Prehospital Pain and Analgesic Therapy in Elderly Patients with Hip Fractures.

INTRODUCTION: As a part of aging, hip fractures are becoming more common. The connection between increased pain and a poor outcome has previously been shown. Therefore, even in prehospital situations, analgesic therapy appears to be reasonable. We established a prospective study with 153 patients to evaluate the patients' pain levels during the prehospital phase of treatment and prehospital analgesic therapy. METHODS: We performed a prospective study on 153 patients the age of 60 years or older in a University hospital setting between 2010 and 2011 who suffered hip fracture. Analgesics given and the type of medical staff that was involved were documented. Pain was measured using the NRS upon initial contact of the medical staff and upon admission to our emergency department. RESULTS: Initial pain level evaluated by EMS (emergency medical service) was 6.8 (SD = 2.7). Twenty-two percent of the patients reported an NRS of 10 as the highest value following their injury. Forty-three of 153 patients (28%) received analgesics. The mean initial pain score for those 43 patients who did receive pain medication was 7.0 (SD = 2.6). However, this score dropped to a mean of 2.8 (SD = 1.4) upon hospital arrival (P < 0.001). The patients who did not receive pain medication had an initial pain score of 4.5 (SD = 1.9). Upon admission to the hospital, this score decreased to a mean of 4.0 (SD = 1.7, P = 0.092). CONCLUSION: Only a minority of patients with hip fractures received prehospital analgesia. The administration of prehospital analgesia was associated with significant pain relief.

The efficacy of a percutaneous expandable titanium device in anatomical reduction of vertebral compression fractures of the thoracolumbar spine.

OBJECTIVES: To evaluate the feasibility of a minimally invasive technique using a titanium expandable device to achieve anatomical restoration of vertebral compression fractures (VCF) of the thoracolumbar spine. METHODS: This prospective study included 27 patients diagnosed with VCF (Magerl classification A.1.2, A.1.3, and A.3.1) of the thoracolumbar spine treated with percutaneous cement augmentation using the SpineJack® device. The study was conducted in Valladolid University Hospital, Valladolid, Spain from January to December 2012, with a minimum one-year follow up. Preoperative evaluation included visual analogue scale (VAS) for pain, and radiological assessment of the VCF using 3-dimensional computed tomography (3D-CT) scans for measurements of vertebral heights and angles. The patients were followed at 3, 6, and 12 months with clinical VAS and radiological assessments. RESULTS: The procedure was performed in 27 patients with a mean age of 55.9 ± 17.3 years, 55.6% females. All patients underwent surgery within 6 weeks from time of injury. No procedure related complications occurred. Pain measured by VAS score decreased from 7.0 preoperatively to 3.2 within 24 hours, and remained 2.2 at 3 months, 2.1 at 6 months, and 1.5 at 12-months follow-up (p<0.05). Mean height restorations for the anterior was 3.56 mm, central was 2.49, and posterior vertebral was 1.28 mm, and maintained at 12-months follow-up (p=0.001). CONCLUSION: This new percutaneous technique for VCF has shown good clinical results in pain control and the possibility to reduce both vertebral kyphosis angles and fractured endplates seen in 3D-CT scans assessment method. Further studies are needed to confirm those results on larger cohorts with long-term follow up. 

Early or delayed stabilization in severely injured patients with spinal fractures? Current surgical objectivity according to the Trauma Registry of DGU: treatment of spine injuries in polytrauma patients.

BACKGROUND: Because of a lack of evidence, the appropriate timing of surgical stabilization of thoracic and lumbar spine injuries in severely injured patients is still controversial. Data of a large international trauma register were analyzed to investigate the medical care situation of unstable spinal column fractures in patients with multiple injuries, so as to examine the outcome related to timing of surgical stabilization. METHODS: Data sets of the Trauma Registry of German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie [DGU]) (1993-2010) were analyzed. The Trauma Registry of DGU is a prospective, multicenter register that provides information on severely injured patients. All patients with an Injury Severity Score (ISS) of 16 or greater caused by blunt trauma, subsequent treatment of 7 days or more, 16 years or older, and thoracic or lumbar spine injuries (spine Abbreviated Injury Scale [AIS] score ≥ 2) were included in our analysis. Patients with relevant spine injuries classified as having a spine AIS score of 3 or greater were further analyzed in terms of whether they got early (<72 hours) or late (>72 hours) surgical treatment due to unstable spinal column fractures. RESULTS: Of 24,974 patients, 8,994 (36.0%) had documented spinal injuries (spine AIS score ≥ 2). A total of 1,309 patients who sustained relevant thoracic spine injuries (spine AIS score ≥ 3) and 994 patients who experienced lumbar spine trauma and classified as having spine AIS score of 3 or greater were more precisely analyzed. Of these, 68.2% and 71.0%, respectively, received an early thoracic or lumbar spine fixation. With an increase in spinal injury severity, an increase in early stabilization in the thoracic and lumbar spine was seen. In the group of patients with early surgical stabilization, significantly shorter hospital stays, shorter intensive care unit stays, fewer days on mechanical ventilation, and lower rates of sepsis were seen. In the case that additional body regions were affected, for example, when patients were critically ill, a delayed spinal stabilization was more often performed. CONCLUSION: A spinal stabilization at an early stage (<72 hours) is presumed to be beneficial. Although some patients may require delay due to necessary medical improvement, every reasonable effort should be made to treat patients with instable spinal column fractures as soon as possible. If an early surgical treatment is feasible, severely injured patients may benefit from a shorter period of hospital treatment and a lower rate of complications. LEVEL OF EVIDENCE: Therapeutic study, level III.

Height restoration and preservation in osteoporotic vertebral compression fractures: a biomechanical analysis of standard balloon kyphoplasty versus radiofrequency kyphoplasty in a cadaveric model.

STUDY DESIGN: Biomechanical cadaver study. OBJECTIVE: The aim of the present study was to evaluate 2 different methods with respect to height restoration and preservation in a cadaver model under cyclic loading. SUMMARY OF BACKGROUND DATA: Standard balloon kyphoplasty (BKP) represents a well-established treatment opportunity for osteoporotic vertebral compression fractures. BKP was developed to restore vertebral height and improve sagittal alignment. Its use has grown significantly over the last 2 decades. In contrast, distinct biomechanical data are missing. Within the last few years, several alternative techniques with regard to height restoration have emerged, such as radiofrequency kyphoplasty (RFK). METHODS: Twenty-five vertebral bodies of 2 female cadavers with secured osteoporosis were examined. Standardized vertebral wedge compression fractures were created. Afterward, 2 groups were randomly assigned: 12 vertebral bodies were treated with BKP and 13 vertebral bodies by RFK under a preload of 100 N. Then the vertebral bodies underwent cyclic loading (100,000 cycles, 100 to 600 N, 5 Hz). Anterior, central, and posterior vertebral body heights were evaluated by CT scans. RESULTS: Anterior height was reduced after fracture 6.3 mm (SD 3) for the BKP group and 7.2 mm (SD 3) in the RFK group (P>0.1). After treatment, the difference in the initial anterior height was 4.5 mm (SD 2) for the BKP group and 4.7 mm (SD 3) for the RFK group (P>0.1). After cyclic loading, the difference was 5.3 mm (SD 3) for the BKP group and 5.2 mm (SD 3) for the RFK group (P>0.1). The average cement volume used was 8.7 mL (SD 1) for the BKP group and 4.8 mL (SD 2) for the RFK group (P<0.0001). CONCLUSIONS: On the basis of our results, the unipedicular RFK in osteoporotic compression fractures might represent a promising alternative for the clinical setting.

Detection of pulmonary cement embolism after balloon kyphoplasty : should conventional radiographs become routine?

Fatal pulmonary cement embolism is the worst complication after balloon kyphoplasty. Therefore the authors conducted a prospective study about the use of postoperative plain radiographs of the chest as a screening tool for the detection of pulmonary cement embolism. More specifically, they tried to determine its incidence. Postoperative AP and lateral plain radiographs of the chest confirmed this diagnosis in only one out of 94 patients (1%). Systematic use of CT would probably have led to a higher incidence. To the authors' knowledge this is the only study assessing the incidence of pulmonary cement embolism after balloon kyphoplasty. Computed tomography confirmed the diagnosis in the single patient affected , but she remained asymptomatic. Given the low incidence, routine postoperative plain radiographs of the chest do not seem to be indicated in asymptomatic patients, although the radiation exposure is low. Reasonable suspicion (dyspnea, peroperative findings via image amplifier) warrants computed tomography for confirmation of the diagnosis.

Higher incidence of new vertebral fractures following percutaneous vertebroplasty and kyphoplasty--fact or fiction?

New vertebral fractures after percutaneous vertebroplasty or kyphoplasty are said to result from biomechanical changes induced by cementation. Fact or fiction? The reported incidences for new vertebral fractures after cementation or after conservative therapy vary widely. This is mainly due to differences in their design, more specifically as to the duration of followup. Therefore a systematic review of the literature was performed, searching for comparable publications to assess the potential risk of new vertebral fractures following vertebroplasty and kyphoplasty versus conservative treatment. Studies were only included if they granted a standardized one-year radiological follow-up, so improving comparability. However, a high degree of heterogeneity was still seen among the results, which made it impossible to state that cement augmentation is as safe as conservative treatment with respect to new fractures. In other words, it was impossible to separate facts from fiction with the studies available to-day. The combined odds ratio of vertebroplasty and kyphoplasty versus conservative treatment, namely 0.96, gave a hint that there might be little difference. Large scale randomized studies will be necessary.

Management of pulmonary cement embolism after percutaneous vertebroplasty and kyphoplasty: a systematic review of the literature.

Balloon kyphoplasty and percutaneous vertebroplasty are relatively recent procedures in the treatment of painful vertebral fractures. There are, however, still some uncertainties about the incidence and treatment strategies of pulmonary cement embolisms (PCE). In order to work out a treatment strategy for the management of this complication, we performed a review of the literature. The results show that there is no clear diagnostic or treatment standard for PCE. The literature research revealed that the risk of a pulmonary embolism ranges from 3.5 to 23% for osteoporotic fractures. In cases of asymptomatic patients with peripheral PCE we recommend no treatment besides clinical follow-up; in cases of symptomatic or central embolisms, however, we recommend to proceed according to the guidelines regarding the treatment of thrombotic pulmonary embolisms, which includes initial heparinization and a following 6-month coumarin therapy. In order to avoid any types of embolisms, both procedures should only be performed by experienced surgeons after critical determination of the indications.