Nonsurgical and surgical management of osteoporotic vertebral body fractures : Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU)

Abstract

Prospective clinical cohort study (data collection); expert opinion (recommendation development). Treatment options for nonsurgical and surgical management of osteoporotic vertebral body fractures differ widely. Based on the current literature, the knowledge of the experts, and their classification for osteoporotic fractures (OF classification), the Spine Section of the German Society for Orthopaedics and Trauma has now introduced general treatment recommendations. Atotal of 707 clinical cases from 16hospitals were evaluated. An OF classification-based score was developed for guidance in the option of nonsurgical versus surgical management. For every classification type, differentiated treatment recommendations were deduced. Diagnostic prerequisites for reproducible treatment recommendations were defined: conventional X‑rays with consecutive follow-up images (standing position whenever possible), magnetic resonance imaging, and computed tomography scans. OF classification allows for upgrading of fracture severity during the course of radiographic follow-up. The actual classification type is decisive for the score. Ascore of less than 6points advocates nonsurgical management; in cases with more than 6points, surgical management is recommended. The primary goal of treatment is fast and painless mobilization. Because of the expected comorbidities in this age group, minimally invasive procedures are preferred. As ageneral rule, stability is more important than motion preservation. It is mandatory to restore the physiological loading capacity of the spine. If the patient was in acompensated unbalanced state at the time of fracture, reconstruction of the individual prefracture sagittal profile is sufficient. The instrumentation technique has to account for compromised bone quality. We recommend the use of cement augmentation or high purchase screws. The particular situations of injuries with neurological impairment, the necessity to fuse, multiple level fractures, consecutive and adjacent fractures and fractures in ankylosing spondylitis are addressed separately. The therapeutic recommendations presented here provide areliable and reproducible basis to decide for the treatment choices available. However, intermediate clinical situations with ascore of 6points remain, allowing for both nonsurgical and surgical options. As aresult, individualized treatment decisions may still be necessary. In the subsequent step, the recommendations presented will be further evaluated in amulticentre controlled clinical trial.