Analysis of injected cement volume and clinical outcomes following kyphoplasty for vertebral compression fractures
- Department of Neurosurgery, School of Medicine, The University of Alabama at Birmingham, United States.
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, United States.
Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, United States.
DOI:10.25259/SNI_22_2020Copyright: © 2020 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Mitchell Self, James Mooney, John Amburgy, Bonita Agee, Leah Schoel, Patrick Pritchard, Melissa Chambers. Analysis of injected cement volume and clinical outcomes following kyphoplasty for vertebral compression fractures. 28-Mar-2020;11:56
How to cite this URL: Mitchell Self, James Mooney, John Amburgy, Bonita Agee, Leah Schoel, Patrick Pritchard, Melissa Chambers. Analysis of injected cement volume and clinical outcomes following kyphoplasty for vertebral compression fractures. 28-Mar-2020;11:56. Available from: https://surgicalneurologyint.com/surgicalint-articles/9928/
Background: It has been suggested that greater volumes of cement injected during kyphoplasty correlate with improved vertebral body height restoration and kyphotic angulation correction. However, there is little evidence tying cement volume to patient outcomes. Here, we analyzed the association between cement volume and outcome utilizing indices of pain, disability, and quality of life.
Methods: One hundred and thirty-six patients undergoing kyphoplasty were analyzed retrospectively. The total volume of bone cement injected was recorded intraoperatively for each patient; the average total cement volume was 5.44 cc. Pre- and postoperative outcome indices were documented, using the visual analog scale (VAS), Roland-Morris disability index (RMDI), and the EuroQol 5 Dimension instrument (EQ5D). Pearson’s correlations and linear regression models were derived for the association of total cement volume with each of the patient outcome measures. This was a retrospective cohort study.
Results: The average change in VAS, RMDI, and EQ5D scores for all patients was −6.8, +8.3, and +0.41, respectively. For VAS, RMDI, and EQ5D improvements, neither Pearson’s correlations nor multiple linear regression models revealed a correlation or an association with total cement volume.
Conclusion: For patients undergoing kyphoplasty, outcomes were not associated with the total injected cement volume; all had a significant reduction in pain and most exhibited decreased disability with improved quality of life.
Keywords: Cement volume, Kyphoplasty, Vertebral compression fracture
Many studies have shown the effectiveness of kyphoplasty in restoring vertebral height and relieving pain.[
Here, we uniquely correlated cement volumes injected with pain, disability, and quality of life indices in those undergoing percutaneous kyphoplasty for the treatment of vertebral compression fractures.
This retrospective series of 136 consecutive patients undergoing kyphoplasty for vertebral compression fractures was approved by an IRB. Two neurosurgeons treated 230 vertebral fractures with kyphoplasty in these 136 patients [
Assessment of outcomes
Pain was measured prospectively before and after surgery with the visual analog scale (VAS, range: 0 (none)–10 [worst]), the Roland-Morris disability index (RMDI, range: 0 [no disability]–24 [high disability]), and EuroQol 5 Dimension instrument (EQ5D, range: −0.11 [poor quality of life]–1.0 [perfect health]), respectively. Postoperative evaluations were completed at 2 and 6 weeks after surgery and at specific catchment points: March 2007 and September 2012.
Pre- and postoperative narcotic usage was recorded from medical records and correlated with total cement volume injected.
Diagnosis compression fractures
The diagnosis of compression fractures was made by preoperative history, physical examination, and correlated with radiographs, computed tomography (CT), magnetic resonance, and/or nuclear bone scan imaging studies. All patients had failed conservative treatment for 4 prior weeks.
Documentation of osteoporosis
The diagnosis of osteoporosis was confirmed on dual axial absorptiometry (DXA, Hologic, and GE Lunar) scanning.
Kyphoplasty was performed under fluoroscopic guidance and utilized semi-solid polymethylmethacrylate cement mixed with radiopaque contrast injected under low pressure; its location was confirmed using anteroposterior and lateral fluoroscopic imaging.[
Mean pain VAS, EQ5D scores, and RMDI scores were recorded preoperatively and postoperatively. Pearson’s correlations and linear regression models were derived for the association of total cement volume and vertebral height restoration with patient outcomes [
All patients had reduced pain (n = 136; 100.0%), most had reduced disability (n = 134; 98.5%), and most exhibited an improved quality of life (n = 135; 99.3%). The average improvement in VAS, RMDI, and EQ5D scores for all patients was −6.8, +8.3, and +0.41, respectively [
The biomechanical literature suggests that cement-filling volumes may play an important role in vertebral augmentation and its effectiveness in relieving pain.[
No optimal kyphoplasty cement volume to relieve pain
No optimal volume of injected cement during kyphoplasty relieves pain and/or optimizes function and quality of life. Although our results demonstrated no significant relationships between injected cement volume and outcomes, all patients improved on VAS, RMDI, and EQ-5D outcome measures.
In future studies, CT volumetric analysis would more accurately define injected cement volumes and cement leakage and could be better correlated with quality of life measures, adjacent vertebral body fractures, postinjection vertebral body height restoration, and resultant kyphotic angle reduction.
All patients improved on all outcome scales (e.g., VAS, RMDI, and EQ5D) regardless of the injected cement volume following kyphoplasty.
The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.
All authors hereby declare that all experiments have been examined and approved by the appropriate ethics committee and have, therefore, been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki.
Patient’s consent not required as there are no patients in this study.
There are no conflicts of interest.
There are no funding sources to report for this project.
1. Molloy S, Mathis JM, Belkoff SM. The effect of vertebral body percentage fill on mechanical behavior during percutaneous vertebroplasty. Spine (Phila Pa 1976). 2003. 28: 1549-54
2. Röder C, Boszczyk B, Perler G, Aghayev E, Külling F, Maestretti G. Cement volume is the most important modifiable predictor for pain relief in BKP: Results from SWISSspine a nationwide registry. Eur Spine J. 2013. 22: 2241-8
3. Rotter R, Schmitt L, Gierer P, Schmitz KP, Noriega D, Mittlmeier T. Minimum cement volume required in vertebral body augmentation--A biomechanical study comparing the permanent SpineJack device and balloon kyphoplasty in traumatic fracture. Clin Biomech (Bristol Avon). 2015. 30: 720-5
4. Suh SP, Kim CW, Jo YH, Kang CN. Height restoration after balloon kyphoplasty in rheumatoid patients with osteoporotic vertebral compression fracture. Asian Spine J. 2015. 9: 581-6
5. Tolba R, Bolash RB, Shroll J, Costandi S, Dalton JE, Sanghvi C. Kyphoplasty increases vertebral height, decreases both pain score and opiate requirements while improving functional status. Pain Pract. 2014. 14: E91-7
6. Van Meirhaeghe J, Bastian L, Boonen S, Ranstam J, Tillman JB, Wardlaw D. A randomized trial of balloon kyphoplasty and nonsurgical management for treating acute vertebral compression fractures: Vertebral body kyphosis correction and surgical parameters. Spine (Phila Pa 1976). 2013. 38: 971-83
7. Vogl TJ, Pflugmacher R, Hierholzer J, Stender G, Gounis M, Wakhloo A. Cement directed kyphoplasty reduces cement leakage as compared with vertebroplasty: Results of a controlled, randomized trial. Spine (Phila Pa 1976). 2013. 38: 1730-6
8. Wardlaw D, Cummings SR, Van Meirhaeghe J, Bastian L, Tillman JB, Ranstam J. Efficacy and safety of balloon kyphoplasty compared with non-surgical care for vertebral compression fracture (FREE): A randomised controlled trial. Lancet. 2009. 373: 1016-24