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A 79-year old female sustains a low energy fall and is hospitalized for low back pain that prevents her from ambulating. She denies any symptoms of buttock or leg pain. On physical exam she has point tenderness over the T12 vertebral body. Examination of her lower extremities is normal. Radiographs are shown in Figure A and B. An MRI is performed which shows signal intensity within the T12 vertebral body on T2-weighted images and no evidence of retropulsion or spinal cord compression. Which of the following statements is true regarding this injury pattern?
There is no association between this fracture and future osteoporotic fragility fractures.
Prospective, randomized, double blinded studies have recently showed improvement with vertebroplasty.
2-year mortality rates are roughly equivalent to those associated with hip fractures.
This fracture results in chronic back pain in the majority of patients regardless of treatment.
Neurologic deterioration is a common complication with this injury pattern.
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The clinical presentation and radiographs are consistent with an acute osteoporotic vertebral compression fracture. The mortality rate of patients with vertebral fractures exceeds that of patients with hip fractures when they are followed beyond 6 months.
Osteoporotic compression fractures are the most common fragility fracture. Due to the high prevalence of this injury there is a large socioeconomic burden associated with the disease and there has been significant controversy regarding optimal treatment. Several recent prospective, randomized, double blinded studies failed to show any significant improvement with vertebroplasty. Studies looking at the treatment effects of kyphoplasty, as opposed to vertebroplasty, remain controversial.
Buchbinder et al. performed a multicenter, randomized, double-blind, placebo-controlled trial in which participants with one or two painful osteoporotic vertebral fractures that were of less than 12 months' duration and unhealed were randomly assigned to undergo vertebroplasty or a sham procedure. They found improvements in pain and pain-related disability associated with osteoporotic compression fractures in patients treated with vertebroplasty were similar to the improvements in the control group.
Kallmes et al. performed multicenter trial which randomly assigned 131 patients who had one to three painful osteoporotic vertebral compression fractures to undergo either vertebroplasty or a simulated procedure without cement. They found improvements in pain and pain-related disability associated with osteoporotic compression fractures in patients treated with vertebroplasty were similar to the improvements in the control group.
In the recently published treatment guidelines for osteoporotic spinal compression fractures the AAOS recommends strongly against the use of vertebroplasty. They report kyphoplasty is an option for patients who present with an osteoporotic spinal compression fracture on imaging with correlating clinical signs and symptoms, although they note the strength of their recommendation is "limited".
Figure A and B show the radiographs of an osteoporotic compression fracture at T12. Diffuse osteopenia is apparent.
Answer 1: After the initial fracture patients have a 20% risk of further fractures.
Answer 2: Recent prospective, randomized, double blinded studies have failed to show improvement with vertebralplasty compared to nonoperative treatment.
Answer 4: With nonoperative treatment patient have good outcomes and there is not a high association with chronic back pain.
Answer 5: Osteoporotic vertebral compression fractures are associated with neurologic complications in less than 1% of patients.
Buchbinder R, Osborne RH, Ebeling PR, Wark JD, Mitchell P, Wriedt C, Graves S, Staples MP, Murphy B
N. Engl. J. Med.. 2009 Aug;361(6):557-68. PMID: 19657121 (Link to Abstract)
Buchbinder, NEJM 2009
Kallmes DF, Comstock BA, Heagerty PJ, Turner JA, Wilson DJ, Diamond TH, Edwards R, Gray LA, Stout L, Owen S, Hollingworth W, Ghdoke B, Annesley-Williams DJ, Ralston SH, Jarvik JG
N. Engl. J. Med.. 2009 Aug;361(6):569-79. PMID: 19657122 (Link to Abstract)
Kallmes, NEJM 2009
Esses SI, McGuire R, Jenkins J, Finkelstein J, Woodard E, Watters WC, Goldberg MJ, Keith M, Turkelson CM, Wies JL, Sluka P, Boyer KM, Hitchcock K
J Am Acad Orthop Surg. 2011 Mar;19(3):176-82. PMID: 21368099 (Link to Abstract)
Esses, JAAOS 2011
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In the treatment of acute osteoporotic compression fractures, vertebroplasty has been shown to have which of the following benefits in randomized, double-blind, placebo-controlled trials compared to nonoperative treatment.
Improvement in pain at 3 months, but not difference at 1 year
Improvement in function at 3 months, but not difference at 1 year
Improvement in pain at 2 week and at 1 year, but no difference in function
Improvement in pain and function at all time points
No benefit at any time point
Randomized, double-blind, placebo-controlled trials have shown no beneficial effect of vertebroplasty as compared with a sham procedure in patients with painful osteoporotic vertebral fractures.
Vertebral compression fractures (VCF) are the most common fragility fracture with 700,000 VCF per year in US leading to 70,000 hospitalizations annually and 15 billion in annual costs. The presence of a VCF is considered a risk factor for osteoporosis, and all patients with a VCF should be referred for evaluation and possible medical management of osteoporosis.
Buchbinder et al. performed of randomized, double-blind, placebo-controlled trial. Patients were given a sham procedure to greaten the double blind effect. Outcomes were assessed at 1 week and at 1, 3, and 6 months. The primary outcome was overall pain (on a scale of 0 to 10, with 10 being the maximum imaginable pain) at 3 months. They found vertebroplasty did not result in a significant advantage in any measured outcome at any time point. There were significant reductions in overall pain in both study groups at each follow-up assessment.
The U.S. Preventive Services Task Force recently published their recommendations for screening for osteoporosis. They recommend evaluation and screening for osteoporosis in all women aged 65 years or older and in younger women who have osteoporotic compression fractures.
Illustration A shows a T1 weighted (A) and STIR weighted (B) MR of a patient with an acute vertebral compression fracture.
U.S. Preventive Services Task Force.
N. Engl. J. Med.. 2009 Aug;361(6):557-68. PMID: 21242341 (Link to Abstract)
U.S., ANIM 2011
Average 3.0 of 15 Ratings
A 71-year-old female who has no significant medical comorbidities presents to the emergency department after sustaining a compression fracture of L2. The patient has moderate back pain but is neurologically intact. Radiographs of the entire spine reveal a L2 compression fracture with 30% loss of vertebral body height loss and 15 degrees of local kyphosis. What would be the appropriate management for this patient?
Bedrest for ten days
Oral pain medications, thoracolumbosacral orthosis, and progressive increase in activity level
Posterior percutaneous pedicular fixation from L1 to L5
Posterolateral fusion from L2 to L4 with instrumentation
Anterior column reconstruction with strut grafting and plate fixation
Initial treatment of osteoporotic compression fractures without neurologic compromise consists of pain control, progressive increase in activity levels, and a TLSO, or thoracolumbosacral orthosis.
Compression fractures are common in the elderly with osteoporosis as a result of low energy trauma. Most of these can be managed without surgery in a brace and oral pain medication. Initial management consists of pain control and a gradual return to activity. If pain continues after 6 weeks of non-operative therapy, kyphoplasty or vertebroplasty are available options. If a neurologic deficit is present, management would include surgical decompression and stabilization.
Wood et al. conducted a prospective, randomized trial and showed no significant difference between patients who were treated with and without surgery for a stable thoracolumbar burst fracture in a neurologically intact patient.
Gertzbein conducted a study comprised of 1,1019 traumatic thoracolumbar fractures followed prospectively for 2 years. 10.5% were compression fractures while 63.9% were burst fractures. They found 11 positive relationships, including, relative improvement in neurologic status following surgery, anterior surgery compared to posterior surgery was more effective when evaluated using the Manabe et al criteria, and a kyphotic deformity of >30 degrees was associated with more intense back pain.
Answer 1: While bedrest can help acute pain, it may lead to worsening osteoporosis, DVT, PE, and deconditioning.
Answer 3: This compression fracture is not unstable, and thus, does not require instrumentation.
Answer 4: This compression fracture is not unstable, and thus, does not require instrumentation.
Answer 5: This compression fracture is not unstable, and thus, does not require instrumentation.
Wood K, Buttermann G, Butterman G, Mehbod A, Garvey T, Jhanjee R, Sechriest V
J Bone Joint Surg Am. 2003 May;85-A(5):773-81. PMID: 12728024 (Link to Abstract)
Wood, JBJS 2003
Spine (Phila Pa 1976). 1992 May;17(5):528-40. PMID: 1621152 (Link to Abstract)
Gertzbein, SPINE 1992
Average 3.0 of 26 Ratings
Stryker Vertebroplasty uses a specially formulated acrylic bone cement to stabil...
Dr. Petros Stavros performs a balloon kyphoplasty in an elderly woman who suffer...
HPI - Back pain of 1 year's duration. Recently worse.
How would you manage this patient?
HPI - Severe Back pain since 12 days, with particular exacerbation at night. No history of trauma. Doesn't complain of any numbness in any of her limbs. No Bladder/ Bowel involvement. Has Loss of appetite. No loss of weight recently. Had a febrile illness for three days 15 days ago.
What treatment would you suggest for her Back pain?