Vertebral refracture following percutaneous vertebral augmentation (PVA) is commonly seen in elderly patients with osteoporotic thoracolumbar compression fractures (OTLCF). It can lead to recurrent pain, loss of vertebral height, progression of kyphosis, and even neurological dysfunction, significantly impairing patients′ quality of life. Current diagnosis and treatment face multiple challenges, including high misdiagnosis rate, difficulty in choosing between surgical and non-surgical treatment options, lack of standardized surgical protocols, interference from intralesional bone cement during procedures, inadequate stability of internal fixation in osteoporotic bone, and suboptimal compliance of anti-osteoporotic therapy. Establishing a standardized diagnostic and therapeutic framework is urgently needed. To standardize the management process and improve outcomes for vertebral refractures after PVA in elderly OTLCF patients, Spinal Trauma Group of the Orthopedic Branch of Chinese Medical Doctor Association organized experts in the field to develop Guideline for the diagnosis and treatment of vertebral refracture after percutaneous vertebral augmentation in elderly patients with osteoporotic thoracolumbar compression fractures ( version 2025), based on current literature and clinical experience, and adhering to principles of scientific rigor and clinical applicability. A total of 11 recommendations were proposed, encompassing diagnosis, treatment, and rehabilitation of vertebral refracture after PVA in elderly patients with OTLCF, aiming to provide a foundation for a standardized management.

Objective:To explore the effects of age and gender on the sagittal spinal-pelvic parameters during the natural aging process of healthy adults.Methods:A total of 647 Chinese healthy adults who underwent health check-ups at the Second Affiliated Hospital of Zhejiang University School of Medicine and Songyang County People's Hospital, from January 2017 to September 2024 were collected. There were 277 males and 370 females, aged 18-93 years. Anteroposterior and lateral X-ray films of the whole spine were taken to evaluate the spinal-pelvic sagittal morphology. The following parameters were measured: thoracic kyphosis (TK), lumbar lordosis(LL), sacral slope (SS), pelvic incidence (PI), pelvic tilt (PT), global tilt (GT), T 1-pelvic angle (TPA), sagittal vertical axis (SVA), thoracic Cobb angle (T-Cobb), lower end vertebra of thoracic Cobb angle (T-LEV), apex vertebra of thoracic Cobb angle (T-Apex), lumbar Cobb angle (L-Cobb). Compare the differences in spine-pelvis parameters among patients of different genders and age groups (in this study, the subjects were subdivided into the 18-29, 30-39, 40-49, 50-59, 60-69, 70-79, and 80-93 years groups according to the age range). Results:The results showed that GT, SVA, TPA, and PT increased with age ( P<0.05). For males aged 18-29, 30-39, 40-49, 50-59, 60-69, 70-79, and 80-93 years, PT values were 8.58°±6.47°, 9.60°±5.63°, 12.65°±7.13°, 11.00°±6.99°, 13.01°±8.63°, 15.77°±8.02°, and 18.47°±10.03° respectively; for females in the same age groups, the PT values were 8.44°±6.83°, 9.00°±6.44°, 11.84°±7.35°, 12.07°±7.51°, 15.44°±9.39°, 19.26°±8.28°, and 18.17°±9.43° respectively. For males in these age groups, the global tilt (GT) values were 6.37°±7.20°, 8.77°±6.51°, 10.38°±9.07°, 8.80°±7.49°, 10.80°±8.62°, 16.07°±10.42°, and 21.99°±12.65° respectively; for females, the GT values were 4.46°±8.09°, 5.96°±7.83°, 8.17°±6.88°, 9.41°±8.03°, 9.96°±1.39°, 17.89°±9.39°, and 19.55°±12.34° respectively. The sagittal vertical axis (SVA) values for males in the age groups were -7.94±25.57 mm, -2.98±25.69 mm, -4.63±20.90 mm, -6.43±32.81 mm, 7.85±43.39 mm, 36.49±53.89 mm, and 55.57±51.10 mm respectively; for females, they were -24.12±31.35 mm, -17.49±25.12 mm, -17.88±22.72 mm, -8.25±30.91 mm, 8.80±27.45 mm, 28.67±38.22 mm, and 23.23±35.19 mm respectively. For males, the thoracic pelvic angle (TPA) values across the age groups were 4.46°±5.94°, 6.05°±5.38°, 9.58°±9.35°, 7.52°±7.64°, 11.23°±9.59°, 16.32°±12.38°, and 18.49°±11.70° respectively; for females, the TPA values were 2.72°±6.88°, 3.68°±6.26°, 7.30°±6.11°, 7.44°±6.75°, 12.64°±9.79°, 19.08°±10.39°, and 16.79°±13.19° respectively. T-Cobb, T-LEV, and T-Apex increased slowly with age ( P<0.05). The pelvic incidence (PI) remained relatively constant in males ( P>0.05), while it increased slowly with age in females ( P<0.05). Conclusions:Sagittal anteversion of the spinal-pelvis increases with age. Gender differences are reflected in specific changes in the fluctuation amplitude of certain parameters (such as PI), and the fluctuations of indicators like T-Cobb, T-LEV, and T-Apex are closely related to the natural aging process of the spine.

Vertebral refracture following percutaneous vertebral augmentation (PVA) is commonly seen in elderly patients with osteoporotic thoracolumbar compression fractures (OTLCF). It can lead to recurrent pain, loss of vertebral height, progression of kyphosis, and even neurological dysfunction, significantly impairing patients′ quality of life. Current diagnosis and treatment face multiple challenges, including high misdiagnosis rate, difficulty in choosing between surgical and non-surgical treatment options, lack of standardized surgical protocols, interference from intralesional bone cement during procedures, inadequate stability of internal fixation in osteoporotic bone, and suboptimal compliance of anti-osteoporotic therapy. Establishing a standardized diagnostic and therapeutic framework is urgently needed. To standardize the management process and improve outcomes for vertebral refractures after PVA in elderly OTLCF patients, Spinal Trauma Group of the Orthopedic Branch of Chinese Medical Doctor Association organized experts in the field to develop Guideline for the diagnosis and treatment of vertebral refracture after percutaneous vertebral augmentation in elderly patients with osteoporotic thoracolumbar compression fractures ( version 2025), based on current literature and clinical experience, and adhering to principles of scientific rigor and clinical applicability. A total of 11 recommendations were proposed, encompassing diagnosis, treatment, and rehabilitation of vertebral refracture after PVA in elderly patients with OTLCF, aiming to provide a foundation for a standardized management.

Objective:To explore the effects of age and gender on the sagittal spinal-pelvic parameters during the natural aging process of healthy adults.Methods:A total of 647 Chinese healthy adults who underwent health check-ups at the Second Affiliated Hospital of Zhejiang University School of Medicine and Songyang County People's Hospital, from January 2017 to September 2024 were collected. There were 277 males and 370 females, aged 18-93 years. Anteroposterior and lateral X-ray films of the whole spine were taken to evaluate the spinal-pelvic sagittal morphology. The following parameters were measured: thoracic kyphosis (TK), lumbar lordosis(LL), sacral slope (SS), pelvic incidence (PI), pelvic tilt (PT), global tilt (GT), T 1-pelvic angle (TPA), sagittal vertical axis (SVA), thoracic Cobb angle (T-Cobb), lower end vertebra of thoracic Cobb angle (T-LEV), apex vertebra of thoracic Cobb angle (T-Apex), lumbar Cobb angle (L-Cobb). Compare the differences in spine-pelvis parameters among patients of different genders and age groups (in this study, the subjects were subdivided into the 18-29, 30-39, 40-49, 50-59, 60-69, 70-79, and 80-93 years groups according to the age range). Results:The results showed that GT, SVA, TPA, and PT increased with age ( P<0.05). For males aged 18-29, 30-39, 40-49, 50-59, 60-69, 70-79, and 80-93 years, PT values were 8.58°±6.47°, 9.60°±5.63°, 12.65°±7.13°, 11.00°±6.99°, 13.01°±8.63°, 15.77°±8.02°, and 18.47°±10.03° respectively; for females in the same age groups, the PT values were 8.44°±6.83°, 9.00°±6.44°, 11.84°±7.35°, 12.07°±7.51°, 15.44°±9.39°, 19.26°±8.28°, and 18.17°±9.43° respectively. For males in these age groups, the global tilt (GT) values were 6.37°±7.20°, 8.77°±6.51°, 10.38°±9.07°, 8.80°±7.49°, 10.80°±8.62°, 16.07°±10.42°, and 21.99°±12.65° respectively; for females, the GT values were 4.46°±8.09°, 5.96°±7.83°, 8.17°±6.88°, 9.41°±8.03°, 9.96°±1.39°, 17.89°±9.39°, and 19.55°±12.34° respectively. The sagittal vertical axis (SVA) values for males in the age groups were -7.94±25.57 mm, -2.98±25.69 mm, -4.63±20.90 mm, -6.43±32.81 mm, 7.85±43.39 mm, 36.49±53.89 mm, and 55.57±51.10 mm respectively; for females, they were -24.12±31.35 mm, -17.49±25.12 mm, -17.88±22.72 mm, -8.25±30.91 mm, 8.80±27.45 mm, 28.67±38.22 mm, and 23.23±35.19 mm respectively. For males, the thoracic pelvic angle (TPA) values across the age groups were 4.46°±5.94°, 6.05°±5.38°, 9.58°±9.35°, 7.52°±7.64°, 11.23°±9.59°, 16.32°±12.38°, and 18.49°±11.70° respectively; for females, the TPA values were 2.72°±6.88°, 3.68°±6.26°, 7.30°±6.11°, 7.44°±6.75°, 12.64°±9.79°, 19.08°±10.39°, and 16.79°±13.19° respectively. T-Cobb, T-LEV, and T-Apex increased slowly with age ( P<0.05). The pelvic incidence (PI) remained relatively constant in males ( P>0.05), while it increased slowly with age in females ( P<0.05). Conclusions:Sagittal anteversion of the spinal-pelvis increases with age. Gender differences are reflected in specific changes in the fluctuation amplitude of certain parameters (such as PI), and the fluctuations of indicators like T-Cobb, T-LEV, and T-Apex are closely related to the natural aging process of the spine.

The oblique lumbar interbody fusion (OLIF) procedure has yielded favorable outcomes for individuals afflicted with degenerative lumbar conditions; however, certain complications warrant attention. We present a case of a 48-year-old female experiencing recurrent radicular pain post-OLIF. This patient, who endured persistent lower back discomfort for a decade, underwent MRI scans which revealed an intervertebral disc herniation at the L 4, 5 level and L 4 spondylolisthesis. The length of the right upper articular process of L 5 was 10.46 mm, and the distance between right upper articular process of L 5 and right nerve root of L 4 was 1.34 mm. Subsequent to OLIF, she reported recurrent radicular pain in her right leg. Post-operative CT scans revealed that the inclination of the right upper articular process of L 5 augmented from 59.46° to 65.22°. The distance from this process to the anterior foramen wall diminished from 0.63 mm to 0.25 mm, while its distance from the superior wall expanded from 0.31 mm to 0.39 mm. Furthermore, the foraminal cross-sectional area decreased from 0.29 mm 2 to 0.18 mm 2, and the lordotic angle of the intervertebral space amplified from 0.52° to 7.33°. Such measurements suggest that following OLIF, there was asymmetric retraction of the intervertebral space, accompanied by an anteroinferior tilt of the upper articular process, leading to persistent nerve root compression and thus necessitating immediate surgical nerve root decompression. This paper also elucidates the influence of the anatomical characteristics of the facet joint or articular process on lumbar functionality. Consequently, it could be postulated that hypertrophic or aberrantly elongated articular processes might induce nerve root compression due to intervertebral space retraction post-OLIF. Hence, spine surgeons should diligently assess and recognize the ramifications of such anomalies on OLIF surgical outcomes.

Objective:To investigate the short-term clinical outcomes of posterior percutaneous pedicle screw fixation combined with percutaneous vertebroplasty (PVP) for treating Kümmell's disease with intravertebral instability.Methods:A retrospective case series study was made on 18 patients with Kümmell's disease with intravertebral instability treated at Lishui Hospital of Zhejiang University from January 2012 to February 2016. There were 4 males and 14 females, aged 65-86 years [(76.0±5.5)years]. Segment of injury was T 7 in 1 patient, T 10 in 2, T 11 in 3, T 12 in 4, L 1 in 6, and L 2 in 2. All patients underwent posterior percutaneous pedicle screw fixation combined with PVP. The operation time, intraoperative blood loss, amount of cement injected into the vertebra, and length of postoperative hospital stay were recorded. The visual analogue scale (VAS), Oswestry disability index (ODI), Cobb angle, and wedge angle of the operative segment were recorded and compared preoperatively, postoperatively, and at the latest follow-up. Meanwhile, the complications were recorded. Results:All patients were followed up for 12-28 months [(17.7±4.4)months]. The operation time was 110-175 minutes [(137.9±21.9)minutes] and the blood loss was 50-165 ml [(110.7±35.6)ml]. The amount of cement injected into the vertebra was 2.5-6.0 ml [(4.7±0.9)ml]. The length of hospital stay was 7-14 days [(9.4±2.3)days]. The VAS was (7.8±1.2) points preoperatively, (3.3±0.7) points at 1 week postoperatively and (2.4±0.7)points at the latest follow-up. The ODI was (67.3±7.3)% preoperatively, (30.5±7.5)% at 1 week postoperatively and (21.8±8.3)% at the latest follow-up. The Cobb angle was (26.2±9.5)° preoperatively, (12.6±7.2)° at 1 week postoperatively and (16.7±6.2)°at the latest follow-up. The wedge angle was (21.1±6.1)° preoperatively, (8.4±4.6)° at 1 week postoperatively, and (13.2±4.1)° at the latest follow-up. The above clinical and radiological parameters were significantly improved after operation ( P<0.05), and showed no significant differences at the latest follow-up when compared to that at 1 week postoperatively ( P>0.05). Five patients showed slight screw loosening, but there was no obvious dislocation of internal fixation. One case developed distal vertebral compression fracture at 6 months postoperatively and cured after a second PVP. Conclusion:For Kümmell's disease with intravertebral instability, posterior percutaneous pedicle screw fixation combined with PVP can effectively restore and maintain the spinal sequence, rapidly relieve the pain and improve clinical function. However, the long-term efficacy needs further study.

Objective:To investigate the preliminary clinical and radiographic outcomes of percutaneous endoscopic lumbar discectomy (PELD) combined with oblique lateral interbody fusion (OLIF) for the degenerative lumbar spondylolisthesis, lumbar spine instability or lumbar spinal stenosis with ruptured disc herniation.Methods:Data of 11 patients with degenerative lumbar spondylolisthesis, lumbar spine instability or lumbar spinal stenosis with ruptured disc herniation who had undergone PELD combined with OLIF between March 2017 to July 2018 in our spine surgery center were retrospectively analyzed. There were 5 males and 6 females with an average age of 61.2±6.8 years old. All the patients were diagnosed with degenerative lumbar diseases including lumbar spondylolisthesis (7 cases), lumbar spinal stenosis (3 cases) and segmental instability (1 case). The patients were treated with PELD combined with OLIF. The visual analogue scale (VAS) scores of low back pain and lower limb pain and the Oswestry disability index (ODI) of lumbar function, spinal canal anteroposterior diameter, intervertebral disc height, vertical diameter of intervertebral foramen, segmental angle and the whole lumbar lordotic angle were collected.Results:All patients received PELD with local anesthesia before OLIF with general anesthesia. The mean operation time was 52.3±13.2 min and the mean blood loss was 10.9±4.7 ml for PELD. The mean operation time was 56.8±18.0 min and the mean blood loss was 65.5±24.6 ml for OLIF. All patients were followed up for an average of 11.2 months. At the latest follow-up, the mean VAS score for back pain was 1.3±0.8, the mean VAS score for leg pain 1.1±0.5, the mean ODI 14.6%±5.3%, thus all of those were improved significantly compared to those of pre-operation ( t=10.37, 16.49, 8.73; P< 0.05). The radiographic results showed the mean pre-operative intervertebral disc height, vertical diameter of intervertebral foramen, spinal canal anteroposterior diameter, segmental angle, and lumbar lordosis angle was 7.1±1.2 mm, 15.3±2.2 mm, 6.2±1.3 mm, 10.2°±3.5°, 16.2°±6.2°, and thus all of those were increased significantly to the latest follow-up 11.5±1.8 mm, 19.2±2.6 mm, 10.4±2.5 mm, 19.3°±7.8°, 27.4°±8.3°, respectively ( t=5.83, 4.21, 6.59, 10.32, 7.65; P< 0.05). One of the patients had weakness of flexor hip strength and one had a transient paresthesia immediately post-operation. All symptoms were relieved within 1 month. Another one case had cage subsidence and encountered serious back pain after 1 month, and alleviated after percutaneous pedicle screw fixation. Conclusion:PELD combined with OLIF can overcome the limitations of OLIF with indirect decompression effects, resulting in successful direct neural decompression without posterior decompressive procedures and providing a satisfactory outcome for the patients with degenerative lumbar diseases with ruptured disc herniation.

Objective:To investigate the characteristics and causes of endplate injury in the oblique lateral interbody fusion for the treatment of lumbar diseases, and summarize the precaution of endplate injury.Methods:Thirty-five cases of endplate injury were observed, which were originally treated with oblique lateral interbody fusion with or without pedicle screw fixation from October 2014 to December 2017. There were 7 males and 28 females, and the age ranged from 51 to 78 years old (averagely 62.8±8.13 years). There were 2 cases of lumbar disc degeneration, 10 cases of lumbar canal stenosis, 17 cases of lumbar degenerative spondylolisthesis, 2 cases of lumbar spondylolysis with or without spondylolisthesis, and 4 cases of lumbar degenerative scoliosis. Lesion sites contained L 3,4 in 2 cases, L 4,5 in 21 cases, L 2-4 in 3 cases, L 3-5 in 4 cases, L 2-5 in 3 cases and L 1-5 in 2 cases. Preoperative bone mineral density examination revealed there were 7 cases of T>-1 SD, 24 cases of -2.5 SD

Objective To compare the Roussouly classification of old thoracolumbar fractures combined with post-traumatic kyphosis with that of normal adults, evaluate the effect of different kyphosis angles on sagittal curvature of the thoracolumbar spine so as to provide a theoretical basis for the clinical status and clinical treatment plan of old thoracolumbar fractures combined with post-traumatic kyphosis.Methods A retrospective case control study was made on 49 cases of old thoracolumbar fractures with post-traumatic kyphosis treated from January 2014 to December 2015 (fracture group).Damaged segments of the spine were T11 in four cases, T12 in 14, L1 in 25 and L2 in six.Another 52 normal adult volunteers were chosen as controls.Whole spine X-ray film of the two groups was taken, and the difference in Roussouly classification of the sagittal spine curvature was compared between the two groups.Patients in fracture group were separated into subgroups depending on the Cobb angle (0°-10°, 10°-20°, 20°-30°, 30°-40°, respectively), and the difference in Roussouly classification was compared among subgroups.Results Roussouly classification in control group was five cases of type 1, 12 tpye 2, 25 type 3 and 10 type 4.Results in fracture group was 14 cases of type 1, 11 type 2, eight type 3 and 16 type 4.There were significant differences in Roussouly types between the two groups (P<0.05).According to Roussouly classification, there were two cases of types 1 and 2 and seven cases of types 3 and 4 in subgroup of Cobb angle between 0°-10°;four cases of types 1 and 2 and 10 cases of types 3 and 4 in subgroup of Cobb angle between 10°-20°;12 cases of types 1 and 2 and four cases of types 3 and 4 in subgroup of Cobb angle between 20°-30°;seven cases of types 1 and 2 and three cases of types 3 and 4 in subgroup of Cobb angle between 30°-40°.There were significant differences in Roussouly types among subgroups (P<0.05).Further, Roussouly types 1 and 2 were significantly increased when the Cobb angle was >20° (P<0.05).Conclusions Post-traumatic kyphosis in old thoracolumbar fractures affects spine sagittal curvature.Patients with sagittal spinal imbalance (Roussouly types 1 and 2) are more with increased Cobb angle.Moreover, Cobb angle >20°may be the reference basis for clinical intervention.

Objective To evaluate the clinical effect of interspinous H-shaped bone grafting and bilateral facet interbody fusion in treatment of thoracolumbar fracture with severe disc injury and posterior ligamentous complex (PLC) injury after posterior pedicle screw fixation and its role in prevention of delayed kyphosis.Methods The study involved 19 cases of thoracolumbar fractures with severe disc injury and PLC injury,including 11 males and 8 females,at age of 23-59 years (mean 43.8 years.All cases were treated with posterior pedicle screw fixation (including 11 cases treated with unilateral laminectomy decompression) and C-arm X-ray showed favorable fracture reduction.For prevention of postoperative delayed kyphosis,the interspinous H-shaped bone grafting plus bilateral facet interbody fusion by using the iliac autografts was done.Neurologic recovery was assayed by using Frankel scale and lumbar and iliac pain by visual analogue scale (VAS).Cobb angle was detected as well.Results All cases were followed up for 24-64 months.At final follow-up,all cases showed neurological improvement for at least 1 to 2 Frankel grades except for two cases with Frankel Grade A,with mean Cobb angle of (2.0 ± 3.7) ° (range,-4.9°-8.1 °),mean VAS of lower back pain of (1.1 ± 1.2) points (range,0-4 points) and insignificant angle loss or kyphosis.The thin layer CT scan indicated complete integration of the transplanted bone grafts,with no complications like implant loosening or breakage.Conclusion Interspinous H-shaped bone grafting and bilateral facet interbody fusion is a good choice for prevention of delayed kyphosis after posterior pedicle screw fixation of thoracolumbar fracture with severe disc injury and PLC injury.