Joint Bone Spine 73 (2006) 564–566 http://france.elsevier.com/direct/BONSOI/
Case report
Kyphoplasty for pregnancy-associated osteoporotic vertebral fractures Suheda Bayram a, Cagatay Ozturk b,*, Koncuy Sivrioglu a, Ufuk Aydinli c, Selcuk Kucukoglu a a
b
Department of Physical Medicine and Rehabilitation, Uludag University Medical School, Bursa, Turkey Istanbul Spine Center, Florence-Nightingale Hospital, Abide-i Hürriyet Caddesi No: 290 Şişli-İstanbul, 80220 Istanbul, Turkey c Department of Orthopedic Surgery, Uludag University Medical School, Bursa, Turkey Received 3 June 2005; accepted 30 November 2005 Available online 24 March 2006
Abstract We report a case of pregnancy-associated osteoporotic vertebral fracture treated by kyphoplasty. This case is important for being the first case of postpregnancy osteoporotic vertebral fracture treated with kyphoplasty. Although kyphoplasty is a very successful procedure in short-term pain relief for osteoporotic vertebral fractures, there is a critical need for randomized controlled trials demonstrating short-term complications of kyphoplasty including new vertebral fractures. © 2006 Elsevier SAS. All rights reserved. Keywords: Pregnancy-associated vertebral fracture; Kyphoplasty; Postprocedure new vertebral fracture
1. Introduction
2. Case report
Traditional treatment for patients with osteoporotic vertebral fractures includes bed rest, analgesics, and bracing. This type of medical management obviously does nothing to restore spinal alignment, and lack of mobility itself can increase the rate of demineralization [1,2]. Because of the inherent risks and invasive nature, surgical treatment of osteoporotic vertebral compression fractures has been limited to cases in which there is concurrent spinal instability or neurological compromise.
A 37-year-old woman developed sudden low back pain six weeks after a normal vaginal delivery with epidural anesthesia. She had been suffering from severe pain for nearly 1 month when evaluated for the first time. The pain increased with activity and there were no signs of numbness, weakness and radiation of pain. The severity of pain according to the visual analog scale (VAS) was 10 with activity. She took analgesics which were of no use and the pain kept increasing. The maternal weight gained through the pregnancy was 22 kg and the birth weight of the baby was 4200 g. She used to smoke 10– 15 cigarettes daily for 10 years. Lumbar examination revealed extremely limited flexion. No deficit was found when evaluated neurologically. Systemic examination showed no signs of infectious, malignant or rheumatologic diseases. Compression fractures of the lumbar 2, 3, 4 vertebrae were seen in X-rays and magnetic resonance imaging (Fig. 1). Neural roots were not compressed within the canal or the foramina. There were no signs of metabolic, metastatic or infectious bone diseases in the laboratory and radiological findings.
Postpregnancy spinal osteoporosis is a rare condition that can cause multiple vertebral fractures. Symptoms include back pain which usually occurs in a few months after delivery. We report here a woman who developed non-traumatic vertebral compression fractures over a lactation period of 6 weeks. This case is also important for being the first case of postpregnancy osteoporotic vertebral fracture treated with kyphoplasty. * Corresponding
author. E-mail address:
[email protected] (C. Ozturk).
1297-319X/$ - see front matter © 2006 Elsevier SAS. All rights reserved. doi:10.1016/j.jbspin.2005.11.015
S. Bayram et al. / Joint Bone Spine 73 (2006) 564–566
Fig. 1. MRI images showing the fractures of the patient.
Complete blood count was in normal ranges. Erythrocyte sedimentation rate was slightly increased (25 mm/h). Biochemical and pharmacological results associated with calcium metabolism were within normal ranges (blood calcium: 9.7 mg/dl, parathormone: 24 pg/ml, calcitonin: 5 pg/ml) except the relatively low level of 25-OH vitamin D (16 ng/ml). Renal secretion of calcium, phosphorus and creatinin in 24-hour urine was 149, 726 and 682 mg, respectively. Bone mineral density was measured with dual X-ray absorbsiometry (Hologic 4500 W). T scores in the hip and lumbar region showed osteopenia. The scores were –2.4, –2.1, –2.1 in neck, trochanteric and intertrochanteric regions, respectively, and the total T score of hip was –2.3. Lumbar T scores of 1st, 2nd, 3rd and 4th vertebrae were –2.7, –0.4, –1.7 and –1.1, respectively, and the total T score of lumbar region was –1.5. The clinical findings, laboratory and radiological data strengthen the diagnosis of pregnancy-associated osteoporosis. Medical treatment included daily intake of calcium carbonate which contains 1200 mg ionized calcium, 800 IU vitamin D3, 200 IU nasal calcitonin and weekly 70 mg alendronate sodium. She was also advised to bottlefeed her baby. In order to decrease pain, kyphoplasty was performed for L2, L3 and L4 vertebrae by an orthopedic surgeon (Fig. 2). Her low back pain decreased to a degree of “0” within a few days after kyphoplasty. She was comfortable with her daily living activities. But she experienced a sudden onset of new low back pain while bending forward two weeks after the kyphoplasty. MRI of the spine demonstrated new fractures of L1 and T11 vertebrae (Fig. 3). She was then advised to wear a thoracolumbosacral orthosis, limit physical activities and continue medication. The pain gradually decreased from 10 to 2 according to VAS in a 1-month follow-up.
565
Fig. 2. Kyphoplasty was performed at three levels.
Fig. 3. MRI of the spine demonstrated new fractures of L1 and T11 vertebrae.
3. Discussion Pregnancy has been called a “physiologic absorptive hypercalciuric state”. When the normal adaptations of maternal skeleton fail to take place, rare pathologic conditions like postpregnancy spinal osteoporosis or transient osteoporosis of hip can occur. In normal pregnancy, calcium absorption doubles as a result of elevated calcitriol and PTH-related peptide levels and direct intestinal effect of estrogen. During lactation, calcitriol levels tend to stay high but do not achieve the same con-
566
S. Bayram et al. / Joint Bone Spine 73 (2006) 564–566
centrations seen in pregnancy. Different from pregnancy period, calcium levels are conserved with renal mechanism during lactation [3]. Most of the studies concerning bone mineral changes show little or no change in bone mineral density during pregnancy, while lactation is generally associated with bone loss which is usually recovered after weaning or resumption of menstruation [4–10]. Postpregnancy osteoporosis resulting in vertebral fractures is a rare but very painful condition limiting daily living activities. More than one vertebra is affected generally in the thoracic and lumbar regions. Back pain associated with the vertebral compression usually occurs several months after first or second pregnancy and there is no history of recurrence. Low calcium dietary intake is common in most cases [11–14]. This case of postpregnancy osteoporosis that we report reflects similar clinical characteristics of the women reported in the literature. Differing from the literature, we decided to perform a kyphoplasty operation in order to relieve pain quickly, restore vertebral height and allow early mobilization. This is the first case of postpregnancy osteoporosis treated with kyphoplasty. Options for treatment of painful vertebral compression fractures include non-surgical approaches, such as analgesic medication, bed rest, and back braces. This treatment approach does not address spinal deformity, and the pain and disability may be prolonged while the fractured vertebral body heals [15]. There is no study of kyphoplasty reporting the incidence of postprocedure vertebral fractures. Donovan et al. recently reported a postmenopausal woman with steroid-induced osteoporosis who sustained multiple adjacent vertebral fractures in the days immediately following L2 kyphoplasty [16]. Our patient being the first case of postpregnancy osteoporosis treated with kyphoplasty is also important for the occurrence of postprocedure new vertebral fractures. Although kyphoplasty is a very successful procedure in short-term pain relief for osteoporotic vertebral fractures, there is a critical need for randomized controlled trials demonstrating short-term complications of kyphoplasty including new vertebral fractures.
References [1] Heaney RP. The natural history of vertebral osteoporosis: is low bone mass an epiphenomenon? Bone 1992;13(suppl 2):23–6. [2] Lieberman IH, Dudeney S, Reinhardt MK, Bell G. Initial outcome and efficacy of kyphoplasty in the treatment of painful osteoporotic vertebral compression fractures. Spine 2001;26:1631–8. [3] Kohlmeier L, Marcus R. Osteoporosis associated with pregnancy. In: Marcus R, Feldman D, Kelsey J, editors. Osteoporosis (vol 2). California: Academic Press; 1996. p. 341–9. [4] Holmberg-Marttila D, Sievanen H, Laippala P, Tuimala R. Factors underlying changes in bone mineral during postpartum amenorrhea and lac tation. Osteoporos Int 2000;11:570–6. [5] Karlsson C, Obrant KJ, Karlsson M. Pregnancy and lactation confer reversible bone loss in humans. Osteoporos Int 2001;12:828–34. [6] Kaur M, Pearson D, Godber I, Lawson N, Baker P, Hosking D. Longitudinal changes in bone mineral density during normal pregnancy. Bone 2003;32:449–54. [7] More C, Bettembuk P, Bhattoa HP, Balogh A. The effects of pregnancy and lactation on bone mineral density. Osteoporos Int 2001;12:732–7. [8] Oliveri B, Parisi MS, Zeni S, Mautalen C. Mineral and bone mass change during pregnancy and lactation. Nutrition 2004;20:235–40. [9] Pearson D, Kaur M, San P, Lawson N, Baker P, Hosking D. Recovery of pregnancy mediated bone loss during lactation. Bone 2004;34:570–8. [10] Phillips AJ, Ostlere SJ, Smith R. Pregnancy-associated osteoporosis: does the skeleton recover? Osteoporos Int 2000;11:449–54. [11] Chung HC, Lim SK, Lee MK, Lee MH, Huh KB. Pregnancy-associated osteoporosis. Yonsei Med J 1988;29:286–94. [12] Di Gregorio S, Danilowicz K, Rubin Z, Mautalen C. Osteoporosis with vertebral fractures associated with pregnancy and lactation. Nutrition 2000;16:1052–5. [13] Sarikaya S, Ozdolap S, Acikgoz G, Erdem CZ. Pregnancy-associated osteoporosis with vertebral fractures and scoliosis. Joint Bone Spine 2004; 71:84–6. [14] Yamaga A, Taga M, Takahashi T, Shirai T. A case of postpregnancy osteoporosis. Eur J Obstet Gynecol Reprod Biol 2000;88:107–9. [15] Silverman SL. The clinical consequences of vertebral compression fracture. Bone 1992;13(suppl 2):S27–31. [16] Donovan MA, Khandji AG, Siris E. Multiple adjacent vertebral fractures after kyphoplasty in a patient with steroid-induced osteoporosis. J Bone Miner Res 2004;19:712–3.
