Vivek P. Kushwaha

Thoracolumbar Burst Fractures Treated with Posterior Decompression and Pedicle Screw Instrumentation Supplemented with Balloon-Assisted Vertebroplasty and Calcium Phosphate Reconstruction

BACKGROUND The treatment of unstable thoracolumbar burst fractures with short-segment posterior spinal instrumentation without anterior column reconstruction is associated with a high rate of screw breakage and progressive loss of reduction. The purpose of the present study was to evaluate the functional, neurologic, and radiographic results following transpedicular, balloon-assisted fracture reduction with anterior column reconstruction with use of calcium phosphate bone cement combined with short-segment posterior instrumentation and a laminectomy. METHODS A consecutive series of thirty-eight patients with an unstable thoracolumbar burst fracture with or without neurologic deficit were managed with transpedicular, balloon-assisted fracture reduction, calcium phosphate bone cement reconstruction, and short-segment spinal instrumentation from 2002 to 2005. Twenty-eight of the thirty-eight patients were followed for a minimum of two years. Demographic data, neurologic function, segmental kyphosis, the fracture severity score, canal compromise, the Short Form-36 score, the Oswestry Disability Index score, and treatment-related complications were evaluated prospectively. RESULTS All thirteen patients with incomplete neurologic deficits had improvement by at least one Frankel grade. The mean kyphotic angulation improved from 17 degrees preoperatively to 7 degrees at the time of the latest follow-up, and the loss of vertebral body height improved from a mean of 42% preoperatively to 14% at the time of the latest follow-up. Screw breakage occurred in two patients, and pseudarthrosis occurred in one patient. CONCLUSIONS The present study demonstrates that excellent reduction of unstable thoracolumbar burst fractures with and without associated neurologic deficits can be maintained with use of short-segment instrumentation and a transpedicular balloon-assisted reduction combined with anterior column reconstruction with calcium phosphate bone cement performed through a single posterior incision. The resultant circumferential stabilization combined with a decompressive laminectomy led to maintained or improved neurologic function in all patients with neurologic deficits, with a low rate of instrumentation failure and loss of correction.

Vertebral height restoration after kyphoplasty

Abstract Purpose of study: Previous kyphoplasty studies have shown good results in acute and subacute fractures, with regard to restoration of height and pain relief. The purpose of our study was to evaluate the effectiveness of kyphoplasty in older fractures compared with recent fractures, specifically as regard to height restoration. Methods used: Kyphoplasty was performed in 131 fractured vertebra in 85 patients. Indications for surgery were painful pathologic compression fractures. All surgeries were performed by the primary author. Seventy-nine patients had general anesthesia, and six had local. The patients were evaluated preoperatively with plain film, computed tomography or magnetic resonance imaging and evaluated postoperatively with plain film. Vertebral body height was measured preoperatively by obtaining a ratio of the fractured vertebra to the next available intact vertebra. This ratio was then recalculated postoperatively, and any height increase was measured and expressed as a percentage. The patients were divided in four groups, those with acute fractures (less than 1 month), subacute (1 to 3 months), established (3 to 6 months) or chronic (greater than 6 months). Clinical results were evaluated by monitoring of pain medication usage and visual analog scale pain ratings by the patients. of findings: A total of 131 fractured vertebra were treated in 85 patients. The average age was 72 years. Seventy-nine patients had a diagnosis of primary or secondary osteoporosis, four had multiple myeloma and two had metastatic cancer. Twenty fractures were acute, 32 were subacute, 18 were established and 51 were chronic. One patient has postoperative pneumonia. Thirteen patients had asymptomatic extravasation of methylmethacrylate. The 20 acute fractures had average increase in height of 39%, the subacute group had an increase of 35.4%, the established group had an increase of 54.7% and the chronic group had an increase of 30.8%. Only the established groups increase was found to be statistically significant compared with the others. Ten patients preoperatively required high-dose narcotics (morphine). Eight of these were completely off pain medication after the surgery, and two others required low-level narcotics (propoxyphene). Seventy-five patients went from an average of seven pain pills a day to less than one a day. No differences were found in results among the four groups. Pain was related as an average of 9.1 before the surgery and decreased to an average of 1.2 after the surgery. No differences were found among the four groups with regard to pain relief. Relationship between findings and existing knowledge: Previous studies have found kyphoplasty to be a safe and effective procedure for both pain relief and height restoration, especially for fractures less than 3 months in duration. We have compared results in patients with acute (less than 1 month), subacute (1 to 3 months), established (3 to 6 months) and chronic (greater than 6 months) fractures. Our evaluation has shown that not only can pain relief occur in older fractures, but that height restoration is possible in older fractures as well. Overall significance of findings: Kyphoplasty is effective for pain relief and height restoration in even older fractures. These findings suggest age of a fracture alone is not a contraindication to kyphoplasty. Quality of the bone and healing status are parameters involved in height restoration that are independent of time. Kyphoplasty of older fractures should be considered if, based on the physical examination, they are symptomatic. Disclosures: Device or drug: Kyphon balloon. Status: approved. Device or drug: methylmethacrylate. Status: not approved. Conflict of interest: Vivek Kushwaha, speakers bureau.