Vertebral Compression Fracture Management - Dushan Atkinson 26/5/2005

Osteoporotic vertebralcompression fractures. 700,000 annually in US, requiring 150,000 hospitalisations. Costing $746 million in 1995.

Reduction in vertebral bodyheight, with wedging, usually anteriorly

Chronic/severe pain, limitedfunction and reduced mobility, loss of independence in daily activities,difficulty sleeping, clinical anxiety /depression,

Decreased lung capacityVC and FEV1,

23% increase in mortality (KadoDM Arch Intern Med 1999 1:59) increasing further with higher number offractures.

Can also cause neurologicalcompromise (usually requiring surgery).

Commonly at thoracolumbarjunction. Rarely above T6 (Riggs BL Bone 1995 17(5):505s-511s).

CONSERVATIVE TREATMENT

• Bed rest ( > 4 days can lead to further OP and muscular deconditioning),
• Analgesia and muscle relaxants (acute pain usually resolves in 4-6 weeks (Sinaki M Phys Med Rehabil 1995 9:105)
• Calcitonin
• Physiotherapy (extension exercise) after pain reduces (flexion exercises can increase risk of further fracture (Sinaki M Arch Phys Med Rehabil 1984 65:593), therefore avoid spinal flexion, WBing exercise increases BMD (Orwoll ES Arch Intern Med 1989 149:2197)
• Hospitalization and Nursing care

• Braces (allow early mobilisation): recommended if >30% loss of anterior vertebral body height.

- Principle to off loadanterior column, reducing pain and preventing further kyphosis (Fidler MW JBJS1983 65-A 943-947).

- TLSO offers stability,but is uncomfortable, and has poor compliance. Also 3-point hyperextension brace can overcome kyphotic forces, and avoid spinal flexion (Sinaki again). undefined

- If <30% reduction,don’t have to brace, but can do for comfort. If you don’t brace, then follow # closely to look for progression of collapse.

However many suffer prolonged pain and immobility throughout life (150,000 annually in US) (Riggs BL NEJM 1986 314(26):1676-86).

PERCUTANEOUS VERTEBROPLASTY

Used in France in 1984 for a painful haemangioma. Used for vertebral osteoporotic fractures, mets and myeloma since mid 90s.

• Pre-op CT or MRI needed to determine canal compromise and posterior wall integrity,and other causes of back pain. PMMA (with barium/tungsten opacifier) is injected into a painful vertebral body fracture, under II , LA or GA.

• Patient prone. 11-G needle advanced into vertebral body para or trans-pedicular.

• Lower viscocity cement injected at HIGHER pressure than kyphoplasty and diffuses throughout the intertrabecular space.

• Process usually repeated through other pedicle unless adequate cross-filling. Usually 4-12 mls.

• Patient lies supine for 1hour as cement sets. Observed for 2 hours after which they can mobilise.

• Cement stabilises the fracture and allows a reduction in pain and increase in function, but does not restore height. It is believed that pain relief is achieved by mechanical support and stability provided by the cement. Post-mortems show restoration ofstrength and vertebral body stiffness (Tohmeh AG Spine 1999 24:1772-6)

Indications

Predey TA, Am Fam Phy 2002 66(4)

• Osteoporotic vertebral compression fractures more than two weeks old in the cervical, thoracic, and lumbar spine causing moderate to severe pain and unresponsive to conservative therapy

• Painful metastasis and multiple myelomas with or without adjuvant radiation or surgical therapy

• Painful vertebral hemangiomas

• Vertebral osteonecrosis

• Reinforcement of a pathologically weak vertebral body before a surgical stabilization procedure

Contraindications

Absolute

Osteoporotic vertebral fracture that is completely healed or is clearly responding to conservative management

Presence of untreated coagulopathy

Presence of discitis/osteomyelitis or sepsis

Relative

Significant compromise of the spinal canal by retropulsed bone fragment or tumor

Fracture older than one year

Greater than 80 to 90 percent collapse of the vertebral body

RESULTS

- No RCTs (3 inprogress), but complete/partial pain relief 90-97%. (Jensen ME AJNR 199718:1897-904, Cotton A Radiology 1996200: 525-30)

- Favourable outcomes in 78-90% OP #s, 73-80% haemangiomas, 80-83% malignancy (Deramond H Radiol ClinNorth Am 1998 36:533-46, Weill A Radiology 1996 199:241-7)