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FRACTURE
From The CORE Institute in Phoenix, Arizona.
Update on Vertebral Augmentation for Thoracolumbar Fragility Fractures Thoracolumbar fragility fractures are the most common osteoporotic fracture worldwide and are thought to occur in 30% to 50% of individuals older than 50 years.1 While many osteoporotic vertebral fractures are asymptomatic, Brandon P. Hirsch, MD they have the potential to cause significant pain and functional disability in cases of delayed healing or nonunion. Historically, nonsurgical treatment has been the mainstay of care for stable-appearing thoracolumbar vertebral fractures; however there is a paucity of evidence supporting its effectiveness.2,3 Vertebral augmentation, also known as vertebroplasty or kyphoplasty, involves injecting polymethylmethacrylate cement into fractured vertebrae via a percutaneous approach. While the efficacy of the procedure was disputed following its development in the 1990s, a robust body of literature now supports its ability to reduce pain and improve function in patients with osteoporotic vertebral fractures.2,4–8 Nonsurgical treatment has historically been the mainstay of the initial treatment of osteoporotic vertebral fractures and often includes analgesics, activity modification and bracing. Despite their widespread use, evidence supporting the effectiveness of orthoses in
Fall 2023
Vertebral Columns
improving outcomes after vertebral fractures is lacking.9 A 2009 randomized prospective study of treatment with thoracolumbosacral orthoses (TLSO) by Bailey et al demonstrated no significant differences in pain scores or functional outcomes when compared with unbraced patients.10 Similar findings were described by Kim et al in a 2014 prospective study comparing rigid versus soft orthoses versus no bracing for osteoporotic vertebral fractures. No differences in pain reduction were demonstrated in patients treated with bracing versus those who were not.11 While the majority of patients with symptomatic vertebral compression fractures go on to heal regardless of treatment modality, approximately 10% to 20% of patients fail to improve without procedural intervention.3,12 Several authors have studied risk factors for treatment failure with conservative management.13 Age, presence of middle column injury, hyperintensity on T2-weighted imaging, and location within the thoracolumbar junction have all been cited as risk factors for nonunion and persistent pain.14,15 The use of opioids for treatment of fracture-related pain is of concern due to the potential for dependence as well their side effect profile (ie, constipation, nausea, delirium). The side effects of opioid use are
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