Vertebral Compression Fractures after Lumbar Instrumentation&#x0D; &#x0D;

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In this case, an 80-year-old active patient developed an acute osteoporotic fracture after a fall at L1 above a previous interlaminar implant at L4-5 for stenosis with neurogenic claudication. Radiologic studies found both intra-discal and intra-vertebral vacuum clefts that are highly correlated with instability and progressive kyphosis. Long-term experience with kyphoplasty has shown that acute and subacute fractures can often be re-expanded; however, over three months to one year, the correction is frequently lost and the vertebral height continues to decrease leading to increased risk of both continued deformity and especially adjacent level fractures. The use of newly available titanium intra-vertebral implants combined with bone cement restores and maintains vertebral height and correction of deformities. Long-term studies also demonstrate a reduced risk of adjacent level fractures compared to balloon kyphoplasty. Using vertebral body implants that remain in place within the fractured vertebral body the initial height correction can be better maintained leading to less adjacent level fractures.

Section: Introductionmentioning

confidence: 99%

Treatment of a High-risk Thoracolumbar Compression Fracture Using Bilateral Expandable Titanium SpineJack Implants

Hartman¹,

Granville²,

Jacobson³

2019

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“…Since VCFs occur in an older population, these same patients often have concurrent lumbar degenerative osteoarthritis, spondylolisthesis, and stenosis, so care needs to be taken in reviewing symptoms as well as radiologic studies for lumbar pain after a minor fall or accident [ 12 ]. Patients with previous lumbar surgery and fusions, especially with spinal instrumentation, are more prone to developing a VCF above the fusion, which may not be initially recognized, as attention is focused on the previous lumbar surgery [ 13 ]. In these cases, it will be the persistence of pain despite physical therapy or a recognition that the pain is in a different location than the lower lumbar spine in combination with new radiologic tests demonstrating a VCF that leads to the fracture being recognized as a cause of the pain.…”

Section: Discussionmentioning

confidence: 99%

Radiologic Evaluation of Chronic Vertebral Compression Fractures and Role of Vertebral Augmentation

Hatgis

Palea²,

Ghomri

et al. 2018

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The literature has classified chronic vertebral compression fractures (VCF) as those still "symptomatic" four or more months after onset. Pain is regarded as the predominant chronic symptom; however, radiologic changes are important in evaluating fracture progression. This review examines a series of patients with chronic fractures and both persistence of spinal pain combined with radiologic changes, such as worsening collapse, spinal angulation, the development of vertebral edema and clefts, as well as the development of new fractures at adjacent spinal levels. In patients with clear progressive radiologic changes in addition to pain, vertebral augmentation on an average of 9.3 months after injury was effective in reducing the pain and stabilizing these more chronic osteoporotic fractures. A comparison of the pre- and post-procedure visual analog scale score (VAS) indicated an average of 66% reduction in pain. There are several reasons for the development of chronic symptomatic fractures. Most commonly, interventional treatment is delayed in a patient already diagnosed with VCF after a long period of conservative treatment, yet pain persists, or the initial clinical and radiologic evaluation misses the fracture, leading to a delay in diagnosis and treatment. In this report, management in these patients and the role of late vertebral augmentation for chronic symptomatic fractures is clarified based on the findings of various radiologic changes seen on both initial and follow-up radiologic studies.

“…This progression is a result of the lateral load shift and uneven axial load bearing on weakened cancellous bone at the adjacent vertebra and sacral alae [ 27 ]. Patient comorbidities, chronic steroid use, and especially non-compliance with medication and lack of bracing are additional factors that contribute to progressive deterioration with multiple recurrent lumbar fractures [ 29 - 30 ].…”

Section: Reviewmentioning

confidence: 99%

“…In some of these patients, there may be a role for preventive vertebroplasty to decrease the chance of future cascading fractures [ 36 - 38 ]. If the lumbar curve continues to progress and especially if there is radiculopathy associated with lumbar stenosis or degenerative spondylolisthesis, decompression with multilevel screw fixation is an option [ 30 ]. However, since the vertebrae in these patients are severely osteoporotic, over multiple levels, screw fixation may need to include supplemental bone cement and the use of multilevel bicortical screws that avoid the cancellous bone and take purchase on the vertebral endplate cortex [ 39 ].…”

Section: Reviewmentioning

confidence: 99%

Multilevel Contiguous Osteoporotic Lumbar Compression Fractures: The Relationship of Scoliosis to the Development of Cascading Fractures

Sabo¹,

Hatgis²,

Granville

et al. 2017

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Osteoporotic patients can present with either single or multiple fractures secondary to repeated falls and progressive osteoporosis. Multiple fractures often lead to additional spinal deformity and are a sign of more severe osteoporosis. In the thoracic spine, multiple fractures are associated with the development of gradual thoracic kyphosis but neurologic deficits are uncommon. In the lumbar spine, patients with multiple lumbar fractures have more constant lumbar pain, may have symptoms related to concurrent lumbar stenosis or degenerative scoliosis, and may present with radiculopathy, especially with fractures at L4 and L5. In a review of a series of patients with recurrent multiple lumbar fractures or 'cascading' fractures, it was found that all the patients were female, had severe osteoporosis, often untreated, had a previous history of multiple previous thoracic and lumbar fractures, and all had associated scoliotic spinal deformities ranging from 6 o to 50 o . It was found that if the curve progressed and the greater the degree of curvature, the more frequently subsequent multiple fractures developed, leading to recurrent acute episodes of pain. Forty percent also had additional sacral insufficiency fractures, an unusually high percentage. Biomechanically, the lumbar spine is both more mobile and supports a larger portion of the spinal load compared to the thoracic spine. The existence or worsening of a lumbar spinal deformity from degenerative lumbar scoliosis shifts the mechanical forces more to one side on already weakened osteoporotic lumbar vertebrae and sacrum, leading to an increased incidence of these fractures. Because of the chronic and uneven lower lumbar spinal load with severe vertebral osteoporosis in certain patients with repeat lumbar fractures and worsening degenerative lumbar scoliosis, there may be a rationale to add preventive vertebroplasty at adjacent vertebral endplates when treating acute recurrent lumbar fractures to decrease the incidence of recurrence in other vertebrae.