Early Balloon Kyphoplasty Treatment for Osteoporotic Vertebral Fracture Reduces Adjacent Vertebral Fractures.

Background and Objectives: This study retrospectively examined whether the incidence rates of adjacent vertebral fractures (AVFs) can be reduced through balloon kyphoplasty (BKP) for osteoporotic vertebral fractures (OVFs) in the early stages, when there is little vertebral height variation. Materials and Methods: A total of 95 patients (22 males, 73 females, mean age: 80.7 years) who had undergone BKP were divided into two groups: the Early group (underwent BKP within 2 weeks after injury, n = 62), and the Non-early group (underwent BKP > 2 weeks after injury, n = 33). The following data were analyzed: patient characteristics; fracture level; the presence of old vertebral fractures, posterior wall injury, and intravertebral cleft; duration of surgery; duration of hospitalization; cement volume; the occurrence of AVF; the timing of AVF occurrence; Numerical Rating Scale (NRS) scores at the preoperative, postoperative, and final follow-up assessments; posterior vertebral kyphosis angle of the affected vertebra on plain lateral X-ray; vertebral wedge ratio; local kyphotic angle; and changes in posterior vertebral kyphosis angle, vertebral wedge ratio, and local kyphotic angle between preoperative and postoperative assessments. The patients were divided based on the occurrence or non-occurrence of AVF after BKP: the Non-AVF group, in which AVF did not occur, and the AVF group, in which AVF occurred. Results: The incidence of AVF was 15.8% (15/95 patients), with a notably lower incidence rate in the Early group at 6.5% (4/62 patients) compared to the Non-early group at 33.3% (11/33 patients). NRS scores significantly improved in both groups at the postoperative assessment and final follow-up. The changes in posterior vertebral kyphosis angle and vertebral wedge ratio were significantly lower in the Early group. In the Non-AVF group, the time from injury to surgery was significantly shorter. Conclusions: The Early group had a significantly lower incidence of AVF. The time from injury to surgery was a risk factor for AVF occurrence, suggesting that early BKP is recommended.

Can We Rely on Prophylactic Two-Level Vertebral Cement Augmentation in Long-Segment Adult Spinal Deformity Surgery to Reduce the Incidence of Proximal Junctional Complications?

Background and Objectives: Proximal junctional kyphosis (PJK) and failure (PJF), the most prevalent complications following long-segment thoracolumbar fusions for adult spinal deformity (ASD), remain lacking in defined preventive measures. We studied whether one of the previously reported strategies with successful results-a prophylactic augmentation of the uppermost instrumented vertebra (UIV) and supra-adjacent vertebra to the UIV (UIV + 1) with polymethylmethacrylate (PMMA)-could also serve as a preventive measure of PJK/PJF in minimally invasive surgery (MIS). Materials and Methods: The study included 29 ASD patients who underwent a combination of minimally invasive lateral lumbar interbody fusion (MIS-LLIF) at L1-2 through L4-5, all-pedicle-screw instrumentation from the lower thoracic spine to the sacrum, S2-alar-iliac fixation, and two-level balloon-assisted PMMA vertebroplasty at the UIV and UIV + 1. Results: With a minimum 3-year follow-up, non-PJK/PJF group accounted for fifteen patients (52%), PJK for eight patients (28%), and PJF requiring surgical revision for six patients (21%). We had a total of seven patients with proximal junctional fracture, even though no patients showed implant/bone interface failure with screw pullout, probably through the effect of PMMA. In contrast to the PJK cohort, six PJF patients all had varying degrees of neurologic deficits from modified Frankel grade C to D3, which recovered to grades D3 and to grade D2 in three patients each, after a revision operation of proximal extension of instrumented fusion with or without neural decompression. None of the possible demographic and radiologic risk factors showed statistical differences between the non-PJK/PJF, PJK, and PJF groups. Conclusions: Compared with the traditional open surgical approach used in the previous studies with a positive result for the prophylactic two-level cement augmentation, the MIS procedures with substantial benefits to patients in terms of less access-related morbidity and less blood loss also provide a greater segmental stability, which, however, may have a negative effect on the development of PJK/PJF.

Hydraulic Polymethylmethacrylate Pressure Delivery System Versus Manual Balloon Tamp System in Balloon Kyphoplasty.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Osteoporotic vertebral compression fractures (VCFs) are prevalent among the elderly population, and Balloon kyphoplasty (BKP) is a minimally invasive solution for these. However, Polymethylmethacrylate (PMMA) leakage is a significant complication with potentially severe consequences. This study compares the safety and efficacy of manual balloon tamp system (MTS) and hydraulic Polymethylmethacrylate pressure delivery system (HPDS) in BKP. METHODS: A retrospective study involving 160 patients, comparing MTS (2008-2014) and HPDS (2016-2020) cohorts, assessed PMMA leakage, radiation exposure, and surgery duration. RESULTS: PMMA leakage occurred in 52.8% of MTS and 62.5% of HPDS cases. Intradiscal leakage was the most common pattern in both groups. Multivariate logistic regression revealed that multilevel BKP and HPDS were associated with higher PMMA leakage rates. Radiation exposure was significantly lower with HPDS, while surgery duration was shorter. DISCUSSION: This study provides novel insights into PMMA leakage and radiation exposure in BKP. HPDS was associated with a higher PMMA leakage rate. HPDS, however, offers advantages in terms of reduced radiation exposure and shorter surgery duration. Multilevel BKP also increased the risk of leakage. Further investigation is needed to better understand the impact of HPDS on PMMA leakage. CONCLUSION: This study underscores that while HPDS offers advantages regarding radiation exposure and surgery duration, it is associated with a higher PMMA leakage rate.

Prognostic Factors Associated with Poor Treatment Outcomes After Balloon Kyphoplasty in Elderly Patients Aged ≥81 years.

OBJECTIVE: Balloon kyphoplasty (BKP) is an effective procedure for osteoporotic vertebral compression fractures; however, there is limited data regarding its outcomes in patients aged ≥81 years. This study investigated the treatment outcomes and prognostic factors for BKP in this age group. METHODS: A retrospective analysis was conducted on 115 patients with osteoporotic vertebral compression fracture undergoing single-level BKP after failed conservative treatment, classified into the <81 years (n=70) and ≥81 years (n=45) groups. Surgical results were evaluated as good outcomes (independent indoors 1 year postoperatively) and poor outcomes, followed by univariate and multivariate analyses to determine prognostic factors correlating with these outcomes. RESULTS AND CONCLUSION: The majority of patients (<81 years: 85.7%; ≥81 years: 73.3%) had a good degree of independence at 1 year postoperatively, which was comparable in both groups. Further analysis of patients aged ≥81 years showed that longer duration from onset to surgery, more subsequent vertebral fractures, and lower preoperative body mass index were correlated with poorer outcomes postoperatively, and low body mass index, time from onset to surgery, and female sex were independent risk factors for these outcomes (area under the receiver operating characteristics curve: 0.91).

Risk Factors for Residual Back Pain After Balloon Kyphoplasty for Osteoporotic Vertebral Fracture.

Background: Balloon kyphoplasty (BKP) is a method for the management of osteoporotic vertebral body fracture (OVF). However, improvement in back pain (BP) is poor in some patients, also previous reports have not elucidated the exact incidence and risk factors for residual BP after BKP. We clarified the characteristics of residual BP after BKP in patients with OVF. Hypothesis: In this study, we hypothesize that some risk factors may exist for residual BP 2 years after the treatment of OVF with BKP. Patients and Methods: A multicenter cohort study was performed where patients who received BKP within 2 months of OVF injury were followed-up for 2 years. BP at 6 months after surgery and final observation was evaluated by Visual Analog Scale (VAS) score. Patients with a score of 40 mm or more were allocated to the residual BP group, and comparisons between the residual back pain group and the improved group were made for bone density, kyphosis, mobility of the fractured vertebral body, total spinal column alignment, and fracture type (fracture of the posterior element, pedicle fracture, presence or absence of posterior wall damage, etc.). Also, Short Form 36 (SF-36) for physical component summary (PCS) and mental component summary (MCS) at the final follow-up was evaluated in each radiological finding. Results: Of 116 cases, 79 (68%) were followed-up for 2 years. Two years after the BKP, 26 patients (33%) experienced residual BP. Neither age nor sex differed between the groups. In addition, there was no difference in bone mineral density, BKP intervention period (period from onset to BKP), and osteoporosis drug use. However, the preoperative height ratio of the vertebral body was significantly worse in the residual BP group (39.8% vs. 52.1%; p = 0.007). Two years after the operation, the vertebral body wedge angle was significantly greater in the residual BP group (15.7° vs. 11.9°; p = 0.042). In the multiple logistic regression model with a preoperative vertebral body height ratio of 50% or less [calculated by receiver operating characteristic (ROC) curve], the adjusted odds ratio for residual BP was 6.58 (95% confidence interval 1.64-26.30; p = 0.007); similarly, patients with vertebral body height ratio less than 50% had a lower score of SF-36 PCS 24.6 vs. 32.2 p = 0.08. Conclusion: The incidence of residual BP 2 years after BKP was 33% in the current study. The risk factor for residual BP after BKP was a preoperative vertebral body height ratio of 50% or less, which should be attentively assessed for the selection of a proper treatment scheme and to provide adequate stabilization. Level of Evidence: III.

Percutaneous Vertebroplasty Versus Balloon Kyphoplasty in the Treatment of Osteoporotic Vertebral Compression Fractures: Evaluating the Overlapping Meta-analyses.

BACKGROUND: Numerous meta-analyses and systematic reviews have explored the differences between percutaneous vertebroplasty (PVP) and percutaneous balloon kyphoplasty (PKP) for treating osteoporotic vertebral compression fractures (OVCFs), however, their final conclusions have been inconsistent. The inconsistent conclusions drawn from these meta-analyses create uncertainty among clinicians about the best treatment approach for OVCFs. OBJECTIVE: The aim of this study was to conduct a cross-sectional analysis of overlapping meta-analyses comparing PVP and PKP treatments for OVCF in order to help clinicians have access to the best available evidence and provide treatment recommendations based on the best available evidence. STUDY DESIGN: A cross-sectional analysis of overlapping meta-analyses. METHODS: We conducted a comprehensive search of meta-analyses published up to February 2023 in PubMed, Embase, Cochrane Library and Web of Science databases to identify relevant studies. The methodological quality of these studies was assessed using the Assessment of Multiple Systematic Reviews tool (original AMSTAR) and the Oxford Centre for Evidence-based Medicine Levels of Evidence. Two researchers independently extracted the data and assessed the quality of these meta-analyses. To determine which meta-analyses represented the best evidence, we employed the Jadad decision algorithm. RESULTS: Seventeen meta-analyses were included in the study, with AMSTAR scores ranging from 4 to 9, with an average of 7. After rigorous scrutiny, the Zhu et al study was determined to provide the best evidence. According to their findings, both PVP and PKP effectively alleviate pain and improve function in the treatment of OVCFs, without any statistically significant differences between them. In addition, PKP can reduce the risk of polymethylmethacrylate leakage compared to PVP. LIMITATIONS: This study analyzed published overlapping meta-analyses, inherently confining our investigation to the meta-analysis level. Furthermore, based on the AMSTAR scores, several included studies exhibited lower methodological quality. CONCLUSIONS: Currently, the best evidence indicates that PVP and PKP are equally effective at alleviating pain and enhancing function in the treatment of OVCFs, but PKP had a lower incidence of polymethylmethacrylate leakage. However, there is still a need for high-quality randomized controlled trials to provide higher levels of evidence regarding other aspects of the differences between the 2 procedures.

Risk factors for bone cement dislodgement following balloon kyphoplasty for osteoporotic vertebral compression fracture.

OBJECTIVE: The study aimed to determine the incidence and risk factors associated with bone cement dislodgement in patients with osteoporotic vertebral compression fracture following balloon kyphoplasty treatment. METHODS: A retrospective study was conducted on 203 patients who underwent kyphoplasty in 255 vertebral bodies between January 2017 and December 2021. The patients were categorized into two groups: the bone cement dislodgment group (n = 16) and the non-bone cement dislodgement group (n = 239). Various patient characteristics and radiologic parameters were evaluated. Statistical analysis involved the assessment of the background homogeneity of the group by using independent sample t tests, chi-square tests, and Fisher's exact. Univariate and multivariate logistic regression analyses were performed to explore the impact of background variables on cement dislodgement. RESULTS: The results revealed that split-type fracture (χ2 = 31.706, p < 0.001), DISH (χ2 = 18.827, p = 0.011), pedicle fracture (χ2 = 22.246, p < 0.001), endplate deficit (χ2 = 14.023, p < 0.001), posterior wall injury (χ2 = 29.124, p < 0.001), and intervertebral vacuum cleft (χ2 = 21.469, p < 0.001) were the factors that significantly differed between the two groups. The multivariate logistic regression analysis revealed posterior wall injury (OR = 12.983, p = 0.025) and intervertebral vacuum cleft (OR = 5.062, p = 0.024) to be independent risk factors. CONCLUSION: The incidence of bone cement dislodgement in our study was 6.3%. This study underscores the importance of using preoperative radiologic parameters to predict the risk of bone cement dislodgement following balloon kyphoplasty.

Outcomes of Balloon Kyphoplasty for Vertebral Compression Fractures in Patients with Diffuse Idiopathic Skeletal Hyperostosis at the Distal End or Adjacent Vertebra of the Fused Segments.

STUDY DESIGN: A retrospective cohort study. PURPOSE: To investigate the outcomes of balloon kyphoplasty (BKP) for vertebral compression fractures (VCFs) at the distal end or adjacent vertebra of the fused segments in patients with diffuse idiopathic skeletal hyperostosis (DISH). OVERVIEW OF LITERATURE: Vertebral fractures in the midportion of the fused segments in patients with DISH are generally unstable; thus, immobilization is recommended. However, VCFs classified as type A in the AO classification are observed at the distal end and adjacent vertebra of the fused segments, and treatment strategies for VCFs associated with DISH remain controversial. METHODS: The outcomes of 72 patients who underwent BKP for VCFs between 2015 and 2021 were retrospectively investigated. Patients with DISH were assigned to group D (n=21), whereas those without DISH were assigned to group ND (n=51). Back pain, incidence of subsequent adjacent fractures, reoperation rates, and local kyphosis were statistically analyzed. RESULTS: VCFs in group D occurred at the distal end or adjacent vertebra of the fused segments, and no fractures occurred in the midportion of the fused segment. Back pain improved in both groups, with no significant differences between them. Subsequent adjacent fractures were observed in three of the 21 patients in group D and 11 of the 51 patients in group ND, with no significant difference between them. Reoperation was performed in one patient each in groups D and ND, with no significant difference between the groups. Postoperatively, local kyphosis progressed significantly in group D. CONCLUSIONS: Although local kyphosis is more advanced in patients with DISH, BKP is effective for VCFs at the distal end or adjacent vertebra of the fused segments and may be useful in older patients with high complication rates.

Comparative analysis of anti-osteoporosis medications in preventing vertebral body fractures after balloon kyphoplasty.

This retrospective study compared the efficacy of anabolic agents (romosozumab and teriparatide) with that of alendronate in preventing subsequent vertebral body fractures (SVBFs) after balloon kyphoplasty (BKP). All anabolic agents significantly reduced SVBFs. Romosozumab was most effective in increasing bone mineral density (BMD) and completely suppressed distant vertebral body fractures. INTRODUCTION: To determine optimal anti-osteoporosis medications, we compared romosozumab and teriparatide to alendronate as a control from perioperative BKP to the 1st postoperative year for treatment and secondary fracture prevention in osteoporosis. METHODS: A total of 603 patients who underwent initial BKP for osteoporotic vertebral fractures were evaluated and categorized into five groups based on drug administration: romosozumab (group R, 155 patients), twice-weekly teriparatide (group TW, 48), weekly teriparatide (group W, 151), daily teriparatide (group D, 138), and alendronate (control) (group C, 111). The 1-year incidence of SVBFs, BMD change rate, and probability of requiring BKP were compared among the groups. RESULTS: SVBF incidence was 3.9%, 6.5%, 8.3%, 6.0%, and 14.4% in groups R, D, TW, W, and C, respectively, with all other groups exhibiting significantly lower rates than group C. The groups that administered the anabolic agents had a notably lower incidence of distant fractures than group C. Compared with group C, group R showed significantly higher BMD change rates in lumbar vertebral bodies at 4, 8, and 12 months and group D at 12 months. Anabolic agent groups exhibited significantly higher improvement rates than group C after conservative treatment alone. CONCLUSION: The anabolic agents were found to be more effective at reducing the incidence of SVBF (especially distant vertebral fractures) than alendronate. These agents decreased the rate of repeat BKP even after the occurrence of a fracture. Overall, the use of an anabolic agent for the treatment of osteoporosis after BKP is better than the use of alendronate, even when treatment is initiated in the perioperative stage.

Transoral balloon kyphoplasty in a myeloma patient with painful osseous destruction of the corpus vertebrae axis.

Multiple myeloma is the most common primary malignant disease of the spine, which can lead to pathological fractures with consecutive instability and immobilizing pain, due to osseous destruction of individual vertebral bodies. The different surgical care is challenging, although good stabilization should be achieved if possible. The resulting blocking of micro-movements leads to pain minimization. However, this is a symptomatic therapy and does not address the primary disease. In the following, we report on successful transoral balloon kyphoplasty for the treatment of myeloma-related osteolysis with a pathological fracture of vertebral body C2, which led to a significant clinical improvement.

Cement Embolism After Kyphoplasty.

Kyphoplasty is used for the treatment of vertebral compression fractures. The procedure involves inflating a balloon at the compression site; then, polymethylmethacrylate (PMMA) cement is added into the space created by the balloon, where it polymerizes, achieving stabilization, with possible expansion of the vertebral angle. The process is guided by X-rays. Complications are rare, especially when compared to vertebroplasty, and one rare complication is pulmonary cement embolism (PCE). Although many cases are likely undetected due to a lack of symptoms, symptomatic cases require treatment, as they can sometimes prove fatal. We present a case of a patient who underwent kyphoplasty and later presented with a PCE. The PCE was diagnosed using X-rays and computed tomography (CT).

Beyond Pain Relief: An In-Depth Review of Vertebral Height Restoration After Balloon Kyphoplasty in Vertebral Compression Fractures.

This comprehensive review delves into the intricate landscape of vertebral height restoration after balloon kyphoplasty in cases of vertebral compression fractures. With a comprehensive examination of procedural intricacies, radiological evaluations, clinical outcomes, and influential factors, a nuanced comprehension unfolds. Beyond its immediate alleviation of pain, vertebral height restoration emerges as a linchpin in enhancing spinal alignment, fostering functional recuperation, and augmenting the overall quality of life. This review underscores the pivotal role of balloon kyphoplasty, transcending its mere medical utility to become a conduit for renewed independence and well-being among individuals grappling with vertebral compression fractures. The ongoing advancements in medical science and the continued pursuit of research stand poised to amplify the significance of vertebral height restoration, manifesting a promising horizon for individuals seeking respite from pain, a revitalised capacity for movement, and a life unburdened by its constraints.

Surgical Treatment of Vertebral Compression Fracture in a Patient with Idiopathic Normal Pressure Hydrocephalus.

Idiopathic normal pressure hydrocephalus (iNPH) with gait disturbance can be effectively treated with a cerebrospinal fluid shunt. Furthermore, balloon kyphoplasty (BKP) is a successful minimally invasive treatment for osteoporotic vertebral compression fractures (VCFs). This case report presents the surgical management of an elderly patient with iNPH who presented after a VCF due to a fall. A 77-year-old woman who had been experiencing progressive gait disturbance for five years reported experiencing back pain one month after a fall. Imaging revealed a recent L1 VCF that did not compromise the spinal canal. Furthermore, the Mini-Mental State Examination results and the timed up-and-go test were 20 points and 17.96 seconds, respectively. Magnetic resonance imaging revealed ventriculomegaly with an Evans' index of 0.35. Her symptoms improved temporarily after a tap test, and she was diagnosed with probable iNPH. BKP was performed for VCFs, followed by the lumboperitoneal (LP) shunt placement for iNPH one month later. Following the operation, her symptoms improved without complications. After one month of performing BKP, an LP shunt would be placed to prevent shunt complications, such as infection and catheter-related neurological symptoms. Screening for iNPH in the elderly who present after VCFs due to a fall may identify iNPH patients who may benefit more from surgical treatments.

Early experience with percutaneous balloon kyphoplasty for treatment of osteoporotic vertebral compression fracture in Nepal: A case report.

Key Clinical Message: Balloon kyphoplasty is a promising treatment option for osteoporotic vertebral compression fractures with posterior cortical defect, offering pain relief, vertebral height restoration, and low risk of cement leakage. Abstract: Millions of people worldwide suffer from osteoporotic vertebral compression fractures (OVCFs) annually, which cause pain and functional limitations, particularly in the elderly. Conservative treatments such as pain management, rest, and medication are frequently used, while surgical options such as vertebroplasty and kyphoplasty are considered. We present a case of 68-year-old female with vertebral compression fracture of L1 vertebra with posterior cortical defect and posterior wall retropulsion. She was treated successfully with balloon kyphoplasty. Kyphoplasty appears to be a better option than vertebroplasty in cases with posterior cortical defect due to lower chance of cement leakage.

A novel device with pedicular anchorage provides better biomechanical properties than balloon kyphoplasty for the treatment of vertebral compression fractures.

PURPOSE: To compare the biomechanical behavior of vertebrae with vertebral compression fractures (VCF) treated by a novel system with pedicular anchorage (dowelplasty) versus balloon kyphoplasty. METHODS: Four cadaveric spines (T12-L5) were harvested, cleaned from soft tissues, and separated into vertebrae. Axial compressive loads were applied to each vertebra until a VCF was generated. Half of the vertebrae (n = 11) were instrumented using the "dowelplasty" system, consisting of a hollow titanium dowel anchored into the pedicle, through which a cannulated titanium nail is inserted and locked and through which cement is injected. The other half (n = 11) were instrumented using balloon kyphoplasty. Axial compressive loads were re-applied to each vertebra until fracture. Fracture load and fracture energy were calculated from load-displacement data for the pre- and post-treatment states. RESULTS: Compared to balloon kyphoplasty, dowelplasty granted greater net change in fracture load (373N; 95%CI,-331-1076N) and fracture energy (755Nmm; 95%CI,-563-2072Nmm). A sensitivity analysis was performed without L4 and L5 vertebrae from the dowelplasty group, since the length of the cannulated nails was too short for these vertebrae: compared to balloon kyphoplasty, dowelplasty granted an even greater net change in fracture load (680N; 95%CI,-96-1457N) and fracture energy (1274Nmm; 95%CI,-233-2781Nmm). CONCLUSION: Treating VCFs with dowelplasty grants increased fracture load and fracture energy compared to the pre-treatment state. Furthermore, dowelplasty grants greater improvement in fracture load and fracture energy compared to balloon kyphoplasty, which suggests that dowelplasty may be a good alternative for the treatment of VCF. LEVEL OF EVIDENCE: level IV.

Preoperative Scoring System for Prediction of Early Adjacent Vertebral Body Fracture After Balloon Kyphoplasty Using X-Rays Taken in a Non-Weight-Bearing Position.

BACKGROUND: Prevention of adjacent vertebral body fracture (AVF) following balloon kyphoplasty (BKP) is a key challenge. The objective of this study was to develop a scoring system that could be more extensively and effectively used to determine the surgical indications for BKP. METHODS: The study involved 101 patients aged 60 years or older who had undergone BKP. Logistic regression analysis was used to identify risk factors for early AVF within 2 months following BKP. Scoring was based on the odds ratio for risk factors, and cut-off values were determined from the receiver operating characteristics curve. The correlation between the total scores and the incidence of early AVF, and the area under the curve for the logistic regression model predicting early AVF using the scoring system were investigated. RESULTS: 29 cases (28.7%) experienced early AVF after BKP. The scoring system was created as follows: 1) age (<75 years: 0 points (P), ≥75 years: 1P), 2) number of previous vertebral fractures (0: 0P, 1 or more: 2P), and 3) local kyphosis (<7°: 0P, ≥7°: 1P). The total scores were found to be positively correlated with the incidence of early AVF (r = 0.976, P = 0.004). The area under the curve of the scoring system for predicting early AVF was 0.796. The incidence of early AVF was 4.2% at ≤1P and 44.3% at ≥2P (P < 0.001). CONCLUSIONS: A scoring system which can be applied to a broader patient population was developed. In cases where the total score is 2P or more, alternatives to BKP should be considered.

Timing of Percutaneous Balloon Kyphoplasty for Osteoporotic Vertebral Compression Fractures.

BACKGROUND: Percutaneous balloon kyphoplasty (PKP) is widely used to treat osteoporotic vertebral compression fractures (OVCFs). In addition to rapid and effective pain relief, the ability to recover the lost height of fractured vertebral bodies and reduce the risk for complications are believed to be the main advantages of this procedure. However, there is no consensus on the appropriate surgical timing for PKP. OBJECTIVES: This study systematically evaluated the relationship between the surgical timing of PKP and clinical outcomes to provide more evidence for clinicians to choose the intervention timing. STUDY DESIGN: Systematic review and meta-analysis. METHODS: The PubMed, Embase, Cochrane Library, and Web of Science databases were systematically searched for relevant randomized controlled trials and prospective, and retrospective cohort trials published up to November 13, 2022. All included studies explored the influence of PKP intervention timing for OVCFs. Data regarding clinical and radiographic outcomes and complications were extracted and analyzed. RESULTS: Thirteen studies involving 930 patients with symptomatic OVCFs were included. Most patients with symptomatic OVCFs achieved rapid and effective pain relief after PKP. In comparison to delayed PKP intervention, early PKP intervention was associated with similar or better outcomes in terms of pain relief, improvement of function, restoration of vertebral height, and correction of kyphosis deformity. The meta-analysis results showed there was no significant difference in cement leakage rate between early PKP and late PKP (odds ratio [OR] = 1.60, 95% CI, 0.97-2.64, P = 0.07), whereas delayed PKP had a higher risk for adjacent vertebral fractures (AVFs) than early PKP (OR = 0.31, 95% CI: 0.13-0.76, P = 0.01). LIMITATIONS: The number of included studies was small, and the overall quality of the evidence was very low. CONCLUSIONS: PKP is an effective treatment for symptomatic OVCFs. Early PKP may achieve similar or better clinical and radiographic outcomes for treating OVCFs than delayed PKP. Furthermore, early PKP intervention had a lower incidence of AVFs and a similar rate of cement leakage compared with delayed PKP. Based on current evidence, early PKP intervention might be more beneficial to patients.

Balloon kyphoplasty combined with percutaneous pedicle screw (PPS) for the treatment of osteoporotic thoracolumbar fractures has minimum correction loss 2 years after surgery: compared to vertebroplasty using hydroxyapatite block combined with PPS.

BACKGROUND: Balloon kyphoplasty (BKP) is a useful treatment performed in patients with painful osteoporotic vertebral body fracture (OVF). However, in cases with large intra-vertebral clefts and cases with posterior spinal tissue damage, adjacent vertebral body fractures (AVFs), and cement migration may occur early after BKP, which may be a factor for poor results. In such cases, percutaneous vertebroplasty (PVP) combined with percutaneous pedicle screw (PPS) is useful treatment. This study compared BKP combined with PPS (BKP + PPS) compared to PVP using hydroxyapatite (HA) block combined with PPS (HAVP + PPS) for thoracolumbar OVF (TLOVF). METHODS: Twenty-eight patients who sustained painful TLOVFs without neurologic deficits underwent HAVP + PPS (group H, n=14) or BKP + PPS (group B, n=14). We evaluated time from injury to surgery, pre- and post-operative visual analogue scale (VAS) of low back pain, wedging angle of fractured vertebra, duration of operation, intraoperative blood loss, number of instrumented vertebra, and length of stay at hospital. RESULTS: Group B had significantly less surgery time and less blood loss during surgery. VAS of low back pain improved equally in both groups, but at 1 year and 2 years postoperatively, wedging angle of fractured vertebra progressed significantly in group H compared with group B. CONCLUSIONS: PPS fixation combined with percutaneous vertebral cement augmentation with BKP for OVF was suggested to be minimally invasive in the elderly patients. In addition, there is no correction loss of the fractured vertebral body after BKP + PPS, which is considered to be a useful surgical procedure.

The Relationship Between Global Sagittal Balance and the Incidence of Early Adjacent Vertebral Fractures Following Balloon Kyphoplasty.

BACKGROUND: Recently, it is widely known that global sagittal balance (GSB) influences the postoperative outcome of the spine. The purpose of this study was to investigate the relationship between GSB and the incidence of early adjacent vertebral fracture (AVF) following balloon kyphoplasty (BKP). METHODS: This study included 96 patients (19 males, 77 females, mean age 77.4 ± 5.5 years) who underwent BKP for osteoporotic vertebral fracture and who were over 60-years-old. We investigated the effect of GSB on early AVF within 2 months after surgery. Of the 96 patients, 76 patients (16 males, 60 females, mean age 77.0 ± 5.4) underwent BKP at the thoracolumbar junction (T11-L2) and were investigated independently. After the two-group comparison, logistic regression analysis was performed. RESULTS: During the observation period (18.3 ± 14.7 months), 27 of 96 patients (28.1%) suffered AVF after BKP, and 24 of 96 patients (25.0%) suffered early AVF. In the logistic regression analysis, spinopelvic parameters were not detected as significant risk factors. In cases of BKP at the thoracolumbar junction (T11-L2), 24 of 76 patients (31.6%) suffered AVF after BKP during the observation period (15.3 ± 19.5 months), and 21 of 76 patients (27.6%) suffered early AVF. Logistic regression analysis detected pelvic tilt (PT): odds ratio 1.087 (P = 0.046∗) and local kyphosis: 1.147 (P = 0.003∗) as risk factors for early AVF. The cutoff value was PT≥29° from the receiver operating characteristics curve. CONCLUSIONS: At the thoracolumbar junction (T11-L2), PT ≥29° is one of the risk factors of early AVF following BKP.

Stand-alone kyphoplasty in recent thoracolumbar split fractures: A series of 36 patients reviewed at 19months.

INTRODUCTION: Spinal fractures with a split component present specific bone union problems (pseudarthrosis). The purpose of this study was to assess the rate of pseudarthrosis after stand-alone percutaneous kyphoplasties and analyze clinical and radiographic parameters that are predictive of its efficacy in thoracolumbar spine fractures with a split-type of injury. HYPOTHESIS: Stand-alone kyphoplasty results in satisfactory bone union of the treated vertebral body despite the diastasis of fracture fragments. MATERIALS AND METHODS: A retrospective single-center study of 36 patients with posttraumatic monosegmental thoracolumbar vertebral fractures, that were classified as either Magerl A2 or A3.2, without any neurologic deficits. Patients were treated with percutaneous kyphoplasty and PMMA bone cement. The assessment included both clinical (visual analog pain scale [VAS] and Oswestry disability index) and radiographic (pseudarthrosis, fracture gap, disk incarceration, vertebral height and length, and vertebral and regional kyphosis) criteria. RESULTS: A total of 36 patients (mean age 58years) were included, with a mean follow-up of 19.1months. Five of these patients (14%) had a pseudarthrosis. The fracture gap was significantly greater in these patients than in those who had bone union preoperatively (+3.94 mm, p<0.001) and at the last follow-up consultation (+9.3 mm, p<0.001). There was an association between the incarceration of adjacent disks located above (p=0.008) and below (p=0.003) the fracture site and the pseudarthrosis. The mean VAS decreased significantly on the first postoperative day (p<0.001) and remained lower than the initial assessment until the last follow-up (p<0.001). DISCUSSION: Stabilization by stand-alone kyphoplasty produces good clinical and radiographic results for split fractures, provided that the extent of the fragment diastasis has been carefully assessed preoperatively to prevent the risk of pseudarthrosis. LEVEL OF EVIDENCE: IV; retrospective.