Search

The treatment of vertebral compression fractures using percutaneous augmentation is an effective method to reduce pain and decrease mortality rates. Surgical methods include vertebroplasty, kyphoplasty, and vertebral augmentation with implants. A previous study suggested that a titanium implantable vertebral augmentation device (TIVAD) produced superior height restoration compared to balloon kyphoplasty (BKP) but was based on a less clinically relevant biomechanical model. Moreover, the introduction of high pressure balloons and directional instruments may further aid in restoring height.The objective was to evaluate three procedures (BKP, BKP w/ Kyphon Assist (KA; directional instruments), and TIVAD) used for percutaneous augmentation of vertebral fractures with respect to height restoration and sustainability post-operatively.This is an in vitro cadaver study performed in a laboratory setting.Five osteoporotic female human cadaver thoracolumbar spines (age: 63-77 years, T-score: -2.5 to -3.5, levels: T7-S1) were scanned using computed tomography and dissected into 30 two-functional spine units (2FSUs). Vertebral wedge compression fractures were created by reducing the anterior height of the vertebrae by 25% and holding the maximum displacement for 15 minutes. Post-fracture, surgery was performed on each 2FSU with a constant 100 N load. Surgeries included BKP, BKP w/ KA, or TIVAD (n=10 per treatment group). Post-surgery, cyclic loading was performed on each 2FSU for 10,000 cycles at 600 N (walking), followed by 5,000 cycles at 850 N (standing up/sitting down), and 5,000 cycles at 1250 N (lifting a 5-10kg weight from the floor). Fluoroscopic images were taken and analyzed at the initial, post-fracture, post-surgery, and post-loading timepoints. Anterior, central, and posterior heights, Beck Index, and angle between endplates were assessed.No difference in height restoration was observed among treatment groups (p=.72). Compared to the initial height, post-surgery anterior height was 96.3±8.7% for BKP, 94.0±10.0% for BKP w/ KA, and 95.3±5.8% for TIVAD. No difference in height sustainability in response to 600 N (p=.76) and 850 N (p=.20) load levels was observed among treatment groups. However, after 1250 N loading, anterior height decreased to 93.8±6.8% of the post-surgery height for BKP, 95.9±6.4% for BKP w/ KA, and 86.0±6.6% for TIVAD (p=.02). Specifically, the mean anterior height reduction between post-surgery and post-1250 N loading timepoints was lower for BKP w/ KA compared to TIVAD (p=.02), but not when comparing BKP to TIVAD (p=.07). No difference in Beck Index or angle between endplates was observed at any timepoint among the treatment groups.The present study, utilizing a clinically relevant biomechanical model, demonstrated equivalent height restoration post-surgery and at relatively lower-level cyclic loading using BKP, BKP w/ KA, and TIVAD, contrary to results from a previous study. Less anterior height reduction in response to high-level cyclic loading was observed in the BKP w/ KA group compared to TIVAD.All three treatments can restore height similarly after a vertebral compression fracture, which may lead to pain reduction and decreased mortality. BKP w/ KA may exhibit less height loss in higher-demand patients who engage in physical activities that involve increased weight resistance.

Few researchers have verified the clinical efficacy and safety of the modified unilateral extrapedicular approach (mUEP) applied to the percutaneous kyphoplasty (PKP) in comparative studies with other puncture techniques. Compared with the bilateral transpedicular approach (BTP), whether mUEP PKP is a preferred treatment for lumbar osteoporotic vertebral compression fracture (OVCF) remains unclear.Patients treated by PKP for single-level lumbar OVCF in our institution from September 2019 to December 2020 were retrospectively enrolled. Patients were grouped according to the puncture techniques. Clinical and radiologic outcomes were evaluated preoperatively, postoperatively, and at follow-up. The clinical evaluation was performed by using visual analog scale for pain relief and Oswestry Disability Index for health status. Radiologic measurements contained anterior vertebral height, kyphotic angle, and bone cement distribution.In total, 76 patients with a mean follow-up duration of 16.6 months were enrolled, including 34 patients in the mUEP PK group and 42 patients in the BTP PKP group. In the mUEP group, operation time, fluoroscopy times, and injected cement volume were significantly less than that in the BTP group (P0.01). Both visual analog scale and Oswestry Disability Index scores of all patients decreased significantly after surgery (P0.01), with no significant differences between the 2 groups at each follow-up. Both mUEP PKP and BTP PKP showed significant anterior height restoration and kyphotic angle correction (P0.01), with no significant differences between the 2 groups at each follow-up. Meanwhile, the mUEP PKP reduced the incidence of intraspinal cement leakage (P0.05), and no facet joint violation was found in mUEP PKP.mUEP PKP could be clinically and radiographically equivalent to BTP PKP. However, it has advantages in reducing operation time and fluoroscopy times, lowering the risk of intraspinal cement leakage, and preventing the presence of facet joint violation. Compared with BTP PKP, the mUEP PKP seems to be an effective and alternative puncture technique for the treatment of lumbar OVCF after appropriate patient selection.

The rib approach is a new extrapedicular approach for vertebral augmentation in the thoracic spine. This article discusses the surgical essentials and therapeutic effect.Computed tomography (CT) imagings were obtained from 100 subjects to stimulate a Φ 4-mm puncture needle via the rib approach to determine the anatomical parameters of the channel and the position of the needle inserted in the vertebral body. Application results for 26 patients with T5-10 lesions were observed, four patients were treated under general anesthesia and 22 were treated under local anesthesia.The channel diameter was 5.9-7.0mm. In T5-10, the puncture needle could reach the middle of the midsagittal line of vertebral bodies in the transverse plane and only reached the middle and upper parts of the vertebral body in the sagittal plane. One week after surgery, the visual analog scale (VAS) sores decreased to 2.4±0.8, the ODI decreased to 13.4±5.9, and the anterior and posterior vertebral body height ratios recovered to 82.2±13.7% and 86.3±13.2%, respectively (all, P0.05). No intraspinal cement leakage or nerve injury was noted.Vertebral augmentation via the rib approach is suitable only for patients with T5-10 lesions located in the middle and upper parts of the vertebral body. The puncture needle should be inclined inward and downward. This method is characterized by simple execution and low risks of intraspinal cement leakage and nerve injury.

Kyphoplasty (KP) is a surgery used to reduce pain and increase stability by injecting medical bone cement into broken vertebrae. The purpose of this study was to determine the ideal amount of cement and injection site by analyzing forces with the finite element method.We modeled the anatomical structure of the vertebra and injected the cement at T12. By increasing the amount of cement from 1 cc to 22 cc, stress applied to T11 and L1 cortical was calculated. In addition, stress applied to the adjacent KP level was calculated with different injection sites (medial, anterosuperior, posterosuperior, anteroinferior, and posteroinferior). After 5 cc cement was inserted, adjacent end plate stress was analyzed.In this study, break point adjacent bone stress according to the capacity of cement was bimodal. Flexion/extension and lateral bending conditions showed similar break points (11.5-11.7 cc and 18.5-18.6 cc, respectively). When cement injection was changed, front under and back under had the highest stress values among various parts, whereas the center position showed the lowest stress value.With increasing amount of bone cement, stress on the upper and lower end plates of the cemented segment increased significantly. Thus, increasing cement amount to be more than 11.5 cc has a potential risk of adjacent fracture. Centrally injected bone cement can lower the risk of adjacent fracture after percutaneous KP.

Approximately 10% of all cancer patients develop spinal metastases. When a symptomatic compression fracture occurs without associated deformity or neurologic deficit, it can be treated with kyphoplasty with or without radiofrequency ablation (RFA). Treatment with kyphoplasty is well established but does not address the underlying oncologic disease.Retrospective medical chart analysis of breast cancer patients (n = 23) with metastatic spinal fractures (n = 50 vertebral levels) who underwent RFA and kyphoplasty was undertaken. Key variables of interest included: fracture location, pain levels, and local recurrence. Local recurrence data were compared to published rates of recurrence in breast cancer-related metastatic spinal fractures treated with vertebroplasty or kyphoplasty alone. Data were analyzed using χThe mean preoperative pain level for this cohort was 6.9 on a 10-point visual analogue scale. Significant reductions in pain levels were observed postoperatively, at discharge (3.5; P0.05), at 1-month follow-up (2.8; P0.05), at 3-month follow-up (1.1; P0.05), and at 6-month follow-up (0.7 P0.05). Compared with published data of breast cancer patients with metastatic spinal fractures treated with vertebroplasty or kyphoplasty alone, the addition of RFA resulted in reduced local tumor recurrence (2% vs. 14%; P0.05). Average length of follow-up was 39 months.The results suggest that the addition of RFA to kyphoplasty may reduce local tumor recurrence while providing similar pain relief benefits. The extrapolation of this added benefit to metastases from other primary cancers should be examined in future studies.

As science and technology have advanced, novel bone cements with numerous formulated ingredients have greatly evolved and been commercialized for vertebroplasty. Recently, viscosity has been a focus to achieve better clinical outcomes and fewer complications. Meanwhile, the experience in the treatment of mid (T7-9) to high (T4-6) thoracic vertebral compression fractures is limited.The objective of this study was to identify the different outcomes between high-viscosity bone cement (HVBC) and low-viscosity bone cement (LVBC) used to repair mid (T7-9)- and high (T4-6)- thoracic vertebral compression fractures.This study was a single-center, retrospective cohort study PATIENT SAMPLE: A consecutive series of 107 patients with a total of 144 vertebrae was included.The anterior vertebral height (AVH), middle vertebral height (MVH), posterior vertebral height (PVH), local kyphotic angle (KA), Cobb angle (CA), and other associated parameters were evaluated radiologically at several time points-preoperative, surgery day 0, postoperative day 1, and 6-month follow-up. Pain evaluation was assessed by using a visual analog scale (VAS) before and 6 months after the procedure.The patients were divided into two groups according to the viscosity of the bone cement used, and plain film and magnetic resonance imaging (MRI) of the vertebrae were used to calculate parameters. The patient characteristics; bone cement brand; changes in AVH, MVH, PVH, KA, CA, and VAS; and complications of each patient were recorded and then analyzed.Both groups showed increased vertebral body height, corrected KA, and CA after vertebroplasty. There were no significant differences between the HVBC and LVBC groups (ΔAVH: 2.19±2.60 vs. 2.48±3.09, p=.555; ΔMVH: 1.25±3.15 vs. 1.89±2.58, p=.192; ΔKA: -5.46±4.58 vs -5.37±4.47, p=.908; and ΔCA: -4.22±4.23 vs. -4.56±5.17, p=.679). There were significant preoperative to postoperative and preoperative to follow-up changes in AVH (HVBC, p=.012 and .046, respectively; LVBC, p=.001 and .015, respectively); a significant preoperative to postoperative change in MVH (HVBC, p=.045; LVBC, p=.001); and significant preoperative to postoperative and preoperative to follow-up changes in KA and CA (KA: HVBC, p=0.000 and .003, respectively; LVBC, p=.000 and .000, respectively; CA: HVBC, p=.017 and .047, respectively; LVBC, p=.006 and .034, respectively). The volume of cement injected was significantly higher with HVBC (3.66±1.36 vs. 3.11±1.53, p=.024), and the use of HVBC was associated fewer cases with cement leakage (26 vs. 45, p=.002). Furthermore, there was no difference between the groups in the incidence of adjacent fracture. Both groups showed an improved VAS score at follow-up, with statistically greater improvement in the HVBC group (2.40±1.53 vs. 3.07±1.69, p=.014). Moreover, significantly fewer patients with a VAS score ≥ 3 were found in the HVBC group (22 vs. 39, p=.004) CONCLUSIONS: HVBC and LVBC are safe and effective to treat mid-to-high level thoracic vertebral compression fractures. Compared with LVBC, HVBC shows less cement leakage, a greater injection volume, and better postoperative pain relief.

To study the relationship between distribution of bone cement and intravertebral cleft of patients with Kummell disease on the clinical effect of percutaneous kyphoplasty (PKP).According to the relationship between the distribution of bone cement and the cleft in the vertebrae, a total of 92 patients with Kummell disease who underwent PKP in our hospital were divided into 2 groups. Specifically, the bone cement of patients in group A was localized in the cleft of the vertebrae and did not infiltrate around the cleft, while that of group B patients not only filled the cleft of the vertebrae, but also distributed diffusely around the cleft of the vertebrae. The amount of bone cement injected, leakage rate, visual analogue scale (VAS) score, Oswestry Disability Index (ODI), and vertebral imaging changes before operation, and 2 days and 1 year after operation were compared between the 2 groups.The amount of bone cement injected and the permeability of bone cement in group B were higher than those in group A (P0.05). The scores of VAS and ODI in both groups were significantly improved after operation, but the two scores in group B were better than those in group A one year after operation. The height of anterior vertebral body and Cobb's angle of kyphosis in the 2 groups were significantly improved after operation, but 1 year after operation, those in group B were better than those in group A.PKP was an effective method for treating Kummell disease. At the same time, the relationship between the distribution of bone cement and the cleft in the vertebral body was an important factor affecting the curative effect after PKP. The effect of the distribution pattern of bone cement filled with intravertebral cleft and diffusely distributed around the fissures was better than that of bone cement confined in the vertebral cleft.

To retrospectively evaluate the clinical efficacy and safety of percutaneous kyphoplasty (PKP) for the management of osteoblastic-related metastatic vertebral lesions.A total of 31 patients with 58 osteoblastic-related metastatic vertebral lesions underwent PKP were reviewed. The clinical efficacy was assessed based on parameters including visual analogue scale, Oswestry Disability Index, vertebral body height variation and quality of life. Major and minor complications were systematically evaluated to assess the safety of the procedure.Average follow-up period was 22.5 ± 11.1 months(range, 3 to 46 months). The procedure duration time ranged from 50 to 180 minutes (average 96.8 ± 36.9 minutes). Mean visual analogue scale scores decreased significantly from 6.1 ± 1.8 pre-operatively to 2.7 ± 1.5 at 3 days after PKP (p0.001), and remained largely immutable at 1 month (2.0 ± 0.7; 31 patients; p0.001), 3 months (2.4 ± 1.2; 30 patients; p0.001) and 1 year (3.0 ± 1.0; 27 patients; p0.001). Oswestry Disability Index scores and vertebral body height variation also changed after the procedure, with significant differences between pre-operative scores and at each follow-up examination (p0.001). Mean quality of life scores were 90.8 ± 12.9 pre-operatively and improved to 99.5 ± 12.1(27 patients, p0.001) at 1 year after PKP. The only minor encountered complication was bone cement leakage, which was seen in 6.5%(2 of 31) of patients. None of the patients experienced major complications.PKP is a safe and effective treatment strategy for osteoblastic-related metastatic vertebral lesions from a variety of tumor etiologies.

The purpose of this retrospective review was to evaluate SpineJack implantation in cancer-related vertebral compression fractures in 13 consecutive patients (mean age, 62.8 years ± 18.8). A total of 36 devices were inserted at 20 levels (13 [65%] lumbar and 7 [35%] thoracic vertebrae), with a mean Spinal Instability Neoplastic Score of 9.1 ± 2.1. Vertebral height restoration was observed in 10 levels (50%), with a mean height restoration of 5.6 mm ± 2.2 (interquartile range [IQR], 4-7.5). A total of 6 cement leakages were observed in 3 (23%) patients without clinical consequences. No severe adverse events were observed. One adjacent fracture occurred. Average pain scores on the visual analog scale significantly improved from 5.5 ± 1.8 (IQR, 4-7) preoperatively to 1.5 ± 2.2 (IQR, 0-3.3) at 1 month (P.01) and to 1.5 ± 1.3 (IQR, 0.3-2.8) at 6 months (P .01). In this small cohort, SpineJack offered pain relief in cancer-related fractures without an observed increase in adverse events.

Non–thrombotic pulmonary embolism can occur from rare but diverse etiology and is not well understood. Increasing prevalence of osteoporosis in the aging population has contributed to increased utilization of percutaneous vertebral augmentation procedures of vertebroplasty and its recent modification, kyphoplasty. Though these procedures are relatively well tolerated, there is risk of potentially fatal complication of bone cement embolization to distant vasculature. We report a case of symptomatic pulmonary cement emboli developed 2 day's post kyphoplasty and its successful treatment with novel anticoagulant for 6 months. We also summarize evidence to assist clinicians and radiologists for early identification, treatment, and prevention of cement pulmonary emboli.

BACKGROUND CONTEXT: Osteoporotic vertebral fractures (OVFs) can lead to severe pain and reduced function and quality-of-life, but the strength of evidence for treatments remains low, particularly in younger populations. PURPOSE: To determine whether patients with OVFs who received kyphoplasty had different patterns of healthcare utilization compared to propensity-matched patients who did not receive vertebral augmentation. DESIGN: Observational cohort study. PATIENT SAMPLE: We identified patients with OVFs from 2007-2018 in the IBM® MarketScan® Commercial Claims and Encounters Databases who received kyphoplasty and compared them to propensity-matched controls who did not receive vertebral augmentation (either kyphoplasty or vertebroplasty). OUTCOME MEASURES: Major medical complications within 30 days, fills of opioids from 1-week through 1-month post-augmentation, and spine-related gross covered payments from 3-days post-kyphoplasty through 1-year post-OVF. METHODS: We used logistic regression to obtain odds ratios (ORs) and 95% confidence intervals (95% CIs) to compare binary outcomes and median analysis to compare continuous outcomes. RESULTS: Of the 15,197 OVF patients identified, 1969 (13%) received kyphoplasty and 1928 (98%) of these were propensity matched to non-augmented controls. We did not observe differences in the odds of major medical complications within 30 days (adjusted OR (95% CI): 1.0 (0.6, 1.8)) but patients who received kyphoplasty were more likely to have filled opioid medications within 30 days (adjusted OR (95% CI): 1.3 (1.1, 1.5)) and had greater spine-related gross covered payments (kyphoplasty median (95% CI): $1340 ($240, $4850); non-augmented: $7870 ($7480, $8270); adjusted difference in medians (95% CI): $260 ($190, $2050)). CONCLUSIONS: In this cohort of patients

Spine tumors encompass a wide range of diseases with a commensurately broad spectrum of available treatments, ranging from radiation for spinal metastases to highly invasive en bloc resection for primary vertebral column malignancies. This high variability in treatment approaches stems both from variability in the goals of surgery (e.g., oncologic cure vs. symptom palliation) and from the significant advancements in surgical technologies that have been made over the past 2 decades. Among these advancements are improvements in surgical technique, namely minimally invasive approaches, increased availability of focused radiation modalities (e.g., proton therapy and linear accelerator devices), and new surgical technologies, such as carbon fiber-reinforced polyether ether ketone rods. In addition, several groups have described nonsurgical interventions, such as vertebroplasty and kyphoplasty for spinal instability secondary to pathologic fracture, and lesion ablation with spinal laser interstitial thermoablation, radiofrequency ablation, or cryoablation. We provide an overview of the latest technological advancements in spinal oncology and their potential usefulness for modern spinal oncologists.

Spinal metastasis are a daily challenge in clinical practice. Stereotactic body radiotherapy (SBRT) allows delivery of definitive treatment with excellent long-term control rates. Its implementation needs dedicated devices and day-to-day image-guided radiotherapy (IGRT). The XSight™ spine tracking system, integrates with the CyberKnife® (Accuray™), provides a fiducial-free tracking system for spinal SBRT. We report a rare case of tracking failure during treatment due to the occurrence of a vertebral compression fracture (VCF).

Background Global sagittal malalignment after osteoporotic vertebral fracture is correlated with decreased quality of life. Balloon kyphoplasty promotes short-term global alignment, but long-term correction is difficult in patients with such fractures. Adjacent vertebral fracture is one of the major complications of balloon kyphoplasty. We investigated the correlation of the incidence of adjacent vertebral fracture with the loss of global alignment correction after balloon kyphoplasty. Methods Forty patients were enrolled in this retrospective study. Adjacent vertebral fracture occurred in 17 patients. Sagittal vertical axis, the angle between the two vertebrae above and below the balloon kyphoplasty site (local alignment angle), and the vertebral kyphotic angle at the kyphoplasty site were measured pre- and post-operatively. Clinical results were assessed. Results There were no significant differences between the sagittal vertical axis before and after balloon kyphoplasty in groups with (+) or without (−) adjacent vertebral fracture. Local alignment angles decreased soon after balloon kyphoplasty, but increased during follow-up in both groups. Vertebral kyphotic angles decreased significantly soon after balloon kyphoplasty in both groups; although this increased significantly in the adjacent vertebral fracture (−) group, but not in the adjacent vertebral fracture (+) group, during follow-up. Correction loss of alignment was found in both adjacent vertebral fracture (+) and (−) groups, attributed to adjacent vertebral fracture in the former and re-collapse of the balloon kyphoplasty site in the latter. No significant differences in clinical results were observed between the groups, although these were strongly correlated with sagittal vertical axis before balloon kyphoplasty. Conclusions The adjacent vertebral fracture (+) and (−) groups exhibited similar correction loss of alignment and improved quality of life. The presence or absence of adjacent vertebral fractures had no effect on long-term global alignment and patient quality of life.

Background Context In 2010, the American Academy of Orthopedic Surgeons published guidelines strongly recommending against the use of vertebroplasty following the publication of randomized control trials that failed to show significant improvement in pain. Vertebroplasty has remained controversial since those findings. Purpose To study and provide an update on utilization of vertebroplasty and kyphoplasty procedures among Medicare beneficiaries by physician specialty and practice setting following publication of recommendations against vertebroplasty in 2010. Study Design/Setting This study uses Medicare Part B Physician/Supplier Procedure Summary Master File (PSPSMF) for the years 2010 to 2018 to determine trends in volume and reimbursement by physician specialty and practice setting. Patient Sample All vertebral augmentation procedures with a physician reimbursement claims approved by Medicare Part B from 2010 to 2018. Outcome Measures This study analyzes trends in volume and physician payment of vertebroplasty and kyphoplasty procedures by physician specialty for the time period 2010 to 2018. Methods Claims from the Medicare Part B PSPSMF for the years 2010 to 2018 were extracted using the Current Procedural Terminology codes for vertebroplasty and kyphoplasty. Total volumes, payment amounts (professional component), and trends were analyzed by physician specialty. Results Between 2010 and 2018, the total volume of vertebroplasties decreased by 61.2% (29,995 to 11,654), whereas the volume of kyphoplasties increased modestly by 14.4% (59,691 to 68,294). Radiologists performed an increasing share of both procedures over this time period, from 68.5% to 75.1% for vertebroplasties and 28.9% to 37.1% for kyphoplasties. Total payment for vertebroplasties decreased by 74.3% from $14.8 million in 2010 to $3.8 million in 2018; whereas it increased by 235.3% for kyphoplasty procedures from $26.7 million to $89.7 million. This is driven in large part by a 6,833% increase in office based kyphoplasties which bill at the higher nonfacility rate that incorporates overhead, staff, and equipment. Conclusions Previous studies have demonstrated mixed evidence for benefits of vertebroplasty procedures and decreasing volumes over time. Data show continued downtrend in vertebroplasty and increased utilization of kyphoplasty among Medicare beneficiaries. In addition, the growing number of kyphoplasties correlated with a sharp rise in volume and increased reimbursement for office-based procedures. Radiologists have been performing an increasing share of both procedures.

Background Although the majority of available evidence suggests that vertebroplasty and kyphoplasty (KP) can relieve pain associated with vertebral compression fractures (VCFs) and improve function, evidence of clinical and radiographic outcome in highly viscous cement vertebroplasty (HVC) or KP for the treatment of VCFs is limited. The purpose of this study was to compare the clinical effects between HVC and KP in the treatment of single-level osteoporotic VCFs including radiographic and clinical outcomes. Methods From January 2017 to October 2018, 96 patients with single-level osteoporotic vertebral compression fracture who had undergone either KP or HVC surgery at our hospital were reviewed retrospectively, with at least 1 year follow-up. All patients were divided into the HVC group (n = 50) or the KP group (n = 46). Clinical data including clinical and radiologic evaluation results were performed pre- and postoperatively. Results The operation time of the HVC group (32.24 ± 10.08 minutes) was less than that of the KP group (40.76 ± 9.49 minutes), with significant differences. Compared with preoperative data, the visual analog scale scores, Oswestry disability index scores, vertebral body height, and local kyphotic angle were improved after surgery. There were no significant differences between the 2 groups in local kyphotic angle, vertebral body height, leakage rate of bone cement, and incidence of adjacent-level vertebra fracture. Conclusions Restoring the vertebral height and local kyphotic angle corrections of HVC are similar with those of KP. Additionally, KP is not superior in the leakage rate of bone cement and incidence of adjacent-level vertebra fracture compared to HVC.

There are few reports on the robot-assisted percutaneous kyphoplasty (PKP) for osteoporotic vertebral compression fractures (OVCF), and we aimed to explore the learning curve of the robot-assisted PKP for treating OVCF.A total of 44 patients (71 vertebral fractures) with OVCF treated with robot-assisted PKP were divided into 4 groups, namely groups 1, 2, 3, and 4, according to the date of operation, with 11 cases in each group. Another 11 patients (18 vertebral fractures) treated with PKP without robot assistance were included in group 5. The success rate of robot-assisted puncture, total operation time, robot-assisted operation time, PKP operation time, and complications were analyzed.All patients underwent operation successfully. The success rates of puncture in the robot-assisted groups were 92.9%, 94.4%, 94.7%, and 100%, respectively, with no statistical difference (P0.05). The success rate of puncture in group 5 was 63.2%, with a statistical difference (P0.05) compared with groups 1-4. The total operation time and robotic operation time reduced significantly and remained relatively stable since the third group, and groups 1 and 2 showed a statistical significance compared with groups 3 and 4 (P0.05), but there was no difference among groups 3, 4, and 5 (P0.05). The main intraoperative complication was leakage of bone cement in the anterior vertebral space and intervertebral space, with an incidence of 8.5% in the robot-assisted groups and 26.3% in group 5.The puncture accuracy of robot-assisted PKP for treating OVCF does not change with the increase in the number of operations. The total operation time and robotic-assisted operation time decreases with the increase in the number of cases.

Vertebral augmentation procedures are used for treatment of osteoporotic compression fractures. Prior studies have reported disparities in the treatment of patients with osteoporotic vertebral fractures, particularly with regards to the use of vertebroplasty and kyphoplasty.The purpose of this study is to report updates in racial and health insurance inequalities of spine augmentation procedures in patients with osteoporotic fractures.With the use of the National Inpatient Sample, we identified hospitalized patients with osteoporotic fractures between the period of 2011 and 2015. Patients with spine augmentation, defined by the utilization of vertebroplasty and kyphoplasty, were also identified. Our primary outcome was defined as the utilization of spine augmentation procedures across ethnic (white, hispanic, black, and asian/pacific islander) and insurance (self-pay, private insurance, Medicare, and Medicaid) groups. Variables were identified from the NIS database using International Classification of Diseases, Ninth and Tenth diagnosis codes. Univariate and multivariate regression analysis was used for statistical analysis with p value.05 considered significant. A subgroup analysis was performed across the utilization of kyphoplasty, vertebroplasty, and Medicare coverage.We identified a total of 110,028 patients with a primary diagnosis of vertebral fracture between 2011 and 2015 (mean age: 74.4±13.6 years, 68% women). About 16,237 patients (14.8%) underwent any type of spine augmentation with over 75% of the patients receiving kyphoplasty. Multivariate analysis showed that black patients (odds ratio [OR]=0.64, 95% confidence interval [CI]: 0.58-0.70, p.001), Hispanic patients (OR=0.79, 95% CI: 0.73-0.86, p.001), and Asian/Pacific Islander (OR=0.79, 95% CI: 0.70-0.89, p.001) had significantly lower odds for receiving any spine augmentation compared with white patients. Patients with Medicaid (OR=0.59, 95% CI: 0.53-0.66, p.001), private insurance (OR=0.90, 95% CI: 0.85-0.96, p=.001), and those who self-pay (OR=0.57, 95% CI: 0.47-0.69, p.001) had significantly lower odds of spine augmentation compared with those with Medicare. Comparative use of kyphoplasty was not significantly different between white and black patients (OR=0.85, 95% CI: 0.70-1.04, p=.12). However, Hispanic patients (OR=0.84, 95% CI: 0.71-0.99, p=.04) and Asian/Pacific Islander patients (OR=0.73, 95% CI: 0.58-0.92, p=.007) had significantly lower use of kyphoplasty compared with white patients. The comparative use of kyphoplasty among patients receiving spine augmentation was not significantly different across each insurances status when compared with patients with Medicare.Our study suggests that racial and socioeconomic disparities continue to exist with the utilization of spine augmentation procedures in hospitalized patients with osteoporotic fractures.

Introduction Over the last several decades, both percutaneous kyphoplasty (PKP) and percutaneous vertebroplasty (PVP) have been used for pain relief in patients with osteoporotic vertebral compression fractures. The purpose of our study was to use citation analysis to identify and review the top 100 most-cited publications regarding PKP and PVP. Methods All databases of the Web of Science were searched using the keywords “kyphoplasty” and “vertebroplasty.” All publications with >100 citations were identified and the results were ranked in descending order of citations. The 100 most-cited publications were included for analysis. Results A total of 6271 publications on PKP and PVP were identified. The number of citations of the 100 most-cited studies ranged from 735 to 109, with a mean of 225.3 citations per study. The most productive period was 2001–2010, which produced 79 of the top 100 publications. Thirteen journals published these 100 studies, with Spine publishing the largest number (23) of studies. Most of the identified articles originated in the United States, with France and Switzerland found to be the next most heavily represented countries of origin of the 11 countries that produced them. Most of the studies focused on treatment of osteoporotic vertebral compression fractures, followed by pathologic fractures caused by tumors. Conclusions We identified the 100 most-cited publications on PKP and PVP and performed a bibliometric analysis characterizing distinguishing features of these studies. This list can help guide clinical decision making and future research directions as clinicians and researchers continue to explore these controversial therapeutic techniques.

Background Radiofrequency ablation (RFA) focally destroys abnormal or dysfunctional tissue using thermal energy generated from alternating current. The utilization of RFA has gained popularity as a minimally invasive procedure for the treatment of skeletal metastases with a particular focus on palliative pain treatments to the spine, pelvis, long bones, sternum, and glenoid. More recently, single-session procedures that combine RFA with vertebral augmentation techniques have allowed treatment to areas of pain associated with pathologic fractures secondary to metastatic disease. Although many studies have been done to investigate the safety and efficacy of RFA, there have been no reported cases to date in which the use of RFA for the treatment of spinal metastases has led to any major permanent neurological injury. Case Description This report describes a case of a 61-year-old woman who underwent RFA and kyphoplasty for spinal metastases and noted the immediate onset of lower extremity paralysis after the procedure. To the best of our knowledge, this is the first documented case of permanent lower extremity paralysis in the medical literature after radiofrequency thermal ablation of spine metastases. Conclusions Postoperative magnetic resonance imaging and physical examination suggest RFA-induced thermal injury as the most likely mechanism of paralysis. In this report, a review of previous in vivo models used in studying the efficacy and safety of spine RFA is conducted. Additionally, the literature has been reviewed for any neurological events reported with the use of RFA in the treatment of patients with vertebral pathology.

Background A considerable propotion of patients with cancer got thoracolumbar vertebral metastatic epidural spinal cord compression, which affected their quality of life. Traditional surgical management involves early decompression with concomitant spine stabilization with long instrumentation. However, complications are caused by massive blood loss and long operation time. This study aimed to compare the safety and efficacy of short posterior instrumentation with kyphoplasty and the traditional method for thoracolumbar metastatic epidural spinal cord compression. Methods Between January 2004 and December 2015, a retrospective study was conducted on 120 patients with metastatic epidural spinal cord compression from T6 to L5 and divided into 2 groups: short posterior instrumentation with the balloon kyphoplasty group (group I, n = 50) and the long posterior instrumentation group (group II, n = 70). The clinical and radiographic parameters of patients in the 2 groups were compared with a nonrandomized cohort method. Patients were followed up from 3 to 40 months after surgery according to survival time. Results In group I, the surgery had a mean blood loss of 650 mL and a survival time of 19.1 months. In group II, the surgery had a mean blood loss of 2100 mL and a survival time of 14.14 months. A significant difference in blood loss amount (P = 0.002) was observed. Complications, including deep wound infection, durotomy, and uncontrolled bleeding, were observed in both groups. No postoperative cement-induced neurologic deterioration, implant failure occurred. Conclusions Kyphoplasty with short posterior instrumentation is a novel technique that can be performed safely and effectively for the treatment of thoracolumbar metastatic epidural spinal cord compression. Rigid stability, reduced blood loss, and short fixation decrease surgical morbidity of spinal metastasis.

Symptomatic metastatic spine disease (MSD), is a challenging disease involving 3%-20% of patients with bone metastases. Different surgical options are available and must be tailored to the general and neurologic conditions of the patients. Open kyphoplasty (OKP) refers to decompressive hemilaminectomy, associated with a contralateral percutaneous kyphoplasty, and in some cases, to a posterior stabilization. The aim of the study was to critically review our experience during the last decade with OKP in patients with cancer.Fifty-three patients with cancer underwent OKP for symptomatic MSD. The Tokuhashi score and Spinal Instability Neoplastic Score were calculated for each patient. Length of hospital stay, perioperative complications, incidence of adjacent-level fractures, and median survival after surgery were evaluated. Karnofsky Performance Status, visual analog scale, and Dennis Pain Score were calculated preoperatively, postoperatively, and at last follow-up.Median Tokuhashi score and Spinal Instability Neoplastic Score were 10 and 10, respectively. The mean volume of filling material inserted was 3.6 mL. Median operative time was 180 minutes. Complications included 8 leakages (15%), 2 permanent motor deficits (3.8%), and 2 asymptomatic pulmonary embolisms (3.8%). Mean length of hospital stay was 7 days. A significant improvement was observed in Karnofsky Performance Status, visual analog scale score, and Dennis Pain Score (P0.0001). Median follow-up was 16 months and overall survival 22 months.OKP was an effective treatment of symptomatic MSDs in selected oncologic patients with low Tokuhashi scores. It relieved lateral epidural compressions, expanded indications of palliative surgery in patients who were not otherwise surgical candidates, and rapidly dealt with cement leakages.

It has been reported the distribution of bone cement in percutaneous kyphoplasty (PKP) has an impact on the curative effect. No studies have compared between confluent and separated cement pattern of bilateral bone cement in PKP for patients with osteoporotic vertebral compression fractures.Between 2010 and 2016, 1341 patients were enrolled and divided into 2 groups. Group A (n = 723), bilateral cement was confluent; Group B (n = 618), bilateral cement was separated. The visual analogue scale (VAS), Oswestry Disability Index (ODI), anterior vertebral height (AVH), and local kyphotic angle (LKA) were obtained preoperatively, 2 days after surgery, and at the final follow-up to assess the functional and radiographic efficacy of the surgery.The VAS, ODI, AVH, and LKA 2 days after operation and at the final follow-up were significantly improved compared with the preoperative for both groups (P0.05). There existed no significant difference between groups at various time point in ODI, AVH, and LKA (P0.05). Group A showed better VAS than group B 2 days after surgery (1.91 ± 0.98 vs. 2.35 ± 0.78, P0.001), also with better pre-postoperative VAS change (6.23 ± 0.76 vs. 5.75 ± 1.02, P0.001). Multiple linear regression for pain relief degree revealed group A (P0.001), older age (P0.001), and more cement volume (P0.001) contribute to rapid improvement of back pain. The cement leakage rate was 3.7% in group A and 2.9% in group B, with no significant difference (P = 0.405).Patients achieved rapider pain relief with confluent rather than separated bilateral bone cement pattern in PKP for osteoporotic vertebral compression fracture.

Background Kyphoplasty is commonly employed in the treatment of compression fractures in the elderly and is increasingly used in the treatment of adult trauma along with concomitant instrumentation. Although kyphoplasty with instrumentation has been reported in pediatric patients, concerns regarding retardation of spinal growth and iatrogenic spinal deformity have been raised. The utilization of kyphoplasty without instrumentation has yet to be reported in the case of pediatric patients. Case Description A 13-year-old male presented to the emergency department with a traumatic L2 burst fracture with 50% loss of height, which continued to cause severe pain after a trial of bracing. He was subsequently treated with a kyphoplasty without instrumentation. He experienced a rapid and excellent recovery and resumed all previous activity. Conclusions Kyphoplasty alone without instrumentation is a less invasive means to treat these patients and also prevents iatrogenic deformity or retardation of growth in the pediatric spine.

Objective Osteoporotic vertebral compression fracture (OVCF) is a common disease in the aged population that can greatly affect the quality of life. Percutaneous kyphoplasty (PKP) has become a mainstream approach for treating OVCF, but the optimal surgical timing for treating OVCF with PKP remains controversial. In the current study, we retrospectively studied patients with OVCF that underwent PKP, and aimed to find out whether surgical timing could affect the clinical and radiological outcomes. Patients and methods We retrospectively studied 62 patients who underwent PKP for OVCF. Patients were divided into 2 groups based on the timing of PKP: operation within 4 weeks (group A) and operation later than 4 weeks (group B). VAS, ODI, height of fracture vertebra, restored height rate, local kyphosis angle and complications were assessed preoperatively and throughout the follow-up. Results There were 36 cases (58 fracture vertebra) in the group A and 26 cases (40 fracture vertebra) in the group B. There was no significant difference between the two groups regarding to the demographic data before surgery. In terms of the VAS and ODI, no statistical difference was observed before operation, after operation and at the 6th month follow-up between the two groups. The HRR after operation and at the 6th month follow-up in the group A was 17.5 ± 5.3% and 10.5 ± 3.7%, and that in the group B was 7.2 ± 3.2% and 3.6 ± 1.1%, and there is significant difference between the two groups (p Conclusion Both surgical timings of PKP showed similar outcomes in terms of the VAS and ODI. Early PKP could result in better restoration of vertebral body height and reduced rate of subsequent fracture compared to late PKP.

A meta-analysis of randomized controlled trials (RCTs) was performed to compare the incidence of cement leakage between unilateral and bilateral percutaneous vertebral augmentation (PVA) in treating osteoporotic vertebral compression fractures (OVCFs).PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were searched to retrieve the reported data from the establishment of the databases until August 1, 2018. The RCTs on unilateral and bilateral PVA for OVCFs were included. RevMan software, version 5.3, was used for the meta-analysis.Six RCTs were selected from the reported data. The studies included a total of 676 vertebras, 339 of which had received unilateral PVA and the rest, bilateral PVA. The incidence of cement leakage in the unilateral PVA group was less than that in the bilateral PVA group, and the difference between the 2 groups was statistically significant (risk ratio, 0.50; 95% confidence interval, 0.35-0.72; P = 0.0002). The cement dosage in the unilateral PVA group was less than that in the bilateral PVA group, and the difference between the 2 groups was statistically significant (weighted mean difference, -1.98; 95% confidence interval, -2.24 to -1.72; P0.00001). The cement dosage and the incidence of cement leakage in the unilateral PVA group were lower than those in the bilateral PVA group.The results of our meta-analysis have provided sufficient evidence to show that the unilateral approach can decrease the incidence of cement leakage in PVA. We believe the unilateral approach could reduce the risk of cement leakage owing to the lower cement dosage in the treated vertebra.

Objective Data reporting percutaneous vertebroplasty (PVP) or percutaneous balloon kyphoplasty (PKP) application to the midthoracic vertebrae remain limited. This study aimed to summarize our experiences and explore the efficacy and safety of PVP or PKP in dealing with osteoporotic vertebral compression fracture (OVCF) in the midthoracic vertebrae. Methods Patients receiving PVP or PKP for midthoracic OVCF in our institution from January 2015 to January 2018 were retrospectively enrolled. All patients were grouped according to cement augmentation procedure types, surgical approaches, and puncture routes. All patients underwent a postoperative follow-up of 2–36 months. Visual analog scale (VAS) and ECOG Scale of Performance Status scores were evaluated pre- and postoperatively. Cement distribution and rate of cement leakage were assessed by radiographs. Associations of these variables and clinical scores and radiographic indices were analyzed. Results A total of 101 consecutive patients with 111 fractured centrums were enrolled. Both VAS and ECOG Scale of Performance Status scores of all patients decreased significantly after the operation, and progressively decreased at the final follow-up. The cement distribution of the bipedicular group was significantly better than the unipedicular group, but the total leakage rate of the former (71.7%) was significantly higher than the latter (43.1%). The rate of epidural cement leakage in the PKP group (5.4%) was significantly lower than that of the PVP group (20.3%), whereas the left puncture group (28.6%) was significantly higher than that of the right puncture group (2.7%). Conclusions PKP and a bipedicular approach can help improve cement distribution and reduce the epidural cement leakage rate and therefore should be preferred over PVP or a unipedicular approach in OVCF of the midthoracic vertebrae.

Objective To determine whether the facet joint violation (FJV) impacts clinical outcomes after percutaneous kyphoplasty (PKP) in patients with osteoporotic vertebral compression fractures. Methods Patients undergoing bilateral PKP were enrolled and divided into FJV and non-FJV groups depending on their postoperative axial computed tomography scans. Radiologic parameters, visual analogue scale (VAS), and Oswestry Disability Index (ODI) scores were obtained preoperatively and each follow-up time postoperatively (1day, 1 week, 1 month, 3 months, 6 months, and 1 year). Finally, patient satisfaction surveys also were noted. Results A total of 157 patients completed the 1-year follow-up. The incidence of FJV resulting from puncture trocars was 15.9% (25/157). Approximately 5.7% (9/157) and 10.2% (16/157) of patients were considered to have grade 1 and grade 2 violation, respectively. PKP decreased the VAS and ODI scores compared with the preoperative values in both groups. Patients with FJV had much greater VAS and ODI scores than did those without FJV at 1-day, 1-week, and 1-month follow-up. No significant differences were found between groups at 3-month, 6-month, and 1-year follow up. Patients in the FJV group were less satisfied with the surgical outcomes than were those without FJV at the last survey. Conclusions Approximately 15.9% of patients were diagnosed with FJV by postoperative computed tomography scans. FJV had a negative influence on clinical outcomes after PKP in osteoporotic vertebral compression fractures, primarily at short-term follow-up. In addition, FJV was also a risk factor in the long-term surgical satisfaction.

The present study introduced ultrasound volume navigation (UVN) to reduce the radiation exposure and puncture time of percutaneous transpedicular puncture in percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP).We retrospectively reviewed the medical records of patients with osteoporotic vertebral compression fracture who had undergone PVP or PKP guided by UVN or fluoroscopy from September 2017 to December 2017.We enrolled 10 patients (6 women, 4 men) with 24 pedicles involved in the present study. Significant reductions in fluoroscopy frequency (2.58 vs. 17.42; P0.01), exposure time (2.36 vs. 15.69 seconds; P0.01), and puncture time (4.13 vs. 19.21 minutes; P0.01) for each pedicle were observed in the UVN group compared with the fluoroscopy group. Obvious correlations among fluoroscopy frequency, exposure time, and puncture time for each pedicle were observed (P0.01). The visual analog scale scores and Oswestry Disability Index were both significantly improved after the procedures. All patients achieved excellent or good clinical outcomes. No complications were observed in any patient.UVN could obviously reduce the radiation exposure and puncture time of percutaneous transpedicular puncture in PVP and PKP.

Vertebral compression fractures are a common clinical occurrence in elderly individuals with osteoporosis. No current evidence exists on risk factors and clinical impact of discharge to inpatient (IP) care facility after vertebral augmentation procedures.The 2012-2014 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database files were queried using Current Procedural Terminology codes for vertebroplasty (22520, 22521, and 22522) and kyphoplasty (22523, 22524, and 22525). Discharge to IP care facility included skilled-care facilities and IP rehabilitation units. A total of 2361 patients were included in the final cohort.Of 2361 patients, 1962 (83.1%) were discharged home and 399 (16.9%) were discharged to an IP care facility. Multivariate analysis identified age ≥65 years (P0.001), dependent preoperative functional health status (P0.001), hypertension (P = 0.001), preoperative transfusion (P = 0.043), IP admission status (P0.001), thoracolumbar procedure versus thoracic-only procedure (P = 0.012), and length of stay1 day (P0.001) to be significant predictors for a discharge to an IP care facility. In addition, discharge to an IP care facility was associated with a significant greater risk of 30-day mortality (P = 0.001). No significant associations were found with between IP-care discharge destination and any 30-day complication, 30-day readmission, and 30-day reoperation.Discharge to IP care facilities after vertebroplasty/kyphoplasty is associated with a 3.6 times greater odds of mortality as compared with home discharge. Providers can use the risk profile data to better allow preoperative stratification of patients to ensure that discharge location is appropriate to a patient's need to minimize the risk of adverse outcomes.

Objective This study sought to determine whether implantation of a newly designed nonfusion intracorporeal enhancement (NICE) system is an effective and safe way to treat osteoporotic vertebral compression fracture (OVCF). Methods Thirteen patients with OVCF (10 women, 3 men; mean age 69 years, T11–L4) were included. From June 2014 to June 2016, all patients were treated with the NICE system. The clinical and radiologic results were evaluated preoperatively, postoperatively, and at 24 months follow-up based on the visual analog scale and the Oswestry Disability Index, radiography, magnetic resonance imaging, and computed tomography (height of fractured body and kyphosis Cobb angle). Results There was a significant improvement in pain intensity (visual analog scale score decreased from 8.3 preoperatively to 2.2 postoperatively, and decreased to 1.5 twenty-four months postoperatively). Also, a significant reduction was observed in that the mean Oswestry Disability Index decreased from 71.9% preoperatively to 17.6% after 24 months. The mean Cobb angle had a significant improvement, which decreased from 6.6° preoperatively to 1.3° postoperatively and then decreased to 1.2° after 24 months. Height of fractured body improved significantly from 66.4% to 86.5% and slightly decreased to 82.4% after 24 months. No specific complications were identified to be associated with this technique. Conclusions With a low complication rate, the clinical midterm results are satisfactory. The treatment of symptomatic OVCF with the NICE system is a safe and effective procedure.

Adjacent vertebral body fracture is described as a risk after vertebroplasty and kyphoplasty. It may be true that this phenomenon is caused precisely because of the frequently used polymethylmethacrylate cement (PMMA), which shows a higher level of stiffness than bone material and may ultimately lead to shifting stress levels within the entire spine. The goal of the present study was to evaluate and compare the pressure distribution in the endplate of human vertebrae after kyphoplasty with PMMA and aluminum-free glass-polyalkenoate cement (gpc). For the present study, 8 fresh frozen human cadaveric vertebral bodies from the thoracolumbar junction were used. All vertebrae were augmented transpedicularly on one side with gpc and on the other side with PMMA. A loading of 600 N, 800 N and 1000 N was applied. In the data processing an individual region of interest (roi) was generated for each vertebra. The following parameters were determined for each roi: maximum force [N], maximum pressure [kPa], mean pressure [kPa], roi area [cm2]. We found significantly higher mean pressure values in the areas of the vertebrae augmented with PMMA, compared to the ones after augmentation with gpc (p = 0.012) when applying 1000 N. In the groups with lower forces there were no statistical relevant differences. The pressure distribution shows an advantage for gpc. A material, which does not create load concentration onto the cranial and caudal vertebral surface, could have major advantages concerning the risk of adjacent vertebral fractures. Thus the results of the 1000 N loading protocol suggest gpc being a possible alternative to ordinary PMMA cement, regarding its influence on stiffness in kyphoplasty. These and other general aspects like incorporation should be addressed and elaborated more detailed in further studies.

Background Context Cement augmentation techniques are standard treatments for osteoporotic vertebral fractures. Compared with vertebroplasty, kyphoplasty is associated with lower rates of cement leak and better deformity correction; however, posterior wall fractures are relative, but not absolute; contraindications for both techniques and hence treatment practices vary among spine centers. Purpose The primary aim of this study was to assess our center's incidence of posterior cement leakage in osteoporotic vertebral fractures with posterior wall injury treated by balloon kyphoplasty (BKP). Secondarily, physiological results, pain relief, complication rates, and non-posterior cement leakage were also evaluated. Study Design This is a prospective cohort study done in a high-volume spine center in Germany. Patient Sample Eighty-two patients with 98 osteoporotic vertebral fractures with posterior wall cortical injury were studied from 2012 to 2016. Outcome Measures The following were the outcome measures: (1) physiological measures: standing plain x-rays (anteroposterior and lateral views), with the following parameters evaluated: cement leak behind the posterior vertebral body border, Cobb angle for local sagittal deformity, vertebral wedge angle, and anterior vertebral height; (2) cement volume injected in each vertebra; and (3) self-report measures: visual analog scale (VAS). Methods All patients underwent BKP using a bipedicular approach. Preoperative clinical and neurologic evaluations were done. Radiological evaluations included plain X-ray images, computed tomography scans and magnetic resonance imaging. The average follow-up period was 18 months. Results No cement leakage into the spinal canal occurred in any of the patients. Asymptomatic leakage into other sites was seen in 22 vertebrae (22.45%). There was significant improvement in the Cobb angle, the vertebral wedge angle, and the anterior vertebral height in all cases. The mean preoperative VAS was 8.1, and this improved to 2.3 on the third postoperative day. Conclusion Balloon kyphoplasty is a viable option for the treatment of osteoporotic vertebral fractures even with posterior wall involvement.

Spinal metastases occur in 30%-50% of patients with systemic cancer. The primary goals of palliation are pain control and prevention of local recurrence.This study aimed to test the safety and efficacy of a combined modality approach consisting of kyphoplasty and intraoperative radiotherapy (Kypho-IORT).Kyphoplasty and intraoperative radiotherapy was a prospective, single-center phase I/II trial. Patients were enrolled in a classical 3+3 scheme within the initial phase I, where Kypho-IORT was applied using a needle-shaped 50 kV X-ray source at three radiation dose levels (8 Gy in 8-mm, 8 Gy in 11-mm, and 8 Gy in 13-mm depth). Thereafter, cohort expansion was performed as phase II of the trial. The trial is registered with clinicaltrials.gov, number NCT01280032.Patients aged 50 years and older with a Karnofsky Performance Status of at least 60% and with one to three painful vertebral metastases confined to the vertebral body were eligible to participate.The primary end point was safety as per the occurrence of dose-limiting toxicities. The secondary end points were pain reduction, local progression-free survival (L-PFS), and overall survival (OS).Pain was measured using the visual analog scale (VAS) and local control was assessed in serial computed tomography or magnetic resonance imaging scans.None of the nine patients enrolled in the phase I showed dose-limiting toxicities at any level and thus, 52 patients were subsequently enrolled into a phase II, where Kypho-IORT was performed at various dose levels. The median pain score significantly dropped from 5 preoperatively to 2 at the first postoperative day (p.001). Of 43 patients who reported a pre-interventional pain level of 3 or more, 30 (69.8%) reported a reduction of ≥3 points on the first postoperative day. A persistent pain reduction beyond the first postoperative day of ≥3 points was seen in 34 (79.1%) patients. The 3, 6, and 12 month L-PFS was excellent with 97.5%, 93.8%, and 93.8%. The 3, 6, and 12 months OS was 76.9%, 64.0%, and 48.4%.Kyphoplasty and intraoperative radiotherapy is safe and immediately provided sustained pain relief with excellent local control rates in patients with painful vertebral metastases.

Thoracolumbar malunion is the result of loss of correction, insufficient correction or even no correction (both in the frontal and sagittal planes) of a thoracolumbar fracture. The main causes are incorrect assessment of the fracture's complexity (burst fracture), its potential progression to kyphosis and associated disc or ligament damage. It can also be the result of a poorly conducted initial treatment. The types of malunion have changed over the years because of the introduction of vertebroplasty and kyphoplasty. The malunion can be well tolerated if there is only a moderate deformity. However, the functional and pain-related limitations can be severe with large deformities. Functional limitation is mainly related to sagittal imbalance, but also to sequelae associated with the injury in various ways (non-union, disc degeneration, spinal cord compression, syringomyelia, etc.). The deformity and its consequences are evaluated globally using full-body standing radiographs (EOS), CT scan and MRI. Comparison of MRI images taken in a lying position to weight bearing views or even dynamic ones is an additional means to evaluate whether the lesions are reducible. Differences in spine morphology and compensatory mechanisms to combat the sagittal imbalance induced by the deformity must also be analyzed. These provide more complete information about the consequences of the malunion and help to establish the best corrective strategy. These compensatory mechanisms consist of accentuation of lumbar lordosis along with reduction of thoracic kyphosis. As a last resort, the pelvis and femur contribute to this compensation when there is a large deformity or a stiff spine due to preexisting osteoarthritis. Treatment strategies are fairly well standardized. When the deformity is reducible, a two-stage surgery is indicated. When the deformity is not reducible, posterior transpedicular closed wedge osteotomy is the gold standard. Nevertheless, the best way to treat thoracolumbar malunion is to prevent it.

Minimally invasive methods, such as balloon kyphoplasty (BKP) and percutaneous sacroplasty (PS), which are now widely used for the surgical treatment of compression fractures, involve injection of a bolus of poly (methyl methacrylate) bone cement (hereafter, “bone cement”) into the fractured tissue. Many of the common complications following these surgeries, such as cement leakage and adjacent-level fractures (in the case of BKP), have been postulated to be related to the quality of the cancellous bone–bone cement interface, which, in turn, is a function of its fracture resistance. It is common to use bovine cancellous bone or polyurethane foam (PF) as a substitute for human cancellous bone in biomechanical studies of these surgical methods. The literature is lacking in studies of determination of fracture properties of human cancellous bone–bone cement interface, bovine cancellous bone–bone cement interface, and PF–bone cement interface. In the present work, an integrated methodology (combination of wedge splitting test and Heaviside-based digital image correlation) was used to make these determinations as well as those for the bone cement, bones and the PF alone. The fracture properties determined were maximum fracture load ( F max ), fracture toughness (K c ), and specific fracture energy (G f ). For example, G f values for human cancellous bone and human cancellous bone–bone interface were 0.48±0.14 N/mm and 0.38±0.05 N/mm, respectively, whereas in the case of bovine cancellous bone and bovine cancellous bone–bone cement interface, they were 1.08±0.11 N/mm and 0.22±0.05 N/mm, respectively, and for PF (Grades 12.5 and 15.0) and PF–bone cement interface, they were 0.81±0.12 and 0.55±0.06 N/mm, respectively. The same trends were seen in the F max and K c results. These results suggest that it may not be justified to use either bovine cancellous bone or either of the PF grades as a substitute for human cadaveric cancellous bone in biomechanical studies of BKP, PS, and similar surgical methods.

Kyphoplasty and Vertebroplasty (VP) are accepted therapeutic approaches to treat pain associated with vertebral compression fractures. Major complications such as cord or root compression, subdural and epidural hematomas (EDH), as well as pulmonary emboli, have been reported in less than 1 of patients. Spinal EDH is an extremely rare complication that usually happens a few hours after the procedure. We report a case of spinal EDH that developed four days after a successful kyphoplasty. © 2021 The Author(s)

Background Posterior fixation and fusion is the primary treatment for thoracolumbar fractures, although this treatment may sacrifice range of motion (ROM) to achieve stability, rather than treating the fracture itself. Two issues addressed when treating thoracolumbar fractures are 1) replacing the fractured vertebrae, especially the upper end plate of the injured vertebrae and 2) providing strong fixation with biomechanical stability and flexibility. Methods This retrospective study included 61 consecutive patients with thoracic or lumbar fractures treated from October 2010 to May 2014. Patients were divided into 1 of 2 groups: group A, intravertebral bone graft with balloon kyphoplasty (nonfusion surgery), and group B, traditional posterior fixation and fusion surgery. The visual analog scale was used preoperatively and at 3 months, 1 year, and 2 years. Radiography, computed tomography, and magnetic resonance imaging were performed preoperatively. Radiography was performed postoperatively at 3 months and 2 years. At 3 months after surgery, computed tomography was used to confirm healing of the vertebral fracture. Results All fractures in both groups were reduced successfully, and deformities were improved. After the removal of hardware in group A, ROM at the injury level recovered, and at 2 years, there was no loss of vertebral height or recurrence of deformity. There was no hardware failure in group A, but there was evidence of screw loosening in 3 screws in group B. Conclusions Nonfusion treatment of intravertebral bone graft assisted with balloon kyphoplasty showed good fracture reduction, deformity correction, fracture healing, and ROM maintenance. There were no complications associated with the implant.

To meet the requirements of minimally invasive surgical treatments for osteoporotic vertebral compression fracture, various strategies have been proposed to enhance the properties of calcium phosphate cement (CPC). Here, a new strategy was developed by incorporating poly (γ-glutamic acid) (γ-PGA) and its strontium salt into the formulation of alpha tricalcium phosphate (α-TCP)-based CPC. Effects of γ-PGA on the injectability, cohesion, setting times, mechanical compressive strengths and cytocompatibility were systematically studied. Results showed that the injectability, cohesion and setting times were considerably improved by introducing γ-PGA into the CPC. Moreover, after setting for 7 days, the compressive strengths increased from 14.6 ± 1.4 MPa for pure CPC to 35.3 ± 1.7 MPa for CPC with 8.9 wt% γ-PGA and further to 61.2 ± 5.4 MPa for CPC with 8.9 wt% γ-PGA combined with its strontium salt. In vitro osteoblast proliferation tests showed that the group of CPC modified by γ-PGA and its strontium salt had better cytocompatibility than the pure CPC group. All results suggest that optimal properties were obtained for the cement with 8.9 wt% γ-PGA added to its solid phases and using strontium salt as the reactive liquid phase, making it as a promising candidate for application in kyphoplasty.

Study design Burst fractures not associated with any neurological deficits are frequent but not therapeutic agreement on their management is available to date. This case-control study was conducted to try to help guide therapeutic decision in the treatment of such fractures. Materials and methods This case-control study includes consecutive retrospective evaluation of 25 case-patients treated by posterior short-segment fixation associated with kyphoplasty (SFK) in the treatment of A3 thoracolumbar unstable fractures, as compared to a control-group composed of 82 patients treated by long-segment (LF) pedicle screws. Results SFK patients bled significantly less than the LF patients (p = 0.04). Assessment of deformation progression, vertebral height restoration and reduction of the regional kyphotic angle in the SFK and LF groups revealed no statistically significant superiority of one approach on another. In contrast, the height of endplates was significantly increased in the SFK group (p = 0.006). The patients’ pain levels were significantly improved in the SFK group (p = 0.002). However, patients from the SFK group stood earlier postoperatively (1.7 vs 3.7 days, p = 0.001). Conclusion We believe that SFK in vertebral fractures is as efficient as LF for bone consolidation and spine stabilization. In addition, SFK patients may use fewer analgesics.

Aggressive hemangiomas invade the spinal canal and/or paravertebral space and may cause cord compression and neurological symptoms. Radiation therapy was recognized as an effective strategy for the treatment of aggressive hemangiomas. Here, it is reported the first case of aggressive vertebral hemangioma treated by a combination of intraoperative radiation therapy and kyphoplasty (Kypho-IORT).

In spite of the success of vertebroplasty (VP) and balloon kyphoplasty (BKP), which are widely used for stabilizing painful vertebral compression fractures, concerns have been raised about use of poly(methyl methacrylate) (PMMA) bone cements for these procedures since the high compressive modulus of elasticity (E) of the cement is thought to be one of the causes of the higher number of adjacent-level vertebral fractures. Therefore, bone cements with E comparable to that of cancellous bone have been proposed. While the quasi-static compressive properties of these so-called “low-modulus” cements have been widely studied, their fatigue performance remains underassessed. The purpose of the present study was to critically compare a commercial bone cement (control cement) and its low-modulus counterpart on the basis of quasi-static compressive strength (CS), E, fatigue limit under compression-compression loading, and release of methyl methacrylate (MMA). At 24 h, mean CS and E of the low-modulus material were 72% and 77% lower than those of the control cement, whereas, at 4 weeks, mean CS and E were 60% and 54% lower, respectively. The fatigue limit of the control cement was estimated to be 43–45 MPa compared to 3–5 MPa for the low-modulus cement. The low-modulus cement showed an initial burst release of MMA after 24 h followed by a plateau, similar to many other commercially available cements, whereas the control cement showed a much lower, stable release from day 1 and up to 1 week. The low-modulus cement may be a promising alternative to currently available PMMA bone cements, with the potential for reducing the incidence of adjacent fractures following VP/BKP.

Background Kyphoplasty is a popular treatment option for osteoporotic vertebral compression fractures (OVCFs). However, there is still a lack of comprehensive clinical evidence demonstrating whether kyphoplasty is suitable for treatment of OVCFs complicated by chronic kidney disease (CKD). The purpose of this study was to evaluate the effectiveness and safety of kyphoplasty in the treatment of OVCFs in CKD. Methods Twelve OVCF patients with CKD who received kyphoplasty were retrospectively reviewed. Visual analogue scale (VAS), painkiller score, and the Oswestry Disability Index (ODI) questionnaire were measured one day preoperatively, three days postoperatively, and at final follow-up to evaluate the functional outcomes of patients. Additionally, changes in the anterior, middle, and posterior vertebral heights of the fractured vertebral body (VB), as well as changes in the Cobb's angle of the thoracic spine were used to assess improvements in local kyphosis correction. Results A rapid improvement in pain and disability was achieved in our patients, which was manifested by a significant reduction in VAS, painkiller score, and ODI three days after kyphoplasty. In addition, the use of kyphoplasty offered the benefit of restoring vertebral body height and significantly improved the Cobb's angle. These findings support the value of kyphoplasty in the correction of local kyphosis for OVCF patients with CKD. Conclusions Kyphoplasty can rapidly relieve pain and disability, and improve local kyphosis caused by fracture in OVCF patients accompanied by CKD. These findings provide new evidence that kyphoplasty may be a safe and effective option for the treatment of OVCFs in patients with CKD.

Purpose This study compared the radiologic and clinical outcomes of kyphoplasty with intravertebral reduction device (IRD) and vertebroplasty (VP) in treating osteoporotic vertebral compression fractures (OVCFs). Materials and Methods We enrolled 75 patients with OVCFs who were aged >60 years and treated them through VP or kyphoplasty with IRD. The radiologic outcomes, namely the anterior and middle body heights (ABH and MBH, respectively) and kyphotic angle (KA), were measured preoperatively and at postoperative 1 week, 3 months, 6 months, and 1 year. The refracture was identified on the basis of a decrease in ABH, MBH, or KA compared with those at postoperative 1 week. Visual analog scale (VAS) for pain and complications were recorded. The incidence of adjacent and nonadjacent fractures was also recorded. Results We treated 36 patients with kyphoplasty with IRD (IRD group) and 39 through VP (VP group). The patient characteristics were comparable in both groups. The KA and its restoration were more favorable after IRD than after VP. Although ABHs were not different in either group, their restoration was more efficient after IRD than after VP. MBHs, their restoration, and their refracture rates were better after IRD than after VP. VAS pain scores and complication rates were not different between the groups. The incidences of adjacent or nonadjacent fractures were not different between the 2 groups. Conclusion Our findings reveal significantly more efficient height restoration and kyphosis correction and fewer refractures in the IRD group. IRD may not increase the risk of adjacent or nonadjacent fractures.

Pain is a significant burden for patients with cancer and is particularly prevalent among those with advanced cancer. Appropriate interventional cancer pain therapies complement conventional pain management by reducing the need for systemic opioid therapy and its associated toxicity; however, these therapies are often underutilized. This article reviews techniques, indications, complications, and outcomes of the most common interventional approaches for the management of cancer-related pain. These approaches include intrathecal drug delivery, vertebral augmentation, neurolysis of the celiac, superior hypogastric and ganglion impar plexus', image-guided tumor ablation, and other less commonly performed but potentially beneficial interventions.

We put forward an assessment system of thoracolumbar osteoporotic fracture (ASTLOF) evaluating the severity of thoracolumbar osteoporotic fracture. This study was to investigate its efficacy in guiding clinical practice.Three hundred and eighty-one patients with thoracolumbar vertebral osteoporosis fracture admitted to the hospital from January 2010 to December 2011 were enrolled in the study. All cases were evaluated by ASTLOF including evaluation of morphological changes, MRI, bone mineral density and pain. The patients were treated with different methods according to ASTLOF score. All patients were followed up on a regular basis. The treatment results were assessed by VAS and ODI.All patients were followed up with an average of 20.1 (range: 6-30) months. There were 91 cases of ASTLOF score4 points. Their average VAS score decreased from 8.0 ± 1.7 points to 2.0 ± 1.3 with statistical significance (P0.05) and the average ODI score decreased from 69.5 ± 2.8 to 38.1 ± 1.5 (P0.05). One hundred and thirty-two cases were with ASTLOF score=4, with the average VAS score decreased from 8.2 ± 1.4 to 1.9 ± 1.2 (P0.05) and the average ODI score decreased from 71.5 ± 3.7 to 36.2 ± 2.5 (P0.05). There were 158 cases of ASTLOF score ≥ 5, with the VAS score decreased from 8.0 ± 1.7 to 2.0 ± 1.3 and the ODI score decreased from 69.5 ± 2.8 to 38.1 ± 1.5.ASTLOF based on the severity of thoracolumbar osteoporotic fracture was suggested to be helpful in guiding clinical practice.