summary Osteoporotic Vertebral Compression Fractures are very common fragility fractures of the spine that affect up to 50% of people over 80 years old. Diagnosis can be made with lateral radiographs. Determining the acuity of a fracture requires an MRI or bones scan. Treatment is usually observation and pain management. Kyphoplasty is reserved for patients with recalcitrant symptoms after nonoperative treatment for 4-6 weeks fails. Assessment and management of osteoporosis is indicated in the presence of these injuries. 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 Etiology 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 increased risk of mortality from pulmonary dysfunction Presentation 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 Imaging 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 Studies 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 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 Treatment 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 controversial AAOS recommends strongly against the use of vertebroplasty in 2011 but then changed their stance in 2014 based on recent studies 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 Techniques 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 Complications 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 Vertebral body osteonecrosis (aka Kummell's disease) Delayed post-traumatic osteonecrosis Prognosis Mortality 1-year mortality ~ 15% (less than hip fx) 2-year mortality ~20% (equivalent to hip fx)
QUESTIONS 1 of 19 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ14.233) A morbidly obese 80-year-old woman presents with back pain for 2 months. Sagittal T2-weighted, sagittal T1-weighted, coronal short tau inversion recovery (STIR) images are shown in Figures A through C, respectively. Which of the following statements is true of her diagnosis? QID: 5643 FIGURES: A B C Type & Select Correct Answer 1 MR fluid sign suggests that this is an osteoporotic vertebral compression fracture 54% (2286/4229) 2 Convex posterior vertebral border suggests that this is an osteoporotic vertebral compression fracture 9% (397/4229) 3 Replacement of the normal marrow signal suggests that this is a malignant vertebral compression fracture 26% (1104/4229) 4 Retropulsion of a vertebral body fragment suggests that this is a malignant vertebral compression fracture 1% (51/4229) 5 The band-like low T1 signal suggests that this is a malignant vertebral compression fracture 8% (328/4229) L 4 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ13.260) A 66-year-old Caucasian female presents to the ER with severe new low back pain after she slipped on the curb yesterday night. You see her 3 hours after admission, and two hours after she was given 5 mg of oxycodone. She states she had no back pain prior to the fall, and a CT scan of the abdomen obtained 2 months earlier for abdominal pain demonstrated no evidence of a fracture. Her past medical history is significant for hypertension and hyperlipidemia. On physical exam she has 5/5 strength in all major muscle groups, normal sensation, 1+ patellar and achilles reflexes, no clonus and a down-going Babinski sign. While it causes her significant pain, she is able to stand and walk to the exam room door and back. A lateral radiograph is seen in Figure A. What would be the most appropriate first line of treatment. QID: 4895 FIGURES: A Type & Select Correct Answer 1 Kyphoplasty 3% (46/1837) 2 Thoracolumbar Custom Orthosis (clamshell brace) 36% (668/1837) 3 Opioids for pain control with gradual activity such as walking with no restrictions 51% (929/1837) 4 NSAID therapy alone, strict bed rest for 7 days, followed by structured physical therapy 4% (82/1837) 5 Calcitonin therapy alone, strict bed rest for 7 days, followed by structured physical therapy 5% (95/1837) L 4 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ12.106) 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? QID: 4466 FIGURES: A B Type & Select Correct Answer 1 There is no association between this fracture and future osteoporotic fragility fractures. 2% (119/5515) 2 Prospective, randomized, double blinded studies have recently showed improvement with vertebroplasty. 15% (833/5515) 3 2-year mortality rates are roughly equivalent to those associated with hip fractures. 56% (3097/5515) 4 This fracture results in chronic back pain in the majority of patients regardless of treatment. 25% (1371/5515) 5 Neurologic deterioration is a common complication with this injury pattern. 1% (51/5515) L 4 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ12.155) 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. QID: 4515 Type & Select Correct Answer 1 Improvement in pain at 3 months, but not difference at 1 year 27% (1499/5617) 2 Improvement in function at 3 months, but not difference at 1 year 3% (148/5617) 3 Improvement in pain at 2 week and at 1 year, but no difference in function 9% (499/5617) 4 Improvement in pain and function at all time points 5% (291/5617) 5 No benefit at any time point 56% (3143/5617) L 4 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ09.270) 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? QID: 3083 Type & Select Correct Answer 1 Bedrest for ten days 0% (7/2798) 2 Oral pain medications, thoracolumbosacral orthosis, and progressive increase in activity level 97% (2716/2798) 3 Posterior percutaneous pedicular fixation from L1 to L5 1% (28/2798) 4 Posterolateral fusion from L2 to L4 with instrumentation 1% (27/2798) 5 Anterior column reconstruction with strut grafting and plate fixation 0% (12/2798) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
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