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Objective:To compare the clinical efficacies of O-arm combined with CT three-dimensional navigation system assisted screw placement versus manual screw placement in treating lower cervical fracture and dislocation.Methods:A retrospective cohort study was used to analyze the clinical data of 41 patients with lower cervical fracture and dislocation, who were treated in Honghui Hospital, Xi′an Jiaotong University from May 2021 to February 2022. The patients included 26 males and 15 females, aged 31.5-48.6 years [(41.5±15.0)years]. The injured segments were C 3 in 3 patients, C 4 in 12, C 5 in 13, C 6 in 10 and C 7 in 3. Nineteen patients were treated with cervical pedicle screws by O-shaped arm combined with CT three-dimensional navigation system (navigation group, 76 screws) and 22 by bare hands (traditional group, 88 screws). The total operation time, effective operation time, single nail placement time, single screw correction times, screw distance from anterior cortex, intraoperative blood loss, intraoperative fluoroscopic radiation dose, incision length and length of hospital stay were compared between the two groups, and the height of intervertebral space, Cobb angle, interbody slip distance and American Spinal injury Association (ASIA) grade were compared before operation and at 3 days after operation. Visual analogue score (VAS), Japanese Orthopedic Association (JOA) score, and neck dysfunction index (NDI) were evaluated before operation, at 3 days, 3 months after operation and at the last follow-up. Accuracy of screw placement and incidence of complications (adjacent facet joint invasion, infection, screw loosening) were detected as well. Results:All the patients were followed up for 11.1-13.9 months [(12.5±1.4)months]. The total operation time, intraoperative blood loss, intraoperative fluoroscopic radiation dose and incision length in the navigation group were more or longer than those in the traditional group (all P<0.05). The effective operation time, single nail placement time, single nail correction times and screw distance from anterior cortex in the navigation group were markedly less or smaller than those in the traditional group (all P<0.05). There was no significant difference in the length of hospital stay between the two groups ( P>0.05). There were significant improvements in the height of intervertebral space, Cobb angle and interbody slip distance between the two groups at 3 days after operation (all P<0.05). There was no significant difference in the height of intervertebral space, Cobb angle, interbody slip distance or ASIA grade between the two groups before operation or at 3 days after operation (all P>0.05). Compared with pre-operation, the VAS, JOA score and NDI were significantly improved in both groups at 3 days, 3 months after operation and at the last follow-up (all P<0.05), with further improvement with time. There was no significant difference in VAS between the two groups before operation or at 3 months after operation (all P>0.05), but it was markedly lower in the navigation group compared with the traditional group at 3 days after operation and at the last follow-up (all P<0.05). There were no significant differences in JOA score or NDI between the two groups before operation or at 3 days and 3 months after operation (all P>0.05), but both were lower in the navigation group compared with the traditional group at the last follow-up (all P<0.05). The accuracies of placement of grade 0 and grade 0+1 screws were 92.0% (70/76) and 96.6% (73/76) in the navigation group, respectively, which were markedly higher than 88.7% (78/88) and 93.5% (82/88) in the traditional group (all P<0.05). The rates of adjacent facet joint invasion of A, B, and C degrees were 71.2% (54/76), 28.8% (22/76) and 0% (0/76) in the navigation group, respectively, while the invasion rates were 60.5% (53/88), 32.3% (28/88) and 7.3% (7/88) in the traditional group ( P<0.05). No screw loosening was noted in the navigation group, but the screw loosening rate was 9.1% (8/88) in the traditional group ( P<0.01). Conclusion:Compared with manual screw placement, O-arm combined with CT three-dimensional navigation system assisted screw placement for lower cervical fracture and dislocation has the advantages of shorter effective operation time, quicker screw placement, stronger screw holding force, better cervical stability, slighter postoperative pain, higher screw placement accuracy, and lower facet joint invasion and screw loosening rates.
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Objective:To compare the efficacy of robot-assisted and conventional fluoroscopy-guided percutaneous vertebroplasty (PVP) combined with pediculoplasty in treating symptomatic chronic thoracolumbar osteoporotic vertebral fracture (SCOVF) without neurological symptoms.Methods:A retrospective cohort study was used to analyze the clinical data of 120 patients with thoracolumbar SCOVF without neurological symptoms, who were admitted to Honghui Hospital Affiliated to Xi′an Jiaotong University from January 2015 to January 2020. The patients included 34 males and 86 females, aged 63-85 years [(72.9±5.7)years]. All patients were treated with PVP combined with pediculoplasty. A total of 87 patients were treated with robot-assisted and C-arm X-ray machine guided puncture (robot group) and 33 patients with C-arm X-ray machine fluoroscopic-guided puncture (conventional group). The operation time, amount of bone cement injection and puncture accuracy were compared between the two groups. The results of vertebral body index, Cobb angle, visual analogue scale (VAS), and Oswestry disability index (ODI) were also compared before operation, at 1 day and 1 year after operation and at the final follow-up. Complications such as bone cement leakage and displacement were observed.Results:All patients were followed up for 24-36 months [(29.4±3.4)months]. The operation time was (85.2±10.5)minutes in the robot group, significantly longer than (37.2±3.7)minutes in the conventional group ( P<0.01). The amount of bone cement injection was (5.0±0.7)ml in the robot group, significantly less than (5.3±0.8)ml in the conventional group ( P<0.05). The puncture accuracy in the robot group was 95.4% (83/87), significantly higher than 81.8% (27/33) in the conventional group ( P<0.01). There were no significant differences in vertebral body index, Cobb angle, VAS or ODI between the two groups before operation (all P>0.05). The values of vertebral body index were 87.1±4.5, 86.9±4.3, 86.8±4.3 in the robot group at 1 day after operation, 1 year after operation and the final follow up, respectively, which were significantly higher than 83.6±4.4, 84.1±3.8, 84.4±3.9 in the conventional group (all P<0.01). There were no significant differences in Cobb angle or ODI between the two groups at 1 day after operation, 1 year after operation or the final follow-up (all P>0.05). The values of VAS were (2.9±1.0)points, (1.8±0.7)points, (1.8±0.7)points in the robot group at 1 day after operation, 1 year after operation and the final follow-up, respectively, which were significantly lower than (4.4±1.1)points, (3.1±0.8)points, (3.0±0.9)points in the conventional group (all P<0.01). The bone cement leakage occurred in 7 patients in the robot group [8.0%(7/87)] and in 10 in the conventional group [30.3%(10/33)] ( P<0.01). No delayed bone cement displacement [0.0%(0/87)] occurred in the robot group from 1 day after operation to the final follow-up, but 3 patients [9.1%(3/33)] were noted in the conventional group ( P<0.05). Conclusion:Both robot-assisted and conventional fluoroscopy-guided PVP combined with pediculoplasty have satisfactory effect for SCOVF patients without neurological impairment, but the robot-assisted one has the advantages of higher puncture accuracy, more satisfactory vertebral height recovery, more rapid pain relief, lower incidence of bone cement leakage and effective avoidance of cement displacement.
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Objective:To compare the clinical efficacies of robot-assisted and free-hand long segment screw fixation combined with wedge osteotomy in the treatment of type IV chronic symptomatic osteoporotic thoracolumbar fractures (CSOVCFs).Methods:A retrospective cohort study was conducted to analyze the clinical data of 72 patients with type IV CSOVCFs who were admitted to Honghui Hospital of Xi′an Jiaotong University from May 2019 to December 2021, including 22 males and 46 females; aged 61-82 years [(71.2±12.3)years]. Fracture segments were located at T 11-T 12 in 37 patients and at L 1-L 2 in 31. A total of 32 patients were treated with robot-assisted long segment screw fixation combined with wedge osteotomy (robot group) and 36 with free-hand long segment screw fixation combined with wedge osteotomy (free-hand group). The operation time, intraoperative bleeding volume, dosage of radiation exposure, intraoperative needle adjustment, time of single pedicle screw placement and accuracy of pedicle screw placement were compared between the two groups. The kyphotic Cobb angle, sagittal vertical axis (SVA), thoracic kyphosis (TK), lumbar kyphosis (LL), visual analogue scale (VAS) and Oswestry disability index (ODI) were measured preoperatively, at 3 days postoperatively and at the last follow-up. The incidences of facet joint violation, deviation in guide needle placement, cerebrospinal leak and proximal junctional kyphosis (PJK) were observed. Results:All patients were followed up for 12-26 months [(18.2±5.1)months]. The operation time and time of single pedicle screw placement showed no significant differences between the two groups (all P>0.05). The intraoperative bleeding volume was (502.5±58.3)ml in the robot group, less than that in the free-hand group [(690.2±45.9)ml]. The dosage of radiation exposure was (32.6±10.8)μSv in the robot group, lower than that in the free-hand group [(48.6±15.2)μSv]. The intraoperative needle adjustment was (2.1±0.3)times in the robot group, higher than that in the free-hand group [(20.7±5.8)times], and the accuracy of pedicle screw placement was 99.7% in the robot group, less than that in the free-hand group (91.8%) (all P<0.01). Compared with pre-operation, the kyphotic Cobb angle, SVA, TK and LL were significantly improved in both groups at postoperative 3 days and at the last follow-up (all P<0.05). Compared with postoperative 3 days, the kyphotic Cobb angle, SVA and TK were increased at the last follow-up within the two groups, but with no significant differences (all P>0.05). Compared with postoperative 3 days, the LL was decreased within the two groups at the last follow-up, but with no significant differences (all P>0.05). The VAS and ODI in the two groups were significantly lower at postoperative 3 days and at the last follow-up when compared with those before operation (all P<0.05), and both values were significantly lower at the last follow-up than those at postoperative 3 days (all P<0.05). There were no significant differences in the VAS or ODI at all time points between the two groups (all P>0.05). The incidence of facet joint violation in the robot group was 1.6%, markedly lower than that in the free-hand group (9.6%) ( P<0.01). The incidences of deviation in guide needle placement, cerebrospinal leak and PJK showed no differences between the two groups (all P>0.05). Conclusion:For type IV CSOVCFs, the robot-assisted long segment screw fixation combined with wedge osteotomy can better reduce intraoperative blood loss, decrease radiation exposure, improve accuracy of pedicle screw placement, and reduce facet joint violation when compared with free-hand long segment screw fixation combined with wedge osteotomy.
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The incidence of osteoporotic vertebral compression fractures (OVCF) is increasing year by year. OVCF is manifested by thoracolumbar back pain, kyphosis and limitation of motion, which severely reduces the quality of life and life expectancy of the patients. It is often caused by minor violence with an insidious onset, and has a high rate of missed diagnoses on routine examination. Currently, percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) are effective treatments for OVCF, but postoperative complications such as cement leakage and vertebral re-fracture occur often. Digital orthopedic technology is an emerging interdisciplinary discipline that combines computer digital technology with orthopedic clinics. As a new orthopedic clinical technology, digital orthopedic technology is pushing the boundaries of spinal surgery research and clinical application due to its advantages in individualization, precision, and minimally invasiveness, and is currently at a rapid development stage with high endurance and high throughput. To this end, the authors outlined the current application of digital orthopedic technology in OVCF, so as to provide a reference for achieving rapid and accurate diagnosis of OVCF and formulating reasonable treatment plans.
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Objective:To compare the efficacy of percutaneous vertebroplasty (PVP) in the treatment of osteoporotic lumbar compression fracture (OLCF) via the approach through midpoint transverse process-transition zone of articular process and the unilateral transpedicular approach.Methods:A prospective cohort study was conducted to analyze the clinical data of 794 patients with OLCF treated in Honghui Hospital affiliated to Xi′an Jiaotong University School of Medicine from January 2017 to December 2019. The patients were divided into transitional-zone puncture group (400 patients, 400 vertebrae) and pedicle puncture group (394 patients, 394 vertebrae) according to the envelope method. The transitional-zone puncture group was treated with PVP via the approach through midpoint transverse process-transition zone of articular process, and the pedicle puncture group was treated with PVP via the unilateral transpedicular approach. The operation time and radiation dose were documented. The visual analogue score (VAS) and Oswestry dysfunction index (ODI) were evaluated before operation and at 1 day, 3 months, 1 year after operation. The cement distribution and the incidence of complications such as cement leakage, re-fracture of the injured vertebra, spinal cord nerve injury and facet joint injury were detected.Results:The patients were composed of 270 males and 524 females, at the age of 68.9-78.5 years [(73.7±4.8)years]. All patients were followed up for 12-14 months [(13.4±0.8)months]. The operation time and radiation dose in transitional-zone puncture group were reduced compared with pedicle puncture group ( P<0.01). There was no significant difference in VAS and ODI between the two groups before operation (all P>0.05). The VAS between transitional-zone puncture group [(2.1±0.9)points, (2.3±1.1)points, (2.7±1.3)points] and pedicle puncture group [(2.3±0.7)points, (2.5±0.9)points, (2.9±1.1)points] was obviously reduced from that before operation (all P<0.01), significantly different at 1 day, 3 months, 1 year after operation ( P<0.05 or 0.01). The ODI between transitional-zone puncture group (14.3±1.8, 13.6±3.4, 11.3±4.4) and pedicle puncture group (25.5±5.7, 20.7±6.3, 20.6±6.9) was significantly different at 1 day, 3 months, 1 year after operation (all P<0.01), and all were obviously reduced from that before operation (all P<0.01). With regard to the cement distribution, the number of bilaterally cemented vertebrae in transitional-zone puncture group (324) was more than that in pedicle puncture group (94) ( P<0.01). The incidence of cement leakage, re-fracture of the injured vertebra and facet joint injury was 8.25%(22/400), 0.00%(0/400) and 3.25%(13/400) in transitional-zone puncture group, significantly different from 20.81%(82/394), 2.03%(8/394) and 9.90%(39/394) in pedicle puncture group ( P<0.05 or 0.01). There was no significant difference in spinal cord nerve injury between the two groups ( P>0.05). Conclusion:For OLCF, PVP via the approach through the midpoint transverse process-transition zone of articular process and the unilateral transpedicular approach are both effective, but the former has advantages of shorter operation time, smaller radiation dose, greater dispersion of bone cement and lower incidence of cement leakage, re-fracture of the injured vertebra and facet joint injury.
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The acute combination fractures of the atlas and axis in adults have a higher rate of neurological injury and early death compared with atlas or axial fractures alone. Currently, the diagnosis and treatment choices of acute combination fractures of the atlas and axis in adults are controversial because of the lack of standards for implementation. Non-operative treatments have a high incidence of bone nonunion and complications, while surgeries may easily lead to the injury of the vertebral artery, spinal cord and nerve root. At present, there are no evidence-based Chinese guidelines for the diagnosis and treatment of acute combination fractures of the atlas and axis in adults. To provide orthopedic surgeons with the most up-to-date and effective information in treating acute combination fractures of the atlas and axis in adults, the Spinal Trauma Group of Orthopedic Branch of Chinese Medical Doctor Association organized experts in the field of spinal trauma to develop the Evidence-based guideline for clinical diagnosis and treatment of acute combination fractures of the atlas and axis in adults ( version 2023) by referring to the "Management of acute combination fractures of the atlas and axis in adults" published by American Association of Neurological Surgeons (AANS)/Congress of Neurological Surgeons (CNS) in 2013 and the relevant Chinese and English literatures. Ten recommendations were made concerning the radiological diagnosis, stability judgment, treatment rules, treatment options and complications based on medical evidence, aiming to provide a reference for the diagnosis and treatment of acute combination fractures of the atlas and axis in adults.
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Ankylosing spondylitis (AS) combined with spinal fractures with thoracic and lumbar fracture as the most common type shows characteristics of unstable fracture, high incidence of nerve injury, high mortality and high disability rate. The diagnosis may be missed because it is mostly caused by low-energy injury, when spinal rigidity and osteoporosis have a great impact on the accuracy of imaging examination. At the same time, the treatment choices are controversial, with no relevant specifications. Non-operative treatments can easily lead to bone nonunion, pseudoarthrosis and delayed nerve injury, while surgeries may be failed due to internal fixation failure. At present, there are no evidence-based guidelines for the diagnosis and treatment of AS combined with thoracic and lumbar fracture. In this context, the Spinal Trauma Academic Group of Orthopedics Branch of Chinese Medical Doctor Association organized experts to formulate the Clinical guideline for the diagnosis and treatment of adult ankylosing spondylitis combined with thoracolumbar fracture ( version 2023) by following the principles of evidence-based medicine and systematically review related literatures. Ten recommendations on the diagnosis, imaging evaluation, classification and treatment of AS combined with thoracic and lumbar fracture were put forward, aiming to standardize the clinical diagnosis and treatment of such disorder.
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Objective:To evaluate the efficacy between pedicle screws combined with vertebroplasty (PSV) and pedicle screws combined with intermediate screws (PSIS) for the treatment of osteoporotic thoracolumbar fracture (OTLF).Methods:PubMed, Cochrane Library, Web of Science, CNKI, VIP and Wanfang database were searched for all randomized controlled trial (RCT) or case-control trial (CCT) studies that comparing PSV and PSIS for the treatment of OTLF. Two reviewers independently screened the studies in the light of the inclusion and exclusion criteria, extracted data and evaluated the quality of the included studies. The Meta-analysis was performed using the RevMan 5.4 software. The subjects were divided into PSV group and PSIS group according to different treatment methods. Operation time, intraoperative blood loss, postoperative incision infection rate, postoperative short-, mid- and long-term visual analogue scale (VAS) score, postoperative short- and mid-term Oswestry disability index (ODI), hospitalization time, postoperative short-, mid- and long-term Cobb angle, postoperative short-, mid- and long-term anterior vertebral height ratio (VBH) and implant failure rate were compared between the two groups.Results:A total of 12 studies were enrolled for review, involving 870 subjects (433 in PSV group and 437 in PSIS group). The results showed insignificant difference between the two groups in operation time ( WMD=7.07, 95% CI -4.00, 18.13, P>0.05), intraoperative blood loss ( WMD=0.62, 95% CI -7.19, 8.43, P>0.05), postoperative incision infection rate ( OR=0.65, 95% CI 0.10, 4.08, P>0.05), postoperative short-term Cobb angle ( WMD=-0.19, 95% CI -0.43, 0.05, P>0.05) and postoperative short-term VBH ( WMD=0.91, 95% CI -1.30, 3.13, P>0.05). However, there was significant difference between the two groups in postoperative short-term VAS score ( WMD=-0.59, 95% CI -1.02, -0.15, P<0.05), mid-term VAS score ( WMD=-0.41, 95% CI -0.65, -0.16, P<0.05), long-term VAS score ( WMD=-0.51, 95% CI -0.59, -0.43, P<0.05), postoperative short-term ODI ( WMD=-6.26, 95% CI -9.65, -2.87, P<0.05), postoperative mid-term ODI ( WMD=-2.44, 95% CI -3.43, -1.45, P<0.05), hospitalization time ( WMD=-2.65, 95% CI -4.61, -0.68, P<0.05), postoperative mid-term Cobb angle ( WMD=-1.40, 95% CI -2.41, -0.39, P<0.05), postoperative long-term Cobb angle ( WMD=-1.06, 95% CI -1.59, -0.52, P<0.05), postoperative mid-term VBH ( WMD=3.06, 95% CI 1.31, 4.81, P<0.05), postoperative long-term VBH ( WMD=4.11, 95% CI 2.44, 5.77, P<0.05) and implant failure rate ( OR=2.06, 95% CI 0.11, 0.59, P<0.05). Conclusion:Compared with PSIS, PSV can not reduce the operation time, intraoperative blood loss and incision infection in the treatment of OTLF, but it can significantly relieve pain, improve function, decrease reduce hospitalization time, help to maintain Cobb angle and anterior vertebral height after operation, and reduce implant failure rate.
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Objective:To investigate the physicochemical and biological properties of different magnesium modified calcium phosphate bone cements.Methods:The different magnesium modified calcium phosphate bone cements were divided into magnesium citrate, magnesium lactate, magnesium malate, magnesium phosphate and magnesium glycinate groups, each of which was added with different magnesium agents in the proportion of 0%, 1%, 3% and 5% of the total weight of calcium phosphate bone cements. The initial and final setting time, injectability, anti-collapse performance and compressive strength of different magnesium modified calcium phosphate bone cements were tested. Furthermore, the screened bone cement extracts were used to culture with third generation osteoblasts. Bioactivity assays were performed using the Cell Proliferation and Toxicity Assay Kit (CCK-8). Alkaline phosphatase (ALP) staining and Alizarin Red S (ARS) staining were performed on osteoblasts to observe the osteogenic activity of magnesium malate modified calcium phosphate bone cements.Results:The addition of different proportions of different magnesium agents led to the shortening of the initial and final setting time of modified calcium phosphate bone cements. Moreover, the final setting time of 5% magnesium malate modified calcium phosphate bone cements was the shortest (<40 minutes), which was significantly shorter compared with other magnesium agents in the same proportion (all P<0.05). With the addition of different magnesium agents in different proportions, the injectability of bone cements was gradually increased, and the injectability of 5% magnesium malate calcium phosphate bone cements reached the highest for (87.3±1.9)%, which was significantly increased compared with other magnesium agents in the same proportion (all P<0.05). The anti-collapse performance of bone cements was decreased with the addition of different magnesium agents in different proportions. Magnesium citrate, magnesium phosphate and magnesium glycinate modified calcium phosphate bone cements could not resist the flushing of deionized water. In particular, magnesium malate modified calcium phosphate bone cements had the best anti-collapse performance, with the maximum weight loss rate for only (9.8±2.3)% after 30 minutes of deionized water flushing, which was better than the rest of the groups (all P<0.05). The compressive strength of magnesium lactate and magnesium phosphate modified calcium phosphate bone cements showed a decrease compared with original calcium phosphate bone cements, while the compressive strength of magnesium citrate and magnesium malate modified calcium phosphate bone cements was significantly increased compared with original calcium phosphate bone cements, of which 3% magnesium malate modified calcium phosphate bone cements had the greatest compressive strength of (6.2±0.2)MPa, significantly higher than the rest of the groups (all P<0.05). The sieve test yielded magnesium malate modified calcium phosphate bone cement, which had a weight loss of (27.0±0.9)% at 35 days in vitro. The release of magnesium ions was increased with increasing magnesium malate dose in the in vitro environment of magnesium malate modified calcium phosphate bone cements in different ratios. A stable magnesium ion release was achieved within 35 days.Also, the pro-proliferative and osteogenic effects of modified calcium phosphate bone cements on osteoblasts were more obvious with increase of magnesium malate dose. For 5% magnesium malate modified calcium phosphate bone cements, the cell number, ALP staining area ratio and calcium nodule area ratio were significantly increased compared with the groups in the proportion of 0% and 1% magnesium malate (all P<0.05). Conclusions:Among magnesium citrate, magnesium lactate, magnesium malate, magnesium phosphate and magnesium glycinate modified calcium phosphate bone cements, magnesium malate modified calcium phosphate bone cements have relatively suitable setting time, excellent anti-collapse performance and mechanical strength. Meanwhile, 5% magnesium malate modified calcium phosphate bone cements have better biological activity among different ratios of magnesium malate modified calcium phosphate bone cements, suggesting a potential value for clinical application.
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Re-fracture of the injured vertebrae is a serious complication after vertebral augmentation for osteoporotic thoracolumbar fractures (OTLF), manifested by recurrent lower back pain, limitation of spinal motion and increased retroflexion deformity. The clinical treatment of re-fracture of the injured vertebrae is difficult, and some patients even need spinal function reconstruction to stabilize the fractured vertebrae, which has a serious impact on their postoperative rehabilitation, quality of life and economic burdens. Re-fracture of the injured vertebrae after vertebral augmentation for OTLF is closely related to patient factors, bone cement factors and perioperative factors. To this end, the authors discuss the risk factors for re-fracture of the injured vertebrae after vertebral augmentation for OTLF and propose corresponding management methods to provide a reference for understanding the risk of re-fracture of the injured vertebrae and improving the clinical treatment.
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Osteoporotic thoracolumbar fracture in the elderly will seriously reduce their quality of life and life expectancy. For osteoporotic thoracolumbar fracture in the elderly, spinal reconstruction is necessary, which should comprehensively consider factors such as the physical condition, fracture type, clinical characteristics and osteoporosis degree. While there lacks relevant clinical norms or guidelines on selection of spinal reconstruction strategies. In order to standardize the concept of spinal reconstruction for osteoporotic thoracolumbar fracture in the elderly, based on the principles of scientificity, practicality and progressiveness, the authors formulated the Clinical guideline for spinal reconstruction of osteoporotic thoracolumbar fracture in elderly patients ( version 2022), in which suggestions based on evidence of evidence-based medicine were put forward upon 10 important issues related to the fracture classification, non-operative treatment strategies and surgical treatment strategies in spinal reconstruction after osteoporosis thoracolumbar fracture in the elderly, hoping to provide a reference for clinical treatment.
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The incidence of acute symptomatic thoracolumbar osteoporotic compression fractures (ASTOCFs) has increased significantly with population aging in China. Vertebral augmentation has been widely used because of its minimally invasive, safe and effective characteristics. However, many problems in the diagnosis and treatment of ASTOCFs remain controversial. In order to standardize the diagnosis and treatment of ASTOCFs, the editorial board of "Chinese Journal of Trauma "and expert panel of Spinal Trauma Committee of Orthopedics Branch of Chinese Medical Doctor Association formulated the"clinical guidelines for vertebral augmentation for acute symptomatic thoracolumbar osteoporotic compression fractures" (hereafter referred to as the "guideline"). The guideline provided evidence-based recommendations on key issues regarding the use of vertebral augmentation in such fracture. Since orthopedic surgeons at different levels of medical institutions have different understanding of the guideline, the authors made an in-depth interpretation of some key points in the guideline to help clinicians better understand the guideline and guide clinical practice.
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Objective:To investigate the efficacy of the novel bone cement bridging screw system combined with percutaneous vertebroplasty (PVP) in the treatment of symptomatic chronic osteoporotic vertebral fractures (SCOVF) with intravertebral vacuum cleft (IVC).Methods:A retrospective case series study was used to analyze the clinical data of 27 patients with SCOVF admitted to Honghui Hospital affiliated to Xi′an Jiaotong University from August 2016 to August 2018, including 6 males and 21 females; age 69-88 years [(75.2±4.9)years]. All patients were treated by the novel bone cement bridging screw combined with PVP. The operation time, amount of bone cement injected and occurrence of bone cement leakage or displacement were recorded. The vertebral body index (VBI), vertebral body angle (VBA), two-segment Cobb angle (BCA), visual analogue score (VAS) and Oswestry disability index (ODI) were compared preoperatively, at day 1 after operation and at the last follow-up. The results of the MOS 36-item short form health survey (SF-36) and Odom′s criteria were compared preoperatively and at the last follow-up to evaluate pain relief and neurological recovery.Results:All patients were followed up for 36-48 months [(40.2±3.7)months]. The operation time was 37-70 minutes [(49.6±10.8)minutes], with the amount of bone cement injected for 3-6 ml [(34.7±0.9)ml]. Intraoperative bone cement leakage occurred in 4 patients (15%), among which 3 had lateral vertebral leakage and 1 superior intervertebral disc leakage. There was no bone cement displacement during the postoperative period to the last follow-up. The VBI, VBA, BCA, VAS and ODI were (43.1±5.9)%, (21.0±2.6)°, (45.0±6.3)°, 7.6 (7.0, 8.0)points, (79.9±7.6)% preoperatively, were (78.7±2.6)%, (12.7±2.1)°, (26.1±4.7)°, 3.2 (3.0, 4.0)points, (50.0±9.3)% at day 1 after operation, and were (78.0±2.3)%, (13.2±2.4)°, (27.1±4.9)°, 2.0 (2.0, 2.0)points, (22.9±5.1)% at the last follow-up. There were significant differences in above five measures at day 1 after operation and at the final follow-up in comparison with the preoperative values (all P<0.05), and their values measured at day 1 after operation and at the final follow-up were also significantly different (all P<0.05). The SF-36 score in physical function, role physical, body pain, vitality and social function was 45.2 (40.0, 50.0)points, 28.7 (25.0, 50.0)points, 15.9 (10.0, 22.0)points, 48.3 (40.0, 60.0)points, 29.2 (25.0, 37.5)points preoperatively, significantly different from 78.0 (75.0, 85.0)points, 75.0 (75.0, 75.0)points, 68.1 (64.0, 74.0)points, 62.0 (55.0, 70.0)points, 34.7 (25.0, 37.5)points at the last follow-up (all P<0.05). However, there were no significant differences in SF-36 before operation and at the last follow-up in dimensions of general health, emotional function and mental health (all P>0.05). According to Odom′s criteria, 19 patients were graded as excellent, 7 good, 1 fair and 0 poor, with an excellent and good rate of 96%. Conclusion:For SCOVF patients with IVC, the novel bone cement bridging screw system combined with PVP has advantages of no displacement of bone cement, satisfactory fixation, significant pain relief and satisfactory functional recovery.
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The symptomatic chronic thoracolumbar osteoporotic vertebral fracture (SCOVF) is complex in symptom and pathological character. Various treatment methods are employed for SCOVF, but there still lacks standard criteria for proper selection. Therefore, Spine Trauma Division of Chinese Association of Orthopedic Surgeons together with the relevant experts formulated and released the clinical guideline on surgical treatment for SCOVF. Due to space limitations, the guideline did not make full elaboration and analysis on some recommendations. In this study, the authors aim to interpret some key clinical issues in the diagnosis, choice of operation methods and choice of internal fixation methods of SCOVF, hoping to help peers better grasp the connotation of the guideline and apply it correctly in clinical practice.
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Objective:To explore the risk factors of cement displacement after percutaneous vertebral augmentation in patients with osteoporotic vertebral compression fracture (OVCF).Methods:A case-control analysis was made on clinical data of 1 538 patients with OVCF admitted to Honghui Hospital Affiliated to Xi′an Jiaotong University from January 2016 to June 2021. There were 377 males and 1 161 females, aged from 45-115 years [(71.7±10.8)years]. Percutaneous vertebroplasty (PVP) or percutaneous vertebroplasty (PKP) was performed. Patients were divided into cement displacement group ( n=78) and cement non-displacement group ( n=1 460) according to the radiographic outcomes. Factors related to cement displacement were analyzed by univariate analysis, including age, gender, body mass index (BMI), preoperative bone mineral density, underlying diseases, involved vertebral segments, surgical methods, surgical approaches, cement leakage (anterior edge), viscosity of cement, dispersion ratio of cement, degree of cement interweaving, sagittal position of cement, targeted location of cement, distance from cement to upper and lower endplates and duration of brace wearing. Independent risk factors for bone cement displacement were identified by multivariate Logistic regression analysis. Results:Univariate analysis showed that bone cement displacement was significantly correlated with BMI, preoperative bone mineral density, involved vertebral segments, operation methods, cement leakage (anterior edge), viscosity of cement, dispersion ratio of cement, degree of cement interweaving, sagittal position of cement, targeted location of cement, distance from cement to upper and lower endplates and duration of brace wearing (all P<0.05), but there was no correlation with gender, age, underlying diseases or surgicales approach (all P>0.05). Multivariate Logistic analysis showed that the preoperative bone mineral density ( OR=2.45, 95% CI 1.81-7.50, P<0.01), operation methods ( OR=4.56, 95% CI 1.86-8.44, P<0.01), cement leakage (anterior edge) ( OR=5.77, 95% CI 2.85-9.20, P<0.01), viscosity of cement ( OR=7.36, 95% CI 1.01-1.77, P<0.01), dispersion ratio of cement ( OR=6.84, 95% CI 1.69-13.39, P<0.01), degree of cement interweaving ( OR=8.97, 95% CI 2.29- 14.97, P<0.01), sagittal position of cement ( OR=6.39, 95% CI 1.06-9.47, P<0.01), targeted location of cement ( OR=7.93, 95% CI 1.64-11.84, P<0.01), distance from cement to upper and lower endplates ( OR=6.78, 95% CI 1.84-6.96, P<0.01) and duration of brace wearing ( OR=9.55, 95% CI 2.26- 9.38, P<0.01) were significantly correlated with bone cement displacement after percutaneous vertebral augmentation. Conclusion:Low bone mineral density preoperatively, PKP, cement leakage into the vertebral anterior edge, low viscosity of cement, small dispersion ratio of cement, small degree of cement interweaving, cement filling in the anterior 1/3 and anterior middle 2/3 of the vertebral body in sagittal plane, non-targeted injection of cement, long distance from cement to upper and lower endplates and short duration of brace wearing are independent risk factors of cement displacement after percutaneous vertebral augmentation for OVCF.
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With the large use of vertebral augmentation in the treatment of osteoporotic thoracolumbar fracture (OTLF), the complication of cement leakage has become an increasing concern. Although most cement leakage has no obvious clinical symptoms, some patients still sustain serious complications such as vertebral fracture, pulmonary embolism and spinal nerve compression. Cement leakage is closely related to patients′ own factors, cement factors and perioperative related factors. To clarify the risk factors of cement leakage with implementation of preventive measures accordingly is of great guiding significance to improve the clinical efficacy and surgical safety. Therefore, the authors discuss bone cement leakage in aspects of the risk factors and preventive measures so as to provide a reference for reducing the incidence of cement leakage.
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Osteoporotic vertebral compression fracture (OVCF) is a kind of fragility fracture, and osteoporotic thoracolumbar fracture (OTLF) is the most common type. At present, OTLF has gradually been a common disease in the elderly, among which improper treatments may cause serious complications and even death, bringing a heavy burden to the family and society. Accordingly, in-depth researches on the prevention and treatment of this disease is significant to improve the quality of life for the elderly and reduce social burden. Accurate choices of treatments depend on fracture classifications. A variety of OTLF classifications have been proposed by domestic and foreign scholars, but each has its own defects, and to distinguish their differences may be problematic. Therefore, it is difficult to apply each classification. In this study, the authors review the research progress in different classification and scoring sytems for OTLF to provide a reference for clinical diagnosis and treatment.
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Objective:To investigate the risk factors associated with the occurrence of proximal junctional kyphosis (PJK) after posterior long-segment internal fixation for type IV chronic symptomatic osteoporotic thoracolumbar fracture (CSOTLF) in the elderly.Methods:A case-control study was used to analyze the clinical data of 95 elderly patients with type IV CSOTLF treated in Honghui Hospital affiliated to Xi′an Jiaotong University from January 2013 to June 2018, including 32 males and 63 females, aged from 60 to 85 years［(67.4±6.5) years］. Injured segments were T 11 in 17 patients, T 12 in 37, L 1 in 30 and L 2 in 11. All patients were treated with posterior long-segment internal fixation and divided into PJK group ( n=30) and non-PJK group ( n=65) according to whether PJK occurred after surgery. Univariate analysis was performed for the correlation of the following indices with the incidence of postoperative PJK, including general information such as gender, age, body mass index (BMI), bone mineral density (BMD), history of smoking, cause of injury, comorbidities, injury segments, American Spinal Injury Association (ASIA) classification and time from injury to surgery, preoperative imaging data such as posterior junctional angle (PJA), sagittal vertical axis (SVA), pelvic incidence-lumbar lordosis difference (PI-LL), pelvic tilt (PT) and sacral slope (SS), basic surgical data such as posterior ligament complex (PLC) injury, location of upper instrumented vertebrae (UIV), location of lower instrumented vertebrae (LIV) and number of fixed segments. Multifactorial Logistic regression analysis was used to measure the independent risk factors associated with the occurrence of postoperative PJK. Results:Univariate analysis showed that the incidence of postoperative PJK was correlated with age, BMI, BMD, preoperative PJA, preoperative SVA, preoperative PI-LL, PLC injury, location of UIV, location of LIV and number of fixed segments (all P<0.05), rather than gender, history of smoking, cause of injury, comorbidities, injury segments, ASIA classification, time from injury to surgery, preoperative PT and preoperative SS (all P>0.05). Multifactorial Logistic regression analysis showed that age ≥70 years ( OR=32.28, 95% CI 3.83-272.29, P<0.01), BMI>28.0 kg/m 2 ( OR=7.88, 95% CI 1.63-37.99, P<0.01), BMD T value<-3.5 SD ( OR=20.84, 95% CI 2.36-183.93, P<0.01), preoperative PI-LL>20° ( OR=13.30, 95% CI 1.54-113.87, P<0.05) and PLC injury ( OR=13.98, 95% CI 1.37-142.34, P<0.05) were significantly associated with the occurrence of postoperative PJK. Conclusions:Age≥70 years, BMI>28 kg/m 2, BMD T value<-3.5 SD, preoperative PI-LL>20° and PLC injury are independent risk factors for the incidence of PJK after posterior long-segment internal fixation in elderly patients with type IV CSOTLF. Attention should be paid to soft tissue protection and sagittal balance restoration of the spine intraoperatively and weight control and anti-osteoporosis treatment postoperatively.
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Osteoporotic vertebral fracture (OVF) is mostly noted in the elderly with many comorbidities and most of them are treated by non-surgical treatments such as analgesia, antiosteoporosis or rehabilitation and by minimally invasive vertebroplasty. However, when there is instability, neurological dysfunction or severe kyphosis, open surgery is still necessary. The authors discuss the relevant issues in the indications, surgical approaches, results and complications of open surgery for OVF so as to provide a reference for better clinical treatment.
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Objective:To explore the clinical effects of unilateral secondary puncture percutaneous vertebroplasty (PVP) in the treatment of type ⅡA acute symptomatic osteoporotic thoracolumbar fractures (ASOTLF).Methods:A retrospective case-control study was conducted to analyze the clinical data of 193 patients with type ⅡA ASOTLF who had been admitted to Department of Spine Surgery, Honghui Hospital from February 2016 to October 2018. They were 71 males and 122 females, aged from 65 to 90 years [average, (73.9±4.3) years]. The segments injured were T10 in 21 cases, T11 in 27 cases, T12 in 44 cases, L1 in 48 cases, L2 in 29 cases, L3 in 14 cases, and L4 in 10 cases. Of them, 85 received unilateral secondary puncture PVP (observation group) and 108 did not (control group). The clinical effects were evaluated by comparing between the 2 groups the operation time, bone cement injection volume, intraoperative blood loss, hospital stay, and visual analogue scale (VAS) for back pain, spinal Oswestry disability index (ODI), anterior height of the injured vertebral body (AH) and kyphosis angle (KA) of the injured vertebra before operation, at 3 days after operation and the last follow-up. The bone cement leakage and fracture of adjacent vertebral body were observed.Results:All patients were followed up for 12 to 24 months (average, 15.8 months). There was no significant difference in the preoperative general data between the 2 groups, showing they were comparable ( P>0.05). The operation time and bone cement injection volume [(36.2±1.4) min and (5.5±0.7) mL] in the observation group were significantly longer or more than those in the control group [(32.3±1.7) min and (4.0±0.7) mL] ( P<0.05). There was no significant difference in the hospital stay or intraoperative blood loss between the 2 groups ( P>0.05). The VAS, ODI, AH and KA at 3 days after operation and the last follow-up were significantly improved compared with those before operation in both groups ( P<0.05). There was no significant difference in VAS, ODI, AH or KA between the 2 groups before operation or at 3 days after operation ( P>0.05). However, the VAS, ODI, AH and KA at the last follow-up in the observation group [(2.2±0.8) points, 19.2%±5.8%, (2.90±0.21) cm, and 12.2°±1.5°] were better than those in the control group [(3.1±0.9) points, 22.8%±5.3%, (2.41±0.15) cm, and 13.3°±1.2°]. There was no significant difference between the 2 groups in the incidence of postoperative bone cement leakage or that of adjacent vertebral fracture ( P>0.05). Conclusions:In the treatment of type ⅡA ASOTLF, unilateral secondary puncture PVP can result in satisfactory clinical effects, because it effectively promotes dispersion of bone cement and prevents re-collapse of the vertebra operated but does not increase the risks of bone cement leakage and adjacent vertebral fracture.