Spinal Fractures (Osteoporotic)
"Percutaneous Vertebroplasty - An approach to Management of Osteoporotic spine Fractures."
Osteoporosis is definedas a systemic skeletal disease, characterized by low bone mass and micro-architectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fractures. Bone mass value more than 2.5 S.D. below the young adult mean value. (W.H.O.) Suggests osteoporosis.
Most data published, is on hip fractures in osteoporosis. However 50% of women above 80 yrs age have osteoporotic vertebral fracture. More than 300,000 osteoporotic spine fractures per year in USA.The data available in India is no less alarming. It is an important Cause of pain, deformity and significant disability in the elderly. There may be NO history of any significant trauma…it could be just a - Bumpy car/ bus ride, Violent bout of coughing etc!
Clinical Presentation
Back pain may be the predominant symptom with or without neurological deficit and ensuing deformity . Thorough clinical evaluation especially with regard to neurological status including bladder and bowel status is mandatory.
The causes of back pain are Intra osseous venous congestion, Microfractures, Vertebral fractures, Neurological compression (cord / root) and OCC Secondary spinal canal stenosis.
Pathomechanics is as shown in the flow chart alongside
Investigations
Xrays
Codfishing of end plates, Wedge compression fracture, Concertina collapse, Burst fracture may be the eventual radiological features.
Painful pseudarthrosis may be a sequelae of such fractures. Skeletal survey to rule out other differential diagnosis.
Blood investigations include CBC, ESR, Ca, Phos, Alk Phos, Vit D3, PTH & Myeloma Profile
CT Scan provides bone details and MRI scan gives soft tissues details Especially if Suspected neural injury / instability, Suspicious etiology, When intervention is contemplated.
Bone scan to rule out Metastasis, Multiple myeloma and koch s spine.
Bone Densitometry to evaluate extent of osteoporosis.
Management
Conservative (Non Interventional) methods should be provided to the patient at the outset especially if there is no neurological weakness and fracture seems inherently stable . It includes •prolonged rest atleast for six weeks preferably complete bed rest, Pain control with analgesics, Epidural blocks, Braces and Medical therapy (for osteoporosis). Though they are prolonged and cumbersome, Intervention should be deffered till these modalities have proved to have failed.
Radiologically guided therapeutic procedure which consists of Percutaneous injection of liquid polymer (bone cement) into a destroyed vertebral body constitutes Percutaneous Vertebroplasty invented in 1989 in France, first for treating vertebral body haemangioma.
Indications:
- Osteoporotic Fracture
- Tumors of Spine
- Benign
- Malignant
- Osteogenesis Imperferta
- Focal pagets disease refractory to medical line
- Fracture Spine
Contraindications:
- Neurological deficit
- Doubtful diagnosis
- Progressive Deformity
- High Dorsal or Cervical lesion
The procedure can be done with the help of a Biplanar CT (in the CT Dept) or a C-Arm Image Intensifier (in the Operating Theatre).
Developed by Havre - Deramond transpedicular vertebroplasty
Requires image guided 11-13 gauge needle transpedicularly into which readymade available Vertebroplastic cement is instilled so as to stabilize the fractured vertebrae and alleviate pain.
Advantages
Immediate Stability of vertebral body( pt mobilized the same or next day), Prompt relief of pain (minimal pain killers), percutaneous technique (no surgical scar), Local anesthesia with some sedation (No risk of general anesthesia with patient awake). Patient usually discharged in a couple of days.
Like any procedure Vertebroplasty has its own set of complications. Though Complication rates are low at 1 - 10% (1% to 3% - Osteoporotic fracture) commonest being Cement Embolization and cement leakage into the spinal canal with neurological weakness.
An Example
A 75 year old diabetic lady had a fall and sustained a D12 compression Fracture with no fracture induced neurological weakness was given conservative trial for four weeks and continued to have severe pain despite the trial . She could not get out of bed even for toilet activities.
Her Preoperative Xrays and CT scans were as shown alongside
Intraoperative images in the ot with pt in sedation and under local anesthesia with full asepsis
Postoperative Images were as shown below:
- Patient was mobilized the same evening and discharged the next day . She is off all pain killers.
- Prevention however is the key.Aggressive osteoporosis management is an important adjuvant.
