in the name of god. osteoprotic spine fractures what should we be doing? (or not doing ….)...
TRANSCRIPT
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
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.
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
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