J Korean Neurosurg Soc.  2018 Jan;61(1):1-9. 10.3340/jkns.2017.0505.010.

Posttraumatic Delayed Vertebral Collapse : Kummell's Disease

Affiliations
  • 1Department of Neurosurgery, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea. swchoi@cnu.ac.kr

Abstract

Posttraumatic delayed vertebral collapse, known as Kummell's disease, is increasing in number of patients. This disease is already progressive kyphosis due to vertebral collapse at the time of diagnosis and it causes intractable pain or neurologic deficit due to intravertebral instability. Treatment is very difficult after progression of the disease, and the range of treatment, in hospital day, and cost of treatment are both increased. Clinical features, pathogenesis and radiologic findings of these disease groups were reviewed to determine risk factors for delayed vertebral collapse. The purpose of this article is to suggest appropriate treatment before vertebral collapse for patients with osteoporotic vertebral compression fracture who have risk factors for posttraumatic delayed vertebral collapse.

Keyword

Osteoporosis; Vertebral fracture; Osteonecrosis; Intravertebral cleft; Kummell's disease

MeSH Terms

Diagnosis
Fractures, Compression
Humans
Kyphosis
Neurologic Manifestations
Osteonecrosis
Osteoporosis
Pain, Intractable
Risk Factors

Figure

  • Fig. 1 Case 1. A 62-year-old woman was admitted with severe backache who was suffering from rheumatoid arthritis relying on prednisolone for many years. She was diagnosed with compression fracture of T12. Her had appearance resembling that of the Cushing’s, bone mineral density examination showed severe osteoporosis, T score of -3.7. She was followed for 3 weeks with conservative treatment and osteoanabolic agent. However, T12 vertebral compression aggravated in follow up X-ray images and vertebroplasty was performed. However simple radiography, 1 month after the vertebroplasty, showed gradual progression of compression fracture and kyphosis of the T12 vertebrae but the clinical symptoms subsided, so progressive kyphosis was followed up without additional treatment. A : Serial simple spine lateral radiography showed compression fracture of T12 and progressive kyphosis. B : MRI showed high SI in fat suppressed T2WI and diffuse low SI in T1WI of T12. As well as, MRI revealed that the fluid content of the superior endplate of T12 high SI in T2WI and the low SI area of necrotic content (black arrows : IVC sign) and enhancing vertebral body in T1WI enhanced image. C : Postoperative serial simple radiographys showed progressive kyphosis. MRI : magnetic resonance image, IVC : intraverteral cleft.

  • Fig. 2 A 77-year-old man presented with persistent lumbago, progressive kyphosis and radiating pain on both lower extremities lasting about 3 months after minor trauma. He underwent conservative treatment with diagnosis of L1 compression fracture 2 months ago. A : A transverse radiolucent line of IVC sign (black arrow) was observed in anteroposterior view. And the intravertebral pseudoarthrosis and IVC sign (black arrows) were observed in the flexion-extension view. B : Spine MRI showed that typical IVC sign (white arrows) and ventral portion of spinal cord was compressed due to kyphosis. At first, vertebral body replacement was considered, but long level posterolateral fusion was performed due to elder and dementia. C : The restoration of the L1 body was observed in the postoperative image. However, recollapse of the restored L1 body, L3 screw loosening and posterior pull back were observed in the image 1 month after the fusion. AP : anteroposterior view, Lat. : lateral view, IVC : intraverteral cleft, MRI : magnetic resonance image.

  • Fig. 3 A 74-year-old woman presented with persistent back pain that had fallen 2 weeks ago. Radiologic examination at the time of admission revealed recent first lumbar compression fracture (A and B) and the patient underwent vertebroplasty (C). Her symptoms were improved and she was discharged with orthrosis and biphosphonate medication. Four months later, she revisited with progressive kyphosis, persistant backache and both lower leg weaknesses. Intravertebral instability at L1 body was suspected on the thoracolumbar flexion/extension simple radiographys (C). Dynamic spine CT showed intravertebral instability at L1 and compressed thecal sac due to fractured bony fragement of L1 (D). In MRI, there was no accurate intravertebral vaccum cleft, and compressed thecal sac was observed. We thought that her pain was caused by intravertebral instability, progressive neurologic deficit was caused by more protrusion of fractured bony fragment at flexion or weight bearing. We performed L1 corpectomy with mesh cage insertion and posterolateral fusion via posterior approach (E). Neurologic deficit and persistent backache disappeared. VP : vertebroplasty, CT : computerized tomography, MRI : magnetic resonance image.


Reference

References

1. Ahn SE, Ryu KN, Park JS, Jin W, Park SY, Kim SB. Early bone marrow edema pattern of the osteoporotic vertebral compression fracture : can be predictor of vertebral deformity types and prognosis? J Korean Neurosurg Soc. 59:137–142. 2016.
Article
2. Antonacci MD, Mody DR, Rutz K, Weibaecher D, Heggeness MH. A histologic study of fractured human vertebral bodies. J Spinal Disord Tech. 15:118–126. 2002.
Article
3. Ates A, Gemalmaz HC, Deveci MA, Simsek SA, Cetin E, Şenköylü A. Comparison of effectiveness of kyphoplasty and vertebroplasty in patients with osteoporotic vertebra fractures. Acta Orthop Traumatol Turc. 50:619–622. 2016.
Article
4. Baur A, Stäbler A, Arbogast S, Duerr HR, Bartl R, Reiser M. Acute osteoporotic and neoplastic vertebral compression fractures: fluid sign at MR imaging. Radiology. 225:730–735. 2002.
Article
5. Benedek TG, Nicholas JJ. Delayed traumatic vertebral body compression fracture; part II: pathologic features. Semin Arthritis Rheum. 10:271–277. 1981.
Article
6. Carlier RY, Gordji H, Mompoint DM, Vernhet N, Feydy A, Vallée C. Osteoporotic vertebral collapse: percutaneous vertebroplasty and local kyphosis correction. Radiology. 233:891–898. 2004.
Article
7. Chen L, Dong R, Gu Y, Feng Y. Comparison between balloon kyphoplasty and short segmental fixation combined with vertebroplasty in the treatment of Kümmell’s disease. Pain Physician. 18:373–381. 2015.
8. Cho JH, Shin SI, Lee JH, Yeom JS, Chang BS, Lee CK. Usefulness of prone cross-table lateral radiographs in vertebral compression fractures. Clin Orthop Surg. 5:195–201. 2013.
Article
9. D’Ippolito G, Schiller PC, Ricordi C, Roos BA, Howard GA. Age-related osteogenic potential of mesenchymal stromal stem cells from human vertebral bone marrow. J Bone Miner Res. 14:1115–1122. 1999.
Article
10. Fabbriciani G, Pirro M, Floridi P, Callarelli L, Manfredelli MR, Scarponi AM, et al. Osteoanabolic therapy: a non-surgical option of treatment for Kümmell’s disease? Rheumatol Int. 32:1371–1374. 2012.
Article
11. Ha KY, Kim YH. Risk factors affecting progressive collapse of acute osteoporotic spinal fractures. Osteoporos Int. 24:1207–1213. 2013.
Article
12. Heo DH, Chin DK, Yoon YS, Kuh SU. Recollapse of previous vertebral compression fracture after percutaneous vertebroplasty. Osteoporos Int. 20:473–480. 2009.
Article
13. Ishiyama M, Numaguchi Y, Makidono A, Kobayashi N, Fuwa S, Ohde S, et al. Contrast-enhanced MRI for detecting intravertebral cleft formation: relation to the time since onset of vertebral fracture. AJR Am J Roentgenol. 201:W117–W123. 2013.
Article
14. Kim DY, Lee SH, Jang JS, Chung SK, Lee HY. Intravertebral vaccum phenomenon in osteoporotic compression fracture: report of 67 cases with quantitative evaluation of intravertebral instability. J Neurosurg. 100(1 Suppl Spine):24–31. 2004.
Article
15. Kim H, Jun S, Park SK, Kim GT, Park SH. Intravertebral vaccum cleft sign: a cause of vertebral cold defect on bone scan. Skeletal Radiol. 45:707–712. 2016.
Article
16. Kim YC, Kim YH, Ha KY. Pathomechanism of intravertebral clefts in osteoporotic compression fractures of the spine. Spine J. 14:659–666. 2014.
Article
17. Krauss M, Hirschfelder H, Tomandl B, Lichti G, Bär I. Kyphosis reduction and the rate of cement leaks after vertebroplasty of intravertebral clefts. Eur Radiol. 16:1015–1021. 2006.
Article
18. Lee SH, Kim ES, Eoh W. Cement augmented anterior reconstruction with short posterior instrumentation: a less invasive surgical option for Kummell’s disease with cord compression. J Clin Neurosci. 18:509–514. 2011.
Article
19. Libicher M, Appelt A, Berger I, Baier M, Meeder PJ, Grafe I, et al. The intravertebral vacuum phenomen as specific sign of osteonecrosis in vertebral compression fractures: results from a radiological and histological study. Eur Radiol. 17:2248–2252. 2007.
Article
20. Love C, Din AS, Tomas MB, Kalapparambath TP, Palestro CJ. Radionuclide bone image: an illustrative review. Radiographics. 23:341–358. 2003.
21. Maldague BE, Noel HM, Malghem JJ. The intravertebral vacuum cleft: a sign of ischemic vertebral collapse. Radiology. 129:23–29. 1978.
Article
22. Matzaroglou C, Georgiou C, Assimakopoulos K, Giannakenas C, Karageorgos A, Saridis A. Kümmell’s disease: pathophysiology, diagnosis, treatment and the role of nuclear medicine. Rationale according to our experience. Hell J Nucl Med. 14:291–299. 2011.
23. Matzaroglou C, Georgiou CS, Panagopoulos A, Assimakopoulos K, Wilke HJ, Habermann B, et al. Kümmell’s disease: clarifying the mechanisms and patients’ inclusion criteria. Open Orthop J. 8:288–297. 2014.
Article
24. McKiernan F, Jensen R, Faciszewski T. The dynamic mobility of vertebral compression fractures. J Bone Miner Res. 18:24–29. 2003.
Article
25. Nakamae T, Fujimoto Y, Yamada K, Takata H, Shimbo T, Tsuchida Y. Percutaneous vertebroplasty for osteoporotic vertebral compression fracture with intravertebral cleft associated with delayed neurologic deficit. Eur Spine J. 22:1624–1632. 2013.
Article
26. Nieuwenhuijse MJ, Van Erkel AR, Dijkstra PS. Cement leakage in percutaneous vertebroplasty for osteoporotic vertebral compression fractures: identification of risk factors. Spine J. 11:839–848. 2011.
Article
27. Niu J, Song D, Zhou H, Meng Q, Meng B, Yang H. Percutaneous Kyphoplasty for the treatment of osteoporotic vertebral fractures with intravertebral fluid or air: a comparative study. Clin Spine Surg. 30:367–373. 2016.
Article
28. Sarli M, Pérez Manghi FC, Gallo R, Zanchetta JR. The vacuum cleft sign: an uncommon radiological sign. Osteoporos Int. 16:1210–1214. 2005.
Article
29. Steel HH. Kümmell’s disease. Am J Surg. 81:161–167. 1951.
Article
30. Sugita M, Watanabe N, Mikami Y, Hase H, Kubo T. Classification of vertebral compression fractures in the osteoporotic spine. J Spinal Disord Tech. 18:376–381. 2005.
Article
31. Theodorou DJ. The intravertebral vacuum cleft sign. Radiology. 221:787–788. 2001.
Article
32. Tsujio T, Nakamura H, Terai H, Hoshino M, Namikawa T, Matsumura A, et al. Characteristic radiographic or magnetic resonance images of fresh osteoporotic vertebral fractures predicting potential risk for nonunion: a prospective multicenter study. Spine (Phila Pa 1976). 36:1229–1235. 2011.
Article
33. Venmans A, Klazen CA, Lohle PN, Mali WP, van Rooij WJ. Natural history of pain in patients with conservatively treated osteoporotic vertebral compression fractures: results from VERTOS II. AJNR Am J Neuroradiol. 33:519–521. 2012.
Article
34. Wang F, Wang D, Tan B, Dong J, Feng R, Yuan Z, et al. Comparative study of modified posterior operation to treat Kümmell’s disease. Medicine (Baltimore). 94:e1595. 2015.
Article
35. Young WF, Brown D, Kendler A, Clements D. Delayed post-traumatic osteonecrosis of a vertebral body (Kummell’s disease). Acta Orthop Belg. 68:13–19. 2002.
36. Yu CW, Hsu CY, Shih TT, Chen BB, Fu CJ. Vertebral osteonecrosis: MR imaging findings and related changes on adjacent levels. AJNR. 28:42–47. 2007.
37. Zhang GQ, Gao YZ, Zheng J, Luo JP, Tang C, Chen SL, et al. Posterior decompression and short segmental pedicle screw fixation combined with vertebroplasty for Kümmell’s disease with neurological deficits. Exp Ther Med. 5:517–522. 2013.
Article
38. Zhang X, Hu W, Yu J, Wang Z, Wang Y. An effective treatment option for Kümmell disease with neurological deficits: modified transpedicular subtraction and disc osteotomy combined with long-segment fixation. Spine (Phila Pa 1976). 41:E923–E930. 2016.
Full Text Links
  • JKNS
Actions
Cited
CITED
export Copy
Close
Share
  • Twitter
  • Facebook
Similar articles
Copyright © 2024 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: koreamed@kamje.or.kr