Novel Surgical Strategy for Treating Osteoporotic Vertebral Fractures with Cord Compression

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.

Factors affecting the quality of life in the chronic phase of thoracolumbar osteoporotic vertebral fracture managed conservatively with a brace

BACKGROUND CONTEXT

Although osteoporotic vertebral fractures (OVFs) are the most common type of osteoporotic fracture, few reports have closely investigated the factors contributing to the quality of life (QOL) in the chronic phase after thoracolumbar OVFs using detailed radiographic evaluation.

PURPOSE

This study aimed to identify factors associated with the QOL in the chronic phase after thoracolumbar OVF.

DESIGN

Post hoc analysis of a prospective randomized study.

PATIENT SAMPLE

Participants included 195 patients with fresh thoracolumbar OVF managed conservatively with a brace who were available for radiographic analysis 48 weeks after injury.

OUTCOME MEASURES

The degree of QOL impairment at 48 weeks after thoracolumbar OVF was assessed using the Japanese three-level version of the EuroQol five-dimensional questionnaire (EQ-5D) score.

METHODS

Univariate and multivariate regression analyses were used to evaluate the relationships between the QOL and radiographic factors.

RESULTS

The univariate analysis showed that age, analgesic use, T10/L5 Cobb angle on magnetic resonance imaging (MRI), subsequent vertebral fracture, and nonunion were significantly associated with the EQ-5D score at 48 weeks after thoracolumbar OVF. The multiple regression analysis showed that nonunion, analgesic use, subsequent vertebral fracture, and sacral slope on MRI were independently associated with the EQ-5D score at 48 weeks after thoracolumbar OVF. Receiver operating characteristic analysis for the deterioration of QOL showed that the cutoff value for sacral slope on MRI was 35 degrees.

CONCLUSIONS

This study demonstrated that nonunion, subsequent vertebral fracture, and lower sacral slope were independently associated with poorer QOL in the chronic phase of thoracolumbar OVF managed conservatively with a brace. Therefore, improving or preventing these factors in patients with thoracolumbar OVF in the chronic phase may improve the QOL of the affected patients.

Decompression and fusion surgery for osteoporotic vertebral fractures: WFNS Spine Committee Recommendations

INTODUCTION

Osteoporotic vertebral fractures (OVF) are common due to aging populations. Their clinical management remains controversial. Although conservative approaches are sufficient in most cases, there are certain conditions where decompression or fusion surgery are necessary. This manuscript aims to clarify the indications and types of surgeries for OVF.

EVIDENCE ACQUISITION

A Medline and Pubmed search spanning the period between 2010 and 2020 was performed using the keywords "osteoporotic vertebral fractures and decompression surgery" and "osteoporotic vertebral fractures and fusion surgery". In addition, we reviewed up-to-date information on decompression and fusion in osteoporotic vertebral fracture (OVF) to reach an agreement in two consensus meetings of the World Federation of Neurosurgical Societies (WFNS) Spine Committee that was held in January and February 2021. The Delphi method was utilized to improve the validity of the questionnaire.

EVIDENCE SYNTHESIS

A total of 19 studies examining decompression and fusion surgery in OVF were reviewed. Literature supports the statement that decompression and fusion surgery are necessary for progressive neurological deficits after OVF. The Spine Section of the German Society for Orthopedics and Trauma (DGOU) classification revealed that it might help make surgical decisions. We also noted that in patients planning to undergo surgery to correct significant kyphosis after OVF, several techniques, including multilevel fixation, cement augmentation, preservation of sagittal balance, and avoiding termination at the apex of kyphosis are necessary to prevent complications. Additionally, it became clear that there is no consensus to choose the type of open surgery (anterior, posterior, combined, using cement or bone or vertebral body cage, the levels, and kind of instrumentation). The current literature indicated that implant failure in the osteoporotic spine is a common complication, and many techniques have been described to prevent implant failure in the osteoporotic spine. However, the superiority of one method over another is unclear.

CONCLUSIONS

Open surgery for osteoporotic vertebral fractures should be considered if neurologic deficits and significant painful kyphosis. The apparent indications of surgery and most ideal surgical technique for OVF remain unclear in the literature; therefore, the decision must be individualized.

Posterior Stabilization Without Neural Decompression in Osteoporotic Thoracolumbar Fractures With Dynamic Cord Compression Causing Incomplete Neurological Deficits

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

Management of osteoporotic vertebral compression fracture (OVCF) remains an unsolved problem for a spine surgeon. We hypothesize that instability at the fracture site rather than neural compression is the main factor leading to a neurological deficit in patients with OVCF.

METHODS

In this study, the prospective data of patients with osteoporotic fractures with incomplete neurological deficits from January 2015 to December 2017 was analyzed in those who underwent posterior instrumented fusion without neural decompression.

RESULTS

A total of 61 patients received posterior indirect decompression via ligamentotaxis and stabilization only. Of these 17 patients had polymethylmethacrylate (PMMA) augmented screws and in 44 patients no PMMA augmentation was done. The mean preoperative kyphosis was 27.12° ± 9.63°, there was an improvement of 13.5° ± 6.87° in the immediate postoperative period and at the final follow-up, kyphosis was 13.7° ± 7.29° with a loss of correction by 2.85° ± 3.7°. The height restoration at the final follow-up was 45.4% ± 18.29%. In all patients, back pain was relieved, and neurological improvement was obtained by at least 1 American Spinal Injury Association Impairment Scale in all except 3 patients.

CONCLUSION

We propose that neural decompression of the spinal cord is not always necessary for the treatment of neurological impairment in patients with osteoporotic vertebral collapse with dynamic mobility. Dynamic magnetic resonance imaging is a valuable tool to make an accurate diagnosis and determine precise surgical plan and improving the surgical strategy of OVCF.

Comparison of clinical effectiveness of fenestrated and conventional pedicle screws in patients undergoing spinal surgery: a systematic review and meta-analysis

INTRODUCTION

Pedicle screws are commonly used for spinal procedures for fusion stability, which is particularly important in osteoporotic patients, who are at an increased risk of requiring revision procedures.

AREAS COVERED

A systematic review and meta-analysis were conducted to compare clinical effectiveness of conventional pedicle screws (CPS) vs fenestrated pedicle screws (FPS) in patients undergoing spinal surgery. Primary outcomes included screw loosening, revision surgeries (involving an implant) and reoperations (not involving intervention on an implant) in patients treated with CPS vs FPS, sub-stratified by with and without osteoporosis. Secondary outcomes included changes in pain scores. Forty-eight studies with 8,302 patients were included, with 1,565 (19.18%) treated with FPS and 6,710 (80.82%) treated with CPS. FPS was associated with a lower risk of screw loosening (p = 0.001) vs CPS. In the general population, there was a non-significant trend of lower revision rate, but no difference in reoperation rate, between patients treated with FPS vs CPS. In osteoporotic patients, revision rates were significantly lower for FPS vs CPS (p = 0.009).

EXPERT OPINION

This review suggests that FPS are effective for surgical fixation and reduce rates of screw loosening, and in osteoporotic patients, revision surgeries, compared to CPS.