Osteoporosis and Vertebral Compression Fractures
Osteoporosis and Vertebral Compression Fractures
A vertebral compression fracture occurs when a vertebral body, or the primary bony component of the spine, collapses. The cause is often related to osteoporosis, a metabolic disease leading to loss of bone density that increases the risk of fracture.
The aging population has increased the number of severely osteoporotic subjects, mostly women. An estimated 10 million Americans have osteoporosis, and an additional 34 million are estimated to have osteopenia. Compression fractures and other spinal fractures can also be caused by certain types of cancer-related tumors or trauma.
An estimated 750,000 vertebral compression fractures occur every year in the US, which is becoming a public health problem of major proportions. The prevalence of those fractures is around 39% in subjects over age 65 years. Many people do not realize that sudden and intense back pain may be a sign of a spinal compression fracture. Sometimes people assume their back pain and other symptoms are just part of growing older.
Osteoporosis can cause a minor fall or simple bending and lifting movements to result in a major fracture. Whether painful or not, compression fractures can lead to additional fractures, spinal deformity, and loss of the ability to function. Recent studies have shown that osteoporotic vertebral compression fractures are associated with a significantly increased risk of mortality and decreased quality of life.
While vertebral compression fractures had previously been considered a burden to affected patients, there now are several minimally invasive treatment modalities that can be very effective. Vertebral augmentation techniques not only deal with the problem of pain, but also aim to restore the compressed vertebral body height and avoid possible kyphotic deformities.
A vertebral compression fracture should be suspected in any patient over 50 years of age with acute onset of lumbar or thoracic pain. In addition to pain, other signs and symptoms include:
- Loss of height (one of the reasons many older people seem to shrink as they age)
- Kyphosis (or humpback)
- Loss of balance (increases the risk of falling)
- Neurological symptoms such as numbness, tingling, or weakness (increases the risks of falling and breaking other bones)
The medical treatment of the aging spine deserves special attention in view of the generally reduced health situation of the involved patients. General health status, expectations of the patient, and social environment are nonsurgical factors to be considered before undertaking surgery.
There are alternatives to surgery that consist of conservative management. This includes bed rest, narcotic pain medications, and braces. Unfortunately these modalities are typically associated with prolonged immobilization that may further exacerbate bone loss, fail to relieve symptoms, and usually do not provide long-term functional improvement. In addition, in the best case scenario there is no attempt to restore anatomy but rather freeze the fracture in the current “broken” position. This changes the biomechanics of the spine such that each fracture makes it approximately 5 times more likely to re-fracture.
Vertebral Augmentation Techniques
In certain cases where patients are in severe pain, or the vertebrae are rapidly collapsing, minimally invasive procedures are considered without conservative treatment. The advances in vertebral augmentation technology over the past 5 years have been remarkable, offering most patients substantial resolution of their fracture pain with a high degree of safety. Clinical outcome studies demonstrate early and sustained pain relief, improved mobility and function, improved quality of life, and high patient satisfaction rates after vertebral augmentation procedures.
Given the low rate of complications and the high rate of clinical success, minimally invasive surgical procedure are typically a better option over conservative care for the vast majority of patients. Vertebroplasty and kyphoplasty have been recently developed for their potential to provide immediate pain relief and stability with a minimally invasive surgical intervention. Both procedures involve injecting bone cement into the fracture. Physicians at Boulder Neurosurgical & Spine Associates (BNA) have extensive experience in using several vertebral augmentation techniques and have literally “written the book” on the development of some of these techniques and approaches.
Balloon Kyphoplasty (Medtronic, Memphis, TN) is a minimally invasive surgical treatment option that utilizes an inflatable bone tamp to reduce the fracture, restore anatomical relationship, and provide stability to the spine. The entire surgery typically lasts less than an hour and involves the percutaneous placement of cannulae into the vertebral body through the pedicles. An Inflatable Bone Tamp (or balloon) is inserted through the cannula into the vertebral body and inflated while controlling the pressure. The balloon compacts cancellous bone and creates the void, which is filled with bone cement.
StabiliT™ Vertebral Augmentation
Another minimally invasive technique is called StabiliT™ Vertebral Augmentation (DFine, San Jose, CA) System. This new, minimally invasive procedure builds on the original kyphoplasty technique by offering a number of potential advancements.
Cohesive, ultra-high viscosity cement is delivered into the vertebral body during the procedure. The surgeon who performs the procedure can change the viscosity of the bone cement, and allow for vertebral body height restoration with minimal cement.
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At Boulder Neurosurgical & Spine Associates we further advance these technique by enhancing them using image guidance. Intraoperative three-dimensional fluoroscopy-based computerized tomography guidance for percutaneous Kyphoplasty was developed and first described in the literature by Dr. Villavicencio (Villavicencio AT, Burneikiene S, Bulsara KR, Thramann J. Intraoperative Three-dimensional Fluoro-based CT Guidance for Percutaneous Kyphoplasty. Neurosurgical Focus 18(3):E3, pp. 1-7, March 2005).
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