» Guidelines for the Treatment of Spine Fractures Caused by Osteoporosis
Guidelines for the Treatment of Spine Fractures Caused by Osteoporosis

The American Academy of Orthopaedic Surgeons (AAOS) has just released Clinical Practice Guidelines (CPGs) for the treatment of symptomatic (painful) spinal compression fractures. A brief summary of these guidelines is presented. These guidelines are based on research, published studies, and the resulting evidence currently available. The AAOS points out that all guidelines are intended to be used as one tool in the treatment decision. All patient characteristics and individual factors must be taken into consideration when making the final decision.

Compression fractures are the most common type of fracture affecting the spine. A compression fracture of a spine bone (vertebra) causes the bone to collapse in height. Compression fractures are commonly the result of osteoporosis (brittle bones).

About 700,000 cases of compression fractures due to osteoporosis occur each year in the United States. Spine bones that are weakened from osteoporosis may become unable to support normal stress and pressure. As a result, something as simple as coughing, twisting, or lifting can cause a vertebra to fracture.

Osteoporosis is a disease that weakens bone. Sometimes the bones in the spine weaken to the point that even mild forces can lead to a compression fracture. A simple action like reaching down to pull on a pair of socks can cause a weakened vertebra to fracture. The front of the vertebra (the part closest to the front of the body) crumbles, causing the round vertebral body to become wedge-shaped. This angles the spine forward, producing a hunch-backed appearance, called kyphosis.

The majority of patients with compression fractures are treated conservatively (without surgery). Most compression fractures heal within eight weeks with simple remedies of medicine, rest, and a special back brace.

Medications are used to control pain. Although medications can help ease pain, they are not designed to heal the fracture. With pain under control, patients find it easier to get up and move about, avoiding the problems that come from remaining immobile in bed. Patients are usually prescribed a short period of rest. This gives the fracture a chance to heal and aids in pain control. In some cases, the doctor may have a patient stay in bed for up to one week.

A special back brace, called an orthosis may be prescribed. This type of brace is molded to the patient's body. It limits spine movement in general, though the brace is usually fashioned to keep patients from bending forward. This protects the fractured vertebral body so it can heal. Patients who wear a brace may be advised to move about but to limit strenuous activities, such as lifting and bending.

Surgeons have begun using two new procedures to treat compression fractures caused by osteoporosis. Both are considered minimally invasive. Minimally invasive means the incisions used are very small, and there is little disturbance of the muscles and bones where the procedure is done. These two procedures help the fracture heal without the problems associated with more involved surgeries. These new procedures are vertebroplasty and kyphoplasty.

Vertebroplasty helps reduce pain and strengthens the fractured bone, thus enabling patients to rehabilitate faster. A needle is inserted into the collapsed vertebra and a bone cement is injected into the main body of the vertebra. This fixes the bone so that it does not collapse any further as it heals. More than 80 percent of patients get immediate pain relief with this procedure.

Kyphoplasty is another way for surgeons to treat vertebral compression fractures. Like vertebroplasty, this procedure halts severe pain and strengthens the fractured bone. However, it also gives the advantage of improving some or all of the lost height in the vertebral body, helping prevent kyphosis.

Needles are inserted through the sides of the spinal column into the fractured vertebral body. These needles guide the surgeon while drilling two holes into the vertebral body. The surgeon then slides a hollow tube with a deflated balloon on the end through each drill hole. Inflating the balloons restores the height of the vertebral body and corrects the kyphosis deformity. Before the procedure is complete, the surgeon injects bone cement into the hollow space formed by the balloon. This fixes the bone in its corrected size and position.

Now, how do the current evidence and recommended guidelines compare with this typical approach to osteoporotic spinal compression fractures?

There is strong evidence that vertebroplasty benefits patients with osteoporotic spinal compression fractures who are in pain but not experiencing any neurologic problems. Kyphoplasty as an option is supported but the evidence is still weak and further studies are needed.

There is moderate support for acute fractures to be treated in the first four weeks with medications (calcitonin). Calcitonin is a non-sex, non-steroid hormone. Calcitonin binds to osteoclasts (the bone cells that reabsorb bone). It decreases osteoclast numbers and activity levels. The end result is that it prevents bone from melting away. It doesn't build up missing bone but it at least keeps the bone that's there from being broken down and reabsorbed.

Calcitonin is available in a nasal spray and should be used for osteoporotic spinal fractures within five days of the injury. Calcitonin has been shown to relieve pain when tested in four different positions (e.g., in bed, sitting, standing, and walking).

All other treatment recommendations (e.g., bed rest, use of complementary and alternative medicine, narcotics for pain) are not supported by enough evidence to make a strong case for or against them. The evidence is said to be weak or inconclusive. Likewise, evidence for the use of electrical stimulation to encourage bone growth is inconclusive.

For those who want to read the full guidelines along with a detailed discussion of the evidence and processes used to obtain that evidence, go to http://www.aaos.org/research/guidelines/SCFguideline.pdf.

Reference: Stephen I. Esses, MD, et al. American Academy of Orthopaedic Surgeons Clinical Practice Guideline on The Treatment of Osteoporotic Spinal Compression Fractures. In The Journal of Bone and Joint Surgery. October 19, 2011. Vol. 93A. No. 20. Pp. 1934-1936.