THIEME 710 Technical Report GLOBAL SPINE JOURNAL Staged Correction of Severe Thoracic Kyphosis in Patients with Multilevel Osteoporotic Vertebral Compression Fractures Eyal Behrbalk1 OfirUri1 Yoram Folman1 Marcus Rickert2 Radek Kaiser2 Bronek Maximilian Boszczyk2 1 The Spine Unit, Hillel-Yaffe Medical Center, Hadera, Israel Address for correspondence Dr. Eyal Behrbalk, The Spine Unit, Hillel- 2 The Centre for Spinal Studies and Surgery, Queen’sMedicalCentre, Yaffe Medical Center, Ha-Shalom Street, Hadera, 38100, Israel Nottingham, United Kingdom (e-mail: [email protected]). Global Spine J 2016;6:710–720. Abstract Study Design Technical report. Objective Multilevel osteoporotic vertebral compression fractures may lead to con- siderable thoracic deformity and sagittal imbalance, which may necessitate surgical intervention. Correction of advanced thoracic kyphosis in patients with severe osteo- porosis remains challenging, with a high rate of failure. This study describes a surgical technique of staged vertebral augmentation with osteotomies for the treatment of advanced thoracic kyphosis in patients with osteoporotic multilevel vertebral compres- sion fractures. Methods Five patients (average age 62 Æ 6 years) with multilevel osteoporotic vertebral compression fractures and severe symptomatic thoracic kyphosis underwent staged vertebral augmentation and surgical correction of their sagittal deformity. Clinical and radiographic outcomes were assessed retrospectively at a mean postoper- ative follow-up of 34 months. Results Patients’ self-reported back pain decreased from 7.2 Æ 0.8 to 3.0 Æ 0.7(0to 10 numerical scale; p < 0.001). Patients’ back-related disability decreased from 60 Æ 10% to 29 Æ 10% (0 to 100% Oswestry Disability Index; p < 0.001). Thoracic kyphosis was corrected from 89 Æ 5 degrees to 40 Æ 4 degrees (p < 0.001), and the Keywords sagittal vertical axis was corrected from 112 Æ 83 mm to 38 Æ 23 mm (p ¼ 0.058). ► thoracic kyphosis One patient had cement leakage without subsequent neurologic deficit. Decreased ► severe osteoporosis blood pressure was observed in another patient during the cement injection. No ► osteoporotic correction loss, hardware failure, or neurologic deficiency was seen in the other patients. fractures Conclusion The surgical technique described here, despite its complexity, may offer a ► deformity correction safe and effective method for the treatment of advanced thoracic kyphosis in patients ► staged procedure with osteoporotic multilevel vertebral compression fractures. Introduction midthoracic vertebrae are the most commonly involved vertebrae, causing a loss of lumbar lordosis and/or increased – Vertebral compression fractures are frequent in patients with thoracic kyphosis, leading to positive sagittal balance.1 3 osteoporosis. The estimated occurrence is 15% in females and Frequent sequelae are back pain, early muscle fatigue, ambu- 5% in males of Caucasian origin.1,2 The thoracolumbar and lation difficulty, and substantial decrease in quality of life.1,4,5 received DOI http://dx.doi.org/ © 2016 Georg Thieme Verlag KG September 5, 2015 10.1055/s-0035-1569460. Stuttgart · New York accepted after revision ISSN 2192-5682. October 5, 2015 published online December 2, 2015 Staged Correction of Severe Thoracic Kyphosis Behrbalk et al. 711 Conservative treatment includes immobilization, analge- the whole spine and pelvis (for assessment of sagittal balance sia, and physiotherapy as well as antiresorptive and anabolic parameters), and magnetic resonance imaging of the whole medications, which may reduce the risk of future fractures spine (►Fig. 1). and kyphosis progression.6,7 If conservative treatment fails, unhealed fractures can be managed surgically by performing Surgical Considerations percutaneous vertebral cement augmentation. Cement injec- Preoperative planning was performed using whole-spine tion may restore vertebral height and provide rapid analgesia unsupported standing radiographs and magnetic resonance – and functional improvement.8 13 However, in the case of imaging. Multiple chevron osteotomies around the apex multiple healed (old) osteoporotic fractures with established vertebra were planned based on deformity shape and the kyphotic deformity and sagittal imbalance, more extensive amount of sagittal balance correction required, assuming intervention may be indicated. correction of 5 to 8 degrees per osteotomy.24 In the cases Several surgical techniques have been described for the of vertebral collapse with a sharp thoracic kyphotic angle, a correction of symptomatic sagittal imbalance in patients with pedicle subtraction osteotomy (PSO) without vertebral body – osteoporosis.12 14 These techniques usually involve lumbar augmentation was planned.24 To minimize the risk of failure subtraction osteotomy with fusion of the construct to the S1 in the osteoporotic spine, the fusion included at least three and the pelvis.15,16 Although effective in restoring sagittal levels above and below the last osteotomized vertebrae to balance, spinal pelvic fusion is associated with a high failure avoid ending the instrumentation at or near a kyphotic rate and the loss of movement in all the lumbar motion segment.20,22,25 Cement augmentation of the vertebrae was segments.17 Moreover, the correction of the sagittal balance performed to increase the pedicle screw pullout strength, alone by lumbar osteotomy does not address the cosmetically restore vertebrae stiffness to its prefractured values, and disturbing thoracic hump. Because pedicle screw loosening prevent new formation of adjacent-level fractures. As stiff- and adjacent-level vertebral body fracture are common ness of the vertebral body is strongly influenced by the among patients with osteoporosis, surgeons tend to avoid volume of cement injected and 14 to 16% of vertebral body – correction of these challenging cases.18 23 volume fill was shown to restore stiffness to the predamaged This study presents our staged surgical correction tech- values, vertebrae bodies were augmented with a minimum of nique and preliminary outcomes in a group of patients whose 6 mL per level of cement in the lumbar vertebrae and a – life quality was severely affected by their thoracic deformity minimum of 4 mL per level in thoracic ones.21,26 28 Augmen- and sagittal imbalance as a result of their multilevel osteopo- tation was performed at all levels involved in the fusion and at rotic vertebral compression fractures. the very least in the first mobile vertebrae below the fusion mass (transition vertebrae are prone to develop new frac- 20–23,28–30 ’ Materials and Methods tures). At the surgeon s discretion, one vertebra may be left uncemented (usually L3 or L4) to allow for future Patient Population PSO. Five patients (two women and three men, average age 62 Æ 6 Several studies showed direct correlation between the years) with multiple osteoporotic vertebral compression volume of cement injection and occurrence of pulmonary fractures (four or five levels involved) and severe symptom- fat emboli and systemic hypotension. To reduce these risks, atic thoracic kyphosis (an average kyphosis of 89 Æ 5de- only 30 mL of cement was injected per procedural stage.31,32 grees) underwent staged surgical correction of their spinal Because fat embolism syndrome can develop 12 to 36 hours deformity, and results were reviewed at a mean of 34 Æ 5 after surgery (e.g., petechial rash, tachypnea, dyspnea, tachy- months (►Table 1). The study was conducted as a retrospec- cardia, pyrexia, oliguria, thrombocytopenia),32,33 we waited tive case series and as such, Institutional Review Board at least 3 days before proceeding with the next stage. Aug- approval was not needed. The indications for surgery were mentation of several vertebrae per stage may be a prolonged back pain with severe thoracic deformity causing sagittal procedure, thus we preferred to perform vertebral augmen- imbalance and related disability (difficulty in ambulation tation under general anesthesia rather than sedation. The and in activities of daily living) and evidence of kyphosis number of stages required was based on the patients’ medical progression due to new osteoporotic fractures seen on con- condition to withstand a long operation and on the number of secutive radiographs. For all patients, pain and disability did vertebrae needed to be augmented before the final deformity not diminish with nonoperative treatment over a period of at correction. Between stages, the patients were discharged least 12 months. None had a neurologic deficit. All had severe home (apart from patient 1 who remained in the hospital osteoporosis (an average T-score of À3.2 Æ 0.3, range À2.8 to between his third and forth stages). A detailed description of À3.6) secondary to long-standing corticosteroid use, which the surgical steps for each patient is presented in ►Table 2. was prescribed as an adjunct to chemotherapy for two The pros and cons of a staged procedure, including the patients with multiple myeloma and as immunotherapy for risks of repeated anesthesia, long operations, and reopening three patients (two with rheumatoid arthritis and one with the same surgical wound, were discussed thoroughly with the inflammatory bowel disease). The preoperative assessment patients preoperatively. All of the patients understood the included a detailed physical examination, dual-energy X-ray complexity of the procedure and the involved risks. Never- absorptiometry scan for bone density measurement, stand- theless, due to the severity of their