Osteoporotic compression fractures of the spine; current options and considerations for treatment

doi:10.1016/j.spinee.2006.04.013

The Spine Journal

Volume 6, Issue 5, September–October 2006, Pages 479-487

https://doi.org/10.1016/j.spinee.2006.04.013 Get rights and content

Abstract

Background context

Vertebral compression fractures affect at least one-fourth of all postmenopausal women. The most significant risk factor is osteoporosis, most commonly seen among Caucasian women a decade or so after menopause. Osteoporosis typically results from inadequate accumulation of bone mass during childhood and early adulthood followed by rapid resorption after menopause. Primary treatment of osteoporosis includes consideration of underlying metabolic abnormalities and provision of supplemental calcium/vitamin D in conjunction with bisphosphonates or calcitonin, or both. Routine hormone replacement therapy has fallen out of favor because of concerns regarding adverse effects identified in long-term follow-up studies. Acute osteoporotic vertebral compression fracture management includes bracing, analgesics, and functional restoration. Patients with chronic pain beyond 2 months may be appropriate candidates for vertebral body augmentation, ie, vertebroplasty or balloon tamp reduction. Open surgical management with decompression and stabilization should be reserved for the rare patient with neural compression and progressive deformity with neurologic deficits.

Purpose

To review current principles in the evaluation and treatment of osteoporotic compression fractures of the spine.

Study design/setting

A literature review on management of the osteoporotic spine.

Methods

MEDLINE search of all English-language literature published between 1981 and 2005 on surgical and nonsurgical treatment of the osteoporotic spine. The references selected for listing at the conclusion of this review are those containing specific information cited within the text.

Results

Over 200 separate scientific and clinical studies addressing the epidemiology, pathophysiology, diagnosis, and treatment of osteoporotic vertebral compression fractures were reviewed.

Conclusions

Osteoporotic vertebral compression fractures are a common presenting complaint to spinal care specialists. Thorough differential diagnosis should be considered before attributing fractures to osteoporosis. Appropriate evaluation and medical treatment of underlying osteoporosis should be recommended or instituted. Nonsurgical management of the spinal fracture should focus on pain control and maximizing functional outcome. The role of surgical treatment remains controversial and should be reserved for patients who fail initial nonsurgical management options.

Introduction

Osteoporosis is the most common metabolic disorder of bone, affecting approximately 100 million people worldwide. In the United States, it is estimated that at least 10 million people suffer from osteoporosis and an additional 18 million people are at significant risk for development of the disorder. Within this affected group, approximately 700,000 vertebral body compression fractures occur each year, twice the rate of hip fractures. Approximately 70,000 compression fractures result in hospitalization each year with an average hospital stay per patient of 8 days. It has been estimated that at least 25% of American women reaching menopause will experience at least one osteoporotic vertebral compression fracture (OVCF) in their lifetime [1]. Although considered a women's health issue, osteoporosis also affects 33% of men by age 75 [2]. For any given patient, the diagnosis of a single OVCF increases the risk of subsequent fractures by a factor of five. Patient population studies suggest an increased mortality rate in patients with OVCFs that correlates with the number of involved vertebrae [3]. A benign natural history has long been assumed for OVCFs, but up to 30% of those who are symptomatic and seek treatment do not respond adequately to nonsurgical treatment [4], [5].

Section snippets

Historic background

As recently as 1925, osteoporosis was relatively unrecognized and its metabolic causes were unknown. By the early 1980s, estrogen and calcium supplementation had become widely prescribed medical treatments for this condition. Over the past 20 years, additional medications including bisphosphonates, calcitonin, and parathormone have been introduced and successfully used in both treatment and prevention of osteoporosis [6], [7].

Osteoporotic vertebral compression fractures have traditionally been

Anatomy/Pathophysiology

Osteoporosis is characterized by decreased bone mass or increased porosity and results in diminished structural support of the osseous spinal column. Primary osteoporosis is considered to have two etiologic variants. Type I affects postmenopausal women and is related to rapid loss of bone after menopause, whereas Type II affects individuals over 70 years old and involves age-related loss of bone or senile osteoporosis [9]. Secondary osteoporosis is loss of bone caused by an agent or disease

Risk factors

In general, the risk of osteoporotic related fracture increases significantly with age for both men and women. The lifetime risk of all types of skeletal fractures for Caucasian women older than 50 years of age approaches 75%. The lifetime risk of clinically significant OVCF is 16% in this group. In women, the risk of OVCF increases sixfold from menopause to age 85 [10]. Women with a history of one OVCF have a fivefold risk of developing subsequent compression fractures [15].

The World Health

Clinical presentation

Most patients with identified OVCF are asymptomatic at the time of initial diagnosis, and the age of the fracture may be impossible to determine. Patients presenting with back pain typically report the sudden or acute onset of pain in temporal relationship with relatively atraumatic activities such as bending forward, standing from a seated position, or even with vigorous coughing or sneezing. Pain may not be localized to the site of the fracture, as thoracolumbar fractures often present with

Clinical management

Although many patients with osteoporotic vertebral compression fractures experience a relatively benign course with predictable pain improvement over 6 to 8 weeks, some patients experience persistent pain and disability. A study of patients with multiple osteoporotic vertebral compression fractures found significant decreases in trunk extension torque, spinal motion, functional reach, mobility skills and walking distance compared with the normal age-matched population [26]. Of potentially

Nonsurgical treatment

The most important treatment principle in osteoporosis is prevention. Two goals of prevention are to ensure attainment of peak premenopausal bone mass and prevent postmenopausal resorption. However, once osteoporosis is clearly recognized, active treatment needs to be instituted to reduce the risk of pathological fracture. Postmenopausal women with osteoporosis should be treated with 1,500 mg of supplemental calcium and 400 IU of vitamin D daily. All men with compression fractures should be

Vertebral body augmentation

Patients with chronic pain after vertebral compression fracture have traditionally had few treatment options. However, new vertebral body augmentation techniques offer these patients the attractive alternative of a minimally invasive procedure with relatively low risk and high—at least short-term—clinical success rates. Because fracture biomechanics are primarily determined by disruption of the trabecular microarchitecture [36], [37] and ongoing symptoms may be related to ineffective structural

Vertebroplasty

Originally developed in France in the late 1980s, vertebroplasty was introduced in the United States in 1994 [38], [39]. This procedure is now being performed in an outpatient setting or associated with an overnight hospital admission. An attempt at postural reduction is performed by careful prone positioning on the operating room table. A 10- or 11-gauge needle is then introduced percutaneously into the involved vertebra using either a transpedicular or posterolateral extrapedicular approach.

Balloon tamp reduction

The technique of balloon tamp reduction is similar to vertebroplasty, but includes the step of percutaneous insertion of a balloon tamp through the pedicle into the involved vertebral body. Balloon inflation purportedly achieves compaction of surrounding cancellous bone and varying degrees of elevation of the compressed vertebra. Potential advantages of balloon tamp reduction over vertebroplasty include the possibility of improved deformity correction and decreased potential for cement leakage.

Dynamic fracture mobility

Dynamic fracture mobility has been observed in a significant percentage of osteoporotic vertebral compression fractures and is defined as any measurable change in vertebral body height between standing lateral radiographs and cross-table lateral supine radiographs as observed by unaided vision [53]. The amount of change varies significantly among patients and can allow substantial height restoration with vertebroplasty alone. A retrospective review of 73 fractures treated with vertebroplasty

Surgical management

Indications for surgical intervention in the setting of osteoporotic compression fractures have not been strictly defined. The current consensus includes progressive neurological loss, severe unrelenting pain, and significant deformity.

Neurologic deficit typically occurs in association with spinal canal compromise resulting from “two-column” fracture associated with retropulsion of bone into the canal in association with severe deformity. These patients have traditionally been treated with

Discussion

Although most OVCFs are benign, a subset may cause significant morbidity and cost to society both economically and in decreased quality of life and productivity of our growing elderly population. Medical advances have allowed for more focused and effective treatment of osteoporosis. Prevention is the most important strategy with recognition and treatment of osteoporosis and bone loss before the fracture occurrence. Once a fracture has been diagnosed, nonsurgical management with activity

Future topics

The long-term natural history of osteoporotic vertebral compression fractures requires more detailed study. Longer term outcome studies following specific treatments such as vertebroplasty, balloon tamp reduction, and more traditional surgical reconstruction will allow refinement of appropriate indications for these different surgical procedures. Newer materials for augmentation are being introduced and may provide more favorable biomechanical properties and decreased toxicity. There may also

Conclusions with key points

Osteoporotic vertebral compression fractures are becoming increasing sources of significant pain and disability as the population ages. Preventive measures remain the most clinically effective and cost-effective. When fractures occur, most patients experience rapid symptomatic resolution over the course of several weeks and require only nonsurgical treatment measures such as activity limitation, pain medication, and sometimes bracing. For those experiencing persistent pain, vertebral

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Hidden blood loss (HBL), as a perioperative complication of percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP), affects the quality of life of older adults with poor health status, but it is often ignored by clinical surgeons. The purpose of this study was to discuss the risk factors for perioperative HBL through meta-analysis.
We systematically searched PubMed, Embase, Cochrane Library, Web of Science, Scopus, Google Scholar, Chinese National Knowledge Infrastructure, and Wan Fang from establishment of the database to September 2022. All eligible studies regarding risk factors for HBL after PVP or PKP were included. Heterogeneity was assessed using the χ² test and I² statistic percentages. If I² >50% or P < 0.1, the random-effect model was used; otherwise, the fixed-effect model was used. Data were analyzed with Revman 5.4 and Stata 16.0.
Eleven studies involving 1506 patients were included and the average HBL of PKP and PVP was 278.57 mL and 276.12mL. The results showed that bone cement leakage (P < 0.0001), thoracic vertebra (P < 0.00001), bilateral surgical approach (P = 0.0008), ≥2 fracture segments (P < 0.00001), vertebral body height loss rate (≥1/3) (P < 0.00001), and vertebral body height restoration rate (≥1/3) (P < 0.00001) were risk factors for increased HBL. Diabetes (P = 0.12) and hypertension (P = 0.52) were not significantly associated with HBL.
The findings of this meta-analysis suggested that fracture level, surgical approach, number of fracture levels, cement leakage, vertebral height loss and restoration rate were significant risk factors for HBL, which had certain guiding significance for clinical surgeons to take reasonable measures to deal with this complication.
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Vertebral compression fractures (VCFs) can have a variety of etiologies, including trauma, osteoporosis, or neoplastic infiltration. Osteoporosis related fractures are the most common cause of VCFs and have a high prevalence among all postmenopausal women with increasing incidence in similarly aged men. Trauma is the most common etiology in those >50 years of age. However, many cancers, such as breast, prostate, thyroid, and lung, have a propensity to metastasize to bone, which can lead to malignant VCFs. Indeed, the spine is third most common site of metastases after lung and liver. In addition, primary tumors of bone and lymphoproliferative diseases such as lymphoma and multiple myeloma can be the cause of malignant VCFs. Although patient clinical history could help raising suspicion for a particular disorder, the characterization of VCFs is usually referred to diagnostic imaging.
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Titanium implantable vertebral augmentation device (TIVAD) are regarded as having potential in the treatment of vertebral compression fractures (VCFs). However, improper design in current TIVADs results in the inability to effectively restore VCF height and maintain stability. There is still an unmet clinical need for improvement.
The authors tested a newly developed a TIVAD (Tri-blade fixed system) that can provide enough endplate collapse support to restore the vertebral body height in a safe retraction mechanism for VCFs using minimally invasive surgery (MIS).
The performed biomechanical tests included blade expansion force, lifetime of cement embedded and vertebral height restoration efficiency of porcine osteoporosis VCFs for its feasibility.
A cylinder with 3 surface cuts that form blades that can be expanded into a conical space was designed (Tri-blade fixed system). The 3 blades can be expanded outward with angles between blades as 105°/ 105°/150° for lower left/lower right/upper arms, respectively that reach 15mm in height and 14.8 mm in width. A frame was specifically designed to measure the contact force using force sensing resistors during blade expansion. The Tri-blade fixed system was embedded into a cement block to perform fatigue testing under 2000N pressure (5*10⁶ cycles) for understanding the device lifetime limitation. The Tri-blade system was then inserted into porcine osteoporosis VCFs to examine the vertebral height restoration efficiency.
The average maximum contact force for the top, bottom left and right blades were 299.0N, 283.5N and 279.3N, respectively with uniformly outward expansion forces. The fatigue test found that there were no obvious cracks or damage to the cement block. The porcine osteoporosis vertebral body at the anterior, middle, and posterior heights can be restored to 21.9%, 12.6% and 6.4%, respectively.
This study developed a novel TIVAD with conical shape that can provide a more stable structure with sufficient/uniform expansion force, passing the fatigue test with bone cement and high effective in vertebral height restoration tests for porcine osteoporosis VCFs.
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Patients who experience vertebral compression fractures are vulnerable to subsequent vertebral compression fractures (SVCFs). The purpose of this nationwide population-based study was to determine the age-specific cumulative incidence and factors associated with SVCFs in South Korea.
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Both groups showed increased vertebral body height, corrected KA, and CA after vertebroplasty. There were no significant differences between the HVBC and LVBC groups (ΔAVH: 2.19±2.60 vs. 2.48±3.09, p=.555; ΔMVH: 1.25±3.15 vs. 1.89±2.58, p=.192; ΔKA: -5.46±4.58 vs -5.37±4.47, p=.908; and ΔCA: -4.22±4.23 vs. -4.56±5.17, p=.679). There were significant preoperative to postoperative and preoperative to follow-up changes in AVH (HVBC, p=.012 and .046, respectively; LVBC, p=.001 and .015, respectively); a significant preoperative to postoperative change in MVH (HVBC, p=.045; LVBC, p=.001); and significant preoperative to postoperative and preoperative to follow-up changes in KA and CA (KA: HVBC, p=0.000 and .003, respectively; LVBC, p=.000 and .000, respectively; CA: HVBC, p=.017 and .047, respectively; LVBC, p=.006 and .034, respectively). The volume of cement injected was significantly higher with HVBC (3.66±1.36 vs. 3.11±1.53, p=.024), and the use of HVBC was associated fewer cases with cement leakage (26 vs. 45, p=.002). Furthermore, there was no difference between the groups in the incidence of adjacent fracture. Both groups showed an improved VAS score at follow-up, with statistically greater improvement in the HVBC group (2.40±1.53 vs. 3.07±1.69, p=.014). Moreover, significantly fewer patients with a VAS score ≥ 3 were found in the HVBC group (22 vs. 39, p=.004)
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This Contemporary Concepts Review article has been reviewed by the Board of Directors of the North American Spine Society (NASS). As such, it represents the current position of the state of knowledge of the above subject in spine care. Prior to entering the review process for The Spine Journal, the authors were assisted by members of the NASS Committee on Contemporary Concepts, Alexander R. Vaccaro, MD, Chair; Alan S. Hilibrand, MD and Gordon Donald, MD, reviewers.

FDA device/drug status: approved for this indication: balloon tamp reduction; investigational: methylmethacrylate. not approved for this indication: vertebroplasty.

Nothing of value received from a commercial entity related to this manuscript.

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Contemporary Concepts in Spine CareOsteoporotic compression fractures of the spine; current options and considerations for treatment

Abstract

Background context

Purpose

Study design/setting

Methods

Results

Conclusions

Introduction

Section snippets

Historic background

Anatomy/Pathophysiology

Risk factors

Clinical presentation

Clinical management

Nonsurgical treatment

Vertebral body augmentation

Vertebroplasty

Balloon tamp reduction

Dynamic fracture mobility

Surgical management

Discussion

Future topics

Conclusions with key points

Orthop Clin North Am

Orthop Clin North Am

Orthop Clin North Am

Lancet

Am J Med

Bone

Bone Miner

Radiol Clin North Am

Clin Imaging

Epidemiology of spinal osteoporosis

Spine

American Academy of Orthopaedic Surgery. Osteoporosis and falls

Your Orthopaedic Connection

Incidence of clinically diagnosed vertebral compression fractures: a population-based study in Rochester, Minnesota

J Bone Miner Res

Vertebral fracture epidemiology

Bone

Epidemiology of vertebral fractures in women

Am J Epidemiol

Osteoporosis: the role of the orthopaedist

J Am Acad Orthop Surg

Osteoporosis: current modes of prevention and treatment

J Am Acad Orthop Surg

Pre-existing fractures and bone mass may predict vertebral fracture incidence in women

Ann Intern Med

Osteoporosis: bone density tests

American Academy of Orthopaedic Surgeons Bulletin

NOF issues guide to osteoporosis

American Academy of Orthopaedic Surgeons Bulletin

Osteoporosis: definition and clinical presentation

Spine

The osteoporotic spine

Clin Orthop

Classification of vertebral compression fractures in the osteoporotic spine

J Spinal Disord Tech

Intravertebral clefts in osteoporotic vertebral compression fractures

Arthritis Rheum

Magnetic resonance imaging differentiation of compression spine fractures or vertebral lesions caused by osteoporosis or tumor

Spine

Contemporary Concepts in Spine Care
Osteoporotic compression fractures of the spine; current options and considerations for treatment