November 2012 Dear Colleague: Due mainly to osteoporosis, Americans experience 700,000 vertebral body compression fractures (VCFs) annually. That’s more than the number of hip and wrist fractures combined. Approximately 150,000 of these patients are hospitalized for medical management of pain—with an average stay of eight days at a collective cost of $1.6 billion a year. Add nursing home care into the mix and the estimated direct cost for osteoporotic and associated fractures soars to $17 billion annually (or $47 million a day.) Having recently returned from the annual meeting of the Society for Minimally Invasive Spine Surgery in Miami, where I presented an abstract on minimally invasive spine surgery performed at Michigan Neurosurgical Institute, I thought it might be helpful to pass along some information about VCFs. Our practice has special expertise in minimally invasive procedures for treating VCFs—kyphoplasty and vertebroplasty—both of which are usually done on an outpatient basis. Compression fractures tend to occur at the thoracic curve and thoracolumbar junction. Failure to diagnose and treat can result in a downward spiral as one VCF leads to another, and then to kyphotic angulation or over-curvature of the spine. This can leave patients in chronic pain, with decreased lung function, height loss, impaired gait or poor balance, and a greater risk of age-adjusted mortality. Fortunately, this progressive decline in health-related quality of life can often be delayed or prevented with three forms of intervention: Nonsurgical, Pharmacological, and Surgical. Prevention and Treatment Nonsurgical intervention may include bed rest, analgesics, physical therapy, and bracing. While this may relieve pain, it doesn’t restore the anatomy or provide long-term functional improvement, and the inactivity can exacerbate bone loss. Pharmacological intervention may also involve pain medication (usually short-term), as well as calcium supplements, vitamin D, bisphosphonate drugs and certain hormones, such as calcitonin, to increase bone growth and density and prevent vertebral fractures. Surgical intervention is either via an open approach or a minimally invasive approach. The open approach is considered when there is radiographic spinal instability, canal stenosis, or neurologic impairment. The minimally invasive approach is the prevalent surgical treatment option for most compression fracture patients. Patient Selection VCFs call for complete neurological and radiological evaluation. At MNI, our screening criteria for recommending a minimally invasive surgical approach include the following: • • • •
The patient is 60 years of age or older He or she experiences pain in response to percussion at the level of the vertebra in question The injury or compression fracture is > 4-6 weeks old or < 1 year old Positive MRI or bone scan imaging supports the above clinical/historical findings and may support this treatment option in patients who fall outside of the above parameters (i.e. age <60 years old, etc.)