Rehabilitation After the Compression Fracture

Soo Yeon Kim, MD

Jeffrey Algra, MD, MS

Alok D. Sharan, MD, MHCDS

Dr. Sharan or an immediate family member serves as a paid consultant to Paradigm Spine; and serves as a board member, owner, officer, or committee member of Wolters Kluwer Health–Lippincott Williams & Wilkins. Neither of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Algra and Dr. Kim.

Introduction

The health care expenditures attributable to osteoporotic vertebral compression fractures (VCF) in the United States exceed a billion dollars a year, with most costs related to inpatient and nursing home services. The incidence of VCF rises significantly with age especially for Asian and Caucasian postmenopausal women with low bone mass density (BMD); the risk for vertebral fracture increases twofold for each single standard deviation (SD) decrease in lumbar spine BMD.

Only a third of all VCFs diagnosed on imaging mandate medical care and 10% will mandate a hospital admission. Consequences of VCFs are increased mortality and morbidity such as chronic back pain, loss of function, difficulties in activities of daily living (ADLs), and increased risk for subsequent fractures. Although not all fractures are symptomatic, back pain, kyphosis, and loss of height are common signs. In the acute phase, pain can last from weeks to months and most fractures will have significant pain reduction at 3 months, even though some fractures do show a protracted course. Conservative treatment consists of pharmacotherapy, a short period of bed rest, physical therapy, and back bracing. Vertebral augmentation is an acceptable option after conservative treatment has failed for VCFs as well as for painful benign and malignant spinal tumors (hemangiomas, multiple myeloma).

Vertebroplasty and balloon kyphoplasty are both minimally invasive vertebral augmentation options performed by injecting bone cement into the vertebral body (VB). Both augmentation methods have end goals of relief of fracture-related pain and stabilization of the deformed spine, but kyphoplasty will additionally attempt to restore VB height.

The optimal timing and indication for the procedure is debatable, but it seems that both percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) are safe and adequate treatments for acute fracture-related pain when conservative treatment has failed. PVP seems to be indicated for persistent pain after 6 weeks to 3 months of conservative treatment and PKP is best indicated in the window of 3 weeks to 6 weeks after diagnosis, especially for more complex spinal deformity.

Physical therapy is one of the major treatments for VCF. There are only a handful of studies on what constitutes appropriate postoperative rehabilitation treatment. There are studies showing improvement in pain, posture, physical function, and quality of life after comprehensive physical therapy especially targeting the back extensor muscles in hyperkyphotic elderly with or without compression fractures. Also, physical therapy after vertebroplasty has been shown to decrease subsequent fracture recurrence.

The correlation of the severity of hyperkyphosis to the degree of weakness of the back extensor muscles would make back extensor muscle exercises a primary focus for postoperative vertebral augmentation rehabilitation.

Surgical Procedure

Vertebral Cementoplasty (VC): Vertebroplasty and Balloon Kyphoplasty (Table 67.1)

Indications

VCFs of the thoracolumbar spine due to osteoporosis with kyphotic VB deformity with a loss of VB height causing pain are the main indication for performing VC.
VCFs due to metastasis or hematopoietic and lymphoid neoplasms (e.g., multiple myeloma)
Vertebral body neoplasm or vascular tumors without fracture (e.g., hemangioma) with pain as primary symptom

Patient Selection and Vertebral Level

The best clinical outcome will be obtained when patients are selected based on diagnosis of acute compression fracture as the main pain generator and the level of augmentation is selected precisely. Multilevel augmentation can be indicated in cases of severe instability but should be performed in a multistep process (one to two levels/day). Correlation of symptoms (acute, focal,
or referred axial back pain) per history and on examination with radiologic findings—magnetic resonance imaging (MRI) with short tau inversion recovery (STIR) images showing bone edema, bone scan showing increased uptake or computed tomography (CT) scan—is essential for precise identification of the acute fracture.

Table 67.1 INDICATIONS AND CONTRAINDICATIONS FOR KYPHOPLASTY AND VERTEBROPLASTY

	Indications	Contraindications
	Indications	Absolute	Relative
Kyphoplasty	• VCF of TL spine with pain and kyphotic deformity and loss of VB height • VCF due to metastasis or neoplasm • VB neoplasm or vascular tumor with pain and without fracture	• Spinal infection • Coagulation disorder • Allergy to PMMA, contrast • Defined sensory deficits • Bowel or bladder involvement • Pregnancy	• Pulmonary comorbidity limiting prone-lying position • Marked obscured anatomic landmarks due to morbid obesity or prior instrumentation • Mild posterior cortex instability • Spinal canal stenosis due to posterior displaced bone fragments
Vertebroplasty	• VCF of TL spine with pain • VCF due to metastasis or neoplasm • VB neoplasm or vascular tumor with pain and without fracture	Same as kyphoplasty with the addition of: • spinal canal stenosis due to posterior displaced bone fragments	Same as kyphoplasty with the addition of: Vertebra plana and excluded: • Spinal canal stenosis due to posterior displaced bone fragments
PMMA = polymethyl methacrylate, TL = thoracolumbar, VB = vertebral bodies, VCF = vertebral compression fractures.

Contraindications

Absolute contraindications include recent spinal infection, uncorrected coagulation disorder, allergy to polymethyl methacrylate (PMMA) or contrast, pregnancy and neurologic compromise with defined sensory deficits, or bowel and bladder involvement.

Relative contraindications include, but are not limited, to pulmonary comorbidity limiting the patient’s ability to adequately ventilate while prone during the procedure, marked obesity, or prior spinal instrumentation obscuring adequate fluoroscopically guided anatomic landmarks, and mild posterior displaced bone fragment.

Procedure

Relevant Anatomy

The VB is the target of this procedure and is augmented by filling with cement. For osteoporotic compression fractures, the most involved levels are lower thoracic and upper lumbar vertebrae, especially T12 and L1.

For the transpedicular approach, which is the most performed and preferred, the pedicles form the target direction. The orientation of the thoracic pedicles is more anterior and medially angled while the lumbar pedicle axis is more parallel to the sagittal plane. This leads to an alternative and sometimes necessary parapedicular approach for thoracic levels (above T10) to ensure cement filling in the center (both in a sagittal and axial plane) of the VB (Figure 67.1).

Compression fractures mostly involve the superior endplate with a collapsed anterior vertebral cortex in a typical wedge pattern, although lateral cortex collapse is very common. Imaging should clarify the precise VB deformation/destruction and, most important, posterior cortex integrity should be assessed prior to augmentation (Figure 67.2).

Technique

A single or biplanar fluoroscope is used and preferred for most typical approaches, with every step being confirmed through anteroposterior (AP) as well as lateral views. CT-assisted guidance augmentation can be performed for adequately trained and qualified professionals for complex cases involving complete destruction of the posterior vertebral cortex or severe vertebra plana.

The target zone for VC is the anterior third of the VB, which is reached through either a parapedicular (along the lateral cortex of the pedicle) or more commonly performed transpedicular approach. The parapedicular approach is used for the following:

high thoracic levels (above T10)
small, fractured or tumor-invaded pedicles
inadequate pedicle visualization

With the parapedicular approach, the needle will enter the VB at the pedicle–VB junction and will allow for a more medially, centrally placed needle tip position. When placed correctly, a single-needle method could cover the entire target zone, but VC usually involves bilateral placement (Figure 67.3). In

kyphoplasty, the balloon tamp is used to create a cavity in the VB and correct the kyphotic deformity prior to cement filling (Figure 67.4).

Figure 67.1 Illustration of the orientation of the pedicles on the (A) axial cross-section and (B) sagittal view for both the thoracic and lumbar vertebrae.

Figure 67.2 This illustration shows the typical anterior wedging pattern seen with a compression fracture. (Reproduced with permission from Raj PP: Interventional Pain Management. Image-guided Procedures. ed 2. Philadelphia, PA, Elsevier, 2008.)

Figure 67.3 The green arrow in this illustration depicts the typical transpedicular approach to the vertebroplasty. When this approach is difficult, a parapedicular approach (red arrow) may be used. (Reproduced with permission from Molina G, Campero A, Feito R, Pombo: Kyphoplasty in the treatment of osteoporotic vertebral compression fractures (VCF), in Alexandrea A, ed: Advances in Minimally Invasive Surgery and Therapy for Spine and Nerves. Wien: Springer, 2011.)

Figure 67.4 This illustration depicts the typical steps taken in approaching the vertebral body (A, B) and the raising of the balloon along with filling the void with cement (C). (A reproduced with permission from Fayyazi AH, Phillips FM: Kyphoplasty, in Slipman CW, ed: Interventional Spine: An Algorithmic Approach. Philadelphia, PA, Elsevier, 2008. B and C reproduced with permission from Bono CM, Garfin SR: Thoracic and lumbar kyphoplasty, in Ozgur B, Benzel EC, Garfin SR: Minimally Invasive Spine Surgery: A Practical Guide to Anatomy and Techniques. New York, Springer, 2009.)

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