Object. Percutaneous vertebro- and kyphoplasty have become established methods for the treatment of uncomplicated osteoporotic vertebral fractures. In the setting of severe fractures involving fragmentation of the posterior wall and neural compromise, however, decompressive surgery cannot be performed and epidural cement leakage is poorly controlled. A microsurgical interlaminary approach for vertebro- and kyphoplasty was developed to allow spinal decompression and control of the spinal canal during augmentation.Methods. Interlaminary vertebro- or kyphoplasty was performed in 24 patients with osteoporotic fractures involving neural compression or posterior wall fragmentation. After unilateral microsurgical fenestration, decompression of the spine, and gentle mobilization of the thecal sac, vertebro- or kyphoplasty was performed directly through the posterior wall of the fractured vertebral body. Cement was injected under microscopic and fluoroscopic control, with the option of immediate exploration of the exposed spinal canal. Thirty-four levels (T-8 to L-5) were treated. Mean blood loss was less than 100 ml and augmentation added 10 to 40 minutes to the entire procedure. Cement leakage associated with the kyphoplasty procedure was less than that in vertebroplasty. There were no major complications. One patient was lost to follow up. Clinical outcome was good or excellent in 17 of the 23 patients available for follow-up (1 to 31—month) evaluation.Conclusions. The present microsurgical interlaminary approach for vertebro- and kyphoplasty enables treatment of severe osteoporotic fractures involving fragmentation of the posterior wall and neural compromise. Decompressive surgery is possible and the risk of epidural cement leakage is controlled intraoperatively. This technique can be regarded as a procedure on the treatment continuum between percutaneous augmentation and conventional open reconstruction.
Spondylitis is a rare complication of vertebroplasty. In the presented case a satisfactory result could be achieved through conservative antibiotic therapy and restriction of movement.
Kyphoplasty is a young method which was developed for the minimally invasive augmentation of osteoporotic vertebral fractures. In contrast to vertebroplasty, the kyphoplasty technique allows an age-dependent fracture reduction through the inflation of a special balloon in the fractured cancellous bone of the vertebral body. The cancellous bone of the fracture zone is compressed by the balloon, so that a cavity remains in the vertebral body after removing the balloon, which is filled with highly viscous augmentation material. The reduced risk of serious complications, for example epidural leakage of augmentation material, justifies progressively expanding the indications for this technique to traumatic fractures with involvement of the posterior vertebral wall and neoplastic vertebral collapse due to osteolytic metastasis. Besides the indications for the conventional percutaneous approaches, the microsurgical interlaminary approach allows the use of kyphoplasty in more complex fractures involving compression of the neural structures. Kyphoplasty induces swift pain relief and allows rapid mobilisation of patients due to the immediate stabilisation of the affected vertebral bodies. Apart from the operative intervention, the medical treatment of the primary disease and the rehabilitation of the individual patient should be optimised through an interdisciplinary approach.
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