operative treatment of osteoporotic spinal fractures

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George Sapkas 1 st Orthopaedic Dept. “Attikon” University Hospital Medical School Athens University Operative treatment of osteoporotic spinal fractures

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Osteoporosis is a systemic disease, which results in : progressive bone mineral loss concurrent changes in bony architecture leaving the spinal column vulnerable to compression fractures, usually after minimal or no trauma.

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Page 1: Operative treatment of osteoporotic spinal fractures

George Sapkas

1st Orthopaedic Dept.“Attikon” University Hospital

Medical SchoolAthens University

Operative treatment of osteoporotic spinal fractures

Page 2: Operative treatment of osteoporotic spinal fractures

• OsteoporosisOsteoporosis is a systemic disease, is a systemic disease, which results in : which results in : • progressive bone mineral loss progressive bone mineral loss • concurrent changes in bony architecture concurrent changes in bony architecture • leaving the spinal column vulnerable to leaving the spinal column vulnerable to

compression fractures, usually after minimal or compression fractures, usually after minimal or no trauma.no trauma.

Riggs:Riggs: N Engl J Med 1986 N Engl J Med 1986

Normal Bone Osteoporotic Bone

Page 3: Operative treatment of osteoporotic spinal fractures

• VCFs VCFs contribute to: contribute to: • a fivefold increased risk of a fivefold increased risk of

further fracturefurther fracture by virtue of by virtue of force transmission to weak force transmission to weak vertebrae, above or below, vertebrae, above or below,

• while these have been shown while these have been shown to be associated with up to a to be associated with up to a 25%25% age-adjusted increase age-adjusted increase in in mortality.mortality.

HeaneyHeaney: Bone 1992: Bone 1992KadoKado: Arch Intern Med 1999: Arch Intern Med 1999

Page 4: Operative treatment of osteoporotic spinal fractures

Traditional treatmentTraditional treatment for patients with for patients with painful VCFs includes :painful VCFs includes :

• bed restbed rest

• narcotic analgesics narcotic analgesics

• bracing bracing

resulting in increased pain because of:resulting in increased pain because of:

• acceleration bone loss acceleration bone loss

• and muscle weakness.and muscle weakness.

UthoffUthoff: JBJS 1978: JBJS 1978ConvertinoConvertino: Med Sci Exerc 1997: Med Sci Exerc 1997

Page 5: Operative treatment of osteoporotic spinal fractures

Investigations Investigations

Page 6: Operative treatment of osteoporotic spinal fractures

CT - scanCT - scan

Page 7: Operative treatment of osteoporotic spinal fractures

MRIMRI

Page 8: Operative treatment of osteoporotic spinal fractures

Bone ScanningBone Scanning

Page 9: Operative treatment of osteoporotic spinal fractures

Management of osteoporotic spinal fractures

Conservative

Operative

Page 10: Operative treatment of osteoporotic spinal fractures

Spinal fixationSpinal fixation

Posterior stabilizationPosterior stabilization

Page 11: Operative treatment of osteoporotic spinal fractures
Page 12: Operative treatment of osteoporotic spinal fractures
Page 13: Operative treatment of osteoporotic spinal fractures
Page 14: Operative treatment of osteoporotic spinal fractures

Anterior – Posterior

Stabilization

Page 15: Operative treatment of osteoporotic spinal fractures

Π.Μ.F 80

28-7-06

Osteoporosis: T-Score: - 3.5

Posterior Correction & Stabilization

Page 16: Operative treatment of osteoporotic spinal fractures

Anterior Anterior Posterior Posterior

Stabilization Stabilization

Page 17: Operative treatment of osteoporotic spinal fractures

N(+)VEN(+)VE

Page 18: Operative treatment of osteoporotic spinal fractures
Page 19: Operative treatment of osteoporotic spinal fractures

Spinal fixationSpinal fixation

Vertebroplasty Vertebroplasty

plusplus

Page 20: Operative treatment of osteoporotic spinal fractures

Technical problems Technical problems & &

Complications Complications

Related to osteoporosisRelated to osteoporosis

Page 21: Operative treatment of osteoporotic spinal fractures

Early post-operative

hardware failure

Page 22: Operative treatment of osteoporotic spinal fractures

Late post-operative

hardware failure

Page 23: Operative treatment of osteoporotic spinal fractures

• the pullout strength, • cutout torque,

and • maximum insertional

torque for pedicle screws have been shownto correlate with bone mineral density and are significantly decreased in osteoporotic vertebrae.

Halvorson TL, Spine 1994Okuyama K, Spine 1993

Considerations for Instrumentation of the Osteoporotic Spine

Page 24: Operative treatment of osteoporotic spinal fractures
Page 25: Operative treatment of osteoporotic spinal fractures

Using multiple points of fixation, such as

segmental pedicle screws

• the load applied to individual screws is reduced and

• the stiffness of the overall construct is increased.

Page 26: Operative treatment of osteoporotic spinal fractures

A similar principle applies to hooks or wires, although these implants generally require longer constructs than pedicle screws to provide adequate fixation

Hu SS, Spine 1997Hart R, et al, Spine 2006

Page 27: Operative treatment of osteoporotic spinal fractures

In the presence of osteoporosis the strength of bone anchors may not allow

• strong compression

• distraction or

• vertebral rotation forces to be applied.

Glassman SD, et al, Instr Course Lect 2003Hu SS, Spine 1997;

Hettwer WH, et al, Advances in Osteoporotic Fracture Management 2004

Page 28: Operative treatment of osteoporotic spinal fractures

Improving the bone-implant interface is fundamental to optimize pedicle screw fixation in osteoporotic bone.

Hettwer WH, et al, Advances in Osteoporotic Fracture Management 2004

Page 29: Operative treatment of osteoporotic spinal fractures

Injectable cements of several types have been shown

to substantially increase the pullout strength of screw fixation in osteoporotic bone.

Glassman SD, et al, . Instr Course Lect 2003Soshi S, et al, Spine 1991

Zindrick MR, et al, Clin Orthop Relat Res 1986Taniwaki Y, et al, J.Orthop Sc 2003

Page 30: Operative treatment of osteoporotic spinal fractures

However, • cement extravasation

can potentially injure surrounding structures, and

• permanent cements such as polymethylmethacrylate represent a potential locus for late infection.

Glassman SD, Instr Course Lect 2003Soshi S, et al, Spine 1991

Page 31: Operative treatment of osteoporotic spinal fractures

Several unique pedicle screw designs have been described for use in osteoporotic.

Page 32: Operative treatment of osteoporotic spinal fractures

• Conical screws, which better approximate pedicle morphometry, have been shown to increase pullout resistance in osteoporotic bone.

• It should be noted, however, that conical screws lose a significant portion of their strength when backed out by even a half turn, which may limit their ability to accommodate rod contour by backing out the screw.

Ono A, Brown MD, et al, J. Spinal Disord 2001Kwok AW, et al, Spine 1996

Page 33: Operative treatment of osteoporotic spinal fractures

• Expandable screws offer additional improvement in pullout strength in severely osteoporotic bone.

• Clinical series using these devices, which include 21 patients with osteoporosis, demonstrated radiographic evidence of fusion in 86% of patients.

• One concern with such implants is that increasing screw diameter could fracture the pedicle placing the adjacent nerve root at risk Islam NC, et al, Spine 2001

Kostuik JP, et al, Instr Course Lect 2003Brantley AG, et al, Spine 1994

Page 34: Operative treatment of osteoporotic spinal fractures

• In patients with

osteoporosis o undertapping

or o avoiding tapping

of the pilot hole altogether before screw insertion does help improve screw fixation especially in the lumbar spine

Havolosn TL, et al, Spine, 1994Carmouche JJ, et al, J. Neur.

Spine, 1998

Page 35: Operative treatment of osteoporotic spinal fractures

Screw orientation also should be optimized in patients with osteoporosis. Screw triangulation via a medial orientation

• takes advantage of the bone mass between the converging screws for fixation,

• rather than only that bone lying between threads of a single screw, and

• has been shown to improve pullout strength in osteoporotic, bone.

Ono A, et al J.spinal Disord 2001Rulad CM, et al, Spine 1991

Page 36: Operative treatment of osteoporotic spinal fractures

Similarly, screws oriented

o caudal or

o parallel relative to the vertebral end plate, as opposed to

o a cranial orientation, avoid increased bending moments at the screw hub in normal vertebrae, and use of this technique is also prudent in osteoporotic bone.

McKinley TO, et al, Spine 1999Youssef JA, et al, Spine 1999

Page 37: Operative treatment of osteoporotic spinal fractures

• HA – coated screws

have been shown to increase pullout forces presumably by increasing botho the contact surface area

as well as o the frictional coefficient at

the bone implant interface

• The mechanical behavior of these implants over time as resorption of the HA coating occurs has not been studied, however.Hasegawa T, et al , Spine, 2005

Page 38: Operative treatment of osteoporotic spinal fractures

Minimal invasive techniques

Minimal invasive techniques

Vertebroplasty - KyphoplastyVertebroplasty - Kyphoplasty

Page 39: Operative treatment of osteoporotic spinal fractures

S.S.E.P.S.S.E.P. S.M.E.PS.M.E.P

Page 40: Operative treatment of osteoporotic spinal fractures

Vertebroplasty

Page 41: Operative treatment of osteoporotic spinal fractures
Page 42: Operative treatment of osteoporotic spinal fractures

Kyphoplasty Kyphoplasty

Page 43: Operative treatment of osteoporotic spinal fractures
Page 44: Operative treatment of osteoporotic spinal fractures
Page 45: Operative treatment of osteoporotic spinal fractures

SKy bone expander system for

percutaneous Kyphoplasty

Unilateral - BilateralUnilateral - Bilateral

Page 46: Operative treatment of osteoporotic spinal fractures
Page 47: Operative treatment of osteoporotic spinal fractures
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Page 50: Operative treatment of osteoporotic spinal fractures
Page 51: Operative treatment of osteoporotic spinal fractures

V.B.S. System (Zimmer)

Page 52: Operative treatment of osteoporotic spinal fractures
Page 53: Operative treatment of osteoporotic spinal fractures

Vertebroplasty – KyphoplastyIndications

• Vertebral fractures (compression ± burst)

• Osteoporotic fractures (compression ± burst)

• Pathologic fractures of the spinal vertebra (metastasis)

• Haemangioma of the vertebra• Multiple myeloma

Page 54: Operative treatment of osteoporotic spinal fractures

• Destruction of the posterior spinal elements

• Burst fractures (±)• Neurologic compression syndromes

(due to dislocated bony fragments)• Destruction of dorsal structures

(vertebral arch and facet joints) • Vertebra plana• Spinal infection • Allergy

(methylmethacrylate etc)• Coagulopathy • Untreated cardiovascular disturbances

Vertebroplasty – KyphoplastyContraindications

Page 55: Operative treatment of osteoporotic spinal fractures

CONCLUSIONS

Page 56: Operative treatment of osteoporotic spinal fractures

Osteoporosis is a particularly prevalent comorbidity in the elderly population.

Page 57: Operative treatment of osteoporotic spinal fractures

Osteoporotic spinal fractures Osteoporotic spinal fractures can be treated can be treated

successfully by internal fixationsuccessfully by internal fixationor by M.I.T. or by M.I.T.

Page 58: Operative treatment of osteoporotic spinal fractures

Vertebroplasty - Kyphoplastyadvantages

• May be performed under local anaesthesia as a day case

Page 59: Operative treatment of osteoporotic spinal fractures

Vertebroplasty - Kyphoplasty advantages

• Provide significant relief of pain

Page 60: Operative treatment of osteoporotic spinal fractures

VERTEBROPLASTY

• Seems to be more favourable in recent vertebral fractures (osteoporotic etc) without major deformity

Page 61: Operative treatment of osteoporotic spinal fractures

VERTEBROPLASTYVERTEBROPLASTY

• No substantial loss of the obtained correction at the follow up

• No substantial loss of the obtained correction at the follow up

Page 62: Operative treatment of osteoporotic spinal fractures

• Is unable to restore the lost height of the vertebra

VERTEBROPLASTY disadvantage

Page 63: Operative treatment of osteoporotic spinal fractures

Balloon Kyphoplasty advantages

• Restores sufficiently the height of the collapsed vertebra

• Is associated with inferior possibility of cement leakage

Page 64: Operative treatment of osteoporotic spinal fractures

Balloon Kyphoplasty disadvantages

• The risk of fracture in the adjacent levels is enhanced in the balloon kyphoplasty

• Increased operative time and radiation exposure

Page 65: Operative treatment of osteoporotic spinal fractures

University Hospital “ATTIKON”