•  A fragility fracture of the spine
  •  Epidemiology
    • incidence
      • vertebral compression fractures (VCF) are the most common fragility fracture
      • 700,000 VCF per year in US
      • 70,000 hospitalizations annually
      • 15 billion in annual costs
    • demographics
      • affects up to 
        • 25% people over 70 years
        • 50% people over 80 years
    • risk factors
      • history of 2 VCFs
        • is the strongest predictor of future vertebral fractures in postmenopausal women 
  • Pathoanatomy
    • osteoporosis 
      • characteristics
        • bone is normal quality but decreased in quantity
          • cortices are thinned
          • cancellous bone has decreased trabecular continuity
        • bone mineral density in the lumbar spine (BMD)
          • peaks at
            • between 33 to 40 yrs in women
            • between 19 to 33 years in men
              • peak BMD is widely variable based on demographic factors and location in body
          • decreases with age following peak mass
          • correlate well with bone strength and is a good predictor of fragility fracture
      • definition
        • WHO defines osteoporosis as T score below -2.5
  • Associated conditions
    • compromised pulmonary function
      • increased kyphosis can affect pulmonary function
      • each VCF leads up to 9% reduction in FV
  • Prognosis
    • mortality
      • 1-year mortality ~ 15% (less than hip fx) 
      • 2-year mortality ~20% (equivalent to hip fx)
  • Symptoms
    • pain
      • 25% of VCF are painful enough that patients seek medical attention
      • pain usually localized to area of fracture
        • but may wrap around rib cage if dermatomal distribution
  • Physical exam
    • focal tenderness
      • pain with deep palpation of spinous process
    • local kyphosis
      • multiple compression fractures can lead to local kyphosis
    • spinal cord injury
      • signs of spinal cord compression are very rare
    • nerve root deficits
      • may see nerve root deficits with compression fractures of lumbar spine that lead to severe foraminal stenosis
  • Radiographs 
    • obtain radiographs of the entire spine (concomitant spine fractures in 20%)
    • will see loss of anterior, middle, or posterior vertebral height by 20% or at least 4mm 
  • CT scan 
    • usually not necessary for diagnosis
    • indications
      • fracture on plain film
      • neurologic deficit in lower extremity
      • inadequate plain films
  • MRI 
    • usually not necessary for diagnosis
    • useful to evaluate for
      • acute vs chronic nature of compression fracture
      • injury to anterior and posterior ligament complex
      • spinal cord compression by disk or osseous material
      • cord edema or hemorrhage
  • Laboratory
    • a full medical workup should be performed with CBC, BMP
    • ESR may help to rule out infection
    • Urine and serum protein electrophoresis may help rule out multiple myeloma
Differential Diagnosis
  • Metastatic cancer to the spine
    • must be considered and ruled out
    • the following variables should raise suspicion
      • fractures above T5
      • atypical radiographic findings
      • failure to thrive and constitutional symptoms
      • younger patient with no history of fall
  • Nonoperative
    • observation, bracing, and medical management
      • indications
        • majority of patients can be treated with observation and gradual return to activity 
        • PLL intact (even if > 30 degrees kyphosis or > 50% loss of vertebral body height) 
      • technique
        • if the fracture is less than five days old  
          • calcitonin can be used for four weeks to decrease pain
        • medical management can consist of bisphosphonates 
          • to prevent future risk of fragility fractures
        • some patients may benefit from an extension orthosis
          • although compliance can be an issue
  • Operative
    • vertebroplasty 
      • indications
        • not indicated
          • AAOS recommends strongly against the use of vertebroplasty
      • outcomes
        • randomized, double-blind, placebo-controlled trials have shown no beneficial effect of vertebroplasty  
        • vertebroplasty has higher rates of cement extravasation and associated complications than kyphoplasty
    • kyphoplasty
      • indications
        • patient continues to have severe pain symptoms after 6 weeks of nonoperative treatment
        • AAOS recommend may be used, but recommendation strength is limited
      • technique
        • kyphoplasty is different than vertebroplasty in that a cavity is created by balloon expansion and therefore the cement can be injected with less pressure
        • pain relief thought to be from elimination of micromotion
    • surgical decompression and stabilization
      • indications
        • very rare in standard VCF
        • progressive neurologic deficit
        • PLL injury and unstable spines
      • technique
        • to prevent possible failure due to osteoporotic bone
          • consider long constructs with multiple fixation points
          • consider combined anterior fixation
  • Kyphoplasty vs. vertebroplasty
    • performed under fluoroscopic guidance
    • percutaneous transpedicular approach used for cannula
    • vertebroplasty
      • PMMA injected directly into cancellous bone without cavity creation
      • performed when cement is more liquid
      • requires greater pressure because no cavity is created
        • increased risk of extravasation into spinal canal is greater
    • kyphoplasty
      • cavity created with expansion device (e.g., balloon) prior to PMMA injection
      • performed when cement is more viscous
      • may be possible to obtain partial reduction of fracture with balloon expansion  
  • Neurological injury
    • can be caused by extravasation of PMMA into spinal canal 
      • higher risk with vertebroplasty than kyphoplasty
      • important to consider defects in the posterior cortex of the vertebral body

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