July-September 2003

• Patient was hospitalized for hypotension due to medications from 7/12-21

• In rehabilitation from 7/21-8/15

• A house call on 8/20 found her clinical CHF exacerbated and labs showed ARF with K=6.7

• She was hospitalized for CHF from 8/21-27

• Again, in rehabilitation from 8/27-9/24

Over these few months, the patient suffered repeated hospitalization and functional decline with a corresponding decrease in her overall sense of satisfaction with her life.

September-November 2003

• Patient had intermittent increases in low back pain, managed with short-acting morphine

• Occasional CHF exacerbations were managed at home with diuretics

• Patient experienced symptomatic uterine prolapse

• UroGYN recommended against surgery, patient unable to manage pessary at home alone

• Spontaneous resolution

• Prednisone taper was attempted from 10 mg to 7.5 mg

• Recurrence of GCA symptoms (headache/diplopia)

She was able to stay out of the hospital for a few months, but continued to have poor functional status and the above medical issues compromising her quality of life.

November 2003
In November, the patient had minor trauma caused by sitting down abruptly on the commode.  This resulted in excruciating low back pain the following day.  She was hospitalized for pain control, and no new fractures were found.  She was discharged to rehab on 11/24. 

The week of Thanksgiving marked the beginning of an important change in her living situation.  Initially, her goals of care centered on returning home to live independently.

November 2003 – January 2004
Unfortunately, her functional status steadily worsened along with her pain, and she was considered for minimally invasive spinal surgery  (vertebroplasty).  She experienced delirium and respiratory depression on  morphine.  A fentanyl PCA/patch was tried with some relief.  She was taken to the interventional radiology suite for vertebroplasty but after extensive discussion with the radiologist, it was decided that the risk of sedation outweighed the potential benefit of the procedure and she received an epidural steroid injection instead. While her pain improved, no functional benefits were noted.

January 2004-December 2004
She was unable to realize her goal of returning home and after several weeks of unsuccessful attempts at physical rehabilitation, she was discharged to the nursing home, where she had continued medical issues (vaginal bleeding, CHF exacerbations) but was able to avoid hospitalization for almost a year.

December 2004
On 12/10/04, she reported pain in her vulvar/labial region.  Blood work was done: WBC 26K, INR 10.8.  Her code status was revised and she was sent to the emergency department and on to the CICU.  She was hypotensive (77/36; HR 73) and her condition declined despite antibiotics and pressors.  Upon the patient and family’s request, the pressors were withdrawn on 12/13.  She died hours later.

Vertebroplasty is the percutaneous injection of polymethylmethacrylate (PMMA) cement into a fractured vertebral body.  It is generally performed under conscious sedation, although general anesthesia may be required when numerous vertebrae are treated or the pain due to the fracture while in the prone position is intolerable to the patient. 

Criteria include the following:
– Severe pain and loss of mobility not relieved by conventional medical therapy
– Other causes of pain excluded
– Affected vertebra not significantly destroyed and at least 1/3 of original height
– Focal pain correlating to an identified vertebral compression fracture

Several case series and a few prospective but uncontrolled clinical studies support vertebroplasty as a safe and effective treatment for osteoporotic compression fractures.  Significant and nearly immediate pain relief is obtained in about 90% of patients, and lasts up to 18 months.  Measures of quality of life improve within 2 weeks and remain improved for up to 6 months.  

Importantly, minimally invasive spinal surgery was considered as a possible means of relieving her pain and improving her quality of life, although the decision was made to proceed with even less invasive intervention because of her pulmonary and cardiac status.
 
From a geriatric medicine perspective, her osteoporosis was only a small part of her overall complex clinical picture and may not have been a major contributor to her functional decline and death.  For patients with less comorbidity or better functional status, minimally invasive spinal surgery for osteoporosis may be a useful therapy.