Kummell’s illness is a selected sort of osteoporotic fracture in older adults. The attribute imaging manifestation is a vacuum fissure signal attributable to absorption of osteonecrotic tissue of the vertebral physique, with gasoline or liquid inside, usually within the central a part of the anterior vertebral physique.1–4 Sufferers normally current with extreme again ache, which compromises quality-of-life and responds poorly to conservative remedy. Surgical procedure is required. Percutaneous vertebroplasty (PVP), percutaneous kyphoplasty (PKP), or bone graft fusion with inner fixation of a pedicle screw are normally employed.4–9 Nonetheless, these strategies are related to bone cement leakage, long-term bone cement loosening (and even displacement), and inner fixation surgical procedure trauma that impacts spinal mobility.2,3,10 Because the cortex of the anterior fringe of the vertebral physique or the higher endplate is incomplete, the bone cement leakage price throughout PVP is 34.4–79%. Because the hardened bone on either side of the vertebral fissure of Kummell’s illness exerts a blocking impact, it’s troublesome for bone cement to enter unfastened trabecular bone, and cement thus can’t be used to anchor the bone, making a free smooth-edged mass of cement within the vertebral physique. This cement block doesn’t stabilize the vertebral physique, and is vulnerable to loosening, displacement, and prolapse in the long run.2–4 A typical case is described in Determine 1.
Determine 1 Bone cement loosening and displacement after conventional PVP in a affected person with Kummell’s illness. A feminine 82 years of age complained of “low again ache and discomfort for two months”. (A) The preoperative lateral X-ray instructed a discount within the peak of the L2 vertebral physique. (B and C) Preoperative CT revealed dehiscence of the anterior center area of vertebra L2 and formation of a vacuum fissure throughout the vertebra. (D–F) Preoperative magnetic resonance imaging (MRI) confirmed that the L2 vertebral physique was a contemporary fracture. Additionally, the vacuum fissure within the vertebral physique evidenced a fluid sign. (G) An X-ray taken on the primary day after surgical procedure confirmed that the bone cement crammed the fissure in the course of the anterior vertebral physique, and that the vertebral physique peak was good. (H and I) Three months after operation, an X-ray and CT confirmed that the peak of the L2 vertebral physique was clearly much less, and the vertebral physique cement seemed to be displaced ahead. (J–L) Three months postoperatively, MRI revealed a liquid sign across the bone cement.
Earlier research have described good scientific outcomes after three-column enhanced PVP to deal with Kummell’s illness.4 Right here, we retrospectively analyze 39 such sufferers who underwent three-column enhanced PVP from April 2017 to April 2020. We (1) summarize the scientific efficacy; and, (2) focus on the operative particulars, precautions, and indications for remedy.
A complete of 39 sufferers recognized with Kummell’s illness through imaging from April 2017 to April 2020 underwent three-column enhanced PVP beneath native anesthesia. There have been 12 males and 27 females aged from 58 to 86 years (common 70.23±7.41 years). The preoperative, bone mineral density T-score measured through dual-energy X-ray absorption ranged from –2.5 to –5.5 (common –3.55 ± 0.52). The fracture websites have been: T9 1, T10 1, T11 9, T12 14, L1 11, and L2 3. After being educated concerning the process, all sufferers signed an knowledgeable consent type licensed by our native ethics committee.
Inclusion and Exclusion Standards
Inclusion standards: (1) Minor trauma (fall or pressure) adopted by ache that worsens with postural modifications, lasts for a minimum of 4 weeks on common, and results in kyphosis; (2) MRI, CT, and X-ray scan exhibiting typical “vertebral physique vacuum fissure” signal or effusion, with the posterior wall of the physique was intact; (3) age > 55 years and a bone mineral density T worth ≤ –2.5; and, (4) no apparent nerve or spinal wire compression or damage.
Exclusion standards: (1) Signs of nerve damage; (2) a malignant tumor, an an infection, metabolic bone illness, or a coagulation dysfunction; and, (3) extreme compression of the vertebral physique rendering puncture unimaginable.
All sufferers have been operated upon beneath native anesthesia and their very important indicators have been monitored. Every was positioned susceptible on a delicate pillow within the chest and iliac area and the stomach was suspended. The fracture was lowered within the hyperextension place. C-arm fluoroscopy was used to find injured vertebrae and pedicles. The medial edges of the higher and outer pedicle projection of the injured vertebra served because the puncture factors, and the needles have been slowly rotated throughout entry. When a tip attained the medial 1/3 of the pedicular anteroposterior projection, insertion ceased. The contralateral pedicle was punctured in the identical method. The lateral fluoroscopic view confirmed that the tip had attained the posterior fringe of the vertebral physique, and confirmed that the needle had not entered the spinal canal. The needle was very slowly superior alongside the route of the unique puncture; this ceased when the tip attained the anterior 1/3 of the vertebral physique (as revealed by lateral fluoroscopy). Orthopedic fluoroscopy confirmed that the tip lay between the medial facet of the vertebral pedicle and the spinous course of. The needle core was pulled out, and a 10-mL syringe linked to the top of the puncture trocar (to take away the effusion from the vertebral physique). Unformed bone cement and coagulant have been concurrently (and slowly) injected on either side throughout the elimination interval. When the vertebral physique fissure was satisfactorily crammed and cement diffusion into the injured vertebra satisfactory, the puncture needle was slowly retracted (stepwise) to the anterior fringe of the vertebral pedicle. The bone cement was pushed in slowly whereas the puncture needle was being withdrawn; injection ceased when the posterior fringe of the pedicle was attained. The bone cement was lower off by sliding it in all instructions on the fringe of the puncture trocar. This ensured that no cement remained in subcutaneous delicate tissue when the puncture trocar was pulled out. After the puncture needle was eliminated, the cement distribution within the vertebral physique and pedicle was once more confirmed to be passable, thus reinforcing the three columns. The absence of cement from subcutaneous tissue was confirmed. The puncture website was lined with a sterile dressing. After the cement was fully set, every affected person was turned over and the very important indicators checked previous to return to the ward. The puncture was strictly intra-pedicle; this route solely was used to position cement within the vertebral physique. Throughout puncture and cement injection, decrease limb sensory and motor capabilities have been intently monitored to make sure the absence of spinal wire damage or compression.
An X-ray was obtained and CT carried out 12–24 h after surgical procedure. The affected person was discharged after confirming the suitable cement location and making certain that the affected person was capable of comfortably get off the bed carrying the waist. Calcium, vitamin D3, vitamin K2, bisphosphonates, and different medication have been added to the common anti-osteoporosis remedies.
The operative time, quantity of bone cement injected, and intraoperative cement leakage have been recorded. The sufferers have been re-examined at 1 day; and at 1, 3, 6, and 12 months postoperatively. A visible analog scale (VAS, 0: no ache in any respect; 10: worst ache conceivable) was used to judge the extent of low again ache.4 The Oswestry Incapacity Index (ODI) (0%: greatest purposeful state;100%: worst purposeful state) rating was used to judge enchancment in high quality of life.7
SPSS ver. 21.0 statistical software program was used for all evaluation. Information are expressed as means ± normal deviations. One-way evaluation of variance was employed to carry out the paired-samples t-test. P < 0.05 was taken to point a statistically important distinction.
All 39 sufferers have been efficiently operated upon. The postoperative X-ray and CT confirmed that the cement was well-positioned; the imply operative time was 35.1 ± 4.7 min (vary 25–45 min). The typical quantity of cement injected was 4.5 ± 0.92 mL (vary 3.5 to six mL). There was little or no intraoperative blood loss. Intraoperative cement leakage occurred in 5 circumstances (12.8%). In two sufferers, cement infiltrated the intervertebral disc and, in three circumstances, cement entered the anterior and higher vertebral margins. No leakage into the vertebral canal was famous. There was no critical complication (nice vessel or spinal wire damage). The imply hospital keep was 2.50 ± 0.86 days (vary 2 to 4 days). A typical case is described in Determine 2.
Determine 2 Remedy of Kummell’s illness through three-column enhanced PVP. A feminine aged 85 years complained of “low again ache and discomfort for two months”. (A) The preoperative lateral X-ray instructed a discount within the peak of the T12 vertebral physique. (B and C) Preoperative CT revealed dehiscence of the anterior center area of vertebra T12 and formation of a vacuum fissure throughout the vertebra. (D–F) Preoperative MRI confirmed that the T12 vertebral physique was a contemporary fracture. Additionally, the vacuum fissure within the vertebral physique evidenced a fluid sign. (G) The affected person underwent three-column, enhanced PVP. An X-ray taken on the primary day after surgical procedure revealed that the bone cement was evenly distributed within the vertebral physique and the pedicle. (H) A postoperative plain cross-sectional CT scan confirmed that the bone cement was evenly distributed within the vertebral physique and bilateral pedicle, with out leakage into the vertebral canal. (I–Okay) A postoperative plain sagittal CT scan confirmed that the bone cement was evenly distributed within the vertebral physique and bilateral pedicle. (L) A lightweight-red clear liquid was drawn from the vertebral fissure throughout the operation.
All signs improved considerably after operation. Low again ache was alleviated; the VAS scores have been 2.91 ± 0.09, 2.04 ± 0.07, 1.59 ± 0.05, 1.28 ± 0.15, and 0.98 ± 0.18 at 1 day; and 1, 3, 6, and 12 months after operation respectively. All have been considerably higher than the 7.47 ± 0.24 rating earlier than surgical procedure (P < 0. 05) (Determine 3A). The ODI scores at 1 day; and 1, 3, 6, and 12 months after surgical procedure have been 30.08 ± 1.79, 25.35 ± 0.94, 23.19 ± 1.76, 20.49 ± 0.65, and 20.05 ± 0.58; all considerably higher than the preoperative rating of 72.97 ± 1.45 (P < 0. 05) (Determine 3B).
Determine 3 The VAS and ODI scores. (A) The VAS scores at 1 day; and 1, 3, 6 and 12 months after surgical procedure have been considerably higher than these earlier than surgical procedure. (B) The ODI scores at 1 day; and 1, 3, 6 and 12 months after surgical procedure have been considerably higher than these earlier than surgical procedure. *P < 0.05 in comparison with the preoperative scores.
We used three-column enhanced PVP to deal with Kummell’s illness. We modified the standard technique of injecting bone cement immediately into the vertebral fissure: we used the three column levels of the injured vertebra to slowly inject bone cement; this enhanced three-column fixation of the vertebral physique and the pedicle. The cement not solely subtle effectively within the vertebral physique but additionally within the bilateral pedicle, strongly anchoring the injured vertebral physique and lowering the long-term danger of cement loosening, displacement, and prolapse.
The Puncture Level
Utilizing C-arm fluoroscopic positioning, choose the internal sides of the outer higher edges of the pedicle projection because the puncture factors. The internal fringe of the left pedicle at 9 o’clock is a puncture level, as is the internal fringe of the fitting pedicle at 3 o’clock.7
Sufferers with Kummell’s illness are usually older with underlying illnesses. All sufferers accomplished surgical procedure beneath native anesthesia (1% (w/v) lidocaine hydrochloride injections across the puncture website). The anesthetists have been ready to offer midazolam sedation and propofol analgesia; this was not needed. Very important indicators have been monitored all through.
After puncture, rotate the needle slowly and keep away from extreme abduction. When the needle tip attains the internal 1/3 of the anterior pedicle projection, pause. The tip ought to have attained or handed the posterior fringe of the vertebral physique, and the puncture path presently runs completely via the bony construction of the vertebral pedicle. Creation of this channel prevents later cement leakage. Proceed to rotate the needle alongside the unique puncture route till lateral fluoroscopy reveals that the needle tip has attained the anterior 1/3 of the vertebral physique. Cease the puncture then. Frontal fluoroscopy ought to reveal that the needle tip lies between the internal fringe of the pedicle and the outer fringe of the spinous course of.
Take away the Vertebral Physique Effusion
After absorption of osteonecrotic tissue within the vertebral physique, the vacuum fissure signal kinds, and the fissure comprises fluid.3 When puncture ceases, pull out the needle and join the top of the puncture cannula to a 10-mL syringe to take away the vertebral physique fluid, which now can not have an effect on later cement dispersion and distribution.
Push Bone Cement into the Vertebra
Evenly combine bone cement and coagulant. When the cement enters the drawing section, slowly inject the puncture sleeves (either side) beneath steady fluoroscopy and withdraw the puncture sleeves.4 Right now, if a small quantity of cement leaks out of the vertebral physique, bolus injection must be suspended. Underneath steady fluoroscopy, slowly pull again the puncture sleeve, and step by step push it in once more when the cement turns into extra viscous and injection resistance will increase. This can cut back leakage.
Intrapedicular Cement Injection
When the vertebral physique fissure is crammed and cement diffusion throughout the vertebra is passable, transfer the puncture needle slowly backward into the vertebral pedicle whereas slowly injecting cement. Monitor the sensory and motor standing of the decrease limbs. At this level, the cement must be linearly distributed alongside the puncture route. Cease injecting when the posterior fringe of the pedicle is attained. If the cement reveals apparent diffusion to the highest or backside of the pedicle, the potential for leakage into or out of the pedicle must be thought-about and injection ought to stop. Use the sting of the puncture cannula to slip and lower the cement in all instructions to make sure that no cement stays within the subcutaneous tissue. After the needle is eliminated, re-confirm that the cement distribution within the vertebral physique and pedicle is passable, and that enhanced three-pillar fixation is clear. Re-confirm the absence of cement in subcutaneous tissue.
Benefits of the Three-Column Enhanced PVP Know-how
The three-column enhanced PVP approach with stable cement fixation reduces the dangers of cement loosening, displacement, and prolapse that aren’t unusual after conventional PVP and PKP.1 The extent of trauma is low, restoration fast, nursing simple, and the associated fee low. There isn’t any want for bone graft fusion through pedicle screw inner fixation. The choice strategies are related to appreciable trauma, results on spinal exercise and different situations, inconvenient nursing, and excessive price.8,9,11
Disadvantages of the Three-Column Enhanced PVP Know-how
Given the fast solidification of cement in vivo, the a number of operative steps, and the slim time window, fixed fluoroscopy is required throughout cement injection. As cement is injected, the puncture sleeve is pushed again, growing the radiation dose to the operator and affected person. If injection is just too sluggish, pedicle strengthening is probably not achieved earlier than the cement units. The three-column enhancement approach requires very high-quality puncture and injection, and have to be carried out by a surgeon skilled in percutaneous puncture vertebroplasty. Inexperienced surgeons shouldn’t use the approach.4
Problems of the Three-Column Strengthening Method and Their Prevention
Leakage of Bone Cement Exterior the Vertebral Physique
Most websites of extracorporeal vertebral leakage develop on the anterior fringe of the vertebral physique within the route of the higher endplate. When the cement enters the wire drawing stage, some cement is slowly pushed to either side beneath steady fluoroscopy.4 Early cement injection is related to good dispersion, anchoring the fracture finish and sealing the fracture hole. Underneath steady fluoroscopy, the puncture sleeve is slowly pushed again. Because the cement step by step thickens, the injection resistance will increase and the sleeve is step by step pushed again into the vertebral physique. Gradual, staged, and fluoroscopically guided downthrust injection reduces the chance of cement leakage from the vertebral physique.
Bone Cement Leakage into the Spinal Canal
Preoperative CT of the vertebral physique was carried out to substantiate that the bony construction of the pedicle was intact. Throughout operation, the bone of the vertebral pedicle was meticulously punctured, establishing a channel to stop later leakage of bone cement. Extreme abduction must be prevented after needle insertion on the puncture level. When the tip attains the medial 1/3 of the pedicular anteroposterior projection, lateral fluoroscopy is carried out to substantiate that the tip has reached or crossed the posterior fringe of the vertebral physique. If important cement is dispersed on and/or beneath the bony pathway of the pedicle puncture, the potential for leakage into or out of the pedicle must be thought-about and injection must be terminated.
Indications for the Three-Column Enhancement Method
Sufferers with Kummell’s illness of pathological levels I and II could also be handled utilizing this process. Stage III sufferers exhibit extreme collapse of the vertebral physique posterior wall, leading to compression of the spinal wire or nerve roots. The process isn’t then really useful; sufferers could be handled through decompression and inner fixation.10,12 The three-column enhanced PVP approach isn’t really useful for sufferers with widespread osteoporotic vertebral compression fractures.
In conclusion, three-column enhanced PVP remedy of Kummell’s illness is characterised by much less surgical trauma and quicker restoration than different strategies, and agency fixation with bone cement. The tactic reduces the chance of cement loosening, displacement, and prolapse after conventional PVP and PKP, and can be utilized to deal with Kummell’s illness successfully, particularly sufferers of pathological levels I and II. Nonetheless, there’s a danger of bone cement leakage into the spinal canal. To keep away from cement leakage from the pedicle, transpedicular puncture have to be meticulously carried out when establishing a bone puncture channel.
Ethics Approval and Consent to Take part
This examine was carried out in settlement with the Ethics Committee of Second Affiliated Hospital of Luohe Medical School. All contributors had supplied a written knowledgeable consent. This examine follows the Declaration of Helsinki, in addition to native and nationwide laws.
The authors thank sufferers and their households for his or her participation within the examine, and colleagues similar to LP, HXW, and WGL for his or her suggestions on the examine.
All authors made a major contribution to the work reported, whether or not that’s within the conception, examine design, execution, acquisition of information, evaluation and interpretation, or in all these areas; took half in drafting, revising or critically reviewing the article; gave ultimate approval of the model to be revealed; have agreed on the journal to which the article has been submitted; and conform to be accountable for all features of the work.
This work was supported by Key Scientific Analysis Tasks of Universities in Henan Province (21B320004), Joint Co-construction Undertaking of Henan Medical Science and Know-how Analysis Plan (LHGJ20200887), Luohe Youth Skills Fund of China (2018QNBJRC01004), and Luohe Medical School Innovation and Entrepreneurship Promotion Undertaking (2019-LYZKYZD004 & 2019-LYZKYYB016).
The authors declare that they haven’t any conflicts of curiosity on this work.
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