VA can immediately rebuild the stability of the spine and effectively relieve pain through the insertion and support between the bone cement and the fractured end of the vertebral body. However, bone cement leakage, refracture, bone cement toxicity, and PSVA are still important complications that restrict the wide clinical application of VA. The incidence of PSVA is low, but the consequences are very serious, even threatening the lives of patients. Since Yu et al. first reported the PSVA, different scholars have summarized the characteristics, clinical manifestations, diagnostic methods, and treatment principles of PSVA. The bone cement currently used in clinic has no biological activity, and the polymerization of bone cement monomer leads to an increase in temperature inside the vertebral body. The bone tissue that is burnt and necrotic often forms an isolation zone between the bone cement and the normal bone tissue. The aforementioned factors are all important reasons why it is challenging to cure PSVA using conservative treatment. Patients with PSVA often suffer from uncomfortable severe pain, local kyphosis, and neurological deficits. Hence, it is difficult to achieve satisfactory results with antibiotics alone. Surgical treatment has become an indispensable choice for such patients. However, in-depth and systematic research on the surgical method of such patients lacks due to the small sample size. The scholars in the past often recommended the use of anterior debridement combined with posterior internal fixation for the treatment of PSVA to completely remove the lesions, pus, and bone cement[3,6,10,17-20]. However, such patients often have multiple diseases due to their advanced age, and multiple-organ dysfunction throughout the body can hardly tolerate such large surgical trauma. Since the 21st century, most spinal diseases could be completed via a single approach with an in-depth understanding of the pathophysiological mechanism of spinal diseases, anatomical structure of the spinal column, highly developed spinal surgical instruments and increasing proficiency of surgical techniques. This study was performed on 19 patients with PSVA, which is the largest sample used so far. All surgical patients in this study were treated with sPVRIF. The surgical time was 175.0 ± 16.8 (155–210) min and the intraoperative blood loss was 465.6 ± 166.0 (300–900) mL, which were significantly lower than those reported in previous studies. This was mainly due to the simultaneous completion of lesion removal and internal fixation via a single surgical approach. In addition, piezosurgery is vital in the resection of the vertebral body and bone cement. Among the 16 patients with PSVA, 14 completed the last follow-up. The daily activities of the other patients significantly improved, except for two patients who still needed to be in a wheelchair after the surgery. Only one patient died of postoperative refractory septic shock, and the mortality rate was significantly lower than that reported by Abdelrahman. Besides the improvement in the surgical method, the following improvements were made during the perioperative period: (1) Patients' CRP, ESR, Neu, and other inflammatory indicators were dynamically observed besides following the basic principles of antibiotic use. The types of antibiotics used to avoid bacterial imbalance and double infections were dynamically adjusted based on the results of the drug sensitivity test. (2) The stability of the patient's internal environment was maintained, and the nutritional status was improved. The plasma protein level of such patients was maintained at more than 35 g/L, and continuous maintenance of the hemoglobin level more than 100 g/L was essential to enhance the patient's disease resistance. (3) The surgical area for each patient was routinely flushed for 7–10 days after the surgery to reduce the concentration of local pathogens and inflammatory mediators. (4) The patients' oral and perineal care was strengthened to prevent urinary tract and lung infections.
Previous studies[10,12,16-17]reported that the incidence of PSVA was 0%–1.6%, and the incidence in this study was 0.83%. Although the incidence was low, it resulted in catastrophic consequences to patients. Previous scholars suggested the use of bone cement mixed with tobramycin for VA, while some recommended the use of perioperative intravenous prophylactic antibiotics, to prevent the occurrence of such complications in high-risk patients. However, the clinical efficacy of the aforementioned methods still requires large-sample prospective comparative studies for validation. In this study, neither cement-loaded antibiotics nor systemic perioperative prophylactic intravenous antibiotics were used; instead, a single intraoperative prophylactic dose of a first-generation cephalosporin was used. The experience was as follows: (1) If the levels of inflammation indicators were elevated before the surgery, pulmonary infection and urinary tract infection needed to be carefully checked. If a clear infection of other parts was detected, it was recommended to perform VA 2 weeks after the infection was cured. (2) If infectious diseases of the vertebral body could not be ruled out, it was recommended to give priority to conservative treatment after 2 weeks and re-examine the magnetic resonance imaging and computed tomography of the fractured vertebral body. If it was an infectious disease, the progress of vertebral body disease was often found at this time. During conservative treatment, a biopsy of the destroyed vertebral body was performed. (3) Routine radionuclide bone scintigraphy was recommended for patients initially diagnosed with OVF.
Obtaining etiological evidence is key to the treatment of infectious diseases. Patients with PSVA often start using antibiotics before obtaining pathogenic evidence, and it is generally difficult to cultivate pathogenic microorganisms. In addition, Vats HS et al. reported that polymerase chain reaction (PCR) increased the detection rate of pathogenic microorganisms. Elderly people have long-term oral usage of multiple drugs to treat other basic diseases and lack personal hygiene and health protection knowledge, leading to significant changes in the bacterial spectrum of infectious diseases. Hence, routine urine culture, sputum culture, and blood culture are recommended. Blood for blood culture should be withdrawn before using antibiotics and during chills. In addition, three blood samples from both sides of the human body for blood culture are required to increase the detection rate of pathogenic microorganisms. While searching for pathogenic evidence, attention should be paid to rare pathogenic microorganisms, such as mycobacteria, fungi, and anaerobic bacteria.
This study was novel in reporting the clinical efficacy of sPVRIF in the treatment of PSVA. However, it had some limitations. This study was a single-center retrospective study and lacked comparative findings. Also, the follow-up time of this study was short. Further, since most patients in this study required oral administration of multiple drugs (such as nonsteroidal anti-inflammatory and analgesic drugs) for other comorbidities, it was impossible to use a unified standard to evaluate the fusion of intervertebral body grafts after the surgery.