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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.

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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.

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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.

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Vertebral fractures in diffuse idiopathic skeletal hyperostosis (DISH) are often unstable. We encountered a case of vertebral fracture at the caudal end of DISH in which vertebroplasty was performed via a double endplate penetrating screw (DEPS) trajectory, and short posterior fixation was performed using the DEPS technique on the cranial vertebrae, including the fractured vertebra; conventional pedicle screw to the caudal vertebrae; and cement-augmented fenestrated pedicle screws to the caudal end vertebra. A 93-year-old man presented with a vertebral fracture at the caudal end of a DISH after a fall. He underwent surgery for lower back pain due to spinal instability. Vertebroplasty via DEPS trajectory can shorten the posterior fixation range. Using cement-augmented fenestrated pedicle screws to the caudal end vertebra enables balancing of the posterior fixation force. This strategy should be considered when a vertebral fracture is found at the caudal end of the DISH.

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Background: A downward penetrating endplate screw (PES) technique combined with caudal anchor screws inserted in the upward direction under O-arm navigation (i.e., crossing screw technique) avoided screw backout and proximal junctional kyphosis (PJK) in three patients with osteoporotic vertebral body fractures and diffuse idiopathic skeletal hyperostosis (DISH). Methods: The PES techniques were utilized for patients with T12 (one patient) and L1 (two patients) spontaneous fusion across the targeted vertebrae, with minimal damage to the involved endplates/intervertebral discs. The average number of instrumented vertebrae was 5.3. Results: There were no perioperative complications over the mean follow-up period of 28.7 months; no screw loosening, and no PJK. Conclusion: The PES technique prevented screw backout, and PJK in three patients with lumbar osteoporotic vertebral fractures and DISH.

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PURPOSE: The Osteoporotic Fracture Working Group (Spine Division of the German Orthopaedic and Trauma Society) has developed a classification system for osteoporotic thoracolumbar fractures, namely the osteoporotic fracture (OF) classification system. The purpose of this study was to determine the inter- and intraobserver reliabilities of the OF classification system for osteoporotic vertebral body fractures (VFs) at a level-one trauma centre. METHODS: Conventional radiography, magnetic resonance imaging (MRI), and computed tomography (CT) scans of 54 consecutive women who sustained an osteoporotic VF were analysed by six orthopaedic traumatologists with varying levels of experience. The inter- and intraobserver reliabilities of the OF classification system were determined using intraclass correlation coefficients (ICCs) and Cohen's kappa. RESULTS: The overall interobserver reliability of the OF classification system was good (ICC, 0.62 [0.51, 0.72]). The intraobserver reliability was found to be substantial (overall weighted Cohen's kappa estimate [95% confidence interval {CI}] = 0.74 [0.67, 0.80]) and better when the radiography, MRI, and CT scans were assessed together than when only the radiography and MRI scans were evaluated, although the difference was not significant. CONCLUSION: The OF classification system is easy to use. It shows good interobserver reliability and substantial intraobserver reliability if diagnostic prerequisites (conventional radiography, MRI, and CT scans) are met.

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The combined anteroposterior fusion with vertebral body replacement (VBR) using a wide footplate expandable cage with a minimally invasive lateral approach has been widely used for pseudoarthrosis after osteoporotic vertebral fractures. The purpose of this study is to evaluate the radiological results of combined anteroposterior surgery using VBR and to recommend the optimal procedure. Thirty-eight elderly patients were included in this study. The mean preoperative local kyphosis angle was 29.3°, and the mean correction loss angle was 6.3°. Cage subsidence was observed in ten patients (26.3%), and UIV or LIV fracture in twelve patients (31.6%). Patients with cage subsidence were compared to those without cage subsidence to determine the causal factors. The mean number of fixed vertebrae was 5.4 vertebrae with cage subsidence and 7.4 vertebrae without cage subsidence. In addition, to precisely clarify the optimal number of fixed vertebrae, those patients with two above-two below fixation were compared to those with less than two above-two below fixation, which revealed that the correction loss angle was significantly less in two above-two below fixation (p = 0.016). Based on these results, we recommend at least two above-two below fixation with VBR to minimize the correction loss angle and prevent cage subsidence.

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BACKGROUND: The evidence for the treatment of midthoracic fractures in elderly patients is weak. The aim of this study was to evaluate midterm results after posterior stabilization of unstable midthoracic fractures in the elderly. METHODS: Retrospectively, all patients aged ≥65 suffering from an acute unstable midthoracic fracture treated with posterior stabilization were included. Trauma mechanism, ASA score, concomitant injuries, ODI score and radiographic loss of reduction were evaluated. Posterior stabilization strategy was divided into short-segmental stabilization and long-segmental stabilization. RESULTS: Fifty-nine patients (76.9 ± 6.3 years; 51% female) were included. The fracture was caused by a low-energy trauma mechanism in 22 patients (35.6%). Twenty-one patients died during the follow-up period (35.6%). Remaining patients (n = 38) were followed up after a mean of 60 months. Patients who died were significantly older (p = 0.01) and had significantly higher ASA scores (p = 0.02). Adjacent thoracic cage fractures had no effect on mortality or outcome scores. A total of 12 sequential vertebral fractures occurred (35.3%). The mean ODI at the latest follow up was 31.3 ± 24.7, the mean regional sagittal loss of reduction was 5.1° (± 4.0). Patients treated with long segmental stabilization had a significantly lower rate of sequential vertebral fractures during follow-up (p = 0.03). CONCLUSION: Unstable fractures of the midthoracic spine are associated with high rates of thoracic cage injuries. The mortality rate was rather high. The majority of the survivors had minimal to moderate disabilities. Thereby, patients treated with long segmental stabilization had a significantly lower rate of sequential vertebral body fractures during follow-up.

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INTRODUCTION: We have developed the single or double endplates penetrating screw (SEPS/DEPS) technique, which is a novel percutaneous pedicle screw (PPS) insertion technique suitable for osteoporotic vertebral body fracture (OVF) patients with diffuse idiopathic skeletal hyperostosis (DISH). This study aims to compare the effectiveness of this SEPS/DEPS technique with the conventional pedicle screw technique. METHODS: The screw is inserted upward from the outer caudal side of the pedicle toward the inner cranial side. Vertebrae affected with DISH were inserted with screws using the SEPS/DEPS technique, whereas non-fused vertebrae were inserted with screws using the conventional PPS technique. Twelve OVF patients with DISH were included in this study; three with SEPS/DEPS technique only and nine with a hybrid of both the DEPS and the conventional PPS techniques. As a control group, 12 OVF patients with DISH treated by conventional PPS. The rates of implant failures and of surgical complications were compared between the SEPS/DEPS group and the control group. The insertion torque was measured and compared between DEPS and conventional PPS in three hybrid patients. RESULTS: In the SEPS/DEPS group, 70 screws were inserted with the SEPS/DEPS technique and 56 screws were inserted with the conventional PPS technique. In the control group, 116 screws were inserted using the conventional PPS and the PS techniques. The loosening of screws was significantly less in screws inserted with the SEPS/DEPS technique (0/70 screws, 0%) than with screws inserted with the conventional technique (12/116 screws, 10.3%). The average insertion torque of DEPS was 2.25 Nm, which was 134% higher than that of conventional PPS which was 1.64 Nm (p = 0.04). CONCLUSIONS: This novel SEPS/DEPS technique has a higher insertion torque compared with the conventional PPS techniques and demonstrated itself to be an effective option for patients with concomitant bone fragility due to DISH.

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STUDY DESIGN: A retrospective study. OBJECTIVE: To analyze the outcome of the surgical treatment for lumbar spinal stenosis with fracture in multiple osteoporotic vertebral body compression fractures. SUMMARY OF LITERATURE REVIEW: An osteoporotic vertebral compression fracture, without neurological symptom, has mainly been treated with conservative care. Sometimes, vertebroplasty or kyphoplasty has been used as a surgical treatment. In the case of a single thoracolumbar fracture with neurological symptoms, not improved by conservative care, decompression, fusion and instrumentation through an anterior or a posterior approach has been attempted. MATERIALS AND METHODS: 10 patients, who had received surgical treatment for symptomatic lumbar spinal stenosis with fracture out of those with multiple osteoporotic vertebral body compression fractures, and over the age of 60, were assessed. The surgical treatment was performed on the patient with all of the following five criteria; (1) severe back pain caused by fractures, (2) neurological symptoms of lumbar spinal stenosis, (3) radiological evidences of stenosis by lumbar fracture, (4) no response to conservative treatment for over 3 months, and (5) adequate physical ability for daily living without a severe medical condition. The surgical procedure included: decompressive laminectomy, posterior instrumentation using pedicle screw fixation, and fusion in situ. The pedicle screws were located 2-3 above and below the most cephalad and caudad fractured vertebral bodies. RESULTS: Clinically, favorable results were obtained in 8 of the 10 patients. In the roentgenographic assessment, the operated states were well maintained, without the metallic failure or instability. Halos around the pedicle screws were seen in 4 patients, but there was no significant evidence of loosening. There were no serious medical and systemic complications in the peri- and postoperative periods. Additional vertebral body fractures and pain were seen in 5 patients, but they had been well managed, conservatively. CONCLUSION: Favorable clinical results could be expected for the surgical treatment of lumbar spinal stenosis, with fracture, in the patients with multiple osteoporotic vertebral fractures, as long as the surgical treatment was indicated exactly and carefully.

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