IN THE NAME OF GOD

Osteoprotic spine fractures WHAT SHOULD WE BE DOING? (OR NOT DOING ….) ANDALIB.ALI.MD ISFAHAN MEDICAL SCIENCES UNIVERSITY KASHANI HOSPITAL

VERTEBRAL COMPRESSION FX Vertebral compression fractures usually occur when the front of the vertebral body collapses.

Osteoporotic vertebral compression fractures can cause the spine to curve and lose height pain difficulties in breathing gastrointestinal problems sleep disturbances difficulties in performing activities of daily living

High doses of analgesics used to treat such pain can have significant adverse effects. The symptoms and treatment of osteoporotic vertebral compression fractures can worsen quality of life and cause loss of self-esteem.

Epidemiology  incidence  vertebral compression fractures (VCF) are the most common fragility fracture  700,000 VCF per year in US  70,000 hospitalizations annually  15 billion in annual costs

The prevalence of osteoporotic vertebral compression fractures is difficult to estimate because not all fractures come to the attention of clinicians and they are not always recognised on X-rays

Predictors of fracture 19.2% of females with a confirmed incidental fracture had a second fracture within one year. 24% of females with two or more fractures developed a further fracture within a year. Lindsay et al. JAMA 2001; 285:

demographics demographics  affects up to 25% people over 70 years 50% people over 80 years risk factors  history of 2 VCFs is the strongest predictor of future vertebral fractures in postmenopausal women    

SYMPTOMS  pain  25% of VCR are painful enough that patients seek medical attention  pain usually localized to area of fracture but may wrap around rib cage if dermatomal distribution

PHSICAL EXAMINATION  focal tenderness  pain with deep palpation of spinous process  local kyphosis  multiple compression fractures can lead to local kyphosis  spinal cord injury  signs of spinal cord compression are very rare  nerve root deficits  may see nerve root deficits with compression fractures of lumbar spine that lead to severe foraminal stenosis

RADIOGRAPHY  obtain radiographs of the entire spine (concomitant spine fractures in 20%) Imaging

CT SCAN  usually not necessary for diagnosis  indications  neurologic deficit in lower extremity  inadequate plain films

MRI  usually not necessary for diagnosis  useful to evaluate for  acute vs chronic nature of compression fracture  injury to anterior and posterior ligament complex  spinal cord compression by disk or osseous material  cord edema or hemorrhage

Differentual DX of VCF Acute vertebral compression fractures are common and may occur because of trauma osteoporosis neoplastic infiltration in a vertebral body.

Differentiation of benign versus pathologic compression fractures Although trauma does not pose a diagnostic problem, the determination of the benign or malignant causes of vertebral compression fractures may be challenging

Differentiation of benign versus pathologic compression fractures Particularly in the elderly population, a neoplastic fracture may represent the first manifestation of a malignancy. On the other hand, osteoporosis is common, and vertebral fractures may occur even without trauma or after minor trauma

Differentiation of benign versus pathologic compression fractures Magnetic resonance (MR) imaging has proved useful in the distinction of osteoporotic from malignant fractures.

Morphologic signs such as the degree and pattern of bone marrow replacement, paravertebral soft-tissue masses, and infiltration of posterior elements of the vertebrae are signs for assessing the cause of the fracture

Differentiation of benign versus pathologic compression fractures all benign vertebral compression fractures were hypo- to isointense to adjacent normal vertebral bodies. Pathologic compression fractures were hyperintense to normal vertebral bodies.

LABORATORY STUDY  a full medical workup should be performed with CBC  ESR may help to rule out infection  Urine and serum protein electrophoresis may help rule out multiple myeloma

Differential Diagnosis Metastatic cancer to the spine  must be considered and ruled out  the following variables should raise suspicion  fractures above T5  atypical radiographic findings  failure to thrive and constitutional symptoms  younger patient with no history of fall

Think twice! Fractures above T6 Less than 55 yrs without history of trauma Patients with known malignancy Evaluation

Treating vertebral compression fractures aims to restore mobility, reduce pain and minimise the incidence of new fractures

Treatment modalities general medical management(nonoperative) percutaneous vertebral body augmentation. (vertebroplasty,kyphoplasty) open surgical treatment(PSF with instrument)

Treatment Nonoperative  observation, bracing, and medical management  indications majority of patients can be treated with observation and gradual return to activity PLL intact (even if > 30 degrees kyphosis or > 50% loss of vertebral body height)  technique medical management can consist of bisphosphonates to prevent future risk of fragility fractures some patients may benefit from an extension orthosis although compliance can be an issue

Vertebroplasty injecting bone cement, into the vertebral body using local anaesthetic and an analgesic. Vertebroplasty aims to relieve pain in people with painful fractures and to strengthen the bone to prevent future fractures.

Kyphoplasty inserting a balloon-like device (tamps) into the vertebral body, using local or general anaesthetic. The balloon is slowly inflated until it restores the normal height of the vertebral body or the balloon reaches its highest volume. When the balloon is deflated, the space is filled with bone cement, and a stent may or may not be placed.

How is it done?

VERTEBROPLASTY  indications not indicated AAOS recommends strongly against the use of vertebroplasty  outcomes randomized, double-blind, placebo-controlled trials have shown no beneficial effect of vertebroplasty vertebroplasty has higher rates of cement extravasation and associated complications than kyphoplasty

KYPHOPLASTY  indications patient continues to have severe pain symptoms after 6 weeks of nonoperative treatment AAOS recomend may be used, but recomendation strength is limited technique kyphoplasty is different than vertebroplasty in that a cavity is created by expansion baloon and therefore the cement can be injected with less pressure pain relief thought to be from elimination of micromotion

Contraindications Infection Uncorrectable coagulopathy Anaesthetic Risk Neurology Post.cortex Fx

Complications Neurological injury  can be caused by extravasation of PMMA into spinal canal  important to consider defects in the posterior cortex of the vertebral body

surgical decompression and stabilization  indications very rare in standard VCF progressive neurologic deficit PLL injury and unstable spines  technique to prevent possible failure due to osteoporotic bone should consider long constructs with multiple fixation points should consider combined anterior fixation

Recommendation 1 Acute injury (0 to 5)days after an identifiable event or onset of symptoms, and who are neurologically intact, be treated with calcitonin for 4 weeks(200 IU nasal). Calcitonin reduced pain in four positions (bed rest, sitting, standing, and walking) as well as the number of bedridden patients at 1, 2, 3, and 4 weeks. Journal of the American Academy of Orthopaedic Surgeons 2011

RECOMMENDATION2 Ibandronate is options to prevent additional symptomatic fractures in patients who present with an osteoporotic spinal compression fracture. Journal of the American Academy of Orthopaedic Surgeons 2011

Recommendation 3 We recommend against vertebroplasty for patients who present with an osteoporotic spinal compression fracture Journal of the American Academy of Orthopaedic Surgeons 2011

Recommendation 4 Kyphoplasty is an option for patients who present with an osteoporotic spinal compression fracture who are neurologic intact. Journal of the American Academy of Orthopaedic Surgeons

Recommandation 5-9 We are unable to recommend for or against : bed rest, complementary and alternative medicine, or the use of opioids/analgesics brace supervised or unsupervised exercise program electrical stimulation for patients improvement of kyphosis angle in the treatment of patients Journal of the American Academy of Orthopaedic Surgeons 2011

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