What is the appropriate treatment and management for a patient with endplate deformity, considering their unique medical history and overall health status?

Management of Endplate Deformity

For vertebral endplate deformities, imaging with MRI is essential to characterize the lesion and guide treatment, with surgical intervention (vertebroplasty or kyphoplasty) reserved for symptomatic cases with significant deformity or neurological compromise, while most asymptomatic endplate fractures can be managed conservatively.

Initial Diagnostic Approach

Imaging is the cornerstone of diagnosis and treatment planning for endplate deformities:

• MRI of the complete spine is the primary imaging modality to detect and characterize endplate abnormalities, assess for associated disc herniation, and evaluate for spinal cord or nerve root compression 1
• 3D fast spoiled gradient (3D FSPGR) MRI sequences are particularly effective for detecting both bony and cartilaginous endplate lesions, with endplate abnormalities present in up to 97% of symptomatic cases 2
• CT with multiplanar and 3D reconstruction should be obtained when surgical planning is considered, as it provides superior visualization of bony architecture and fracture patterns 1
• Weight-bearing radiographs (AP and lateral views) are useful for assessing alignment and mechanical axis deviation in cases involving deformity 3

Classification and Clinical Significance

The location and type of endplate deformity determines prognosis and treatment approach:

• Superior endplate fractures predominate in natural osteoporotic fractures (57% superior vs 11% inferior), while inferior endplate fractures are more common adjacent to treated vertebrae after vertebroplasty 4
• Bony endplate failure is associated with more severe neurological deficits and reduced chance of recovery with conservative management compared to isolated cartilaginous endplate lesions 2
• Endplate fractures during spinal fusion procedures occur in 85% of levels but are not necessarily associated with subsequent cage subsidence or poor fusion outcomes 5

Conservative Management

Most endplate deformities without significant neurological compromise can be managed non-operatively:

• Optimize medical therapy for at least 12 months before considering surgical intervention for metabolic bone disease-related deformities 1
• Physical therapy to maintain joint range of motion and maximize strength is recommended for patients with endplate-related deformity 1
• Serial imaging at 6-month intervals to monitor for progression, with more frequent assessment if clinical deterioration occurs 1
• Conservative management is less successful in patients with bony endplate failure who present with neurological deficits 2

Surgical Intervention Criteria

Surgery should be considered when specific thresholds are met:

• Mechanical axis deviation into Zone 2 or greater despite optimized medical treatment warrants surgical consideration 1, 3
• Presence of spinal cord compression, disc protrusion, or hematoma causing neurological symptoms requires MRI evaluation and potential surgical decompression 1
• Persistent symptomatic deformity interfering with function after 12 months of maximized medical therapy 1
• Progressive kyphotic deformity with loss of anterior vertebral height that compromises adjacent disc mechanics 6

Surgical Options and Timing

The choice of surgical technique depends on patient age, growth potential, and deformity characteristics:

• Vertebroplasty or kyphoplasty can restore anterior vertebral height and reduce kyphosis in osteoporotic compression fractures with endplate involvement, though complete correction may not be achieved 1, 6
• PEEK wafer kyphoplasty (StaXx FX) restores disc pressurization mechanics even when height and kyphosis are not fully corrected 6
• Guided growth techniques must be performed at least 2-3 years before skeletal maturity (age 14 in girls, age 16 in boys) to be effective 1
• Osteotomy procedures should ideally be delayed until skeletal maturity to reduce complication rates, which can reach 57% in young children with poor metabolic control 1
• Surgery should be performed by surgeons with expertise in metabolic bone diseases or spinal deformity 1

Important Complications and Pitfalls

Awareness of specific complications guides treatment decisions:

• Cement leakage occurs in up to 72% of vertebroplasty cases on post-procedural CT, though most are asymptomatic discal or venous leaks 1
• Inferior endplate fractures of the vertebra immediately above a cemented level occur disproportionately (57% inferior vs 30% superior), suggesting altered biomechanics after vertebroplasty 4
• Major complications occur in <1% of patients treated for osteoporotic fractures and <5% for neoplastic involvement, with acceptable thresholds of 2% and 10% respectively 1
• Endplate fractures during fusion procedures (85% incidence) do not necessarily predict poor outcomes regarding fusion status or alignment maintenance 5

Post-Treatment Monitoring

Regular follow-up is essential to detect complications and assess outcomes:

• Clinical and radiographic assessment at 12 months post-surgery, or earlier if deformity worsens or clinical concern arises 1
• Intermittent assessments should continue until skeletal maturity in pediatric patients 1
• CT imaging is superior to plain radiographs for detecting cement leakage and new fractures 1