Three-level thoracolumbar vertebroplasty with screw-rod- wire construct in Kummels disease patient with neurological deficit after low impact injury

In 1895, a German surgeon named Kummel reported for the first time 6 patients with minimal post-traumatic spinal compression fractures which later is named after him as Kummel disease (KD). KD is characterized by osteonecrosis of the vertebrae which often occurs in the thoracic area with compression fractures, intravertebral vacuum clefts, The incidence of Kummel disease increases every year with increasing age and the presence of osteoporosis.1,2 Osteoporosis is the leading cause of non-traumatic vertebral compression fractures and accounts for 750,000 vertebral fractures per year in the USA.3 Compression fractures caused by osteoporosis are often preceded by minimal trauma to previous history, 30% of compression fractures caused by osteoporosis cannot be treated with conservative therapy and the presence of KD can accelerate the deterioration of the vacuum cleft.4 Recent studies on patients reveal that the osteolysis incidence among patients with KD is faster than the process of bone callus formation.5 Vertebroplasty is a minimally invasive procedure to reduce and heal fractured bones and reduce pain. The procedure uses a guide of fluoroscopy by inserting bone cement into the Abstract

Vertebroplasty is a minimally invasive procedure to reduce and heal fractured bones and reduce pain. The procedure uses a guide of fluoroscopy by inserting bone cement into the Abstract Kummel disease (KD) or avascular necrosis is characterized by osteonecrosis of the vertebrae which often occurs in the thoracic area with compression fractures, intravertebral vacuum clefts, change in posture to kyphotic within months to years after minor trauma. KD is a rare disease but its incidence continues to increase with age and osteoporosis increases.
Fixation of unstable thoracic fractures using the transpedicular pedicle screw (TPS) has been accepted as a procedure performed by experts. However, TPS itself has several complications combination with vertebroplasty and wire can reduce the incidence of the misplaced screw. vertebral body via transpedicular access. As age increases in the population, bone cement vertebroplasty has also increased in terms of its use as an alternative procedure. 3,6-10 The procedure was carried out with sterility techniques. After a linear skin incision and unilateral hemilaminotomy decompression on severe symptoms-side was performed. Unipediculate vertebroplasty technique was performed according to operator discretion considering the high risk cement leakage during augmentation. Jamshidi needle advance until the anterior third of the vertebrae and was followed by injection of a 3 cc bone cement mixture with adequate mixing to prevent leaks outside the vertebrae, then was continued with the installation of a pedicle screw with rod of Th 12 screw was tightened first then L2 screws compressed with the help of the compressor force applied using both L2 screw as pivot points and using wire put into spinous process Th12, L1 and L2. 9,10,11

Case report
A 67-years-old woman experienced persistent and severe thoracolumbar back pain and bilateral leg weakness after slipped at home. She was unable to perform her daily activities with moderate pain for 6-months then developed severe pain in the same region. The Hematological examination and biochemical evaluation did not reveal any significant findings suggestive of infection or malignancy. As the patient did not respond to conservative management and the pain was so severe that it was affecting her daily activities; we performed surgery ( Figure 2).   However, the pedicle screw itself has several complications, especially in the thoracic bone which has a small pedicle, combination with vertebroplasty can reduce the incidence of misplaced screw and kyphosis after surgery. 7,13 In this case, we adopted interspinous wiring as an adjunct to screw-rod to strengthen the construct based on the previous review by Chandran et al., 14 and Ghori et al., 15 interspinous wirings could restore the posterior tension band and this technique also offers a stable fixation. Based on previous studies the authors did not found any longterm complications of wire-like fatigue and fractures in the thoracolumbar region during follow-up. 14,15 Upper and lower vertebrae are selected segment in the instrumentation because this is a potential way to balance the amount of cement and the stability of the surgical segment. 16 Regarding leakage of bone cement into the disc is not common during vertebroplasty but it can happen; and often, it does not have significant complaints after the procedure. The incidence of leakage is 6% -52% without symptoms. The most severe symptoms that arise due to this leak are pulmonary and brain embolism, perforation of the heart, and death.
Blood vessels disorders in the vertebrae, low cement viscosity, high energy pressure at injection, although it is not common it can cause asymptomatic pulmonary embolism to occur in 4.6% of all patients. 7-

13,17
Our case is unique because multiple burst fractures and neurological deficits occurred after low impact injury.

Conclusion
Multilevel VP in thoracolumbar is effective and safe in treating burst fractures in KD patients. VP which is accompanied by a screwrod-wire construct has a significant effect in reducing pain, improving disability and kyphotic posture.

Acknowledgement
There is no potential conflict of interest relevant to this article reported. No specific grant was provided for this article. All authors