| Objective:To investigate the methods, efficacy, complications and precautions of percutaneous kyphoplasty for the treatment of benign and malignant VCFs, evaluate its clinical significance and the importance of percutaneous vertebral biopsy.Methods:(1)117patients including169thoracolumbar benign VCFs treated by PKP from June2007to June2010were retrospectively analyzed. According to the number of pedicle punctured during PKP, the patients were divided into unilateral pedicle-punctured group and bilateral pedicle-punctured group; according to the duration time from pain generated to the PKP, the patients were divided into the acute phase group, sub-acute phase and chronic phase group. The data of operation time, amount of bleeding, amount of injected PMMA, VAS, ODI, vertebral height restoration and degree of kyphotic correction of the whole group and subgroup were statistically collected; each subgroup data were statistically analyzed. (2)46patients including67vertebrae suspected malignant VCFs by MR I from June2007to June2010were retrospectively analyzed. All patients were treated with percutaneous vertebral biopsy and PKP treatment. The characteristics diagnosed of the malignant VCFs in preoperative MRI and postoperative pathology results were statistically analyzed; the data of operation time, amount of bleeding, amount of injected PMMA, VAS and ODI of the whole group and benign and malignant group were collected; the subgroup data were statistical analyzed.Results:(1) The general results of PKP treatment of the benign VCFsThe average operation time of each VCFs was (45.8±11.3) min, amount of bleeding (32.4±7.0) ml and amount of injected PMMA (4.16±1.10) ml. Preoperative, VAS was (8.26±1.12) point, ODI (81.20±6.70) point, local kyphotic angle (22.97±4.04) degree, anterior vertebral relative height (62.32±7.66)%, central vertebral relative height (67.22±6.43)%;3-day after postoperation, VAS was (2.70±0.90), ODI (30.09±6.34), local kyphotic angle (13.96±3.04) degrees, anterior vertebral relative height (84.74±7.85)%, central vertebral relative height (86.98±8.15)%, statistically different compared with preoperative data (P<0.05); the VAS of last follow-up (2.09±0.88), ODI (24.32±8.20), local kyphotic angle (13.96±2.65) degrees, anterior vertebral relative height (83.85±8.07)%, central vertebral relative height (86.66±8.30)%, statistically different compared with preoperative data (P<0.05). PMMA extravasations were found in16patients (9.5%) including21vertebral, and did not present any clinical symptoms.(2) Comparison of the unilateral and bilateral group of the benign VCFs treated by PKP before and after surgeryThe average operation time of each VCFs, amount of bleeding and amount of injected PMMA in the unilateral group was (34.8±2.9) min,(27.1±4.8) ml and (3.3±0.5) ml respectively, while in the bilateral group; the data was (55.7±5.3) min,(38.2±3.4) ml and (5.0±0.7) ml respectively. The difference between the two groups was statistically different (P<0.05)In the unilateral group, the VAS of the preoperation,3-day postoperation and the last follow-up were (8.20±1.10),(2.69±0.89) and (2.13±0.88) point respectively, while in the bilateral group, the data were (8.32±1.15),(2.71±0.93) and (2.04±0.87) point respectively. The postoperative scores compared with preoperative were statistically different (P<0.05), however, the scores between the two groups over the same period showed no significant difference (P>0.05). The ODI of the preoperation,3-day postoperation and the last follow-up were (80.89±6.40),(29.80±6.19) and (25.15±7.40) point respectively, while in the bilateral group, the data were (81.54±7.05),(30.39±6.53) and (23.43±8.98) point respectively. The postoperative scores compared with preoperative were statistically different (P<0.05), however, the scores between two groups over the same period showed no significant difference (P>0.05)In the unilateral group, the local kyphotic angle of the preoperation,3-day postoperation and the last follow-up were (23.15±3.73),(13.47±3.17), and (14.74±2.78) degree respectively. While in the bilateral group, the data were (22.79±4.37),(12.41±2.81) and (13.11±2.23) degree respectively. The postoperative kyphotic angle of the two groups decreased when compared with that of preoperation, and the difference was statistically significant (P<0.05); however, the scores between the two groups over the same period showed no significant difference (P>0.05)In the unilateral group, the anterior vertebral relative height of the preoperation,3-day postoperation and the last follow-up were (61.74±7.92)%,(83.69±8.10)%and (82.87±8.59)%respectively. While in the bilateral group, the data were (63.00±7.40)%,(85.88±7.48)% and (85.82±8.30)%respectively. The central vertebral relative height of the preoperation,3-day postoperation and the last follow-up were (66.49±6.87)%,(86.20±8.16)%and (84.91±7.40)%respectively, while in the bilateral group, the data were (68.02±5.86)%,(87.84±8.12)%and (87.57±8.33)%respectively. Both the anterior and central height of the fractured vertebral body of the two groups increased after operation, the difference was statistically different when compared with that of preoperation (P<0.05); however, the scores between the two groups over the same period showed no significant difference (P>0.05)In the unilateral group,10cases of bone cement extravasations were found during operation, and the rate was11.2%. In the bilateral group,11cases of bone cement extravasations were found during operation, and the rate was13.8%. The bone cement leakage rate between the two groups showed no significant difference with Pearson χ2test (P>0.05)(3) Comparison of the acute, sub-acute and chronic phase of the benign VCFs treated by PKP before and after surgeryIn the acute phase, the VAS of t the preoperation,3-day postoperation and the last follow-up were (8.26±1.17),(2.83±0.83) and (2.14±0.72) score respectively; in the sub-acute phase, the data were (8.26±1.12),(2.59±0.91) and (2.05±1.05) point respectively; in the chronic phase, the data were (8.25±1.11),(2.67±0.97) and (2.06±0.86) point respectively. The low back pain of the three groups significantly improved postoperatively. The VAS score of3-day postoperation and the last follow-up were statistically different when compared with that of preoperation (P<0.05); however, the scores among three phases over the same period showed no significant difference (P>0.05)In the acute phase, the ODI of the preoperation,3-day postoperation and the last follow-up were (80.90±6.875),(31.24±5.708) and (24.33±6.712) point respectively; in the sub-acute phase, the data were (81.38±6.459),(29.54±6.316) and (24.00±10.643) point respectively; in the chronic phase, the data were (81.33±6.928),(29.33±7.010) and (24.67±6.829) point respectively. The ODI score of3-day postoperation and the last follow-up were statistically different when compared with that of preoperation (P<0.05); however, the scores among the three phases over the same period showed no significant difference (P>0.05)In the acute phase, the local kyphotic angle of the preoperation,3-day postoperation and the last follow-up were (24.33±6.712),(14.52±3.278) and (12.02±2.363) degree respectively; in the sub-acute phase, the data were (23.66±3.819),(13.33±2.698) and (14.26±2.500) degree respectively; in the chronic phase, the data were (20.39±3.901),(13.64±3.796) and (14.42±2.802) degree respectively. The postoperative kyphotic angle of the three phases decreased compared with that of preoperation, and the difference was statistically significant (P<0.05); however, the scores among the three phases over the same period showed no significant difference (P>0.05)In the acute phase, the anterior vertebral relative height of the preoperation,3-day postoperation and the last follow-up were (63.24±6.308)%,(86.57±6.929)%and (85.95±7.057)%respectively; in the sub-acute phase, the data were (62.36±7.117)%,(85.72±6.164)%and (84.74±6.038)%respectively; in the chronic phase, the data were (61.22±9.529)%,(81.53±9.548)%and (80.42±9.981)%respectively. All the anterior height of the fractured vertebral bodies of the three phases increased after operation, and the difference was statistically different compared with that of preoperation (P<0.05); however, the scores among the three phases over the same period showed no significant difference P>0.05)In the acute phase, the central vertebral relative height of the preoperation,3-day postoperation and the last follow-up were (67.62±4.988)%,(87.24±6.942)%and (86.81±7.082)%respectively; in the sub-acute phase, the data were (68.05±5.291)%,(89.13±6.879)%and 3.85±6.998)%respectively; in the chronic phase, the data were (65.86±8.636)%,(84.36±9.992)%and (84.11±10.209)%respectively. All the central height of the fractured vertebral bodies of the three phases increased after operation, the difference was statistically different compared with that of preoperation (P<0.05); however, the scores among the three phases over the same period showed no significant difference (P>0.05)PMMA extravasations were found13vertebrae in the acute phase group (20.6%),4in the sub-acute phase group(7.1%) and13in the chronic phase group (8.0%). with Pearson χ2test, the difference between the acute group and sub-acute group or chronic group were statistically significant, however, the difference between the sub-acute group and chronic group was not significant.(4) The general results of PKP treatment of suspected malignant VCFsThe average operation time of each VCFs was (40.39±7.72) min, the amount of bleeding (38.52±5.32) ml and injected PMMA (4.41±0.93) ml. The VAS score was (8.24±1.04) and ODI (83.30±6.86) point preoperatively. The VAS score was (3.09±0.81) and ODI (30.65±4.99) score three days after operation, which was statistically different compared with that of preoperation (P<0.05). Bone cement extravasations took place in11vertebral fractures (16.4%) during PKP, which showed no clinical symptoms.(5) The results of biopsy of suspected malignant VCFs and the positive rate of MRI diagnosis64vertebras'specimens were obtained and pathologically diagnosed eventually. The success rate of biopsy was95.52%. The pathology reported15benign and49malignant in all of the64vertebral biopsy specimens, and the positive biopsy rate was76.56%. Benign results were all osteoporotic vertebral fractures. Malignant results included16lung cancer,11gastrointestinal cancer,7breast cancer,4renal cell carcinoma,3myeloma,2liver cancer,2uterine cancer, and the others did not identify the primary lesion including poorly differentiated2adenocarcinoma and2squamous cell carcinoma.The sensitivity, specificity and accuracy of the malignant VCFs characteristics in MRI were73.47%,53.33%,68.7%of the spherical bulge of posterior edge;79.59%,80%,79.69%of the epidural mass;91.84%,66.67%,84.62%of the pedicle involvement;89.80%,40%,78.13%of uniform low signal on T1WI. The highest sensitivity, specificity and accuracy were pedicle involvement, the epidural mass and pedicle involvement respectively; and the lowest sensitivity, specificity and accuracy were the spherical bulge of posterior edge, low signal on T1WI and the spherical bulge of posterior edge respectively.(6) Comparison of the benign and malignant VCFs treated by PKPThe operation time of the benign and malignant group was (40.80+8.06) min and (39.09±6.67) min, blood loss was (39.20±5.42) ml and (3.636±4.52) ml, the amount of injected PMMA (4.40±0.91) ml and (4.44±1.04) ml respectively. No significant difference was seen when the two groups were compared (P>0.05). The benign group's VAS was (7.73±1.10) point before PKP, which was (2.82±0.75) point3days after operation; the malignant group's VAS was (8.40±0.98) point before PKP, which was (3.17±0.82) point3days after operation. Postoperative score was significantly different compared with that of preoperation (P<0.05). The benign group's ODI was (81.27±6.89) point before PKP, which was (30.73±4.67) point3days after operation; the malignant group's ODI was (83.94±6.82) point before PKP, which was (30.63±5.15) point3days after operation. Postoperative score was significantly different compared with that of preoperation (P<0.05)PMMA extravasations were found in2VCFs in the benign group (13.3%) and9VCFs in the malignant group (18.37%). With Pearson χ2test, the difference of the bone cement extravasations rate between benign and malignant group was not statistically different (P>0.05). All extravasations did not present any clinical symptoms.Conclusion:(1) PKP is a reliable method for the treatment of benign and malignant VCFs, which can quickly relieve pain, stabilize vertebral fracture, restore vertebral height, decrease kyphotic angle, prevent vertebral collapse and improve patients' quality of life.(2) Both unilateral and bilateral PKP could treat benign VCFs effectively. However, the unilateral PKP has the advantages of shorter operation time, less trauma, less bleeding and less pain, etc.(3) PKP could achieve better kyphotic deformity correction and smaller PMMA extravasation rate when perfomed in sub-acute phase.(4) MRI can identify benign and malignant VCFs preliminarily. Percutaneous vertebral biopsy could identify the nature of the VCFs accurately and should be performed in suspected cases. |
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