Prospective Study and follow-up Comparing Operative with Nonoperative Treatment of a Patient with Neurologically Intact Thoracolumbar Burst Fracture

Contrasting opinions exist in terms of preferred or ideal management of burst fractures located at the thoracolumbar region without neurological deficit. In 2003, a prospective study was conducted comparing surgical and non-surgical outcomes for patients suffering from thoracolumbar burst fractures without neurologic deficit. Results demonstrated that there was no significant differences between the two groups with respect to pain, return to work, pain and functional disability. Conflicting positions have been found in other studies. With review of these varying positions it is thought principal differences among the reports may be attributed, in part, to variances in follow-up duration among the studies. The authors of the 2003 study wished to conduct a fifteen-twenty year follow-up of their original patients to find out how their results would pan out over a longer term follow-up. They hypothesized that the original findings would be upheld. Nineteen of the original twenty-four patients treated operatively and eighteen of the original twenty-three patients treated non-operatively were contacted and follow-up data was obtained. The average duration of long-term follow-up was 18.6 years.

Radiologic findings demonstrated that average kyphosis remained thirteen degrees at long-term follow-up in the operative group. No correlation was found between the final rate of kyphosis and degree of pain reported or disability. In the non-operative treatment group the average kyphosis was fourteen degrees at four-year follow-up and at longer term follow-up the average kyphosis was nineteen degrees. Similar to the surgically treated group, no correlation was found between final kyphosis reported and pain reported or disability.

Median pain scores for long-term follow-up demonstrated an average of four cm on the ten cm visual analog scale for those treated surgically and 1.5 cm for those treated non-operatively with a cast or brace. At long-term follow-up there was clinical significance between difference of pain scores between those treated non-operatively and those treated operatively. The functional disability outcome for patients treated operatively measured using the Roland and Morris functional disability score was seven on a scale of twenty five (with zero measuring no disability while twenty-five indicates complete disability). In the patient group treated non-operatively the median score was one. This difference demonstrated clinical significance. There was very little change in the median score over the years in the group treated operatively, however, there was clinically significant improvement in this score within the group treated non-operatively. Median scores on the Oswestry questionnaire at long-term follow-up was twenty for the operative group and two for nonsurgical treatment group. The difference between groups was significant but within each treatment group there was very little change overall throughout the years. Long-term follow-up scores from the short-form-36 showed that nonoperative management was favored to a significant degree.

With regards to return to work status, 58 per cent of patients treated surgically had returned at the four-year point, while long-term follow-up demonstrated that 47 per cent remained employed. Six patients in this group had voluntarily retired and four had lost employment. Of the patients treated non-operatively, 83 per cent were able to return to work at intermediate follow-up. At long-term follow-up 72 per cent were still working while three retired and two lost employment.

The authors of this study conclude that non-operative treatment was the optimal management option for patients with a thoracolumbar burst fracture without neurologic deficit.

Use of Orthosis (brace) or Not for Thoracolumbar Burst Fractures

Treatment for thoracolumbar burst fracture traditionally included surgery, bracing and long term bed rest. In recent years this treatment is changing because of the increased medical risks that go with long term bed rest. There has also been some interest in treating these injuries without surgery as well, again because of risks and increased costs associated with surgery. But, there haven’t been many high quality studies to determine the best course of action. Bailey et al have tried to create a study to provide information for medical professionals to reduce risks, improve outcomes and decrease costs after a thoracolumbar burst fracture.

This study compared ninety six patients who had a thoracolumbar burst fracture without any nerve damage. Forty seven patients were fitted with a thoracolumbosacral brace and forty nine were treated without any brace at all. The people with the brace used it for ten weeks. Both groups were given a lifting restriction of less than five pounds and a bending restriction not past ninety degrees at the waist for eight weeks. After this period they were encouraged to return to normal activities. Both groups were given physiotherapy during and after this first restricted period.

Results were measured after three months with a questionnaire. There was no difference between the two groups after analyzing the results of the questionnaire. This study provides evidence that there is no difference between treatment of a thoracolumbar burst fracture with a brace or without one, and that treatment without a brace is safe and effective.

Motor Vehicle Collisions and Thoracic Disc Injury

TDHs (Thoracic disc herniations) have a variable presentations and can mimic other diseases and many are misdiagnosed because of this. A TDH is thought be relatively rare compared to cervical or lumbar herniation. A traumatic origin has been estimated in up to 25 per cent of TDHs.

Whiplash injury has an estimated occurrence of 300 per 100,000 adults in western countries and is associated with pain, disability and cost. The symptoms of whiplash injury vary widely and can range from mild to severe but in most patients no specific pathology is identified.

In this study, 10 patients were found to have severe upper back pain after a motor vehicle collision (MVC) and a TDH at the level of pain. The study demonstrates that pain caused by TDHs may be relieved by surgical decompression.

All 10 patients underwent thoracoscopic microdisectomy. At one year after the operation results were excellent in seven, good in two and poor in one. One year after the operation, four patients returned to full time work, from being unable to work; two patients increased their hours at work; one did not return to work due to another medical issue but reported an excellent surgical outcome; the final patient had a poor outcome and the reason for her persisting pain remains obscure.

Many people that have MVCs have persistent pain that is difficult to diagnose and regarded as nonspecific. This study has found that some of MVC victims experience a TDH. The TDH may have been present before the accident without causing symptoms but accident triggered symptoms.

Is There an Association of Kyphosis and Diffuse Idiopathic Skeletal Hyperstosis in the Aging Population?

Skeletal changes are common in the aging population. Two of these changes that or prevalent among this population are kyphosis and DISH (diffuse idopathic skeletal hyperstosis) and are found through radiolographical findings. Kyphosis is an increased spinal curvature and the increase prevalence in the aging population can be associated with a decrease in bone density and decrease in back muscle density. Typically kyphosis is measured with a lateral radiograph where spine curvature can be measured using a method known as the Cobb angle measurement. DISH is diagnosed by the presence of ossification in the soft tissue in four continuous segments around the front and side of the thorocolumbar spine with the absence of degenerative disc changes. The cause of DISH is relatively unclear at this time, however, research points out there may be a genetic association hormonal, mechanical, and medication influences on its presence as well as a possible association with diabetes mellitus type 2, obesity, hyperuricemia, and male sex. While it is known that these both are prevalent in the aging population a recent study wanted to examine if there was a possible association between DISH and kyphosis.

The cross-sectional study utilized data for the Health Aging and Body Composition Study (Health ABC) which is an ongoing cohort of participants aged 70-79 years old. They recruited a random sample of age appropriate medicare-eligible Caucasian and African American subjects from the Pittsburgh, PA region. All participants were independent with activities of daily living, could walk one-fourth of a mile and up to 10 steps without rest breaks required. Radiologic assessment with the use of CT scan were utilized to examine for the presence of kyphosis and DISH. They used data from 1172 subject participants. CT scans were studied by two different musculoskeletal radiologists in assessment of DISH for reliable findings. Among participants 152 subjects were diagnosed with DISH, 101 of the cases were located in the thoracic spine and 51 cases were located in both the thoracic and lumbar regions. Overall findings showed a significant interaction of race and DISH with Cobb angle. The presence of DISH among African Americans was associated with an increase in Cobb angle of 8.9 degrees with 95 per cent confidence interval as compared to those without DISH. Among Caucasians, DISH was not significantly associated with Cobb angle. When the location of DISH was further analyzed it was found that when located in the thoracic spine alone there was a significantly associated increase in Cobb angle in both races. However, when DISH was present in both the thoracic and lumbar spine there was not an associated increase in Cobb angle in either races. Overall, these findings indicate the presence of ossification among the anterior longitudinal ligament may change the structure of the spine and affect spinal curvatures. It was found that further research would be warranted to learn whether the presence of DISH is a predictor of worsening kyphosis over time.

Motor Vehicle Collisions and Thoracic Disc Injury

TDHs (Thoracic disc herniations) have a variable presentations and can mimic other diseases and many are misdiagnosed because of this. A TDH is thought be relatively rare compared to cervical or lumbar herniation. A traumatic origin has been estimated in up to 25 per cent of TDHs.

Whiplash injury has an estimated occurrence of 300 per 100,000 adults in western countries and is associated with pain, disability and cost. The symptoms of whiplash injury vary widely and can range from mild to severe but in most patients no specific pathology is identified.

In this study, 10 patients were found to have severe upper back pain after a motor vehicle collision (MVC) and a TDH at the level of pain. The study demonstrates that pain caused by TDHs may be relieved by surgical decompression.

All 10 patients underwent thoracoscopic microdisectomy. At one year after the operation results were excellent in seven, good in two and poor in one. One year after the operation, four patients returned to full time work, from being unable to work; two patients increased their hours at work; one did not return to work due to another medical issue but reported an excellent surgical outcome; the final patient had a poor outcome and the reason for her persisting pain remains obscure.

Many people that have MVCs have persistent pain that is difficult to diagnose and regarded as nonspecific. This study has found that some of MVC victims experience a TDH. The TDH may have been present before the accident without causing symptoms but accident triggered symptoms.

Surgeons in Greece Report on Efforts to Reduce Problems with Balloon Kyphoplasty

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 be improved with conservative care. This may include physical therapy, rest, pain relieving medications, and sometimes a brace or cast.

But for those individuals who have persistent pain (which is usually severe), a surgical procedure called balloon kyphoplasty (BK) may be recommended. The surgeon inserts a thin needle into the fractured vertebra (spinal bone) with a deflated balloon on the end. The balloon is placed inside the vertebra and inflated to restore the height of the bone. Then the balloon is removed and a liquid cement is injected into the space left by the balloon inflation. When the cement hardens, the expanded vertebral body retains its shape, 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 can leave a space that is 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.

In this study, results using the KIVA implant are compared with results using the balloon kyphoplasty. The surgeons used a variety of different ways to measure results. 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 conclude 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.

Technical and Metabolic Risk Factors Found in Vertebral Compression Fractures

Severe pain, loss of mobility and independence, disability, hospitalization, depression, and decreased quality of life are all possible consequences of vertebral compression fractures. Even with today’s improved treatment for this problem, one out of every five adults who experience a vertebral compression fracture will suffer another one within the next 12 months.

What can be done to stop this potentially devastating health problem? 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.

It makes sense then to explore ways bone metabolism might contribute to the development of vertebral compression fractures. One specific measure that can be used is the level of vitamin D, a vitamin known to be important in the building of strong bones.

In this study, researchers from the Athens, Greece Laboratory for the Research of Musculoskeletal System take a closer look at the role of hypovitaminosis D as a risk factor for second (or third) vertebral compression fractures in postmenopausal women after having a kyphoplasty procedure. 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.

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. To test this idea out, these researchers measured bone mineral density and bone turnover after 98 kyphoplasty procedures performed in 40 women. Blood levels of calcium and phosphate were measured along with parathyroid hormone levels (important in maintaining good calcium levels in the blood) and vitamin D.

Patients who developed a second vertebral fracture were compared with those who did not. X-rays were taken at regular intervals during the first 18 months after the kyphoplasty procedure. Other possible variables were evaluated, too such as age, body mass index, history of tobacco use, and the use of antiosteoporosis medications.

Bone mineral density was not statistically different between the two groups. Even so, 22.5 per cent of the entire group developed a second compression fracture. What made the difference between the two groups (those who did fracture versus those who did not)?

The women who did experience further fractures had lower levels of vitamin D (metabolic factor) and experienced cement leakage (technical factor) into the disc area from the first kyphoplasty. The cement increases how stiff the treated vertebra becomes, which then increases the load placed on the next vertebra. The women who did NOT have a second compression fracture were more likely to be taking calcium and Vitamin D supplementation along with antiosteoporosis medication.

The authors suggest two things as a result of their findings in this study. First, patients with vertebral compression fractures should be evaluated for bone metabolism before treatment begins for the fracture(s). Other risk factors for possible recurrent fractures should be noted (e.g., decreased vitamin D levels). And every effort should be made to prevent cement leakage during the procedure.

Risk Factors for Vertebral Fractures After Vertebroplasty

Patients with osteoporosis 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.

There is a surgical procedure to help with this problem called vertebroplasty. 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 is the subject of this study: 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.

Patients in this study did receive follow-up care after the vertebroplasty procedure. A protective brace was worn for three months. Medical treatment with calcium supplementation and medications to reduce bone loss was started to help address the underlying problem of weak, brittle bones.

Physical therapy was recommended to get patients performing specific exercises known to improve osteoporosis and to increase general levels of activity. The therapists also addressed posture and body alignment, two key areas of focus in the treatment of osteoporosis and vertebral bone fractures.

The authors suggest variations in the refracture rate could be linked with different ways patients handled 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 one-third of the group did 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.

Update on Scheuermanns Disease for Adults: What’s the Latest?

In this 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).

They also bring us up to date on what is known about the natural history of this condition (i.e., what happens over time). Both nonsurgical and surgical care are presented along with complications of surgical treatment. Before and after X-rays to show results are presented for half a dozen patients.

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 condition starts in childhood and affects boys slightly more often than girls. 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.

What causes this type of wedging deformity? During normal growth, the cartilage around the vertebral body turns 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.

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.

What is the natural history of Scheuermann’s? 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.

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.

Treatment for the adult with Scheuermann’s kyphosis 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. The authors present a detailed discussion of surgical approaches, techniques used, and fixation devices used (hardware such as screws, rods, metal plates).a

Like any spinal surgery, there are risks involved. Blood loss, infection, spinal cord or nerve damage, and failed back surgery (pain and loss of fusion) are the biggest potential post-operative complications patients face. Loss of correction is an additional concern for the adult group treated surgically. Second surgeries may be required for adults with these complications.

All-in-all, the authors say that improvements in surgical technique have helped reduce such problems. Better results with fewer problems, less blood loss, and lower costs (due to shorter surgical times) are reported.

A Review of Spinal Cord Injuries

In this review article, neurosurgeons from Thomas Jefferson University Hospital in Philadelphia take a look at the diagnosis, treatment, and results of treatment for spinal cord injuries. They focus specifically on fractures and cord injury at the thoracolumbar area.

The thoracic spine ends at T12 (the last thoracic vertebra). The lumbar spine (L1) begins right after T12. The union between T12 and L1 is call the thoracolumbar junction. Spinal cord injuries at this level can result in one of two neurologic injury syndromes. These are the cauda equina syndrome (CES) and the conus medullaris syndrome (CMS).

The word “syndrome” tells us that each one of these conditions is defined by a set or collection of signs and symptoms that are always present. The cauda equina syndrome affects the spinal cord where the main cord ends and a “tail” of nerves forms down to the tip of the tailbone and down the legs. The conus medullaris syndrome occurs when the injury has affected the area between the spinal cord and the spinal nerve roots.

Clinical signs and symptoms of these two syndromes can be so similar as to be confused and misdiagnosed. The clinical presentation may vary slightly depending on where the damage has occurred. In the case of the cauda equina syndrome, there is often an asymmetric presentation. In other words, the symptoms occur on one side (not both sides). In the conus medullaris syndrome, symptoms are more likely to occur symmetrically (evenly on both sides). The most common symptoms are loss of sensation, motor control, and bowel and/or bladder function.

Injuries to these areas of the spinal cord are most often the result of car accidents or traumatic sports injuries in young patients. Men in their 40s to 50s are more likely to experience spinal cord injury from disc herniation (damaged, degenerated disc presses on the spinal cord). Violence, falls, and other traumatic sources can also be linked with spinal cord injuries leading to cauda equina syndrome or conus medullaris syndrome.

At first, the spinal cord may go into “shock.” The patient loses all function below the level of the injury. There may be paralysis of the legs, loss of bowel and bladder control, and for men, loss of penis erection. These symptoms may last a short time with recovery in 24 to 48 hours or there may be a longer period of time for recovery (several weeks).

These injuries are diagnosed based on history (what happened), clinical presentation (signs and symptoms), and imaging studies. MRIs have the best chance of showing damage to the nerve tissue but studies have shown the results are not 100 per cent reliable. In fact as many as 43 per cent false positives for cauda equina syndrome have been reported. In other words, the test shows there is a problem when nothing is really wrong.

Treatment is an area that remains under heavy debate. The two main goals of any treatment are first to stabilize the spine and second to restore as much neurologic function as possible. Surgery is required to accomplish both goals. And the sooner the better — experts suggest surgery should be done within eight hours of the trauma whenever possible.

There’s no disagreement about that. The best way to do the surgery isn’t clear. The surgeon must decide if an anterior approach (from the front of the body) is better than a posterior procedure. Both have advantages and disadvantages.

Pressure must be removed from the spinal cord, the spinal nerve roots, and/or any compromised neural tissue. The procedure is called decompression. There are several different ways to perform a surgical decompression for thoracolumbar spinal cord injury.

From the front (anterior approach), the surgeon can remove the entire vertebral body, a procedure called a corpectomy. When the spine is opened from the back (posterior approach), just the posterior column of bone (called the lamina is removed. If the spine is still unstable, then a spinal fusion is done next.

The authors of this review also report on some of the newer treatments being tried with spinal cord injuries. For example, giving patients a powerful steroid drug (methylprednisolone) intravenously is supposed to reduce the swelling and minimize the damage done.

But research to assess the long-term results of this type of treatment aren’t all consistently supporting this treatment as necessary or gaining anything more than treatment without it. And there is a potential for significant side effects (e.g., pneumonia, gastrointestinal bleeding). These authors say, “don’t use methylprednisolone.”

What else is on the forefront? Some scientists are looking into the use of biologic agents to stimulate bone growth. This method referred to as osteosynthesis or nonfusion technology could make it possible to avoid using plates and screws to fuse the spine. Eliminating hardware reduces the risk of hardware breaking (requiring another surgery) or loss of spinal correction.

For sure there is a need for continued study of thoracolumbar spinal cord injuries. Results of various treatments must be compared in order to identify the best treatment approach for each patient. Level and severity of injury may be deciding factors. Other important patient factors may include age, body-mass index (BMI), and general health.

Additional studies looking at prognostic factors are also advised. If surgeons can predict who should have each different surgical procedure based on patient factors, it might be possible to streamline the entire decision-making process while improving long-term results. And finally, more study is needed to confirm the current belief and practice of decompression as soon as possible in order to achieve the best long-term results.

Guidelines for the Treatment of Spine Fractures Caused by Osteoporosis

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).

About 700,000 cases of compression fractures due to osteoporosis occur each year in the United States. Spine bones that are weakened from osteoporosis may become unable to support normal stress and pressure. As a result, something as simple as coughing, twisting, or lifting can cause a vertebra to fracture.

Osteoporosis is a disease that weakens bone. Sometimes the bones in the spine weaken to the point that even mild forces can lead to a compression fracture. A simple action like reaching down to pull on a pair of socks can cause a weakened vertebra to fracture. The front of the vertebra (the part closest to the front of the body) crumbles, causing the round vertebral body to become wedge-shaped. This angles the spine forward, producing a hunch-backed appearance, called kyphosis.

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.

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. Patients are usually prescribed a short period of rest. This gives the fracture a chance to heal and aids in pain control. In some cases, the doctor may have a patient stay in bed for up to one week.

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.

Surgeons have begun using two new procedures to treat compression fractures caused by osteoporosis. Both are considered minimally invasive. Minimally invasive means the incisions used are very small, and there is little disturbance of the muscles and bones where the procedure is done. These two procedures help the fracture heal without the problems associated with more involved surgeries. These new procedures are vertebroplasty and kyphoplasty.

Vertebroplasty helps reduce pain and strengthens the fractured bone, thus enabling patients to rehabilitate faster. A needle is inserted into the collapsed vertebra and a bone cement is injected into the main body of the vertebra. This fixes the bone so that it does not collapse any further as it heals. More than 80 percent of patients get immediate pain relief with this procedure.

To read more about this, see A Patient’s Guide to Vertebroplasty.

Kyphoplasty is another way for surgeons to treat vertebral compression fractures. Like vertebroplasty, 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 kyphosis.

Needles are inserted through the 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 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. This fixes the bone in its corrected size and position.

To read more about this, see A Patient’s Guide to Kyphoplasty.

Now, how do the current evidence and recommended guidelines compare with this typical approach to osteoporotic spinal compression fractures?

There is strong evidence that vertebroplasty benefits patients with osteoporotic spinal compression fractures who are in pain but not experiencing any neurologic problems. Kyphoplasty as an option is supported but the evidence is still weak and further studies are needed.

There is moderate support for acute fractures to be treated in the first four weeks with medications (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).

All other treatment recommendations (e.g., bed rest, use of complementary and alternative medicine, narcotics for pain) are not supported by enough evidence to make a strong case for or against them. The evidence is said to be weak or inconclusive. Likewise, evidence for the use of electrical stimulation to encourage bone growth is inconclusive.

For those who want to read the full guidelines along with a detailed discussion of the evidence and processes used to obtain that evidence, go to http://www.aaos.org/research/guidelines/SCFguideline.pdf.

Surgeons Compare Techniques for Kyphoplasty to Treat Vertebral Compression Fractures

Patients experiencing pain and loss disability from vertebral compression fractures (VCFs) may find relief with a procedure called balloon kyphoplasty. The procedure is designed to restore height of the fractured and collapsed vertebra (spinal bone).

Compression fractures are the most common type of fracture affecting the spine.
Multiple-level vertebral compression fractures are commonly the result of osteoporosis. Spine bones weakened from osteoporosis (brittle bones) may become unable to support normal stress and pressure.

As a result, something as simple as coughing, twisting, or lifting can cause a vertebra to fracture. In fact, a simple action like reaching down to pull on a pair of socks can cause a weakened vertebra to crack or fracture. The front of the vertebra (the part closest to the front of the body) crumbles, causing the round vertebral body to become wedge-shaped. This angles the spine forward, producing a hunch-backed appearance, called kyphosis.

That’s where a balloon kyphoplasty comes in. 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.

In this study, surgeons compared results when the balloon kyphoplasty procedure was done from one side (unilateral) versus inserting needles from both sides (bilateral) of the vertebral bone.

Safety is always an issue with any spinal procedure. Inserting needles from both sides of the spine has the potential to create more problems and complications compared with a unilateral approach. Surgeons want a safe procedure that is also effective. Can a balloon kyphoplasty for multiple-level fractures be done both safely and effectively using the unilateral technique? Let’s find out.

For the record, multiple-level fractures in this study referred to two or more painful vertebral compression fractures (VCFs) in each patient. The VCFs were in the thoracic or lumbar spine of 49 patients. There were a total of 114 VCFs (all caused by osteoporosis). Patients ranged in age from 52 to 91 years old.

One half of the group had a unilateral balloon kyphoplasty. The other half had a bilateral approach. Details of how the procedures were done are described by the author for surgeons who perform this technique or who are interested for other reasons.

The idea of doing the procedure from both sides is that this would provide a more even lift of the collapsed vertebra. Another potential advantage of the bilateral injection is to create a large cavity to inject as much cement as possible.

On the other hand, a unilateral approach takes less time. This advantage translates into money that can be saved with shorter operative procedures. With less time required to complete the kyphoplasty, the patient is exposed to less radiation from X-rays (fluoroscopy).

A unilateral approach reduces the risk of puncturing nerves or blood vessels with the needles. Inserting one instead of two needles also reduces the chances of fracturing a bone unintentionally.

Results were measured before and after surgery using patient surveys of pain levels, disability, and general health. X-rays were used to look at before and after height of the vertebrae and the angle of kyphosis (forward bent spinal curve).

Everyone was followed for at least two years. This type of follow-up provides an idea of mid- to long-term results (i.e., how long and how well the benefits last). Both groups did equally well! Patients were relieved of pain and improved back function. Those benefits were still present two years later.

A few of the patients did end up having more compression fractures but these were at new levels and not previously treated by kyphoplasty. The most common “problem” that occurred was leaking of the cement into the disc or vein alongside the vertebra.

The word problem is in quotes because this isn’t supposed to happen and it is technically considered a complication of the procedure. But none of the patients experienced any real problems (pain, sensory changes) because of it. If X-rays had not been taken, no one would have even known this had happened.

The authors conclude that unilateral balloon kyphoplasty for multi-level vertebral compression fractures are both safe and effective. Performing this procedure from one side instead of injecting cement through needles inserted on both sides has many advantages. Strength of vertebral repair and stiffness are not compromised in any way. All corrections made through this procedure are maintained for at least two years.

Chances of Second Vertebral Fracture Increase with Steroid Use

Our senior adults are at risk for vertebral compression fractures (VCFs) due to low bone density and brittle bones (osteoporosis). Other risk factors include advancing age, steroid use, tobacco use (smoking), sex (female), and thoracic kyphosis (forward curve of the mid-spine).

Treatment is important in order to reduce pain, prevent disability, and maintain independence. Kyphoplasty is one treatment option but there’s a concern about a second (or third) vertebral compression fracture (VCF) after kyphoplasty. This study explores how often additional VCFs requiring another kyphoplasty procedure occur. They also track how soon this happens.

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. Kyphoplasty to treat the problem involves inserting a deflated balloon into the fractured and collapsed vertebral body.

Hydraulic pressure is used to inflate the balloon. The balloon is inflated until the vertebral body height is restored to normal or until the balloon is fully inflated. The balloon is then collapsed and removed. The empty space left by the inflated balloon is quickly filled in with cement that is injected into the area.

Kyphoplasty procedures are minimally invasive — that’s one good advantage. They aren’t supposed to be a “quick fix”. They really are used to stabilize the spine and prevent further problems. But all too often, patients go on to develop another compression fracture. In most cases, the second fracture affects the adjacent vertebral body (next spine bone above or below the original compression fracture).

Can these additional fractures be prevented? Are they caused by the kyphoplasty or something else? To find out, the authors of this study followed 256 cases of vertebral compression fracture treated with kyphoplasty. They gathered all kinds of data on each patient in order to analyze it for any possible risk factors.

Besides information on the typical risk factors, they also paid attention to the use of bisphosphonates and patient outcomes. Bisphosphonates are used to prevent bone fractures. They keep bone cells from being absorbed or destroyed.

You may be taking one of these or heard about them on TV. Boniva (ibandronate sodium) and Fosamax, known to the pharmacist and doctor as alendronate are the most commonly prescribed bisphosphonates. Others include Actonel (risedronate), Aredia (pamidronate), and Zometa (zolendronate).

Do bisphosphonates help prevent future vertebral compression fractures? That’s another question the researchers raised and tried to answer. The study was done at a single medical center. Three surgeons participated. Patients who had kyphoplasty for vertebral compression fractures over a period of seven years were included.

Two-thirds were women and the remaining one-third of the patients were men. Participants were divided into two groups based on age (over or under 75 years old). Data was also analyzed from the viewpoint of smoker vs. nonsmoker, bisphosphonate user vs. nonbisphosphonate user, and steroid user vs. nonsteroid user.

About one-fourth (22 per cent) of the entire group had a second vertebral compression fracture after the first was treated with kyphoplasty. All were treated conservatively (without kyphoplasty) at first. The kyphoplasty was only done when symptoms did not improve with nonoperative care.

Second fractures were more common in the thoracic spine compared with the lumbar spine (low back). There may be some reasons for this difference. The authors suggest perhaps the smaller sized thoracic bones just can’t support the same pressure inch-for-inch that the larger lumbar vertebrae can.

The fact that many patients who suffer thoracic vertebral compression fractures tend to be in a position of kyphosis (forward curve of the spine) might be an added factor. The kyphotic position shifts the center of gravity forward. This posture can change the dynamic shift of energy and force through the spine.

Smoking and age did not seem to factor in to additional compression fractures. Bisphosphonates did not prevent future fractures (at least not in the short-run). And the single most important risk factor for second fractures was the chronic (long-term) use of steroid medications.

What are the clinical implications of this study? First, patients who have had one vertebral compression fracture (VCF) should be monitored closely. Any signs of additional fractures must be reported and checked out right away. Older patients taking steroids who have already had one fracture are already at increased risk of another fracture and should be watched closely.

Second, if the cement used to stiffen up the vertebral segment transfers load to the next segment, is there a better way to get the same results without adding pressure above or below the fractured level? This is something surgeons may want to consider for future studies.

This study raises some interesting questions. If bisphosphonates don’t prevent additional vertebral compression fractures, does the patient benefit by taking them? Based on results of other studies, it’s possible that only long-term use (three years or more) of bisphosphonates makes a difference. But it’s something that should be investigated further.

Can dual energy x-ray absorptiometry (DXA) scans predict vertebral compression fractures? DXA scan is a bone density text to see if someone has decreased bone density (osteopenia) or brittle bones (osteoporosis). And if so, what can be done to prevent them?

With 44 million Americans expected to develop vertebral compression fractures in the next year, the answers to these questions could help prevent fractures, save lives, and reduce medical costs.

Early Intervention Advised For Vertebral Compression Fractures

There’s an expression among comedians that timing is everything. That same concept can be applied to many things including medical treatment for vertebral compression fractures (VCFs). In this study, surgeons in Korea took a look at the use and timing of kyphoplasty for this type of fracture.

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 (decreased bone density or “brittle bones”).

About 750,000 cases of compression fractures due to osteoporosis occur each year in the United States. Spine bones that are weakened from osteoporosis may become unable to support normal stress and pressure. As a result, something as simple as coughing, twisting, or lifting can cause a vertebra to fracture.

Kyphoplasty to treat the problem involves inserting a deflated balloon into the fractured and collapsed vertebral body. Hydraulic pressure is used to inflate the balloon. The balloon is inflated until the vertebral body height is restored to normal or until the balloon is fully inflated. The balloon is then collapsed and removed. The empty space left by the inflated balloon is quickly filled in with cement that is injected into the area.

The optimal timing for kyphoplasty remains unknown. There isn’t a lot of data yet on the best timing for treatments using this technique. This study compared two groups of women diagnosed with an osteoporotic vertebral compression fracture at one spinal level (between T10 and L2). Everyone in both groups was treated with kyphoplasty. Half the women (a total of 20 adults) were treated within two weeks of the fracture. The other half (group two with the same number of women) had the kyphoplasty procedure at least two weeks after the fracture occurred.

The results were measured and compared before and after treatment using patient perceived level of pain and X-ray analysis of spinal correction/deformity. They found that everyone improved but the early group had measurably better results. Pain levels were reduced equally between the two groups. It was the degree to which the spine could be restored to its natural height that was better in the early-to-surgery group. Spinal alignment was also significantly better in the early-to-surgery group.

Should everyone have a kyphoplasty right away after the fracture occurs? There are some good reasons to make that suggestion but some drawbacks as well. On the “yes” side of things, early treatment reduces pain and the need for pain medications. Function is improved and quality of life is reportedly better.

With a delay in treatment, there is the potential for increased spinal deformity. As the vertebral body collapses further, pressure on the spinal nerve roots creates more pain. The flexed posture of the spine (called kyphosis) shifts the center of gravity forward and puts pressure on the vertebrae above and below the fractured segment. The result can be additional vertebral compression fractures.

One major reason why kyphoplasty gets delayed has to do with insurance. In Korea, the National Health Insurance plan requires bed rest for at least three weeks for spinal fractures. Since studies haven’t proven the need for early intervention with kyphoplasty, the results of this study are especially important for policy change in that country. Associated cost savings from early treatment and return-to-work, social function, or normal activities of daily living are enough to support such a policy change.

Do the Benefits of Vertebroplasty and Kyphoplasty Outweigh the Risks?

Vertebral compression fractures (VCFs) are a bad deal all the way around. They cause pain, disability, and even death. The patient can end up with a stooped posture, which then cuts down on their air flow and lung function. The pain keeps them on the couch, in the recliner, or in bed. The resultant immobility can put the person at risk for pneumonia and deadly blood clots.

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.

About 750,000 cases of compression fractures due to osteoporosis occur each year in the United States. Spine bones that are weakened from osteoporosis may become unable to support normal stress and pressure. As a result, something as simple as coughing, twisting, or lifting can cause a vertebra to fracture.

In this review article, orthopedic surgeons bring us up-to-date on the latest research on the role and effectiveness of vertebroplasty and kyphoplasty. These procedures are used when painful symptoms develop as a result of vertebral compression fractures. The treatment can be done early on to help prevent further complications such as pneumonia or loss of function due to the pain.

To perform a vertebroplasty, the surgeon uses a fluoroscope to guide a needle into the fractured vertebral body. A fluoroscope is a special X-ray television that allows the surgeon to see your spine and the needle as it moves. Once the surgeon is sure the needle is in the right place, a special bone cement is injected through the needle into the fractured vertebra. A reaction in the cement causes it to harden very quickly. This fixes the bone so that it does not collapse any further as it heals.

Kyphoplasty is another way for surgeons to treat vertebral compression fractures. Like vertebroplasty, 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 kyphosis.

Two long needles are inserted through the 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 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 removes the balloon and then injects bone cement into the hollow space formed by the balloon. This fixes the bone in its corrected size and position.

These two procedures have been around long enough now to have some research data on how well they are working. Stabilizing the fractured vertebral body seems to provide the pain relief needed. Up to 95 percent of patients get immediate pain relief with this treatment. The vertebroplasty or kyphoplasty restores spinal stiffness and increases spine strength needed for pain free stability.

But complications such as fever and cement leaking out have been reported. The oozing cement can put pressure on the spinal cord or nearby nerves or even travel to the lungs as a cement clot (embolism). There have been some studies showing that patients can develop other fractures in the adjacent vertebrae. But whether these new fractures are a result of the osteoporosis that caused the first vertebral compression fractures or perhaps the result of the vertebroplasty or kyphoplasty is unknown.

Long-term studies now available show that the results don’t last. And recovery is about the same when compared with patients who were treated conservatively with physical therapy, postural exercises, and pain relievers. The main difference is how quickly pain relief is delivered: immediately with vertebroplasty versus two to four weeks later with nonoperative care.

For patients in acute pain and in danger of lung compromise, vertebroplasty is a safe procedure that can provide immediate results. But to use either vertebroplasty or kyphoplasty on a routine basis for every compression fracture isn’t advised.

There have been enough studies comparing vertebroplasty with a sham treatment and no difference in results to slow down the routine use of the vertebroplasty procedure. It’s likely that the benefits of vertebroplasty/kyphoplasty were over estimated early on.

The true value of either procedure is more apparent now. There are still some patients who can really benefit from these procedures. But more studies are needed to identify exactly who those patients are so that surgeons can administer the treatment to the right people at the right time for the best results.

Back to the Drawing Board on Vertebral Compression Fractures

Efforts to treat vertebral compression fractures (VCFs) with kyphoplasty or vertebroplasty have fallen flat for some patients. Both of these techniques involve injecting cement into the broken and collapsed vertebral body. But the cement oozes out and damages nearby blood vessels and nerves.

The oozing cement can also form an emboli (clot) that can travel to the heart or brain and make matters much worse. One other problem is that injecting cement into the main body of the vertebral bone creates a rigid bone that is actually too stiff for the weak (osteoporotic) bone. The result can be even more fractures in the vertebrae above and below the cemented level.

But vertebral compression fractures (VCFs) caused by weak, osteoporotic bones can’t be just left to heal on their own. The end result would be further collapse of spine, chest, and abdomen affecting breathing, appetite, and digestion. And since most of the VCFs occur in adults aged 65 or older, there can be additional complications associated with these problems.

Older patients aren’t the only ones affected. Younger patients can experience any of these problems, too. In addition, the implant is expected to be permanent. It doesn’t break down and it isn’t absorbed by the body. This feature could cause problems later for the younger patients.

So what can be done for patients with vertebral compression fractures that can’t be treated locally with surgery? That’s what this study is all about. Medical researchers took five human spines from cadavers (human bodies preserved after death for study purposes), created vertebral compression fractures, and then treated them three different ways. All vertebral bodies from the thoracic spine (T4) to the lumbar spine (down to and including L5) were used.

The first treatment was with kyphoplasty — just the way a patient would be treated with this technique. A deflated balloon was inserted into the collapsed vertebral body. Hydraulic pressure was used to inflate the balloon. The balloon was then collapsed and removed. The empty space left by the inflated balloon was quickly filled in with the injected cement (polymethylmethacrylate or PMMA).

The second treatment was with a titanium mesh implant cemented in place. The implant looks like a diamond-shaped Chinese finger trap with the center expanded out on each side. The collapsed mesh implants are inserted into a channel or pathway drilled into the vertebral body. A special machine is used to expand the device.

The third treatment was with the same titanium mesh implant but without cement. Fluoroscopy, a special 3-D moving X-ray was used to guide implantation in all three treatment methods. Details of surgical treatment and implantation for all three techniques were provided by the authors.

Results were measured by calculating the stiffness of the vertebral bodies and the mechanical load they could withstand. These values were then compared to normal, intact, healthy bone. Subgroups that were compared included males versus females and thoracic (midspine) versus lumbar (low back) vertebral fractures. The outcomes were very interesting.

They found that the best results came when using the titanium cage without cement. The results were most like normal bone with this approach. The kyphoplasty was the least likely to restore strength and stiffness of the bone to normal. No matter what treatment technique was used, nothing returned the vertebral body stiffness back to normal. There were no differences based on sex (males versus females) or type of vertebrae treated (thoracic versus lumbar spine).

The authors concluded that titanium mesh implants may provide a safe and effective alternative to kyphoplasty for the treatment of vertebral body compression fractures. Cement isn’t really needed, so leaving that out can reduce the complications that can occur when the cement oozes out and comes in contact with other body parts.

The results of this study are considered preliminary — too early to make firm recommendations. Further study is needed to test the abilities and limits of titanium mesh implants. At first glance, these devices appear to provide a protective mechanical scaffold when placed inside the vertebral bones. But the long-term effects have not been calculated or compared against kyphoplasty.

Another Look at Major Complications with Vertebroplasty

Just about the time a surgical procedure becomes fairly standard and accepted as an effective treatment approach to a problem, someone steps in and takes a look back to see if, indeed, all is well. In this case series (seven patients), major and minor complications of vertebroplasty for vertebral compression fractures are reviewed. Vertebroplasty gives surgeons a way to fix the broken bone without the problems associated with open surgery.

Surgeons hold the fragmented bone in place by squeezing special cement into the broken bone. The cement strengthens and stiffens the vertebra, which reduces pain considerably and helps the patient return to normal activities. Unlike open surgery, vertebroplasty is a minimally invasive procedure. It requires small openings in the skin and small instruments.

This percutaneous (through the skin) approach lessens the chance of bleeding, infection, and injury to muscles and tissues. The surgeon uses a special real-time X-ray called fluoroscopy to see inside the body and accurately guide the needle used to inject the vertebral body with the cement. More than 80 percent of patients get immediate relief of pain with this procedure.

Patients with osteoporosis (brittle bones) are prone to compression fractures in the spine bones, or vertebrae. 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 often cause poor back posture, debilitating pain, and difficulty completing routine activities. Vertebroplasty is a quick and easy way to address this problem but it’s not without a few complications of its own.

As the authors show in this seven case series, problems can develop from cement leakage, puncture of the meninges, and splitting of the fractured vertebral bone. Cement leaking into the space for the spinal cord or spinal nerve root can cause severe back and/or leg pain, loss of motor function, weakness, and other neurologic problems including paralysis. Puncture of the arachnoid layer of the meninges, a lining that covers the brain and spinal cord can result in infection and inflammation of this area. This condition called arachnoiditis is the name for the type of inflammation that can happen any time the meninges is punctured, even for well-controlled medical procedures such as vertebroplasty.

Treatment is according to the underlying problem. In the case of cement leakage, the surgeon must go back in and carefully remove as much of the cement as possible without disrupting or damaging the nerve tissue in the process. Arachnoiditis and any other infection or inflammatory process can be treated with antibiotics, steroids, and antiinflammatory drugs. For those patients who suffered paralysis, the treatment can restore the patient to full function but sometimes permanent paralysis remains. That was the case in one of these seven patients.

The authors also noted that other studies have reported adverse reactions to the bone cement, sudden drop in blood pressure during the operation, punctured lung, blood clot or fragment of cement to the lungs, and injury to a blood vessel with subsequent hemorrhaging. Sometimes the already compromised vertebral bone fractures again and collapses even further. As noted in this study, paralysis affecting patients from the waist down called paraplegia and even death can occur.

This study includes photographs of CT scans and MRIs showing the cement leakage, arachnoiditis, and compression fractures. Successful restoration of the spine with an alternate procedure called kyphoplasty was shown for the patient with the split vertebral body. Kyphoplasty is similar to vertebroplasty but with an added benefit: before the cement is inserted into the fractured site, a needle is placed inside the bone and a balloon inflated in the collapsed area. Once the balloon restores the vertebral height, then the cement is injected into the balloon. Vertebroplasty by itself just fills in the cracks of the fracture, it doesn’t balloon the bone back into place or reshape it.

In summary, these seven cases reflect only the rare complications with vertebroplasty. Of the more than 65,000 adults who have this procedure every year in the United States, only 0.5 per cent ever has any significant problems. When the procedure is performed by skilled surgeons, neurosurgeons, radiologists, or anesthesiologists, it is considered safe and effective. Quality of life is improved dramatically, which is why the procedure remains a popular treatment approach to vertebral fractures of all types, not just compression fractures in the aging population from osteoporosis.

The authors caution against using vertebroplasty (or kyphoplasty) in young patients who do not have positive neurologic findings (muscle weakness, motor impairment, paralysis). They advise surgeons to order CT scans before performing the procedure and the use of fluoroscopy during the procedure in order to limit (avoid) major complications.

Is a Back Brace Really Needed for a Burst Fracture of the Spine?

In this study, the use of a brace for thoracolumbar burst fractures is investigated. Do patients really need a back brace for this condition? If they do, what kind of brace works best? How long should they wear it? The first step in answering questions like these is to find out if patients wearing the brace have any better results than those who don’t wear a brace.

Thoracolumbar burst fractures occur in the spine where the end of the 12 thoracic vertebrae meet the start of the five lumbar vertebrae. A high-energy load through the spine causes the vertebra to break or shatter into many tiny pieces. That’s why they call them burst fractures.

Burst fractures are most often caused by car accidents or by falls. The danger of these fractures is that the bone fragments can shift and press into the spinal cord or spinal nerve roots causing temporary and even permanent neurologic damage. Bracing might help keep the spine stable while the bone heals and prevent neurologic damage of this type.

Everyone in the study had a Type A3 burst fracture between the 11th thoracic vertebra (T11) and the third lumbar vertebra (L3). Type A3 is a classification made by the radiologist at the time X-rays are taken. It is a specific designation letting the medical doctor know that the patient has a burst fracture as opposed to some other type of fracture (e.g., Type A1 is a wedge compression fracture, Type A2 is a coronal split fracture). Only adults under the age of 60 were included. They were seen within 72 hours of the injury and did not have any apparent nerve damage or neurologic injury.

Past studies with a small number of patients have shown that it didn’t seem to matter whether patients wore a brace or not. And different types of specific braces seemed to yield the same results. There hasn’t been one individual brace to rise above all others as giving the best results. The authors of this study thought it was more likely that the type of fracture treated was stable and didn’t need brace stabilization. In the case of a thoracolumbar burst fracture, if the posterior ligaments aren’t damaged, the burst fracture is stable (not likely to shift or move out of place).

To test this theory, they compared 72 patients with thoracolumbar burst fractures. The patients were randomly assigned to one of two groups. One group of 36 patients was given a thoracolumbrosacral orthosis (TLSO). This type of rigid support encompasses the trunk including the thoracic and lumbar spine and sacrum. Patients in this group were kept on bed rest until the brace was in place. They just used an off-the-shelf (prefabricated) TLSO, rather than one that was specifically designed for each individual person. The brace was worn all the time for eight weeks unless the patient was lying flat in bed.

An equal number of patients in the second group (36) did not get a brace. They were allowed to get up and walk unassisted right away. Patients in both groups were seen by a physical therapist who explained which movements to avoid during the eight-week healing process. Once the patients in group one had a brace, they were allowed to get up and walk around as much as they felt comfortable. They were told not to bend the hips past 90-degrees of flexion. Patients without the brace were told not to bend or twist the trunk and not to flex the hips past 90-degrees. Restrictions for both groups were in place for eight weeks.

For three months, patients in both groups participated in a rehab program supervised by a physical therapist. An exercise program of spinal stabilization exercises was started at four weeks and progressed from isometric (muscle contraction without movement) to isotonic (muscle contraction with movement) exercises. When the patient was ready, the program was advanced to specific activities to prepare them for return-to-work. The brace group slowly stopped wearing the brace at the end of the first eight weeks.

Results were compared after three months by measuring differences in pain, function, health-related quality of life, spinal alignment, number of days in the hospital, and any complications that occurred. The Roland-Morris Disability Questionnaire was used to assess pain, function, and quality of life. X-rays and CT scans showed before and after spinal alignment.

Some of the patients in both groups ended up having surgery before they even left the hospital. There were a few reports in both groups of radicular pain (pain from the back down the leg). In those cases, surgery was needed to remove bone fragments from impinging or pressing on a spinal nerve. A couple of other patients were unable to get up and walk without severe pain, so they also had surgery to stabilize the spine (even though the X-rays showed a stable fracture).

For the rest of the patients, comparisons of variables measured showed no difference in results with or without bracing. And patients were equally satisfied with their treatment no matter which group they were in. Not only that, but there were no major differences in before and after results as seen on imaging studies. Spinal healing was just as good in one group as it was in the other. Spinal alignment and posture was also comparable. The authors intend to follow these patients for a full two-years to see if there are any long-term differences.

The only possible reason to use a brace might be for pain control in the first two-week period of time. The test scores for pain showed a slight increase in pain control for patients wearing a brace early on. The difference was only slight and by the end of six weeks, there was no difference at all. The amount of additional pain control experienced by some of the patients in the brace group might not be warranted by the price of the brace since the results will be the same in just a few short weeks. This can be decided on a case-by-case basis.

When it was all said and done, the authors concluded that for stable burst fractures, immobilization in a cast or brace just isn’t necessary. Keeping good posture and avoiding extremes of spinal movement can save these patients the financial cost of the brace as well as the physical cost of wearing an uncomfortable suit of body armor (as patients sometimes refer to this type of brace). Long-term studies are needed to confirm that the results will continue over the next year’s worth of time. Therefore, these results and recommendations are considered preliminary by the authors until they complete the full two-years of the study.

The Dowager’s Hump: What Is It? What Can Be Done About It?

The Dowager’s hump in medical terms is called hyperkyphosis. It is an increase in the forward curvature of the spine — usually in the lower cervical (neck) and upper thoracic areas. A visible hump appears along the back of the spine and the head juts forward and eventually down if the curve is pronounced enough.

What causes it? And what can be done about it? Doctors and scientists are starting to pay more attention to this problem. It’s not that it hasn’t been around for a long time. But more of the Baby Boomers have this problem and they are concerned. Experts estimate hyperkyphosis may affect as many as four out of every 10 older adults. And it’s not just women who develop this problem. Men are just as likely as women to become stooped over as they age. There is concern for how it looks but even more worrisome is the fact that vertebral fractures and even death may be more likely among folks with this condition.

Let’s take a step back and answer the first question. What causes it? It’s not entirely clear what causes it — or if there is just one possible cause. There may be many underlying causes making this a multifactorial problem. Muscle weakness, muscle imbalance, degenerative disc disease, ligament problems, and certain metabolic problems top the list of potential causes. Since it seems to run in families, there could be a genetic link as well.

There are some inherited genetic conditions that include hyperkyphosis. These include Scheuermann disease, osteogenesis imperfecta, Ehlers Danlos syndrome, Marfan syndrome, and cystic fibrosis. Most of these problems directly affect the muscles and bones, but why hyperkyphosis is an outcome remains uncertain.

Usually the person with hyperkyphosis isn’t as aware of the problem as others (family and friends) around them. Since it is more obvious when viewed from the side and most people view themselves in the mirror from the front, it can progress quite a bit before anyone seeks help for it. It can be completely asymptomatic (no symptoms), but neck pain and headaches can develop. Even in moderate cases, it can become difficult to lie on the backs comfortably because the head is flexed so far forward.

What can be done to treat this condition? Once again, there are more questions than answers. There haven’t been a lot of studies done comparing the results of one treatment approach to another. This is an area wide open for future research. Possible treatment options include bracing, postural exercises, strength training, flexibility training, and surgery.

Even more important is the question: can this problem be prevented? Because hyperkyphosis has been observed in other conditions such as heart disease (e.g., atherosclerosis or hardening of the arteries) and there are an increased number of deaths in people with hyperkyphosis, finding ways to prevent the problem is a good idea. There’s been some suggestion that hyperkyphosis isn’t just a simple problem of spinal curvature. From a big picture point-of-view, hyperkyphosis may be just one part of a larger number of health issues. It is certainly a signal that other health and functional problems are at hand.

For now, despite the fact that this condition has been around for hundreds of years, what we know about it isn’t very much and highly questionable. It’s definitely time to take a closer look and get some answers to the many questions.

The Jury is In: Vertebroplasty Reduces Pain and Improves Function

Doctors know that anyone over the age of 50 experiencing sharp and sudden mid-to-low back pain could be suffering a vertebral compression fracture (VCF). These fractures of the vertebra can occur without obvious trauma. Osteoporosis (weakened or brittle bones) is the major risk factor. When stress on the spine from everyday movements is greater than the strength of the bone, the bone fractures and collapses down on itself. That’s a vertebral compression fracture (VCF).

More and more people are being affected by VCFs every day. In fact, it’s estimated that a new VCF occurs every 45 seconds. This adds up when over 10 million people have osteoporosis and the potential for a VCF. And once you’ve had one VCF, your risk for another one goes up five times.

But there’s some good news in all of this. A treatment procedure called vertebroplasty was developed about 15 years ago. A long, thin tube called a cannula (needle) is inserted through the skin into the vertebral bone. Cement is injected through the needle into the compressed area. The cement hardens quickly and stabilizes the fracture.

The surgeon uses a special X-ray imaging called fluoroscopy to guide the needle and ensure accurate placement of the cement. The surgeon is careful to only inject cement into the anterior (front half) of the vertebral body. Every effort is made to avoid cement leaking into the posterior (back) portion of the vertebral body. This is to prevent any cement from getting into the spinal canal where the spinal cord is located.

It doesn’t take long for the cement to harden. Then the surgeon removes the needle. Just a simple (sterile) bandage is needed to cover the puncture site(s). The patient remains in the recovery room for a couple of hours while the nurses check to make sure there are no problems or complications.

Studies are showing that percutaneous vertebroplasty works well for the treatment of VCFs. It reduces pain, maintains the height of the vertebral body, and can prevent serious health problems. Some minor soreness or discomfort may be present at the place where the needle was inserted.

But the majority of patients do well. The procedure reduces their back pain and this, in turn, increases their movement and return to daily function. Nine out of 10 patients are able to reduce (or stop) taking pain relievers. By the end of three months, patients can begin to gradually start lifting objects that weigh more than five pounds.

Not everyone can have this procedure. If the fracture is stable and isn’t causing any symptoms, the surgeon may adopt a wait-and-see approach. Anyone with cancer causing the vertebral compression fracture and collapse may not be a good candidate. Cement leaks are much more common when the fracture is caused by cancer that has eaten away at the bone. This doesn’t mean that cancer patients can’t have a vertebroplasty. Vertebroplasty for cancer patients must be evaluated on an individual basis.

Vertebroplasty can’t be done if a bone fragment from the fracture has shifted or moved into the spinal canal or is pressing on the spinal cord. And there are some patients who are allergic to the bone cement.

All in all, with good technique, the surgeon can perform a vertebroplasty quickly and easily. The procedure is done when more conservative care (bracing, exercises, medications) is unable to reduce or relieve painful symptoms.

With the help of fluoroscopy, vertebroplasty is a safe procedure. Surgeons are trained in ways to place the needles so that the least amount of bone and tissue are affected. Type of cement, amount of cement, and ways to inject the cement have all been developed and improved since this procedure was first introduced.