Treatment of Osteoporotic Fractures

Kyphoplasty and Vertebroplasty
The treatment of painful osteoporotic compression fractures has advanced considerably with the development of minimally invasive fracture stabilization in the form of vertebral augmentation (ie, kyphoplasty and vertebroplasty). The clinical results of these techniques have been extremely encouraging, demonstrating pain relief in 95% to 100% of patients treated.(3-7)

Kyphoplasty, in particular, has enjoyed considerable publicity because it can reduce vertebral compression fractures and stabilize them for pain relief. As symptomatic kyphosis is often the result of multiple compression fractures, kyphoplasty, in contrast to vertebroplasty, can be used to correct or prevent such deformity.

It is commonly believed that correcting the deformity may biomechanically reduce further fracture risk at other levels. While this remains to be proved in a prospective clinical series, kyphoplasty is the only method of vertebral augmentation that has demonstrated the ability to correct kyphosis.(2,4) Vertebroplasty does not have this ability and should be considered only as a method of pain relief.

Braces are Important, Underused
Bracing is an important component of nonoperative management of osteoporotic compression fractures, in addition to proper pharmacologic and analgesic therapy.

Various types of braces are available. A shell-type device, such as a thoracolumbosacral orthosis, offers stability during rotation, flexion, and extension. However, because of the encasing plastic shell design, patients often complain of uncomfortable itching and sweating underneath the brace.

Shell-type braces are useful in the treatment of acute high-energy traumatic fractures. While some surgeons might prescribe them for osteoporotic compression fractures, they are generally considered "overkill." The deforming forces pushing the spine into kyphosis can be overcome by a hyperextension brace, such as a Jewett-type device, which is much less bulky, more comfortable, less expensive, and easier to apply and remove.

Unfortunately, poor overall patient compliance with brace therapy is a major factor limiting its effectiveness.

Neurologic Sequelae
Mazanec et al (1) briefly discuss the neurologic sequelae of osteoporotic spinal fractures. Neurologic compromise is due to compromise of the spinal canal.

Compromise of the thoracic spinal canal leads to myelopathy, which presents as an upper motor neuron condition. Hyperreflexia in the lower extremities, clonus, and varying patterns of motor and sensory deficit can be present.

Compromise of the lumbar spinal canal compresses the cauda equina, resulting in a presentation similar to degenerative lumbar stenosis. This is a lower motor neuron phenomenon, leading to hyporeflexia in the lower extremities, which may or may not be accompanied by motor or sensory deficit.

Senile burst fractures. Neurologic injury is extremely rare with osteoporotic compression fractures, but is more characteristic of a senile burst fracture-an osteoporotic fracture that extends to the posterior aspect of the vertebral body. Not all senile burst fractures cause spinal canal encroachment, however.

On plain radiographs, senile burst fractures can appear similar to compression fractures. Computed tomography or magnetic resonance imaging can better demonstrate the retropulsion of bony fragments into the spinal canal that is characteristic of this injury.

This lesion is better treated with open anterior decompression and stabilization with hardware to maximize neurologic recovery.

It is not amenable to kyphoplasty or vertebroplasty because of the risk of cement extravasation into the spinal canal through the fracture site.

References

1. Mazanec DJ, Mompont A, Podichetty VK, Pontis A. Vertebral compression fractures: Manage aggressively to prevent sequelae. Cleve Clin J Med 2003; 70:147-156.

2. Baillie SP, Davison CE, Johnson FJ, Francis RM. Pathogenesis of vertebral crush fractures in men. Age Ageing 1992; 21:139-141.

3. Garfin SR, Yuan HA, Reiley MA. New technologies in spine: kyphoplasty and vertebroplasty for the treatment of painful osteoporotic compression fractures. Spine 2001; 26:1511-1515.

4. Deramond H, Depriester C, Galibert P, Le Gars D. Percutaneous vertebroplasty with polymethylmethacrylate. Technique, indications, and results. Radiol Clin North Am 1998; 36:533-546.

5. Lieberman IH, Dudeney S, Reinhardt MK, Bell G. Initial outcome and efficacy of "kyphoplasty" in the treatment of painful osteoporotic vertebral compression fractures. Spine 2001; 26:1631-1638.

6. Centenera LV, Choi S, Hirsch JA. Percutaneous vertebroplasty treats compression fractures. Diagn Imaging (San Franc) 2000; 22:147-153.

7. Cortet B, Cotten A, Boutry N, et al. Percutaneous vertebroplasty in the treatment of osteoporotic vertebral compression fractures: an open prospective study. J Rheumatol 1999; 26:2222-2228.

Cleveland Clinic Journal of Medicine, Volume 70, Number 2, February 2003.

This paper discusses therapies that are experimental or that are not approved by the US Food and Drug Administration for the use under discussion.

Price: $219.00 USD M. Goytan, M.D., B. Jeanneret, M.D., F. Magerl, M.D., M.B. Williamson Jr., M.D., Max Aebi, M.D., John S. Thalgott, M.D., John K. Webb, M.D. ISBN: 3-540-62763-4 Edited by: M. Goytan, Mc Gill University, Montreal, Que., Canada B. Jeanneret, Las Vegas, NV F. Magerl, Nottingham, UK M.B. Williamson Jr. Max Aebi John S. Thalgott, John K. Webb ABOUT THIS BOOK Following a dramatic evolution in spine surgery in the last decades the long and eagerly awaited spine manual provides a comprehensive overview on the methods developed in co-operation with the AO as well as the indications and pre-requisites of spine surgery. The authors - outstanding experts in spine surgery - describe the most up to date instruments, implants and techniques as well as their correct application. The spine manual itself thus becomes an essential and indispensable instrument for the spine surgeon. TABLE OF CONTENTS Aims and Principles. - Implants. - Biomechanics of Implants. - Biology of Fusion. - Classification of Fractures. - Stabilization Techniques: Upper Cervical Spine, Lower Cervical Spine, Thoraco-lumbar Spine. - Modular Stabilization System: Universal Spine System. - Other Fixation Systems. 1998 Hardcover, 244 pages 296 illus.,

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