What are some emerging techniques for treatment of osteoporotic fractures

Investigational techniques include use of bioactive cements and implantation of devices in combination with PMMA into the fractured vertebral body. Hybrid surgical procedures have been reported that combine vertebral body augmentation procedures with traditional open surgical techniques. In patients with spondylolisthesis or kyphotic deformity, posterior pedicle screw-rod fixation has been performed in combination with posterior surgical decompression and cement augmentation. Although compromise of the posterior vertebral body cortex was originally considered an absolute contraindication to vertebral augmentation due to risk of cement leakage into the spinal canal, intraoperative visualization of the posterior vertebral body wall during open surgical decompression combined with cement augmentation has been described in the treatment of patients with symptomatic neurologic compression related to fractures. This technique permits immediate detection and treatment of cement extravasation and allows for optimal cement placement, as well as immediate spinal canal decompression if a critical cement leak occurs. This technique has been applied to osteoporotic vertebral fractures, as well as vertebral defects resulting from metastatic tumors. Use of cement products not receiving United States Food and Drug Administration clearance specifically for vertebroplasty or kyphoplasty represents off-label use.

Key Points

1. Vertebral compression fractures are the most common type of fracture due to osteoporosis.

2. Kyphoplasty and vertebroplasty provide pain relief and improvement in quality of life measures in appropriately selected patients with acute and subacute osteoporotic vertebral body compression fractures.

3. When placing a needle into the vertebra during a kyphoplasty or vertebroplasty procedure, the needle should not cross the medial pedicle border on the AP fluoroscopic view until the needle has passed the posterior cortex of the vertebral body on the lateral view.

4. Major reconstructive spinal surgery for osteoporotic spine fractures has a high rate of complications and is reserved for patients with significant neurologic deficits, spinal instability, or severe spinal deformities.

Websites

1. Primer on compression fractures and kyphoplasty: http://www.kyphon.com/us/physician.aspx?contentid=83&siteid=1

2. Primer on compression fractures and vertebroplasty: http://www.vertebroplasty.com/

3. Treatments for compression fractures: kyphoplasty and vertebroplasty: http://www.spineuniverse.com/displayarticle.php/article1525.html

BiBLiOGRAPHY

1. Buchbinder R, Osborne RH, Ebeling PR et al. A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med 2009;361(6):557-68.

2. Burval DJ, McLain RF, Milks R, et al. Primary pedicle screw augmentation in osteoporotic lumbar vertebrae. Spine 2007;32(10):1077—83.

3. Kallmes DF, Comstock BA, Heagerty PJ et al. A randomized trial of vertebroplasty for osteoporotic spinal fractures. N Engl J Med 2009;361(6):569-79.

4. Klazen CAH, Lohle PNM, deVries J, et al. Vertebroplasty versus conservative treatment in acute osteoporotic vertebral compression fractures (Vertos II): An open-label randomised trial. Lancet 2010; 376:1085-92.

5. Lee MJ, Dumonski M, Cahill P et al. Percutaneous treatment of vertebral compression fractures; a meta-analysis of complications. Spine 2009;34:1228-32.

6. Patel AA, Vaccaro AR, Martyak GG, et al. Neurologic deficit following percutaneous vertebral stabilization. Spine 2007;32:1728-34.

7. Singh K, Heller JG, Samartzis D, et al. Open vertebral cement augmentation combined with lumbar decompression for the operative management of thoracolumbar stenosis secondary to osteoporotic burst fractures. J Spinal Disord Tech 2005;18:413-9.

8. Suk S, Kim JH, Lee SM, et al. Anterior-posterior surgery versus posterior closing wedge osteotomy in posttraumatic kyphosis with neurologic compromised osteoporotic fracture. Spine 2003;28:2170-5.

9. Taylor RS, Taylor RJ, Fritzell P. Balloon kyphoplasty and vertebroplasty for vertebral compression fractures: A comparative systematic review of efficacy and safety. Spine 2007;31:2747-55.

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