Refracture of osteoporotic vertebral body after treatment by balloon kyphoplasty: Three cases report

Abstract

Rationale: Balloon kyphoplasty is a widely accepted treatment of osteoporotic vertebral compression fractures (OVCFs) with good results and a low risk for complications. A refracture of previously treated vertebra is a relatively rare condition.

Patient concerns: We reported our 3 cases and reviewed all relevant literatures of 11 cases with refracture of osteoporotic vertebral body after kyphoplasty.

Diagnoses: Follow-up radiographs or magnetic resonance imaging examination confirmed refractures of previously treated vertebrae after kyphoplasty.

Interventions: One patient with 1 refracture of osteoporotic vertebral body after kyphoplasty was treated conservatively, but the other 2 patients were treated surgically because of multiple vertebral fractures or neurological deficits.

Outcomes: The average age of the patients was 76.8 years (range, 63-86 years). All the patients had severe osteoporosis with a mean T-score of -3.46 (range -5.0 to -3.0). The sites of refractures are in the lumbar and thoracolumbar regions. Severe osteoporosis, the presence of intravertebral cleft, and a solid lump injection pattern of polymethylmethacrylate would result in insufficient strengthening effects of cement augmentation and therefore increased the likelihood of refractures of the kyphoplasty vertibrae.

Lessons: Patients with OVCFs and intravertebral cleft who did not obtain complete pain-relief at the treated vertebral level after kyphoplasty should be strictly followed up. Early finding of this condition and rapid intervention might contribute to avoiding the occurrence of the cemented vertebral refracture after kyphoplasty. Conservative treatments such as back brace and antiosteoporotic medications were strongly recommended.

Figure 1

A preoperative lateral radiograph: a compression fractured T12 vertebra with an intraosseous cleft (A). Anterior vertebral body height and kyphotic angle were notably corrected after kyphplasty (B). Two weeks later, an unfilling intraosseous cleft containing fluid with high-signal (C). One month later, the injected PMMA cement was condensed and reduced in size with slight anterior height loss (D). Ten months later, 1 significant compression fracture of T12 vertebral body (E). Sixteen months follow-up radiograph: bony union of T12 vertebral body (F). MRI: no bone marrow edema with high-signal at T2 image (G). MRI = magnetic resonance image, PMMA = polymethylmethacrylate.

Figure 2

A preoperative lateral radiograph: a compression fractured L3 vertebra with an intraosseous cleft (A). Kyphplasty was used to treat L3 OVCF with PMMA cement (B). Two months later, MRI confirmed that bone marrow edema around the cement with high signal at the previously treated L3 level (C). Two weeks later, repeated CT and MRI examination of the lumbar spine confirmed a L3 vertebral refracture and 1 new OVCF at L2 level with an intravertebral cleft (D, E). ECT image further confirmed a L3 vertebral refracture and 1 new L2 fracture (F). A kyphoplasty was used to treat L2 fracture and the pedicle screws reinforced with PMMA cement were inserted percutaneously at L1 and L4 levels (G). CT = computed tomography, ECT = emission computed tomography, MRI = magnetic resonance image, OVCF = osteoporotic vertebral compression fracture, PMMA = polymethylmethacrylate.

Figure 3

A postoperative lateral radiograph showed decompression and instrumented fusion for lumbar degenerative scoliosis (A). Four months after the primary operation, radiograph and MRI confirmed a L1 OVCF (B, C). L1 kyphoplasty with PMMA cement was performed (D). Three months later, repeated MRI demonstrated refracture of the L1 vertebral body with cement fragmentation, and resultant neural canal encroachment (E). One cage with autograft was inserted, and 6 pedicle screws combined with PMMA cement reinforcement were performed (F). MRI = magnetic resonance image, OVCF = osteoporotic vertebral compression fracture, PMMA = polymethylmethacrylate.

Figure 4

An illustration of the kyphoplasty process in the treatment of 1 OVCF with an intravertebral cleft. One OVCF with an intravertebral cleft (A). The expansion of the balloon tamp within the cleft mainly pushed the fractured segments up and down (B). After that, the vacuum was produced at the site of a previous intravertebral cleft. OVCF = osteoporotic vertebral compression fracture.