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Introduction
  •  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)
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 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
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
        • 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
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
 

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(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? Review Topic

QID: 4466
FIGURES:
1

There is no association between this fracture and future osteoporotic fragility fractures.

2%

(83/3894)

2

Prospective, randomized, double blinded studies have recently showed improvement with vertebroplasty.

16%

(620/3894)

3

2-year mortality rates are roughly equivalent to those associated with hip fractures.

54%

(2111/3894)

4

This fracture results in chronic back pain in the majority of patients regardless of treatment.

26%

(1013/3894)

5

Neurologic deterioration is a common complication with this injury pattern.

1%

(33/3894)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(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. Review Topic

QID: 4515
1

Improvement in pain at 3 months, but not difference at 1 year

27%

(1141/4277)

2

Improvement in function at 3 months, but not difference at 1 year

3%

(109/4277)

3

Improvement in pain at 2 week and at 1 year, but no difference in function

9%

(395/4277)

4

Improvement in pain and function at all time points

5%

(226/4277)

5

No benefit at any time point

56%

(2383/4277)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(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? Review Topic

QID: 3083
1

Bedrest for ten days

0%

(6/1982)

2

Oral pain medications, thoracolumbosacral orthosis, and progressive increase in activity level

97%

(1931/1982)

3

Posterior percutaneous pedicular fixation from L1 to L5

1%

(16/1982)

4

Posterolateral fusion from L2 to L4 with instrumentation

1%

(15/1982)

5

Anterior column reconstruction with strut grafting and plate fixation

0%

(8/1982)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2
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