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Treatment of Phase III with Bone Filling Container Combined with Pedicle Anchorage Technology Reversible Kummell's disease
Kummell's disease seriously affects the quality of life of elderly people. At present, the pathogenesis of this disease is still unclear, and there are various terms describing its pathological basis, including ischemic bone necrosis in the vertebral body, vertebral fissure sign (IVC), formation of intravertebral pseudojoints, old vertebral fracture non union, and delayed vertebral collapse after injury. Hur et al. found that X-ray images of Kummell's disease patients showed signs of sclerosis at the fractured end of the vertebral body. CT plain scan revealed signs of sclerosis within the vertebral body, while CT reconstruction clearly showed signs of IVC and sclerosis at the fractured end. Severe osteoporosis with corresponding intervertebral disc degeneration was also observed in the vertebral body around the hardened end. The "vacuum fissure sign", "opening phenomenon", and "bilateral sign" within the vertebral body are important but non-specific imaging features. At present, it is believed that conservative treatment for Kumell's disease is not effective, and there may be further spinal kyphosis or even spinal nerve symptoms in the later stage.
PVP and PKP have achieved satisfactory results in the treatment of Kummell's disease stages I and II. With the increase of surgical cases, it has been found that especially in Kummell's disease stage III patients, leakage of bone cement and slippage of later bone cement masses are still serious complications.
The causes of bone cement leakage and slippage in Kummell's disease are related to multiple factors, first related to the pathological structure of the formation of vertebral fractures. Hasegawa et al. found that synovial tissue formed around the bone walls of the vertebral fractures during vertebral augmentation surgery. They believed that bone cement was mostly present in the vertebral fractures, making it difficult to penetrate through the synovial tissue into the surrounding trabeculae, hindering the formation of a stable interlocking structure between the bone cement and the vertebral trabeculae, which could not maintain the stability of the vertebral body. This led to bone cement leakage and the sliding of bone cement masses, affecting the long-term treatment effect. At the same time, it is also related to the pressure inside the vertebral body of Kummell disease and the surgical skills of the operator. Kummell disease recurs repeatedly, and the course of the disease is prolonged. The fibrous tissue on the surface of the hardened bone in the vertebral body will proliferate and form a closed capsule, which is filled with fluid. The pressure inside the vertebral body will increase, and bone cement will leak along the vertebral vein. During clinical practice, doctors have found that when the cavity wall is intact, the resistance to pushing cement into the diseased vertebra increases, which also increases the risk of bone cement leakage. Hoppe et al. found that applying irrigation techniques before injecting bone cement into patients under general anesthesia can reduce the pressure inside the vertebral body, thereby reducing the probability of bone cement leakage along the vertebral vein and cortical defect type leakage. The degree of pain relief and spinal stability of postoperative patients are closely related to the amount of bone cement filling. Kim et al. believe that the poor pain relief after percutaneous vertebroplasty in patients with Kummell's disease is related to insufficient vertebral stability due to insufficient bone cement injection.
Bone Filling Container is a spherical mesh structure made of new materials. This mesh bag is woven vertically and horizontally, and has good compression resistance and ductility. The working principle of bone filling mesh bags mainly reduces bone cement leakage through the "wolf tooth effect" and "onion effect". During surgery, the bone cement filling bag is placed in the center of the vertebral fissure, and bone cement is pushed into it. The bone cement filling bag gradually fills, and through the fluid static pressure of the bone cement mesh bag, the compressed vertebral body is lifted to restore the height of the diseased vertebral body, thereby restoring the biomechanics of the spine. Most of the bone cement is wrapped in a pouch, reducing leakage. A small portion passes through the mesh structure and interlocks with the surrounding bone trabeculae, forming a "wolf tooth effect" that stabilizes and reduces the sliding of bone cement clumps. The pressure of the fluid in the mesh gradually decreases from the center to the periphery, forming an "onion effect" that reduces the risk of bone cement leakage. Xie Shengrong et al. reported that vertebral body reconstruction surgery for Kummell's disease resulted in a bone cement leakage rate of 55.6%. Chen Shuwei a total of 35 patients with stage III reversible Kummell disease treated from January 2018 to December 2022 were reported, all of whom were treated with bone cement mesh bag combined with pedicle anchoring technology. Among them, 6 cases experienced leakage, with a leakage rate of 17.1% and a significant decrease.
Experience in the operation of Bone Filling Container and pedicle anchoring technology: (1) Carefully review the X-ray and CT images before surgery to understand the location of internal vertebral fractures, the size and position of bone defects, the size and completeness of pedicle structure, and develop accurate puncture paths and anchoring sites for bone cement pedicle. At the same time, choose the appropriate size of mesh bags based on the size of the fractures; (2) During surgery, it is necessary to have clear fluoroscopy, accurately puncture according to the preoperative puncture path, and avoid repeated punctures, forming false passages or penetrating the vertebral body to form iatrogenic leakage puncture. At the same time, for elderly patients with osteoporosis, the operation should be gentle to avoid puncturing the cyst wall and damaging internal organs and blood vessels; (3) Extract the fluid from the vertebral fissures, reduce the pressure inside the vertebral body, and reduce the risk of bone cement leakage; (4) Grasp the injection period of bone cement, usually during the "drawing period", using a rotating push rod, slowly pushing, and closely monitoring the filling of the capsule and the flow of bone cement inside the vertebral body; (5) Bone cement filling bags are generally placed in the anterior and middle columns of the injured vertebrae to facilitate the restoration of vertebral morphology and biomechanics, while reducing the risk of bone cement leakage into the spinal canal. At the same time, most Kummell disease injured vertebrae have bone defects that are connected to vertebral fractures. Filling with gelatin sponge debris before injecting bone cement can reduce bone cement leakage; (6) Due to repeated stress stimulation near the pedicle of the vertebral arch, a bone hardening zone is formed during the bone repair process, and the local bone is relatively hard, making it easy for bone cement to be used for tail fixation. In this group of cases, bilateral pedicle puncture and tailing anchoring were performed to provide more secure fixation of bone cement masses. At the same time, this operation was performed in a working sleeve to avoid the risk of bone cement leakage near the pedicle.
In summary, the combination of Bone Filling Container and pedicle anchoring technology can effectively restore vertebral height, prevent the sliding of bone cement masses in vertebral fissures, rebuild the stability of spinal biomechanics, effectively alleviate clinical symptoms, improve spinal function, and enhance the quality of life of the elderly in the treatment of reversible stage III Kummell disease. With the extension of life, long-term effects still need to be followed up.