Elsevier

World Neurosurgery

Volume 116, August 2018, Pages e1079-e1086
World Neurosurgery

Original Article
Long-Segment or Bone Cement–Augmented Short-Segment Fixation for Kummell Disease with Neurologic Deficits? A Comparative Cohort Study

https://doi.org/10.1016/j.wneu.2018.05.171Get rights and content

Highlights

  • Use of BCASSF was evaluated for treating Kummell disease with neurologic deficits.

  • Lower blood loss and shorter hospital stay was observed for BCASSF compared with LSF.

  • BCASSF and LSF had similar clinical outcomes and radiographic findings.

  • No differences were observed in operation time and complications between LSF and BCASSF.

  • BCASSF is better than LSF for treating Kummell disease with neurologic deficits.

Background

The standard treatment for Kummell disease with neurologic deficit remains controversial. Traditional posterior long-segment fixation (LSF) has been widely used, but the procedure results in significant trauma and carries the risk of multiple complications. Therefore, bone cement–augmented short-segment fixation (BCASSF) has been recommended for this condition.

Methods

The study included 36 patients treated with LSF or BCASSF between January 2012 and June 2015. The visual analog scale (VAS), Oswestry Disability Index (ODI) score, anterior height of fractured vertebrae, kyphotic Cobb angle, and neurologic function by the Frankel classification were evaluated and compared, and duration of operation, blood loss, length of hospital stay, and complications were recorded.

Results

Significant differences were observed in the VAS, ODI, anterior height of affected vertebrae, and kyphotic Cobb angle between preoperatively and 7 days postoperatively and between preoperatively and at the final follow-up, whereas no significant differences were observed between 7 days postoperatively and at final follow-up. No significant differences in the aforementioned parameters were observed between the groups at 7 days postoperatively and at the final follow-up. Neurologic function was improved in both groups; however, no significant differences were observed between the 2 groups either preoperatively or postoperatively. Blood loss and length of hospital stay were significantly lower in the BCASSF group compared with the LSF group, but no significant between-group differences were observed in operation time and complications.

Conclusions

Lower blood loss and shorter hospital stay were associated with BCASSF compared with LSF; the 2 techniques had similar clinical outcomes and radiographic findings. Therefore, we recommend BCASSF for treating patients with Kummell disease with neurologic deficits.

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.

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Conflict of interest statement: This study was supported by the National Natural Science Foundation of China (Grant 81772357).

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