The role of kyphoplasty and expandable intravertebral implants in the acute treatment of traumatic thoracolumbar vertebral compression fractures: a systematic review

in EFORT Open Reviews
Author:
Diogo Lino Moura Spine Unit, Department of Orthopedics, Coimbra University Hospital, Coimbra, Portugal, Coimbra, Portugal
Anatomy Institute and Orthopedics Department, Faculty of Medicine, University of Coimbra, Coimbra, Portugal

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Correspondence should be addressed to D L Moura; Email: dflcoluna@gmail.com
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Purpose

  • The aim of the study was to assess the role of kyphoplasty and expandable intravertebral implants in the treatment of traumatic vertebral compression fractures.

Design

  • This is a systematic review.

Methods

  • A bibliographic search was carried out in the PubMed/MEDLINE database according to PRISMA guidelines regarding kyphoplasty and expandable intravertebral implants in the treatment of traumatic thoracolumbar vertebral fractures.

Results

  • A total of 611 records were screened. In total, 51 studies were obtained referring to traumatic vertebral fractures treated with kyphoplasty; however, of these, only studies addressing traumatic burst fractures were selected, resulting in 12 studies: 10 about kyphoplasty and 2 regarding armed kyphoplasty. In all studies, there was a statistically significant improvement in clinical and functional parameters, restoration of vertebral height and decreasing of vertebral and segmental kyphosis. Overall, there was only a residual loss of height and a slight increase in kyphosis throughout the follow-up period, while complications consisted essentially of cement leakage, all with no clinical repercussions.

Conclusion

  • After the discussion, where we address the concepts of direct and indirect reduction, the association of kyphoplasty with pedicle fixation, the potential advantages of expandable intravertebral implants, as well as the vertebral body type of filling in kyphoplasty, it is concluded that kyphoplasty demonstrates favorable outcomes as a method of posterior percutaneous transpedicular access for reconstruction of the anterior column in burst fractures. It allows for the reconstruction of the vertebral body closer to its original anatomy, carried out in a minimally invasive and safe way, which provides a clinical-functional and imaging improvement maintained at the medium–long term.

Abstract

Purpose

  • The aim of the study was to assess the role of kyphoplasty and expandable intravertebral implants in the treatment of traumatic vertebral compression fractures.

Design

  • This is a systematic review.

Methods

  • A bibliographic search was carried out in the PubMed/MEDLINE database according to PRISMA guidelines regarding kyphoplasty and expandable intravertebral implants in the treatment of traumatic thoracolumbar vertebral fractures.

Results

  • A total of 611 records were screened. In total, 51 studies were obtained referring to traumatic vertebral fractures treated with kyphoplasty; however, of these, only studies addressing traumatic burst fractures were selected, resulting in 12 studies: 10 about kyphoplasty and 2 regarding armed kyphoplasty. In all studies, there was a statistically significant improvement in clinical and functional parameters, restoration of vertebral height and decreasing of vertebral and segmental kyphosis. Overall, there was only a residual loss of height and a slight increase in kyphosis throughout the follow-up period, while complications consisted essentially of cement leakage, all with no clinical repercussions.

Conclusion

  • After the discussion, where we address the concepts of direct and indirect reduction, the association of kyphoplasty with pedicle fixation, the potential advantages of expandable intravertebral implants, as well as the vertebral body type of filling in kyphoplasty, it is concluded that kyphoplasty demonstrates favorable outcomes as a method of posterior percutaneous transpedicular access for reconstruction of the anterior column in burst fractures. It allows for the reconstruction of the vertebral body closer to its original anatomy, carried out in a minimally invasive and safe way, which provides a clinical-functional and imaging improvement maintained at the medium–long term.

Introduction

The treatment of fractures of the thoracolumbar spine, specifically compression fractures, has suffered an important development in the past 30 years, with a considerable change of techniques, indications and surgical implants. The objective is still to reduce fracture deformity, to obtain stabilization of the segment and to keep the reduction in long term, with the least surgical aggression possible, also resorting to a minimum number of fused levels. Surgical burden and morbidity of anterior approaches used for vertebral body corpectomy and replacement (Fig. 1), even though showing good imaging and clinical outcomes, has led to an excessive trend to treat vertebral compression fractures merely by posterior pedicular instrumentation. The latter is at the moment the most common surgical technique, many times rising the number of fixed levels (1, 2, 3, 4, 5, 6). In spite of the overall adequate clinical outcomes after adjacent level bridge pedicle screws fixation (Fig. 2A) concerning the treatment of vertebral fractures, there is sometimes loss of vertebral body height, instrumentation failure and local and posttraumatic segmental kyphosis, leading to functional and clinical consequences (7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19).

Figure 1
Figure 1

Complete burst fracture surgical treatment by anterior approach – corporectomy and intersomatic fusion with structural bone graft or intersomatic cage and fixation with plate plus pedicle screw instrumentation at adjacent levels.

Citation: EFORT Open Reviews 9, 4; 10.1530/EOR-23-0190

Figure 2
Figure 2

Complete burst fracture surgical treatment options performed by posterior approach: (A) Adjacent levels bridge pedicle screw short instrumentation; (B) Adjacent levels pedicle screw instrumentation plus intermediate pedicle screws at the fractured vertebral body level; (C) Adjacent levels pedicle screw instrumentation plus kyphoplasty; (D) Adjacent levels pedicle screw instrumentation plus armed kyphoplasty with use of expansive intravertebral implants.

Citation: EFORT Open Reviews 9, 4; 10.1530/EOR-23-0190

One of the options that emerged after the classic bridge pedicle fixation was to add intermediate fixation of the fractured vertebra (Fig. 2B), also termed six-screw construction as a posterior short-segment fixation (20). Several studies have focused on this theme, confirming the advantage of fixing the fractured vertebra by significantly increasing the instrumentation stability and decreasing the stress on screws at adjacent levels. At the same time it permits to avoid fixation of more adjacent levels and ensures a stability similar to a longer fixation, allowing to decrease posttraumatic flattening of the vertebral body compared to bridge fixation. Since then, the option of short posterior fixation with screws at the level of the fracture has become the gold standard in compression fractures and has taken on particular importance, given its additional stability, in fractures with significant somatic comminution, in which corpectomy and vertebral body replacement are not performed (20, 21, 22, 23, 24, 25, 26). Nevertheless, the loss of support in the anterior column, which gets 80% of all axial loads, inevitably leads to the overload of the posterior instrumentation. This may originate failure of the posterior construct and/or vertebral body flattening and collapse when the fixation is not robust enough to compensate the lack of anterior support, specifically in what concerns burst fractures (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12).

This way, minimally invasive techniques of augmentation of the fractured vertebral body, previously only applied with success in osteoporotic fractures, have acquired increasing demand in trauma, as they are able to support and stabilize the anterior column by a percutaneous posterior pathway, this way avoiding the aggression of the anterior approaches. At the same time, they increase the construct stiffness, reducing the load and bending moments on the pedicle screw instrumentation, and preventing its failure as well as anterior column collapse (Fig. 2C) (27, 28, 29, 30, 31, 32). Kyphoplasty has come out as an evolution of vertebroplasty, permitting to associate its stabilizing and analgesic effect regarding the application of intravertebral cement, to the restoration of the height of the fractured vertebral body, by creating intrasomatic cavities with an expandable balloons, which are then filled with cement. Besides reducing the fractured vertebral body, the creation of previous intrasomatic cavities with less pressure and covered by impacted bone trabeculae (which work as a shield) and by the walls of the vertebral body, decreases the possibility of cement extravasation, reducing the risks of related complications (28, 33, 34, 35, 36, 37). However, one of the criticisms pointed out to kyphoplasty concerns its incapacity to keep the restored height of the vertebral body after balloon removal and before cement application, leading to vertebra flattening through elastic recoil by ligament and annulotaxis (also known as deflation effect). Even when the patient lies down on the table with the spine in hyperextension, compression forces of approximately 110 N keep acting on the fractured vertebra, resulting in its flattening (12, 28, 29, 30, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49). In order to try to compensate for this disadvantage, expandable intravertebral implants were developed (Fig. 2D). These are devices capable of controlled self-expansion applied percutaneously by posterior transpedicular access. They are placed inside the fractured vertebral body, which often presents a compression fracture. Their expansion can reduce the fracture of the vertebral body, restoring its height, stability, and integrity (50, 51). The application of expandable intravertebral implants, also known asarmed kyphoplasty, not only allows for immediate analgesia and stabilization advantages of vertebroplasty and kyphoplasty, but also permits the maintenance of the restored vertebral height, which is proven in several studies with medium and long-term follow-up (28, 29, 30, 41, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63). This happens because, after restoration of the height of vertebral endplates’, they are mechanically supported by the expanded devices, working as an interior support or sustentaculum that prevent or decrease vertebral flattening, lowering the risk of posttraumatic local and segmental kyphosis and assuring a stable anterior support of the vertebral body’s height (28, 29, 64, 65, 66, 67). Consequently, expandable intravertebral implants have become popular in what concerns the treatment of vertebral body compression fractures, thanks to their guarantee of stable anterior support at the level of the vertebral body, carried out percutaneously and transpedicularly, and leaving the invasiveness of corpectomy and reconstruction with massive allograft or spacers for cases that demand anterior neurological decompression of the vertebral canal (64, 65, 68).

Materials and methods

A systematic review was carried out searching the Medline/PubMed® database, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (69), in the English language, from database inception to September 2023, using the following string of words: kyphoplasty OR intravertebral expandable OR stentoplasty OR vertebral body stenting OR spinejack OR balloon vertebroplasty AND Spinal Fractures OR vertebral fractures OR thoracolumbar fractures OR lumbar fractures , with no limit specified. A total of 611 records were screened, and the search sequence is shown in Fig. 3. In the end, 51 studies were obtained referring to traumatic vertebral fractures treated with kyphoplasty. However, among these, only studies that address the traumatic burst fractures were included, resulting in 12 studies, 10 relating to kyphoplasty (Supplementary Table 1, see section on supplementary materials given at the end of this article) and 2 relating to armed kyphoplasty, that is, with the use of expandable intravertebral implants (Supplementary Table 2).

Figure 3
Figure 3

PRISMA flow diagram of the systematic review.

Citation: EFORT Open Reviews 9, 4; 10.1530/EOR-23-0190

Results

The main studies referring to treatment with kyphoplasty or armed kyphoplasty in acute traumatic thoracolumbar burst-type vertebral fractures are summarized in Supplementary Tables 1 and 2 (3, 5, 12, 37, 46, 52, 70, 71, 72, 73, 74, 75). Several other studies, some of them randomized clinical trials, include in their sample vertebral compression fractures types A1, A2 and A3 of the AOSpine classification (45, 65, 70, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88). However, in this review we will only focus on burst fractures, namely incomplete or AOSpine type A3 fractures, which are those where kyphoplasty or armed kyphoplasty are most often applied. We have not identified any case series studies on kyphoplasty including complete burst fractures or AOSpine type A4, only sporadic clinical cases and review papers are published regarding this subject (50, 76, 89). The objective of this research selection is to reduce the heterogeneity of the review and thus we excluded from the final analysis the AOSpine types A1 and A2 fractures, which in most centers are successfully treated conservatively. Even so, we agree that in accordance with the principle of anatomical restoration of the vertebral body, some AOSpine types A1 and A2 fractures with more severe degrees of kyphosis may require surgical treatment with kyphoplasty. Several studies report that symptomatic relief and functional recovery occur more quickly in kyphoplasty compared to conservative treatment in these patients (50, 51, 76, 88, 79).

Historically, cementoplasty techniques, that is, the application of bone cement inside the vertebral body, were contraindicated in fractures that affected the posterior wall, namely burst fractures, due to the high risk of intracanal cement leakage. Despite this and due to the initial success in osteoporotic fractures and traumatic compression fractures without reaching the posterior wall, their indication was expanded and studies began to appear regarding burst fractures, in which the risk of increased intracanal extravasation did not materialize. The fracture reaching the posterior wall certainly increases the risk of intracanal cement leakage. Nevertheless, if the cement is applied in a progressive and controlled manner to the anterior third of the vertebral body and its injection is stopped when it reaches the posterior quarter of the vertebral body, the risk of canal extravasation is greatly decreased (90). Supplementary Table 1 bring together the ten studies currently available on kyphoplasty applied exclusively to traumatic burst fractures, and their analysis allows us to verify that the majority of authors applied the combination of kyphoplasty with pedicle instrumentation of the adjacent vertebrae (3, 5, 12, 37, 46, 70, 71, 72, 73, 74, 75). Most studies are retrospective. In fact, there are five prospective studies. In all studies, there was a statistically significant improvement in clinical and functional parameters, restoration of vertebral height and decrease of vertebral and segmental kyphosis. Overall, there was only a residual loss of height and a slight increase in kyphosis throughout the follow-up period, with no clinical repercussions, while complications consisted essentially of cement leakage, always asymptomatic. All authors conclude that this is a safe, minimally invasive procedure, which guarantees satisfactory clinical results, with practically immediate post-operative pain relief and rapid functional recovery. Regarding the imaging aspect, this restoration of the anterior column carried out by a posterior percutaneous transpedicular approach is effective and maintained throughout the studies follow-up periods, which makes it an important alternative to corporectomy, particularly in patients of advanced age and comorbidities. As for expandable intravertebral implants, exclusively in acute traumatic burst fractures, only two main studies were identified (Supplementary Table 2): a retrospective by Hartmann et al. (52), regarding VBS® stents, and a prospective one by Noriega DC (75) et al., regarding Spinejack® devices. Both also address incomplete burst fractures. However, they apply armed kyphoplasty in isolation, without any adjacent pedicle fixation. The first study presents an average follow-up time of 2 years and the second one of 5.6 years. Both conclude that it is a safe and effective minimally invasive therapeutic option, which allows for an anatomical restoration of the vertebral body maintained in the medium term, in a similar way and with potential advantages over kyphoplasty.

Discussion

Kyphoplasty and expandable intravertebral implants introduce the concept of direct fracture reduction (Figs. 4 and 5), which means performed by an expanded balloon or device at the exact fracture location within the vertebral body. If the fracture happens by mechanism in compression, the implants will act the opposite way. This way, they expand the vertebral body, which is the reverse mechanism to the one that led to the fracture, representing therefore a very effective method of fracture reduction (12, 50, 51). The classic indirect reduction by distraction and lordosis maneuvers through pedicle instrumentation of adjacent vertebrae reduces the vertebral body’s cortical ring and the peripheral portions of the vertebral endplates due to the effects of containment of the anterior and posterior longitudinal ligaments and of the intervertebral disc’s annulus fibrous, respectively. On the other hand, according to experimental studies and a few recent clinical papers, direct reduction by kyphoplasty permits the restoration of the vertebral endplates’ central part, correcting its central depression. As such, although scientific evidence on the reduction of endplate central depression is still limited, this concept is highly promising and relevant in post-traumatic vertebral anatomical restoration, as the vertebral endplates morphology reconstruction, in theory, promotes a more suitable disc pressurization and healing, minimizing accelerated disc degeneration and also decreasing its intrusion through the fractured endplate into the weakened vertebral body, which could lead to fracture nonunion and vertebral body flattening (Figs. 4 and 5) (1, 2, 6, 12, 28, 29, 30, 40, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 67, 68, 82, 89, 91, 92, 93, 94, 95, 96, 97). Also, different studies have demonstrated that, once expandable intravertebral implants are correctly positioned, the fear that they increase posterior wall retropulsion in burst compression fractures is unverified. On the contrary, by performing annulotaxis and ligamentotaxis at the time of implant expansion, the increased vertebral body’s height makes the posterior wall to move anteriorly, distancing from the vertebral canal and getting close to its original position, this way restoring the posterior vertebral body’s height and leading to an indirect decompression of the vertebral canal (1, 28, 53, 54, 60, 92, 95, 96, 98). Furthermore, the technique with intermediate pedicle screws fixation depends only on the indirect reduction carried out from adjacent vertebrae. As such, it does not allow for a direct reduction of the central depression of the vertebral endplate, neither for a significant filling of the fractured vertebral body. Moreover, in theory, the presence of intermediate screws in the fractured body may decrease the effectiveness of reducing the posterior wall retropulsion to anterior position during maneuvers, as its space in the vertebral body will be occupied by the intermediate screws themselves. It is also true that, in particular, the isolated posterior distraction maneuver can result in lumbar lordosis flattening and in overstretching healthy adjacent facet joints, which can lead to early degenerative changes (3, 97). Therefore, while pedicle fixation including intermediate screws improves biomechanical stability by providing protection to the fractured vertebral body by indirectly supporting the anterior column by a short fixation, in theory, kyphoplasty techniques associated with adjacent pedicle fixation have the following advantages: a) they ensure stable filling and sustained structural support of the fractured vertebral body, minimizing its post-traumatic flattening and sharing loads with the pedicle instrumentation, which reduces its overload due to tension forces and its risk of failure. Therefore, they increase stability in the fractured vertebral body (circumferential stabilization over the vertebral functional unit), which favors its healing and minimizes the risk of non-union); b) they increase the effectiveness of anatomical restoration, adding a more etiological option of direct reduction which allows for the correction of the central depression of the vertebral endplates, restoring the anatomy of the borders of the intervertebral disc space, allowing for a pressurization of the adjacent intervertebral discs closer to the physiological, and thus minimizing its accelerated degeneration, loss of effective load-damping function and the early onset of the degenerative cascade of the spine; c) The bone cement that fills the vertebral body has antialgic properties that allow for, through a mechanical stabilizing effect on the bone fragments and chemical effect on the local nociceptors, a less painful and faster postoperative functional recovery and smaller rates of chronic residual low back pain. These anatomical, physiological, biomechanical and clinical advantages of kyphoplasty demonstrate the need and importance of complete anatomical reduction of the vertebral body in the treatment of acute vertebral body fractures, which, through this technique can be performed by a percutaneous transpedicular posterior approach (1, 2, 6, 9, 12, 27, 40, 41, 48, 56, 58, 59, 60, 62, 67, 82, 91, 109, 100). Depending on the type of fracture, direct reduction maneuvers with kyphoplasty may be sufficient, or it can be necessary to combine indirect and direct reduction techniques to obtain a more adequate anatomical restoration (Figs. 4 and 5) (1, 2, 6, 9, 12, 28, 29, 30, 41, 45, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 67, 68, 71, 89, 91, 92, 93, 94, 95, 96, 98, 99, 100).

Figure 4
Figure 4

Demonstration of surgical procedure of adjacent levels pedicle screw instrumentation plus kyphoplasty (A) or armed kyphoplasty (B) – combined indirect and direct reduction techniques, for the goal of achieving total anatomical restoration of the vertebral body, that is, the reduction of the cortical ring and also of the central portion of the vertebral platforms. The second images of the sequences are the indirect fracture reduction by distraction and lordosis maneuvers performed through instrumentation in the pedicles of adjacent vertebrae. Note the reduction of posterior wall retropulsion and restoration of anterior and posterior sagittal heights of the vertebral body. However, central flattening of the upper vertebral platform persists with no complete restoration of the middle sagittal height of the vertebral body (red arrowhead at the third images of the sequences); The fourth images of the sequences represent the direct reduction of vertebral endplates by expansion of the kyphoplasty balloons or the intravertebral expansive implants. Note the elevation of the entire upper vertebral platform (arrowhead); The fifth images of the sequences represent the filling of the balloons or the stabilization of the intravertebral implants with bone cement.

Citation: EFORT Open Reviews 9, 4; 10.1530/EOR-23-0190

Figure 5
Figure 5

Current types and methods of vertebral fracture reduction, including the applied implants (12, 40, 48, 50, 51, 79, 91, 92, 93).

Citation: EFORT Open Reviews 9, 4; 10.1530/EOR-23-0190

Several studies demonstrate the treatment of acute vertebral fractures with kyphoplasty alone (with or without expandable intravertebral implants). However, the important role of pedicle fixation of adjacent vertebrae has come to be understood, particularly in burst fractures, not only as an additional method for indirect reduction of the fracture, but even in cases where direct reduction by isolated kyphoplasty is sufficient and adjacent pedicle instrumentation works as an additional stabilization method (5, 46, 52, 61, 63, 64, 65, 72, 75, 77, 79, 81, 86, 87, 90, 100, 101, 102, 103, 104, 105). Complementing kyphoplasty with short adjacent pedicle fixation allows the fractured vertebral body to be more efficiently protected from compression and rotational forces, minimizing the loads it suffers during the bone healing process. This is particularly important in burst fractures in relation to the posterior wall, as, by allowing them to be unloaded in a reduced position, it minimizes their residual posterior wall retropulsion and favors bone healing in an anatomical position. In the same way, instrumentation also allows for the unloading on the adjacent intervertebral discs that are frequently injured, favoring their more effective and anatomical healing, as well as making pressurization and height more similar to the original ones. For example, He D et al. (101) studied, in a randomized clinical trial carried out over 2 years, 43 traumatic thoracolumbar fractures AOSpine type A3, treated only with kyphoplasty (n = 22) and kyphoplasty associated with adjacent pedicle fixation (n = 21). The authors verified that the last group showed a significantly greater reduction in VAS and improvement in the ODI score, better correction of vertebral kyphosis and a lower loss of correction achieved over time. Furthermore, in the isolated kyphoplasty group there were two patients with refractures and one adjacent fracture, without any other complications. This helps to demonstrate that kyphoplasty combined with adjacent short pedicle instrumentation is an ideal technique, as it associates the stability offered by three-column reconstruction to the morbidity level related to a single percutaneous short-segment posterior approach only (104). The main disadvantage appears to be the need to extract the pedicle instrumentation without arthrodesis after fracture healing, with the aim of avoiding prolonged immobilization of adjacent discs and zygapophyses and their consequent accelerated arthrosis, in addition to allowing mobility to be recovered at these levels and avoiding failure of bars or screws. In theory, after freeing the fixed adjacent levels, a spine with mobility similar to the previous one is obtained, including the fractured vertebral body already healed with an anatomical reduction, or close to it, and without the risk of significant residual flattening, as the vertebral body is internally stabilized and supported by kyphoplasty (37, 90, 106).

Although there are currently no comparative studies between kyphoplasty and armed kyphoplasty (with expandable intravertebral implants) in traumatic fractures, the potential advantages of the devices are the following: (a) more effective restoration of the vertebral body height, as these expandable implants with a hydraulic or mechanic expansion method have a high expansion capacity; (b) more effective maintenance of vertebral height in the medium–long term, as the vertebral body is maintained with internal metallic supports that prevent it from flattening, for example after removing the kyphoplasty balloons, as well as by increasing the vertebral body stiffness and strength because of the implant–cement–bone trabeculae set; (c) decreasing in cement leakage rates in the cases of cylindrical intravertebral implants, such as stents, because, besides creating low-pressure intrasomatic cavities, such as kyphoplasty, these are surrounded by the resistant metal mesh assembly of the implant and impacted bone trabeculae, in addition to allowing for the injection of a smaller amount of cement to obtain stability of the fracture. Furthermore, armed kyphoplasty may be associated with lower rates of pain and adjacent vertebral fractures, probably due to its superior capacity for vertebral reduction and maintenance of this reduction in the long term, which is also associated with a higher quality of life due to improved posture, reduction of tension moments, and relaxation of the paravertebral muscles, minimizing its fatigue. These theoretical conclusions, in comparison with kyphoplasty, have already been demonstrated in some biomechanical studies on human cadavers and in clinical studies regarding fractures of osteoporotic and neoplastic origin, and are therefore likely, but still to be defined, to be similar also regarding fractures of the traumatic nature (28, 29, 30, 40, 42, 43, 44, 45, 46, 47, 54, 59, 61, 62, 65, 75, 103, 105, 107). Furthermore, we consider that currently there are two main types of expandable intravertebral implants with different indications for vertebral fractures: reducing and space-occupying implants, which replace the majority of the interior of the vertebral body, such as VBS® stents; and reducing implants, which elevate vertebral endplates and preserve intact bone trabeculae, such as Spinejack®. However, their indications are not the subject of this work (51, 52). It should be noted that in the case of traumatic fractures in resistant healthy young bone, sometimes the hydraulic expansion of kyphoplasty or hydraulic expansion intravertebral implants (e.g. VBS® stents) may not be sufficient for a complete reduction of the vertebral body (51, 52, 79). The limitation of this mechanism is that the expansion does not occur if bone resistance is superior to the hydraulic pressure force of the balloon expansion. Therefore, it makes sense to prefer, in resistant young bone with preserved cortical shell, the use of intravertebral devices with mechanical expansion (e.g. SpineJack®), which have a superior expansion force, theoretically allowing for a more effective elevation of the vertebral endplates and gain in vertebral height (51, 52).

Regarding the filling of the vertebral body after kyphoplasty, most studies apply biologically inert cement of polymethyl methacrylate (PMMA) type. However, some surgeons, faced with young patients with healthy bone, prefer the options of the biologically active bone cement calcium phosphate and even cancellous bone graft, seeking, in this way, to obtain a vertebra morphologically and biomechanically more similar to the native vertebra, allowing for a more physiological load distribution compared to PMMA, which in an active patient who will require significant effort from their spine in the long term, can affect the normal balance of the rachis in terms of elasticity and segmental stiffness, possibly leading to early discovertebral degeneration. Therefore, the calcium phosphate cement is osteoconductive and is slowly absorbed and replaced by bone, while the cancellous bone provides a bone matrix capable of osteoconduction and osteoinduction, whose objective is to be colonized by osteoprogenitor cells, vascular invasion, and bone incorporation (2, 3, 6, 12, 50, 64, 65, 89, 97, 106, 107, 108, 109, 110, 111, 112, 113, 114). Different studies have evaluated the isolated intrasomatic application of bone graft in vertebral fractures and verified a progressive flattening of these vertebrae and graft resorption, most probably due to the insufficient mechanical support capacity of the isolated bone graft, which has gone through excessive loads that compromised its incorporation and integrity (4, 115, 116, 117, 118, 119). This way, in order to avoid this, we believe that the application of bone graft inside intravertebral implants (such as stents) is essential, assuring both the maintenance of vertebral height and the protection the bone graft, also minimizing its resorption until full incorporation is achieved. As a result, we obtain a healed vertebral body with a metallic endoskeleton, which is completely filled by the incorporated bone (51, 52, 89, 98). Nonetheless, long-term prospective studies are needed in order to determine the benefits of intrasomatic bone graft application, or its substitute, together with intravertebral implants in type of fractures (4, 115, 116, 117, 118, 119).

Despite favorable outcomes in the studies regarding kyphoplasty in acute compression fractures, around half of the studies are prospective and the remaining retrospective, which represents some limitations and bias risk of the analysis. Also, follow-up periods vary between 14.6 months and 6 years, which demonstrates an important limitation in its generalization as medium and long-term results. Scientific literature remains embryonic on these techniques for anatomical reconstruction of burst-type thoracolumbar vertebral fractures. As such, more prospective, randomized, and large-scale blinded studies are needed to clearly confirm the advantages of this promising surgical option.

Conclusion

The current scientific literature demonstrates favorable outcomes in kyphoplasty as a minimally invasive method of transpedicular access for reconstruction of the anterior column in burst fractures. The efficacy and greater safety of kyphoplasty in vertebral body reconstruction compared to anterior approaches for vertebral body replacement, as well as the combination of kyphoplasty with adjacent pedicle fixation and the use of expandable intravertebral implants (armed kyphoplasty) appear to, theoretically, offer clear advantages and to be promising in the treatment of this type of fractures. These techniques can provide a complete reduction of the vertebral body anatomy closer to its original one, performed in a common, safe and minimally invasive transpedicular posterior access, allowing for a clinical-functional and imaging improvement, which can be maintained in the medium–long term. However, the literature remains embryonic on this promising option for anatomical reconstruction of burst-type thoracolumbar vertebral fractures. More prospective, randomized, and large-scale blinded studies are needed to determine the best surgical therapeutic option, particularly regarding the type of kyphoplasty, with or without expandable intravertebral implants, types of implants and respective indications, with or without adjacent pedicle fixation.

Supplementary materials

This is linked to the online version of the paper at https://doi.org/10.1530/EOR-23-0190.

Declaration of interest

The author declares that there is no conflict of interest that could be perceived as prejudicing the impartiality of the study reported.

Funding

This research did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sector.

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  • Figure 1

    Complete burst fracture surgical treatment by anterior approach – corporectomy and intersomatic fusion with structural bone graft or intersomatic cage and fixation with plate plus pedicle screw instrumentation at adjacent levels.

  • Figure 2

    Complete burst fracture surgical treatment options performed by posterior approach: (A) Adjacent levels bridge pedicle screw short instrumentation; (B) Adjacent levels pedicle screw instrumentation plus intermediate pedicle screws at the fractured vertebral body level; (C) Adjacent levels pedicle screw instrumentation plus kyphoplasty; (D) Adjacent levels pedicle screw instrumentation plus armed kyphoplasty with use of expansive intravertebral implants.

  • Figure 3

    PRISMA flow diagram of the systematic review.

  • Figure 4

    Demonstration of surgical procedure of adjacent levels pedicle screw instrumentation plus kyphoplasty (A) or armed kyphoplasty (B) – combined indirect and direct reduction techniques, for the goal of achieving total anatomical restoration of the vertebral body, that is, the reduction of the cortical ring and also of the central portion of the vertebral platforms. The second images of the sequences are the indirect fracture reduction by distraction and lordosis maneuvers performed through instrumentation in the pedicles of adjacent vertebrae. Note the reduction of posterior wall retropulsion and restoration of anterior and posterior sagittal heights of the vertebral body. However, central flattening of the upper vertebral platform persists with no complete restoration of the middle sagittal height of the vertebral body (red arrowhead at the third images of the sequences); The fourth images of the sequences represent the direct reduction of vertebral endplates by expansion of the kyphoplasty balloons or the intravertebral expansive implants. Note the elevation of the entire upper vertebral platform (arrowhead); The fifth images of the sequences represent the filling of the balloons or the stabilization of the intravertebral implants with bone cement.

  • Figure 5

    Current types and methods of vertebral fracture reduction, including the applied implants (12, 40, 48, 50, 51, 79, 91, 92, 93).

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