Purpose. To evaluate whether continuous training and education of posture can help children to improve kyphosis. Method. A smart harness consisting of a tight-fitting harness and a posture sensing system was developed to measure kyphosis and to provide vibratory feedback during daily activities. The posture sensing system consisted of two sensor units and both units contained a 3-axis accelerometer and a 2-axis gyroscope to calculate the orientation. The dimensions and weight of each unit were 55 mm x 35 mm x 15 mm and 25g, respectively. One unit served as a master (placed at the T3 vertebral level) and the second unit served as a slave (placed at the T12 level) and they communicated wirelessly. The master unit calculated the kyphotic angle, similar to the vertebral centroid method but based on the sagital profile, and provided the vibratory feedback. One volunteer wore the unit and performed different postures and activities (walking, sitting, bending and sudden change from sitting to walking) in a gait analysis laboratory. The posture sensing system was sampled at 30Hz and a gait analysis 8-camera system was sampled at 60Hz. The kyphotic angles captured by the smart harness and camera system were compared. After this validation, the system was tested by 5 normal subjects (M, 25 10 years old) 3 hours per day for 4 consecutive days. For the first 2 days there was no feedback and the last 2 days there was feedback. The system took a sample every 30 seconds. When an undesirable posture was detected, the system switched to a fast sample mode at which time the system took ten measurements with a sample rate of 10 Hz for 1 second to further validate the measured kyphotic angle. These 10 measures were averaged to avoid feedback for postures that lasted only for a very short period of time. Posture orientation data was stored in the sensing unit memory and downloaded for outcomes evaluation. Results. Compared with the gait analysis camera system, the differences in the kyphotic angle during static and dynamic activities were 1.6 1.2, and 3.5 1.9 degrees, respectively. The largest error was 6.8 degrees which occurred during a dramatic change in posture during dynamic activities. The baseline data from the first 2 days (without feedback) showed the kyphotic angle was 48 12 degrees, during which time all subjects were working in front of a computer. The feedback days showed a slight improvement of kyphotic angles from day 1 to day 2, from 45 11 to 42 8 degrees, respectively. There was 12% improvement on day 2 when compared with the baseline data. Conclusion. This study showed the kyphotic angle could be fairly accurately measured using the smart harness. The kyphotic angle had a slight improvement when feedback was provided, however a longer clinical trial will be required to determine how lasting the effect will be

Scheuermann’s disease is defined as thoracic kyphosis greater than 45° with greater than 5° of anterior wedging in 3 consecutive vertebrae. We describe a new technique for the surgical treatment of thoracic kyphosis. Eleven patients were treated in our series. The average preoperative kyphotic angle was 83.3 degrees (58–94 degrees). Multiple posterior closing wedge osteotomy was performed and four rods (two proximal and two distal) were contoured and fixed to pedicle screws and the deformity reduced by the cantilever technique. The average postoperative kyphotic angle was 41.1 degrees (range 25–54 degrees) giving an average correction of 42.2 degrees per patient. The average postop lumbar angle was 51.8 degrees (range 20–70 degrees). The average follow up time was 25.3 months (range 6–60 months). At follow up the kyphotic angle was found to be 42.8 degrees average (range 24–55 degrees) and the lumbar angle was 57.6 degrees average (range 42–70 degrees). We find this technique simple and effective in reducing curves of high magnitude and the curve was maintained in the long term. Our complication rate was comparable to that quoted in literature. This technique is superior as it avoids sudden stretching of the anterior vasculature and possible rupture of the anterior longitudinal ligament (ALL) and provides correction at multiple levels, avoiding build-up of stress at any single level

Introduction: Scheuermann’s disease is defined as thoracic kyphosis greater than 45° with greater than 5° of anterior wedging in 3 consecutive vertebrae. We describe a new technique for the surgical treatment of thoracic kyphosis due to Scheuermann’s disease. Eleven patients were treated in our series. Results: The average preoperative kyphotic angle was 83.3 degrees (58 – 94 degrees). Multiple posterior closing wedge osteotomy was performed and four rods (two proximal and two distal) were contoured and fixed to pedicle screws and the deformity reduced by the cantilever technique. The average postoperative kyphotic angle was 41.1 degrees (range 25–54 degrees) giving an average correction of 42.2 degrees per patient. The average postop lumbar angle was 51.8 degrees (range 20–70 degrees). The average follow up time was 25.3 months (range 6–60 months). At follow up the kyphotic angle was found to be 42.8 degrees average (range 24–55 degrees) and the lumbar angle was 57.6 degrees average (range 42–70 degrees). This technique is superior as it avoids sudden stretching of the anterior vasculature and possible rupture of the anterior longitudinal ligament (ALL) and provides correction at multiple levels, avoiding build-up of stress at any single level. Conclusion: We find this technique simple and effective in reducing curves of high magnitude and the reduction was maintained in the long term. Our complication rate was comparable to that quoted in literature

Purpose: A complete collapse of osteoporotic vertebral fractures is difficult to treat. Restoration of vertebral height is very difficult, if ever possible. Kyphoplasty has been shown to restore vertebral compression fractures; however the best results are achieved in fractures without total collapse. Nevertheless some fractures develop osteonecrosis and pseudarthosis which can be easily seen on X-ray. For those cases we performed a retrospective study in order to evaluate the capacity of kyphoplasty in those difficult situations. Methods: We analyzed the pre- and postoperative X-rays of vertebra plana treated between 2002 and 2005. Vertebral height (vh -anterior, middle and posterior) and kyphotic angle were measured with a digital imaging system. 2 independent examiners classified the preoperative X-rays into fractures with osteonecrosis/pseud-arthrosis (group 1) and without osteonecrosis (group 2). Statistical analysis with the non-parametric Mann-Whitney test was performed. Results: Between 2002 and 2005 we performed 315 kyphoplasties. A total collapse of the vertebra (vertebra plana) was treated in 15 cases. Mean age 76 years, SD 5.2 years, average time of treatment after fracture 4 months. Osteonecrosis was persistent in 8 cases. The osteonecrosis group found a statistically significant higher degree of vertebral reconstruction (p < 0.013 - group 1: anterior vh 33%, middle vh 37,8%, posterior vh 19,1%; group 2: anterior vh 4,9%, middle vh 17,5%, posterior vh 1,8%). No significant difference was found in the analysis of the pre- and postop. kyphotic angle which could be due to the small sample size as the mean values are three-fold elevated in group 1 (p = 0.146, group 1: restoration mean 9,1° - maximum 18°; group 2: restoration mean 3,5° - maximum 13°). Conclusions: Osteonecrosis is a positive predictive sign for the potential of vertebral reconstruction. Vertebral height can be significantly improved in those patients and the major changes of the kyphotic angle are possible. Even after 4 months, correction of the deformity is possible with kyphoplasty. However, without this sign, restoration of the vertebral height and correction of kyphosis is limited to rare cases

This study assesses whether balloon kyphoplasty (BKP) can safely restore height and correct deformity for cancer-related vertebral compression fractures (VCFs) involving the posterior vertebral body wall (PVBW), which is normally considered a relative contraindication. Retrospective cohort study of 158 patients (99M:59F; mean age 63 years) with 228 cancer-related VCFs, who underwent BKP. 112 had VCFs with PVBW defects, and 46 had VCFs with no PVBW defect. Data was assessed preoperatively and at 3 months. In the PVBW defect group, mean pain score decreased from 7.5 to 3.6 (p<0.001). There was a significant decrease in kyphotic angle (p<0.01), anterior vertebral body height (AVBH) (p<0.01) and mid-vertebral body height (MVBH) (p<0.05). In the PVBW intact group, mean pain score decreased from 7.3 to 3.3 (p<0.001). There was a significant improvement in AVBH and MVBH (p<0.001). When comparing groups, kyphotic angle, AVBH and MVBH were significantly worse in the PVBW defect group (P<0.05). More cement leaks occurred in the PVBW defect group. BKP can alleviate pain but does not restore height or correct kyphosis in patients with cancer-related VCFs and PVBW defects. There is no appreciable increase in surgical risk

Reviewing 40 consecutive cases over a two-year period, we tested the efficacy of variable screw plate fixation postoperatively. A Codman plate was used in all cases. We compared radiological preoperative measurements of the kyphotic angle and disc height with immediate postoperative measurements and measurements at a mean of eight months postoperatively. In no case was there an increase in kyphotic angle. Disc height remained within two mm of that shown on immediate postoperative radiographs. We concluded that satisfactory results are obtained with variable screw plate fixation, with no compromised stability

PURPOSE: To record our experience in surgical treatment of thoracic spine fractures with posterior stabilization, decompression and ligamentotaxis. MATERIALS AND METHODS: From January 2000 until July 2006, 67 patients (48 males and 19 females), aged 16 to 85 years old (average 41,2 y.o) were surgically treated in our department due to thoracic spine fractures. Preoperative X-Ray and CT scan were used in all cases while in most of the cases we performed MRI to further evaluate the damage. In all cases we performed decompression and posterior stabilization using four different hardware types and whenever possible ligamentotaxis. Continuous electrophysiological monitoring was alo ued in all operations. We recorded the pre- and postoperative neurological status, the vertebral height loss, the kyphotic angle and spinal canal occupation. Moreover we recorded the average hospitalization time, the transfusion needs as well as major and minor complications. At the follow-up we measured the loss of correction at 3, 6 and 12 months postoperatively. The follow up ranged from 4 to 48 months. RESULTS: Neurological damage was recorded in 43 % of the patients. The average preoperative kyphotic angle was 38.2° while the average spinal canal occupation was 29.8 %. The immediate postoperative correction was 16.7 °. During the follow-up we observed small, insignificant loss of correction. There were no major complications. CONCLUSION: In cases of thoracic spine fractures the surgical treatment with posterior stabilization and ligamentotaxis is offering significant stability and adequate long term results

Aim: To evaluate the outcome of late anterior decompression in patients with dorsal and lumbar spinal injuries with neurological deficit. Background: Anterior decompression and bone graft stabilisation of the spinal injuries allows direct decompression of the spinal canal and provides favourable environment for neurological and functional recovery. Proponents of both early and delayed decompression have shown favourable results. However, what is unclear is the timing of the surgery. Methods: A prospective study of 12 patients with spinal injuries, who had anterior decompression a minimum of 4 weeks after the injury (mean 7.5 weeks). 5 had incomplete and 7 had complete neurological deficit at presentation. The indication for the operation was persistent neurological deficit with retropulsed fragment of bone causing canal compromise. Anterior stablisation after decompression was by means of a tri-cortical iliac crest graft or a rib graft. Results: 8 males, 4 females with average age 26.8 years. 7 lumbar and 5 dorsal spine injuries. Average follow-up of 5.5 years with minimum of 5 years. Post-operative improvement was seen only in patients who sustained injury at the lumbar level, with 6 of the 7 patients regaining normal bladder and bowel function after decompression. Immediate post-operative improvements obtained in the Kyphotic angle were not maintained probably due to the settling of the graft, so posterior or anterior stabilisation may be needed in addition to anterior bone grafting to prevent worsening of the kyphotic angle. Conclusion: Delayed anterior decompression of the lumbar spine in patients who had spinal fractures, is an effective procedure, which may help neurological recovery, especially of the bowel and bladder function

BACKGROUND. Osteoporosis with subsequent osteoporotic vertebral compression fractures is an increasingly important disease due not only to its significant economic impact but also to the increasing age of our population. Pain reduction and stabilization are of primary importance with osteoporotic vertebral compression fractures. OBJECTIVE. To compare the efficacy and safety of balloon kyphoplasty and vertebroplasty for the treatment of vertebral compression fractures. MATERIALS & METHODS. From January 2004 to December 2009, 142 patients (32 males and 110 females), from 54 to 84 years old (mean age 67.4) were treated for 185 osteoporotic vertebral fractures of the thoracic or lumbar spine (level of fracture at Th5 or lower), with back pain for more than 8 weeks, and a visual analogue scale (VAS) score of 5 or more. Twenty-two patients (29 fractures) were lost at follow-up period and excluded. Patients were randomly allocated to percutaneous kyphoplasty (64%) or vertebroplasty (36%). All fractures were analyzed for improvement in sagittal alignment (Cobb angle, kyphotic angle, sagittal index, vertebral height). The patients were evaluated using the visual analog scale (VAS) and the Oswestry Disability Score. Radiographs were performed postoperatively, and at 1, 3, 6, and 12 months. RESULTS. The score according to pain, the patient's ability to ambulate independently and without difficulty, and the need for medications improved significantly (P < 0.001) after kyphoplasty or vertebroplasty. No significant difference could be found between both groups for the mean VAS and ODI preoperative and postoperative. Vertebral body height and kyphotic wedge angle of the T-L spine were also improved (p < 0.001); although kyphosis correction seems to be improved better in kyphoplasty than vertebroplasty. The rate of leakage was 12% for kyphoplasty and 32% for vertebroplasty; nevertheless most of the leakage was clinically asymptomatic and the rate of serious problems remained low (pulmonary embolism 0.01% kyphoplasty vs 0.6% vertebroplasty). New fractures in the next 6 months at the adjacent vertebrae were observed ∼ 15% in both groups. More PMMA was used in the kyphoplasty group than in the vertebroplasty group (5.5 +/− 0.8 vs. 4.1 +/− 0.5 mL, p < 0.001). Operation time was longer in balloon kyphoplasty compared to vertebroplasty (mean time 20±5min/vertebral fracture in group B vs 30±5min in group A). CONCLUSION. Both balloon kyphoplasty and vertebroplasty provided a safe and effective treatment for pain and disability in patients with vertebral compression fractures due to trauma or osteoporosis. Balloon kyphoplasty led to an ongoing reduction of fractured vertebrae and was followed by a lower rate of cement leakage

Objective: Effectiveness and safety of Balloon Kyphoplasty as a method of treatment for osteoporotic vertebral fractures of the thoracolumbar spine. Materials and Methods: From January 2003 to December 2008, 102 patients (27 males and 75 females), from 56 to 82 years old (mean age 72) were treated with balloon kyphoplasty procedures for 156 osteoporotic vertebral fractures of the thoracic or lumbar spine, in a mean follow up of 24 months (6 to 45 months). The patients had progressive and painful compression fractures more than 2 months. All fractures were analyzed for improvement in sagittal alignment (Cobb angle, kyphotic angle, sagittal index, vertebral height). The patients were evaluated using the visual analog scale (VAS) and the Oswestry Disability Score. Radiographs were performed postoperatively, and at 1, 3, 6, and 12 months. Results: The score according to pain, the patient’s ability to ambulate independently and without difficulty, and the need for medications improved significantly (P < 0.001) after kyphoplasty. Vertebral height significantly increased at all postoperative intervals, with ≥10% height increases in 88% of fractures. Morphometric height ratios for treated fractures also significantly increased. There were no severe kyphoplasty-related complications, such as neurological defects, cement leakage or narrowing of the spinal canal whereas additional fractures occurred at the adjacent vertebrae at a rate of 10%. Conclusions: Kyphoplasty provided a safe and effective treatment for pain and disability in patients with vertebral compression fractures due to osteoporosis

Anterior only procedure for stable thoraco-lumbar burst fractures is controversial. Prospective collection of clinical and radiological data in stable burst fractures with neurological deficit undergoing anterior only decompression and stabilisation with 2-year follow-up. 14 consecutive patients (8 females, 6 males) with two-column thoracolumbar burst fracture and neurological deficit underwent anterior corpectomy/hemi-corpectomy and instrumentation, from February 2007 to February 2009. Radiological data included classification of fracture (AO classification), kyphus angle and degree of canal compromise. Post-operative CT scans done to assess radiological improvement. Clinical data included neurological deficit at presentation, improvement or changes in neurology, length of surgery, estimated blood loss, post-operative complications and length of stay. Commonest mechanism was fall from height. 10 patients had incomplete burst fractures amenable to hemi-corpectomy. 8 of our patients were ASIA D, 4 were ASIA C or lower. They all improved by at least one grade. 2 patients had identical ASIA grade pre and post operatively. Pre-operative spinal canal compromise averaged 52.6% and vertebral body height loss averaged 48.9%. The mean kyphotic angles improved from 19.6° to 7.9 °. There were two cases with minor injury to the diaphragm, one developing a pneumothorax. Mean length of surgery and hospital stay were 4hours and 21minutes and 11.8 days respectively. The fractures in which the top part is burst and causing canal compromise, could be dealt with by top hemi-corpectomy requiring smaller approach. One stage anterior – only stabilization can yield successful clinical results

To study the preliminary clinical results of patients submitted to kyphoplasty with an expandable titanium cage (OsseoFix). Between 09-2008 and 02-2009 16 patients (6 men, 10 women, total 36 vertebrae) with a mean age of 67 (23 to 81) were submitted to kyphoplasty using a system involving the implantation of an expandable titanium cage (OsseoFix) for the treatment of fractures in the lower thoracic and lumbar spine. Five patients were submitted to kyphoplasty at one level, 4 at two levels, 5 at three levels, and 2 at four levels. Two patients additionally needed a posterior spinal fusion. The underlying causes for the spinal fractures were: secondary osteoporosis (7), recent acute trauma (5), and malignancy (4: 1 Hodgkin lymphoma, 1 Non-Hodgkin lymhoma, 1 metastatic breast cancer, 1 metastatic prostate cancer). In 8 patients biopsy specimens were harvested at the same procedure. Mean follow-up time was 4 months (2 to 6). No intra-operative complication occurred. No bone cement leakage or pulmonary embolism was observed. The mean pain improvement, as measured with the VAS scale, was 5,12 (7,81 preop – 2,69 postop). The mean vertebral body height restoration was 19,5%, and the kyphotic angle was corrected by a mean of 2,24°. The main advantage of using an expandable metal cage in kyphoplasty is the improved reduction of the vertebral body compression and the minimal risk of bone cement leakage. Especially in young patients, the maintenance of the reduction could potentially be achieved even without cementation, by the mere support provided by the cage. A longer follow-up time is needed for the safe validation of these preliminary encouraging results

Purpose of study: To demonstrate the safety and efficacy 3 and 4-level ACDF with stand-alone (no additional anterior fixation) intervertebral cages. Methods and results: A consecutive cohort of 19 patients undergoing 3 (n=15) and 4-level (n=4) ACDF with Solis cages over 4 years was studied (mean follow-up 24 months). Outcome measures were clinical (VAS scores for neck and arm pain, myelopathy scores) and radiological (disc height, kyphotic angles, fusion). Neck pain scores improved from 5.1 pre-operatively (range 0–10, s.d. 4) to 2.8 post-operatively (range 0–10, s.d.5), t=3.7, P< 0.0002. Arm pain scores improved from 5.3 pre-operatively (range 0–10, s.d. 5) to 2.5 post-operatively (range 0–8, s.d. 3), t=2.8, P< 0.009. Pre-operative myelopathy scores averaged 10.6 (range 7–16, s.d. 4.7) rising to 12.8 post-operatively (range 10–17, s.d. 3.9). Although there was no statistically significant change in myelopathy scores, no patient experienced a worsening of their myelopathy score after surgery. There were no operative complications. Radiological follow-up demonstrated early improvement in disc space heights (pre-op 3.1 mm, range 1–6 mm; post-op 5.6 mm, range 4–9 mm) but, at 12 months, two patients demonstrated asymptomatic evidence of cage settling and loss of disc height. There was no incidence of pseudarthrosis. No patient has thus far required further surgery. Conclusion: Multi-level cervical disc disease can be managed safely and effectively by 3 or 4-level discectomy and fusion with stand-alone intervertebral cages. Ethics approval: None – audit. Interest Statement: None

Purpose: To determine the reliability of six measurement techniques for lumbosacral kyphosis. Method: Using custom computer software, four raters evaluated 60 standing lateral radiographs of the lumbosacral spine during two sessions at a one week interval. The sample size consisted of 20 normal, 20 low and 20 high grade spondylolisthetic subjects. Six parameters were included for analysis: Boxall’s slip angle; Dubousset’s lumbosacral angle (LSA); the Spinal Deformity Study Group’s (SDSG) LSA; dysplastic SDSG LSA; sagittal rotation (SR); kyphotic Cobb angle (k-Cobb). Intra- and inter- rater reliability for all parameters was assessed using intra-class correlation coefficients (ICC). Correlations between parameters and slip percentage were evaluated with Pearson coefficients. Results: The intra-rater ICC’s for all the parameters ranged between 0.81 and 0.97 and the inter-rater ICC’s were between 0.74 and 0.98. All parameters except sagittal rotation showed a medium to large correlation with slip percentage. Dubousset’s LSA and the kyphotic Cobb angle showed the largest correlations (r=−0.78 and r=−0.50, respectively). Sagittal rotation was associated with the weakest correlation (r=−0.10). All other parameters had medium correlations with percent slip (r=0.31 to 0.43). Conclusion: All measurement techniques provided substantial to almost perfect inter- and intra- rater reliability. Dubousset’s LSA showed the strongest correlation with slip grade. However, this parameter does not reflect the local dysplastic changes that occur in lower L5 and upper S1 endplates. A longitudinal study evaluating the best suited parameter for predicting the risk of progression and response to surgical treatment is warranted

Introduction: We report the result of cervical osteotomy in 11 patients using a controlled reduction technique and assess the safety and efficacy of this operation. Methods: Between 1993 and 2006, 11 patients with ankylosing spondylitis underwent correction of cervical kyphosis utilizing an extension osteotomy at the C7/T1 junction. The procedure was carried out under general anaesthesia with spinal cord monitoring. Lateral mass screws were placed from C3–C6 and thoracic pedicle screws placed from T2 to T5. After completion of the osteotomy, the reduction manoeuvre was carried out by the senior surgeon lifting the halo, while bilateral temporary malleable rods (fixed to cervical lateral mass screws) were allowed to pass through top loading thoracic pedicle screws, before tightening by the assistant when the desired position had been achieved. The temporary malleable rods were then replaced with definitive rods, thereby creating a solid internal fixation. A halo vest was maintained for 12 weeks to support the instrumentation and allow the fusion mass to develop. Results: Surgery was performed on 10 males and one female. The mean age at surgery was 56 years (range 40–74). Duration of symptoms averaged 2.7 years (range 1–5 yrs). The average duration of surgery was 4.7 hours (range 3–6.5) with a mean blood loss of 1938cc (range 1000–3600). The mean follow up was 6.5 years (range 2–13). The mean pre-op chin brow vertical angle was 54º (range 20–70) reducing to 7º (range 2–20) at final follow-up. The mean pre-operative kyphotic angle was 19.2º reducing to minus 34º at final follow up. Restoration of normal forward gaze was achieved in all cases. No patient suffered spinal cord injury or permanent nerve root palsy. Conclusion: Cervico-thoracic osteotomy is a potentially hazardous procedure. The technique described reduces the risk of translation during the reduction manoeuvre thereby reducing the risk of serious neurological injury

Thoracic kyphosis increases with age. The resultant increase in compression forces on the anterior vertebral bodies leads to further kyphotic deformity and, an increased likelihood of vertebral collapse. This study aimed to determine the relative efficacy of two therapeutic strategies commonly used to treat hyperkyphosis. 69 subjects (26 male: 43 female) were randomised into 4 groups: strengthening, postural re-education (PEd), both and control. The strengthening group attended a gym 3 times a week for 12 weeks to perform seated extension exercises. The PEd group had 3 physiotherapy sessions within a 12 week period in which they received postural assessment and a home exercise programme. The combined group received both interventions while the control group received neither. Outcome measurements were assessed at baseline and 12 weeks. They included static (inclinometer) and 6-hour angular measurements (using flexible electrogoniometer (FEG)) and physical function tests. There were no significant differences between the marginal means of the angular measurements for any of the intervention groups. However, the group which received both interventions demonstrated reduced kyphosis as measured by the FEG angles (apex of the curve between T3 and T11), while the strengthening group showed reduced inclinometer angles (between T1 and T12). The strengthening group showed improvement in back extensor strength (BES) (0.6 +/− 0.2 N/kg, p < 0.01), time to walk 10 metres (−0.3 +/− 0.6 s, p < 0.05), and time to stand and sit 5 times (−0.9 +/− 0.6 s, p < 0.05). However, there was no relationship between change in BES and change in kyphotic angle. The PEd group showed the greatest improvement in the timed up and go test but this was not significant. Improvement in inclinometer angle over the 12 weeks was associated with degree of kyphosis at baseline (upright inclinometer r = −0.47, p=0.0001) but this relationship was not apparent in the FEG measurements. Both the FEG and inclinometer angles showed a marked decrease in degree of improvement in subjects aged >70. (50/50). A combination of strengthening and PEd was most effective at reducing hyperkyphosis. BES was improved with resisted strengthening but not with home-based postural exercises. However, increased BES was not associated with decreased kyphosis. Larger baseline kyphosis was associated with greater angular improvement. Subjects aged >70 were less likely to improve

BACKGROUND. As life expectancy in the population rises, osteoporotic fractures are seen most frequently in the vertebral column. Percutaneous kyphoplasty is increasingly used for pain reduction and stabilization in these patients, but the efficacy, cost-effectiveness, and safety of the procedure remain uncertain. OBJECTIVE. To clarify whether kyphoplasty has additional value compared with optimum pain treatment in patients with acute vertebral fractures. MATERIALS & METHODS. From January 2004 to June 2009, 122 patients (31 males and 91 females), from 56 to 85 years old (mean age 68.5) were treated for 165 osteoporotic vertebral fractures of the thoracic or lumbar spine (minimum 15% height loss; level of fracture at Th5 or lower; bone oedema on MRI), with back pain for 6 weeks or less, and a visual analogue scale (VAS) score of 5 or more. Twelve patients (15 fractures) were lost at follow-up period and excluded. Patients were randomly allocated to percutaneous kyphoplasty (75 patients) or conservative treatment by computer-generated randomization codes. All fractures were analyzed for improvement in sagittal alignment (Cobb angle, kyphotic angle, sagittal index, vertebral height); and pain relief at 1, 6, 12, 24 months, as measured by VAS score. RESULTS. Percutaneous kyphoplasty resulted in direct and greater pain relief than did conservative treatment; difference in mean VAS score between baseline and 1 month was −6,5 after kyphoplasty and −2.4 after conservative treatment, and between baseline and 1 year was −7.2 after kyphoplasty and −3.8 after conservative treatment. No serious complications or adverse events were reported. Apart from the pain, the patient's ability to ambulate independently and without difficulty, and the need for medications improved significantly (P < 0.001) after kyphoplasty. Vertebral height significantly increased at all postoperative intervals, with 10% height increases in 88% of fractures, in kyphoplasty group at 2 years. There were no severe kyphoplasty-related complications, such as neurological defects, cement leakage or narrowing of the spinal canal whereas additional fractures occurred at the adjacent vertebrae at a rate of 10%. 35% of patients treated conservatively, had limitations in everyday activities the first 6 months, whereas additional fractures occurred at the adjacent vertebrae at a rate of 14%. CONCLUSION. In patients with acute osteoporotic vertebral compression fractures and persistent pain, balloon kyphoplasty is effective and safe. Pain relief after kyphoplasty is immediate, is sustained for at least 2 years, and is significantly greater than that achieved with conservative treatment, at an acceptable cost

Injection of PMMA bone cement into fractured vertebral bodies has been used clinically and proved to be effective. However, there are concerns about thermal injury to the cord and interferece of bone remodling .The purpose of this study is to use the biodegradable bone substitute as an alternative for augumentation of fractured vertebral bodies . Material and Methods: From April 1998 to January 2000, 10 patients(Nine females and one male, age from 55 to 74 years) with osteoporotic compression fractures were retrospectively reviewed. The level of compression fracture mostly occurred at T12-L1 (Nine of ten cases). Eight of the ten cases were osteonecrosis of vertebral body with vaccum phenomenon. While other two cases had gross kyphotic deformity. Surgical indications for these ten patients include back pain, progressive kyphosis and failure of conservative medical treatment. (No neurological deficits were noted in all ten cases.) All ten cases underwent posterior instrumentation with vertebroplasty (Bipedicle impaction of osteoset and iliac bone autograft). The anterior body height and the kyphotic angle were measured preoperatively and postoperatively. The fusion mass was observed and followed up with T-L spine AP and Lateral X-ray regularly. Result: The anterior body height increased over 50% in all cases in this series. The average correction of kyphosis angle is 10 degree. Stable arthrodesis with obvious fusion mass occurred in all patients under X-ray image. Postoperative pain relief were noted in all ten patients. No major complications were related to this procedure. Conclusion: This preliminary study shows that vertebroplasty using osteoconductive biodegradable bone substitute and osteoinductive iliac bone autograft in osteoporotic compression fracture with osteonecrosis is feasable and effective. The technique might also provide an alternative for treatment of osteoporotic compression fractures instead of PMMA bone cement

Introduction Vertebroplasty and kyphoplasty have been gaining popularity for treating vertebral fractures. Current reviews provide an overview of the procedures but are not comprehensive and tend to rely heavily on personal experience. This paper aimed to compile all available data and evaluate the clinical outcome of the two procedures. The objective was to evaluate the safety and efficacy of vertebroplasty and kyphoplasty using the data presented in published clinical studies, with respect to patient pain relief, restoration of mobility and vertebral body height, complication rate, and incidence of new adjacent vertebral fractures. Methods This is a systematic review of all the available data presented in peer reviewed published clinical trials (69 papers). Where possible a quantitative aggregation of the data was performed. Data was collected for each study under the headings: general information, participants, intervention, outcomes, complications, and follow-up. Outcome data was collected detailing: pain relief, general health, functional improvements, satisfaction with treatment, and reduction in kyphosis. Complications included: cement leakage (asymptomatic and symptomatic), neurological deficits, cardiovascular, pulmonary and any other clinically relevant complication. Long term follow-up information included all the items recorded under the heading “outcome” with the addition of new fracture details. Results A large proportion of subjects experienced some pain relief (87% vertebroplasty, 92% kyphoplasty). Vertebral height restoration was possible using kyphoplasty (average 6.6°) and for a subset of patients using vertebroplasty. Cement leaks occurred for 41% and 9% of treated vertebrae for vertebroplasty and kyphoplasty respectively. New fractures of adjacent vertebrae occurred for both procedures at rates that are greater than the general osteoporotic population but approximately equivalent to the general osteoporotic population that had a previous vertebral fracture. Discussion The pain relief experienced by patients is promising for both kyphoplasty and vertebroplasty in the short term (< 1 year). Leakage of the PMMA is the most common complication and may pose significant danger. Higher leakage rates have been reported for vertebroplasty studies compared to kyphoplasty studies. Particularly kyphoplasty has the ability to reduce the kyphotic angle and restore vertebral height. The critical factor for the restoration of vertebral height would appear to be fracture age

Purpose: Stability of thoracic vertebrae affected by metastatic disease has been shown to be dependent on tumour size and bone density, but additional structural and geometric factors may also play a role in burst fracture risk assessment. The objective of this study was to use parametric finite element modeling to determine the effects of vertebral level, geometry, and metastatic compromise to the cortical shell on the risk of burst fracture initiation in the thoracic spine. Methods: An experimentally validated parametric biphasic finite element model of a metastatically involved spinal motion segment was analysed with scenarios representing motion segments from T2-T4 through T10-T12. Variations in vertebral geometry, kyphotic angulation and endplate angulation were evaluated. Additionally, four scenarios with transcortical breach of the tumour were compared to a central tumour scenario to determine the effect of cortical destruction. Vertebral bulge (VB), load induced canal narrowing (LICN), and posterior wall tensile hoop strain (PWTHS) were utilised as the main outcome parameters to assess burst fracture risk. Results: Burst fracture risk outcome parameters were largest in upper vertebrae, decreasing inferiorly at each subsequent level, with T11 exhibiting a 35.5% decrease in VB relative to T3, despite greater applied loads. An increase in endplate angles led to a 6.59% decrease in VB and a 2.38% decrease in LICN. A 5° increase in kyphotic angle further decreased VB and LICN by 7.29% and 4.34% respectively. Transcortical tumour scenarios led to an average decrease in PWTHS of 25.8%. Conclusions: Patients affected by spinal metastases in upper thoracic vertebrae may be at greater risk of burst fracture. Decreased burst fracture risk with greater thoracic kyphotic angulation may be due to a change in loading direction for curved segments, reducing the amount of pure axial load applied. Decreased tensile hoop strains are generated during loading of transcortical tumours. This may be attributed to large deformation of tumour tissue through the breach in the cortical shell, reducing the potential for burst fracture. Improved burst fracture risk assessment in the thoracic spine may motivate more informed clinical decision-making. Funding: Other Education Grant. Funding Parties: Natural Sciences and Engineering Research Council