Principles of management of osteometabolic disorders affecting the aging spine

Abstract

Osteoporosis is the most common contributing factor of spinal fractures, which characteristically are not generally known to produce spinal cord compression symptoms. Recently, an increasing number of medical reports have implicated osteoporotic fractures as a cause of serious neurological deficit and painful disabling spinal deformities. This has been corroborated by the present authors as well. These complications are only amenable to surgical management, requiring instrumentation. Instrumenting an osteoporotic spine, although a challenging task, can be accomplished if certain guidelines for surgical techniques are respected. Neurological deficits respond equally well to an anterior or posterior decompression, provided this is coupled with multisegmental fixation of the construct. With the steady increase in the elderly population, it is anticipated that the spine surgeon will face serious complications of osteoporotic spines more frequently. With regard to surgery, however, excellent correction of deformities can be achieved, by combining anterior and posterior approaches. Paget's disease of bone (PD) is a non-hormonal osteometabolic disorder and the spine is the second most commonly affected site. About one-third of patients with spinal involvement exhibit symptoms of clinical stenosis. In only 12-24% of patients with PD of the spine is back pain attributed solely to PD, while in the majority of patients, back pain is either arthritic in nature or a combination of a pagetic process and coexisting arthritis. In this context, one must be certain before attributing low back pain to PD exclusively, and antipagetic medical treatment alone may be ineffective. Neural element dysfunction may be attributed to compressive myelopathy by pagetic bone overgrowth, pagetic intraspinal soft tissue overgrowth, ossification of epidural fat, platybasia, spontaneous bleeding, sarcomatous degeneration and vertebral fracture or subluxation. Neural dysfunction can also result from spinal ischemia when blood is diverted by the so-called "arterial steal syndrome". Because the effectiveness of pharmacologic treatment for pagetic spinal stenosis has been clearly demonstrated, surgical decompression should only be instituted after failure of antipagetic medical treatment. Surgery is indicated as a primary treatment when neural compression is secondary to pathologic fractures, dislocations, spontaneous epidural hematoma, syringomyelia, platybasia, or sarcomatous transformation. Five classes of drugs are available for the treatment of PD. Bisphosphonates are the most popular antipagetic drug and several forms have been investigated. Keywords

Complications and Outcomes of Lumbar Spine Surgery in Elderly People: A Review of the Literature

“…Physical examination may reveal tenderness over the fractured vertebra, although this does not distinguish between a fracture of the anterior and posterior elements. An increasing number of medical reports have indicated that OVCFs can lead to serious neurological deficits as well 13 . The most frequent site of fracture is the thoracolumbar junction, with the midthoracic site being the second most frequent location.…”

Long-term efficacy and safety of bone cement-augmented pedicle screw fixation for stage III Kümmell diseaseLong-term efficacy and safety of bone cement-augmented pedicle screw fixation for stage III Kümmell disease

“…Posterior osteotomy is a common treatment; the advantages include dissection of the posterior cortex by posterior spinal shortening osteotomy and correction of kyphosis [28,29]. Moreover, these major surgical interventions can be challenging in patients of advanced age, and confer numerous morbid complications and frequent instrumentation failure secondary to severe osteoporosis [1]. Traditional posterior long-segment fixation was not appropriate for stage III Kümmell disease because the procedure was associated with significant trauma and multiple complications, which are worrisome in elderly patients with comorbidities [30].…”

“…The frequency of Kümmell disease, a complication of osteoporotic vertebral fracture (OVF), is increasing globally [1]. Since the condition was first described by Herman Kümmell in 1891, the literature has referred to Kümmell disease as being characterized by delayed osteonecrosis after trauma [2], nonunion of compression fracture [3], delayed collapse of OVF [4], intravertebral pseudarthrosis [5], and vertebral vacuum sign [6].…”

Delayed Neurological Deficits after Osteoporotic Vertebral Fractures: Clinical Outcomes after Surgery

“…Frankel grading was used in many studies to document motor neurological deficits. In a series of 15 patients, one patient with Frankel grade A exhibited no recovery, whereas the remaining 14 patients with Frankel grades B–D exhibited improvement by two grades [ 19 ]. In another series, all 14 patients showed improvement from preoperative grades of C in seven and D in seven patients to postoperative grades of D in two and E in 11 patients [ 20 ].…”