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Compression fracture — Clinical Guidelines

Overview

Compression fractures involve collapse of vertebral bone, often due to osteoporosis or trauma, leading to significant back pain and potential spinal deformity. 5

Diagnosis

Clinical Presentation: Severe back pain, particularly in the thoracic or lumbar spine.

Imaging: X-rays typically show vertebral body collapse; MRI and CT scans help assess severity and rule out other conditions.

Grading: Often classified using the Genant Severity Grading Scale (mild, moderate, severe).

Management

First-Line Treatments:

- Conservative Management: Pain relief with NSAIDs, analgesics, and bracing. 2 - Physical Therapy: To maintain mobility and strength.

Adjunctive Treatments:

- Vertebroplasty/Kyphoplasty: Percutaneous procedures to stabilize fractures and relieve pain. 5 - Sedation/Anesthesia: Use of remifentanil or dexmedetomidine for monitored anesthesia care during procedures. 6

Special Populations

Elderly: Higher risk of complications from general anesthesia; IV sedation may be safer. 8

Comorbidities: Presence of sarcopenia (paraspinal muscle fatty degeneration) increases risk of residual back pain post-procedure. 1

Key Recommendations

Consider Vertebral Augmentation for Conservative Failure: For patients failing conservative management, percutaneous vertebral augmentation (vertebroplasty or kyphoplasty) can be effective in relieving pain and stabilizing fractures. (Evidence: Moderate 2 5)

Evaluate Paraspinal Muscle Health: Assess paraspinal muscle fatty degeneration preoperatively as it predicts residual back pain post-augmentation. (Evidence: Moderate 1)

Monitor for Adjacent Segment Degeneration: Patients undergoing percutaneous kyphoplasty should be monitored for radiographic adjacent segment degeneration, particularly in those with multiple risk factors. (Evidence: Moderate 3 4)

Select Appropriate Anesthesia Care: For elderly patients, consider intravenous sedation over general anesthesia to mitigate risks associated with comorbid conditions. (Evidence: Weak 8)

References

1 Gao X, Du J, Hao D, He B, Yan L. Risk factors for residual back pain following percutaneous vertebral augmentation: the importance of paraspinal muscle fatty degeneration. International orthopaedics 2023. link 2 Petitt JC, Desai A, Kashkoush A, Ahorukomeye P, Potter TO, Stout A et al.. Failure of Conservatively Managed Traumatic Vertebral Compression Fractures: A Systematic Review. World neurosurgery 2022. link 3 Wang T, Si F, Zang L, Fan N, Yuan S, Du P et al.. Radiographic adjacent segment degeneration and risk factors for osteoporotic vertebral compression fractures treated with percutaneous kyphoplasty. International orthopaedics 2022. link 4 Tao W, Biao W, Xingmei C, Hu Q, Jinpeng S, Yue G et al.. Predictive Factors for Adjacent Vertebral Fractures After Percutaneous Kyphoplasty in Patients With Osteoporotic Vertebral Compression Fracture. Pain physician 2022. link 5 Tsoumakidou G, Too CW, Koch G, Caudrelier J, Cazzato RL, Garnon J et al.. CIRSE Guidelines on Percutaneous Vertebral Augmentation. Cardiovascular and interventional radiology 2017. link 6 Lee JM, Lee SK, Lee SJ, Hwang WS, Jang SW, Park EY. Comparison of remifentanil with dexmedetomidine for monitored anaesthesia care in elderly patients during vertebroplasty and kyphoplasty. The Journal of international medical research 2016. link 7 Hong SJ, Lee S, Yoon JS, Kim JH, Park YK. Analysis of intradiscal cement leakage during percutaneous vertebroplasty: multivariate study of risk factors emphasizing preoperative MR findings. Journal of neuroradiology = Journal de neuroradiologie 2014. link 8 Mohr M, Pillich D, Kirsch M, Mueller JU, Fleck S, Hosten N et al.. Percutaneous balloon kyphoplasty with the patient under intravenous analgesia and sedation: a feasibility study. AJNR. American journal of neuroradiology 2011. link 9 Lin BF, Huang YS, Kuo CP, Ju DT, Lu CH, Cherng CH et al.. Comparison of A-line autoregressive index and observer assessment of alertness/sedation scale for monitored anesthesia care with target-controlled infusion of propofol in patients undergoing percutaneous vertebroplasty. Journal of neurosurgical anesthesiology 2011. link 10 Jha RM, Yoo AJ, Hirsch AE, Growney M, Hirsch JA. Predictors of successful palliation of compression fractures with vertebral augmentation: single-center experience of 525 cases. Journal of vascular and interventional radiology : JVIR 2009. link 11 Teng MM, Cheng H, Ho DM, Chang CY. Intraspinal leakage of bone cement after vertebroplasty: a report of 3 cases. AJNR. American journal of neuroradiology 2006. link 12 Cover KL, Slasky BS, Bonadio PM. Ascending colon compression by psoas muscle hypertrophy. The American journal of gastroenterology 1983. link

Compression fracture