The natural course of the paravertebral muscles after the onset of osteoporotic vertebral fracture

Adjacent Vertebral Refracture Prediction Model Based on Imaging Data After Vertebroplasty for Osteoporotic Vertebral Compression Fracture

OBJECTIVES

To establish a predictive model to evaluate the risk of adjacent vertebral refracture (VRF) after percutaneous kyphoplasty (PKP) for osteoporotic vertebral compression fracture (OVCF) based on perioperative imaging data.

METHODS

This study was a retrospective cohort study which established a predictive model of VRF after PKP for OVCF. Patients who underwent PKP for OVCF in our hospital between January 2018 and December 2020 were enrolled and divided into a refracture group and normal group. Perioperative imaging data including preoperative bone mineral density (BMD), fatty infiltration (FI%) of paravertebral muscle, sagittal parameters of the spine and pelvis, and recovery rate of vertebral height were collected. The prediction model is obtained by multifactor logistic regression analysis.

RESULTS

A total of 242 patients were included, including 23 cases in the VRF group and 219 cases in the normal group. There were statistical differences in BMD, FI%, recovery rate of vertebral height, and sagittal imbalance between the 2 groups. Receiver operating characteristic curve analysis of continuous variables showed that BMD ≤-2.80, FI% ≥40%, and recovery rate of vertebral height ≥ 10% were the cutoff values. Logistic regression analysis showed that BMD ≤-2.80, FI% ≥40%, and sagittal imbalance were independent risk factors for VRF. The area under the curve according to the predicted probability was 0.85 (P < 0.05). After simplifying the model, the total point of the model was 7 points, with a cutoff value of 5 points.

CONCLUSIONS

The prediction model obtained in this study can predict refracture after PKP for OVCF early and effectively. It has an excellent predictive effect which is suitable for clinicians.

Lower psoas mass indicates worse prognosis in percutaneous vertebroplasty-treated osteoporotic vertebral compression fracture

The correlation between lower psoas mass and the prognosis of osteoporotic vertebral compression fractures (OVCF) is still unclear. This study aims to investigate the impact of lower psoas mass on the prognosis of patients undergoing percutaneous vertebroplasty (PVP). One hundred and sixty-three elderly patients who underwent single-segment PVP from January 2018 to December 2021 were included. The psoas to L4 vertebral index (PLVI) via MRI were measured to assess psoas mass. Patients were divided into high PLVI (> 0.79) and low PLVI (≤ 0.79) groups based on the median PLVI in the cohort. The basic information (age, gender, body mass index (BMI) and bone mineral density (BMD)), surgical intervention-related elements (duration of operation, latency to ambulation, period of hospital stay, and surgical site), postoperative clinical outcomes (Visual Analog Scale (VAS) scores, Oswestry Disability Index (ODI) scores, Japanese Orthopaedic Association (JOA) scores), and incidence of secondary fractures) were compared. Patients showed no statistically significant differences in terms of age, gender, surgical sute, BMI, BMD and preoperative VAS, ODI, JOA scores (P > 0.05) between the two groups. However, there were significant differences in terms of latency to ambulation, period of hospital stay (P < 0.05). VAS, ODI, and JOA scores at 1, 6, and 12 months after surgery showed that the high PLVI group had significantly better outcomes than the low PLVI group (P < 0.05). Additionally, the low PLVI group had a significantly higher incidence of recurrent fracture (P < 0.05). Lower psoas mass can reduce the clinical effect of PVP in patients with osteoporotic vertebral compression fractures, and is a risk factor for recurrent vertebral fracture.

Paraspinal muscle parameters' predictive value for new vertebral compression fractures post-vertebral augmentation: Nomogram development and validation

Objective

Prior research underscores the significance of paraspinal muscles in maintaining spinal stability. This study aims to investigate the predictive value of paraspinal muscle parameters for the occurrence of new vertebral compression fractures (NVCF) following percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP) in patients with osteoporotic vertebral compression fractures (OVCF).

Methods

Retrospectively collected data from October 2019 to February 2021 (internal validation, n = 235) and March 2021 to November 2021 (external validation, n = 105) for patients with OVCF treated with PVP/PKP at our institution. They were randomly divided into training (188 cases) and validation groups (47 cases) at an 8:2 ratio. Lasso regression and multivariable logistic regression identified independent risk factors in the training set, and a Nomogram model was developed. Accuracy was assessed using receiver operating characteristic curves (ROC), calibration was evaluated with calibration curves and the Hosmer-Lemeshow test, and clinical utility was analyzed using decision curve analysis (DCA) and clinical impact curve (CIC).

Results

Surgical approach, spinal computed tomography (CT) values, and multifidus skeletal muscle index (SMI) are independent predictors of postoperative NVCF in OVCF patients. A Nomogram model, based on the identified predictors, was developed and uploaded online. Internal validation results showed area under the curve (AUC) values of 0.801, 0.664, and 0.832 for the training set, validation set, and external validation, respectively. Hosmer-Lemeshow goodness-of-fit tests (χ2 = 7.311-14.474, p = 0.070-0.504) and calibration curves indicated good consistency between observed and predicted values. DCA and CIC demonstrated clinical net benefit within risk thresholds of 0.06-0.84, 0.12-0.23, and 0.01-0.27. At specificity 1.00-0.80, the partial AUC (0.106) exceeded that at sensitivity 1.00-0.80 (0.062).

Conclusion

Compared to the spinal CT value, the multifidus SMI has certain potential in predicting the occurrence of NVCF. Additionally, the Nomogram model of this study has a greater negative predictive value.

Myosteatosis and bone marrow adiposity are not associated among postmenopausal women with fragility fractures

Objectives

Although paravertebral intramuscular fatty infiltration (known as myosteatosis) following a vertebral fracture is well-known, scarce data are available regarding interactions between muscle, bone, and other fat depots. Based on a homogeneous cohort comprising postmenopausal women with or without a history of fragility fracture, we aimed to better depict the interrelationship between myosteatosis and bone marrow adiposity (BMA).

Methods

102 postmenopausal women were included, 56 of whom had a fragility fracture. Mean proton density fat fraction (PDFF) was measured in the psoas (PDFF_Psoas) and paravertebral (PDFF_{Paravertebral}) muscles at the lumbar level, as well as in the lumbar spine and non-dominant hip using chemical shift encoding-based water-fat imaging. Visceral adipose tissue (VAT) and total body fat (TBF) were assessed using dual X-ray absorptiometry. Statistical models were adjusted for age, weight, height (all comparisons), and bone mineral density (when considering BMA).

Results

PDFF in the psoas and paravertebral muscles was higher in the fracture group compared to controls even after adjustment for age, weight, and height (PDFF_Psoas = 17.1 ± 6.1% versus 13.5 ± 4.9%, p=0.004; PDFF_{Paravertebral} = 34.4 ± 13.6% versus 24.9 ± 8.8%, p=0.002). Higher PDFF_{Paravertebral} was associated with lower PDFF at the lumbar spine (β = -6.80 ± 2.85, p=0.022) among controls but not in the fracture group. In both groups, a significant relationship between higher PDFF_Psoas and higher VAT was observed (β = 20.27 ± 9.62, p=0.040 in the fracture group, and β = 37.49 ± 8.65, p<0.001 in the control group). Although solely observed among controls, a similar relationship was observed between PDFF_{Paravertebral} and TBF (β = 6.57 ± 1.80, p<0.001). No significant association was observed between BMA and other fat depots.

Conclusion

Myosteatosis is not associated with BMA among postmenopausal women with fragility fractures. Whereas myosteatosis was associated with other fat depots, BMA appears uniquely regulated.

Role of paraspinal muscle degeneration in the occurrence and recurrence of osteoporotic vertebral fracture: A meta-analysis

Purpose

Recently, the effects of paraspinal muscle degeneration on osteoporotic vertebral fractures (OVFs) have attracted the attention of researchers; however, studies are limited, and their results vary. Hence, this study aimed to determine the role of paraspinal muscle degeneration in the occurrence and recurrence of OVF.

Methods

Following the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guideline, the PubMed, Embase, Web of Science, Wanfang Data, China National Knowledge Infrastructure, and ClinicalTrials.gov databases were comprehensively searched for relevant studies. Studies comparing the cross-sectional area (CSA) or fatty infiltration (FI) of the paraspinal muscles (including the psoas (PS), erector spinae plus multifidus (ES+MF), quadratus lumborum) in patients with and without initial OVF, or with and without recurrent OVF were included and analyzed.

Results

Eleven studies were included in the meta-analysis. Seven studies investigated the effects of paraspinal muscles on initial OVF, and the overall results revealed significantly lower CSAES+MF (SMD: -0.575, 95% CI: -0.866 to -0.285) and CSAPS (SMD: -0.750, 95% CI: -1.274 to -0.226), and higher FI (SMD: 0.768, 95% CI: 0.475 to 1.062) in the fracture group. Meanwhile, four studies evaluated the effects of the paraspinal muscles on recurrent OVF, and the pooled results demonstrated significantly higher FI (SMD:0.720, 95% CI: 0.258 to 1.182) in the refracture group, although no significant difference in CSAES+MF (SMD: -0.103, 95% CI: -0.395 to 0.189) was observed between the two groups.

Conclusions

Paraspinal muscle degeneration plays a role in the occurrence and recurrence of OVF. Assessing the paraspinal muscles may be useful for identifying high-risk populations.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier (CRD42021276681).

Relationship between sarcopenia/paravertebral muscles and the incidence of vertebral refractures following percutaneous kyphoplasty: a retrospective study

BACKGROUND

This study aimed to reveal the associations of osteoporotic vertebral compression refracture (OVCRF) incidence with sarcopenia and paravertebral muscles (PVM).

METHODS

A total of 214 elderly patients who underwent percutaneous kyphoplasty in our hospital between January 2017 and December 2019 were analyzed. Data on possible risk factors, including sex, age, weight, height, diabetes, treated vertebral levels (thoracolumbar junction [(T10-L2]), vacuum clefts, and body mass index (BMI), were collected. Preoperative bone mineral density (BMD) and appendicular muscle mass were evaluated using dual-energy X-ray absorptiometry. Nutritional status was evaluated using the Mini Nutritional Assessment. Magnetic resonance imaging was performed to evaluate the physiological cross-sectional area of the PVM.

RESULTS

Overall, 74 (15 men and 59 women) and 60 (55 women and 14 men) patients developed OVCRF and sarcopenia, respectively. Sarcopenia is related to advanced age, ower BMD and BMI values. Sarcopenia-related indicators (PVM fat rate, appendicular muscle mass index, grip strength) were significantly lower in the sarcopenia group. Univariate analysis showed a correlation between OVCRF and BMD, BMI, diabetes, sarcopenia, and age. Multivariate analysis suggested that fatty infiltration of the PVM, BMD, sarcopenia, diabetes, BMI, and treated vertebral level remained as the independent predictors of OVCRF (p < 0.05).

CONCLUSIONS

The association between sarcopenia and PVM as independent risk factors for OVCRF was established in this study; therefore, sarcopenia should be greatly considered in OVCRF prevention.

Correlation Between Bone Mineral Density (BMD) and Paraspinal Muscle Fat Infiltration Based on QCT: A Cross-Sectional Study

To investigate the correlation between fatty infiltration of the paraspinal muscle and bone mineral density (BMD). In total, 367 subjects (182 men and 185 women) who underwent quantitative computed tomography (QCT) examination were enrolled in this study. A QCT Pro workstation was used to obtain the mean BMD of the lower lumbar spine (L3, L4, L5) and fat fraction (FF) of the paraspinal muscle (psoas and erector spinae) at the corresponding levels. The patient's age, sex, body mass index, number of previous vertebral fractures, physical activity level, and visual analog scale (VAS) score for lower back pain were recorded. For categorical variables, one-way ANOVA and independent-samples t tests were performed. Spearman and Pearson correlation coefficients were used to analyze the correlations among continuous variables. Influential factors were analyzed by multivariate linear regression analysis. Regarding the mean paraspinal muscle FF, there were significant differences between the different vertebral fracture groups (P < 0.05). Age and VAS score showed a positive correlation with the mean paraspinal muscle FF (r = 0.389, 0.454). BMD showed a negative correlation with the mean paraspinal muscle FF (r =  - 0.721). The multiple linear regression analysis showed that vertebral fracture (β = 0.851, P = 0.021) and BMD (β =  - 4.341, P = 0.004) were independent factors of the mean paraspinal muscle FF. This study demonstrated that an advanced age, a greater VAS score, a higher number of vertebral fractures, and a lower BMD may be associated with more severe fatty infiltration of the paraspinal muscle.

Relationship between oseteoporosis with fatty infiltration of paraspinal muscles based on QCT examination

INTRODUCTION

To investigate the correlation between paraspinal muscles features and osteoporosis in lumbar spine.

MATERIALS AND METHODS

A total of 367 subjects who underwent quantitative computed tomography (QCT) examination were enrolled in this study. QCT pro workstation was used to obtain the mean bone mineral density (BMD) of the lower lumbar spine. Fat fraction (FF) and cross-section area (CSA) of the paraspinal muscles at the corresponding levels were measured. All participants were divided into normal, osteopenia, and osteoporosis groups. One-way ANOVA and independent samples t tests were performed to compare differences between groups. Pearson and Spearman correlation coefficients and partial correlation analysis after controlling for confounding factors were used to analyze the correlation between BMD and paraspinal muscles measurements.

RESULTS

Among the 367 participants included, 116 were in the normal group, 130 in the osteopenia group and 121 in the osteoporosis group. There were significant differences among the three groups for the mean and multifidus FF. BMD showed negative correlations with the FF of the paraspinal muscles. Multifidus and mean FF showed the best correlation (r = - 0.654, - 0.777). There were also significant differences in the mean and multifidus FF between different age groups, while after controlling for confounding factors, there was no correlation between age and FF of the paraspinal muscles.

CONCLUSION

This preliminary study demonstrated the association of BMD with fatty infiltration of paraspinal muscles. Different muscles might have specific effects in different sex and age groups.

Impact of Multifidus Muscle Atrophy on the Occurrence of Secondary Symptomatic Adjacent Osteoporotic Vertebral Compression Fractures

To assess the potential influence of multifidus atrophy and fatty degeneration on the incidence of adjacent vertebral compression fractures within one year after the index fracture. In a retrospective cohort study, patients who underwent surgery for an OVCF were identified and baseline characteristics, fracture patterns and the occurrence of secondary adjacent fractures within one year were obtained by chart review. Multifidus muscle atrophy and fatty degeneration were determined on preoperative MRI or CT scans. In this analysis of 191 patients (mean age 77 years, SD 8, 116 female), OF type 3 was the most common type of OVCF (49.2%). Symptomatic adjacent OVCFs within one year after index fracture were observed in 23/191 patients (12%) at mean 12, SD 12 weeks (range 1-42 weeks) postoperatively. The mean multifidus muscle area was 264, SD 53 mm² in patients with an adjacent vertebral fracture and 271, SD 92 mm² in patients without a secondary fracture (p = 0.755). Mean multifidus fatty infiltration was graded Goutallier 2.2, SD 0.6 in patients with an adjacent fracture and Goutallier 2.2, SD 0.7 in patients without an adjacent fracture (p = 0.694). Pre-existing medication with corticosteroids was associated with the occurrence of an adjacent fracture (p = 0.006). Multifidus area and multifidus fatty infiltration had no significant effect on the occurrence of adjacent vertebral fractures within one year after the index fracture. Patients with a pre-existing medication with corticosteroids were more likely to sustain an adjacent fracture.

Osteoporotic Fractures of the Thoracic and Lumbar Vertebrae: Diagnosis and Conservative Treatment

BACKGROUND

The prevalence of osteoporotic vertebral body fractures in Europe is 18-26%. Although most of these injuries can be treated conservatively, the underlying concepts have not been defined clearly or uniformly. In this article, we present the current state of the evidence on the diagnosis and conservative treatment of osteoporotic fractures of the thoracic and lumbar vertebrae.

METHODS

A systematic review of the literature up to May 2020 was carried out in the PubMed and Web of Science Core Collection databases. 549 articles were identified, of which 36 were suitable for inclusion in the review. Articles were sought in the areas of diagnosis, provision of physical aids, pharmacotherapy, physiotherapy, and treatments from the realm of alternative medicine.

RESULTS

The primary diagnostic technique was conventional x-ray in two planes (with the patient standing, if possible), which had 51.3% sensitivity and 75% specificity. If a fracture was suspected, magnetic resonance imaging (MRI) of the entire spine and regional computed tomography (CT) were carried out. The overall state of the evidence on treatment is poor; the best available evidence is for exercise therapy and physiotherapy, which are supported by three level I and four level II studies. Improvements were seen mainly in mobility and a reduced fear of falling. The use of an active orthosis can be useful as well. No evidence was found on the use of drugs or alternative medicine exclusively in the conservative treatment of osteoporotic vertebral body fractures.

CONCLUSION

It is reasonable to evaluate instability with imaging repeatedly, at regular intervals, over a period of six months. There is still a lack of reliable data on the optimal intensity and duration of physiotherapy, and on the use of orthoses.

Gender-specific analysis for the association between trunk muscle mass and spinal pathologies

We investigated the relationship between trunk muscle mass and spinal pathologies by gender. This multicenter cross-sectional study included patients aged ≥ 30 years who visited a spinal outpatient clinic. Trunk and appendicular muscle mass were measured using bioelectrical impedance analysis. The Oswestry Disability Index (ODI), visual analog scale (VAS) score for low back pain, sagittal vertical axis (SVA), and EuroQol 5 Dimension (EQ5D) score were investigated to evaluate spinal pathology. The association between trunk muscle mass and these parameters was analyzed by gender using a non-linear regression model adjusted for patients’ demographics. We investigated the association between age and trunk muscle mass. We included 781 men and 957 women. Trunk muscle mass differed significantly between men and women, although it decreased with age after age 70 in both genders. Lower trunk muscle mass was significantly associated with ODI, SVA, and EQ5D score deterioration in both genders; its association with VAS was significant only in men. Most parameters deteriorated when trunk muscle mass was < 26 kg in men and < 19 kg in women. Lower trunk muscle mass was associated with lumbar disability, spinal imbalance, and poor quality of life in both genders, with significant difference in muscle mass.

Trunk Muscle Mass Measured by Bioelectrical Impedance Analysis Reflecting the Cross-Sectional Area of the Paravertebral Muscles and Back Muscle Strength: A Cross-Sectional Analysis of a Prospective Cohort Study of Elderly Population

Trunk muscles play an important role in supporting the spinal column. A decline in trunk muscle mass, as measured by bioelectrical impedance analysis (TMM-BIA), is associated with low back pain and poor quality of life. The purpose of this study was to determine whether TMM-BIA correlates with quantitative and functional assessments traditionally used for the trunk muscles. We included 380 participants (aged ≥ 65 years; 152 males, 228 females) from the Shiraniwa Elderly Cohort (Shiraniwa) study, for whom the following data were available: TMM-BIA, lumbar magnetic resonance imaging (MRI), and back muscle strength (BMS). We measured the cross-sectional area (CSA) and fat-free CSA of the paravertebral muscles (PVM), including the erector spinae (ES), multifidus (MF), and psoas major (PM), on an axial lumbar MRI at L3/4. The correlation between TMM-BIA and the CSA of PVM, fat-free CSA of PVM, and BMS was investigated. TMM-BIA correlated with the CSA of total PVM and each individual PVM. A stronger correlation between TMM-BIA and fat-free CSA of PVM was observed. The TMM-BIA also strongly correlated with BMS. TMM-BIA is an easy and reliable way to evaluate the trunk muscle mass in a clinical setting.

Impact of paravertebral muscle in thoracolumbar and lower lumbar regions on outcomes following osteoporotic vertebral fracture: a multicenter cohort study

We investigated the effect of paravertebral muscle (PVM) on poor prognosis in osteoporotic vertebral fracture (OVF) and remaining lower back pain (LBP) in the thoracolumbar and lower lumbar regions. Additional OVF occurrence in the thoracolumbar and remaining LBP in the lumbar region was significantly related to PVM fat infiltration percentage.

PURPOSE

Paravertebral muscle (PVM) is an important component of the spinal column. However, its role in the healing process after osteoporotic vertebral fracture (OVF) is unclear. This study aimed to clarify the effect of PVM in thoracolumbar and lower lumbar regions on OVF clinical and radiological outcomes.

METHODS

This was a multicenter prospective cohort study from 2012 to 2015. Patients ≥ 65 years old who presented within 2 weeks after fracture onset were followed up for 6 months. PVM was measured at the upper edge of the L1 and L5 vertebral body in the magnetic resonance imaging (MRI) T2-axial position at registration. The cross-sectional area (CSA), relative CSA (rCSA), and fat infiltration percentage (FI%) were measured. Severe vertebral compression, delayed union, new OVF, and remaining low back pain (LBP) were analyzed.

RESULTS

Among 153 patients who were followed up for 6 months, 117 with measurable PVM were analyzed. Their average age was 79.1 ± 7.2 years, and 94 were women (80.3%). There were 48 cases of severe vertebral compression, 21 delayed unions, 11 new OVF, and 27 remaining LBP. Among all poor prognoses, only the FI% of the PVM was significantly associated with new OVF (p = 0.047) in the thoracolumbar region and remaining LBP (p = 0.042) in the lumbar region.

CONCLUSION

The occurrence of additional OVF in the thoracolumbar region and remaining LBP in the lumbar region was significantly related to the FI% of the PVM. Physicians should be aware that patients with such fatty degeneration shown in acute MRI may require stronger treatment.

Age- and BMI-related variations of fat distribution in sacral and lumbar bone marrow and their association with local muscle fat content

This analysis investigated the age- and BMI-related variations of fat distribution in sacral and lumbar bone marrow and their association with local muscle fat content in order to detect fat distribution patterns and variations in healthy adults using proton density fat fraction (PDFF) measurements. A six-echo 3D spoiled gradient-echo sequence was used for chemical shift encoding-based water-fat separation at the sacral and lower lumbar region in 103 healthy volunteers. PDFF values of the sacrum, 5^th lumbar vertebral body, the gluteal and paraspinal muscles were determined. Correlation with age was significant (p < 0.05) for PDFF of the sacrum (men (m): r = 0.58; women (w): r = 0.54), L5 (m: r = 0.58; w: r = 0.54), the gluteal (m: r = 0.51; w: r = 0.44) and paraspinal (m: r = 0.36; w: r = 0.49) muscles in both genders. BMI correlated significantly with the paraspinal musculature in men (r = 0.46) and women (r = 0.33). Correlation testing revealed significant correlations (p < 0.05) between the two osseous (m: r = 0.63, w: r = 0.75) and the muscle compartments (m: r = 0.63, w: r = 0.33) in both genders. Bone marrow and muscle fat infiltration patterns were not significantly associated with each other at the sacral and lower lumbar spine region. The presented data suggest that the two compartments may have distinct pathophysiological fat infiltration patterns. However, further clinical studies are needed to support the results.