SAT-LB64 Teriparatide and Its Bone Healing Power

Introduction: Teriparatide, a parathyroid hormone analog, is an important anabolic agent approved by the U.S. Food and Drug Administration to increase bone mineral density in osteoporotic patients. Parathyroid hormone (PTH) regulates calcium, phosphate, and active vitamin-D metabolites.The amino terminal peptide fragments of PTH has been known to increase bone mass and are being used in clinical practice for osteoporosis management (1). Current literature shows the efficacy of teriparatide in increasing bone density of lumbar spine and femoral neck, and decreasing the risk of vertebral and non-vertebral fractures both in postmenopausal women and men. It is also known to prevent fractures in patients with osteoporosis and promote healing of fractures (2). Case Description: A 79-year-old Hispanic female with history of osteopenia and major lumbar spine wedge compression fractures presented to our clinic for consultation. She was on ibandronate for the past four months and was having symptoms of pill esophagitis. Her last bone mineral density done on August 2017 revealed T-score of -2.5 at the lumbar spine, -1.5 at the left femoral neck, and 3.3% bone loss on the left femoral head. Rather than being started on teriparatide, zoledronic acid, or denosumab, she continued ibandronate along with calcium and vitamin D. Two months after the initial consultation, she sustained a traumatic fracture of the posterior arch and body of C2 bilaterally following a motor vehicle accident. There were discussions about starting anabolic treatment, as serial imaging did not show any significant improvement in the healing process despite the use of a collar. Two months after sustaining C2 fracture, she was started on teriparatide. Repeat cervical spine x-ray three months later showed complete healing of the C2 fracture. Discussion: There are a limited number of cases reported in regards to teriparatide induced healing of non-osteoporotic fractures (3). Our case is one of the very few reported to have shown complete radiographic and clinical healing of a traumatic, non-osteoporotic fracture after use of teriparatide for 12 weeks.

Tulip-Screw Head Disjunction from Posterior C2 Fracture Fixation Instrumentation

This report presents an unusual case of instrumentation failure after posterior fixation of a C2 fracture and reviews currently available treatment alternatives. The patient, a 53-year-old female, initially presented to the emergency department at an outside facility with acute alcohol intoxication and acute neck pain following a fall from a ladder. CT demonstrated bilateral C2 pars fractures and unstable posteroinferior displacement of the posterior elements. She underwent an emergent C2 open-reduction internal fixation (ORIF) at the outside facility with 3.5 mm polyaxial synapse pedicle screws (DePuy Synthes, Switzerland). There were no known complications and the patient was discharged. Two years after the index operation, cervical CT scan at a different facility revealed that although the fracture was fully healed, bilateral tulip caps had detached from the pedicle screw heads at C2. All implants were removed without postoperative complications. Industry review of alternate lag screws approved for the cervical spine demonstrated that there is not currently an ideal implant for fixation of C2 fractures without fusion. Cannulated trauma screws, which are low profile and would have avoided the instrumentation failure seen here, are not currently FDA approved for the cervical spine.

Chronic hypertrophic malunion of C2 Fracture causing cervical quadriparesis; Case report and focused literature review

Background: Pseudarthrosis of Type II C2 odontoid fractures typically leads to displacement and subluxation resulting in canal compression/cervical myelopathy. Case Description: Here, we present a 43-year-old male who sustained cervical trauma 28 years ago. He now presented with an acute 10-day onset of quadriparesis attributed to a chronic malunion of an unstable type II odontoid fracture. He successfully underwent a circumferential decompression and fusion (e.g., warranting a trans-oral odontoidectomy followed by C1-C3 posterior fusion). Conclusion: Progressive cervical myelopathy attributed to a chronic malunion of a type II odontoid fracture may require circumferential decompression/stabilization (e.g., an anterior decompression with osteophyte resection and posterior C1-C3 spinal stabilization).

Clinical Outcome Analysis of Posterior C1 and C2 Screw Rod Fixation (Harms–Goel Technique) in Traumatic Atlantoaxial Dislocation

Aims Evaluation of clinical profile, mode of injury, and clinical outcome in patients of traumatic atlantoaxial dislocation (AAD) who underwent posterior C1 and C2 screw and rod fixation by using Harms and Goel technique. Materials and Methods It is a retrospective study involving all traumatic AAD patients of all age groups admitted at Department of Neurosurgery, RMLIMS, Lucknow, during the last two years. Inclusion criteria was all cases having traumatic AAD with or without C2 fracture and underwent posterior C1 and C2 screw and rod fixation by Harms and Goel technique. Clinical profile, age, sex, mode of injury, types of injury (detected in MRI and CT of cranio-vertebral junction), preoperative and postoperative (after one month of surgery) neurological status were evaluated and outcome analyzed. Results Over all, out of 14 patients, 12 (85.7%) patients improved in the form of either reduced spasticity, improved sensation, increased power of one or more limbs, or bladder and bowel control. One (7.1%) patient retained preoperative status, neither improved nor deteriorated. However, one (7.1%) patient deteriorated, lost all sensations, motor functions below the lesion, bladder and bowel control, and died due to respiratory failure after one and half month of the surgery. Conclusion We concluded that Harms and Goel technique is a safe and effective system for achieving C1–C2 fusion in traumatic AAD. Although this study is very small, does not provide Class 1 data, and is subject to the bias of any retrospective series, we believe our findings to be a useful addition to the body of literature on the surgical treatment of C1–C2 instability.

Clenching Reduction Technique for Osteosynthesis of Atypical C2 Fractures with the Combining Use of Laminar and Pedicle Screw: A Technical Note

Atypical C2 fractures refer to all fracture types of the C2 body excluding odontoid fractures and traumatic spondylolisthesis of C2. A 55-year-old male patient presented with neck pain after a vehicular accident. Computed tomography (CT) showed an oblique fracture line of the C2 vertebral body through the pedicle and lamina with fracture gap and posterior displacement. We used a clenching reduction technique to treat this fracture by using an ipsilateral laminar screw and contralateral pedicle screw. The final follow-up CT scan showed complete bone union. Neck motion was preserved including rotation. For this unstable atypical C2 fracture, the clenching reduction technique proved to be a safe and effective technique while salvaging neck motion.