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Compression fracture with back pain
Introduction
Osteoporotic vertebral fracture is increasing in prevalence with our aging population. It has a reported incidence of 30% to 50% in those over the age of 50. This condition often affects postmenopausal women and can result spontaneously or following minor trauma. Osteoporotic fractures are suspected to total more than 3 million by 2025, which is an increase of 48%, surpassing a national burden of $25 billion dollars in 2025 with a cumulative 10-year burden of $228 billion. Vertebral compression fractures result in frequent neurosurgical consultation particularly in older adult and postmenopausal women. The most common presenting symptom is back pain. Occasionally, patients may complain of subjective weakness secondary to limited mobility and pain but without objective findings. Rarely, neurological deficit can occur from compression of the nerve root or compression of the spinal cord. The treatment is typically nonsurgical, although in rare causes surgical intervention may be warranted. The Thoracolumbar Injury Classification and Severity score has been developed and widely accepted as a scoring system to identify those requiring surgical intervention by scoring based on fracture type, neurological deficit, and integrity of posterior ligament complex ( Table 24.1 ).
Example case
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Chief complaint: back pain
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History of present illness: A 62-year-old female with a history of seizures suffered a fall and presented with back pain. She was admitted for ongoing back pain, which was poorly controlled. The pain improved in the recumbent position and worsened with ambulation. She denies weakness or bowel/bladder dysfunction. She underwent imaging which revealed a compression fracture ( Figs. 24.1–24.3 ).
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Medications: none
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Allergies: no known drug allergies
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Past medical and surgical history: hypertension, osteoporosis, reflux
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Family history: noncontributory
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Social history: office worker, no smoking history, occasional alcohol
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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
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Reflexes: 2+ in bilateral biceps/triceps/brachioradialis with negative Hoffman; 2+ in bilateral patella/ankle; no clonus or Babinski; sensation intact to light touch
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| Preoperative | ||||
| Additional tests requested |
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DEXA |
| Surgical approach selected | T10 corpectomy vis costotransversectomy, T8-L1 fusion with possible cement augmentation | T8-L1 fusion with indirect reduction of T10 | If fails pain control and TLSO brace, T9–10 laminectomy with robot-assisted T8–12 fusion | Surgery only for instability |
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| Goal of surgery | Stabilization, fusion, long-term relief of pain | Reduce risk of neurological deterioration, stabilize spine and prevent progressive deformity, correct sagittal alignment | Decrease back pain | Stabilize spine |
| Perioperative | ||||
| Positioning | Prone | Prone, no pins, on Wilson frame | Prone, no pins, on Jackson table | Prone, no pins |
| Surgical equipment |
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| Medications | Tranexamic acid | Antiosteoporotic medication | Steroids | None |
| Anatomical considerations | Spinal column and pedicles, rib cage, pleura, spinal cord and nerve roots, neurovascular bundle, great vessels | Ribs for counting, pedicles, spinal cord | Spinal canal, nerve roots | Spinous process, facet joints |
| Complications feared with approach chosen | Pneumothorax, infection, medical complications, nonunion | Retropulsed fragment while positioning, cortical pedicle breach, spinal cord injury | Neurological injury, adjacent segment disease, failure of construct | Bleeding |
| Intraoperative | ||||
| Anesthesia | General | General | General | General |
| Exposure | T8-L1 | T8-L1 | T9–12 | T9-T11 |
| Levels decompressed | T9–11 | T10 | T9–10 | T10 |
| Levels fused | T8-L1 | T8-L1 | T9–12 | T9–11 |
| Surgical narrative | Preflip IOM signals, position prone, midline longitudinal incision centered over fractured vertebrae, subperiosteal exposure to transverse process two to three levels above and below depending on the length of the construct, expose right of fractured vertebrae on right side along its dorsal surface 4–5 cm lateral to transverse process, place pedicle fenestrated screws under fluoroscopic guidance, laminectomy from pedicle above to pedicle below fracture level, two-level bilateral facetectomy above and below pedicle of fractured level, remove right T10 transverse process, left-side temporary rod, expose rib circumferentially, section rib approximately 5 cm from costovertebral joint, dissect costovertebral attachments and remove rib fragments, ligate nerve within neurovascular bundle medial to dorsal root ganglion, dissect bluntly around right lateral aspect of vertebral body, slide malleable ribbon retractor anterior to vertebral body, incise annulus at T9–10 and T0–11 on right, resect bulk of T10, drill pedicle down on left side, use osteotome along left side of posterior cortex to osteotomize between disc above and below, fold posterior cortex into corpectomy defect on right to complete corpectomy, resect cartilaginous end plates above and below, place expandable cage filled with corpectomy bone with x-ray and pack bone graft around it, cement screw augmentation and vertebroplasties above and below if osteoporotic, place right-sided contour rod, replace left temporary rod with full length rod, x-rays to confirm alignment and hardware position, decorticate remaining posterior elements and add morcellized bone graft, BMP if considered for nonunion, vancomycin powder in wound, layered closure over drain | Preflip IOM signals, log roll into prone position on Wilson frame, x-rays to identify surgical level, mark T10 vertebral lesion, longitudinal midline incision over spinous process, dissect down along spinous process and along lamina to facets, tip of spinous process used to confirm T10 level, place pedicle screws from T8-L1 based on anatomical landmarks and screw size based on preoperative CT, fluoroscopic images to help assess placement, assess screw placement with O-arm, inject PMMA under pressure through fenestrated titanium screws except T10, connect rods to screws, indirect reduction of injured vertebra, reposition retropulsed fragment with ligamentotaxis, final fluoroscopic image, closure with local anesthetic and subfascial drains | Position prone, attach tracker and reference array, intraoperative x-ray to register to preoperative CT, incision from T8–12, subperiosteal dissection, trajectories are planned for instrumentation, instrumentation with robot including possibility of percutaneous screws, T9–10 laminectomy with or without facetectomies to decompress spinal canal if needed, decorticate facet joints and place demineralized bone matrix, place top loading rods and caps, final x-ray to confirm placement of hardware, wound irrigated with antibiotic solution, place vancomycin powder, drain placement as needed, layered closure | Midline incision, dissection of paraspinous muscles, confirm level with fluoroscopy, surgical navigation, pedicle screws at T9 and T11, laminectomy at T10, no drain |
| Complication avoidance | Preflip signals, laminectomy and facetectomy from pedicle to pedicle, ligate nerve in neurovascular bundle, malleable ribbon to protect surrounding structures, cement screw augmentation and vertebroplasties above and below if osteoporotic, BMP if concerned for nonunion | Preflip signals, anatomical landmarks for screws, fluoroscopy to help assess screw placement, O-arm to assess screws, placement of fenestrated screws for PMMA, ligamentotaxis to fix retropulsed fragment | Robotic navigation, facetectomies as needed | Minimize levels involved, avoid surgery if possible |
| Postoperative | ||||
| Admission | ICU | ICU | Floor | Floor |
| Postoperative complications feared | Pneumothorax, infection, medical complications, nonunion | Spinal cord injury, PMMA extravasation | Neurological injury, adjacent segment disease, failure of construct | Screw misplacement |
| Anticipated length of stay | 3–5 days | 3–4 days | 3–4 days | 2–3 days |
| Follow-up testing |
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Standing scoliosis x-rays within 72 hours of surgery, 6 weeks after surgery | CT scans after surgery and 12 months later |
| Bracing | None | None | TLSO when out of bed for 8–12 weeks | None |
| Follow-up visits | 3 weeks, 3 months, 6 months, 12 months after surgery | 2 weeks, 3 months intervals until 1 year after surgery | 2 weeks and 6 weeks after surgery | 3 months and 1 year after surgery |
BMD , Bone mineral density; BMP , bone morphogenic protein; CT , computed tomography; DEXA , dual-energy x-ray absorptiometry; ICU , intensive care unit; IOM , intraoperative monitoring; MEP , motor evoked potentials; MIS , minimally invasive surgery; MRI , magnetic resonance imaging; PMMA , polymethylmethacrylate; SSEP , somatosensory evoked potentials; STIR , short tau inversion recovery; TLSO , thoracic lumbar sacral orthosis.
Table 24.1
Thoracolumbar Injury Classification and Severity score used to guide management of thoracolumbar fractures
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| Neurological status |
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| Integrity of posterior ligamentous complex |
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| Total points |
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Differential diagnosis
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Compression fracture
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Burst fracture
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Osteomyelitis
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