Osteoporosis surgery
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2]
Overview
Surgery is not the first-line treatment option for patients with osteoporosis. Vertebroplasty, kyphoplasty, lordoplasty, and vesselplasty are the procedures that are usually reserved for patients with either pathological or osteoporotic vertebral fractures and also in patients refractory to medical therapy. Surgery options for osteoporosis are very limited. In case of hip fracture, open reduction internal fixation or total hip replacement surgery, in rare cases, are the options.
Surgery
Surgery is not the first-line treatment option for patients with osteoporosis. Vertebroplasty, kyphoplasty, lordoplasty, and vesselplasty are the procedures that are usually reserved for patients with either pathological or osteoporotic vertebral fractures and also in patients refractory to medical therapy. Surgery options for osteoporosis are very limited. In case of hip fracture, open reduction internal fixation or total hip replacement surgery, in rare cases, are the options.
| Fracture site | Surgery method | Brief description | Indications | Contraindications | Complications |
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| Vertebrae | Vertebroplasty {{#ev:youtube|L_NpAJND_II}} |
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| Kyphoplasty |
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| Lordoplasty |
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| 89o6r8bcs0w}} |
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| Hip | Open reduction internal fixation (ORIF) |
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| Total hip replacement |
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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 a very satisfying outcome. The success of this procedure in a favorable way led to extend its usage to other destructive bone diseases, such as multiple myeloma, metastatic bone tumors, and also osteoporotic vertebral fractures.[1]
- In patients, who are refractory to long term medical therapy and have encountered vertebral compression fracture, vertebroplasty would be a good option. Vertebroplasty is a minimally invasive surgery that needs an image-guided fluoroscopy assistance. In this method, some bone cement (mostly polymethylmethacrylate (PMMA)) is injected into the body of the vertebra that has been fractured. This procedure may lead to improve the 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 the spinal canal. The most important advantages of the vertebroplasty procedure are minimal invasion rather than other open surgical methods, and rapid symptomatic relief as compared to other medical treatments.[2]
- Vertebroplasty may cause a rapid response in patients with osteoporosis. The patients may experience immediate pain and discomfort relief, along with gradual correction of the stooped spine (kyphosis) that occurs because of the compression fracture in the anterior aspect of vertebrae. The main risk for the procedure is that sometimes the cement injection may compromise the foraminal spaces, leading to radicular pains.[3]
- The mechanism of lowering pain in osteoporotic patients following vertebroplasty is not clear completely. Some of the proposed theories include correcting micro-fractures, along with vascular, chemical, and also thermal factors. It is assumed that either temperature properties of injected cement destroy pain receptors, or compression effect of the cement crushed the nerve endings in situ.[4] In 2009, Kallmes found that rapid pain relief and symptomatic cure in osteoporotic patients with vertebral compression fracture was not significantly different from control group.[5]
Indications
- Indications for vertebroplasty for osteoporosis include osteoporotic patients refractory to medical therapy and having 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 material that may be used during the operation is included, too.[6]
- Relative contraindications for vertebroplasty for osteoporosis include the fracture or defect in the posterior aspect of the vertebral body, tumor extension into the spinal canal and vertebra plana.[6]
Complications
- Potential complications of vertebroplasty for osteoporotic surgical treatment include cement leakage into other spaces (e.g., paraspinal and intradiskal), compression destruction of nerve roots due to cement leakage, pulmonary embolism, cardiac perforation, and adjacent vertebrae fracture.[7]
Kyphoplasty
- If the osteoporotic patient is referred within 3 months from the vertebral fracture, it would be possible to cure the resulted kyphosis through balloon kyphoplasty, completely. The procedure is, in fact, an adjunctive method for vertebroplasty, in which initially a balloon is used to inflate the fractured vertebra; then, a larger amount of bone cement is applied there to meet the original vertebral height and a lesser amount of cement extravasation. Generally, kyphoplasty results in favorable outcomes and osteoporotic patients can go back to normal life.[8]
- It has found that kyphoplasty is better when comapred to vertebroplasty in the final outcome, spinal height correction, and preventing leakage of cement. Kyphoplasty has an obvious priority to vertebroplasty in middle spinal height correction and also wedge fractures of vertebrae.[9]
- Kyphoplasty procedure last about 1.5 hours. The patient usually needs to be observed for only a few hours, but in some cases, it may be necessary to hospitalize the patient for a day.[10]
Indications
- Indications for kyphoplasty include:
Contraindications
Contraindications for kyphoplasty for osteoporosis include:
- Infection
- Coagulation disorders,
- Allergy to bone cement or any other material that may be used during the operation
- Any anatomical variations that would disturb the normal route of surgery, such as posterior vertebral cortical bone fusion and retroverted fragments.[3]
Complications
The main complication is cement leakage following the procedure. Other possible complications include pulmonary embolism and rarely balloon rupture.[11]
Lordoplasty
- The most cost effective procedure to alleviate the vertebral compression fracture is lordoplasty.
- It is commonly done following kyphoplasty, when the balloon is deflated and the vertebrae is ready to be injected with cement. It is often used as an alternative to vertebroplasty as it is more cost effective. This procedure may correct the kyphotic angle of the spinal column by 11 to 13 degrees, leading to significant pain relief in 90% of patients.[12] Lordoplasty has a much better 3 months outcome than kyphoplasty, especially in postural and anatomical deviations.[13]
- 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 dense cement and strengthened with cannulas that have 4 pedicles. Then, with the support of cranial and caudal vertebrae, the kyphotic osteoporotic vertebra could be pushed toward the lordosis and rearranged in a normal position. All vertebral positions are allied by use of a cross bolt, while 2 cannulas in fracture site deliver the polymethylmethacrylate (PMMA) cement to the collapsed vertebra; been left to cement become hard. Finally, cannulas are replaced from the site.[14]
Indications
Indications for lordoplasty for osteoporosis include
Contraindications
Contraindications for surgery for osteoporosis include:
- Infection
- Coagulation disorders
- Allergy to bone cement or any other material used during the operation
- Any anatomical variations that would disturb the normal route of surgery, such as posterior vertebral cortical bone fusion and retroverted fragments.[3]
Complications
- Cement leakage as 6 cannulas are introduced in vertebrae. High viscosity cement and wide cannulas may be used to inject the cement to prevent the cement leakage.
Vesselplasty
- This procedure is based on pre-injection of a "porous" material, polyethylene terephthalate, at the site of osteoporotic vertebral fracture. The main purpose is to prepare a hollow container in a place where the cement is about to be injected; therefore, the cement goes through the vertebral bodies much deeper and has lesser chances of leakage than kyphoplasty or lordoplasty. The operated vertebrae will be more stable and have lesser height loss during the time.[16]
- Vesselplasty is also known as modified kyphoplasty as it uses a non-stretchable balloon to inject the cement material into the fractured vertebra. It not only prevents the cement leakage but also the re-collapse of soft tissue around the fracture.[17]
- Vesselplasty, like kyphoplasty, has safe cement delivery to the fractured bone and also less cement leakage, postoperatively.[18]
Indications
Indications for vesselplasty for osteoporosis include:
- Osteoporotic vertebral fracture
- Pathological vertebral fracture due to soft tumor tissues.
Contraindications
Contraindications include:
- Infection
- Coagulation disorders
- Allergy to bone cement or any other material used during the operation
- Anatomical variations that would disturb the normal route of surgery, such as posterior vertebral cortical bone fusion and retroverted fragments.[3]
Complications
The complications of vesselplasty include:
- Allergic reaction to bone cement or other material used during the operation,
- Pneumothorax,
- Pulmonary embolism,
- Epidural hematoma,
- Arterial injury such as anterior spinal artery syndrome.[17]
Hip fracture surgery
- Hip fractures may be treated by open reduction internal fixation (ORIF).
- Some patients with a hip fracture who are at high risk for another fracture may benefit from a total hip replacement surgery.
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 3.3 3.4 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.
- ↑ Kim KH, Kuh SU, Chin DK, Jin BH, Kim KS, Yoon YS, Cho YE (2012). "Kyphoplasty versus vertebroplasty: restoration of vertebral body height and correction of kyphotic deformity with special attention to the shape of the fractured vertebrae". J Spinal Disord Tech. 25 (6): 338–44. doi:10.1097/BSD.0b013e318224a6e6. PMID 21705918.
- ↑ "Balloon kyphoplasty: an evidence-based analysis". Ont Health Technol Assess Ser. 4 (12): 1–45. 2004. PMC 3387743. PMID 23074451.
- ↑ Ledlie JT, Renfro M (2003). "Balloon kyphoplasty: one-year outcomes in vertebral body height restoration, chronic pain, and activity levels". J. Neurosurg. 98 (1 Suppl): 36–42. PMID 12546386.
- ↑ 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.
- ↑ Own work, CC BY-SA 3.0, <https://commons.wikimedia.org/w/index.php?curid=7614604>
- ↑ 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.
- ↑ 17.0 17.1 Klingler JH, Sircar R, Deininger MH, Scheiwe C, Kogias E, Hubbe U (2013). "Vesselplasty: a new minimally invasive approach to treat pathological vertebral fractures in selected tumor patients - preliminary results". Rofo. 185 (4): 340–50. doi:10.1055/s-0032-1330443. PMID 23471680.
- ↑ Bouza C, López-Cuadrado T, Cediel P, Saz-Parkinson Z, Amate JM (2009). "Balloon kyphoplasty in malignant spinal fractures: a systematic review and meta-analysis". BMC Palliat Care. 8: 12. doi:10.1186/1472-684X-8-12. PMC 2746801. PMID 19740423.