Osteoporotic Vertebral Fractures Recommendations
Osteoporotic Vertebral Fractures
Recommendations of WFNS Spine Committee
Epidemiology and natural course of osteoporosis and osteoporotic spine fractures / Preventive measures for osteoporotic spine fractures
1-Patients with acute osteoporotic compression fractures (OCF) may have sufficient pain relief during the first 3 months with conservative treatment.
2-At one-year follow-up with conservative treatment, 60% of patients have sufficient pain relief, while 40% still have pain with VAS scores≥4.
3-With an aging population, the incidence of OCF continues to rise and is nearly 8 fold higher in women aged 85-89, compared to those aged 60–64.
4-The prevalence of OCF varies across the globe. The highest rates are from North America and some countries in Asia.
5-Preventive treatment of osteoporotic vertebral fractures includes active life-style, adequate nutrition, and prevention of immobilization with physical therapy and pharmacological therapy.
6-To assess the pharmacological treatment the physician has available predictors of fracture risk such as fracture risk assessment (FRAX) (clinical factors + BMD + BMI) or DEXA (dual-energy X-ray absorptiometry) alone or history of previous fragility fractures.
7-Oral integration with calcium and vitamin D represents first-line intervention to prevent bone mass loss (BMD) in post-menopausal women. Selective estrogen-receptor modulators (SERMs) are an effective treatment for the prevention and treatment of postmenopausal osteoporosis.
8-Bisphosphonate represents second-line intervention in case of positive fracture risk or previous fractures. Denosumab and parathormone (PTH) peptides (teriparatide) represent third line treatment and may be prescribed after endocrinologic- rheumatologic evaluation.
9-All the actually employed anti-osteoporotic drugs are effective in prevent vertebral fracture and are cost-effective. The indication of one respect the others is based on patient preference, compliance and risk of discontinuation related to adverse events and administration method. Medical treatment should last longer than 5 years and there is no need of repeated DEXA evaluation.
Radiologic diagnosis, clinical and radiological factors affecting surgical decision making.
1-Dynamic lateral X-rays may be done to evaluate nonunion of osteoporotic compression fractures.
2-Standard X-ray / DXA should be applied for radiological diagnosis of moderate to severe osteoporotic vertebral fractures.
3-Radiological morphometric plus morphologic assessment should be applied for radiological diagnosis of mild osteoporotic vertebral fractures.
4-MRI /CT may be applied to estimate ligamentous injury, spinal cord injury and bony encroachment.
5-MRI (STIR sequence) /CT should be applied for estimation of aging of vertebral fracture.
6-Atypical vertebral fracture, such as combination of pedicle lysis or posterior element involvement or epidural mass or soft tissue mass, should be differentiated from osteoporotic fracture.
7-Surgical management of osteoporotic VCFs is recommended if pain is at least VAS >3 and refractory to medical management.
8-Surgical management of osteoporotic VCFs is suggested in the presence of neurologic deficit along with radiological findings of a significant retropulsed bony fragment and kyphotic instability.
9-Surgical management of osteoporotic VCFs without neurological deficit may be considered in the presence of radiological parameters associated with pseudoarthrosis and deformity.
10-Spinopelvic parameters on spine alignment and stability, may be considered in the surgical management of osteoporotic VCFs.
Pedicle screw fixation in osteoporotic fractures/ Fixation and Fusion techniques in osteoporotic bones without fracture
1-Open surgery for OCFs should be considered if there is neurologic deficits and significant painful kyphosis.
2-The classification of the Spine Section of the German Society for Orthopedics and Trauma (DGOU) may be helpful indecision of conservative or surgical management.
3-Although DGOU classification considers type 4 and 5 OCF as unstable, there is no clear definition of unstable osteoporotic vertebral fractures.
4-The type of open surgery (anterior, posterior, combined, using cement or bone or vertebral body cage, the levels and type of instrumentation) should be decided case based.
5-If surgery is planned to correct a significant kyphosis after OCF, multilevel fixation, cement augmentation, preserving the sagittal balance and avoiding to end the instrumentation at the apex of kyphosis are necessary to prevent complications.
6-There are many techniques recommended to increase the strength of fixation in osteoporotic spine: a) screws with larger diameters, b) longer screws penetrating anterior cortex, c) expandable screws, d) using more fixation points, e) using cement augmentation by cannulated screws or vertebroplasty, f) avoiding forceful correction maneuvers. However, superiority of one technique to another is not well known, decision must be done according to surgeon’s choice.
7-Screws with cement augmentation increase pullout strength. However, increase of cement volume does not have any effect on pullout strength.
8-Augmented screws have less screw loosening, less reduction loss and high fusion rates compared to non-augmented screws.
9-Implant failure in osteoporotic spine is a common complication. Pseudoarthrosis, screw loosening, proximal and distal junctional kyphosis, loss of correction are among those complications.
10-Implant failure in osteoporotic spine can be prevented by: a) Achieving a good sagittal balance by adding interbody fusion or osteotomy b) Decreasing loads on upper instrumented vertebra by hooks, prophylactic vertebroplasty c) Decreasing instrument rigidity, using hybrid systems Superiority of one technique to another is not clear and decision must be made according to the patient’s conditions.
Vertebral augmentation in osteoporotic spine fractures
1-There have been multiple conflicting studies regarding cement augmentation in osteoporotic compression fractures of the spine. Some studies showed no significant reduction in pain, or improvement in QOL with vertebral augmentation, when compared to controls. We suggest that further high quality, better designed studies are required.
2-The results of meta-analyses regarding the efficacy of vertebral augmentation procedures to reduce pain have been largely inconclusive, and thus the patient need to be counselled about conservative option and the benefits and complications associated with vertebral augmentation.
3-There is not enough evidence to define the correct timing for vertebral augmentation techniques. We suggest indication of VA procedure < 6weeks from acute event to achieve better pain control and QoL.
4-There is no statistically significant difference between monolateral and bilateral approaches in the different VA techniques for osteoporosis.
5-Different VA techniques do not provide statistically significant differences for pain control, QoL and mobilization, to suggest one technique instead of another.
Nonsurgical treatment, chemotherapy, endocrine assessment, and rehabilitation for osteoporotic spine fractures
1-Spine fracture in postmenopausal women and men aged 50 years and above is an indication for pharmacologic treatment with osteoporosis medication to reduce subsequent fracture risk.
2-It is recommended that treatment review for drug holiday should be performed after 5 years for alendronate, risedronate, or ibandronate, and after 3 years for zoledronate.
3-Exercise, in the form of strength training and balance, gait, and coordination training and assistive devices, are recommended to prevent and reduce falls in elderly.
4-Non-surgical management is useful for treatment of osteoporotic vertebral compression fractures.
5-Braces are useful for conservative management of Osteoporotic Vertebral Compression Fracture (OVCF) for patient satisfaction, and selective use of orthotics help reduce discomfort, prevent falls and fractures, and improve quality of life after fracture.
6-Further studies are required to lay down protocol for chemotherapy.
7-Multidisciplinary primary approach for conservative management seems effective in alleviating pain, reducing morbidity, reducing disease progression clinically and radiologically, though the evidence is lacking.
8-Premenopausal women and men <50 years with osteopenia, osteoporosis or fragility fracture will need endocrine assessment for osteoporosis as DXA alone may not be predictive of fracture.
9-A Z-score ≤-2.0 warrants investigations for secondary osteoporosis including a detailed assessment for endocrine causes of osteoporosis.
10-Patients with endocrine disorders, such as hyper-parathyroidism, hyperthyroidism, hypogonadism, and Type I diabetes, are associated with fragility fracture & osteoporosis. They need biochemical assessment for osteoporosis.
11-Strength and weight training under supervision is recommended as part of a comprehensive plan to maintain bone density and prevent osteoporotic fractures of the spine.
12-Rehabilitation is part of the overall treatment to help patients return to function after an osteoporotic fracture of the spine.
13-The use of orthoses for temporary stabilization after osteoporotic spine fracture is an option. There is not enough data to recommend it, nor to recommend a specific bracing approach.
14-There is not enough information for specific recommendations regarding bed rest, timing and types of physical therapy or other rehabilitation modalities immediately after asymptomatic osteoporotic spine fracture.