The efficacy of prophylactic vertebroplasty for preventing proximal junctional complications after spinal fusion: a systematic review.

BACKGROUND CONTEXT: Prophylactic vertebroplasty (VP) is performed at the upper level of instrumentation during spinal fusion to reduce the risk of proximal junctional kyphosis (PJK), proximal junctional fracture (PJFx), and proximal junctional failure (PJF). This study investigated the effect of VP on patient outcomes after spinal fusion. PURPOSE: The aim of this systematic review was to evaluate the effect of prophylactic VP on the incidence of PJK in patients with spinal fusion. STUDY DESIGN/SETTING: Level III, systematic review without meta-analysis. PATIENT SAMPLE: Adult patients undergoing spinal fusion with VP. METHODS: A PRISMA-compliant systematic literature review was conducted using PubMed/MEDLINE, Cochrane, and Embase. Included studies were published in English between January 1, 2001, and May 27, 2021, and reported primary data on adult patients undergoing spinal fusion with VP. Studies were excluded for insufficient surgical details; treatment for vertebral compression fracture; and case series and/or reports with <5 patients. The Newcastle-Ottawa Scale was used to assess risk of bias. The primary outcome of interest was PJK. Other outcomes included PJFx, PJF, and adverse events (eg, cement extravasation). Data were expressed as descriptive statistics. RESULTS: Eight studies with 685 total patients (VP: 293 [42.8%]; No VP: 392 (57.2%)) were included. Five studies were comparative and three were single-arm. PJK incidence was reported in five studies (three comparatives, two single-arm) and ranged from 7.9% to 46.4%; incidence was lower in patients with VP in two of three (66.7%) comparative studies, and equal in one of three (33.3%). PJFx was reported in five studies (four comparatives, one single-arm) and ranged from 0.0% to 39.3%; incidence was lower in the VP group in two of four (50.0%) comparative studies, equal in one of four (25.0%), and higher in one of four (25.0%). PJF was reported in five studies (three comparatives, two single-arm) and ranged from 0.0% to 39.3%; incidence was lower in the VP group in two of three (66.7%) comparative studies and equal in one of three (33.3%). Cement extravasation was reported by four studies and ranged from 0% (0/36) to 48.3% (57/118) in patients with prophylactic VP. CONCLUSIONS: Evidence on whether prophylactic VP decreases the incidence of PJK, PJFx, and PJF after spinal fusion is inconclusive and conflicting. Additionally, the risk of cement extravasation following prophylactic VP could not be evaluated due to insufficient evidence. Further research is needed to determine whether VP has a significant impact on patient outcomes and risks.

Height restoration and sustainability using bilateral vertebral augmentation systems for vertebral compression fractures: a cadaveric study.

BACKGROUND CONTEXT: The treatment of vertebral compression fractures using percutaneous augmentation is an effective method to reduce pain and decrease mortality rates. Surgical methods include vertebroplasty, kyphoplasty, and vertebral augmentation with implants. A previous study suggested that a titanium implantable vertebral augmentation device (TIVAD) produced superior height restoration compared to balloon kyphoplasty (BKP) but was based on a less clinically relevant biomechanical model. Moreover, the introduction of high pressure balloons and directional instruments may further aid in restoring height. PURPOSE: The objective was to evaluate three procedures (BKP, BKP w/ Kyphon Assist (KA; directional instruments), and TIVAD) used for percutaneous augmentation of vertebral fractures with respect to height restoration and sustainability post-operatively. STUDY DESIGN/SETTING: This is an in vitro cadaver study performed in a laboratory setting. METHODS: Five osteoporotic female human cadaver thoracolumbar spines (age: 63-77 years, T-score: -2.5 to -3.5, levels: T7-S1) were scanned using computed tomography and dissected into 30 two-functional spine units (2FSUs). Vertebral wedge compression fractures were created by reducing the anterior height of the vertebrae by 25% and holding the maximum displacement for 15 minutes. Post-fracture, surgery was performed on each 2FSU with a constant 100 N load. Surgeries included BKP, BKP w/ KA, or TIVAD (n=10 per treatment group). Post-surgery, cyclic loading was performed on each 2FSU for 10,000 cycles at 600 N (walking), followed by 5,000 cycles at 850 N (standing up/sitting down), and 5,000 cycles at 1250 N (lifting a 5-10kg weight from the floor). Fluoroscopic images were taken and analyzed at the initial, post-fracture, post-surgery, and post-loading timepoints. Anterior, central, and posterior heights, Beck Index, and angle between endplates were assessed. RESULTS: No difference in height restoration was observed among treatment groups (p=.72). Compared to the initial height, post-surgery anterior height was 96.3±8.7% for BKP, 94.0±10.0% for BKP w/ KA, and 95.3±5.8% for TIVAD. No difference in height sustainability in response to 600 N (p=.76) and 850 N (p=.20) load levels was observed among treatment groups. However, after 1250 N loading, anterior height decreased to 93.8±6.8% of the post-surgery height for BKP, 95.9±6.4% for BKP w/ KA, and 86.0±6.6% for TIVAD (p=.02). Specifically, the mean anterior height reduction between post-surgery and post-1250 N loading timepoints was lower for BKP w/ KA compared to TIVAD (p=.02), but not when comparing BKP to TIVAD (p=.07). No difference in Beck Index or angle between endplates was observed at any timepoint among the treatment groups. CONCLUSIONS: The present study, utilizing a clinically relevant biomechanical model, demonstrated equivalent height restoration post-surgery and at relatively lower-level cyclic loading using BKP, BKP w/ KA, and TIVAD, contrary to results from a previous study. Less anterior height reduction in response to high-level cyclic loading was observed in the BKP w/ KA group compared to TIVAD. CLINICAL SIGNIFICANCE: All three treatments can restore height similarly after a vertebral compression fracture, which may lead to pain reduction and decreased mortality. BKP w/ KA may exhibit less height loss in higher-demand patients who engage in physical activities that involve increased weight resistance.

Management of vertebral fragility fractures: a clinical care pathway developed by a multispecialty panel using the RAND/UCLA Appropriateness Method.

BACKGROUND CONTEXT: Vertebral fragility fractures (VFFs), mostly due to osteoporosis, are very common and are associated with significant morbidity and mortality. There is a lack of consensus on the appropriate management of patients with or suspected of having a VFF. PURPOSE: This work aimed at developing a comprehensive clinical care pathway (CCP) for VFF. STUDY DESIGN/SETTING: The RAND/UCLA Appropriateness Method was used to develop patient-specific recommendations for the various components of the CCP. The study included two individual rating rounds and two plenary discussion sessions. METHODS: A multispecialty expert panel (orthopedic and neurosurgeons, interventional [neuro]radiologists and pain specialists) assessed the importance of 20 signs and symptoms for the suspicion of VFF, the relevance of 5 diagnostic procedures, the appropriateness of vertebral augmentation versus nonsurgical management for 576 clinical scenarios, and the adequacy of 6 aspects of follow-up care. RESULTS: The panel identified 10 signs and symptoms believed to be relatively specific for VFF. In patients suspected of VFF, advanced imaging was considered highly desirable, with MRI being the preferred diagnostic modality. Vertebral augmentation was considered appropriate in patients with positive findings on advanced imaging and in whom symptoms had worsened and in patients with 2 to 4 unfavorable conditions (eg, progression of height loss and severe impact on functioning), dependent on their relative weight. Time since fracture was considered less relevant for treatment choice. Follow-up should include evaluation of bone mineral density and treatment of osteoporosis. CONCLUSIONS: Using the RAND/UCLA Appropriateness Method, a multispecialty expert panel established a comprehensive CCP for the management of VFF. The CCP may be helpful to support decision-making in daily clinical practice and to improve quality of care.