Surgical Management of Spinal Conditions in the Elderly Osteoporotic Spine

Abstract

Osteoporosis, the most common form of metabolic bone disease, leads to alterations in bone structure and density that have been shown to compromise the strength of spinal instrumentation. In addition, osteoporosis may contribute to high rates of fracture and instrumentation failure after long posterior spinal fusions, resulting in proximal junctional kyphosis and recurrent spinal deformity. As increasing numbers of elderly patients present for surgical intervention for degenerative and traumatic spinal pathologies, current and future generations of spine surgeons will increasingly be faced with the challenge of obtaining adequate fixation in osteoporotic bone. The purpose of this review is to familiarize the reader with the impact of osteoporosis on spinal instrumentation, the broad variety of techniques that have been developed for addressing these issues, and the biomechanical and clinical evidence in support of the use of these techniques.

Reduction of intradiscal pressure by the use of polycarbonate-urethane rods as compared to titanium rods in posterior thoracolumbar spinal fixation

“…Spinal fusion using long segment rigid instrumentation is currently the only surgical treatment to correct or stop curve progression in patients suffering from severe thoracolumbar hyperkyphosis [ 2 , 3 , 7 ]. Instrumentation failure or transitional fractures often occur as a result of diminished bone quality or sagittal imbalance of the patient, which leads to high rates of revision surgery [ 6 , 8 , 14 ]. Some of these complications can be attributed to high device stiffness.…”

“…Operative correction is not typically recommended as the first treatment option due to the high prevalence of osteoporosis and other medical comorbidities in the elderly patient population [ 2 , 6 , 7 ]. Instrumented spinal fusion is regarded more as an end-stage salvage procedure only reserved for patients suffering from intractable pain, severe disability, significant pulmonary function impairment or progressive neurological deficit not amenable to conservative treatment [ 3 , 6 – 9 ]. This implies that patients considered for surgery are in an advanced stage of the degenerative process, with frequently compromised bone quality due to osteoporosis or osteopenia and/or severe global sagittal imbalance.…”

“…This implies that patients considered for surgery are in an advanced stage of the degenerative process, with frequently compromised bone quality due to osteoporosis or osteopenia and/or severe global sagittal imbalance. As a result, surgery in these patients is associated with high rates of complications, such as proximal junctional failure (PJF), instrumentation breakout and recurrent spinal deformity [ 6 , 8 , 10 ]. In patients older than 55 years the risk of PJF is close to 40%, and as many as one-third of the patients undergo early revision within 1 year [ 6 ].…”

“…Conversely, the occurrence in young patients suffering from Scheuermann’s disease is relatively low and ranges from 0 to 3% [ 14 ]. Mechanical stiffness mismatch between rigid spinal instrumentation and osteoporotic bone contributes to the increased incidence of failure in the surgical treatment of hyperkyphosis in the elderly [ 2 , 6 , 14 , 15 ].…”

Die sagittale Wirbelsäulenbalance – klinische Bedeutung und radiologische Bemessung

“…Die Knochenmatrix durch Demineralisierung schwächende Erkrankungen wie die Osteoporose gefährden eine stabile Schraubenlage und können ein Pull-out oder Cutting-out der Implantate begünstigen. Hier sind, ähnlich anderen Operationen an der Wirbelsäule, alternative OP-Techniken wie zementaugmentierte Schrauben sowie verlängerte Instrumentierungen zu diskutieren [35,36]. Zudem ist stets die Operationsindikation vor dem Hintergrund von Begleiterkrankungen kritisch zu überprüfen [37].…”