[Abstract] Objective To investigate the surgical technique, indications and therapeutic effects of percutaneous balloon-expandable vertebroplasty for the treatment of osteoporotic vertebral compression fractures in the elderly. Methods In 30 patients with osteoporotic vertebral compression fractures in the elderly, percutaneous puncture through the pedicle into the vertebral body was performed under the surveillance of C-arm X-ray machine, and a balloon was placed to expand and inject polymethylmethacrylate (pmma), and each vertebral body was filled with an average of about 5 ml of pmma. results All 30 vertebroplasty operations were successful, pain symptoms began to be relieved 4-6 h after surgery, and hospitalization was 7-10 days after surgery. At a follow-up of 6 to 18 months, with an average of 12 months, all patients returned to normal living conditions, with no recurrence of pain symptoms, basic correction of posterior synostosis deformity, and no serious complications such as spinal nerve injury, pulmonary embolism, or pmma leakage. Conclusion Percutaneous balloon dilatation vertebroplasty is a minimally invasive procedure for the treatment of osteoporotic vertebral compression fractures in the elderly, which can effectively relieve the pain caused by osteoporotic vertebral fractures, maintain the stability of the vertebral body and restore the height of the vertebral body, and is a new method that is simple, safe and effective.
[Keywords] Percutaneous balloon-expandable vertebroplasty; osteoporosis; compression fracture
Osteoporosis has become an important problem for human beings, especially for women after menopause, and the vertebral body is the most common site for fractures complicated by osteoporosis. 16% of women suffer from compression fractures of single or multiple vertebral bodies after menopause, and 700,000 cases of vertebral compression fractures caused by osteoporosis are reported each year in the United States alone, resulting in severe back pain, limited mobility, and even spinal cord compression due to fractures. The quality of life of patients is seriously affected. In 1987, Galibert et al. in France first reported the successful treatment of cervical vertebral hemangioma with percutaneous puncture injection of bone cement, which pioneered percutaneous vertebroplasty (PVP). In 1997, PVP was introduced and reported in the United States for the treatment of vertebral osteoporosis with compression fractures, and it was gradually taken seriously, and a “PVP fever” was rapidly formed. To date, PVP has been widely used to treat intractable pain caused by compression fractures including metastatic tumors of the vertebral body, hemangioma, myeloma, and osteoporosis.
Percutaneous balloon-expandable vertebroplasty is a micro-innovative technique in spinal surgery based on percutaneous vertebroplasty (PVP), which involves creating a working channel in the vertebral body, inserting an expandable balloon, restoring the height of the compressed vertebral body and forming a cavity with four walls of bone tissue, and then filling it with polymethylmethacrylate (pmma), a “bone cement “After filling the cavity with polymethylmethacrylate (pmma)—“bone cement” to relieve the pain caused by osteoporotic vertebral fracture, maintain the stability of the vertebral body, and achieve the purpose of correcting the posterior spinal deformity further than the PVP technique, it has become a new effective method for treating osteoporotic vertebral compression fracture in the elderly, and our department has used percutaneous balloon expansion vertebroplasty on 30 cases of osteoporotic vertebral fracture in the elderly since March 2007 Since March 2007, our department has been using percutaneous balloon-expandable vertebroplasty to treat 30 cases of osteoporotic vertebral fractures in the elderly, with satisfactory results.
1. Data and methods
1.1 General data There were 30 patients in this group, 11 males and 19 females, aged 63-80 years old, with an average of 70 years old. All patients had obvious pain symptoms in the injured vertebral region, and no obvious neurological symptoms and signs of spinal cord and nerve root compression. Bone density examination showed varying degrees of osteoporosis, CT showed that the posterior wall of the vertebral body was intact, single vertebral body compression in 25 cases, double vertebral body compression in 5 cases.
1.2 Surgical method: Prone position, local anesthesia, cardiac monitoring, bilateral transforaminal approach, C-arm X-ray machine to determine the position of the vertebral arch, the entry point is located in the left 10 points of the arch projection and the right 2 points, penetrate the cortex with a cortical opener, insert the guide needle, confirm the entry of the guide needle into the arch under fluoroscopy, establish a working channel, make a 0.5 cm incision on the skin with the guide needle as the center, and insert a 0.5 cm incision in the skin. Make a 0.5 cm incision in the skin centered on the guide needle, insert a dilatation tube to the anterior middle 1/3 junction of the vertebral body, place a working cannula, and repeatedly shape the channel with a filler in and out several times to make the inner wall of the channel smooth and avoid puncturing the balloon, then place the balloon and apply pressure until the end plate is elevated and the height of the vertebral body is restored satisfactorily, retract the balloon to the minimum volume of the vacuum, blend the pmma to the appropriate viscosity, inject it into the vertebral body with a filler and apply pressure in the lateral position. The filling and diffusion of pmma were monitored, and the injection volume was about 5 ml on average, and the vital signs were observed intraoperatively. Postoperatively, antibiotics were used to prevent infection, and the patient could walk on the ground 3 days after surgery, and radiographs and CT review were routinely performed.
2.Results
The average amount of pmma injected into each vertebral body was about 5 ml, and the operation time was 40-65 min, with an average of 55 min, with minimal bleeding. The postoperative radiographs and CT examinations showed that the height of the vertebral body was basically restored and the posterior protrusion deformity was basically corrected. The patients were hospitalized for 7 to 10 days (average 8 days) after surgery, and the follow-up period was 6 to 18 months (average 12 months), and all patients returned to normal living conditions without recurrence of pain symptoms.
3. Discussion
The clinical treatment of osteoporotic vertebral compression fractures in the elderly is generally divided into two categories: conservative treatment and surgical treatment. Traditional conservative treatment such as bed rest, taking pain-relieving drugs and wearing orthopedic braces, however, long-term bed rest can cause dysfunction of the body, accelerate the loss of bone mass and aggravate pain. Other treatments for osteoporosis, such as hormone therapy and calcium supplements, are effective in the long term, but have poor short-term analgesic effects. While traditional open surgery is traumatic and the internal fixation is prone to loosening, percutaneous balloon expansion vertebroplasty is a micro-innovative technique of spinal surgery developed on the basis of percutaneous vertebroplasty (PVP), in which a minimally invasive technique is used to place a balloon and inflate it under pressure until the end plate is elevated and the vertebral body height is restored satisfactorily, and a cavity is formed in the vertebral body, and polymethyl methacrylate (pmma ) — “bone cement” is injected into the vertebral body through the skin and arch to fill in the cavity, restore the height of the vertebral body, increase the strength of the diseased vertebral body, prevent further collapse and re-fracture of the vertebral body, correct posterior protrusion deformity, relieve pain and improve somatic function. It also avoids complications such as bone cement leakage, and the clinical results are satisfactory.
3.1 Indications and contraindications for percutaneous balloon-expandable vertebroplasty Indications for percutaneous balloon-expandable vertebroplasty include: compression fracture of the thoracolumbar segment of the spine due to osteoporosis, no combined neurological injury, the diseased vertebrae maintain at least 1/3 of the height of the original vertebrae, the compression height of the thoracic vertebrae is within 50%, and the lumbar vertebrae can be relaxed to 75%; pain symptoms are obvious, drugs are not effective, pain symptoms remain after conservative treatment The pain symptoms cannot be relieved or prevent complications that may arise from long-term bed rest; other causes of pain such as lumbar disc herniation are excluded by imaging; multi-segment compression fractures of the upper and lower adjacent vertebrae secondary to osteoporotic compression fractures. Contraindications include: severe compression fracture of the diseased vertebral body, collapse of more than 75% of the original vertebral body height; fracture line of the vertebral body passing through the posterior edge of the vertebral body on imaging, incomplete destruction of the posterior edge of the vertebral body; fracture with spinal nerve injury, coagulation dysfunction, bleeding tendency; poor general condition, unable to tolerate surgery; no conditions for emergency spinal decompression surgery.
3.2 Operational considerations
3.2.1 Percutaneous arch puncture technique and bone cement infusion technique The percutaneous balloon-expanded vertebroplasty approach requires the operator to have skilled spinal surgery and pedicle screw technique to ensure that the puncture needle accurately enters the vertebral body through the arch, and the puncture needle should reach the anterior 1/3 of the vertebral body because osteoporotic vertebral compression fractures rarely involve the posterior column structure, and pmma infusion into the anterior 1/3 of the vertebral body can make the vertebral body The injection of pmma into the anterior 1/3 of the vertebral body can increase the strength of the anterior column, improve the loading capacity, and contribute to the stability of the vertebral body, and also reduce the possibility of pmma leakage into the spinal canal. Theoretically, bilateral arch root injection of pmma can improve the degree of filling of the vertebral body, but some studies have shown that there is no difference in biomechanics and better pain relief between injection through one arch root and through bilateral arch root injection. We believe that the bilateral arch root route can increase the strength of the diseased vertebral body, so the bilateral arch root route was used in this clinical study. The viscosity of the injected material and the injection pressure should be mastered, too dry can not be injected into the vertebral body, too thin in liquid form is easy to leak, and extremely fine powder particles can cause complications such as pulmonary embolism. The injection volume and filling rate are not proportional to the pain relief, but are related to the distribution of the injected material in the vertebral body. The filling volume or complete filling of the vertebral body should not be pursued excessively, and it is enough for the injected material to cross the midline and reach the contralateral side, and the amount of pmma should not be increased blindly to increase the chance of complications.
3.2.2 Balloon expansion technique for vertebral body repositioning The presence of posterior spinal deformity in elderly patients with osteoporotic vertebral compression fractures makes the patient’s center of weight-bearing shift forward and easy to lose balance, increasing the risk of falling, and also increases the load on the vertebral body due to the change of the center of weight-bearing, making the vertebral body prone to fracture, so restoring the height of the vertebral body and correcting the posterior deformity is the main purpose of this treatment, so the compressed vertebral body must be clearly To obtain satisfactory repositioning, indicators for stopping balloon expansion and measures to prevent balloon rupture.
(1) The fracture has been repositioned;
(2) The balloon is dilated to the endplate;
(3) The balloon is in contact with the cortex on one side;
(4) The balloon is at maximum volume and pressure;
(5) The channel is shaped so that the inner wall is smooth, allowing the balloon to enter the vertebral body smoothly;
(6) Slowly pressurize rather than rapidly pressurize to prevent uneven expansion of the balloon due to different surrounding bone density and puncture.
Percutaneous balloon expansion vertebroplasty is a minimally invasive spinal surgery for the treatment of osteoporotic vertebral compression fractures in the elderly, which can effectively relieve the pain caused by osteoporotic vertebral fractures, maintain the stability of the vertebral body, restore the height of the vertebral body and correct the posterior protrusion deformity, and is a new method that is simple, safe and effective.