IN THE NAME OF GOD

Osteoprotic spine fractures

WHAT SHOULD WE BE DOING?

(OR NOT DOING ….)

ANDALIB.ALI.MDISFAHAN MEDICAL SCIENCES

UNIVERSITYKASHANI 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

breathinggastrointestinal

problemssleep 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: 320-3.

demographics

affects up to 25% people over 70

years 50% people over 80

yearsrisk 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

traumaosteoporosis 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 T6Less 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?

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

techniquekyphoplasty 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

InfectionUncorrectable

coagulopathyAnaesthetic RiskNeurologyPost.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

bracesupervised or unsupervised exercise programelectrical stimulation for patientsimprovement of kyphosis angle in the treatment of

patients Journal of the American Academy of Orthopaedic Surgeons

2011

THANK YOU FOR ATTENTION