Rene Orler

Kyphoplasty for treatment of osteoporotic vertebral fractures: a prospective non-randomized study.

BackgroundMinimally invasive augmentation techniques of vertebral bodies have been advocated to treat osteoporotic vertebral body compression fractures (VBCFs). Kyphoplasty is designed to address both fracture-related pain as well as kyphotic deformity usually associated with fracture. Previous studies have indicated the potential of this technique for reduction of vertebral body height, but there has been little investigation into whether this has a lasting effect. The current study reports on our experience and the one-year results in 27 kyphoplasty procedures (24 patients) for osteoporotic VBCFs.ResultsAll but one patient experienced pain relief following the procedure (on VAS 1–10)—with a lasting effect over the follow-up period in 25 cases. An average vertebral kyphosis reduction of 47.7% was achieved with no loss of reduction after one year. The potential for reduction was statistically related to the pre-operative amount of kyphosis, the level treated, and the age of the fracture, but not to the age of the patient. During follow-up, one fracture adjacent to a treated level was observed. Pain relief was not related to the amount of reduction.ConclusionKyphoplasty is an effective treatment of VBCFs in terms of pain relief and durable reduction of deformity. Whether spinal realignment results in an improved long-term clinical outcome remains to be investigated.

Kyphoplasty for treatment of osteoporotic vertebral fractures

Cement reinforcement for the treatment of osteoporotic vertebral fractures is efficient mean with high success in pain release and prevention of further sintering of the reinforced vertebrae; however, the technique does not allow to address the kyphotic deformity. Kyphoplasty was designed to address the kyphotic deformity and help to realign the spine. It involves the percutaneous placement of an inflatable bone tamp into a vertebral body. Restoration of VB height and kyphosis correction is achieved by inflation of the bone tamp with liquid. After deflation, a cavity is created that eases the cement application. The potential of kyphosis reduction is given in fresh fractures with a range of 0–90% for height restoration and absolute correction of the kyphotic angle of 8.5°. The cavity formation, on one hand, and the different cementing technique leads to lower risk for cement extravasation. An alternative method for kyphosis correction represents the so-called lordoplasty where the adjacent vertebrae are reinforced first and with the cannulas in place acting as a lever the reduction of the collapsed vertebra can be performed. The results with respect to kyphosis correction are superior in comparison with a kyphoplasty procedure.

Radiation exposure to the surgeon during fluoroscopically assisted percutaneous vertebroplasty: a prospective study

Study Design. A prospective case control study design was conducted. Objectives. The purpose of the current study was to determine the intraoperative radiation hazard to spine surgeons by occupational radiation exposure during percutaneous vertebroplasty and possible consequences with respect to radiation protection. Summary of Background Data. The development of minimally invasive surgery techniques has led to an increasing number of fluoroscopically guided procedures being done percutaneously such as vertebroplasty, which is the percutaneous cement augmentation of vertebral bodies. Methods. Three months of occupational dose data for two spine surgeons was evaluated measuring the radiation doses to the thyroid gland, the upper extremities, and the eyes during vertebroplasty. Results. The annual risk of developing a fatal cancer of the thyroid is 0.0025%, which means a very small to small risk. The annual morbidity (the risk of developing a cancer including nonfatal ones) is 0.025%, which already means a small to medium risk. The dose for the eye lens was about 8% of the threshold dose to develop a radiation induced cataract (150 mSv); therefore, the risk is very low but not negligible. The doses measured for the skin are 10% of the annual effective dose limit (500 mSv) recommended by the ICRP (International Commission on Radiologic Protection); therefore, the annual risk for developing a fatal skin cancer is very low. Conclusion. While performing percutaneous vertebroplasty, the surgeon is exposed to a significant amount of radiation. Proper surgical technique and shielding devices to decrease potentially high morbidity are mandatory. Training in radiation protection should be an integral part of the education for all surgeons using minimally invasive radiologic-guided interventional techniques.

Lordoplasty: report on early results with a new technique for the treatment of vertebral compression fractures to restore the lordosis

Cement augmentation using PMMA cement is known as an efficient treatment for osteoporotic vertebral compression fractures with a rapid release of pain in most patients and prevention of an ongoing kyphotic deformity of the vertebrae treated. However, after a vertebroplasty there is no chance to restore vertebral height. Using the technique of kyphoplasty a certain restoration of vertebral body height can be achieved. But there is a limitation of recovery due to loss of correction when deflating the kyphoplastic ballon and before injecting the cement. In addition, the instruments used are quite expensive. Lordoplasty is another technique to restore kyphosis by indirect fracture reduction as it is used with an internal fixateur. The fractured and the adjacent vertebrae are instrumented with bone cannulas bipediculary and the adjacent vertebrae are augmentated with cement. After curing of the cement the fractured vertebra is reduced by applying a lordotic moment via the cannulas. While maintaining the pretension the fractured vertebra is reinforced. We performed a prospective trial of 26 patients with a lordoplastic procedure. There was a pain relief of about 87% and a significant decrease in VAS value from 7.3 to 1.9. Due to lordoplasty there was a significant and permanent correction in vertebral and segmental kyphotic angle about 15.2° and 10.0°, respectively and also a significant restoration in anterior and mid vertebral height. Lordoplasty is a minimal invasive technique to restore vertebral body height. An immediate relief of pain is achieved in most patients. The procedure is safe and cost effective.

Minimal-invasive percutaneous reduction and transsacral screw fixation for U-shaped fractures.

Study Design: Technical note and case series. Objective: To introduce an innovative minimal-invasive surgical procedure reducing surgery time and blood loss in management of U-shaped sacrum fractures. Summary of Background: Despite their seldom appearance, U-shaped fractures can cause severe neurological deficits and surgical management difficulties. According to the nature of the injury normally occurring in multi-injured patients after a fall from height, a jump, or road traffic accident, U-shaped fractures create a spinopelvic dissociation and hence are highly unstable. In the past, time-consuming open procedures like large posterior constructs or shortening osteotomies with or without decompression were the method of choice, sacrificing spinal mobility. Insufficient restoration of sacrococcygeal angle and pelvic incidence with conventional techniques may have adverse long-term effects in these patients. Methods: In a consecutive series of 3 patients, percutaneous reduction of the fracture with Schanz pins inserted in either the pedicles of L5 or the S1 body and the posterior superior iliac crest was achieved. The Schanz pins act as lever, allowing a good manipulation of the fracture. The reduction is secured by a temporary external fixator to permit optimal restoration of pelvic incidence and sacral kyphosis. Insertion of 2 transsacral screws allow fixation of the restored spinopelvic alignment. Results: Anatomic alignment of the sacrum was possible in each case. Surgery time ranged from 90 to 155 minutes and the blood loss was <50 mL in all 3 cases. Two patients had very good results in the long term regarding maintenance of pelvic incidence and sacrococcygeal angle. One patient with previous cauda equina decompression had loss of correction after 6 months. Conclusions: Percutaneous reduction and transsacral screw fixation offers a less invasive method for treating U-shaped fractures. This can be advantageous in treatment of patients with multiple injuries.

Monostotic fibrous dysplasia of the spine: report of a case involving a cervical vertebra

Monostotic fibrous dysplasia of the spine is a rare entity. Only 26 cases, of which 11 were located in the cervical spine, are to be found in the literature. We report a 56-year-old male patient with cervicobrachialgia of half year’s duration. Radiographs showed a diffuse destruction of the vertebral body and the spinous process of C4. A biopsy of the spinous process confirmed histopathologically a fibrous dysplasia. Due to minor symptoms, no surgical treatment was performed or is planned unless in case of increasing pain, an acute instability or neurological symptoms.

Autologous blood donation in total knee arthroplasties is not necessary

BACKGROUND This study intends to prove the hypothesis that preoperative autologous blood donation in total knee arthroplasties (TKA) is dispensable. PATIENTS AND METHODS The study comprises a prospective analysis of 81 consecutive TKA without preoperative autologous blood donation (AB-donation). Guidelines for blood retransfusion were used. Surgery, as well as the pre- and postoperative procedures were identical for each patient. In the analysis of the data, the consecutive TKAs were divided into patients who were eligible for preoperative autologous blood donation (group 1, n = 46) and those with relevant risk factors not permitting preoperative autologous blood donation (group 2, n = 35). RESULTS None of the patients in group 1 needed a blood transfusion. 14 of 35 patients in group 2 needed an allogenic blood transfusion. INTERPRETATION Total knee arthroplasty can be managed without preoperative AB-donation if it is performed using a tourniquet, if a postoperative collection and direct retransfusion system is used for the wound blood, and if the transfusion algorithm is defined according to compulsory and practical guidelines.

The external fixator: a tool for evaluation of complex low back pain problems.

Background The selection of patients with low back pain for fusion is especially difficult when previous surgical interventions failed and/or invasive tests (discograms, facet blocks) do not allow or do not clearly identify the painful motion segment. Test fixation with an external fixator may mimic a definite internal fixation, such as a fusion, and may help select patients for a more favorable result. The purpose of the study was to clarify if temporary back pain relief by external fixation is predictive for back pain relief after final internal fixation and fusion. Methods A retrospective study of 63 patients up to 6 years after evaluation of low back pain problems with an external fixator (index operation) was conducted. The data were collected from the charts based on a protocol that patients had to fill in during evaluation, and the actual state was checked during a clinical investigation at the outpatient clinic. The protocol monitored pain (Visual Analog Scale), pain medication, and work status. Based on the first two parameters, the effect of external fixation was defined as a general estimation as positive, doubtful, or negative. The same parameters were reassessed at follow-up control. Results In 38 patients, the immobilization test did improve the pain situation, in 11 it remained unchanged, and in 14 the pain got worse. Thirty-eight patients (not identical with the above) underwent definitive fusion afterward, whereas 25 were not operated on. Twenty-one of 30 patients with a positive effect undergoing surgery showed an improved situation after fusion, and 8 of 22 patients without further operation were improved at follow-up. Nine of 12 patients with a negative immobilization test did stay in a bad situation at follow-up. Conclusion The external fixator as a tool for evaluation of patients with low back pain is an expensive measure with a considerable complication risk and only justified in selected patients when any other measure fails to assess and evaluate a patients situation. If the test fixation reveals no benefit, the patients will remain in a bad situation whatever the therapeutic measure will be. Therefore the main value of the external fixator assessment is the selection of these patients that should not undergo surgery. A positive test fixation means a 72% chance for a satisfactory outcome at least two years after surgery, whereas without surgery the chance for some spontaneous improvement is 57% if the test immobilization did show some improvement. With respect of the “negative” selection of this group of patients (complex history, previous interventions) in our as well as in others series, the obtained results seem acceptable and the use of this invasive diagnostic measure in this group of patients seems justified. Statistical analysis did not show differences of significance as the numbers in the individual groups was too small.

Balloon Kyphoplasty and Lordoplasty

The expected increase in the elderly population over the next decades will present major challenges for the health care systems in Western countries. Maladies of the musculoskeletal system represent the second or third most important burden of disease, and osteoporosis and osteoporotic fractures are the leading causes of disability among the elderly (1). The fracture incidence increases exponentially as patient age increases (2,3). The spine is the most commonly affected site of osteoporotic fractures. At the age of 75 years, about 25% of all women have at least one fractured vertebra. By the age of 80 years this percentage grows to 50% (4).

Alternative methods to kyphoplasty: vertebroplasty — lordoplasty

Percutaneous cement augmentation (vertebroplasty) was used for the first time in the 1980s, primarily for treatment of vertebral hemangioma [Galibert 1987]. It was only in the middle of the 1990s that it was used for treatment of metastases and increasingly for osteoporotic fractures of the spine [Cotten 1996; Weill 1996; Jensen 1997; Cortet 1999; Heini 2000]. In the meantime, this method has become established for treatment of painful osteoporotic fractures and for tumorous osteolysis of the spine. The clinical success rate is very high, with rapid pain relief in 70–90% of treated patients [Legroux-Gerot 2004; Zoarski 2002; Peh 2002; Barr 2000].