法 2009年12月~2013年12月, 采用小剂量骨水泥PKP治疗老年椎体压缩骨折患者46例(58个椎体),测量术前、术后X线片椎体高度变化,并采用视觉模拟量表(visual analogue scale, VAS)评分及Oswestry功能障碍指数(Oswestry disability index, ODI)评估手术疗效。结果 所有手术均顺利完成,无椎体后缘和椎管骨水泥渗漏;所有患者疼痛感明显缓解或消失, 42例患者术后生活可自理,3例患者1~3个月逐渐恢复正常生活,1例患者生活不能自理,但疼痛症状改善。术后随访1年,椎体前缘、椎体中部高度均较术前增加,差异有统计学意义(P< 0.05);术后VAS评分及ODI均较术前改善,差异有统计学意义(P< 0.05)。结论 小剂量骨水泥PKP治疗老年OVCF能有效缓解疼痛,恢复椎体高度,且骨水泥渗漏并发症发生率低,是一种安全可靠的手术方法。     

椎体后凸成形术治疗骨质疏松性胸腰椎压缩骨折的非骨水泥渗漏相关并发症

目的:分析椎体后凸成形术治疗骨质疏松性胸腰椎压缩骨折的非骨水泥渗漏相关并发症。方法:自2008年10月至2012年10月,178例胸腰椎压缩骨折患者,在局麻下行椎体后凸成形术治疗;其中男72例,女106例;年龄58～92岁,平均75.3岁。共224节椎体,胸椎93节,腰椎131节。对患者术中及术后出现的并发症进行记录,分析椎体后凸成形术非骨水泥渗漏相关并发症。结果:所有患者顺利完成手术,无死亡病例。随访时间12～60个月,平均26.2个月。发生骨水泥渗漏27例,占15.1%;非骨水泥渗漏相关并发症15例,其中心脏骤停1例,经心肺复苏,抢救成功,无后遗症;呼吸暂停1例,经抢救恢复;血压下降、心率减慢3例;肠梗阻1例;局部血肿2例;肋间神经痛1例;骨水泥致椎体骨折分离2例;邻椎骨折4例。结论:非骨水泥渗漏相关并发症不常见,心肺并发症是椎体后凸成形术中风险最大的非骨水泥渗漏相关并发症,其可能原因与骨水泥的毒性、神经反射、脂肪栓塞以及椎体内压力变化有关。     

Vertebral body stenting: a new method for vertebral augmentation versus kyphoplasty

Vertebroplasty and kyphoplasty are well-established minimally invasive treatment options for compression fractures of osteoporotic vertebral bodies. Possible procedural disadvantages, however, include incomplete fracture reduction or a significant loss of reduction after balloon tamp deflation, prior to cement injection. A new procedure called “vertebral body stenting” (VBS) was tested in vitro and compared to kyphoplasty. VBS uses a specially designed catheter-mounted stent which can be implanted and expanded inside the vertebral body. As much as 24 fresh frozen human cadaveric vertebral bodies (T11-L5) were utilized. After creating typical compression fractures, the vertebral bodies were reduced by kyphoplasty (n = 12) or by VBS (n = 12) and then stabilized with PMMA bone cement. Each step of the procedure was performed under fluoroscopic control and analysed quantitatively. Finally, static and dynamic biomechanical tests were performed. A complete initial reduction of the fractured vertebral body height was achieved by both systems. There was a significant loss of reduction after balloon deflation in kyphoplasty compared to VBS, and a significant total height gain by VBS (mean ± SD in %, p < 0.05, demonstrated by: anterior height loss after deflation in relation to preoperative height [kyphoplasty: 11.7 ± 6.2; VBS: 3.7 ± 3.8], and total anterior height gain [kyphoplasty: 8.0 ± 9.4; VBS: 13.3 ± 7.6]). Biomechanical tests showed no significant stiffness and failure load differences between systems. VBS is an innovative technique which allows for the possibly complete reduction of vertebral compression fractures and helps maintain the restored height by means of a stent. The height loss after balloon deflation is significantly decreased by using VBS compared to kyphoplasty, thus offering a new promising option for vertebral augmentation.     

Outcome of percutaneous balloon kyphoplasty in vertebral compression fractures

Background:Incidence of vertebral compression fractures (VCFs) is increasing due to increase in human life expectancy and prevalence of osteoporosis. Vertebroplasty had been traditional treatment for pain, but it neither attempts to restore vertebral body height nor eliminates spinal deformity and is associated with a high rate of cement leakage. Balloon kyphoplasty involves introduction of inflatable balloon into the fractured body of vertebra for elevation of the end-plates prior to fixation of the fracture with bone cement. This study evaluates short term functional and radiological outcomes of balloon kyphoplasty. The secondary aim is to explore short-term complications of the procedure.Results:Statistically significant improvements in SF-36 (from 34.29 to 48.53, an improvement of 14.24, standard deviation (SD) - 20.08 P < 0.0001), VAS (drop of 4.49, from 6.74 to 2.24, SD - 1.44, P < 0.0001), percentage restoration of lost vertebral height (from 30.62% to 16.19%, improvement of 14.43%, SD - 15.37, P < 0.0001) and kyphotic angle correction (from 17.41° to 10.59°, improvement of 6.82, SD - 7.26°, P < 0.0001) were noted postoperatively. Six patients had cement embolism, 65 had cement leak and three had adjacent level fracture which required repeat kyphoplasty later. One patient with history of ischemic heart disease had cardiac arrest during the procedure. No patients had neurological deterioration in the followup period.Conclusions:Kyphoplasty is a safe and effective treatment for VCFs. It improves physical function, reduces pain and corrects kyphotic deformity.