What is the recommended treatment for an 80-year-old man with an old compression wedge fracture and vertebra plana of the D12 vertebra with spinal cord compression?

Management of Old Compression Wedge Fracture with Spinal Cord Compression in an Elderly Patient

For an 80-year-old man with an old compression wedge fracture of D12 vertebra causing spinal cord compression, vertebral augmentation (vertebroplasty or kyphoplasty) is strongly recommended as the primary intervention to reduce pain and improve function. 1

Initial Assessment and Diagnosis

• The patient presents with:

  • Old compression wedge fracture with vertebra plana of D12
  • Posterior retropulsion causing spinal canal narrowing (6.7 mm)
  • Spinal cord compression

• This represents a severe vertebral compression fracture (VCF) with neurological compromise, requiring prompt intervention.

Treatment Algorithm

1. Interventional Procedures

• Vertebral augmentation is the primary treatment option:

  • Provides rapid pain relief and structural reinforcement
  • Indicated when there is significant pain, neurological compromise, or risk of neurological compromise 1
  • Both vertebroplasty (VP) and balloon kyphoplasty (BK) are equally effective in substantially reducing pain and disability 1
  • Particularly beneficial in this case with spinal deformity (vertebra plana)

• Surgical decompression should be considered due to:

  • Presence of spinal cord compression from bony retropulsion
  • Narrowing of the spinal canal (6.7 mm)
  • Surgical intervention is indicated when there is bony compression causing cord compression 2

2. Pain Management

• Medication management:

  • Tailor analgesics to pain severity:
    • Acetaminophen or NSAIDs for mild pain
    • Short-term opioids for moderate to severe pain 2
  • Add corticosteroids (high-dose dexamethasone) if there is significant edema around the cord compression 2

• Bisphosphonates:

  • Consider for pain relief and to prevent further fractures 2, 3
  • Alendronate has shown a 47% relative reduction in vertebral fracture risk 3

3. Supportive Care

• Physical therapy:

  • Structured program specifically targeting lumbar stabilization 2
  • Early introduction of physical training and muscle strengthening
  • Long-term continuation of balance training 2

• Bracing:

  • May provide temporary support and pain relief
  • Should not be used long-term as it may lead to muscle deconditioning 4

• Calcium and vitamin D supplementation:

  • Calcium (1000-1200 mg/day)
  • Vitamin D (800 IU/day) 2

Special Considerations for This Patient

1. Age factor: At 80 years old, the patient's age must be considered when weighing surgical risks versus benefits. However, age alone should not preclude intervention if neurological compromise is present.

2. Chronicity of fracture: Despite being an "old" fracture, studies have shown that the age of the fracture does not independently affect outcomes of vertebral augmentation 1. Patients with VCF >12 weeks compared to VCF <12 weeks had equivalent benefit from vertebroplasty 1.

3. Spinal cord compression: The posterior retropulsion causing spinal canal narrowing (6.7 mm) and cord compression represents a serious complication requiring more aggressive intervention than uncomplicated VCFs.

Potential Pitfalls and Caveats

• Cement leakage: A potential complication of vertebroplasty, which can be minimized with proper technique and potentially reduced with kyphoplasty 1

• Neurological monitoring: Close monitoring of neurological status is essential during and after treatment 2

• Adjacent level fractures: New fractures can occur at adjacent levels after vertebral augmentation, requiring ongoing monitoring and preventive measures 5

• Conservative management alone: While conservative management is typically first-line for uncomplicated VCFs, it does not prevent further collapse or kyphosis, and approximately 40% of conservatively treated patients may not achieve significant pain relief after 1 year 1. Given the spinal cord compression in this case, more definitive intervention is warranted.

By implementing this treatment approach, the goal is to address both the structural compromise and neurological symptoms, ultimately improving the patient's pain, function, and quality of life.