Cement for Fractures

The lifetime risk of suffering a fracture of the spine from osteoporosis is approximately 10% after the age of 50.  These fractures can lead to a spinal deformity where the individual heals in a bent forward or kyphotic (round back) posture. 

The most common portion of the spine to suffer an osteoporotic fracture is the thoracolumbar juntion, or where the chest area of the body meets the lower back.  Osteoporosis fractures can be treated with pain medicines alone, bracing, or a cement augmentation procedure.

Osteoporosis fractures of the spine usually heal within 6-8 weeks.  During the healing process, the fracture can cause considerable pain which sometimes can be controlled with pain medicines.  Some patients can be treated with braces that hold the spine in place.  Braces can prevent further collapse of the spine and also immobilize the spine to reduce pain from motion.  Braces work best with people who are thin and capable of constant adjustments to the position of the brace. 

Fracture pain in a brace usually subsides after approximately two weeks in most people.  In general the brace needs to be worn for the entire healing time of the fracture, which is usually about 2-3 months.  Persistent pain is a sign that the fracture has not healed.  Those who smoke cigarettes take longer to heal.

A minimally invasive surgical option for fracture treatment is cement augmentation.  The cement is polymethylmethacrylate originally used in dental procedures.  Fractures can be given immediate strength and support by inserting cement into the vertebral body of the fractured bone.  The cement hardens in minutes and therefore the pain associated with the fracture is gone almost immediately.  The cement also supports the fractured bone so that the bone does not collapse further.  The procedure is usually sometimes called “vertebroplasty” or “kyphoplasty.” 

The benefit of the cement augmentation procedure is immediate pain relief, no need for bracing, and quicker recovery.  The incisions are usually two quarter inch poke holes in the skin.  The cement is inserted with the use of one or two tubular instruments that are about the size of a pencil.  Under the use of a powerful x-ray machine, the tubes are carefully inserted into the fractured bone of the spine.  The cement is then inserted slowly under the use of the x-ray machine into the fractured bone.  The patient can go home immediately after the procedure or the next day. 

All procedures carry complication risks.  In a cement augmentation procedure, there is an extremely small (but possible) risk of the cement flowing into the spinal canal or veins of the spine which can cause paralysis or death.

SPONDYLOLISTHESIS

Spondylolisthesis is a condition of the spine where the individual bones of the spine are shifted from their usually aligned position.  The Greek origins of the long word "spondylolisthesis" is literally spondylos (vertebra: bone of the spine) and -olisthesis (a slipping and falling).  

Imagine the spinal canal as a tube that carries the spinal cord and nerves, and that this tube is made up of many small sections that are connected together.  If the sections of the tube do not align perfectly (spondylolisthesis), the area for the tube becomes constricted (spinal stenosis).

When the spine is not aligned perfectly from spondylolisthesis there are three basic areas that can cause symptoms of pain and dysfunction. During spondylolisthesis anatomical structures can experience abnormal motion or stress.  When anatomical structures experience these abnormal motion or stress they can become inflamed.  The general components of inflammation are pain, swelling, redness, and heat. 

The first anatomical area is the spinal canal.  As the spinal canal, or tube, that carries the nerves becomes smaller in size, or stenotic, this constricts the nerves and spinal cord.  When the nerves and spinal cord experience compression or stenosis the nerves can become inflamed and possibly injured.  Patients can experience pain from the nerves as low back pain and also pain running down the area of the nerves themselves (dermatome). 

In the neck this pain can be present in the middle of the neck running down the arms to fingers.  In the lumbar spine the pain can be present in the middle lower back running down the legs. 
Each individual nerve has a characteristic portion of the body that it covers for sensation (dermatome) and muscular motor strength (myotome).  This is why a physician asks a patient to fully describe exactly where the pain is present during the interview or on a pain diagram to get an idea where the problem is present within the spine.  When the individual nerves in the spine become damaged the patient can experience weakness (motor deficit), numbness (sensory deficit), and a pins and needles sensation (paresthesias).

The second anatomical area that can cause pain in spondylolisthesis is the disc between the two bones of the spine (vertebra).  The abnormal motion present can stretch the outer fibers of the disc and cause inflammation and pain.

The third anatomical area of pain in spondylolisthesis is the facet.  Each spinal segment, i.e. L3L4, has a joint connecting the two bones (facet articulation) on the left and on the right.  These facets are joints with cartilage, similar to the knee or hip.  Like the knee and hip, these tiny joints can become arthritic, inflamed, and painful.

There are many reasons that the spine can suffer abnormal alignment.  In patients ages 40 and older, the bones of the spine (vertebrae) lose their capacity to keep the spine straight in alignment.  The connections are the facets and the disc and it isn’t clear which area fails first .

Another cause of spondylolisthesis is spondylolysis.  The medical term literal means spondylos- (Greek for vertebra of the spine) and –lysis (Greek for loosening).  In spondylolysis, there is a fracture or broken portion of the vertebral body.  The fracture is specifically in the area between the two joints of the spinal segments or facets.  In this condition, the front (anterior) portion of the bone of the spine (vertebra) is completely separated from the back (posterior) portion of the bone of the spine (vertebra).  The vertebra is split in two.  The body commonly attempts to repair the fracture.  Unlike many other broken bones of the body this type of fracture usually cannot heal.  If the vertebra separates significantly, it can cause a misalignment of the spine or spondylolisthesis.

These fractures are usually found in the lower back (lumbar spine). Approximately 5% of the population has these fractures and not all of them cause pain or dysfunction.  Some people have very little motion at the level of the fracture and some people have a lot.  Some of these fractures are nearly healed with an abundant amount of extra bone about the fractures and some have no extra bone about it.  However, the vast majority of pars fractures are not painful.

Some children can develop spondylolisthesis while they are growing.  This can lead to a severe misalignment of the spine where one vertebra is completely dislocated from the adjacent vertebra.  This condition in children is usually at the bottom level of the spine, or L5S1. Spondyloptosis (-optosis Greek for a falling) is defined as when the L5 vertebral body is completely in front of (anterior) and lower than (distal) to the top portion of the S1 spinal bone (S1 superior endplate).

Operative treatment for spondylolisthesis consists of removing any compression on the nerves of the spine with a decompression and followed by fusion of the spine when necessary.  Surgery for lumbar (lower back) spondylolisthesis usually requires a posterior (back side) approach to decompress the spinal canal and nerves.  The incision is usually in the middle of the back just above the buttocks.  The bones of the spine are exposed.  Surgery on the lower back (lumbar) can cause some level of damage to the muscles of the lower back (lumbar spine) and cause residual weakness and stiffness.  Frequently the bones of the spine are unstable and surgical treatment of instability requires fusion surgery.

Spinal instability is defined as motion (under normal stresses of activities of daily living) across a spinal segment that is excessive (compared to a range of normal) and that causes pain and nerve dysfunction or damage.  The diagnosis of spinal instability can be subjective.  Instability can present following decompression surgery.  Fusing the vertebral bodies of the spine can prevent postoperative instability.


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