current management vertebral fractures -...
TRANSCRIPT
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Current Management of Vertebral Compression
Fractures
Michael E. Zychowicz, DNP, FAAN, FAANP
Professor and Director, MSN Program
Orthopedic NP Specialty Lead Faculty
Duke University School of Nursing
As a result of this activity, the learner will be able to…1. As a result of this activity, the learner will be able to describe the clinical
importance of vertebral fractures
2. As a result of this activity, the learner will be able to articulate the typical history and physical exam findings for vertebral compression fractures
3. As a result of this activity, the learner will be able to articulate the current evaluation and treatment methods for vertebral compression fractures
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Disclosures
• I have nothing to disclose
What Is A Compression Fracture?
• Fracture of vertebral body
• Due to diminished bone strength• Osteoporosis• Tumor
• Infection• Long term steroid use
• Public health problem
• Frequently unnoticed• 1:3 come to clinical attention
https://openi.nlm.nih.gov/detailedresult.php?img=PMC3598560_1471‐2474‐14‐75‐5&query=vertebral+fracture&it=xg&req=4&npos=3
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Epidemiology
• Hallmark of osteoporosis
• US = 2million fractures (2005)
• > 700,000 vertebral compression fractures in US annually• >25% over 70 y/o affected• >50% over 80 y/o affected• >70,000 hospitalized annually• > $15,000,000 annual cost for treatment
• Vertebral fractures account for 27% of all fractures
http://neuros.net/wp‐content/uploads/osteoporosis_steps_en.gif
Public Health Burden
• By 2040• World population > 65 y/o expected to double (1.3 billion)
• 14% of total population• More people/ society burden with osteoporosis and fractures
• If fracture rate remains same• 2040 increased total # fractures by 48%
• >3million annually
• $25.3 Billion annually
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Risk Factors
• Most patients who fracture do not have osteoporosis by WHO criteria• Stone, et al. (2003)
• Only 39% with vertebral fracture had WHO DEXA dx of osteoporosis
• Prior compression fracture• Diagnostic of osteoporosis
• National Osteoporosis Foundation: “A vertebral fracture is consistent with a diagnosis of osteopororsis, even in the absence of bone density diagnosis, and is an indication for pharmacologic treatment with osteoporosis medication to reduce fracture risk”
• Highly predictive of future fracture• Presence of a fracture is better predictor then BMD for future fracture
• Fracture risk increases exponentially with increased # and severity of VCF• Called “fracture cascade”
Anatomy & Physiology
• Patients will generally have osteoporosis
• But maybe not
• Decreased crystal size and distribution
• Altered collagen composition
• Microdamage and viability of one cells
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More Than The Spine
• Compromised pulmonary function• Kyphosis
• Affect pulmonary function
• 9% reduction in FV with each compression Fx• 40% of “older” women will have kyphosis
• Only 1/3 will have fractures found on x‐ray• Kyphosis is exacerbated by degenerative disc disease• Increases “fracture cascade” and risk of future fracture
• Bone loss• Significant cortical and trabecular bone loss with prolonged bed rest
• Muscle strength loss• 10‐15% loss weekly with complete bed rest
http://www.texasdiabetes.com/wp‐content/uploads/2016/09/Osteo.jpghttps://upload.wikimedia.org/wikipedia/commons/thumb/d/d8/Spine_‐_Kyphosis_from_Tuberculosis.jpg/1280px‐Spine_‐_Kyphosis_from_Tuberculosis.jpg
More Than The Spine
• One fracture• Increases mechanical stress and load on vertebra/ disc above and below
• 46% of recurrent fractures are adjacent to original fracture
• Degenerative disc disease contributes
https://upload.wikimedia.org/wikipedia/commons/6/66/Intravertebral_vacuum_cleft_sign.jpg
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Morbidity and Mortality
• 1‐year mortality ~ 15% (less than hip fx)
• 2‐year mortality ~20% (equivalent to hip fx)
• Patients with diagnosed VCF• 15% greater mortality than those without
History
• Loss of height• Clothes poorly fitting
• Early satiety• Sudden onset of back pain
• Moderate to severe• Typically where the fracture is located
• May or may not have a traumatic event
• Only 25% seek health care for the pain• Ask about bowel or bladder dysfunction
• May have nerve root or cord compression
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Physical Exam
• Tenderness on palpation over the spinous process• Kyphosis
• Loss of height
• Possibly protuberant abdomen
• Spinal cord injury• Cord compression is very rare
• Nerve root compression or irritation• Due to foraminal stenosis• Evaluate for numbness, tingling, weakness, or loss of reflexes
• Look for a hematoma
https://upload.wikimedia.org/wikipedia/commons/thumb/0/02/Osteoporosis.JPG/368px‐Osteoporosis.JPG
Undiagnosed Fractures!!!!!
• (Nuti, Caffarelli, Gugliemi, Gennari, Gonneli, 2014)
• Study 2450 women – no back pain > 60 y/o• Evaluated quality of life (QUALEFFO tool)• Evaluated calcaneus ultrasound• Radiographs of T/L spine
• 23% had one or more undiagnosed vertebral fracture• More with advancing age
• Quality of life score• Older age, increasing BMI, and severity of fracture associated with worse quality of life
• What does this mean?
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Radiographs
• Obtain X‐rays of the entire spine
• May see loss of anterior, middle, or posterior vertebral height • 20% or at least 4mm
• Anterior height of vertebra body may be diminished • While posterior height remains normal
• Typically no anterior or posterior translation of the vertebral bodies
• Amount of anterior compression usually no more than 40 % (relative to posterior vertebral body height)• If so a burst fx may be present
https://en.wikipedia.org/wiki/Osteoporosis#/media/File:L1_2_vertebral_fracture.jpg
CT Scan
• Usually not necessary• Indications
• Fracture on x ray• Neurologic deficit• Unable to obtain good x rays
• Allows good visualization of the posterior elements
• Visualizes spinal canal and degree of neural compromise
• Evaluate posterior element involvement with a burst fracture
• Disadvantage• Inability to detect subtle horizontally fractures of vertebral bodies, pedicles, or lamina• Minimal vertebral body compression fractures may be missed• Might be overcome by frontal & sagittal reformation
https://commons.wikimedia.org/wiki/File:Ct‐scan.jpg
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MRI
• Usually not necessary for diagnosis
• Useful to evaluate for• Acute vs chronic nature of compression fracture
• Injury to anterior and posterior ligament complex
• Spinal cord compression by disk or osseous material
• Cord edema or hemorrhage
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Lab Work
• A full medical workup should be performed with CBC, BMP
• ESR may help to rule out infection
• Urine and serum protein electrophoresis may help rule out multiple myeloma
• Serum calcium• Incr. w. metastatic bone disease
• Phosphate• Hypoparathyroid, secondary hyperparathyroidism
• Alk Phosphatase• Incr w. hyper parathyroidism, osteomalacia, and pagets
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Differentials
• Disc herniation• Thoracic or lumbar muscle strain
• Metastatic cancer to the spine• must be considered and ruled out• the following variables should raise suspicion
• fractures above T5• atypical radiographic findings• failure to thrive and constitutional symptoms• younger patient with no history of fall
• Pagets disease• Multiple myeloma
• Hyperparathyroidism• Osteomalacia
https://commons.wikimedia.org/wiki/File:L4‐l5‐disc‐herniation.png
Non‐Operative Treatment
• Non operative treatment remains the standard for compression fx
• Goal• Pain relief and rehabilitation• Management of underlying osteoporosis
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Non‐Operative Treatment
• Indications• Majority of patients can be treated with observation and gradual return to activity • PLL intact (even if > 30 degrees kyphosis or > 50% loss of vertebral body height)
• Pain medication• Pain usually resolves in 6‐12 weeks• NSAIDS/ COX‐2 inhibitors with caution• Narcotics with caution• Muscle relaxers best in first 2 weeks
• If the fracture is less than five days old calcitonin can be used for four weeks to decrease pain• (AAOS) “Patients who present with an osteoporotic spinal compression fracture on imaging with correlating
clinical signs and symptoms suggesting an acute injury (0‐5 days after identifiable event or onset of symptoms) and who are neurologically intact be treated with calcitonin for 4 weeks.” Strength of Recommendation: Moderate
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Non‐Operative Treatment
• Medical management can consist of bisphosphonates to prevent future risk of fragility fractures
• (AAOS) “Ibandronate and strontium ranelate are options to prevent additional symptomatic fractures in patients who present with an osteoporotic spinal compression fracture on imaging with correlating clinical signs and symptoms.” Strength of Recommendation: Limited
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Non‐Operative Treatment
• Bracing
• Reduce pain, stabilize spine, and limit progression of deformity
• Earlier mobilization/ reduced bed rest
• Some patients may benefit from an extension orthosis although compliance can be an issue
• (AAOS) “Unable to recommend for or against treatment with a brace for patients who present with an osteoporotic spinal compression fracture on imaging with correlating clinical signs and symptoms and who are neurologically intact.” Strength of Recommendation: Inconclusive
https://www.braceability.com/media/catalog/product/cache/1/image/460x/9df78eab33525d08d6e5fb8d27136e95/c/y/cyb‐cstl‐nb‐tlsox4‐cyberspine‐tlso‐thoracic‐postural‐kyphosis‐brace‐back.jpg
Non‐Operative Treatment
• Most pts can be treated symptomatically w/ short period of bed rest until pain is diminished; • (AAOS) “Unable to recommend for or against bed rest, complementary and alternative medicine, or opioids/analgesics for patients who present with an osteoporotic spinal compression fracture on imaging with correlating clinical signs and symptoms and who are neurologically intact.” Strength of Recommendation: Inconclusive
• Rarely an NG tube is required for severe ileus• If bowel sounds and flatus are not present then patient should be made NPO, should receive IV Fluid
• Early ambulation is encouraged in a hyperextention orthosis
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Non‐Operative Treatment
• Avoid compression overload for 8‐12 weeks
• Depending on degree of compression• pt may be treated effectively by hyperextension exercises
• avoidance of compression overloads for period of approximately 12 weeks.
• Early ambulation is encouraged in a hyperextension orthosis.• No bending, stooping, twisting, or lifting more than 20 lbs
• Avoid bone and muscle loss• May need pain meds and muscle relaxers
https://pixabay.com/en/lifting‐box‐wood‐heavy‐crate‐24401/
Non‐Operative Treatment
• Physical therapy
• Can assist with pain management, modalities, and ambulation
• (AAOS) “Unable to recommend for or against a supervised or unsupervised exercise program for patients who present with an osteoporotic spinal compression fracture on imaging with correlating clinical signs and symptoms and who are neurologically intact.” Strength of Recommendation: Inconclusive
• (AAOS) “Unable to recommend for or against electrical stimulation for patients who present with an osteoporotic spinal compression fracture on imaging with correlating clinical signs and symptoms and who are neurologically intact.” Strength of Recommendation: Inconclusive
• Return to work
• Asap with modifications
https://cdn.pixabay.com/photo/2016/02/13/18/20/physical‐therapy‐1198344_960_720.jpg
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Unstable Fracture
• Treatment• definition of unstable frx:
• loss of 50% of vertebral body height• angulation of thoracolumbar junction > 20 deg• multiple adjacent compression frx• failure of 2/3 of columns of spine
• spinal segment will fail with weight bearing• even w/ spinal instability ‐may have good response w/ a hyperextsion cast
• note: a brace should not be considered a substitute for a well molded hyperextension cast
• (AAOS) “We are unable to recommend for or against any specific treatment for patients who present with an osteoporotic spinal compression fracture on imaging with correlating clinical signs and symptoms and who are not neurologically intact.” Strength of Recommendation: Inconclusive
https://openi.nlm.nih.gov/detailedresult.php?img=PMC2856395_IJOrtho‐44‐191‐g003&query=unstable+fracture&it=xg&req=4&npos=50
Vertebroplasty
• Not indicated• AAOS recommends strongly against the use of vertebroplasty
• Outcomes• randomized, double‐blind, placebo‐controlled trials have shown no beneficial effect of vertebroplasty
• Vertebroplasty has higher rates of cement extravasation and associated complications than kyphoplasty
• (AAOS) “Recommend against vertebroplasty for patients who present with an osteoporotic spinal compression fracture on imaging with correlating clinical signs and symptoms and who are neurologically intact.” Strength of Recommendation: Strong
https://openi.nlm.nih.gov/detailedresult.php?img=PMC3309392_arm‐35‐844‐g001&query=vertebroplasty&it=xg&req=4&npos=72
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Kyphoplasty
• Indications• Patient continues to have severe pain symptoms after 6 weeks of nonoperative treatment
• Technique• Kyphoplasty is different than vertebroplasty in that a cavity is created by expansion balloon and therefore the cement can be injected with less pressure
• Pain relief thought to be from elimination of micromotion
• (AAOS) “Kyphoplasty is an option for patients who present with an osteoporotic spinal compression fracture on imaging with correlating clinical signs and symptoms and who are neurologically intact.” Strength of Recommendation: Limited
https://openi.nlm.nih.gov/detailedresult.php?img=PMC3598560_1471‐2474‐14‐75‐9&query=&req=4&npos=‐1
Surgical Decompression and Stabilization
• Indications• rare in typical compression fracture
• progressive neurologic deficit• PLL injury and unstable spines
https://upload.wikimedia.org/wikipedia/commons/6/6b/Spinal_cord_compression.jpg
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Referral and Follow Up
• Any neurologic deficit
• Instability noted on x‐ray
• Increasing kyphotic deformity
• Pain has not resolved
• Elective stabilization and arthrodesis should be considered
Thank You – Questions???
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References
• Cauley, J.A. (2013) . Public Health Impact of Osteoporosis. Journal of Gerontology, 68(10). 1243‐1251.
• Nuti, R., Caffarelli, C., Guglielmi, G., Gennari, L., Gonnelli., S. (2014). Undiagnosed Vertebral FracturesInfluence Quality of Life in Postmenopausal Women with Reduced Ultrasound Parameter. Clinical Orthopedic Related Research, 472(7). 2254‐2261.
• Kendler, D., Bauer, D., Davison, K., Dian, L., Hanley, D., Harris, S., McClung, M., Miller, P., Schousboe, J., Yuen, C., & Lewiecki, E. (2016). Vertebral Fractures: Clinical Importance and Management. The American Journal of Medicine. 129(2) 221e1‐221e10.
• Broy, S. (2016). The Vertebral Fracture Cascade: Etiology and clinical implications. Journal of clinical desitometry, 19(1). 29‐34.
• Longo, U., Loppini, M., Denaro, M., Maffulli, M. & Denaro, V. (2012). Conservative management of patients with an osteoporotic vertebral fractures. The journal of bone and joint surgery. 94B(2). 152‐157.
• Armstrong, A. & Hubbard, M. (2015) Essentials of Musculoskeletal Care (5th Edition) American Association of Orthopedic Surgeons: Rosemont, Il