Therapeutisches Vorgehen bei osteoporotischen Wirbelkörperfrakturen

Zusammenfassung

Die Inzidenz von Rückenschmerzen aufgrund osteoporotischer Wirbelkörperfrakturen nimmt vor dem Hintergrund der demogra-fischen Entwicklung in Deutschland zu. Die Diagnostik umfasst neben Anamnese und Untersuchung ein Röntgenbild möglichst im Stand. Bei Frakturverdacht sollte ein MRT erfolgen, bei instabilen Frakturen zusätzlich ein CT. Des Weiteren sind eine DXA-Knochendichtemessung und ein Osteoporose-Basislabor erforderlich. Eine konservative Therapie ist ausreichend bei mobilen Patienten ohne neurologische Defizite und ohne Progredienz der Sinterung. Eine operative Behandlung ist indiziert bei immobilisierenden Schmerzen, neurologischer Symptomatik und/oder Frakturprogredienz. Eine neue Klassifikation osteoporotischer Wirbelfrakturen wird vorgestellt (OF-Klassifikation) sowie ein damit verbundener Score als Hilfe für die therapeutische Indikationsfindung. Die operativen Behandlungsmöglichkeiten sind vielfältig und müssen Frakturmorphologie, Wirbelsäulenprofil und Nervenkompressionen berücksichtigen. Es sollten möglichst minimalinvasive Techniken zur Anwendung kommen. Bei allen Wirbelkörperfrakturen mit einem DXAT-Score < –2,0 wird die Einleitung einer medikamentösen Osteoporosetherapie empfohlen.

Summary

Due to the demographic trend in Germany, there is increasing incidence of back pain related to osteoporotic vertebral fractures. Diagnostics include history and clinical examination, as well as an x-ray in standing position. If a fracture is suspected, an MRI should be done. In instable fractures, a CTscan should be added. In addition, a DXAdensitometry and a blood test for secondary osteoporosis should be carried out. A conservative treatment is indicated in mobile patients without neurological symptoms or progression of the fracture deformity. A surgical treatment is indicated in patients with immobilizing pain, neurological symptoms and/or progression of the fracture. A new classification of osteoporotic vertebral fractures is presented (OF-classification), as well as a connected score to help making the right therapeutic decision. Surgical treatment options are diverse and have to take fracture morphology, spinal curvature and additional neural compression into account. In general, minimally invasive techniques should be used. In all patients treated conservatively or surgically for vertebral fractures with a T-score < –2,5, a specific osteoporosis medication should be initiated.

Schlüsselwörter

Osteoporotische Wirbelkörperfrakturen - OFKlassifikation

Keywords

Osteoporotic vertebral fractures - OF-classification

• Literatur

• 1 Dachverband Osteologie (DVO) e. V. Leitlinie Osteoporose 2014 Langfassung. www.dv-osteologie.org/dvo_leitlinien/osteoporose-leitlinie-2014
• 2 Schürer C, Wallaschofski H, Nauck M. et al. Fracture risk and risk factors for osteoporosis. Dtsch Arztebl Int 2015; 112: 365-371.
• 3 Hadji P, Klein S, Gothe H. et al. The epidemiology of osteoporosis – Bone Evaluation Study (BEST): an analysis of routine health insurance data. Dtsch Arztebl Int 2013; 110: 52-57.
• 4 Fink HA, Milavetz DL, Palermo L. et al.; Fracture Intervention Trial Research Group. What proportion of incident radiographic vertebral deformities is clinically diagnosed and vice versa?. J Bone Miner Res 2005; 20: 1216-1222.
• 5 Dennison EM, Compston JE, Flahive J. et al.; GLOW Investigators. Effect of co-morbidities on fracture risk: findings from the Global Longitudinal Study of Osteoporosis in Women (GLOW). Bone 2012; 50: 1288-1293.
• 6 Schnake KJ, Hahn P, Franck A. et al.; AG Osteoporotische Wirbelfrakturen. Development of a classification system (OF-classification) and of a score for therapeutic decision making (OF-score) for osteoporotic thoracolumbar fractures. Eur Spine J 2013; 22: 2590.
• 7 Schnake K, Bouzakri N, Blattert T. et al.; AG Osteoporotische Frakturen. Validation of a classification system for osteoporotic thoracolumbar fractures (OF-classification). Eur Spine J 2014; 23: 2511.
• 8 Longo UG, Loppini M, Denaro L. et al. Conservative management of patients with an osteoporotic vertebral fracture: a review of the literature. J Bone Joint Surg Br 2012; 94: 152-157.
• 9 Pfeifer M, Begerow B, Minne HW. Effects of a new spinal orthosis on posture, trunk strength, and quality of life in women with postmenopausal osteoporosis: a randomized trial. Am J Phys Med Rehabil 2004; 83: 177-186.
• 10 Pfeifer M, Kohlwey L, Begerow B, Minne HW. Effects of two newly developed spinal orthoses on trunk muscle strength, posture, and quality-of-life in women with postmenopausal osteoporosis: a randomized trial. Am J Phys Med Rehabil 2011; 90: 805-815.
• 11 Rzewuska M, Ferreira M, McLachlan AJ. et al. The efficacy of conservative treatment of osteoporotic compression fractures on acute pain relief: a systematic review with meta-analysis. Eur Spine J 2015; 24: 702-714.
• 12 Anderson PA, Froyshteter AB, Tontz WL. Metaanalysis of vertebral augmentation compared with conservative treatment for osteoporotic spinal fractures. J Bone Miner Res 2013; 28: 372-382.
• 13 McGirt MJ, Parker SL, Wolinsky JP. et al. Vertebroplasty and kyphoplasty for the treatment of vertebral compression fractures: an evidenced-based review of the literature. Spine J 2009; 09: 501-508.
• 14 Wardlaw D, Cummings SR, Van Meirhaeghe J. et al. Efficacy and safety of balloon kyphoplasty compared with non-surgical care for vertebral compression fracture (FREE): a randomised controlled trial. Lancet 2009; 373: 1016-1024.
• 15 Chang X, Lv YF, Chen B. et al. Vertebroplasty versus kyphoplasty in osteoporotic vertebral compression fracture: a meta-analysis of prospective comparative studies. Int Orthop 2015; 39: 491-500.
• 16 Ma XL, Xing D, Ma JX. et al. Balloon kyphoplasty versus percutaneous vertebroplasty in treating osteoporotic vertebral compression fracture: grading the evidence through a systematic review and meta-analysis. Eur Spine J 2012; 21: 1844-1859.
• 17 Wang H, Sribastav SS, Ye F. et al. Comparison of Percutaneous Vertebroplasty and Balloon Kyphoplasty for the Treatment of Single Level Vertebral Compression Fractures: A Meta-analysis of the Literature. Pain Physician 2015; 18: 209-222.
• 18 Bouza C, López-Cuadrado T, Almendro N, Amate JM. Safety of balloon kyphoplasty in the treatment of osteoporotic vertebral compression fractures in Europe: a meta-analysis of randomized controlled trials. Eur Spine J 2015; 24: 715-723.
• 19 Bula P, Lein T, Straßberger C, Bonnaire F. Ballonkyphoplastie zur Behandlung osteoporotischer Wirbelfrakturen: Indikationen – Behandlungsstrategie – Komplikationen. Z Orthop Unfall 2010; 148: 646-656.
• 20 Gonschorek O, Lorenz M, Bühren V. Wirbelsäulenverletzungen – Fraktur bei Osteoporose. Trauma Berufskrankh 2015; 17 (Suppl. 01) 157-163.
• 21 Gu Y, Zhang F, Jiang X. et al. Minimally invasive pedicle screw fixation combined with percutaneous vertebroplasty in the surgical treatment of thoracolumbar osteoporosis fracture. J Neurosurg Spine 2013; 18: 634-640.
• 22 Allen RT, Kum JB, Weidner N. et al. Biopsy of osteoporotic vertebral compression fractures during kyphoplasty: unsuspected histologic findings of chronic osteitis without clinical evidence of osteomyelitis. Spine 2009; 34: 1486-1491.
• 23 Mukherjee S, Thakur B, Bhagawati D. et al. Utility of routine biopsy at vertebroplasty in the management of vertebral compression fractures: a tertiary center experience. J Neurosurg Spine 2014; 21: 687-697.