Treating Osteoporotic Spinal Fractures in Elderly Patients via a Modified Clinical Bone Cement Injection Technique

Summary

Presented here is a modified procedure for minimally invasive injections of bone cement to treat osteoporotic spinal fractures in elderly patients.

Abstract

The minimally invasive injection of bone cement (MIIBC) is an effective way to treat senile osteoporotic spinal fractures (OSF) in clinical practice. However, the intraspinal dura and nerves may be damaged when the puncture needle passes through the pedicle. Therefore, in this protocol, the puncture site was optimized during the surgery, selecting the same 1-2 cm away from the surface projection of the diseased vertebra. The needle was punctured along the lateral cortex of the pedicle from the junction of the pedicle and the vertebral body into the vertebral body. Meanwhile, bone cement was used as a filling material, and the MIIBC was performed by a percutaneous puncture at the external edge of the pedicle under C-arm fluoroscopy. This modified puncture site is far away from the spinal canal as possible, thereby reducing the risk of the puncture needles penetrating the spinal canal and damaging the nerves and dura mater. In conclusion, a modified MIIBC by percutaneous lateral pedicle puncture can effectively relieve pain in elderly patients with OSF.

Introduction

Osteoporosis is a common disease among middle-aged and elderly women. Statistics show that about 54% of postmenopausal women have abnormal bone density, and the chance of vertebral fracture over the age of 50 is about 32%¹. Osteoporotic spinal fractures (OSF) occur most commonly in women and are mainly compression fractures caused by direct or indirect external forces^1,2. After the fracture, the sagittal balance of the spine is broken, resulting in vertebral deformation, diffuse lumbar and back pain, and kyphosis². In addition, some patients also experience abdominal pressure and breathing difficulties³. Clinical trials have reported that the key to the treatment of OSF is the restoration of bone continuity⁴. Without effective and timely treatment for OSF patients, it is easy for spinal deformities, secondary nerve injury, spinal canal stenosis, angulation deformity, delayed fracture healing, and bone nonunion to occur, and the lives of the patients may even be threatened⁵.

Current clinical treatments for OSF include conservative treatment and surgical treatment⁶. Although the conservative treatment of OSF can provide temporary relief of the symptoms, the course of treatment is long, and the recovery of the injured vertebral height is poor⁷. Overall, the traditional conservative treatment of OSF requires patients to stay in bed for a long time, and its overall efficacy is not ideal. For now, clinical, surgical treatment for OSF embraces traditional open internal fixation, Sextant minimally invasive pedicle screw fixation, percutaneous vertebroplasty (PVP), and percutaneous kyphoplasty (PKP)⁸. Similar to the conservative treatment of long-term bed rest, traditional open internal fixation can lead to aggravated osteoporosis, deep venous thrombosis of the lower limbs, lung infection, urinary tract infection, calculi and decubitus, and other complications, which seriously affect the quality of life of the patient and cause a high disability rate⁹. Nevertheless, Sextant minimally invasive pedicle screw fixation is a complicated operation with a long operation time, and the operation itself can further aggravate secondary injury of the diseased vertebra¹⁰. Obviously, the characteristics of lost vertebral bone density in senile OSF patients are more likely to lead to screw loosening and even removal, resulting in the failure of the internal fixation surgery¹¹.

As commonly used clinical treatments for a senile osteoporotic spinal fracture, PVP and PKP can restore vertebral function and improve the mobility of patients with higher surgical safety and better postoperative pain relief. However, the merits and demerits of both in treating osteoporotic spinal compression fractures are still debated. High-pressure perfusion in PVP surgery can cause leakage of the bone cement into the vertebrae, thus damaging the spinal cord and nerve roots and reducing the surgical effect to a certain extent¹². Compared with PVP, PKP can observably reduce and avoid the risk of bone cement leakage, but the operation is longer¹³. Inevitably, the use of a balloon to dilate the diseased vertebra during PKP surgery also carries a potential risk of secondary vertebral injury¹⁴. Therefore, in this study, on the basis of PVP, elderly patients with OSF were treated by optimizing the puncture site during surgery, thus avoiding the risk of the spinal cord and nerve injury caused by the puncture itself. In this protocol, the case of a 68-year-old female patient with OSF who underwent a modified minimally invasive injection of bone cement (MIIBC) for the treatment of a seventh thoracic vertebra fracture is presented in detail.

Protocol

The surgical operation using MIIBC for the treatment of an osteoporotic fracture of the seventh thoracic vertebra in a 68-year-old woman was approved by the Ethics Committee of Linfen People's Hospital of Shanxi Medical University (T20220829006). The patient provided written informed consent. 1. Collection and recording of the patient's medical history Communicate with the patient to determine the history of trauma, heavy lifting, bumpy rides, jerking, or e…

Representative Results

The OSF patient selected for the modified MIIBC had no history of trauma, heavy lifting, bumpy rides, jerking, or even coughing. Further physical examination showed that the patient had no percussion pain or pressing pain in the chest, waist, or back and had normal sensation and movement in the lower limbs. A new vertebral fracture was first identified in the seventh thoracic vertebra with perivertebral edema using MRI imaging (Figure 1). After that, the X-ray examination demonstrated a vert…

Discussion

Traditional open internal fixation is used with patients who have the neurological symptoms of a vertebral compression fracture and a fractured mass entering the spinal canal and pressing on the spinal cord and nerve roots¹⁵. This technique is especially suitable for individuals with severe violent vertebral trauma, such as from a car accident or falling from height. This kind of emergency surgery usually requires spinal canal decompression, which has a long operation time and a large area of trau…

Materials

Bone cement	Heraeus Medical GmbH	61805335
Chest pad	Hengshui Hejia Medical Device Co., Ltd.	1.00297E+13
Computed tomography instrument	General Electric Company	Discovery  CT750 HD
Dualenergy X-ray absorptiometry	General Electric Company	Discovery  XR656
Kirschner wire	Tianjin Yutong Medical Device Factory	210401
Lidocaine	Shiyao Silver Lake Pharmaceutical Co., Ltd.	C22B042
Nuclear magnetic resonance apparatus	General Electric Company	Achieva 1.5T
Povidone iodine solution	Wen Shui Greatly Industrial Co., Ltd.	20220801
Puncture needle	Dragon Crown Medical Co., Ltd.	22040601
Soft pad	Yueyang Zhengyang Medical Device Co., Ltd.	HRT445
Sterile covering	Suqian Hongzhilong E-commerce Co., Ltd.	56200331882
Sterile surgical gauze	Hainuo Group Co. Ltd.	7918087
Surgical hammer	Hengshui Wankai Trading Co., Ltd.	5.20808E+11
Syringe	Shandong Weigao Group Medical Polymer Co., Ltd.	20220101
Vertebroplasty bone cement filler set	Shenzhen Hanqiang Medical Device Co., Ltd.	TF210301
X-ray instrument	Shenzhen Rayvision Technology Co., Ltd.	ALC-200H