Single-level lumbar osteoporotic compression fracture treated with unilateral approach percutaneous vertebroplasty via intervertebral foramen-A retrospective controlled study

doi:10.21203/rs.3.rs-5298100/v1

Purpose

To present a novel surgical strategy for the management of lumbar spine osteoporotic vertical compression fracture (OVCF).

Methods

182 patients with lumbar single segment OVCF who underwent PVP surgery between June 2020 and June 2021 were included in this retrospective study. Of them, 104 (as members of the bilateral group) received conventional bilateral puncture, while 78 (as members of the unilateral group) underwent unilateral PVP through the intervertebral foramen. Imaging results, follow-up clinical indicators, and perioperative period parameters were compared between the two groups.

Results

Both patient groups underwent the treatment effectively, with 39 instances in the bilateral group and 27 cases in the unilateral group reporting bone cement leakage; no serious issues, such as spinal cord or nerve injury, occurred. The unilateral group experienced shorter hospital stays, shorter X-ray exposure times during surgery, and lower overall costs (P < 0.05) than the bilateral group. There were no statistically significant differences between the two groups for any of these measures, which included postoperative ambulation time, hospitalization duration, and bone cement injection volume, distribution, and leakage. Two patient groups were followed for a total of 24–48 months, with an average follow-up of 31.97 ± 7.15 months. In the event that the patient breaks another bone while being monitored, the follow-up will terminate. For both patient groups, there was a significant decrease (P > 0.05) in VAS and ODI scores over time, and a significant increase (P < 0.05) in Japanese Orthopaedic Association (JOA) scores over time; however, there was no statistically significant difference (P > 0.05) in VAS, ODI, and JOA scores between the two groups at the corresponding time intervals. Comparing imaging data from postoperative patients in both groups to preoperative findings, there was a decrease in the local Cobb angle (P < 0.05) and an increase in the height of the anterior border of the injured vertebra (P < 0.05). At the comparable time point, there was no statistically significant difference (P > 0.05) in the anterior vertebral edge height and local Cobb angle between the two groups. The unilateral group's learning curve had a steeper slope.

Conclusion

While there is a learning curve associated with modified unilateral puncture PVP treatment for lumbar OVCF, it can also optimize surgical procedures and save expenses while achieving inspiring therapeutic outcomes.

Osteoporosis

lumbar compression fracture

vertebroplasty

The symptoms of osteoporotic vertebral compression fractures (OVCFs) include severe lower back discomfort, difficulty walking on uneven surfaces, difficulty bearing weight, and difficulty turning over in bed. These are more prevalent in postmenopausal women and elderly people. Conservative therapy often leads to several difficulties or even death, greatly impairing the quality of life of patients [1]. Vertebral augmentation (VA), which includes percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP), is the most common surgical treatment [2].

There are two types of transpedicular punctures for lumbar vertebral VA: unilateral and bilateral. This puncture technique is widely used. It may be difficult for bone cement to spread to the other side of the perforation when using a unilateral pedicle technique. This may result in a recurrence of vertebral fractures as well as a biomechanical imbalance in the vertebral body [3]. Research has shown that by using unilateral puncture, the transpedicular approach can achieve bilateral diffusion of bone cement. However, the size of this puncture makes it simple to harm segmental arteries in anatomical relationships [4–5], which could result in dangerous consequences. While the bilateral puncture approach through the pedicle can achieve good bone cement diffusion effect and clinical efficacy, it is not superior in terms of surgical time or ease of usage.

Since its creation, the lateral foraminal endoscope has demonstrated many benefits, including less stress, quicker recovery, and reduced bleeding, when treating painful lumbar disc herniation in the lower limb. The lateral approach of the intervertebral foramen endoscope to reach the target site [6] served as inspiration for our team. Lumbar OVCF was treated with a modified unilateral puncture PVP, specifically the lateral approach PVP through the intervertebral foramen, and satisfactory therapeutic effects were obtained. We provide the report that follows.

2.1 Patient Demographics.

Between June 2020 and June 2021, 182 patients who met the inclusion criterion were enrolled, respectively. 78 patients were treated with unilateral PVP, and 104 patients were treated with bilateral PVP. All procedures were approved by the Affiliated Hospital of Wuhan Sport University Research Ethics Committee and in accordance with the Helsinki Declaration. Written informed consent was obtained from each participant. The definition of the indications was as follows:(1) Lower back pain with limited mobility and no signs of nerve or spinal cord compression was the primary complaint; (2) single segment fresh OVCF was diagnosed on lumbar MRI; (3) lumbar CT excluded burst fractures and spinal canal masses; (4) lumbar plain film revealed a compression degree of less than 1/4; and (5) OTLICS standard score [7] ≥ 4 points. The following were the contraindications: (1) combined infection of the spine; (2) pathological fractures due to tumors; (3) combined neurological symptoms in the lower limbs or signs of injury to the cauda equina nerve; (4) relatively high compression of the affected vertebrae with kyphosis deformity; and (5) history of prior surgeries on the affected vertebrae.

2.2. Surgical approach.

Unilateral group: The surgical puncture path was preoperatively constructed to establish the puncture needle's transverse and longitudinal lengths, head tilt, and abduction angles from the spinous process using preoperative CT plain scan pictures (Fig. 1a). The patient was positioned prone, with the abdomen hanging and the chest and pelvis raised. Following position preparation, skin puncture sites were marked, and the damaged vertebrae were verified via fluoroscopy (Fig. 1b). A local anesthetic was used for the procedure after cleaning and toweling. Layer by layer, the mixture of lidocaine and ropivacaine was infused and anesthetized. An 18G puncture needle was placed along the preoperatively designated location during fluoroscopy, and the head tilt and abduction angle were assessed via the route of the intervertebral foramen prior to operation. Next, a matching puncture sleeve that formed a vertebral body was placed along the puncture needle (Fig. 1c). When the position was confirmed to be correct by fluoroscopy (Fig. 1d), the vertebral body was conventionally punctured. The lateral location was at the upper posterior angle of the vertebral body (Fig. 1f), and the fluoroscopy position was at the pedicle's outer edge (Fig. 1e). This was the path that the puncture continued down. A tapping was installed once the channel position was verified.In order to eventually inject bone cement into the vertebral body during the drawing stage, it was ideal for the front end of the positive tapping to cross the midline of the vertebral body (Fig. 1g) and the lateral tapping to reach the anterior and center one-third of the vertebral body (Fig. 1h). Use fluoroscopy to closely monitor the dispersion and leaking of bone cement under observation. Remove the sheath, clean the incision, and cover it with adhesive tape once the bone cement has solidified.

Bilateral group: Routine bilateral transpedicular PVP treatment was performed [8].

During the 48 hours following surgery, antibiotics were routinely given to each patient. Patients were advised to engage in physical activity while wearing an adjustable brace. However, for the four weeks that followed the procedure, intense and strenuous activity was forbidden.

2.3.Clinical Assessment.

The preoperative demographic indicators, including age, gender, BMI, disease duration, follow-up intervals, BMD, operation level, and OTLICS score. The intraoperative demographic indicators, including operation time, X-ray exposure frequency, and volume of bone cement. The postoperative demographic indicators, including distribution of bone cement, bone cement leakage, postoperative ambulation time, hospital stay, and total cost. The criteria of the OTLICS score was based on Xu et al.[7] The functional recovery was assessed by the Japanese Orthopaedic Association (JOA), visual analogue scale (VAS) score, and Oswestry Disability Index (ODI) preoperatively and at each follow-up (1 day after surgery and the latest follow-up) at our orthopedic outpatient department. Sometimes, follow-ups were achieved by telephone or WeChat app.

2.4. Radiographic Evaluation

Radiological data were obtained and compared preoperatively and at each follow-up (1day after surgery, and the latest follow-up) at our orthopedic outpatient department.

Radiographic parameters, including the anterior edge height and local Cobb angle of the injured vertebra, were obtained by plain radiographs; and three-dimensional reconstruction of postoperative CT. Meanwhile, distribution of bone cement and bone cement leakage were observed. The distribution of bone cement was evaluated according to Li KC et al.[9], and its distribution types were classified as excellent, good, fair, and poor for diffuse, block type, double band, and single band, respectively (Fig. 2).

2.5.Statistical analysis.

Statistical analysis was conducted using SPSS 29.0 software (SPSS, Inc., Chicago, USA). Significant differences between intragroup comparisons were used in the paired sample t-test. The χ2 test was used to compare the data between groups, and the Fisher's exact test was used when the number was less than five. The grade data were tested using the Kruskal-Wallis rank-sum test. Enumeration data was shown by rate (%), and measurement data were expressed as mean ± standard deviation. P < 0.05 was considered as a significant difference.

3.1 Comparison of demographic characteristics. There were 182 participants throughout the research (78 cases of unilateral PVP and 104 cases of bilateral PVP). Table 1 displayed and contrasted the demographic data (age, gender, BMI, duration of symptoms, follow-up intervals, BMD, operation level, and OTLICS). There were no discernible variations between the two groups in terms of these demographic traits.

Table 1: Comparison of Demographic Characteristics

Indicators	Unilateral group(n=78)	Bilateral group(n=104)	P-value
Age(years)	75.09±6.06	74.78±5.69	0.724
Male n(%)	10(12.82%)	15(14.42%)	0.756
BMI(kg/m²)	20.46±2.45	20.55±2.52	0.810
Duration of symptoms(days)	11.67±6.08	11.68±6.69	0.992
Follow-up intervals(months)	31.85±7.12	32.06±7.20	0.845
BMD(g/cm²)	0.83±0.14	0.82±0.16	0.661
Operation level L1 L2 L3 L4 L5	29 21 17 7 4	26 23 27 6 3	0.487
OLTICS (scores)	5.38±0.59	5.43±0.57	0.565

3.2 Comparison of surgery-related indicators. Both patient groups successfully completed the operations. In 27 patients in the unilateral group and 39 cases in the bilateral group, postoperative lumbar CT scans revealed posterior vertebral canal, paraspinal, intervertebral space, and vascular bone cement leakage. However, none of the groups experienced serious adverse effects such as vascular issues, nerve damage, spinal cord injury, or pulmonary embolism. The unilateral group had a significantly shorter operation duration (32.05±11.80 vs. 37.75±6.80 min, p=0.000 ) than the bilateral group. They also experienced lower hospitalization costs (18.49±0.09 vs. 2.22±0.13, p=0.000 ) and X-ray exposure frequency (18.49±3.02 vs. 20.58±2.08, p=0.000 ) than the bilateral group (Table 2).

Table 2: Comparison of Surgery-related Indicators

Indicators	Unilateral group(n=78)	Bilateral group(n=104)	P-value
operative duration(min)	32.05±11.80	37.75±6.80	0.000
X-ray exposure frequency (time)	18.49±3.02	20.58±2.08	0.000
Volume of bone cement (ml)	5.37±1.39	5.58±1.25	0.287
Distribution of bone cement(Excellent/Good/Fair/Poor)	64/11/2/1	89/12/3/0	0.514
Bone cement leakage	27(34.61%)	39(37.50%)	0.689
Postoperative ambulation time (h)	23.72±3.02	22.92±3.41	0.102
Hospital stay (d)	6.24±1.07	6.19±1.29	0.781
Total cost (Ten thousand RMB)	1.84±0.09	2.22±0.13	0.000
Full weight-bearing tine (week)	6.51±1.35	6.53±1.29	0.919
Adjacent vertebral fracture (case)	5(6.41%)	7(6.73%)	0.931

3.3 Comparison of radiological indicators. No significant differences were found between the two groups concerning the height of the anterior edge of injured vertebra and local Cobb angle at the same follow-up point. Compared with preoperative results, the height of the anterior edge of the injured vertebra significantly increased to 21.62±2.65 in unilateral group and 21.83±2.52 in bilateral group at 1 day after surgery, and then decreased to 21.38±2.65 in the unilateral group and 21.51±2.46 in the bilateral group at latest follow-up. The local Cobb angle significantly decreased to 12.41±3.72 in the unilateral group and 12.76±3.58 in the bilateral group at 1 day after surgery, and then increased to 13.79±3.28 in the unilateral group and 13.25±3.69 in the bilateral group at the latest follow-up. Compared with 1 day after surgery, there was a loss of correction in the anterior edge height and local Cobb angle of the injured vertebrae in both groups at the latest follow-up, which may be related to natural degeneration because of further osteoporosis. (Table 3 and Figure 3).

Table 3: Comparison of Radiological Indicators

Indicators	Unilateral group(n=78)	Bilateral group(n=104)	P-value
Height of anterior edge of injured vertebra (mm)
Preoperative	17.84±2.57	17.86±2.84	0.961
1 day postoperative	21.62±2.65	21.83±2.52	0.587
Latest follow-up	21.38±2.65	21.51±2.46	0.733
P-value	0.000	0.000
Local Cobb angle (º)
Preoperative	17.20±5.32	17.57±5.91	0.663
1 day postoperative	12.41±3.72	12.76±3.58	0.522
Latest follow-up	13.79±3.28	13.25±3.69	0.307
P-value	0.000	0.000

3.4. Comparison of clinical and functional outcomes. The average back pain VAS and ODI improved in two groups following the surgery.The average back pain VAS was significantly reduced immediately from 7.26±1.43 to 2.10±0.85 in the unilateral group; and from 7.38±1.46 to 2.01±0.90 in the bilateral group at 1 day postoperative. The average ODI was significantly reduced immediately from 70.76±16.19 to 28.59±2.94 in the unilateral group, from 68.63±15.57 to 28.40±2.59 in the bilateral group at 1 day postoperative. The average JOA score also improved following the operation. The average JOA significantly improved immediately from 12.89±2.51 to 22.04±2.77 in the unilateral group, from 12.55±2.74 to 22.09±2.83 in the bilateral group at 1 day postoperative. (Table 4. and Figure 4). However, there was no significant difference between the two groups at each follow-up regarding the average VAS of back pain and ODI and JOA. The details are shown in Table 4. and Figure 4.

Table 4:Comparison of VAS of back,ODI and JOA scores

Indicators	Unilateral group(n=78)	Bilateral group(n=104)	P-value
VAS
Preoperative	7.26±1.43	7.38±1.46	0.581
1 day postoperative	2.10±0.85	2.01±0.90	0.495
Latest follow-up	2.32±0.47	2.23±0.59	0.269
P-value	0.000	0.000
ODI
Preoperative	70.76±16.19	68.63±15.57	0.371
1 day postoperative	28.59±2.94	28.40±2.59	0.645
Latest follow-up	30.24±2.30	29.88±2.47	0.318
P-value	0.000	0.000
JOA
Preoperative	12.89±2.51	12.55±2.74	0.392
1 day postoperative	22.04±2.77	22.09±2.83	0.905
Latest follow-up	24.78±2.76	25.31±3.61	0.281
P-value	0.000	0.000

3.4 Comparison of learning curves. Bilateral approach PVP technology was a fairly mature procedure that had been established in our department for many years, so its surgical time had been steady for a long time and did not represent its natural learning curve. Conversely, the unilateral intervertebral foramen approach to PVP showed a somewhat steep learning curve that stabilized around the 25th case. (Figure 5).

The most prevalent bone disease, osteoporosis, is characterized by reduced bone mass, increased fragility of the bone due to microstructural damage to the bone tissue, and a predisposition to fractures. It was described as a skeletal system disease with diminished bone strength and an elevated risk of fractures by the National Institutes of Health (NIH) in 2001 [10, 11]. As people age, osteoporotic fractures become more common. According to a 2013 International Osteoporosis Foundation (IOF) report, one osteoporotic fracture case occurs every three seconds globally. After the age of 50, 20% of men and 50% of women will suffer their first osteoporotic fracture. Of those who have already experienced one, 50% may experience another. Female patients who have osteoporotic vertebral fractures are four times more likely to experience subsequent fractures [12]. In senior individuals, osteoporotic fractures are a leading cause of disability and mortality, causing immense misery. Families and society are also severely strained by them [13, 14].

The most widely used minimally invasive treatment for osteoporotic vertebral compression fractures (OVCF) is vertebral augmentation surgery, such as percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP). As of right now, opinions about the relative merits of minimally invasive surgery versus non-surgical treatment for OVCF are divided [15–17]. At one month [18] and six months [19] following surgery, there was no statistically significant difference in total pain between the PVP and sham surgery groups, according to two randomized controlled trials with 131 and 78 patients, respectively. While PVP can reduce pain more quickly, randomized controlled research with 125 patients indicated that, at 12 months following surgery, the risk of new vertebral fractures was considerably higher in the PVP group than in the placebo group [20]. However, a large number of Level I evidences support opposing viewpoints. The results of a multicenter prospective controlled trial were reported in The Lancet in 2016, demonstrating the superiority of PVP treatment over a placebo group for OVCF within 6 weeks of damage [21]. According to a meta-analysis of more than 2 million cases of osteoporotic vertebral fractures, patients who received vertebral augmentation surgery had a 22% lower 10-year risk of death than patients who did not receive surgical treatment [22]. In our study, every patient who was either directly refused or failed conservative treatment asked to return to a painless state as soon as possible in order to resume their regular lives as soon as possible. Before the procedure, each of them signed an informed consent form outlining the treatment plan.

The thermal and effective supporting effects of bone cement are the fundamental concepts of VA [23–24]. Studies have demonstrated that following surgery, the dispersion and unequal distribution of bone cement raise the risk of subsequent vertebral fractures [25–29]. The surgical puncture technique and the diffusion effect of bone cement are connected [30]. In the past, VA cases frequently underwent both unilateral and bilateral transpedicular surgical techniques [31], each with its own specialties. Although the bilateral transpedicular technique increases surgical time and costs, it has certain advantages in bone cement diffusion [2, 32]. The unilateral pedicle method is constrained by the pedicle and is unable to freely modify the angle. The midline of the vertebral body is difficult to reach with unilateral puncture, which can lead to an uneven distribution of bone cement and possibly problems [5, 33].

The two conventional PVP techniques' inadequacies are made up for by the unilateral PVP approach via the intervertebral foramen [34]. This puncture technique uses the safe triangle region of the intervertebral foramen to access the posterior upper edge of the vertebral body without having to go through the pedicle [35], which is relatively safe anatomically. It is especially useful in situations of severe osteoporosis, tiny pedicles, developmental variations, or even pedicle loss, scoliosis, or rotation of the vertebral bodies. The present investigation employs the bone cement dispersion evaluation method, as suggested by Li KC et al. [9], to set a benchmark for the superior bone cement distribution. The excellent bone cement distribution rates in the unilateral group and the bilateral approach group were 90.20% and 97.14%, respectively, based on this criteria. The PVP bone cement distribution through the lateral intervertebral foramen is good, as evidenced by the lack of a statistically significant difference (P > 0.05) between the groups. The fact that neither patient group experienced any recurrence vertebral fractures during the follow-up period suggests that PVP technology's good bone cement dispersion rate was achieved by the lateral approach of the intervertebral foramen.

The unilateral approach PVP technique through the lateral intervertebral foramen has demonstrated comparable clinical efficacy to the bilateral pedicle approach PVP at the same time. The PVP technique through the lateral intervertebral foramen has demonstrable short-term efficacy, as evidenced by the two patient groups' significantly lower postoperative ground time, hospitalization time, postoperative VAS score, ODI, and JOA score compared to before surgery. However, there is no statistical difference in the corresponding time points between the groups. Similar to the benefits of the conventional unilateral puncture technique PVP, the unilateral group's hospitalization expenditures, intraoperative fluoroscopy rates, and number of surgical durations are all significantly reduced in comparison to the bilateral group [36]. There is no discernible difference between the unilateral group's 34.61% bone cement leakage rate and the bilateral group's 37.50% rate. In a large sample multicenter trial, Klazen et al. [37] observed a leakage rate of up to 72% in PVP utilizing CT, suggesting that this technology does not enhance the bone cement leakage rate. The suggested dose for single-stage thoracolumbar OVCF is 4–6 ml, as researchers have confirmed [38]. The average amount of bone cement injected into the two groups in this investigation was commensurate with this recommended dose, showing no variation between the groups. According to a different study [39], treatment efficacy can be maintained with a lower injection volume while lowering the chance of neighboring vertebral fractures and bone cement leaking.

PVP can successfully restore vertebral collapse height and avoid kyphosis deformity, whereas OVCF can readily cause loss of vertebral height and the formation of kyphosis deformity following injury [40]. The results of this study demonstrate that the improved unilateral PVP technique can effectively restore vertebral height and provide effective support for the vertebrae. Both the unilateral and bilateral groups exhibit significant improvements in the anterior edge height and local Cobb angle of the injured vertebrae at 1 month and the last follow-up after surgery. Compared to one month following surgery, the anterior vertebral height and local Cobb angle of the two groups of cases are lost at the last follow-up, which may be associated with the progression of osteoporosis. As a result, following OVCF surgery, ongoing and consistent anti-osteoporosis therapy is crucial. Following OVCF surgery, adjacent vertebral fractures are frequently the result. According to this study, both groups experienced contiguous vertebral fractures (6.41% vs. 6.73%), which could be related to an overabundance of bone cement injection [39]. Nonetheless, it is comparatively modest when compared to the incidence rate that has been reported in the literature [41], which may be because every case in this investigation had early surgical intervention. There has been preliminary confirmation of this conclusion [42]. In this study, no corresponding events occurred because the patients underwent local anesthesia for their surgeries, and the pain feedback generated by nerve stimulation during the procedure can prevent iatrogenic nerve injury in a timely manner. Intraoperative nerve root injury is a common complication of the lateral approach through the intervertebral foramen.

We think that the modified unilateral approach PVP method needs greater focus on a few important areas. Initially, intervertebral disc puncture needles can be used because standard syringe needles are not suitable for the lengthy anesthetic and puncture paths involved in this procedure. Second, in comparison to more conventional puncture techniques, this procedure is more suited for external displacements of roughly 1–2 cm. Thirdly, in order to decrease needless injuries, prevent blind punctures, and maximize the number of fluoroscopy sessions, preoperative lumbar CT measurement is especially critical.Fourth, the facet joint should be employed as the bone marker during the puncture to avoid the needle accidentally entering the spinal canal or the abdominal cavity through the intervertebral foramen. Lastly, this procedure should not be used due to the risk of injury to the exit nerve root in the event that lateral curvature or intervertebral space collapse restricts the intervertebral foramen [34].

The enhanced unilateral puncture PVP approach can be regarded as an alternative surgical approach for treating lumbar OVCF with promising results.While it does come with a learning curve and a risk of surgical complications.

One of the study's limitations is that only a small number of individuals with relatively minor compression fractures were included. As a result, this methodology approach—which is a retrospective study—is currently limited to use in PVP surgery. Research findings on the use of this approach in multi-level OVCF or PKP are lacking, and there are no reports on its use in thoracic vertebral OVCF. Larger sample sizes and additional multicenter prospective trials are therefore required in the future.

Availability of data and materials

Not applicable.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

Authors’ Contributions

Tao Li, Zhihong Wang, and Tonghui Zhang contributed equally to this work. Tao Li, Zhihong Wang, and Tonghui Zhang were responsible for designing the study. Xugui Li and Zhou Zhao collected the clinical data. He Huang, Liu Liu, and Xuewei Gao and Peng Ji analyzed the data. Tao Li and Zhihong Wang wrote the manuscript. Jin Tang completed all the surgeries. Jin Tang and Wei Xie approved the manuscript. All authors gave approval to the final version of the manuscript.

Funding

There was no Funding for the research.

Human Ethics and Consent to Participate declarations: not applicable.

Clinical trial number: not applicable.

Ethical Approval

This study was approved by the Affiliated Hospital of Wuhan Sport University Research Ethics Committee .

Cheng J, Muheremu A, Zeng X, et al. Percutaneous vertebroplasty vs balloon kyphoplasty in the treatment of newly onset osteoporotic vertebral compression fractures: A retrospective cohort study[J]. Med (Baltim). 2019;98(10):e14793.
Cheng X, Long HQ, Xu JH, et al. Comparison of unilateral versus bilateral percutaneous kyphoplasty for the treatment of patients with osteoporosis vertebral compression fracture(OVCF): a systematic review and meta-analysis[J]. Eur Spine J. 2016;25(11):3439–49.
Sun H, Li C. Comparison of unilateral and bilateral percutaneous vertebroplasty for osteoporotic vertebral compression fractures: a systematic review and meta-analysis. J Orthop Surg Res. 2016;11(1):156.
Liu L, Cheng S, Wang Q, et al. An anatomical study on lumbar arteries related to the extrapedicular approach applied during lumbar PVP (PKP) [J]. Volume 14. PLo S One; 2019. p. e0213164. 3.
Heo DH, Cho YJ. Segmental artery injury following percutaneous vertebroplasty using extrapedicular approach [J]. J Kor Neurosurg Soc. 2011;49(2):131–3.
Pan M, Li Q, Li S, et al. Percutaneous Endoscopic Lumbar Discectomy: Indications and Complications. Pain Physician. 2020;23(1):49–56.
Xu ZW, Hao DJ, He LM, et al. An assessment system for evaluating the severity of thoracolumbar osteoporotic fracture and its clinical application: A retrospective study of 381 cases [J]. Clin Neurol Neurosurg. 2015;139(1):70–5.
Tan Y, Liu J, Li X, et al. Multilevel unilateral versus bilateral pedicular percutaneous vertebroplasty for osteoporotic vertebral compression fractures. Front Surg. 2023;9:1051626.
Li KC, Hsieh CH, Liao TH, et al. A novel classification of cement distribution patterns based on plain radiographs associated with cement filling rate and relevance to the clinical results of unipedicle vertebroplasty. Eur Spine J. 2023;32(1):101–9.
Nuti R, Brandi ML, Checchia G, et al. Guidelines for the management of osteoporosis and fragility fractures [J]. Intern Emerg Med. 2019;14(1):85–102.
NIH Consensus Development Panel on Osteoporosis Prevention, Diagnosis, and Therapy, March 7–29, 2000: highlights of the conference [J]. South Med J. 2001,94(6):569–573.
Geusens P, Bours S, Wyers CE, et al. Fracture liaison programs [J]. Best Pract Res Clin Rheumatol. 2019;33(2):278–89.
Lems WF, Dreinhöfer KE, Bischoff-Ferrari H, et al. EULAR/EFORT recommendations for management of patients older than 50 years with a fragility fracture and prevention of subsequent fractures[J]. Ann Rheum Dis. 2017;76(5):802–10.
Willson T, Nelson SD, Newbold J, et al. The clinical epidemiology of male osteoporosis: a review of the recent literature[J]. Clin Epidemiol. 2015;7:65–76.
Staples MP, Kallmes DF, Comstock BA, et al. Effectiveness of vertebroplasty using individual patient data from two randomised placebo controlled trials: meta-analysis[J]. BMJ. 2011;343:d3952.
Papanastassiou ID, Phillips FM, Van Meirhaeghe J, et al. Comparing effects of kyphoplasty, vertebroplasty, and non-surgical management in a systematic review of randomized and non-randomized controlled studies[J]. Eur Spine J. 2012;21(9):1826–43.
Bauer DC. Vertebral augmentation vs nonsurgical therapy: improved symptoms, improved survival, or neither?[J]. JAMA Intern Med. 2013;173(16):1522–3.
Kallmes DF, Comstock BA, Heagerty PJ, et al. A randomized trial of vertebroplasty for osteoporotic spinal fractures[J]. N Engl J Med. 2009;361(6):569–79.
Buchbinder R, Osborne RH, Ebeling PR, et al. A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures[J]. N Engl J Med. 2009;361(6):557–68.
Blasco J, Martinez-Ferrer A, Macho J, et al. Effect of vertebroplasty on pain relief, quality of life, and the incidence of new vertebral fractures: a 12-month randomized follow-up, controlled trial[J]. J Bone Min Res. 2012;27(5):1159–66.
Clark W, Bird P, Gonski P, et al. Safety and efficacy of vertebroplasty for acute painful osteoporotic fractures (VAPOUR): a multicentre, randomised, double-blind, placebo-controlled trial[J]. Lancet. 2016;388(10052):1408–16.
Hinde K, Maingard J, Hirsch JA, et al. Mortality outcomes of vertebral augmentation (vertebroplasty and/or balloon kyphoplasty) for osteoporotic vertebral compression fractures: a systematic review and meta-analysis[J]. Radiology. 2020;295(1):96–103.
Quan Q, Gongping X, Ruisi N, et al. New Research Progress of Modified Bone Cement Applied to Vertebroplasty. World Neurosurg. 2023;176:10–8.
Wang Q, Dong JF, Fang X, et al. Application and modification of bone cement in vertebroplasty: A literature review. Jt Dis Relat Surg. 2022;33(2):467–78.
Steinmann J, Tingey CT, Cruz G, et al. Biomechanical comparison of unipedicular versus bipedicular kyphoplasty. Spine. 2005;30(2):201–5.
Chen BL, Li YQ, Xie DH, et al. Comparison of unipedicular and bipedicular kyphoplasty on the stiffness and biomechanical balance of compression fractured vertebrae. Eur Spine J. 2011;20(8):1272–80.
Liebschner MA, Rosenberg WS, Keaveny TM. Effects of bone cement volume and distribution on vertebral stiffness after vertebroplasty. Spine. 2001;26(14):1547–54.
He D, Lou C, Yu W, et al. Cement distribution patterns are associated with recompression in cemented vertebrae after percutaneous vertebroplasty: a retrospective study[J]. World Neurosurg. 2018;120:e1–7.
Liang D, Ye LQ, Jiang XB et al. Biomechanical effects of cement distribution in the fractured area on osteoporotic vertebral compression fractures: a three-dimensional finite element analysis[J]. J Surg Res 2015,195(1): 246–56.
Ma JH, Li M, Zhang XQ, et al. Modified percutaneous kyphoplasty with better cement diffusion and improved biomechanics. Asian J Surg. 2021;44(12):1546–8.
Zhuo Y, Liu L, Wang H, et al. A Modified Transverse Process-Pedicle Approach Applied to Unilateral Extrapedicular Percutaneous Vertebroplasty. Pain Res Manag. 2021;2021:6493712.
Huang Z, Wan S, Ning L et al. Is unilateral kyphoplasty as effective and safe as bilateral kyphoplasties for osteoporotic vertebral compression fracture? A meta-analysis [J]. Clin Orthop 2014,472(9):2833–42.
Cavka M, Delimar D, Rezan R, et al. Complications of Percutaneous Vertebroplasty: A Pictorial Review. Med (Kaunas). 2023;59(9):1536.
Jiang Y, Li J, Yuan S, et al. A modified trajectory of kyphoplasty via superior pedicle notch for osteoporotic vertebral compression fractures: Technique note and clinical result. Front Surg. 2022;9:1012160.
Ozer AF, Suzer T, Can H, et al. Anatomic assessment of variations in Kambin's Triangle: a surgical and cadaver study[J]. World Neurosurg. 2017;100:498–503.
Sun H, Li C. Comparison of unilateral and bilateral percutaneous vertebroplasty for osteoporotic vertebral compression fractures: a systematic review and meta-analysis. J Orthop Surg Res. 2016;11(1):156.
Klazen CA, Lohle PN, de Vries J, et al. Vertebroplasty versus conservative treatment in acute osteoporotic vertebral compression fractures (VertosⅡ): an open-label randomised trial[J]. Lancet. 2010;376(9746):1085–92.
Wang M, Zhang L, Fu Z, et al. Selections of Bone Cement Viscosity and Volume in Percutaneous Vertebroplasty: A Retrospective Cohort Study. World Neurosurg. 2021;150:e218–27.
Wang M, Li B, Wang Y, et al. The Effects of Bone Cement Volume in Percutaneous Vertebroplasty for Thoracolumbar Junction Vertebral Compression Fractures: A Clinical Comparative Study. Mediators Inflamm. 2022;2022:4230065.
Dragan SF, Urbański W, Żywirski B, et al. Kyphosis correction after vertebroplasty in osteoporotic vertebral compression fractures. Acta Bioeng Biomech. 2012;14(4):63–9.
Tang B, Liu L, Cui L, et al. Chen X. Analysis of adjacent vertebral fracture after percutaneous vertebroplasty: do radiological or surgical features matter? Eur Spine J. 2024;33(4):1524–32.
Yang CC, Chien JT, Tsai TY, et al. Earlier Vertebroplasty for Osteoporotic Thoracolumbar Compression Fracture May Minimize the Subsequent Development of Adjacent Fractures: A Retrospective Study. Pain Physician. 2018;21(5):E483–91.

No competing interests reported.

Single-level lumbar osteoporotic compression fracture treated with unilateral approach percutaneous vertebroplasty via intervertebral foramen-A retrospective controlled study

Status:

Version 1

Abstract

Purpose

Methods

Results

Conclusion

Figures

1. Introduction

2. Materials and Methods

2.1 Patient Demographics.

2.2. Surgical approach.

2.3.Clinical Assessment.

2.4. Radiographic Evaluation

2.5.Statistical analysis.

3. Results

4. Discussion

5. Conclusions

Limitations

Declarations

References

Additional Declarations

Status:

Version 1