Management of patients with vertebral compression fractures

Review of Current Spinal Robotic Orthoses

Osteoporotic spine fractures (OSF) are common sequelae of osteoporosis. OSF are directly correlated with increasing age and incidence of osteoporosis. OSF are treated conservatively or surgically. Associated acute pain, chronic disabilities, and progressive deformities are well documented. Conservative measures include a combination of initial bed rest, analgesia, early physiotherapy, and a spinal brace (orthosis), with the aim for early rehabilitation to prevent complications of immobile state. Spinal bracing is commonly used for symptomatic management of OSF. While traditional spinal braces aim to maintain the neutral spinal alignment and reduce the axial loading on the fractured vertebrae, they are well known for complications including discomfort with reduced compliance, atrophy of paraspinal muscles, and restriction of chest expansion leading to chest infections. Exoskeletons have been developed to passively assist and actively augment human movements with different types of actuators. Flexible, versatile spinal exoskeletons are designed to better support the spine. As new technologies enable the development of motorized wearable exoskeletons, several types have been introduced into the medical field application. We have provided a thorough review of the current spinal robotic technologies in this paper. The shortcomings in the current spinal exoskeletons were identified. Their limitations on the use for patients with OSF with potential improvement strategies were discussed. With our current knowledge of spinal orthosis for conservatively managed OSF, a semi-rigid backpack style thoracolumbar spinal robotic orthosis will reduce spinal bone stress and improve back muscle support. This will lead to back pain reduction, improved posture, and overall mobility. Early mobilization is an important part of management of patients with OSF as it reduces the chance of developing complications related to their immobile state for patients with OSF, which will be helpful for their recovery.

Use of corticosteroids is not associated with repeated vertebroplasty or kyphoplasty within one year after the surgery in patient older than 50 years

OBJECTIVE

The aim of this study was to investigate whether corticosteroid use increases the incidence of repeated PVP or kyphoplasty patients older than 50 years.

METHODS

This study enrolled the data of 2,753 eligible patients from the Taiwan National Health Insurance Research Database who were exposed to systemic corticosteroids for at least 3 months during the first year preceding the first PVP or kyphoplasty. These steroid users were matched 1:1 in age, sex, and the index date of surgery with non-user controls during the enrollment period. All patients were followed for 1 year after the first PVP or kyphoplasty. The incidence of repeated PVP or kyphoplasty was compared between the steroid users and controls. A Cox proportional hazards model was developed to account for multiple confounding factors.

RESULTS

The number of patients receiving repeated PVP or kyphoplasty was 233 (8.46%) and 205 (7.45%) in the corticosteroid and control groups, respectively. The Cox proportional hazards model revealed no association between corticosteroid use and repeated PVP or kyphoplasty.

CONCLUSIONS

Systemic corticosteroid use for longer than 3 months is not associated with repeated PVP or kyphoplasty within one year of surgery in patient older than 50 years old.

LEVEL OF EVIDENCE

Level III, Therapeutic study.

The Efficacy of Fentanyl Transdermal Patch as the First-Line Medicine for the Conservative Treatment of Osteoporotic Compression Fracture

Objective

There are no strong guidelines on how long or how we should undertake conservative treatment during the acute period of an osteoporotic vertebral compression fracture (VCF).

Methods

We treated 202 patients with conservative treatment on VCF from March 2012 to August 2015. On inclusion criteria, 75 patients (22 males and 53 females) were included in the final analysis. After admission, a transdermal fentanyl patch with low dose (12.5 µg) application was attempted in all patients. In an unresponsive patient, the fentanyl patch was increased by 25 µg. After identifying the tolerable toilet ambulation of the patient without any assistance, hospital discharge was recommended. We classified two patient groups into one favorable group and one unfavorable group and compared several clinical and radiological factors.

Results

Among 75 patients, the clinical outcome of 57 patients (76%) was favorable, but that of 18 patients (24%) was unfavorable. In clinical outcomes, the numeric rating scale at 6 and 12 months and Odom's criteria at 12 months was significantly different between the favorable and the unfavorable groups. The dose of the patches used showed statistically significant differences between the two groups (p=0.001).

Conclusion

The only statistically significant affecting factor for an unfavorable outcome was the use of a higher dose fentanyl patch. Our data inferred that the unresponsiveness to a low-dose fentanyl patch could be helpful to select patients necessary for percutaneous vertebroplasty or kyphoplasty.

Non-surgical management of acute osteoporotic vertebral compression fracture: A review

Osteoporosis is a major public health problem. Last decade has seen rise in osteoporotic vertebral fractures. Pragmatic management of osteoporotic VCF is challenging to the surgeons. In clinical settings, the situation becomes more complex when it comes to managing painful osteoporotic vertebral compression fractures (VCFs) due to various co-morbid factors that may limit aggressive interventions. Patients with Osteoporotic vertebral fractures are often characterized by general/relative immobility and physical frailty. Osteoporotic VCF not only affects the quality of life (e.g. pain) but also decreases the lifespan of the individual. The present review critically evaluates the currently prevailing non-surgical management modalities (conservative) offered in acute symptomatic osteoporotic VCFs that occur either within (0-5 days) of any incident event or present with the onset of symptoms such as pain.

Patient variables and referral paradigms associated with osteoporosis screening and treatment in neurosurgical patients undergoing kyphoplasty

OBJECT Vertebral fractures are the most common osteoporotic fracture. Bone density testing and medical treatment with bisphosphonates or parathormone are recommended for all patients with an osteoporotic fracture diagnosis. Inadequate testing and treatment of patients presenting with low-impact fractures have been reported in various specialties. Similar data are not available from academic neurosurgery groups. The authors assessed compliance with treatment and testing of osteoporosis in patients with vertebral compression fractures evaluated by the authors' academic neurosurgery service, and patient variable and health-systems factors associated with improved compliance. METHODS Data for patients who underwent percutaneous kyphoplasty for compression fractures was retrospectively collected. Diagnostic and medical interventions were tabulated. Pre-, intra-, and posthospital factors that had been theorized to affect the compliance of patients with osteoporosis-related therapies were tabulated and statistically analyzed. RESULTS Less than 50% of patients with kyphoplasty received such therapies. Age was not found to correlate with other variables. Referral from a specialist rather than a primary care physician was associated with a higher rate of bone density screening, as well as vitamin D and calcium therapy, but not bisphosphonate/parathormone therapy. Patients who underwent preoperative evaluation by their primary care physician were significantly more likely to receive bisphosphonates compared with those only evaluated by a hospitalist. Patients with unprovoked fractures were more likely to undergo multiple surgeries compared with those with minor trauma. CONCLUSIONS These results suggest poor compliance with current standard of care for medical therapies in patients with osteoporotic compression fractures undergoing kyphoplasty under the care of an academic neurosurgery service.

Osteoporotic vertebral fractures: current concepts of conservative care

INTRODUCTION

Osteoporotic vertebral compression fractures (VCFs) are a growing public health problem with important socio-economic effects in western countries. In the USA, 10 million people over 50 suffer from osteoporosis. In these patients, 1.5 million annual fractures have been registered, and 50% of these are vertebral compression.

SOURCES OF DATA

We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL and Embase databases using various combinations of the keywords 'osteoporosis', 'vertebral compression fractures', 'brace', 'bracing', 'orthosis', 'conservative management' and 'rehabilitation' over the years 1966-2011. All articles relevant to the subject were retrieved, and their bibliographies were hand searched for further references in the context of conservative management of osteoporotic vertebral fractures.

AREAS OF AGREEMENT

Conservative management for patients with osteoporotic vertebral fractures includes bed rest, pain medication, physiotherapy and bracing.

AREAS OF CONTROVERSY

A conservative management for patients with osteoporotic VCFs s has not been standardized. The utility of vertebral augmentation techniques has been questioned by recent randomized controlled trials.

GROWING POINTS

Randomized controlled trials are being performed worldwide on vertebral augmentation techniques.

AREAS TIMELY FOR DEVELOPING RESEARCH

Although spinal orthoses are commonly used for the management of patients with osteoporotic vertebral fractures, in the literature there is only one randomized controlled trial on bracing for this condition. While the best conservative management for subjects with osteoporotic VCFs s is not defined and standardized, no conclusions on the superiority of vertebral augmentation techniques over conservative management can be drawn.

Conservative management of patients with an osteoporotic vertebral fracture

Osteoporotic vertebral compression fractures (VCFs) are an increasing public health problem. Recently, randomised controlled trials on the use of kyphoplasty and vertebroplasty in the treatment of these fractures have been published, but no definitive conclusions have been reached on the role of these interventions. The major problem encountered when trying to perform a meta-analysis of the available studies for the use of cementoplasty in patients with a VCF is that conservative management has not been standardised. Forms of conservative treatment commonly used in these patients include bed rest, analgesic medication, physiotherapy and bracing.

In this review, we report the best evidence available on the conservative care of patients with osteoporotic VCFs and associated back pain, focusing on the role of the most commonly used spinal orthoses. Although orthoses are used for the management of these patients, to date, there has been only one randomised controlled trial published evaluating their value. Until the best conservative management for patients with VCFs is defined and standardised, no conclusions can be drawn on the superiority or otherwise of cementoplasty techniques over conservative management.

Predictors and prevalence of patients undergoing additional kyphoplasty procedures after an initial kyphoplasty procedure

BACKGROUND CONTEXT

Vertebral cement augmentation, including kyphoplasty, has been shown to be a successful treatment for pain relief for vertebral compression fracture (VCF). Patients can sustain additional symptomatic VCFs that may require additional surgical intervention.

PURPOSE

To examine the prevalence and predictors of patients who sustain additional symptomatic VCFs that were treated with kyphoplasty.

STUDY DESIGN

A retrospective review of patients who previously underwent kyphoplasty for VCFs and had additional VCFs that were treated with kyphoplasty.

PATIENT SAMPLE

A total of 256 patients underwent kyphoplasty for VCFs from 2000 to 2007 at a single medical center.

OUTCOME MEASURES

The outcome measure of interest was the need for an additional kyphoplasty procedure for a symptomatic VCF.

METHODS

Risk factors such as age, sex, smoking status, and steroid use were assessed, as well as bisphosphonate use. Sagittal spinal alignment via Cobb angles for thoracic, thoracolumbar, and lumbar regions was assessed.

RESULTS

About 22.2% of the patients had an additional symptomatic VCF that was treated with a kyphoplasty procedure. Steroid use was the only significant risk factor for predicting patients with additional symptomatic VCFs who underwent additional kyphoplasty. The average time to the second VCF was 33 days. Adjacent-level VCFs were most common in the thoracic and thoracolumbar spine. Bisphosphonate use was not shown to be protective of preventing additional VCFs during this follow-up period.

CONCLUSION

This is the first single-center review of a large cohort of patients who underwent additional-level kyphoplasty for symptomatic VCFs after an index kyphoplasty procedure. Our results suggest that patients with a VCF who use chronic oral steroids should be carefully monitored for the presence of additional symptomatic VCFs that may need surgical intervention. Patients with prior thoracic VCFs who have additional back pain should be reevaluated for a possible adjacent-level fracture.

CT fluoroscopically guided percutaneous placement of transiliosacral rod for sacral insufficiency fracture: case report and technique

Treatment of sacral insufficiency fractures (SIFs) has traditionally been conservative, but several patients have been treated with percutaneous sacroplasty. Unfortunately, in the setting of severe, bilateral SIFs, cement may not withstand shear forces present at the lumbosacral junction, and surgical hardware may not provide adequate fixation in osteoporotic, cancellous bone of the sacrum, leading to eventual pseudarthrosis. Thus, we propose a novel technique in which guidance with CT fluoroscopy allows placement of a transiliosacral bar in conjunction with sacroplasty.

Vertebroplasty and Kyphoplasty

Percutaneous vertebroplasty and kyphoplasty provide minimally invasive options for the management of osteoporotic and osteolytic vertebral compression fractures. These techniques provide substantial pain relief and support without requiring long periods of recumbency, and have an acceptable complication rate. Vertebral augmentation techniques such as vertebroplasty and kyphoplasty provide pain relief and improvement in quality of life in the highly selected patient. Complications can be avoided with careful surgical technique, and good outcomes can be achieved with proper patient selection.

Osteoporotic compression fractures of the spine; current options and considerations for treatment

BACKGROUND CONTEXT

Vertebral compression fractures affect at least one-fourth of all postmenopausal women. The most significant risk factor is osteoporosis, most commonly seen among Caucasian women a decade or so after menopause. Osteoporosis typically results from inadequate accumulation of bone mass during childhood and early adulthood followed by rapid resorption after menopause. Primary treatment of osteoporosis includes consideration of underlying metabolic abnormalities and provision of supplemental calcium/vitamin D in conjunction with bisphosphonates or calcitonin, or both. Routine hormone replacement therapy has fallen out of favor because of concerns regarding adverse effects identified in long-term follow-up studies. Acute osteoporotic vertebral compression fracture management includes bracing, analgesics, and functional restoration. Patients with chronic pain beyond 2 months may be appropriate candidates for vertebral body augmentation, ie, vertebroplasty or balloon tamp reduction. Open surgical management with decompression and stabilization should be reserved for the rare patient with neural compression and progressive deformity with neurologic deficits.

PURPOSE

To review current principles in the evaluation and treatment of osteoporotic compression fractures of the spine.

STUDY DESIGN/SETTING

A literature review on management of the osteoporotic spine.

METHODS

MEDLINE search of all English-language literature published between 1981 and 2005 on surgical and nonsurgical treatment of the osteoporotic spine. The references selected for listing at the conclusion of this review are those containing specific information cited within the text.

RESULTS

Over 200 separate scientific and clinical studies addressing the epidemiology, pathophysiology, diagnosis, and treatment of osteoporotic vertebral compression fractures were reviewed.

CONCLUSIONS

Osteoporotic vertebral compression fractures are a common presenting complaint to spinal care specialists. Thorough differential diagnosis should be considered before attributing fractures to osteoporosis. Appropriate evaluation and medical treatment of underlying osteoporosis should be recommended or instituted. Nonsurgical management of the spinal fracture should focus on pain control and maximizing functional outcome. The role of surgical treatment remains controversial and should be reserved for patients who fail initial nonsurgical management options.

Reduced risk of back pain following teriparatide treatment: a meta-analysis

Vertebral fractures are the most common osteoporotic fracture and may result in back pain with functional limitations and diminished quality of life. Teriparatide [rhPTH (1-34)] has been shown to increase bone mass and reduce the risk of vertebral and other osteoporotic fractures. The aim of this study was to evaluate the effects of teriparatide on the risk of back pain in patients with osteoporosis. A systematic review of the literature was performed, and five trials were identified and included in our analyses. All trials were randomized, double-blinded, and parallel with either new vertebral fracture (n=1) or bone mineral density as the primary endpoint (n=4). Four studies were in postmenopausal women with osteoporosis, and one was in men with idiopathic or hypogonadal osteoporosis. Two trials were placebo controlled, two trials were alendronate controlled, and one trial involved teriparatide plus hormone replacement therapy versus hormone replacement therapy alone. Reports of back pain, defined as new or worsened back pain after initiating the study drug, were obtained from adverse event databases, and the risk of back pain was analyzed using a multivariate Cox proportional hazards model. Results were not statistically heterogeneous (P=0.60) across trials, and there were no differences between groups administered teriparatide 20 or 40 mcg/day doses (P=0.64). The rates of back pain, moderate or severe back pain, and severe back pain per 100 patient-years were numerically lower in the teriparatide versus comparator groups in each study. Compared with the pooled comparator, patients in the pooled teriparatide group had reduced risk for any back pain [relative risk, 0.66 (95% CI, 0.55-0.80)], moderate or severe back pain [relative risk, 0.60 (95% CI, 0.48-0.75)] and severe back pain [relative risk, 0.44 (95% CI, 0.28-0.68)]. Separate meta-analyses comparing teriparatide versus placebo or antiresorptive drugs gave similar results. In conclusion, patients randomized to teriparatide had a reduced risk of new or worsening back pain compared to patients randomized to placebo, hormone replacement therapy or alendronate.

Kyphoplasty treatment of vertebral fractures: 2-year outcomes show sustained benefits

STUDY DESIGN

Retrospective single-center consecutive case series with two [corrected] year follow-up.

OBJECTIVES

To examine kyphoplasty [corrected] patients for long-lasting clinical and radiological outcomes [corrected] including effects on [corrected] vertebral body shape.

SUMMARY OF BACKGROUND DATA

Kyphoplasty is the minimally-invasive [corrected] reduction and stabilization of vertebral body fractures [corrected] resulting in pain relief and improved physical function as described in our previously published one-year outcomes report [corrected]

METHODS

Safety (complications and cement extravasation) was monitored in all 117 patients (151 fractures) treated through December 2001. Preoperative and postoperative VAS [corrected] pain scores, analgesia usage, and ambulatory status were compared in 77 [corrected] of these patients with at least two-year [corrected] follow-up. Anterior, midline, posterior vertebral body heights, and height ratios from this cohort were assessed pre-operatively, [corrected] immediately postoperative [corrected] and after 2 years of follow-up.

RESULTS

Pain scores, patient ability to ambulate independently and without difficulty, and need for prescription pain medications improved significantly (P < 0.001) after kyphoplasty [corrected] and remained unchanged or improved at 2 years [corrected] Vertebral heights significantly (P < 0.001) [corrected] increased at all postoperative intervals, with > or = 10% height increases in 84% [corrected] of fractures. Morphometric height ratios for treated fractures also significantly increased (P < 0.001): 0.67 +/- 0.24 to 0.81 +/- 0.21 and 0.64 +/- 0.24 [corrected] to 0.83 +/- 0.11. Asymptomatic cement extravasation occurred in 11.3% of fractures, and during the follow-up period [corrected] additional fractures occurred in previously untreated levels at a rate of 4.5% per year. There were no kyphoplasty-related [corrected] complications.

CONCLUSIONS

Kyphoplasty markedly improves clinical outcome [corrected] and results in significant vertebral height restoration and normalization of morphologic shape indices [corrected] that remain stable for at least two [corrected] years following treatment.

Undertreatment of osteoporosis in residents of nursing homes: population-based study with use of the Systematic Assessment of Geriatric Drug Use via Epidemiology (SAGE) database

OBJECTIVE

To determine the proportion of nursing home residents >65 years of age with osteoporosis who were receiving antiosteoporosis pharmacotherapy and to identify the predictors of administration of such drugs.

METHODS

We identified 29,357 patients with osteoporosis documented on the Minimum Data Set collected on residents of all nursing home facilities in 5 states during the period from 1992 through 1996. A multiple logistic regression model was used for analysis, with the dependent variable being use of any antiosteoporosis drug.

RESULTS

Among the nursing home residents with osteoporosis, 25% received antiosteoporosis drugs. Women were more likely than men to receive antiosteoporosis drugs (adjusted odds ratio [OR], 1.41; 95% confidence interval [CI], 1.26 to 1.57). Both increasing age and level of cognitive impairment were inversely related to receipt of antiosteoporosis drugs. A history of fracture or falls was not predictive of use of such drugs. Treatment was less likely for nursing home residents with > or = 6 medical conditions (OR 0.55, 95% CI 0.51 to 0.59); those admitted to a nursing home from a hospital (OR 0.86, 95% Cl 0.80 to 0.92); and those with a terminal prognosis (OR 0.60,95% CI 0.42 to 0.87).

CONCLUSION

The majority of nursing home residents with osteoporosis in this study did not receive drug therapy for this disabling and treatable disease. Although acceptable reasons may exist in some of these residents,others--especially the oldest old--may not be receiving adequate care.