FLS Champions’ Summit

Management of Acute Vertebral Fractures

Professor Opinder SahotaConsultant Physician

QMC, Nottingham University Hospitals

Vertebral Fragility Fractures (VFF)

KyphoticNormal

Location of Vertebral Fractures

1. Nevitt MC et al. Bone. 1999;25:613–619.2. Cooper C et al. J Bone Min Res. 1992;7:221–227.

Are most commonly located at the midthoracic region (T7–T8) and the thoracolumbar junction (T12–L1)1

– Midthoracic region–thoracic kyphosis is most pronounced and loading (stress) during flexion is increased

– Thoracolumbar junction–the relatively rigid thoracic spine connects to the more freely mobile lumbar segments2

Progressive Kyphosis & Spine Compensation

• Impairs gait and mobility• Para spinal muscle fatigue• Increases strain on

posterior facet joints

Back Pain

Knee flexion and contraction of the posterior muscles ofthe lower back to tilt the hips

Long-term Consequences

Acute Fracture

Acute Fracture :Optimise Pain Control

• Paracetamol• Tramadol• NSAIDs• Fentenyl• Buprenorphine

Acute Fracture :Imaging

DXA

•••

•• •

Osteoporosis-Imaging

Lateral Vertebral Assessment

••

Vertebral Fragility Fractures

Genant HK et al. J Bone Miner Res. 1993;8:1137–1148.

Severe(≥40% height loss)

Normal Wedge Biconcave Crush

Moderate(25-40% height loss)

Mild(20-25% height loss)

Measurements used for assessment:Hp=posterior height;Hm=middle height;Ha=anterior height

Hp Hm Ha

Lateral Vertebral Assessment

Osteoporosis-Imaging

LVA Assessment

• 337 patients, presenting with low trauma non-vertebral fractures

• LVA 83 (25%) vertebral fracture confirmed(37 (45%) more than one vertebral fracture

• Of those with vertebral fractures, 75% has deformities of grade 2 or 3

Gallacher SJ et al. Osteop Int . 2006; 18: 185-192

Acute Fracture :Exclude Secondary Metabolic Causes

• FBC / ESR• Biochemisty Profile• TFTs, Coeliac Screen• Calcium (PTH)• Myeloma screen• PSA

Acute Fracture :Admission to Hospital

Acute Fracture :Secondary Care

• Optimise Analgesia• Regular bowel care• Consider urgent MR

Imaging• Discussion with spine

team

Acute Fracture :Discussion with spine team• On call• HCOP Dedicated 4 PAs• Spinal Osteoporosis Specialist Nurse

Vertebral Augmentation

Vertebral Augmentation

• Ms OG

• 82 Female, normally fit and well

• Acute back pain, following light gardening

• Presented to ED-log rolled

• X-ray spine confirmed L4#

• Plan transfer to medicine for analgesia and physio

Case Presentation 1

Case Presentation 1

Case Presentation 1

Case Presentation 1

Case Presentation 1

Case Presentation 1

Case Presentation 1

• Ms KH

• 91 Female, normally fit and well, no aids

• Awoke with acute lower back pain

• Managed by GP regular analgesia, 48 hours

• Struggling to mobilise

• Admitted to hospital

Case Presentation 2

Case Presentation 2

Case Presentation 2

Case Presentation 2

Case Presentation 2

Case Presentation 2

Case Presentation 2

Acute Pelvic Fracture

Acute Pelvic Fracture

Acute Pelvic Fracture

Sacral Fractures Pubic Rami

Fracture

Acute Pelvic Fracture

Pelvic Fractures

• CT• MRI• PARACEMATOL (IV) • SACROPLASTY / SCREW FIXATION• PARATHYROID HORMONE

Pelvic Fractures

• Teriparatide (1-34 parathyroid hormone)• Parathyroid Hormone (1-84)• 65 Patients with pubic / ischial rami fracture• Fracture healing time reduced by 4.6 weeks (p<0.01)• Improved pain scores and Timed Up and Go (p<0.01)

Peichl et al, JBJS, 2011; 93: 1-5

The Optimal Acute Pathway

• Acute Vertebral / Sacral Fracture

• Clinical Assessment

• Analgesia• Investigations

• X-ray Imaging• MR Imaging

• Spinal Augmentation• Intensive rehabilitation

• Secondary prevention