Pathologic Fractures

Abstract

As new technologies emerge, the applications of minimally invasive spine surgery continue to expand. The need for minimizing the morbidity of surgical access in debilitated patients has propelled a movement toward the increased use of minimally invasive spine surgery for the treatment of pathologic spine fractures.

Vertebroplasty and kyphoplasty provide an alternative for intractable back pain in patients with pathologic fractures who do not respond to nonoperative measures and who are not medically fit for an open procedure. Anterior endoscopic procedures reduce pulmonary dysfunction and prolonged hospital stay associated with open thoracotomies but have a steep learning curve. Posterior mini-open surgery and percutaneous pedicle screws avoid the complications of anterior surgery while minimizing blood loss and the extensive muscle dissection associated with traditional open surgery. The direct lateral approach allows access to the anterior column, avoiding the approach-related complications of the anterior and posterior approaches but requiring detailed anatomic knowledge to avoid injury to the great vessels and nervous plexus.

Surgical treatment of pathologic vertebral compression fracture continues to change as new medical treatments emerge such as new hormone therapies for osteoporosis, new chemotherapy agents, and stereotactic high-dose radiotherapy for cancer. Even when open radical resections are needed to provide a cure, the principles of minimally invasive surgery of respecting soft tissues and minimizing collateral damage should be applied to reduce infection rates, decrease recovery time, improve functionality, and ultimately improve patients’ quality of life.

Appendices

Quiz Questions

• 1. How does the mortality of patients with osteoporotic vertebral compression fractures (OVCP) compare to that of age-matched controls?

• 2. What are the potential benefits of MIS for pathologic compression fracture?

• 3. What should indications for surgery in the setting of pathologic fracture include?

• 4. Decompression and stabilization are generally considered in patient with a life expectancy greater than _____ months.

• 5. In pathologic compression fracture of the thoracic spine, posterior stabilization should be performed in what setting?

• 6. True or false: Vertebroplasty/kyphoplasty should be used in the setting of primary spinal tumor.

• 7. True or false: A single posterior midline incision is preferred to multiple percutaneous incisions in the setting of the mini-open posterior approach.

• 8. True or false: MIS anterior approaches are considered appropriate for curative surgery in the setting of spinal tumors.

• 9. In patients treated for fracture, infection, disc herniation, and malignancy of the thoracic and thoracolumbar spine, the mini-open anterior approach has been found to have what advantages over VATS?

Answers

• 1. Patients with OVCP have two times the mortality of age-matched controls over 8 years.

• 2. Limited blood loss and soft tissue dissection in debilitated patients who may not be candidates for open surgery thereby avoiding prolonged immobilization and pain relief in the case of failed nonoperative management.

• 3. Intractable pain, spinal instability, and progressive neurologic deficit.

• 4. Decompression and stabilization are generally not considered unless the patient is predicted to have greater than 3-month life expectancy.

• 5. Posterior stabilization should be strongly considered if there is disruption of the posterior elements, if multiple levels are involved, and in the presence of severe kyphotic deformity.

• 6. False. Recent evidence demonstrates a temporary increase in circulating tumor cells after cement augmentation in the setting of pathologic compression fracture of the spine. This raises concern for possible neoplastic embolization during these procedures.

• 7. True. Several authors report an increase in wound complications with multiple stab incisions and prefer a single midline incision with percutaneous placement of pedicle screws through the fascia.

• 8. False. Due to the small working window utilized in tubular-assisted anterior approaches, they are generally not considered a good option for curative surgery.

• 9. The mini-open anterior approach has been found to have significantly less blood loss, operative time, and technique-related complications than VATS without a significant difference in overall complication rate.