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PubMed1999

Biomechanical efficacy of unipedicular versus bipedicular vertebroplasty for the management of osteoporotic compression fractures.

STUDY DESIGN: Cadaveric study on the biomechanics of osteoporotic vertebral bodies augmented and not augmented with polymethylmethacrylate cement. OBJECTIVES: To determine the strength and stiffness of osteoporotic vertebral bodies subjected to compression fractures and 1) not augmented, 2) augmented with unipedicular injection of cement, or 3) augmented with bipedicular injection of cement. SUMMARY OF BACKGROUND DATA: Percutaneous vertebroplasty is a relatively new method of managing osteoporotic compression fractures, but it lacks biomechanical confirmation. METHODS: Fresh vertebral bodies (L2-L5) were harvested from 10 osteoporotic spines (T scores range, -3.7 to -8.8) and compressed in a materials testing machine to determine intact strength and stiffness. They were then repaired using a transpedicular injection of cement (unipedicular or bipedicular), or they were unaugmented and recrushed. RESULTS: Results suggest that unipedicular and bipedicular cement injection restored vertebral body stiffness to intact values, whereas unaugmented vertebral bodies were significantly more compliant than either injected or intact vertebral bodies. Vertebral bodies injected with cement (both bipedicular and unipedicular) were significantly stronger than the intact vertebral bodies, whereas unaugmented vertebral bodies were significantly weaker. There was no significant difference in loss in vertebral body height between any of the augmentation groups. CONCLUSIONS: This study suggests that unipedicular and bipedicular injection of cement, as used during percutaneous vertebroplasty, increases acute strength and restores stiffness of vertebral bodies with compression fractures.

Absorptiometry, Photon↗
PubMed1997

Vertebral compression fractures in multiple myeloma. Part II. Assessment of fracture risk with MR imaging of spinal bone marrow.

PURPOSE: To determine the utility of bone marrow magnetic resonance (MR) imaging in the assessment of risk of vertebral compression fractures in patients with multiple myeloma. MATERIALS AND METHODS: In 50 patients with stage III multiple myeloma, 280 MR examinations of the thoracolumbar spine obtained at diagnosis and during treatment (mean follow-up, 28 months) were analyzed to determine MR patterns of bone marrow involvement before treatment and the occurrence of vertebral compression fracture at follow-up. Four MR patterns of marrow involvement were determined: A, normal marrow appearance; B, fewer than 10 focal lesions; C, more than 10 focal lesions; and D, diffuse infiltration. Fracture-free survival was compared according to these patterns. RESULTS: During follow-up, 131 vertebral compression fractures appeared in 37 patients. Patients with pattern A (n = 10) or B (n = 16) had significantly longer fracture-free survival before occurrence of the first, second, and third fractures than those with pattern C or D (P < 10(-5)). Relative risks of first, second, and third fracture occurrence for patients with pattern C or D compared with those with pattern A or B were 6.2, 9.1, and 11.0, respectively. CONCLUSION: Determination of MR patterns of spinal bone marrow involvement is a potential relevant factor to predict the risk of vertebral fractures in patients with stage III multiple myeloma.

Adult↗
PubMed1988

Subacute osteoporotic compression fracture: misleading magnetic resonance appearance.

Three patients with benign subacute osteoporotic vertebral compression fractures are presented. T1 weighted magnetic resonance (MR) images (SE 500/30) showed decreased vertebral signal. Because the results of the MR examination were thought to indicate malignant disease, extensive medical workups, including one biopsy, were pursued in all three patients. Routine (SE 500/30) spin-echo pulse sequences cannot definitively distinguish between benign and malignant vertebral compression fractures.

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PubMed2004

Calcitonin for treating acute pain of osteoporotic vertebral compression fractures: a systematic review of randomized, controlled trials.

Vertebral collapse is one of the most common fractures associated with osteoporosis. The subsequent back pain is severe and often requires medications, bed rest and hospitalization to control pain and improve mobilization. The purpose of this systematic review was to assess the effects of calcitonin versus placebo for the treatment of acute pain in patients sustaining stable, recent, osteoporotic vertebral compression fractures. MEDLINE (1966-2003), EMBASE (1980-2003), Cochrane Controlled Trial Registry (2003, volume 3), other databases, and conference proceedings were searched for relevant research. Primary study authors and the pharmaceutical manufacturer were contacted, and bibliographies of relevant papers were hand-searched. Randomized, double-blind, placebo-controlled trials comparing calcitonin versus placebo for the acute pain of recent osteoporotic vertebral compression fractures were included. Two reviewers extracted data, performed numeric calculations and extrapolated graphical data independently. The combined results from five randomized controlled trials, involving 246 patients, determined that calcitonin significantly reduced the severity of pain using a visual analogue scale following diagnosis. Pain at rest was reduced as early as 1 week into treatment (weighted mean difference [WMD] =3.08; 95% confidence interval [CI]: 2.64, 3.52) and this effect continued weekly to 4 weeks (WMD =4.03; 95% CI: 3.70, 4.35). A similar pattern was seen for pain scores associated with sitting, standing, and walking. Side effects were gastrointestinal, minor and often self-limited. Calcitonin appears to be effective in the management of acute pain associated with acute osteoporotic vertebral compression fractures by shortening time to mobilization.

Acute Disease↗
PubMed2004

Vertebral reconstruction with biodegradable calcium phosphate cement in the treatment of osteoporotic vertebral compression fracture using instrumentation.

OBJECTIVE: To assess the efficacy of posterior instrumentation and vertebral reconstruction with biodegradable calcium phosphate cement (CPC) in the treatment of osteoporotic vertebral compression fracture with neurologic deficit. BACKGROUND: Vertebroplasty consists of the injection of polymethylmethacrylate (PMMA) cement into the vertebral body. While PMMA has high mechanical strength, it cures fast and thus allows only a short handling time. Other potential problems of using PMMA injection may include damage to surrounding tissues due to the high polymerization temperature or by the toxic unreacted monomer and the lack of long-term biocompatibility. Bone mineral cements such as calcium carbonate and CPCs have a longer working time and low thermal effect. They are also biodegradable while providing good mechanical strength. However, the viscosity of injectable mineral cements is high, and the infiltration of these cements into the vertebral body has been questioned. Recently, the infiltration properties of CPC have been significantly improved, making it more suitable for injection into the vertebral bodies for vertebral reconstruction. METHODS: Five patients were included in this open prospective study. Inclusion criteria were delayed collapsed vertebral compression fractures responsible for severe pain and neurologic dysfunction necessitating posterior decompression surgery. Of five patients, two were male and three were female with an average age at surgery of 80.4 years (71-85 years) and an average duration of follow-up of 2.5 years (2-3.5 years). Evaluation of clinical data was based on x-ray, Japanese Orthopaedic Association (JOA) score for low back pain (full score is 29 points), and Visual Analog Scale (VAS). RESULTS: The levels of the delayed collapsed vertebrae were T10, L1, and L2 (for one patient each) and L4 (two patients). All patients were in poor condition, for example, renal failure, heart failure, and chronic hepatitis. The average operative time was 2 hours (1 hour 36 minutes to 2 hours 16 minutes), and intraoperative bleeding was 181 mL (85-236 mL). As for clinical symptoms, preoperative JOA score averaged 17.8 points and was improved to 26 points postoperatively, while the preoperative VAS score of 8.6 points improved to 2 points postoperatively. Morphologic evaluation showed preoperative vertebral compression ratio averaged 41% and improved to 74% immediately after the operation and finally settled at 68%. Just one of five cases experienced late vertebral collapse 3 months after the operation. CONCLUSION: Vertebral reconstruction with biodegradable CPC in the treatment of osteoporotic vertebral compression fracture using instrumentation was a safe and useful surgical treatment.

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PubMed1988

Vertebral osteomyelitis presenting as spinal compression fracture. Six patients with underlying osteoporosis.

Six patients with osteoporosis had vertebral osteomyelitis (VO) with infection of a single vertebra that presented with a collapsed vertebral body, thought to be a simple compression fracture. The resulting delay in correctly diagnosing VO was associated with disabling sequelae in a high proportion of cases. This distinctive presentation accounted for 13% of all hospitalized patients with VO and 2.4% of inpatients with osteoporotic compression fractures during the last five years; it may be more common than suggested by the paucity of published cases. In patients with osteoporosis and vertebral compression fractures, osteomyelitis should be considered when there is severe back pain, persistent unexplained fever, unexplained elevation of the erythrocyte sedimentation rate, or bacteremia without an obvious extravertebral focus of infection, particularly if the patient is immunocompromised. Early biopsy and culture of the collapsed vertebral body will facilitate diagnosis and therapy.

Acute Disease↗
PubMed2004

Percutaneous pediculoplasty in osteoporotic compression fractures.

Percutaneous pediculoplasty is a vertebroplasty-complementary technique that can be carried out with one needle for each single approach. This report describes five cases of osteoporotic vertebral and pedicular compression fractures that were treated with percutaneous vertebroplasty and bilateral pediculoplasty with use of polymethylmethacrylate and high-quality fluoroscopic guidance. All patients reported complete pain relief. This is a safe, fast, and effective treatment for osteoporotic compression fractures with pedicle compromise.

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PubMed2006

Endoscopic vertebroplasty for the treatment of chronic vertebral compression fracture. Technical note.

The authors describe a new vertebroplasty technique for the treatment of chronic painful vertebral compression fractures (VCFs). A urinary balloon catheter is introduced into the vertebral body (VB) via a bilateral transpedicular approach and inflated with contrast medium to obtain sufficient space for endoscopic observation. The granulation tissue occupying the VB is then removed using a punch or curette inserted through one pedicle, with the guidance of an endoscope introduced through the contralateral pedicle. After endoscopic resection of granulation tissue in the fractured VB, vertebroplasty is performed by injecting calcium phosphate cement (CPC) into the VB. Fourteen patients in whom chronic painful VCFs were diagnosed underwent surgery involving the aforementioned technique. In all cases, intractable pain and ambulatory function improved after surgery, and there were no significant systemic complications. On radiological evaluation in eight cases in which the follow-up period exceeded 1 year, the mean height of the fractured VB improved from 38% of that of adjacent intact VBs to 85%. Although a slight loss of correction was routinely observed at 1 month postoperatively, an additional loss of VB height was not noted up to 1 year later. Bone formation was commonly seen along the anterior wall of the involved vertebrae in all cases. Vertebroplasty involving the endoscopic removal of granulation tissue proved to be an efficacious procedure for the treatment of chronic painful VCFs. The osteoconductive capacity of CPC facilitated callus formation and ultimately restoration of vertebral bone structure.

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PubMed1985

[Experience with the treatment of compression fractures of the vertebrae in children].

Based on an analysis of observation of 176 children with compressive fractures of vertebral bodies the authors consider the method of "evolutionary physical culture" in children with stable compressive fractures of vertebral bodies to be more physiological, convenient and endurable for patients. Most of the children followed up in the remote period (up to 6 years) showed a complete recovery of the structure and form of the injured vertebrae.

Adolescent↗
PubMed2004

Non-traumatic compression fractures of the thoracic spine following a seizure -- treatment by percutaneous kyphoplasty.

A 26-year-old male presented with acute mid-thoracic back pain following a witnessed grand mal seizure. There was no trauma and the patient was on steroids for systemic lupus erythematosus. X-rays and CT scans of the thoracic spine revealed compression fractures at T5 and T6, with 50 % loss of vertebral height and kyphosis. He underwent percutaneous kyphoplasty of both vertebrae, with symptomatic improvement. Non-traumatic compression fractures of the thoracic spine following seizures are a rare injury. This may be related to the compressive forces exerted on the vertebral column by the contractions of the truncal muscles, during a seizure. These compression fractures are suitable for treatment by minimally invasive techniques, such as kyphoplasty.

Adult↗
PubMed2002

Percutaneous vertebroplasty in the management of a patient with malignant pain and associated osteolytic compression fractures.

Percutaneous vertebroplasty is a minimally invasive procedure that is effective in the treatment of pain resulting from pathologic compression fractures, osteolytic bone metastases from solid tumors, myeloma, vertebral hemangioma, and osteoporotic compression fractures. A discussion of a patient with severe, aggressive metastatic breast cancer to the spine with compression and osteolysis of multiple lumbar vertebral bodies is presented. Despite treatment with opiates, chemotherapy, radiation therapy, and the implantation of a morphine pump, her pain was not adequately treated until she underwent multilevel vertebroplasty. The clinical and technical application of vertebroplasty in the context of the management of vertebral pain of malignant origin is presented as an integral part of multidisciplinary pain management.

Adult↗
PubMed2005

Histological evaluation of biopsies obtained from vertebral compression fractures: unsuspected myeloma and osteomalacia.

STUDY DESIGN: A histological evaluation of biopsies obtained from presumed osteoporotic vertebral compression fractures (VCF) to confirm possible osteomalacia after tetracycline labeling. OBJECTIVE: To describe the results of a series of biopsies obtained at the time of vertebral augmentation in presumed osteoporotic VCF, with special reference to the presence of unmineralized bone (osteomalacia) and occult or unconfirmed plasma cell dyscrasia. SUMMARY OF BACKGROUND DATA: Vertebral augmentation is now widely performed as a method to treat osteoporotic or osteolytic VCF. However, the influence of underlying pathology on the effect of treatment is unclear. METHODS: As of October 2003, 178 biopsies were obtained from 142 patients with VCF during 246 kyphoplasty procedures. There were 110 one-level, 28 two-level, and 4 three-level biopsies. Patients included 41 men and 101 women, with an average age of 72 years (range 40-90). The patients consented to this procedure, and 25 received tetracycline (1g/day, in 2 doses separated by 6 days). Vertebral body biopsies were taken using a trephine just before the kyphoplasty procedure. The biopsies were fixed, embedded, and stained with toluidine blue and hematoxylin eosin, and were viewed with transmitted light. Unstained sections were viewed under fluorescent light to detect tetracycline labels. RESULTS: The 178 biopsy levels included: T4 (3), T5 (1), T6 (4), T7 (13), T8 (12), T9 (8), T10 (11), T11 (17), T12 (28), L1 (25), L2 (14), L3 (13), L4 (17), and L5 (12). All specimens showed fragmented bone with variable amounts of unmineralized bone (osteoid), suggesting bone remodeling and/or fracture healing. Woven bone and cartilaginous tissue were often present, representing fracture callus formation. The biopsies obtained from 30 patients (21%), including 4 who received tetracycline, showed significantly increased osteoid, suggesting either increased bone remodeling activity or mineralization defect (osteomalacia). One sample from these 4 patients who received tetracycline showed no tetracycline labels, essentially diagnostic of osteomalacia. The biopsies also provided definitive diagnoses for one case of unsuspected and 3 cases of unconfirmed plasma cell dyscrasia. CONCLUSIONS: The majority of biopsies from this series of patients revealed findings consistent with various stages of fracture healing. Osteoid seams were increased in 30 patients, representing either increased bone remodeling or osteomalacia. More cases with tetracycline labeling will help elucidate the true incidence of osteomalacia in this population. As we confirmed 4 cases of plasma cell dyscrasia, we advocate a biopsy during each first-time vertebral augmentation procedure.

Adult↗
PubMed2003

The dynamic mobility of vertebral compression fractures.

We have observed that some osteoporotic vertebral compression fractures (VCFs) are mobile. The purpose of this report was to document the existence of dynamic fracture mobility, estimate the frequency of dynamic mobility in patients referred for vertebroplasty, define the magnitude and nature of dynamic mobility, and consider the implications of the dynamic mobility of osteoporotic VCFs. This was a prospective radiographic analysis of 41 consecutive patients with 65 VCFs who underwent vertebroplasty. Preoperative standing lateral radiographs of the fractured vertebrae were compared with supine cross-table lateral radiographs to determine the presence or absence of dynamic mobility. Postoperative standing lateral radiographs were evaluated to document fracture mobility and assess final vertebral height restoration. Radiographs were manually digitized to calculate vertebral body morphometrics. Dynamic fracture mobility was demonstrated in 44% of patients (35% of treated vertebrae) who underwent vertebroplasty. Postoperatively, in mobile fractures, average anterior vertebral height increased 106% compared with initial fracture height (absolute increase, 8.41 +/- 0.4 mm). Mean lateral vertebral area increased from 48% to 80% of normal, and kyphotic angle decreased 40%. Mobile fractures dominated at the thoracolumbar junction. Intravertebral clefts were defined and identified in every mobile fracture and were absent from every nonmobile (fixed) fracture. This radiographic series documents the previously unrecognized occurrence of dynamic fracture mobility in many osteoporotic VCFs. Fracture mobility can be substantial and clinically significant. Any intervention that claims vertebral height restoration must control for the occurrence of dynamic fracture mobility.

Aged↗
PubMed2005

Correlation of back pain, compression fracture and quadriceps muscle strength with bone mineral density in renal insufficiency patients.

AIM: The purpose of this study was to evaluate bone mineral density (BMD), bone parameters, complete blood count, erythrocyte sedimentation rate, electrolyte values, back pain, compression fracture and quadriceps muscle strength in mild and moderate renal insufficiency patients. METHODS: Thirty-six female, 3 male, patients with the diagnosis of osteoporosis in addition to mild or moderate chronic renal insufficiency who were followed in Istanbul University, Cerrahpasa Faculty of Medicine, Physical Therapy and Rehabilitation Department, Osteoporosis and Nephrology Outpatient Clinics between March 2003 and March 2004, were included in the study. In the control group there were 17 female, 5 male patients with osteoporosis but without renal insufficiency. The inclusion criteria were to have osteoporosis, be aged between 40-70 with a creatinine clearance between 30-70 mL/min in the case group, >70 mL/min in the control group. The patients whose creatinine clearance was <30 mL/min, and whose BMD was normal or osteopenic even though creatinine clearance was >30 mL/min were excluded from the study. RESULTS: There was no significant difference with respect to back pain, compression fracture and quadriceps muscle strength between the 2 groups. The mean value of neck BMD, T and Z score were significantly lower in the case group (P<0.05). CONCLUSIONS: As a conclusion, PTH related bone disease had an important effect on BMD, although, the risk factors for osteoporosis were equally important. In various researches, the relationship between BMD values and history of fracture in renal osteodystrophy patients could not be shown. In our study, the history of prior fracture or fracture in the family were important risk factors for osteoporosis. Renal osteodystrophy patients had low BMD values in mild and moderate stages of the disease. Prior fracture as well as osteoporotic fractures in the family should be part of a comprehensive evaluation of the patient.

Adult↗
PubMed2004

Intravertebral vacuum phenomenon in osteoporotic compression fracture: report of 67 cases with quantitative evaluation of intravertebral instability.

OBJECT: The objectives of this study were to: 1) describe the incidence and clinical features of intravertebral vacuum phenomenon (IVVP) in a relatively large number of cases; 2) quantitatively evaluate intravertebral instability and determine the factors affecting instability; and 3) evaluate the efficacy of percutaneous vertebroplasty in the treatment of this phenomenon. METHODS: A retrospective review was conducted of the records of 67 patients with IVVP among 652 consecutive cases of osteoporotic compression fracture. Comparisons between the IVVP group and a control group, a stable group, and an unstable group were conducted. Percutaneous vertebroplasty was performed in all patients. There were 67 patients (10.3%) in whom there were 70 vacuum phenomena of the intravertebral space. Intravertebral vacuum phenomena occurred predominantly in the thoracolumbar junction (81%) and in patients with a longer duration of symptoms (10.6 +/- 9.8 months) compared with the control group. Of 59 vertebrae for which flexion-extension radiographs were available, 26 vertebrae were categorized as stable and 33 as unstable. Twenty-one vertebrae (64%) had undergone compression fracture in the unstable group compared with nine (35%) compression fractures in the stable group. There were 28 (85%) fractures of the wedged vertebrae in the unstable group compared with 16 (61%) fractures in wedged vertebrae in the stable group. Percutaneous vertebroplasty was performed with successful clinical outcome. CONCLUSIONS: Intravertebral vacuum phenomenon is more common than has been previously appreciated. The results of this study indicate that biomechanics, not ischemic or avascular theory, may play an important role in pathogenesis of this phenomenon. Percutaneous vertebroplasty was found to be a minimally invasive and effective procedure for the treatment of IVVP.

Aged↗
PubMed2002

FDG-PET findings of vertebral compression fractures in osteoporosis: preliminary results.

The aim of this study was to evaluate FDG-PET findings in patients with osteoporosis or preclinical osteoporosis and acute vertebral compression fractures in order to determine whether FDG-PET has a value for distinction of pathological from osteoporotic vertebral fractures. 17 patients with a spontaneous compression fracture of the spine were evaluated by bone scanning with Tc-99m HDP, positron emission tomography with fluorine-18 deoxyglucose (FDG-PET) and magnetic resonance imaging (MRI). Osteoporosis had been established in all cases by X-ray and osteodensitometry. PET and bone scan images were scored independently from 0 (no pathological uptake) to 4 (definitive pathological uptake) by two blinded nuclear medicine physicians. The results of the blinded scoring were compared to MRI findings which served as gold standard. In 13 out of 17 patients, MRI demonstrated a vertebral fracture generating from osteoporosis. In 12 of these 13 cases, PET scans were scored with 0 or 1 and categorized as true negative. Standard uptake values (SUV) ranged between 1.1 and 2.4. In one of the 13 patients, PET was interpreted false positive with an uptake score of 3 (SUV = 2.9). Of the 17 patients, MRI revealed a pathological fracture caused by spondylodiscitis in three patients and by plasmacytoma in one patient. In these patients, all PET scans were highly positive with a score of 3 and 4 and SUV values between 3.8 to 9.8. The bone scans of all 17 patients were positive with scores of 3 or 4 but a differentiation between osteoporotic and pathological fractures was not possible. Our preliminary results indicate that acute vertebral fractures that originated from osteoporosis or preclinical osteoporosis tend to have no pathologically increased FDG uptake. Since a high FDG uptake is characteristic for malignant and inflammatory processes, use of FDG-PET may have potential value for differentiation between osteoporotic and pathological vertebral fractures.

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PubMed2003

Biomechanical evaluation of kyphoplasty and vertebroplasty with calcium phosphate cement in a simulated osteoporotic compression fracture.

Kyphoplasty and vertebroplasty with polymethylmethacrylate (PMMA) have been used for the treatment of osteoporotic vertebral compression fractures. We performed kyphoplasty and vertebroplasty with alpha-tricalcium phosphate cement (CPC) and PMMA to compare the biomechanical properties. Thirty osteoporotic vertebrae were harvested from nine embalmed cadavers. We randomized the vertebrae into four treatment groups: (1) kyphoplasty with CPC; (2) kyphoplasty with PMMA; (3) vertebroplasty with CPC; and (4) vertebroplasty with PMMA. Prior to injecting the cement, all vertebrae were compressed to determine their initial strength and stiffness. They were then recompressed to determine their augmented strength and stiffness. Although the augmented strength was greater than the initial strength in all groups, there was no significant difference between the two bone cements for either kyphoplasty or vertebroplasty. The augmented stiffness was significantly less than the initial stiffness in the kyphoplasty groups, but the difference between the two cements did not reach significance. In the vertebroplasty groups, the augmented stiffness was not significantly different from the initial stiffness. There was no significant difference between the two bone cements for either procedure when cement volume and restoration of anterior height were assessed. We concluded that kyphoplasty and vertebroplasty with CPC were viable treatment alternatives to PMMA for osteoporotic vertebral compression fractures.

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