The Dynamic Mobility of Vertebral Compression Fractures Volume 18:24-29, 2003 JBMR FERGUS McKIERNAN,...
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Transcript of The Dynamic Mobility of Vertebral Compression Fractures Volume 18:24-29, 2003 JBMR FERGUS McKIERNAN,...
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The Dynamic Mobility of Vertebral Compression Fractures
Volume 18:24-29, 2003 JBMRFERGUS McKIERNAN, RON JENSEN, TOM FRACISZEWSKI
Marshfield Clinic, Wisconsin, USA
Report: R3 范姜治澐Supervisor: 李晏瑤主任
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Introduction Kyphoplasty
Restore vertebral height Restore sagittal alignment Reduce chronic morbidity
Both vertebroplasty and kyphoplasty relieve fracture pain
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Introduction
Dynamic mobility was seen in many vertebral compression fractures (VCFs)
Improve sagittal alignment can be also achieved during vertebroplasty
To define the magnitude and nature of dynamic mobility
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Materials & methods
41 patients, 65 VCFs
Vertebral fracture pain (local knocking pain), impair activities, failure of medical therapy, technical feasibility, absent of contraindication
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Pre-op evaluation Standing A-P and lateral view centered on
index vertebra Supine cross-table lateral view STIR-MRI
4-in foam bolster
Index vertebra
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Pre-op evaluation Dynamic fracture mobility Non-mobile fixed compression fracture
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Pre-op evaluation Intravertebral clefts: low resistence, confluented re
servoirs for PMMA
Intravertebral gasSignal void
PMMA fixation
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Digitizing the lateral view Hp: ab Hm: cd Ha: ef Lateral vertebral area (LVA):
ab x ae Kyphotic angle (Ka): inters
ection of lines ae, bf
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Pre-op evaluation Fracture severity:
Mild (20-25%) Moderate (25-40%) Severe (> 40%)
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OP method
General anesthesia Padded prone in extension Mono- or bi-pedicular or para-pedicular Barium-fortified PMMA Kept supine 4h post-op Dismissed the next day, follow-up 2 week
s later
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Results
41 patients (28 F, 13 M) 46 procedures, 65 VCFs Mean age: 75.4 y/o Mean fracture age: 117 days 18 patients (44%) had at least one mobile
VCF 23 mobile (35%), 42 non-mobile (65%)
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Results Bimodal distribution (midthoracic and T-L juncti
on) Fracture at T-L junction: 17 of 26 (65%) mobile Intravertebral clefts presented in every mobile fr
acture, absent in every non-mobile (p<0.001)
T-L junction other
Mobile 17 (74%) 6
Non-mobile 9 (21%) 33
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Results 18 of 23 mobile fractures were severe, 5
were moderate
Post-op Absolute increase P value
Hp + 15%
Hm + 93% P<0.001
Ha + 106% (42%70%) 8.41 +/- 0.4mm P<0.001
LVA + 67% (48% 80%) P<0.001
Ka + 40% (-7.18°) P<0.001
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Results Mobile fractures underwent vertebroplasty earlier
(89 vs 133 days) (p=0.15)
1.33 fractures per patient in patients with mobile fracture
1.83 fractures per patient in patients with only fixed fractures (p=0.29)
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Results Both mobile and non-mobile fractures repor
ted significant pain relief post-op
No clinical adverse events
4 small intradiscal cement leaks, 1 leak into the anterior spinal venous plexus
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Discussion 1/3 of all fractured vertebrae were mobile
Significant improvement in Ha, Hm, LVA and Ka
Most mobile fractures occurred at T-L junction (where bears greatest dynamic load)
Presence of intravertebral clefts
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Implications Fracture morphology (crush, biconcave, wedge) an
d severity need to accommodate the dynamic deformity
Vertebral height variance attributed to measurement error or “rebound”
Epidemiologic miscalculation and erroneous conclusions from therapeutic trials in which VCFs is the primary outcome
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Discussion
Vertebral fracture mobility predicated on the “permissive” corticocancellous disruption, whether intrinsic or induced
More painful in mobile fractures (afferents from adjacent periosteum and ligment)
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Discussion Mechanisms of pain relief from vertebroplasty:
Mechanical Neurolytic Thermal Chemical
Organization of hematoma and cicatrization of surrounding soft tissue result in early pain reduction
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Discussion Kummel’s disease
Post-traumatic ischemic necrosis and collapse of vertebral body
Osteoporotic elders with T-L junction fractures
Risk for delayed ischemic necrosis Intravertebral vacuum cleft = Kummel’s sig
n Shared final pathway for certain high and lo
w energy vertebral injuries
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Limitation
Supine extension radiographic technique needs to be standardized
Limited patient numbers
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Conclusion Dynamic fracture mobility must be
considered when performing vertebral augmentation, or any intervention that claims vertebral height restoration
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Thanks for your attention !!