management of compression fractures cover

Management of Vertebral Compression Fractures

Case Presentation

A 75 year old caucasian female presents to the emergency department with increasing mid back discomfort.  She denies any trauma and plain radiographs show a compression fracture at the T10 level.  Which of the following is NOT a risk factor for a vertebral compression fracture? 

 

A. Radiation therapy

B. Osteoporosis

C. Hormonal dysregulation

D. Obesity

Introduction

Vertebral compression fractures (VCFs) can cause severe physical limitations, including back pain, functional disability, and progressive kyphosis of the spine that ultimately results in decreased appetite, poor nutrition, and impaired pulmonary function [1].  Morbidities associated with vertebral compression fractures are substantial and can result in permanent loss of mobility and quality of life and lead to substantial disability [2].  It is important for sports medicine providers to be comfortable with the management of compression fractures depending on their practice. 

VCFs are relatively common, with approximately 1.5 million adults affected in the US population annually [1].  The Thoracolumbar junction (T12 to L2) has been reported to be the most frequently affected site with 60% to 75% of VCFs, followed by the L2 to L5 region comprising 30% of VCFs [1]. VCFs are also the most common sequelae of osteoporosis, another common disease affecting primarily the elderly population [3]. In younger patients, 50% of VCFs are due to motor vehicle collisions with another 25% due to falls [1]. 

Risk factors compression fractures

Table 1: Risk factors for compression fracture.  Adopted from [24].

Management of vertebral compression fractures has been extensively discussed with opponents arguing against the augmentation and restricting to conservative management [4].  Management of vertebral compression fractures ranges from conservative pharmacologic analgesia to more invasive solutions like percutaneous vertebroplasty or percutaneous kyphoplasty. Despite the range of therapies, the heterogeneity of the affected patient population and misinterpretation of evidence has made it difficult to establish appropriate guidance [5].

Conservative Management

Current conservative treatment options for management of VCFs include oral analgesics (NSAIDs or opioids), rehabilitative exercise, osteoporosis treatment (calcitonin, bisphosphonates), spinal orthotics, and multimodal therapy [6].  Many patients achieve pain relief over 6-8 weeks as the fracture heals, but some experience persistent pain and disability.  Nonsteroidal antiinflammatory drugs (NSAIDs) are frequently first-line medications for pain relief due to their perceived safety profile, low cost, and accessibility [7].   Opioid pain medication may be beneficial in acute pain management, although long-term use can lead to dependence and tolerance, and should not be routinely utilized for vertebral compression fracture [7].

Calcitonin is a 32-amino acid polypeptide available as a nasal spray, subcutaneous or intramuscular injection, or rectal suppository. It may act as an analgesic by directly stimulating calcitonin binding receptors in the central nervous system and increasing beta-endorphin plasma levels [8].  A systematic review and meta-analysis found that calcitonin had strong efficacy in the management of acute back pain associated with vertebral compression fracture, but insufficient evidence for older fractures causing chronic pain [9]. 

Although medications are very commonly used as first line treatment, a systematic review of national guidelines across the United States, United Kingdom, and Canada found inconsistent guidance and weak evidence for the use of these medications [10].   In the face of mixed data, patients and clinicians may initiate nonsurgical management, but should follow closely and try to prevent any further complications. 

A brace can also be used for pain relief because it stabilizes the spine. Bracing can be used initially in the acute and subacute phases but should not be used long-term because atrophy of the core musculature can occur with prolonged use [20].  The efficacy of bracing in preventing future vertebral body collapse has not been established and it is often poorly tolerated in older patients [21].  The AAOS is also inconclusive in its stance on bracing and other forms of therapy such as exercise [22]. 

Imaging

Compression fracture XR

Figure 1.  AP and lateral radiographs.  Adopted from [13].

Nonsurgical prevention strategies to avoid future compression fractures include adequate management of the underlying cause. Vertebral compression fractures are most commonly due to osteoporosis, but they can also occur due to trauma, infection, or neoplasms [11].  In patients under 50 years old without a history of trauma, malignancy should be high on the differential diagnosis.  In osteoporosis, this involves obtaining a DEXA scan to monitor bone mineral density; physical therapy/exercise to strengthen antigravity muscles; and prescription of appropriate medications [12].  Medications have previously been discussed in a previous post.

Grading compression fracture

Figure 3.  Grading of compression fractures.  Adopted form [13].

Treatment

Determining when to refer for surgical management of a vertebral compression fracture can be challenging.  One consensus panel of primary care physicians noted that leg pain or weakness in the context of a vertebral compression fracture can warrant immediate referral to the surgical team [12].   Referral for surgical management should be considered if the level of pain, disability, or kyphotic deformity is substantial, or if there is no response to nonsurgical management over 4-6 weeks. Additionally, if there is progressive kyphosis on follow-up radiographs, a referral to spine surgery or interventional radiology.  Regional variations in practice patterns may dictate which specialty to refer to for cement augmentation.

Two common minimally invasive treatments utilized in the surgical management of vertebral compression fractures are kyphoplasty and vertebroplasty, in which bone cement, or polymethylmethacrylate, is injected into the fractured vertebral body (cement augmentation) [13].  In a vertebroplasty, physicians use image guidance, typically fluoroscopy, to percutaneously inject cement into the cancellous bone of the fractured vertebral body, with the aim of alleviating pain and preventing deformity and further loss of height. 

Kyphoplasty was later introduced as a modification of vertebroplasty by inflating a balloon tamp to create a cavity within the vertebral body. Theoretically, this reduces the pressure needed to inject the cement and minimizes extravasation [13].  Additional benefits of kyphoplasty include restoration of the vertebral body height and reduced kyphosis, although clinical studies have found both procedures to be similarly effective and there are no differences among patient-reported outcome measures.  Kyphoplasty is associated with a reduced risk of cement leakage and therefore, this may be a preferred treatment option for patients in whom this is a great concern [13].

 

There has been a significant decline in utilization of interventional techniques [14-16] and significant debate surrounding this recently.  Since 2009, multiple systematic reviews, clinical trials, and quality of life studies have demonstrated the effectiveness of vertebral augmentation procedures in the treatment of compression fractures. 

A 2018 Cochrane Review by Buchbinder et al. [17] concluded that the review found “no demonstrable clinical important benefits of percutaneous vertebroplasty compared with placebo or sham procedure, and sensitivity analysis confirmed that open trials comparing vertebroplasty with usual care are likely to have overestimated any benefit of vertebroplasty.” Further, they stated that correcting for these biases would likely drive any benefits observed of vertebroplasty towards the null, in keeping with findings from placebo control trials.

Subsequently, Beall et al. [18] published a meta-analysis comparing outcomes following vertebroplasty, balloon kyphoplasty, vertebral augmentation with implant, and nonsurgical management. This review utilized 25 studies meeting inclusion criteria for the meta-analysis and concluded that “based on Level I and Level II studies, balloon kyphoplasty had significantly better and vertebroplasty tended to have better pain reduction compared with non-surgical management.”  There have also been critiques of the 2018 Cochrane review citing misrepresentation of the data.

Balloon kyphoplasty vertebral compression fracture

Image 4: Images from a balloon kyphoplasty  Adopted from [25].

Other surgical interventions include decompression then screw implantation and vertebral fixation. Decompression is indicated if the patient has neurological deficits due to neural compression. Screw augmentation can be used to increase the pull-out strength and may be combined with cement injection if fenestrated screws are used [23].   Vertebral fixation, specifically posterior vertebral fixation, has limited indications, including burst fractures, multiple VCFs causing kyphotic deformity, and malunion [23].  Both of these interventions can be combined with cement injection, so they can result in similar complications as vertebroplasty and kyphoplasty, such as cement extravasation.  These are less common procedures overall.

Treatment algorithm compression fractures

Figure 5.  Algorithm for treatment of osteoporotic compression fractures.  Adopted from [20].

Summary

In conclusion, vertebral compression fractures (VCFs) are the most common complication of osteoporosis and can also have other etiologies. Although many patients are asymptomatic and diagnosed incidentally, some experience debilitating pain and disability. Most will attempt nonsurgical management for the first four to six weeks.  If this fails and there is persistent pain, kyphotic deformity, pseudoarthrosis, or neurological deficits, cement augmentation via vertebroplasty or kyphoplasty should be considered.

Case Conclusion

D is the correct answer. Previous vertebral compression fractures are associated with an increased risk of future vertebral compression fractures. Having one previous vertebral compression fracture increases the risk of a future one by fivefold, and having 2 previous vertebral compression fractures increases the risk of future such fractures by 12-fold. Furthermore, with a decrease in bone mineral density of 2 standard deviations, the risk of a vertebral compression fracture increases by four- to sixfold.  Modifiable risk factors for vertebral compression fractures include factors that are also associated with an increased risk of osteoporosis, such as early menopause, bilateral salpingo-oophorectomy, alcohol use, tobacco use, calcium or vitamin D deficiency, and physical inactivity.  Non modifiable risk factors include advanced age >70 years, white or Asian race, female sex, history of steroid use, and history of treatment with anticonvulsants. Obesity is protective against vertebral compression fractures due to the increased bone remodeling and formation induced by physical stress on bones, increased estrogen production by adipose tissue, and hyperinsulinemia leading to increased insulin-like growth factor 1, which stimulates bone formation.

– Read More @ Wiki Sports Medicine: https://wikism.org/Compression_Fracture

References

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