Elsevier

The Spine Journal

Volume 13, Issue 12, 1 December 2013, Pages 1726-1732
The Spine Journal

Clinical Study
Anterior decompression and strut graft versus posterior decompression and pedicle screw fixation with vertebroplasty for osteoporotic thoracolumbar vertebral collapse with neurologic deficits

https://doi.org/10.1016/j.spinee.2013.05.041Get rights and content

Abstract

Background context

With the increase of the elderly population, osteoporotic vertebral fractures have been frequently reported. Surgical intervention is usually recommended in osteoporotic vertebral collapse with neurologic deficits. However, very few reports on surgical interventions exist.

Purpose

To compare surgical results of anterior and posterior procedures for treating osteoporotic thoracolumbar vertebral collapse with sustained neurologic deficits.

Study design

Retrospective comparative study.

Patient sample

Fifty patients who sustained osteoporotic thoracolumbar vertebral collapse with neurologic deficits were treated either by anterior decompression and strut graft (n=32) or by posterior decompression and pedicle screw fixation with vertebroplasty (n=18).

Outcome measures

Incidence of complications, sagittal Cobb angle, spinal canal encroachment, and Japanese Orthopedic Association score.

Methods

The authors retrospectively reviewed the results of a consecutive series of patients undergoing anterior decompression and strut graft or posterior decompression and pedicle screw fixation with vertebroplasty for osteoporotic thoracolumbar vertebral collapse with neurologic deficits. Operative notes, clinical charts, and radiographs were analyzed.

Results

Operative time was similar between the groups, but intraoperative blood loss was significantly lower in the posterior group. All patients showed neurologic recovery. No significant difference was observed in the neurologic improvement, kyphosis correction angle, and loss of correction. Perioperative respiratory complications were found in 11 patients (34%) in the anterior group. In the anterior group, early posterior reinforcement was required in patients with very low bone density below 0.60 g/cm2 and/or in those with three segments of instrumentation for two vertebral collapses. Posterior group patients did not undergo additional surgery.

Conclusions

Anterior reconstruction for osteoporotic vertebral collapse is significant because anterior elements, particularly those at the thoracolumbar junction, play a major role in load bearing. However, difficulties arise when anterior reconstruction is performed in cases with very low bone density and in those with multiple vertebral collapse.

Introduction

Evidence & Methods

Posterior decompression, vertebral augmentation, and pedicle screw instrumentation is being used more frequently for osteoporotic burst fractures. The authors compare their outcomes with the more traditional anterior corpectomy approaches.

In this retrospective cohort of consecutive cases, the authors found that blood loss, need for revision surgery, and respiratory complications were higher in the anterior group while outcomes were otherwise comparable between groups.

While ideally an RCT or well-matched cohort study would have better answered this question, the findings are commensurate with many surgeons’ experiences. Taking down the diaphragm and obtaining good fixation anteriorly can be difficult in this population and associated with complications. Alternatively, decompression and anterior column support can often be obtained adequately with vertebroplasty or kyphoplasty through an all-posterior approach. The publication of additional series with similar results may make equipoise difficult for higher level investigation.

The number of patients with osteoporosis is increasing, especially in developed countries [1], [2]. Patients with femoral neck fractures are immediately at an increased risk of fatality and have disrupted activities of daily living [3]. The magnitude of these clinical effects has led to the implementation of intensive preventive therapy. There is a high incidence of osteoporotic vertebral compression fractures among patients with osteoporosis; however, sufficient research and preventive measures have not been undertaken, probably because the disease has relatively mild symptoms and the response to conservative treatment is good. If appropriate medical treatment is not given to elderly patients with fracture, their quality of life (QOL) will eventually deteriorate [4]. Worsening truncal ataxia with kyphosis and neurologic disorders resulting from progressive vertebral collapse are cited as the two major causes of decreased QOL in elderly patients [5].

Osteoporosis impairs healing of vertebral compression fractures, causing a decrease in vertebral body and intervertebral disc height and aggravating local kyphosis, eventually resulting in spinal column instability [6], [7], [8], [9]. Surgical intervention is highly recommended for patients with this delayed vertebral collapse with sustained neurologic deficit. The advantages of anterior instrumentation surgery with a vertebral spacer are direct resection of the retropulsed bony fragment and the reconstruction of the stable anterior spinal column [8], [10], [11]. Conversely, with the advent of new posterior instrumentation techniques and increasing experience with vertebroplasty, a greater percentage of surgeries can be performed from all posterior approaches [12]. Recently, there have been several reports trying one-stage posterior decompression and stabilization with vertebroplasty in the treatment of osteoporotic vertebral collapse [9], [13].

Although the number of reports describing osteoporotic vertebral fracture has been steadily increasing, there have been only two reports comparing surgical results of anterior and posterior procedures for the treatment of osteoporotic vertebral collapse [14], [15]. This study aimed to compare surgical results of anterior and posterior procedures for treating osteoporotic thoracolumbar vertebral collapse with sustained neurologic deficits and provide a detailed explanation of the associated problems.

Section snippets

Materials and methods

After obtaining the approval of the institutional review board, 50 patients (43 women, 7 men; mean age 70.9 years; range 53–89 years) who underwent surgery for osteoporotic thoracolumbar vertebral collapse with sustained neurologic deficits were analyzed retrospectively. Every patient had body collapse at one or two continued vertebral body level. Surgical indication for this study was vertebral collapse in thoracolumbar spine with neurologic problems with difficulty in walking because of

Patient demographics

No significant differences were observed between the two groups with respect to age, sex, injury-surgery duration, BMD, preoperative JOA score, or follow-up period (Table 1). The number and levels of the collapsed vertebrae in each group were also shown in Fig. 2. In the anterior group, the mean operative time was 219 minutes (range 132–306 minutes) with a mean blood loss of 708 mL (range 90–2,000 mL). Mean operative time was 218 minutes (range 140–320 minutes) in the posterior group with

Discussion

Vertebral bodies progressively collapse in 36.6% patients with compression fractures, and 13.9% of the patients develop pseudarthrosis [22]. Results of a multicenter investigation revealed that 5.3% patients hospitalized for osteoporotic vertebral fractures showed neurologic disorders [23]. These neurologic disorders involved in osteoporotic vertebral collapse were because of neural compression by retropulsed bony fragments from the delayed collapsed vertebral body or by kyphosis with

Conclusions

Osteoporotic vertebral collapse is associated with impaired fracture healing. Neurologic disorders involved in osteoporotic vertebral collapse occur because of spinal instability, pseudarthrosis, and nerve and spinal cord compression occurring as a result of increased kyphotic deformity associated with delayed vertebral collapse and protrusion of the posterior vertebral body into the spinal canal. Anterior reconstruction is significant because anterior elements, particularly at the

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    FDA device/drug status: Approved (Kaneda anterior spinal instrumentation system; Harms cage; and calcium phosphate cement); Not applicable (Nesplon cable system).

    Author disclosures: HS: Nothing to disclose. MI: Nothing to disclose. KK: Nothing to disclose. KA: Nothing to disclose. YK: Nothing to disclose. KN: Nothing to disclose. AM: Nothing to disclose. NI: Nothing to disclose.

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