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Non-Union of Osteoporotic Vertebral Fractures – Identification and Treatment of an Underestimated Pathology in Elderly Patients with Persistent Back Pain

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Non-Union of Osteoporotic Vertebral Fractures – Identification and Treatment of an Underestimated Pathology in Elderly Patients with Persistent Back Pain Acta Orthop. Belg., 2014, 80, 444-450 ORIGINAL STUDY Non-union of osteoporotic vertebral fractures – identification and treatment of an underestimated pathology in elderly patients with persistent back pain Daniel ADLER, Sven K. TSCHOEKE, Nicolas VON DER HOEH, Jens GULOW, Georg VON SALIS-SOGLIO, Christoph-E. HEYDE From Department of Orthopaedic Surgery, University Hospital Leipzig, Leipzig, Germany Objective : Non-union of osteoporotic vertebra frac- INTRODUCTION tures are a seldom entity. However, when back pain persists in the course of conservatively treated osteopo- Osteoporosis is defined as the significant reduc- rotic vertebra fractures, a non-union should be consid- tion of bone mass with changes in the trabecular ered. We thus sought to validate our diagnostic algo- rithm in patients with known osteoporotic vertebra architecture and consecutive loss of stability lead- fractures presenting persistent back pain and advert to ing to an increased risk of fracture (12,19,23). the diagnosis and treatment of vertebral non-unions. Vertebral compression fractures of the thoracic and Patients and Methods : Patients admitted with pre- lumbar spine are the most common complication of existing osteoporotic vertebra fractures and therapy- osteoporosis and often the first sign and symptom of resistant back pain were retrospectively analysed. All this particular disease (13,16,17,19). While the inci- admitted patients were subject to standard plain radiographs in erect position and conventional CT or MR imaging of the spine, respectively. In addition, patients with suspected non-union were subject to n Daniel Adler1, 3, MD (fellow). lateral fulcrum radiographs in supine position. n Sven K. Tschoeke2, 3, MD (chief attending). Results : From a total of 172 admitted patients, four n Nicolas von der Hoeh3, MD (fellow). patients presented with non-union of a fractured n Jens Gulow3, MD (attending). osteoporotic vertebra (2%). The subsequent surgical n Georg von Salis-Soglio3, MD (professor and department therapy included cement-augmented rod-and-screw director). stabilization, with or without additional correction of n Christoph-E. Heyde3, MD (professor and department deformity, and kyphoplasty (N = 3) or kyphoplasty director). alone (N = 1). All surgical interventions were success- 1Department of Orthopaedic Surgery, Hospital Ingolstadt, ful in pain reduction and allowed immediate and Ingolstadt, Germany. 2 improved postoperative mobilisation. Department of Spine Surgery, Park Hospital GmbH, Leipzig, Germany. Conclusions : Non-union of osteoporotic vertebra 3 fractures must be considered when symptoms outlast Department of Orthopaedic Surgery, University Hospital conservative treatment. In these cases, plain lateral Leipzig, Leipzig, Germany. fulcrum radiographs are a simple and effective Correspondence : Daniel Adler, Department of Orthopaedic Surgery, Hospital Ingolstadt, Krumenauerstrasse 25, 85049 adjunct to the conventional diagnostic methods. Ingolstadt, Germany. E-mail : [email protected] Surgical stabilization then proves to be the effective © 2014, Acta Orthopædica Belgica. treatment of choice. Keywords : persistent back pain ; osteoporosis ; verte- bral non-union ; kyphoplasty ; spine surgery. Conflict of Interest : All contributing authors declare no con- flict of interest. All diagnostics and therapy were performed at the Depart- ment of Orthopaedic Surgery, University Hospital Leipzig. Acta Orthopædica Belgica, Vol. 80 - 4 - 2014 D. Adler and S. K. Tschoeke contributed equally to the article. adler-.indd 444 21/11/14 09:19 NON-UNION OF OSTEOPOROTIC VERTEBRAL FRACTURES 445 dence of osteoporotic vertebral fractures continu- patients, symptoms presented either spontaneously or ously increases, they similarly resemble a high so- after an incident of inadequate or low-energy trauma. cioeconomic burden worldwide. Recent studies Osteoporotic patients presenting acute or chronic back have estimated approximately 20 million patients in pain with a history for adequate or high-energy trauma the US and 2.8 million in Germany to be affected by were excluded from the study. Imaging diagnostics in- cluded conventional two-plane radiographs in erect posi- osteoporotic fractures of the spine (7). Acute verte- tion, lateral fulcrum radiographs in supine position as bral fractures show a high mobility within the frac- described by McKiernan and colleagues (17) and an MRI ture zone, thus being of avail to selected surgical of the spine. Computed tomography (CT) was only used reduction techniques, including cement-augmented in place of MRI in patients presenting specific contra­ stabilization procedures (17,19). Yet, the majority of indications (e.g. cardiac pace-maker). Fractures were osteoporotic vertebral fractures may be successfully classified according to the Magerl classification (15). treated conservatively and as bony union and stabil- Hospital admission was indicated in cases of kyphotic or ity progresses, the associated pain gradually sub- scoliotic deformity, progressive sintering or persistent sides. However, in cases where bony union is not back pain unamenable to further ambulant conservative achieved within the average consolidation period in treatment. Patients discharged from in-ward treatment conservative treatment, the fracture consequently received a clinical and radiographical follow-up after maintains its dynamics, subsequently representing a 6 weeks, 3, 6 and 12 months, respectively. Severity of pain was subjectively assessed by the average level of non-union (9,11,17,19). This dynamic fracture mobil- back pain at the time of initial consultation using the ity has been demonstrated to appear radiographi- Visual Analogous Scale (VAS). Functional disability cally evident as an intravertebral cleft, induced by was evaluated by the Oswestry Disability Index (ODI). forced elevation of vertebral height in a supine hy- Comorbidities and risk factors with regard to osteo- perextension cross-table (lateral fulcrum) radio- porosis were recorded. In cases were osteoporosis was graphic technique (17). Due to the associated patho- suspected, patients were subject to osteodensitometric morphology of delayed, ostensibly posttraumatic analyses via dual-energy x-ray absorptiometry (DEXA). ischemic osteonecrosis and collapse of the vertebral All patients admitted for further in-patient treatment body, this observation has become synonymous underwent routine laboratory investigation. with Kummel’s disease and is thus referred to as Kummel’s sign (9,13). Indication for Surgery Therefore, in the standard diagnostic follow-up of patients with osteoporotic vertebra fractures the Patients presenting a kyphotic deformity of more than conventional two-plane x-ray in an erect position or equal to 15 degrees at the thoracic or greater than 20 degrees at the lumbar level, as well as patients with occasionally lacks sufficient informative value, progressive sintering of greater than 10 per cent within while MRI and/or CT are predominantly subject to 14 days, were indicated to receive surgical stabilization. specific objectives. In the following study we sought Furthermore, indication for surgery included patients to evaluate our patient cohort presenting with complaining of persistent pain for more than 7 days in persistent back pain and a history of osteoporotic spite of intensified in­patient analgesic treatment, but vertebral compression fractures and advert to the without significant deformity. diagnosis and treatment of non-unions, respectively. RESULTS PATIENTS AND METHODS Patient demographics Patients A total of 172 consecutive patients (N = 172) From January 2009 through December 2009 patients were diagnosed with osteoporotic vertebral frac- treated for osteoporotic vertebral fractures at the Depart- tures and enrolled into the study. 68 (N = 68) of ment of Orthopaedic Surgery, University Hospital these patients (39,5%) (average age of 69.3 ± Leipzig, Germany, were retrospectively analysed. In all 6.8 years (54-87 years)) were admitted to further in- Acta Orthopædica Belgica, Vol. 80 - 4 - 2014 adler-.indd 445 21/11/14 09:19 446 D. ADLER, S. K. TSCHOEKE, N. VON DER HOEH, J. GULOW, G. VON SALIS-SOGLIO, C.-E. HEYDE Table I. — In-Patient treatment Conservative Surgery n Female (mean age) 13 (76) 39 (73) n Male (mean age) 8 (76) 8 (63) Table II. — Surgical procedures n Female n Male Kyphoplasty (1 segment) 27 5 Kyphoplasty (> 1 segment) 2 3 Posterior screw-and-rod 5 4 Instrumentation cement-augmented 5 4 additional corrective osteotomie 3 0 A B Fig. 1. — A) Conventional lateral X-ray of the thoracolumbar junction in erect position showing the collapsed Th10 vertebra. B) Lateral fulcrum radiograph revealing the non-union of Th10 patient treatment according to the criteria mentioned with its pathognomonic intravertebral cleft (Kummel’s sign) above (Table I). The average level of back pain was (white arrow). indicated to be 8.0 ± 1.6 on the VAS. Of these, 21 patients were successfully treated with opti- mized pain medication and physiotherapy indicat- enon. The additional fulcrum radiographs in supine ing an average VAS of 3.0 ± 1.2 at the time of dis- position ultimately confirmed the instable vertebra charge. 4 patients required additional bracing for and intravertebral vacuum phenomenon in all 4 pa- supportive stabilization within a continued conser- tients (Fig. 1). This was further confirmed by an in- vative treatment concept. The remaining 47 patients crease in signal intensity in the Turbo-Inversion (N = 47, 69% of all patients admitted
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