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PubMed2004

Value of multidetector spiral CT in diagnosis of acute thoracolumbar spinal fracture and fracture-dislocation.

OBJECTIVE: To investigate the diagnostic value of multidetector spiral CT (MSCT) in acute thoracolumbar spinal fracture and fracture-dislocation. METHODS: CT imaging files of 152 consecutive traumatic patients with thoracolumbar fractures were retrospectively reviewed. MSCT scannings were performed with a collimation of 3-5 mm and a pitch of 5.5. The postprocessing included sagittal and coronal multiplannar reconstruction, and 3-D reconstruction. RESULTS: There were 88 cases of compression fracture, 54 cases of burst fracture and 10 cases of fracture-dislocation. Transverse images of MSCT could visualize all fractures directly and determine whether spinal canal was intact. Postprocessing image was helpful in depicting the displacement of fragment and orientation of dislocation. CONCLUSIONS: MSCT plays an important role in diagnosis and management of acute thoracolumbar spinal fracture and fracture-dislocation.

Adult↗

PubMed2006

[Clinical sign--height loss and vertebral deformity].

Loss of height may be an important clinical sign of vertebral deformation and/or fracture in postmenopausal women and elderly men. The presence of at least one spine fracture will lead to about a 2 cm decrease in height. Guidelines in the U.S. say that height loss greater than 1.5 inches or more from the maximum height among asymptomatic women may be associated with osteoporotic vertebral compression fractures. In Japan, the prevalence of spine deformation starts to increase among individuals in their early 70's, as does the prevalence of those with spine deformation at two or more vertebrae. It has been reported that not only individuals with clinical spine fracture but those with spine deformation show diminished activity of daily living (ADL) and quality of life (QOL) and also high mortality. Spine fracture should be suspected among individuals whose stature has decreased even if they manifest no symptoms.

Aged↗

PubMed2005

Estimated risk score for spine fracture in the specific bending activity of normal Taiwanese men and women.

OBJECTIVE: To investigate the effects of biologic age, as well as chronologic age, on the vertebral ultimate load (strength) and risk score of vertebral fracture (Phi) between the genders. SUMMARY OF BACKGROUND DATA: Previous studies have shown a good correlation between the biomechanical strength of vertebral bodies and measured bone mineral parameters, whereas other factors also contribute to the bone strength and risk of fractures. Combining multiple factors into a single assessment may provide more comprehensive and individualized estimations of the fracture risk. In this study, we applied the measured bone mineral content (BMC) and bone projection area of the second through the fourth lumbar vertebrae (L2-L4) to assess the biomechanical strength of lumbar vertebrae. In addition, we used the body segment model to estimate the load of the L3 vertebral body during a bending-forward activity, to then estimate the risk score (Phi) of vertebral compression fracture in healthy Chinese volunteers in Taiwan, and to analyze the effects of gender and age on the risk score (Phi). METHODS: A total of 611 females and 235 males aged 22-80 years were included in this study. The anteroposterior BMC and projection area of lumbar spine were measured by a Norland XR-26 dual energy radiograph absorptiometer (Norland Corp., Ft. Atkinson, WI). The estimated ultimate strength (L) of lumbar spine was calculated from the regression equation using anteroposterior lumbar BMC and bone area according to Bassman et al (Paper presented at: 39th Annual Meeting of Orthopedic Research Society; February 1993; San Francisco, CA). The estimated spinal load (F) for a person bending over with back horizontal, either with hand free (F0), lifting a 20 kg weight (F20), or a 30 kg weight (F30), was calculated from a force diagram according to William and Lissner. Risk score (Phi) was defined as the quotient of F/L. RESULTS: The results showed an age-related decrease of bone mineral density (P < 0.001) in both genders corrected for weight and height. Using the multiple linear regression analysis and analysis of covariance, Phi for F0, F20, and F30 increased significantly, with increasing age only in females (P < 0.0001), especially after menopause, but not in males. The Phi of postmenopausal females was significantly larger than those of younger females (i.e., F0 (Phi) 0.533 +/- 0.075 vs. 0.458 +/- 0.064, P < 0.001; F20 (Phi) 0.903 +/- 0.101 vs. 0.789 +/- 0.080, P < 0.001; and F30 (Phi) 1.087 +/- 0.117 vs. 0.954 +/- 0.090, respectively, P < 0.001). In females, the ultimate load of the spine and Phi began to decrease to a significant level since the fifth decade, whereas in the males, the similar trends occurred since the sixth decade. Comparing both genders, the F0 (Phi) was slightly yet significantly larger in the young males (< 50 years) than the premenopausal females with similar ages (P < 0.001), but older females had higher F0 (Phi) values than males older than 60 years. Moreover, the Phi increased more prominently in the postmenopausal females with the weight lifted. As a result, both F20 (Phi) and F30 (Phi) were significantly larger in females older than 50 years as compared to males with the similar ages (P < 0.001). CONCLUSIONS: Our findings emphasize the importance of Phi, which considers BMC, bone size, body weight, body height, and weight lifted, for evaluating a more individualized risk of spine fracture in elderly men and postmenopausal women. The Phi increased more prominently with lifting weight and increased with aging only in the early postmenopausal females. The study showed that a combination of bone mass and anthropometric parameters provides a more individualized assessment of fracture risk than bone mineral density alone.

Adult↗

PubMed1999

An in vitro biomechanical evaluation of bone cements used in percutaneous vertebroplasty.

The purpose of this study was to determine the strength and stiffness of osteoporotic vertebral bodies (VBs) subjected to compression fractures and subsequently treated with bipedicular injections of various polymethylmethacrylate cements. Ten spines were harvested from nonembalmed female cadavers (age 68.6 +/- 13.7 years) and evaluated for bone mineral density using the dual energy X-ray absorptiometry method (t-score = -2.3 +/- 2.4). The 50 VBs (L1-L5) were disarticulated, compressed in a materials testing machine to determine initial strength and stiffness, and then assigned to one of six groups. Two of these groups (n = 8, n = 9) concerned experimental cements, the results of which are not reported here. The 33 vertebral bodies in the remaining four groups were left untreated or were repaired using a transpedicular injection of one of three commercially available polymethylmethacrylate cements. These four groups were: a) no treatment (no cement, n = 8); b) Simplex P (n = 9); c) Cranioplastic (n = 8); and d) Osteobond (n = 8). The VBs were then compressed again according to the initial protocol, and posttreatment strength and stiffness were measured. Results suggested that bipedicular injection of Simplex P and Osteobond restored VB stiffness to initial values, whereas VBs injected with Cranioplastic were significantly less stiff than in their initial state. VBs injected with cement (regardless of type) were significantly stronger than they were initially.

Absorptiometry, Photon↗

PubMed2002

Percutaneous vertebroplasty: A to Z.

Percutaneous vertebroplasty has been performed in the United States since 1995, and widespread application of the procedure for osteoporotic and neoplastic compression fractures or vertebral infiltration has demonstrated remarkable efficacy with rare complications. Appropriate patient selection criteria and a thorough understanding of safe technique is essential for clinical success; imaging studies must be combined with careful physical examination to direct treatment to the appropriate level in patients with multiple compression deformities. Preoperative consultation with the patient and their family provides an opportunity to clarify the patient's treatment expectations and helps to anticipate and obviate potential obstacles to treatment.

Bone Cements↗

PubMed1999

Antegrade locked nailing for humeral shaft fractures.

Treatment results of antegrade locked nailing of acute humeral shaft fractures, including union rate and recovery of shoulder function, have been inconsistent. This led the current authors to hypothesize that implant design and surgical techniques might account for this inconsistency. In the current study, 47 fractures (38 acute; nine pathologic) in 47 patients achieved union with the techniques of closed nailing, short to long segment nailing, and fracture compression. Satisfactory recovery of shoulder function occurred because of minimal surgical trauma, prevention of impingement by the nail or locking screws, and prevention of axillary nerve injury or comminution of the humeral head. Forty-seven patients with 38 acute fractures and nine pathologic fractures were treated with humeral locked nails. Mean followup time was 21.4 months. With a single operation, all 38 acute fractures proceeded to eventual union; the average time to union was 7.8 weeks. Thirty-five patients had excellent or satisfactory recovery of shoulder function. Complications included slipout of the proximal screw, nail breakage, fragment displacement, and transient postoperative radial nerve palsy. All nine patients with pathologic fractures had substantial pain relief and increased arm function after surgery. The current study shows the reliability of antegrade locked nailing for proximal and middle third fractures of the humeral shaft.

Adult↗

PubMed2006

Clinical inquiries. Who should receive vertebroplasty?

Percutaneous vertebroplasty has been used to treat aggressive vertebral hem-angiomas, osteoporotic vertebral compression fractures, and vertebral lesions from metastatic disease or myeloma. Consider it for patients with severe acute or chronic pain related to one of these lesions who have failed a reasonable course of medical therapy (strength of recommendation [SOR]: B, based on structured reviews of observational studies). Contraindications include an uncorrectable coagulation disorder, infection in the area, spinal cord compression, destruction of the posterior wall of the vertebral body, and severe degrees of vertebral body collapse (SOR: B, based on structured reviews of observational studies). Pain relief from vertebroplasty for osteoporotic vertebral fractures may be less for older fractures (SOR: C).

Back Pain↗

PubMed2004

Incidence of subsequent vertebral fracture after kyphoplasty.

STUDY DESIGN: A retrospective review of charts and radiographs of all consecutive patients who underwent kyphoplasty at the authors' center from the initial procedure in September 2000 to the end of the collection period in July 2002. SUMMARY OF BACKGROUND DATA: The best available natural history data would suggest that after experiencing an osteoporotic vertebral compression fracture, patients have a 19% incidence of subsequent fracture in the following year when no surgical intervention is performed. When kyphoplasty is performed, there are conflicting data regarding the incidence of subsequent fracture, ranging anywhere from 3 to 29%. These fractures occur at adjacent levels between 30 and 90% of the time, with no clear explanation for the wide variation in the results of three different studies. There are biomechanical data to suggest that injection of cement does increase the stiffness of the treated vertebra and that this increases strain on adjacent vertebrae, especially in forward bending. METHODS: A database was created containing patient age, gender, height, weight, medication history, comorbidities, fracture levels, and pain level before and after surgery. Subsequent fractures were confirmed with radiographs and MRI. Statistical analysis was performed. RESULTS: Thirty-eight patients (10 men and 28 women) were treated for 47 levels initially. L1 and L2 were the most common level of fracture managed initially. The gender, smoking and medication history, location of fracture, and number of fracture levels of the patients did not correlate with the risk of subsequent fracture. Over the follow-up period (average, 8 months), 10 patients sustained 17 subsequent fractures. Eight patients sustained fractures in the first 2 months after the index procedure, all with at least one fracture at an adjacent level. Of the 17 subsequent fractures, there were nine at the adjacent-above levels, four at adjacent-below levels, and four at remote levels. The remote fractures occurred at significantly greater time intervals after the index procedure (P < 0.001). CONCLUSION: This study demonstrated a higher rate of subsequent fracture after kyphoplasty compared with natural history data for untreated fractures. Most of these occurred at an adjacent level within 2 months of the index procedure. After this 2-month period, there were only occasional subsequent fractures, which occurred at remote levels. This confirms biomechanical studies showing that cement augmentation places additional stress on adjacent levels. Patients with an increase in back pain after kyphoplasty should be evaluated carefully for subsequent adjacent fractures, especially during the first 2 months after the index procedure.

Aged↗

PubMed1988

Nuclear medicine studies of aging--VI. Dual photon absorptiometry and bone scans in "at risk" women with back pain.

We studied 20 women who were at risk for osteoporosis (postmenopausal, or on dialysis, or on steroids), who presented with severe back pain. Patients underwent a dual photon (153Gd) densitometry study of the L2-L4 vertebrae, as well as an emission bone scan (99mTc-MDP). The dual photon method revealed abnormal results (20% or more below the mean expected value) in 13/20 patients (65%), and below the "fracture threshold" in 15/20 (75%). The emission bone scan delineated abnormal foci of uptake in 15/19 (79%). We conclude that women at risk for osteoporosis, who present with severe back pain, are likely to have a positive bone scan due to compression fracture or other derangements related to bone demineralization.

Adult↗

PubMed2003

Prediction of osteoporotic spinal deformity.

STUDY DESIGN: A biomechanical model was developed from full-spine lateral radiographs to predict osteoporotic spinal deformity in elderly subjects. OBJECTIVE: To investigate the biomechanics of age-related spinal deformity and concomitant height loss associated with vertebral osteoporosis. SUMMARY OF BACKGROUND DATA: Vertebral bone loss and disc degeneration associated with aging causes bone and disc structures to weaken and deform as a result of gravity and postural stresses. METHODS: An anatomically accurate sagittal-plane, upright-posture biomechanical model of the anterior spinal column (C2-S1) was created by digitizing lateral full-spine radiographs of 20 human subjects with a mean height of 176.8 cm and a mean body weight of 76.6 kg. Body weight loads were applied to the model, after which intervertebral disc and vertebral body forces and deformation were computed and the new spine geometry was calculated. The strength and stiffness of the vertebral bodies were reduced according to an osteopenic aging model and modulus reduction algorithm, respectively. RESULTS: The most osteopenic model (L3 F(ult) = 750 N) produced gross deformities of the spine, including anterior wedge-like fracture deformities at T7 and T8. In this model, increases in thoracic kyphosis and decreases in vertebral body height resulted in a 25.2% decrease in spinal height (C2-S1), an 8.6% decrease in total body height, and a 15.1-cm anterior translation of the C2 spine segment centroid. The resulting deformity qualitatively resembled deformities observed in elderly individuals with osteoporotic compression fractures. CONCLUSIONS: These predictions suggest that postural forces are responsible for initiation of osteoporotic spinal deformity in elderly subjects. Vertebral deformities are exacerbated by anterior translation of the upper spinal column, which increases compressive loads in the thoracolumbar region of the spine.

Age Factors↗

PubMed2001

Effect of intermittent cyclical treatment with etidronate disodium (HEBP) and calcium plus alphacalcidol in postmenopausal osteoporosis.

We evaluated intermittent cyclical treatment with etidronate disodium (HEBP) and calcium plus alphacalcidol in postmenopausal osteoporosis, with special reference to bone mineral density (BMD) and prevention of spinal fracture. The patients were 40 women, over 50 years of age, with lumbo-dorsal pain and low BMD (less than 0.70 g/cm(2)), measured by dual-energy X-ray absorptiometry (DXA). The patients were randomly assigned to two groups. The first group (HEBP) received 200 mg of HEBP per day for 2 weeks, followed by 2 g calcium lactate and 0.5 microg alphacalcidol per day for the next 10 weeks. This 12-week cycle was repeated eight times for 2 years. The second group (Ca. D) received 2 g calcium lactate and 0.5 microg alphacalcidol per day for 2 years. Lumbar BMD was measured before the treatment and every 6 months during the treatment until 24 months, and changes were evaluated. The number of fractured vertebrae was counted on X-ray films before treatment and at the final assessment. After 6 months of treatment, a significant and continuous increase in BMD was observed in the HEBP group. Moreover, the percentage of patients with new vertebral compression fractures in the HEBP group was one-tenth of that in the Ca. D group. These results suggest that intermittent cyclical treatment with HEBP and calcium plus alphacalcidol may be effective for increasing BMD and preventing fractures in postmenopausal osteoporosis.

Aged↗

PubMed2002

Beneficial effect of long term intravenous bisphosphonate treatment of osteogenesis imperfecta.

AIM: To find an effective symptomatic treatment for osteogenesis imperfecta (OI). METHODS: In a prospective observational study disodium pamidronate (APD) was given as monthly intravenous infusions to 28 children and adolescents (aged 0.6-18 years) with severe OI or a milder form of the disease, but with spinal compression fractures. RESULTS: During treatment for 2-9 years, dual energy x ray absorptiometry measurements of the total body and of the lumbar spine showed a gradual increase in bone density. All bone metabolism variables in serum (alkaline phosphatase, osteocalcin, procollagen 1 C-terminal peptide, collagen 1 teleopeptide) and urine (deoxypyridinoline) indicated that there was a decrease in bone turnover. All patients experienced beneficial effects and the younger patients reported a major improvement in wellbeing, pain, and mobility without significant side effects. Vertebral remodelling was also seen. CONCLUSIONS: APD seems to be an efficient symptomatic treatment for children and adolescents with OI.

Absorptiometry, Photon↗

PubMed2000

The strengthening effect of percutaneous vertebroplasty.

AIM: To examine whether single-needle vertebroplasty is effective in strengthening vertebrae. MATERIALS AND METHODS: Four adjacent intact lumbar vertebrae were removed from each of nine adult post-mortem subjects. One or two vertebra of each set was injected with low viscosity acrylic bone cement using a single-track posterolateral approach. Vertebral strength was measured during constant rate axial compression. RESULTS: Single-needle injection delivered different quantities of cement (1-8 ml) in an asymmetric distribution. Injected vertebrae were stronger than controls in 10 out of 12 cases (P < 0.01), suggesting that cement injection increases the load needed to cause initial vertebral fracture. Compression was continued past the point of initial failure, to simulate progressive vertebral collapse. Injected specimens were more resistant to deformation than control specimens (P < 0.05), most of which initially deformed with little increase in load. CONCLUSION: Single-track injection of bone cement appeared to strengthen vertebrae against both initial failure and subsequent collapse. The magnitude of strength increase from vertebroplasty was variable, and did not correlate with the volume of cement injected. Further investigation is needed to optimize the technique.Gishen, P. (2000). Clinical Radiology55, 471-476.

Aged↗

PubMed2001

Stress fracture of the femoral neck in a child. Case report and review of the literature.

Fatigue fractures generally appear in normal bone following increased repetitive activity or strenuous exercise, when imbalance occurs between applied force and elastic resistance. Femoral neck fatigue fractures are most common in athletes and young military recruits; such fractures in children with open physes are very rare. This paper reports a fatigue fracture of the femoral neck in an 8-year-old girl presenting with pain in the anterior aspect of the right thigh, of one month duration and without evidence of previous injury. Bed rest and relief of weight bearing are indicated for nondisplaced compression fractures. Surgical treatment is indicated for tension fractures. In most cases, the outcome is favorable, and complications are rarely reported.

Bed Rest↗

PubMed2006

[Percutaneous sacroplasty].

Sacral insufficiency fracture is a debilitating injury for which no active treatment is currently available. It frequently causes significant pain and limits activities of daily living in patients with osteoporosis. Percutaneous vertebroplasty is a common procedure to alleviate the pain associated with thoracic and lumbar vertebral compression fractures. The sacral percutaneous cimentoplasty procedure (sacroplasty) has recently been introduced as an alternative to medical management of osteoporotic sacral insufficiency fractures. The purpose of this article is to illustrate the effectiveness and the utility of percutaneous sacroplasty in this kind of pathology and to show how this procedure can provide symptom relief without having major complications.

Bone Cements↗

PubMed2001

The biomechanics of vertebroplasty. The effect of cement volume on mechanical behavior.

STUDY DESIGN: Ex vivo biomechanical study using osteoporotic cadaveric vertebral bodies. OBJECTIVE: To determine the association between the volume of cement injected during percutaneous vertebroplasty and the restoration of strength and stiffness in osteoporotic vertebral bodies, two investigational cements were studied: Orthocomp (Orthovita, Malvern, PA) and Simplex 20 (Simplex P with 20% by weight barium sulfate content; Stryker-Howmedica-Osteonics, Rutherford, NJ). SUMMARY OF BACKGROUND DATA: Previous biomechanical studies have shown that injections of 8-10 mL of cement during vertebroplasty restore or increase vertebral body strength and stiffness; however, the dose-response association between cement volume and restoration of strength and stiffness is unknown. METHODS: Compression fractures were experimentally created in 144 vertebral bodies (T6-L5) obtained from 12 osteoporotic spines harvested from female cadavers. After initial strength and stiffness were determined, the vertebral bodies were stabilized using bipedicular injections of cement totaling 2, 4, 6, or 8 mL and recompressed, after which post-treatment strength and stiffness were measured. Strength and stiffness were considered restored when post-treatment values were not significantly different from initial values. RESULTS: Strength was restored for all regions when 2 mL of either cement was injected. To restore stiffness with Orthocomp, the thoracic and thoracolumbar regions required 4 mL, but the lumbar region required 6 mL. To restore stiffness with Simplex 20, the thoracic and lumbar regions required 4 mL, but the thoracolumbar region required 8 mL. CONCLUSION: These data provide guidance on the cement volumes needed to restore biomechanical integrity to compressed osteoporotic vertebral bodies.

Aged↗

PubMed1997

[Diagnostic problems in fractures of the occipital condyles].

Three cases involving fractures of the occipital condyle were recently treated by the authors. Since plain radiographs of the upper cervical spine often fail to reveal this lesion, it can be difficult to diagnose. It seems to be more common than previously suspected and described. We found one axial compression fracture and two avulsion fractures with different degrees of atlanto-occipital instability. Mandibular fracture occurred in all cases. There was no severe craniocervical trauma. The atlanto-occipital junction should always be included in the CT evaluation of facial or craniocervical trauma. Thin-section CT of the craniocervical region can best visualize this fracture and should be used when it is suspected. All cases were treated by orthotic immobilisation.

Adult↗

PubMed1987

Atypical insufficiency fractures confused with Looser zones of osteomalacia.

Six women, aged 24-67 years, had osteopenia and insufficiency fractures, which suggested a diagnosis of osteomalacia. The insufficiency fractures occurred at traditional sites for Looser zones, were multiple in number, were symmetrically distributed in three patients, and did not heal promptly. Bone mass was low, as assessed by single-energy photon absorptiometry at the midshaft of the radius. Two postmenopausal women had vertebral compression fractures. Biochemical indices and bone histomorphometric analysis excluded osteomalacia, and in vivo double tetracycline labeling in five patients revealed both high and low bone turnover states. We propose more stringent radiographic criteria for the designation of the term "Looser zone" that retains the customary association between the radiologic event and osteomalacia. This paper also outlines a diagnostic strategy for future cases of atypical insufficiency fractures and proposes reasons for their resemblance to true Looser zones.

Adult↗