Surgical treatment of osteoporotic thoracolumbar compressive fractures with open vertebral cement augmentation of expandable pedicle screw fixation: a biomechanical study and a 2-year follow-up of 20 patients.
BACKGROUND
The incidence of screw loosening increases significantly in elderly patients with severe osteoporosis. Open vertebral cement augmentation of expandable pedicle screw fixation may improve fixation strength in the osteoporotic vertebrae.


METHODS
Twenty cadaveric vertebrae (L1-L5) were harvested from six osteoporotic lumbar spines. Axial pullout tests were performed to compare the maximum pullout strength (Fmax) of four methods: 1. Conventional pedicle screws (CPS), 2. Expandable pedicle screws (EPS), 3. Cement augmentation of CPS (cemented-CPS), 4. Cement augmentation of EPS (cemented-EPS). Thirty-six consecutive patients with single-vertebral osteoporotic compressive fractures received posterior decompression and spinal fusion with cemented-CPS (16 cases) or cemented-EPS (20 cases). Plain film and/or CT scan were conducted to evaluate the spinal fusion and fixation effectiveness.


RESULTS
The Fmax and energy absorption of cemented-EPS were significantly greater than three control groups. The mean BMD in the severe osteoporosis group was significantly lower than that in the osteoporosis group (t = 2.04, P = 0.036). In the osteoporosis group, cemented-EPS improved the Fmax by 43% and 21% over CPS and cemented-CPS group. In the severe osteoporosis group, cemented-EPS increased the Fmax by 59%, 22%, and 26% over CPS, EPS, and cemented-CPS, respectively. The clinical results showed that all patients suffered from severe osteoporosis. Six months after operation, the JOA and VAS scores in cemented-EPS group improved from 11.4 ± 2.6 and 7.0 ± 1.4 mm to 24.9 ± 1.6 and 2.1 ± 1.3 mm, respectively. No screw loosening occurred in the cemented-EPS group and spinal fusion was achieved. In the cemented-CPS group, four screws loosened (4.2%) according to the radiolucency. Six months after operation, the JOA and VAS scores improved from 13.1 ± 1.9 and 7.6 ± 1.5 mm to 22.8 ± 2.2 and 2.5 ± 1.6 mm, respectively. No cement leaked into the spinal canal in both groups.


CONCLUSIONS
Cemented-EPS could increase fixation strength biomechanically. It could reduce the risks of screw loosening in patients with severe osteoporosis, requiring instrumented arthrodesis.
Institute of Orthopedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi Province, PR China.
Zi-xiang
ZX
Wu
Ming-xuan
MX
Gao
Hong-xun
HX
Sang
Zhen-sheng
ZS
Ma
Geng
G
Cui
Yang
Y
Zhang
Wei
W
Lei
D000368:Aged; D000369:Aged, 80 and over; D001696:Biomechanical Phenomena; D001843:Bone Cements; D001863:Bone Screws; D002102:Cadaver; D004868:Equipment Failure; D005260:Female; D005500:Follow-Up Studies; D005593:Fracture Fixation, Internal / Q000295:instrumentation / Q000379:methods*; D050815:Fractures, Compression / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D016268:Internal Fixators; D008159:Lumbar Vertebrae / Q000000981:diagnostic imaging / Q000293:injuries* / Q000601:surgery; D008297:Male; D058866:Osteoporotic Fractures / Q000000981:diagnostic imaging / Q000601:surgery*; D019904:Polymethyl Methacrylate; D011859:Radiography; D012189:Retrospective Studies; D016103:Spinal Fractures / Q000000981:diagnostic imaging / Q000601:surgery*; D013904:Thoracic Vertebrae / Q000000981:diagnostic imaging / Q000293:injuries* / Q000601:surgery; D016896:Treatment Outcome
D001843:Bone Cements; D019904:Polymethyl Methacrylate