1
|
Luz D, Sousa C, Silva M, Pais P, Ferreira VC. Surgical Strategies for Tuberculous Spondylodiscitis With Severe Osteoporosis: A Case Illustrating the Challenges of Delayed Intervention. Cureus 2023; 15:e49021. [PMID: 38111399 PMCID: PMC10727488 DOI: 10.7759/cureus.49021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2023] [Indexed: 12/20/2023] Open
Abstract
Tuberculous spondylodiscitis (Pott's spine) is a complex extrapulmonary manifestation of tuberculosis (TB) that poses significant medical challenges, characterized by vertebral destruction affecting approximately 2% of all TB cases. The management of this condition involves a multidisciplinary approach, with surgical intervention indicated for specific cases, including those with neurological complications, spinal instability, and kyphosis. We report a case of a 49-year-old female with a confirmed diagnosis of tuberculous spondylodiscitis who had undergone eight months of tuberculostatic therapy. She was referred for neurosurgical consultation due to uncontrollable axial pain, despite favorable clinical and imaging responses, which had rendered her immobile for six months. Imaging revealed a complete collapse of the L5 vertebral body, and a complementary dual x-ray absorptiometry (DEXA) scan demonstrated severe osteoporosis. A two-stage surgical approach was chosen to address her condition, involving corpectomy through an anterior approach, followed by lumbopelvic stabilization. Postoperative recovery was uneventful, with progressive improvement in pain and mobility. This case highlights the challenges of managing tuberculous spondylodiscitis and underscores the significance of early detection to prevent complications like severe osteoporosis. In this case, delayed referral for surgery following an extended period of immobility added complexity to an already difficult case. The severe osteoporosis, with a t-score of -5.7, had a substantial impact on surgical planning, leading to a more robust approach to arthrodesis with substantial lumbopelvic instrumentation in order to mitigate the risks associated with implant failure. This case shows that timely intervention and a comprehensive multidisciplinary approach are essential for the effective management of tuberculous spondylodiscitis, especially in cases complicated by severe osteoporosis.
Collapse
Affiliation(s)
- Diogo Luz
- Neurosurgery, Hospital Garcia de Orta, Almada, PRT
| | - Carla Sousa
- Neurosurgery, Hospital Garcia de Orta, Almada, PRT
| | | | - Pedro Pais
- Neurosurgery, Hospital Garcia de Orta, Almada, PRT
| | | |
Collapse
|
2
|
Soumya SL, Cherian KE, Kapoor N, Paul TV. Severe Idiopathic Osteoporosis in a Premenopausal Woman: A Case for Dual Therapy. J Midlife Health 2021; 11:260-263. [PMID: 33767569 PMCID: PMC7978054 DOI: 10.4103/jmh.jmh_168_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 12/15/2020] [Accepted: 12/16/2020] [Indexed: 12/03/2022] Open
Abstract
Currently available agents improve bone mineral density (BMD) values on their own in monotherapy but may not completely restore microarchitecture and the patient may continue to sustain fragility fractures. Current monotherapies can only address either increased bone resorption or decreased bone formation. In this setting, combination therapy with antiresorptive and anabolic agents appears to be a promising option. A 49-year-old premenopausal woman presented with severe low backache associated with significant height loss. Evaluation elsewhere revealed severe osteoporosis, which prompted treatment with three doses of parenteral zoledronate 4 mg annually, followed by oral alendronate 70 mg once weekly for 7 years. However, her symptoms persisted despite treatment, and investigations done at our center confirmed severe osteoporosis, with multiple vertebral compression fractures. She was initiated on teriparatide therapy but despite 1 year of treatment, there was persistent height loss. In addition, there was a marked elevation of bone resorption, which prompted us to add denosumab which was administered subcutaneously every 6 months. On follow-up, there was marked relief from pain, no further decrease in height, and progressive improvement in BMD, and bone turnover markers were noted. A dual therapy with anabolic agent teriparatide and antiresorptive agent denosumab for osteoporosis may be a viable option in individuals with severe osteoporosis who do not respond well to a single agent.
Collapse
Affiliation(s)
- Sudarsanababu Lalitha Soumya
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Kripa Elizabeth Cherian
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Nitin Kapoor
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Thomas Vizhalil Paul
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| |
Collapse
|
3
|
Liu D, Sheng J, Wu HH, Kang X, Xie QY, Luo Y, Zhou JJ, Zheng W. Biomechanical study of injectable hollow pedicle screws for PMMA augmentation in severely osteoporotic lumbar vertebrae: effect of PMMA distribution and volume on screw stability. J Neurosurg Spine 2019; 29:639-646. [PMID: 30192220 DOI: 10.3171/2018.4.spine171225] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 04/18/2018] [Indexed: 12/25/2022]
Abstract
OBJECTIVEThe purpose of this study was to compare stability of injectable hollow pedicle screws with different numbers of holes using different volumes of polymethylmethacrylate (PMMA) in severely osteoporotic lumbar vertebrae and analyze the relationship between screw stability and distribution and volume of PMMA.METHODSForty-eight severely osteoporotic cadaveric lumbar vertebrae were randomly divided into 3 groups-groups A, B, and C (16 vertebrae per group). The screws used in group A had 4 holes (2 pairs of holes, with the second hole of each pair placed 180° further along the thread than the first). The screws used in group B had 6 holes (3 pairs of holes, placed with the same 180° difference in position). Unmodified conventional screws were used in group C. Each group was randomly divided into subgroups 0, 1, 2, and 3, with different volumes of PMMA used in each subgroup. Type A and B pedicle screws were directly inserted into the vertebrae in groups A and B, respectively, and then different volumes of PMMA were injected through the screws into the vertebrae in subgroups 0, 1, 2, and 3. The pilot hole was filled with different volumes of PMMA followed by insertion of screws in groups C0, C1, C2, and C3. Distributions of PMMA were evaluated radiographically, and axial pull-out tests were performed to measure the maximum axial pullout strength (Fmax).RESULTSRadiographic examination revealed that PMMA surrounded the anterior third of the screws in the vertebral bodies (VBs) in groups A1, A2, and A3; the middle third of screws in the junction area of the vertebral body (VB) and pedicle in groups B1, B2, and B3; and the full length of screws evenly in both VB and pedicle in groups C1, C2, and C3. In addition, in groups A3 and B3, PMMA from each of the screws (left and right) was in contact with PMMA from the other screw and the PMMA was closer to the posterior wall and pedicle than in groups A1, A2, B1, and B2. One instance of PMMA leakage was found (in group B3). Two-way analysis of variance revealed that 2 factors-distribution and volume of PMMA-significantly influenced Fmax (p < 0.05) but that they were not significantly correlated (p = 0.078). The Fmax values in groups in which screws were augmented with PMMA were significantly better than those in groups in which no PMMA was used (p < 0.05).CONCLUSIONSPMMA can significantly improve stability of different injectable pedicle screws in severely osteoporotic lumbar vertebrae, and screw stability is significantly correlated with distribution and volume of PMMA. The closer the PMMA is to the pedicle and the greater the quantity of injected PMMA used, the greater the pedicle screw stability is. Injection of 3.0 mL PMMA through screws with 4 holes (2 pair of holes, with the screws in each pair placed on opposite sides of the screw) produces optimal stability in severely osteoporotic lumbar vertebrae.
Collapse
Affiliation(s)
- Da Liu
- Departments of1Orthopaedics and
| | | | | | | | | | - Yang Luo
- 2Anesthesiology, Chengdu Military General Hospital, Chengdu, Sichuan Province; and
| | - Jiang-Jun Zhou
- 3Department of Orthopaedics, 184 Hospital of Nanjing Military Region, Yingtan, Jiangxi Province, People's Republic of China
| | | |
Collapse
|
4
|
Zhang D, Miranda M, Li X, Han J, Sun Y, Rojas N, He S, Hu M, Lin L, Li X, Ke HZ, Qin YX. Retention of osteocytic micromorphology by sclerostin antibody in a concurrent ovariectomy and functional disuse model. Ann N Y Acad Sci 2019; 1442:91-103. [PMID: 30644553 DOI: 10.1111/nyas.13991] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 09/20/2018] [Accepted: 10/26/2018] [Indexed: 12/26/2022]
Abstract
Prolonged mechanical unloading in bedridden patients and concurrent hormonal dysregulation represents the cause of one of the severest forms of osteoporosis, a condition for which there are very few efficacious interventions available to date. Sclerostin, a Wnt antagonist, acts as a negative regulator of bone formation. Sclerostin antibody (Scl-Ab)-mediated blockade of sclerostin can dramatically enhance bone formation and reduce bone resorption. This study was designed to investigate the therapeutic effect of the Scl-Ab on severe bone loss induced by concurrent mechanical unloading and estrogen deficiency in a hindlimb-suspended and ovariectomized rat model, and to study the cellular mechanisms underlying severe osteoporosis and Scl-Ab action. Unloading and ovariectomy resulted in severe loss of trabecular and cortical bone mass and strength; Scl-Ab can significantly counteract the deterioration of bone in unloaded and/or ovariectomized rats, with noticeably increased cortical bone formation. Scanning electron microscopy analysis revealed that unloading and ovariectomy lead to multiple morphological and structural abnormalities of osteocytes in cortical bone and the abnormalities were abolished by Scl-Ab administration. This study extends our previous conclusion that Scl-Ab represents a promising therapeutic approach for severe bone loss that occurs after being exposed to estrogen deficiency and prolonged mechanical unloading.
Collapse
Affiliation(s)
- Dongye Zhang
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York
| | - Mariana Miranda
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York
| | - Xiaofei Li
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York
| | - Jiangmeng Han
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York
| | - Yueli Sun
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York
| | - Nancy Rojas
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York
| | - Shan He
- Department of Materials Science and Chemical Engineering, Stony Brook University, Stony Brook, New York
| | - Minyi Hu
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York
| | - Liangjun Lin
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York
| | - Xiaodong Li
- Department of Metabolic Disorders, Amgen, Inc., Thousand Oaks, California
| | | | - Yi-Xian Qin
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York
| |
Collapse
|
5
|
Behrbalk E, Uri O, Folman Y, Rickert M, Kaiser R, Boszczyk BM. Staged Correction of Severe Thoracic Kyphosis in Patients with Multilevel Osteoporotic Vertebral Compression Fractures. Global Spine J 2016; 6:710-720. [PMID: 27781192 PMCID: PMC5077718 DOI: 10.1055/s-0035-1569460] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Accepted: 10/05/2015] [Indexed: 12/12/2022] Open
Abstract
Study Design Technical report. Objective Multilevel osteoporotic vertebral compression fractures may lead to considerable thoracic deformity and sagittal imbalance, which may necessitate surgical intervention. Correction of advanced thoracic kyphosis in patients with severe osteoporosis remains challenging, with a high rate of failure. This study describes a surgical technique of staged vertebral augmentation with osteotomies for the treatment of advanced thoracic kyphosis in patients with osteoporotic multilevel vertebral compression fractures. Methods Five patients (average age 62 ± 6 years) with multilevel osteoporotic vertebral compression fractures and severe symptomatic thoracic kyphosis underwent staged vertebral augmentation and surgical correction of their sagittal deformity. Clinical and radiographic outcomes were assessed retrospectively at a mean postoperative follow-up of 34 months. Results Patients' self-reported back pain decreased from 7.2 ± 0.8 to 3.0 ± 0.7 (0 to 10 numerical scale; p < 0.001). Patients' back-related disability decreased from 60 ± 10% to 29 ± 10% (0 to 100% Oswestry Disability Index; p < 0.001). Thoracic kyphosis was corrected from 89 ± 5 degrees to 40 ± 4 degrees (p < 0.001), and the sagittal vertical axis was corrected from 112 ± 83 mm to 38 ± 23 mm (p = 0.058). One patient had cement leakage without subsequent neurologic deficit. Decreased blood pressure was observed in another patient during the cement injection. No correction loss, hardware failure, or neurologic deficiency was seen in the other patients. Conclusion The surgical technique described here, despite its complexity, may offer a safe and effective method for the treatment of advanced thoracic kyphosis in patients with osteoporotic multilevel vertebral compression fractures.
Collapse
Affiliation(s)
- Eyal Behrbalk
- The Spine Unit, Hillel-Yaffe Medical Center, Hadera, Israel,Address for correspondence Dr. Eyal Behrbalk The Spine Unit, Hillel-Yaffe Medical CenterHa-Shalom Street, Hadera, 38100Israel
| | - Ofir Uri
- The Spine Unit, Hillel-Yaffe Medical Center, Hadera, Israel
| | - Yoram Folman
- The Spine Unit, Hillel-Yaffe Medical Center, Hadera, Israel
| | - Marcus Rickert
- The Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham, United Kingdom
| | - Radek Kaiser
- The Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham, United Kingdom
| | | |
Collapse
|
6
|
Abstract
Vertebral compression fractures (VCF's) are the most common form of osteoporotic fractures. Whether symptomatic or asymptomatic, they both represent a high risk for not only vertebral but also nonvertebral fractures in untreated populations. This high risk of future fracture after a VCF is independent of the T-score because bone strength is a combination of bone mineral density and bone quality. VCFs are the single greatest risk for future fractures at all other skeletal sites in untreated populations, including hip fractures. They are often unrecognized despite their exceptionally high prevalence in all genders and most ethnic groups as age increases. This article highlights some of the key messages about VCF's, and how assessment for their presence and then management will reduce the risk of all osteoporotic fractures.
Collapse
Affiliation(s)
- Paul D Miller
- Medical Director, Colorado Center for Bone Research, Lakewood, CO, USA.
| |
Collapse
|
7
|
Abstract
INTRODUCTION Severe osteoporosis represents a disease of high mortality and morbidity. Recognition of what constitutes and causes severe osteoporosis and aggressive intervention with pharmacological agents with evidence to reduce fracture risk are outlined in this review. AREAS COVERED This review is a blend of evidence obtained from literature searches from PubMed and The National Library of Medicine (USA), clinical experience and the author's opinions. The review covers the recognition of what constitutes severe osteoporosis, and provides up-to-date references on this sub-set of high risk patients. EXPERT OPINION Severe osteoporosis can be classified by using measurements of bone densitometry, identification of prevalent fractures, and, knowledge of what additional risk factors contribute to high fracture risk. Once recognized, the potential consequences of severe osteoporosis can be mitigated by appropriate selection of pharmacological therapies and modalities to reduce the risk for falling.
Collapse
Affiliation(s)
- Paul D Miller
- a University of Colorado Health Sciences Center , Colorado Center for Bone Research , Lakewood , CO , USA
| |
Collapse
|
8
|
Sarli MA, Zanchetta MB, Rey PG, Spivacow FR. [ Severe osteoporosis treatment with teriparatide]. Medicina (B Aires) 2013; 73:428-432. [PMID: 24152398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023] Open
Abstract
The primary objective of this retrospective study was to evaluate the treatment of severe osteoporosis with teriparatide (PTH) and to compare our results with those published in the literature. We included 46 patients, 42 women and four men, mean age: 69.15 ± 9.43 years. Six patients were treatment naive and forty previously treated with bisphosphonates. Thirty-two patients had had 93 fractures of which 86 vertebral. Forty-six received PTH for 6 months, twenty-nine for 12 months and twenty completed the 18 months suggested. Bone mineral density (BMD) of the lumbar spine increased significantly at the first control performed at six months of treatment (p < 0.0001), and the femoral neck BMD reached a significant increase at the end of treatment (p = 0.002). Serum osteocalcin values significantly increased from the first month of treatment, followed by Β crosslaps (beta-CTx, serum test) and bone-specific alkaline phosphatase, returning all the markers of bone turnover to baseline levels at 18 months. Serum and urinary calcium did not change significantly at any time, but 8 (17.9%) patients developed mild hypercalcemia and 3 (6.5%) asymptomatic hypercalciuria. The treatment was well tolerated and there were no serious adverse events requiring discontinuation. In conclusion, PTH is a safe and useful alternative for the treatment of primary severe osteoporosis. Our results agree with those previously reported in the literature.
Collapse
|