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PubMed1990

Fractures of the osteoporotic spine.

Prior to fracture, the osteoporotic spine can be analyzed in several ways. After fracture occurs, however, a simple plain roentgenogram usually suffices to make the diagnosis of compression fracture. If severe deformity threatens, or if there is a neurologic lesion, the surgeon now has options not previously available. Open reduction, decompression, and internal fixation with polymethylmethacrylate can be carried out safely by surgeons with expertise in spinal instrumentation. Generally, symptomatic treatment is all that is required, and if this includes an orthosis, it is an individual decision which can probably be made without fear of harming the patient further. With treatment of the acute fracture undertaken, one proceeds to employ whatever pharmacologic treatment is appropriate. Last, the patient should be allowed only the briefest period of rest.

Fractures, Spontaneous↗

PubMed2005

Importance of the peridural membrane in percutaneous vertebroplasty.

OBJECTIVE: The peridural membrane is a fibrous membrane that lies anterior to the posterior longitudinal ligament and attaches to its deep layer. It spans the width of the vertebral body and encircles the bony canal around the outside of the dura. The purpose of this study was to determine if the peridural membrane helps contain posterior cement leakage during percutaneous vertebroplasty. METHODS: Compression fractures were experimentally created in cadaveric spines. The bodies were stabilized using bipedicular injection of cement, and injection was continued until cement was evident beyond the posterior border of the vertebral body. The vertebral segments were then dissected and the extravasated cement localized anatomically. CONCLUSIONS: All extravasated cement was constrained by the peridural membrane, and no direct contact of the cement with the dura was seen.

Bone Cements↗

PubMed2003

Anterior-posterior surgery versus posterior closing wedge osteotomy in posttraumatic kyphosis with neurologic compromised osteoporotic fracture.

STUDY DESIGN: Retrospective study. OBJECTIVES: To compare the surgical results between combined anterior-posterior procedures and posterior closing wedge osteotomy procedures in patients with posttraumatic kyphosis and neurologic compromise secondary to osteoporotic fractures. SUMMARY OF BACKGROUND DATA: Combined anterior-posterior procedures are usually recommended in cases of kyphotic deformities with neurologic deficit secondary to osteoporosis. However, combined anterior-posterior surgery is associated with significant morbidity in elderly patients. MATERIALS AND METHODS: Twenty-six patients with posttraumatic kyphosis and neurologic compromise secondary to osteoporotic fracture were indicated for operative intervention using either a combined anterior-posterior surgery (n = 11) or a posterior closing wedge osteotomy procedure (n = 15). The results of the two procedures were analyzed. The average patient age at the operation was 62.6 years (range: 50-82) with a 12:14 male-to-female ratio. Mean follow-up was 3.5 years (range: 2.1-5.4). Preoperative interval from injury to operation was 15.4 months (range: 1-36). There were 20 thoracolumbar (T12-L1) fractures and six lumbar fractures indicated for operative intervention. RESULTS: In the combined anterior-posterior group, the mean operative time was 351 minutes with a mean blood loss of 2,892 mL. In the posterior closing wedge osteotomy group, the mean operative time was 215 minutes with blood loss of 1,930 mL. Eighteen patients showed a postoperative improvement in Frankel grading, 64% (7/11) in the combined anterior-posterior group, and 73% (11/15) in posterior closing wedge osteotomy group. There were no neurologic or vascular complications in either group. In the combined anterior-posterior group, there were five complications: two postoperative pneumonias, one superficial infection, and two distal screw loosening. There were only two complications in the posterior closing wedge osteotomy group: two distal screw loosening. One of the four cases of distal screw loosening required surgical revision. The other three cases were treated by bracing for more than 6 months. CONCLUSIONS: Although technically demanding, the posterior closing wedge osteotomy procedure demonstrated a better surgical result with significant less mean operative time and mean blood loss (P < 0.05). It may be a better alternative than a combined anterior-posterior procedure in patients with posttraumatic kyphosis and neurologic compromise secondary to osteoporotic fracture.

Accidental Falls↗

PubMed2004

The current treatment--a survey of osteoporotic fracture treatment. Osteoporotic spine fractures: the spine surgeon's perspective.

For the spine surgeon the problems of the osteoporotic spine can be a painful simple compression fracture, the persisting instability after a fracture, the silent loss of posture due to progressive collapse of multiple vertebrae, and neurological complications related to an osteoporotic fracture. The use of polymethylmethacrylate (PMMA) for the reinforcement of osteoporotic vertebral bodies has turned out to be extremely efficient. Although the natural course of pain due to vertebral fractures decreases within the first weeks in the majority of patients, there remains a number of them with persistent pain and/or ongoing vertebral collapse. With percutaneous cement injection one can achieve fast and lasting pain reduction in 80% to 93% of patients. With multilevel injections it is possible to address the severe osteoporotic spine as a whole where we can halt the ongoing collapse and preserve posture efficiently. Rectification of lordosis can be achieved in fresh fractures with the kyphoplasty technique and, even more efficiently, with the lordoplasty procedure. Kyphosis correction ranges from 8.5 degrees to 14 degrees , and restoration of vertebral body (VB) height goes up to 90%. When surgical stabilization is required, the combination of PMMA reinforcement and fixation with screws appears the only alternative in order to anchor the implants in the severely osteoporotic bone.

Acute Disease↗

PubMed2001

Blood-pool scintigraphic diagnosis of fractured lumbar vertebral hemangioma.

A 57-year-old woman complained of lumbago of 1 year's duration. Radiographs showed a compression fracture of the third lumbar vertebra. CT and MR images revealed an enhancing mass confined to the vertebral body suggestive of a malignant process. A blood-pool scintigram with 99mTc-human serum albumin combined with DTPA (HSA-D) revealed marked accumulation. This strongly suggested a hemangioma, which was confirmed by biopsy.

Female↗

PubMedDate not supplied

Kyphoplasty: report of eighty-two thoracolumbar osteoporotic vertebral fractures.

OBJECTIVES: Document initial outcomes of balloon kyphoplasty. DESIGN: Retrospective analysis of the first 52 patients with 82 painful vertebral body compression fractures secondary to osteoporosis treated at our institution. SETTING: Operation on subacute painful fractures with office follow-up. PATIENTS/PARTICIPANTS: First 82 fractures in 52 patients treated. All patients had failed nonoperative treatment and had magnetic resonance imaging scans documenting edematous changes of the vertebral body. Forty-nine out of 52 patients presented for follow-up at an average of 37 weeks. INTERVENTION: Minimally invasive balloon reduction via bilateral transpedicular or extrapedicular approaches followed by polymethyl methacrylate fixation. MAIN OUTCOME MEASURES: Vertebral body height, Cobb angle, visual analogue pain scale, Roland-Morris Disability Survey, and complication rate. RESULTS: Mean length of follow-up was 9 months (37 weeks, range 4-99 weeks); improved height 4.6 and 3.9 mm in the anterior and medial columns, respectively (P > 0.05); Cobb angle increased 14% (P < 0.05), visual analogue pain scale score improved 7 points (P < 0.05); Roland-Morris Disability Survey improved 11 points (P < 0.05); no adverse medical or procedural complications; 9.8% cement leakage rate. CONCLUSION: Balloon kyphoplasty safely improves vertebral body height and patient quality of life.

Aged↗

PubMed1989

[Rehabilitation treatment of patients with uncomplicated fractures of the spine at a hospital rehabilitation center].

The authors make an analysis of treatment of 188 patients with noncomplicated compressive fractures of the vertebral column in the thoracolumbar part performed at the stationary rehabilitation center. The course of restorative treatment was as long as 31-40 days and included individual and group trainings of exercise therapy, massage, hydrokinesotherapy, thermo-, electro-, photo- and magnetotherapy. Results of the treatment were followed in 81 patients. Excellent and good results were obtained in 43 patients (53%), unsatisfactory--in 7 patients (8.6%). The period of follow-up observation was from 1 month to 1 year.

Adult↗

PubMed1999

Encapsulated verses hand-mixed zinc phosphate dental cement.

Zinc phosphate cements are commonly supplied as two components, powder and liquid, and the proportions of the constituents are determined by operator experience. A capsulated system which is mechanically mixed has been marketed and this study investigated the performance of the encapsulated cement system. The mean fracture strength, standard deviation and associated Weibull Moduli (m) of encapsulated cements were determined by compressive fracturing 20 cement specimens filled directly from the mixing syringe or from narrower cement tubes. Pore distribution within the cylindrical specimens was determined using image analysis to assess the influence of the method of mould filling with the cement. The strength data showed variation in magnitude and consistency ranging from 44.6+/-13.7 MPa (m = 3.18+/-0.71) for cements filled directly from the syringe to 61.0+/-7.8 MPa (m = 8.35+/-1.87) for cements filled from cement tubes. Larger pores were found in specimens consolidated directly from the cement syringe. Mechanical mixing of the encapsulated cement resulted in air entrapment in the cement mix which manifested itself as large pores (over 200 microm diameter) within the cylindrical specimens. The smaller orifice of the cement tube compared with the syringe was considered to be responsible for eliminating the majority of the air entrapped in the cement mass during mixing. Whilst mechanical mixing of encapsulated cements is quicker and more convenient, the encapsulated specimens consolidated according to the manufacturers instructions from the syringe offered no significant advantage in terms of reliability or strength over hand-mixed cements in this investigation.

Biocompatible Materials↗

PubMed2006

Surgical removal of extravasated epidural and neuroforaminal polymethylmethacrylate after percutaneous vertebroplasty in the thoracic spine.

Although extravasations of polymethylmetharylate during percutaneous vertebroplasty are usually of little clinical consequence, surgical decompression is occasionally required if resultant neurologic deficits are severe. Surgical removal of epidural polymethylmetharylate is usually necessary to achieve good neurologic recovery. Because mobilizing the squeezed spinal cord in a compromised canal can cause further deterioration, attempts to remove epidural polymethylmetharylate in the thoracic region need special consideration. A 66-year-old man had incomplete paraparesis and radicular pain on the chest wall after percutaneous vertebroplasty for osteoporotic compression fracture of T7. Radiological studies revealed polymethylmetharylate extravasations into the right lateral aspect of spinal canal that caused marked encroachment of the thecal sac and right neuroforamina. Progressive neurologic deficit and poor responses to medical managements were observed; therefore, surgical decompression was performed 4 months later. After laminectomy and removal of facet joints and T7 pedicle on the affected side, extravasated polymethylmetharylate posterior and anterior to the thecal sac was completely removed without retracting the dura mater. Spinal stability was reconstructed by supplemental spinal instrumentation and intertransverse arthrodesis with banked cancellous allografts. Myelopathy and radicular pain gradually resolved after decompression surgery. The patient was free of sensory abnormality and regained satisfactory ambulation two years after surgical decompression.

Aged↗

PubMed1976

Roentgen findings in fractures of the vertebral column in childhood examination of 35 patients and its results.

In the past 10 years we examined 35 children with fractures of the spine. The most important cause was an injury by a fall from a tree or a climbing stage (23 cases). Traffic accidents or other direct trauma was the cause in 10 patients. Two children had tetanus, The ages of the children range from 2 to 12 years. Clinical symptoms may be diagnostic of vertebral trauma, but quite often symptoms are insignificant or atypical. We detected fractures in every vertebra of the thoracic and lumbar part of the spine. The greatest number of fractures was found between T4 and L2. The typical injury of the spine is a compression fracture of the vertebral body with a wedgeshaped deformity (111 vertebrae); fractures of the transverse processus of lumbar vertebrae were not frequent (10 vertebrae). Other parts of the vertebrae were not involved. The value of scintigraphy in case of doubtful roentgenologic finding is pointed out.

Child↗

PubMedDate not supplied

Calcaneal fractures in diabetic patients.

We would like to present 23 calcaneal fractures in 22 patients of whom 21 had type I diabetes mellitus. There appear to be three basic fracture types: (1) a superiorly displaced extra-articular avulsion fracture of the posterior calcaneus (or Iowa fracture), which occurred in 12 patients (five men, seven women); (2) a mid-calcaneal compression fracture in six patients (four men, two women), and (3) a cleavage or "wedge" type fracture in four patients extending from the calcaneal tubercle (one man, 3 women). All four of this last group of patients had a history of a chronic penetrating ulcer, and this is noteworthy since only one other patient out of the remaining 18 in groups 1 and 2 had a similar history. Most patients had decreased bone mineralization: 15 patients were on long-term, high-dose steroids, and 18 patients had either poor renal function or complete renal failure (11 of 12). Fourteen patients had received either renal or pancreas transplants. Eight patients were on restricted weight bearing prior to their fractures. We believe that diabetic patients are more prone to calcaneal fractures than the general population, and early diagnosis is imperative, followed by early treatment to prevent significant bony deformity.

Adult↗

PubMed2002

Evaluation of spinal curvatures after a recent osteoporotic vertebral fracture.

OBJECTIVES: To evaluate spinal curvature changes over a 3-year period in postmenopausal women who had had an osteoporotic vertebral fracture within the last 3 months. METHODS: Thoracic kyphosis and lumbar lordosis were measured using a curviscope at baseline and after 1, 3, 6, 12, and 36 months. Anteroposterior and lateral radiographs of the thoracolumbar spine were obtained after 1 and 3 years. RESULTS: Sixty-one patients were included. At baseline, a significant increase in thoracic curvature was found in the subgroup with thoracic fractures as compared to the subgroups with thoracolumbar or lumbar fractures (64 degrees +/- 9 degrees, 56 degrees +/- 10, and 56 degrees +/- 13, respectively; P < 0.05). No lumbar curvature differences were found. Thoracic curvature was significantly correlated with age (r = -0.48, P < 0.001) and with the vertebral deformity index (r = 0.6, P < 0.001). A significant increase in thoracic curvature was apparent 3 months into the study; after 3 years, the increase was 5.6 degrees +/- 0.7 (P < 0.01). A moderate increase in lumbar curvature was found after 3 years (P < 0.01). Five of 13 patients and five of 10 patients had at least one incident fracture after 1 and 3 years, respectively. Mean thoracic curvature was greater among the patients with than without incident fractures after 1 and 3 years, although the difference was not statistically significant. CONCLUSION: Thoracic compression fractures significantly increase thoracic kyphosis as compared to dorsolumbar and lumbar fractures. Thoracic kyphosis worsens overtime in patients with prevalent vertebral fractures. These data invite an evaluation of techniques capable of providing early correction of alignment disorders, such as widespread use of bracing or kyphoplasty.

Absorptiometry, Photon↗

PubMed2004

Evolution of vertebroplasty: a biomechanical perspective.

This paper is a collection of computational, finite element studies on vertebroplasty performed in our laboratory, which attempts to provide new biomechanical evidence and a fresh perspective into how the procedure can be implemented more effectively toward the goal of preventing osteoporosis-related fractures. The percutaneous application of a bone cement to vertebral defects associated with osteoporotic vertebral compression fracture has proven clinical successful in alleviating back pain. When the biomechanical efficacy of the procedure was examined, however, vertebroplasty was found to be limited in its ability to provide sufficient augmentation to prevent further fractures without risking complications arising from cement extravasations. The procedure may instead be more efficient biomechanically as a prophylactic treatment, to mechanically reinforce osteoporotic vertebrae at risk for fracture. Patient selection for such intervention may be reliably achieved with the more accurate fracture risk assessments based on vertebral strength, predicted using geometrically detailed, specimen-specific finite element models, rather than on bone density alone. Optimal cement volume, placement, and material properties were also recommended. The future of vertebroplasty involving biodegradable augmentation material laced with osteogenic agents that upon release will stimulate new bone growth and increase bone mass was proposed.

Animals↗

PubMed2005

The vertebral body fracture in osteoporosis: restoration of height using percutaneous vertebroplasty.

BACKGROUND AND PURPOSE: Percutaneous vertebroplasty is an effective tool for the relief of pain caused by osteoporotic spine fractures. Our purpose is to evaluate this technique and its effectiveness in restoring the height of such fractures. METHODS: Forty osteoporotic vertebral body fractures in 30 consecutive patients (24 female, six males; mean age, 70 years) were analyzed retrospectively, before and after percutaneous vertebroplasty, for changes in vertebral body height, kyphosis angle, and wedge angle. The ages of the fractures range from 1 to 5 months. RESULTS: Percutaneous vertebroplasty improved the pretreatment height of compression fractures in these patients by a mean of 47.6% (P < .001), with only 15% showing no improvement. These figures compare favorably with published results for kyphoplasty (47% mean improvement in height in 70% of fractures; no improvement in 30% of fractures). In addition, we achieved a mean improvement in kyphosis angle of 6 degrees and an improvement in the wedge angle of 3.5 degrees (as compared with published results for kyphoplasty of 7.4 and 4.3 degrees , respectively; P < .001). CONCLUSION: Percutaneous vertebroplasty should be viewed not only as a pain-relieving procedure, but also an effective method for improving vertebral body height, kyphosis angle, and wedge angle.

Adult↗

PubMed1988

[Acute management of spinal injuries. The thoracic and lumbar spine, conservative and functional therapy].

Fractures of the thoracic spine are commonly treated functionally. In the thoracolumbar and lumbar region compression fractures with angulation can be treated by closed reduction and casting according to the Boehler method. Yet, stable fractures with minor deformities may be treated with advantage by early weight bearing. Primarily unstable thoracic and lumbar vertebra fractures gradually become stable with increasing fracture healing and may also be treated functionally but with prolonged bed rest of 6-12 weeks. Thus open reduction and internal fixation achieve better anatomical alignment and also allow early mobilisation and ambulation. They are therefore recently favoured.

Fracture Fixation, Internal↗

PubMed1975

The treatment of trochanteric hip fractures using a compression screw.

One hundred and four consecutive intertrochanteric hip fractures treated with a compression screw were reviewed. Despite death and lack of follow-up, the late results in sixty-two cases of fracture were analyzed. Three non-unions and one malunion gave the technique a failure rate of only 6.4 per cent. Twenty-two patients with both stable and unstable fractures were allowed to bear weight as early as tolerated, in an average of fourteen days. Early weight-bearing did not appear to compromise the end result.

Adult↗

PubMed2003

[Kyphoplasty and vertebroplasty in fractures in the elderly: effort and effect].

Kyphoplasty and vertebroplasty are two minimally invasive percutaneous techniques used for treatment of osteoporotic vertebral compression fractures in the thoracic and lumbar spine. The injection of polymethylmetacrylate (PMMA) is often a final attempt at therapeutic treatment of complications due to such fractures. Vertebroplasty involves injection of cement via one or both pedicles under high pressure, thus filling and stabilizing the vertebra without reduction of fracture. Extravertebral cement leakage is a common complication: an intact posterior wall normally prevents cement leakage into the epidural space. Kyphoplasty involves transpedicular inflation of balloon tamps, thus creating a cavity which is then filled with PMMA under low pressure. Restoration of vertebral height is possible and the potential for extravertebral cement leakage lessened.

Age Factors↗

PubMed2006

Percutaneous vertebroplasty in patients with intractable pain from osteoporotic or metastatic fractures: A prospective study using quality-of-life assessment.

PURPOSE: Percutaneous vertebroplasty (PVP) is a minimally invasive outpatient procedure whereby vertebral compression fractures are stabilized by the injection of bone cement, or polymethyl methacrylate (PMMA). Rapid partial or complete pain relief can usually be achieved through this procedure. We prospectively evaluate the efficacy of PVP in the relief of pain and improvement in quality of life of patients with intractable pain from osteoporotic and metastatic fractures. MATERIALS AND METHODS: Patients with intractable pain from vertebral metastases (many resistant to palliative radiation therapy) and patients with intractable painful osteoporotic fractures were treated with parapedicular or transpedicular injection of PMMA. Plane X-rays, computed tomography (CT) scan, and magnetic resonance imaging (MRI) scan were performed on all patients. With a reflex hammer, percussion pain was correlated to the imaging abnormalities. The preplanning CT scan was used to calculate the exact entry point and angle of the bone-biopsy needle. All patients were assessed before and after the procedure for quality of life and amount of pain. The following measures were used: 1) the Edmonton Symptom Assessment System (ESAS), for global pain, nausea, tiredness, depression, anxiety, drowsiness, appetite, sense of well-being, and shortness of breath; 2) a site-specific pain score (SSPS); 3) the amount of analgesic intake in morphine equivalents in the last 24 hours; and 4) the Townsend Functional Assessment Scale (TFAS), ascertaining mobility. A postprocedural CT scan was performed the same day on all patients. Follow-up assessment consisted of a phone call at Days 1, 2, and 4 and Weeks 1, 2, 4, 8, and 12. Patients with recurrent back pain or complications were followed in the bone metastases clinic. RESULTS: Thirty patients (19 women, 11 men) were evaluated. Their median age was 68 years (range 31 to 87 years). Thirty procedures (n = 30) at 45 vertebral levels were performed; 13 were for pathologic fractures, and 17 were for osteoporotic fractures. SSPS showed a decrease of 2 or more levels in 88.5% of patients at 12-week follow-up. The mean SSPS with movement was 8.7 preprocedure and 1.8 postprocedure (P < 0.0001). Also, there was significant improvement in all 9 ESAS domains (P < 0.0004). The ingestion of analgesics in morphine equivalents showed a trend toward reduction post-PVP (P < 0.0599). When the patients with pathologic fractures were separated out, the reduction in ingestion of analgesics was significant (P < 0.0008). The TFAS demonstrated significant improvement in patient mobility and function. Extravertebral extravasation of cement was noted in 55.6% of the levels. We used a general linear mixed-model repeated-measures analysis of variance to analyze the data. CONCLUSIONS: PVP in osteoporotic and metastatic fractures significantly improved many patients' global quality-of-life scores and function by markedly decreasing their back pain and reducing their intake of pain medications. The procedure is safe, with no serious complications noted in our study.

Adult↗