Percutaneous vertebroplasty for osteoporotic vertebral compression fracture

Static study and numerical simulation of the influence of cement distribution in the upper and lower adjacent vertebrae on sandwich vertebrae in osteoporotic patients: Finite element analysis

Objective

We analyzed the influence of the location of the upper and lower cement on the sandwich vertebrae (SV) by computer finite element analysis.

Materials and Methods

A finite element model of the spinal segment of T11-L1 was constructed and 6 mL of cement was built into T11 and L1 simultaneously. According to the various distributions of bone cement at T11 and L1, the following four groups were formed: (i) Group B-B: bilateral bone cement reinforcement in both T11 and L1 vertebral bodies; (ii) Group L-B: left unilateral reinforcement in T11 and bilateral reinforcement in L1; (iii) Group L-R: unilateral cement reinforcement in both T11 and L1 (cross); (iv) Group L-L: unilateral cement reinforcement in both T11 and L1 (ipsilateral side). The maximum von Mises stress (VMS) and maximum displacement of the SV and intervertebral discs were compared and analyzed.

Results

The maximum VMS of T12 was in the order of size: group B-B < L-B < L-R < L-L. Group B-B showed the lowest maximum VMS values for T12: 19.13, 18.86, 25.17, 25.01, 19.24, and 20.08 MPa in six directions of load flexion, extension, left and right lateral bending, and left and right rotation, respectively, while group L-L was the largest VMS in each group, with the maximum VMS in six directions of 21.55, 21.54, 30.17, 28.33, 19.88, and 25.27 MPa, respectively.

Conclusion

Compared with the uneven distribution of bone cement in the upper and lower adjacent vertebrae (ULAV), the uniform distribution of bone cement in the ULAV reduced and uniformed the stress load on the SV and intervertebral disc. Theoretically, it can lead to the lowest incidence of sandwich vertebral fracture and the slowest rate of intervertebral disc degeneration.

Systematic Review and Meta-Analysis of the Effect of Osteoporosis on Reoperation Rates and Complications after Surgical Management of Lumbar Degenerative Disease

BACKGROUND

There is considerable heterogeneity in findings and a lack of consensus regarding the interplay between osteoporosis and outcomes in patients with lumbar degenerative spine disease. Therefore, the purpose of this systematic review and meta-analysis was to gather and analyze existing data on the effect of osteoporosis on radiographic, surgical, and clinical outcomes following surgery for lumbar degenerative spinal disease.

METHODS

A systematic review was performed to determine the effect of osteoporosis on the incidence of adverse outcomes after surgical intervention for lumbar degenerative spinal diseases. The approach focused on the radiographic outcomes, reoperation rates, and other medical and surgical complications. Subsequently, a meta-analysis was performed on the eligible studies.

RESULTS

The results of the meta-analysis suggested that osteoporotic patients experienced increased rates of adjacent segment disease (ASD; p=0.015) and cage subsidence (p=0.001) while demonstrating lower reoperation rates than non-osteoporotic patients (7.4% vs. 13.1%; p=0.038). The systematic review also indicated that the length of stay, overall costs, rates of screw loosening, and rates of wound and other medical complications may increase in patients with a lower bone mineral density. Fusion rates, as well as patient-reported and clinical outcomes, did not differ significantly between osteoporotic and non-osteoporotic patients.

CONCLUSIONS

Osteoporosis was associated with an increased risk of ASD, cage migration, and possibly postoperative screw loosening, as well as longer hospital stays, incurring higher costs and an increased likelihood of postoperative complications. However, a link was not established between osteoporosis and poor clinical outcomes.

Robot-assisted percutaneous vertebroplasty for osteoporotic vertebral compression fracture treatment and risk factor screening for postoperative refracture

Osteoporotic vertebral compression fracture (OVCF) is a serious complication of osteoporosis, and percutaneous vertebroplasty (PVP) is a major therapeutic method for OVCF. This study aimed to evaluate the clinical efficacy and postoperative complications of robot-assisted targeted PVP for the treatment of OVCF. The data from 202 OVCF patients were analyzed in this study, including 72 cases received traditional PVP (PVP group), 68 cases received robot-assisted PVP (R-PVP group), and 62 cases underwent robot-assisted PVP combined with targeted plugging (R-PVP + TP group). The fluoroscopic exposure conditions, operative duration, lengths of stay, postoperative bone cement leakage, refracture, Visual Analog Scale (VAS) score, and Oswestry Disability Index (ODI) score were obtained and compared between the three groups. The Kaplan-Meier method and logistic regression model were adopted to screen the risk factors related with postoperative refracture. R-PVP and R-PVP + TP group had significantly reduced fluoroscopic frequency and radiation dose, and reduced cement leakage compared with PVP group. R-PVP + TP not only showed more obvious advantages in these aspects, but also had a lower probability of postoperative refracture. In addition, BMD, fracture vertebral distribution, cement leakage, and surgery methods were independent related with refracture. All the results demonstrated robot assistance could improve the application of PVP in the treatment of OVCF, and robot-assisted PVP combined with targeted plugging showed significantly reduced fluoroscopic exposure, bone cement leakage, and rate of postoperative refracture. BMD, fracture vertebral distribution, cement leakage, and operation methods were identified as four risk factors for the onset of refracture after PVP.

Complex Compression Fracture in the Thoracolumbar Junction: A Case Report

Compression fractures in the thoracolumbar junction are one of the most frequent types of spine injuries. They can be the result of trauma or underlying conditions of the vertebrae. We present a case report of a 68-year-old patient with pain and loss of mobility in the lumbar spine after sustaining a trauma via falling from a significant height. Lumbar spondylography and a following CT scan revealed a complex compression fracture of L1 with degenerative osteoporotic changes of lumbar vertebrae and several pathologies of the lumbosacral junction. A surgical intervention was performed in the form of posterior transpedicular vertebral stabilization with titanium rods and screws. Postoperatively, relief from the lumbar region pain was reported. No neurological deficit was observed. The patient was mobilized, rehabilitated, and discharged from the hospital. This case report emphasizes the use of reliable imaging methods for the diagnosis of thoracolumbar compression fracture and highlights the reliability of surgical treatment of the condition via posterior transpedicular vertebral stabilization.

Vertebral compression fractures: pain relief, progression and new fracture rate comparing vertebral augmentation with brace

BACKGROUND

Osteoporotic vertebral compression fracture (VCF) is the third most frequent fragility fracture in the world. Conservative treatment, vertebroplasty, and kyphoplasty are all recognized therapies. However, diagnostic and therapeutic recommendations must be more consistent when comparing clinical guidelines. This study aims to compare the efficacy of vertebral augmentation therapy and conservative management for treating VCFs, the risk of subsequent complications, and the length of hospital stay.

METHOD

All patients over 50 years old with a diagnosis of thoracic or lumbar VCF without underlying oncological process, treated conservatively or surgically, and consecutively attended at our department from January 2017 to June 2021 were retrospectively selected for analysis. Patients who missed follow-up or died during the first three months were excluded.

RESULTS

A total of 573 cases were selected for analysis. Most patients were treated conservatively (85.3%). Both groups were homogenous regarding epidemiological and clinical features. The median time elapsed to achieve pain relief was significantly lower in the surgical cohort (4.5 vs. 10 weeks, p < 0.001), and the proportion of patients reporting pain at the first outpatient visit was also significantly lower with a vertebral augmentation procedure (p = 0.004). The new fracture rate and the adjacent level rate did not differ significantly when comparing both treatments, whereas the progression of the diagnosed fracture was more frequent in the conservative group (4.8% vs. 29.7%; p < 0.001). The median hospital stay was significantly lower in the conservative group (3 vs. 10 days; p < 0.001).

CONCLUSION

Surgical treatment (vertebroplasty/kyphoplasty) of VCFs was associated with sooner pain relief without an increased risk of new or adjacent fractures. Moreover, the progression of treated fractures was significantly lower in the surgical cohort. The only unfavorable aspect was the more extended hospital stay compared with the conservative treatment group.

Prediction model of adjacent vertebral compression fractures after percutaneous kyphoplasty: a retrospective study

OBJECTIVES

The purpose of this study was to develop a prediction model to assess the risk of adjacent vertebral compression fractures (AVCFs) after percutaneous kyphoplasty (PKP) surgery.

DESIGN

A retrospective chart review.

SETTING AND PARTICIPANTS

Patients were collected from the Quzhou People's Hospital, from March 2017 to May 2019. Patients were included if they suffered from osteoporotic vertebral compression fractures (OVCFs), underwent PKP surgery and were followed up for 2 years.

INTERVENTIONS

None.

METHODS

This was a retrospective cohort study of all PKP surgery procedures of the thoracic, lumbar and thoracolumbar (TL) spine that have been performed for OVCF from 1 March 2017 up to 1 May 2019. The least absolute shrinkage and selection operator (LASSO) regression model was used to optimise feature selection for the AVCF risk model. Multivariable logistic regression analysis was applied to build a predicting model incorporating the feature selected in the LASSO regression model. The C-index, calibration plot and decision curve analysis were applied to assess this model.

RESULTS

Gender, age, the number of surgical vertebrae, cement volume, bone mineral density, diabetes, hypertension, bone cement leakage, duration of anti-osteoporosis treatment after surgery and TL junction were identified as predictors. The model displayed good discrimination with a C-index of 0.886 (95% CI 0.828-0.944) and good calibration. High C-index value of 0.833 could still be reached in the interval validation. Decision curve analysis showed that the AVCF nomogram was clinically useful when intervention was decided at the AVCF possibility threshold of 1%.

CONCLUSIONS

This study developed a clinical prediction model to identify the risk factors for AVCF after PKP surgery, and this tool is of great value in sharing surgical decision-making among patients consulted before surgery.

TRIAL REGISTRATION NUMBER

researchregistry7716.

Effects of robot-assisted minimally invasive surgery on osteoporotic vertebral compression fracture: a systematic review, meta-analysis, and meta-regression of retrospective study

OBJECTIVE

To conduct a systematic review on the effect of robot-assisted minimally invasive surgery (R-MIS) on the clinical outcomes and complications of patients with osteoporotic vertebral compression fractures (OVCFs).

METHODS

The researchers searched the papers published on PubMed, The Cochrane Library, Web of Science, Embase, Scopus, Ovid MEDLINE, Wiley Online Library, China National Knowledge Infrastructure (CNKI), Chinese biomedical literature service system (SinoMed), and China Medical Association Data. The standardized mean difference (SMD) or mean difference (MD), relative risk (RR), and 95% confidence interval (CI) were calculated. Besides, the data was merged through the random-effect model or common-effect model. A meta-regression mixed-effects single-factor model was utilized to analyze the sources of heterogeneity.

RESULTS

Twelve studies were included, involving 1042 OVCFs cases. The prognosis of patients treated with R-MIS was significantly improved, such as Oswestry disability index (ODI) score (MD = -0.65, P = 0.0171), Cobb's angles (MD = -1.03, P = 0.0027), X-ray fluoroscopy frequency (SMD = -2.41, P < 0.0001), Length of hospital stay (MD = -0.33, P = 0.0002), and Cement leakage (RR = 0.37, P < 0.0001). However, no obvious improvement was found in the results of Visual analog scale (VAS) score (MD = -0.16, P = 0.1555), Volume of bone cement (MD = 0.22, P = 0.8339), and Operation time (MD = -3.20, P = 0.3411) after being treated by R-MIS. The meta-regression analysis demonstrated that R-MIS presented no significant impact on the covariates of VAS and Operation time.

CONCLUSION

R-MIS can significantly reduce the patients' ODI, Cobb's angles, X-ray fluoroscopy frequency, and Cement leakage ratio, and shorten the Length of hospital stay. Therefore, R-MIS may be an effective method to promote the patients' functional recovery, correct spinal deformity, reduce the X-ray fluoroscopy frequency, shorten the Length of hospital stay, and reduce the complications of OVCFs bone Cement leakage.

Thoracolumbar fascia injury in osteoporotic vertebral fracture: the important concomitant damage

BACKGROUND

Thoracolumbar fascia injury (FI) is rarely discussed in osteoporotic vertebral fracture (OVF) patients in previous literature and it is usually neglected and treated as an unmeaning phenomenon. We aimed to evaluate the characteristics of the thoracolumbar fascia injury and further discuss its clinical significance in the treatment of kyphoplasty for osteoporotic vertebral fracture (OVF) patients.

METHODS

Based on the presence or absence of FI, 223 OVF patients were divided into two groups. The demographics of patients with and without FI were compared. The visual analogue scale and Oswestry disability index scores were compared preoperatively and after PKP treatment between these groups.

RESULTS

Thoracolumbar fascia injuries were observed in 27.8% of patients. Most FI showed a multi-level distribution pattern which involved a mean of 3.3 levels. Location of fractures, severity of fractures and severity of trauma were significantly different between patients with and without FI. In further comparison, severity of trauma was significantly different between patients with severe and non-severe FI. In patients with FI, VAS and ODI scores of 3 days and 1 month after PKP treatment were significantly worse compared to those without FI. It showed the same trend in VAS and ODI scores in patients with severe FI when compared to those patients with non-severe FI.

CONCLUSIONS

FI is not rare in OVF patients and presents multiple levels of involvement. The more serious trauma suffered, the more severe thoracolumbar fascia injury presented. The presence of FI which was related to residual acute back pain significantly affected the effectiveness of PKP in treating OVFs.

TRIAL REGISTRATION

retrospectively registered.

Comparison of the effectiveness of different machine learning algorithms in predicting new fractures after PKP for osteoporotic vertebral compression fractures

BACKGROUND

The use of machine learning has the potential to estimate the probability of a second classification event more accurately than traditional statistical methods, and few previous studies on predicting new fractures after osteoporotic vertebral compression fractures (OVCFs) have focussed on this point. The aim of this study was to explore whether several different machine learning models could produce better predictions than logistic regression models and to select an optimal model.

METHODS

A retrospective analysis of 529 patients who underwent percutaneous kyphoplasty (PKP) for OVCFs at our institution between June 2017 and June 2020 was performed. The patient data were used to create machine learning (including decision trees (DT), random forests (RF), support vector machines (SVM), gradient boosting machines (GBM), neural networks (NNET), and regularized discriminant analysis (RDA)) and logistic regression models (LR) to estimate the probability of new fractures occurring after surgery. The dataset was divided into a training set (75%) and a test set (25%), and machine learning models were built in the training set after ten cross-validations, after which each model was evaluated in the test set, and model performance was assessed by comparing the area under the curve (AUC) of each model.

RESULTS

Among the six machine learning algorithms, except that the AUC of DT [0.775 (95% CI 0.728-0.822)] was lower than that of LR [0.831 (95% CI 0.783-0.878)], RA [0.953 (95% CI 0.927-0.980)], GBM [0.941 (95% CI 0.911-0.971)], SVM [0.869 (95% CI 0.827-0.910), NNET [0.869 (95% CI 0.826-0.912)], and RDA [0.890 (95% CI 0.851-0.929)] were all better than LR.

CONCLUSIONS

For prediction of the probability of new fracture after PKP, machine learning algorithms outperformed logistic regression, with random forest having the strongest predictive power.

The role of endplate injury in intervertebral disc degeneration after vertebral augmentation in OVCF patients

Background

Whether vertebral augmentation can induce or aggravate the degeneration of adjacent intervertebral discs remains controversial. The purpose of this study is to explore the role of endplate injury in intervertebral disc degeneration after vertebral augmentation.

Methods

The imaging data of patients with single-segment osteoporotic vertebral compression fractures (OVCFs) were retrospectively analyzed. The upper and lower discs of the fractured vertebrae were defined as cranial and caudal discs, and the discs adjacent to the cranial discs were defined as control discs. According to the integrity of the cranial and caudal endplates, they were divided into an injury group and a noninjury group. At follow-up, the increase in the modified Pfirrmann score on MRI compared with the baseline grade was defined as the occurrence of a degenerative disc change (DDC). The changes in the disc height and the number of DDC cases on MRI during the follow-up in each group were analyzed.

Results

A total of 56 patients with OVCFs were included in this study, with an average follow-up time of 18.8 ± 14.1 months (3-62 months). In the cranial and caudal discs, the number of DDC cases in the endplate injury group was significantly higher than that in the noninjury group (P = 0.007 and P = 0.018). However, the number of DDC cases in the whole endplate injury group (including the cranial and caudal endplates) was significantly higher than that of the whole noninjury group (P = 0.000) and the control group (P = 0.000). The number of DDC cases in the whole noninjury group was not different from that of the control group (P = 0.192). At follow-up, the disc height of the cranial and caudal endplate injury group was significantly lower than the baseline (P = 0.000 and P = 0.001), but the disc height of the noninjury group was not significantly lower than the baseline (P = 0.074 and P = 0.082).

Conclusion

Endplate injury is associated with adjacent intervertebral disc degeneration in OVCF patients after vertebral augmentation. Evaluation of endplate damage before vertebral enhancement in OVCF patients has an important reference value for predicting the outcome of adjacent intervertebral discs after surgery.

Current status and challenges of percutaneous vertebroplasty (PVP)

A narrative review regarding percutaneous vertebroplasty (PVP) for osteoporotic vertebral fracture (OVF) is provided herein, addressing the epidemic of OVF in Japan, the latest response to the criticism of PVP for OVFs, the indications and potential risks of PVP for OVFs, and a future perspective for PVP. Each year in Japan, approximately 32,000 patients aged 55 years or older suffer from chronic low back pain for several months to several years due to a compression fracture. PVP is one of the surgical treatments for an OVF, and it is less invasive compared to the traditional open surgery. PVP is suitable for OVF patients who have difficulty walking as assessed by the modified Yokoyama's activities of daily living (ADL) scoring system, and for patients with Kummell's disease diagnosed by CT and MRI examinations. Serious adverse events related to PVP occur in 1.1-3.3% of the cases, but direct deaths from PVP are extremely rare at less than 1%. Recent studies demonstrated that OVF patients treated with PVP are less likely to die after the treatment than non-surgically treated patients, which conflicts with the Cochran reviews' conclusion not supporting PVP for OVFs. Novel robotic systems and procedure-support devices are being developed, providing a next step toward fully automated PVP procedures.

Pre-operative anemia was associated with all-cause mortality in patients with vertebral fracture who underwent percutaneous vertebroplasty

PURPOSE

We investigated the association between pre-operative anemia and long-term all-cause mortality in patients with vertebral fracture who underwent a vertebroplasty.

MATERIALS AND METHODS

We retrospectively selected patients who were admitted for vertebroplasty for vertebral compression fracture between 2013 and 2020. Patients who had pathologic fractures or had no assessment of bone mineral density were excluded. Relevant information was collected from electronic medical records. Patients' survival status was confirmed at the end of March 2021. Cox-proportional hazard models were conducted to examine the effects of anemia (<12 g/dL vs. ≥12 g/dL) and pre-operative hemoglobin levels (as a continuous variable) on all-cause mortality with multivariate adjustments.

RESULTS

A total of 167 patients were analyzed (mean age 75.8 ± 9.3 years, male 25.7%). After a median follow-up duration of 2.1 years, pre-operative anemia (hemoglobin <12 g/dL vs. ≥12 g/dL) was independently associated with a higher risk of all-cause mortality (hazard ratio 2.762, 95% CI 1.184 to 6.442, p = 0.019). An increase in pre-operative hemoglobin was associated with a lower risk of all-cause mortality after multivariate adjustment (hazard ratio 0.775, 95% CI 0.606 to 0.991, p = 0.042).

CONCLUSION

Pre-operative anemia (<12 g/dL) was independently associated with survival outcome among patients with vertebral compression fractures who underwent vertebroplasty. Our findings highlight anemia as a risk factor of long-term mortality in this elderly surgical population.

Biomechanical comparison between unilateral and bilateral percutaneous vertebroplasty for osteoporotic vertebral compression fractures: A finite element analysis

Background and objective: The osteoporotic vertebral compression fracture (OVCF) has an incidence of 7.8/1000 person-years at 55–65 years. At 75 years or older, the incidence increases to 19.6/1000 person-years in females and 5.2–9.3/1000 person-years in males. To solve this problem, percutaneous vertebroplasty (PVP) was developed in recent years and has been widely used in clinical practice to treat OVCF. Are the clinical effects of unilateral percutaneous vertebroplasty (UPVP) and bilateral percutaneous vertebroplasty (BPVP) the same? The purpose of this study was to compare biomechanical differences between UPVP and BPVP using finite element analysis.

Materials and methods: The heterogeneous assignment finite element (FE) model of T11-L1 was constructed and validated. A compression fracture of the vertebral body was performed at T12. UPVP and BPVP were simulated by the difference in the distribution of bone cement in T12. Stress distributions and maximum von Mises stresses of vertebrae and intervertebral discs were compared. The rate of change of maximum displacement between UPVP and BPVP was evaluated.

Results: There were no obvious high-stress concentration regions on the anterior and middle columns of the T12 vertebral body in BPVP. Compared with UPVP, the maximum stress on T11 in BPVP was lower under left/right lateral bending, and the maximum stress on L1 was lower under all loading conditions. For the T12-L1 intervertebral disc, the maximum stress of BPVP was less than that of UPVP. The maximum displacement of T12 after BPVP was less than that after UPVP under the six loading conditions.

Conclusion: BPVP could balance the stress of the vertebral body, reduce the maximum stress of the intervertebral disc, and offer advantages in terms of stability compared with UPVP. In summary, BPVP could reduce the incidence of postoperative complications and provide promising clinical effects for patients.

Manifestations of radiation toxicity in the head, neck, and spine: An image-based review

BACKGROUND AND PURPOSE

Radiation therapy is an important component of treatment in patients with malignancies of the head, neck, and spine. However, radiation to these regions has well-known potential side effects, many of which can be encountered on imaging. In this manuscript, we review selected radiographic manifestations of therapeutic radiation to the head, neck, and spine that may be encountered in the practice of radiology.

METHODS

We conducted an extensive literature review of known complications of radiation therapy in the head, neck, and spine. We excluded intracranial and pulmonary radiation effects from our search. We selected complications that had salient, recognizable imaging findings. We searched our imaging database for illustrative examples of these complications.

RESULTS

Based on our initial literature search and imaging database review, we selected cases of radiation-induced tumors, radiation tissue necrosis (osteoradionecrosis and soft tissue necrosis), carotid stenosis and blowout secondary to radiation, enlarging thyroglossal duct cysts, radiation myelopathy, and radiation-induced vertebral compression fractures.

CONCLUSIONS

We describe the clinical and imaging features of selected sequelae of radiation therapy to the head, neck, and spine, with a focus on those with characteristic imaging findings that can be instrumental in helping to make the diagnosis. Knowledge of these entities and their imaging findings is crucial for accurate diagnosis. Not only do radiologists play a key role in early detection of these entities, but many of these entities can be misinterpreted if one is not familiar with them.

Prevention and Treatment of Glucocorticoid-Induced Osteoporosis in Adults: Consensus Recommendations From the Belgian Bone Club

Glucocorticoids are effective immunomodulatory drugs used for many inflammatory disorders as well as in transplant recipients. However, both iatrogenic and endogenous glucocorticoid excess are also associated with several side effects including an increased risk of osteoporosis and fractures. Glucocorticoid-induced osteoporosis (GIOP) is a common secondary cause of osteoporosis in adults. Despite availability of clear evidence and international guidelines for the prevention of GIOP, a large treatment gap remains. In this narrative review, the Belgian Bone Club (BBC) updates its 2006 consensus recommendations for the prevention and treatment of GIOP in adults. The pathophysiology of GIOP is multifactorial. The BBC strongly advises non-pharmacological measures including physical exercise, smoking cessation and avoidance of alcohol abuse in all adults at risk for osteoporosis. Glucocorticoids are associated with impaired intestinal calcium absorption; the BBC therefore strongly recommend sufficient calcium intake and avoidance of vitamin D deficiency. We recommend assessment of fracture risk, taking age, sex, menopausal status, prior fractures, glucocorticoid dose, other clinical risk factors and bone mineral density into account. Placebo-controlled randomized controlled trials have demonstrated the efficacy of alendronate, risedronate, zoledronate, denosumab and teriparatide in GIOP. We suggest monitoring by dual-energy X-ray absorptiometry (DXA) and vertebral fracture identification one year after glucocorticoid initiation. The trabecular bone score might be considered during DXA monitoring. Extended femur scans might be considered at the time of DXA imaging in glucocorticoid users on long-term (≥ 3 years) antiresorptive therapy. Bone turnover markers may be considered for monitoring treatment with anti-resorptive or osteoanabolic drugs in GIOP. Although the pathophysiology of solid organ and hematopoietic stem cell transplantation-induced osteoporosis extends beyond GIOP alone, the BBC recommends similar evaluation, prevention, treatment and follow-up principles in these patients. Efforts to close the treatment gap in GIOP and implement available effective fracture prevention strategies into clinical practice in primary, secondary and tertiary care are urgently needed.

UK clinical guideline for the prevention and treatment of osteoporosis

The National Osteoporosis Guideline Group (NOGG) has revised the UK guideline for the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women, and men age 50 years and older. Accredited by NICE, this guideline is relevant for all healthcare professionals involved in osteoporosis management.

INTRODUCTION

The UK National Osteoporosis Guideline Group (NOGG) first produced a guideline on the prevention and treatment of osteoporosis in 2008, with updates in 2013 and 2017. This paper presents a major update of the guideline, the scope of which is to review the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women, and men age 50 years and older.

METHODS

Where available, systematic reviews, meta-analyses and randomised controlled trials were used to provide the evidence base. Conclusions and recommendations were systematically graded according to the strength of the available evidence.

RESULTS

Review of the evidence and recommendations are provided for the diagnosis of osteoporosis, fracture-risk assessment and intervention thresholds, management of vertebral fractures, non-pharmacological and pharmacological treatments, including duration and monitoring of anti-resorptive therapy, glucocorticoid-induced osteoporosis, and models of care for fracture prevention. Recommendations are made for training; service leads and commissioners of healthcare; and for review criteria for audit and quality improvement.

CONCLUSION

The guideline, which has received accreditation from the National Institute of Health and Care Excellence (NICE), provides a comprehensive overview of the assessment and management of osteoporosis for all healthcare professionals involved in its management. This position paper has been endorsed by the International Osteoporosis Foundation and by the European Society for the Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases.

Application of Machine Learning in Developing Decision-Making Support Models for Decompressed Vertebroplasty

BACKGROUND

The common treatment methods for vertebral compression fractures with osteoporosis are vertebroplasty and kyphoplasty, and the result of the operation may be related to the value of various measurement data during the operation.

MATERIAL AND METHOD

This study mainly uses machine learning algorithms, including Bayesian networks, neural networks, and discriminant analysis, to predict the effects of different decompression vertebroplasty methods on preoperative symptoms and changes in vital signs and oxygen saturation in intraoperative measurement data.

RESULT

The neural network shows better analysis results, and the area under the curve is >0.7. In general, important determinants of surgery include numbness and immobility of the lower limbs before surgery.

CONCLUSION

In the future, this association model can be used to assist in decision making regarding surgical methods. The results show that different surgical methods are related to abnormal vital signs and may affect the length of hospital stay.

Implanted spinal neuromodulation interventions for chronic pain in adults

BACKGROUND

Implanted spinal neuromodulation (SNMD) techniques are used in the treatment of refractory chronic pain. They involve the implantation of electrodes around the spinal cord (spinal cord stimulation (SCS)) or dorsal root ganglion (dorsal root ganglion stimulation (DRGS)), and a pulse generator unit under the skin. Electrical stimulation is then used with the aim of reducing pain intensity.

OBJECTIVES

To evaluate the efficacy, effectiveness, adverse events, and cost-effectiveness of implanted spinal neuromodulation interventions for people with chronic pain.

SEARCH METHODS

We searched CENTRAL, MEDLINE Ovid, Embase Ovid, Web of Science (ISI), Health Technology Assessments, ClinicalTrials.gov and World Health Organization International Clinical Trials Registry from inception to September 2021 without language restrictions, searched the reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing SNMD interventions with placebo (sham) stimulation, no treatment or usual care; or comparing SNMD interventions + another treatment versus that treatment alone. We included participants ≥ 18 years old with non-cancer and non-ischaemic pain of longer than three months duration. Primary outcomes were pain intensity and adverse events. Secondary outcomes were disability, analgesic medication use, health-related quality of life (HRQoL) and health economic outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened database searches to determine inclusion, extracted data and evaluated risk of bias for prespecified results using the Risk of Bias 2.0 tool. Outcomes were evaluated at short- (≤ one month), medium- four to eight months) and long-term (≥12 months). Where possible we conducted meta-analyses. We used the GRADE system to assess the certainty of evidence.

MAIN RESULTS

We included 15 unique published studies that randomised 908 participants, and 20 unique ongoing studies. All studies evaluated SCS. We found no eligible published studies of DRGS and no studies comparing SCS with no treatment or usual care. We rated all results evaluated as being at high risk of bias overall. For all comparisons and outcomes where we found evidence, we graded the certainty of the evidence as low or very low, downgraded due to limitations of studies, imprecision and in some cases, inconsistency. Active stimulation versus placebo SCS versus placebo (sham) Results were only available at short-term follow-up for this comparison. Pain intensity Six studies (N = 164) demonstrated a small effect in favour of SCS at short-term follow-up (0 to 100 scale, higher scores = worse pain, mean difference (MD) -8.73, 95% confidence interval (CI) -15.67 to -1.78, very low certainty). The point estimate falls below our predetermined threshold for a clinically important effect (≥10 points). No studies reported the proportion of participants experiencing 30% or 50% pain relief for this comparison. Adverse events (AEs) The quality and inconsistency of adverse event reporting in these studies precluded formal analysis. Active stimulation + other intervention versus other intervention alone SCS + other intervention versus other intervention alone (open-label studies) Pain intensity Mean difference Three studies (N = 303) demonstrated a potentially clinically important mean difference in favour of SCS of -37.41 at short term (95% CI -46.39 to -28.42, very low certainty), and medium-term follow-up (5 studies, 635 participants, MD -31.22 95% CI -47.34 to -15.10 low-certainty), and no clear evidence for an effect of SCS at long-term follow-up (1 study, 44 participants, MD -7 (95% CI -24.76 to 10.76, very low-certainty). Proportion of participants reporting ≥50% pain relief We found an effect in favour of SCS at short-term (2 studies, N = 249, RR 15.90, 95% CI 6.70 to 37.74, I2 0% ; risk difference (RD) 0.65 (95% CI 0.57 to 0.74, very low certainty), medium term (5 studies, N = 597, RR 7.08, 95 %CI 3.40 to 14.71, I2 = 43%; RD 0.43, 95% CI 0.14 to 0.73, low-certainty evidence), and long term (1 study, N = 87, RR 15.15, 95% CI 2.11 to 108.91 ; RD 0.35, 95% CI 0.2 to 0.49, very low certainty) follow-up. Adverse events (AEs) Device related No studies specifically reported  device-related adverse events at short-term follow-up. At medium-term follow-up, the incidence of lead failure/displacement (3 studies N = 330) ranged from 0.9 to 14% (RD 0.04, 95% CI -0.04 to 0.11, I2 64%, very low certainty). The incidence of infection (4 studies, N = 548) ranged from 3 to 7% (RD 0.04, 95%CI 0.01, 0.07, I2 0%, very low certainty). The incidence of reoperation/reimplantation (4 studies, N =5 48) ranged from 2% to 31% (RD 0.11, 95% CI 0.02 to 0.21, I2 86%, very low certainty). One study (N = 44) reported a 55% incidence of lead failure/displacement (RD 0.55, 95% CI 0.35, 0 to 75, very low certainty), and a 94% incidence of reoperation/reimplantation (RD 0.94, 95% CI 0.80 to 1.07, very low certainty) at five-year follow-up. No studies provided data on infection rates at long-term follow-up. We found reports of some serious adverse events as a result of the intervention. These included autonomic neuropathy, prolonged hospitalisation, prolonged monoparesis, pulmonary oedema, wound infection, device extrusion and one death resulting from subdural haematoma. Other No studies reported the incidence of other adverse events at short-term follow-up. We found no clear evidence of a difference in otherAEs at medium-term (2 studies, N = 278, RD -0.05, 95% CI -0.16 to 0.06, I2 0%) or long term (1 study, N = 100, RD -0.17, 95% CI -0.37 to 0.02) follow-up. Very limited evidence suggested that SCS increases healthcare costs. It was not clear whether SCS was cost-effective.

AUTHORS' CONCLUSIONS

We found very low-certainty evidence that SCS may not provide clinically important benefits on pain intensity compared to placebo stimulation. We found low- to very low-certainty evidence that SNMD interventions may provide clinically important benefits for pain intensity when added to conventional medical management or physical therapy. SCS is associated with complications including infection, electrode lead failure/migration and a need for reoperation/re-implantation. The level of certainty regarding the size of those risks is very low. SNMD may lead to serious adverse events, including death. We found no evidence to support or refute the use of DRGS for chronic pain.

Development and validation of a nomogram for predicting the probability of new vertebral compression fractures after vertebral augmentation of osteoporotic vertebral compression fractures

INTRODUCTION

New vertebral compression fractures (NVCFs) are adverse events after vertebral augmentation of osteoporotic vertebral compression fractures (OVCFs). Predicting the risk of vertebral compression fractures (VCFs) accurately after surgery is still a significant challenge for spinal surgeons. The aim of our study was to identify risk factors of NCVFs after vertebral augmentation of OVCFs and develop a nomogram.

METHODS

We retrospectively reviewed the medical records of patients with OVCFs who underwent percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP). Patients were divided into the NVCFs group and control group, base on the patients with or without NVCFs within 2 years follow-up period after surgery. A training cohort of 403 patients diagnosed in our hospital from June 2014 to December 2016 was used for model development. The independent predictive factors of postoperative VCFs were determined by least absolute shrinkage and selection operator (LASSO) logistic regression, univariate analysis and multivariate logistic regression analysis. We provided a nomogram for predicting the risk of NVCFs based on independent predictive factors and used the receiver operating characteristic curve (ROC), calibration curve, and decision curve analyses (DCA) to evaluated the prognostic performance. After internal validation, the nomogram was further evaluated in a validation cohort of 159 patients included between January 2017 and June 2018.

RESULTS

Of the 403 patients in the training cohort, 49(12.16%) were NVCFs at an average of 16.7 (1 to 23) months within the 2 years follow-up period. Of the 159 patients in the validation cohort, 17(10.69%) were NVCFs at an average of 8.7 (1 to 15) months within the 2 years follow-up period. In the training cohort, the proportions of elderly patients older than 80 years were 32.65 and 13.56% in the NVCFs and control group, respectively (p = 0.003). The percentages of patients with previous fracture history were 26.53 and 12.71% in the NVCFs and control group, respectively (p = 0.010). The volume of bone cement were 4.43 ± 0.88 mL and 4.02 ± 1.13 mL in the NVCFs and Control group, respectively (p = 0.014). The differences have statistical significance in the bone cement leakage, bone cement dispersion, contact with endplate, anti-osteoporotic treatment, post-op Cobb angle and Cobb angle restoration characteristics between the two groups. The model was established by multivariate logistic regression analysis to obtain independent predictors. In the training and validation cohort, the AUC of the nomogram were 0.882 (95% confidence interval (CI), 0.824-0.940) and 0.869 (95% CI: 0.811-0.927), respectively. The C index of the nomogram was 0.886 in the training cohort and 0.893 in the validation cohort, demonstrating good discrimination. In the training and validation cohort, the optimal calibration curves demonstrated the coincidence between prediction and actual status, and the decision curve analysis demonstrated that the full model had the highest clinical net benefit across the entire range of threshold probabilities.

CONCLUSION

A nomogram for predicting NVCFs after vertebral augmentation was established and validated. For patients evaluated by this model with predictive high risk of developing postoperative VCFs, postoperative management strategies such as enhance osteoporosis-related health education and management should be considered.

A Pilot Study of Radiculopathy Following Osteoporotic Vertebral Fracture in Elderly Patients: An Algorithmic Approach to Surgical Management

Background: Osteoporotic vertebral compression fractures (OVCF) due to severe and refractory back pain or neurological complications require surgical treatment. In this study, patients with radiculopathy due to foraminal stenosis following OVCF were surgically managed by performing transforaminal full-endoscopic lumbar foraminoplasty and/or discectomy (FELFD). Methods: From May 2015 to November 2019, fifteen patients underwent transforaminal FELFD. Patient data, Charlson comorbidity index (CCI), and American Society of Anesthesiologists (ASA) score were collected. Clinical outcomes, including pre- and postoperative Visual Analog Scale (VAS) scores for back and leg pain, Oswestry Disability Index (ODI), and MacNab criteria of response to surgical treatment, were evaluated. Results: Mean of age, bone mineral density (T-score), CCI, ASA, and follow-up duration were 69.5 ± 6.6 years, −2.6 ± 0.8, 5.2 ± 2.3, 2.4 ± 0.5, and 24.5 ± 8.8 months, respectively. Mean VAS for leg pain significantly decreased from 6.9 ± 0.8 preoperatively to 2.9 ± 1.1 (P < .05). Mean ODI decreased from 39.9 ± 3.2 preoperatively to 19.3 ± 4.6 postoperatively (P < .05). The satisfaction rate is 86.7% (based on Macnab criteria), showed six patients had excellent outcomes and seven had good outcomes. Conclusions: Transforaminal FELFD is an effective treatment option for patients with radiculopathy due to lumbar OVCF, including those with severe osteoporosis and elderly patients.

The burden of percutaneous vertebroplasty: an epidemiological nationwide study in Italy from 2009 to 2015

PURPOSE

Percutaneous vertebroplasty (PV) is a minimally invasive technique requiring the injection of polymethylmethacrylate cement into a collapsed or weakened vertebral body to stabilize the fracture. The present study aims to determine the trends in PV procedures over the recent years. The longitudinal analysis of national registers may help to understand the yearly trends and the economic burden of PV. The evaluation of the yearly national costs of this procedure is essential to surgeons, policymaker, hospital administrator and the healthcare system. Moreover, to observe possible variation in the trend of hospitalization between countries, the data of the present study were compared to the US population.

METHODS

Data of this study were collected from the National Hospital Discharge Reports reported at the Italian Ministry of Health regarding the years of this paper (2009-2015). The yearly number of hospital admission for PV, sex, age, days of hospitalization and primary diagnoses in the whole Italian population were calculated.

RESULTS

31,887 vertebroplasties were performed in Italy, with an incidence of 8.8 procedures for every 100,000 inhabitants. Females represented the majority of patients undergoing PV. The median length of hospital stay was 4.15 days. The mean hospital reimbursement was 4,629€ for each PV hospitalization.

CONCLUSION

The burden of vertebral fracture is relevant in the Italian population, and PV constitutes a rapid and effective treatment. Compared to other countries, the costs of PV in Italy are relatively lower; however, it is important to define the incidence of this procedure to understand the economic trend of PV.

Complications and healthcare utilization in commercially-insured osteoporotic vertebral compression fracture patients: a comparison of kyphoplasty versus propensity-matched controls

BACKGROUND CONTEXT

Osteoporotic vertebral fractures (OVFs) can lead to severe pain and reduced function and quality-of-life, but the strength of evidence for treatments remains low, particularly in younger populations.

PURPOSE

To determine whether patients with OVFs who received kyphoplasty had different patterns of healthcare utilization compared to propensity-matched patients who did not receive vertebral augmentation.

DESIGN

Observational cohort study.

PATIENT SAMPLE

We identified patients with OVFs from 2007 to 2018 in the IBM MarketScan Commercial Claims and Encounters Databases who received kyphoplasty and compared them to propensity-matched controls who did not receive vertebral augmentation (either kyphoplasty or vertebroplasty).

OUTCOME MEASURES

Major medical complications within 30 days, fills of opioids from 1-week through 1-month postaugmentation, and spine-related gross covered payments from 3-days postkyphoplasty through 1-year post-OVF.

METHODS

We used logistic regression to obtain odds ratios (ORs) and 95% confidence intervals (95% CIs) to compare binary outcomes and median analysis to compare continuous outcomes.

RESULTS

Of the 15,197 OVF patients identified, 1,969 (13%) received kyphoplasty and 1,928 (98%) of these were propensity matched to nonaugmented controls. We did not observe differences in the odds of major medical complications within 30 days (adjusted OR [95% CI]: 1.0 [0.6, 1.8]) but patients who received kyphoplasty were more likely to have filled opioid medications within 30 days (adjusted OR [95% CI]: 1.3 [1.1, 1.5]) and had greater spine-related gross covered payments (kyphoplasty median [95% CI]: $1,340 [$240, $4,850]; nonaugmented: $7,870 [$7,480, $8,270]; adjusted difference in medians [95% CI]: $260 [$190, $2,050]).

CONCLUSIONS

In this cohort of patients <65 years, receipt of kyphoplasty was associated with greater likelihood of opioid fills and somewhat greater spine-related gross covered payments, but no difference in major medical complications. In this retrospective study of administrative data, we did not detect advantages of treatment with kyphoplasty compared with nonaugmentation for any of our outcomes.

Comparison of different predicting models to assist the diagnosis of spinal lesions

In neurosurgical or orthopedic clinics, the differential diagnosis of lower back pain is often time-consuming and costly. This is especially true when there are several candidate diagnoses with similar symptoms that might confuse clinic physicians. Therefore, methods for the efficient differential diagnosis can help physicians to implement the most appropriate treatment and achieve the goal of pain reduction for their patients.In this study, we applied data-mining techniques from artificial intelligence technologies, in order to implement a computer-aided auxiliary differential diagnosis for a herniated intervertebral disc, spondylolithesis, and spinal stenosis. We collected questionnaires from 361 patients and analyzed the resulting data by using a linear discriminant analysis, clustering, and artificial neural network techniques to construct a related classification model and to compare the accuracy and implementation efficiency of the different methods.Our results indicate that a linear discriminant analysis has obvious advantages for classification and diagnosis, in terms of accuracy.We concluded that the judgment results from artificial intelligence can be used as a reference for medical personnel in their clinical diagnoses. Our method is expected to facilitate the early detection of symptoms and early treatment, so as to reduce the social resource costs and the huge burden of medical expenses, and to increase the quality of medical care.

Practice Patterns of Spine Surgeons Regarding Osteoporosis: An International Survey

BACKGROUND

Osteoporosis (OP) represents a great challenge for the spine surgeon. Despite having effective pharmacological treatments for OP and surgical technical innovations, the awareness of spine surgeons regarding OP seems low. The purpose of this research was to assess practice patterns on the diagnosis and treatment of spine surgeons regarding OP.

METHODS

An electronic survey of ten multiple-choice questions was administered to members of the European Association of Neurosurgical Societies (EANS). The survey asked about the specialty, the workplace, and practice patterns and attitudes regarding OP and spine fusion surgery, pseudoarthrosis, and vertebral compression fractures (VCF).

RESULTS

A total of 122 surgeons completed the survey. In patients with suspected OP, 31.4% of surgeons would refer the patient to the OP specialist before surgery and 21.5% chose to perform the surgery without additional studies. A 66.4% of respondents would modify the surgical strategy in the case of OP. The most popular surgical techniques elected were cemented augmented screws (77.9%) and long-segment instrumentation (45.1%). Regarding pseudoarthrosis, 29.5% of surgeons opted to refer to the OP specialist, and 23.8% didn't consider any additional studies Concerning VCF management, 41.32% of respondents would refer the patient for treatment of OP, and the most common therapeutic strategy was conservatively treatment for 4 to 6 weeks and vertebroplasty or kyphoplasty if no improvement (55.74%).There was a higher proportion of surgeons that would not consider preoperative studies or referring patients with suspected OP for spine surgery (χ2 = 4.48, P = .03) and pseudoarthrosis (χ2 = 9.5, P = .002) compared to VCF.

CONCLUSIONS

There was a greater awareness regarding optimizing OP management in VCF compared to patients with suspected OP for spine arthrodesis or pseudoarthrosis. There still opportunities for improvement for the timely diagnosis and treatment of OP in spine surgery patients.

PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews

The methods and results of systematic reviews should be reported in sufficient detail to allow users to assess the trustworthiness and applicability of the review findings. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement was developed to facilitate transparent and complete reporting of systematic reviews and has been updated (to PRISMA 2020) to reflect recent advances in systematic review methodology and terminology. Here, we present the explanation and elaboration paper for PRISMA 2020, where we explain why reporting of each item is recommended, present bullet points that detail the reporting recommendations, and present examples from published reviews. We hope that changes to the content and structure of PRISMA 2020 will facilitate uptake of the guideline and lead to more transparent, complete, and accurate reporting of systematic reviews.

Performance of Double-Arm Digital Subtraction Angiography (DSA)-Guided and C-Arm-Guided Percutaneous Kyphoplasty (PKP) to Treat Senile Osteoporotic Vertebral Compression Fractures

Background

Osteoporotic vertebral compression fracture (OVCF) is a common fracture in the elderly. Conservative treatment requires prolonged bedding, which may lead to serious complications. To explore optimized use of percutaneous kyphoplasty (PKP) in the treatment of senile osteoporotic thoracolumbar vertebral compression fractures, in this study, we used C-arm-guided and double-arm digital subtraction angiography (DSA)-guided PKP to treat OVCF in elderly patients and analyzed the effective recovery.

Material/Methods

In all, 60 patients who presented with osteoporotic vertebral compression fractures at our hospital between July 2017 and February 2019 were analyzed. They were randomly divided into C-arm-guided group and the double-arm DSA-guided groups. Both groups were treated with percutaneous kyphoplasty.

Results

A pain VAS score analysis revealed that there was no significant difference between the two groups before surgery (P>0.05). After surgery, the VAS scores showed a significant difference between the C-arm-guided group and the double-arm DSA-guided PKP treatment group (P<0.01). Moreover, with respect to the bone cement dosage, vertebral correction height, operation time, cumulative radiation dose, percolation rate, and volume of bone cement, the double-arm DSA-guided PKP treatment showed significantly better results than the C-arm-guided PKP treatment (P<0.01).

Conclusions

Our data revealed that double-arm DSA-guided PKP was more accurate in treatment of senile osteoporotic thoracolumbar vertebral compression fractures, producing excellent performance with more accurate intraoperative evaluation, shorter operative time, lower incidence of bone cement leakage, less intraoperative radiation dose, and higher safety, and thus, could be extensively applied to clinical surgery.

Cochrane vertebroplasty review misrepresented evidence for vertebroplasty with early intervention in severely affected patients

The Cochrane vertebroplasty review of April 2018 was replaced with an updated version in November 2018 to address complaints of errors in analysis. The updated version continues to misrepresent the evidence supporting early intervention with vertebroplasty for patients with uncontrolled, severe pain and fracture duration <6 weeks. The VAPOUR trial is the only blinded trial of vertebroplasty restricted to this patient group. It showed the benefit of vertebroplasty over placebo, particularly when the intervention occurred within 3 weeks of fracture. The Cochrane vertebroplasty review has ignored the positive outcomes in the VAPOUR trial. Open randomised trials of fractures <6-week duration support the positive findings of the VAPOUR trial. This is not described in the Cochrane review. The VAPOUR trial is clinically heterogeneous from other blinded trials. Cochrane protocol stipulates that clinically heterogeneous trials be described separately, as independent evidence, and not combined in analysis with dissimilar trials. Failure to observe this represents a serious protocol breach in the Cochrane review.

Early vertebroplasty within 3 weeks of fracture for acute painful vertebral osteoporotic fractures: subgroup analysis of the VAPOUR trial and review of the literature

BACKGROUND

VAPOUR found vertebroplasty (V) more effective than placebo (P) in patients with severe pain and fracture duration less than 6 weeks. Exploratory analysis suggested that benefits were concentrated in the subgroup of patients with fractures ≤ 3-week duration. This difference may account for the three negative blinded trials that included few patients within this fracture time frame.

PURPOSE

To assess the safety and efficacy of early vertebroplasty for acute painful vertebral osteoporotic fractures within 3 weeks of fracture onset in the VAPOUR study.

METHODS

Spearman's rank log coefficients were calculated to reassess the relationship of pain reduction from vertebroplasty and fracture duration in the VAPOUR trial. We more fully report baseline and outcome data in patients with fractures ≤ 3-week duration.

RESULTS

There were 46V and 47P patients with fractures ≤ 3-week duration. Baseline characteristics were similar. In total, 86 patients (41V, 45P) completed the 14-day questionnaire. The proportion of patients with reduction in pain from severe (NRS ≥ 7/10 was an inclusion requirement) to mild (NRS < 4) at 14 days was 21 (51%) V-group and 9 (20%) in the P-group (between-group difference 31 percentage points, 95% CI 12-50; p = 0.002). Early vertebroplasty provided greater reductions in mean NRS pain and Roland-Morris Disability.

CONCLUSION

Analysis of this patient subgroup from the VAPOUR trial, in the context of other randomised trial evidence, suggests clinically significant benefits from early vertebroplasty if performed within 3 weeks of fracture. These slides can be retrieved from Electronic Supplementary Material.

Efficacy analysis of percutaneous pedicle screw fixation combined with percutaneous vertebroplasty in the treatment of osteoporotic vertebral compression fractures with kyphosis

BACKGROUND

To investigate the clinical effect of percutaneous pedicle screw fixation (PPSF) combined with percutaneous vertebroplasty (PVP) in the treatment of osteoporotic compression vertebral fracture (OVCF) of the thoracolumbar vertebra with kyphosis.

METHODS

One hundred sixty-six patients before June 2017 were retrospectively analyzed, and patients were divided into PPSF + PVP group A and PVP group B. Operative time, bone mineral density, postoperative bed time, high compression ratio, bone cement leakage rate, and bone cement dose were recorded. Comparison of vertebral anterior edge height, Cobb angle, visual analogue score (VAS), and low back pain dysfunction index (ODI) between the two groups in preoperative, postoperative 3 days, postoperative 6 months, postoperative 12 months, and postoperative 24 months, postoperative complications were observed in the two groups.

RESULTS

The operation time of group A was longer than that of group B (59.0 ± 8.6 min, 26.6 ± 5.2 min), longer postoperative bed rest time (3.3 ± 0.7 days, 1.2 ± 0.5 days), the differences were statistically significant (P < 0.01), there was no difference in the amount of bone cement between the two groups (5.4 ± 0.6 ml, 5.3 ± 0.8 ml) (P > 0.05). The height of the anterior edge and Cobb angle of the two groups recovered significantly in postoperative 3 days. The height of anterior edge (2.7 ± 0.3 cm, 2.6 ± 0.2 cm, 2.5 ± 0.7 cm; 2.3 ± 0.6 cm, 1.7 ± 0.5 cm, 1.6 ± 0.3 cm) and Cobb angle (4.9 ± 2.2, 5.5 ± 2.3, 5.7 ± 2.3; 12.4 ± 3.2, 17.2 ± 2.5, 13.2 ± 2.3) was statistically significant in postoperative 6 months, postoperative 12 months, and postoperative 24 months (P < 0.01). VAS and ODI scores of postoperative 6 months and 12 months were significantly different between the two groups (P < 0.05). Postoperative complications in group B were much higher than those in group A.

CONCLUSION

The efficacy of PVP alone was not satisfactory, and the rate of complications was high for OVCF patients with severe anterior edge compression with kyphosis. PPSF combined with PVP is recommended, the vertebral height loss was not obvious, the satisfaction was good, and the complication rate was lower during 2 years follow-up.

"Targeted Percutaneous Vertebroplasty" Versus Traditional Percutaneous Vertebroplasty for Osteoporotic Vertebral Compression Fracture

Objective. In this randomized, nonblinded, controlled study, the feasibility and precision of "targeted percutaneous vertebroplasty" ("targeted PVP") for osteoporotic vertebral compression fracture (OVCF) was evaluated. Methods. A total of 42 patients, aged 50 to 87 years, with OVCF were randomly divided into 2 groups: A and B. Group A underwent "targeted PVP," and group B underwent traditional PVP with the guidance of C-arm fluoroscopy. Fluoroscopy times for skin puncture points (FTSPP), total radiation doses (TRD), total fluoroscopy times (TFT), and operation time were set as the main evaluation indicators. Results. FTSPP (1.52 ± 0.51 in group A vs 6.62 ± 2.58 in group B, U < .001), TRD (6.26 ± 1.51 in group A vs 11.32 ± 4.21 in group B, P < .001), TFT (16.57 ± 2.79 in group A vs 26.05 ± 6.18 in group B, P < .001), and operation time (20.05 ± 3.38 in group A vs 25.43 ±5.11 in group B, U < .001) were statistically different in the 2 groups. The incidence of cement leakage that occurred in group A (1/21, 4.76%) was significantly less than that in group B (9/21, 42.9%, P < 0.05). Conclusions. "Targeted PVP" may achieve (1) less skin positioning fluoroscopy times, less total fluoroscopy times and dose, shorter operation time, which is more precise than traditional PVP; (2) less incidence of cement leakage; and (3) visualization of the fractured vertebra, which is probably more valuable for the treatment of complicated OVCF patients.

Vertebroplasty for acute painful osteoporotic vertebral compression fractures: An update

Vertebral compression fractures (VCFs) are a common cause of back pain and disability and are usually osteoporotic in nature. Therapy aims to adequately control pain and allow early mobilisation and return of function while preventing additional fractures. A proportion of patients do not achieve adequate pain relief using conservative measures alone. Unwanted adverse effects from medications may also ensue. Vertebroplasty represents an alternative treatment option for VCFs. Patients with acute VCFs (≤6 weeks old) may gain the most benefit from vertebroplasty as healed fractures are not as amenable to cement injection. High-quality studies have reported conflicting results regarding the use of vertebroplasty in the treatment of acute VCFs. Despite high-quality evidence, varying study designs and heterogenous patient cohorts make interpretation of this data difficult. Only one sham-controlled randomised controlled trial (RCT) has evaluated vertebroplasty exclusively in patients with acute VCFs, reporting favourable results. Pooled data from RCTs also suggest vertebroplasty to be safe. This article provides a concise and critical review of the current literature regarding vertebroplasty for the treatment of acute VCFs.

Fatal cardiac perforation and pulmonary embolism of leaked cement after percutaneous vertebroplasty

Percutaneous vertebroplasty consists of percutaneous injection of polymethylmethacrylate (PMMA) via a transpedicular approach for the treatment of collapsed osteoporotic or metastatic vertebrae. Even if percutaneous vertebroplasty is considered to be minimally invasive, threatening complications can occur. Cement leakage is the most common complication of percutaneous vertebroplasty. Rigorous patient selection and individual therapeutic strategy may reduce the occurrence of leakage, in particular the risk of cement entry into the venous system and the spinal canal is the potent major hazard of this technique. Cement pulmonary and cardiac embolism are reported in literature as a cause of unexpected death after percutaneous vertebroplasty. Authors report a fatal case of pulmonary cement embolization occurred after vertebroplasty with haemopericardium, due to the perforation of the right atrium wall from a cement solidified fragment. A complete post mortem examination documented the presence of multiple cement fragments in the pulmonary arteries and transmural perforation of the wall of the right atrium by a whitish needle-like foreign body. Pulmonary microembolization was observed under polarized light.

Prophylactic vertebroplasty versus kyphoplasty in osteoporosis: A comprehensive biomechanical matched-pair study by in vitro compressive testing

Vertebroplasty and kyphoplasty are alternative augmentation techniques of osteoporotic vertebral compression fractures. However, shortly after augmentation, new vertebral compression fractures may occur, mostly in the adjacent vertebrae. To prevent this, prophylactic cement injection can be applied to the neighboring vertebral bodies. Although there are many evidence-based clinical studies on the potential hazards of vertebroplasty and kyphoplasty, there are only few studies comparing the prophylactic potential of the two treatments. In this matched-pair experimental biomechanical study, the two treatments were compared via destructive compressive testing of 76 non-fractured osteoporotic human lumbar vertebral bodies from 24 cadavers, augmented pair-wise with vertebroplasty or kyphoplasty. Strength, stiffness and deformability were analyzed in terms of donor age, CT-based bone density, vertebral morphometry, and cement-endplate contacts. These were investigated in a paired analysis and also in terms of the number of cement-endplate contacts. Vertebroplasty resulted in significantly, but only 19% larger stiffness, approximately equal failure load and smaller failure displacement compared to kyphoplasty. Cement-endplate contacts affect augmentation differently for the two techniques, namely, strength significantly increased with increasing number of contacts in vertebroplasty, but decreased in kyphoplasty. The reasons for these contrasting behavior included the fundamentally different augmentation method, the resulting different construction and location of cement clouds and the different form and location of failure. These results indicate that both prophylactic vertebroplasty and kyphoplasty of non-fractured adjacent vertebrae may be advantageous to avoid subsequent fractures after post-fracture vertebroplasty and kyphoplasty, respectively. However, cement bridging in vertebroplasty and central cement placement in kyphoplasty are advantageous in prevention.