Clinical StudyPercutaneous vertebral augmentation: an elevation in adjacent-level fracture risk in kyphoplasty as compared with vertebroplasty
Introduction
In the United States, approximately 1.5 million fractures annually are attributable to osteoporosis with approximately 700,000 occurring in the spine [1]. Because of our aging population, the frequency of osteoporotic fractures is increasing necessitating improved preventative as well as safe and effective surgical strategies.
Vertebral fractures compression fractures (VCFs) can result in intractable pain [2], progressive deformity, reduced pulmonary function [3], [4], sleep disorders [2], weight loss [2], impaired function, and decreased quality of life [5], ultimately resulting in increased morbidity and mortality [6]. As such, VCFs are being more aggressively treated with minimally invasive techniques using bone cement such as polymethylmethacrylate (PMMA) both with (balloon kyphoplasty) [7], [8], [9], [10], [11], [12], [13], [14] and without (vertebroplasty) [7], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26] attempts at fracture reduction.
The use of PMMA in balloon kyphoplasty and vertebroplasty must be done with caution because of a number of potential serious complications that may occur with intraosseous injection of bone cement. The risk of extraosseous PMMA leakage in various series ranged between 3% and 74% [17], [19], [25], [27], [28], [29], [30], [31], with resultant neurological deficits such as radiculopathy and cord compression occurring in 0% to 3.7%, and 0% to 0.5%, respectively [32], [33], [34], [35]. Additionally, there appears to be an increased incidence of adjacent-level fractures after PMMA vertebral body augmentation procedures, possibly related to an increase in the stiffness of treated vertebra [36], [37] or some other poorly defined underlying etiology [38]. The risk of subsequent fracture occurrence appears to be greater in kyphoplasty [39], [40] than vertebroplasty [41]; however, this question has not been previously addressed in a single series. Here we present a series of 36 patients with VCFs that underwent 46 augmentation procedures, 20 kyphoplasty and 26 vertebroplasty. Vertebroplasties were performed with a new technique for cement delivery, a fenestrated bone tap system. The technique, complications, and clinical results of each procedure are compared.
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Materials and methods
Over a 3.5-year period, the clinical and radiographic results of 36 patients with osteoporotic compression fractures were reviewed. All patients had undergone a vertebral augmentation procedure by the senior author (BMF) as an outpatient procedure and were followed for a minimum of 6 months postoperatively. Plain X-ray films were obtained routinely at 1 and 3months postoperatively or if they developed new onset or worsening of back pain. Patients were taking alendronate, vitamin D, and calcium
Results
Thirty-six patients underwent a total of 46 vertebral augmentation procedures. These results are summarized in Table 1. Of these 36 patients treated, 17 patients had 20 fractures treated by kyphoplasty, and 19 patients had 26 fractures treated via vertebroplasty. The mean patient age in the kyphoplasty group was 70 (range, 46–83) and 72 (range, 38–90) in the vertebroplasty group. There were no significant differences in age between these groups (p=.4).
Vertebroplasty procedures were performed
Discussion
The use of PMMA in augmentation procedures must be done with caution because of a number of potential serious complications that may occur with intraosseous injection of bone cement. The risk of cement extravasation in various series ranges between 3% and 74% [17], [19], [25], [27], [28], [29], [30], [31], with resultant neurological deficits such as radiculopathy and cord compression occurring in 0% to 3.7% and 0% to 0.5%, respectively [32], [33], [34], [35]. Similar to these studies, we
Conclusions
Vertebroplasty appears to offer a comparable rate of postoperative pain relief as kyphoplasty while using less bone cement, more often via a unilateral approach, and perhaps with a lower attendant risk of adjacent-level fracture.
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FDA device/drug status: approved for this indication.
Authors acknowledge a financial relationship (Abbott Spine), which may indirectly relate to the subject of this research.