Operative treatment of osteoporotic spinal fractures can be done successfully with internal fixation or minimally invasive techniques like vertebroplasty or kyphoplasty. Osteoporosis is a common comorbidity in elderly patients that weakens the bone and increases risks of spinal compression fractures after minimal trauma. Vertebroplasty and kyphoplasty can provide significant pain relief and may be performed as outpatient procedures, though kyphoplasty aims to restore lost vertebral height while vertebroplasty does not correct deformity. Instrumentation techniques for osteoporotic spines require considerations like multiple fixation points, cement augmentation, and screw design to optimize fixation given reduced bone strength.

1. Operative treatment
of osteoporotic
spinal fractures
George Sapkas
1st Orthopaedic Dept.
“Attikon” University Hospital
Medical School
Athens University

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Normal Bone Osteoporotic Bone

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5. IInnvveessttiiggaattiioonnss

6. CCTT -- ssccaann

7. MMRRII

8. BBoonnee SSccaannnniinngg

9. Management of osteoporotic spinal
fractures
Conservative
Operative

10. SSppiinnaall ffiixxaattiioonn
PPoosstteerriioorr ssttaabbiilliizzaattiioonn

14. Anterior –
Posterior
Stabilization

15. Π.Μ.
F 80
28-7-06
Osteoporosis: T-Score: - 3.5
Posterior Correction & Stabilization

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AAnntteerriioorr PPoosstteerriioorr

17. NN((++))VVEE

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pplluuss
VVeerrtteebbrrooppllaassttyy

20. TTeecchhnniiccaall pprroobblleemmss
&&
CCoommpplliiccaattiioonnss
RReellaatteedd ttoo oosstteeooppoorroossiiss

21. Early
post-operative
hardware failure

22. Late
post-operative
hardware failure

23. Considerations for Instrumentation of the Osteoporotic Spine
• the pullout strength,
• cutout torque,
and
• maximum insertional
torque
for pedicle screws
have been shown
to correlate with
bone mineral density
and are
significantly decreased
in osteoporotic
vertebrae.
Halvorson TL, Spine 1994
Okuyama K, Spine 1993

25. Using multiple points
of fixation, such as
segmental
pedicle screws
• the load applied to
individual screws is
reduced and
• the stiffness of the
overall construct is
increased.

26. A similar principle
applies
to hooks
or wires,
although these
implants generally
require longer
constructs than
pedicle screws
to provide
adequate fixation
Hu SS, Spine 1997
Hart R, et al, Spine 2006

27. In the presence of
osteoporosis
the strength of bone
anchors may not allow
• strong compression
• distraction
or
• vertebral rotation
forces
to be applied.
Glassman SD, et al, Instr Course Lect 2003
Hu SS, Spine 1997;
Hettwer WH, et al, Advances in Osteoporotic Fracture
Management 2004

28. Improving
the bone-implant
interface
is fundamental
to optimize pedicle
screw fixation in
osteoporotic bone.
Hettwer WH, et al, Advances in Osteoporotic
Fracture Management 2004

29. Injectable cements
of several types
have been shown
to substantially
increase
the pullout strength
of screw fixation in
osteoporotic bone.
Glassman SD, et al, . Instr Course Lect 2003
Soshi S, et al, Spine 1991
Zindrick MR, et al, Clin Orthop Relat Res 1986
Taniwaki Y, et al, J.Orthop Sc 2003

30. However,
• cement extravasation
can potentially injure
surrounding structures,
and
• permanent cements
such as
polymethylmethacrylate
represent a potential
locus for late infection.
Glassman SD, Instr Course Lect 2003
Soshi S, et al, Spine 1991

31. Several unique
pedicle screw
designs have been
described for use
in osteoporotic.

32. • Conical screws,
which better approximate
pedicle morphometry,
have been shown
to increase pullout
resistance in osteoporotic
bone.
• It should be noted,
however, that
conical screws lose
a significant portion
of their strength
when backed out
by even a half turn,
which may limit
their ability to
accommodate rod contour
by backing out the screw.
Ono A, Brown MD, et al, J. Spinal Disord 2001
Kwok AW, et al, Spine 1996

33. • Expandable screws
offer additional
improvement
in pullout strength
in severely osteoporotic
bone.
• Clinical series using these
devices, which include 21
patients with osteoporosis,
demonstrated radiographic
evidence of fusion
in 86% of patients.
• One concern with such
implants is that increasing
screw diameter could
fracture the pedicle placing
the adjacent nerve root at
risk Islam NC, et al, Spine 2001
Kostuik JP, et al, Instr Course Lect 2003
Brantley AG, et al, Spine 1994

34. • In patients with
osteoporosis
o undertapping
or
o avoiding tapping
of the pilot hole
altogether
before screw insertion
does help improve
screw fixation
especially in the
lumbar spine
Havolosn TL, et al, Spine, 1994
Carmouche JJ, et al, J. Neur.
Spine, 1998

35. Screw orientation
also should be optimized in
patients with osteoporosis.
Screw
triangulation via a
medial orientation
• takes advantage of the bone
mass between the
converging screws for
fixation,
• rather than only that bone
lying between threads of a
single screw, and
• has been shown to improve
pullout strength in
osteoporotic, bone.
Ono A, et al J.spinal Disord 2001
Rulad CM, et al, Spine 1991

36. Similarly,
screws oriented
o caudal
or
o parallel relative to the
vertebral end plate,
as opposed
to
o a cranial orientation,
avoid increased
bending moments at
the screw hub in normal
vertebrae,
and
use of this technique is
also prudent in
osteoporotic bone.
McKinley TO, et al, Spine 1999
Youssef JA, et al, Spine 1999

37. • HA – coated screws
have been shown to
increase pullout forces
presumably by increasing
both
o the contact surface area
as well as
o the frictional coefficient at
the bone implant interface
• The mechanical behavior
of these implants
over time
as resorption
of the HA coating occurs
has not been studied,
howeveHra.segawa T, et al , Spine, 2005

38. Minimal invasive
techniques
Vertebroplasty - Kyphoplasty

39. S.S.E.P. S.M.E.P

40. Vertebroplasty

42. Kyphoplasty

45. SKy bone expander system
for
percutaneous Kyphoplasty
Unilateral - Bilateral

51. V.B.S. System (Zimmer)

53. Vertebroplasty – Kyphoplasty
Indications
• Vertebral fractures
(compression ± burst)
• Osteoporotic fractures
(compression ± burst)
• Pathologic fractures of the spinal
vertebra (metastasis)
• Haemangioma of the vertebra
• Multiple myeloma

54. Vertebroplasty – Kyphoplasty
Contraindications
• Destruction of the posterior spinal
elements
• Burst fractures (±)
• Neurologic compression syndromes
(due to dislocated bony fragments)
• Destruction of dorsal structures
(vertebral arch and facet joints)
• Vertebra plana
• Spinal infection
• Allergy
(methylmethacrylate etc)
• Coagulopathy
• Untreated cardiovascular disturbances

55. CONCLUSIONS

56. Osteoporosis
is a particularly
prevalent
comorbidity
in the elderly
population.

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ccaann bbee ttrreeaatteedd
ssuucccceessssffuullllyy bbyy iinntteerrnnaall ffiixxaattiioonn
oorr bbyy MM..II..TT..

58. Vertebroplasty - Kyphoplasty
advantages
• May be performed
under local
anaesthesia as a day
case

59. Vertebroplasty - Kyphoplasty
advantages
• Provide significant
relief of pain

60. VERTEBROPLASTY
• Seems to be more
favourable in recent
vertebral fractures
(osteoporotic etc)
without major
deformity

61. VERTEBROPLASTY
• No substantial loss
of the obtained
correction at the
follow up

62. VERTEBROPLASTY
disadvantage
• Is unable to restore the
lost height of the
vertebra

63. Balloon Kyphoplasty
advantages
• Restores sufficiently
the height of the
collapsed vertebra
• Is associated with
inferior possibility of
cement leakage

64. Balloon Kyphoplasty
disadvantages
• The risk of fracture in the adjacent levels is
enhanced in the balloon kyphoplasty
• Increased operative time and radiation
exposure

65. University Hospital “ATTIKON”