Clinician-to-Clinician Update Clinician-to-Clinician Update

Recovery of Ambulation in Patient with Complex Vertebral Fracture

November 2015 - Neurosurgery

Fig-1-MRI-scan-of-compressed-thoracic-spinal-cord
— Figure 1. MRI scan of patient’s compressed thoracic spinal cord secondary to osteoporotic vertebral fracture, resulting in near-total paraplegia.

Contributed by Matthew A. Hunt, MD, FRCS, FAANS

Vertebral fractures are the most common complication of osteoporosis, resulting in significant morbidity and reductions in quality of life.1

The presence of one or more radiographically documented vertebral fractures has been associated with a five- to tenfold increased risk of further vertebral fractures.2

Long-term studies have shown mortality rates increase approximately twofold in the 5 years after vertebral fracture and increase further with the greater number of fractures.3

Here we describe a middle-aged man with paraplegia secondary to osteoporotic vertebral fracture. His paraplegia was present for longer than 48 hours prior to spinal decompression and reconstruction surgery at University of Minnesota Medical Center. Nevertheless, he recovered independent ambulation within a year of surgery.

Fig-2-MRI-scan-of-spine-postsurgery
— Figure 2. X-ray of the patient’s spine postsurgery, showing instruments used for reconstruction.

Patient

A 45-year-old man was referred from another center to the University of Minnesota Health Neurosurgery Clinic for treatment of compression of the thoracic spinal cord secondary to osteoporotic vertebral fracture (Figure 1). The patient was found to have near total paralysis of his lower limbs. It was unclear if spinal reconstruction surgery would reverse the paraplegia at that stage. However, the team proposed and patient agreed to surgical intervention.

Management

The patient underwent spinal decompression and reconstruction surgery via a costotransversectomy approach. Bony fragments were removed from the spinal canal, and titanium cage instrumentation was used for stabilization (Figure 2). The patient recovered from the procedure without sequelae. At 12-months postsurgery, the patient was able to walk unassisted and was pain free.

Fig-3-MRI-scan-of-2nd-ost.-vertebral-fracture
— Fig 3. MRI of second osteoporotic vertebral fractures

Unfortunately, at 36-months postsurgery, the patient presented with back pain and partial paralysis of his lower limbs. He was found to have an osteoporotic fracture at the base of the previous surgical site. He again underwent spinal decompression and reconstruction and recovered without sequelae. He regained his ability to ambulate unassisted 12 months after the second surgery.

Discussion

Osteoporotic vertebral fracture is usually treated conservatively. However, occasionally progressive collapse and resulting neurological deficits can be indications for surgical spinal decompression and reconstruction.4

For patients with traumatic spinal cord compression, outcomes generally worsen significantly when decompression is initiated more than 48 hours after the onset of paraplegia. For nontrauma patients with paraplegia, however, questions remain concerning the timing of surgical intervention.5 In the above case, surgical intervention resulted in restoration of ambulation within a year of surgery.

Fig-4-X-ray-of-spine-after-2nd-surgery
— Fig 4 X-ray of spine after 2nd surgery

References

1. Yoon SP, Lee SH, Ki CH, et al. Quality of life in patients with osteoporotic vertebral fractures. Asian Spine J. 2014;8:653-658.

2. Samelson EJ, Hannan MT, Zhang Y, et al. Incidence and risk factors for vertebral fracture in women and men: 25-year follow-up results from the population-based Framingham study. J Bone Miner Res. 2006;21(8):1207-1214.

3. Bliuc D, Nguyen ND, Milch VE, et al. Mortality risk associated with low-trauma osteoporotic fracture and subsequent fracture in men and women. JAMA. 2009;301(5):513-521.

4. Kim KT, Suk KS, Kim JM, Lee SH. Delayed vertebral collapse with neurological deficits secondary to osteoporosis. Int Orthop. 2003;27:65-69.

5. Giacomini L, Mathias RN, Joaquim AF, et al. Is there a right time for surgery in paraplegic patients secondary to non traumatic spinal cord compression? Einstein (Sao Paulo). 2012;10:508-511.

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