Osteoporosis
- Quantitative loss of bone mass
- Mineralisation & fracture healing normal
- WHO definition is T score <-2.5
- Senile or Post-menopausal
- Senile: age-related reduction in bone mass
- Post-menopausal: due to loss of oestrogen
- Worst in first 5 years
- Total bone mass loss of 3% per year
Vertebral Compression Fractures
- Increased incidence in proportion to age
- For each SD below 2.5, risk of vertebral fracture increases by 2x
- 5-year mortality after VCF higher than after hip fracture
- Each thoracic VCF causes 9% decrease in lung FVC
- Wedge – thoracic spine
- Biconcave – lumbar spine
- Mild, moderate, or severe (>40% height reduction)
Differential Diagnosis
- Metastatic disease
- More likely with fracture above T5
- Lymphoma/leukaemia
- Infection
- Haemangioma
- Myeloma
Management
- Non-operative – supportive treatment is mainstay
- Medical therapy for pain relief and future fracture prevention
Surgical
- Failed non-operative Rx (6 weeks) – consider biopsy to rule out tumour
- Open surgery
- For neurologic compromise & instability (rare)
- Kyphoplasty & Vertebroplasty
- Contraindications
- Posterior cortex disruption – cement extrusion (VP > KP)
- Retropulsed bone fragments
- Neurologic Injury
- Instability
- Healed, sclerotic vertebra that is painful
- Indications
- Intractable pain
- Failure of non-operative management
- Fracture < 3 months old
Kyphoplasty
- Aim: Pain relief and correction of deformity
- Technique
- Transpedicular – any level where pedicles are >4mm size
- Extrapedicular – in upper T-spine – uses rib & pedicle as a complex
- Posterolateral – For L2-4, which have small pedicles
- Procedure
- Balloon is inflated within vertebra to check it works
- Balloon deflated
- Cement passed into balloon
- Complications
- Transient fever
- Cement extrusion – rarely of clinical significance if it occurs
- Epidural haematoma
- Cord injury
Vertebroplasty
- For Pain relief – no kyphosis correction
- Same approaches but transpedicular preferred
- Posterolateral has higher rate of cement leakage
- Procedure
- Cement injected at low viscosity under low pressure
- Fills fracture lines – spider-like
- Once reaches posterior cortex, injection is stopped
- Complications as for KP
Outcomes
- Equivalent outcomes at 6 months in terms of pain relief
- Kyphoplasty does improve radiographic appearance
- Not proven to correlate to better clinical outcome
- No long-term data
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