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European Spine Journal

, Volume 27, Supplement 2, pp 190–197 | Cite as

Vertebral body osteonecrosis: proposal of a treatment-oriented classification system

  • Matteo Formica
  • Andrea Zanirato
  • Luca Cavagnaro
  • Marco Basso
  • Stefano Divano
  • Claudio Lamartina
  • Pedro Berjano
  • Lamberto Felli
  • Carlo Formica
Ideas and Technical Innovations

Abstract

Purpose

To present a classification system for vertebral body osteonecrosis (VBON) based on imaging findings and sagittal alignment and consequently to propose treatment guidelines.

Methods

Chart review and classification of imaging and clinical findings. An analysis of literature about VBON has been evaluated to conceive the classification. The current data allows to correlate radiological findings with different stages of the pathophysiological process and consequently to propose a patient-tailored treatment plan.

Results

The classification identifies 4 stages: stage 0 (theoretical phase), stage 1 (early phase), stage 2 (instability phase) and stage 3 (fixed deformity phase). Local (angular kyphosis expressed as anterior–posterior wall height ratio) and global (sagittal vertical axis and pelvic tilt) sagittal alignment are considered as complementary modifiers to tailor the most suitable treatment. Stage 1 is generally managed conservatively. Stage 2 and 3 often require different surgical approaches according to local and global sagittal alignment.

Conclusions

The classification allows a systematic staging of this disease and can help establish a proper and patient-oriented treatment plan. Further researches are advocated to fully validate the proposed classification system.

Graphical abstract

These slides can be retrieved under Electronic Supplementary Material.

Keywords

Vertebral osteonecrosis Vertebral non-union Classification Sagittal alignment Adult deformity 

Notes

Funding

There is no funding source for this article.

Compliance with ethical standards

Conflict of interest

Pedro Berjano received honorarium for surgeons’ education activities from Nuvasive, Medacta, DepuySynthes and his department received unrestricted research grants from Nuvasive, Medacta, DepuySynthes and K2 M. Claudio Lamartina received honorarium for surgeons’ education activities from Nuvasive, Medacta, DepuySynthes and K2 M and his department received unrestricted research grants from Nuvasive, Medacta, DepuySynthes and K2 M. No other disclosures by the rest of authors.

Supplementary material

586_2018_5600_MOESM1_ESM.pptx (191 kb)
Supplementary material 1 (PPTX 191 kb)

References

  1. 1.
    Shah KN, Racine J, Jones LC, Aaron RK (2015) Pathophysiology and risk factors for osteonecrosis. Curr Rev Musculoskelet Med 8(3):201–209CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Lafforgue P (2006) Pathophysiology and natural history of avascular necrosis of bone. Jt Bone Spine 73(5):500–507CrossRefGoogle Scholar
  3. 3.
    Ma R, Chow R, Shen FH (2010) Kummell’s disease: delayed post-traumatic osteonecrosis of the vertebral body. Eur Spine J 19(7):1065–1070CrossRefPubMedGoogle Scholar
  4. 4.
    Young WF, Brown D, Kendler A et al (2002) Delayed post-traumatic osteonecrosis of a vertebral body (Kümmell’s disease). Acta Orthop Belg 68:13–19PubMedGoogle Scholar
  5. 5.
    Swartz K, Fee D (2008) Kummell’s disease: a case report and literature review. Spine (PhilaPa 1976) 33(5):E152–E155CrossRefGoogle Scholar
  6. 6.
    Hajnovic L, Sefranek V, Schütz L (2017) Influence of blood supply on fracture healing of vertebral bodies. Eur J Orthop Surg Traumatol.  https://doi.org/10.1007/s00590-017-2069-7. [Epub ahead of print]
  7. 7.
    Fabbriciani G, Pirro M, Floridi P et al (2012) Osteoanabolic therapy: a non-surgical option of treatment for Kümmell’s disease? Rheumatol Int 32:13714Google Scholar
  8. 8.
    Rossini M, Viapiana O, Gatti D et al (2010) Capacitively coupled electric field for pain relief in patients with vertebral fractures and chronic pain. Clin Orthop Relat Res 468(3):735–740CrossRefPubMedGoogle Scholar
  9. 9.
    Heo DH, Choi JH, Kim MK et al (2012) Therapeutic efficacy of vertebroplasty in osteoporotic vertebral compression fractures with avascular osteonecrosis: a minimum 2-year follow-up study. Spine (Phila Pa 1976) 37(7):E423–E429CrossRefGoogle Scholar
  10. 10.
    Vanni D, Pantalone A, Magliani V et al (2017) Corpectomy and expandable cage replacement versus third generation percutaneous augmentation system in case of vertebra plana: rationale and recommendations. J Spine Surg 3(3):379–386CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Zhang GQ, Gao YZ, Chen SL et al (2015) Comparison of percutaneous vertebroplasty and percutaneous kyphoplasty for the management of Kümmell’s disease: a retrospective study. Indian J Orthop 49(6):577–582CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Formica M, Basso M, Cavagnaro L et al (2016) Kümmell disease: illustrative case for definition criteria. Spine J 16(10):e707–e708CrossRefPubMedGoogle Scholar
  13. 13.
    Cho Y (2017) Corpectomy and circumferential fusion for advanced thoracolumbar Kümmell’s disease. Musculoskelet Surg 101(3):269–274CrossRefPubMedGoogle Scholar
  14. 14.
    Zhang X, Hu W, Yu J, Wang Z, Wang Y (2016) An effective treatment option for Kümmell’s disease with neurological deficits: modified transpedicular subtraction and disc osteotomy combined with long-segment fixation. Spine (Phila Pa 1976) 41(15):E923–E930CrossRefGoogle Scholar
  15. 15.
    Lim J, Choi SW, Youm JY et al (2017) Posttraumatic delayed vertebral collapse: Kummell’s disease. J Korean Neurosurg Soc 61(1):1–9CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Nakamae T, Fujimoto Y, Yamada K et al (2017) Relationship between clinical symptoms of osteoporotic vertebral fracture with intravertebral cleft and radiographic findings. J Orthop Sci 22(2):201–206CrossRefPubMedGoogle Scholar
  17. 17.
    Libicher M, Appelt A, Berger I et al (2007) The intravertebral vacuum phenomenon as specific sign of osteonecrosis in vertebral compression fractures: results from a radiological and histological study. Eur Radiol 17:2248–2252CrossRefPubMedGoogle Scholar
  18. 18.
    Yu CW, Hsu CY, Shih TT et al (2007) Vertebral: MR imaging findings and related changes on adjacent levels. AJNR Am J Neuroradiol 28:42–47CrossRefPubMedGoogle Scholar
  19. 19.
    Nardi A, Tarantino U, Ventura L et al (2011) Domino Effect: mechanic factors role. Clin Cases Miner Bone Metab 8(2):38–42PubMedPubMedCentralGoogle Scholar
  20. 20.
    Garbossa D, Pejrona M, Damilano M et al (2014) Pelvic parameters and global spine balance for spine degenerative disease: the importance of containing for the well being of content. Eur Spine J 23(Suppl 6):616–627CrossRefPubMedGoogle Scholar
  21. 21.
    Diamond TH, Clark WA, Kumar SV (2007) Histomorphometric analysis of fracture healing cascade in acute osteoporotic vertebral body fractures. Bone 40(3):775–780CrossRefPubMedGoogle Scholar
  22. 22.
    Piazzolla A, Solarino G, Lamartina C et al (2015) Vertebral bone marrow edema (VBME) in conservatively treated acute vertebral compression fractures (VCFs): evolution and clinical correlations. Spine (Phila Pa 1976) 40(14):E842–E848CrossRefGoogle Scholar
  23. 23.
    Formica M, Cavagnaro L, Basso M, Zanirato A, Felli L, Formica C, Di Martino A (2016) Which patients risk segmental kyphosis after short segment thoracolumbar fracture fixation with intermediate screws? Injury 47(suppl 4):S29–S34.  https://doi.org/10.1016/j.injury.2016.07.048 CrossRefPubMedGoogle Scholar
  24. 24.
    Zanirato A, Damilano M, Formica M et al Eur Spine J (2018).  https://doi.org/10.1007/s00586-018-5535-y. [Epub ahead of print]
  25. 25.
    Krüger A, Oberkircher L, Figiel J et al (2015) Height restoration of osteoporotic vertebral compression fractures using different intravertebral reduction devices: a cadaveric study. Spine J 15(5):1092–1098CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Matteo Formica
    • 1
  • Andrea Zanirato
    • 1
  • Luca Cavagnaro
    • 1
  • Marco Basso
    • 1
  • Stefano Divano
    • 1
  • Claudio Lamartina
    • 2
  • Pedro Berjano
    • 2
  • Lamberto Felli
    • 1
  • Carlo Formica
    • 2
  1. 1.Clinica Ortopedica – Ospedale Policlinico San MartinoGenoaItaly
  2. 2.Gspine4 - IRCCS Istituto Ortopedico GaleazziMilanItaly

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