Radiculopathy Following Vertebral Body
Compression Fracture: The Role of Percutaneous
Cement Augmentation

Background: Vertebral cement augmentation is a commonly used procedure in patients with vertebral body compression fractures from primary or secondary osteoporosis, metastatic disease, or trauma. Many of these patients present with radiculopathy as a presenting symptom, and can experience symptomatic relief following the procedure. Objectives: To determine the incidence of preprocedural radiculopathy in patients with vertebral body compression fractures presenting for cement augmentation, and present their postoperative outcomes. Study Design: Retrospective cohort study. Setting: Interventional pain practice in a tertiary care university hospital. Methods: In this cohort study, all patients who underwent kyphoplasty (KP) or vertebroplasty (VP) procedures in a 7-year period within our practice were evaluated through a search of the electronic medical records. The primary endpoint was to evaluate the prevalence of noncompressive preprocedural radiculopathy in our patients. Evaluation of each patient’s relative improvement following the procedure, respective to the initial presence or absence of radicular symptoms (including and above T10, above and below T10, and below T10) was included as a secondary endpoint. Additional subanalysis was performed with respect to patients demographics, fracture location, and primary indication for the procedure (osteoporosis, trauma, etc.). Results: A total of 302 procedures were performed during this time period, encompassing 544 total vertebral body levels. After exclusion criteria were applied to this cohort, 31.6% of patients demonstrated radiculopathy prior to the procedure that could not be explained by nerve impingement. Nearly half of patients demonstrated an optimal clinical outcome (48.5% nearly complete/complete resolution of symptoms, 40.1% partial resolution of symptoms, 11.4% little to no resolution of symptoms). Patients with fractures above T10 were more likely to see complete resolution, whereas patients with fractures above and below T10 were likely to not see any resolution. Men and women without initial radiculopathy symptoms were more likely to see little to no resolution, regardless of fracture location. Limitations: This retrospective study used an electronic chart review of clinicians’ notes to determine the presence of radiculopathy and their relative improvement following the procedure. Conclusions: Preprocedural radiculopathy is a common symptom of patients presenting for the evaluation of VP or KP. The presence of radiculopathy in the absence of nerve impingement may be an important marker for those patients who may experience greater benefit from the procedure. Key words: Radiculopathy, kyphoplasty, vertebroplasty, osteoporosis, compression fracture, spine, cement augmentation

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Intra-Operative Complic atio n of Lumbar Kyphoplasty Instrumentatio n in Non-Osteoporotic Patients with Compression Fractures

Pain Management Case Reports ◽

10.36076/pmcr.2018/2/221 ◽

2018 ◽

pp. 221-226

Author(s):

Calvin R. Chen

Keyword(s):

Vertebral Body ◽

Small Sample Size ◽

Compression Fracture ◽

Cord Compression ◽

Distal Portion ◽

Small Sample ◽

Pain Clinic ◽

Becton Dickinson ◽

Compression Fractures ◽

Instrumentation Failure

Background: Vertebral augmentation is a surgical procedure used to stabilize fractured vertebrae and reduce pain in patients with compression fractures. When intra-operative and post-operative complications do occur, they can have dire consequences. Some of the common risks associated with kyphoplasty are worsening of the fracture, infections, spinal cord compression, etc. Typically, we do not consider the risk of instrumentation failure. Objectives: In 2 cases, we describe patients who has undergone kyphoplasties with live fluoroscopic guidance. Both procedures used a unipedicular approach and the CareFusion system (Becton Dickinson, Franklin Lakes, NJ). The CareFusion AVAFlex curved augmentation needle was used, and intra-operatively the handle broke off at the neck making it difficult to remove the cannula and curved needle. To remove the system, an Arthrex Reamer (Arthrex Inc., Naples, NY).was used with Chuck Key (Arthrex Inc., Naples, NY). Study Design: Case report. Setting: Outpatient Interventional Pain Clinic. Methods: The vertebral body was accessed with an AVAFlex curved needle, a CareFusion AVAMax vertebral balloon, and Cement injection with polymethylmethacrylate, were used. The removal of the AVAFlex cannula was attempted with a gripping and pulling motion of the blue handle on the cannula, which resulted in the handle breaking at the most distal portion of the cannula. The cannula was then removed using the Arthrex Reamer with Chuck Key. The entire cannula was successfully removed from the vertebral body after cement had been delivered. Results: The density of bone tissue in a traumatic compression fracture of a nonosteoporotic individual will be higher and less porous when placing the needle and cannulas. Also, it is important to have an understanding of the different instruments that are available in the operative setting. Limitations: Small sample size. Conclusion: Instrumentation experience, understanding how to handle instrument failures, bone health of the patient, and the history of mechanism for compression fracture should all be considered when performing kyphoplasty. Key words: Kyphoplasty, vertebroplasty, compression fracture, instrumentation failure

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Kyphoplasty Technique for Thoraco-Lumbar Compression Fracture

Neurologico Spinale Medico Chirurgico ◽

10.15562/nsmc.v1i2.114 ◽

2018 ◽

Vol 1 (2) ◽

pp. 36

Author(s):

Alfred Sutrisno Sim

Keyword(s):

Elderly Patients ◽

Vertebral Body ◽

Treatment Options ◽

Body Height ◽

Compression Fracture ◽

Vertebral Compression Fractures ◽

Compression Fractures ◽

Reduction Of Pain ◽

Surgical Fixation ◽

Osteoporotic Compression Fractures

Osteoporotic vertebral compression fracture (VCF) is a significant cause of morbidity and mortality among elderly patients. Fractures can happen because of osteoporosis, tumours, or other conditions.In the past two decades, kyphoplasty has emerged as surgical options that play a central role in the treatment of vertebral compression fractures. Before the common use of kyphoplasty, the principal surgical option for treatment of compression fractures was decompression and fusion. However, surgical fixation frequently failed in elderly patients because of osteopenia. Kyphoplasty has expanded to include treatment of osteoporotic compression fractures, traumatic compression fractures, and metastatic compression fractures. Osteoporotic compression fractures are now the most common indication for this procedure.Kyphoplasty utilizes an inflatable balloon to create a cavity for the cement with the additional potential goals of restoring height and reducing kyphosis. Kyphoplasty is an effective treatment options for the reduction of pain associated with vertebral body compression fractures. Biomechanical studies demonstrate that kyphoplasty is initially superior for increasing vertebral body height and reducing kyphosis, but these gains are lost with repetitive loading. Complications secondary to extravasation of cement include compression of neural elements and venous embolism. These complications are rare but more common with vertebroplasty. Kyphoplasty is a safe and effective procedure for the treatment of vertebral body compression fractures.

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MRI PATTERN OF VERTEBRAL FRACTURES DUE TO OSTEOPOROSIS, INFECTION, AND MALIGNANT TUMORS

Journal of Musculoskeletal Research ◽

10.1142/s0218957710002491 ◽

2010 ◽

Vol 13 (02) ◽

pp. 57-63

Author(s):

Mohamed El-Sayed Abdel-Wanis ◽

Mohamed Tharwat Mahmoud Solyman ◽

Nahla Mohamed Ali Hasan

Keyword(s):

Vertebral Body ◽

Vertebral Fractures ◽

Malignant Tumors ◽

Compression Fracture ◽

Osteoporotic Fractures ◽

Spinal Infection ◽

Vertebral Compression Fractures ◽

Vertebral Collapse ◽

Compression Fractures ◽

Vertebral Wedging

No previous studies discussed the significance of the MRI pattern of vertebral collapse in differentiation between vertebral compression fractures due to malignancy, osteoporosis, and infections. MRI was used in the evaluation of 152 atraumatic vertebral compression fractures in 80 patients: 85 malignant, 34 osteoporotic, and 33 infective. Central collapse of the fractured vertebral body was the commonest pattern in malignant fractures (57 vertebrae, 67%), followed by uniform collapse (21 vertebrae, 24.7%), then anterior wedging (5 vertebrae, 5.9%), and finally posterior wedging (2 vertebrae, 2.4%). In osteoporotic fractures, anterior wedging was the commonest pattern (18 vertebrae, 53%), followed by central collapse (11 vertebrae, 32.3%), then uniform collapse (4 vertebrae, 11.8%), and finally posterior wedging (1 vertebra, 2.9%). In vertebral compression fractures due to spinal infection, anterior wedging was the commonest pattern (20 vertebrae, 60.6%), followed by uniform collapse (12 vertebrae, 36.4%), while only one vertebra (3%) was centrally collapsed. Central collapse of the vertebral body is highly suggestive of malignant compression fracture while anterior vertebral wedging is highly suggestive of a benign compression fracture.

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Complete percutaneous treatment of vertebral body tumors causing spinal canal compromise using a transpedicular cavitation, cement augmentation, and radiosurgical technique

Neurosurgical FOCUS ◽

10.3171/2009.9.focus09184 ◽

2009 ◽

Vol 27 (6) ◽

pp. E9 ◽

Cited By ~ 54

Author(s):

Peter C. Gerszten ◽

Edward A. Monaco

Keyword(s):

Vertebral Body ◽

Spinal Canal ◽

Open Surgery ◽

Cement Augmentation ◽

Compression Fractures ◽

Fracture Stabilization ◽

Spinal Radiosurgery ◽

Treatment Paradigm

Object Patients with symptomatic pathological compression fractures require spinal stabilization surgery for mechanical back pain control and radiation therapy for the underlying malignant process. Spinal radiosurgery provides excellent long-term radiographic control for vertebral metastases. Percutaneous cement augmentation using polymethylmethacrylate (PMMA) may be contraindicated in lesions with spinal canal compromise due to the risk of displacement of tumor resulting in spinal cord or cauda equina injury. However, there is also significant morbidity associated with open corpectomy procedures in patients with metastatic cancer, especially in those who subsequently require adjuvant radiotherapy. This study evaluated a treatment paradigm for malignant vertebral compression fractures consisting of transpedicular coblation corpectomy combined with closed fracture reduction and fixation, followed by spinal radiosurgery. Methods Eleven patients (6 men and 5 women, mean age 58 years) with symptomatic vertebral body metastatic tumors associated with moderate spinal canal compromise were included in this study (8 thoracic levels, 3 lumbar levels). Primary histologies included 4 lung, 2 breast, 2 renal, and 1 each of thyroid, bladder, and hepatocellular carcinomas. All patients underwent percutaneous transpedicular coblation corpectomy immediately followed by balloon kyphoplasty through the same 8-gauge cannula under fluoroscopic guidance. Patients subsequently underwent radiosurgery to the affected vertebral body (mean time to treatment 14 days). Postoperatively, patients were assessed for pain reduction and neurological morbidity. Results There were no complications associated with any part of the procedure. Adequate cement augmentation within the vertebral body was achieved in all cases. The mean radiosurgical tumor dose was 19 Gy covering the entire vertebral body. The procedure provided long-term pain improvement and radiographic tumor control in all patients (follow-up range 7–44 months). No patient later required open surgery. No radiation-induced toxicity or new neurological deficit occurred during the follow-up period. Conclusions This treatment paradigm for pathological fractures of percutaneous transpedicular corpectomy combined with cement augmentation followed by radiosurgery was found to be safe and clinically effective. This technique combines minimally invasive procedures that avoid the morbidity associated with open surgery while providing spinal canal decompression and immediate fracture stabilization, and then administering a single-fraction tumoricidal radiation dose.

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Comparison of Rigid and Soft-Brace Treatments for Acute Osteoporotic Vertebral Compression Fracture: A Prospective, Randomized, Multicenter Study

Journal of Clinical Medicine ◽

10.3390/jcm8020198 ◽

2019 ◽

Vol 8 (2) ◽

pp. 198 ◽

Cited By ~ 8

Author(s):

Tsuyoshi Kato ◽

Hiroyuki Inose ◽

Shoichi Ichimura ◽

Yasuaki Tokuhashi ◽

Hiroaki Nakamura ◽

...

Keyword(s):

Quality Of Life ◽

Back Pain ◽

Outcome Measures ◽

Vertebral Body ◽

Compression Fracture ◽

Secondary Outcome ◽

Vertebral Compression Fractures ◽

Brace Treatment ◽

Compression Fractures

While bracing is the standard conservative treatment for acute osteoporotic compression fracture, the efficacy of different brace treatments has not been extensively studied. We aimed to clarify and compare the preventive effect of the different brace treatments on the deformity of the vertebral body and other clinical results in this patient cohort. This multicenter nationwide prospective randomized study included female patients aged 65–85 years with acute one-level osteoporotic compression fractures. We assigned patients within four weeks of injury to either a rigid-brace treatment or a soft-brace treatment. The main outcome measure was the anterior vertebral body compression percentage at 48 weeks. Secondary outcome measures included scores on the European Quality of Life-5 Dimensions (EQ-5D), visual analog scale (VAS) for lower back pain, and the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ). A total of 141 patients were assigned to the rigid-brace group, whereas 143 patients were assigned to the soft-brace group. There were no statistically significant differences in the primary outcome and secondary outcome measures between groups. In conclusion, among patients with fresh vertebral compression fractures, the 12-week rigid-brace treatment did not result in a statistically greater prevention of spinal deformity, better quality of life, or lesser back pain than soft-brace.

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Treatment of Old Vertebral Compression Fracture With Kyphosis by Different Reconstruction Methods: a Finite Element Analysis

10.21203/rs.3.rs-129832/v1 ◽

2020 ◽

Author(s):

Han Ye ◽

Wang Xiaodong ◽

Wu Jincheng ◽

Xu Hanpeng ◽

Zhang Zepei ◽

...

Keyword(s):

Internal Fixation ◽

Vertebral Body ◽

Compression Fracture ◽

Vertebral Compression Fractures ◽

Lateral Bending ◽

Short Segment ◽

Compression Fractures ◽

Reconstruction Methods ◽

Short Segment Fixation ◽

Vertebral Resection

Abstract Background: In repair of vertebral compression fractures, there is a lack of effective biomechanical verification as to whether only half of the vertebral body and the upper and lower intervertebral discs has any effect on spinal biomechanics; there also remains debate as to the appropriate length of fixation.Methods: A model of old vertebral compression fractures with kyphosis was established based on CT data. Vertebral column resection (VCR) and posterior unilateral vertebral resection and reconstruction (PUVCR) were performed at T12; long- and short-segment fixation methods were applied, and we analyzed biomechanical changes after surgery.Results: Range of motion (ROM) decreased in all fixed models, with lumbar VCR decreasing the most and short posterior unilateral vertebral resection and reconstruction (SPUVCR) decreasing the least; in the long posterior unilateral vertebral resection and reconstruction (LPUVCR) model, the internal fixation system produced the maximum VMS stress of 213.25 MPa in a lateral bending motion, and a minimum stress of 40.22 MPa in a lateral bending motion in the SVCR.Conclusion: There was little difference in thoracolumbar ROM between PUVCR and VCR models, while thoracolumbar ROM was smaller in long-segment fixation than in short-segment fixation. In all models, the VMS was greatest at the screw-rod junction and greatest at the ribcage–vertebral body interface, which partly explains the high probability of internal fixation failure and prosthesis migration in these two positions.

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Predictors of delayed failure of structural kyphoplasty for pathological compression fractures in cancer patients

Journal of Neurosurgery Spine ◽

10.3171/2014.11.spine14909 ◽

2015 ◽

Vol 23 (2) ◽

pp. 228-232 ◽

Cited By ~ 8

Author(s):

Gary Rajah ◽

David Altshuler ◽

Omar Sadiq ◽

V. Kwasi Nyame ◽

Hazem Eltahawy ◽

...

Keyword(s):

End Of Life ◽

Cancer Patients ◽

Vertebral Body ◽

Surgical Decompression ◽

Cement Augmentation ◽

Invasive Technique ◽

Neural Element ◽

Compression Fractures ◽

Delayed Failure ◽

The Mean

OBJECT Pathological compression fractures in cancer patients cause significant pain and disability. Spinal metastases affect quality of life near the end of life and may require multiple procedures, including medical palliative care and open surgical decompression and fixation. An increasingly popular minimally invasive technique to treat metastatic instabilities is kyphoplasty. Even though it may alleviate pain due to pathological fractures, it may fail. However, delayed kyphoplasty failures with retropulsed cement and neural element compression have not been well reported. Such failures necessitate open surgical decompression and stabilization, and cement inserted during the kyphoplasty complicates salvage surgeries in patients with a disease-burdened spine. The authors sought to examine the incidence of delayed failure of structural kyphoplasty in a series of cement augmentations for pathological compression fractures. The goal was to identify risk predictors by analyzing patient and disease characteristics to reduce kyphoplasty failure and to prevent excessive surgical procedures at the end of life. METHODS The authors retrospectively reviewed the records of all patients with metastatic cancer from 2010 to 2013 who had undergone a procedure involving cement augmentation for a pathological compression fracture at their institution. The authors examined the characteristics of the patients, diseases, and radiographic fractures. RESULTS In total, 37 patients underwent cement augmentation in 75 spinal levels during 45 surgeries. Four patients had delayed structural kyphoplasty failure necessitating surgical decompression and fusion. The mean time to kyphoplasty failure was 2.88 ± 1.24 months. The mean loss of vertebral body height was 16% in the patients in whom kyphoplasty failed and 32% in patients in whom kyphoplasty did not fail. No posterior intraoperative cement extravasation was observed in the patients in whom kyphoplasty had failed. The mean spinal instability neoplastic score was 10.8 in the patients in whom kyphoplasty failed and 10.1 in those in whom kyphoplasty did not fail. Approximately 50% of the kyphoplasty failures occurred at junctional spinal levels. All the patients in whom kyphoplasty failed had fractures in 3 or more cortical walls before treatment, whereas 46% of patients in the nonfailure group had fractures with breaching of 3 or more walls. CONCLUSIONS Although rare, delayed failures of structural augmentation with cement during kyphoplasty do occur and can lead to additional surgeries. A possible predictive index may include wall integrity of the vertebral body, competency of the posterior tension band, and location of the kyphoplasty at a junctional spinal level. Additional studies are required to confirm these findings.

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Treatment of Osteoporotic Vertebral Compression Fracture with Target-Anchored Vertebral Body Plasty

Journal of Biomaterials and Tissue Engineering ◽

10.1166/jbt.2019.2073 ◽

2019 ◽

Vol 9 (8) ◽

pp. 1081-1085

Author(s):

Liu Yang ◽

Xiangbei Qi ◽

Tao Lei ◽

Jingtao Zhang ◽

Junming Cao

Keyword(s):

Bone Cement ◽

Vertebral Body ◽

Vertebral Compression Fracture ◽

Compression Fracture ◽

Target Group ◽

Vertebral Compression Fractures ◽

Osteoporotic Vertebral Compression Fractures ◽

Traditional Group ◽

Compression Fractures ◽

Fracture Area

Objective: To analyze the clinical effect of target-anchored vertebroplasty and traditional percutaneous vertebroplasty on the treatment of osteoporotic vertebral compression fractures. Methods: 50 female New Zealand rabbits were selected for establishing the osteoporotic vertebral compression fracture model and divided into two groups, traditional group and target group followed by analysis of the anterior, posterior, and posterior vertebral body anterior height of the fracture and the injection volume of the bone cement at full filling, and to compare the ultimate compressive strength and stiffness differences between the two groups of specimens by biomechanical testing. Results: In traditional group, the operative time was significantly shorter than that of target group, and the intraoperative bleeding was significantly lower than that of target group (P < 0.05). The fracture area of target group was filled with sufficient bone cement, in the traditional group, 3 cases (12%) showed that bone cement was not filled in the fracture area (P < 0.05), but the total bone cement filling volume was not significantly different between the two groups, but the traditional group had more complete bone cement filling than the bone cement filling, the difference was statistically significant (P < 0.05). In addition, the anterior vertebral body height of each group was significantly higher than other observation points in the group (P < 0.05). However, the distribution of permeability and osmotic type of bone cement between the two groups was not significantly different (P > 0.05). Conclusion: Target-anchored vertebroplasty can improve the quality of clinical treatment of osteoporotic vertebral compression fractures, indicating that it might be a new surgical method.

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Percutaneous Vertebroplasty-Induced Adjacent Vertebral Compression Fracture

January 2018 - Pain Physician ◽

10.36076/ppj.2012/15/e527 ◽

2012 ◽

Vol 4;15 (4;8) ◽

pp. E527-E532

Author(s):

Ki Seong Eom

Keyword(s):

Case Report ◽

Vertebral Body ◽

Vertebral Compression Fracture ◽

Percutaneous Vertebroplasty ◽

Single Case ◽

Rare Complication ◽

Compression Fracture ◽

Fracture Line ◽

Compression Fractures ◽

First Case

Background: The risks associated with percutaneous vertebroplasty (PV) are low. Patients show marked improvement and are able to rapidly resume normal activities after PV. The sudden development of postoperative vertebral compression fracture (VCF) is a common complication, and additional PV is frequently performed in these cases. However, there have been no studies reporting acute compression fractures of an adjacent vertebra immediately after PV. Objective: This case report presents a rare case in which the patient had to undergo a second PV because of PV-induced adjacent VCF. Further, we review previous studies and discuss the possible pathogenesis of this rare complication. Study Design: Case report. Setting: Pain management clinic. Methods: A 62-year-old woman presented with a severe pain in the lower back, which started after she slipped. A radiograph showed severe vertebral collapse with a vertebral vacuum cleft in the T12 vertebral body. T1-weighted magnetic resonance imaging showed low signal intensity in T12, suggesting acute VCF, but the signals from the other vertebrae were normal. Results: The patient underwent PV at T12. When the cannula was inserted into the fracture line of the vertebral body, reduction of the collapsed T12 was developed. Although the postoperative course was uneventful, the patient’s pain did not resolve. Postoperative radiographic image obtained 4 hours after the PV showed reduction of T12 and adjacent acute VCF in T11. We performed a second PV at T11. However, 2 weeks later, adjacent acute VCF in L1 was developed and PV was performed. Limitations: This report describes a single case. Conclusion: To the best of our knowledge, this is the first case report of adjacent VCF that developed almost immediately after PV. Although the exact mechanism underlying this rare complication remains unclear, we assume that the VCF was induced by PV, although this was not proven. However, we suggest that the insertion of the cannula into the fracture line induced the iatrogenic dynamic mobility of the fractured vertebra. Reduction was caused by the cannula and positional gravity. The upward reduction may have had an effect on the upper and adjacent vertebrae. Key words: Compression fractures, vertebroplasty, cannula, complication.

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A Longitudinal Cohort Investigation of the Development of Symptomatic Adjacent Level Compression Fractures Following Balloonassisted Kyphoplasty in a Series of 726 Patients

January 2018 - Pain Physician ◽

10.36076/ppj/2016.19.e1167 ◽

2016 ◽

Vol 8;19 (8;11) ◽

pp. E1167-E1172

Author(s):

Peter C. Gerszten

Keyword(s):

Risk Factors ◽

Tobacco Use ◽

Compression Fracture ◽

Cement Augmentation ◽

Adjacent Level ◽

Steroid Use ◽

Longitudinal Cohort ◽

Compression Fractures ◽

Lumbar Fracture ◽

Mean Time

Background: Balloon-assisted kyphoplasty (BAK) is a well-accepted treatment for symptomatic vertebral compression fractures (VCF) secondary to osteoporosis. Some have raised a concern of an increased incidence of adjacent fractures due to alterations in spine biomechanics after cement augmentation. The incidence of subsequent VCFs following BAK is poorly understood. The aim of this study was to investigate the timing, location, and incidence of new VCFs following BAK and to identify risk factors associated specifically with the occurrence of new adjacent level fractures. Objectives: The study was performed to determine the incidence of symptomatic subsequent adjacent and remote level compression fractures in a cohort of patients undergoing BAK. Study Design: Longitudinal cohort investigation at an academic medical center and a central referral center for VCFs. Setting: A consecutive single surgeon series of 726 patients with osteoporotic compression fractures. Methods: A prospectively collected cohort of 726 patients who underwent BAK between 2001 and 2014 for osteoporotic VCFs was evaluated. Seventy-seven patients were identified who underwent a second BAK for a new compression fracture and were include in the present series. The indication for BAK treatment was pain unresponsive to non-surgical management for all cases. Variables were recorded for each patient, including the time between index and subsequent fracture, fracture level, and number of initial fractures as well as with tobacco use, body mass index (BMI), and chronic steroid use. Results: Seventy-seven of 726 patients (10.6%) underwent a second BAK procedure on average 350 days following the initial procedure (range 21 to 2,691 days). Third and fourth procedures were less common, treated in 11 and 3 patients, respectively. Forty-eight of 77 patients (62%) suffered a fracture at a level immediately adjacent to the index level at mean time of 256 days. Remote level fractures were treated at a mean time of 489 days, but no statistical difference was noted. There was no statistically significant difference between tobacco use, BMI, and chronic steroid use between patients suffering from remote and adjacent level VCFs. Limitations: This was not a population based study, and the true incidence of subsequent fractures after BAK might be underestimated by this analysis. Conclusions: Symptomatic compression fractures after BAK are relatively uncommon and may occur long after the initial kyphoplasty procedure. Only half of subsequent fractures occur immediately adjacent to the initially treated level; the others occur remotely. Patients with a single symptomatic thoracic or lumbar fracture suffered from remote and adjacent level fractures equally. In contrast, all patients who suffered both a thoracic and lumbar fracture at the same time had a second fracture at an adjacent level. Specific risk factors for remote versus adjacent level fractures could not be determined. Key words: Balloon kyphoplasty, cement augmentation, osteoporosis, vertebral compression fracture, adjacent level fracture, vertebroplasty

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