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Osteoporotic compression fracture


Introduction

Vertebral compression fracture (VCF) is the most common complication of osteoporosis. Osteoporotic VCFs can lead to pain, functional disability, and decreased quality of life. These types of fractures are related to significant rates of morbidity and mortality and, with their overall high prevalence, lead to serious health and economic problems. VCFs occur in 25% of postmenopausal women over 50 years of age. This increases to 40% in those older than 80 years. Furthermore, it is estimated that VCFs affect 700, 000 patients in the United States annually. These fractures are associated with a 16% reduction in an expected 5-year survival. More than two-thirds of the patients with compression fractures are asymptomatic. When symptoms are present, abrupt onset of axial pain is the most common complaint. Most of the fractures are diagnosed between the T8 and L4 levels. Osteoporotic fractures are associated with anterior loss of vertebral height, kyphosis, and a higher risk for secondary fractures. Moreover, spinal deformity is linked to decreased pulmonary function, impaired gait, reduced mobility, and psychosocial stress. Lateral radiographs with or without anteroposterior views are usually sufficient for the diagnosis. An anterior wedge fracture is the classical radiographic finding. Further imaging is indicated in the setting of neurological deficit or instability assessment. Goals of treatment include pain relief, restoration of function, and prevention of future fractures. Pain relief is the priority when treating VCFs, especially in the older adult population. Standard nonsurgical management includes bed rest, analgesics, and bracing. Percutaneous vertebral augmentation in the form of vertebroplasty or kyphoplasty is recommended for patients with inadequate pain relief after conservative management. In the uncommon cases with neurological deterioration or instability, surgical intervention should be considered. In this chapter, we present a case of a young patient with a history of metastatic brain cancer and multiple compression fractures in the thoracic and lumbar spine.

Example case

  • Chief complaint: low back pain

  • History of present illness:

    This is a 46-year-old female patient with a history of metastatic breast cancer who presented with new onset lower back pain and decreased mobility in the setting of osteoporosis. She had a previous spinal radiation and multiple thoracolumbar vertebral fractures treated with kyphoplasty. New spine radiographs demonstrated superior end plate fractures of L2 and L4 ( Fig. 22.1 ).

    Fig. 22.1, Preoperative radiographs of the thoracolumbar spine. Lateral x-rays showing previous T8-T12 deformities and kyphoplasties. There is marked thoracic kyphosis, more evident at a previously treated compression fracture at T9. There is multilevel disc space narrowing and the presence of superior end plates fractures of the L2 and L4 vertebrae with mild compression deformity. L1 and L3 compression fractures with prior augmentations.

  • Medications: fentanyl patch

  • Allergies: no known drug allergies

  • Past medical and surgical history: stage IV breast cancer, chronic pain, previous kyphoplasties for pathological vertebral fractures

  • Family history: none

  • Social history: former smoker

  • Physical examination: awake, alert, and oriented to person, place, and time; cranial nerves II–XII intact; bilateral deltoids/triceps/biceps 5/5; interossei 5/5; iliopsoas/knee flexion/knee extension/dorsi, and plantar flexion 5/5

  • Reflexes: 2+ in bilateral biceps/triceps/brachioradialis with negative Hoffman; 2+ in bilateral patella/ankle; no clonus or Babinski; sensation intact to light touch

  • Todd J. Albert, MD

  • Orthopaedic Surgery

  • Hospital for Special Surgery

  • Weill Cornell Medical College

  • New York, New York, United States

  • Richard J. Bransford, MD

  • Orthopaedic Surgery

  • University of Washington

  • Seattle, Washington, United States

  • Adrian Casey, MD

  • Neurosurgery

  • National Hospital for Neurosurgery and Neurosurgery

  • Queen Square, Holborn, London, United Kingdom

  • Nicholas Theodore, MD

  • Dr. A. Karim Ahmed

  • Ann Liu, MD

  • Neurosurgery

  • Johns Hopkins University

  • Baltimore, Maryland, United States

Preoperative
Additional tests requested

  • CT T- and L-spine

  • MRI T- and L-spine

  • DEXA

  • Oncology evaluation

  • MRI complete spine

  • CT chest/abdomen/pelvis

  • DEXA

  • Oncology evaluation

  • Endocrinology/osteoporosis evaluation

  • CT T- and L-spine

  • MRI T- and L-spine

  • Standing scoliosis x-rays

  • Oncology evaluation

  • Pain management

Surgical approach selected L4 vertebroplasty Pain control L2 and L4 kyphoplasty Pain control and TLSO
Goal of surgery Pain control Pain control, prevent further collapse and instability
Perioperative
Positioning Prone on Jackson table Prone on Montreal mattress
Surgical equipment Surgical navigation

  • Surgical navigation

  • Fluoroscopy

Medications None None
Anatomical considerations Nerves, vascular structures Thecal sac, nerve roots
Complications feared with approach chosen Cement extrusion, misdirected trocars Progressive vertebral collapse
Intraoperative
Anesthesia General General
Exposure L4 L2, L4
Levels decompressed None None
Levels fused None None
Surgical narrative Position prone, surgical navigation registration, cannulate pedicles, insert cement, standard closure Position prone, preoperative level check, AP and lateral x-ray for insertion of Jamshidi needles in L2 and L4 pedicles, AP check until posterior wall passed, lateral x-ray check for needle depth, inject cement, check for absence of cement leak, remove needles, standard closure
Complication avoidance Surgical navigation Surgical navigation, x-rays to determine medial-lateral and anterior-posterior needle placement
Postoperative
Admission Floor Floor Floor
Postoperative complications feared Neurological deterioration, ongoing pain Neurological deterioration, ongoing pain Infection, cement leakage, vascular complication
Anticipated length of stay Overnight Overnight Overnight
Follow-up testing AP/lateral T- and L-spine x-rays prior to discharge and 3 months after surgery AP/lateral T- and L-spine x-rays 3 weeks after discharge

  • L-spine x-rays 3–6 weeks after surgery

  • MRI or CT L-spine 6 weeks after surgery if needed

Standing scoliosis x-rays within 72 hours and 6 weeks after discharge
Bracing None TLSO for comfort None TLSO when out of bed for 8 weeks
Follow-up visits 2–3 weeks 3 weeks after discharge 6 weeks after surgery 2 weeks and 6 weeks after discharge
AP , Anteroposterior; CT , computed tomography; DEXA , dual-energy x-ray absorptiometry; MRI , magnetic resonance imaging; TLSO , thoracic lumbar sacral orthosis.

Differential diagnosis

  • ▪

    Osteoarthritis

  • ▪

    Musculoskeletal pain

  • ▪

    Spinal stenosis

  • ▪

    Multiple myeloma

  • ▪

    Bone neoplasms

  • ▪

    Metastatic tumors

  • ▪

    Osteomyelitis

  • ▪

    Scheuermann disease

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