Percutaneous intervertebral bridging cementoplasty for adjacent multilevel osteoporotic thoracolumbar fractures with vertebral endplate-disc complex injury: technical note

Abstract

this paper describes a minimally invasive technique of percutaneous intervertebral bridging cementoplasty (piBc) to augment the fractured vertebrae and immobilize the intervertebral space with endplate-disc complex injury simultaneously. thirty-two patients with adjacent multilevel osteoporotic thoracolumbar fractures (AMotLfs) and vertebral endplate-disc complex injury (eDci) treated by piBc were retrospectively reviewed. the piBc technique was a combination of puncture, balloon expansion and bridging cementoplasty. the clinical and radiological assessments were reviewed. The operation time was 82.8 ± 32.5 min, and blood loss was 76.9 ± 31.7 mL. A cement bridge was connected between the two fractured vertebrae across the injured intervertebral space. VAS at three time points including pre-operation, post-operation 1 day and final follow-up was 6.9 ± 0.9, 2.9 ± 0.8 and 1.7 ± 0.8, respectively; ODI at three time points was (71.1 ± 7.8)%, (18.4 ± 5.7)%, and (10.3 ± 5.7)%, respectively; Cobb angle at three time points was 46.0° ± 10.4°, 25.9° ± 8.5°, and 27.5° ± 7.1°, respectively. Compared with pre-operation, VAS, ODI and Cobb angle were significantly improved at post-operation 1 day and final follow-up (P < 0.05). Clinical asymptomatic cement leakage was observed in thirteen patients. no vessel or neurological injury was observed. piBc may be an alternative way of treatment for AMotLfs with eDci. the technique is a minimally invasive surgery to augment the fractured vertebrae and immobilize the injured intervertebral space simultaneously. Osteoporotic vertebral fracture is an increasing common spinal disorder among the elderly patients. Thoracolumbar vertebrae are frequently involved segments and they can cause disabling pain and kyphotic deformity 1. Although conservative pain management is recommended for some patients, minimally invasive vertebral augmentation is generally advocated for symptomatic osteoporotic vertebral fracture 2,3. Patients with symptomatic acute or subacute osteoporotic vertebral compression fracture (OVCF) are often considered potential candidates for treatment with vertebral augmentation. Percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) are the preferred augmentation techniques which provided rapid pain relief and sustained improvement of physical function 3,4. Furthermore, PKP has advantages of correcting the kyphotic deformity and restoring the height of the fractured vertebrae. However, some OVCFs are characterized not only by vertebral compression fractures, but also by vertebral endplate-disc complex injury (EDCI) 5. Current treatment strategies, such as vertebroplasty and kyphoplasty, are aimed only at stabilizing these painful vertebral fractures. EDCI cannot be treated by traditional augmentation techniques. Consequently, EDCI may account for cement leakage into the disc and persistent back pain after vertebral augmentation. In addition, EDCI may be labeled as new adjacent levels fracture or instability 6 .

Investigation of Preoperative Traction Followed by Percutaneous Kyphoplasty Combined with Percutaneous Cement Discoplasty for the Treatment of Severe Thoracolumbar Osteoporotic Vertebral Compression Fractures

“…If these complicated injuries are ignored, postoperative pain symptoms cannot be completely relieved, and the kyphosis would be gradually aggravated due to the cartilage endplate and intervertebral disc injuries, which cannot be prevented by vertebroplasty. 20,26 In addition to minimally invasive treatment, some scholars use osteotomy and internal fixation to fix compressed fractures and correct kyphosis. In order to improve fixing strength, long-segment fixing or cement-enhanced screws are required.…”

“…8 In recent years, some scholars have utilized this method to treat the degenerative diseases of lumbar and achieved good clinical outcomes. 9,10 Since 2015, Song Wang et al 20 have used percutaneous intervertebral bridging cementoplasty (PIBC) to treat thoracolumbar adjacent multi-segmental vertebral compression fractures with intervertebral disc-endplate complex injury. Through the bridging effect of bone cement, the compressed vertebral body and the injured intervertebral disc-endplate complex are fixed together to achieve the purpose of analgesia and stabilization of the vertebral body.…”

“…The extrapedicular approach was used for all cases, and we adopted the approach introduced by Song Wang et al to perform percutaneous intervertebral bridging cementoplasty. 20 Firstly, the fractured vertebrae was punctured, the distance and angle between the needle tip and the midline was confirmed by the cross-section CT imaging. The puncture was performed using extrapedicular approach to keep the puncture needle in the center of the vertebral body and make it stop at the anterior cortex of the vertebral body.…”

Image classification of osteoporotic vertebral fracture with endplate-disc complex Injury

“…If the EDC injury is classified as grade 3 or 4 and the patient can tolerate surgery, then discectomy, reduction of the fractured vertebral body and injured endplate, intervertebral bone grafting, and internal fixation are preferred for the patients. If the patient cannot withstand general anesthesia, percutaneous vertebral body-intervertebral disc cementoplasty may also be an effective treatment methods [ 29 ]. However, when injecting bone cement, it is necessary to prevent the bone cement from leaking into the spinal canal through the fracture line of the posterior wall of the vertebral body.…”

Image Classification of Osteoporotic Vertebral Fracture with Endplate-disc Complex Injury

“…If the EDC injury is classi ed as grade 3 or 4, according to the patient's tolerance to surgery, discectomy, reduction of fractured vertebral body and injuried endplate, intervertebral bone grafting, and internal xation are preferred for the patients. If the patient cannot withstand general anesthesia, percutaneous vertebral body-intervertebral disc cementoplasty may also be one of the effective treatment methods for such patients [23]. However, when injecting bone cement, it is necessary to prevent the bone cement from leaking into the spinal canal through the fracture line of the posterior wall of the vertebral body.…”