Osteoporosis is a systemic disease, which results in : progressive bone mineral loss concurrent changes in bony architecture leaving the spinal column vulnerable to compression fractures, usually after minimal or no trauma.

1. George Sapkas
Professor at Orthopaedics
Spinal Unit
Metropolitan Hospital
Operative treatment
of osteoporotic
spine

2. • OsteoporosisOsteoporosis is a systemic disease,is a systemic disease,
which results in :which results in :
• progressive bone mineral lossprogressive bone mineral loss
• concurrent changes in bony architectureconcurrent changes in bony architecture
• leaving the spinal column vulnerable toleaving the spinal column vulnerable to
compression fractures, usually after minimal orcompression fractures, usually after minimal or
no trauma.no trauma.
Riggs:Riggs: N Engl J Med 1986N Engl J Med 1986
Normal Bone Osteoporotic Bone

3. • VCFsVCFs contribute to:contribute to:
• a fivefold increased risk ofa fivefold increased risk of
further fracturefurther fracture by virtue ofby virtue of
force transmission to weakforce transmission to weak
vertebrae, above or below,vertebrae, above or below,
• while these have been shownwhile these have been shown
to be associated with up to ato be associated with up to a
25%25% age-adjusted increaseage-adjusted increase inin
mortality.mortality.
HeaneyHeaney: Bone 1992: Bone 1992
KadoKado: Arch Intern Med 1999: Arch Intern Med 1999

4. Traditional treatmentTraditional treatment for patients withfor patients with
painful VCFs includes :painful VCFs includes :
• bed restbed rest
• narcotic analgesicsnarcotic analgesics
• bracingbracing
resulting in increased pain because of:resulting in increased pain because of:
• acceleration bone lossacceleration bone loss
• and muscle weakness.and muscle weakness.
UthoffUthoff: JBJS 1978: JBJS 1978
ConvertinoConvertino: Med Sci Exerc 1997: Med Sci Exerc 1997

5. Management of osteoporotic spinal
fractures
Conservative
Operative

6. Spinal fixationSpinal fixation
Posterior stabilizationPosterior stabilization

10. Anterior –
Posterior
Stabilization

11. AnteriorAnterior PosteriorPosterior
StabilizationStabilization

12. N(+)VEN(+)VE

14. Spinal fixationSpinal fixation
VertebroplastyVertebroplasty
plusplus

15. Spinal deformities
(Kyphosis – Scoliosis)
related to osteoporosis

17. 82 82

19. Kyphotic deformity

20. Ponte osteotomies

21. Sacral – Iliac fixation

22. Technical problemsTechnical problems
&&
ComplicationsComplications
Related to osteoporosisRelated to osteoporosis

23. Early
post-operative
hardware failure

24. Late
post-operative
hardware failure
Instability above spondylodesia
(proximal junctional kyphosis)

25. Considerations
for
Instrumentation
of the
Osteoporotic Spine

26. • 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

28. 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.

29. 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

30. 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

31. 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

32. 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

33. 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

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

35. • 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

36. • 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

37. • 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

38. 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

39. 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

40. • 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,
however.Hasegawa T, et al , Spine, 2005

41. Minimal invasive
techniques
Vertebroplasty - Kyphoplasty

42. S.S.E.P. S.M.E.P
neuromonitoring

43. Vertebroplasty

44. Vertebroplasty

45. Kyphoplasty

46. Kyphoplasty

47. Kyphoplasties

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

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

51. • 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
Vertebroplasty – Kyphoplasty
Contraindications

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

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

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

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

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

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

58. CONCLUSIONS

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

60. Osteoporotic spineOsteoporotic spine
can be treatedcan be treated
successfully by internal fixationsuccessfully by internal fixation
or by M.I.T.or by M.I.T.