FAQ Category: Thoracic Spine

According to a recent study by Bailey et al in 2015, treatment of a thoracolumbar burst fracture can include a brace or not with equivalent results. The group utilizing the brace was instructed to wear it at all times, unless in bed, for ten weeks, with a weening out period after eight weeks. In both groups there was a lifting limitation of less than five pounds, and no bending past ninety degrees at the hips for eight weeks. However you should always ask your physician for their specific instructions about use of the brace following your injury, as individual circumstances may indicate a different course of treatment.

In the past, recovery from a burst fracture in the thoracolumbar region could include any combination of significant bed rest, surgery, and a brace (orthosis). However, recent treatments have been moving away from these due to the increased costs and risks of surgery and bed rest. In a recent study by Bailey et al they demonstrated that there was no difference between treatment of this injury with or without a brace. The treatment for both groups included a lifting restriction of less than five pounds, and a bending restriction not past ninety degrees at the waist. Neither group was instructed in bed rest and restrictions were lifted after eight weeks. The results of this study indicate that neither a brace or significant bed rest is required for safe recovery. It is important however to discuss your injury with your physician because there can be individual circumstances which would call for different course of treatment.

Ultimately this is up to the treating physician. Recent research has demonstrated that stable benign osteoporotic compression fractures treated without a brace did not result in inferior outcomes in patient disability as compared to soft or rigid-brace treatments.

Yes, as far as thoracolumbar injuries, a burst fracture in this region has been shown to make up 20 per cent of all thoracolumbar injuries.

A burst fracture is a more severe form of compression fracture that typically occurs from a high energy axial load (i.e. car accident, fall from a high height). The vertebral body can be crushed in all directions causing a bursting of fragments which can cause neurologic deficit.

DISH stands for diffuse idiopathic skeletal hyperostosis. This means there is a presence of ossification of your soft tissue along the front and side portion of your spine in the lower thoracic and upper lumbar region. Usually this occurs between four continuous segments.

We are unable to answer this at this time as further investigation needs to occur through longitudinal studies.

People experience pain for months after motor vehicle collision. The time frames vary between individuals. This is something to discuss with your medical provider.

Yes, it is possible. In this study some of the herniations were thought to be from before the injury but only after the motor vehicle collision did the herniations become symptomatic.

There are several ways to treat older adults who suffer pain, loss of height, and disability from osteoporotic vertebral compression fractures. For some patients, pain relief and quality of life can still be improved with conservative care. This may include physical therapy, rest, pain relieving medications, and sometimes a brace or cast. This approach is still usually the first recommendation.

Balloon kyphoplasty is considered an invasive procedure and therefore reserved for those individuals who have persistent pain (which is usually severe). As you probably know from the treatment she received two years ago, with a balloon kyphoplasty, the surgeon inserts a thin needle into the fractured vertebra (spinal bone).

There is a deflated balloon on the end of the needle. The balloon is placed inside the vertebra and inflated to restore the height of the bone. The balloon is pulled out and a liquid cement is injected into the space formed by the inflated balloon. When the cement hardens, the compressed vertebral body expands, restoring height of the bone and relieving pain.

But there have been problems with cement leakage. The cement can ooze out through the fracture lines or enter into the blood vessels. The result can be direct injury to the nerves and/or blood vessels, causing paralysis or blood clots. Rigidity of the bone from the cement can also lead to new fractures.

These problems with balloon kyphoplasty have sent researchers back to the drawing board for new ideas. Scientists have experimented with finding better cements. Surgeons have tried using less cement. Companies making surgical instruments have designed better needles.

And now, a new device called KIVA has been invented to restore vertebral height. Both balloon kyphoplasty (BK) and KIVA are considered augmentation devices. They both restore bone height in different ways. Whereas BK is an inflated balloon that leaves a space that can be filled with cement, KIVA is a system of coils placed inside the bone using much less cement. The coils can be stacked on top of each other to re-elevate the ends of the vertebral bone. This type of system creates a uniform cylinder shape so that when the cement is injected into the bone, there is even distribution from front to middle to back.

Studies are being done comparing results using the KIVA implant with results using the balloon kyphoplasty. In a recent study from Greece, the surgeons used a variety of different ways to measure and compare results using these two techniques. X-rays and CT scans were used to view vertebral height and look for wedging of the vertebral bones.

If the entire vertebral body is not restored (front, middle, and back), the front of the bone remains collapsed. An X-ray taken from the side will show the fractured vertebra looks like a pie-shaped wedge. Unless the full vertebral body is restored, any wedging causes spinal deformity and kyphosis (spine curved forward). The extra compression on the bone can lead to pressure on the spinal cord, spinal nerves, and/or lead to new fractures.

Other ways they measured and compared results included amount of cement leakage, complications from cement leakage, pain levels, and patients’ perception of quality of life. Kyphotic spinal angle and cement leakage were measured digitally using a special e-film software. The software made it possible to measure even one-degree of difference in spinal alignment.

Patients were followed for just slightly more than one year (13 to 15 months). Results showed that patients in both groups did get significant pain relief and improved physical function. Both treatment approaches restored vertebral height. But only the KIVA implant was able to prevent kyphosis in the spine. The number of new fractures was about the same between the two groups.

But the big difference was that cement leakage was much less with the KIVA. And cement leakage with the KIVA was always outside the spinal canal with less risk of neurologic damage. In fact, there were two cases of intracanal (inside the spinal canal) leakage with balloon kyphoplasty (BK) (and none with the KIVA implant). Those two BK patients had to have emergency surgery to avoid being paralyzed for life.

The authors concluded by restating there is a need to improve on balloon kyphoplasty. Cement leakage is a problem. Sometimes the balloon deflates too much before the cement is injected into the space. Loss of vertebral height (especially when there is wedging) can lead to spinal deformity, more pain, and another fracture.

The new KIVA implant may help overcome some of these problems. There were better results with the KIVA over balloon kyphoplasty in two areas: less kyphosis and less cement leakage. The KIVA device doesn’t push and crush the bone like the balloon does. And there is very low pressure with the KIVA to form an evenly round cement column inside the bone.

More studies are needed to see if the better results with KIVA over balloon kyphoplasty (BK) stand up to the test of time. This study was short-term at best (follow-up slightly more than one year). Following patients longer and assessing back pain, quality of life, and new fractures are the next steps before KIVA devices can be recommended over other treatment approaches.

Although your mother’s surgeon may not be using the KIVA, it doesn’t hurt to ask what he or she knows about the latest treatments and what is recommended for your mother. Conservative (nonoperative care) may be the best option for now. Or a second balloon kyphoplasty may be recommended. At least with this new information in hand, you know what challenges the surgeon is facing in providing the best treatment with the fewest complications.

This is a good question that deserves an answer. Osteoporosis (decreased bone density) that affects all the bones should be addressed with treatment (usually medication and specific exercises). But the immediate problem must be dealt with first — to provide pain relief if nothing else.

Patients with painful vertebral compression fractures tend to give in to their pain. They find that a stooped, flexed forward posture helps take pressure off the spinal nerves and is more comfortable than standing up straight. Unfortunately, the stooped posture accompanied by spinal kyphosis (forward curvature of the spine) can lead to spinal deformity and more pressure on the bones.

Restoring vertebral height with the balloon kyphoplasty procedure addresses the fracture-related pain and the kyphotic deformity. As you suspect, it doesn’t always mean prevention of other fractures from developing. In fact, cement leakage and increased rigidity from the procedure are two problems surgeons are still trying to address in an effort to reduce new fractures.

The bottom line is that vertebral compression fractures from osteoporosis cause disabling pain and deformity. These two factors together negatively affect a person’s physical function and ultimately reduce quality of life. Stop-gap measures like balloon kyphoplasty are offered to patients who do not respond well to conservative care and who therefore end up with persistent pain. Balloon kyphoplasty isn’t always accompanied by complications and it can be a very successful treatment technique.

One thing you can do as a family for your father is to support him through this rough spot. Make sure he receives adequate treatment for the underlying osteoporosis that is affecting the other bones. Follow-up is important — and with osteoporosis, follow-up is for the rest of his life, not just until the immediate crisis is over.

His primary care physician will be able to direct and guide you as to what is needed whether that is medication, an exercise program, or other avenues of treatment. A physical therapist can get him set up on a home program for the exercise program specific to osteoporosis, monitor his strength, and aid in improving posture. There is much that can be done for osteoporosis to prevent future problems from developing.

Vertebral compression fracture refers to a mini-collapse of a vertebra in the spine. Tiny fracture lines in the bone (usually the front half of the vertebra) result in the bone taking on a wedge- or pie shape when viewed on X-rays from the side.

This type of fracture is most common in older adults who have osteoporosis (decreased bone mass or brittle bones). Just the weight of the body and pressure from postural changes (stooped head and shoulders) can put enough pressure (or compression, hence the name compression fracture) on the bone to cause a collapse.

The balloon kyphoplasty procedure is designed to restore height of the fractured and collapsed vertebra.

Two long needles are inserted through one or both sides of the spinal column into the fractured vertebral body. These needles guide the surgeon while drilling two holes into the vertebral body. The surgeon uses a fluoroscope (special 3-D real-time X-rays) to make sure the needles and drill holes are placed in the right spot.

The surgeon then slides a hollow tube with a deflated balloon on the end through each drill hole. Inflating the balloons restores the height of the vertebral body and corrects the kyphosis deformity. Before the procedure is complete, the surgeon injects bone cement into the hollow space formed by the balloon. The cement is injected a little bit at a time until the cavity is filled. They try to keep most of the cement in the front three-fourths of the vertebral body. This fixes the bone in its corrected size and position and supports the front part that has collapsed the most.

This procedure halts severe pain and strengthens the fractured bone. However, it also gives the advantage of improving some or all of the lost height in the vertebral body, helping prevent or correct kyphosis. It does not, however, prevent a second or subsequent fracture from occurring at the next (adjacent) level. In fact, there is some concern that the kyphoplasty might actually increase the risk of another vertebral compression fracture.

There is no doubt that the kyphoplasty procedure reduces acute pain and improves mobility because of the pain reduction. This is an important feature for the older adult who is also concerned about losing function and independence. But as you suggested, there are some potential complications with this procedure. Bleeding, cement leakage, spinal infection, rib fractures, and pulmonary embolism (blood clot to the lungs) head the list of possible problems.

When cement injected into the vertebral body leaks out, it hardens and can put pressure on the spinal cord and/or spinal nerves. Leakage into the disc space puts pressure on the vertebral bodies potentially increasing the risk of adjacent segment collapse. Studies show that about 20 per cent (one in five patients) will experience a second (recurrent) vertebral compression fracture after kyphoplasty.

Many patients consider it worth the risk in order to gain pain relief and improved quality of life and maintain their current level of activity and independence.

Vertebral compression fracture refers to a mini-collapse of a vertebra in the spine. Tiny fracture lines in the bone (usually the front half of the vertebra) result in the bone taking on a wedge- or pie shape when viewed on X-rays from the side.

This type of fracture is most common in older adults who have osteoporosis (decreased bone mass or brittle bones). Just the weight of the body and pressure from postural changes (stooped head and shoulders) can put enough pressure (or compression, hence the name compression fracture) on the bone to cause a collapse.

The balloon kyphoplasty procedure is designed to restore height of the fractured and collapsed vertebra.

Two long needles are inserted through one or both sides of the spinal column into the fractured vertebral body. These needles guide the surgeon while drilling two holes into the vertebral body. The surgeon uses a fluoroscope (special 3-D real-time X-rays) to make sure the needles and drill holes are placed in the right spot.

The surgeon then slides a hollow tube with a deflated balloon on the end through each drill hole. Inflating the balloons restores the height of the vertebral body and corrects the kyphosis deformity. Before the procedure is complete, the surgeon injects bone cement into the hollow space formed by the balloon. The cement is injected a little bit at a time until the cavity is filled. They try to keep most of the cement in the front three-fourths of the vertebral body. This fixes the bone in its corrected size and position and supports the front part that has collapsed the most.

This procedure halts severe pain and strengthens the fractured bone. However, it also gives the advantage of improving some or all of the lost height in the vertebral body, helping prevent or correct kyphosis. It does not, however, prevent a second or subsequent fracture from occurring at the next (adjacent) level. In fact, there is some concern that the kyphoplasty might actually increase the risk of another vertebral compression fracture.

One reason for this is the oozing cement you mentioned. Leakage of the stiff cement into the disc area of a person with osteoporosis increases the stress and load on the endplate. The endplate is a cartilaginous structure between the disc and the vertebral bone. Any change in the forces placed on the endplate are translated to the adjacent vertebral bone. Studies clearly show that cement leakage increases the risk of a second (recurrent) vertebral compression fracture.

But there may be other risk factors that contribute to adjacent compression fractures. Another possible reason for recurrent vertebral fractures is bone metabolism. Decreased bone mineral density from altered bone metabolism may be an important risk factor in compression fractures. Other possible variables include age, body mass index, history of tobacco use, and the use of antiosteoporosis medications.

So, although cement leakage is an important risk factor in recurrent vertebral compression fractures, it isn’t the only one. Altered bone metabolism combined with cement leakage may double the risk but the exact proportion of influence from each one has not been determined.

Surgical treatment of burst fractures has been reported successful in the majority of patients. The most likely surgical approach is spinal fusion. The fusion may (or may not) require the use of hardware such as metal plates, rods, screws or wires. Use of these devices is called instrumentation or fixation.

The real challenge is in deciding which approach to use (anterior, posterior, or a combination of both) for the best results. A new classification system has been developed to help guide surgeons in this decision-making process. It is called the Thoracolumbar Injury Classification and Severity (TLICS) System.

The TLICS guides the surgeon in making the best decision for each individual patient. It takes into consideration 1) the type of fracture you have and 2) any neurologic problems present as a result of the fracture. The TLICS also takes into account 3) whether or not the ligaments supporting the spine are damaged leaving the spine unstable.

The goal of surgery is to stabilize the spine but also provide long-lasting good spinal alignment without deformity or loss of correction. After surgery, loss of spinal alignment and the development of spinal deformities can be evaluated and given a number based on severity. Likewise, neurologic status and spinal stability can be rated and classified.

The TLICS system is a reliable and evidence-based tool for directing treatment of thoracolumbar burst fractures. It doubles as a guiding tool for who needs surgery and will eventually reveal which surgery is advised for each patient.

The added value of such a system is in tracking the results of minimally invasive surgeries. And minimally invasive can mean less time in surgery, low blood loss, faster return-to-home, and fewer neurologic complications. Metal rods placed in the spine can (and sometimes do) break or shift position. Predicting when this might happen has not been possible until now.

A tool like the TLICS can be used in research to study optimal surgical methods for burst fractures. Surgeons can use this tool to track results and compare them when using one of several different surgical techniques. In the future, it may be possible to predict who will develop specific types of complications like rod breakage. For now surgeons rely on their experience and knowledge or certain risk factors (e.g., brittle bones) when making treatment decisions about when to use fixation devices and what type are best.

It is possible these days to evaluate each patient for severity and stability (or instability) of spinal fractures. A special tool called the Thoracolumbar Injury Classification and Severity (TLICS) System.

The TLICS guides the surgeon in making the best decision for each individual patient. It takes into consideration 1) the type of fracture you have and 2) any neurologic problems present as a result of the fracture. The TLICS also takes into account 3) whether or not the ligaments supporting the spine are damaged leaving the spine unstable.

Not all burst fractures require surgical treatment. Some can be treated with conservative (nonoperative) care. The question is: who needs surgery and who doesn’t? Are there ways to predict the most optimal treatment?

The score given to each patient assigns a value from zero to three for each of the three categories mentioned. A total score of three or less suggests conservative care without surgery is possible. Patients with a score of five will need surgery. Anyone with a four falls in a gray zone that requires careful consideration of all the individual patient factors. Surgeon experience, judgment, and expertise are required for these “inbetween” cases.

Patients like yourself who have osteoporosis (brittle bones) are prone to compression fractures in the vertebrae (spinal bones). The front of a vertebra cracks under pressure, causing it to collapse in height. More than 700,000 such fractures occur every year in the United States. These fractures can be asymptomatic (no symptoms). But more often, they cause debilitating pain, poor back posture, and difficulty completing routine activities.

The surgical procedure you are considering (called vertebroplasty) is used to help with this problem . The surgeon uses a special type of X-ray called fluoroscopy to insert a long, thin needle through the skin and soft tissues directly into the fractured vertebra.

A special bone cement, called polymethylmethacrylate (PMMA), is then injected through the needle into the fractured vertebra. A chemical reaction in the cement causes it to harden in about 15 minutes. This fixes the bone so it can heal.

Vertebroplasty restores the strength of the fractured bone, thereby reducing pain quickly. More than 80 percent of patients get immediate relief of pain with this procedure. It is a simple procedure that can be done under a local anesthesia. But there can be problems such as damaging nerves nearby, infection, and blood clot formation.

One other complication has recently been brought to light and that is vertebral fracture after vertebroplasty. Studies show there is a range of frequency for this problem that extends from 12 to 52 per cent. Fifty-two per cent is significantly high. Studies are underway to investigate what is causing this and to look for risk factors we can do something about.

You will want to sit down with your surgeon and weigh all the pros and cons of this procedure for yourself. Besides increasing the height of your vertebra and helping restore normal alignment and posture, this procedure has the capability of improving lung function and digestion. It can also restore sleep for some patients and even improve depression. These are all important benefits of this procedure.

You are asking about the natural history of a condition still called Scheuermann’s disease or Scheuermann’s kyphosis. Scheuermann’s disease (also called Scheuermann’s kyphosis) is named after the physician who first described the condition. It is an excess of thoracic kyphosis (when viewed from the side, this is a C-shaped curvature of the mid-back). The section of spine from below the neck to the bottom of the rib cage is called the thoracic spine.

From the side, the thoracic spine appears slightly rounded. Its shape is like the letter “C” with the opening facing the front of the body. This normal curve is called kyphosis. With excessive kyphosis, the thoracic spine takes on a hunchbacked appearance. With Scheuermann’s kyphosis, there is wedging of five-degrees or more affecting at least three consecutive vertebrae. The structural changes that form this type of hyper-kyphosis are seen on X-rays.

In a recently published article, surgeons from the Combined Orthopaedics Residency Program at Harvard Medical School put together a review of the evaluation and management of Scheuermann’s kyphosis for adults. They included discussion of who is affected, cause of the disease, pathogenesis (what happens with this condition), and clinical presentation (signs and symptoms).

What is the natural history of Scheuermann’s? Besides having a forward curved spine, most people affected by Scheuermann’s report back pain, stiffness, and loss of flexibility. The neck and low back try to compensate by increasing the natural lordotic curves in these two areas. Since the person cannot straighten the thoracic spine, the cervical and lumbar spines increase their curves to compensate for the round back. All of these changes in posture are usually accompanied by tight shoulder, hip, and leg muscles.

There is an increased awareness of physical appearance among those adults with Scheuermann’s. Those who do not get proper treatment for the condition during childhood often experience severe back pain from the spinal deformity as adults.

Studies over three decades (30 years) reveal varying results. Some studies have shown that adults with Scheuermann’s are just as well-educated as those of similar age who don’t have this condition. Although adults with Scheuermann’s kyphosis have less demanding jobs compared with the age-matched control group, the Scheuermann’s group do not miss work or use more pain medication than the control group.

Degenerative spondylosis is also reported as part of the natural history in middle-aged adults with Scheuermann’s kyphosis. Degenerative changes in the spine (usually from aging) can cause bone spurs to form around the spinal joints. The joint spaces start to narrow. This condition is called spondylosis.

Treatment for the adult with Scheuermann’s kyphosis may not be needed but ranges from conservative care with antiinflammatory medications and physical therapy to surgery to either keep the deformity from getting worse or possibly improve or correct the curvature. Physical therapy is a key part of the nonsurgical management of adult kyphosis.

Exercises to improve strength and posture won’t straighten the spine but will improve general conditioning and help reduce pain. Core training is an important part of the exercise management program. Some adults try using a brace but most do not like the brace because it is too confining and uncomfortable. Bracing is most likely to be recommended to or tried by adults who are not good candidates for surgery.

Surgery is primarily focused on providing patients with pain relief. This applies most often to those patients who have tried nonsurgical treatment without a change in their painful symptoms. In some cases, appearance is the main reason surgery is done. Spinal fusion is the most common surgical technique used for this condition.

Yes, Scheuermann’s disease is around. Some reports say that less than one percent of the U.S. population is affected. But there are other reports of an incidence up to 8.3 per cent. The disease occurs mostly in children between the ages of 10 and 12. But there are some cases in which Scheuermann’s develops in the adult years.

Scheuermann’s disease (also called Scheuermann’s kyphosis) is named after the physician who first described the condition. It is an excess of thoracic kyphosis (when viewed from the side, this is a C-shaped curvature of the mid-back). The section of spine from below the neck to the bottom of the rib cage is called the thoracic spine.

From the side, the thoracic spine appears slightly rounded. Its shape is like the letter “C” with the opening facing the front of the body. This normal curve is called kyphosis. With excessive kyphosis, the thoracic spine takes on a hunchbacked appearance. With Scheuermann’s kyphosis, there is wedging of five-degrees or more affecting at least three consecutive vertebrae. The structural changes that form this type of hyper-kyphosis are seen on X-rays.

The cause of this type of wedging deformity remains a mystery. During normal growth, the cartilage around the vertebral body changes evenly and completely to bone. If the change from cartilage to bone doesn’t happen evenly, one side of the vertebral body grows at a faster rate. By the time the entire vertebral body turns to bone, one side is taller than the other. This is the wedge shape that leads to abnormal kyphosis.

Dr. Scheuermann thought a lack of blood to the cartilage around the vertebral body caused the wedging. Though scientists have since disproved this theory, the root cause of the disease is still unknown. Current theories include osteoporosis as a cause, mechanical factors (abnormal biomechanical stresses on the bones), and/or tight hamstring muscles (along the back of the thigh). Above-average disc height, increased levels of growth hormone, and genetics have also been suggested as possible contributing factors/causes.

Although Scheuermann’s doesn’t affect a large number of children, it remains on the medical “radar” so-to-speak. It is a condition that will continue to be studied in order to understand its causes and effects. As with anything that develops in children, efforts are directed toward prevention first and treatment for those affected.

Vertebroplasty restores the strength of the fractured bone, thereby reducing pain quickly. More than 80 percent of patients get immediate relief of pain with this procedure. It is a simple procedure that can be done under a local anesthesia. But there can be problems such as damaging nerves nearby, infection, and blood clot formation.

One other complication is vertebral fracture after vertebroplasty. Studies show there is a range of frequency for this problem that extends from 12 to 52 per cent. Fifty-two per cent is significantly high. There must be some reason for this happening.

To help look for risk factors for vertebral fractures after vertebroplasty, surgeons from the Republic of China took a look back at 166 of their patients who had the vertebroplasty procedure. They analyzed the medical records to look for any common cause(s) that might explain this complication.

They found one major risk factor and that was the amount of cement injected into the bone. Too much cement (excess volume) was linked with problems later on down the road. In fact, in 38 per cent of their patients, fracture of another vertebra occurred within three months of the vertebroplasty procedure. Two-thirds of these fractures affected the next level vertebra (called the adjacent vertebra). The remaining one-third were remote fractures (farther away from the vertebra corrected with vertebroplasty).

This new understanding of the cause of future vertebral fractures after vertebroplasty comes with some challenges of its own. The higher volume of cement is often needed to correct the fractured and collapsed vertebra. In fact, the more cement is used the better deformity correction is possible. So, it’s not just a matter of using less cement.

Follow-up care after the vertebroplasty procedure may be an important feature in preventing future fractures. Surgeons often recommend patients wear a protective brace for three months after the injection. Medical treatment with calcium supplementation and medications to reduce bone loss should be started immediately. This approach is designed to help address the underlying problem of weak, brittle bones.

Physical therapy is also recommended. The therapist will help get you started on specific exercises known to improve osteoporosis. The therapist will help monitor your level of activity during recovery. You will likely be encouraged to modify activities that put force and load through the spine during the healing and recovery period with gradual increase after that. The physical therapist will address posture and body alignment, two key areas of focus in the treatment of osteoporosis and vertebral bone fractures.

Variations in the refracture rate could be linked with different ways patients handle the postoperative period. Although it looks as though cement volume is the only significant risk factor for refracture after vertebroplasty, further study is needed.

It’s possible that just getting older or having the osteoporosis could be enough to put someone at risk for another fracture. But since some patients do not have any further fractures, further analysis and study of this fracture-free group is needed. And a second feature that deserves further investigation is the fact that two-thirds of the fractures were adjacent, while one-third were remote. It remains unknown whether there is some significance to this finding.

Various theories have been suggested. For example, maybe some patients are more active than others. This could put more pressure and load through the vertebrae, thereby increasing the risk of a fracture. It’s possible that some patients did not wear the protective brace as prescribed. Brace wearing time and pattern of use could be a significant factor and should be studied further.

Since volume of cement seems to be the most significant risk factor, additional studies are also needed to determine the optimal volume of cement to use. Research may be able to uncover the minimum amount of cement needed to restore vertebral height as well as the maximum amount that can be safely used. Coming from a different approach, the authors also suggest measuring the angle of vertebral correction to see if there is an optimal kyphotic angle for vertebroplasties to be maximally successful with minimal complications.

The American Academy of Orthopaedic Surgeons (AAOS) has just released Clinical Practice Guidelines (CPGs) for the treatment of symptomatic (painful) spinal compression fractures. A brief summary of these guidelines is presented. These guidelines are based on research, published studies, and the resulting evidence currently available. The AAOS points out that all guidelines are intended to be used as one tool in the treatment decision. All patient characteristics and individual factors must be taken into consideration when making the final decision.

Compression fractures are the most common type of fracture affecting the spine. A compression fracture of a spine bone (vertebra) causes the bone to collapse in height. Compression fractures are commonly the result of osteoporosis (brittle bones).

The majority of patients with compression fractures are treated conservatively (without surgery). Most compression fractures heal within eight weeks with simple remedies of medicine, rest, and a special back brace. Treatment recommendations for bed rest are not supported by enough evidence to make a strong case for or against them. The evidence is said to be weak or inconclusive.

Medications are used to control pain. Although medications can help ease pain, they are not designed to heal the fracture. With pain under control, patients find it easier to get up and move about, avoiding the problems that come from remaining immobile in bed. There is moderate support for acute fractures to be treated in the first four weeks with calcitonin.

Calcitonin is a non-sex, non-steroid hormone. Calcitonin binds to osteoclasts (the bone cells that reabsorb bone). It decreases osteoclast numbers and activity levels. The end result is that it prevents bone from melting away. It doesn’t build up missing bone but it at least keeps the bone that’s there from being broken down and reabsorbed.

Calcitonin is available in a nasal spray and should be used for osteoporotic spinal fractures within five days of the injury. Calcitonin has been shown to relieve pain when tested in four different positions (e.g., in bed, sitting, standing, and walking).

A special back brace, called an orthosis may be prescribed. This type of brace is molded to the patient’s body. It limits spine movement in general, though the brace is usually fashioned to keep patients from bending forward. This protects the fractured vertebral body so it can heal. Patients who wear a brace may be advised to move about but to limit strenuous activities, such as lifting and bending.

Generally, a combination of conservative measures are used in the treatment of this condition. If the patient fails to respond and continues to experience moderate-to-severe pain or pain that limits function, then surgery may be considered.