Vertebral compression factures are common and painful in patients with osteoporosis and osteogenesis imperfecta (OI). Adequate treatment is required to relieve serious back pain, restore activities of everyday life, and maintain spine alignment in the sagittal profile. Conservative treatment frequently provides only short-term pain relief [
We extended the indication of RF-TVA to a 54-year-old woman with multiple compression fractures of Th8–12, L1, and L3, along with diminished osseous stability owing to type I osteogenesis imperfecta and osteoporosis. To our knowledge, this is the first case report describing treatment of a multilevel-fractured spine with RF-TVA.
A 54-year-old woman with type I OI, osteoporosis (
Because of severe back pain, the patient was not able to walk for more than 500 m and had several limitations in everyday life. She had experienced approximately 25 fractures without external force since the age of 1 year. Further, she reported having a brother, father, and grandmother, each with osteogenesis imperfecta.
Conservative treatment with pain killers and physiotherapy failed. The recommended bisphosphonate therapy was not started due to time issues. Physical examination revealed hyperkyphosis of the thoracic spine without scoliosis. The patient had throbbing pain of the thoracolumbar spine, and paravertebral myogelosis was observed. There was no sign of spinal cord compression or cauda equine syndrome. The patient rated her back pain as 7/10 on the numerical rating scale (NRS). When lying, the pain worsened to 10/10. The Oswestry Disability Index (ODI) was 72%, constituting a crippling condition. The ODI was determined in German [
Radiographs showed multiple compression fractures in the thoracic and lumbar regions, and high signal on the STIR sequence of an MRI was observed at levels Th8–12, L1, and L3 (see also Figure
Preoperative sagittal magnetic resonance image (STIR sequence) of the lumbar spine showing edema of multiple vertebral bodies.
Regarding the sagittal profile, X-ray of the whole vertebrae showed a thoracic hyperkyphosis of 70 degrees and a C7 offset of 4.3 cm.
The patient was placed in a prone position on a radiolucent operating table. The compression fractures were localized fluoroscopically using a conventional C-arm device (Endura/Philips/Netherlands). Under fluoroscopic guidance, an introducer was inserted through a small skin incision into either the right or the left pedicle at levels T8–T12 and L3. Access was bipedicular only at level L1. The navigational MidLine Osteotome (DFINE) was inserted through the introducer and guided fluoroscopically. After creating a three-dimensional cavity in the center of the fractured vertebrae, the radiofrequency-activated cohesive ultrahigh-viscosity PMMA cement was delivered at a controlled rate into the cavity under continuous pressure from the hydraulic assembly. The cement volume per vertebral body ranged from 2.2 to 4.3 mL. The intent was to restore and strengthen the vertebrae by injecting the cement primarily into the anterior part of each vertebral body. The total time from incision to suturing was 100 minutes. The patient tolerated the intervention well without pulmonary or neurological complications.
The procedure was conducted during a brief in-hospital stay. Immediately after the treatment, the patient’s NRS back pain rating decreased from 7 to 5, allowing some activities of her daily life to be restored. Pain reduction in the lying position was more evident, with a decrease in the NRS rating from 10 to 2. Immediately after surgery, the patient reported being able to sleep at night without pain interruptions. At the 6-week follow-up, the ODI had decreased from 72% to 63%.
Figure
Postoperative anteroposterior (a) and lateral (b) radiographs of the spine.
Because of ongoing pain 3 months after surgery, we performed another MRI of the lumbar spine. The MRI revealed small hyperintense signals at levels T11 and T12, indicating the possibility of slight recollapsing (see also Figure
Postoperative sagittal magnetic resonance image of the spine 3 months after surgery, showing increased signal and signs of slight recollapsing, especially in the thoracolumbar transition on the STIR sequence.
The patient in this study had type I osteogenesis imperfecta, which is the most benign form of a group of connective tissue disorders that cause skeletal abnormalities such as bone fragility and deformity [
Corporal disability and severe lumbago unresponsive to conservative therapy indicated that surgical intervention was appropriate for the patient. Several operative procedures were available for treatment, but the large number of fractures and very low bone quality limited the practical options. Standard approaches would have required extensive instrumentation, with high risks of screw loosening, establishing bone union, and perioperative complications. Under these circumstances, we considered vertebroplasty and kyphoplasty as possible alternatives before selecting RF-TVA. This treatment had several novel characteristics and improvements over standard therapy. In particular, the operating time in RF-TVA was shortened because the unipedicular approach is often sufficient to achieve adequate cement distribution [
Similar to balloon kyphoplasty, RF-TVA is associated with some common adverse events. However, both procedures are considered safe and the rates of PMMA extravasation are low [
Although the patient reported noticeable pain relief, she remained disabled because of ongoing severe lumbago and was consequently not able to work. Nevertheless, the patient appreciated the pain relief, which enabled her to sleep continuously and improved her quality of life. Her stagnating improvement at the 6-month follow-up may have been related to the disease severity and the presence of fractures across 7 vertebral levels. Most published studies have evaluated patients with only up to 3-level fractures. The patient did not have an adjacent segment fracture, though she had a segmental thoracic hyperkyphosis, which might be a risk factor for new fractures at adjacent levels [
Another reason for ongoing pain may have been the application of an insufficient cement volume in some of the vertebrae. This could have resulted in the enhanced signals seen on the postoperative magnetic resonance image 3 months after surgery, indicating a process of recollapsing without significant secondary loss of height restoration. There is no recommendation in the literature for a specific amount of cement to achieve optimal results, although a biomechanical study by Liebschner et al. suggests that 3.5 mL in L1 is necessary to adequately restore stiffness [
RT-TVA should be considered as a potential treatment for patients with OI who have numerous vertebral fractures and for whom conservative treatment has been ineffective. We believe that it is probably the most suitable surgical procedure in such cases, even though the pain relief observed in this study was not comparable to what may be expected for patients with 1-level or 2-level fractures. The patient reported that the initial pain relief at night immediately after RF-TVA was of sufficient value that in hindsight she would elect to undergo the treatment again.
RF-TVA is a minimally invasive therapeutic procedure offering an alternative to standard treatments for multiple vertebral fractures in patients with type I osteogenesis imperfecta and pain that is unresponsive to conservative treatment. In this case report, the patient improved only slightly in overall ODI and pain level, but this may have been because of the multilevel fractures or segmental kyphosis. The patient did, however, experience immediate and significant pain relief at night, which led her to report that the procedure was worthwhile.
Written informed consent for publication of the clinical details and/or clinical images was obtained from the patient.
This manuscript was written in accordance with the current CARE guidelines for case reports [
Each author certifies that he or she has no commercial associations (e.g., consultancies, stock ownership, equity interest, or patent/licensing arrangements) that might pose conflicts of interest in connection with the submitted article.
Leonard Westermann made substantial contributions to conception and design, acquisition of data, and analysis and interpretation of data and participated in drafting and writing the article. Peer Eysel made substantial contributions to analysis and interpretation of data and participated in revising it critically for important intellectual content. Marvin Simons contributed to acquisition and interpretation of data and participated in drafting and writing the article. Kourosh Zarghooni made substantial contributions to conception and design and participated in revising the paper critically for important intellectual content. All authors read and approved the final manuscript.