J Korean Soc Spine Surg.  2016 Mar;23(1):41-53. 10.4184/jkss.2016.23.1.41.

Considerations for Surgical Treatment of Osteoporotic Spinal Fracture: Surgical Indication, Approach, Fixation, and Graft Material

• Kim H
• Chang BS
• Lee CK

• KMID: 2161012
• DOI: http://doi.org/10.4184/jkss.2016.23.1.41

Abstract

STUDY DESIGN: A review of the literature.
OBJECTIVES
To review the current evidence on the development of a viable surgical strategy for successful treatment of patients with osteoporotic vertebral fractures. SUMMARY OF LITERATURE REVIEW: Achieving rigid and stable spinal column reconstruction in elderly patients with osteoporosis is challenging because of the poor healing capacity and weak mechanical strength of their bones.
MATERIALS AND METHODS
A literature search of clinical and biomechanical studies on the issues of surgical treatment of patients with osteoporotic vertebral collapse was performed and reviewed in terms of the surgical approach, fixation, graft material, and medical considerations. Illustrative cases of the authors' experiences were presented and reflected upon.
RESULTS
Posterior spinal fusion and vertebral augmentation showed shorter operating times, less bleeding, and fewer complications with comparable or superior clinical results than anterior corpectomy and fusion or a posterior closing wedge vertebral shortening procedure in multiple studies. Therefore, we recommend the former as a first-line surgical plan for patients with osteoporotic vertebral collapse. However, in some patients who suffer fixed kyphosis, or spinal cord compression by a retropulsed bony fragment or bone cement, or infected vertebroplasty, an anterior approach could be considered to remove the pertinent lesion and to restore anterior spinal column. For the enhancement of the purchasing strength of the screw in the osteoporotic vertebra (e), a technique of prefilled bone cement in the instrumented vertebra(e) or injection of bone cement through a fenestrated screw is useful. Further, preoperative assessment and correction of systemic and local factors that affect bone healing is required when spinal fusion surgery is considered in elderly osteoporotic patients. The selection of the graft material should be individualized according to the property among osteoconduction, osteoinduction, and ostegenesis, or structural support that is the most important for the successful bone healing of each patient.
CONCLUSIONS
Comprehensive geriatric assessment and management of elderly patients before surgery and careful and meticulous surgical planning with respect to the surgical approach, instrumentation, and the graft material are important to achieve the best outcome of the surgical treatment of patients with osteoporotic vertebral collapse.

Keyword

Osteoporosis; Spine surgery; Surgical approach; Instrumentaion; Fixation; Graft choice

MeSH Terms

Aged
Bone Regeneration
Geriatric Assessment
Hemorrhage
Humans
Kyphosis
Osteoporosis
Spinal Cord Compression
Spinal Fractures*
Spinal Fusion
Spine
Transplants*
Vertebroplasty

Figure

• 

  Fig. 1. Simple radiography and magnetic resonance image (MRI) of a patient with delayed osteoporotic vertebral collapse (A). Postoperative simple radiography (B) and computed tomography (C) images of a patient who underwent anterior corpectomy/decompression and reconstruction with a femoral shaft allograft and instrumentation with triangulated dual-screw fixation with a bicortical purchase for the treatment of spinal cord compression with delayed osteoporotic vertebral collapse.

• 

  Fig. 2. Preoperative and postoperative simple radiography (A, C) and MRI (B, D) of a 68-year-old female patient who had dynamic spinal cord compression due to an intravertebral instability showing a spinal cord signal change on the MRI without a significant canal compromise in the supine position. She underwent posterior decompression and fusion combined with vertebral body augmentation with polymethylmethacrylate to provide anterior spinal column support for the treatment of the osteoporotic vertebral collapse of T12.

• 

  Fig. 3. Simple radiography (A, B) showing cortical bone trajectory screw fixation for L5–S1 interbody fusion.

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