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PubMedDate not supplied

Restoring geometric and loading alignment of the thoracic spine with a vertebral compression fracture: effects of balloon (bone tamp) inflation and spinal extension.

BACKGROUND CONTEXT: In patients with osteoporosis, changes in spinal alignment after a vertebral compression fracture (VCF) are believed to increase the risk of fracture of the adjacent vertebrae. The alterations in spinal biomechanics as a result of osteoporotic VCF and the effects of deformity correction on the loads in the adjacent vertebral bodies are not fully understood. PURPOSE: To measure 1) the effect of thoracic VCFs on kyphosis (geometric alignment) and the shift of the physiologic compressive load path (loading alignment), 2) the effect of fracture reduction by balloon (bone tamp) inflation in restoring normal geometric and loading alignment and 3) the effect of spinal extension alone on fracture reduction and restoration of normal geometric and loading alignment. STUDY DESIGN/SETTING: A biomechanical study using six fresh human thoracic specimens, each consisting of three adjacent vertebrae with all soft tissues and bony structures intact. METHODS: In order to reliably create fracture, cancellous bone in the middle vertebral body was disrupted by inflation of bone tamps. After removal of the bone tamps, the specimen was compressed using bilateral loading cables until a fracture was observed with anterior vertebral body height loss of >/=25%. Fracture reduction was performed under a compressive preload of 250 N first under the application of extension moments, and then using inflatable bone tamps. The vertebral body heights, kyphotic deformity of the fractured vertebra and adjacent segments and location of compressive load (cable) path in the fractured and adjacent vertebral bodies were measured on video-fluoroscopic images. RESULTS: The VCF caused anterior wall height loss of 37+/-15%, middle-height loss of 34+/-16%, segmental kyphosis increase of 14+/-7.0 degrees and vertebral kyphosis increase of 13+/-5.5 degrees (p<.05). The compressive load path shifted anteriorly by about 20% of anteroposterior end plate width in the fractured and adjacent vertebrae (p=.008). Bone tamp inflation restored the anterior wall height to 91+/-8.9%, middle-height to 91+/-14% and segmental kyphosis to within 5.6+/-5.9 degrees of prefracture values. The compressive load path returned posteriorly relative to the postfracture location in all three vertebrae (p=.004): the load path remained anterior to the prefracture location by about 9% to 11% of the anteroposterior end plate width. With application of extension moment (6.3+/-2.2 Nm) until segmental kyphosis and compressive load path were fully restored, anterior vertebral body heights were improved to 85+/-8.6% of prefracture values. However, the middle vertebral body height was not restored and vertebral kyphotic deformity remained significantly larger than the prefracture values (p<.05). CONCLUSIONS: The anterior shift of the compressive load path in vertebral bodies adjacent to VCF can induce additional flexion moments on these vertebrae. This eccentric loading may contribute to the increased risk of new fractures in osteoporotic vertebrae adjacent to an uncorrected VCF deformity. Bone tamp inflation under a physiologic preload significantly reduced the VCF deformity (anterior and middle vertebral body heights, segmental and vertebral kyphosis) and returned the compressive load path posteriorly, approaching the prefracture alignment. Application of extension moments also was effective in restoring the prefracture geometric and loading alignment of adjacent segments, but the middle height of the fractured vertebra and vertebral kyphotic deformity were not restored with spinal extension alone.

Aged↗
PubMed2004

[Minimal invasive stabilization of osteoporotic vertebral compression fractures. Methods and preinterventional diagnostics].

PURPOSE: Minimal invasive stabilizations represent a new alternative for the treatment of osteoporotic compression fractures. Vertebroplasty and balloon kyphoplasty are two methods to enhance the strength of osteoporotic vertebral bodies by the means of cement application. MATERIAL AND METHODS: Vertebroplasty is the older and technically easier method. The balloon kyphoplasty is the newer and more expensive method which does not only improve pain but also restores the sagittal profile of the spine. RESULTS: By balloon kyphoplasty the height of 101 fractured vertebral bodies could be increased up to 90% and the wedge decreased from 12 to 7 degrees. Pain was reduced from 7.2 to 2.5 points. The Oswestry disability index decreased from 60 to 26 points. This effect persisted over a period of two years. Cement leakage occurred in only 2% of vertebral bodies. Fractures of adjacent vertebral bodies were found in 11%. CONCLUSION: Good preinterventional diagnostics and intraoperative imaging are necessary to make the balloon kyphoplasty a successful application.

Catheterization↗
PubMed2003

Leakage of cement in percutaneous transpedicular vertebroplasty for painful osteoporotic compression fractures.

e analysed the CT scans and radiographs of 76 vertebrae in 49 patients who underwent vertebroplasty for painful osteoporotic compression fractures. Leaks of cement were classified into three types: those via the basivertebral vein (type B), via the segmental vein (type S), and through a cortical defect (type C). More leaks were identified on CT scans than on radiographs by a factor of 1.5 (74/49). Most type-B (93%) and type-S (86%) leaks were missed or underestimated on a lateral radiograph which is usually the only view used during the injection of cement. Of the leaks into the spinal canal, only 7% (2/28) were correctly identified on radiographs. The areas on lateral radiographs where this type of leak may be observed were divided into four zones, and their diagnostic value in predicting a leak into the spinal canal was evaluated. The results showed that cement in the neural foramina had the highest positive predictive value (86%).

Aged↗
PubMed1987

Dorsal fractures of the triquetrum-avulsion or compression fractures?

In 76 wrists, which had a dorsal fracture of the os triquetrum, the mean size of the ulnar styloid process was radiologically measured and found to be significantly larger (p less than 0.0001) that those in a control group of 100 noninjured hands. This finding supports the view that such injuries are not avulsions, as they are assumed to be, but are the product of a chisel action of a powerful ulnar styloid process on the dorsum of the triquetrum during strong dorsiflexion and ulnar deviation. In accordance, persons with a long styloid process have an increased chance of this kind of injury.

Carpal Bones↗
PubMed1988

Hematogenous osteomyelitis complicating a closed compression fracture of the spine.

A case of hematogenous osteomyelitis of a vertebral body following a closed compression fracture is presented. Staphylococcus septicemia developed 7 days after the injury. In spite of prompt antibiotic treatment, osteomyelitis of the compressed T12 was recognized 5 weeks later. The role of indium white blood cell (WBC) scanning in establishing the diagnosis is highlighted.

Fractures, Closed↗
PubMed2006

Percutaneous vertebroplasty of a myelomatous compression fracture in the presence of previous posterior instrumentation. Report of two cases.

The authors report the use of percutaneous transpedicular vertebroplasty performed using polymethylmethacrylate (PMMA) in two patients. These men (53 and 57 years old) had previously undergone open surgery and posterior instrumentation to treat myelomatous compression fractures. Both patients presented with acute back pain that manifested after minor activities. Kyphotic wedge fractures were diagnosed at T-1 in one case and at L-1 in the other. Both patients were treated at other hospitals with laminectomy and instrumented fusion; multiple myeloma was diagnosed after surgery. The patients experienced severe, recalcitrant, and progressive pain; on referral, they were found to have persistent kyphosis. Multiple myelomatous lesions of the spine were seen in one case and in the other the L-1 fracture represented the only site of disease. Percutaneous vertebroplasty was performed by injecting PMMA into the anterior third of the compressed vertebral body. Both patients experienced a 50% reduction in pain immediately after treatment; 3 months later both were walking and reported minimal back pain while undergoing treatment for multiple myeloma. Three years after surgery one patient reported no back pain and no progressive instability of the spine. Four years after surgery the other patient remains pain free, ambulatory, and with overall disease remission. Percutaneous vertebroplasty provided effective analgesia in these two patients with progressive back pain despite posterior stabilization. In both cases, the anterior column was effectively stabilized. A much larger operative intervention with its attendant risks of morbidity was avoided. In addition, subsequent aggressive medical treatment was well tolerated.

Adult↗
PubMed1987

Osteoporosis with vertebral compression fractures, retropulsed fragments, and neurologic compromise.

Osteoporosis frequently affects the vertebral column and causes compression fractures, biconcave ("fish-mouth") vertebrae, kyphosis, and pain. The cases are reported of three postmenopausal osteoporotic women who had neurologic symptoms of the lower extremities because of vertebral body fractures with a retropulsed fragment narrowing the spinal canal. None of the women had experienced trauma. The fractures resembled burst-type fractures that result from axial loading with major trauma. The retropulsed fragments could be seen best on computed tomographic or magnetic resonance images and were very subtle on conventional radiographs, on which an abnormal posterior vertebral body line was the only abnormality detected. This complication of osteoporosis of the spine is important to recognize so that appropriate treatment can be instituted.

Aged↗
PubMed2005

Preliminary results of balloon kyphoplasty for vertebral compression fractures in organ transplant recipients.

OBJECT: Organ transplant recipients are at risk for vertebral compression fractures (VCFs). The goal of this study was to determine whether kyphoplasty is an effective treatment for VCFs that develop in this patient population. METHODS: Six consecutive patients who had undergone an organ transplant (five liver and one kidney transplant) had a total of 13 symptomatic VCFs that were treated with balloon kyphoplasty. Postprocedure follow-up duration ranged from 6 to 12 months. The mean visual analog scale pain score was 9.3 before treatment and declined to 1.8 after treatment. This improvement was highly significant (p < 0.001). Intake of narcotic drugs decreased or was eliminated in all patients, and there were no complications related to the procedure. There was one instance of clinically insignificant extraosseous cement extravasation. Sagittal alignment was improved by 5 degrees in one patient and was unchanged in the remaining five. During the follow-up period, a new fracture developed adjacent to a treated level in one patient. This was successfully treated with an additional kyphoplasty procedure. CONCLUSIONS: Kyphoplasty can be performed safely in organ transplant recipients with VCF, in whom results are just as favorable as those seen in patients with no history of organ transplantation.

Aged↗
PubMedDate not supplied

Preliminary outcomes and efficacy of the first 360 consecutive kyphoplasties for the treatment of painful osteoporotic vertebral compression fractures.

BACKGROUND CONTEXT: Osteoporosis is a major cause of morbidity in worldwide elderly populations. Patients may become susceptible to vertebral compression fractures (VCFs) from low-impact situations. For patients who have failed conventional, palliative medical therapy, kyphoplasty not only reduces pain associated with vertebral fractures, but also offers a minimally invasive procedure with the potential to address fracture reduction and spinal sagittal alignment. Kyphoplasty involves expanding an inflatable balloon tamp to create a cavity within a vertebral body before cement deposition. PURPOSE: To evaluate the safety and efficacy of kyphoplasty to reduce and fix painful osteoporotic VCFs. STUDY DESIGN/SETTING: A retrospective, single-arm cohort study of consecutive kyphoplasty patients treated at a single center. PATIENT SAMPLE: Three hundred sixty VCFs were treated during 254 kyphoplasty procedures on 222 osteoporotic patients (mean age, 76 years [range, 28-98]; 28% male and 72% female). OUTCOME MEASURES: Patient-reported pain ratings were examined. Cement extravasation was monitored by intraoperative fluoroscopy and on postoperative radiographs. Anterior and midline vertebral height were assessed from standing, lateral radiographs obtained preoperatively and postoperatively. The number of patients who returned with symptomatic, new fractures was monitored. Perioperative complications were recorded. Mean follow-up occurred 21 months after kyphoplasty (range, 6 months through 36 months). RESULTS: Immediate pain relief was reported by 89% of patients by the first follow-up visit. One patient experienced postoperative pain as a result of radiculopathy related to bone filler leakage into the foramen. The remaining patients had persistent pain and were diagnosed with either a new fracture or underlying degenerative disc disease. Greater than or equal to 20% restoration of lost vertebral height (anterior) was observed in 63% of fractures with an overall mean restoration of 30%, and > or = 20% restoration of lost vertebral height (midline) was detected in 69% of fractures with an overall mean restoration of 50%. In this cohort, 12% (30/254) of the patients required additional kyphoplasty procedures to treat 36 symptomatic, new adjacent and remote fractures. No device-related complications occurred. CONCLUSIONS: Kyphoplasty is a safe and effective, minimally invasive procedure for relief of pain associated with VCF. In our series we also demonstrated some restoration of vertebral height and partial correction of sagittal alignment.

Adult↗
PubMed1985

The role of three-dimensional trabecular microstructure in the pathogenesis of vertebral compression fractures.

We compared indices of three-dimensional microstructure of iliac trabecular bone between 26 patients with vertebral compression fractures due to postmenopausal osteoporosis and 24 control subjects without vertebral fracture, who were matched for age, sex, race, menopausal status, and several densitometric and histologic indices of both cortical and trabecular bone mass. The patients with fracture had a significantly lower mean value (1.03 +/- 0.15 vs. 1.26 +/- 0.26; P less than 0.005) for indirectly calculated mean trabecular plate density, an index of the number and connectivity of structural elements, and as a necessary corollary, a significantly higher mean value for the mean thickness of structural elements. Plate density was more than one standard deviation below the age-adjusted mean value for normal postmenopausal white females in 19 (73%) of the fracture cases and in only 5 (21%) of the nonfracture cases (P less than 0.001). We conclude that the biomechanical competence of trabecular bone is dependent not only on the absolute amount of bone present but also on the trabecular microstructure.

Aged↗
PubMed1995

The value of CT in determining potential instability of simple wedge-compression fractures of the lumbar spine.

PURPOSE: To determine whether plain films alone are sufficient in the evaluation of stability of simple wedge-compression fractures of the lumbar spine. METHODS: Plain films and CT scans of 53 consecutive patients seen during a 2-year period with lumbar spine fractures were retrospectively reviewed. Six readers blinded to the CT diagnosis independently read each patient's plain films. Plain-film findings were scored on a five-point graded response scale using criteria proposed by Gehweiler and Daffner. In addition, a fracture was considered to be possibly unstable if there was involvement of more than one vertebral level or greater than 50% loss of anterior vertebral body height. CT findings represented the standard for comparison. CT scans were independently evaluated by three additional readers. Two-column involvement, middle-column involvement alone but with retropulsion, multiple-level involvement, or greater than 50% loss of vertebral height indicated potential instability. RESULTS: For 14 stable and 39 potentially unstable lumbar spine fractures, the pooled (mean) plain-film negative predictive value for detection of potentially unstable fractures was 0.62 (95% confidence interval, 0.53 to 0.70), with a sensitivity of 0.83 (95%, confidence interval; 0.78 to 0.87), and specificity of 0.80 (95% confidence interval, 0.70 to 0.87). CONCLUSION: Plain films are not adequate for determining stability of lumbar spine fractures.

Diagnosis, Differential↗
PubMed2003

Intravertebral clefts in osteoporotic vertebral compression fractures.

OBJECTIVE: To describe the characteristics, radiographic appearance, and significance of intravertebral clefts in vertebral compression fractures (VCFs) of patients with osteoporosis presenting for vertebroplasty. METHODS: This was a prospective radiographic study of 50 consecutive patients with 82 VCFs who underwent vertebroplasty at a tertiary referral center. Patients underwent imaging preoperatively with standing lateral and supine cross-table lateral radiographs and magnetic resonance imaging (MRI). Standing lateral radiographs were also obtained postoperatively. Clefts were defined at the time of vertebroplasty as confluent reservoirs for polymethylmethacrylate (PMMA). Postoperatively, all images were reexamined for the presence and characterization of intravertebral clefts. RESULTS: Twenty-four of 50 patients (48%) had clefted VCFs, and 30 of 82 VCFs (37%) contained clefts. Clefted VCFs were severe, dynamically mobile, and occurred primarily in the thoracolumbar junction. Clefts were detectable by standing lateral radiography in 14%, by supine cross-table radiography in 64%, and by MRI in 96% of fractured vertebrae. Clefts occurred primarily in the anterosuperior portion of the vertebral body, and cleft margins appeared increasingly sclerotic in persistently mobile VCFs. PMMA fill patterns of clefted and unclefted VCFs were distinct. CONCLUSION: Intravertebral clefts occur frequently in osteoporotic VCFs of patients who present for vertebroplasty. The radiographic characteristics of clefts evolve over time and can be indistinguishable from Kümmell's disease in severe, persistently mobile, clefted osteoporotic VCFs.

Aged↗
PubMed2004

Vertebroplasty and kyphoplasty: rapid pain relief for vertebral compression fractures.

Vertebroplasty and kyphoplasty are minimally invasive procedures aimed at relieving symptoms associated with vertebral compression fractures. They have become accepted, highly effective, safe procedures, and are known for their high patient satisfaction rates. Although they are image-guided percutaneous spine therapies, differences do exist. They have each arisen from different backgrounds and are championed by different subspecialties and each involves slightly different techniques. In addition, a prospective, randomized trial comparing the two techniques has yet to be performed. This lack of objective data allows market forces and opinions to have a large influence on utilization and patient referral.

Aged↗
PubMed1998

Personal experience in managing acute compression fractures, their aftermath, and the bone pain syndrome, in osteoporosis.

Recovery from acute symptomatic vertebral compression fractures in osteoporosis patients can be said to occur in three broad stages. For over three decades the author managed them in the following way. In the 3-week-long acute stage after the fracture, the patient usually stayed in bed for 4-8 days until able to turn easily from side to side. Then a back support was provided and the patient was allowed up for frequent but brief intervals. In the following approximately 10-week-long healing stage, the patient lay down for 20 min every 2 h (the Intermittent Horizontal Rest Regimen or IHRR). Patients who developed a subsequent lordotic low back pain stage did the IHRR for a further 10 weeks. In the uncommon bone pain syndrome, doing the IHRR for 10 weeks, or occasionally longer, also relieved pain. When the IHRR failed to provide early pain relief in a compliant patient, other causes of the pain were sought and were usually found.

Acute Disease↗
PubMedDate not supplied

Percutaneous polymethylmethacrylate vertebroplasty in the treatment of osteoporotic vertebral body compression fractures: technical aspects.

PURPOSE: To describe a technique for percutaneous vertebroplasty of osteoporotic vertebral body compression fractures and to report early results of its use. METHODS: The technique was used over a 3-year period in 29 patients with 47 painful vertebral fractures. The technique involves percutaneous puncture of the involved vertebra(e) via a transpedicular approach followed by injection of polymethylmethacrylate (PMMA) into the vertebral body. RESULTS: The procedure was technically successful in all patients, with an average injection amount of 7.1 mL PMMA per vertebral body. Two patients sustained single, nondisplaced rib fractures during the procedure; otherwise, no clinically significant complications were noted. Twenty-six patients (90%) reported significant pain relief immediately after treatment. CONCLUSION: Vertebroplasty is a valuable tool in the treatment of painful osteoporotic vertebral fractures, providing acute pain relief and early mobilization in appropriate patients.

Adult↗
PubMed2003

Surgical removal of epidural and intradural polymethylmethacrylate extravasation complicating percutaneous vertebroplasty for an osteoporotic lumbar compression fracture. Case report.

The authors report the case of patient with a lumbar vertebral body osteoporotic compression fracture who underwent percutaneous transpedicular polymethylmethacrylate (PMMA)-assisted vertebroplasty in whom extravasation of the cement into the spinal canal caused immediate neurological deterioration. Lateral lumbar radiography and computerized tomography scanning demonstrated the presence of intraspinal PMMA. The patient suffered severe low-back pain, left-sided sciatica, and profound left L2-4 distribution weakness and numbness. She underwent immediate L-2 laminectomy, the extra- and intradural PMMA was removed, and instrumentation-assisted lateral mass fusion was performed. The patient recovered without incident and her neurological deficit improved. Extravasation of cement into the spinal canal, neural foramen, paraspinal veins, or disc space has been reported in 11 to 73% of percutaneous transpedicular PMMA-assisted vertebroplasty procedures. It is disturbing that more than one group of authors has documented symptomatic spinal canal PMMA extravasation and that the patients were left severely handicapped because of a stated fear that surgery to remove the cement would be difficult and make them worse. The results achieved in this case refute that published notion. It is important to document that decompressive surgery and PMMA removal from the spinal canal are easy and can lead to immediate neurological improvement. With the increasing popularity of percutaneous transpedicular PMMA-assisted vertebroplasty, the authors suspect that more of these cases will be seen.

Bone Cements↗