vertebral fracture management, professor opinder sahota #flschampions
TRANSCRIPT
FLS Champions’ Summit
Management of Acute Vertebral Fractures
Professor Opinder SahotaConsultant Physician
QMC, Nottingham University Hospitals
Vertebral Fragility Fractures (VFF)
KyphoticNormal
Location of Vertebral Fractures
1. Nevitt MC et al. Bone. 1999;25:613–619.2. Cooper C et al. J Bone Min Res. 1992;7:221–227.
Are most commonly located at the midthoracic region (T7–T8) and the thoracolumbar junction (T12–L1)1
– Midthoracic region–thoracic kyphosis is most pronounced and loading (stress) during flexion is increased
– Thoracolumbar junction–the relatively rigid thoracic spine connects to the more freely mobile lumbar segments2
Progressive Kyphosis & Spine Compensation
• Impairs gait and mobility• Para spinal muscle fatigue• Increases strain on
posterior facet joints
Back Pain
Knee flexion and contraction of the posterior muscles ofthe lower back to tilt the hips
Long-term Consequences
Acute Fracture
Acute Fracture :Optimise Pain Control
• Paracetamol• Tramadol• NSAIDs• Fentenyl• Buprenorphine
Acute Fracture :Imaging
DXA
•••
•• •
Osteoporosis-Imaging
Lateral Vertebral Assessment
••
Vertebral Fragility Fractures
Genant HK et al. J Bone Miner Res. 1993;8:1137–1148.
Severe(≥40% height loss)
Normal Wedge Biconcave Crush
Moderate(25-40% height loss)
Mild(20-25% height loss)
Measurements used for assessment:Hp=posterior height;Hm=middle height;Ha=anterior height
Hp Hm Ha
Lateral Vertebral Assessment
Osteoporosis-Imaging
LVA Assessment
• 337 patients, presenting with low trauma non-vertebral fractures
• LVA 83 (25%) vertebral fracture confirmed(37 (45%) more than one vertebral fracture
• Of those with vertebral fractures, 75% has deformities of grade 2 or 3
Gallacher SJ et al. Osteop Int . 2006; 18: 185-192
Acute Fracture :Exclude Secondary Metabolic Causes
• FBC / ESR• Biochemisty Profile• TFTs, Coeliac Screen• Calcium (PTH)• Myeloma screen• PSA
Acute Fracture :Admission to Hospital
Acute Fracture :Secondary Care
• Optimise Analgesia• Regular bowel care• Consider urgent MR
Imaging• Discussion with spine
team
Acute Fracture :Discussion with spine team• On call• HCOP Dedicated 4 PAs• Spinal Osteoporosis Specialist Nurse
Vertebral Augmentation
Vertebral Augmentation
• Ms OG
• 82 Female, normally fit and well
• Acute back pain, following light gardening
• Presented to ED-log rolled
• X-ray spine confirmed L4#
• Plan transfer to medicine for analgesia and physio
Case Presentation 1
Case Presentation 1
Case Presentation 1
Case Presentation 1
Case Presentation 1
Case Presentation 1
Case Presentation 1
• Ms KH
• 91 Female, normally fit and well, no aids
• Awoke with acute lower back pain
• Managed by GP regular analgesia, 48 hours
• Struggling to mobilise
• Admitted to hospital
Case Presentation 2
Case Presentation 2
Case Presentation 2
Case Presentation 2
Case Presentation 2
Case Presentation 2
Case Presentation 2
Acute Pelvic Fracture
Acute Pelvic Fracture
Acute Pelvic Fracture
Sacral Fractures Pubic Rami
Fracture
Acute Pelvic Fracture
Pelvic Fractures
• CT• MRI• PARACEMATOL (IV) • SACROPLASTY / SCREW FIXATION• PARATHYROID HORMONE
Pelvic Fractures
• Teriparatide (1-34 parathyroid hormone)• Parathyroid Hormone (1-84)• 65 Patients with pubic / ischial rami fracture• Fracture healing time reduced by 4.6 weeks (p<0.01)• Improved pain scores and Timed Up and Go (p<0.01)
Peichl et al, JBJS, 2011; 93: 1-5
The Optimal Acute Pathway
• Acute Vertebral / Sacral Fracture
• Clinical Assessment
• Analgesia• Investigations
• X-ray Imaging• MR Imaging
• Spinal Augmentation• Intensive rehabilitation
• Secondary prevention