OVCF is a common and frequently-occurring disease in the elderly [9]. For acute fresh fractures, patients tend to be treated with minimally invasive vertebral augmentation, and studies have confirmed that satisfactory results can be achieved [10, 11]. As OVCF is a kind of low-energy damage, post-injury pain is easily confused with fatigue pain. Moreover, most elderly patients are not sensitive to pain, which may easily delay the disease and eventually develop into old fractures. Most of these patients developed osteonecrosis, leading to prolonged back pain. And conservative treatments, such as bedridden, wearing braces, and anti-osteoporosis medications, do not work for most patients. It has been reported in the literature that 36.6% of patients will develop progressive vertebral compression, and 13.9% will form pseudarthrosis [12]. Non-healing of the injured vertebra and recollapse of the vertebral body will lead to local instability of the spine, leading to intractable pain [13, 14], even kyphosis of the spine [15], nerve injury [16], etc., which requires surgical treatment. However, the patient's advanced age and many other factors such as other internal and surgical diseases increase the difficulty and risk of surgery.
As mentioned earlier, many scholars have proposed classification for OVCF, but there are many problems as follows: 1) The classification lacks clinical manifestations such as nerve damage; 2) There is no corresponding treatment plan for typing; 3) There is a duplication between the types, which does not guide clinical treatment well; 4) There is no specificity in the classification, which also contains high energy injury fractures [5, 6, 8]. Therefore, based on the previous research, our study proposes five new types of grades, and proposes corresponding treatment plans for the classification.
A total of 238 patients were enrolled in this study, all of whom obtained satisfactory results in grading treatment. In this study, patients with grade I had local instability of the vertebral body, intractable low back pain, and radiographic examination revealed a cavity in the vertebral body. For these symptoms, vertebral augmentation is performed to reconstruct spinal stability by filling the cavity with bone cement. Postoperative pain was significantly relieved and the effect was satisfactory [17]. However, in the follow-up, 7 patients were found to have re-loss of vertebral height after half a year, which may be related to the reason that the patients did not strictly follow the doctor's advice on anti-osteoporosis treatment in the later stage. Significant pseudoarticular activity can be seen in the dynamic radiographs of patients with grade II, and pain is associated with changes in activity or position. The key to surgery in such patients is to fix unstable segments. In this study, this type of patient underwent posterior reduction fixation and fusion. If necessary, combined with vertebral augmentation, it can stabilize the spine and relieve pain caused by height loss and local instability [18]. Finally, with the nail rod fixed fusion to eliminate the pseudoarticular activity. After surgery, the spinal stability of the patient was well reconstructed, SI was improved from 72.82 ± 7.78 to 84.17 ± 5.30, and the height of the injured spine was recovered satisfactorily. Grade III patients were accompanied by nerve damage, and radiographic findings showed spinal canal stenosis. Such patients undergo surgery to relieve nerve compression and restore spinal stability. As expected, the patient's lower back pain was significantly relieved, and 10 patients with significant nerve injury had a significant improvement in postoperative AISA grade. Our results are also consistent with previous reports [3, 19]. Part IV patients had local instability of the vertebral body, and the biomechanics of the spine was destroyed. Later, the secondary collapse caused kyphosis [20, 21], accompanied by low back pain, and even serious nerve damage [22]. The purpose of this part of the patient's surgery is to correct the kyphosis and restore the sagittal balance. Some scholars argue that a posterior approach with osteotomy and orthopedic fusion can achieve satisfactory results [21, 23], however, others argue that anterior surgery can be more direct and complete decompression [24]. Currently, posterior surgery is mostly adopted. For surgeons, posterior surgery is more familiar with anatomical structure and less surgical trauma, and simple posterior surgery can achieve similar results as combined approach [23, 25]. For grade V patients, the surgical procedure depends on the main symptoms. In this study, 18 patients received posterior surgery, among which 12 patients with severe kyphosis received Posterior osteotomy and fusion internal fixation, and 6 patients with severe spinal stenosis received posterior decompression and internal fixation, all of which obtained satisfactory results.
Since most patients are associated with severe osteoporosis, postoperative complications such as screw loosening and vertebral height loss may occur. Therefore, anti-osteoporosis treatment is particularly important in the treatment of old OVCF. Studies have shown that the technique of bone cement augmentation can significantly improve the pull-out resistance of the screw [23]. Therefore, according to the bone condition of patients, some patients were augmented with bone cement. From the follow-up findings, the surgical method has achieved remarkable results. However, there were still patients with postoperative height loss of injured vertebra, which was speculated to be related to the patient's failure to strictly follow the doctor's advice on anti-osteoporosis treatment.