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Bracing for Osteoporotic Thoracolumbar Fractures
Compression fractures of the thoracolumbar spine as a result of osteoporotic insufficiency are another common problem faced by spine surgeons. Although according to the Denis and AO classification systems compression fractures are not considered unstable fractures, OVFs encountered in the osteoporotic patient represent a unique challenge in elderly patients with impaired physiology, especially postmenopausal women. Similar to traumatic fractures, OVFs have multiple treatment options such as vertebroplasty or kyphoplasty, or even stabilization with surgery. Most surgeons are reluctant to pursue surgery given the inherent risks in elderly patients with multiple comorbidities. In addition, the pathophysiological etiology of the fracture itself poses unique challenges involving hardware pullout and pseudarthrosis. Cement augmentation procedures such as vertebroplasty and balloon kyphoplasty offer minimally invasive options for treatment of OVFs. These procedures are not without risks, such as cement pulmonary embolism and cement extravasation resulting in neurological compromise.
Hoshino et al. published a report on the impact of conservative treatment in patients with OVFs. The study enrolled 362 patients over the age of 65 years, and the SF-36 and VAS were used to assess independence and pain, respectively. The study used a cutoff of PCS or MCS less than 40 as an indicator for poor physical and mental function, respectively. The study examined 4 cohorts: custom hard brace, custom elastic brace, ready-made elastic brace, and no brace. For the entire study, 71.3% of patients had a PCS less than 40 and 22.9% had an MCS less than 40 at follow-up. Ninety-three patients (25.7%) in the study complained of prolonged back pain at follow-up, and the mean VAS score was 6.67 within this group. In contrast, the remaining 269 patients who did not complain of prolonged back pain had a mean VAS score of 1.78. A multivariate analysis performed by the authors revealed no significant difference for treatment intervention factors, including brace type. The authors did find that middle column injury was significantly associated with an SF-36 PCS score less than 40 (odds ratio 1.86) and having prolonged back pain (odds ratio 1.70). Therefore, the study was unable to identify bracing as a positive modifier of outcome.
Thus there are some limited data on the efficacy of bracing for OVF, yet the treatment role of bracing for this indication has not been studied as robustly as its use in thoracolumbar burst fractures. Unfortunately, none of the randomized studies that evaluated the use of vertebroplasty or kyphoplasty used any standardization in the nonsurgical treatment arms, a limitation reflected in a recent review by Longo et al. The American Association of Orthopedic Surgeons Guidelines for Treatment of Osteoporotic Spinal Compression Fractures were unable to recommend for or against bracing in patients with osteoporotic compression fractures. Only 1 study was quoted in the rationale, and the guideline cites insufficient evidence to show any benefit or harm from bracing for OVF. Therefore, further studies will be necessary to determine the role of bracing in the treatment of osteoporotic compression fractures.
Bracing is not without risks, particularly in the elderly population. Pressure sores from rigid braces can result in decubitus ulcers and subsequent soft-tissue infections. Noncompliance is another issue as many patients may find bracing uncomfortable. Lastly, bracing is associated with other problems such as diminished pulmonary capacity and weakening of the axial musculature. Thus, bracing must be performed for a finite period of time, and patients must be continually observed for any of the aforementioned complications.
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