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Osteoporotic Fractures
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LuizR.Vialle andEmilianoN.Vialle
10.1 Definition
An osteoporotic fracture occurs when the bone trabeculae cannot support the normal compression forces under physiologic conditions or slight trauma; such injuries
are also named “stress fractures,” “frailty fractures,” or “insufciency fractures.”
10.2 Natural History
Osteoporotic fractures are becoming more frequent due to the increased life expectancy, combined with metabolic alterations such as Vitamin D deciency, poor calcium intake, sedentarism, and genetic inuence. It is a common problem in women
after menopause related to hormonal changes, even though it can also affect about
20% of men.
Patients may admit with minor trauma, coughing or sneezing, or even no trauma.
Without detection and adequate care, the fractured vertebra may collapse, leading to
increased kyphosis and eventually compression of the neural elements.
Supplementary Information The online version contains supplementary material available at
[https://doi.org/10.1007/978- 3- 030- 80356- 8_10].
L. R. Vialle (*)
Pontical Catholic University, Curitiba, Brazil
e-mail: vialle@vialle.com.br
E. N. Vialle
Cajuru University Hospital, Curitiba, Brazil
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
A. Şenköylü, F. Canavese (eds.), Essentials of Spine Surgery,
https://doi.org/10.1007/978-3-030-80356-8_10
61
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L. R. Vialle and E. N. Vialle
10.3 Physical Examination
In general, a patient’s main complaint is pain over the affected area, sometimes so
intense that clinical examination may become difcult. Local tenderness can help to
localize the affected vertebra (or vertebrae). This is an important step because initial
imaging must be requested precisely; otherwise, the osteoporotic fracture may be
missed. Some patients present with pain at the lumbo-sacral junction (irradiated
pain), thus leading to wrong imaging level and potential misdiagnosis.
10.4 Imaging
Plain radiographs centered over the most painful area are needed. Sometimes the
fracture is not visible on plain radiographs. However, persistent pain or worsening clinical picture may require a new set of radiographs; at this stage, the fracture will become visible, together with the associated deformity (collapse)
(Figs.10.1, 10.2, and 10.3). In this case, a magnetic resonance imaging (MRI)
Fig. 10.1 Lateral direct
radiogram reveals no signs
of fracture of lumbar spine
after a minor trauma
10 Osteoporotic Fractures
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Fig. 10.2 Follow-up
X-ray of the patient in
Fig.10.1 that taken
2weeks later shows an L1
osteoporotic fracture
63
should be requested to better assess the fracture and to differentiate recent from
old fractures (Fig.10.4).
10.5 Differential Diagnosis
Insufciency fractures are due to the weakness of the bone (trabeculae) and are
indeed osteoporotic. However, the cause of osteoporosis must be thoroughly investigated in order to rule out a potential underlying disease; a full physical examination and laboratory data are needed. Primary tumors of the spine (mainly myeloma)
are frequently related to secondary osteoporosis and insufciency fractures (Chap.
61) though metastatic lesions can share the same clinical picture (Chap. 63). The
practitioner must be aware of this condition in order to avoid misdiagnosis and subsequent complications.
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Fig. 10.3 Follow-up
X-ray of the patient in
Fig.10.1 that taken
1month later shows
kyphotic deformity at L1
level
L. R. Vialle and E. N. Vialle
10.6 Classification
A classication for osteoporotic fractures was proposed by the German Spine
Society and has been accepted by surgeons as a guideline for treatment together
with other criteria [1] (Appendix E).
10.7 Treatment Options
Two actions are needed once the diagnosis of osteoporotic fracture is conrmed:
treatment and prevention.
(a) Treatment is related to the fracture and aims to provide the best possible pain
relief to the patient.
Conservative treatment is based on oral analgesics; non-steroidal antiinammatory drugs should be administered carefully while opioids should be
avoided. Opioids represent an additional risk factor in this patients’ population, decreasing their cognitive ability. The patient should be stimulated to
walk whenever possible and, despite the pain, should be trained on daily life
activities such as how to get out from bed or seating, among others. A physical
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Fig. 10.4 T1-weighed
MRI image showing signs
of recent L1 and L2
fractures
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therapist can be helpful at this stage. In some cases, a Jewett brace, forcing
hyperextension, may be prescribed. With a careful clinical approach, effective
medication, and psychological and family support, the majority of the patients
can tolerate the pain during the rst few weeks following injury. Conservative
approach is the rst option; the only reason to switch to an invasive method is
unbearable pain for more than 3weeks.
Surgery is indicated in case of persistent pain and/or neurological involvement. For pain control, cement injection (vertebroplasty) is a powerful method.
When well indicated and performed, the pain relief is immediate, allowing the
patient to return to normal life activities. Vertebroplasty is a non-demanding
technique, with several companies producing many tools for safe injection of
acrylic cement. To avoid cement leakage and correct the vertebral deformity,
other techniques such as kyphoplasty and stents can also be performed. Recent
literature reviews [2, 3] showed no essential differences among the various
techniques, all being effective on pain treatment. Considering all procedures,
techniques, and costs, vertebroplasty is the procedure of choice.
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Some patients may present with neurological involvement. It may be from
the initial trauma, with a posterior wall fragment compressing the dural sac.
Depending on the level, some may present a spinal cord compression. Other
cases may develop a kyphotic deformity, where the neurological decit is progressive. In both cases, more aggressive intervention is needed to decompress
the cord and to correct the deformity. The best surgical approach is a combined
procedure (anterior decompression and mechanical support with a cage or mesh
followed by percutaneous posterior screws) (Video 10.3); short fusions are better than long fusions: the osteoporotic spine when operated on with long fusions
needs the association of augmentation techniques, making the procedure more
riskier. However, in such cases, even with the associated morbidity, there is no
other way to get a full decompression and segmental stabilization.
(b) Prevention is the second action to be taken; it requires evaluating the amount of
osteoporosis and timely beginning the medical treatment, to avoid further bone
loss and to improve bone quality and stock. Delaying the medical treatment
increases the risk of new fractures. As soon as the pain is under control, the
patient needs a lifestyle change and a continuous medical check of the osteoporosis status.
L. R. Vialle and E. N. Vialle
10.8 Expected Outcomes
Following the recommended protocols, conservative treatment is able to control
pain in 3–4weeks, with a progressive reduction in pain severity day after day.
Patients treated with vertebroplasty will experience signicant pain improvement immediately after the procedure. However, new fractures should be expected,
sometimes during the early post-procedural period. When open surgery is indicated,
recovery is longer, and systemic complications can develop.
10.9 Potential Complications
The most dangerous complication of an osteoporotic fracture is the neurological
decit which can be secondary to a retro pulsed bone fragment of the posterior vertebra wall pushing on to the spinal cord, or to progressive kyphosis leading to spinal
cord compression (Fig.10.5); sagittal malalignment may be the result of multiple
osteoporotic fractures (Fig.10.6).
Intra-canal cement leakage may occur during vertebroplasty. The majority of
cases will not have any consequence even though it may cause neural damage. In
such cases, an open surgical decompression is recommended. Leakage into the
intervertebral disc space is not uncommon and is not necessarily a complication, as
it is usually asymptomatic.
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Fig. 10.5 T2-weighed
MRI image showing a
retro pulsed posterior wall
due to an osteoporotic
fracture
Fig. 10.6 T2-weighed
MRI image demonstrating
multi-level fractures and
overall kyphosis
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L. R. Vialle and E. N. Vialle
10.10 What Should Patient andFamily Know?
Fractures related to osteoporosis mostly affect the aged population. The pain gradually improves during the rst 3 to 4weeks; most patients are generally pain-free
after 3 to 4months of medical treatment. Patients with co-morbidities or bedridden
due to excruciating pain will benet from surgery (and immediate pain relief).
Lifestyle changes, physical exercises, nutrition, and medical treatment are necessary to avoid new fractures.
Further Readings
1. Blattert T, Schnake K, Gonschorek O, etal. Nonsurgical and surgical management of osteopo-
rotic vertebral body fractures. Global Spine J. 2018;8(25):50S–5S.
2. Sanli I, van Kuijk S, de Bie R, et al. Percutaneous cement augmentation in the treatment
of osteoporotic vertebral fractures (OVFs) in the elderly: a systematic review. Eur Spine
J. 2020;29:1553–72.
3. Sanli I, van Kuijk SMJ, de Bie RA, van Rhijn LW, Willems PC.Percutaneous vertebroplasty
versus conservative treatment in aged patients with acute osteoporotic vertebral compression
fractures. Spine. 2016;41(8):653–60.
Part III
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Pediatric Spine Pathology
Back Pain inChildren
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FedericoCanavese
11.1 Definition
Painful sensation along the spine or back, sometimes with radiation down to one or
both lower extremities.
11.2 Natural History
Pediatric dogma suggests that children with serious back pain (BP) may have serious pathology, including malignancy and infection. In the past, BP was considered
a rare event highly associated with signicant pathology. More recently, BP has
been presented as a common occurrence unlikely caused by a signicant underlying
pathology.
However, there is still a small group of children with BP associated with a
significant pathology; this is particularly true if the child is 4 years old or
younger, or if a child of any age has BP associated with fever or weight loss,
weakness or numbness, abnormal gait, pain that radiates down one or both legs,
bowel or bladder dysfunction, and night pain that keeps the child from sleeping
(red flags).
Supplementary Information The online version contains supplementary material available at
[https://doi.org/10.1007/978- 3- 030- 80356- 8_11].
F. Canavese (*)
Department of Pediatric Orthopedic Surgery, Lille University Center, Jeanne de Flandre
Hospital, Lille, France
Faculty of Medicine Henri Warembourg, Nord-de-France University, Lille, France
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
A. Şenköylü, F. Canavese (eds.), Essentials of Spine Surgery,
https://doi.org/10.1007/978-3-030-80356-8_11
71
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