THIS WEEK'S ARTICLES
Keys to Treating Spine Fractures Due to Osteoporosis - Sponsored Content
Early Detection of Osteoporosis Is Lacking
Evidence of vertebral fractures is often not reported, which can lead to missed opportunities for early detection.
A recent study that examined the epidemiology and reporting of osteoporotic vertebral fractures (VFs) based on routine clinical CT imaging of patients with long-term hospital records found that approximately 30% of elderly patients showed VFs, but only one quarter of the CT reports mentioned them.
"Osteoporosis management could be improved by consequent reporting of VFs in CT, opportunistic bone density measurements and early involvement of fracture liaison services," the authors write in the study published earlier this year in Osteoporosis International.
VFs typically signify increased risk of future fractures and mortality, and commonly lead to a diagnosis of osteoporosis. "Few studies report the prevalence of osteoporotic VF in patients seen in clinical routine," say the authors. The study examined more than 700 patients, aged 45 years and older, with a CT scan and prior hospital record of at least five years between September 2008 and May 2017. Imaging requirements were a CT scan with sagittal reformations including at least T6-L4, and patients with multiple myeloma were excluded. CT reports mentioned a VF in only 24.7% of patients with a prevalent VF on CT review.
The authors say the majority of these imaging episodes represent a lost potential for osteoporosis screening. "Despite the relatively high prevalence of osteoporotic VFs, there was no reference to bone health in clinical records of 94% of all patients," they write. "Furthermore, radiology reports of CT imaging did not mention a VF or decreased bone quality in 58% of fractured patients." They say a diagnosis at that juncture could help these patients avoid negative consequences in terms of their morbidity, mortality and quality of life.
They note that this diagnostic gap is not new and, in fact, has been documented for the last 20 years, first in radiographs, then in CT imaging. The situation has improved somewhat over that time, but the diagnostic gap remains too large, they say. In particular, a lack of standard terminology in imaging reports adds to the problem. "A little less than one-third of CT reports that mentioned vertebral anomalies in patients used secondary terminology instead of the preferred terminology ‘fracture,'" note the authors.
Computer-aided diagnosis using automatic algorithms to detect VF could help improve detection rates, according to the authors. "Being able to diagnose osteoporosis in patients with increased fracture risk before an initial fracture occurs should be the goal," they write.
Osteoporosis Linked to Hearing Loss in Women
Study shows the association was particularly prevalent in patients with histories of spinal fractures.
Women with weak and brittle bones are at risk of experiencing moderate to severe hearing loss, according to researchers at Brigham and Women's Hospital in Boston. The findings, based on data collected from 144,000 women who were followed for more than three decades, show osteoporosis and low bone density (LBD) were associated with a 40% higher likelihood of suffering the third most common chronic health condition in the United States. The researchers also found that bisphosphonates, which are often prescribed to prevent fractures in patients with LBD, did not impact the level of hearing loss.
The researchers accessed the data of two ongoing prospective cohorts of female registered nurses to analyze the level of hearing loss the women self-reported every two years as well as their level of hearing sensitivity. "Adult-onset hearing loss is typically irreversible, so our study focuses on identifying potentially modifiable risk factors that may contribute to hearing loss," says study leader Sharon Curhan, MD, ScM, an assistant professor of medicine and member of the Channing Division of Network Medicine at Brigham and Women's Hospital.
More research is needed to determine if the risk of hearing loss is impacted by the type and dosing of bisphosphonates, according to the study, which was published in the Journal of the American Geriatrics Society.
Interestingly, the risk of hearing loss was associated with vertebral fractures but not hip breaks, both of which are commonly related to osteoporosis. This finding indicates bones in the spine and hip have different composition and metabolism, and could provide insights into how osteoporosis impacts bones in the middle and inner ear, notes Dr. Curhan.
"Osteoporosis and LBD might be important contributors to aging-related hearing loss," she says. "Building lifelong healthy diet and lifestyle habits could provide important benefits for protecting bone and hearing health in the future."
Keys to Treating Spine Fractures Due to Osteoporosis
Prompt attention and follow-up pave pathway to success for painful VCFs.
Working closely with primary care physicians, and monitoring patients after they have been treated, are the keys to successful outcomes from treatment for painful vertebral compression fractures due to osteoporosis. That's according to Dr. Avery Jackson III, a board-certified neurosurgeon, chief executive officer and medical director of Michigan Neurosurgical Institute in Grand Blanc, Mich.
"The primary care physicians we have a relationship with, we tell them, ‘If you have someone over 50 who has back pain, please order a chest or lumbar X-ray, diagnose the height loss, then do a bone scan, and that bone scan will look at the density of the vertebrae. That gives us more information so that we are both thinking about reducing the fracture, then treating osteoporosis proactively so we don't continue to get these fractures."
For suitable patients with osteoporotic vertebral compression fractures (VCFs), Jackson favors treatment with vertebral augmentation procedures like Balloon Kyphoplasty. Balloon Kyphoplasty is a minimally invasive surgical procedure for the treatment of spinal fractures due to osteoporosis, cancer or non-cancerous tumors.
"In my experience, it's one of the simplest procedures a person can do," Jackson says. "The procedure takes less than an hour, and recovery is about 45 minutes. The pain usually resolves within just a couple weeks."
Although the complication rate for Balloon Kyphoplasty is low, as with most surgical procedures serious adverse events, some of which can be fatal, can occur including heart attack, cardiac arrest (heart stops beating), stroke and embolism (blood, fat or cement that migrates to the lungs or heart). Other risks include infection; leakage of bone cement into the muscle and tissue surrounding the spinal cord and nerve injury that can, in rare instances, cause paralysis; leakage of bone cement into the blood vessels resulting in damage to the blood vessels, lungs and/or heart.
Avoiding Health Problems
For Jackson, prompt treatment with vertebral augmentation is a way to avoid a downward spiral of health problems stemming from VCFs.1-3 He cited a recent case of a 76-year-old woman who felt a pop after lifting bags of groceries. The pain in her back made it difficult for her to breathe properly.
"Her primary care physician obtained a bone score that showed she has osteoporosis," Jackson says. "He performed an X-ray and referred her to us. We saw her promptly within a couple of days. We gave them a date to come in, showed them images, showed them a video on kyphoplasty, told them we have done over 1,000 cases, showed them research papers we have presented in peer-reviewed journals on outcomes, and the family was fine with it," says Jackson.
The Balloon Kyphoplasty procedure was a success, Jackson says. "Within three or four days, she improved significantly, and she went back to her things she likes to do. Her pulmonary function improved, and she said she could physically tell a difference in her breathing. That's really impressive."
Jackson, who hosts a monthly Bone Health ECHO extension program, also said he is vigilant about making sure VCF patients have a plan to manage their underlying disease.
"We want to be very aggressive about treating osteoporosis," he says. "A spine fracture is a harbinger that another one is on its way."
1. Schlaich C et al. Reduced pulmonary function in patients with spinal osteoporotic fractures. Osteoporos Int. 1998;8(3):261-7
2. Gold DT. The clinical impact of vertebral fractures: quality of life in women with osteoporosis. Bone. 1996;18(3 Suppl):185S-189S
3. Old J, Calvert M. Vertebral Compression Fractures in the Elderly. Am Fam Physician. 2004 Jan 1;69(1):111-6
Note: The preceding testimonial contains the opinions of and personal surgical techniques practiced by Dr. Avery Jackson III. The opinions and techniques presented herein are for information purposes only, and the decision of which technique to use in a particular surgical application should be made by the surgeon based on the individual facts and circumstances of the patient and previous surgical experience.
Note: For more information, please go to https://www.medtronic.com/us-en/healthcare-professionals/therapies-procedures/spinal-orthopaedic/vertebral-augmentation/procedural-solutions/balloon-kyphoplasty.html?cmpid=Article_TradePublication_OutpatientSurgeryArticle3_DrAveryJacksonIII_UC202207583EN_BKP_FY22.
Can ERAS Improve Lumbar Spinal Fusion Outcomes?
Multidisciplinary group urges procedure-specific research on the effectiveness of evidence-based protocols.
Like many service lines, there is great potential for improved patient pain management when perioperative teams incorporate evidence-based Enhanced-Recovery After Surgery (ERAS) protocols into spine procedures such as lumbar spinal fusions. One study says that for this potential to be fully realized, however, more quality research is needed.
That's one of the key takeaways from a multidisciplinary consensus review under the impetus of the ERAS Society in The Spine Journal that summarized the current literature and proposed recommendations for incorporating ERAS protocols for patients undergoing lumbar fusion surgeries. The review ultimately identified 22 ERAS items for lumbar fusion procedures, with the researchers excluding one item, prehabilitation, from their final summary due to "very poor quality and conflicting evidence."
Using the remaining 21 ERAS items, the group issued 28 recommendations on everything from pre-op education and nutritional evaluation to postoperative multimodal analgesic strategies. Each recommendation also included information on the level of evidence (high, moderate, low or very low) for the use of each. Ultimately, the group produced nine preoperative recommendations, 11 intraoperative recommendations and six post-op recommendations.
The authors note that ERAS protocols have led to a number of outcome improvements, including reduced complications and length of stay and improved patient experience, for several surgical areas, but nonetheless acknowledge that ERAS represents a relatively new paradigm in spine, and in lumbar fusion surgery in particular. As such, they say the guidelines serve as an important means of summarizing the large volume of heterogeneous studies across all ERAS items for lumbar fusion.
The review urges providers to engage in procedure-specific research on the effectiveness of ERAS. "While the few clinical studies available seem promising, studies of high methodological quality are needed," they write.
Finding a Basis for Managing Cancer Pain
New guidelines aim to fill in providers' knowledge and practice gaps.
Last year, 1.8 million Americans were diagnosed with cancer, and more than 600,000 died from the disease. The obvious worst outcome notwithstanding, a high percentage of cancer patients say associated pain is the biggest hindrance to a good quality of life. One study shows 20% to 50% of patients in remission continue to feel pain and live with pain-induced lifestyle limitations years after their successful cancer treatments have ended.
A wide variance on how to treat cancer pain exists, depending on doctors' patient volumes, the cancer institution with which they're affiliated, and their levels of expertise and training, among other factors. The challenge of integrating traditional pain management techniques such as medication with surgical and other interventions often remains a mystery.
To address this problem, the American Society of Pain and Neuroscience (ASPN) this year created a set of best practices and guidelines for how doctors should address cancer pain. ASPN believes the document is the first of its kind to present evidence-based recommendations for how to treat the pain and suffering associated with malignancy, and would be "instrumental to bridge the gap between evidence and clinical practice."
ASPN's multi-institutional working group reviewed the bodies of evidence that exist on a vast array of cancer pain interventions, including opioids, adjunct medications, interventional therapies, neuromodulation, vertebral tumor ablation/augmentation, radiotherapy and other surgical techniques. ASPN hopes its document will provide more certainty about how to best apply various treatments and interventions, as well as spark additional discussions among experts about the best ways to manage cancer pain and how various interventional techniques could be integrated into therapeutic strategies.
The stakes are high. The document containing the guidelines and recommendations notes that 35% of all cancer patients and 80% of patients in the advanced stages of the disease experience moderate to severe pain. It cites a major study that reports 62% of cancer patients go to emergency rooms due to their pain, and 68% of end-stage patients report somatic pain related to their primary tumor. More than half of patients report significant pain from their anti-cancer treatments as well.
Metastatic bone disease is a significant source of morbidity and a common manifestation of advanced cancer, according to the guideline, which notes the most common sites of metastases include the spine and sacrum, with patients often presenting with pain, pathologic fractures and spinal cord compression.
"Cancer pain is associated with significantly increased emotional stress, with pain causing disability for active cancer patients an average of 12 to 20 days a month," state the guidelines. The authors note uncontrolled pain using limited therapies often leads to patient distress, loss of productivity, shorter life expectancy, longer hospital stays and increased healthcare utilization. They say that the proper addition of interventional treatments to medication regimens can relieve pain and symptoms as well as reduce opioid intake.