A triple minimally invasive surgery combination for subacute osteoporotic lower lumbar vertebral collapse with neurological compromise: a potential alternative to the vertebral corpectomy/expandable cage strategy

Yoichi TaniDepartment of Orthopaedic Surgery, Kansai Medical University, Osaka, Japan

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Takahiro TanakaDepartment of Orthopaedic Surgery, Kansai Medical University, Osaka, Japan

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Koki KawashimaDepartment of Orthopaedic Surgery, Kansai Medical University, Osaka, Japan

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Kohei MasadaDepartment of Orthopaedic Surgery, Kansai Medical University, Osaka, Japan

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Masaaki PakuDepartment of Orthopaedic Surgery, Kansai Medical University, Osaka, Japan

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Masayuki IshiharaDepartment of Orthopaedic Surgery, Kansai Medical University, Osaka, Japan

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Takashi AdachiDepartment of Orthopaedic Surgery, Kansai Medical University, Osaka, Japan

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Shinichirou TaniguchiDepartment of Orthopaedic Surgery, Kansai Medical University, Osaka, Japan

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Muneharu AndoDepartment of Orthopaedic Surgery, Kansai Medical University, Osaka, Japan

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Takanori SaitoDepartment of Orthopaedic Surgery, Kansai Medical University, Osaka, Japan

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OBJECTIVE

Acute/subacute osteoporotic vertebral collapses (OVCs) in the lower lumbar spine with neurological compromise, although far less well documented than those in the thoracolumbar junction, may often pose greater treatment challenges. The authors clarified the utility of 3 familiar combined techniques of minimally invasive surgery for this condition as an alternative to the corpectomy/expandable cage strategy.

METHODS

This report included the authors’ first 5 patients with more than 2 years (range 27–48 months) of follow-up. The patients were between 68 and 91 years of age, and had subacute painful L4 OVC with neurological compromise and preexisting lumbar spinal stenosis. The authors’ single-stage minimally invasive surgery combination consisted of the following: step 1, balloon kyphoplasty for the L4 OVC to restore its strength, followed by L4–percutaneous pedicle screw (PPS) placement with patients in the prone position; step 2, tubular lateral lumbar interbody fusion (LLIF) at the adjacent disc space involved with endplate injury, with patients in the lateral position; and step 3, supplemental PPS–rod fixation with patients in the prone position.

RESULTS

Estimated blood loss ranged from 20 to 72 mL. Neither balloon kyphoplasty–related nor LLIF-related potentially serious complications occurred. With CT measurements at the 9 LLIF levels, the postoperative increases averaged 3.5 mm in disc height and 3.7 mm in bilateral foraminal heights, which decreased by only 0.2 mm and 0 mm at the latest evaluation despite their low bone mineral densities, with a T-score of −3.8 to −2.6 SD. Canal compromise by fracture retropulsion decreased from 33% to 23% on average. As indicated by MRI measurements, the dural sac progressively enlarged and the ligamentum flavum increasingly shrank over time postoperatively, consistent with functional improvements assessed by the physician-based, patient-centered measures.

CONCLUSIONS

The advantages of this method over the corpectomy/expandable cage strategy include the following: 1) better anterior column stability with a segmentally placed cage, which reduces stress concentration at the cage footplate-endplate interface as an important benefit for patients with low bone mineral density; 2) indirect decompression through ligamentotaxis caused by whole-segment spine lengthening with LLIF, pushing back both the retropulsed fragments and the disc bulge anteriorly and unbuckling the ligamentum flavum to diminish its volume posteriorly; and 3) eliminating the need for segmental vessel management and easily bleeding direct decompressions. The authors’ recent procedural modification eliminated step 3 by performing loose PPS–rod connections in step 1 and their tight locking after LLIF in step 2, reducing to only once the number of times the patient was repositioned.

ABBREVIATIONS

BKP = balloon kyphoplasty; BMD = bone mineral density; CSA-D = cross-sectional area of the dural sac; CSA-L = cross-sectional area of the ligamentum flavum; DH-a = disc height at the anterior edge; DH-m = disc height at the middle edge; DH-p = disc height at the posterior edge; EBL = estimated blood loss; FH = foraminal height (i.e., pedicle-to-pedicle distance); FH-l = left intervertebral foraminal height; FH-r = right intervertebral foraminal height; HSD = honestly significant difference; JOA = Japanese Orthopaedic Association; LFT-l = left ligamentum flavum thickness; LFT-r = right ligamentum flavum thickness; LL = lumbar lordosis; LLIF = lateral lumbar interbody fusion; LSS = lumbar spinal stenosis; MIS = minimally invasive surgery; ODI = Oswestry Disability Index; OVC = osteoporotic vertebral collapse; PEEK = polyetheretherketone; PMMA = polymethyl methacrylate; PPS = percutaneous pedicle screw; PS = pedicle screw; RLA = regional lordotic angle; SE = standard error.

OBJECTIVE

Acute/subacute osteoporotic vertebral collapses (OVCs) in the lower lumbar spine with neurological compromise, although far less well documented than those in the thoracolumbar junction, may often pose greater treatment challenges. The authors clarified the utility of 3 familiar combined techniques of minimally invasive surgery for this condition as an alternative to the corpectomy/expandable cage strategy.

METHODS

This report included the authors’ first 5 patients with more than 2 years (range 27–48 months) of follow-up. The patients were between 68 and 91 years of age, and had subacute painful L4 OVC with neurological compromise and preexisting lumbar spinal stenosis. The authors’ single-stage minimally invasive surgery combination consisted of the following: step 1, balloon kyphoplasty for the L4 OVC to restore its strength, followed by L4–percutaneous pedicle screw (PPS) placement with patients in the prone position; step 2, tubular lateral lumbar interbody fusion (LLIF) at the adjacent disc space involved with endplate injury, with patients in the lateral position; and step 3, supplemental PPS–rod fixation with patients in the prone position.

RESULTS

Estimated blood loss ranged from 20 to 72 mL. Neither balloon kyphoplasty–related nor LLIF-related potentially serious complications occurred. With CT measurements at the 9 LLIF levels, the postoperative increases averaged 3.5 mm in disc height and 3.7 mm in bilateral foraminal heights, which decreased by only 0.2 mm and 0 mm at the latest evaluation despite their low bone mineral densities, with a T-score of −3.8 to −2.6 SD. Canal compromise by fracture retropulsion decreased from 33% to 23% on average. As indicated by MRI measurements, the dural sac progressively enlarged and the ligamentum flavum increasingly shrank over time postoperatively, consistent with functional improvements assessed by the physician-based, patient-centered measures.

CONCLUSIONS

The advantages of this method over the corpectomy/expandable cage strategy include the following: 1) better anterior column stability with a segmentally placed cage, which reduces stress concentration at the cage footplate-endplate interface as an important benefit for patients with low bone mineral density; 2) indirect decompression through ligamentotaxis caused by whole-segment spine lengthening with LLIF, pushing back both the retropulsed fragments and the disc bulge anteriorly and unbuckling the ligamentum flavum to diminish its volume posteriorly; and 3) eliminating the need for segmental vessel management and easily bleeding direct decompressions. The authors’ recent procedural modification eliminated step 3 by performing loose PPS–rod connections in step 1 and their tight locking after LLIF in step 2, reducing to only once the number of times the patient was repositioned.

Acute or subacute, painful osteoporotic vertebral collapses (OVCs) in the lower lumbar spine with neurological compromise, although much less commonly encountered and thereby far less well documented than those in the thoracolumbar spine, may often pose greater treatment challenges to spine surgeons. As shown previously, this condition occurs in the older age group1 and in those with lower bone mineral density (BMD),2 compared with OVCs at the thoracolumbar junction. A similar demographic group also tends to have clinically silent lumbar spinal stenosis (LSS),35 increasing the likelihood that lower lumbar OVCs will accompany neurological symptoms even with a relatively mild osseous retropulsion into the spinal canal.

A recent large multicenter survey2,6 showed that the participating spine surgeons most commonly (85%) used decompression and instrumentation via a posterior-only approach, which required extensive instrumentation to restore the biomechanical stability in this condition, but otherwise resulted in a high rate of hardware failure. One of the survey’s implications was the importance of adequate anterior column reconstruction in treating such patients with a short-segment fusion.2,7 To address this biomechanical need by using the minimally invasive surgery (MIS) techniques, several recent reports introduced corpectomy of the fractured vertebra, followed by expandable cage reconstruction via a mini-open, direct lateral approach on traumatic as well as osteoporotic burst fractures.816 However, a negative aspect of this corpectomy/expandable cage strategy is that the corpectomy not only needs meticulous management of the segmental vessels overlying the fractured vertebral body, but also involves the technical challenge of removing the retropulsed fragments while controlling epidural bleeding.8,9,1215 In addition, an expandable cage placed for reconstructing the corpectomy defect is subjected to a greater stress concentration as compared with a single-level cage at the interface between the cage footplate and the vertebral endplate. Consequently, even with a wide-footprint expandable cage, corpectomy may require supplemental pedicle screw (PS) fixation at the segments longer than 1 level above and below the fracture in osteoporotic patients.11,12

To circumvent these problems, Fukuda et al.17 more recently proposed to restore the anterior column not by using a corpectomy/expandable cage strategy but by the segmental MIS technique of oblique lateral interbody fusion1820 for lower lumbar OVCs. However, they added traditional open posterior procedures for decompression, autogenous local bone grafting, and PS placements.

Our surgical strategy for this condition, although following the same lines used by Fukuda et al.—i.e., reconstructing the anterior column segmentally without corpectomy—realized the concept as a single-stage all-MIS procedure. The procedure consisted of the following: 1) balloon kyphoplasty (BKP) for the dynamically mobile fractured vertebra to restore its strength,2123 followed by PS placement into the fractured vertebra itself24 before the injected cement hardens; 2) tubular lateral lumbar interbody fusion (LLIF)20,25 at 1 or 2 disc spaces adjacent to the fracture; and 3) percutaneous PS (PPS) placements at the vertebra or vertebrae adjacent to the fracture, followed by PS–rod instrumentation over the LLIF levels. The current study describes the application of this all-MIS technique in 5 elderly, medically frail patients with osteoporosis who all had subacute, painful L4 OVC with neurological compromise and preexisting LSS, resulting in favorable outcomes at more than 2 years of follow-up.

Methods

Patients

Of a series of patients with subacute, painful, lower lumbar OVC who had a triple MIS combination, this report included the first 5 patients with more than 2 years (range 27–48 months) of follow-up. The patients all had an L4 OVC with neurological compromise, for which they underwent the operation at a mean age of 81 (range 68–91) years. All had 2–3 comorbidities such as hypertension, heart disease, diabetes, neurological sequelae of cerebral infarction or cervical myelopathy, and disabilities resulting from previous osteoporotic hip or vertebral fractures. Presurgical symptoms included low-back pain with radicular buttock/thigh/leg pain and/or numbness in all 5 patients, either bilaterally (in 3) or unilaterally (in 2). Neurological examination revealed sensory deficits (4) in the distribution of the L4 and/or L5 dermatomes, and/or motor deficits (2) in the lower limb or limbs. Three patients showed diminished or absent stretch reflexes for both the quadriceps and the gastrocnemius bilaterally.

A dual-energy x-ray absorptiometry (DEXA) scan confirmed low BMD in all patients, with a T-score ranging from −3.8 to −2.6 SD at the hip. They all had MRI evidence of endplate injuries preoperatively:17,26 both superior and inferior endplate injuries in 4 patients, who underwent 2-level LLIFs at L3–4 and L4–5; and only a superior endplate injury in 1 patient, who had a single L3–4 LLIF (Table 1). All patients agreed in writing to undergo the operation and participate in the study after reading an IRB-approved informed consent form.

TABLE 1.

Preoperative evaluation and surgical outcome in 5 patients with OVCs

Case No.Age (yrs)/SexOVCBMD (g/cm2)/ T-ScoreEndplate Injury on MRILLIF LevelBony Retropulsion Into Canal on CT (%), Preop/Postop/FinalMeasurements on Plain Radiographs & Clinical Outcome Measures, Preop/FinalFU (mos)OR Time (mins)EBL (mL)
RostralCaudalRLA (°)LL (°)JOA ScoreODI Score
185/FL40.483/−3.8++L3–4, L4–532.1/29.8/22.116.7/24.436.4/47.26/2882/424817944
291/FL40.533/−3.3++L3–4, L4–545.6/40.9/35.80.3/17.76.8/24.36/1972/483616572
382/ML40.624/−2.6++L3–4, L4–526.3/22.2/14.60.9/2025.1/43.910/2184/283317450
478/FL40.550/−3.2++L3–4, L4–523.5/22.9/17.80.5/9.28.0/17.814/2256/143017120
568/FL40.539/−2.8+L3–439.3/28.5/25.21.4/7.29.6/17.212/2686/182710958
Mean80.8NA0.546/−3.1NANANA33.4/28.9/23.14.0/15.717.2/30.19.6/23.276/3034.8159.648.8

FU = follow-up; NA = not applicable; OR time = operative time; + = present; − = absent.

The BMD was measured with a dual-energy x-ray absorptiometry (DEXA) examination of the hip; the LL was measured between L1 and S1; and the RLA was measured between L3 and L5. "Final" denotes the latest follow-up evaluation.

Spine Imaging Studies

Plain Radiography

Measurements of spine radiographs included regional lordotic angle (RLA) between L3 and L5 and lumbar lordosis (LL) between L1 and S1. We used Vue PACS version 11.4.1.1102 software (Carestream Health, Inc.) to calculate all measurements.

CT Evaluation

All patients underwent 3D CT examinations with SOMATOM Perspective (Siemens Healthcare K.K.) preoperatively, within 7 days postoperatively, and at latest follow-up. To evaluate indirect neural decompression, CT measurements included canal compromise by displaced fracture fragments. At the LLIF levels, we measured disc height at the anterior edge (DH-a), at the middle edge (DH-m), and at the posterior edge (DH-p) of the vertebral body on midsagittal CT images, and we measured the right and left intervertebral foraminal heights (i.e., pedicle-to-pedicle distance; FH-r and FH-l, respectively) on sagittal CT images through the pedicles.27 We used AquariusNet Viewer version 4.14 software (TeraRecon, Inc.) to obtain CT-based data.

MRI Evaluation

MRI scans with 4-mm-thick slices were obtained preoperatively, 1 year postoperatively, and at the latest follow-up evaluation with a superconducting system (1.5-T Signa, GE Corp.). MRI measurements at the LLIF levels included the cross-sectional area (CSA) of the dural sac (CSA-D) on axial T2-weighted imaging, CSA of the ligamentum flavum (CSA-L) and the right and left ligamentum flavum thickness (LFT-r and LFT-l, respectively) at its midportion on axial T1-weighted imaging through the center of the intervertebral disc.27,28 We used Vue PACS software version 11.4.1.1102 (Carestream Health, Inc.) to obtain MRI-based data.

Outcome Measures

We used two outcome measures: patient-centered Oswestry Disability Index (ODI) scores and physician-based Japanese Orthopaedic Association (JOA) scores29 preoperatively and at the latest follow-up.

Surgical Procedure

The procedure we used is outlined in Fig. 1.

FIG. 1.
FIG. 1.

Illustrations depicting the 3 surgical steps of the triple MIS combination for a subacute, painful OVC in the lower lumbar spine with neurological compromise. A: Step 1 for BKP with PMMA cement injection in the unhealed fractured vertebra to restore its strength, followed by PPS placement into the fractured vertebra itself before the cement hardens, with the patient in the prone position. B: Step 2 for tubular LLIF at the adjacent disc space involved with endplate injury, with the patient in the lateral position. C: Step 3 for PPS placements at the vertebra or vertebrae adjacent to the fracture, followed by PPS–rod instrumentation over the LLIF levels, with the patient in the prone position.

Step 1: we used a bilateral transpedicular approach for BKP by placing the patient prone with the hips in a neutral or slightly extended position. As usual, a 15-mm balloon inserted through the trocar was inflated with radiopaque contrast under fluoroscopic control, creating a cavity within the damaged vertebral body and elevating the fractured cortices. We then introduced polymethyl methacrylate (PMMA) cement of an optimal viscosity into the void under imaging surveillance, watching out for cement extravasation beyond the vertebral body margins. Immediately after injecting the bone cement, before it hardened, we inserted a guidewire into the L4 fractured vertebra through the cement introducer, which was then removed. Over the guidewire left behind, we inserted and tightened the cannulated PPS of appropriate diameter and length bilaterally under nerve root monitoring with PPS stimulation.30

Step 2: the patient was repositioned to the lateral position facing the side with a more caudal iliac crest.31 With a 5-cm horizontal single incision along the pen mark on the skin over the disc margins, we performed a blunt dissection of the 3 abdominal muscle layers followed by developing the retroperitoneal space to identify the psoas muscle. The dilators were then introduced sequentially onto the disc space either through the psoas muscle (transpsoas approach) or anterior to the muscle (prepsoas approach), and we then opened the retractor blades, which were centered over the anterior two-thirds of the disc space as a table-mounted retractor under lateral fluoroscopic guidance. When using the transpsoas approach, an evoked potential analyzing system (NVM5 system; NuVasive, Inc.) was connected to each dilator, and threshold-based electromyographic monitoring of the lower-limb muscle was used to confirm safe passage of the dilators through the psoas muscle.25,27 A thorough discectomy, performed carefully so as not to violate the subchondral bone of the endplates,32,33 included release of the contralateral anulus by using a Cobb elevator, placing the widest possible implant that spanned the lateral margins of the apophyseal ring bilaterally to maximize endplate support.27,3335 For 3 patients who underwent the transpsoas approach, we used a 10° lordotic angle porous bioactive titanium LLIF cage (X-TAL Alkali porous spacer; Osaka Yakin Kogyo Co., Ltd.).3639 For 2 patients who underwent the prepsoas approach, we used a 6° lordotic angle polyetheretherketone (PEEK) cage (Clydesdale PTC; Medtronic Sofamor Danek, USA, Inc.), which was packed with demineralized bone matrix (Grafton DBM; Medtronic Sofamor Danek Co., Ltd.)40,41 after soaking it in autogenous iliac bone marrow aspirate. With the application of manual pressure over the spinal segment from behind, we placed the tallest possible cage that could be accommodated in the space.

Step 3: the patient was placed prone again for supplemental PPS placement bilaterally at both L3 and L5 for 2-segment LLIFs or at L3 alone for a single L3–4 LLIF. The newly developed Less Imaging Cannulated Awl and Probe (LICAP) system (Tanaka Corp.), coupled with nerve root monitoring with PPS stimulation, facilitated safe screw placement without the use of fluoroscopy or computer-aided navigation systems.27,30,42,43 After inserting the extender to load the L4 pedicle screws, which had already been inserted in step 1, we passed the subfascial rods through all the extenders bilaterally, and locked them in place with the setscrews.

Postoperative Management

All patients were allowed to ambulate as soon as clinically possible with a supportive spinal brace for additional stability. We encouraged the patients to continue wearing the brace for at least 3 months.

Statistical Analysis

We used SAS JMP version 9 software (SAS Institute, Inc.) for statistical analysis, which used repeated-measures ANOVA followed by the Tukey-Kramer honestly significant difference (HSD) test to examine 3 groups of related data, with p < 0.05 considered significant. Values are shown as the mean ± standard error (SE) and corresponding 95% confidence intervals in brackets, unless otherwise indicated.

Results

Clinical Results

Despite the extended operative time with a mean of 160 (range 109–179) minutes as a result of repositioning the patient twice during surgery, the estimated blood loss (EBL) ranged from 20 to 72 mL. None of the potentially serious complications occurred, such as BKP-related pulmonary embolism or neurological injury and LLIF-related vascular/visceral/ureteral injury. All patients showed marked improvements of radicular pain and distinct recovery of motor/sensory deficits postoperatively, but all except 1 patient had varying degrees of residual motor/sensory impairments, resulting in an improvement in ODI score from a mean of 76 (range 56–86) preoperatively to 30 (range 14–48) at the latest follow-up of a mean of 34.8 (range 27–48) months, and in the JOA score from 9.6 (range 6–14) to 23.2 (range 19–28) (Table 1).

Lordotic Angles and Bony Retropulsion

Lateral radiographs revealed increases of RLA from the average 4.0° (range 0.3°–16.7°) preoperatively to 15.7° (range 7.2°–24.4°) at the latest follow-up, and of LL from 17.2° (range 6.8°–36.4°) to 30.1° (range 17.2°–47.2°). CT measurements showed a progressive reduction of canal compromise by bony retropulsion from the average 33.4% (range 23.5%–45.6%) preoperatively to 23.1% (range 14.6%–35.8%) at the latest follow-up (Table 1).

Indirect Neural Decompression and Cage Subsidence Measured With CT

Figure 2 summarizes quantitative CT-based data for the 9 LLIF levels. Compared with the preoperative values, measures in early postoperative studies increased from 11.0 ± 0.3 [8.8–12.3] mm to 15.2 ± 0.4 [13.7–16.7] mm (p < 0.0001) in DH-a; from 11.6 ± 1.0 [7.3–14.6] mm to 14.5 ± 0.7 [11.0–17.1] mm (p < 0.05) in DH-m; from 5.3 ± 0.7 [1.3–7.9] mm to 8.8 ± 0.5 [7.0–11.6] mm (p < 0.005) in DH-p; from 13.5 ± 0.6 [10.9–16.0] mm to 17.7 ± 0.5 [15.2–20.8] mm (p < 0.0001) in FH-r; and from 14.1 ± 0.7 [10.6–16.0] mm to 17.3 ± 0.6 [14.2–19.6] mm (p < 0.005) in FH-l. Values are expressed as the mean ± SE [95% CI]. None of these early postoperative increases significantly changed in the latest studies, indicating little or no subsidence of LLIF cages.

FIG. 2.
FIG. 2.

Bar graphs with error bars showing postoperative changes in sagittal reformatted CT measurements at the LLIF levels for DH-a, DH-m, and DH-p of the vertebral body, as well as FH-r and FH-l. The bars represent the mean values and the error bars represent 1 SE values at the preoperative, postoperative, and the latest follow-up (FU) evaluations. Note the statistically significant postoperative increases in the disc height and bilateral foraminal heights, followed by no significant changes at the latest follow-up. Significant difference (*p < 0.05; **p < 0.005; or ***p < 0.0001) was calculated according to repeated-measures ANOVA followed by the Tukey-Kramer HSD test. NS = not significant.

Indirect Neural Decompression Measured With MRI

Figure 3 summarizes quantitative MRI-based data for the 9 LLIF levels, showing that the dural sac progressively enlarged and the ligamentum flavum increasingly shrank at longer postoperative time points. Compared with the preoperative values, measures at the latest postoperative studies increased from 73.9 ± 10.7 [26.1–111.1] mm2 to 146.2 ± 17.4 [95.4–234.7] mm2 (p < 0.05) in CSA-D; and decreased from 105.9 ± 6.7 [78.4–146.8] mm2 to 57.5 ± 5.2 [33.5–73.5] mm2 (p < 0.0001) in CSA-L; from 4.7 ± 0.6 [3.2–7.6] mm to 2.1 ± 0.2 [1.3–2.9] mm (p < 0.0001) in LFT-r; and from 4.5 ± 0.3 [3.7–6.0] mm to 2.3 ± 0.2 [1.5–3.4] mm (p < 0.0001) in LFT-l. Values are expressed as the mean ± SE [95% CI].

FIG. 3.
FIG. 3.

Bar graphs with error bars showing postoperative changes in axial MRI measurements at the LLIF levels for the CSA-D on T2-weighted imaging and the CSA-L on T1-weighted imaging (left panel); the LFT-r and LFT-l were measured on T1-weighted imaging (right panel). The bars represent the mean values and the error bars represent 1 SE values at the preoperative, 1 year postoperative, and latest follow-up evaluations. Note that the progressive postoperative increase in CSA-D was accompanied by progressive decreases in CSA-L, LFT-r, and LFT-l at longer postoperative time points. Significant difference (*p < 0.05; **p < 0.005; or ***p < 0.0001) was calculated according to repeated-measures ANOVA followed by the Tukey-Kramer HSD test.

Illustrative Cases

Case 1

An 85-year-old woman was referred to our university hospital for an MIS capable of minimizing EBL, because she refused a blood transfusion for surgery on religious grounds. When initially seen, she had weakness of the quadriceps and the tibialis anterior bilaterally with aching pains across the low back and lower limbs, which made it difficult to get out of bed. Her ODI score was 82 and her JOA score was 6.

Imaging studies (Figs. 4 and 5) revealed unhealed L4 OVC with retropulsed fracture fragments and central as well as lateral LSS at L3–4 and L4–5. She underwent the triple MIS combination including 2-level LLIF via the transpsoas approach, resulting in an operative time of 179 minutes and an EBL of 44 mL. Postoperative improvements in pain and motor/sensory deficits made her ambulatory. Although she suffered from additional fall-associated T12 and L1 compression fractures 15 months postoperatively, which were successfully treated conservatively, the latest 48-month follow-up evaluation showed a decrease in the ODI score to 42 and an increase in the JOA score to 28.

FIG. 4.
FIG. 4.

Case 1. Preoperative imaging studies obtained in an 85-year-old woman with subacute, painful L4 OVC and preexisting LSS. Lateral (A) and anteroposterior (B) radiographs show L4 OVC and mild L4 spondylolisthesis. Sagittal reformatted (C) and axial (D) CT myelograms clearly show the relation between retropulsed fracture fragments and the anterior surface of the thecal sac. Sagittal T2-weighted MRI sequence (E) reveals still unhealed L4 OVC with distinct fracture lines of low signal intensity, involving both superior and inferior endplates. This sagittal MRI sequence together with axial T2-weighted MRI sequences (F and G) demonstrate central as well as lateral LSS at L3–4 and L4–5 due to fracture retropulsion and bulging anulus anteriorly and hypertrophic facets and ligamentum flavum posteriorly.

FIG. 5.
FIG. 5.

Case 1. Postoperative imaging studies obtained at an early postoperative period (A and B) and at 48 months of follow-up (C–I). Anteroposterior and lateral plain radiographs (A–D) show BKP at L4, LLIF at L3–4 and L4–5, and PPS–rod instrumentation at L3–5. Comparisons between studies at an early postoperative period (A and B) and those at the latest follow-up (C and D) indicate neither screw loosening nor cage subsidence over time. Sagittal reformatted (E) and axial (F) CT scans show no cement extravasation beyond the L4 vertebral body margins, screw loosening, or cage subsidence. Sagittal (G) and axial (H and I) T2-weighted MR images demonstrate indirect neural decompression at L3–4 and L4–5 with reduced fracture retropulsion/disc bulge anteriorly and diminished thickness of the ligamentum flavum posteriorly. In panel G, the sagittal MRI sequence also shows additional fall-associated compression fractures at the thoracolumbar junction that were suffered 15 months postoperatively, but were successfully treated conservatively.

RLA increased from 16.7° preoperatively to 24.4° in the latest study, and LL increased from 36.4° to 47.2°. In the early postoperative CT evaluations, DH-p increased by 2.9 mm at L3–4 and by 2.0 mm at L4–5, and the average of FH-r and FH-l increased by 4.7 mm at L3–4 and by 4.2 mm at L4–5. None of these values decreased at the latest follow-up evaluation. Canal compromise by bony retropulsion decreased from 32.1% preoperatively to 22.1% at the latest follow-up. Compared with preoperative MRI evaluations, the average values for the 2 LLIF levels increased to 317% in CSA-D, and decreased as follows: to 70% in CSA-L, to 58% in LFT-r, and to 56% in LFT-l at the latest follow-up.

Case 3

An 82-year-old man with medical comorbidities of valvular heart disease, hypertension, and diabetes visited our hospital with persistent low-back pain after a fall from a sitting height. Imaging studies (Figs. 6 and 7) revealed unhealed L4 OVC with retropulsed fragments and central as well as lateral LSS at L3–4 and L4–5.

FIG. 6.
FIG. 6.

Case 3. Preoperative imaging studies obtained in an 82-year-old man with subacute, painful L4 OVC and preexisting LSS. Lateral (A) and anteroposterior (B) radiographs show L4 OVC. Sagittal (C) and coronal (D) reformatted CT myelograms clearly show a burst-type fracture pattern of the L4 vertebral body and the relation between retropulsed fracture fragments and the anterior surface of the thecal sac. Sagittal T2-weighted MR image (E) reveals still unhealed L4 OVC with bone marrow edema of high signal intensity, involving both superior and inferior vertebral endplate–disc complexes. This sagittal MRI sequence together with axial T2-weighted MR images (F and G) demonstrate central as well as lateral LSS at L3–4 and L4–5 due to fracture retropulsion/ disc bulge anteriorly and hypertrophic facets and ligamentum flavum posteriorly.

FIG. 7.
FIG. 7.

Case 3. Postoperative imaging studies obtained at an early postoperative period (A and B) and at 33 months of follow-up (C–I). Anteroposterior and lateral plain radiographs (A–D) show BKP at L4, LLIF at L3–4 and L4–5, and PPS–rod instrumentation at L3–5. Comparisons between the studies at an early postoperative period (A and B) and those at the latest follow-up (C and D) indicate neither screw loosening nor cage subsidence over time. Sagittal (E) and coronal (F) reformatted CT images indicate near-complete bridging between L3 and L4 vertebral bodies by newly formed bone without any cage subsidence. Sagittal and axial T2-weighted MR images (G–I) demonstrate indirect neural decompression at L3–4 and L4–5 with reduced fracture retropulsion/disc bulge anteriorly and diminished thickness of the ligamentum flavum posteriorly.

He underwent the triple MIS combination for bilateral radicular leg pain and neurogenic claudication, which developed 6 weeks after the fall, with basically the same technique as in case 1. The only difference lay in step 2, in which this patient had PEEK cage placement via the prepsoas approach, resulting in an operative time of 174 minutes and an EBL of 50 mL. Radicular pain and neurogenic claudication had been almost completely resolved, improving the ODI score from 84 preoperatively to 28 at the latest (33-month) follow-up, and the JOA score from 10 to 21.

RLA increased from 0.9° preoperatively to 20° in the latest study, and LL increased from 25.1° to 43.9°. At early postoperative CT evaluations, DH-p increased by 4.2 mm at L3–4 and by 5.0 mm at L4–5, and the average of FH-r and FH-l increased by 3.6 mm at L3–4 and by 3.3 mm at L4–5. Of these values, only the average of FH-r and FH-l decreased by 0.2 mm at the latest follow-up. Canal compromise by bony retropulsion reduced from 26.3% preoperatively to 14.6% at the latest follow-up. Compared with the preoperative MRI evaluations, the averaged values for the 2 LLIF levels increased to 209% in CSA-D, and decreased as follows: to 63% in CSA-L, to 43% in LFT-r, and to 53% in LFT-l at the latest follow-up.

Discussion

The current study has shown that a combined use of 3 familiar MIS techniques worked effectively in treating elderly, medically frail patients with osteoporosis who had lower lumbar OVCs with neurological compromise. Although the number of patients was small, this method consistently improved radicular pain and neurological deficits in all 5 patients, showing postoperative improvements in the ODI scores from 76 to 30 and in the JOA scores from 9.6 to 23.2 on average, with a mean follow-up of 34.8 (range 27–48) months. This triple MIS combination provided stable anterior column restoration segmentally as well as adequate neural decompression indirectly,20,27,28,4246 with a small amount of EBL (range 20–72 mL), which resulted from minimizing soft-tissue dissection and avoiding easily bleeding direct spinal canal decompression.

This technique has the biomechanical advantage of providing better anterior column stability with a segmentally placed cage, which reduces the stress concentration at the interface between the cage footplate and vertebral endplate as compared with the vertebral corpectomy/expandable cage strategy. In general, cage subsidence develops as a function of footplate–endplate interaction. The benefit of load reduction at the footplate–endplate interface in this method bears particular importance for better treatment of patients with poor bone quality who suffer OVC. The CT-based data in the current study attest to the benefit of this technique, which is protective against cage subsidence. According to the CT measurements at the 9 LLIF levels, the postoperative increases averaged 3.5 mm in DH-p, 4.2 mm in FH-r, and 3.2 mm in FH-l. The loss of the increase in disc height averaged 0.2 mm and there were no losses of foraminal height on either side at the latest follow-up, indicating that little if any cage subsidence occurred over time postoperatively. If treating patients with osteoporosis using the corpectomy/expandable cage strategy, which allows for distraction to achieve correction of local kyphosis caused by the fracture, the surgeon may use supplemental PS fixation at the segments longer than 1 level above and below the fracture, even with a wide-footprint, expandable corpectomy cage.11,12

The CT scans also revealed a progressive decrease in spinal canal compromise due to retropulsed vertebral body fragments, averaging 33.4% preoperatively, 28.9% postoperatively, and 23.1% at the latest evaluation. However, it remains unknown to what degree of severity in osseous retropulsion this strategy can continue to be effective.

Such a whole-segment spine lengthening at the LLIF level20,27,43 as shown by CT must have stretched the posterior longitudinal ligament anteriorly to push back both the retropulsed fragments and the disc bulge, unbuckled the ligamentum flavum posteriorly to diminish its volume, and eventually enlarged the dural sac as shown by MRI.27 Interestingly, all these beneficial MRI changes, which reflect the indirect neural decompression through ligamentotaxis,44 further improved rather than diminished at longer postoperative time points.

In OVCs, this kind of segmental lengthening after LLIF, which contributes to indirect neural decompression, relies on restoration of the fractured vertebral body strength afforded by BKP.2123 In fact, a biomechanical experiment using human cadaveric osteoporotic lumbar spines demonstrated that injectable cement augmentation resulted in a significant enhancement of the endplate stability.47 Therefore, a sequence error (e.g., in performing LLIF before BKP) will result in further collapse of the fractured vertebra with focal kyphosis, failing to achieve indirect neural decompression. Consequently, a potential contraindication for this triple MIS combination may include a vertebra plana, in which BKP faces a difficulty in temporarily inflating a balloon tamp to restore height and create a cavity within the residual, collapsed vertebral body.

Our triple MIS combination, which is capable of achieving indirect neural decompression associated with favorable clinical outcomes, eliminates the need for corpectomy, which allows for direct neural decompression. As a distinct advantage, the corpectomy provides a direct pathway for removing the posterior cortical fracture fragments from the spinal canal. However, this surgical procedure presents some technical challenges: the surgeon must perform the easily bleeding maneuver at a right-angled direction to the floor with the patient in the lateral position, while controlling the bleeding from the basivertebral sinus and the epidural venous plexus.10,13,14

In contrast, a major disadvantage of our strategy is its dependence on repositioning the patient twice intraoperatively, which interrupts the flow of surgery each time, and prolongs the duration of general anesthesia as well as the operative time. Our recent modification has eliminated step 3, reducing the number of times the patient was repositioned to just once. In this modified technique, step 1 in the prone position involved not only the BKP but also all the necessary PPS placements bilaterally, followed by loosely fixing the rods in place by turning the setscrews halfway against the rod. Such loose PPS–rod connections allowed the rods to slide under the setscrews to adapt to the segmental lengthening of the vertebral column achieved by the LLIF at the subsequent step 2 in the lateral position. Maintaining the same lateral position, we could finally lock the setscrews tightly into place after LLIF procedures. This procedural modification will enhance the utility of the triple MIS combination strategy for treating lower lumbar OVCs with neurological compromise.

Conclusions

Acute or subacute, painful lower lumbar OVCs with neurological compromise and preexisting LSS may pose a significant treatment challenge to spine surgeons. A triple MIS combination strategy for this condition worked well for reconstructing the anterior column segmentally without corpectomy and achieving indirect neural decompression with a short-segment fusion as a single-stage all-MIS procedure.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Tani, Paku, Ishihara, Ando, Saito. Acquisition of data: Tani, Tanaka, Kawashima, Masada, Paku, Adachi. Analysis and interpretation of data: Tani, Taniguchi, Ando. Drafting the article: Tani. Critically revising the article: Tani. Reviewed submitted version of manuscript: Tani, Ando. Approved the final version of the manuscript on behalf of all authors: Tani. Statistical analysis: Taniguchi. Administrative/technical/material support: Tani, Paku. Study supervision: Tani, Ando, Saito.

References

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  • Expand

Illustration from Chan et al. (E2). © Andrew K. Chan, published with permission.

  • View in gallery
    FIG. 1.

    Illustrations depicting the 3 surgical steps of the triple MIS combination for a subacute, painful OVC in the lower lumbar spine with neurological compromise. A: Step 1 for BKP with PMMA cement injection in the unhealed fractured vertebra to restore its strength, followed by PPS placement into the fractured vertebra itself before the cement hardens, with the patient in the prone position. B: Step 2 for tubular LLIF at the adjacent disc space involved with endplate injury, with the patient in the lateral position. C: Step 3 for PPS placements at the vertebra or vertebrae adjacent to the fracture, followed by PPS–rod instrumentation over the LLIF levels, with the patient in the prone position.

  • View in gallery
    FIG. 2.

    Bar graphs with error bars showing postoperative changes in sagittal reformatted CT measurements at the LLIF levels for DH-a, DH-m, and DH-p of the vertebral body, as well as FH-r and FH-l. The bars represent the mean values and the error bars represent 1 SE values at the preoperative, postoperative, and the latest follow-up (FU) evaluations. Note the statistically significant postoperative increases in the disc height and bilateral foraminal heights, followed by no significant changes at the latest follow-up. Significant difference (*p < 0.05; **p < 0.005; or ***p < 0.0001) was calculated according to repeated-measures ANOVA followed by the Tukey-Kramer HSD test. NS = not significant.

  • View in gallery
    FIG. 3.

    Bar graphs with error bars showing postoperative changes in axial MRI measurements at the LLIF levels for the CSA-D on T2-weighted imaging and the CSA-L on T1-weighted imaging (left panel); the LFT-r and LFT-l were measured on T1-weighted imaging (right panel). The bars represent the mean values and the error bars represent 1 SE values at the preoperative, 1 year postoperative, and latest follow-up evaluations. Note that the progressive postoperative increase in CSA-D was accompanied by progressive decreases in CSA-L, LFT-r, and LFT-l at longer postoperative time points. Significant difference (*p < 0.05; **p < 0.005; or ***p < 0.0001) was calculated according to repeated-measures ANOVA followed by the Tukey-Kramer HSD test.

  • View in gallery
    FIG. 4.

    Case 1. Preoperative imaging studies obtained in an 85-year-old woman with subacute, painful L4 OVC and preexisting LSS. Lateral (A) and anteroposterior (B) radiographs show L4 OVC and mild L4 spondylolisthesis. Sagittal reformatted (C) and axial (D) CT myelograms clearly show the relation between retropulsed fracture fragments and the anterior surface of the thecal sac. Sagittal T2-weighted MRI sequence (E) reveals still unhealed L4 OVC with distinct fracture lines of low signal intensity, involving both superior and inferior endplates. This sagittal MRI sequence together with axial T2-weighted MRI sequences (F and G) demonstrate central as well as lateral LSS at L3–4 and L4–5 due to fracture retropulsion and bulging anulus anteriorly and hypertrophic facets and ligamentum flavum posteriorly.

  • View in gallery
    FIG. 5.

    Case 1. Postoperative imaging studies obtained at an early postoperative period (A and B) and at 48 months of follow-up (C–I). Anteroposterior and lateral plain radiographs (A–D) show BKP at L4, LLIF at L3–4 and L4–5, and PPS–rod instrumentation at L3–5. Comparisons between studies at an early postoperative period (A and B) and those at the latest follow-up (C and D) indicate neither screw loosening nor cage subsidence over time. Sagittal reformatted (E) and axial (F) CT scans show no cement extravasation beyond the L4 vertebral body margins, screw loosening, or cage subsidence. Sagittal (G) and axial (H and I) T2-weighted MR images demonstrate indirect neural decompression at L3–4 and L4–5 with reduced fracture retropulsion/disc bulge anteriorly and diminished thickness of the ligamentum flavum posteriorly. In panel G, the sagittal MRI sequence also shows additional fall-associated compression fractures at the thoracolumbar junction that were suffered 15 months postoperatively, but were successfully treated conservatively.

  • View in gallery
    FIG. 6.

    Case 3. Preoperative imaging studies obtained in an 82-year-old man with subacute, painful L4 OVC and preexisting LSS. Lateral (A) and anteroposterior (B) radiographs show L4 OVC. Sagittal (C) and coronal (D) reformatted CT myelograms clearly show a burst-type fracture pattern of the L4 vertebral body and the relation between retropulsed fracture fragments and the anterior surface of the thecal sac. Sagittal T2-weighted MR image (E) reveals still unhealed L4 OVC with bone marrow edema of high signal intensity, involving both superior and inferior vertebral endplate–disc complexes. This sagittal MRI sequence together with axial T2-weighted MR images (F and G) demonstrate central as well as lateral LSS at L3–4 and L4–5 due to fracture retropulsion/ disc bulge anteriorly and hypertrophic facets and ligamentum flavum posteriorly.

  • View in gallery
    FIG. 7.

    Case 3. Postoperative imaging studies obtained at an early postoperative period (A and B) and at 33 months of follow-up (C–I). Anteroposterior and lateral plain radiographs (A–D) show BKP at L4, LLIF at L3–4 and L4–5, and PPS–rod instrumentation at L3–5. Comparisons between the studies at an early postoperative period (A and B) and those at the latest follow-up (C and D) indicate neither screw loosening nor cage subsidence over time. Sagittal (E) and coronal (F) reformatted CT images indicate near-complete bridging between L3 and L4 vertebral bodies by newly formed bone without any cage subsidence. Sagittal and axial T2-weighted MR images (G–I) demonstrate indirect neural decompression at L3–4 and L4–5 with reduced fracture retropulsion/disc bulge anteriorly and diminished thickness of the ligamentum flavum posteriorly.

  • 1

    Nakajima H, Uchida K, Honjoh K, Sakamoto T, Kitade M, Baba H. Surgical treatment of low lumbar osteoporotic vertebral collapse: a single-institution experience. J Neurosurg Spine. 2016;24(1):3947.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2

    Isogai N, Hosogane N, Funao H, et al. The surgical outcome of spinal fusion for osteoporotic vertebral fractures in the lower lumbar spine with a neurological deficit. Spine Surg Relat Res. 2020;4(3):199207.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 3

    Granville M, Berti A, Jacobson RE. Vertebral compression fractures after lumbar instrumentation. Cureus. 2017;9(9):e1729.

  • 4

    Sasaki M, Aoki M, Nishioka K, Yoshimine T. Radiculopathy caused by osteoporotic vertebral fractures in the lumbar spine. Neurol Med Chir (Tokyo). 2011;51(7):484489.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5

    Sasaki Y, Aoki Y, Nakajima A, et al. Delayed neurologic deficit due to foraminal stenosis following osteoporotic late collapse of a lumbar spine vertebral body. Case Rep Orthop. 2013;2013:682075.

    • Search Google Scholar
    • Export Citation
  • 6

    Hosogane N, Nojiri K, Suzuki S, et al. Surgical treatment of osteoporotic vertebral fracture with neurological deficit: a nationwide multicenter study in Japan. Spine Surg Relat Res. 2019;3(4):361367.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7

    Machino M, Ando K, Kobayashi K, et al. A comparative study of two reconstruction procedures for osteoporotic vertebral fracture with lumbar spinal stenosis: posterior lumbar interbody fusion versus posterior and anterior and combined surgery. J Orthop Sci. 2020;25(1):5257.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8

    Muhlbauer M, Pfisterer W, Eyb R, Knosp E. Minimally invasive retroperitoneal approach for lumbar corpectomy and reconstruction. Technical note. Neurosurg Focus. 1999;7(6):e4.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9

    Payer M, Sottas C. Mini-open anterior approach for corpectomy in the thoracolumbar spine. Surg Neurol. 2008;69(1):2532.

  • 10

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