Nonsurgical and Surgical Management of Osteoporotic Vertebral Body Fractures: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU)

Abstract

Study Design:Prospective clinical cohort study (data collection); expert opinion (recommendation development).Objectives:Treatment options for nonsurgical and surgical management of osteoporotic vertebral body fractures are widely differing. Based on current literature, the knowledge of the experts, and their classification for osteoporotic fractures (OF classification) the Spine Section of the German Society for Orthopaedics and Trauma has now introduced general treatment recommendations.Methods:a total of 707 clinical cases from 16 hospitals were evaluated. An OF classification–based score was developed to guide in the option of nonsurgical versus surgical management. For every classification type, differentiated treatment recommendations were deduced. Diagnostic prerequisites for reproducible treatment recommendations were defined: conventional X-rays with consecutive follow-up images (standing position whenever possible), magnetic resonance imaging, and computed tomography scan. OF classification allows for upgrading of fracture severity during the course of radiographic follow-up. The actual classification type is decisive for the score.Results:A score of less than 6 points advocates nonsurgical management; more than 6 points recommend surgical management. The primary goal of treatment is fast and painless mobilization. Because of expected comorbidities in this age group, minimally invasive procedures are being preferred. As a general rule, stability is more important than motion preservation. It is mandatory to restore the physiological loading capacity of the spine. If the patient was in a compensated unbalanced state at the time of fracture, reconstruction of the individual prefracture sagittal profile is sufficient. Instrumentation technique has to account for compromised bone quality. We recommend the use of cement augmentation or high purchase screws. The particular situations of injuries with neurological impairment; necessity to fuse; multiple level fractures; consecutive and adjacent fractures; fractures in ankylosing spondylitis are being addressed separately.Conclusions:The therapeutic recommendations presented here provide a reliable and reproducible basis to decide for treatment choices available. However, intermediate clinical situations remain with a score of 6 points allowing for both nonsurgical and surgical options. As a result, individualized treatment decisions may still be necessary. In the next step, the recommendations presented will be further evaluated in a multicenter controlled clinical trial.

Risk factors of adjacent segmental fractures when percutaneous vertebroplasty is performed for the treatment of osteoporotic thoracolumbar fractures

“…Compared with those of conservative treatment, the outcomes of PV have been reported to benefit patients, thus providing better pain relief. However, the beneficial effects of PV have been reported to be associated with a higher incidence of new ASFs compared to conservative treatment [1][2][3][4][5][6][7][8] . Studies have reported that PV is not Table 3.…”

“…Osteoporotic thoracolumbar fractures (OTFs) occur frequently in the elderly population, leading to chronic back pain and progressive sagittal imbalance and even neurological impairment [1][2][3][4] . Conservative treatments, including bed rest, nonsteroidal anti-inflammatory drugs, osteoporotic drugs, deep venous thrombosis prevention management and the use of a thoracolumbar brace in the erect position, have been demonstrated for OTFs 5,6 .…”

Which anatomic structures are responsible for the reduction loss after hybrid stabilization of osteoporotic fractures of the thoracolumbar spine?

“…Some of the patients might have comparable clinical outcomes without surgery or with augmentation procedures of the fractured vertebral body alone. Generally, we have seen the indication for an operative stabilization very strictly and in accordance with the recommendation of the spine section of the German Society of Orthopaedics and Trauma (DGOU) [5]. Surgery was indicated in patients with unstable vertebral fracture and relevant destruction of the anterior column defined by OF scores of three and higher or failed conservative therapy [25].…”

“…Fracture classification was done in accordance with the new AO spine classification [3], the OF-classification [4], and an OF score of at least 6 [5]. The indication for surgery was in accordance with the spine section of the German society for orthopaedics and trauma (DGOU) [5].…”

Klassifikation und Therapieempfehlung der osteoporotischen Wirbelkörperfraktur

“…Elemente der konservativen Behandlung von osteoporotischen Wirbelkörperfrakturen sind neben den allgemeinen Maßnahmen zur Anpassung des sozialen Umfeldes an die gegebenen Umstände und der systemischen Osteoporosebehandlung vor allem initiale Bettruhe, die adäquate Schmerztherapie, die physiotherapeutisch angeleitete Mobilisation und die Verwendung von Rumpforthesen [20].…”