What is the recommended treatment for a patient with an endplate compression deformity?

Treatment of Endplate Compression Deformity

Conservative medical management is the initial treatment for osteoporotic endplate compression deformities, with most patients experiencing gradual pain improvement over 2-12 weeks; however, percutaneous vertebral augmentation (vertebroplasty or balloon kyphoplasty) should be strongly considered for patients who fail to achieve adequate pain relief by 3 months, or earlier in those with significant spinal deformity, worsening symptoms, or pulmonary dysfunction. 1

Initial Conservative Management

• Medical management with analgesics and immobilization is the first-line approach for painful vertebral compression fractures (VCFs), as the natural history shows gradual improvement in pain over 2-12 weeks with variable return of function 1
• Bone marrow edema associated with acute fractures on MRI typically resolves within 1-3 months 1
• All patients should receive supplemental calcium and vitamin D if dietary intake is inadequate 2
• For patients at high risk for fracture, teriparatide 20 mcg subcutaneously once daily may be considered to increase bone mass and reduce future fracture risk, though treatment duration should not exceed 2 years during a patient's lifetime 2

Critical Decision Point: When to Escalate Beyond Conservative Care

The key clinical challenge is recognizing when conservative management has failed, as 40% of conservatively treated patients have no significant pain relief after 1 year despite higher-class prescription medications 1. The following criteria indicate need for intervention:

Indications for Vertebral Augmentation:

• Failure to achieve adequate pain relief by 3 months of conservative treatment 1
• Presence of spinal deformity defined as: 15% kyphosis, 10% scoliosis, 10% dorsal wall height reduction, or vertebral body height loss ≥20% 1
• Worsening symptoms despite medical management 1
• Pulmonary dysfunction related to the fracture 1
• Neurologic deficits (requires surgical consultation) 1

Vertebral Augmentation Techniques

Both vertebroplasty (VP) and balloon kyphoplasty (BK) are equally effective in substantially reducing pain and disability, with immediate and considerable improvement in pain and patient mobility 1

Evidence Supporting Vertebral Augmentation:

• VA provides superior pain relief compared to prolonged medical treatment and improves functional outcomes 1
• Studies demonstrate VA is superior to placebo for pain reduction in acute osteoporotic VCF of <6 weeks' duration 1
• Age of fracture does not independently affect outcomes - patients with VCF >12 weeks have equivalent benefit to those with VCF <12 weeks 1
• VA has been shown to improve pulmonary function in patients with VCF 1
• Meta-analysis shows improvements in pain intensity, vertebral height, sagittal alignment, functional capacity, and quality of life with BK compared to conservative management 1

Choosing Between VP and BK:

• Both techniques are equally effective for pain relief and disability reduction 1
• BK may have advantages in complex cases where better angular and fracture correction is needed 1
• Unilateral versus bilateral techniques show no significant difference in outcomes 1

Special Considerations for Endplate Fractures

Endplate fractures significantly impact outcomes and require special attention, as they are commonly associated with vertebral compression fractures:

• Superior endplate injury occurs in 39% of VCFs, inferior endplate injury in 12%, and combined injury in 29% 3
• Superior endplate fractures are associated with higher risk of progressive kyphotic deformity - 75.9% of patients with superior endplate fractures develop significant segmental kyphotic deformity 4
• Endplate fractures lead to postoperative vertebral height loss and increased kyphotic deformity even after successful vertebral augmentation 5
• Complete superior endplate fractures show the most severe vertebral height loss and increased kyphotic deformity after surgery 5

Clinical Implication:

When endplate fractures are present, surgery should not only restore compressed vertebral body height and correct kyphosis, but also correct the deformity of the endplate to achieve effective treatment 5. This may require balloon-assisted endplate reduction (BAER) with calcium phosphate cement augmentation to restore disc space boundaries and prevent intervertebral disc creep through fractured endplates 6.

Risk Factors for Progressive Kyphotic Deformity

Patients at highest risk for significant segmental kyphotic deformity include:

• Fractures at the thoracolumbar junction (82.5% develop significant kyphosis) 4
• Superior endplate fractures (75.9% develop significant kyphosis) 4
• Anterior cortical wall fractures (86.9% develop significant kyphosis) 4
• Adjacent level fractures (71.4% develop significant kyphosis) 4

Pathophysiology: Two-Stage Process

Understanding the mechanism helps guide timing of intervention. Vertebral wedge deformity develops through a two-stage process: 7

1. Initial endplate damage from excessive loading decompresses the adjacent intervertebral disc, reducing nucleus pressure by 55% and increasing neural arch load bearing by 166% 7
2. Progressive anterior cortex collapse occurs with subsequent cyclic loading, concentrating compressive stress within the anterior annulus and causing progressive wedging 7

Detecting initial endplate damage early may be important to minimize vertebral deformity in patients with osteoporosis 7.

When Surgical Consultation is Required

Surgical intervention is reserved for:

• Neurologic deficits 1
• Spinal deformity (e.g., junctional kyphosis, retropulsion) 1
• Spinal instability 1
• Failure of vertebral augmentation in the setting of severe vertebral body comminution 6

Common Pitfalls to Avoid

• Do not delay intervention beyond 3 months in patients without adequate pain relief, as approximately 1 in 5 patients with osteoporotic VCFs will develop chronic back pain 1
• Do not overlook endplate and adjacent disc injuries on MRI, as these are frequently under-reported but have important implications for management and outcomes 3
• Do not use radiation therapy in patients without cancer diagnosis - RT is reserved for spinal metastatic disease only 1
• Do not ignore spinal deformity or pulmonary dysfunction, as these warrant intervention beyond medical management alone 1
• Recognize that conservative medical treatment does not prevent further collapse or kyphosis 1