Safety and efficacy studies of cross-unilateral, sequential unilateral, and bilateral percutaneous kyphoplasty for double-adjacent thoracolumbar osteoporotic vertebral compression fractures

Osteoporotic vertebral compression fractures (OVCFs) are a significant cause of morbidity in the elderly population and can lead to severe pain, decreased mobility, and reduced quality of life [ 1 ]. Double-adjacent thoracolumbar (DATL)-OVCFs are a severe form of OVCFs [ 2 ]. Percutaneous kyphoplasty (PKP) under local anesthesia is currently a widely used and effective method for treating DATL-OVCFs, with well-established outcomes [ 3 ]. However, for patients with DATL-OVCFs, PKP presents several challenges [ 4 ]. Some patients experience severe pain and restlessness during surgery, making them unable to cooperate with doctors to complete the operation [ 5 , 6 , 7 ]. The traditional bilateral transpedicular approach remains the predominant surgical technique for PKP [ 8 ]. However, it has significant limitations, including prolonged operative time, increased intraoperative blood loss, frequent fluoroscopy utilization, intense intraoperative pain and poor patient tolerance for prolonged positioning, and high local anesthetic consumption [ 8 , 9 , 10 , 11 ]‌. These drawbacks are particularly pronounced in DATL-OVCFs‌. With surgeons’ increasing proficiency in puncture techniques, the ‌unilateral puncture approach‌ has now entered clinical implementation [ 12 ]. When performing ‌simultaneous unilateral transpedicular punctures ‌of adjacent vertebrae ‌via the same lateral approach‌, puncture instruments are prone to ‌mutual interference and operational conflict [ 2 , 12 , 13 ]‌. Consequently, treatment ‌generally necessitates sequential unilateral puncture procedures‌, which have inherent drawbacks, including ‌prolonged operative time, increased fluoroscopy utilization, intense intraoperative pain, and compromised patient tolerance for prolonged positioning [ 14 ]‌. As a result, minimizing the operative time, reducing intraoperative blood loss, decreasing fluoroscopy utilization, and alleviating intraoperative pain are crucial to avoid complications in elderly patients and ensure the successful completion of surgery [ 15 , 16 ]. The cross-unilateral puncture approach has distinct advantages and allows access to both the left and right vertebral pedicles without instrument interference between the two sides [ 12 ]. This may lead to reduced operative time, blood loss, intraoperative fluoroscopy, and intraoperative pain. However, to date, there have been no comparative studies on cross-unilateral (CU), sequential unilateral (SU), and bilateral (BI) PKP for DATL-OVCFs. This study aimed to compare the clinical efficacy and safety of CU versus SU or BI PKP for the treatment of DATL-OVCFs. The clinical study proposal was approved by the Medical Ethics Committee of the authors’ institute (Approval number: YJ2020006). From June 2019 to June 2024, 182 consecutive patients with DATL-OVCFs who underwent PKP were included in this study. The patients were divided into three groups according to the surgical approach: CU ( n = 42), SU ( n = 76), and BI ( n = 64) groups. All patients provided written informed consent before the procedures. The clinical characteristics of the 182 patients are summarized in Table 1 . Inclusion criteria were as follows: (1) elderly (≥ 60 years); (2) thoracolumbar (T10–L5) double adjacent fresh OVCFs (type A1 according to AOSpine thoracolumbar spine injury classification system) [ 17 ]; (3) minor injury or no history of trauma without neurological deficit; (4) persistent pain and fatigue in thoracolumbar vertebrae significantly affecting daily life; (5) diagnosis of osteoporosis with a T value of bone density test less than − 2.5 using dual-energy X-ray absorptiometry (DXA). The exclusion criteria were as follows: (1) neurological deficits; (2) polytrauma; (3) preexisting spinal deformity or previous spinal surgery; (4) clinical or imaging evidence of metastatic bone tumor or multiple myeloma; (5) asymptomatic fractures; (6) systemic or local infections or severe bleeding disorders. Preoperatively, standard clinical examinations and evaluations, including medical history, physical examination for percussion pain, assessment of pain intensity using the visual analog scale (VAS), and activity level using the Oswestry Disability Index (ODI), were performed. X-rays of the relevant spinal region in two planes, computed tomography, magnetic resonance imaging (T1-weighted and T2-weighted sequences, including short tau inversion recovery sequences), and bone density measurement using DXA were performed. All patients underwent surgery within 3 days of admission to relieve pain, restore vertebral body height, and collect segmental kyphosis data. All patients received calcium (1000 mg of elemental calcium daily), vitamin D (600 IU/day), and alendronate (70 mg/week).