European Radiology

, Volume 17, Issue 9, pp 2248–2252

The intravertebral vacuum phenomen as specific sign of osteonecrosis in vertebral compression fractures: results from a radiological and histological study

  • Martin Libicher
  • Andreas Appelt
  • Irina Berger
  • Martin Baier
  • Peter-Jürgen Meeder
  • Ingo Grafe
  • Katharina DaFonseca
  • Gerd Nöldge
  • Christian Kasperk


This study investigated the prevalence of the intravertebral vacuum phenomenon (IVP) and osteonecroses in vertebral compression fractures (VCFs). We therefore performed an histological analysis of biopsies obtained from VCFs prior to balloon kyphoplasty. Computed tomography (CT) scans were reviewed regarding the presence of an IVP (i.e. cleft sign, Kümmell disease). We reviewed the data of 266 consecutive patients treated by balloon kyphoplasty in 501 procedures from 2002 to 2004. From 180 patients (68%) we obtained adequate bone tissue for histological evaluation. Biopsy specimens were analysed regarding the presence of osteoporosis, infection, malignancy and osteonecrosis. CT scans of all 180 patients were reviewed for presence of an IVP. Histological examination revealed 135 (75%) osteoporoses, 20 (11%) neoplasms, 12 (7%) trauma cases and 13 (7%) osteonecroses. An IVP was present in 12 (7%) patients. There was a significant association of osteonecrosis and IVP (P < 0.0001). Eleven of 12 patients with a vacuum phenomenon showed an osteonecrosis on histology, wheras 11 of 13 patients with osteonecrosis showed an IVP on CT. The IVP is a specific sign of osteonecrosis in vertebral compression fractures (sensitivity 85%, specificity 99%, positive predictive value 91%). Our findings strongly support the thesis that an IVP indicates local bone ischemia associated with a non-healing vertebral collapse and pseudarthrosis.


Intravertebral vacuum phenomenon Kümmell disease Osteonecrosis of the vertebral body Balloon kyphoplasty 


  1. 1.
    Kümmell H (1895) Die rarefizierende Ostitis der Wirbelkörper. Deutsche Med 21:180–181CrossRefGoogle Scholar
  2. 2.
    Resnick D, Niwayama G, Guerra J Jr, Vint V, Usselman J (1981) Spinal vacuum phenomena: anatomical study and review. Radiology 139:341–348PubMedGoogle Scholar
  3. 3.
    Maldague BE, Noel HM, Malghem JJ (1978) The intravertebral vacuum cleft: a sign of ischemic vertebral collapse. Radiology 129:23–29PubMedGoogle Scholar
  4. 4.
    Stabler A, Schneider P, Link TM et al (1999) Intravertebral vacuum phenomenon following fractures: CT study on frequency and etiology. J Comput Assist Tomogr 23:976–980PubMedCrossRefGoogle Scholar
  5. 5.
    Grafe IA, Da Fonseca K, Hillmeier J et al (2005) Reduction of pain and fracture incidence after kyphoplasty: 1-year outcomes of a prospective controlled trial of patients with primary osteoporosis. Osteoporos Int 16:2005–2012PubMedCrossRefGoogle Scholar
  6. 6.
    Kasperk C, Hillmeier J, Noldge G et al (2005) Treatment of painful vertebral fractures by kyphoplasty in patients with primary osteoporosis: a prospective nonrandomized controlled study. J Bone Miner Res 20:604–612PubMedCrossRefGoogle Scholar
  7. 7.
    Dafonseca K, Baier M, Grafe I et al (2006) Balloon kyphoplasty in the treatment of vertebral fractures. Unfallchirurg 109:391–400PubMedCrossRefGoogle Scholar
  8. 8.
    Togawa D, Lieberman IH, Bauer TW, Reinhardt MK, Kayanja MM (2005) Histological evaluation of biopsies obtained from vertebral compression fractures: unsuspected myeloma and osteomalacia. Spine 30:781–786PubMedCrossRefGoogle Scholar
  9. 9.
    Garfin SR, Yuan HA, Reiley MA (2001) New technologies in spine: kyphoplasty and vertebroplasty for the treatment of painful osteoporotic compression fractures. Spine 26:1511–1515PubMedCrossRefGoogle Scholar
  10. 10.
    Lieberman IH, Dudeney S, Reinhardt MK, Bell G (2001) Initial outcome and efficacy of “kyphoplasty” in the treatment of painful osteoporotic vertebral compression fractures. Spine 26:1631–1638PubMedCrossRefGoogle Scholar
  11. 11.
    Da Fonseca K, Baier M, Grafe I et al (2006) OP-Technik der Ballon-Kyphoplastie. Unfallchirurg 109:401–405PubMedCrossRefGoogle Scholar
  12. 12.
    Libicher M, Hillmeier J, Liegibel U et al (2006) Osseous integration of calcium phosphate in osteoporotic vertebral fractures after kyphoplasty: initial results from a clinical and experimental pilot study. Osteoporos Int 17:1208–1215PubMedCrossRefGoogle Scholar
  13. 13.
    Libicher M, Vetter M, Wolf I et al (2005) CT volumetry of intravertebral cement after kyphoplasty. Comparison of polymethylmethacrylate and calcium phosphate in a 12-month follow-up. Eur Radiol 15:1544–1549PubMedCrossRefGoogle Scholar
  14. 14.
    Baur A, Stabler A, Arbogast S, Duerr HR, Bartl R, Reiser M (2002) Acute osteoporotic and neoplastic vertebral compression fractures: fluid sign at MR imaging. Radiology 225:730–735PubMedCrossRefGoogle Scholar
  15. 15.
    Golimbu C, Firooznia H, Rafii M (1986) The intravertebral vacuum sign. Spine 11:1040–1043PubMedCrossRefGoogle Scholar
  16. 16.
    Harverson G (1988) Intravertebral vacuum phenomenon. Clin Radiol 39:69–72PubMedCrossRefGoogle Scholar
  17. 17.
    Kumpan W, Salomonowitz E, Seidl G (1986) The intravertebral vacuum phenomenon. Skeletal Radiol 15:444–447PubMedCrossRefGoogle Scholar
  18. 18.
    Bhalla S, Reinus WR (1998) The linear intravertebral vacuum: a sign of benign vertebral collapse. AJR Am J Roentgenol 170:1563–1569PubMedGoogle Scholar
  19. 19.
    Theodorou DJ (2001) The intravertebral vacuum cleft sign. Radiology 221:787–788PubMedCrossRefGoogle Scholar
  20. 20.
    Lane JI, Maus TP, Wald JT, Thielen KR, Bobra S, Luetmer PH (2002) Intravertebral clefts opacified during vertebroplasty: pathogenesis, technical implications, and prognostic significance. AJNR Am J Neuroradiol 23:1642–1646PubMedGoogle Scholar
  21. 21.
    McKiernan F, Faciszewski T (2003) Intravertebral clefts in osteoporotic vertebral compression fractures. Arthritis Rheum 48:1414–1419PubMedCrossRefGoogle Scholar
  22. 22.
    Peh WC, Gelbart MS, Gilula LA, Peck DD (2003) Percutaneous vertebroplasty: treatment of painful vertebral compression fractures with intraosseous vacuum phenomena. AJR Am J Roentgenol 180:1411–1417PubMedGoogle Scholar
  23. 23.
    Brower AC, Downey EF (1981) Kümmell disease: report of a case with serial radiographs. Radiology 141:363–364PubMedGoogle Scholar
  24. 24.
    Ford LT, Gilula LA, Murphy WA, Gado M (1977) Analysis of gas in vacuum lumbar disc. AJR Am J Roentgenol 128:1056–1057PubMedGoogle Scholar
  25. 25.
    Malghem J, Maldague B, Labaisse MA et al (1993) Intravertebral vacuum cleft: changes in content after supine positioning. Radiology 187:483–487PubMedGoogle Scholar
  26. 26.
    Dupuy DE, Palmer WE, Rosenthal DI (1996) Vertebral fluid collection associated with vertebral collapse. AJR Am J Roentgenol 167:1535–1538PubMedGoogle Scholar
  27. 27.
    Naul LG, Peet GJ, Maupin WB (1989) Avascular necrosis of the vertebral body: MR imaging. Radiology 172:219–222PubMedGoogle Scholar
  28. 28.
    McKiernan F, Jensen R, Faciszewski T (2003) The dynamic mobility of vertebral compression fractures. J Bone Miner Res 18:24–29PubMedCrossRefGoogle Scholar
  29. 29.
    Hasegawa K, Homma T, Uchiyama S, Takahashi H (1998) Vertebral pseudoarthrosis in the osteoporotic spine. Spine 23:2201–2206PubMedCrossRefGoogle Scholar
  30. 30.
    Bielecki DK, Sartoris D, Resnick D, Van Lom K, Fierer J, Haghighi P (1986) Intraosseous and intradiscal gas in association with spinal infection: report of three cases. AJR Am J Roentgenol 147:83–86PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2007

Authors and Affiliations

  • Martin Libicher
    • 1
  • Andreas Appelt
    • 2
  • Irina Berger
    • 3
  • Martin Baier
    • 2
  • Peter-Jürgen Meeder
    • 2
  • Ingo Grafe
    • 4
  • Katharina DaFonseca
    • 2
  • Gerd Nöldge
    • 5
  • Christian Kasperk
    • 4
  1. 1.Department of RadiologyUniversity of CologneKölnGermany
  2. 2.Department of Trauma SurgeryUniversity of HeidelbergHeidelbergGermany
  3. 3.Department of PathologyUniversity of HeidelbergHeidelbergGermany
  4. 4.Department of Internal Medicine, Division of OsteologyUniversity of HeidelbergHeidelbergGermany
  5. 5.Department of RadiologyUniversity of HeidelbergHeidelbergGermany

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