Treatment of osteoporotic vertebral fractures Prost, Solène; Pesenti, Sébastien; Fuentes, Stéphane ...
Orthopaedics & traumatology, surgery & research,
February 2021, 2021-Feb, 2021-02-00, 20210201, Letnik:
107, Številka:
1
Journal Article
Recenzirano
Odprti dostop
Osteoporosis is a public health problem that is contributing to an increasing number of osteoporotic vertebral fractures. The aim of this lecture is to summarize the current state of knowledge about ...osteoporotic fractures by answering five questions. 1/How does the spine typically age and how is osteoporosis diagnosed? Various normal aging processes will gradually modify the vertebral column (static, dynamic, bone quality). Osteoporosis is diagnosed through a DEXA scan. 2/How is an osteoporotic fracture evaluated clinically and radiologically? Magnetic resonance imaging is the preferred modality for making the diagnosis and selecting the most appropriate treatment. 3/What are the treatment options for an osteoporotic fracture? The options are conservative treatment, conventional surgery, and minimally invasive techniques (cementoplasty, percutaneous instrumentation). 4/Which fractures should be treated, and which technique should be used? The choice is clear when neurological deficits are present, although the indications are less firm when there is no deficit. The treatment can be conservative (back brace) if the fracture is non-displaced and minimally painful, vertebroplasty if the fracture is painful and shows hyperintensity on T2-STIR sequences, vertebral expansion if the radiological deformity worsens along with symptoms. 5/What are the technical challenges and complications related to the presence of osteoporosis when treating vertebral fractures surgically? The reduced bone stock increases the risk of poor implant hold and postoperative mechanical complications (adjacent fracture, junctional kyphosis). Technical solutions have been developed (augmented screw fixation, transitional zone) to limit their impact. It is essential to know and master these techniques, and their indications. Treatment of the osteoporosis itself is crucial. Level of evidence V; Expert opinion.
Abstract
BACKGROUND:
Global sagittal malalignment is significantly correlated with health-related quality-of-life scores in the setting of spinal deformity. In order to address rigid deformity ...patterns, the use of spinal osteotomies has seen a substantial increase. Unfortunately, variations of established techniques and hybrid combinations of osteotomies have made comparisons of outcomes difficult.
OBJECTIVE:
To propose a classification system of anatomically-based spinal osteotomies and provide a common language among spine specialists.
METHODS:
The proposed classification system is based on 6 anatomic grades of resection (1 through 6) corresponding to the extent of bone resection and increasing degree of destabilizing potential. In addition, a surgical approach modifier is added (posterior approach or combined anterior and posterior approaches). Reliability of the classification system was evaluated by an analysis of 16 clinical cases, rated 2 times by 8 different readers, and calculation of Fleiss kappa coefficients.
RESULTS:
Intraobserver reliability was classified as “almost perfect”; Fleiss kappa coefficient averaged 0.96 (range, 0.92-1.0) for resection type and 0.90 (0.71-1.0) for the approach modifier. Results from the interobserver reliability for the classification were 0.96 for resection type and 0.88 for the approach modifier.
CONCLUSION:
This proposed anatomically based classification system provides a consistent description of the various osteotomies performed in spinal deformity correction surgery. The reliability study confirmed that the classification is simple and consistent. Further development of its use will provide a common frame for osteotomy assessment and permit comparative analysis of different treatments.
Abstract
BACKGROUND:
Global sagittal malalignment is significantly correlated with health-related quality-of-life scores in the setting of spinal deformity. In order to address rigid deformity ...patterns, the use of spinal osteotomies has seen a substantial increase. Unfortunately, variations of established techniques and hybrid combinations of osteotomies have made comparisons of outcomes difficult.
OBJECTIVE:
To propose a classification system of anatomically-based spinal osteotomies and provide a common language among spine specialists.
METHODS:
The proposed classification system is based on 6 anatomic grades of resection (1 through 6) corresponding to the extent of bone resection and increasing degree of destabilizing potential. In addition, a surgical approach modifier is added (posterior approach or combined anterior and posterior approaches). Reliability of the classification system was evaluated by an analysis of 16 clinical cases, rated 2 times by 8 different readers, and calculation of Fleiss kappa coefficients.
RESULTS:
Intraobserver reliability was classified as "almost perfect"; Fleiss kappa coefficient averaged 0.96 (range, 0.92-1.0) for resection type and 0.90 (0.71-1.0) for the approach modifier. Results from the interobserver reliability for the classification were 0.96 for resection type and 0.88 for the approach modifier.
CONCLUSION:
This proposed anatomically based classification system provides a consistent description of the various osteotomies performed in spinal deformity correction surgery. The reliability study confirmed that the classification is simple and consistent. Further development of its use will provide a common frame for osteotomy assessment and permit comparative analysis of different treatments.
Based on global knowledge regarding sagittal alignment, preoperative planning is a crucial point in the management of adult spinal deformity (ASD). Patient-specific rods (PSR) have been recently ...developed in order to change preoperative planning into a postoperative reality. The aim of this study was therefore to analyze the 1-year radiographic results of prospective ASD cohorts managed using PSR.
In this prospective study, all patients managed for an ASD using PSR since 2014 and with a minimal follow-up of 1-year were included. Radiographic parameters were evaluated pre and postoperatively and patients were stratified according to their final sagittal alignment status (A: aligned vs. MA: malaligned) according to the age-related Schwab classification. Statistical analyses were performed using the Student's-t-test in order to compare groups.
Eighty-six patients were included in the study, with a mean age of 57.2 years. At one-year follow-up, mean sagittal vertical axis and pelvic incidence-lumbar lordosis mismatch were significantly improved. Twenty-two patients were aligned on both sagittal and coronal planes, 52 patients were still considered as malaligned in the sagittal plane, 3 were still malaligned in the coronal plane and 9 patients were malaligned in both planes (vs. 42 patients preoperatively). At final follow-up, the rate of mechanical complications was 18%.
Based on our results, patient-specific rods can represent a useful supplementary tool in the management of ASD and transform preoperative planning into a postoperative reality. Corrections rates are comparable to other series in the literature with conventional rods, and fewer complications have been reported. However, further studies will be required in order to confirm these results.
Prospective study.
The aim of this prospective study is to analyze the influence of Modic type on the clinical results of lumbar total disc arthroplasty.
Some patients with lumbar disc degeneration ...have endplate signal changes on magnetic resonance images, which have been classified by Modic. Modic-1 endplates changes are associated with an inflammatory phase of the disease whereas Modic-2 endplates changes correspond to a quiescent phase with a fatty replacement. The effect of Modic endplate changes on the clinical results of lumbar fusion has been studied by multiple authors, but the influence of Modic type on clinical outcomes of lumbar disc replacement is not known.
A total of 221 patients with a mean age of 42 years were included in this study. Of which, 107 patients were classified Modic 0, 65 Modic 1, and 49 Modic 2. Clinical evaluation (Oswestry Disability Index ODI, lumbar and radicular pain using the Visual Analog Score VAS) was performed preoperatively and at 3, 6, 12, and 24 months minimum postoperatively.
Mean follow-up was 30 months (24-72 months). Significant clinical improvement (P < 0.05) was observed in pain and ODI between the preoperative evaluation and final follow-up. Multivariate analysis between the 3 groups demonstrated a significant difference in Oswestry Disability Index (size of the effect was measured at -0.3 -0.55-0.04) and on the radicular pain (size of the effect was measured at -0.4 -0.7-0.1), with lower scores in the group classified Modic 1.
Superior results were achieved in the group of patients with Modic-1 endplate changes on magnetic resonance images. These data may be helpful in patient selection and in preoperative patient counseling.
Retrospective review.
To determine clinical and radiographic outcomes of thoracolumbar and lumbar burst fractures without neurologic injury treated by closed reduction and casting. Patient factors ...associated with poor outcome are identified.
The results of ambulatory bracing, surgery, and prolonged recumbency for burst fractures have been reported. There are no reports of results of closed reduction and casting.
Retrospective review of 41 neurologically intact patients with thoracolumbar and lumbar burst fractures was performed. Four patients with neurologic injury who refused surgery were included, for a total of 45 patients. All patients had closed reduction and casting. Functional, pain, and employment status were assessed using the Denis system. Neurologic function was graded using the Frankel scale. Radiographic evaluation of vertebral kyphosis, regional kyphosis, anterior body compression, and sagittal index were performed at time of injury, postreduction, 4 months, and final follow-up.
Sixty-four percent of patients had minimal or no pain. Eight percent had constant, severe pain. At time of injury, 71% of patients were employed. At 8-month follow-up, 58% of patients were employed. Closed reduction resulted in significant correction of vertebral wedging from a mean of 15 degrees to 5 degrees. Deformity tended to recur by 4 months, but the degree of residual deformity appears to be less than that reported in other series. No complications resulted from the fracture reduction procedure.
Closed reduction and casting of thoracolumbar and lumbar burst fractures is a safe treatment method that yields acceptable functional and radiographic results.
Retrospective radiographic and chart review.
To examine the relationship between lumbar total disc replacement (TDR) range of motion (ROM) and clinical outcome at 8.6-year follow-up.
There are no ...studies on the relationship between TDR motion and clinical outcomes.
We reviewed 38 patients who underwent 1 or 2-level TDR implantation with 51 TDR. Flexion-extension ROM was measured on lateral radiographs. Clinical outcomes were measured at 8.6 years by modified Stauffer-Coventry scores, Oswestry Disability Questionnaires (ODQ), and subjective ratings of back pain, leg pain, and disability. Spearman rank correlation coefficient was used to determine if ROM was correlated with clinical outcome. Patients were divided into 2 groups by motion (< or = 5 degrees and > 5 degrees ). Statistical differences in outcome were sought.
Spearman rank correlation coefficient revealed weak-to-moderate but statistically significant associations between ROM and outcome for postoperative back pain (r = -0.35, P = 0.034), ODQ (r = -0.33, P = 0.046), and modified Stauffer-Coventry scores (r = 0.42, P = 0.0095). Patients with motion of > 5 degrees had superior outcomes in ODQ (mean difference 12.6 points, P = 0.026) and Stauffer-Coventry scores (mean difference 2.2 points, P = 0.015).
The radiographic ROM at 8.6-year follow-up was positively correlated with several outcomes measures. Patients with motion > 5 degrees had clinically modest but statistically better outcomes in ODQ and modifiedStauffer-Coventry scores. Longer follow-ups will be necessary to measure fully the impact of TDR ROM on outcome.
Background. The development of postural analysis thanks to force and pressure platforms, in order to determine the center of pressure, can be valuable in the setting of spinal malalignment. The ...purpose of this study was to compare “pressure” and “force” platforms for the evaluation of the center of pressure. In other words, can we neglect the horizontal ground reaction force in the evaluation of intersegmental moments during standing posture? Methods. Postural data from two healthy adult volunteers were analyzed. Analysis of the posture was done according to a protocol providing sagittal intersegmental moments. A set of 36 markers was used to divide the body in 10 segments. Postacquisition calculations were done in order to obtain the sagittal net intersegmental moments. To evaluate the differences in intersegmental moments between force and pressure platforms, the postacquisition calculations were done with a simulated pressure platform. Mean intersegmental moments between each body segment for each volunteer were compared. Findings. There were significant differences between the 2 platforms in intersegmental moments for the lumbo-sacral junction, hips, knees, and ankles (p<0.005). All differences were inferior to intrasubject variability measured with the force platform (p<0.001). Results from intra- and interobserver comparisons showed that differences measured with the pressure platform were all inferior to the standard error obtained with the force platform for every intersegmental moment (p<0.001). Interpretation. The use of a simulated pressure platform to determine intersegmental moments has the same clinical efficiency as force platforms. Moreover, the possibility to set the platform into the radiograph room will allow in a second time a correlation between radiographic parameters and biomechanical constraints applied to the spine.
PDF
