**Author details**

following the conservative management of osteoporotic vertebral fractures reaches 14.8% at 1 month and 21.8% at 6 months [119]. However, when conservative management fails, minimally invasive procedures such as vertebroplasty or kyphoplasty are suggested to stabilize the fracture site, align the vertebral segment and consequently alleviate pain [23]. The first reports in the literature on the treatment of KD emphasize conservative management, whereas the latest information has demonstrated that patients can be treated successfully with surgery. The choice of surgical treatment has depended to a large extent upon three factors, the severity of the back pain, the degree of kyphotic deformity, and the neurologic deficit [5, 7]. The main objective of the surgery lies in the decompression of the neural elements and

Techniques such as percutaneous kyphoplasty (PKP) or percutaneous vertebroplasty (PVP) with polymethyl methacrylate (PMMA) have been used in patients with osteoporotic CF with and without IVC [10, 121–127]. It was reported on both types of surgical procedures to relieve pain and restore collapsed vertebral body immediately after surgery. However, they reported aggravation of vertebral collapse and kyphotic deformity within 2 years after surgery in those patients with IVC. This also conditioned an increase in back pain, suggesting that this progression was due to intravertebral instability [121]. Therefore, both PVP and PKP have been considered as noneffective procedures in chronic spinal compression or acute vertebral compression with posterior cortical rupture, suggesting surgical stabilization via fusion [128]. The response to a foreign body that can occur with the use of PMMA with extensive fibrosis that could induce micromotion and secondary instability should also be mentioned [129, 130]. In addition, the mass of PMMA could spontaneously migrate to extra vertebral sites such as the

Likewise, the distribution pattern and proportion of bone cement required in PVP could be predicted according to the area of ischemic necrosis on MRI [134]. Also, taking into account the proportion of necrosis on MRI recently raised that this variable could allow selecting the type of surgical procedure vertebroplasty, kyphoplasty, or surgery. Those cases with IVC, as well as those that required a surgical procedure were those that presented a higher percentage

Another reported proposal was the management of the posttraumatic osteoporotic vertebral ON with balloon kyphoplasty. It was suggested that restoration of the vertebral body and correction of kyphotic deformation could be achieved in relation to the sufficient volume of cement used. In addition, cement injection was performed in middle to later stages of solidification in patients with a defect of the anterior wall of the vertebral body or supported by X-ray fluoroscopy and balloon expansion in posterior defects to avoid leakage of the same [127].

The anterior decompression via corporectomy and fusion with intervertebral tricortical graft [135, 136] or ceramic glass spacers [137], posterior decompression with pedicle subtraction osteotomy [138–140] or the combination of both approaches [139] have been proposed in several studies. In the previous decompression, the fusion can be achieved with a spacer and a plate with a screw and in the posterior approach by means of the placement of transpedicular screws and hooks [141]. Spinal fusion, however, has been associated with procedural compli-

sagittal alignment, consequently, earlier ambulation is promoted [120].

disc space or the anterior vertebral space [8, 131–133].

of necrosis [119].

30 Osteonecrosis

cations and long surgical time.

Elizabeth Pérez Hernández\*, Eulalio Elizalde Martínez and Juan Manuel Torres Fernández

\*Address all correspondence to: elizabeth.perez@imss.gob.mx

UMAE de Traumatología, Ortopedia y Rehabilitación "Dr. Victorio de la Fuente Narváez," Instituto Mexicano del Seguro Social, Ciudad de México, México
