Publication: Perkütan Balon Kifoplasti Prosedürü Uygulanan Multipl Myelom ve Osteoporoza Bağlı Vertebral Kompresyon Kırığı Olan Hastalarda Radyolojik ve Klinik Sonuçların Değerlendirilmesi
Abstract
Giriş:Osteoporotik vertebral kompresyon kırıkları, yaşlanan nüfusla birlikte artmakta ve yüksek tedavi maliyetleri oluşturmaktadır.Multipl myelom(MM)ve osteoporoz(OP), vertebral kompresyon kırıklarının başlıca nedenleri olup, bu kırıklar sinir basısı, omurga instabilitesi ve kifotik deformite gibi ciddi klinik sonuçlara yol açarak yaşam kalitesini olumsuz etkilemektedir. Multipl myelom hastalarında bağışıklık baskılanması ve enfeksiyon riski, osteoporozda ise kemik kalitesi sonucu gelişen implant problemleri, perkütan yöntemleriön plana çıkarmaktadır. Tedavide kullanılan vertebroplasti(VP) ve perkütan balon kifoplasti(PBK), kırık stabilizasyonunda etkili olan perkütan yöntemlerdir. Perkütan balon kifoplasti, sagittal planda restorasyonudaha iyi sağlarken, vertebroplastisementekstravazasyon riski taşımaktadır. Literatürde klinik ve radyolojik iyileşmeler arasındaki korelasyonu gösteren sınırlı sayıda çalışma mevcut olup, çalışmamızda iki farklı hasta grubunda elde edilen klinik ve radyolojik sonuçları literatür bilgileri ile karşılaştırmak ve karşılaştırılan parametreler arasındaki korelasyonu göstermek amaçlanmıştır. Gereç ve Yöntem:Ondokuz Mayıs Üniversitesi Ortopedi ve Travmatoloji Anabilim Dalı'nda 01.06.2021 ve 31.01.2024 tarihleri arasında perkütan balon kifoplasti işlemi uygulanmış ve 12 aydan uzun süre takip edilen hastalar çalışmaya dahil edildi. Demografik özellikleri kaydedilen hastaların preoperatif dönemde gerekli muayene, laboratuvar ve görüntüleme sonuçları mevcuttu. Hastalar osteoporoz ve multipl myelom grubu olarak 2'ye ayrıldı.STIR sekans MR incelemedehiperintensalanları bulunan ve 6 hafta konservatif tedavi sonrası persistan ağrı varlığında,hastalara perkütan balon kifoplasti işlemi uygulandı. Cerrahi işlem öncesi aydınlatılmış onam alındı ve hastaların VAS, Oswestry Engellilik İndeksi (ODI) ve Kısa Form-36(SF-36)skorlarıkaydedildi. Multipl myelom lezyonlarının aktif dönemde olup olmadığı preoperatif PET/BT raporlarından taranarak elde edildi. Postoperatif 1. günde hastalar torakolomber korse ile mobilize edildi. Hastalar taburcu edilmeden önce radyolojik kontroller yapıldı ve belirlenen takip dönemlerinde düzenli kontrollerde değerlendirildi ve son kontrollerinde VAS, ODI ve SF-36 skorlamaları dolduruldu. Ayrıca, PACS veritabanı kullanılarak iki omurga cerrahı tarafından lokal kifoz açısı (LK), anterior vertebral korpus yüksekliği (AVH) ve mid-sagittal vertebral korpus yükseklikleri (MVH) hesaplanarak radyolojik değerlendirmeler yapıldı. Bulgular:Polikliniğe vertebral kompresyon kırığı nedenli başvuran 203 hasta içerisinden 40 hastanın 51 seviyesine PBK prosedürü uygulayıp kesitsel olarak analiz edildi. Yaş ortalaması 64,9(49-78), ortalama takip süresi 17,2(14,6-19,8) aydı. PBK uygulanan MM ve OP nedenli kırıklar arasında yapılan karşılaştırmalarda, Lokal Kifoz Açısı Farkı(LKfark) değerleri arasında anlamlı değişim bulunamamıştır (MM'da ort. 3,3 derece iyileşme, OP'de 4,1 derece). Mid-sagittal vertebra yükseklik restorasyonu(MVHR) değerlerindeMM'da %16,9iyileşme görülürken, OP'de % 12,6 görüldü ve aradaki değişim istatistiksel olarak anlamlı bulundu (p<0,01). Anterior vertebral yükseklik restorasyonu(AVHR)'de MM'da ortalama %11,8 değişim mevcutken, OP'de %9,1 görüldü(p:0,152). LKfark ile Vizüel Analog Skala(VAS) (p:0,018, r:0,372)ve LKfark ile Oswestry Engellilik İndeksi(ODI)(p:0,034,r:0,335) değerleri arasında düşük orta derecede korelasyon gözlenirken diğer radyolojik parametreler ile klinik parametreler arasında korelasyon gözlenmedi. Aktif MM mevcut olan 4 hastadaliteratürün aksine 100,200,250,500 ml kanamalar gözlendi. Sonuç: Perkütan balon kifoplasti, multipl myelom ve osteoporotik kırıklar için güvenle uygulanabilir ve özellikle ağrı skorlarında radyolojik parametrelerden bağımsız, anlamlı bir iyileşme ile sonuçlanır. Çalışmamızda, radyolojik parametreler ile klinik parametreler arası korelasyon olmadığı gözlenmiş ancaklokal kifoz açısının klinik sonuçlarla düşük-orta derecede ilişki gösterebileceği bulunmuştur. Perkütan bir işlem olmasına rağmen, özellikle aktif dönemde olan multipl myeloma bağlı lezyonlara uygulanan perkütan balon kifoplasti işleminde,kanama olabileceği göz önünde bulundurulmalıdır. Anahtar Kelimeler:Kifoplasti, Multipl Myelom, Osteoporoz, Vertebra Kompresyon Kırığı
Introduction:Osteoporotic vertebral compression fractures are increasing with the aging population and impose significant treatment costs. Multiple myeloma (MM) and osteoporosis (OP) are the primary causes of vertebral compression fractures, which can lead to serious clinical outcomes such as nerve compression, spinal instability, and kyphotic deformity, thereby adversely affecting quality of life. In patients with multiple myeloma, immunosuppression and infection risk, and in osteoporosis, implant-related problems due to poor bone quality highlight the importance of percutaneous techniques. Vertebroplasty (VP) and percutaneous balloon kyphoplasty (PBK) are effective percutaneous methods used in the treatment for fracture stabilization. While PBK provides better sagittal plane restoration, vertebroplasty carries a risk of cement extravasation. There are limited studies in the literature demonstrating the correlation between clinical and radiological improvements. This study aims to compare the clinical and radiological outcomes obtained in two patient groups, analyze the correlation between the evaluated parameters, and discuss these findings in light of the existing literature. Materials and Methods:Patients who underwent percutaneous balloon kyphoplasty (PBK) at the Department of Orthopedics and Traumatology, Ondokuz Mayıs University, between June 1, 2021, and January 31, 2024, with follow-up durations exceeding 12 months, were included in the study. Demographic characteristics were recorded, and all patients had available preoperative examination findings, laboratory results, and imaging studies. The patients were divided into two groups: osteoporosis and multiple myeloma. PBK was performed in patients with hyperintense areas observed in STIR sequence MRI and persistent pain after six weeks of conservative management. Informed consent was obtained before surgery, and the Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and Short Form(SF-36) scores were documented.The activity status of multiple myeloma lesions was determined from preoperative PET/CT reports. Postoperatively, patients were mobilized on the first day using a thoracolumbar brace. Radiological evaluations were performed before discharge, and patients were assessed at regular intervals during the follow-up period. At the final follow-up, VAS, ODI, and SF-36 scores were recorded again. Additionally, radiological parameters, including local kyphosis angle (LKA), anterior vertebral body height (AVH), and mid-sagittal vertebral body height (MVH), were measured using the PACS database by two spine surgeons. Results:Among 203 patients who presented to the outpatient clinic with vertebral compression fractures, 40 patients underwent PBK procedures at 51 levels and were analyzed cross-sectionally. The mean age was 64.9 years (49–78), and the mean follow-up duration was 17.2 months (14.6–19.8). Comparisons between fractures caused by MM and OP treated with PBK revealed no significant difference in Local Kyphosis Angle improvement values (mean improvement: 3.3° in MM vs. 4.1° in OP). In mid-sagittal vertebral height restoration (MVHR), MM fractures showed a 16.9% improvement, while OP fractures showed a 12.6% improvement, which was statistically significant (p<0.01). For anterior vertebral height restoration (AVHR), the mean improvement was 11.8% in MM and 9.1% in OP, with no statistically significant difference (p=0.152). A low to moderate correlation was observed between LKAdifference and the Visual Analog Scale (VAS) difference (p=0.018, r=0.372), as well as between LKAdifference and the Oswestry Disability Index (ODI) difference (p=0.034, r=0.335). No correlation was identified between other radiological and clinical parameters. Contrary to the literature, significant blood loss (100 mL, 200 mL, 250 mL, and 500 mL) was observed in 4 patients with active MM lesions. Conclusion:Percutaneous balloon kyphoplasty can be safely performed for fractures caused by multiple myeloma and osteoporosis, resulting in significant improvement in pain scores independent of radiological parameters. In our study, no correlation was observed between radiological and clinical parameters; however, local kyphosis angle was found to have a low-to-moderate association with clinical outcomes. Despite being a minimally invasive procedure, the possibility of bleeding should be considered, particularly when performing percutaneous balloon kyphoplasty for lesions associated with active multiple myeloma. Keywords:Kyphoplasty, Osteoporosis, Multiple Myeloma, Compression fractures
Introduction:Osteoporotic vertebral compression fractures are increasing with the aging population and impose significant treatment costs. Multiple myeloma (MM) and osteoporosis (OP) are the primary causes of vertebral compression fractures, which can lead to serious clinical outcomes such as nerve compression, spinal instability, and kyphotic deformity, thereby adversely affecting quality of life. In patients with multiple myeloma, immunosuppression and infection risk, and in osteoporosis, implant-related problems due to poor bone quality highlight the importance of percutaneous techniques. Vertebroplasty (VP) and percutaneous balloon kyphoplasty (PBK) are effective percutaneous methods used in the treatment for fracture stabilization. While PBK provides better sagittal plane restoration, vertebroplasty carries a risk of cement extravasation. There are limited studies in the literature demonstrating the correlation between clinical and radiological improvements. This study aims to compare the clinical and radiological outcomes obtained in two patient groups, analyze the correlation between the evaluated parameters, and discuss these findings in light of the existing literature. Materials and Methods:Patients who underwent percutaneous balloon kyphoplasty (PBK) at the Department of Orthopedics and Traumatology, Ondokuz Mayıs University, between June 1, 2021, and January 31, 2024, with follow-up durations exceeding 12 months, were included in the study. Demographic characteristics were recorded, and all patients had available preoperative examination findings, laboratory results, and imaging studies. The patients were divided into two groups: osteoporosis and multiple myeloma. PBK was performed in patients with hyperintense areas observed in STIR sequence MRI and persistent pain after six weeks of conservative management. Informed consent was obtained before surgery, and the Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and Short Form(SF-36) scores were documented.The activity status of multiple myeloma lesions was determined from preoperative PET/CT reports. Postoperatively, patients were mobilized on the first day using a thoracolumbar brace. Radiological evaluations were performed before discharge, and patients were assessed at regular intervals during the follow-up period. At the final follow-up, VAS, ODI, and SF-36 scores were recorded again. Additionally, radiological parameters, including local kyphosis angle (LKA), anterior vertebral body height (AVH), and mid-sagittal vertebral body height (MVH), were measured using the PACS database by two spine surgeons. Results:Among 203 patients who presented to the outpatient clinic with vertebral compression fractures, 40 patients underwent PBK procedures at 51 levels and were analyzed cross-sectionally. The mean age was 64.9 years (49–78), and the mean follow-up duration was 17.2 months (14.6–19.8). Comparisons between fractures caused by MM and OP treated with PBK revealed no significant difference in Local Kyphosis Angle improvement values (mean improvement: 3.3° in MM vs. 4.1° in OP). In mid-sagittal vertebral height restoration (MVHR), MM fractures showed a 16.9% improvement, while OP fractures showed a 12.6% improvement, which was statistically significant (p<0.01). For anterior vertebral height restoration (AVHR), the mean improvement was 11.8% in MM and 9.1% in OP, with no statistically significant difference (p=0.152). A low to moderate correlation was observed between LKAdifference and the Visual Analog Scale (VAS) difference (p=0.018, r=0.372), as well as between LKAdifference and the Oswestry Disability Index (ODI) difference (p=0.034, r=0.335). No correlation was identified between other radiological and clinical parameters. Contrary to the literature, significant blood loss (100 mL, 200 mL, 250 mL, and 500 mL) was observed in 4 patients with active MM lesions. Conclusion:Percutaneous balloon kyphoplasty can be safely performed for fractures caused by multiple myeloma and osteoporosis, resulting in significant improvement in pain scores independent of radiological parameters. In our study, no correlation was observed between radiological and clinical parameters; however, local kyphosis angle was found to have a low-to-moderate association with clinical outcomes. Despite being a minimally invasive procedure, the possibility of bleeding should be considered, particularly when performing percutaneous balloon kyphoplasty for lesions associated with active multiple myeloma. Keywords:Kyphoplasty, Osteoporosis, Multiple Myeloma, Compression fractures
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