Clinical application of targeted sealing with high viscosity bone cement and secondary injection of low viscosity bone cement in vertebroplasty / 中国骨伤

OBJECTIVE@#To observe the clinical efficacy of targeted sealing with high viscosity bone cement and secondary injection of low viscosity bone cement in the treatment of OVCFs patients with the fracture lines involved vertebral body margin.@*METHODS@#The elderly patients who underwent vertebroplasty for osteoporotic vertebral compression fractures from January 2019 to September 2021 were selected as the screening objects. Through relevant standards and further CT examination, 56 patients with fracture lines involving the anterior wall or upper and lower endplates of the vertebral body were selected for the study. There were 21 males and 35 females, aged from 67 to 89 years old with an average of (76.58±9.68) years. All 56 patients underwent secondary injection of bone cement during operation. Only a small amount of high viscosity cement was targeted to seal the edge of the vertebral body for the first time, and low viscosity cement was injected to the vertebral bodies during second bolus with well-distributed. The operation time, bone cement volume and bone cement leakage were recorded, and the pain relief was evaluated by visual analogue scale (VAS).@*RESULTS@#All patients were followed up for more than 3 months and the surgeries were successfully complete. The operation time was (50.41±10.30) min and the bone cement volume was (3.64±1.29) ml. The preoperative VAS was (7.21±2.41) points, which decreased significantly to (2.81±0.97) points 3 days after operation(P<0.05). Among the 56 patients, 2 cases(3.57%) had bone cement leakage, 1 case leaked to the paravertebral vein, and 1 case slightly bulged to the paravertebral through the crack when plugging the vertebral crack. Both patients had no obvious clinical symptoms.@*CONCLUSION@#In vertebroplasty surgery, targeted sealing of high viscosity bone cement and secondary injection of low viscosity bone cement can reduce intraoperative bone cement leakage and improve the safety of operation.

Instrumentación anterior y posterior para tratamiento de fractura por Metástasis Vertebral / Anterior and posterior instrumentation for fracture treatment due to Vertebral Metastasis

Las fracturas tumorales en columna vertebral son parte de la etiología de las fracturas patológicas a este nivel, que por edad de presentación, así como la clínica observada puede otorgar directrices del tipo de tumor que afecta al esqueleto axial. Por tanto, resulta importante su identificación, clasificación y terapéutica a seguir, en especial en aquellos casos donde se encuentra afectada la parte neurológica distal. Teniendo en consideración estos aspectos planteamos este caso clínico.

Tumoral fractures in spine are part of the etiology of pathologic fractures in this level, age of presentation and the observed clinical can give guidance on the type of tumor that affects the axial skeleton, it is important to identify, classification and therapeutic to follow, especially those who are affected neurological distal part. Considering this aspect propose clinical case below.

Manejo con instrumentación 360 o de enfermedad ósea metastásica que condiciona inestabilidad en columna cervical. Reporte de un caso clínico / 360 degrees instrumentation for cervical instability due to metastatic bone disease. Case report

Resumen: Introducción: La columna vertebral es el sitio más frecuente de localización para las metástasis óseas; siendo los tumores de mama, próstata y pulmón los que mayor afectación presentan. La columna torácica es afectada en un 70% de los casos, seguida de la región lumbar y cervical. Material y métodos: se presenta el caso de un paciente con diagnóstico de adenocarcinoma mamario derecho, con enfermedad ósea metastásica en región cervical a nivel de C2, C3, inestabilidad del segmento cervical por fractura por compresión del cuerpo C3 de mayor al 80%, sin invasión a canal medular, inicia con parestesias de extremidades torácicas. Se realiza instrumentación 360º en dos tiempos. Posterior al procedimiento la paciente evolucionó sin dolor cervical y tolerando la vía oral. Discusión: la enfermedad ósea metastásica genera lesiones importantes en la columna vertebral condicionando inestabilidad; la instrumentación mejora el estado funcional y el pronóstico.

Abstract: Introduction: The spine is the most common site for bone metastases; being the breast, prostate and lung cancer which have most affected. The thoracic spine is involved in 70% of cases, followed by the lumbar and cervical region. Material and methods: This is a 59 years old female diagnosed with breast adenocarcinoma and metastatic bone disease in cervical spine C2, C3 level and instability of that segment because of a compression fracture of C3 greater than 80% without invasion of the spinal canal, she begins with paresthesias of upper limbs. A 360º instrumentation was performed in two stages. After the surgical procedure the patient were without neck pain and a good neurological status. Discussion: Metastatic bone disease causes significant damage to the spine sometimes create instability proper instrumentation is needed to improve the functional status and prognosis of these lesions.

Identification of fresh and old vertebral compression fractures by MRI / 法医学杂志

OBJECTIVE@#To analyze and explore the value of MRI in distinguishing fresh from old vertebral compression fractures.@*METHODS@#The features of MRI in 43 cases with compression fractures of thoracic or lumbar vertebral bodies were analyzed. MRI sequences included T1WI, T2WI and STIR.@*RESULTS@#Fifty-five vertebral bodies in total were found compression fractures in 43 cases. Forty-six vertebral bodies, which showed low signals or low signals mixing a few high signals on T1WI, high signals on T2WI and significantly high signals on STIR, were identified as fresh compression fractures. Nine vertebral bodies were identified as old compression fractures, because they showed the same signals as normal vertebral bodies on T1WI, T2WI and STIR.@*CONCLUSION@#MRI could accurately distinguish fresh and old vertebral compression fractures, so it is valuable for the distinguishment in forensic identification.

Multiple Vertebral Involvement of Rheumatoid Arthritis in Thoracolumbar Spine: A Case Report

Although little attention has been paid to the less common rheumatoid involvement of the thoracic and lumbar regions, some studies have shown that rheumatoid synovitis with erosive changes can develop in these diarthrodial joints. We report a patient with seropositive rheumatoid arthritis (RA) involving the thoracic and lumbar vertebra with a collapse of the T12 vertebra, who was treated with percutaneous vertebroplasty. In this case of a painful pathological fracture due to RA, percutaneous vertebroplasty was found to be helpful in eliminating the pain. The paper presents the histological evidence, the pathogenesis and treatment of the thoracolumbar lesions affected by RA with a review of the relevant literature.

Revision Surgery after Vertebroplasty or Kyphoplasty

BACKGROUND: We wanted to investigate the leading cause of failed vertebroplasty or kyphoplasty. METHODS: Twelve patients (10 females and 2 males) who underwent revision surgery after vertebroplasty or kyphoplasty were included. In 4 cases, vertebroplasty was done for two or more levels. Six cases with kyphoplasty were included. Through the retrospective review of the radiographic studies and medical record, we analyzed the etiology of the revision surgery. RESULTS: Uncontrolled back pain was the main clinical presentation. In 4 cases, neurological symptoms were noted, including one case with conus medullaris syndrome. The average time to the revision surgery after vertebroplasty or kyphoplasty was 15 months. Infection (4 cases) and progressive kyphosis with collapse (8 cases) were the causes for the revision. A solid pattern of inserted bone cement and bone resorption around the cement were noted in the all cases with progressive collapse and kyphosis. CONCLUSIONS: Infection, misdiagnosis and progressive kyphosis were causes of the revision surgery after vertebroplasty and kyphoplasty. A solid pattern of accumulation of bone cement and peri-cement bone resorption might be related with the progressive collapse.

Preliminary Results for the Treatment of a Pain-Causing Osteoporotic Vertebral Compression Fracture with a Sky Bone Expander

OBJECTIVE: Vertebral compression fractures (VCFs) are common complications of osteoporosis. The expansion of VCFs with a Sky Bone Expander is a new procedure which improves kyphotic deformities and decreases pain associated with VCFs. The purpose of this study was to investigate the preliminary results for the treatment of painful osteoporotic VCFs with a Sky Bone Expander. MATERIALS AND METHODS: Twenty-six patients with pain-causing VCFs were treated with a Sky Bone Expander. This operation involved the percutaneous insertion of the Sky Bone Expander into a fractured vertebral body transpedicularly. Following the expansion, the Sky Bone Expander was contracted and removed, resulting in a cavity to be filled with bone cement. All fractures were analyzed for improvement in sagittal alignment. Clinical complications, pain relief and ambulation status were evaluated 1 day, 1 week, 1 month, and 3 months after the operation. RESULTS: Twenty-four hours after the operation, all the patients treated experienced some degree of pain relief. In addition, no postoperative neurologic complications were noted. The average operative time was 42.4 +/- 15.5 min per vertebra. Moreover, an average cement volume of 3.5 mL (range, 2.5 +/- 5.0 mL) was injected per vertebra. The average anterior height was 18.4 +/- 5.1 mm preoperatively and 20.5 +/- 5.3 mm postoperatively (p < 0.01). Furthermore, the average midline height was 15.5 +/- 5.2 mm preoperatively and 18.9 +/- 4.0 mm postoperatively (p < 0.01). The Cobb angle improved from 18.5 +/- 8.2 degrees preoperatively to 9.2 +/- 4.0 degrees postoperatively (p < 0.01). The Visual Anabog Scale scores decreased from 7.7 +/- 1.8 points preoperatively to 3.1 +/- 2.0, 2.9 +/- 1.7, 2.6 +/- 1.5 and 2.9 +/- 11.3 after 1 day, 1 week, 1 month and 3 months after the operation, respectively. Cement extrusion was observed in four patients without any neurologic symptoms. CONCLUSION: As a result of this study, we can postulate that the expansion of compressed vetrebra with a Sky Bone Expander is a safe and minimally invasive procedure resulting in the restoration of vertebral body height and the relief of pain associated with VCFs.

Clinical Relevance of Pain Patterns in Osteoporotic Vertebral Compression Fractures

Few studies have been conducted to explain the pain patterns resulting from osteoporotic vertebral compression fractures (OVCF). We analyzed pain patterns to elucidate the pain mechanism and to provide initial guide for the management of OVCFs. Sixty-four patients underwent percutaneous vertebroplasty (N=55) or kyphoplasty (N=9). Three pain patterns were formulized to classify pains due to OVCFs: midline paravertebral (Type A), diffuse paravertebral (Type B), and remote lumbosacral pains (Type C). The degree of compression was measured using scale of deformity index, kyphosis rate, and kyphosis angle. Numerical rating scores were serially measured to determine the postoperative outcomes. As vertebral body height (VBH) decreased, paravertebral pain became more enlarged and extended anteriorly (p<0.05). Type A and B patterns significantly showed the reverse relationship with deformity index (p<0.05), yet Type C pattern was not affected by deformity index. Postoperative pain severity was significantly improved (p<0.05), and patients with a limited pain distribution showed a more favorable outcome (p<0.05). The improvement was closely related with the restoration of VBH, but not with kyphosis rate or angle. Thus, pain pattern study is useful not only as a guide in decision making for the management of patients with OVCF, but also in predicting the treatment outcome.