Microsurgical interlaminary vertebro- and kyphoplasty for severe osteoporotic fractures

Abstract

<jats:p content-type="fine-print"><jats:italic>Object.</jats:italic> 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.</jats:p> <jats:p content-type="fine-print"><jats:italic>Methods.</jats:italic> 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.</jats:p> <jats:p content-type="fine-print"><jats:italic>Conclusions.</jats:italic> 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.</jats:p>

Surgical patterns in osteoporotic vertebral compression fractures

“…The small case series of Singh et al [12], shows good results following limited decompression and open VP/KP, at a short follow-up of 44 weeks. Boszczyk et al [13] showed similar results with interlaminar decompression and thecal sac mobilization, followed by VP/KP. In contrast to above, our series has 10 patients, with OVCF nonunion and significant spinal canal stenosis at thoracolumbar junction (cord level), who showed significantly improved clinical outcome at a longer follow-up of 38 months (Fig.…”

Percutaneous vertebroplasty for osteoporotic vertebral compression fracture with intravertebral cleft associated with delayed neurologic deficit

“…This cement augmentation technique produces excellent outcomes in [85 % of patients treated [14]. However, percutaneous vertebroplasty for OVCF with IVC with DND may have been considered relatively contraindicated because of the possibility of neural complications induced by epidural cement leakage [4,10,14]. No definitive treatment of OVCF with IVC with DND has yet been established.…”

Intra-Operative Vertebroplasty Combined with Posterior Cord Decompression

“…Boszczyk et al 16 described the injection of cement into the vertebral body directly through the posterior wall in 34 vertebrae of 24 patients during the application of a microsurgical approach in osteoporotic burst fractures with neurological involvement. The operator appears to be more confident with a trans-somatic access because the cement diffusion into the vertebral body is more easily controlled, while a trans-pedicular access might appear slightly more difficult also considering that Table 1 Summary of all patients who underwent intra-operative vertebroplasty.…”