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BackTable / VI / Article
Guiding Your Patient Through Vertebral Compression Fracture Treatment
Delaney Aguilar • Dec 9, 2021 • 209 hits
Vertebral compression fracture treatment can consist of medical management such as calcium and vitamin D supplementation, or surgical management like vertebroplasty or kyphoplasty. This article will address when treatment should be given, what treatment options there are, and what to expect during recovery after vertebral compression fracture treatment.
Join us in a conversation with Dr. Tom Andreshak as we go through the patient experience of vertebral compression fracture treatment. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable Brief
• Vertebral compression fracture treatment is not limited to acute fractures. Fractures as old as 1.5 years can still be treated with vertebral augmentation.
• Choosing between vertebroplasty and kyphoplasty should take into consideration how much of a reduction is possible.
• Vertebral augmentation can greatly improve patient pain, but be aware that stagnant progress can be a sign of an adjacent level fracture.
Table of Contents
(1) When to Offer Vertebral Compression Fracture Treatment
(2) Vertebral Compression Fracture Treatment Options
(3) Recovery Expectations
When to Offer Vertebral Compression Fracture Treatment
Vertebral compression fractures are a common occurrence for patients with an acute trauma or underlying bone disease. Trauma patients are usually seen earlier as compared to those with chronic disease due to the mechanism of fracture formation. A concern many of these chronic patients have is whether it is too late to have vertebral augmentation done. Dr. Andreshak explains that while getting treatment done during the acute phase of fracture is preferable, fractures as far out as a 1.5 years that have failed to heal can benefit from augmentation.
[Dr. Michael Barraza]:
So, that brings up an important point about the timing of the fracture in terms of treatment. When you're working these patients up, I mean, ideally we want to get them in the acute phase, but I mean, how long do you consider too long after an injury to forego treatment?
[Dr. Tom Andreshak]:
That's an interesting question because really there is no too long of a treatment so long as you have a DEMA, MRI scan or stir image. If you have activity in a bone scan or you see fractured clefts on CT, I've treated patients a year, almost a year and a half out that still have micro motion and fracture.
[Dr. Michael Barraza]:
Yeah, we kind of do the same. We basically, and unless we know for sure, it's very acute, you know what I mean? If somebody comes in with trauma or an acute injury, we'll be fine with a CT. But for pretty much everybody else we're requiring an MRI. Is that the same for you?
[Dr. Tom Andreshak]:
If possible. Yeah, absolutely. It seems like the cardiologists in my area have given everyone pacemakers, defibrillators, or now bladder stimulators. So we're kind of messed up on getting an MRI, but truly MRI is the gold standard, yes.
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Vertebral Compression Fracture Treatment Options
For nearly any mechanism of compression fracture, whether it be acute or chronic, vertebral compression fracture treatment can include interventions such as vertebroplasty and kyphoplasty. While both aim to achieve the same result, there are conditions where one might be superior to the other. For example, Dr. Andreshak prefers vertebroplasty over kyphoplasty to stabilize older fractures which are much harder to reduce.
[Dr. Michael Barraza]:
So Tom, in terms of treating these patients, are you doing exclusively kyphoplasty or do you also perform vertebroplasty or other forms of vertebral augmentation for compression fractures?
[Dr. Tom Andreshak]:
Probably 90-95% are vertebral augmentation. I do a vertebroplasty if I do a big degenerative spine scoliosis to offset the proximal junctional kyphosis and my proximal screws. If I see an older real chronic type fracture, mild edema, I know I'm not going to get a reduction. So to me a vertebroplasty is great for that. Or if they have one of those segmental fractures between a fixed level, that little bit of a demon in the anterior edge, which I think is a common missed thing not read by some of the colleagues, I will put a vertebroplasty in there to stabilize it.
[Dr. Michael Barraza]:
Okay. And you do that at the same time as a kyphoplasty for other levels? Or occasionally just bring that patient in and treat a vertebroplasty at that level?
[Dr. Tom Andreshak]:
The same time.
[Dr. Michael Barraza]:
Okay. Yeah. I'm with you. It's interesting, in my last job I was at least 90% kyphoplasty. I would occasionally, as you said, for like an older looking fracture and then for me, sometimes for vertebral plane where I'm nervous about inflating a balloon there, I'll sometimes just go with cement, but I joined a new practice here and it was a group that did exclusively vertebroplasty. There was a guy who didn't really believe in using the balloons. And so that was a battle I had in my first year here. I still am a believer. You know, one of the things we brought you on to talk about today was, doing these from unipedicular bipedicular access.
I mean, for me, that wasn't really an option until like five years ago. But, interesting to note that, I was talking about the guys in my group, they actually do all of their vertebroplasties from unipedicular access. But without curved needles they rotate the eyes such that they can get the needle directly in the middle. And that's how they do all of them. For you, roughly what proportion of compression fractures are you treating for unipedicular access compared to bipedicular?
Recovery Expectations
Pain and function are two of the most important aspects of a patient’s recovery after vertebral compression fracture treatment. It is important that your patient understands that despite the minimally invasive approach of vertebroplasty or kyphoplasty, recovery is complex. Dr. Andreshak expects his patients to achieve 50-70% reduction in pain right after the procedure and up to 80% better at follow up. Stagnant recovery can be indicative of an adjacent level fracture that may need to be treated.
[Dr. Tom Andreshak]:
Yup. Standard lecture to the patient in pre-op is that we fix the fracture. You should be 50 to 70% better right away. Your sharp, transitional, and mechanical pain is that pain getting up, getting down, moving should be gone. I see them back at two weeks. I tell them to be careful bending and lifting, not to lift more than 10 pounds and keep weights close.
And when I see them back, first thing I ask them is how’s your pain. Not a scale, but getting up and down. I make him stand up and show me their pain, point to it. Where's it at? And I ask them what their pain level is. If they're 75 - 80% better, I'm not too worried about adjacent level fracture. If they're like well, yeah, it still hurts. It still hurts here. It's 60 - 40% better, they have an adjacent level fracture. So I then get standing upright x-ray right there in the office. And almost always you see that adjacent level fracture.
[Dr. Michael Barraza]:
No kidding. And so where do you go from there?
[Dr. Tom Andreshak]:
Well, then I talked to him about, is this something we should fixt? Is it because we made it too stiff? Did they have a fracture? Say they only had a CT scan that didn't show the fracture. Or are they willing to go through “medical augmentation:” calcium, vitamin D, brace, give them a couple of weeks, see them back in two weeks, get another upright x-ray. If they show a fracture, then we talk about surgery, but I give them the option of going back and doing the adjacent segmentation.
[Dr. Michael Barraza]:
And so when you say surgery, are you talking about a fusion? Are you talking about doing another vertebral augmentation?
[Dr. Tom Andreshak]:
Another augmentation. Or possibly vertebroplasty, especially if that inferior end plate is starting to break, I'd want to make it stiff because I have seen same horribly osteoporotic patient who, as a side, I always try to get a DEXA scan before their procedure so I know what I'm dealing with. But if they have terrible primary osteoporosis, I'll then recommend like a vertebroplasty instead, because I think it's less stiff.
Podcast Contributors
Dr. Thomas Andreshak
Dr. Thomas Andreshak is an orthopaedic spine surgeon at Consulting Orthopaedic Associates, Inc. in Toledo, Ohio.
Dr. Michael Barraza
Dr. Michael Barraza is a practicing interventional radiologist (and all around great guy) with Radiology Associates in Baton Rouge, LA.
Cite This Podcast
BackTable, LLC (Producer). (2021, November 15). Ep. 165 – Unipedicular vs. Bipedicular Approach for Kyphoplasty [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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