1、SURGICAL TREATMENT OF SPINE OSTEOPOROSISConcept of Osteoporosis A systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and a susceptibility to fracture. the above definition developedin Hong Kong in
2、 1993 Pathophysiology of OPBone Remodeling Imbalance of bone remodeling, In pathologic situations, bone mass may be sacrificed to satisfy the bodys intra- and extracellular calcium needs. A specific quantity of bone is resorbed from the remodeling site and then a reversal occurs and the cavity is oc
3、cupied by osteoblasts which refill that cavity with boneT The he P Progression of rogression of B Bone one R Remodelingemodeling Mechanisms of Bone LossAn increased number of bone remodeling units can be activated which, when combined with either of the above two processes, may result in increased b
4、one loss. bone loss is equal to bone formation and the amount of bone tissue present represents normal bone mass increased number of remodeling sites increased porosity of the bone, ie the remodeling space, and this gives decreased bone mas Bone Loss: Cancellous vs. Cortical BoneAlthough cancellous
5、bone may account for less than 25% of the total bone mass in healthy adults, its surface area far exceeds that of cortical bone. Bone Loss: Cancellous vs. Cortical BoneCancellous bone is more metabolically active than cortical bone. If bone remodeling becomes uncoupled, with osteoclastic activity ex
6、ceeding osteoblastic activity, the mass and structural integrity of cancellous bone is more severely affected than cortical bone. Bone Loss: Cancellous vs. Cortical BoneDuring the accelerated period of bone loss occurring immediately post-menopause, cancellous bone loss is increased 3-fold, while ra
7、tes of cortical bone loss are slower. Therefore, fractures related to osteoporosis most commonly occur in areas rich in cancellous bone (ie, the vertebrae and wrist), and BMD measurements have focused on these critical anatomic siteshigh turnover with either increased formation or increased resorpti
8、on or both Patterns of Age-Related Bone LossGradual bone loss begins in both men and women between the age 30 and 40, paralleling an age-related decline in muscle mass. menopause women begin a period of accelerated bone loss, averaging from 2%-5% per year over the next ten years. Estrogen-Related Bo
9、ne LossAdditionally, it is thought that estrogen deficiency is more directly associated with accelerated bone loss, but not age-related bone loss.Accelerated Bone Loss Accelerated bone loss is greatest in the first 3-6 yrs after menopause, levels off, and then gradually assumes the level of premenop
10、ausal bone loss. This period of accelerated bone loss, coupled with the lower average BMD in women compared to men, explains the higher incidence of osteoporosis and osteoporotic fractures in womenVertebrae and Cancellous BoneThe vertebrae have a high percentage of cancellous bone. Therefore, verteb
11、ral fractures are the most common fracture site in the early menopausal years;Hip fractures tend to occur in later life. The degree of bone loss may vary from site to site in the same individual. Menopausal Bone LossMenopausal bone loss can vary among women from 2%-5% per year. Higher rates of bone
12、loss have been classified as fast losers. It is thought that this category of women (about 5%-10% of all menopausal women) may be at higher risk for fractures; NFO Recommendations for BMD Testing All postmenopausal women under age 65 who have one or more additional risk factors for osteoporosis(besi
13、des menopause); All women aged 65 and older, regardless of additional risk factors; Postmenopausal women who present with fractures(to confirm diagnosis and determine disease severity);NFO Recommendations for BMD Testing Women who are considering therapy for osteoporosis, if the BMD testing facilita
14、te the decision; Women on hormone replacement therapy for prolonged periods.Issues in Bone Mineral Testing Considerations A womans willingness to be treated; Commitment to HRT therapy; Patient who is uncertain about HRT; Technology and anatomic site considerations;Bone Mineral Density - Defining Dia
15、gnostic Categories Normal. BMD within 1 SD of the young normal adult (T-score above -1). Low bone mass (osteopenia). BMD is between 1 and 2.5 SD below that of a young normal adult (T-score between -1 and -2.5).Bone Mineral Density - Defining Diagnostic CategoriesOsteoporosis. BMD is 2.5 SD or more b
16、elow that of a young normal adult (T-score at or below -2.5). Women in this group who have already experienced one or more fractures are deemed to have severe or established osteoporosis.Limitations of Diagnostic Criteria Based on T-Scores The use of different young normal reference databases, diffe
17、rent densitometric devices, that may result in different T-scores other risk factors for fracture besides BMD and the intermediary nature of BMD. These vary depending on the instrument used to obtain the data Other Risk Factors for FractureNonmodifiable: Personal history of fracture as an adult Hist
18、ory of fracture in first-degree relative Race Advanced age Female sex Dementia Poor health/frailty Other Risk Factors for FracturePotentially modifiable: Current cigarette smoking Low body weight/thinness (127 lbs.) Estrogen deficiency: Early menopause (1 year) Other Risk Factors for FracturePotenti
19、ally modifiable:Low calcium intake (lifelong) Alcoholism Impaired eyesight despite adequate correction Recurrent falls Inadequate physical activity Poor health/frailty WHO Definition Estimates 30% of all postmenopausal white women will be diagnosed with osteoporosis; 54% will have low bone mass at t
20、he hip, spine or wrist. More than half the women with osteoporosis will have a history of prior fracture of the proximal femur, spine, distal forearm, proximal humerus or pelvis.Fractures Associated with OPVertebral FractureHip FractureDistal Forearm FractureOther Fractures Fracture of the proximal
21、humerus, pelvis, proximal tibia and distal femur.Impact of Vertebral and Hip FracturesBoth fractures may be associated with significant morbidities and increased mortality as follows:About 1/2 the women with hip fractures will spend some time in a nursing home.Only 1/3 of hip fracture patients regai
22、n their prefracture level of function, with many unable to walk independently or perform basic activities of daily living. Impact of Vertebral and Hip Fractures20% of women who suffer a hip fracture will die in the following year as an indirect consequence of the fracture. A history of vertebral fra
23、cture is associated with an increased risk of a subsequent fragility fracture Impact of Vertebral and Hip FracturesVertebral fracture may be associated with back pain, disability or physical deformity (eg, kyphosis, height loss, abdominal protrusion). In fact, the threat of physical deformity may be
24、 a powerful influence on a womans commitment to therapy. Additionally, there is an increase in mortality related to frailty, comorbidities and an increased risk of pneumonia. Vertebroplastyand Kyphoplasty A new technique of Minimal Invasive Spinal Surgery Carry out in China from 2001Vertebroplasty-
25、Minimal Invasive Treatment of Compression FrxVertebroplasty literally means fixing the vertebral body. A metal needle is passed into the vertebral body and a cement mixture containing polymethylmethacrylate (PMMA), barium powder, tobramycin, and a solvent are injected under imaging guidance by the p
26、hysician. Vertebroplasty- Minimal Invasive Treatment of Compression FracturesThe cement hardens rapidly and buttresses the weakened bone. The barium makes the cement visible on x-ray and the tobramycin is an antibiotic. Risks of Procedure1). Leakage of cement into veins and or lungs2). Infection 3).
27、 Bleeding4). Rib or Pedicle fracture 5). Pneumothorax 6). Worsened pain 7). Paralysis secondary to leakage of cementWhat are indications for Vertebroplasty?1). Painful compression fracture secondary to osteoporosis 2). Painful compression fracture secondary to tumor which does not respond to convent
28、ional therapy 3). Prevent further compression fractures 4). Buttress weakened bone for spine fusionsRelative Contraindications1) Young patient - the long term effects of the cement mixture are unknown2) Vertebral bodies above the T5 level - the procedure is riskier and more difficult3) Patients with
29、 prior unsuccessful spine surgeryPatient Evaluation 1) History and Physical Examination 2) Current x-rays3) MRI +/- bone scanSurgical Procedure of Vertebroplasty 1. be carried out in an operating room or in a special X-ray suite. A needle is placed in a vein so that the patient can get medication fo
30、r sedation and pain. The patient lies prone with padding under the body and with the hips slightly bent. The arms are positioned above the shoulder. Surgical Procedure of Vertebroplasty 2,A radiopaque (visible on X-ray) marker is placed on the patient over the vertebra to be injected. Positioning of
31、 the marker is guided by fluoroscope (video-like X-ray machine). Clearly seeing the correct vertebra is more difficult in the severely osteoporotic patientSurgical Procedure of Vertebroplasty 3,Local anesthetic; injected into the skin and along the path toward the pedicle of the vertebra to be injec
32、ted. The needle is left in against the pedicle to mark the path of the special needle used for injecting the cement. The special needle is an 11-gauge bone biopsy needle. A small skin incision is made and bone biopsy needle insertedSurgical Procedure of Vertebroplasty 4,The tip of the bone biopsy ne
33、edle is stuck for about 1-2 mm into the pedicle. Positioning of the this needle is continuously guided with the fluoroscope in both the anterior-posterior (AP, front to back) and lateral (side to side) viewsSurgical Procedure of Vertebroplasty 5, Advance the bone biopsy needle to the front one-third
34、 of the vertebra. On the AP view the needle lies near the midline of the body of the vertebra. The needle is filled with saline to prevent air injection. A contrast solution that can be seen on X-ray is injected. Takes X-ray pictures during the injection to see how the contrast flows from the center
35、 of the vertebra into the local veins. Surgical Procedure of Vertebroplasty 6, Prepare the plastic material to be injected. Mix the PMMA powder with tungsten powder or barium sulfate to make it visible on X-ray. Add the liquid to the powder and mixed to a thick yet pourable consistency similar to ho
36、neySurgical Procedure of Vertebroplasty 7, Load the PMMA into several small syringes. The syringe is connected to the bone biopsy needle and injected under fluoroscopic guidance to be sure that the material does not run off into the veins. The PMMA hardens after injected to support the vertebra (Axi
37、al and sagittal animations)ComplicationsComplications occur in1. approximately 3% of osteoporotic patients2. approximately 5% of patients with hemagiomas3. approximately 10% of patients with cancer to the vertebraComplicationsThe most common complications are 1. Rib fracture due to the downward on t
38、he back needed to insert the needle in the bony vertebra2. Irritation of an adjacent nerve root3. These complications usually resolve on their own in a few monthsPneumothorax (punctured lung)ComplicationsPneumothorax (punctured lung) Fracture of the pediclePMMA pulmonary embolus - the PMMA enters th
39、e veins through the bone and is taken to the lungCompression of the spinal cord with paralysis or loss of feelingComplicationsIncreased back painPMMA may go outside the bone into the soft tissuesWound InfectionPneumoniaFollow Up Care1. Pain medications - usually tapered over several days after proce
40、dure2. Muscle relaxants 3. Adjust medications to prevent further mineral lossVertebroplasty Statistics1. 80% moderate to marked pain relief2. 5% induced fractures from procedure3. 1% symptomatic embolism or infection Experiences of Our Hospital Case 2Case3 T12CompressionVertebra FractureDuring opera
41、tionCase3 T12 CompressionVertebra FracturePost-operationCase 4 PostoperationCASE 5. Female, 84 Y L2 Compression Vertebra FractureDuring operationCASE 5. Female, 84 Y L2 CompressionVertebra FracturePostoperationCASE5. Female, 84 Y L2 CompressionVertebra FracturePostoperationCase 6 72 yrs, Female.Comp
42、ressive Frx Cervical Spine Fractures and Osteoporosis Fractures of the cervical spine usually result from major trauma (traffic accidents, falls from great heights or dives into shallow water). In elderly patients severe cervical spine injuries may already result from simple falls. little informatio
43、n available on treatment and outcome of cervical spine injuries in the elderly, especially regarding the subaxial spineCervical Spine Fractures and Osteoporosis In the general population, about 50% of fractures involve the C5-6 and C6-7 level, with dens fractures being the second most frequent local
44、ization. The incidence of lower cervical spine injuries continuously declines with age. In contrast, the incidence of upper cervical spine injuries rises in the elderly. Fractures of the dens are the most common location in patients above theage of 70 yearsCervical Spine Fractures and OsteoporosisA
45、68-year-old patient, presenting with incomplete tetraplegia after falling from a tree.a. The lateral radiograph shows no apparent fracture, but there is advanced multilevel degeneration,b. MRI confirms severe spinal canal stenosis, mainly at levels C4-5 to C6-7. The patient died a few days later due
46、 to pulmonary complications.Cervical Spine Fractures and OsteoporosisA 62-year-old patient presenting with cervical myelopathy 2 years after an initially missed dens fracture. MRI shows the pseudarthrosis and a bulging tissue mass posterior to the dens. Cervical Spine Fractures and OsteoporosisFract
47、ures of the Dens AxisOwn Material of Anterior Screw Fixation of Dens FracturesThoracic and Lumbar Spine FracturesIndications for surgery: devastating neurological compromise orincreasingly unstable kyphosis at the fracture site.Thoracic and Lumbar Spine FracturesLate Neurological Compromise after Os
48、teoporoticFracturesThoracic and Lumbar Spine FracturesPosture and ApproachThoracic and Lumbar Spine FracturesReconstructive Surgery ofOsteoporotic-Post-traumatic Vertebral CollapseThoracic and Lumbar Spine FracturesReconstructive Surgery ofOsteoporotic-Post-traumatic Vertebral CollapseThoracic and L
49、umbar Spine FracturesReconstructive Surgery ofOsteoporotic-Post-traumatic Vertebral CollapseThoracic and Lumbar Spine FracturesReconstructive Surgery ofOsteoporotic-Post-traumatic Vertebral CollapseThoracic and Lumbar Spine FracturesReconstructive Surgery ofOsteoporotic-Post-traumatic Vertebral CollapseThoracic and Lumbar Spine FracturesReconstructive Surgery ofOsteoporotic-Post-traumatic Vertebral Collapse Reconstructive Surgery ofOsteoporotic-Post-traumatic Vertebral Collapse
