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Osteoporotic Vertebral Compression Fractures: Diagnosis and Management

Osteoporotic Vertebral Compression Fractures: Diagnosis and Management

Teaser: 

Michael M.H. Yang, MD, M.Biotech,1 W. Bradley Jacobs, MD, FRCSC,2

1Division of Neurosurgery, Department of Clinical Neuroscience, University of Calgary, Calgary, Alberta, Canada.
2Division of Neurosurgery, Department of Clinical Neuroscience, University of Calgary, Calgary, Alberta, Canada.

CLINICAL TOOLS

Abstract: Osteoporotic vertebral compression fractures (VCFs) are the most common fragility fracture and have significant impact on numerous indices of health quality. High risks patients should be identified and appropriate preventative therapy initiated. The majority of VCFs can be managed in a non-operative fashion, with analgesia as required to support progressive mobilization. Patients who fail non-operative measures may be considered for percutaneous vertebral augmentation. However, the efficacy of these procedures in altering the natural history of recovery is controversial. Surgery has a limited role in the initial management of VCFs and is typically restricted to the rare circumstance of VCF associated with acute neurological dysfunction.
Key Words: osteoporosis, vertebral compression fracture, vertebroplasty, kyphoplasty.

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1. Osteoporosis is under diagnosed in Canada. Early diagnosis, fragility fracture risk stratification and initiation of preventative treatment is important, as osteoporotic vertebral compression fractures (VCFs) have a significant associated personal and societal health utility cost.
2. Patients suspected of having a VCF should have an AP and lateral X-ray of the suspected region. If VCF is confirmed, an upright X-ray should be performed to assess for stability. CT and/or MR imaging has limited utility in the absence of red flag signs or symptoms.
3. VCFs should be managed with initiation of an appropriate pain management regiment, early bed rest as required for pain control and gradual mobilization. Patients with refractory pain 4–6 weeks after onset can be considered for percutaneous vertebral cement augmentation (e.g. vertebroplasty), although the clinical efficacy of such procedures remains unclear.
A few screening measurements can be performed in the office setting to help significantly improve the likelihood of detecting a VCF on radiological studies. They include prospective height loss of greater than 2cm or a height loss, or a height loss based on history of more than 6cm, a rib-to-pelvis distance of less than 2 fingerbreadths, or an occipital-to-wall distance greater than 5cm.
Most patients with osteoporotic VCFs do not need a referral to a spine surgeon. Acute pain from a new VCF usually improves over a period of 6 weeks. Non-operative management should follow the WHO analgesic ladder starting with acetaminophen/NSAIDs followed by opioids, as necessary. The goal of treatment is to provide pain relief and facilitate early functional rehabilitation.
Patients with high or medium 10-year fracture risk should be considered for pharmacotherapy to prevent the progression of low bone mineral density and osteoporotic fractures.
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Kyphoplasty and Vertebroplasty for the Treatment of Osteoporotic Vertebral Compression Fractures

Kyphoplasty and Vertebroplasty for the Treatment of Osteoporotic Vertebral Compression Fractures

Teaser: 

Karen Beattie, BSc, PhD Candidate and Dr. A. Papaioannou, MSc, MD, FRCP(C), Associate Professor of Medicine; Department of Geriatrics, McMaster University, Hamilton, ON.
Dr. P. Boulos, MD, FRCP(C) and Dr. J.D. Adachi, MD, FRCP(C), Professors of Medicine; Department of Rheumatology, McMaster University, Hamilton, ON.

Osteoporosis is a major health concern in Canada, affecting 25% of women and 12% of men. Vertebral compression fractures, the most common of all osteoporotic fractures, are clinically diagnosed only 30% of the time. Treatment for such fractures is primarily pharmacological. However, newer, non-invasive methods of treatment, namely vertebroplasty and kyphoplasty, stabilize compression fractures, provide pain relief and even improve posture and functional ability. While vertebroplasty involves the injection of a cement product into one or more compressed vertebrae, kyphoplasty adds another step of inserting a balloon into the vertebra to re-establish original vertebral height. Clinical studies of these procedures suggest kyphoplasty provides better symptomatic relief and is associated with fewer complications than vertebroplasty. However, further randomized, controlled evidence comparing these procedures is required.
Key words: kyphoplasty, vertebroplasty, osteoporosis, vertebral fracture, compression fracture.