Osteoporosis surgery
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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
Surgery is not the first-line treatment option for patients with osteoporosis. Vertebroplasty, kyphoplasty, lordoplasty, and vesselplasty are procedures that usually reserved for patients with either pathological or osteoporotic vertebral fractures in patients, refractory to medical therapy. Surgery options for osteoporosis are very limited. In case of hip fracture open reduction internal fixation or in rare cases total hip replacement surgery are the options.
Surgery
- Surgery is not the first-line treatment option for patients with osteoporosis. Vertebroplasty, kyphoplasty, lordoplasty, and vesselplasty are procedures that is usually reserved for patients with either pathological or osteoporotic vertebral fractures in patients, refractory to medical therapy. Surgery options for osteoporosis are very limited. In case of hip fracture open reduction internal fixation or in rare cases total hip replacement surgery are the options.
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 radicular 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
Indications 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 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, 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]
It has found that kyphoplasty is much more better than vertebroplasty in 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 is always last about 1.5 hours. The patient usually need to be observed only a few hours, but in some cases it may be necessary to hospitalize a whole night to ensure about possible complications.[10]
Indications
Indications 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, coagulation 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]
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 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.[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 denser cement to be introduced and strengthened with cannulas 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.[14]
Indications
Indications for lordoplasty for osteoporosis include osteoporotic and pathological vertebral fractures.
Contraindications
Contraindications for surgery for osteoporosis include infection, coagulation 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]
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 vertebral 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.[15]
Mainly, kyphoplasty procedure is to inject the cement materials in fractured vertebrae in place of removed deflated balloon, that is the main fact of correction in vertebral osteoporotic fractures. Whereas, in some cases the main tissue in place is not as hard as main vertebral bone tissue and may collapsed after removing or deflating the balloon, such as soft tumor tissue that has led to pathological fracture, indeed. The best way to solve this problem is a modified kyphoplasty, also named vesselplasty, used to treat osteoporotic fractures. The non-stretchable balloon that is used in vesselplasty to inject the cement through, prevent the re-collapse of soft tissue around the fracture.[16]
Vesselplasty, like kyphoplasty, has safer cement delivery to the fractured bone and also less cement leakage, postoperatively.[17]
Indications
Indications for vesselplasty for osteoporosis include patients with osteoporotic vertebral fracture and also pathological vertebral fracture due to soft tumor tissues.
Contraindications
Contraindications for surgery for osteoporosis include infection, coagulation 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]
Complications
The complications of vesselplasty procedure include any allergic reaction to bone cement or other material that used during operation, pneumothorax, pulmonary embolism, epidural hematoma, arterial injury, anterior spinal artery syndrome, and death.[16]
Hip fracture surgery
Hip fractures are 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.
- ↑ 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.
- ↑ 16.0 16.1 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.