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PubMed1998

[Thoracolumbar fractures. Pathomorphology and indications for treatment].

The indications for conservative and surgical management of fractures of the thoracolumbar spine are reviewed, based upon the morphology of the lesions, which is assessed by meticulous analysis of radiographs, CT scan and in some cases MRI. The author advocates using the AO classification, which considers several subtypes of fractures: compression fractures, distraction fractures and fractures with multidirectional displacement. The indication for treatment is based upon morphological analysis of the lesions, while other factors such as the general condition of the patient or the locally available surgical environment must also be taken into consideration. Up to 50% of thoracolumbar fractures can benefit from surgical management, with posterior or anterior stabilisation, the latter performed through thorascoscopy in selected cases.

Humans↗
PubMedDate not supplied

Discrimination of metastatic from acute osteoporotic compression spinal fractures with MR imaging.

A study was performed to determine which magnetic resonance (MR) imaging findings are useful in discrimination between metastatic compression fractures and acute osteoporotic compression fractures of the spine. The MR imaging findings in 27 patients with metastatic compression fractures and 55 patients with acute osteoporotic compression fractures were compared by using the chi(2) test. MR imaging findings suggestive of metastatic compression fractures were as follows: a convex posterior border of the vertebral body, abnormal signal intensity of the pedicle or posterior element, an epidural mass, an encasing epidural mass, a focal paraspinal mass, and other spinal metastases. MR imaging findings suggestive of acute osteoporotic compression fractures were as follows: a low-signal-intensity band on T1- and T2-weighted images, spared normal bone marrow signal intensity of the vertebral body, retropulsion of a posterior bone fragment, and multiple compression fractures. The signal intensity on fast spin-echo T2-weighted images obtained without fat suppression played little role in distinguishing between metastatic compression fractures and acute osteoporotic compression fractures.

Acute Disease↗
PubMed2005

Dynamic contrast-enhanced perfusion MR imaging of diseased vertebrae: analysis of three parameters and the distribution of the time-intensity curve patterns.

OBJECTIVE: To assess the diagnostic value of perfusion MR imaging of diseased vertebrae by analysis of three parameters and the distribution of the time-intensity curve (TIC) patterns. DESIGN AND PATIENTS: Dynamic MR imaging was performed on 34 patients with 48 lesions. All lesions were assigned to one of four groups: osteoporotic compression fracture, benign lesion without compression fracture, pathologic compression fracture, or metastatic lesion without fracture. Peak enhancement, steepest slope, and slope value were calculated from the TIC of diseased vertebrae. TICs were classified into five types. Comparisons were made among groups by analysis of the three parameters and the distributions of the TICs pattern. RESULT: All parameters of pathologic compression fracture were significantly higher than those of osteoporotic compression fracture (P<0.05). The steepest slopes of metastatic lesions with and without pathologic compression fracture were significantly higher than those of benign lesions without compression fracture (P<0.05). No characteristic distribution of the TIC pattern helpful for the differentiation of benign and metastatic lesions was found. CONCLUSION: In distinguishing osteoporotic from pathologic compression fractures, semiquantitative analysis of the perfusion MR imaging may be useful. However, the analysis of the TIC patterns can not significantly contribute to the differential diagnosis.

Aged↗
PubMed1995

Magnetic resonance imaging differentiation of compression spine fractures or vertebral lesions caused by osteoporosis or tumor.

STUDY DESIGN: This study reviewed the magnetic resonance imaging characteristics of atraumatic compression fractures or vertebral lesions caused by osteoporosis of tumor. OBJECTIVES: The purpose of this study was to evaluate the magnetic resonance imaging characteristics that will allow differentiation of compression fractures or vertebral lesions due to osteoporosis or tumor. SUMMARY OF BACKGROUND DATA: Previous reports have identified several magnetic resonance imaging characteristics of benign and malignant compression fractures. However, diagnosis has been confirmed primarily by clinical follow-up and not pathologic biopsy specimen. METHODS: Thirty-four cases of atraumatic compression fractures or vertebral lesions that had undergone magnetic resonance imaging evaluation followed by biopsy were retrospectively reviewed. Conventional magnetic resonance imaging with T1- and T2-weighted images were obtained in all cases and gadolinium was used in 21 cases. Each case was evaluated for magnetic resonance imaging characteristics of the compression fractures or vertebral lesions that included decreased T1 and increased T2 signal, marrow preservation on the T1 image, gadolinium lesion enhancement, multiple level involvement, associated soft tissue mass, posterior vertebral expansion, and pedicle involvement. RESULTS: Eighteen of the compression fractures or vertebral lesions were confirmed as tumor and 16 were confirmed as osteoporosis by biopsy. Decreased T1- weighted and increased T2-weighted signals are sensitive but not specific for tumor involvement. Normal marrow preservation of the compressed vertebral body on T1 imaging is consistent with an osteoporotic fracture or lesion. Gadolinium enhancement, multiple level involvement, and posterior vertebral expansion are not useful for differentiation of osteoporotic from tumor fractures or lesions. Pedicle involvement or an associated soft tissue mass are specific for a tumor compression fracture or vertebral lesion. CONCLUSIONS: There are characteristic magnetic resonance imaging findings of compression fractures or vertebral lesions that allow sensitive and specific differentiation of osteoporosis from tumor.

Adolescent↗
PubMed1993

[Local and systemic trauma in plate osteosynthesis of femur shaft fracture].

Compression plating of fractures of the femur has a number of logistic advantages over intramedullary stabilization techniques though it is equally demanding for the surgeon. In this retrospective study of 77 cases, we try to show that compression plating of fractures of the femoral shaft is still a viable alternative to intramedullary fixation, especially in the light of local complications, postoperative systemic implications for the patient with multiple injuries, and the time required to achieve bone union. The data relating to all three of these aspects permit the conclusion that the results reached with compression plating of both simple and comminuted femoral shaft fractures are comparable to those reported following intramedullary nailing. Our treatment regimen does not involve a higher risk to the patient.

Adult↗
PubMedDate not supplied

[Radiation diagnosis of uncomplicated compression spinal fractures in children].

Experiments on rabbits compared the X-ray, morphological, and magnetic resonance imaging of compression fractures of the vertebral body. Edema of the bone marrow of the vertebral body was ascertained to be a basic morphological substrate that evokes a modified MR signal. The data on 178 children with suspected compression fracture of the vertebral body were used to consider the potentialities of MRI and X-ray study in this pathology. The MRI semiotics of uncomplicated compression fractures of vertebral bodies is presented. The sensitivities of MRI and spondylography in the diagnosis of compression fractures of vertebral bodies were 100 and 62.5%, respectively.

Adolescent↗
PubMed2006

Instrumentation-related complications of multilevel fusions for adult spinal deformity patients over age 65: surgical considerations and treatment options in patients with poor bone quality.

STUDY DESIGN: Retrospective follow-up of patients over the age of 65 with a minimum of five-level fusions. OBJECTIVE: To determine the effect on outcomes of long constructs in patients with poor bone stock, and to review surgical techniques used in patients with poor bone stock. SUMMARY OF BACKGROUND DATA: Scoliotic deformities in patients with poor bone stock require alterations in both the surgical technique and preoperative planning. To our knowledge, complications of long constructs in poor bone stock have not been specifically reported. METHOD: Patients over the age of 65 that underwent a minimum of five-level fusion over a 5-year period were reviewed. We reviewed both operative reports and clinic notes and recorded both early and late complications. RESULTS: Early complications included pedicle fractures and compression fractures with an overall rate of 13%. Late complications included pseudarthroses with instrumentation failure, adjacent level disc degeneration with herniation, compression fractures, and progressive kyphosis. Progressive junctional kyphosis occurred in 26% of patients. CONCLUSIONS: Spinal stabilization surgery in patients with poor bone stock is associated with high complication rates. Complications such as progressive kyphosis adjacent to the fusion are difficult to address with instrumentation alone.

Age Factors↗
PubMed1997

[Back pain and neurological deficits in osteoporotic spinal fractures].

Generally osteoporotic compression fractures of the spine cause only localized pain and kyphosis without other significant complications. These fractures usually heal without difficulty by conservative treatment. However, it becomes to be accepted as a general concept that a small number of patients with osteoporotic fracture of the thoracolumbar spine result in delayed vertebral body collapse with neural compromise. We analyzed our series of osteoporotic-posttraumatic vertebral collapse. We had treated 51 consecutive patients with posttraumatic vertebral collapse following osteoporotic compression fractures of the thoracolumbar spine between Jan. 1987 and June 1994. Surgery consisted of anterior spinal reconstruction by strut grafting using a bioactive ceramic vertebral prosthesis (A-WGC) and autogenous rib in combination with the Kaneda device after resecting the collapsed vertebral bodies. After surgery, 80% of the patients with initial neurological deficits showed remarkable neurological recovery. The causes of neural compression were retropulsion of the posterior part of the collapsed vertebral body into the spinal canal and unstable kyphosis. The collapsed portion of the resected vertebral bodies was always less bloody or ischemic. Histology confirmed ischemic necrosis of the collapsed portion. The collapse would be resulted in by the compromised healing process due to repeated micro-traumas to the fragile trabecular bone following osteoporotic vertebral fracture. Autogenous iliac bone as well as fibula cannot be used as another alternative strut graft because of the fragility of the graft and grafted site. The anterior reconstruction with a bioactive ceramic vertebral prosthesis and the Kaneda device has been useful in osteonecrotic-posttraumatic vertebral collapse of the thoracolumbar spine.

Aged↗
PubMed1989

Thoracic spine fractures.

Fractures of the thoracic spine (T2-T12) should be considered as a separate entity because of the anatomic features of the rib cage and spinal canal in this region. Fifty-seven patients sustained this injury over a 10-year period (16% of thoracic, thoracolumbar, and lumbar fractures). Twenty-eight fracture dislocations, 25 compression fractures, and 1 burst fracture were seen. Three injuries, combining elements of a burst fracture and a dislocation, were designated "burst-dislocations." Apart from compression fractures, a direct blow was often the implicated mechanism of injury. Significant associated injuries were uncommon. Fracture-dislocations were often associated with neurologic injury and compression fractures with long-term pain. Operative treatment appeared to afford the best results for stabilization and pain relief.

Adolescent↗
PubMed1993

Role of trabecular morphology in the etiology of age-related vertebral fractures.

Osteoporotic compression fractures of the spine differ from most other age-related fractures in that they usually are associated with minimal trauma and with loads no greater than those encountered during normal activities of daily living. With aging and osteoporosis, there is progressive resorption of bone, resulting in reductions in bone density, thinning of trabeculae, and loss of trabecular contiguity. These changes in trabecular bone structure are associated with losses in bone strength which are disproportionate to the reductions in bone mass alone. To explain this disproportionate loss of bone strength, the prevailing opinion is that density reductions in the vertebral centrum are accompanied by a reduction in the number of trabeculae, by preferential resorption of horizontal trabeculae, and by hypertrophy of the remaining vertical trabeculae. To evaluate this view of vertebral morphology, we performed three-dimensional stereological analysis of trabecular bone extracted from midsagittal sections of first lumbar vertebral bodies from 12 donors spanning an age of 27-81 years. We found that both the number (R2 = 0.63, P < 0.01) and thickness (R2 = 0.91, P < 0.01) of trabeculae decreased linearly with density (as expressed by bone volume fraction) whereas the spacing between the trabeculae (R2 = 0.61, P < 0.01) increased reciprocally. There were more vertical trabeculae with transverse trabeculae at all densities, and the number of vertical trabeculae changed with density at twice the rate of the number of transverse trabeculae (P < 0.001). These data do not support the prevailing view that there is preferential resorption of horizontal trabeculae or hypertrophy of the remaining vertical trabeculae.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2000

Osteotomy, compression and reaming techniques for internal fixation of extracapsular hip fractures.

BACKGROUND: Many different surgical techniques, such as osteotomy, have been used in internal fixation of extracapsular hip fractures. OBJECTIVES: To compare different aspects of surgical technique in internal fixation of extracapsular hip fractures that have been subjected to randomised trials in adults. SEARCH STRATEGY: The Cochrane Musculoskeletal Injuries Group trials register, Medline, CENTRAL and reference lists of relevant articles were searched. Date of the most recent search: March 1999. SELECTION CRITERIA: All randomised and quasi-randomised trials investigating operative technique for the treatment of extracapsular hip fractures. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality, by use of an eleven item check list, and extracted data. Wherever possible and appropriate, results of outcome measures were pooled. MAIN RESULTS: All eight included trials were of only modest methodological quality. One trial of 65 patients undergoing fixation with a fixed nail-plate compared osteotomy versus anatomical reduction. There was a tendency to a reduced fixation failure rate after osteotomy. Four trials involving 465 patients undergoing fixation with a sliding hip screw (SHS) compared osteotomy versus anatomical reduction. Osteotomy was associated with an increased operative blood loss and length of surgery. There was also a tendency to an increased length of hospital stay and limb shortening for osteotomy. One trial of 200 patients undergoing fixation with a SHS compared results with or without compression across the fracture site. The only significant difference in outcomes was increased varus deformity in those fractures treated with compression. One trial of 19 patients reported reduced temperatures generated by a modified method of reaming the femoral head. Another study used oesophageal ultrasound to demonstrate reduced bone marrow intravascular embolism when a Gamma nail was inserted in 50 patients with, rather than without, a distal pressure venting hole in the femur. REVIEWER'S CONCLUSIONS: There is inadequate evidence to determine if any benefits exist for the routine use of osteotomy in conjunction with a SHS for the internal fixation of an unstable trochanteric femoral fracture. Osteotomy may be relevant if used in conjunction with a fixed nail plate. Based on the evidence of one trial only, there is inadequate evidence to support the application of compression across the fracture site of a trochanteric fracture during SHS fixation. Inadequate information exists for different reaming techniques during SHS or Gamma nail fixation to make definite conclusions.

Fracture Fixation, Internal↗
PubMed1989

Quantitative computed tomography reflects vertebral fracture morbidity in osteopenic patients.

We studied the relationship between spontaneous vertebral compression fractures and lumbar vertebral trabecular bone density in 69 consecutive patients with suspected osteopenia. Seven had biopsy-confirmed osteomalacia. The remaining 62 were divided into three groups: group 1--asymptomatic patients suspected of having osteopenia on plain films, but with no vertebral compression fractures (N = 24); group II--those with one to five vertebral compression fractures (N = 16); and group III--those with six or more vertebral compression fractures (N = 22). A quantitative computed tomographic (QCT) scan of the lumbar spine was performed on all patients. Patients in group I had QCT values of 94 +/- 23 mg/cm3 (mean +/- SE); those in group II had QCT values of 66 +/- 28 mg/cm3; and those in group III had values of 34 +/- 28 mg/cm3. There were significant differences among all groups (P less than .001), although there was considerable overlap of individuals among the groups. There was no significant difference between the mean QCT value of patients with one compression fracture and the value of those with between two and five compression fractures. Patients with biopsy-proven osteomalacia had higher vertebral trabecular bone density than patients with osteoporosis and compression fractures. Our study provides evidence suggesting a strong inverse relationship between QCT-measured vertebral bone density and the presence of vertebral compression fractures in a group of osteopenic patients.

Absorptiometry, Photon↗
PubMed2004

Vertebroplasty for the treatment of osteoporotic compression spinal fracture: comparison of remedial action at different stages of injury.

BACKGROUND: Outstanding results have been achieved using vertebroplasty for the treatment of osteoporotic compression spinal fractures, and a number of studies have reported the results from the application of this procedure. This study compared the results of vertebroplasty used at the different stages of injury. METHODS: A retrospective study reviewing the period between January 2001 and July 2001 investigated 68 patients who underwent single-level vertebroplasty: 22 patients within 2 weeks of the injury, 22 patients 2 weeks to 2 months after the injury, and 24 patients more than 2 months after the injury. Clinical evaluations compared the results of treatment at different injury stages during a mean follow-up period of 13 months. RESULTS: Although all the patients undergoing vertebroplasty in the acute and subacute stages reported satisfaction within 1 week of the operation, only 72.7% of the acute-stage group reported satisfaction with 24 hours of surgery. Moreover, evidence of cement leakage after vertebroplasty was detected for 27.3% of the acute-stage patients. This percentage significantly higher than for the patients in the subacute and chronic stages. Radiographic examination showed that new, adjacent compression fracture had occurred for 10.3% of the patients, with anterior interbody restabilization occurring for 11.8%. CONCLUSIONS: The results for vertebroplasty treatment of osteoporotic compression fractures appear to be injury stage dependent, with patients in the acute-injury stage needing longer recovery times, and with cement leakage quite common. These findings lead to the conclusion that the subacute stage is optimal for vertebroplasty. Furthermore, it is suggested that the use of spinal orthoses and postsurgical supplementation for the bone matrix reduces the risk of new, adjacent compression fractures and increases anterior interbody restabilization. Importantly, the findings suggest that a presurgical magnetic resonance imaging evaluation is an absolute necessity.

Acute Disease↗
PubMedDate not supplied

Pain relief following percutaneous vertebroplasty: results of a series of 283 consecutive patients treated in a single institution.

The aim of this study was to assess if percutaneous vertebroplasty (PVP) could relieve back pain, reduce drug consumption, and improve the mobility of patients with metastases and vertebral compression fractures. From August 2002 to July 2004, 283 patients (216 females; mean age: 73.8 +/- 9.9 years) underwent PVP on 749 vertebrae. Pain was evaluated with the pain intensity numeric rating scale (PI-NRS) (0 = no pain; 10 = worst pain) before the procedure and at the end point in September 2004 (follow-up:1-24 months; median: 7 months). A reduction of at least two points of the PI-NRS score was considered clinically relevant. Two hundred four patients were available for evaluation at the end point. Overall results showed a reduction of the median pain score from 8 at baseline to 1 at the end point (p < 0.0001); a clinically relevant pain reduction was observed in 176/205 patients (86%); 89/147 patients (61%) gave up a brace support (p < 0.0001); and 117/190 patients (62%) gave up drug therapy. Results were similar in different subgroups stratified according to age, underlying pathology, number of fractured or treated vertebrae, and length of follow-up. This study adds evidence that PVP is effective in treating painful vertebral fractures. A significant reduction in drug assumption and significant mobility improvement can also be achieved.

Aged↗
PubMedDate not supplied

Vertebroplasty and kyphoplasty: filler materials.

Over 700,000 osteoporotic compression fractures occur each year in the United States, twice the number of hip fractures. These vertebral fractures, most of which occur in the elderly, represent significant personal and societal burdens. Percutaneous vertebroplasty (PVP) is a minimally invasive method that involves the percutaneous injection of polymethylmethacrylate (PMMA) into a collapsed vertebral body to stabilize the vertebra. Kyphoplasty is an advanced minimally invasive technique with a number of potential advantages over PVP, including lower risk of cement extravasation and better restoration of vertebral body height and spinal biomechanics. The filling materials used for both these techniques require good biocompatibility, good biomechanical strength and stiffness, and good radiopacity for the fluoroscopy guided procedures. New filler materials (synthetic bone substitutes, e.g., composite resin materials, calcium phosphate or calcium sulfate cements) in addition to new PMMA formulations are now available for clinical use. In this review paper, we will focus on the issues and characteristics of these filler materials as they pertain to vertebral augmentation procedures.

Animals↗
PubMed1996

Posterior bow and vanishing line signs in diagnosis of burst fractures of the spine on plain radiographs.

It is not uncommon to misdiagnose a burst fracture as a wedge compression fracture initially on plain film, resulting in a late progressive deformity and neurologic damage. The purpose of this study was to analyze the sensitivity, specificity and positive predictive value of plain radiographs in the diagnosis of thoracic and lumbar burst fractures using the posterior bow (PB) and vanishing line (VL) signs. Seven independent examiners, comprising three chief orthopedic residents, two radiologic third-year residents and two emergency attending physicians (orthopedists), randomly reviewed 26 sets of admission anteroposterior and lateral thoracolumbar spine radiographs taken in association with back injuries. They were asked to decide whether patients had a burst or a wedge compression fracture. All patients had computed tomography (CT) scans for diagnostic confirmation. The overall initial sensitivity using discriminant analysis in the diagnosis of burst fractures was 80%. This increased to 90% after the examiners were requested to use the PB and VL signs. The specificity decreased slightly from 75% to 71%, while the positive predictive value remained at 88%. Overdiagnosis of wedge compression fractures as burst fractures occurred, especially when the quality of the films was not ideal. We conclude that, with careful reading, the PB and VL signs help in identifying burst fractures on the initial plain film evaluation.

Adult↗
PubMed1990

Thoracolumbar burst fracture with another spinal fracture.

From January 1985 to May 1988, thirty-six patients with thoracolumbar burst fracture were treated and nine of these (25%) were associated with another burst fracture or wedge compression fracture. The etiology of injury was a fall from a height in four patients, motorcycle accident in three, and elevator crushing and house crushing in each of the other two patients respectively. The neurological implications were caused by the main burst fractures, and L1 was the most involved segment of the main burst fracture (44.4%). All three patients had associated wedge compression fracture, as well as three patients who had associated burst fracture, found adjacent to the main burst fracture. The remaining three associated burst fractures were found at a distant level to the main burst fracture.

Adolescent↗