Osteoporotic vertebral burst fractures with neurologic compromise

Posterolateral Instrumented Fusion in Elderly Patients With a Single Osteoporotic Vertebral Fracture: Evaluation of Health-Related Quality of Life

Introduction Treatment of osteoporotic vertebral fractures (OVFs) is a factor that affects the quality of life and should be considered during management. In patients with a single OVF and neurologic deficit, surgical procedures aiming at neural decompression with instrumented fusion should be considered in elderly individuals. Posterolateral instrumented fusion (PLF) constitutes a largely performed fusion surgery for patients featuring indications for fusion surgery. The aim of this study was to determine the safety, effectiveness, and impact on health-related quality of life (HRQoL) of PLF surgery in elderly patients diagnosed with a single OVF. Methods This study was conducted at Interbalkan European Medical Center, Thessaloniki, Greece. Eighty (80) consecutive individuals with OVFs were subjected to PLF and recruited in this prospectively designed non-randomized study. Clinical evaluation was performed preoperatively and postoperatively at particular chronic intervals at one, three, six, and 12 months and two years. The assessment was conducted via the standardized Visual Analogue Scale (VAS) and Short-Form 36 (SF-36) Medical Health Survey Questionnaire for pain and HRQoL, respectively. Results No major perioperative complications were observed. All parameters of SF-36 presented significant improvement over the entire follow-up period with VAS scores reaching a plateau at six months. Depicted improvement of these parameters proves the beneficial role of PLF in elderly patients who suffered from a single OVF with or without referable neurological deficit. Conclusion OVFs have a significant impact on the quality of life of elderly patients, and surgical treatment with PLF with or without decompression can lead to functional recovery, pain relief, and HRQoL amelioration. Our results demonstrated that the outcomes of PLF in the surgical treatment of these patients are remarkably favorable, demonstrating the safety and efficacy of the technique.

Vertebral mobility is a valuable indicator for predicting and determining bone union in osteoporotic vertebral fractures: a conventional observation study

Background

Conservative treatments for osteoporotic vertebral fractures (OVFs) have not been standardized, and criteria for determining bone union have not been established. To determine bone union, we have adopted a cutoff value of 1.0 mm for vertebral mobility (V-mobility), defined as the difference in anterior vertebral height (Ha) between lateral radiographs taken in weight-bearing and non-weight-bearing positions. The present study aimed to investigate the usefulness of V-mobility for determining bone union and predicting bone union at 6 months after OVF onset.

Methods

The study included 54 acute OVFs from T11 to L3 in 53 patients (12 males, 41 females; mean age 82 years; age range 55–97 years) who were hospitalized at ≤ 3 weeks after OVF onset. Vertebral deformity (V-deformity) and V-mobility were evaluated in accordance with Ha on lateral radiographs taken in the sitting position (SIT), lateral decubitus position (DEC), and supine position (SUP). OVFs showing V-mobility of ≤ 1.0 mm between SIT and DEC radiographs and no intravertebral cleft on DEC radiograph were defined as semi-union, while those showing V-mobility of ≤ 1.0 mm between SIT and SUP radiographs and no intravertebral cleft on SUP radiograph were defined as bone union. We calculated the bone union rates including semi-unions associated with V-mobility cutoff values of 1.0 mm, 1.5 mm, and 2.0 mm and estimated cutoff values for V-mobility at 5 weeks after OVF onset to predict bone union at 6 months after OVF onset.

Results

The cumulative number of bone unions including semi-unions was more influenced by the different V-mobility cutoff values in Ha for determining bone union in the earlier period compared with the later period in the time course of OVF. Receiver-operating characteristic curve analyses revealed that V-mobility cutoff value of 2.1 mm in Ha between SIT and DEC radiographs at 5 weeks after OVF had moderate accuracy for predicting bone union including semi-union at 6 months after OVF. The mean V-deformity value on SIT radiographs did not progress significantly.

Conclusion

V-mobility in the early stage after OVF can predict bone union at 6 months after OVF and is a useful quantitative indicator for determining bone union.

The Surgical Outcomes of Spinal Fusion for Osteoporotic Vertebral Fractures in the Lower Lumbar Spine with a Neurological Deficit

Introduction

Osteoporotic vertebral fracture (OVF) is the most common osteoporotic fracture, and some patients require surgical intervention to improve their impaired activities of daily living with neurological deficits. However, many previous reports have focused on OVF around the thoracolumbar junction, and the surgical outcomes of lumbar OVF have not been thoroughly discussed. We aimed to investigate the surgical outcomes for lumbar OVF with a neurological deficit.

Methods

Patients who underwent fusion surgery for thoracolumbar OVF with a neurological deficit were enrolled at 28 institutions. Clinical information, comorbidities, perioperative complications, Japanese Orthopaedic Association scores, visual analog scale scores, and radiographic parameters were compared between patients with lower lumbar fracture (L3-5) and those with thoracolumbar junction fracture (T10-L2). Each patient with lower lumbar fracture (L group) was matched with to patients with thoracolumbar junction fracture (T group).

Results

A total 403 patients (89 males and 314 females, mean age: 73.8 ± 7.8 years, mean follow-up: 3.9 ± 1.7 years) were included in this study. Lower lumbar OVF was frequently found in patients with lower bone mineral density. After matching, mechanical failure was more frequent in the L group (L group: 64%, T group: 39%; p < 0.001). There was no difference between groups in the clinical and radiographical outcomes, although the rates of complication and revision surgery were still high in both groups.

Conclusions

The surgical intervention for OVF is effective in patients with myelopathy or radiculopathy regardless of the surgical level, although further study is required to improve clinical and radiographical outcomes.

Level of evidence

Level III

The factors related to the poor ADL in the patients with osteoporotic vertebral fracture after instrumentation surgery

PURPOSE

Osteoporotic vertebral fracture (OVF) with nonunion or neurological deficit may be a candidate for surgical treatment. However, some patients do not show improvement as expected. Therefore, we conducted a nationwide multicenter study to determine the predictors for postoperative poor activity of daily living (ADL) in patients with OVF.

METHODS

We retrospectively reviewed the case histories of 309 patients with OVF who underwent surgery. To determine the factors predicting postoperative poor ADL, uni- and multivariate statistical analyses were performed.

RESULTS

The frequency of poor ADL at final follow-up period was 9.1%. In univariate analysis, preoperative neurological deficit (OR, 4.1; 95% CI, 1.8-10.3; P < 0.001), perioperative complication (OR, 3.4; P = 0.006), absence of preoperative bone-modifying agent (BMA) administration (OR, 2.7; P = 0.03), and absence of postoperative recombinant human parathyroid hormone (rPTH) administration (OR, 3.9; P = 0.006) were significantly associated. In multivariate analysis, preoperative neurological deficit (OR, 4.6; P < 0.001), perioperative complication (OR, 3.4; P = 0.01), and absence of postoperative rPTH administration (OR, 3.9; P = 0.02) showed statistical significance.

CONCLUSIONS

Preoperative neurological deficit, perioperative complication, and absence of postoperative rPTH administration were considered as predictors for postoperative poor ADL in patients with OVF. Neurological deficits and complications are often inevitable factors; therefore, rPTH is an important option for postoperative treatment for OVF. These slides can be retrieved under Electronic Supplementary Material.

Therapeutic efficacy of Transpedicular Intracorporeal cement augmentation with short segmental posterior instrumentation in treating osteonecrosis of the vertebral body: a retrospective case series with a minimum 5-year follow-up

Background

Transpedicular intracorporeal cement augmentation (TCA) with short segmental posterior instrumentation (SSPI), which provides an ideal immediate analgesic effect and long-term reconstructive stability, is thought to be a sensible advancement to the operative strategy in treating osteonecrosis of the vertebral body (ONV). However, long-term follow-up studies about the treatment are scarce.

Methods

Forty-six ONV patients (22 males and 24 females, mean age of 62.8 ± 7.11 years) underwent TCA with SSPI were retrospectively analyzed. During follow-up, clinical outcomes, such as the Visual Analogue Scale (VAS) score and the Oswestry Disability Index (ODI) score, were evaluated, as well as radiologic outcomes, such as the average vertebral height and kyphotic angle.

Results

A total of 36 patients completed a follow-up period of at least 5 years (mean follow-up period of 67 ± 4.2 months). Among them, seven patients experienced complications, i.e., pneumonia (2/36, 5.56%), screw loosening (2/36, 5.56%), moderate hematoma in the subcutaneous tissue (1/36, 2.78%), and cement leakage (2/36, 5.56%). Compared to the preoperative score, the mean VAS score was significantly reduced 6 months postoperatively (P < 0.05), and it concluded being virtually identical to the preoperative score (P > 0.05). The mean ODI score exhibited a comparable trend. Regarding the radiologic evaluation, the mean kyphotic angle and average vertebral body height were significantly corrected postoperatively (both P < 0.05). However, these radiological parameters were maximally ameliorated during the direct postoperative period and slowly deteriorated over time.

Conclusion

The present study shows that TCA with SSPI may be only mildly effective for symptom relief and correction of kyphotic deformity during a relatively long follow-up, thus we do not recommend it for ONV.

Bone Cement-Augmented Short-Segment Pedicle Screw Fixation for Kümmell Disease with Spinal Canal Stenosis

Background

This study aimed to explore the feasibility and efficacy of bone cement-augmented short-segmental pedicle screw fixation in treating Kümmell disease.

Material/Methods

From June 2012 to June 2015, 18 patients with Kümmell disease with spinal canal stenosis were enrolled in this study. Each patient was treated with bone cement-augmented short-segment fixation and posterolateral bone grafting, and posterior decompression was performed when needed. All patients were followed up for 12–36 months. We retrospectively reviewed outcomes, including the Oswestry disability index (ODI), visual analog scale (VAS) score, anterior and posterior heights of fractured vertebrae, kyphotic Cobb angle, and neurological function by Frankel classification.

Results

The VAS grades, ODI scores, anterior heights of affected vertebrae, and kyphotic Cobb angles showed statistically significant differences between pre- and postoperative and between preoperative and final follow-up values (P<0.05), whereas the differences between postoperative and final follow-up values were not statistically significant (P>0.05). The differences between posterior vertebral heights at each time point were not statistically significant (P>0.05). Improved neurological function was observed in 12 cases at final follow-up. Three cases had complications, including asymptomatic cement leakage in 2 patients and delayed wound infection in 1 patient.

Conclusions

Bone cement-augmented short-segment pedicle screw fixation is safe and effective for treating Kümmell disease, and can achieve satisfactory correction of kyphosis and vertebral height, with pain relief and improvement in neurological function, with few complications.

Surgical options for osteoporotic vertebral compression fractures complicated with spinal deformity and neurologic deficit

INTRODUCTION

This paper describes surgical options for Osteoporotic vertebral compression fracture (OVCF) with acute flexible or chronic rigid kyphosis, and pseudarthrosis complicated with pain and neurologic deficit.

METHODS

This study has two components. a) A prospective clinical study of surgical treatment of 31 patients (age: 69±11 years) with either acute flexible or progressive pseudarthrotic kyphosis manifested with severe pain or neurological deficit between 2010 and 2014. Eleven patients exhibited neurocompression (Frankel B, C, D). Surgery consisted in indirect reduction, kyphoplasty, and short posterior instrumentation in 28 patients and multilevel instrumentation in three. b) The second component involved a literature search of OVCF complicated with acute or painful chronic deformities and neurologic deficit, managed with open surgical approach.

RESULTS

Indirect reduction, kyphoplasty and short posterior stabilization can restore satisfactory anatomic alignment and neurological deficit. Multilevel instrumentation was used for rigid long kyphosis. Complications were related to a) screw pull out and junctional kyphosis (4 patients) one of the patients also developed anterior migration of cement, b) cement leakage (4 patients). L5 radiculopathy occurred in one patient. The others remained asymptomatic. The literature review concluded that corpectomy with anterior, posterior or combined instrumentations is indicated for burst fractures, or rigid kyphosis with neurocompression. Prompt decompression with anatomical alignment may restore paraplegia. Complications were germane to osteoporotic bone predisposing to hardware loosening or cut out and dislodgement of instrumentation.

DISCUSSION

Neurologic deficit associated with fractures or progressive pseudarthrotic kyphosis effectively may respond to indirect postural reduction, kyphoplasty and posterior percutaneous short segment transpedicle instrumentation. For burst fractures and rigid chronic kyphosis corpectomy reconstructed with cages and anterior, or posterior or combined instrumentations can restore and maintain normal anatomy. The following guidelines for optimal surgical instrumentation have been established: To prevent screw loosening and junctional kyphosis the instrumentation should not end within the kyphotic segment. Screws for anterior instrumentation should penetrate the contralateral cortex. Multiple site of fixation or combined anterior and posterior instrumentations dissipate stresses at any one site. Augmentation of transpedicle screw fixation with cement is a sound technical principle. Cement should inserted in a doughy state with minimal pressure to prevent cement complications.

Delayed Neurological Deficits after Osteoporotic Vertebral Fractures: Clinical Outcomes after Surgery

Study Design

Retrospective cohort.

Purpose

To review the clinical presentation of operated patients with delayed neurological deficits after osteoporotic vertebral fractures (OVFs).

Overview of Literature

Delayed neurological deficits can occur from 1 week to 5.7 months after OVFs. Baba has reported 78% good-to-excellent improvement (i.e., ≥50%) after 20 posterior (Cotrel-Dubousset) and 7 anterior (Kaneda in 4, Zielke ventral derotational spondylodesis in 2, and un-instrumented anterior fusion in 1) fusions. Predictive factors for neurological deficits include burst type, vacuum sign, kyphosis, angular instability, and retropulsion.

Methods

Patients with neurological deficits after OVF who received spinal operations between 2000 and 2016 were included.

Results

Totally, 28 patients with a mean age of 77 years underwent surgery. Neurological deficits occurred at an average of 5.4 weeks after the onset of back pain. The most common site was L1. Burst fracture was present in 14 patients and vacuum sign in seven. Surgery was performed within an average of 3.9 days of the onset of neurological deficit. Baba's score improved significantly from 5.96 to 9.81, with good-to-excellent improvement in 18 (64%) patients. Better outcomes based on Baba's scores (improvement>60% [median]) were associated with compression fractures, preoperative retropulsion of <41%, and correction of >16%. Poor improvement in Baba's scores (<25%) was associated with surgical complications and burst fracture type. Twenty-two patients (79%) regained walking ability, and seven of 15 (47%) patients demonstrated improved sphincter control at the latest follow-up. Six Frankel grade B patients did not achieve neurological recovery, four of whom exhibited postoperative surgical complications and died at 2 years because of medical problems. Implant migration occurred in six patients, albeit this was of no clinical significance.

Conclusions

Although OVFs are commonly considered benign, delayed neurological deficits can occur. The significant improvement in clinical function after surgery for neurological deficits is associated with compression (and not burst) fractures, lack of surgical complications, and optimal restoration of retropulsion.

A Guide to Improving the Care of Patients with Fragility Fractures, Edition 2

Over the past 4 decades, much has been learned about the pathophysiology and treatment of osteoporosis, the prevention of fragility fractures, and the perioperative management of patients who have these debilitating injuries. However, the volume of published literature on this topic is staggering and far too voluminous for any clinician to review and synthesize by him or herself. This manuscript thoroughly summarizes the latest research on fragility fractures and provides the reader with valuable strategies to optimize the prevention and management of these devastating injuries. The information contained in this article will prove invaluable to any health care provider or health system administrator who is involved in the prevention and management of fragility hip fractures. As providers begin to gain a better understanding of the principles espoused in this article, it is our hope that they will be able to use this information to optimize the care they provide for elderly patients who are at risk of or who have osteoporotic fractures.

Minimally invasive transpsoas L2 corpectomy and percutaneous pedicle screw fixation for osteoporotic burst fracture in the elderly: a technical report

BACKGROUND AND IMPORTANCE

Osteoporotic vertebral burst fractures are an increasingly common cause of pain and severe functional disability in the elderly. Although anterior-posterior surgical stabilization offers an efficacious and durable treatment, the associated high blood loss, long durations of surgery, and prolonged hospitalization are often not tolerable for elderly patients, who are most often medically frail with multiple comorbidities.

CLINICAL PRESENTATION

We report a case of an L2 osteoporotic burst fracture in an elderly patient with significant comorbidities treated with a minimally invasive tubular direct lateral transpsoas approach for L2 vertebrectomy and anterior cage placement. The construct was supplemented by a percutaneous pedicle screw construct and adjacent level vertebroplasty. Duration of surgery was 3.5 hours with a total of 35 mL blood loss. The patient was discharged ambulating 36 hours after surgery and reported marked improvement in pain, disability, and quality of life measures at 6 weeks postoperatively.

CONCLUSIONS

L2 vertebrectomy by direct lateral transpsoas tube systems supplemented by percutaneous pedicle screws can be performed safely and may allow for anterior column decompression and reconstruction in elderly or comorbid patients not otherwise able to tolerate traditional stabilization procedures.

Factors affecting postoperative activities of daily living in patients with osteoporotic vertebral collapse with neurological deficits

Surgical treatment of osteoporotic vertebral collapse (OVC) with neurological deficits presents significant clinical challenges because some patients have fragile bones and often have medical comorbidities, which affect the severity of osteoporosis. We hypothesized that clinical results of surgery in these patients depend on the extent of medical comorbidities that induce secondary osteoporosis. The aim of this study is to examine the effects of medical history and comorbidities on surgical outcomes for these patients, along with the factors that predict postoperative function in activities of daily living (ADL). We retrospectively reviewed data for 88 patients with OVC and neurological deficits who underwent surgery. We assessed clinical results regarding neurological deficits and function in ADL. The presence or absence of comorbidities responsible for secondary osteoporosis and treatments or medical events that affect bone metabolism were examined. We performed statistical analysis to examine prognostic factors for postoperative function in ADL. Of 88 patients, the distributions of comorbidities, treatment, and events in medical history were as follows: hypertension, 57 patients (64.8%); chronic kidney disease (CKD) stage 3 or 4, 32 (36.4%); diabetes mellitus, 16 (18.2%); liver dysfunction, 11 (12.5%); cardiovascular disease, 10 (11.4%); rheumatoid arthritis, 9 (10.2%); and glucocorticoid intake, 8 (9.1%). Twenty-five patients (28.4%) represented poor postoperative ADL (chair-bound or bed-bound), and 11 of 25 patients with poor postoperative ADL represented full neurological recovery. Multivariate analysis revealed decreased estimated glomerular filtration rate (odds ratio 0.96; 95% confidence interval 0.93-0.99; p = 0.005) and a high serum alkaline phosphatase (ALP) level (odds ratio 1.01; 95% CI 1.00-1.02; p = 0.01) were strong predictive factors for poor postoperative function in ADL. The majority of patients with poor postoperative function in ADL had advanced CKD with a disorder of bone metabolism as well as bone fragility.

Surgical treatment for osteoporotic vertebral collapse with neurological deficits: retrospective comparative study of three procedures--anterior surgery versus posterior spinal shorting osteotomy versus posterior spinal fusion using vertebroplasty

PURPOSE

In general, osteoporotic vertebral collapse (OVC) with neurological deficits requires sufficient decompression of neural tissues to restore function level in activities of daily living (ADL). However, it remains unclear as to which procedure provides better neurological recovery. The primary purpose of this study was to compare neurological recovery among three typical procedures for OVC with neurological deficits. Secondary purpose was to compare postoperative ADL function.

METHODS

We retrospectively reviewed data for 88 patients (29 men and 59 women) with OVC and neurological deficits who underwent surgery. Three typical kinds of surgical procedures with different decompression methods were used: (1) anterior direct neural decompression and reconstruction (AR group: 27 patients), (2) posterior spinal shorting osteotomy with direct neural decompression (PS group: 36 patients), and (3) posterior indirect neural decompression and short-segment spinal fusion combined with vertebroplasty (VP group: 25 patients). We examined clinical results regarding neurological deficits and function level in ADL and radiological results.

RESULTS

The mean improvement rates for neurological deficits and ADL function level were 60.1 and 55.0%, respectively. There were no significant differences among three groups in improvement rates for neurological deficits or ADL function level. The VP group had a significantly lower estimated mean blood loss (338 mL) and mean duration of surgery (229 min) than both the AR and PS groups (p < 0.001).

CONCLUSION

Direct neural decompression is not always necessary, and the majority of patients can be treated with a less-invasive procedure such as short-segment posterior spinal fusion with indirect decompression combined with vertebroplasty. The high-priority issue is careful evaluation of patients' general health and osteoporosis severity, so that the surgeon can choose the procedure best suited for each patient.

Comparison of the amounts of canal encroachment between semisitting and supine position of computed tomography-myelography for vertebral fractures of the elderly involving the posterior vertebral wall

STUDY DESIGN

A prospective radiographical trial.

OBJECTIVE

To elucidate effects of loading associated with spinal canal encroachment (SCE) in patients with insufficient bone union after vertebral fractures in the elderly, using computed tomography-myelography in 2 different positions.

SUMMARY OF BACKGROUND DATA

In elderly patients with vertebral fractures, influence of loading would be involved in SCE, but the details are not well understood.

METHODS

Seventeen patients (mean age, 77.4 ± 8 yr; range, 62-91 yr) with various degrees of neurological deficit due to insufficient bone union at both vertebral body and posterior vertebral wall were included in this study. Computed tomography-myelography was performed in both semisitting and supine positions. Kyphotic angle, rate of dural compression, ratio of occupation by bony fragments, and posterior vertebral body height ratio were measured and compared between positions.

RESULTS

Mean ratio of occupation by bony fragments was significantly higher in the semisitting position (47.9 ± 9.2%) than in the supine position (33.9 ± 10.0%, P, 0.001). Similarly, mean posterior vertebral body height ratio was significantly lower in the semisitting position (67.8 ± 10.8%) than in the supine position (76.3 ± 13.3%), indicating a significant loss of vertebral height in the semisitting position (P, 0.001). Mean rate of dural compression was likewise significantly higher in the semisitting position (48.6 ± 13.3%) than in the supine position (33.3 ± 16.5%; P, 0.001). Mean change in ratio of occupation by bony fragments, change in posterior vertebral body height ratio, and angular instability between positions were 13.9 ± 8.6%, 8.5 ± 6.7%, and 13° ± 5.7°, respectively. A significant correlation was identified between change in ratio of occupation by bony fragments and change in posterior vertebral body height ratio (P = 0.001).

CONCLUSION

Our study demonstrated that collapse of the nonunited posterior vertebral wall and intracanal protrusion of vertebral fragments would occur simultaneously with axial loading, causing SCE. Computed tomographic scan obtained in semisitting position seems quite useful to evaluate the amount of SCE by an unstable posterior wall.

Total motion generated in the unstable thoracolumbar spine during management of the typical trauma patient: a comparison of methods in a cadaver model

OBJECT

The proper prehospital and inpatient management of patients with unstable spinal injuries is critical for prevention of secondary neurological compromise. The authors sought to analyze the amount of motion generated in the unstable thoracolumbar spine during various maneuvers and transfers that a trauma patient would typically be subjected to prior to definitive fixation.

METHODS

Five fresh cadavers with surgically created unstable L-1 burst fractures were tested. The amount of angular motion between the T-12 and L-2 vertebral segments was measured using a 3D electromagnetic motion analysis device. A complete sequence of maneuvers and transfers was then performed that a patient would be expected to go through from the time of injury until surgical fixation. These maneuvers and transfers included spine board placement and removal, bed transfers, lateral therapy, and turning the patient prone onto the operating table. During each of these, the authors performed what they believed to be the most commonly used versus the best techniques for preventing undesirable motion at the injury level.

RESULTS

When placing a spine board there was more motion in all 3 planes with the log-roll technique, and this difference reached statistical significance for axial rotation (p = 0.018) and lateral bending (p = 0.003). Using logrolling for spine board removal resulted in increased motion again, and this was statistically significant for flexion-extension (p = 0.014). During the bed transfer and lateral therapy, the log-roll technique resulted in more motion in all 3 planes (p ≤ 0.05). When turning the cadavers prone for surgery there was statistically more angular motion in each plane for manually turning the patient versus the Jackson table turn (p ≤ 0.01). The total motion was decreased by almost 50% in each plane when using an alternative to the log-roll techniques during the complete sequence (p ≤ 0.007).

CONCLUSIONS

Although it is unknown how much motion in the unstable spine is necessary to cause secondary neurological injury, the accepted tenet is to minimize motion as much as possible. This study has demonstrated the angular motion incurred by the unstable thoracolumbar spine as experienced by the typical trauma patient from the field to positioning in the operating room using the best and most commonly used techniques. As previously reported, using the log-roll technique consistently results in unwanted motion at the injured spinal segment.

Cement augmented anterior reconstruction with short posterior instrumentation: a less invasive surgical option for Kummell's disease with cord compression

We report the surgical procedure and clinical outcomes of a cement augmented anterior reconstruction with pedicle screw fixation for osteoporotic vertebral collapse with an intravertebral cleft (Kummell's disease). Ten consecutive patients with cord compression were enrolled in this study. The mean number of fused segments was 3.2. Instrumentation and posterolateral bone grafts were performed for one level above and below the collapsed vertebra with the exception of one patient. Polymethylmethacrylate (PMMA) cement was then injected into the intravertebral cleft and posterior decompression was performed when needed. The visual analog scale (VAS) pain score and Frankel grade were used to evaluate the clinical results and radiological parameters were also assessed. The mean VAS score before vertebroplasty was 7.5, which was reduced to 3.2 postoperatively, and was 3.7 at the most recent follow-up. The mean follow-up duration was 12.1 months. Seven (83%) of the eight patients with motor deficits showed an improvement in neurological function by at least 1 Frankel grade. The mean decrease in the kyphosis (Cobb) angle was 12.6° and the wedge angle was 12.1° (p<0.05). However, the angle improvement regressed slightly during follow-up. None of the patients showed vertebral collapse, or loss or leakage of PMMA into the canal. One patient developed wound dehiscence. There was no need for revision or evidence of instrument failure. Based on the preliminary results, we advocate the use of short instrumentation in combination with vertebroplasty with PMMA and posterolateral fusion for Kummell's disease in patients who are elderly or medically compromised.

Quality of life in glaucoma and three other chronic diseases: a systematic literature review

Chronic diseases have a long-term negative impact on quality of life (QOL). Decreased QOL is associated with increased financial burden on healthcare systems and society. However, few publications have investigated the impact of glaucoma on patients' QOL in comparison with other chronic diseases observed in patients with similar demographic characteristics. To this end, a systematic literature search to assess QOL in glaucoma and three other chronic diseases (osteoporosis, type 2 diabetes mellitus and dementia) was performed. A total of 146 publications were identified that reported QOL using six commonly used generic QOL instruments: 36-, 12- and 20-item Short-Form Health Surveys (SF-36, -12 and -20), EuroQoL (EQ-5D), Sickness Impact Profile (SIP) and the Health Utilities Index-Mark III (HUI-III). The publication breakdown was as follows: glaucoma (10%), osteoporosis (26%), diabetes (52%) and dementia (12%); one publication assessed QOL in glaucoma, diabetes and dementia. QOL was affected to a similar or slightly lesser degree by glaucoma than by osteoporosis, diabetes or dementia. Among the publications reporting SF-36, -12 and -20 evaluations, physical component scores were generally lower than mental component scores across all diseases. QOL was affected more in patients with glaucoma than in demographically matched non-glaucomatous controls according to SF-20 assessment. EQ-5D and SIP results showed that QOL decreased as the severity of glaucoma increased. Patients with glaucoma had the lowest scores on the SIP instrument, indicating better QOL than patients with osteoporosis or diabetes (no data were available on dementia). The HUI-III instrument identified poorer QOL in patients with dementia than other diseases, probably due to cognitive deficits. However, for some of the instruments, data were scarce, and interpretation of the results should be conservative. Although there are limited published QOL studies in glaucoma, its impact on QOL appears to be broadly similar to that of other serious chronic diseases. Development of a QOL instrument that measures vision-specific and general health aspects would better document the impact of glaucoma on QOL and would facilitate comparisons with other chronic disease states.

Cervical spine motion generated with manual versus jackson table turning methods in a cadaveric c1-c2 global instability model

STUDY DESIGN.: Cadaveric biomechanical study. OBJECTIVE.: To quantify spinal motion created by transfer methods from supine to prone position in a cadaveric C1-C2 global instability model. SUMMARY OF BACKGROUND DATA.: Patients who have sustained a spinal cord injury remain at high risk for further secondary injury until their spine is adequately stabilized. To date, no study has evaluated the effect of patient transfer methods from supine to prone position in the operating room, on atlantoaxial cervical spine motion. METHODS.: A global instability was surgically created at the C1-C2 level in 4 fresh cadavers. Two transfer protocols were tested on each cadaver. The log-roll technique entailed performing a standard 180 degrees log-roll rotation of the supine patient from a stretcher to the prone position onto the operating room Jackson table (OSI, Union City, CA). The "Jackson technique" involved sliding the supine patient to the Jackson table, securing them to the table, and then rotating them into a prone position. An electromagnetic tracking device registered motion between the C1 and C2 vertebral segments. Three different head holding devices (Mayfield, Prone view, and blue foam pillow) were also compared for their ability to restrict C1-C2 motion. Six motion parameters were tracked. Repeated measures statistical analysis was performed to evaluate angular and translational motion. RESULTS.: For 6 of 6 measures of angulation and translation, manual log-roll prone positioning generated significantly more C1-C2 motion than the Jackson table turning technique. Out of 6 motion parameters, 5 were statistically significant (P < 0.001-0.005). There was minimal difference in C1-C2 motion generated when comparing all 3 head holding devices. CONCLUSION.: The data demonstrate that manual log-roll technique generated significantly more C1-C2 motion compared to the Jackson table technique. Choice of headrest has a minimal effect on the amount of motion generated during patient transfer, except that the Mayfield device demonstrates a slight trend toward increased C1-C2 motion.

Factors affecting neurological deficits and intractable back pain in patients with insufficient bone union following osteoporotic vertebral fracture

The purpose of this study was to examine factors affecting the severity of neurological deficits and intractable back pain in patients with insufficient bone union following osteoporotic vertebral fracture (OVF). Reports of insufficient union following OVF have recently increased. Patients with this lesion have various degrees of neurological deficits and back pain. However, the factors contributing to the severity of these are still unknown. A total of 45 patients with insufficient union following OVF were included in this study. Insufficient union was diagnosed based on the findings of vertebral cleft on plain radiography or CT, as well as fluid collection indicating high-intensity change on T2-weighted MRI. Multivariate logistic regression analysis was performed to determine the factors contributing to the severity of neurological deficits and back pain in the patients. Age, sex, level of fracture, duration after onset of symptoms, degree of local kyphosis, degree of angular instability, ratio of occupation by bony fragments, presence or absence of protrusion of flavum, and presence or absence of ossification of the anterior longitudinal ligament (OALL) in the adjacent level were used as explanatory variables, while severity of neurological deficits and back pain were response variables. On multivariate analysis, factors significantly affecting the severity of neurological deficits were angular instability of more than 15 degrees [adjusted odds ratio (OR), 9.24 (95% confidence interval, CI 1.49-57.2); P < 0.05] and ratio of occupation by bony fragments in the spinal canal of more than 42% [adjusted OR 9.23 (95%CI 1.15-74.1); P < 0.05]. The factor significantly affecting the severity of back pain was angular instability of more than 15 degrees [adjusted OR 14.9 (95%CI 2.11-105); P < 0.01]. On the other hand, presence of OALL in the adjacent level reduced degree of back pain [adjusted OR 0.14 (95%CI 0.03-0.76); P < 0.05]. In this study, pronounced angular instability and marked posterior protrusion of bony fragments in the canal were factors affecting neurological deficits. In addition, marked angular instability was a factor affecting back pain. These findings are useful in determining treatment options for patients with insufficient union following OVF.

Comparison of thoracolumbar motion produced by manual and Jackson-table-turning methods. Study of a cadaveric instability model

BACKGROUND

Patients who have sustained a spinal cord injury remain at risk for further neurologic deterioration until the spine is adequately stabilized. To our knowledge, no study has previously addressed the effects of different bed-to-operating room table transfer techniques on thoracolumbar spinal motion in an instability model. We hypothesized that the conventional logroll technique used to transfer patients from a supine position to a prone position on the operating room table has the potential to confer significantly more motion to the unstable thoracolumbar spine than the Jackson technique.

METHODS

Three-column instability was surgically created at the L1 level in seven cadavers. Two protocols were tested. The manual technique entailed performing a standard logroll of a supine cadaver to a prone position on an operating room Jackson table. The Jackson technique involved sliding the supine cadaver to the Jackson table, securing it to the table, and then rotating it into a prone position. An electromagnetic tracking device measured motion--i.e., angular motion (flexion-extension, lateral bending, and axial rotation) and linear translation (axial, medial-lateral, and anterior-posterior) between T12 and L2.

RESULTS

The logroll technique created significantly more motion than the Jackson technique as measured with all six parameters. Manual logroll transfers produced an average of 13.8 degrees to 18.1 degrees of maximum angular displacement and 16.6 to 28.3 mm of maximum linear translation. The Jackson technique resulted in an average of 3.1 degrees to 5.8 degrees of maximum angular displacement (p < 0.001) and 4.0 to 10.0 mm of maximum linear translation (p < 0.05).

CONCLUSIONS

Compared with the logroll, the Jackson-table transfer method provides superior immobilization of an unstable thoracolumbar spine during transfer of supine cadavers to a prone position on the operating room table.

CLINICAL RELEVANCE

This study addresses in-hospital patient safety. Performing the Jackson turn requires approximately half as many people as required for a manual logroll. This study suggests that the Jackson technique should be considered for supine-to-prone transfer of patients with known or suspected instability of the thoracolumbar spine.

Osteoporotic vertebral fractures and collapse with intravertebral vacuum sign (Kümmel's disease)

The intravertebral vacuum phenomenon was first described by Kümmel and is also known as delayed vertebral collapse or vertebral pseudarthrosis. Clinically, it occurs in approximately 10% of vertebral osteoporotic fractures, mainly in the thoracolumbar zone, is accentuated on extension views and associated with benign fractures. Most patients are neurologically intact, and continued pain is a common symptom that responds well to stabilization. Various theories exist in the literature about the pathogenesis; data support a combination of ischemia and psuedarthrosis. The ultimate treatment plan must be individualized and involve decompression of neurologic elements--when present--and sufficient stabilization, which varies according to surgeon preference and the patient's combordities.

Posterior spinal shortening for paraparesis following vertebral collapse due to osteoporosis

STUDY DESIGN

Retrospective case series.

OBJECTIVES

To assess the efficacy of posterior spinal shortening for paraparetic patients following vertebral collapse owing to osteoporosis, especially on instrumentation loosening.

SETTING

Department of orthopaedic surgery, Jichi Medical University Hospital and Omiya Medical Center in Japan.

METHODS

The clinical records and radiographs of 13 patients with paraparesis following vertebral collapse owing to osteoporosis treated with posterior spinal shortening were retrospectively reviewed to evaluate the usefulness of this method. Assessment of the clinical course was done by direct examination in all cases. Ambulatory ability was divided into four categories.

RESULTS

Upon final observation, nine cases were able to walk with a cane or crutch, one case remained in gait training, two cases remained unable to stand and one case with urinary incontinence improved in urinary function. In one case, paralysis deteriorated. Vertebral compression fracture of the end vertebrae that were fixed occurred in three cases complicated with rheumatoid arthritis.

CONCLUSION

The posterior spinal shortening can be a choice for treating delayed paraparesis following vertebral collapse owing to osteoporosis.

Nonoperative management and treatment of spinal injuries

STUDY DESIGN

Review of literature.

OBJECTIVE

To delineate and discuss nonoperative treatment and treatment of spinal injuries.

SUMMARY OF BACKGROUND DATA

Nonoperative methods have been a mainstay of care for spinal injuries since ancient Egypt. The vast majority of all spinal injuries should be treated in the nonoperative fashion. The indications and methods continue to evolve.

METHODS

A PubMed search of the literature returned more than 1000 articles related to spine trauma. A total of 270 were references to nonoperative treatment, and 100 were thought to be relevant and included in this review.

RESULTS

All spine injuries are treated in a nonoperative manner, at least initially. The vast majority of injuries are successfully and appropriately treated in a definitive manner with nonsurgical methods. Over the past 10-15 years, the advent of better rigid cervical fixation has decreased the use of halo vests as definitive treatment of many cervical injuries. In contrast, during the same time, more thoracolumbar injuries are being treated in a nonsurgical fashion because the outcomes have been shown to be similar or superior.

CONCLUSIONS

As with all of medicine, the treatment of spine trauma will continue to evolve with time. It is paramount that the physician selects the treatment that will provide the best short-term recovery with the least impact on long-term function.

Another option to treat Kümmell's disease with cord compression

The efficiency of short-segment fixation with transpedicle body augmenter (a titanium spacer with bone-ingrowth porous surface, TpBA) to treat Kümmell's disease with cord compression (stage III) was retrospectively evaluated. No laminectomy or instrumentation reduction was done. Inclusion criteria included Frankel CDE, single-level within T10-L2. FU rate was 88%, i.e. 21 cases were included. Frankel function classification was 6E9D6C. Mean age was 72+/-8 years. F:M was 16:5. FU period was 48 M (range, 30-76 M). The hospitalization was 4.5+/-2.2 days; operation time, 70.4+/-17.2 min; blood loss, 150+/-72 cc. Final Frankel class was 20E1D. Complications included two superficial infection and one pneumonia. Body height and kyphosis were all corrected significantly and well preserved at the final visit. No TpBA dislodgement or implant failure was noted; however, three cases developed new compression fractures. The clinical outcome showed 81% with P1 or P2 by Denis pain scale. This method can decompress spinal canal, maintain kyphosis correction and vertebral restoration, prevent implant failure, and attain good clinical results.

Bilateral L5 radiculopathy due to osteoporotic L1 vertebral fracture: A case report

BACKGROUND

The true incidence of osteoporotic vertebral fractures is not well defined because many osteoporotic vertebral fractures are asymptomatic. Although the true incidence of neurological compromise as a result of osteoporotic vertebral fractures is not known, it is thought to be low. In this case report, we present a case of L1 osteoporotic vertebral fracture causing bilateral L5 nerve root compression and manifestation of bilateral foot-drop.

METHODS

Pedicle screws were inserted in the vertebrae, 2 above and 2 below the L1 vertebra. A temporary rod was placed on the left. An L1 right hemilaminectomy via a posterior approach and a corpectomy were performed. The spinal cord was decompressed. Anterior fusion was carried out by placing titanium mesh cage into the vertebrectomy site as a strut graft via posterior approach, and posterolateral fusion with spongious allografts were added to the procedure.

RESULTS

Two years later the patient was completely symptom free and receiving medical treatment for osteoporosis, which was diagnosed as primary type.

CONCLUSION

If a fracture is detected on the posterior wall of the vertebral body in computerized tomography (CT) examination with plain radiographs, a magnetic resonance imaging (MRI) examination should be conducted in the presence of symptoms and physical findings suggestive of neurological compression. Follow-up neurological examinations should be carried out, and it should be kept in mind that most of the neurological symptoms may develop late and manifest as radiculopathy. The majority of the osteoporotic vertebral fractures can be managed conservatively with bed rest and orthosis, but cases with accompanying neurological deficit should be managed surgically using decompression and stabilization by fusion and instrumentation.

[Compound osteosynthesis as treatment for an osteoporotic LWK-1 burst fracture in a 76 year old female patient]

The surgical treatment of osteoporotic vertebral compression fractures is rarely necessary and is mostly done in fractures with neurological deficit. We present a case of compound osteosynthesis in an osteoporotic fracture of the first lumbar vertebra as a "salvage procedure" after a dislocation of a dorsal internal fixator in a 76 year old female sustaining incomplete paraplegia. In this case, an additional ventral stabilization using a vertebral body replacement was not practicable because of old age and previous pneumonia. We performed an additional compound osteosynthesis using bone cement because of insufficient stability when only using cement for augmentation of the pedicle screws.

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.

Functional Outcome After Treatment of Lower-Extremity Nonunions

BACKGROUND

The results for nonunion surgery usually have been judged in terms of bony union, time to union, infection rate, range of motion for the adjacent joints, and muscle strength. The goal of this study was to assess the improvement of patient-oriented physical and mental functional outcomes.

METHODS

The functional status of 23 patients with nonunion of the lower extremity was assessed using the Short-Form Health Survey (SF-36) questionnaire. The SF-36 subscores were compared with preoperative values and with the average values for the U.S. population.

RESULTS

Of the 23 patients, 21 healed. The functional status for nonunions of the lower extremity was greatly improved 1 year after operative intervention in this study. Nevertheless, the results show that it did not reach the level of the average U.S. population.

CONCLUSION

The results of this study can be used to guide patients' expectations regarding the functional outcome of treatment for a nonunion of the lower extremity.

Relationship between axial and bending behaviors of the human thoracolumbar vertebra

STUDY DESIGN

The authors studied the mechanical behavior of vertebrae through the use of finite element analyses.

OBJECTIVES

To determine the relation between axial and bending rigidity, and to determine the geometric and densitometric factors that affect this relation.

SUMMARY OF BACKGROUND DATA

Metrics of vertebral body mechanical properties in bending have not been established despite evidence that anterior bending loads play a significant role in osteoporotic vertebral fracture.

METHODS

Voxel-based finite element models were generated using quantitative computed tomography (QCT) scans of 18 human cadaveric vertebral bodies, and both axial and bending rigidities of the vertebra were computed. Both rigidity measures and their ratio were correlated with vertebral geometric and densitometric factors obtained from the QCT scans.

RESULTS

Bending rigidity was moderately correlated with axial rigidity (r2 = 0.69) and strongly correlated with the product of axial rigidity and vertebral anteroposterior depth squared (r2 = 0.88). The ratio of bending to axial rigidity was independent of bone mineral density (P = 0.20) but was moderately correlated with the square of vertebral depth (r2 = 0.69).

CONCLUSIONS

Vertebral anteroposterior depth plays an important role in bending rigidity. The scatter in the correlation between bending and axial rigidity suggests that some individuals can have vertebrae with a normal axial stiffness but an abnormally low bending stiffness. Because whole-bone stiffness is indicative of bone strength, these results support the concept that use of more than one metric of vertebral strength, for example, compression and bending strengths, may improve osteoporotic fracture risk prediction.

Principles of management of osteometabolic disorders affecting the aging spine

Osteoporosis is the most common contributing factor of spinal fractures, which characteristically are not generally known to produce spinal cord compression symptoms. Recently, an increasing number of medical reports have implicated osteoporotic fractures as a cause of serious neurological deficit and painful disabling spinal deformities. This has been corroborated by the present authors as well. These complications are only amenable to surgical management, requiring instrumentation. Instrumenting an osteoporotic spine, although a challenging task, can be accomplished if certain guidelines for surgical techniques are respected. Neurological deficits respond equally well to an anterior or posterior decompression, provided this is coupled with multisegmental fixation of the construct. With the steady increase in the elderly population, it is anticipated that the spine surgeon will face serious complications of osteoporotic spines more frequently. With regard to surgery, however, excellent correction of deformities can be achieved, by combining anterior and posterior approaches. Paget's disease of bone (PD) is a non-hormonal osteometabolic disorder and the spine is the second most commonly affected site. About one-third of patients with spinal involvement exhibit symptoms of clinical stenosis. In only 12-24% of patients with PD of the spine is back pain attributed solely to PD, while in the majority of patients, back pain is either arthritic in nature or a combination of a pagetic process and coexisting arthritis. In this context, one must be certain before attributing low back pain to PD exclusively, and antipagetic medical treatment alone may be ineffective. Neural element dysfunction may be attributed to compressive myelopathy by pagetic bone overgrowth, pagetic intraspinal soft tissue overgrowth, ossification of epidural fat, platybasia, spontaneous bleeding, sarcomatous degeneration and vertebral fracture or subluxation. Neural dysfunction can also result from spinal ischemia when blood is diverted by the so-called "arterial steal syndrome". Because the effectiveness of pharmacologic treatment for pagetic spinal stenosis has been clearly demonstrated, surgical decompression should only be instituted after failure of antipagetic medical treatment. Surgery is indicated as a primary treatment when neural compression is secondary to pathologic fractures, dislocations, spontaneous epidural hematoma, syringomyelia, platybasia, or sarcomatous transformation. Five classes of drugs are available for the treatment of PD. Bisphosphonates are the most popular antipagetic drug and several forms have been investigated.