Original ArticleLong-Segment or Bone Cement–Augmented Short-Segment Fixation for Kummell Disease with Neurologic Deficits? A Comparative Cohort Study
Introduction
Kummell disease as a complication of osteoporotic vertebral fracture (OVF), also known as OVF nonunion, is an uncommon condition.1, 2, 3 Although most OVFs can be treated conservatively, approximately 10% or more develop nonunion.4 Patients often developed back pain after a mild trauma. Although the pain may disappear in weeks or months, in some cases back pain recurs and aggravates after a few months or years and is accompanied by activity limitation, progressive kyphosis, and even delayed neurologic deficits. Kummell disease was first described in 1891, and several studies have been conducted about this disease. However, to date, the pathology and pathogenesis of Kummell disease remain to be fully elucidated. Most researchers suggested that Kummell disease was secondary to an ischemic necrosis of the vertebral body, and the vascular injury was responsible for impaired bone healing.5, 6
The treatment strategy was controversial until now. For stage I and II Kummell disease, percutaneous kyphoplasty (PKP) or percutaneous vertebroplasty (PVP) has proven to be an effective, minimally invasive procedure.2, 7, 8 For patients with stage III Kummell disease with neurologic deficits, various open operations have been developed to treat this condition.9, 10, 11 Traditional posterior long-segment fixation (LSF) has been widely used. However, this procedure is associated with significant trauma and multiple complications, which are very worrisome in elderly patients with comorbidities. Therefore, some researchers have recently recommended posterior short-segment fixation (SSF) for this particular condition. However, patients with stage III Kummell disease have severe osteoporosis, and SSF carries a high risk of internal fixation failure.6, 11, 12, 13 To address these issues, posterior bone cement–augmented SSF (BCASSF) combined with vertebroplasty was first introduced for this particular condition.
There have been no previous comparative studies on the use of LSF and BCASSF to treat Kummell disease; thus, in this study, the efficacy of LSF and BCASSF in treating Kummell disease with neurologic deficits were evaluated and compared, and a reference for the selection of therapeutic methods was compiled.
Section snippets
Patient Population
A total of 36 patients with Kummell disease with neurologic deficits who were treated in our center between January 2012 and June 2015 were enrolled in this study. The study was approved by the Ethics Committee of Honghui Hospital, Xi'an Jiaotong University. Written consent was obtained from all patients. The 36 patients were divided into 2 groups (LSF and BCASSF) based on the surgical method used. Demographic data (patient age, sex, medical history, damaged segment, bone mineral density, and
Patient Characteristics
No statistically significant difference was observed in the general data (age, sex, medical history, damaged segment, bone mineral density, and duration of follow-up) between the 2 groups (Table 1). The follow-up period ranged from 18 to 48 months (mean, 32.9 ± 8.1 months) in the BCASSF group and from 18 to 46 months (mean, 31.7 ± 8.9 months) in the LSF group (Table 1). The mean duration of operation was 149.4 ± 9.9 minutes in the BCASSF group and 145.3 ± 8.8 minutes in the LSF group (P > 0.05;
Discussion
Kummell disease is rare, occurring mainly in women age >50 years.5 The thoracolumbar junction is the most commonly damaged segment.5, 14 The course of Kummell disease has 3 main stages. First, spinal vertebral bodies are slightly injured by a minor trauma or even without a history of trauma. Second, vertebral bodies experience dynamic instability in the IVC, followed by vertebral collapse. Third, vertebral bodies collapse further with posterior cortical breakage, leading to spinal cord
Conclusions
This study showed that both LSF and BCASSF for treatment of Kummell disease with neurological deficits are safe and effective. Compared with LSF, BCASSF had equivalent clinical outcomes and radiographic findings with decreased blood loss and shorter admission times. BCASSF is less invasive than LSF and can be very beneficial in elderly patients with comorbidities.
References (21)
- et al.
Percutaneous vertebroplasty versus balloon kyphoplasty for osteoporotic vertebral fracture with intravertebral cleft
Spine J
(2014) - et al.
Comparison between balloon kyphoplasty and short segmental fixation combined with vertebroplasty in the treatment of Kümmell's disease
Pain Physician
(2015) - et al.
Cement-augmented anterior reconstruction with short posterior instrumentation: a less invasive surgical option for Kummell's disease with cord compression
J Clin Neurosci
(2011) - et al.
Kyphoplasty for chronic painful osteoporotic vertebral compression fractures via unipedicular versus bipedicular approachment: a comparative study in early stage
Injury
(2010) - et al.
Characteristic radiographic or magnetic resonance images of fresh osteoporotic vertebral fractures predicting potential risk for nonunion: a prospective multicenter study
Spine (Phila Pa 1976)
(2011) - et al.
A review of osteoporotic vertebral fracture nonunion management
Spine (Phila Pa 1976)
(2014) - et al.
Percutaneous kyphoplasty for Kummell disease with severe spinal canal stenosis
Pain Physician
(2015) - et al.
Are intravertebral vacuum phenomena benign lesions?
Eur Spine J
(2011) Expert's comment concerning Grand Rounds case entitled “Kümmell's disease: delayed post-traumatic osteonecrosis of the vertebral body” (by R. Ma, R. Chow, F.H. Shen)
Eur Spine J
(2010)- et al.
A therapeutic efficacy of the transpedicular intracorporeal bone graft with short-segmental posterior instrumentation in osteonecrosis of vertebral body: a minimum 5-year follow-up study
Spine (Phila Pa 1976)
(2013)
Cited by (25)
Impending cauda equina syndrome due to Kummell disease; A case report and literature review
2021, International Journal of Surgery Case ReportsCitation Excerpt :The disease has some characteristic (non-diagnostic) features on imaging that help to differentiate it from post-traumatic kyphosis, infection, osteoporotic fracture, or metastatic involvement [4,5]. Most symptomatic patients show a satisfactory response to conservative or minimally invasive measures such as percutaneous vertebral body cement augmentation, but in those patients with neurological deficit, open surgery may be indicated [6–11]. Here, we reported a case of a 28 years-old man with KD who presented to us with impending cauda equina syndrome due to L5 involvement which is extremely rare in this disease [12].
Study on the Optimal Surgical Scheme for Very Severe Osteoporotic Vertebral Compression Fractures
2023, Orthopaedic SurgeryA comparative study of PSPVP and PSIBG in the treatment of stage II-III Kummell's disease
2023, Bio-Medical Materials and Engineering
Conflict of interest statement: This study was supported by the National Natural Science Foundation of China (Grant 81772357).