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Once-weekly teriparatide administration for an Anderson type II odontoid fracture in an elderly patient: A case report
Journal of Orthopaedic Science xxx (2015) 1e4
Contents lists available at ScienceDirect
Journal of Orthopaedic Science journal homepage: http://www.elsevier.com/locate/jos
Case report
Once-weekly teriparatide administration for an Anderson type II odontoid fracture in an elderly patient: A case report Takahiro Harada a, Takahiko Hamasaki a, *, Shingo Ohkawa a, Ryo Mori a, Yasunori Izuta a, Hiroki Hachisuka a, Toshihiro Matsuo a, Norikazu Hamada a, Nobuhiro Tanaka b, Mitsuo Ochi b, Takashi Sugita a a b
Department of Orthopaedic Surgery, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Kure, Hiroshima, Japan Department of Orthopaedic Surgery, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
a r t i c l e i n f o Article history: Received 21 December 2014 Received in revised form 25 March 2015 Accepted 5 April 2015 Available online xxx
1. Introduction Cervical spine injuries, especially upper cervical, have increased in the elderly [1]. In the elderly, stiffness of the lower cervical spine, caused by degenerative changes and osteopenia, might contribute to upper cervical spine injury, such as odontoid fracture, in response to low energy trauma such as a fall from standing height [2]. Anderson type II odontoid fractures are associated with high rates of mortality in elderly patients regardless of intervention [3]. Teriparatide, for the treatment of osteoporosis, has two types of medications: 1) 20 mg given once daily by self-administration (ForteoR, Eli Lilly and Company, Indianapolis, IN, USA). This medication has been widely used in many countries; 2) 56.5 mg given once weekly, administered by nurse or staff (TeriboneR, Asahi Kasei Pharma, Tokyo, Japan). This once-weekly medication has been used only in Japan. With intermittent use, teriparatide has an anabolic action on the bone, and the effect of bone turnover markers has been shown to differ between these two medications [4]. Although once-daily injection increases bone formation and bone resorption, once-weekly injection increases bone formation moderately and decreases or maintains bone resorption [4]. The effects of both medications on bone mineral density are similar [4].
* Corresponding author. Department of Orthopaedic Surgery, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, 3-1 Aoyama-cho Kure, Hiroshima, 7370023, Japan. Tel.: þ81 823 22 3111; fax: þ81 823 21 0478. E-mail address: [email protected] (T. Hamasaki).
Teriparatide has been shown to promote and even accelerate fracture healing in animal models [5], whereas in humans once-daily medications have seen cases of distal radius fracture [6], and onceweekly medications have seen cases of femoral neck fracture [7]. There have been only 2 reports that undisplaced type III odontoid fractures may be healed by teriparatide administered once daily [8,9]. However, there have been no reports that type II odontoid fractures may be healed by teriparatide given once weekly. The purpose of this report is to describe a case of a patient with a type II odontoid fracture that was successfully treated nonoperatively with teriparatide administered once weekly.
2. Report of the case The patient described below gave her permission for the details of her case to be presented for publication. An 85-year-old woman stumbled and fell, and had a 10 cm contused wound at her left forehead. She was conscious, and had no motor weakness and no sensory loss. She lived alone and independently, and her medical history was unremarkable. AP and lateral X-rays were interpreted as normal, but CT scans revealed that odontoid had osteosclerotic change and fractured an undisplaced Anderson type II. She had no previous cervical spine injury and no history of neck pain. There seemed to be connectivity of the cortex of dens, and there was little or no dislocation and instability (Fig. 1). Sagittal MRI, T1-weighted images showed low intensity and T2-weighted images showed a mixture of iso and high intensity areas at the odontoid, so it was concluded that this was a fresh fracture. There was no compression to the cord (Fig. 2). Dual-energy X-ray absorptiometry at the femoral neck showed a T-score of 2.1 and a bone mineral density (BMD) of 0.637 g/cm2, and at the lumbar showed a T-score of 1.1 and a BMD of 0.876 g/cm2. Laboratory examination for bone metabolic marker showed serum type I procollagen N-terminal pro-peptide (P1NP) of 46.8 (14.9e68.8) mg/l as bone formation marker, and tartrate-resistant acid phosphatase isoform 5b (TRACP-5b) of 297 (120e420) mU/dl as bone resorption marker.
http://dx.doi.org/10.1016/j.jos.2015.06.022 0949-2658/© 2015 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Harada T, et al., Once-weekly teriparatide administration for an Anderson type II odontoid fracture in an elderly patient: A case report, Journal of Orthopaedic Science (2015), http://dx.doi.org/10.1016/j.jos.2015.06.022
2
T. Harada et al. / Journal of Orthopaedic Science xxx (2015) 1e4
Fig. 1. CT with coronal (a) and sagittal (b) reconstructions at the time of injury. Odontoid had osteosclerotic change and fractured an undisplaced Anderson type II. There was connectivity of cortex of dens, and there was no dislocation and instability.
We diagnosed her as having an undisplaced type II odontoid fresh fracture with no spinal cord injury. And she was also considered to be osteoporotic, with the osteosclerotic change of the odontoid. We wondered that it might be difficult for bone union. She was applied with a Philadelphia collar, and 56.5 mg teriparatide subcutaneous injections (TeriboneR) were started and administered once weekly. Operative treatment would have been considered if her fracture had been dislocated or if she had myelopathic symptoms. However, she had neither. Three months after injury, bone formation marker, P1NP, showed the increase to 56.2 mg/l and BMD also showed the increase to 0.882 g/cm2 (lumbar) and 0.674 g/cm2 (femoral neck). CT revealed the re-calcification and some bone resorption at the osteosclerotic change of the odontoid (Fig. 3). The bone resorption area was slightly spread at 6 months (Fig. 4), but at 10 months, CT scans showed the bone formation of the cancellous and cortical of the odontoid, and the fracture had united successfully without dislocation (Fig. 5). During this period, she has remained pain free. Teriparatide were used until 1 year after injury, and were switched to alendronate (BonalonR).
Fig. 2. Sagittal MRI at the time of injury. T1-weighted image (a) showed low intensity and T2-weighted image (b) showed a mixture of iso and high intensity area at odontoid. There was no compression to the cord.
3. Discussion Non-operative treatment for Anderson type II odontoid fractures have been reported to have high non-union rates, as well as significant morbidity and mortality with prolonged cervical orthosis or halo immobilization [3]. So the current management generally favors operative reduction and stabilization. The union rate for type II is 53e64% when treated non-operatively, and 70e93% when treated operatively [3,8,9]. However, operative treatment in elderly patients presents some risks: higher risks during the perioperative period, particularly in patients with osteoporosis; screw related problems, screw back-out, screw loosening and non-union. We treated her non-operatively with cervical orthosis and teriparatide administered once weekly (TeriboneR). We expected
Please cite this article in press as: Harada T, et al., Once-weekly teriparatide administration for an Anderson type II odontoid fracture in an elderly patient: A case report, Journal of Orthopaedic Science (2015), http://dx.doi.org/10.1016/j.jos.2015.06.022
T. Harada et al. / Journal of Orthopaedic Science xxx (2015) 1e4
3
Fig. 3. CT with coronal (a) and sagittal (b) reconstructions at 3 months after injury. Satittal CT (b) revealed the re-calcification and some bone resorption at the osteosclerotic change of the odontoid.
once-weekly teriparatide not only to treat osteoporosis, but also to promote the fracture healing and to increase the bone strength when it might convert to the surgery. She had a Philadelphia collar on her neck and a once-weekly injection administered by the nurse was considered to offer minimum disruption to her cervical flexion position. She might have some more difficulty when a once-daily injection (ForteoR) administered by herself. Three months with a once-weekly teriparatide injection led to increase the BMD and
Fig. 4. CT with coronal (a) and sagittal (b) reconstructions at 6 months after injury. The bone resorption area was slightly spread at this time.
bone formation marker (P1NP), and also it might lead to bony union of odontoid fracture on CT. This is the first report to show the effectiveness of once-weekly teriparatide in Anderson type II odontoid fractures. So even Aderson type II odontoid fracture, 1) little or no dislocation and instability fracture cases, 2) moderate to severe osteoporotic patients
Fig. 5. CT with coronal (a) and sagittal (b) reconstructions at 10 months after injury. CT scans showed the bone formation of the cancellous and cortical of the odontoid. The fracture had united successfully without dislocation.
Please cite this article in press as: Harada T, et al., Once-weekly teriparatide administration for an Anderson type II odontoid fracture in an elderly patient: A case report, Journal of Orthopaedic Science (2015), http://dx.doi.org/10.1016/j.jos.2015.06.022
4
T. Harada et al. / Journal of Orthopaedic Science xxx (2015) 1e4
that may have low screw fixation force, and 3) aged patients with higher risks for general anesthesia, then non-operative treatment with teriparatide could be one option. 4. Conclusion Patients with an Anderson type II odontoid fracture can be treated non-operatively and successfully by teriparatide administered once weekly. Conflict of interests The authors declare no conflict of interests. References [1] Lomoschitz FM, Blackmore CC, Mirza SK, Mann FA. Cervical spine injuries in patients 65 years old and older: epidemiologic analysis regarding the effects of age and injury mechanism on distribution, type, and stability of injuries. AJR Am J Roentgenol 2002;178:573e7. [2] Watanabe M, Sakai D, Yamamoto Y, Sato M, Mochida J. Upper cervical spine injuries: age-specific clinical features. J Orthop Sci 2010;15:485e92.
[3] Schoenfeld AJ, Bono CM, Reichmann WN, Warholic N, Wood KB, Losina E, Katz JN, Harris MB. Type II odontoid fractures of the cervical spine: do treatment type and medical comorbidities affect mortality in elderly patients? Spine (Phila Pa 1976) 2011;36:879e85. [4] Sugimoto T, Shiraki M, Nakano T, Kishimoto H, Ito M, Fukunaga M, Hagino H, Sone T, Kuroda T, Nakamura T. Vertebral fracture risk after once-weekly teriparatide injections: follow-up study of Teriparatide Once-Weekly Efficacy Research (TOWER) trial. Curr Med Res Opin 2013;29:195e203. [5] Alkhiary YM, Gerstenfeld LC, Krall E, Westmore M, Sato M, Mitlak BH, Einhorn TA. Enhancement of experimental fracture-healing by systemic administration of recombinant human parathyroid hormone (PTH 1-34). J Bone Jt Surg Am 2005;87:731e41. [6] Aspenberg P, Genant HK, Johansson T, Nino AJ, See K, Krohn K, Garcíandez PA, Recknor CP, Einhorn TA, Dalsky GP, Mitlak BH, Fierlinger A, Herna Lakshmanan MC. Teriparatide for acceleration of fracture repair in humans: a prospective, randomized, double-blind study of 102 postmenopausal women with distal radial fractures. J Bone Min Res 2010;25:404e14. [7] Mitani Y. Effective treatment of a steroid-induced femoral neck fracture nonunion with a once-weekly administration of teriparatide in a rheumatoid patient: a case report. Arch Osteoporos 2013;8:131. [8] Rubery PT, Bukata SV. Teriparatide may accelerate healing in delayed unions of type III odontoid fractures: a report of 3 cases. J Spinal Disord Tech 2010;23: 151e5. [9] Bednar DA. Teriparatide treatment of a glucocorticoid-associated resorbing nonunion of a type III odontoid process fracture: a case report. J Spinal Disord Tech 2013;26:E319e22.
Please cite this article in press as: Harada T, et al., Once-weekly teriparatide administration for an Anderson type II odontoid fracture in an elderly patient: A case report, Journal of Orthopaedic Science (2015), http://dx.doi.org/10.1016/j.jos.2015.06.022
Contents lists available at ScienceDirect
Journal of Orthopaedic Science journal homepage: http://www.elsevier.com/locate/jos
Case report
Once-weekly teriparatide administration for an Anderson type II odontoid fracture in an elderly patient: A case report Takahiro Harada a, Takahiko Hamasaki a, *, Shingo Ohkawa a, Ryo Mori a, Yasunori Izuta a, Hiroki Hachisuka a, Toshihiro Matsuo a, Norikazu Hamada a, Nobuhiro Tanaka b, Mitsuo Ochi b, Takashi Sugita a a b
Department of Orthopaedic Surgery, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Kure, Hiroshima, Japan Department of Orthopaedic Surgery, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
a r t i c l e i n f o Article history: Received 21 December 2014 Received in revised form 25 March 2015 Accepted 5 April 2015 Available online xxx
1. Introduction Cervical spine injuries, especially upper cervical, have increased in the elderly [1]. In the elderly, stiffness of the lower cervical spine, caused by degenerative changes and osteopenia, might contribute to upper cervical spine injury, such as odontoid fracture, in response to low energy trauma such as a fall from standing height [2]. Anderson type II odontoid fractures are associated with high rates of mortality in elderly patients regardless of intervention [3]. Teriparatide, for the treatment of osteoporosis, has two types of medications: 1) 20 mg given once daily by self-administration (ForteoR, Eli Lilly and Company, Indianapolis, IN, USA). This medication has been widely used in many countries; 2) 56.5 mg given once weekly, administered by nurse or staff (TeriboneR, Asahi Kasei Pharma, Tokyo, Japan). This once-weekly medication has been used only in Japan. With intermittent use, teriparatide has an anabolic action on the bone, and the effect of bone turnover markers has been shown to differ between these two medications [4]. Although once-daily injection increases bone formation and bone resorption, once-weekly injection increases bone formation moderately and decreases or maintains bone resorption [4]. The effects of both medications on bone mineral density are similar [4].
* Corresponding author. Department of Orthopaedic Surgery, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, 3-1 Aoyama-cho Kure, Hiroshima, 7370023, Japan. Tel.: þ81 823 22 3111; fax: þ81 823 21 0478. E-mail address: [email protected] (T. Hamasaki).
Teriparatide has been shown to promote and even accelerate fracture healing in animal models [5], whereas in humans once-daily medications have seen cases of distal radius fracture [6], and onceweekly medications have seen cases of femoral neck fracture [7]. There have been only 2 reports that undisplaced type III odontoid fractures may be healed by teriparatide administered once daily [8,9]. However, there have been no reports that type II odontoid fractures may be healed by teriparatide given once weekly. The purpose of this report is to describe a case of a patient with a type II odontoid fracture that was successfully treated nonoperatively with teriparatide administered once weekly.
2. Report of the case The patient described below gave her permission for the details of her case to be presented for publication. An 85-year-old woman stumbled and fell, and had a 10 cm contused wound at her left forehead. She was conscious, and had no motor weakness and no sensory loss. She lived alone and independently, and her medical history was unremarkable. AP and lateral X-rays were interpreted as normal, but CT scans revealed that odontoid had osteosclerotic change and fractured an undisplaced Anderson type II. She had no previous cervical spine injury and no history of neck pain. There seemed to be connectivity of the cortex of dens, and there was little or no dislocation and instability (Fig. 1). Sagittal MRI, T1-weighted images showed low intensity and T2-weighted images showed a mixture of iso and high intensity areas at the odontoid, so it was concluded that this was a fresh fracture. There was no compression to the cord (Fig. 2). Dual-energy X-ray absorptiometry at the femoral neck showed a T-score of 2.1 and a bone mineral density (BMD) of 0.637 g/cm2, and at the lumbar showed a T-score of 1.1 and a BMD of 0.876 g/cm2. Laboratory examination for bone metabolic marker showed serum type I procollagen N-terminal pro-peptide (P1NP) of 46.8 (14.9e68.8) mg/l as bone formation marker, and tartrate-resistant acid phosphatase isoform 5b (TRACP-5b) of 297 (120e420) mU/dl as bone resorption marker.
http://dx.doi.org/10.1016/j.jos.2015.06.022 0949-2658/© 2015 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Harada T, et al., Once-weekly teriparatide administration for an Anderson type II odontoid fracture in an elderly patient: A case report, Journal of Orthopaedic Science (2015), http://dx.doi.org/10.1016/j.jos.2015.06.022
2
T. Harada et al. / Journal of Orthopaedic Science xxx (2015) 1e4
Fig. 1. CT with coronal (a) and sagittal (b) reconstructions at the time of injury. Odontoid had osteosclerotic change and fractured an undisplaced Anderson type II. There was connectivity of cortex of dens, and there was no dislocation and instability.
We diagnosed her as having an undisplaced type II odontoid fresh fracture with no spinal cord injury. And she was also considered to be osteoporotic, with the osteosclerotic change of the odontoid. We wondered that it might be difficult for bone union. She was applied with a Philadelphia collar, and 56.5 mg teriparatide subcutaneous injections (TeriboneR) were started and administered once weekly. Operative treatment would have been considered if her fracture had been dislocated or if she had myelopathic symptoms. However, she had neither. Three months after injury, bone formation marker, P1NP, showed the increase to 56.2 mg/l and BMD also showed the increase to 0.882 g/cm2 (lumbar) and 0.674 g/cm2 (femoral neck). CT revealed the re-calcification and some bone resorption at the osteosclerotic change of the odontoid (Fig. 3). The bone resorption area was slightly spread at 6 months (Fig. 4), but at 10 months, CT scans showed the bone formation of the cancellous and cortical of the odontoid, and the fracture had united successfully without dislocation (Fig. 5). During this period, she has remained pain free. Teriparatide were used until 1 year after injury, and were switched to alendronate (BonalonR).
Fig. 2. Sagittal MRI at the time of injury. T1-weighted image (a) showed low intensity and T2-weighted image (b) showed a mixture of iso and high intensity area at odontoid. There was no compression to the cord.
3. Discussion Non-operative treatment for Anderson type II odontoid fractures have been reported to have high non-union rates, as well as significant morbidity and mortality with prolonged cervical orthosis or halo immobilization [3]. So the current management generally favors operative reduction and stabilization. The union rate for type II is 53e64% when treated non-operatively, and 70e93% when treated operatively [3,8,9]. However, operative treatment in elderly patients presents some risks: higher risks during the perioperative period, particularly in patients with osteoporosis; screw related problems, screw back-out, screw loosening and non-union. We treated her non-operatively with cervical orthosis and teriparatide administered once weekly (TeriboneR). We expected
Please cite this article in press as: Harada T, et al., Once-weekly teriparatide administration for an Anderson type II odontoid fracture in an elderly patient: A case report, Journal of Orthopaedic Science (2015), http://dx.doi.org/10.1016/j.jos.2015.06.022
T. Harada et al. / Journal of Orthopaedic Science xxx (2015) 1e4
3
Fig. 3. CT with coronal (a) and sagittal (b) reconstructions at 3 months after injury. Satittal CT (b) revealed the re-calcification and some bone resorption at the osteosclerotic change of the odontoid.
once-weekly teriparatide not only to treat osteoporosis, but also to promote the fracture healing and to increase the bone strength when it might convert to the surgery. She had a Philadelphia collar on her neck and a once-weekly injection administered by the nurse was considered to offer minimum disruption to her cervical flexion position. She might have some more difficulty when a once-daily injection (ForteoR) administered by herself. Three months with a once-weekly teriparatide injection led to increase the BMD and
Fig. 4. CT with coronal (a) and sagittal (b) reconstructions at 6 months after injury. The bone resorption area was slightly spread at this time.
bone formation marker (P1NP), and also it might lead to bony union of odontoid fracture on CT. This is the first report to show the effectiveness of once-weekly teriparatide in Anderson type II odontoid fractures. So even Aderson type II odontoid fracture, 1) little or no dislocation and instability fracture cases, 2) moderate to severe osteoporotic patients
Fig. 5. CT with coronal (a) and sagittal (b) reconstructions at 10 months after injury. CT scans showed the bone formation of the cancellous and cortical of the odontoid. The fracture had united successfully without dislocation.
Please cite this article in press as: Harada T, et al., Once-weekly teriparatide administration for an Anderson type II odontoid fracture in an elderly patient: A case report, Journal of Orthopaedic Science (2015), http://dx.doi.org/10.1016/j.jos.2015.06.022
4
T. Harada et al. / Journal of Orthopaedic Science xxx (2015) 1e4
that may have low screw fixation force, and 3) aged patients with higher risks for general anesthesia, then non-operative treatment with teriparatide could be one option. 4. Conclusion Patients with an Anderson type II odontoid fracture can be treated non-operatively and successfully by teriparatide administered once weekly. Conflict of interests The authors declare no conflict of interests. References [1] Lomoschitz FM, Blackmore CC, Mirza SK, Mann FA. Cervical spine injuries in patients 65 years old and older: epidemiologic analysis regarding the effects of age and injury mechanism on distribution, type, and stability of injuries. AJR Am J Roentgenol 2002;178:573e7. [2] Watanabe M, Sakai D, Yamamoto Y, Sato M, Mochida J. Upper cervical spine injuries: age-specific clinical features. J Orthop Sci 2010;15:485e92.
[3] Schoenfeld AJ, Bono CM, Reichmann WN, Warholic N, Wood KB, Losina E, Katz JN, Harris MB. Type II odontoid fractures of the cervical spine: do treatment type and medical comorbidities affect mortality in elderly patients? Spine (Phila Pa 1976) 2011;36:879e85. [4] Sugimoto T, Shiraki M, Nakano T, Kishimoto H, Ito M, Fukunaga M, Hagino H, Sone T, Kuroda T, Nakamura T. Vertebral fracture risk after once-weekly teriparatide injections: follow-up study of Teriparatide Once-Weekly Efficacy Research (TOWER) trial. Curr Med Res Opin 2013;29:195e203. [5] Alkhiary YM, Gerstenfeld LC, Krall E, Westmore M, Sato M, Mitlak BH, Einhorn TA. Enhancement of experimental fracture-healing by systemic administration of recombinant human parathyroid hormone (PTH 1-34). J Bone Jt Surg Am 2005;87:731e41. [6] Aspenberg P, Genant HK, Johansson T, Nino AJ, See K, Krohn K, Garcíandez PA, Recknor CP, Einhorn TA, Dalsky GP, Mitlak BH, Fierlinger A, Herna Lakshmanan MC. Teriparatide for acceleration of fracture repair in humans: a prospective, randomized, double-blind study of 102 postmenopausal women with distal radial fractures. J Bone Min Res 2010;25:404e14. [7] Mitani Y. Effective treatment of a steroid-induced femoral neck fracture nonunion with a once-weekly administration of teriparatide in a rheumatoid patient: a case report. Arch Osteoporos 2013;8:131. [8] Rubery PT, Bukata SV. Teriparatide may accelerate healing in delayed unions of type III odontoid fractures: a report of 3 cases. J Spinal Disord Tech 2010;23: 151e5. [9] Bednar DA. Teriparatide treatment of a glucocorticoid-associated resorbing nonunion of a type III odontoid process fracture: a case report. J Spinal Disord Tech 2013;26:E319e22.
Please cite this article in press as: Harada T, et al., Once-weekly teriparatide administration for an Anderson type II odontoid fracture in an elderly patient: A case report, Journal of Orthopaedic Science (2015), http://dx.doi.org/10.1016/j.jos.2015.06.022