Baseline characteristics of postmenopausal women with osteoporosis treated with teriparatide in a real-world setting in Latin America: a subregional analysis from the Asia and Latin America Fracture Observational Study (ALAFOS)

Abstract Background: Osteoporosis is a major healthcare concern in Latin America. Factors such as changing demographics, fragmented healthcare systems, and financial considerations may result in a huge increase in the burden of osteoporosis in this region. The aim of this article is to describe the baseline clinical characteristics and fracture history of patients who are prescribed teriparatide in normal clinical practice in Latin America. Methods: We conducted a prospective, multinational, observational study (the Asia and Latin America Fracture Observational Study [ALAFOS]) in 20 countries worldwide to assess the incidence of fractures in postmenopausal women with osteoporosis receiving teriparatide as a part of routine clinical practice in a real-world setting. In this subregional analysis of the ALAFOS study, we report the clinical characteristics, fracture history, risk factors for osteoporosis, comorbidities, previous osteoporosis therapies and health-related quality of life measures at baseline for patients from the four participant Latin American countries: Argentina, Brazil, Colombia, and Mexico. Results: The Latin America subregional cohort included 546 postmenopausal women (mean [SD] age: 71.0 [10.1] years; range: 40-94 years), constituting 18% of the ALAFOS total population. The baseline mean (SD) bone mineral density T-scores were - 3.02 (1.23) at the lumbar spine and - 2.31 (0.96) at the femoral neck; 62.8% of patients had a history of low trauma fracture after the age of 40 years and 39.7% of patients had experienced ≥1 fall in the past year. Osteoporosis medications were used by 70.9% of patients before initiating teriparatide. The median (Q1, Q3) EQ-5D-5 L Visual Analog Scale (VAS) scores for perceived health status at baseline was 70 (50, 80). The mean (SD) worst back pain numeric rating scale score for the overall Latin American cohort was 4.3 (3.4) at baseline. Conclusions: This baseline analysis of the Latin America subregion of the ALAFOS study indicates that patients who are prescribed teriparatide in the four participant countries had severe osteoporosis and high prevalence of fractures. They also had back pain and poor health-related quality of life. The proportions of patients with severe or extreme problems on the EQ-5D-5 L individual domains were lower than those in the overall ALAFOS study population.

Instrumentación anterior y posterior para tratamiento de fractura por Metástasis Vertebral / Anterior and posterior instrumentation for fracture treatment due to Vertebral Metastasis

Las fracturas tumorales en columna vertebral son parte de la etiología de las fracturas patológicas a este nivel, que por edad de presentación, así como la clínica observada puede otorgar directrices del tipo de tumor que afecta al esqueleto axial. Por tanto, resulta importante su identificación, clasificación y terapéutica a seguir, en especial en aquellos casos donde se encuentra afectada la parte neurológica distal. Teniendo en consideración estos aspectos planteamos este caso clínico.

Tumoral fractures in spine are part of the etiology of pathologic fractures in this level, age of presentation and the observed clinical can give guidance on the type of tumor that affects the axial skeleton, it is important to identify, classification and therapeutic to follow, especially those who are affected neurological distal part. Considering this aspect propose clinical case below.

Fracturas vertebrales en niños con osteogénesis imperfecta tipo I / Vertebral fractures in children with Type I Osteogenesis imperfecta

La Osteogénesis imperfecta (OI) es una enfermedad hereditaria del tejido conectivo, que se caracteriza principalmente por fragilidad ósea, deformidad y alteración del crecimiento. La OI tipo I (OI tipo I) es la más frecuente, leve y clínicamente homogénea. Su mayor complicación es la presencia de fracturas vertebrales, asociadas a morbilidad esquelética y cardiopulmonar. Objetivo: Caracterizar clinicamente una cohorte de niños con OI tipo I. Pacientes y Método: Se examinó una cohorte histórica de pacientes menores de 20 años mediante la revisión de fichas clínicas, rescatando las características demográficas, clínicas, bioquímicas y radiológicas. Resultados: Se incluyeron 67 pacientes, 55% varones, 69% de la Región Metropolitana. La edad media de diagnóstico fue de 2,9 años, el 70% de los pacientes presentó fracturas vertebrales de predominio torácico, y el 50% lo hizo antes de los 5 años. Un 15% presentó fracturas al momento del diagnóstico, siendo en ellos el diagnóstico de OI tipo I cerca de los 5 años. Los parámetros metabólicos óseos estuvieron en rangos adecuados durante el seguimiento, sin cambios significativos al diagnóstico de las fracturas vertebrales, excepto una disminución de la ingesta recomendada de calcio. Conclusiones: En este estudio, la OI tipo I presenta un diagnóstico precoz, principalmente en preescolares, y se asocia a alta frecuencia de fracturas vertebrales. La disminución en la ingesta de calcio demostrada al momento de la primera fractura requiere especial atención en estos pacientes.

Osteogenesis imperfecta (OI) is an hereditary disease affecting conective tissue, mainly associated to growth retardation and pathological fractures. OI type I (OI type I), is the mildest, most often, and homogeneous in its fenotype. Vertebral fractures are the most significant complications, associated to skeletical and cardiopulmonary morbidity. Objectives: To characterize clinically a cohort of children with OI type I. Patients and Methods: A cohort of OI type I children younger than 20 year old was evaluated. Demographic, clinical, biochemical and radiological data were registered. Results: Sixty seven patients were included, 55% male, 69% resident in the Metropolitan Region. The mean age of diagnose was 2.9 years, 70% presented vertebral fractures on follow-up, mostly thoracic, and 50% before the age of 5 years. Fifty percentage presented vertebral fractures at diagnose, which was about the age of 5 years. Bone metabolic parameters were in the normal range, without significant change at the moment of vertebral fractures. Calcium intake was found to be below American Academy of Pediatrics recommendations at the time of the first fracture. Conclusions: In this study OI type I has an early diagnose, and vertebral fractures show a high incidence, mostly in toddlers. Calcium intake was found to be below reccomended values, and should be closely supervised in these patients.

Risk of Vertebral Fracture in Patients Diagnosed with a Depressive Disorder: A Nationwide Population-Based Cohort Study

OBJECTIVE: Previous studies have reported that depression may play a crucial role in the occurrence of vertebral fractures. However, a clear correlation between depressive disorders and osteoporotic fractures has not been established. We explored the association between depressive disorders and subsequent new-onset vertebral fractures. Additionally, we aimed to identify the potential risk factors for vertebral fracture in patients with a depressive disorder. METHODS: We studied patients listed in the Taiwan National Health Insurance Research Database who were diagnosed with a depressive disorder by a psychiatrist. The comparison cohort consisted of age- and sex-matched patients without a depressive disorder. The incidence rate and hazard ratios of subsequent vertebral fracture were evaluated. We used Cox regression analysis to evaluate the risk of vertebral fracture among patients with a depressive disorder. RESULTS: The total number of patients with and without a depressive disorder was 44,812. The incidence risk ratio (IRR) between these 2 cohorts indicated that depressive disorder patients had a higher risk of developing a subsequent vertebral fracture (IRR=1.41, 95% confidence interval [CI]=1.26-1.57, p<0.001). In the multivariate analysis, the depressive disorder cohort showed a higher risk of vertebral fracture than the comparison cohort (adjusted hazard ratio=1.24, 95% CI=1.11-1.38, p<0.001). Being older than 50 years, having a lower monthly income, and having hypertension, diabetes mellitus, cerebrovascular disease, chronic obstructive pulmonary disease, autoimmune disease, or osteoporosis were considered predictive factors for vertebral fracture in patients with depressive disorders. CONCLUSIONS: Depressive disorders may increase the risk of a subsequent new-onset vertebral fracture.

Manejo con instrumentación 360 o de enfermedad ósea metastásica que condiciona inestabilidad en columna cervical. Reporte de un caso clínico / 360 degrees instrumentation for cervical instability due to metastatic bone disease. Case report

Resumen: Introducción: La columna vertebral es el sitio más frecuente de localización para las metástasis óseas; siendo los tumores de mama, próstata y pulmón los que mayor afectación presentan. La columna torácica es afectada en un 70% de los casos, seguida de la región lumbar y cervical. Material y métodos: se presenta el caso de un paciente con diagnóstico de adenocarcinoma mamario derecho, con enfermedad ósea metastásica en región cervical a nivel de C2, C3, inestabilidad del segmento cervical por fractura por compresión del cuerpo C3 de mayor al 80%, sin invasión a canal medular, inicia con parestesias de extremidades torácicas. Se realiza instrumentación 360º en dos tiempos. Posterior al procedimiento la paciente evolucionó sin dolor cervical y tolerando la vía oral. Discusión: la enfermedad ósea metastásica genera lesiones importantes en la columna vertebral condicionando inestabilidad; la instrumentación mejora el estado funcional y el pronóstico.

Abstract: Introduction: The spine is the most common site for bone metastases; being the breast, prostate and lung cancer which have most affected. The thoracic spine is involved in 70% of cases, followed by the lumbar and cervical region. Material and methods: This is a 59 years old female diagnosed with breast adenocarcinoma and metastatic bone disease in cervical spine C2, C3 level and instability of that segment because of a compression fracture of C3 greater than 80% without invasion of the spinal canal, she begins with paresthesias of upper limbs. A 360º instrumentation was performed in two stages. After the surgical procedure the patient were without neck pain and a good neurological status. Discussion: Metastatic bone disease causes significant damage to the spine sometimes create instability proper instrumentation is needed to improve the functional status and prognosis of these lesions.

Asymptomatic vertebral fractures in patients with low bone mineral density / Fraturas vertebrais assintomáticas em indivíduos com baixa massa óssea

Summary Objective: Vertebral fracture assessment (VFA) is a test technique that can be used to detect asymptomatic vertebral fractures (AVF). It uses dual energy X-ray bsorptiometry (DXA) and can be performed concurrently with bone densitometry. This study aims to assess the prevalence of AVF in patients with low bone mass. Methods: Cross-sectional study including 135 individuals with low bone mineral density (BMD) with a T-score < -2.0 standard deviation (SD) in a densitometry clinic located in the city of Blumenau (state of Santa Catarina). Anthropometric, clinical and lifestyle variables were obtained from history-taking and physical examination. Densitometric variables were obtained by bone mineral densitometry and VFA (Explorer, Hollogic®). Vertebral fractures were classified according to the Genant criteria. Student's t, chi-square and logistic regression were performed for statistical analysis. Results: AVFs occurred in 24.4% of the subjects. They were older compared to those without AVF (65±9.25 versus 60.1±8.66; p=0.005), and had a history of lowimpact fractures (38.24% versus 19.8%; OR 2.5; p=0.03). Half of the patients that reported steroid therapy had AVFs, compared to one fifth of those who did not use steroids (50% versus 21.49%; OR 3.6; p=0.01). Conclusion: Asymptomatic vertebral fractures were present in approximately one fourth of patients. The risk factors associated were history of low-impact fracture, use of steroids and age > 61 years.

Resumo Objetivos: vertebral fracture assessment (VFA) é uma técnica de exame que pode ser aplicada na detecção de fraturas vertebrais assintomáticas (FVA). Utiliza absorciometria de raios-X de dupla energia (DXA) e pode ser realizada concomitantemente ao exame de densitometria óssea. Este estudo visa a avaliar a prevalência de FVA em indivíduos com baixa massa óssea. Métodos: estudo transversal realizado em 135 indivíduos, com baixa densidade mineral óssea (DMO), com T-score < -2,0 desvio padrão (DP), em uma clínica de densitometria de Blumenau (SC). As variáveis antropométricas, clínicas e referentes ao estilo de vida foram obtidas por anamnese e exame clínico; as variáveis densitométricas foram obtidas por DMO e VFA (aparelho modelo Explorer, marca Hollogic®). As fraturas vertebrais foram classificadas de acordo com os critérios de Genant. Os testes estatísticos foram t de student, qui-quadrado e regressão logística. Resultados: FVA ocorreram em 24,4% dos indivíduos. A idade desses indivíduos foi superior à dos indivíduos sem FVA (65±9,25 vs. 60,1±8,66; p=0,005), assim como o antecedente de fratura por baixo impacto (38,24% vs.19,8%; OR 2,5; p=0,03). A metade dos indivíduos que relataram corticoterapia possuíam FVA, contrastando com um quinto dos indivíduos sem corticoterapia (50% vs. 21,49%; OR 3,6; p=0,01). Conclusão: fraturas vertebrais assintomáticas estiveram presentes em aproximadamente um quarto dos pacientes. Os fatores de risco associados foram história de fratura por baixo impacto, corticoterapia e idade > 61 anos.

Evaluation of vertebral hidden fractures in patients with proximal femoral fractures / Avaliação de fraturas vertebrais ocultas em pacientes com fraturas do femur proximal / Evaluación de fracturas vertebrales ocultas en pacientes con fracturas del fémur proximal

Objective: To evaluate the Spine Deformity Index (SDI) and serum levels of vitamin D in patients surgically treated for proximal femur fracture and its relationship with osteoporosis. Methods: Between August and November 2013, patients older than 50 years-old with surgical fracture of the proximal femur by low-energy trauma underwent radiographic evaluation of the spine and the vitamin D levels, and enquired about diagnoses and previous treatment of osteoporosis. Results: Sixty-six patients met the inclusion criteria. The mean age was 78 years; the average level of vitamin D was 19 ng/mL. The SDI ranged between zero and 25, with a mean of 8.2. Eighty percent of these patients had never been treated for osteoporosis. Of the patients analyzed, 89.3% had insufficient levels of vitamin D. Of these, 68.1% had also SDI above 5, and only one fifth of them had any treatment for osteoporosis. Statistical significance was found between age and levels of vitamin D as well as age and SDI. Gender was not predictive of the vitamin D levels or the amount of hidden spine fractures. The season of the year had no direct influence on vitamin D levels. Conclusions: Hospitalized patients with surgical fractures of the proximal femur had a higher SDI associated with vitamin D insufficiency, with osteoporosis most often untreated, which results in delayed spinal fractures diagnosis of spinal fractures and increased risk of new fractures. .

Objetivo: Avaliar o índice de deformidade espinhal (SDI) e níveis séricos de vitamina D em pacientes tratados cirurgicamente por fratura do fêmur proximal e a relação desses dados com osteoporose. Método: Entre agosto e novembro de 2013, pacientes com mais de 50 anos e fratura cirúrgica do fêmur proximal por trauma de baixa energia foram submetidos à avaliação radiográfica da coluna vertebral e do nível sérico de vitamina D e questionados sobre diagnóstico e tratamentos prévios para osteoporose. Resultados: Sessenta e seis pacientes satisfizeram os critérios de inclusão. A média de idade foi 78 anos e o nível sérico médio de vitamina D foi 19 ng/mL. O SDI variou entre zero e 25, com média de 8,2. Oitenta por cento desses pacientes nunca receberam tratamento para osteoporose. Dos pacientes analisados, 89,3% tinham níveis insuficientes de vitamina D. Destes, 68,1% também tinham índice de deformidade espinhal acima de 5, e somente um quinto deles realizou algum tipo de tratamento para osteoporose. Houve significância estatística entre a idade e a concentração de vitamina D e entre a idade e o SDI. O sexo não foi preditivo dos níveis de vitamina D ou da quantidade de fraturas ocultas de coluna. A época do ano não teve influência sobre o nível de vitamina D dos pacientes. Conclusão: Pacientes internados com fratura de fêmur proximal apresentam índice de deformidade espinhal elevado associado ...

Objetivo: Evaluar el índice de deformidad de la columna vertebral (SDI) y los niveles séricos de vitamina D en los pacientes tratados quirúrgicamente por fractura del fémur proximal. Evaluar la relación de estos datos con la osteoporosis. Métodos: Entre agosto y noviembre de 2013, los pacientes con más de 50 años y con fractura quirúrgica del fémur proximal por un traumatismo de baja energía fueron sometidos a la evaluación radiográfica de la columna vertebral y a la determinación del nivel sérico de vitamina D y se les pregunto sobre el diagnóstico y los tratamientos previos para la osteoporosis. Resultados: Sesenta y seis pacientes cumplieron los criterios de inclusión. La edad promedio fue de 78 años la media del nivel sérico de vitamina D fue de 19 ng/mL. El SDI osciló entre zero y 25, con una media de 8,2. El ochenta por ciento de estos pacientes nunca fueron tratados para la osteoporosis. De los pacientes analizados, el 89,3% tenían niveles insuficientes de vitamina D. De ellos, el 68,1% tenían índice de deformidad de la columna superior a 5 y solamente una quinta parte recibió algún tratamiento para la osteoporosis. Se ha verificado significación estadística entre la edad y el nivel de vitamina D y entre la edad y el SDI. El sexo no fue predictivo de los niveles de vitamina D o la cantidad de fracturas de columna ocultas. La época del año no tuvo influencia en la concentración de vitamina D. Conclusión: Los pacientes hospitalizados ...

Apophyseal ring fracture associated with two levels extruded disc herniation: case report and review of the literature / Fratura do anel apofisário associada à hérnia discal extrusa de dois níveis: relato de caso e revisão da literatura

Apophyseal ring fractures are rare injuries that may be associated with lumbar disc herniation in young patients. We report a unique case in the literature of a 15-year-old male patient who played football and was admitted at our service complaining of sciatica radiating into the left leg. An apophysial ring injury of L5 vertebral body was observed. This injury caused two extruded disc herniation in adjacent levels. Surgical procedure was indicated after failure of conservative treatment.

As fraturas do anel apofisário são lesões raras, que podem estar associadas à hérnia de disco lombar nos pacientes jovens. Apresentamos aqui um caso único na literatura de paciente de 15 anos, gênero masculino, praticante de futebol, com queixa de ciatalgia para o membro inferior esquerdo. Houve lesão do anel apofisário, nos planaltos superior e inferior do corpo vertebral de L5, ocasionando hérnias discais extrusas nos níveis adjacentes. O procedimento cirúrgico foi indicado após a falha do tratamento conservador.

Cifoplastia guiada por TC: una opción técnica en el tratamiento de fracturas vertebrales patológicas / CT-guided kyphoplasty: a technical option in the treatment of pathological vertebral fractures

Pathological vertebral fractures are caused by various entities. They cause significant pain and impaired quality of life of patients. The CT-guided kyphoplasty relieves or eliminates pain and stabilizes the fractured vertebral bodies. 49 patients were treated. The procedure is performed percutaneously by inserting a needle that is subsequently removed, leaving a cannula. Through this a balloon-like device is introduced and subsequently inflated to create a cavity, which is then filled with polymethylmethacrylate (PMMA). The technique was performed successfully in all cases without serious complications, with good results. Its advantages are that the needle placement as well as the injection of PMMA can be correctly visualized using real-time CT fluoroscopy. In addition a single needle is used throughout the entire procedure, which minimizes the risk of complications as it is less traumatic.

Las fracturas vertebrales patológicas se originan por diversas entidades. Producen dolor importante y deterioro de la calidad de vida de los pacientes. La cifoplastia guiada por tomografía computarizada (TC) alivia o elimina el dolor y estabiliza los cuerpos vertebrales fracturados. Se han tratado 49 pacientes. El procedimiento se realiza por vía percutánea, mediante la inserción de una aguja que posteriormente se retira dejando una cánula. A través de la misma se introduce un dispositivo que lleva incorporado un balón que se infla creando una cavidad, que se rellena con polimetilmetacrilato (PMMA). La técnica se practicó con éxito en todos los casos sin complicaciones graves, con buenos resultados. Sus ventajas son visualizar correctamente la posición de la aguja y la inyección del PMMA mediante la escopia del TC en tiempo real. Además se utiliza una sola aguja para todo el procedimiento, lo cual minimiza el riesgo de complicaciones siendo menos traumático.

Mastocitosis sistémica: repercusión ósea / Systemic mastocytosis: bone impact

La mastocitosis sistémica es una enfermedad caracterizada por acumulación de mastocitos en varios órganos, de los cuales el más afectado es la piel. La repercusión ósea de esta enfermedad es poco frecuente y en general se la asocia al desarrollo de osteoporosis secundaria con o sin fracturas óseas. Se presentan tres pacientes con lesiones características en piel de mastocitosis y diferentes manifestaciones óseas; el primer caso es una mujer de 51 años en la que se observó una variante esclerosante muy poco frecuente, con densitometría ósea en valores normales-altos y aumento de la densidad ósea observada en varias vértebras por radiografías. Una punción-biopsia de cresta ilíaca confirmó el compromiso óseo de su enfermedad de base. El segundo caso fue una mujer de 57 años que mostró signos característicos de mastocitosis sistémica con diarreas, gastritis, flushes y reacciones cutáneas particulares ante exposición a alérgenos. Se observó además grave disminución de la densidad mineral ósea tanto en columna lumbar como en cuello de fémur con parámetros bioquímicos de aumento de la resorción ósea, por lo que fue necesario tratarla con bisfosfonatos. La tercera paciente, de 67 años de edad, presentó varias fracturas vertebrales, con densitometría ósea levemente disminuida. En esta última paciente se constató una hiperplaquetosis con diagnóstico histológico de trombocitemia esencial, cuadro que suele asociarse a la mastocitosis sistémica. En definitiva, se presentan y discuten tres variantes óseas diferentes de mastocitosis sistémica.

Systemic mastocytosis is a disease characterized by accumulation of mast cells in various organs of which the most affected is the skin. The bone impact of this disease is very rare and generally associated with the development of secondary osteoporosis with or without fractures. We present three cases of patients with skin mastocytosis lesions and different bone manifestations; the first case was a 51 year old woman in whom we observed a rare sclerosing variant with a normal-high bone density and increased density presented in several vertebrae x-rays. An iliac crest biopsy confirmed bone involvement of the underlying disease. The second case was a 57 year old woman who had characteristic signs of systemic mastocytosis with diarrhea, gastritis, flushes and specific cutaneous reactions to exposure to allergens. She also presented severe decrease in bone mineral density in both lumbar spine and femoral neck, with biochemical parameters of increased bone resorption, so had to be treated with bisphosphonates. The third patient, a 67-year-old woman, had several vertebral fractures, with slightly decreased bone densitometry. This last patient showed a hiperplaquetosis with histological diagnosis of essential thrombocythemia, a picture usually associated with systemic mastocytosis. In conclution, we present and discuss three different bone variants of systemic mastocytosis.

Percutaneous vertebroplasty: a comparison between the procedure using the traditional and the new side-opening cannula for osteoporotic vertebral fracture / Vertebroplastia percutânea: uma comparação entre o procedimento usando a cânula tradicional e a nova cânula de orifício lateral para fratura vertebral osteoporótica

A total of 47 percutaneous vertebroplasties (PVs) were performed for osteoporotic vertebral fractures in 31 patients, 25 PVs were performed using the frontal-opening cannula (FOC) and 22 using the new side-opening cannula (SOC), randomly distributed. The incidence of cement extrusion was 27 percent with the SOC, and 68 percent with the FOC, all asymptomatic (p<0.01). The pain control was similar for both groups, with good improvement of pain in most of the patients, and there were no clinical relevant complications. The cement leakage can be significantly reduced with this new SOC, which allows for a better cement injection toward the center of the vertebral body, increasing the safety of the procedure, with no increase in cost.

Um total de 47 vertebroplastias percutâneas (VP) foram realizadas para fraturas vertebrais osteoporóticas em 31 pacientes, 25 VP foram realizadas usando-se a cânula de orifício frontal (COF) e 22 com a nova cânula de orifício lateral (COL), distribuídos randomicamente. A incidência de extrusão de cimento ortopédico ocorreu em 27 por cento com a COL, e 68 por cento com a COF, todas assintomáticas (p<0,01). O controle da dor foi similar em ambos os grupos, com boa melhora da dor na maioria dos pacientes, sem complicações clínicas relevantes. A extrusão do cimento pode ser significativamente reduzida com esta nova COL, que permite uma melhor injeção do cimento para o centro do corpo vertebral, aumentando a segurança do procedimento, sem aumento no seu custo.

Cifoplastia percutanea con balón en fracturas por compresión de etiología no traumática en columna torácica y lumbar / Percutaneous balloon kyphoplasty in non-traumatic lumbar and thoracic spinal compression fractures

Purpose: To describe our experience with percutaneous balloon kyphoplasty for the treatment of non-traumatic vertebral compression fractures. Material and Methods: Between march 2007 and June 2008, 25 vertebrae interventions were performed in 10 patients. Ten cases corresponded to osteoporotic fractures, while fifteen of them revealed a tumoral etiology. Vertebral compromise was evaluated via CT scan or MRI, as appropriate. We applied a percutaneous technique. Balloons were inserted into the vertebral body, and then inflated to create a cavity to be filled with polymethylmethacrylate (PMMA), which reduces and stabilizes the fracture, thus reducing pain. Results: The technique was performed successfully in al I cases. Pain intensity assessed by Visual Analogue Scale (VAS) before and after the procedure showed a variation ranging from 4 to 7 levels per patient. The mean inicial VAS score was 7, whereas average final VAS was 1.2. The decrease in pain levels averaged 5.8 per intervention. Complications occurred in 7 levels: 3 cases of thoracic extravasations and 4 cases in lumbar spine. All of them were asymptomatic. No severe complications were reposed. Conclusions: Percutaneous balloon kyphoplasty offers a good alternative treatment to conservative pain management in vertebral compression fractures.

Propósito: Describir nuestra experiencia en cifoplastía percutanea con balón en fracturas vertebrales debidas a compresión no traumática. Material y Métodos: Se intervinieron 25 vértebras en 10 pacientes, 15 lumbares y 10 torácicas, entre marzo 2007 y junio 2008. La etiología de las fracturas fue osteoporótica en 10 casos y tumoral en 15. Se evaluó el compromiso vertebral mediante tomografía computada o resonancia magnética, según el caso. La técnica fue percutanea; se insertaron balones en el cuerpo vertebral, que se inflaron, creando así una cavidad que se relleno inyectando polimetilme-tacrilato (PMMA), que redujo y estabilizó la fractura, disminuyendo así el dolor. Resultados: La técnica fue realizada satisfactoriamente en todos los casos. La intensidad del dolor medida según la Escala Visual Análoga (EVA), antes y después del procedimiento, varió entre 4 y 7 niveles por paciente. El EVA de ingreso promedio fue de 7, y el de egreso de 1.2. La disminución del dolor fue en promedio 5.8 niveles por intervención. Hubo complicaciones en 7 niveles: 3 casos de extravasación torácica y 4 en columna lumbar, todas asintomáticas. No hubo complicaciones severas. Conclusiones: La cifoplastía con balón es una buena alternativa analgésica al manejo conservador en fracturas vertebrales por compresión.

Fracturas vertebrales osteoporóticas: manejo conservador / Osteoporotic vertebral fractures: conservative management

Osteoporotic vertebral fractures are a consequence of a systemic skeletall disease (osteoporosis) that results in an increase of bone fragility and fracture risk. The Orthopedic Surgeon may be the only doctor who evaluate a patient with a fracture and should be able to show whether this is due to osteoporotic process, to give an integral treatment and prevent future fractures. Vertebral osteoporotic fracture, are associated with pain, disability, increased morbidity and mortality and a major economic impact on society. Conservative treatment of these fractures is composed of non-pharmacological and pharmacological treatment. The nonpharmacological treatment serves as a complement to pharmacological treatment and optimizes the reduction in risk of fractures. The main objective of treatment is to prevent future fractures. The secondary objectives are to reduce pain and disability associated. In this review of the literature, we summarize the drugs and techniques currently used to treat osteoporosis and to prevent future fractures.

Las fracturas vertebrales osteoporóticas son parte de una enfermedad esquelética sistémica (osteoporosis) que resulta en un aumento de la fragilidad ósea y del riesgo a fracturarse. El traumatólogo puede ser el único médico que evalúe a un paciente con una fractura y debe ser capaz de demostrar si esta es de causa osteoporótica, para así dar un tratamiento integral y prevenir fracturas futuras. Las fracturas vertebrales osteoporóticas (FVO) se asocian a dolor, discapacidad, aumento de morbi-mortalidad y un gran impacto económico para la sociedad. El tratamiento de estas fracturas tiene un manejo farmacológico y no farmacológico. El tratamiento no farmacológico complementa el tratamiento farmacológico y optimiza la reducción del riesgo de fracturas. El principal objetivo del tratamiento es el de prevenir nuevas fracturas. Los objetivos secundarios son disminuir el dolor y la discapacidad asociada. En esta revisión de la literatura se señalaran los fármacos y técnicas utilizadas en la actualidad para el tratamiento de la osteoporosis y prevención de nuevas fracturas.

Vertebroplastia percutânea nas fraturas vertebrais por osteoporose: avaliação a longo prazo / Percutaneous vertebroplasty for vertebral osteoporotic fractures: long term analysis

OBJETIVO: Avaliar a resposta terapêutica a longo prazo da vertebroplastia percutânea para o tratamento da dor decorrente de fraturas de corpo vertebral por osteoporose. MÉTODO: Foram realizadas 26 vertebroplastias percutâneas em 15 pacientes com dor por fraturas osteoporóticas de corpo vertebral, durante o período de julho de 2001 a maio de 2004. Imediatamente antes e após o procedimento, foi aferido o grau de dor de cada paciente com base em uma escala verbal álgica entre zero e dez. Esta aferição foi repetida a longo prazo, com um ano de intervalo, sendo ainda investigada a satisfação do paciente, a deambulação e as atividades diárias (escalas de cinco pontos). RESULTADOS: Observou-se que a maioria dos pacientes (n=13) apresentava escala verbal de dor entre 8 e 10 antes da vertebroplastia. Houve importante redução álgica no dia seguinte, com 9 pacientes apresentando ausência de dor e três pacientes escala álgica entre 1 e 4 (p<0,001). No acompanhamento a longo prazo, com um ano de intervalo, a melhora dos sintomas se manteve, sem diferença significativa na escala de dor, na deambulação e nas atividades diárias. Quando questionados se fariam novamente este tratamento no caso de nova fratura vertebral, 14 pacientes responderam que sim. CONCLUSÃO: A vertebroplastia percutânea pode ocasionar importante melhora da dor em pacientes com fraturas osteoporóticas de corpo vertebral, quando bem selecionados, com boa resposta a longo prazo.

OBJECTIVE: To assess the long-term efficacy of percutaneous vertebroplasty for the treatment of pain resulting from osteoporotic vertebral fractures. METHOD: 26 percutaneous vertebroplasty procedures were performed for osteoporotic vertebral fractures in 15 patients during the period between July 2001 and May 2004. Before and after the procedure, a 10-point scale of pain was obtained. These scale was repeated at long-term follow up in two different moments after the procedure with one year interval. During these moments, the satisfaction, ambulation and ability to perform activities of daily living (five-point scale) were also analyzed. RESULTS: The majority of patients (n=13) presented the 10-point pain scale between 8 and 10 before the percutaneous vertebroplasty. After the procedure, there was important improve of the pain, and nine patients presented zero point-scale and three patients between 1 and 4 (p<0.001). At long-term follow up with one year interval, there was no significant difference between the pain scale, the ambulation and the ability to perform activities of daily living. Fourteen patients reported a future willingness to undergo the procedure for treatment in case of a new compression fracture. CONCLUSION: Percutaneous vertebroplasty can be a useful procedure for the treatment of pain and disability after secondary osteoporotic vertebral fractures with durable results in selected patients.

Fracturas vertebrales, osteoporosis y vitamina D en la posmenopausia: Estudio en 555 mujeres en Chile / Vertebral fractures, osteoporosis and vitamin D levels in Chilean postmenopausal women

Background: Approximately one-third of vertebral fractures can be clinically diagnosed. Aim: To study the frequency of vertebral fractures in postmenopausal women. Patients and methods: We recruited 555 postmenopausal women from Santiago, Chile, aged 55-84 years, who manifested interest in their bone health. All were healthy by self-declaration and by general clinical and laboratory tests and had not taken any bone-active therapy. They all underwent a spine and femoral neck (FN) densitometry and a digital lateral spine X-ray from T4 to L4 was obtained. PTH, calcidiol, and other parameters of calcium metabolism were also measured. Results: Overall, 142 of 478 patients with a complete study (29.7 percent) had at least one vertebral fracture. The proportion of women with fractures increased with age. A T score below -2.5 in the spine and hip was found in 32 percent and 14 percent of women, respectively. The proportion of women with spinal opeoporosis doubled between ages 55-70 and remained constant afterwards. In contrast, at the femoral neck, this proportion increased progressively reaching 53.3 percent at age 80-85. However, 56 percent of patients with vertebral fractures did not have densitometric osteoporosis in any location. Calcidiol levels were 16.8±6.8 ng/mL. With a cutoff point of 17 ng/mL, 47.5 percent of the patients had hypovitaminosis D. There was no association between calcidiol levels and vertebral fractures or bone density at the spine or femoral neck. Patients with fractures differed from those without fractures in that they had significantly lower bone density at the spine and hip and were older (p <0.001). However they did not differ in weight, body mass index, or calcidiol levels. Conclusions: Thirty percent of postmenopausal women in this series had a vertebral fractures. Osteoporosis and vitamin D deficiency were also common. Most vertebral fractures were observed in women without osteoporosis by densitometric criteria.

Fracturas tóracolumbares por lomo de toro / Thoracolumbar fractures secondary to speed bumps

Thirty one patients with thoracolumbar fractures secondary a jump inside a motor vehicle over a speed bump were retrospectively analyzed. All patients were treated in the Hospital del Trabajador Santiago between 1996 and 2005. 83 percent of the patients were female and 54.8 percent presented comorbidities. 30 had an accident in a bus, 90 percent seated in the last seat. 100 percent fractures were a type A. Seven patients were surgically treated, with two cases of permanent disability with chronic pain. Mean rest time was 108 days. We analyzed the mechanism of injury, the importance of the injury and the law in Chile related to the construction of these safety devices, concluding a rationalization of these speed bumps is necessary.

Estudio retrospectivo descriptivo de 31 pacientes con fractura toracolumbar secundaria a salto en vehículo motorizado sobre un lomo de toro, tratados en el Hospital del Trabajador de Santiago (HTS) entre los años 1996 y 2005. El 83 por ciento de los pacientes fueron mujeres, y 54.8 por ciento presentaban comorbilidades. Treinta se accidentaron en microbús, 90 por ciento sentados en el último asiento. 100 por ciento fracturas fuero tipo A sin compromiso neurológico. Siete pacientes requirieron cirugía, en dos casos se otorgó incapacidad. Tiempo de reposo promedio e 108 días. Se analiza el mecanismo de lesión, la gravedad y la normativa vigente en Chile sobre la confección de dispositivos de seguridad, concluyendo que es necesaria la racionalización de estos.

Fratura traumática de coluna torácica T1-T10 / Traumatic fracture of the thoracic spine T1-T10

Descrevemos a incidência, causas, manejo e prognóstico das fraturas traumáticas de coluna torácica de T1 a T10. Estudamos retrospectivamente os casos cirúrgicos de fraturas traumáticas da coluna torácica (T1 a T10), durante o período de junho de 1994 a junho de 2003. O tipo de fratura foi determinado segundo a classificação de Gertzbein e o grau de estabilidade através da classificação de Denis. O quadro neurológico à internação e 30 dias após a cirurgia foi avaliado através da classificação de ASIA/IMSOP. O objetivo da cirurgia nos pacientes com lesão medular completa (n=7) foi de estabilização, enquanto nos casos de instabilidade vertebral em que não houve lesão medular ou esta foi incompleta (n=12), optou-se pela descompressão do tecido nervoso, correção do alinhamento da coluna e estabilização da coluna.

Paraplegia complicating percutaneous vertebroplasty for osteoporotic vertebral fracture: case report

Relatamos um caso de compressão medular e radicular durante vertebroplastia percutanea transpedicular com polimetilmetacrilato (VPTP) para tratamento de fratura com compressão por osteoporose. O início súbito de dor lancinante na distribuição do 6º nervo intercostal direito, com hiperemia ao longo de seu trajeto, determinou a interrupção do procedimento. Sob sedação com narcóticos, a paciente foi levada ao CTI, sendo administrados 10mg de dexametazona por via endovenosa. Após algumas horas, ela desenvolveu paraplegia com preservação do tato, e a TC e a RM mostraram extravazamento epidural de polimetilmetacrilato com compressão medular e radicular. Descompressão cirúrgica resultou em recuperação neurológica. O cimento foi removido após ter sua espessura diminuída com o uso de broca de alta rotação, usando técnica microcirúrgica através de laminectomia ampla de tres níveis de T5 a T7. Extravazamento de cimento é comumente encontrado em VPTP, sendo assintomático na maioria das vezes. Compressão radicular pode requerer intervenção cirúrgica se não responsiva ao tratamento com corticosteróides. Compressão medular é vista com menos frequência e requer cirurgia de emergência. O cimento não adere à dura-máter e pode ser removido facilmente.

As fraturas vertebrais e do terço proximal do fêmur como conseqüência da osteoporose / The vertebral fractures and the proximal extremity of the femur as a consequence of the osteoporosis

Propöe-se fazer um resumido levantamento bibliográfico da osteoporose primária Tipo I, ou pós-menopausal, e Tipo II, ou relacionada ao envelhecimento, e as fraturas decorrentes desta alteraçäo, com um enfoque especial nas fraturas vertebrais e do terço proximal do fêmur. Sabe-se que as fraturas têm um impacto muito grande na qualidade de vida dos pacientes osteoporóticos, em especial, o idoso.