|Year : 2017 | Volume
| Issue : 2 | Page : 555-563
Evaluation of clinical and surgical outcomes of management of pathological fractures of the dorsolumbar spine
Esam E Saleh1, Ahmad M Gamal El-Den Azab1, Saeed E Abd El-Rahman Al-Emam1, Mahmoud G Hagag2, Ashraf A Zaki Abd Al Karim3
1 Department of Neurosurgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
3 Department of Neurosurgery, Shibin El-Kom Teaching Hospital, Shibin El-Kom, Egypt
|Date of Submission||02-Jul-2016|
|Date of Acceptance||02-Oct-2016|
|Date of Web Publication||25-Sep-2017|
Ashraf A Zaki Abd Al Karim
Department of Neurosurgery, Shibin El.Kom Teaching Hospital, Shibin El-Kom, 32511
Source of Support: None, Conflict of Interest: None
The aim of this study was to evaluate the clinical and surgical outcomes of management of pathological dorsal and lumbar spine fractures.
Pathological fractures are fractures that occur in diseased bone. Bone can be weakened by cancer, infection, or the natural aging process. In the spine, this usually occurs in the cancellous vertebral body, leading to vertebral compression fractures that can cause pain, neural compromise, and deformity.
Patients and methods
A retrospective study was carried out on 50 patients who underwent surgical treatment for pathological fractures in the dorsal and lumbar spine. The patients were divided into three groups according to the underlying disease causing the fracture: group A (21 patients) included patients with osteoporotic fractures; group B (18 patients) included patients with neoplastic fractures; and group C (11 patients) included patients with pathological fractures due to infection. Preoperative history taking, full clinical examination, and laboratory and radiological investigations were performed for all patients. Preoperative functional assessment was performed using the Karnofsky scale, the American Spinal Injury Association scale, and the visual analog scale of pain and compared with postoperative values after 3, 6, and 12 months.
Postoperative functional evaluations showed improvement in all patients with recent neurological deficit (P = 0.003, 0.016, and 0.001 in groups A, B, and C, respectively). Significant improvement of pain in neurologically intact patients who underwent vertebral augmentations was observed (P = 0.000, 0.00, and 0.03 in groups A, B, and C, respectively).
In patients with pathological dorsal and lumbar spine fracture having neurological deficits or spinal canal compromise, the main treatment is spinal decompression and stable fusion. In the absence of neurological compromise or instability, vertebral augmentation is effective for the management of painful vertebral fractures.
Keywords: neoplastic spine fracture, osteoporotic fractures, pathological spine fracture, spine infection, vertebral augmentation
|How to cite this article:|
Saleh EE, Gamal El-Den Azab AM, Abd El-Rahman Al-Emam SE, Hagag MG, Zaki Abd Al Karim AA. Evaluation of clinical and surgical outcomes of management of pathological fractures of the dorsolumbar spine. Menoufia Med J 2017;30:555-63
|How to cite this URL:|
Saleh EE, Gamal El-Den Azab AM, Abd El-Rahman Al-Emam SE, Hagag MG, Zaki Abd Al Karim AA. Evaluation of clinical and surgical outcomes of management of pathological fractures of the dorsolumbar spine. Menoufia Med J [serial online] 2017 [cited 2019 Jun 20];30:555-63. Available from: http://www.mmj.eg.net/text.asp?2017/30/2/555/215448
| Introduction|| |
Pathological fractures are fractures that occur in diseased bone. Bone can be weakened by cancer, infection, or the natural aging process. In the spine, this usually occurs in the cancellous vertebral body, leading to vertebral compression fractures that can cause pain, neural compromise, and deformity .
Vertebral compression fractures lead to a high rate of morbidity as well as impaired physical function and quality of life. Vertebral compression fractures cause chronic back pain, progressive kyphotic deformity, decreased activity tolerance, difficulty in sleeping, depression, and loss of independence .
Bed rest and decreased physical activity lead to disuse osteoporosis, muscle deconditioning, deep venous thrombosis, pulmonary emboli, urinary tract infections, sacral decubiti, infections, and death. Side-effects from analgesics can include respiratory depression caused by narcotics and renal or gastrointestinal impairment caused by anti-inflammatory medications .
The treatment goals for pathological compression spine fractures are to obtain a definitive diagnosis through biopsy, stabilization of the spinal column, preservation of neurological function, and treatment of the underlying cause of the compression fracture .
The indications for spine surgery in the setting of pathological fractures or lesions have traditionally been spinal instability, progressive deformity or neurological deficits, isolated metastasis, and primary tumor of the spine .
Minimal invasive surgery techniques including percutaneous cement augmentation such as vertebroplasty and kyphoplasty may restore stability to the spinal column while limiting the morbidity associated with an open surgical approach. Minimal invasive surgery techniques may expand the indications for the treatment of intractable and debilitating pain unresponsive to palliative or conservative measures .
| Aim of the Study|| |
The aim of the present study was to evaluate the clinical and surgical outcomes of management of pathological dorsal and lumbar spine fractures.
| Patients and Methods|| |
This retrospective study was carried out at Menoufiya University Hospital, Shibin El-Kom Teaching Hospital, and Al-Helal Hospital starting from April 2014 to March 2016. The present study included 50 patients who underwent surgical treatment for pathological fracture in the dorsal and lumbar spine.
Patients were divided randomly into three groups according to the underlying disease causing the fracture: group A (21 patients) included patients with osteoporotic fractures; group B (18 patients) included patients with neoplastic fractures; and group C (11 patients) included patients with pathological fractures due to infection.
Ethical considerations regarding this study were reviewed and accepted by the Medical Ethical Committee at Menoufia Faculty of Medicine.
Inclusion criteria were as follows: good general condition (patient can withstand anesthesia and operation); patients complaining of back pain with or without leg pain or recent neurological deficits, for example, paraparesis or paraplegia (for not more than 3 days), with intact or affected sphincter control (retention or precipitancy); and the affected spinal levels had to be within the first dorsal vertebra and the fifth lumbar vertebra segments and not more than two affected levels.
Exclusion criteria were as follows: bad general condition including immunosuppression, poor nutritional status, and medical comorbidities (liver cell failure, renal failure, heart failure, etc.); metastasis in major internal organs; neglected onset of neurological deficits such as paraparesis, paraplegia, and sphincter dysfunction (>3 days); more than two affected spinal levels; and the presence of psychiatric disorders and drug or alcohol abuse.
Preoperative assessment included patient complaint regarding duration of symptom, onset, and type of, if any, precipitating trauma. Patients were asked about medication use, especially corticosteroids, and history of chronic medical diseases (gynecological, gastrointestinal, genitourinary or pulmonary disease).
Examination included general assessment for evidence of general illness (toxemia and cachexia), body weight, multiple bone tenderness, and mobility. Local spine examination was performed. Neurological examination included detection of motor grades, detection of sensory level, and evaluation of reflexes and muscle tone.
Functional assessment was carried out using the Karnofsky scale , the American Spinal Injury Association (ASIA) scale , and the visual analog scale of pain (VAS) .
Routine laboratory preoperative investigations were carried out for all patients. Tumor markers were used in cases of suspected malignancy. Serum calcium and phosphorus levels were determined in case of osteoporotic fractures.
Plain radiography of the spine (anteroposterior and lateral views) was used to assess qualitative bony alteration (i.e., lytic, blastic, or sclerotic abnormalities), vertebral collapse, other ancillary findings (paraspinal soft tissue shadow), and evaluation of postoperative stability.
Computed tomography (CT) scans of the spine were used to demonstrate narrowing of the spinal canal by retropulsed bone fragments, state of vertebral cortex, and the degree of bony destruction in the three spinal columns.
MRI of the spine was used to confirm neural elements compression, which helps in planning surgical decompression. It is very sensitive to locate metastasis.
Radioisotope bone scan was performed for the detection of bone metastases, as it can detect these lesions earlier than plain films.
Dual energy X-ray absorptiometry scan was used to measure bone mineral density.
Informed consent from all patients meeting inclusion criteria was obtained for surgical intervention. The consent form explained all the details of the surgical procedure, benefits of the surgery, and all related complications that could occur in the intraoperative and immediate and late postoperative periods.
Group A (osteoporotic spine fracture)
Vertebroplasty: It was performed in nine patients who had painful osteoporotic compression fractures, and clinical examinations showed no neurological deficit. Imaging studies of these patients (plain radiography, CT, and MRI) showed loss of vertebral height of not more than 50%, no bony canal compromise with an intact vertebral cortex, and no compression on neural structures.
Kyphoplasty: It was performed in four patients who had painful osteoporotic compression fractures, and clinical examinations showed no neurological deficit. Imaging studies of these patients (plain radiography, CT, and MRI) showed loss of vertebral height of not more than 70%, no bony canal compromise with disrupted or intact vertebral cortex, and no compression on neural structures.
Posterior decompression and fixation: Thesewere performed in eight patients whose clinical examination showed recent neurological deficits – motor, sensory, or autonomic. The decision was supported by radiological investigations showing vertebral canal compromise (>30%) leading to neural elements compression.
Group B (neoplastic spine fracture)
Vertebroplasty: It was indicated in 10 patients who had painful pathological spine fractures caused by underlying tumors, and clinical examinations showed no neurological deficits. Imaging studies (plain radiography, CT and MRI) showed loss of vertebral height of not more than 50%, no bony canal compromise with an intact vertebral cortex, and no compression on neural structures.
Posterior decompression and fixation: These were performed in five patients whose clinical examination showed recent neurological deficits – motor, sensory, or autonomic. The decision was supported by radiological investigations showing vertebral canal compromise leading to neural elements compression without significant kyphotic deformity (kyphotic angle <20°).
Corpectomy and fixation: These were performed in three patients whose clinical examinations showed recent neurological deficits – motor, sensory, or autonomic. Their radiological investigations showed vertebral canal compromise, neural elements compression, and significant kyphotic deformity (kyphotic angle >20°).
Group C (pathological fracture caused by spinal infection)
Posterior decompression and fixation: These were performed in nine patients whose clinical examinations showed recent neurological deficits – motor, sensory, or autonomic. Their imaging studies showed vertebral canal compromise leading to neural elements compression without significant kyphotic deformity.
Corpectomy and fixation: These were performed in two patients whose clinical examinations showed recent neurological deficits – motor, sensory, or autonomic. Their radiological investigations showed vertebral canal compromise, neural elements compression, and significant kyphotic deformity (kyphotic angle >20°).
- Follow-up of patients was carried out at 3, 6, and 12 months postoperatively
- All patients were assessed by the following methods:
- Functional evaluation:
- The ASIA scale
- The Karnofsky scale
- The VAS of pain.
- Radiological evaluation:
- Plain radiography in dynamic view for all patients to assess stability
- CT and/or MRI scan if required.
Data were collected, tabulated, and statistically analyzed using an IBM personal computer with statistical package for social sciences (SPSS Institute, Cary, North Carolina, USA), version 20 and Epi Info 2000 programs, where the following statistics were applied (CDC), Atlanta, Georgia (USA).
Quantitative data are presented as means, SD, and ranges, and qualitative data are presented as numbers and percentages.
- Student's t-test was used to compare two groups having quantitative parameter variables, and one-way analysis of variance was used for multiple group comparisons with quantitative parameter variables
- For comparing the same group at different times, paired t-test was used for parameter quantitative variables and Wilcoxon's test was used for nonparameteric data
- χ2-Test was used to study associations between two qualitative variables
- A P value of less than or equal to 0.05 was considered statistically significant.
| Results|| |
There were no significant differences between the three groups in relation to sex (P = 0.120). The mean age of patients in the infection group was significantly lower than of osteoporotic patients (mean ± SD: 42.73 ± 15.07 and 58.0 ± 6.94) and also lower than that of tumor patients (56.11 ± 9.59) (P = 0.001); however, there was no significant difference in age between osteoporotic and tumor patients (P = 0.563) [Table 1].
The acute onset of symptoms was the most common presentation between the three groups. Intact motor power was more common in patients with osteoporotic fractures (61.9%) and neoplastic fractures (55.6%), whereas paraparesis was the most common presentation in the infection group [Table 2].
The lumbar spine (L1–L5) was most commonly affected by pathological fractures in all three groups [Table 3].
|Table 3: Comparison of the level of affectability between the studied groups|
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Our study showed that there is significant improvement in functional evaluation of patients with pathological spine fractures with recent neurological deficits while using the Karnofsky scale, the ASIA scale, and the VAS of pain after 3, 6, and 12 months [Table 4],[Table 5],[Table 6].
|Table 4: Comparison of the ASIA in patients with pathological spine fractures|
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|Table 5: Comparison of the Karnofsky scale in patients with pathological spine fractures|
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|Table 6: Comparison of the visual analog scale of pain in patients with pathological spine fractures|
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| Discussion|| |
In our study, 50 patients with dorsal and lumbar pathological fractures were divided according to the precipitating cause into three groups: (a) group A (21 patients) included patients with osteoporotic fractures; (b) group B (18 patients) included patients with neoplastic fractures; and (c) group C (11 patients) included patients with pathological fractures due to infection. They were operated upon by different surgical modalities. Their demographic, clinical, and radiological data revealed the following aspects.
Generally speaking, osteoporosis was the leading cause of pathological spine fractures among the studied patients (21 patients with osteoporotic fracture) constituting about 42% of the entire sample, and this coincides with the study by Alexandra et al. , who stated that the most common cause of pathological vertebral compression fractures is osteoporosis, followed by metastatic spine disease.
It was noted that there was a significant increase in the incidence of osteoporotic fractures in women (16 patients), about 76.2%, compared with male incidence (five patients), about 23.8% in group A, although there was no significant difference in sex distribution in the other two groups.
In Egypt, based on different studies, it has been calculated that 53.9% of postmenopausal women have osteopenia and 28.4% have osteoporosis; among men, 26% have osteopenia and 21.9% have osteoporosis .
Women are more likely to develop osteoporosis than men. This is because of several factors. Women have less bone mass than men, tend to live longer, and take in less calcium. In women, the rate of bone loss speeds up after menopause, when estrogen levels fall. As the ovaries make estrogen, faster bone loss may also occur if both ovaries are removed by surgery .
Dante  in his study mentioned that most patients with metastatic lesions present between 50 and 60 years of age, and there is no difference with regard to the sex of the patients. These patients are at risk of developing pathological vertebral fractures and symptomatic spinal cord compression with neurological deficits. This danger will increase with the improvement of oncologic treatment and prolonged patient life expectancy.
Michael et al.  stated that pathological vertebral fractures vary in degree from mild wedges to complete compressions. The symptoms also vary, but the degree of compression is not necessarily related to the amount of pain. It is possible that some of the fractures occur gradually, and therefore do not cause acute pain, especially in osteoporotic fractures.
In our studied groups of patients, lumbar vertebrae were the most commonly affected regions with pathological fractures regardless of the underlying pathology. In the osteoporotic group, 81% of cases had lumbar fractures, 66.7% of patients who had neoplastic fractures included the lumbar spine, and 63.6% of patients with pathological fractures due to underlying infections included the lumbar spine as well.
Tony et al.  found that the thoracolumbar area is the most susceptible region to osteoporotic compression fractures.
Paul et al.  found that in about 70% of their studied cases the metastatic lesion was localized in the thoracic and thoracolumbar regions of the spine, the lumbar and sacral regions were involved in 22% of cases, and the cervical spine in 8%. It is worth to be mentioned that our designed exclusion criteria of the present study had influenced the previous ratios. We excluded patients with pathological fractures caused by underlying malignant tumors with presence of metastasis in major internal organs. In addition, our study reviewed patient with fractures, and therefore we can safely say that lumbar metastases are more prone to fracture than thoracic spine metastases.
Cagatay et al.  studied 56 patients with spinal infections, and found that the infectious process involved the lumbar region in 33 patients, the thoracolumbar junction (D12–L1) in 13 patients, and the thoracic region (D1–D11) in 10 patients.
In the present study, various surgical modalities were used for each group depending on the pathology of the cause, clinical picture of the patients, comorbidities, the facilities available in each center, and the familiarity of the surgeons to each surgical approach.
Reviewing these surgical techniques and their convenience with respect to the weakened fractured vertebral bone, we found that all surgical methods dealt with the problem aiming to either augment the fragile bone, if not severely fractured, or to completely excise the pathological vertebrae if severely deformed or if the underlying disease has the character of dissemination or progressive growth (as in some tumors and infections).
For osteoporotic spine fractures, vertebroplasty was performed in nine patients (42% of cases) who had no neurological deficits. The vertebral height loss was not more than 50% with no bony canal compromise with an intact vertebral cortex. Kyphoplasty was performed in four (19% of cases) patients who had no neurological deficits. The vertebral height loss was not more than 70% with no bony canal compromise with an intact or disrupted vertebral cortex. Laminectomy and instrumental fixation were performed in eight (38% of cases) patients who clinically presented and were radiologically documented with neural compression.
For neoplastic pathological fractures, vertebroplasty was performed in 10 patients who had the same previous clinical and radiological criteria as the osteoporotic group. Posterior decompression and instrumented fixation were performed in five patients whose clinical examination showed recent neurological deficits. The radiological investigations showed vertebral canal compromise and neural elements compression without significant kyphotic deformity. Corpectomy and fixation were performed in three patients who had recent neurological deficits. Their radiological investigations showed vertebral canal compromise, neural elements compression, and significant kyphotic deformity.
In the infection group, posterior decompression and fixation were performed in nine patients who had recent neurological deficits without significant kyphotic deformity. Corpectomy and fixation were performed in two patients who had recent neurological deficits with significant kyphotic deformity.
In our study, the clinical outcome was measured using the ASIA impairment scale, the VAS, and the Karnofsky scale. Each patient was evaluated using these scales preoperatively and compared with the same scales during the immediate postoperative period and after 3, 6 months, and 1 year postoperatively.
For osteoporotic fractures
- ASIA scale: there was improvement in the ASIA scale postoperatively after 3 months (4.45 ± 0.69), 6 months (4.36 ± 0.67), and after 1 year (4.36 ± 0.67) than preoperatively (3.55 ± 1.04)
- Karnofsky scale: there was improvement in the Karnofsky scale postoperatively after 3 months (85.24 ± 8.73), 6 months (88.57 ± 6.55), and after 1 year (91.43 ± 5.7) than preoperatively (71.90 ± 11.67)
- VAS of pain: there was reduction in pain postoperatively after 3 months (1.71 ± 0.85), 6 months (1.0 ± 0.77), and after 1 year (0.52 ± 0.51) than preoperatively (5.81 ± 1.63).
The causes of pain in osteoporotic spine fractures are multifactorial, due mainly to micromovement of the vertebral fracture . Effective pain reduction and satisfactory clinical outcomes can be obtained after eliminating the microfractures and vertebral stabilization .
Consistent with a previous study performed by Renbin et al. , we found significant pain reduction following both vertebroplasty and kyphoplasty. Pain relief is generally believed to result from the stabilization of the fractured vertebrae and elimination of microscopic and/or macroscopic motion at the fracture site .
Other postulated mechanisms of pain relief include a chemical neurolytic effect of polymethyl methacrylate (PMMA) and a thermal neurolytic effect of the PMMA exotherm. Factors apart from instillation of PMMA may also account for pain relief. Such factors may include the impact of local anesthesia, as well as nonspecific effects such as expectations of pain relief (placebo effect) .
In our present study, the ASIA and Karnofsky scales reflected improvement in the clinical and functional parameters of operated osteoporotic patients, especially among those who had neurological deficits. Maximal improvement was achieved after 1 year (ASIA: 4.36 ± 0.67, Karnofsky: 91.43 ± 5.7) compared with preoperative values (ASIA: 3.55 ± 1.04, Karnofsky: 71.90 ± 11.67).
For neoplastic fractures
- ASIA scale: there was improvement in the ASIA scale postoperatively after 3 months (4.50 ± 0.79), 6 months (4.56 ± 0.70), and after 1 year (4.56 ± 0.70) than preoperatively (4.11 ± 1.08)
- Karnofsky scale: there was improvement in the Karnofsky scale postoperatively after 3 months (77.78 ± 7.32), 6 months (78.89 ± 6.76), and after 1 year (81.11 ± 7.59) than preoperatively (70.0 ± 7.67)
- VAS of pain: there was reduction in pain postoperatively after 3 months (1.72 ± 0.67), 6 months (1.67 ± 0.38), and after 1 year (0.88 ± 0.58) than preoperatively (5.44 ± 0.92).
The previous results coincide with other studies performed by Mohammed et al. , who operated the neoplastic thoracic and lumbar spines of 85 patients; they observed that there was no deterioration in neurological status in any of the patients. All patients except two improved in their functional outcomes, 10 patients were of ASIA grade C, four of them improved to ASIA grade E, and six patients improved to ASIA grade D. Ten patients were of grade D, eight of them improved to ASIA grade E, and two remained in the same grade. All patients who presented with ASIA grade E remained in the same grade postoperatively. All patients had good-to-excellent performance status.
Lih-Huei et al.  evaluated VAS in 24 cases with neoplastic spine fracture who underwent vertebroplasty. They found that within 24 h of the procedure, six patients discontinued the use of analgesics, and the remaining 18 reduced the intake of analgesics by more than half. The mean VAS pain score decreased from 9.0 to 3.8, 3.5, and 4.7 at 24 h, 3 months, and 1 year after the operation, respectively.
For pathological fractures caused by infection
- ASIA scale: there was improvement in the ASIA scale postoperatively after 3 months (4.45 ± 0.69), 6 months (4.36 ± 0.67), and after 1 year (4.36 ± 0.67) than preoperatively (3.55 ± 1.04)
- Karnofsky scale: there was improvement in the Karnofsky scale postoperatively after 3 months (87.27 ± 7.86), 6 months (86.36 ± 5.05), and after 1 year (87.27 ± 7.86) than preoperatively (73.64 ± 12.06)
- VAS of pain: there was reduction in pain postoperative after 3 months (2.90 ± 1.14), 6 months (2.27 ± 1.00) and after 1 year (1.27 ± 1.0) than preoperatively (5.45 ± 0.82).
In surgical treatment, the anterior approach is sometimes required. By this approach, one can directly access the affected vertebral bodies and the intervertebral disc. It enables the surgeon to debride the involved tissues properly and also allows placement of a structural bone graft to reconstitute lost height and provide anterior load sharing. In some of the cases, an additional posterior approach is necessary for the correction and preservation of the sagittal alignment, augmentation of the stability of the affected segments, and posterior reinforcement of lordosis .
Cagatay and colleagues concluded in their study that patients with thoracolumbar osteomyelitis necessitating surgical treatment should undergo combined same-day anterior decompression and posterior stabilization. However, they stated that there was no difference in the outcome whether combined surgery was performed sequentially or simultaneously .
Cement extravasation is a very frequent occurrence in vertebroplasty. It has been reported to occur in 38–72.5% of patients with malignant collapse according to Alain et al. , in 30% of operated patients in the study of Mary et al. , and in about 65% of studied patients with osteoporotic spine fracture according to Cortet et al. .
Fortunately, it is well tolerated in the large majority of patients. However, cement extravasation is also the main source of clinical complications. Cement may leak into a large variety of anatomical compartments, including the needle track, the prevertebral soft tissue, and the spinal canal (epidural space). It may also leak into the intervertebral disc, prevertebral veins and epidural veins, and neural foramina; leakage into the mesenteric artery, inferior vena cava, aorta, and lungs has also been reported .
Intervertebral disk leakage is a frequent occurrence especially in cases of severe vertebral compression fracture. Intervertebral disk leakage is asymptomatic, but may have long-term mechanical consequences on adjacent vertebrae as these leaks may increase the risk of adjacent vertebral collapse .
Regarding our study, vertebroplasy was performed in 19 patients – nine patients with osteoporotic fracture and 10 patients with neoplastic fractures. Four cases of osteoporotic fracture had cement leakage: (a) leakage into paravertebral soft tissue occurred in two cases with no clinical complications; (b) intervertebral disk leakage occurred in one case who had D10 fracture, followed by adjacent D9 fracture, which was augmented by vertebroplasty; and (c) venous, discal, and needle tract leakages with no clinical complication were also observed. Regarding neoplastic fractures, four cases had paravertebral soft tissue leakage with no clinical significance.
Laminectiomy and instrumental fixation were performed in 22 patients: (a) nine patients with infections, (b) eight patients with osteoporotic fracture, (c) and five patients with neoplastic fractures. Unintended durotomy with cerebrospinal fluid leakages intraoperatively occurred in three cases (one patient in each group) and were managed by packing gel foam and fat. Surgical site infections occurred in three cases and were treated with appropriate antibiotics according culture and sensitivity.
Although the indications for spinal instrumentation should be specific and reserved for clear spinal instability, reconstruction and instrumentation of the spine are acceptable during active spinal osteomyelitis, provided that debridement of diseased tissue is complete and an appropriate course of antibiotic therapy is followed. Acceptable materials for reconstruction include autologous graft, allograft, titanium cages, and alloy screw/rod/plate systems. The surgical decision-making process must take into account the overall condition of the patient and the balance of the host defenses against the virulence of the pathogen .
| Conclusion|| |
There are several surgical options available to treat pathological spine fractures. In the presence of neurological deficits, or spinal canal compromise caused by retropulsed fragments, the main treatment is spinal decompression and stable fusion. In the absence of neurological compromise or instability, vertebroplasty and kyphoplasty are two minimally invasive procedures developed for the management of painful vertebral fractures.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Alexandra C, William S, Dean C, Murat P, Vedat D, Sigurd B. Pathologic fractures. In: Frank P, Isador L, David P, editors. Minimally invasive spine surgery: surgical techniques and disease management
. New York, NY: Springer; 2014: 377–393.
Goz V, Koehler SM, Egorova NN, Moskowitz AJ, Guillerme SA, Hecht AC, Qureshi SA. Kyphoplasty and vertebroplasty: trends in use in ambulatory and inpatient settings. Spine J 2011; 11:737–744.
Philip R, James D, Robert E, Richard W. Pain and disability associated with new vertebral fractures and other spinal conditions. J Clin Epidemiol 1994; 47:231–239.
Kevin Y, Stefano B, Ziya G, Narayan S. En bloc spondylectomy for spinal metastases: a review of techniques. Neurosurg Focus 2003; 15:1–6.
Charles F, Christian D, Timothy R, Mark B, Christopher S, Sigurd B, et al.
novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine 2010; 35:1221–1229.
Hutchinson T, Boyd N, Feinstein A. Scientific problems in clinical scales, as demonstrated in the Karnofsky index of performance status. J Chronic Dis 1979; 32:661–666.
Spiros P, George T, Nick L. American Spinal Injury Association – ASIA – impairment scale for neurological deficit. In: Nick L, Nikolaos K, Peter G, editors. Trauma and orthopaedic classifications: a comprehensive overview
. London, UK: Springer; 2015:227–228.
Victor P, Ronald W. Visual analogue scale. handbook of disease burdens and quality of life measures
. New York, NY: Springer; 2010: 4349.
Omaima M, Hala Mohammed S, Yasmin K. Role of family medicine in the early detection and management of osteoporosis. Menoufia Med J 2014; 27:833.
Dante M. Spinal metastasis. In: Norbert B, Max A, editors. Spinal disorders
. Berlin; Heidelberg: Springer; 2008: 977–996.
Michael N, Bruce E, Dennis B, Katie S, Sophie J, Kristine E, et al.
The association of radiographically detected vertebral fractures with back pain and function: a prospective study. Ann Intern Med 1998; 128:793–800.
Tony K, Deed H, Christopher C, Donald H, Tadeusz J. Prediction of osteoporotic spinal deformity. Spine 2003; 28:455–462.
Paul K, Ganesh R, Laurence D. Evaluationand management of spinal axis tumors: metastatic. In: Richard W, editor. Youmans neurological surgery
. Philadelphia, PA: Saunders/Elsevier; 2011: 3154–3165.
Cagatay O, Ufuk A, Recep V, Ali S, Muren M. Simultaneous versus sequential one-stage combined anterior and posterior spinal surgery for spinal infections (outcomes and complications). Int Orthop 2007; 31:363–366.
John B, Michelle B, Thomas L, Richard M. Percutaneous vertebroplasty for pain relief and spinal stabilization. Spine 2000; 25:923–928.
Long C, Hui-lin Y, Tian-si T, Yong-hai J, Jian-wei Z, Yi D, et al.
Experimental and clinical study on barium used to increase radiopacity of bone cement for vertebroplasty. Chin J Med Imaging Technol 2005; 21:1085–1088.
Renbin D, Liang C, Tiansi T, Yong G, Zongping L, Qin S, et al.
Pain reduction following vertebroplasty and kyphoplasty. Int Orthop 2013; 37:83–87.
Rachelle B, Richard O, Peter E, John W, Peter M, Chris W, et al.
randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med 2009; 361:557–568.
Mohammed E, Ioannis P, Nam DT, Elias D, Frank DV. Comparison of polymethylmethacrylate versus expandable cage in anterior vertebral column reconstruction after posterior extracavitary corpectomy in lumbar and thoraco-lumbar metastatic spine tumors. Eur Spine J 2011; 20:1363–1370.
Lih-Huei C, Ming-Kai H, Chi-Chien N, Tsai-Sheng F, Po-Liang L, Wen-Jer C. Percutaneous vertebroplasty for pathological vertebral compression fractures secondary to multiple myeloma. Arch Orthop Trauma Surg 2012; 132:759–764.
Fang D, Cheung K, Dos R, Yk L, Leong J. Pyogenic vertebral osteomyelitis: treatment by anterior spinal debridement and fusion. J Spinal Disord Tech 1994; 7:173–180.
Alain W, Jacques C, Jean MS, Michelle R, Theresa S, Eric E. Spinal metastases: indications for and results of percutaneous injection of acrylic surgical cement. Radiology 1996; 199:241–247.
Mary J, Avery E, John M, David K, Harry C, Jacques D. Percutaneous polymethylmethacrylate vertebroplasty in the treatment of osteoporotic vertebral body compression fractures: technical aspects. Am J Neuroradiol 1997; 18:1897–1904.
Cortet B, Cotten A, Boutry N, Flipo RM, Duquesnoy B, Chastanet P, et al
. Percutaneous vertebroplasty in the treatment of osteoporotic vertebral compression fractures: an open prospective study. J Rheumatol 1999; 26:2222–2228.
Wilfred P, Louis G, Dallas P. Percutaneous vertebroplasty for severe osteoporotic vertebral body compression fractures. Radiology 2002; 223:121–126.
John M. Percutaneous vertebroplasty: complication avoidance and technique optimization. Am J Neuroradiol 2003; 24:1697–1706.
Max L, Michael W, Richard F, Jason L, Daniel K. Instrumentation in patients with spinal infection. Neurosurg Focus 2004; 17:1–6.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]