Management Of Osteoporotic Vertebral Fractures Research Articles

Third-generation percutaneous vertebral augmentation systems.

Currently, there is no general consensus about the management of osteoporotic vertebral fractures (OVF). In the past, conservative treatment for at least one month was deemed appropriate for the majority of vertebral fractures. When pain persisted after conservative treatment, it was necessary to consider surgical interventions including: vertebroplasty for vertebral fractures with less than 30% loss of height of the affected vertebral body and kyphoplasty for vertebral fractures with greater than 30% loss of height. Currently, this type of treatment is not feasible. Herein we review the characteristics and methods of operation of three of the most common percutaneous vertebral augmentation systems (PVAS) for the treatment of OVF: Vertebral Body Stenting(®) (VBS), OsseoFix(®) and Spine Jack(®). VBS is a titanium device accompanied by a hydraulic (as opposed to mechanical) working system which allows a partial and not immediate possibility to control the opening of the device. On the other hand, OsseoFix(®) and Spine Jack(®) are accompanied by a mechanical working system which allows a progressive and controlled reduction of the vertebral fracture. Another important aspect to consider is the vertebral body height recovery. OsseoFix(®) has an indirect mechanism of action: the compaction of the trabecular bone causes an increase in the vertebral body height. Unlike the Vertebral Body Stenting(®) and Spine Jack(®), the OsseoFix(®) has no direct lift mechanism. Therefore, for these characteristics and for the force that this device is able to provide. In our opinion, Spine Jack(®) is the only device also suitable for the treatment OVF, traumatic fracture (recent, old or inveterate) and primary or secondary bone tumors.

Modified Posterior Vertebral Column Resection for the Treatment of Osteoporotic Fractures with Neurological Deficits in Elderly Patients

Introduction The purpose of this retrospective study was to evaluate the results of spinal canal decompression and anterior column support via modified posterior vertebral column resection (PVCR) (Unilateral hemilaminectomy, pediculectomy, subtotal vertebrectomy) performed for eliminating the disadvantages of the anterior or combined A + P approaches, in the management of osteoporotic vertebral fractures with neurological deficits in elderly patients. Patients and Methods A total of 55 patients (40 females and 15 males) with more than 2 years of follow-up were included in this study. The fractures were in the thoracic spine in 16 patients, and thoracolumbar spine in 39 patients. Overall, 11 patients had ASIA grade C and 41 patients had ASIA grade D neurological deficits. Clinical and radiological outcome and complications were also evaluated. Surgical technique included placement of fenestrated titanium pedicle screws, followed by hemilaminectomy, unilateral pediculectomy, and decompression of the spinal canal by subtotal vertebrectomy, and support of anterior column by titanium cage. Contralateral facet joint fusion and grafting was made. Prophylactic vertebroplasties were made in one level above and one level below in all patients. Results Mean age was 74.2 years (range, 66–92), and mean follow-up was 43.5 months (range, 28–102). Mean operation time was 252 minutes (range, 160–340), and blood loss was 580 mL (range, 420–800). Mean preoperative local kyphosis angle was 18.5 degrees and improved to 4.2 degree after the operation and 4.8 degree at the final follow-up. Visual analog scale (VAS) score was eight before the operation and improved to two at final follow-up. Full neurological recovery was achieved in all patients. There were no pseudoarthroses. The major complication was adjacent segment fracture was made three patients (5.4%). The minor complications were superficial wound infections in five patients and dural tear in four patients (16.3%). Conclusion Treatment of osteoporotic vertebral fracture with neurological deficit is a challenging procedure in elderly patients. Modified PVCR provides effective decompression of neural structures. Contralateral intact lamina, pedicle, and cortex of the vertebra increase primary stability and provides more bony surface for fusion.

Risks and benefits of percutaneous vertebroplasty or kyphoplasty in the management of osteoporotic vertebral fractures

Vertebral fracture (VF) is the most common osteoporotic fracture and is associated with high morbidity and mortality. Conservative treatment combining antalgic agents and rest is usually recommended for symptomatic VFs. The aim of this paper is to review the randomized controlled trials comparing the efficacy and safety of percutaneous vertebroplasty (VP) and percutaneous balloon kyphoplasty (KP) versus conservative treatment. VP and KP procedures are associated with an acceptable general safety. Although the case series investigating VP/KP have all shown an outstanding analgesic benefit, randomized controlled studies are rare and have yielded contradictory results. In several of these studies, a short-term analgesic benefit was observed, except in the prospective randomized sham-controlled studies. A long-term analgesic and functional benefit has rarely been noted. Several recent studies have shown that both VP and KP are associated with an increased risk of new VFs. These fractures are mostly VFs adjacent to the procedure, and they occur within a shorter time period than VFs in other locations. The main risk factors include the number of preexisting VFs, the number of VPs/KPs performed, age, decreased bone mineral density, and intradiscal cement leakage. It is therefore important to involve the patients to whom VP/KP is being proposed in the decision-making process. It is also essential to rapidly initiate a specific osteoporosis therapy when a VF occurs (ideally a bone anabolic treatment) so as to reduce the risk of fracture. Randomized controlled studies are necessary in order to better define the profile of patients who likely benefit the most from VP/KP.

Osteoporotic vertebral fractures: current concepts of conservative care

Osteoporotic vertebral compression fractures (VCFs) are a growing public health problem with important socio-economic effects in western countries. In the USA, 10 million people over 50 suffer from osteoporosis. In these patients, 1.5 million annual fractures have been registered, and 50% of these are vertebral compression. We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL and Embase databases using various combinations of the keywords 'osteoporosis', 'vertebral compression fractures', 'brace', 'bracing', 'orthosis', 'conservative management' and 'rehabilitation' over the years 1966-2011. All articles relevant to the subject were retrieved, and their bibliographies were hand searched for further references in the context of conservative management of osteoporotic vertebral fractures. Conservative management for patients with osteoporotic vertebral fractures includes bed rest, pain medication, physiotherapy and bracing. A conservative management for patients with osteoporotic VCFs s has not been standardized. The utility of vertebral augmentation techniques has been questioned by recent randomized controlled trials. Randomized controlled trials are being performed worldwide on vertebral augmentation techniques. Although spinal orthoses are commonly used for the management of patients with osteoporotic vertebral fractures, in the literature there is only one randomized controlled trial on bracing for this condition. While the best conservative management for subjects with osteoporotic VCFs s is not defined and standardized, no conclusions on the superiority of vertebral augmentation techniques over conservative management can be drawn.

Evaluation of percutaneous vertebroplasty in osteoporotic vertebral fractures using a combination of CT fluoroscopy and conventional lateral fluoroscopy

Evaluation of vertebroplasty using a combination of CT-fluoroscopy and conventional lateral fluoroscopy in patients with osteoporotic vertebral fractures. Fifty-eight patients (23male, 35 women, age 69.7 +/- 10.2 years) with painful osteoporotic vertebral fractures were treated with vertebroplasty in conscious sedation and local anesthesia. Spiral-CT with sagittal reconstructions of the respective vertebral bodies was used for classification of the fracture. The cannula was placed under CT-guidance in the ventral third of the respective vertebral bodies and cement instilled under CT fluoroscopy and lateral fluoroscopy. When cement migrated towards the vertebral canal, the injection was immediately stopped for 30 - 60 seconds. After polymerization in this location, the injection was continued until sufficient filling of the vertebra. Results were documented by spiral CT with sagittal reconstructions. A total of 123 vertebral bodies were treated, comprising 39 thoracic and 84 lumbar vertebral bodies, with a mean of 2.1 +/- 1.3 (range 1 to 6) vertebral bodies in each patient and a maximum of 3 vertebral bodies per session. All interventions were successfully completed in conscious sedation and local anesthesia. A mean volume of 5.9 +/- 0.6 ml (range 2 to 14 ml) cement was applied for each vertebra, with 79.7 % of procedures performed using a unilateral access. To achieve a sufficient cement deposit, a bilateral access was used in 20.3 %. The dorsal wall of the vertebra was included in 23.6 % of the fractures. In one case, cement migration into the spinal canal was detected, reducing the diameter of the canal by 30 %. In two other cases, cement leakage was seen at the puncture site of the vertebra (one intercostotransversally in the 10 (th) thoracic vertebra and one dorsolaterally in the 1 (st) lumbar vertebra) with retrograde cement migration through the neuroforamen into the epidural space. In one of these cases, the cannulation of the vertebra had been changed before cement application resulting in a hole in the dorsolateral vertebral wall. However, all patients were discharged without evidence of neurologic complications. Multiplanar reconstructions of CT scans were used for the detection of extraosseous cement leaks: The incidence of extraosseous cement leaks was 4.1 % in epidural veins, 6.5 % in paravertebral vessels (6 veins, 2 arteries), and 17.9 and 11.4 %, respectively, for upper or lower end plates. At discharge, 25 patients (43.1 %) were free of pain and 28 (48.3 %) significantly improved with a considerable reduction of analgetic drugs. Significant complaints persisted in 5 patients (8.6 %) with concomitant degenerative disease in four and vasculitis in one case. Percutaneous vertebroplasty is effective for stabilization and pain management of osteoporotic vertebral fractures. The procedure can be safely performed in conscious sedation and local anesthesia. Compared to conventional fluoroscopy alone, CT fluoroscopy provides an excellent additional monitoring of the procedure and probably contributes to the safety of the procedure.

The Effect of Nerve-Root Injection on Pain Relief in the Management of Osteoporotic Vertebral Fractures

Purpose : The purpose of this study was to evaluate the efficacy of a nerve-root injection for the alleviation of pain in osteoporotic vertebral fracture. Materials and Methods : Eighteen patients with pain from osteoporotic vertebral fracture, without improvement after conservative treatment, were included in this study. The group consisted of sixteen women and two men, and had with a mean age of 71 years. Patients underwent a nerve-root injection with lidocane, bupivacane and depomedrol, and were allowed as many as three injections. The mean follow-up period was 13.5 months. Results : The average pain scores at pre-injection, 1 month and 6 months after the injection and final follow-up were 85, 24.9, 14.1 and 17.4, respectively. According to the criteria used to assess clinical results, there was one excellent, thirteen good and four fair results. A newly developed compression fracture was noted in one patient. No complication was related to the injection. Conclusion : Our data show that nerve-root injections are effective at improving pain. This suggests that patients with pain from osteoporotic vertebral fractures should be considered for treatment with nerve-root injections prior to being considered for percutaneous vertebroplasty or operative intervention.

Osteoporotic vertebral fractures

Osteoporosis is a significant public health problem. Vertebral fractures are the most common fracture in patients with osteoporosis, occurring in approximately 750,000 cases each year. The fractures may cause acute or chronic pain, reduce the quality of life, and shorten life expectancy. Several medications are available that reduce the risk of fracture. Vertebroplasty and kyphoplasty (balloon-inflated expansion of collapsed vertebrae followed by injection of bone cement) may reduce or relieve pain in selected patients. Although surgery is rarely necessary for the management of osteoporotic vertebral fractures, it may be indicated for other reasons. No studies have been conducted to determine if the outcome of spinal fusion is different in patients with osteoporosis and, if it is, whether management of the patient's osteoporosis will improve the outcome.