tips and tricks to achieve stable hardware in osteoporosis vertebra

1. OSTEOPOROSIS
IS IT A SURGICAL PROBLEM?
Dr.Ghazwan A. Hasan
Medical City Complex
2016

2. OSTEOPOROSIS:
• The Nightmare Of Post-menopause/ Old Age.
• The leading cause of disability and morbidity in elderly.
• The Disease of aging.
• The Silent Disease.

3. DEFINITION
 Osteon is bone and porosis is hole in Greek.
 Osteoporosis is a systemic skeletal disorder characterized by
low bone mass, micro architectural deterioration of bone tissue
leading to bone fragility , and consequent increase in fracture
risk .

4. NORMAL MODERATE
SEVERE

5. OSTEOPOROSIS AFFECTS ENTIRE SKELETON
 Osteoporosis is responsible for >36.8 million vertebral and non-vertebral fractures per
year in USA
 Spine, hip, and wrist fractures are most common.
 Vertebral fractures are the most common type of osteoporotic fracture and responsible
for 42–48% of the variation in kyphosis in patients with osteoporosis

6. PREVALENCE
 Osteoporosis is the most prevalent bone disease in the world, 44 million
Americans have or are at risk of osteoporosis.
 According to the International Osteoporosis Foundation, 1 in 3 women over 50
may experience osteoporotic fractures, and 1 in 5 men .
 Affect : 25% people over 70 y.
50% people over 80 y.
 Female to male ratio 6:1

7. PREVALENCE OF OSTEOPOROSIS WILL INCREASE WITH AN INCREASING
AGING POPULATION
Paiement GD, Perrier L. In: Comprehensive Management of Menopause. 1994:32-38. US Census Bureau. 2000.
0
5
10
15
20
%
Projected
Population
>65 Years
1900
1950
1985
2020

8. OSTEOPOROTIC FRACTURE INCIDENCE IS HIGH
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
1,600,000
Breast
Cancer
Heart
Disease
Osteoporotic
Fractures
Cases/Year
Women’s Health Facts and Figures. Washington, DC: ACOG; 2000.

9. NIH/ORBD National Resource Center. October 2000.
Vertebral
46%
(700,000)
Wrist
16%
(250,000)
Hip
19%
(300,000)
Other
19%
(300,000)
Distribution of Fractures

10. HIGH ECONOMIC BURDEN
Estimated $13.8 billion/year
Outpatient
($1.3)
Hospitalization
($8.6)
Nursing
Home
($3.9)
Ray NF et al. J Bone Miner Res. 1997;12:24-35.

11. TYPES OF OSTEOPOROSIS
2 TYPES :-
 a) PRIMARY OSTEOPOROSIS
I. Type-1 : Postmenopausal osteoporosis
II. Type-2 : Age – associated osteoporosis
 b) SECONDARY OSTEOPOROSIS
Loss of bone is caused by an identifiable agent or disease process such as inflammatory disorder ,
bone marrow cellularity disorder and corticosteroid use.

12. SECONDARY OSTEOPOROSIS

13. NON-MODIFIABLE/FIXED RISK FACTORS
 Older age.
 Female gender.
 Ethnic background.
 Small bone structure.
 Family history of osteoporosis or osteoporosis-related
fracture in a parent or siblings.
 Previous fracture.
 Menopause/hysterectomy.
 Some medicines like steroids, anti-epileptics.
 Rheumatoid arthritis.
 Reduced levels of gonadal hormones in men.

14. MODIFIABLE RISK FACTORS
Alcohol.
Smoking.
Poor nutrition.
Vitamin D deficiency/Lack of sunlight exposure.
Insufficient exercise.
Low calcium intake in food.

15. CLINICAL SIGNS AND SYMPTOMS
 Fractures caused by osteoporosis are often painful.
 Osteoporosis is often called the ‘Silent disease’ as many people don’t
recognize they have it until a fracture occurs.
 Back pain: Episodic, acute , low thoracic/high lumbar pain.
 Compression fracture of the spine.

16. VERTEBRAL FRACTURES
 Most common fractures (46%)
 Insidious
 Progressive
 Often unrecognized
 Associated with
 Deformity, height loss, back pain
 Morbidity and mortality
 Predict future vertebral and non-vertebral fractures

17. Most serious clinical event
Morbidity is high
 50% do not regain independence
 50% do not regain previous mobility
Mortality is high
1 in 5 patients die within 1 year
Patients not treated for osteoporosis
NIH Consensus Development Panel. JAMA. 2001;285:785-795.
Hip Fracture

18.  Low BMD
 Maternal history of fracture after 50 years
 Fracture after 50 years
 Age 65 years
 Low body weight (125 lb)
 Smoking
 Corticosteroid use
 Other secondary causes
Black DM et al. Osteoporosis Int. 2001;12:519-528.
All postmenopausal women with the following:
Risk of Fracture

19. Klotzbuecher CM et al. J Bone Miner Res. 2000;15:721-739.
Future Fractures (Fold Increase)
Existing Fracture
Wrist
Vertebral
Hip
Hip
1.9
2.3
2.3
Vertebral
1.7
4.4
2.5
Wrist
3.3
1.4
-
A Fracture Begets a Future Fracture

20. • History
Risk factor assessment
Medical history
Family history
Social history (smoking, alcohol)
Evaluation of fall risk
Physical
Height loss >1.5 inches
Kyphosis
Tests
BMD
X-ray of thoracic/lumbar spine
Bone turnover markers
Laboratory tests as necessary
AACE Guidelines. Endocr Pract. 2001;7:293-312.
Clinical Evaluation

21. PHYSICAL EXAMINATION
 Height loss
 Body weight
 Kyphosis
 Humped back
 Tooth loss
 Skinfold thickness
 Grip strength

22. In case of vertebral fracture:
 Wall- occiput distance
 Rib-pelvis distance

23. BMD
Dual energy x-ray absorptiometry (DEXA) is the best current test to
measure bone density.
The ability of the BMD to predict hip # is better than the
measurement of BP to predict stroke.

25. T-Score* Classification
> -1.0 Normal
-1.0 to -2.5 Osteopenia
< -2.5 or lower Osteoporosis
< -2.5 + fracture Severe osteoporosis
WHO DIAGNOSTIC CRITERIA
The WHO Study Group. Geneva, 1994
*T-score = number of standard deviations (SDs) below or above the peak bone mass
in young adults.

26. BMD TESTS OTHER THAN DEXA
 Quantitative CT vertebral scanning.
 Single photon and dual photon absorptiometry.
 Peripheral DEXA.

27. INDICATION OF BMD
 All postmenopausal women <65 yr who have one or more additional risk factors for
osteoporosis, besides menopause.
 All women >65 yr regardless of additional risk factors
 Osteopenia on a radiograph.
 Estrogen-deficient women.
 Women on estrogen replacement therapy.
 Diagnosing low bone mass in glucocorticoid-treated individuals(Prednisolone at 7.5mg
daily for 6m.)
 Asymptomatic primary or secondary hyperparathyroidism.

28.  Previous low trauma fragility #
 Premature menopause <45y.
 Prolonged secondary amenorrhoea (>1.y.)
 Primary or secondary hypogonadism
 Chronic disorders asso. With osteoporosis
 A meternal h/o hip #
 Alow BMI
Indication of BMD

29. Initial investigations include:
1. ESR
2. Bone profile: serum calcium, phosphate, albumin
3. Alkaline phosphatase
4. Renal function
5. Plain X-rays - lateral thoraco-lumbar spine or hip
LABORATORY TESTS

30. DIFFERENTIAL DIAGNOSES
Other Problems to Be Considered
1. Bony metastases.
2. Multiple myeloma.
3. Primary hyperparathyroidism.
4. Secondary hyperparathyroidism.
5. Osteomalacia.
6. Renal osteodystrophy.
7. Paget disease of bone.

31. TREATMENT

32. PHARMACOLOGICAL MANAGEMENT OSTEOPOROSIS
 Calcium
 Vitamin D
 Estrogens/HRT
 Bisphosphonates.
 Calcitonin
 PTH
 Teriparatide
 Selective Estrogen Receptor Modulator (SERM)Raloxifene

33. OSTEOPOROSIS THERAPEUTICS
Decrease Resorption Enhance Formation
► Bisphosphonates
► Estrogen
► Raloxifene
► Calcitonin
► Parathyroid
Hormone

34.  Calcium intake.
 Diet and/or supplementation: 1200 mg/day
 Vitamin D supplementation
 Diagnose and treat deficiency/insufficiency.
 Supplement: 400-800 IU/day.
 Regular load-bearing and muscle-strengthening exercise (no weight lifting if
BMD in spine is low).
 Fall prevention advice.
 Home safety evaluation.
Nonpharmacologic Approaches

35. NORMAL CALCIUM REQUIREMENT
Age Calcium/day (mg)
Birth-6 months 210
6 months-1 year 270
1-3 500
4-8 800
9-18 1300
19-50 1000
51-70 1200

36. VITAMIN D
Doses:
400IU per day until 60
600-800 IU per day after 60
50,000 IU-D2Every 2-4 weeks
To treat deficiency-50,000 D2IU every week for 2 to 4 m.

37. Orthoses is also used in osteoporotic spine .
 It promote extension of spine.
Hip protectors :-
 Hip protectors are an external hip protection system
that aims to reduce the hip facture.

38. SURGICAL MANAGEMENT
Indicated in:
 Failure of conservative Measures.
 Persistent of pain.
 Neurological Deficit.
 Progressive Kyphosis.

39. Surgical Management
• Vertebroplasty
• Kyphoplasty
• Pedicular Screws fixation +/- Augmentation
• Combinations

41. BACKGROUND:VERTEBROPLASTY
 Vertebroplasty (VP) introduced in France in 1984 by interventional
neuroradiologist
 VP used in US in 1993
 1997: First case series of VP in U.S.

42. KYPHOPLASTY
 Attempt to restore vertebral body height and reduce kyphosis by using
inflatable balloon tamp.
 Orthopedic surgery 1998.
 More expensive, often with general anesthesia.
 Height restoration (may be only 3-4 mm).
 Less risk of cement leak.

43. BACKGROUND DATA (PRIOR TO RECENT STUDIES OF
CONTROVERSY…)
 Multiple small studies of VP demonstrating greater pain reduction, less
analgesic use, and greater mobility compared to medical management
(initially and at few months).
 meta-analyses show reduction in pain.
 Minimal complications.

44. BACKGROUND (CONT)
KP with similar history: multiple small studies demonstrating benefit
with quicker reduction in pain and mobilization compared to medical
treatment
KP and VP: no studies clearly demonstrated any benefit 1-2 years later
when compared to medical treatment

45. KP VS VP: WHICH IS BETTER?
 KP: goal to restore height/reduce kyphosis, but may only increase by 2-4 mm (no
sig difference with VP).
 KP with less cement leak (< 1% vs 3 % or more with VP), although most leaks not
symptomatic.
 Pain and other outcomes similar.
 Most likely similar, although patients referred for KP often have more severe
fractures.

46. COMPLICATIONS
 Cement Leak.
 Cement Pulmonary embolism (?higher than thought).
 Cord compression.
 Hematoma, infection.
 Adjacent vertebral fractures (probable)?

47. TIPS AND TRICKS FOR INSTRUMENTATION IN OSTEOPOROSIS
 Increase the screws length, diameter and design.
 Bicortical Insertion.
(S. W. Breeze, B. J. Doherty, P. S. Noble, A. Leblanc, and M. H. Heggeness, “A
biomechanical study of anterior thoracolumbar screw fixation,” Spine, vol. 23, no. 17, pp.
1829–1831, 1998.)
 Triangulations (Bilaterally), Screw Coupling
(P. S. D. Patel, D. E. T. Shepherd, and D. W. L. Hukins, “The effect of screw insertion angle and
thread type on the pullout strength of bone screws in normal and osteoporotic cancellous
bone models,” Medical Engineering and Physics, vol. 32, no. 8, pp. 822–828, 2010.)
 Undertaping the screws( Pilot Hole size)
(S. Battula, A. J. Schoenfeld, V. Sahai, G. A. Vrabec, J. Tank, and G. O. Njus, “The effect of pilot
hole size on the insertion torque and pullout strength of self-tapping cortical bone screws in
osteoporotic bone,” Journal of Trauma, vol. 64, no. 4, pp. 990– 995, 2008.)

48. TIPS AND TRICKS FOR INSTRUMENTATION IN OSTEOPOROSIS
 Use of Laminar Hook.
(A. Cordista, B. Conrad, M. Horodyski, S. Walters, and G. Rechtine, “Biomechanical evaluation of pedicle screws
versus pedicle and laminar hooks in the thoracic spine,” Spine Journal, vol. 6, no. 4, pp. 444–449, 2006.)
 Cement Augment screws.
(L.-H. Chen, C.-L. Tai, D.-M. Lee et al., “Pullout strength of pedicle screws with cement augmentation in severe osteo- porosis: a
comparative study between cannulated screws with cement injection and solid screws with cement pre-filling,” BMC Musculoskeletal
Disorders, vol. 12, article 33, 2011.)
 Expandable Pedicular screws.
(S. D. Cook, S. L. Salkeld, T. Stanley, A. Faciane, and S. D. Miller, “Biomechanical study of pedicle screw fixation in
severely osteoporotic bone,” Spine Journal, vol. 4, no. 4, pp. 402–408, 2004.)
 Double Pedicle Screws
(L. Jiang, V. Arlet, L. Beckman, and T. Steffen, “Double pedicle screw instrumentation in the osteoporotic spine: a
biomechani- cal feasibility study,” Journal of Spinal Disorders and Techniques, vol. 20, no. 6, pp. 430–435, 2007.)

49. SCREW DESIGN
Conclusions
Pedicle screw with an outer cylindrical and inner conical configuration with a V-
shaped thread may have maximum pullout strength, regardless of bone density.

50. SCREW LENGTH, DIAMETER AND MATERIAL

52. CEMENT AUGMENTED SCREWS
 Type of Augment. ( PMMA,, HA, or CaP)
 Amount of cement ( 1.0 cc in Dorsal, 1.5 cc in Lumbar )
(P. E. Par ́e, J. L. Chappuis, R. Rampersaud et al., “Biomechanical evaluation of a novel fenestrated pedicle screw augmented with
bone cement in osteoporotic spines,” Spine, vol. 36, no. 18, pp. E1210–E1214, 2011.)

53. The use of cement- augmented screw is a valuable option for these fragile patients and can be associated with
percutaneous techniques in order to be as less invasive as possible, with comparable results to conventional
procedures and less morbidities.
Conclusion

54.  Solid screws with retrograde cement pre-filling offer improved initial fixation
strength when compared to that of cannulated screws with cement injection
through perforation for both the conically and cylindrically shaped screw.

55.  PMMA-augmented pedicle screw instrumentation combined with balloon-assisted
kyphoplasty could be an option to address unstable vertebral fractures in “a
minor-invasive way”.

56. EXPANDABLE PEDICULAR SCREWS.
 Conclusion:
The results of this study have shown that
expandable pedicle screws can be efficacious
in cases in which pedicle screw fixation is
difficult and adds a valuable tool to the
growing armamentarium of spinal
instrumentation.

57. CONCLUSIONS
►Osteoporosis is still underdiagnosed.
►Inevitable consequence of aging in both sexes.
►Accelerated following menopause, disease and drugs.
►Early detection and intervention is mandatory.
►Conservative treatment should be done by Orthopedic not only by physician

58. CONCLUSIONS
► Surgery is needed when indicated.
► Different surgical options are available.
► Surgical Technique, Screw design, Supplement options affect the result.
► Surgery is not substitution for medical management.