Management Of Vertebral Fractures Research Articles

Neurosurgery compared to orthopedic spine consultation: A single level I trauma center experience

IntroductionBoth Orthopedic Surgery (OS) and Neurosurgery (NS) perform spine surgery in the setting of trauma. However, it is unknown whether outcomes differ between these specialties. This study compares management and outcomes for vertebral fractures between NS and OS, hypothesizing similar operation rate, length of stay (LOS), and readmission. Research questionDo outcomes differ between NS and OS in the management of vertebral fractures following trauma? MethodsA retrospective single-center study was conducted on adult patients with cervical, thoracic, lumbar, and sacral fractures treated at a single trauma center, where no standardized pathway exists across NS and OS. Patients were compared for injury profile, diagnostic imaging, and operative techniques as well as LOS, mortality, and complications. ResultsA total of 630 vertebral fracture patients (OS:350 (55.6%); NS:280 (44.4%)) were included. NS utilized magnetic resonance imaging (MRI) more commonly (36.4% vs. 22.6%, p < 0.001). NS patients more often underwent operation (13.2% vs. 7.4%, p = 0.016) despite similar fracture number and severity (p > 0.05). Post-operative complications, LOS, and readmission rates were similar between cohorts (p > 0.05). Discussion and conclusionDespite similar injury profiles, NS had higher rates of MRI usage and operative interventions in the context of traumatic spine fractures. Despite differences in management, major clinical outcomes were similar between NS and OS. However, we do call for further standardization of evaluation and treatment of patients based on established algorithms from such as the AOSpine Thoracolumbar Spine Injury Classification System (ATLICS).

241 ‘Please consider bone assessment’: improving the identification and management of Vertebral Fractures by a ‘Fracture Liaison Service’

Abstract Background Osteoporotic fractures are a major public health problem due to an ageing population causing profound disability and reduced quality of life. Vertebral Fractures (VFs) are the second most common osteoporotic fracture with nearly 1 in 4 women having one in their lifetime. Furthermore, a VF is a significant warning sign for another fracture in the following year—known as ‘imminent fracture risk’. Despite this early opportunity for clinical intervention with bone protective medication, VFs are frequently under-diagnosed and under-treated. This observational study aimed to look at the point prevalence of VFs picked up on radiology reports and compare with those identified by the ‘Fracture Liaison Service’ (FLS). Methods The PACs office ran a search for all MRI spine, CT-TAP and a plain radiographic film reports from January 2021 until April 2023 with the terms ‘vertebrae’ and ‘compression’ in the text. Inclusion criteria was all patients &amp;gt;65 without major trauma with a radiologist defined osteoporotic VF. Using excel, we cross-referenced the proportion of these already know to the FLS. Results There were 338 osteoporotic VFs diagnosed on radiological imaging between 2021 &amp; 2023. Of these, 101 had been identified by the FLS. The median age was 77 years old. There were 228 (67.2%) females and 111 (32.8%) males. Conclusion This study helped to highlight that over 67.2% of the osteoporotic VFs are not being identified by the FLS. Therefore, is it assumed that timely intervention and management of their imminent fracture risk may not have been undertaken. This data is being used to drive a quality improvement project with the radiology department where any VF in women &amp;gt;70 will be reported to include—‘please consider bone assessment’.

Thoracolumbar vertebral fracture in unoperated idiopathic scoliosis

IntroductionTraumatic fractures of the thoracolumbar spine are common. Their management considers the fracture type according to the various classifications in existence, as well as the patient's background and age. In some cases, the occurrence of a fracture on a spine with an unoperated scoliotic deformity can be observed. This entity, not described in the literature, can pose a therapeutic challenge and is not present in any existing treatment algorithm. The main objective of this work was to describe the characteristics and management of vertebral fractures in patients with unoperated idiopathic scoliosis. Material and methodsWe carried out a monocentric retrospective study in all patients operated on for a spinal fracture between May 2011 and August 2020, with a history of unoperated adolescent idiopathic scoliosis. We collected epidemiological data including the surgical course of each patient and the final result. The patients were categorized according to the surgical strategy (extensive fusion and correction of the deformity, short osteosynthesis without considering the scoliosis, vertebroplasty and orthopedic treatment) and the final clinical and radiological result evaluated at the last follow-up. ResultsTen patients were included in this study with a total number of 16 fractured vertebrae. The population was 80% female, with an average age of 36.3 years. The majority of fractures were type A, at the thoracolumbar junction. The curves were classified as Lenke 1A in 5 cases, 1B in 2 cases, 1C in 1 case and 5C for 2 patients. Ultimately, 3 patients underwent extended fusion with correction of scoliosis, 6 localized osteosynthesis and 1 percutaneous vertebroplasty. In 50% of cases, a change of surgical strategy had to be made, due to worsening of the deformity or hyperalgesia. The last follow-up was at 19.7 months on average. Five patients had a good final clinical result, 5 patients had persistence of significant pain (lower back pain or cruralgia). ConclusionThis is the first study investigating the association of vertebral fractures and the presence of unoperated idiopathic scoliosis. The results of our study highlight the management challenges and difficulties in therapeutic decision-making. The presence of a pre-existing curve is thus an important parameter to consider and should lead to the discussion of performing an extended fusion secondarily in view of the risk of poor results from localized surgery. Level of EvidenceIV.

Urban–rural differences in outcomes and management of vertebral fractures: A real-world observational study

A fracture liaison services (FLSs) and its modified services reduce refractures and mortality and can be cost-effective. Limited studies have addressed whether urban-rural differences exist in vertebral fracture outcomes and management. Therefore, the aims of the study were to investigate any urban-rural differences in refracture, mortality, prescription pattern, and associated factors of vertebral fractures after receiving assistance from an FLSs. Baseline characteristics and osteoporosis medication prescription patterns of participants were collected. After 1-year follow-up, mortality, refracture rate, and osteoporosis medication switching and adherence were evaluated. Multivariate logistic regressions were performed to identify baseline correlates on one-year mortality. There was higher mortality rate in the rural group but no urban-rural difference in the 1-year refracture rate after implementation of FLSs and medication management services (MMSs). The types of osteoporosis medications prescribed for both groups were similar, but participants in the rural group were less likely to change their osteoporosis medications during the 1-year follow-up timeframe and with lower adherence rate. The likelihood of being older and having chronic kidney disease, osteoarthritis, and neurological disease was higher in the rural group. Our multicomponent services have similar effectiveness in osteoporosis treatment between urban and rural areas. The overall adherence rate was lower in the rural group with higher mortality but no difference in the refracture rate in one year.

UK clinical guideline for the prevention and treatment of osteoporosis

SummaryThe National Osteoporosis Guideline Group (NOGG) has revised the UK guideline for the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women, and men age 50 years and older. Accredited by NICE, this guideline is relevant for all healthcare professionals involved in osteoporosis management.IntroductionThe UK National Osteoporosis Guideline Group (NOGG) first produced a guideline on the prevention and treatment of osteoporosis in 2008, with updates in 2013 and 2017. This paper presents a major update of the guideline, the scope of which is to review the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women, and men age 50 years and older.MethodsWhere available, systematic reviews, meta-analyses and randomised controlled trials were used to provide the evidence base. Conclusions and recommendations were systematically graded according to the strength of the available evidence.ResultsReview of the evidence and recommendations are provided for the diagnosis of osteoporosis, fracture-risk assessment and intervention thresholds, management of vertebral fractures, non-pharmacological and pharmacological treatments, including duration and monitoring of anti-resorptive therapy, glucocorticoid-induced osteoporosis, and models of care for fracture prevention. Recommendations are made for training; service leads and commissioners of healthcare; and for review criteria for audit and quality improvement.ConclusionThe guideline, which has received accreditation from the National Institute of Health and Care Excellence (NICE), provides a comprehensive overview of the assessment and management of osteoporosis for all healthcare professionals involved in its management. This position paper has been endorsed by the International Osteoporosis Foundation and by the European Society for the Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases.

Update on vertebral fractures in pituitary diseases: from research to clinical practice.

Derangement of pituitary hormone axes can induce changes in bone remodeling and metabolism with possible alterations in bone microarchitectural structure and increased susceptibility to fractures. Vertebral fractures (VFs), which are a hallmark of skeletal fragility, have been described in a very large number of patients with pituitary diseases. These fractures are clinically relevant, since they predispose to further fractures and may negatively impact on patients' quality of life. However, the management of skeletal fragility and VFs in the specific setting of pituitary diseases is a challenge, since the awareness for this disease is still low, prediction of VFs is uncertain, the diagnosis of VFs cannot be solely based on a clinical approach and also needs a radiological and morphometric approach, the risk of fractures may not be decreased via treatment of pituitary hormone disorders, and the effectiveness of bone-active drugs in this setting is not always evidence-based. This review is an update on skeletal fragility in patients with pituitary diseases, with a focus on clinical and therapeutic aspects concerning the management of VFs.

OS2.4 Using FineSA MRI for early detection of Spinal Metastases

Abstract BACKGROUND Early detection of spinal metastases is important to facilitate early management and delay vertebral fracture or metastatic cord compression. The gold standard investigation to detect spinal metastasis is MRI, but it cannot quantify the metastasis and prognosis is poor due to its late presentation. Fine Structural Analysis (FineSA) is a custom software added to MRI using a non-radiating proprietary data acquisition technique. It analyses data at a resolution 10 times higher than MRI to quantify the trabecular microstructure which has the potential to enable early detection and management of vertebral fracture or metastatic cord compression. MATERIAL AND METHODS 18 patients with known, symptomatic spinal metastases from Swansea Bay University Health Board and 11 age and sex-matched control subjects were recruited to have a FineSA MRI Spine. FineSA analysed and produced a structural spectrum of a defined area from the metastatic lesion. Statistical comparisons were made with the control data by extracting several metrics from the spectra, which were represented as an index score relative to a normal range. RESULTS Preliminary results using One Way ANOVA show a highly significant difference in trabecular microstructure between patients with spinal metastases and the age and sex-matched control patients, where p= 3.99e-11. CONCLUSION Preliminary results show that there is a highly significant difference between metastatic and control bone structure. Follow-up of the patients after one year will look at if fracture has occurred and whether there is a difference in the FineSA index score between the two groups. FineSA has the potential to be used to identify which metastatic lesions are most likely to be symptomatic and fracture, so that targeted radiotherapy can be done before symptoms are either present or intrusive.

Percutaneous fixation of thoracolumbar vertebral fractures.

Surgical treatment of patients with thoracolumbar vertebral fracture without neurological deficit is still controversial.Management of vertebral fracture with percutaneous fixation was first reported in 2004.Advantages of percutaneous fixation are: less tissue dissection; decreased post-operative pain; decreased bleeding and operative time (depending on the steep learning curve); better screw positioning with fluoroscopy compared with an open freehand technique; and a decreased infection rate.The limitations of percutaneous fixation of vertebral fractures include increased radiation exposure to the patient and the surgeon, together with the steep learning curve for this technique.Adding a screw at the level of the fractured vertebra has the advantages of incorporating fewer motion segments with less operative time and bleeding. This also increases the axial, sagittal and torsional stiffness of the construct.Percutaneous fixation alone without grafting is sufficient for treating type A and B1 (AO classification) thoracolumbar fractures with satisfactory results concerning kyphosis reduction when compared with open instrumentation and fusion and with open fixation.Type C and B2 fractures (ligamentous injuries) should undergo fusion since the ligamentous healing is mechanically weak, increasing the risk of instability.This review offers a detailed description of percutaneous screw insertion and discusses the advantages and disadvantages.Cite this article: EFORT Open Rev 2018;3:604-613. DOI: 10.1302/2058-5241.3.170026.

I009 Non-pharmacological management of vertebral fractures

i009 Non-pharmacological management of vertebral fractures

Percutaneous stabilization of lumbar spine: a literature review and new options in treating spine pain.

Vertebral fracture (VF) is a common condition with >160,000 patients affected every year in North America and most of them with affected lumbar vertebrae. The management of VF is well known and defined by many protocols related to associated clinical neurological symptoms, especially in case of the presence or absence of myelopathy or radicular deficit. In this article, we will explore the percutaneous stabilization of the lumbar spine by showing the newest approaches for this condition.

Orthotics and taping in the management of vertebral fractures in people with osteoporosis: a systematic review

ObjectiveTo establish the current evidence base for the use of orthotics and taping for people with osteoporotic vertebral fracture (OVF).DesignSystematic review of quantitative and qualitative studies.Data sourcesMedline, Medline-In Process, EMBASE,...

Vertebroplasty and kyphoplasty update

Vertebroplasty and kyphoplasty are minimally invasive vertebral augmentation procedures in which a filler material is percutaneously injected into a vertebral body for the treatment of vertebral fractures associated with osteoporosis, malignant conditions, hemangiomas, and osteonecrosis. In vertebroplasty, the filler is injected directly into the bone, whereas in kyphoplasty, the filler is injected into a cavity created by inflation of a balloon tamp. The goals of treatment include pain relief, fracture stabilization, restoration of vertebral height, and strengthening of the vertebral body to reduce the risk of a future fracture at the same level. When performed by a well-trained physician in appropriately selected patients, vertebral augmentation is usually effective in achieving one or more of these goals, with a generally good short-term safety profile. Although these procedures hold great promise in the management of vertebral fractures, many questions about long-term efficacy and safety remain.

Transpedicle Body Augmenter: A Further Step in Treating Burst Fractures

Dear Sir, We read with interest the article “Transpedicle Body Augmenter A Further Step in Treating Burst Fractures” by Li et al. [5]. This article addressed short-segment fixation well by comparing patients treated with a transpedicle body augmenter with a control group of patients treated with short-segment posterior instrumentation. The issue of short-segment versus long-segment fixation is a matter of debate among spine surgeons. Where short-segment fixation allows preservation of more mobile segments of the spine, it compromises the strength of fixation construct [4, 6]. This led to a new dimension in management of vertebral fractures, that is, augmentation of short-segment fixation. The methods used for augmentation of short-segment fixation include kyphoplasty [1], vertebroplasty [2], transpedicle bone grafting [3] and transpedicle body augmenter [5]. Except for transpedicle bone grafting, good results have been reported for all other forms of augmentation as compared with short-segment fixation alone. Short-segment pedicle screw fixation is reportedly associated with a 20% to 50% incidence of pedicle screw failure and progressive spinal deformity. The question today is whether the various techniques used for augmentation of short-segment pedicle screw fixation have results comparable to those of long-segment pedicle screw fixation, which we believe is a gold standard [8] for posterior spine stabilization as far as sagittal index and anterior body compression are concerned. We have some concerns regarding the study by Li et al. [5]. First, the postoperative protocol is important in any kind of spinal surgery, however, the authors provide no details of the protocol in this article. As delayed ambulation after short-segment fixation is known to give good results [7], postoperative protocol with specific mention of ambulation should be provided. Moon et al. [7] reported short-segment fixation without posterolateral fusion is an effective procedure for compression and burst fractures if postoperative mobilization is delayed by 2 to 4 weeks. It would be better if the results of the transpedicle body augmenter were compared with results of long-segment fixation. Second, Li et al. report mean times of surgery as 66.1 ± 12.1 minutes and 63.4 ± 16.6 minutes for the augmenter and control groups respectively. Does this mean no additional time is required for: (1) preparation of bilateral pedicle tunnels to the fractured vertebra by an awl followed by serial custom made trials (enlargers) to prepare for TpBA passage; (2) harvesting the bone graft from the iliac crest; (3) filling the vertebral body with autologous bone graft; (4) inserting the augmenter through the pedicle; and (5) filling the pedicle tunnel space with bone graft? Third, blood losses reported for the augmenter and control groups are 216 ± 65 cc and 240 ± 87 cc, respectively, which means the blood loss was less in the group in which two additional pedicle tunnels were made and bone graft was harvested from the iliac crest. If this is correct, the authors should state the reason. Fourth, in the Materials and Methods section, Li et al. reported that flexion and extension xrays were taken after 1 year and at the final visit. The purpose of flexion-extension xrays is not mentioned in the article. Generally, flexion-extension xrays are required to judge bony union after spinal fusion is attempted. However, Li et al. compared only results of vertebral body augmentation with short-segment fixation alone. Therefore, the authors should state what additional information was acquired from the flexion-extension xrays once the anterior body height and kyphosis angle were measured on neutral thoracolumbar radiographs. Finally, Li et al. reported one failure necessitating implant removal. In this case, the patient had intraoperative pedicle rupture during augmenter insertion, which later caused root irritation and neuralgia. As per our knowledge, it is safe to violate the superior and lateral cortices of the pedicle. The authors should state whether the patient had neurologic symptoms even though the inferior and medial cortices of the pedicle were preserved or if the augmenter was implanted despite violation of the inferior or medial cortex of the pedicle.

Effects of a New Spinal Orthosis on Posture, Trunk Strength, and Quality of Life in Women with Postmenopausal Osteoporosis

One fourth of women > or =50 yrs of age in the general population have one or more vertebral fractures. The orthotic treatment modality in the management of vertebral fractures caused by osteoporosis remains subjective because no objective data from clinical trials are available. The objective of this research was to evaluate the efficacy of a newly developed spinal orthosis in patients with osteoporotic vertebral fractures. We conducted a study that measured trunk muscle strength, angle of kyphosis, body height, body sway, and variables of quality of life such as pain, well-being, and limitations of daily living. Wearing the orthosis for 6-mo period was associated with a 73% increase in back extensor strength, a 58% increase in abdominal flexor strength, an 11% decrease in angle of kyphosis, a 25% decrease in body sway, a 7% increase in vital capacity, a 38% decrease in average pain, a 15% increase in well-being, and a 27% decrease in limitations of daily living. The overall tolerability of the orthosis was good, no side-effects were reported, and the drop-out rate of 3% was rather low. The use of an orthosis increases trunk muscle strength and thus improves posture in patients with vertebral fractures caused by osteoporosis. In addition, a better quality of life is achieved by pain reduction, decreased limitations of daily living, and improved well-being. Therefore, the use of an orthosis may represent an efficacious nonpharmacologic treatment option for spinal osteoporosis.