This study prospectively compared the efficacy of kyphoplasty using a Jack vertebral dilator and balloon kyphoplasty to treat osteoporotic compression fractures between T10 and L5. Between 2004 and 2009, two groups of 55 patients each underwent vertebral dilator kyphoplasty and balloon kyphoplasty, respectively. Pain, function, the Cobb angle, and the anterior and middle height of the vertebral body were assessed before and after operation. Leakage of bone cement was recorded. The post-operative change in the Cobb angle was significantly greater in the dilator kyphoplasty group than in the balloon kyphoplasty group (−9.51° (. sd. 2.56) vs −7.78° (. sd. 1.19), p < 0.001)). Leakage of cement was less in the dilator kyphoplasty group. No other significant differences were found in the two groups after operation, and both procedures gave equally satisfactory results in terms of all other variables assessed. No serious complications occurred in either group. These findings suggest that vertebral dilator kyphoplasty can facilitate better correction of kyphotic deformity and may ultimately be a safer procedure in reducing leakage of bone cement

Vertebral haemangiomas are usually asymptomatic and discovered fortuitously during imaging. A small proportion may develop variable degrees of pain and neurological deficit. We prospectively studied six patients who underwent eight surgical procedures on 11 vertebral bodies. There were 11 balloon kyphoplasties, six lumbar and five thoracic. The mean follow-up was 22.3 months (12 to 36). The indications for operation were pain in four patients, severe back pain with Frankel grade C paraplegia from cord compression caused by soft-tissue extension from a thoracic vertebral haemangioma in one patient, and acute bleeding causing Frankel grade B paraplegia from an asymptomatic vascular haemangioma in one patient. In four patients the exhibited aggressive vascular features, and two showed lipomatous, non-aggressive, characteristics. One patient who underwent a unilateral balloon kyphoplasty developed a recurrence of symptoms from the non-treated side of the vertebral body which was managed by a further similar procedure. Balloon kyphoplasty was carried out successfully and safely in all patients; four became asymptomatic and two showed considerable improvement. Neurological recovery occurred in all cases but bleeding was greater than normal. To avoid recurrence, complete obliteration of the lesion with bone cement is indicated. For acute bleeding balloon kyphoplasty should be combined with emergency decompressive laminectomy. For intraspinal extension with serious neurological deficit, a combination of balloon kyphoplasty with intralesional alcohol injection is effective

This is a prospective randomised study comparing the clinical and radiological outcomes of uni- and bipedicular balloon kyphoplasty for the treatment of osteoporotic vertebral compression fractures. A total of 44 patients were randomised to undergo either uni- or bipedicular balloon kyphoplasty. Self-reported clinical assessment using the Oswestry Disability Index, the Roland-Morris Disability questionnaire and a visual analogue score for pain was undertaken pre-operatively, and at three and twelve months post-operatively. The vertebral height and kyphotic angle were measured from pre- and post-operative radiographs. Total operating time and the incidence of cement leakage was recorded for each group. Both uni- and bipedicular kyphoplasty groups showed significant within-group improvements in all clinical outcomes at three months and twelve months after surgery. However, there were no significant differences between the groups in all clinical and radiological outcomes. Operating time was longer in the bipedicular group (p < 0.001). The incidence of cement leakage was not significantly different in the two groups (p = 0.09). A unipedicular technique yielded similar clinical and radiological outcomes as bipedicular balloon kyphoplasty, while reducing the length of the operation. We therefore encourage the use of a unipedicular approach as the preferred surgical technique for the treatment of osteoporotic vertebral compression fractures. Cite this article: Bone Joint J 2013;95-B:401–6

We investigated the safety and efficacy of treating osteoporotic vertebral compression fractures with an intravertebral cleft by balloon kyphoplasty. Our study included 27 patients who were treated in this way. The mean follow-up was 38.2 months (24 to 54). The anterior and middle heights of the vertebral body and the kyphotic angle were measured on standing lateral radiographs before surgery, one day after surgery, and at final follow-up. Leakage of cement was determined by CT scans. A visual analogue scale and the Oswestry disability index were chosen to evaluate pain and functional activity. Statistically significant improvements were found between the pre- and post-operative assessments (p < 0.05) but not between the post-operative and final follow-up assessments (p > 0.05). Asymptomatic leakage of cement into the paravertebral vein occurred in one patient, as did leakage into the intervertebral disc in another patient. We suggest that balloon kyphoplasty is a safe and effective minimally invasive procedure for the treatment of osteoporotic vertebral compression fractures with an intravertebral cleft

Purpose. To elucidate the efficacy of carrying out additional vertebral biopsy procedure during percutaneous balloon kyphoplasty as a tool in determining malignant etiology. Methods and Results. We performed 138 percutaneous balloon kyphoplasty procedures in 85 patients during august 2007 to march 2010. Gender distribution was 25 males and 60 females. Age distribution was 33 to 85 years, with an average age of 67.4 years. The senior surgeon attempted vertebral biopsy during percutaneous balloon kyphoplasty procedure only when there was a clinical/operative suspicion of malignancy. We did not routinely biopsy all vertebrae, as this would mean additional procedure adding to the cost and operating time. In 42 procedures vertebral biopsy was attempted, of which 5 samples were reported as insufficient specimen. 37 biopsies (88%) were successfully analyzed. 3 biopsies (8.1%) were positive for malignancy. There were no complications encountered in the cases where additional biopsy procedure was carried out. Conclusion. There is not much literature supporting routine use and efficacy of biopsies during percutaneous balloon kyphoplasty procedures. Although the quality of bone could make vertebral biopsy challenging in all cases, we feel that improved technique of taking biopsies and maybe increasingly performing the additional biopsy procedure could detect more positive malignancies. Routine biopsies during percutaneous balloon kyphoplasty may be invaluable in diagnosing malignancies

Vertebral compression fractures are very common. 250,000 are diagnosed annually in the United States with 80% due to osteoporosis. 1. Symptomatic relief with conservative therapy is often difficult to achieve. The consequence of significant pain is deterioration in quality of life and often in level of function. They independently increase mortality rate. 1. . Balloon kyphoplasty is a relatively new technique which stabilises the vertebral body and restores saggital spinal alignment. Excellent pain relief and improved functional outcome is reported. 2,3. We aim to confirm this. All patients receiving balloon kyphoplasty treatment at Derby Hospitals NHS Trust from April 2006 to August 2010 were entered prospectively onto a database. Visual Analogue Score (VAS) for pain and Oswestry Disability Index (ODI) for function were recorded. Technical data including number of levels, cement volume, screening time and kyphosis correction was recorded. 198 patients underwent balloon kyphoplasty between April 2006 and August 2010. Some data was incomplete. 105 patients had sufficient data for meaningful analysis. 170 levels were operated on in 105 patients. 65% (n=68) of patients were female and the average age was 74. The average pre-operative visual analogue score (VAS) was 8.2. This decreased to 4.0 in the immediate postoperative period. This dramatic improvement remained and was 4.1 at 6 weeks, 3.3 at 6 months and 3.6 at 1 year. The average pre-operative Oswestry disability index (ODI) was 58. This improved to 47 in the immediate post-operative period. At 6 weeks this had improved further to 40 and further improvements were seen at 6 months (ODI 37) and 1 year (ODI 38). Balloon kyphoplasty should be considered in all patients with ongoing pain following an acute vertebral compression fracture that doesn't respond to conservative treatment

Osteoporotic vertebral compression fractures (VCFs) are an increasing public health problem. Recently, randomised controlled trials on the use of kyphoplasty and vertebroplasty in the treatment of these fractures have been published, but no definitive conclusions have been reached on the role of these interventions. The major problem encountered when trying to perform a meta-analysis of the available studies for the use of cementoplasty in patients with a VCF is that conservative management has not been standardised. Forms of conservative treatment commonly used in these patients include bed rest, analgesic medication, physiotherapy and bracing. . In this review, we report the best evidence available on the conservative care of patients with osteoporotic VCFs and associated back pain, focusing on the role of the most commonly used spinal orthoses. Although orthoses are used for the management of these patients, to date, there has been only one randomised controlled trial published evaluating their value. Until the best conservative management for patients with VCFs is defined and standardised, no conclusions can be drawn on the superiority or otherwise of cementoplasty techniques over conservative management

Purpose. To evaluate the complications following percutaneous balloon kyphoplasty and assess the advantage of introducing eggshell technique. Methods and Results. We performed 138 Balloon kyphoplasty procedures in 85 patients during august 2007 to march 2010. Data was collected and analyzed in all these cases. Gender distribution was 60 females and 25 males. Age distribution was 33 to 85 years, with an average age of 67.4 years. Indications of surgery were vertebral fractures due to osteoporosis in 81% of the procedures, trauma in 13% and malignancy in 6%. The most common vertebral levels of the kyphoplasty were at T12 in 32 procedures (23%) and L1 in 28 procedures (20%). Eggshell technique was introduced in 2009 where technical problems were encountered during cementing process. All patients had reduced pain levels, which was assessed by visual analog score. The average length of hospital stay was 2.5 days. Complications were 9 (6.5%) cement leaks (all within one cm from the vertebral body) in procedures performed before the introduction of eggshell technique and no cement leak following the introduction of eggshell technique, 5 (3.6%) fresh fractures, 2 (1.4%) intra-operative fractures and 1 (0.73%) rupture of balloon. There were no complications of cord compression, motor deficit, infection, allergy to cement or pulmonary embolism noted. 30-day mortality rate was zero. Conclusion. Our series had 6.5% incidence of cement leak compared to 11-21% quoted in current literature. Since the introduction of eggshell technique, cement leak rate was reduced to zero%. Hence adopting of eggshell technique during percutaneous balloon kyphoplasty procedure may eliminates the risk of cement leak thereby minimizing complications

Balloon kyphoplasty (BKP) is a minimally invasive treatment for vertebral fractures (VCF) aiming to correct deformity using balloon tamps and bone cement to stabilize the body. Patients with 1 - 3 non-traumatic acute VCF were enrolled within three months of diagnosis and randomly assigned to receive either BKP (N=149) or nonsurgical care (N=151). Follow-up was 2 years. The mean SF-36 physical component summary (PCS) score improved 5.1 points (95%CI, 2.8-7.4; p<0.0001) more in the kyphoplasty than the nonsurgical group at one month, the primary endpoint of the study. Kyphoplasty improved the PCS score by an average of 3.0 points (95%CI, 1.6-5.4; p=0.002) during the two-year follow-up. There was a significant interaction between treatment and follow-up time (p=0.003), indicating that the treatment effect over the year is not uniform across follow-up; a result from early improvement that persists in the kyphoplasty group whereas the nonsurgical group shows more incremental improvement over time. Overall, patients assigned to kyphoplasty also had statistically significant improvements over the two years compared to the control group in global quality of life (EQ-5D), pain relief (VAS), back disability (RMDQ) and days of limited activity (within a two-week period). There was no statistical significant difference between groups in the number of patients with adverse events or new VCF's over 24 months. Compared to the control, BKP improved quality of life and reduced back pain and disability and did not increase adverse events including the risk of new vertebral fractures over 2 years

A prospective study was performed to evaluate the efficacy and safety of percutaneous kyphoplasty in patients with osteolytic tumours of thoracic and lumbar spine. To our knowledge this is the only study so far that has followed a cohort of patients prospectively until death. Prospective study of patients with lytic tumours of spine treated with kyphoplasty. A total of 13 patients with osteolytic tumours of spine were treated with kyhpoplasty. There were 8 female and 5 male patients. The age range was 52-81 years with average age of 65 years. A total of 25 vertebrae, from T2 to L3, were treated. The types of tumours included; non-Hodgkin lymphoma (2), myeloma (2), gastric-carcinoma (1), cervix-carcinoma (1), breast-carcinoma (3), prostate-carcinoma (2), small cell lung-carcinoma (1), bladder-carcinoma (1). Outcome was assessed prospectively by visual analogue scale (VAS) for pain, ECOG performance status, walking distance, standing and sitting time. The preoperative average VAS was 7.5 (range: 2.6 – 10). This dropped to 3.0 five days postoperatively and remained below 5 for the duration of follow-up. Average walking distance, standing and sitting time and ECOG performance score showed improvement. The survival time ranged from 2 to 293 weeks. The average survival time was 82 weeks. All patients were able to return home following the procedure. No patient required reoperation or readmission for spinal metastasis. Kyphoplasty is a suitable palliative treatment option for patients with advanced metastatic disease of the spine

Aims

To develop and internally validate a preoperative clinical prediction model for acute adjacent vertebral fracture (AVF) after vertebral augmentation to support preoperative decision-making, named the after vertebral augmentation (AVA) score.

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

Royal Liverpool University Hospital, Liverpool, UK

To retrospectively review outcomes in patients who underwent vertebroplasty in Liverpool in response to recent level 1 publications claiming vertebroplasty to be no better than sham procedure assessed using 2 criteria. We reviewed cases between 2006 and 2009 looking at 5 criteria for procedure.

Visual Analogue Score (VAS)

Oswestry disability index scores (ODI)

96 patients identified. 10 patients excluded (inadequate data recorded) (n=86). Operated levels n=134 (thoracic n=61, lumbar n=71, sacral n=2).

Presenting symptoms included back pain (86/86) and point tenderness was present in 90% (77/86). Average length of symptoms was 11.50 months with 28% reporting greater than 12 months. 72% recalled definite onset of symptoms with 90% being associated with a low velocity injury. Radiological findings showed an average of 54% height collapse and 91% showing high signal on STIR MRI sequences. Number of levels operated – 3 or more (n=9 VAS 5.3 ODI 10.6); 1 to 2 levels (n= 77 VAS 3.7 ODI 13.9)

Average improvement in VAS score was 3.8.and ODI 13.6

47% (40/86) of patients met all 5 current criteria recommended for operation (VAS 3.7, ODI 14). 53% (46/86) of patients met 2-5 criteria (VAS 3.8, ODI 13.4).

There was improvement in pain scores in 91% of patients with an average pre-op VAS 7.8 and post-op VAS 4.0. There was no significant difference in patients meeting all 5 criteria compared to those meeting 2-5 criteria.

Introduction. Most common osteoporotic fracture. 20-30% of patients with OVFs are presented to hospital while 2.2 million remain undiagnosed, as diagnosis is usually opportunistic. 66,000 OVFs occur annually in the UK with increase by 18,000 cases a year until 2025. 20% chance of another OVF in next 12 months and 3 times risk of hip fracture. Acute painful OVFs poorly tolerated by infirm elderly patients, leading to significant morbidity and 8 times increase in age-adjusted mortality. Materials and Methods. Classify fracture severity and patents with ovfs in 12-month period. To assess follow-up status and if kyphoplasty was offered within 6 weeks as per NICE guidelines. To introduce Royal Osteoporosis Society and GIRFT guidelines on management of symptomatic osteoporotic vertebral fractures. Results. Total no. of patients- 62. Initial pain assessment=40. Pain assessed at ≤6 weeks- 21. Duration from decision to operate to kyphoplasty 8.7 weeks. 11% had kyphoplasty of which 50% noted improvement in pain. 11 deaths. Nearly similar findings to NoSH study. Conclusion. To improve pain assessment on admission of patients with acute osteoporotic vertebral fractures. To follow GIRFT guidelines for early assessment and intervention in patients with acute osteoporotic vertebral fractures to improve pain, mobility and early discharge from hospital. Conflicts of interest. None. Sources of funding. None

Introduction/Aims. An increased mortality associated with hip fractures has been recognized, but the impact of vertebral osteoporotic compression fractures (VCF) is still underestimated. The aim of this study was to report on the difference in survival for VCF patients following non-operative and operative [Balloon Kyphoplasty (BKP) or Vertebroplasty (VP)] treatments. Methods. Operated and non-operated VCF patients were identified from the US Medicare database in 2006 and 2007 and followed for a minimum of 24 months. Patients diagnosed with pathological and traumatic VCFs in the prior year were excluded. Overall survival was estimated by the Kaplan-Meier method, and the differences in mortality rates (operated vs non-operated; balloon kyphoplasty vs vertebroplasty) were assessed by Cox regression, with adjustments for patient demographics, general and specific co-morbidities, that have been previously identified as possible causes of death associated with osteoporotic VCFs. Results. A total of 81,662 operated (vertebroplasty or kyphoplasty) patients had a survival rate of 74.8% at 24 months following VCF diagnosis compared to 67.4% for the 329,303 non-operated patients. In operated (Vertebroplasty or kyphoplasty) patients there was 44% less mortality than in non-operated VCF patients (p<0.0001). The survival rates for VCF patients following vertebroplasty or kyphoplasty were 72.3% and 76.2% at 24 months, respectively. In kyphoplasty patients there was 12.5% more survival than in vertebroplasty patients (p<0.0001) after 2 years. Conclusions. This retrospective analysis, in 410,965 patients diagnosed with a VCF confirmed the statistical significant decrease (43%, p<0.0001) in mortality between patients receiving minimally invasive surgery compared to non-operated patients. Additionally the present study confirmed a statistical significant decrease (12.5%, p<0.0001) in mortality in BKP patients compared to VP patients

Clinical and radiological assessment of results of vertebral body stenting procedure. Introduction: Use of metallic stents along with cement have shown good restoration of the vertebral body in cadaveric spines. We have presented the early results of vertebral body stenting done at Royal Derby Hospitals. Patients and Methods: All patients had a transpedicular approach to the vertebral body. The vertebral body stent was expanded using a balloon as in balloon kyphoplasty. The balloon was removed leaving the stent in place. The resultant cavity was filled with partially cured polymethyl methacrylate in osteoporotic fractures and calcium phosphate cement in traumatic fractures. Radiological assessment included pre operative measurement of vertebral body angle, correction achieved and maintenance of correction at follow up. All patients were assessed using the visual analogue score and oswestry disability index. The procedure was done in 14 fractures (10 patients). 9 fractures were traumatic while 5 were osteoporotic fractures. The mean age of the traumatic fractures was 54.28 years while the mean age of osteoporotic fractures was 82.34 years. Mean follow up was 10 months. All traumatic fractures were type A 3.1. Mean vertebral body angle correction achieved was 8.3° (4° to 14.2°). None of the patients lost the reduction at follow up. The mean VAS for pain at 6 months was 3.8. The mean oswestry disability index was 22% for traumatic fractures, while it was 44% for osteoporotic fractures. Vertebral body stenting is a safe procedure. It was successful in restoring the anterior column with encouraging radiological and clinical results

Introduction. Metastatic Spinal Cord Compression (MSCC) is a well recognised complication of cancer and a surgical emergency. We present the results of a prospective audit of process focusing on the timing of intervention for these patients from presentation/diagnosis to surgery. Methods. Prospective audit of all patients referred to a tertiary spine unit over 6 months (April –September 2010). All data captured on an excel database. Results. During the study period, 36 patients were referred to our unit with suspected MSCC. Thirty patients (mean age 64.9 years (46-89)) had confirmed MSCC, and of these 25 underwent decompression/stabilisation surgery (vertebroplasty/kyphoplasty (4), declined operation/unfit (7)). The presenting symptoms in the MSCC group were pain and neurological deterioration (16), pain only (7) and progressive neurology (3). The mean duration of pain was 131 days (3 days-over 2 years), and neurological progression was 14 days (1-120 days; Frankel C (3), D (16), E (7)) Four patients were non-ambulatory and 3 had urinary incontinence. The tumour histologies were Prostate (6), Renal (4), Breast (4), Haematological (4), Lung (3), Unknown (1), Others (3). The time from presentation to surgery was 12.9 hours (160mins- 36 hours) if the MRI was organised in our unit. But, if all patients with MSCC were included, together with those referred from other hospitals, the mean time from radiological diagnosis (MRI) to surgery was 29 hours (range 160 mins- >76 hours). Conclusion. This audit of process over 6 months shows that if MSCC is suspected, then patients should be referred to a specialist centre with out of hours MRI provision and where definitive treatment can take place

Aims

As the population ages and the surgical complexity of lumbar spinal surgery increases, the preoperative stratification of risk becomes increasingly important. Understanding the risks is an important factor in decision-making and optimizing the preoperative condition of the patient. Our aim was to determine whether the modified five-item frailty index (mFI-5) and nutritional parameters could be used to predict postoperative complications in patients undergoing simple or complex lumbar spinal fusion.

Vertebral compression fractures are the most prevalent complication of osteoporosis and percutaneous vertebroplasty (PVP) has emerged as a promising addition to the methods of treating the debilitating pain they may cause.

Since PVP was first reported in the literature in 1987, more than 600 clinical papers have been published on the subject. Most report excellent improvements in pain relief and quality of life. However, these papers have been based mostly on uncontrolled cohort studies with a wide variety of inclusion and exclusion criteria. In 2009, two high-profile randomised controlled trials were published in the New England Journal of Medicine which led care providers throughout the world to question the value of PVP. After more than two decades a number of important questions about the mechanism and the effectiveness of this procedure remain unanswered.

The purpose of this study was to determine whether patients with a burst fracture of the thoracolumbar spine treated by short segment pedicle screw fixation fared better clinically and radiologically if the affected segment was fused at the same time. A total of 50 patients were enrolled in a prospective study and assigned to one of two groups. After the exclusion of three patients, there were 23 patients in the fusion group and 24 in the non-fusion group. Follow-up was at a mean of 23.9 months (18 to 30). Functional outcome was evaluated using the Greenough Low Back Outcome Score. Neurological function was graded using the American Spinal Injury Association Impairment Scale. Radiological outcome was assessed on the basis of the angle of kyphosis.

Peri-operative blood transfusion requirements and duration of surgery were significantly higher in the fusion group (p = 0.029 and p < 0.001, respectively). There were no clinical or radiological differences in outcome between the groups (all outcomes p > 0.05). The results of this study suggest that adjunctive fusion is unnecessary when managing patients with a burst fracture of the thoracolumbar spine with short segment pedicle screw fixation.