Can MRI predict subsequent pseudarthrosis resulting from osteoporotic thoracolumbar vertebral fractures?

Vertebral compression fractures managed with brace: risk factors for progression

PURPOSE

The aim of this study is to identify risk factors for vertebral compression fracture (VCF) progression in patients treated conservatively with a brace. Then, a case-control study was designed.

METHODS

All patients over 50 years old with diagnosis of thoracic or lumbar VCF (T5 to L5) in absence of underlying oncological process, treated conservatively with brace, and consecutively attended at our department from January 2017 to June 2021 were retrospectively selected for analysis. Patients missed for follow-up or dead during the first 3 months of follow-up were excluded.

RESULTS

Five hundred and eighty-two consecutive patients were recorded. Incomplete follow-up excluded 74 patients and other 19 died in the first three months after diagnosis, so 489 cases were finally analyzed. Median follow-up was 21 (IQR 13;30) weeks. Increased collapse of the vertebral body was found in 29.9% of VCFs with a median time to progression of 9 (IQR 7;13) weeks. Male gender (OR 1.6), type A3 fracture of the AOSpine classification (OR 2.7), thoracolumbar junction location (OR 1.7), and incorrect use of the brace (OR 3.5) were identified as independent risk factors for progression after multivariable analysis.

CONCLUSION

Male gender, type A3 fracture of the AOSpine classification, thoracolumbar junction location, and incorrect use of the brace were identified as independent risk factors for VCF progression, which resulted in worse pain control, when treated with brace. Thus, other treatments such as percutaneous vertebral augmentation could be considered to avoid progression in selected cases, since collapse rate has been demonstrated lower with these procedures.

Prospective Study to Identify the Clinical and Radiologic Factors Predictive of Pseudarthrosis Development in Patients with Osteoporotic Vertebral Fractures

BACKGROUND

Although most osteoporotic vertebral fractures (OVFs) heal conservatively, the most crucial undesirable outcome of conservative treatment is the failure to unite. There is paucity of literature on prevalence and risk factors of pseudarthrosis.

METHODS

A prospective study involving patients (aged ≥50 years) undergoing conservative treatment of osteoporotic thoracic/lumbar fractures without neurodeficits was performed. Patients were followed for a minimum of 6 months and classified into 3 groups based on fracture healing: group 1, healing without collapse; group 2, healing with collapse; and group 3, pseudarthrosis. An assessment of all clinicoradiologic parameters at the time of injury and at each follow-up was performed and compared among patients belonging to the groups.

RESULTS

A total of 77 patients (90 fractures) were studied. Sixty-six (73.3%), 16 (17.8%), and 28 (8.9%) fractures were classified under groups 1, 2, and 3, respectively. Mean ages in groups 1, 2, and 3 were 67.9 ± 9.1, 70.4 ± 7.6 and 72.3 ± 7.9 years (P = 0.08). Sex distribution was 62:15 (female/male). Seventy-three fractures (81.1%) occurred at the thoracolumbar junction. Stiff spine, ambulatory status, comorbidities, bone mineral density, and injury level were not associated with pseudarthrosis/collapse (P > 0.05). Male sex was associated with pseudarthrosis (P = 0.03). Based on regression analysis, initial vertebral height loss (radiography; P = 0.028), segmental Cobb (radiography; P = 0.019), vertebral comminution (computed tomography; P = 0.032), posterior ligamentous complex injury (magnetic resonance imaging; P = 0.048), and marrow change pattern (T2-weighted magnetic resonance imaging, Kanchiku classification; P = 0.037) were correlated with poorer outcome. Patients with pseudarthrosis had higher visual analog scale score (P = 0.04; final follow-up).

CONCLUSIONS

Of OVFs, 8.9% developed pseudarthrosis. Male sex, severity of postinjury vertebral deformation (vertebral loss, kyphosis, comminution, and marrow changes) and presence of posterior ligamentous complex injury are risk factors for pseudarthrosis.

Osteoporotic vertebral fractures: radiologic diagnosis, clinical and radiologic factors affecting surgical decision making: WFNS Spine Committee Recommendations

With the varied literature on osteoporotic vertebral fracture that may predispose to diagnostic and management dilemma, it is timely to evaluate and streamline the evidence. The aim of this review is to create recommendations on osteoporotic vertebral fractures regarding radiologic diagnosis, and clinical and radiological factors affecting surgical decision making. A computerized literature search was done using PubMed, Google scholar and Cochrane Database of Systematic Reviews from 2010 to 2020. For radiologic diagnosis, the keywords "osteoporotic vertebral fractures" and "radiologic diagnosis" were used yielding 394 articles (19 relevant articles). For clinical and radiological factors affecting surgical decision making, the keywords "osteoporotic vertebral fractures", "radiologic diagnosis", and "surgery" were used yielding 568 articles (25 relevant articles). All pertinent data were reviewed, and consensus statements were obtained in two virtual separate consensus meetings of the World Federation of Neurosurgical Societies (WFNS) Spine committee. The statements were voted and yielded positive or negative consensus using the Delphi method. This review summarizes the WFNS Spine Committee recommendations on the radiologic diagnosis, and clinical and radiological factors affecting surgical decision making of osteoporotic vertebral fractures.

Risk Factors for Failure in Conservatively Treated Osteoporotic Vertebral Fractures: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

Osteoporosis is one of the most common diseases of the elderly, whereby vertebral body fractures are in many cases the first manifestation. Even today, the consequences for patients are underestimated. Therefore, early identification of therapy failures is essential. In this context, the aim of the present systematic review was to evaluate the current literature with respect to clinical and radiographic findings that might predict treatment failure.

METHODS

We conducted a comprehensive, systematic review of the literature according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) checklist and algorithm.

RESULTS

After the literature search, 724 potentially eligible investigations were identified. In total, 24 studies with 3044 participants and a mean follow-up of 11 months (range 6-27.5 months) were included. Patient-specific risk factors were age >73 years, bone mineral density with a t-score <-2.95, BMI >23 and a modified frailty index >2.5. The following radiological and fracture-specific risk factors could be identified: involvement of the posterior wall, initial height loss, midportion type fracture, development of an intravertebral cleft, fracture at the thoracolumbar junction, fracture involvement of both endplates, different morphological types of fractures, and specific MRI findings. Further, a correlation between sagittal spinal imbalance and treatment failure could be demonstrated.

CONCLUSION

In conclusion, this systematic review identified various factors that predict treatment failure in conservatively treated osteoporotic fractures. In these cases, additional treatment options and surgical treatment strategies should be considered in addition to follow-up examinations.

Paraspinal muscle fatty degeneration as a predictor of progressive vertebral collapse in osteoporotic vertebral compression fractures

BACKGROUND CONTEXT

Most osteoporotic vertebral compression fractures (OVCFs) are treated conservatively; however, in some patients, progressive vertebral body collapse leads to spinal deformity and cord compression. These complications are strongly associated with impaired performance activities of daily living and a poor quality of life.

PURPOSE

To identify the role of the paraspinal muscle as a risk factor for progressive vertebral body collapse in patients with OVCF.

STUDY DESIGN

This was a retrospective observational study.

PATIENT SAMPLE

Fifty-five consecutive patients with OVCF who were treated conservatively from January 2018 to June 2020 in a single spine center and had a minimum follow-up of 6 months.

OUTCOME MEASURES

A lateral plain radiograph in a neutral posture was taken when the patient was first diagnosed and at 1, 3, and 6 months after the first diagnosis. Vertebral height was measured at the point of maximal collapse of the affected vertebral body; vertebral collapse (%) was also measured. The cross-sectional area (CSA) and fatty degeneration of the paraspinal muscle were measured using the open-source software Image J. The visual analogue scale (VAS) scores were collected at the time of initial fracture diagnosis and at 1, 3, and 6 months.

METHODS

The clinical and radiological data were analyzed. In the L4-5 intervertebral disc level, axial T2-weighted magnetic resonance imaging was used to measure the CSA and fatty degeneration of the paraspinal muscles. Correlation and multiple regression analyses were performed to analyze the risk factors associated with progressive vertebral body collapse.

RESULTS

The vertebral collapse difference was strongly associated with paraspinal muscle fatty degeneration (r=0.684, p=.000) and body mass index (r=0.300, p=.026). Multiple linear regression analysis demonstrated that the risk factor for progression of vertebral collapse was paraspinal muscle fatty degeneration (β=0.724, p=.000). There was a statistically significant correlation between the progression in vertebral collapse and VAS score at 3 (r=0.402, p=.002) and 6 months (r=0.604, p=.000).

CONCLUSIONS

In patients with OVCF, fatty degeneration of the paraspinal muscle was a predictive factor for progressive vertebral body collapse. This study suggests that more attention should be paid to patients with paraspinal sarcopenia among those with OVCFs.

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.

Relationship between number of radiological risk factors for delayed union after osteoporotic vertebral fracture and clinical outcomes

This study demonstrated that number of three specific radiological risk factors (MR T2WI confined high-intensity pattern and diffuse low-intensity pattern, thoracolumbar vertebrae involvement, middle column injury) added prognostic information for delayed union, kyphotic deformity, and prolonged pain.

PURPOSE

Delayed union after osteoporotic vertebral fracture (OVF) causes prolonged pain, QOL impairment, progression of collapse, kyphotic deformity, and neurologic impairment. Some specific radiological findings can be useful for predicting delayed union. We aimed to explore the prevalence and concomitance of various types of radiological risk factors for delayed union after osteoporotic vertebral fracture (OVF) and to assess the impact of risk factor number on clinical outcomes.

METHODS

A total of 508 patients with fresh OVF from 25 institutes were evaluated. All patients were treated conservatively without surgical interventions. At the 6-month follow-up, the patients were classified into bone union and delayed union groups based on plain X-ray findings. We examined the presence and absence of three specific radiological risk factors (MR T2WI confined high-intensity pattern and diffuse low-intensity pattern, thoracolumbar vertebrae involvement, middle column injury) and analyzed clinical outcomes according to numbers of radiological risk factors.

RESULTS

Delayed union was observed in 101 patients (19.9%) at the 6-month follow-up. The most common radiological risk factor was thoracolumbar vertebrae involvement (73.8%), followed by middle column injury (33.9%) and specific MRI findings (T2WI confined high-intensity pattern and diffuse low-intensity pattern) (29.7%). Overall, 85 (16.7%) patients had zero radiological risk factors, 212 (42.7%) had one, 137 (27.0%) had two, and 69 (13.6%) had three. When assessing the number of radiographic risk factors which included the MRI findings (the 3-risk factor method), the odds ratio for delayed union after acute OVF was 5.8 in the 2/3-risk factor group and 13.1 in the 3/3-risk factor group. Even when assessing the number of radiographic risk factors without MRI findings (2-risk factor method), the odds ratio was 3.2 in the 1/2-risk factor group and 10.2 in the 2/2-risk factor group.

CONCLUSION

Number of radiological risk factors added prognostic information for delayed union, kyphotic deformity, and prolonged pain.

Use of proton density fat fraction MRI to predict the radiographic progression of osteoporotic vertebral compression fracture

OBJECTIVE

This study evaluated the diagnostic performance of the proton density fat fraction (PDFF) in predicting the progression of osteoporotic vertebral compression fractures (OVCFs).

METHODS

The cohort in this retrospective study consisted of 48 patients with OVCFs who underwent spine MRI that included PDFF between December 2016 and June 2018. The patients were divided into two groups (with versus without OVCF progression, based on the radiographic results obtained at the 6-month follow-up examination). Two musculoskeletal radiologists independently calculated the PDFF of the fracture and the PDFF ratio (fracture PDFF/normal vertebrae PDFF) using regions of interest. The mean values of these parameters were compared between the two groups, and the receiver operating characteristic curves were analysed.

RESULTS

The mean age was significantly higher in the group with OVCF progression (71.6 ± 8.4 years) than in the group without (64.8 ± 10.5 years) (p = 0.018). According to reader 1, the PDFF ratio was significantly lower in the group with OVCF progression versus that without OVCF progression (0.38 ± 0.13 vs 0.51 ± 0.20; p = 0.009), whereas the difference in the PDFF itself was not statistically significant. The PDFF ratio [area under the curve (AUC) = 0.723; 95% confidence interval (CI), 0.575-0.842] had a larger AUC than did the PDFF (AUC = 0.667; 95% CI, 0.516-0.796). The optimal cut-off value of the PDFF ratio for predicting OVCF progression was 0.42; this threshold corresponded to sensitivity, specificity, and accuracy values of 84.0%, 60.9%, and 72.9%, respectively.

CONCLUSION

The age and PDFF ratio can be used to predict OVCF progression.

KEY POINTS

• Chemical shift-encoded magnetic resonance imaging provides quantitative parameters for predicting OVCF progression. • The PDFF ratio is significantly lower in patients with OVCF progression. • The PDFF ratio is superior to the PDFF for predicting OVCF progression.

Can We Predict the Progression of Vertebral Collapse in Conservative Treatment of Osteoporotic Vertebral Fractures? A 3-Year Retrospective Study of 180 Patients From the Emergency Department

BACKGROUND

Osteoporotic vertebral fractures (OVFs) have a high incidence in the elderly population and are usually treated conservatively with good outcomes. Nevertheless, failure of the conservative treatment may lead to serious complications. The aim of the study is to identify clinical, radiographic, and magnetic resonance imaging findings potentially related to the failure of the conservative treatment of OVFs.

METHODS

Data from 620 patients treated in the emergency department for vertebral fracture from 2014 to 2016 were analyzed; after patient identification and inclusion criteria, only fresh OVFs of patients older than 65 years have been included. Main outcome measurements were vertebral collapse, fracture shape types, and progression of vertebral collapse. A progression of vertebral collapse >100% was taken as an independent variable to underline the statistically significant difference among the risk factors.

RESULTS

A total of 180 patients (138 women; 42 men) and 200 OVFs were analyzed (mean age = 77 years, range = 65-94 years). Potential risks factors for the progression of vertebral collapse >100% were found when fractures occurred in the thoraco-lumbar junction. The swelling type and the bow-shaped type showed higher risk of vertebral collapse, while the concave was the most stable type of fracture with good prognosis. Traumatic fractures had lower risks of fracture progression compared to nontraumatic fractures (eg, fractures after an effort). A linear black signal pattern on short inversion time inversion recovery findings of magnetic resonance imaging corresponded to a risk of progression of the vertebral collapse.

CONCLUSIONS

Thoraco-lumbar fractures, swelling and bow-shaped fractures, and a linear black area at MR are negative prognostic factors for the failure of conservative treatment.

LEVEL OF EVIDENCE

4.

CLINICAL RELEVANCE

The identification of negative prognostic factors may lead to different strategies of treatment to prevent vertebral collapse or failure of conservative treatment.

The factors related to the poor ADL in the patients with osteoporotic vertebral fracture after instrumentation surgery

PURPOSE

Osteoporotic vertebral fracture (OVF) with nonunion or neurological deficit may be a candidate for surgical treatment. However, some patients do not show improvement as expected. Therefore, we conducted a nationwide multicenter study to determine the predictors for postoperative poor activity of daily living (ADL) in patients with OVF.

METHODS

We retrospectively reviewed the case histories of 309 patients with OVF who underwent surgery. To determine the factors predicting postoperative poor ADL, uni- and multivariate statistical analyses were performed.

RESULTS

The frequency of poor ADL at final follow-up period was 9.1%. In univariate analysis, preoperative neurological deficit (OR, 4.1; 95% CI, 1.8-10.3; P < 0.001), perioperative complication (OR, 3.4; P = 0.006), absence of preoperative bone-modifying agent (BMA) administration (OR, 2.7; P = 0.03), and absence of postoperative recombinant human parathyroid hormone (rPTH) administration (OR, 3.9; P = 0.006) were significantly associated. In multivariate analysis, preoperative neurological deficit (OR, 4.6; P < 0.001), perioperative complication (OR, 3.4; P = 0.01), and absence of postoperative rPTH administration (OR, 3.9; P = 0.02) showed statistical significance.

CONCLUSIONS

Preoperative neurological deficit, perioperative complication, and absence of postoperative rPTH administration were considered as predictors for postoperative poor ADL in patients with OVF. Neurological deficits and complications are often inevitable factors; therefore, rPTH is an important option for postoperative treatment for OVF. These slides can be retrieved under Electronic Supplementary Material.

Usefulness of Fat Suppression Magnetic Resonance Imaging of Osteoporotic Vertebral Fractures in Preventing Subsequent Fractures After Kyphoplasty

BACKGROUND

Preoperative magnetic resonance imaging with fat suppression (FS-MRI) is useful to detect bone marrow edema in osteoporotic vertebral fractures (OVFs) and thus can improve diagnostic accuracy and influence surgical strategy for percutaneous augmentation. The role of preoperative FS-MRI in preventing subsequent fractures after balloon kyphoplasty has not been investigated in initially subclinical fractures or fractures without obvious morphologic changes.

METHODS

From January 2010 to December 2017, 214 consecutive patients underwent balloon kyphoplasty for painful OVFs. We defined 2 groups based on preoperative imaging (100 patients had preoperative FS-MRI and 114 patients had no MRI) and then compared baseline and surgical characteristics. The primary end point was incidence of subsequent fractures within 12 months after treatment.

RESULTS

The 214 patients underwent kyphoplasty of 414 vertebrae. Comparing FS-MRI with no-MRI groups, spontaneous fractures occurred significantly more (58% vs. 26.3%; P < 0.001) and fractures were more often multilevel (≥ 4 levels) (15% vs. 2.6%; P = 0.001), respectively. Overall incidence of subsequent vertebral fractures was 25.7% (32% in FS-MRI, 20.2% in no-MRI groups; P = 0.048). Average time to diagnosis of subsequent fractures did not differ between the 2 groups (9.3 FS-MRI vs. 11.5 weeks no-MRI; P = 0.411). Age ≥80 years at the time of balloon kyphoplasty was associated with a higher odds ratio (2.3) for subsequent fractures within 12 months (P = 0.039).

CONCLUSIONS

Surgical treatment according to preoperative FS-MRI did not reduce occurrence of subsequent OVFs and did not prolong fracture-free intervals within 12 months after kyphoplasty.

The impact of magnetic resonance imaging in the diagnostic and classification process of osteoporotic vertebral fractures

INTRODUCTION

Standard radiographs are still considered as the gold standard for the early assessment of thoraco-lumbar osteoporotic vertebral fractures (OVFs), although several studies demonstrated superior accuracy of magnetic resonance imaging (MRI) in the diagnostic process of OVFs. The aim of this study was to quantify the misdiagnosis rate of OVFs and analyse the impact of MRI on early diagnosis and classification, compared to standard radiographs alone.

MATERIALS AND METHODS

A total of 173 patients were enrolled in this study. All participants were 55 years of age or older (60 years for men) and complained acute back pain with suspected thoracolumbar OVFs without history of high-energy trauma. Diagnosis of OVF was initially performed on standard radiographs obtained in the emergency room. Then, all the patients underwent MRI scan with short-tau inversion recovery (STIR) sequencing within 7 days. We compared the level and number of fractures identified on standard radiographs with the MRI scan results. The discordance between radiographic and MRI diagnosis was quantified. Fractures were classified according to AO Spine Classification.

RESULTS

Mean age of the study participant was 74.2 years (range 55-92). They were 100 males and 73 females. MRI modified initial diagnosis in 52% (90/173) of our patients: in 43.9% of patients MRI identified one or more new thoracolumbar fracture. In 14 cases (8.1%) MRI disproved the evidence of any thoracolumbar fracture, even those recognized at plain X-rays. Bone bruise was detected by MRI in 19 vertebral bodies in 8 patients (4.6%) at levels that were classified as unremarkable on X-ray alone. In addition, 63 patients (36.4%) presented a total of 93 old fractures. The classification of fracture pattern after MRI changed in 28.90% of the patients (changes mostly involved AO type A1 patterns).

CONCLUSIONS

Underdiagnosis of osteoporotic vertebral fractures is a common problem due to a lack of radiographic detection. Our results showed that the extensive use of MRI imaging allows better accuracy in the diagnostic process and in the classification assessment, compared to conventional radiographs. Further investigation should provide additional information about the impact of early MRI on treatment and management of elderly patients with suspected OVFs, including the decision to hospitalize or not, and how it could affect clinical outcome and social costs.

Impact of Magnetic Resonance Imaging on Treatment-Related Decision Making for Osteoporotic Vertebral Compression Fracture: A Prospective Randomized Trial

Background

The aim of this study was to analyze the impact and usefulness of characteristic signal change of a linear black signal on magnetic resonance imaging (MRI) on treatment-related decision making.

Material/Methods

Forty-one patients with a linear black signal on MRI were enrolled in this prospective study. They were randomly divided into the percutaneous kyphoplasty (PKP) group (n=24) and the conservative treatment group (n=17). Clinical measures, including visual analog scale (VAS) and short-form 36 (SF-36) questionnaire, were analyzed. Radiographic measures, including anterior vertebral body height, kyphosis angle and rate of bone-union, were evaluated.

Results

VAS scores were significantly lower in the PKP group than in the conservative treatment group post-treatment and at one-year follow-up. After one year of treatment, the values for physical functioning, physical health, and body pain were significantly higher in the PKP group than in the conservative treatment group (p<0.05). The PKP group had a significantly higher anterior vertebral body height, rate of bone-union, and lower kyphosis angle than the conservative treatment group at one-year follow-up (p<0.05).

Conclusions

In patients with a linear black signal detected on MRI, the first-choice treatment should be PKP rather than conservative treatment.

Difference of clinical course between cases with bone union and those with delayed union following osteoporotic vertebral fractures

In this prospective multicenter study of osteoporotic vertebral fractures (OVFs), delayed union of OVF at 6-month follow-up caused prolonged pain, QOL impairment, ADL impairment, cognitive status deterioration, and vertebral collapse progression.

PURPOSE

Delayed union following osteoporotic vertebral fracture displayed as an intravertebral cleft on plain X-rays was reported to be a factor for prolonged severe pain. However, the difference of clinical course between bone union and delayed union cases still remains unclear. The purpose of this study was to identify how OVF delayed union following conventional conservative treatment influences the clinical course with a prospective multicenter study.

METHODS

A total of 324 OVF patients from 25 institutes in Osaka, Japan, were included in the study. At the 6-month follow-up after initial visit to each institute, the patients were classified into bone union and delayed union groups based on plain X-ray findings. The outcome assessments included a VAS for back pain, SF-36 for quality of life (QOL), severity of bed-ridden state for activities of daily living (ADL), MMSE for cognitive functions, and degree of vertebral collapse on plain X-rays.

RESULTS

Overall, 280 patients were included into the union group and 44 into the delayed union group. The VAS score at 6 months was significantly worse in the delayed union group (p = 0.01). The scores for the SF-36 scales of physical functioning and bodily pain at 6 months were significantly lower in the delayed union group (p = 0.019, p = 0.01, respectively). The percentage of nearly or completely bed-ridden patients was significantly higher in the delayed union group. The percentage of newly developed cognitive impairment was significantly higher in the delayed union group (p = 0.02). Progression of vertebral collapse during the 6-month follow-up was more pronounced in the delayed union group (p < 0.01).

CONCLUSION

The present results revealed that delayed union following OVF causes prolonged pain, QOL impairment, ADL impairment, cognitive status deterioration, and vertebral collapse progression.

The Michel Benoist and Robert Mulholland yearly European Spine Journal Review: a survey of the "surgical research" articles in the European Spine Journal 2014

This is a review of some 50 papers published in the European Spine Journal in the year 2014. They are selected on the basis that the author felt they were significant contributions to the spinal literature in that year. A brief precis is provided of each paper, and each is accompanied by a short discussion explaining its importance and relevance.