Osteoporosis surgery: Difference between revisions
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==== Indications ==== | ==== Indications ==== | ||
Indication for | Indication for vertebroplasty for osteoporosis include osteoporotic patients refractory to medical therapy, encountering vertebral fracture. | ||
==== Contraindications ==== | ==== Contraindications ==== | ||
* Absolute contraindications for | * Absolute contraindications for vertebroplasty for osteoporosis include asymptomatic vertebral fractures and patients with reasonable response to medical therapy, as well as severe coagulopathies or any ongoing local/systemic infection. However, any allergy to the cement or any other materials that may used during the operation are included, too.<ref name="pmid215001312">{{cite journal |vauthors=Hargunani R, Le Corroller T, Khashoggi K, Murphy KJ, Munk PL |title=Percutaneous vertebral augmentation: the status of vertebroplasty and current controversies |journal=Semin Musculoskelet Radiol |volume=15 |issue=2 |pages=117–24 |year=2011 |pmid=21500131 |doi=10.1055/s-0031-1275594 |url=}}</ref> | ||
* Relative contraindications for | * Relative contraindications for vertebroplasty for osteoporosis include some fracture or defect in posterior aspect of vertebral body and also tumor extension into spinal canal. In case of vertebra plana, a complication of osteoporosis that the height of vertebral body become to one third of its origin, the vertebroplasty procedure is characterized as relative contraindicated; in which high rates of complications may occurred.<ref name="pmid215001312" /> | ||
==== Complications ==== | ==== Complications ==== | ||
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=== Kyphoplasty === | === Kyphoplasty === | ||
If the osteoporotic patients referred within 3 months from vertebral fracture, it would be possible to cure the resulted kyphosis completely through balloon kyphoplasty. The procedure is in fact an adjunctive method for vertebroplasty, in which initially a balloon is used to inflate the fractured vertebra; then, larger amount of bone cement is applied there to meet the original vertebral height and lesser amount of cement extravasation. Generally, kyphoplasty result in favorable outcomes and osteoporotic patients can go back to normal life.<ref name="pmid24462536">{{cite journal |vauthors=Lee JH, Lee DO, Lee JH, Lee HS |title=Comparison of radiological and clinical results of balloon kyphoplasty according to anterior height loss in the osteoporotic vertebral fracture |journal=Spine J |volume=14 |issue=10 |pages=2281–9 |year=2014 |pmid=24462536 |doi=10.1016/j.spinee.2014.01.028 |url=}}</ref> | |||
==== Indications ==== | |||
Indication for kyphoplasty for osteoporosis include pain control in osteoporotic patients or vertebral tumors refractory to medical therapy, encountering vertebral fracture.<ref name="pmid27072339" /> | |||
==== Contraindications ==== | |||
Contraindications for kyphoplasty for osteoporosis include infection, coagualtion disorders, allergy to bone cement or any other material that may used during the operation, and also any anatomical variations that would disturb the normal rout of surgery, such as posterior vertebral cortical bone fusion and retroverted fragments.<ref name="pmid27072339" /> | |||
=== Lordoplasty === | |||
The most cost effective procedure to alleviate the compress fractures in vertebrae is lordoplasty. The procedure is commonly done following kyphoplasty, when the balloon become deflated and the vertebra is ready to inject cement in. This procedure often used as vertebroplasty alternative as more cost effective. This procedure, however, may correct the kyphotic angle of spinal column 11 to 13 degrees, leading to significant pain relief in 90% of patients.<ref name="pmid26895528">{{cite journal |vauthors=Hoppe S, Budmiger M, Bissig P, Aghayev E, Benneker LM |title=Lordoplasty: midterm outcome of an alternative augmentation technique for vertebral fractures |journal=J Neurosurg Spine |volume=24 |issue=6 |pages=922–7 |year=2016 |pmid=26895528 |doi=10.3171/2015.10.SPINE151016 |url=}}</ref> Lordoplasty has a much better 3 months outcome than kyphoplasty, especially in postural and anatomical deviations.<ref name="pmid21165313">{{cite journal |vauthors=Kim SB, Jeon TS, Lee WS, Roh JY, Kim JY, Park WK |title=Comparison of kyphoplasty and lordoplasty in the treatment of osteoporotic vertebral compression fracture |journal=Asian Spine J |volume=4 |issue=2 |pages=102–8 |year=2010 |pmid=21165313 |pmc=2996621 |doi=10.4184/asj.2010.4.2.102 |url=}}</ref> | |||
The procedure consists of applying 6 cannulas , each of them has 2 pedicles, for any single fracture site in vertebrae. On the other hand, the intact cranial and caudal vertebrae are injected with denser cement to be introduced and strengthened with canullas that have 4 pedicles. Then, with support of cranial and caudal vertebrae, the kyphotic osteoporotic vertebra could be pushed toward the lordosis and rearranged in normal position. All vertebral positions are allied by use of a cross bolt, while 2 cannulas in fracture site deliver the PMMA cement to the collapsed vertebra; been left to cement become hard. Finally, cannulas are replaced from the site.<ref name="pmid21629479">{{cite journal| author=Jeon TS, Kim SB, Park WK| title=Lordoplasty: an alternative technique for the treatment of osteoporotic compression fracture. | journal=Clin Orthop Surg | year= 2011 | volume= 3 | issue= 2 | pages= 161-6 | pmid=21629479 | doi=10.4055/cios.2011.3.2.161 | pmc=3095789 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21629479 }}</ref> | |||
==== Complications ==== | |||
Regarding that 6 cannulas are introduced in vertebrae, the most important complication of lordoplasty may be cement leakage. The cement high viscosity and wide cannulas used to inject the cement are the solutions for the problems. | |||
=== Vesselplasty === | === Vesselplasty === | ||
This procedure is based on pre-injection of some "porous" material, polyethylene terephthalate, in the site of osteoporotic vertebrae fracture. The main purpose is to prepare some hollow container in place that the cement is about to injected in; therefore, the cement goes through the vertebral bodies much deeper and leak back from there so much lesser than kyphoplasty or lordoplasty. The concluded vertebrae will be more stable and have less height loss during the time.<ref name="pmid19542417">{{cite journal| author=Flors L, Lonjedo E, Leiva-Salinas C, Martí-Bonmatí L, Martínez-Rodrigo JJ, López-Pérez E et al.| title=Vesselplasty: a new technical approach to treat symptomatic vertebral compression fractures. | journal=AJR Am J Roentgenol | year= 2009 | volume= 193 | issue= 1 | pages= 218-26 | pmid=19542417 | doi=10.2214/AJR.08.1503 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19542417 }}</ref> | |||
* Hip fractures are treated by open reduction and internal fixation. | * Hip fractures are treated by open reduction and internal fixation. | ||
* Some patients with a hip fracture who are at high risk for another fracture, may benefit from a total hip replacement. | * Some patients with a hip fracture who are at high risk for another fracture, may benefit from a total hip replacement. | ||
Revision as of 21:55, 10 August 2017
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Osteoporosis surgery On the Web |
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American Roentgen Ray Society Images of Osteoporosis surgery |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2], Raviteja Guddeti, M.B.B.S. [3], Charmaine Patel, M.D. [4]
Overview
Surgical management is employed for fractures caused by osteoporosis. Vertebroplasty and kyphoplasty are used to treat patients with vertebral compression fractures. For fractures of the hip, the surgical method used is called open reduction and internal fixation, or ORIF.
Osteoporosis surgery
- Surgery is not the first-line treatment option for patients with osteoporosis. Osteoporosis is usually reserved for patients with either vertebral or hip fracture in patients, refractory to medical therapy. Surgery options for osteoporosis are very limited.
Vertebroplasty
The procedure was first performed in 1984 by Galibert and Deramond, French neurosurgeons, in order to treat aggressive hemangioma in C2 vertebra. It had very satisfying outcome. The success of this procedure in a favorable way was lead to extend its usage to other destructive bone diseases, such as multiple myeloma, metastatic bone tumors, and also after a while in 1989, its usage for treatment of osteoporotic vertebral fractures was proven.[1]
In any patients that are refractory to long term medical therapy and encountering vertebral compression fracture, vertebroplasty would be a good option. Vertebroplasty is a minimally invasive surgery that is an image-guided by fluoroscopy assistance. In this method some bone cement (mostly polymethylmethacrylate (PMMA)) is injected in the body of vertebra that been fractured. This procedure may lead to improve stability of fractured vertebra, take it back to the normal shape. PMMA injection is done under precise fluoroscopic observation to prevent any leakage of cement into spinal canal. The most important advantages of the vertebroplasty procedure are minimal invasion rather than other open surgical methods, and rapid symptomatic relief compare to other medical treatments.[2]
Vertebroplasty may cause rapid response in patients with osteoporosis. The patients may experience immediate pain and discomfort relief, along with gradual correction of stooped spine (kyphosis) that is occurred because of compression fracture in anterior aspect of vertebrae. The main risk for the procedure is that sometimes the cement injection may compromise the foraminal spaces, leading to radicaular pains.[3]
The mechanism of lowering pain in osteoporotic patients following vertebroplasty is not clear completely. Some of the proposed theories are include correcting micro-fractures, along with vascular, chemical, and also thermal factors. It is assumed that either temperature properties of injected cement destroys pain receptors, or compression effect of the cement crushed the nerve endings in situ.[4]
Whereas, in 2009, Kallmes have found that rapid pain relief and symptomatic cure in osteoporotic patients with vertebral compression fracture are not significantly different from control group.[5]
Indications
Indication for vertebroplasty for osteoporosis include osteoporotic patients refractory to medical therapy, encountering vertebral fracture.
Contraindications
- Absolute contraindications for vertebroplasty for osteoporosis include asymptomatic vertebral fractures and patients with reasonable response to medical therapy, as well as severe coagulopathies or any ongoing local/systemic infection. However, any allergy to the cement or any other materials that may used during the operation are included, too.[6]
- Relative contraindications for vertebroplasty for osteoporosis include some fracture or defect in posterior aspect of vertebral body and also tumor extension into spinal canal. In case of vertebra plana, a complication of osteoporosis that the height of vertebral body become to one third of its origin, the vertebroplasty procedure is characterized as relative contraindicated; in which high rates of complications may occurred.[6]
Complications
Potential complications of vertebroplasty for osteoporotic surgical treatment are include cement leakage into other spaces (e.g., paraspinal, intradiskal, and etc.), compression destruction of nerve roots due to cement leakage, pulmonary embolism, cardiac perforation, and adjacent vertebrae fracture.[7]
Kyphoplasty
If the osteoporotic patients referred within 3 months from vertebral fracture, it would be possible to cure the resulted kyphosis completely through balloon kyphoplasty. The procedure is in fact an adjunctive method for vertebroplasty, in which initially a balloon is used to inflate the fractured vertebra; then, larger amount of bone cement is applied there to meet the original vertebral height and lesser amount of cement extravasation. Generally, kyphoplasty result in favorable outcomes and osteoporotic patients can go back to normal life.[8]
Indications
Indication for kyphoplasty for osteoporosis include pain control in osteoporotic patients or vertebral tumors refractory to medical therapy, encountering vertebral fracture.[3]
Contraindications
Contraindications for kyphoplasty for osteoporosis include infection, coagualtion disorders, allergy to bone cement or any other material that may used during the operation, and also any anatomical variations that would disturb the normal rout of surgery, such as posterior vertebral cortical bone fusion and retroverted fragments.[3]
Lordoplasty
The most cost effective procedure to alleviate the compress fractures in vertebrae is lordoplasty. The procedure is commonly done following kyphoplasty, when the balloon become deflated and the vertebra is ready to inject cement in. This procedure often used as vertebroplasty alternative as more cost effective. This procedure, however, may correct the kyphotic angle of spinal column 11 to 13 degrees, leading to significant pain relief in 90% of patients.[9] Lordoplasty has a much better 3 months outcome than kyphoplasty, especially in postural and anatomical deviations.[10]
The procedure consists of applying 6 cannulas , each of them has 2 pedicles, for any single fracture site in vertebrae. On the other hand, the intact cranial and caudal vertebrae are injected with denser cement to be introduced and strengthened with canullas that have 4 pedicles. Then, with support of cranial and caudal vertebrae, the kyphotic osteoporotic vertebra could be pushed toward the lordosis and rearranged in normal position. All vertebral positions are allied by use of a cross bolt, while 2 cannulas in fracture site deliver the PMMA cement to the collapsed vertebra; been left to cement become hard. Finally, cannulas are replaced from the site.[11]
Complications
Regarding that 6 cannulas are introduced in vertebrae, the most important complication of lordoplasty may be cement leakage. The cement high viscosity and wide cannulas used to inject the cement are the solutions for the problems.
Vesselplasty
This procedure is based on pre-injection of some "porous" material, polyethylene terephthalate, in the site of osteoporotic vertebrae fracture. The main purpose is to prepare some hollow container in place that the cement is about to injected in; therefore, the cement goes through the vertebral bodies much deeper and leak back from there so much lesser than kyphoplasty or lordoplasty. The concluded vertebrae will be more stable and have less height loss during the time.[12]
- Hip fractures are treated by open reduction and internal fixation.
- Some patients with a hip fracture who are at high risk for another fracture, may benefit from a total hip replacement.
References
- ↑ Lapras C, Mottolese C, Deruty R, Lapras C, Remond J, Duquesnel J (1989). "[Percutaneous injection of methyl-metacrylate in osteoporosis and severe vertebral osteolysis (Galibert's technic)]". Ann Chir (in French). 43 (5): 371–6. PMID 2757346.
- ↑ Hemama M, El Fatemi N, Gana R (2017). "Percutaneous vertebroplasty in Moroccan patients with vertebral compression fractures". Pan Afr Med J. 26: 225. doi:10.11604/pamj.2017.26.225.9872. PMC 5491720. PMID 28690739.
- ↑ 3.0 3.1 3.2 El-Fiki M (2016). "Vertebroplasty, Kyphoplasty, Lordoplasty, Expandable Devices, and Current Treatment of Painful Osteoporotic Vertebral Fractures". World Neurosurg. 91: 628–32. doi:10.1016/j.wneu.2016.04.016. PMID 27072339.
- ↑ Cotten A, Boutry N, Cortet B, Assaker R, Demondion X, Leblond D, Chastanet P, Duquesnoy B, Deramond H (1998). "Percutaneous vertebroplasty: state of the art". Radiographics. 18 (2): 311–20, discussion 320–3. doi:10.1148/radiographics.18.2.9536480. PMID 9536480.
- ↑ Kallmes DF, Comstock BA, Heagerty PJ, Turner JA, Wilson DJ, Diamond TH, Edwards R, Gray LA, Stout L, Owen S, Hollingworth W, Ghdoke B, Annesley-Williams DJ, Ralston SH, Jarvik JG (2009). "A randomized trial of vertebroplasty for osteoporotic spinal fractures". N. Engl. J. Med. 361 (6): 569–79. doi:10.1056/NEJMoa0900563. PMC 2930487. PMID 19657122.
- ↑ 6.0 6.1 Hargunani R, Le Corroller T, Khashoggi K, Murphy KJ, Munk PL (2011). "Percutaneous vertebral augmentation: the status of vertebroplasty and current controversies". Semin Musculoskelet Radiol. 15 (2): 117–24. doi:10.1055/s-0031-1275594. PMID 21500131.
- ↑ Al-Nakshabandi NA (2011). "Percutaneous vertebroplasty complications". Ann Saudi Med. 31 (3): 294–7. doi:10.4103/0256-4947.81542. PMC 3119972. PMID 21623061.
- ↑ Lee JH, Lee DO, Lee JH, Lee HS (2014). "Comparison of radiological and clinical results of balloon kyphoplasty according to anterior height loss in the osteoporotic vertebral fracture". Spine J. 14 (10): 2281–9. doi:10.1016/j.spinee.2014.01.028. PMID 24462536.
- ↑ Hoppe S, Budmiger M, Bissig P, Aghayev E, Benneker LM (2016). "Lordoplasty: midterm outcome of an alternative augmentation technique for vertebral fractures". J Neurosurg Spine. 24 (6): 922–7. doi:10.3171/2015.10.SPINE151016. PMID 26895528.
- ↑ Kim SB, Jeon TS, Lee WS, Roh JY, Kim JY, Park WK (2010). "Comparison of kyphoplasty and lordoplasty in the treatment of osteoporotic vertebral compression fracture". Asian Spine J. 4 (2): 102–8. doi:10.4184/asj.2010.4.2.102. PMC 2996621. PMID 21165313.
- ↑ Jeon TS, Kim SB, Park WK (2011). "Lordoplasty: an alternative technique for the treatment of osteoporotic compression fracture". Clin Orthop Surg. 3 (2): 161–6. doi:10.4055/cios.2011.3.2.161. PMC 3095789. PMID 21629479.
- ↑ Flors L, Lonjedo E, Leiva-Salinas C, Martí-Bonmatí L, Martínez-Rodrigo JJ, López-Pérez E; et al. (2009). "Vesselplasty: a new technical approach to treat symptomatic vertebral compression fractures". AJR Am J Roentgenol. 193 (1): 218–26. doi:10.2214/AJR.08.1503. PMID 19542417.