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The clinical effect of different vertebral body height restoration rates after percutaneous kyphoplasty for osteoporotic vertebral compression fractures

BMC Musculoskeletal Disorders volume 25, Article number: 711 (2024) Cite this article

Abstract

Objective

This study aimed to evaluate the clinical effect of different vertebral body heights restoration rate after percutaneous kyphoplasty (PKP) for the treatment of osteoporotic vertebral compression fractures (OVCF).

Methods

The patients were divided into two groups according to the height restoration rate of the anterior edge of the vertebral body fracture after PKP operation using X-Ray imaging. The group A was below 80%, and the group B was above 80%. Clinical preoperative and postoperative efficacy (1st day, 1st month, 6th month, and 12th month after surgery) were evaluated according to VAS, Oswestry Disability Index(ODI), Quality of Life Questionnaire of the European Foundation for Osteoporosis(QUALEFFO), and Back Pain Life Disorder Questionnaire(RQD). Simultaneously, the preoperative and postoperative local Cobb angles and changes in the injured vertebrae in the two groups were calculated and analyzed.

Results

The postoperative Cobb angle in group A was significantly higher than that in group B. The correction rate in group B was significantly better than that in group A. The VAS, ODI, QUALEFFO, and RQD scores of group B patients were significantly lower than those of patients in group A at each follow-up time point. The correlation coefficients of vertebral body height restoration rate and VAS, ODI, QUALEFFO, and RQD scores at the last follow-up were − 0.607 (P < 0.01), -0.625 (P < 0.01), -0.696 (P < 0.01), and − 0.662 (P < 0.01), respectively.

Conclusions

The results of the correlation analysis between the vertebral body height restoration rate and the above clinical efficacy scores show that increasing the vertebral body anterior height restoration rate is beneficial for pain relief and improves the clinical efficacy of patients. Simultaneously, improving the height restoration rate of the anterior edge of the vertebral body and restoring the normal spinal structure is beneficial for reducing the incidence of refracture of the adjacent vertebral body.

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Introduction

At present, the main methods for the treatment of osteoporotic vertebral compression fracture (OVCF) are conservative treatment and surgical treatment, which are more suitable for no obvious vertebral body height loss, less severe pain, and intolerance to surgery. However, conservative treatment cannot quickly relieve low back pain and long-duration bed rest, which will further aggravate osteoporosis of the vertebral body and even the whole-body bones. Patients are prone to bedsores, hypostatic pneumonia, lower extremity venous thrombosis, cardiovascular disease, and long-term bed rest [1]. Surgical treatment is suitable for patients in whom conservative treatment is ineffective or unable to be performed. Patients with OVCF are often not suitable for traditional open restoration and pedicle screw internal fixation (ORIF) due to osteoporosis. Percutaneous vertebroplasty (PVP) and PKP have been widely used to treat osteoporotic vertebral compression fractures (OVCFs), which can stabilize fractures and relieve pain by injecting bone cement into the fractured vertebral body [2, 3]. Meanwhile, there may be disadvantages of adjacent segment degeneration and vascular and nerve damage due to bone cement leakage. Compared with PVP, PKP has more advantages in vertebral height restoration, kyphosis correction, and bone cement leakage [4, 5].

Although PKP has many advantages in vertebral height restoration. However, the restoration rate of vertebral body height has been controversial. Li et al. found that the risk of adjacent vertebral fractures was positively correlated with the degree of vertebral height restoration [6]. This may be due to biomechanical changes in spinal segment [7]. Kang et al. found that postoperative restoration of vertebral body height can increase the incidence of adjacent vertebral fractures in patients treated for severe vertebral body compression fractures [8]. Yoo et al. found that the excessive restoration of the height of the injured vertebral body was a risk factor for refracture of the adjacent vertebral body after operation [9]. The mechanism shows that the bone cement leaks into the intervertebral disc on the adjacent vertebral bodies, increasing the stress between the vertebral bodies. Therefore, it is possible that the excessively high restoration rate of the anterior vertebral body will bring great pressure to the adjacent vertebral bodies and further lead to refractures of the adjacent segments.

The above studies have shown that the degree of vertebral height restoration after PKP is related to the mechanics and refractures of adjacent segments, but whether the degree of vertebral height restoration also affects the clinical efficacy of PK is unknown. Preliminary investigations found that there were few studies on the correlation between the vertebral body height restoration rate and clinical efficacy. A study of 67 patients completed in 2014 found that PKP increased functional status while increasing vertebral body height, reducing pain scores, and analgesic drug usage [10]. Lee also reported that PKP can effectively relieve pain, reduce the height of the anterior edge, and maintain the kyphosis angle for the vertebral body with > 70% anterior edge compression ratio [11]. Feltes et al. found that PKP can relieve 90–100% of preoperative pain even without significant restoration of vertebral height [12].

In conclusion, this study aimed to investigate whether the restoration rate of different vertebral body heights is related to the clinical efficacy of PKP in the treatment of OVCFs.

Patients and methods

All patients were included in this study according to the following inclusion criteria: (1) acute or subacute non-high-energy external force-induced osteoporotic compression fractures; (2) edema hyperintense area on T2-weighted fat-suppressed (FS) MRI of the fractured vertebral body; (3) single-segment OVCF patients; and (4) more than one-year follow-up. The exclusion criteria were as follows: (1) traumatic compression fractures, burst fractures, chance, and other special types of fractures caused by high-energy trauma such as car accidents or falls from heights; (2) other pathological compression fractures; (3) spinal cord injury before and after PKP; (4) spinal tumor or metastatic cancer; (5) OVCF patients with two or more segments; and (6) preoperative immobility and other chronic pain conditions.

This clinical study was approved by the Ethics Committee of the First Affiliated Hospital of Soochow University (NO. SUDA202300781), and written informed consent was obtained from all subjects. Single-segment OVCF patients who underwent PKP in our department between January 2016 and December 2017 were retrospectively analyzed, and 528 patients with OVCF who had completed more than one year of follow-up survey were retrospectively analyzed. Single-segment OVCF patients were diagnosed via preoperative radiography, CT, and MRI. The patients were divided into two groups according to the difference in the anterior height restoration rate on the X-ray films on the first day after PKP: group A, the anterior height restoration rate was less than 80%; group B, the anterior edge height restoration rate was 80% and above, and the measurement and calculation method of the anterior vertebral height restoration rate are shown below.

All PKP surgical methods and procedures for patients with OVCF were performed at our department according to standard procedures [13]. Preoperative X-ray, CT, and MRI data were recorded. All patients received intravenous antibiotics for one d and their vital signs were closely monitored to observe the sensation and movement of the lower extremities and routinely change dressings. On the 1st day after surgery, the patients could wear a spine brace according to their waist size and get out of bed. Skin sutures are usually removed 14 days after surgery. Regular anti-osteoporosis therapy is continued after surgery as follows: Calcitriol Soft Capsules 0.25ug (R.P.Scherer GmbH & Co.KG) and Calcium Carbonate and Vitamin D3 Tablets (Wyeth, USA) 600D. Bone density is regularly elevated.

Based on the preoperative and postoperative X-ray results, the height of the anterior edge of the injured vertebra and the height of the adjacent upper and lower vertebral bodies were measured, based on the method described by Huang et al. The anterior edge height restoration rate = (postoperative height of the anterior edge of the injured vertebral body)/[(anterior edge height of the previous vertebral body + anterior edge height of the next vertebral body)/2]×100%; the measurement method is shown in Fig. 1. The fractured vertebral bodies were divided into two groups according to the difference in the anterior height restoration rate: group A, the anterior height restoration rate was less than 80%, and group B, the anterior height restoration rate was ≥ 80%. There was no significant difference in the mean time interval from fracture to surgery between the two groups. The age, sex, fracture segment, bone mineral density (BMD), amount of injected bone cement, presence or absence of bone cement leakage (including intervertebral space, paravertebral, spinal canal leakage, etc.), and presence of adjacent segment refractures of each group were recorded during the follow-up period, simultaneously. The preoperative and postoperative local Cobb angles of the injured vertebrae with its adjacent two vertebraes in the two groups were measured, and the changes recorded.

1. The measurement method is illustrated in Fig. 1. Finally, the correlation between the restoration rate of the anterior vertebral body height and the change in the Cobb angle was analyzed.

Fig. 1
figure 1

(A) Schematic diagram of the measurement of the change of the local Cobb angle of the injured vertebral body on X-ray films before and after PKP. The change of Cobb angle = a1-a2(°); (B) Schematic diagram of the measurement of the height restoration rate of the anterior edge of the injured vertebral body on the X-ray film after PKP. H0 = the Preoperative anterior edge height of the injured vertebral body; H1 = the anterior edge height of the superior adjacent injured vertebra; H2 = the anterior edge height of the next vertebral body adjacent to the injured vertebra; the restoration rate of the vertebral body height of the injured vertebra = H0/[(H1 + H2)/2] 100%

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All patients in the two groups were assessed using the relevant questionnaires under the guidance of physicians before surgery, on the 1st day, 1st month, 6th month and 12th month after PKP treatment. The questionnaires included the VAS score [14], the ODI [15], the QUALEFFO [16], and the RQD [17]. They are often used to evaluate postoperative pain, dysfunction, quality of life in patients with osteoporosis and physiological dysfunction. The scores of the two groups of patients at different follow-up time points were compared, and the correlations between the restoration rate of different vertebral body heights and clinical efficacy after 12 months of follow-up were analyzed.

All data were statistically analyzed using the statistical software sigmaplot14. Measurement data were expressed as mean ± SD, one-way analysis of variance was used for comparison between two groups, and the Chi-square test was used for comparison of enumeration data between the two groups. The correlation of ODI, QUALEFFO, and RQD was analyzed using the Pearson correlation test(P < 0.05) which indicated statistically significant differences.

Results

Among them, 182 were male and 346 were female. The average age of the fracture segments was 72.8 years old. Fractured segments: 114 cases were T6-T10, 373 cases were T11-L2, and 41 cases were L3-L5.

General information and comparison of postoperative complications

The statistical results of the basic data of the two groups of patients are shown in Table 1. There were no significant differences in age, sex, BMD value, amount of bone cement, or bone cement leakage between the two groups (P > 0.05). Adjacent segment refracture occurred in group A (20 cases) was significantly higher than that in group B (12 cases)(P < 0.01) during the follow-up period.

Table 1 The basic information of the two groups of patients and the statistical results of postoperative complications
Full size table

Comparison of Cobb angles between two groups

The preoperative and postoperative Cobb angles and changes in the two groups are shown in Table 2. The results showed that the preoperative Cobb angles of the two groups were 17.74 ± 2.29 and 18.17 ± 2.18(°), respectively, and there was no significant difference in the preoperative Cobb angles between the two groups (P > 0.05). The Cobb angle in group A was significantly higher than that in group B (11.92 ± 2.77 vs. 8.818 ± 2.69, P < 0.001). The Cobb angle change in group B was significantly higher than that in group A (9.35 ± 1.55 vs. 5.81 ± 1.44, P < 0.001).

Table 2 Comparison of Cobb angles and changes in the two groups before and after PKP surgery
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Correlation between Cobb angle change and restoration rate of vertebral body height

The correlation between the restoration rate of vertebral body height and the change in Cobb angle in all patients is shown in Fig. 2. The Pearson correlation coefficient (R) between the vertebral body height restoration rate and Cobb angle change was 0.667 (P < 0.001), indicating that the vertebral body height restoration rate was moderately correlated with the Cobb angle change.

Fig. 2
figure 2

Scatter plot of correlation between vertebral height reduction rate and Cobb angle modification in all patients

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Comparison of the clinical efficacy

The preoperative and postoperative VAS, ODI, QUALEFFO, and RQD scores of Groups A and B are shown in Tables 3 and 4, respectively. Preoperative: There was no significant difference between the preoperative VAS, ODI, QUALEFFO, and RQD scores in the two groups. The VAS, ODI, QUALEFFO, and RQD scores of patients in group B were significantly lower than those in group A at each follow-up time point, indicating that patients in group B had more significantly relieved of pain and improved self-care ability and quality of life than those in group A, when measured from the first postoperative day to the end of follow-up period.

Table 3 Comparison of clinical efficacy scores of patients in group A before PKP and during the postoperative follow-up period
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Table 4 Comparison of clinical efficacy scores of patients in group B before PKP and during the follow-up period after PKP.
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Correlation analysis of vertebral body height restoration rate and clinical efficacy score

We performed a Pearson correlation analysis between the restoration rate of vertebral body height and the clinical efficacy scores of VAS, ODI, QUALEFFO, and RQD at the 12-month follow-up (Fig. 3). The results showed that the correlation coefficients between vertebral body height restoration rate and VAS, ODI, QUALEFFO, and RQD scores were − 0.607 (P < 0.01), -0.625 (P < 0.01), -0.696 (P < 0.01) and − 0.662 (P < 0.01), respectively. (Fig. 3A-D indicates that the restoration rate of vertebral body height was moderately correlated with the postoperative clinical efficacy scores of VAS, ODI, QUALEFFO, and RQD (P < 0.01).

Fig. 3
figure 3

The correlation scatter plot results of VAS (A), ODI (B), QUALEFFO (C), and RQD(D) between the restoration rate of anterior vertebral body height and clinical efficacy at 12 months after operation in all patients

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Typical cases

A 72-year-old male patient presented with low back pain after a fall one day previously. Admission diagnosis: T12 osteoporotic vertebral compression fracture. The preoperative T12 local Cobb angle was 17°(Fig. 4A) and the preoperative average BMD of the lumbar spine was − 2.5. Routine preoperative examination was performed, and there were no obvious surgical contraindications. PKP (T12) was administered successfully. The local kyphosis Cobb angle at T12 was 15°on the 1st postoperative day (Fig. 4B), and the change was only 2°. The height restoration rate of the anterior edge in the T12 vertebral body was 1.96/[(2.65 + 2.98)/2] 100% = 69.6% (Fig. 4B). Regular postoperative anti-osteoporosis therapy was administered. The patient developed back pain without obvious trauma for than one month after surgery. The L1 vertebral body displayed compressibility changes on radiography after admission (Fig. 4C). Hyperintensity of edema on fat-suppressed T2-weighted sequences was observed in the patient. This revealed a fresh L1 vertebral compression fracture (Fig. 4D). The patient suffered a secondary fracture of the adjacent vertebral body after PVP because the height of the anterior vertebral body was insufficiently reduced (69.6%), and the Cobb angle change was insufficient (only 2°).

Fig. 4
figure 4

The preoperative X-ray Cobb angle of the typical patient. (A) The Cobb angle and the anterior edge height of the injured vertebra on the first day after PKP. (B) One month after the operation, the X-ray showed the compressive changes of the L1 vertebral body. (C) The MRI fat-suppressed image showed the high signal of the L1 vertebral body edema. (D) Fresh vertebral compression fractures (VCFs) at L1 vertebral body

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Discussion

The study of the correlation between vertebral body height restoration rate and clinical efficacy after PKP is limited. Some reports found that the influencing factors of vertebral height restoration rate included age, sex, duration of disease, degree of vertebral compression, degree of osteoporosis, presence or absence of spinal deformity, degree of Cobb angle, surgical approach, and surgical timing. Among them, the degree of vertebral body compression, osteoporosis degree, and fracture type are the main factors affecting vertebral body height restoration. The reasons are summarized as follows: (1) the degree of vertebral body compression is severe, the bone structure is damaged more, the balloon expansion space is large, and the vertebral body height is likely to recover; (2) the degree of vertebral body osteoporosis is severe, and the trabecular bone is severe. The structure is sparse, and the balloon expansion resistance is small, which is beneficial to the elevation of the upper and lower endplates; (3) in the acute stage, the organized hematoma is less at the fracture ends and the restoration is easy.

The main imaging change after PKP is the recovery of vertebral body height, which is accompanied by the relief of the patient’s low back pain. At present, the correlation between vertebral body height recovery and clinical efficacy after PKP has been proved, but whether the degree of vertebral body height recovery is also related to clinical efficacy is still controversial. The main reasons for restoring vertebral body height include [18]: (1) preventing local angular kyphosis; (2) reducing subsequent complications caused by kyphosis; (3) restoring the biomechanics of the vertebral body and reducing adjacent vertebrae body fractures; (4) improving the clinical efficacy. The relationship between the recovery degree of vertebral body height and clinical effect in PKP has been controversial. The lower limit of the perfect anterior vertebral height restoration rate should be able to effectively relieve pain and ensure the biomechanical properties of the spine, and the upper limit, should be the lowest height restoration rate that may cause complications such as bone cement leakage or adjacent vertebral fractures, there is still no consensus on the perfect vertebral body height restoration rate. Kao et al. reported [19] that to effectively relieve pain, the biomechanical properties of the injured vertebra after PKP should be restored to the same level as those without fracture. Kim et al. [20] reported that every 1% recovery of the height of the injured anterior vertebral body was associated with a 7-fold increase in the risk of adjacent segmental vertebral fractures. This is a contrary view as Lin et al. [21] considered that every 1°correction of the kyphosis angle increased the probability of refracture of the adjacent vertebral body by 9%. Li [22] and Kang et al. [23] found a positive correlation between the degree of vertebral height recovery and the risk of adjacent vertebral fractures, which may be related to biomechanical changes in the spinal segment [24]. Yoo et al. [25] found that the height of the injured vertebral body caused by excessive repair after PKP surgery is a risk factor for adjacent vertebral fractures. Therefore, the reduction rate of vertebral height is crucial, and either too low or too high is not appropriate.

Many previous studies were mainly based on the biomechanical effects of different degrees of vertebral body height restoration on adjacent segments during PKP. However, there are very few studies on the correlation between the degree of vertebral body height restoration and clinical efficacy, and only James et al. [26] reported in 2019 that PKP can effectively improve vertebral body height and improve clinical efficacy; however, there is no clear correlation between the degree of vertebral body height restoration and clinical efficacy. Therefore, the significance of this study is to explore the correlation between different degrees of vertebral body restoration and clinical efficacy after PKP.

In our study, pearson correlation analysis indicated that the correlation coefficient R between the vertebral body height restoration rate and the Cobb angle change in all patients was 0.667 (P < 0.001), indicating that the vertebral body height restoration rate was moderately correlated with the Cobb angle change. The correlation coefficients between the vertebral body height restoration rate and VAS, ODI, QUALEFFO, and RQD scores showed that the restoration rate of vertebral body height was moderately correlated with the postoperative clinical efficacy scores of the VAS, ODI, QUALEFFO, and RQD (P < 0.01).

This study had certain limitations. (1) This was a retrospective study with corresponding bias. A few parameters are included, which are prone to errors. Furthermore, the Cobb angle and height of the anterior vertebral body were measured manually using the PACS software, which is prone to measurement deviations. (2) The clinical efficacy scores were all in the form of questionnaires between doctors and patients, which are likely to cause memory errors in patients. (3) The last follow-up in this study was 12 months, and the average follow-up time was short. In future studies it will be necessary to conduct mid- and long-term follow-ups to evaluate clinical efficacy. (4) The classification of location of the vertebral fracture was lack.

Conclusion

The results of the correlation analysis between the vertebral body height restoration rate and the above clinical efficacy scores show that increasing the vertebral body anterior height restoration rate is beneficial for pain relief and improves the clinical efficacy of patients. Simultaneously, improving the height restoration rate of the anterior edge of the vertebral body and restoring the normal spinal structure is beneficial for reducing the incidence of refracture of the adjacent vertebral body.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to confidentiality but are available from the corresponding author on reasonable request.

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  1. Xiaolan Gu, Jiarong Li and Shenghong Wu contributed equally to this work.

Authors and Affiliations

  1. Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, 188 Shizi St, Suzhou, Jiangsu, 215006, China

    Xiaolan Gu, Yingjie Wang, Huilin Yang, Shaofeng Yang & Jun Zou

  2. Department of Orthopaedic Surgery, Taicang Affiliated Hospital of Soochow University, Taicang, Jiangsu, China

    Xiaolan Gu, Lijie Yuan & Luqiang Qu

  3. Department of Orthopaedic Surgery, Wuzhong People’s Hospital, Suzhou, Jiangsu, China

    Jiarong Li & Chunhua Sun

  4. Department of Anesthesiology and Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China

    Shenghong Wu

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Contributions

XG, JL and SW were responsible for design and drafting of the paper. LY, LQ and YW performed the data collection and statistical analysis. HY, SY, CS and JZ made critical revision of the manuscript for content. All authors read and approved the final manuscript.

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Correspondence to Shaofeng Yang, Chunhua Sun or Jun Zou.

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This clinical study was approved by the Ethics Committee of the First Affiliated Hospital of Soochow University (NO. SUDA202300781), and written informed consent was obtained from all subjects. All methods were carried out in accordance with relevant guidelines and regulations.

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Gu, X., Li, J., Wu, S. et al. The clinical effect of different vertebral body height restoration rates after percutaneous kyphoplasty for osteoporotic vertebral compression fractures. BMC Musculoskelet Disord 25, 711 (2024). https://doi.org/10.1186/s12891-024-07773-8

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BMC Musculoskeletal Disorders

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