Relationship between sagittal spinal alignment and the incidence of vertebral fracture in menopausal women with osteoporosis: a multicenter longitudinal follow-up study

Incidence and risk factors of subsequent vertebral fracture following percutaneous vertebral augmentation in postmenopausal women

PURPOSE

Subsequent vertebral fracture (SVF) is a severe advent event of percutaneous vertebral augmentation (PVA). However, the incidence and risk factors of SVF following PVA for OVCF in postmenopausal women remain unclear. This research aims to investigative the incidence and risk factors of SVF after PVA for OVCF in postmenopausal women.

METHODS

Women who underwent initial PVA for OVCF between August 2019 and December 2021 were reviewed. Univariate logistic regression analysis was performed to identify possible risk factors of SVF, and independent risk factors were determined by multivariate logistic regression.

RESULTS

A total of 682 women after menopause were enrolled in the study. Of these women, 100 cases had an SVF after PVA, with the incidence of 14.66%. Univariate logistic regression analysis demonstrated that age (p = 0.001), body mass index (BMI) (p < 0.001), steroid use (p = 0.008), history of previous vertebral fracture (p < 0.001), multiple vertebral fracture (p = 0.033), postoperative wedge angle (p = 0.003), and HU value (p < 0.001) were significantly correlated with SVF following PVA. Furthermore, BMI (OR [95%CI] = 0.892 [0.825 - 0.965]; p = 0.004), steroid use (OR [95%CI] = 3.029 [1.211 - 7.574]; p = 0.018), history of previous vertebral fracture (OR [95%CI] = 1.898 [1.148 - 3.139]; p = 0.013), postoperative wedge angle (OR [95%CI] = 1.036 [1.004 - 1.070]; p = 0.028), and HU value (OR [95%CI] = 0.980 [0.971 - 0.990]; p < 0.001) were identified as independent risk factors of SVF after PVA by multivariate logistic regression analysis.

CONCLUSIONS

The incidence of SVF following PVA for OVCF in postmenopausal women was 14.66%. BMI, steroid use, history of previous vertebral fracture, postoperative wedge angle, and HU value were independent risk factors of SVF after PVA for OVCF in postmenopausal women.

Changes in spinal sagittal balance after a new osteoporotic vertebral compression fracture

We conduct a longitudinal study to examine how new VCF alter spinal sagittal balance. New VCF increased SVA by an average of 2.8 cm. Sagittal balance deteriorates as a VCF develops in the lower lumbar spine. A new fracture below L1 increased the relative risk of a deterioration of sagittal balance 2.9-fold compared to one above Th12.

PURPOSE

Studies on the relationship between osteoporotic vertebral fractures and spinal sagittal balance have all been limited to cross-sectional studies. The aim of this study is to conduct a longitudinal study to examine how new vertebral compression fracture (VCF) alter spinal sagittal balance.

METHODS

Subjects were patients undergoing periodic examinations after treatment of a vertebral fracture or lumbar spinal canal stenosis. Forty patients who developed a new VCF were included in this study. Full-spine standing radiographs were compared before and after the fracture to examine changes in spinopelvic parameters and factors determining the changes in sagittal balance.

RESULTS

The mean age of the patients was 79.0 years. The mean interval between pre- and post-fracture radiographs was 22.7 months, and the mean time between development of a fracture and post-fracture radiographs was 4.6 months. After a fracture, sagittal vertical axis (SVA) increased an average of 2.78 cm and spino-sacral angle (SSA) decreased an average of 5.3°. Both ⊿SVA and ⊿SSA were not related to pre-fracture parameters. The wedge angle of the fractured vertebra was not related to changes in sagittal balance. ⊿SVA increased markedly in patients with a fracture of the lower lumbar vertebrae. receiver operating characteristic analysis revealed that the relative risk of a deterioration of sagittal balance was 2.9 times higher for a new fracture below L1 than for a fracture above Th12.

CONCLUSION

New VCF increased SVA by an average of 2.8 cm. Sagittal balance deteriorates as a new fracture develops in the lower lumbar spine. Early intervention in osteoporosis is vital for the elderly.

Association Between Spinopelvic Parameters and Intravertebral Cleft in Osteoporosis Vertebral Compression Fractures

BACKGROUND

The high incidence of nonunion in osteoporosis vertebral compression fractures (OVCFs) among the elderly population is a significant concern. But the hypothesis about etiopathogenesis of the intravertebral cleft (IVC) is not convincing. This study aims to investigate the association between spinopelvic parameters and IVC.

METHODS

Patients with single segment IVC or healed vertebral compression fracture (HVCF) were retrospectively recruited for the study. Patients with IVC were assigned to the IVC group, the others were assigned to the HVCF group. We estimated whether IVC or HVCF locates the vertebra inflection point on lumbar lateral radiography. Distance between the sagittal line passing through the anterosuperior corner of S1and the center of the vertebra of healed fracture or with IVC (DSVA) and sacral slope (SS) were measured on lumbar lateral plain films. Intergroup spinopelvic parameters were analyzed. analysis to identify independent variables associated with IVC incidence. The receiver operating characteristics (ROC) curve was generated to identify the optimal cut-off point for statistically significant variables.

RESULTS

Sixty-five patients were included in the study. Thirty patients (mean age: 74 ± 7.16 years) had single-level IVC, and 35 patients (mean age: 67.71 ± 7.30 years) had single-level HVCF. Age, body mass index (BMI), and DSVA were statistically different between the groups (all P < 0.05). The occurrence of IVC was related to the DSVA in the multivariate logistic regression analysis (OR = 0.73, P < 0.05).

CONCLUSIONS

According to the results of this study, large DSVA was a risk factor for IVC formation in patients with OVCFs. Patients with global spinal malalignment should be actively observed during conservative treatment.

Progression of vertebral deformity of prevalent vertebral fractures in the elderly: a population-based study

BACKGROUND

Little is known about the progression pattern of vertebral deformities in elderly patients with prevalent vertebral fractures. This population-based cohort study investigated the incidence, progression pattern, and risk factors of vertebral deformity in prevalent vertebral fractures over a finite period of four years in a population-based cohort study.

METHODS

A total of 224 inhabitants of a typical mountain village underwent medical examinations every second year from 1997 to 2009, and each participant was followed up for four years. The extent (mild, moderate, severe) and type (wedge, biconcave, crush) of prevalent vertebral fractures on spinal radiographs were evaluated using the Genant semi-quantitative method. Of these participants, 116 with prevalent vertebral fractures at baseline (32 men and 84 women; mean age: 70.0 years) were included in this study. The progression patterns of the 187 vertebral fractures with mild and moderate deformities (except severe deformity) were evaluated. Logistic regression analysis was used to identify the risk factors associated with deformity progression.

RESULTS

The progression of vertebral deformities was identified in 13.4% (25 vertebral fractures) of the total 187 prevalent (mild and moderate) vertebral fracture deformities over four years. Among the three deformity types, the prevalence of deformity progression was significantly lower in wedge-type vertebral fractures (P < 0.05). Age and number of prevalent vertebral fractures per participant were independent risk factors associated with the progression of prevalent vertebral deformities.

CONCLUSION

This study clarified the natural history of the progression pattern of vertebral deformities in radiographic prevalent vertebral fractures in elderly individuals. Multiple vertebral fractures in the elderly present a risk for the progression of vertebral deformities.

The influence of osteoporotic vertebral fractures on global sagittal alignment in elderly patients: a systematic review and meta-analysis

BACKGROUND

Thoracic kyphosis, or loss of lumbar lordosis, is often equated with osteoporosis because vertebral fractures are assumed to be a major causative factor, in addition to degeneration related to age. Despite the few studies aiming to measure the natural change in global sagittal alignment (GSA) that occurs with advancing age, the overall effect of conservatively managed osteoporotic vertebral compression fractures (OVCF) on the GSA in the elderly remains poorly understood.

OBJECTIVE

To systematically evaluate the relevant literature regarding the influence of OVCF on the GSA compared to patients of similar age without fractures using the following radiological parameters: Pelvic Incidence (PI), Pelvic Tilt (PT), Lumbar Lordosis (LL), Thoracic Kyphosis (TK), Sagittal Vertical Axis (SVA) and Spino-sacral Angle (SSA).

METHODS

A systematic review of the English language literature dating up until October 2022, was undertaken utilizing the PRISMA guidelines.

RESULTS

Of a total of 947 articles, 10 studies met the inclusion criteria (4 Level II, 4 level III and 2 level IV evidence) and were subsequently analyzed. Overall, 584 patients (8 studies) of mean age 73.7 years (69.3-77.1) had acute OVCF of one or more vertebra that were managed conservatively. The male to female ratio was 82:412. Five studies mentioned the number of fractured vertebrae, with a total of 393 in 269 patients (average of 1.4 fractured vertebrae per patient). Their pre-operative radiological parameters on standing X-rays showed a mean PI of 54.8°, PT 24°, LL 40.8°, TK 36.5°, PI-LL 14°, SVA 4.8 cm, and SSA 115°. In addition, 437 patients were used as a control group with osteoporosis without fractured vertebrae, (6 studies) with an average age of 72.4 years (67-77.8) and male to female ratio of 96:210 (5 studies). They all had upright X-rays to assess their global sagittal alignments. Radiological parameters showed an average PI of 54.3°, PT 17.3°, LL 43.4°, TK 31.25°, PI-LL 10.95°, SVA 1.27 cm and SSA 125°. A statistical analysis comparing the OVCF group with the control group (4 studies), showed a significant increase in PT of 5.97° (95%CI 2.63, 9.32; P < 0.0005), a significant increase in TK by 8.28° (95%CI 2.15, 14.4; P < 0.008), an increase in PI-LL by 6.72° (95%CI 3.39, 10.04; P < 0.0001), an increase in SVA by 1.35 cm (95%CI 0.88, 1.83; P < 0.00001), and a decrease in SSA by 10.2° (95%CI 10.3, 23.4; P < 0.00001).

CONCLUSION

Osteoporotic vertebral compression fractures managed conservatively appear to be a significant causate factor of global sagittal imbalance.

Bone microstructure and volumetric bone mineral density in patients with global sagittal malalignment

PURPOSE

Sagittal spinal malalignment often leads to surgical realignment, which is associated with major complications. Low bone mineral density (BMD) and impaired bone microstructure are risk factors for instrumentation failure. This study aims to demonstrate differences in volumetric BMD and bone microstructure between normal and pathological sagittal alignment and to determine the relationships among vBMD, microstructure, sagittal spinal and spinopelvic alignment.

METHODS

A retrospective, cross-sectional study of patients who underwent lumbar fusion for degeneration was conducted. The vBMD of the lumbar spine was assessed by quantitative computed tomography. Bone biopsies were evaluated using microcomputed tomography (μCT). C7-S1 sagittal vertical axis (SVA; ≥ 50 mm malalignment) and spinopelvic alignment were measured. Univariate and multivariable linear regression analysis evaluated associations among the alignment, vBMD and μCT parameters.

RESULTS

A total of 172 patients (55.8% female, 63.3 years, BMI 29.7 kg/m2, 43.0% with malalignment) including N = 106 bone biopsies were analyzed. The vBMD at levels L1, L2, L3 and L4 and the trabecular bone (BV) and total volume (TV) were significantly lower in the malalignment group. SVA was significantly correlated with vBMD at L1-L4 (ρ = -0.300, p < 0.001), BV (ρ = - 0.319, p = 0.006) and TV (ρ = - 0.276, p = 0.018). Significant associations were found between PT and L1-L4 vBMD (ρ = - 0.171, p = 0.029), PT and trabecular number (ρ = - 0.249, p = 0.032), PT and trabecular separation (ρ = 0.291, p = 0.012), and LL and trabecular thickness (ρ = 0.240, p = 0.017). In the multivariable analysis, a higher SVA was associated with lower vBMD (β = - 0.269; p = 0.002).

CONCLUSION

Sagittal malalignment is associated with lower lumbar vBMD and trabecular microstructure. Lumbar vBMD was significantly lower in patients with malalignment. These findings warrant attention, as malalignment patients may be at a higher risk of surgery-related complications due to impaired bone. Standardized preoperative assessment of vBMD may be advisable.

Dynamic Spine Hyperflexion Is Related to Vertebral Compression Fractures in Postmenopausal Women

OBJECTIVE

Previous studies on osteoporotic vertebral fractures are usually based on the neutral posture of spine; however, the fractures are usually associated with the flexion posture of spine. Therefore, we aimed to ascertain the relationship between vertebral compression fractures and thoracolumbar hyperflexion Cobb angles (TLHCobb) and determine the clinical cut-off of the TLHCobb angle.

METHODS

In this retrospective case-control study, TLHCobbs were collected from 154 postmenopausal women (67.45 ± 6.68 years) with vertebral compression fractures (study group) and 310 postmenopausal women (66.57 ± 8.22 years) without vertebral compression fractures (control group) from June 2017 to July 2019. Demographic data, clinical data, and quantitative computed tomography (QCT) findings were compared between the groups. Chi-squared tests, unpaired t-tests, and Mann Whitney U were used to assess the group characteristics and proportions. Logistic regression was used to examine the association between vertebral compression fractures and TLHCobb. The cut-off of the TLHCobb was determined by ROC curve and Youden's index.

RESULTS

Fracture prevalence was higher in the higher TLHCobb study group than that in the control group [OR = 2.81 (2.15-3.67)] after adjusting for age, BMI, and QCT findings. TLHCobbs at and >20.05° were associated with an increased fracture prevalence and ORs of 2.79 (1.82-4.27) and 4.83 (3.24-7.20), respectively. TLHCobb, disk height (semiquantitative grading score) and QCT values differed between the study and control groups (p < 0.001 for all three). There were no significant differences in body mass index (BMI), or coronal TLCobb between the two groups.

CONCLUSION

There was an association between the prevalence of vertebral compression fractures and TLHCobbs in postmenopausal women, and a TLHCobb > 20.05° can be an indicator of vertebral fracture.

Paraspinal Muscle Degeneration: A Potential Risk Factor for New Vertebral Compression Fractures After Percutaneous Kyphoplasty

Background

The paraspinal muscle is essential for maintaining normal spine function and structure, which degeneration is closely related to various spinal diseases. The main objective of this study was to identify the potential role of paraspinal muscle degeneration in the occurrence of new vertebral compression fractures (NVCF) and develop a clinically applicable nomogram for prospective NVCF risk prediction.

Methods

A total of 202 patients with single-level osteoporotic vertebral compression fractures (OVCF) who underwent percutaneous kyphoplasty treatment between January 2016 and March 2019 were included in this study. Demographic, clinical, radiological, and treatment data were collected and analyzed. The paraspinal muscle cross-sectional area (CSA) and fat signal fraction (FSF) were measured to quantify the extent of muscle degeneration. Multivariate binary logistic regression analysis was performed to select risk factors to build a nomogram that predicted the occurrence of NVCF. The concordance index (C-index) and calibration curve were used to evaluate the discriminative capacity and predictive accuracy of the nomogram.

Results

NVCF occurred in 54 of 202 patients (26.7%). The erector spinae FSF (OR = 1.064; P = 0.001), psoas major FSF (OR = 1.326; P < 0.001), and the difference index of the muscle CSA between multifidus and psoas major (OR = 1.048; P < 0.001) were independent risk factors for the occurrence of NVCF. The nomogram performance was good after evaluation using the calibration curves and C-index (95% confidence interval, 0.854–0.943).

Conclusion

Paraspinal muscle degeneration is a potential risk factor for NVCF occurrence. A nomogram was designed to precisely predict the risk of NVCF. This predictive nomogram may help clinicians to make better clinical decisions and provide more accurate functional exercise protocol for OVCF patients.

Associations between Abdominal Trunk Muscle Weakness and Future Osteoporotic Vertebral Fracture in Middle-Aged and Older Adult Women: A Three-Year Prospective Longitudinal Cohort Study

Potential risk factors associated with future osteoporotic vertebral fracture (OVF) were prospectively investigated in middle-aged and older adult women. We enrolled 197 female patients aged ≥50 years who were scheduled to undergo surgery for lower-extremity degenerative diseases. Patient anthropometric and muscle strength measurements, a bone mineral density measurement of the lumbar spine (L-BMD), and full-spine standing radiographs to examine the presence of old OVFs and spinopelvic sagittal parameters were obtained preoperatively. We evaluated 141 patients who underwent full-spine standing radiographs three years postoperatively to identify new OVFs. We excluded 54 patients who did not undergo a second radiographic examination and 2 with new traumatic OVFs. Univariate and multivariate analyses were performed to identify risk factors associated with new non-traumatic OVF occurrence. Ten (7.1%) patients developed new non-traumatic OVFs during the study period (fracture group). The fracture group had less abdominal trunk muscle strength, lower L-BMD, smaller sacral slopes, and larger pelvic tilt than the non-fracture group. The fracture group showed a higher prevalence of old OVFs preoperatively than the non-fracture group. Abdominal trunk muscle weakness, low L-BMD, and the presence of old OVFs were identified as significant risk factors for OVF occurrence. In middle-aged or older adult women, abdominal trunk muscle weakness, low L-BMD, and old OVFs were associated with future OVF.

Association with sagittal alignment and osteoporosis-related fractures in outpatient women with osteoporosis

The baseline sagittal vertical axis (SVA) and pelvic tilt (PT) are independent risk factors of osteoporosis-related fractures in women with osteoporosis. We clarified the SVA and PT to predict the incidence of osteoporosis-related fractures.

PURPOSE

Sagittal alignment with osteoporosis women deteriorates with advancing age and sagittal alignment may indicate osteoporosis-related fractures in the future. However, whether the sagittal alignment predicts future osteoporosis-related fracture in patients with osteoporosis has not been clarified. We aimed to investigate the association between sagittal alignment and future osteoporosis-related fractures.

METHODS

This was a retrospective cohort study. Of the 313 participants (mean follow-up period, 2.9 years), 236 were included in the analysis. At baseline, we measured bone mineral density (BMD) of the lumbar spine and the femoral neck, sagittal vertical axis (SVA), thoracic kyphosis, pelvic incidence minus lumbar lordosis, sacral slope, pelvic tilt (PT), geriatric locomotive function scale (GLFS), two-step value, and stand-up test. The information on medications and the duration of treatment were reviewed from the medical records. Additionally, participants reported their history of falls at baseline. Multiple logistic regression analysis was used to determine the association of future osteoporosis-related fracture, and adjusted Odds ratios (OR) and 95% confidence interval (CI) were calculated with all predictors as covariates. All continuous variables were calculated using standardized OR (sOR).

RESULTS

Osteoporosis-related fractures occurred in 33 of 313 participants (10.5%). Multiple logistic regression analysis showed that a history of falls (OR =4.092, 95% CI: 1.029-16.265, p =0.045), SVA (sOR =4.228, 95% CI: 2.118-8.439, p <0.001), and PT (sOR =2.497, 95% CI: 1.087-5.733, p =0.031) were independent risk factors for future osteoporosis-related fractures.

CONCLUSIONS

This study revealed the SVA and PT to predict osteoporosis-related fractures.

TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION

UMIN000036516 (April 1, 2019).

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.

Lower pelvic tilt, lower pelvic incidence, and increased external rotation of the iliac wing in patients with femoroacetabular impingement due to acetabular retroversion compared to hip dysplasia

AIMS

The effect of pelvic tilt (PT) and sagittal balance in hips with pincer-type femoroacetabular impingement (FAI) with acetabular retroversion (AR) is controversial. It is unclear if patients with AR have a rotational abnormality of the iliac wing. Therefore, we asked: are parameters for sagittal balance, and is rotation of the iliac wing, different in patients with AR compared to a control group?; and is there a correlation between iliac rotation and acetabular version?

METHODS

A retrospective, review board-approved, controlled study was performed including 120 hips in 86 consecutive patients with symptomatic FAI or hip dysplasia. Pelvic CT scans were reviewed to calculate parameters for sagittal balance (pelvic incidence (PI), PT, and sacral slope), anterior pelvic plane angle, pelvic inclination, and external rotation of the iliac wing and were compared to a control group (48 hips). The 120 hips were allocated to the following groups: AR (41 hips), hip dysplasia (47 hips) and cam FAI with normal acetabular morphology (32 hips). Subgroups of total AR (15 hips) and high acetabular anteversion (20 hips) were analyzed. Statistical analysis was performed using analysis of variance with Bonferroni correction.

RESULTS

PI and PT were significantly decreased comparing AR (PI 42° (SD 10°), PT 4° (SD 5°)) with dysplastic hips (PI 55° (SD 12°), PT 10° (SD 6°)) and with the control group (PI 51° (SD 9°) and PT 13° (SD 7°)) (p < 0.001). External rotation of the iliac wing was significantly increased comparing AR (29° (SD 4°)) with dysplastic hips (20°(SD 5°)) and with the control group (25° (SD 5°)) (p < 0.001). Correlation between external rotation of the iliac wing and acetabular version was significant and strong (r = 0.81; p < 0.001). Correlation between PT and acetabular version was significant and moderate (r = 0.58; p < 0.001).

CONCLUSION

These findings could contribute to a better understanding of hip pain in a sitting position and extra-articular subspine FAI of patients with AR. These patients have increased iliac external rotation, a rotational abnormality of the iliac wing. This has implications for surgical therapy with hip arthroscopy and acetabular rim trimming or anteverting periacetabular osteotomy (PAO). Cite this article: Bone Jt Open 2021;2(10):813-824.

Direct Lateral Corpectomy and Reconstruction Using an Expandable Cage Improves Local Kyphosis but Not Global Sagittal Alignment

Recently, an expandable cage equipped with rectangular footplates has been used for anterior vertebral replacement in osteoporotic vertebral fracture (OVF). However, the postoperative changes in global alignment have not been elucidated. The purpose of this study was to evaluate local and global spinal alignment after anterior and posterior spinal fixation (APSF) using an expandable cage in elderly OVF patients. This retrospective multicenter review assessed 54 consecutive patients who underwent APSF for OVF. Clinical outcomes were compared between postoperative sagittal vertical axis (SVA) > 95 mm and ≤95 mm groups to investigate the impact of malalignment. SVA improved by only 18.7 mm (from 111.8 mm to 93.1 mm). VAS score of back pain at final follow-up was significantly higher in patients with SVA > 95 mm than SVA ≤ 95 mm (42.4 vs. 22.6, p = 0.007). Adjacent vertebral fracture after surgery was significantly more frequent in the SVA > 95 mm (37% vs. 11%, p = 0.038). Multiple logistic regression showed significantly increased OR for developing adjacent vertebral fracture (OR = 4.76, 95% CI 1.10–20.58). APSF using the newly developed cage improves local kyphotic angle but not SVA. The main cause for the spinal malalignment after surgery was postoperative development of adjacent vertebral fractures.

Stand-up test predicts occurrence of non-traumatic vertebral fracture in outpatient women with osteoporosis

INTRODUCTION

The purpose of this retrospective study was to clarify the incidence of non-traumatic vertebral fracture among outpatient women with osteoporosis and to determine whether the stand-up test predicted the occurrence of non-traumatic vertebral fracture.

MATERIALS AND METHODS

A total of 242 postmenopausal women over 60 years of age who received outpatient osteoporosis treatment at our hospital between November 2013 and July 2020 were longitudinally evaluated in this study. We obtained medical information and radiographic parameters, including sagittal vertical axis, thoracic kyphosis, pelvic incidence, lumbar lordosis, pelvic tilt, and sacral slope at baseline. Additionally, we measured physical parameters, including height, weight, body mass index, lumbar bone mineral density, visual analog scale score for pain, and the stand-up test.

RESULTS

Vertebral fractures occurred in 20 of 242 participants (8.3%), and accounted for 48.8% the 41 total fractures in the study group. Among vertebral fractures, eight (40.0%) were traumatic, resulting from falls, and 12 (60.0%) were non-traumatic. Cox multivariate logistic regression analysis adjusted for age, body mass index, lumbar bone mineral density, and the time to non-traumatic vertebral fracture showed that the sagittal vertical axis (HR = 1.013, 95% CI 1.001-1.026), stand-up test score (HR = 3.977, 95% CI 1.156-13.683), and presence of difficulty with standing from a 20-cm-high seat using both legs (HR = 3.329, 95% CI 1.625-6.82) were independent risk factors for the occurrence of non-traumatic vertebral fracture.

CONCLUSION

The stand-up test may be useful as a simple screening tool for non-traumatic vertebral fracture in patients with osteoporosis.

Vertebroplasty for osteoporotic vertebral fracture

Appropriate care of patients with a recent painful osteoporotic vertebral fracture (VF) requires immobilisation, analgesics and spinal orthoses. Some VFs are however responsible for disabling pain and prolonged bed rest. In this context, vertebroplasty techniques have been proposed with a large benefit in case series and open-label randomised studies, but lack efficacy in three among four double-blind randomised studies. The objectives of the treatment of a recent painful VF are to relieve pain and to preserve mechanical conditions. With this in mind, we report an experts’ opinion paper on the indications for vertebroplasty and research agenda for clinical studies.

Prevalence and Characteristics of Spinal Sagittal Malalignment in Patients with Osteoporosis

Spinal sagittal malalignment due to vertebral fractures (VFs) induces low back pain (LBP) in patients with osteoporosis. This study aimed to elucidate spinal sagittal malalignment prevalence based on VF number and patient characteristics in individuals with osteoporosis and spinal sagittal malalignment. Spinal sagittal alignment, and VF number were measured in 259 patients with osteoporosis. Spinal sagittal malalignment was defined according to the SRS-Schwab classification of adult spinal deformity. Spinal sagittal malalignment prevalence was evaluated based on VF number. In patients without VFs, bone mineral density, bone turnover markers, LBP scores and health-related quality of life (HRQoL) scores of normal and sagittal malalignment groups were compared. In 205 of the 259 (79.2%) patients, spinal sagittal malalignment was detected. Sagittal malalignment prevalence in patients with 0, 1, or ≥2 VFs was 72.1%, 86.0%, and 86.3%, respectively. All LBP scores and some subscale of HRQoL scores in patients without VFs were significantly worse for the sagittal malalignment group than the normal alignment group (p < 0.05). The majority of patients with osteoporosis had spinal sagittal malalignment, including ≥70% of patients without VFs. Patients with spinal sagittal malalignment reported worse LBP and HRQoL. These findings suggest that spinal sagittal malalignment is a risk factor for LBP and poor HRQoL in patients with osteoporosis.

Association Between Bone Cement Augmentation and New Vertebral Fractures in Patients with Osteoporotic Vertebral Compression Fractures: A Systematic Review and Meta-Analysis

PURPOSE

To investigate the association between bone cement augmentation and new vertebral fractures (VF) in patients with osteoporotic vertebral compression fractures (OVCFs).

METHODS

A literature search of PubMed, EMBASE, and the Cochrane Library was conducted from 1987 to December 31, 2020, to identify randomized controlled trials that compared bone cement augmentation with non-bone cement treatments in patients with OVCFs. The clinical incidence of new VF and the risk of new adjacent vertebral fractures (AVF) after treatment were calculated. The indexes of the risk ratio or odds ratio, and 95% confidence intervals were determined with RevMan 5.2 software.

RESULTS

A total of 13 randomized controlled trials involving 1949 participants were included in the final quantitative analysis. There was no significant association between bone cement augmentation and the clinical incidence of new VF during the 6-month and 12-month follow-ups or the whole follow-up period. However, there was a significantly lower clinical incidence of new VF in patients who received bone cement augmentation compared with non-bone cement treatments during 24 months or more of follow-up. Pooled data from the relevant trials demonstrated that the risk of new AVF in bone cement augmentation was significantly higher than that in non-bone cement treatments.

CONCLUSIONS

Although the use of bone cement augmentation in OVCFs significantly increased the risk of new AVF compared with non-bone cement treatments, it was not significantly associated with a higher clinical incidence of new VF.

Global sagittal alignment of the spine, pelvis, lower limb after vertebral compression fracture and its effect on quality of life

BACKGROUND

Vertebral compression fractures (VCFs) are the most common among all osteoporotic fractures. The body may compensate to the kyphosis from vertebral compression fractures with lordosis of the adjacent spinal segments, rotation of the pelvis, knee flexion and ankle dorsiflexion. However, the detailed degree of body compensation, especially the lower limb, remains uncertain. Herein, the aim of this study is to investigate the values of global sagittal alignments (GSA) parameters, including the spine, pelvis and lower limbs, in patients with and without VCFs, as well as to evaluate the effect of VCFs on various quality of life (QoL) parameters.

METHODS

A cross-sectional study was conducted from May 2015 to June 2018. A total of 142 patients with VCFs aged over 60 years old and 108 age-matched asymptomatic controls were recruited. Whole body sagittal alignment including thoracic kyphosis (TK), lumbar lordosis (LL), pelvic tilt (PT), pelvic incidence (PI), sagittal vertical axis (SVA), T1-pelvic angle (TPA), knee-flex angle (KA) and ankle-flex angle (AA) were measured. In addition, lower back pain and quality of life were assessed using self-reported questionnaires.

RESULTS

Compared to asymptomatic controls, patients with VCF showed significantly greater TK (33.4^o ± 16.4^o vs 28.4^o ± 11.4^o; p < 0.01), PT (25.4^o ± 10.5^o vs 16.6^o ± 8.9^o; p < 0.001), PI (54.6^o ± 11.8^o vs 45.8^o ± 12.0^o; p < 0.001), SVA (49.1 mm ± 39.6 mm vs 31.5 mm ± 29.3 mm; p < 0.01), and TPA (28.6^o ± 10.8^o vs 14.8^o ± 8.6^o; p < 0.001). Whereas for lower limb alignment, patients with VCF showed significantly higher KA (10.1^o ± 7.8^o vs 6.0^o ± 6.4^o; p < 0.001) and AA (7.0^o ± 3.9^o vs 4.8^o ± 3.6^o; p < 0.001) than controls. The number of VCF significantly correlated with lower limb alignments (KA and AA) and global sagittal balance (TPA). VCF patients showed poorer quality of life assessment scores in terms of SF-12 (30.0 ± 8.3 vs 72.4 ± 16.9; p < 0.001), ODI (37.8 ± 24.0 vs 18.7 ± 16.6; p < 0.001) and VAS (3.8 ± 2.8 vs 1.9 ± 2.2; p < 0.001).

CONCLUSION

This is the first study to illustrate the abnormal lower limb alignment exhibited in patients with VCF. Patients with VCF showed an overall worse global sagittal alignment and decreased quality of life. Poorer global sagittal alignment of VCF patients also imply worse quality of life and more severe VCF.

Impact of appendicular and trunk skeletal muscle mass and back extensor strength on sagittal spinal alignment in Japanese women without vertebral fracture

Objectives

Progressive and generalized loss of skeletal muscle mass (SMM) and strength are characteristics of sarcopenia. However, the impact of appendicular and trunk SMM and back extensor strength (BES) on spinal sagittal alignment remains unclear. Herein, we investigate the relationship between these factors and spinal sagittal alignment.

Methods

In total, 202 women without vertebral fractures (median age, 66.9 years; interquartile range, 61.4–71.9 years) were analyzed at an orthopedic outpatient clinic. Pelvic incidence (PI), lumbar lordosis (LL), sagittal vertical axis (SVA), and pelvic tilt (PT) were measured on whole spine radiographs. Body mass index (BMI), appendicular and trunk relative SMM index, and BES were also evaluated. These measurements were compared between spinal sagittal alignment groups using the Mann–Whitney U test. Finally, the factors contributing to abnormal alignment were analyzed using multiple logistic regression analysis.

Results

BES was significantly lower in all abnormal sagittal alignment groups, as defined by PI-LL (≥ 10°), SVA (≥4 cm), and PT (≥20°) (all P < 0.001). On multivariate analysis, BES was a contributing factor for abnormal PI-LL (P < 0.001), SVA (P = 0.001), and PT (P < 0.001). Conversely, a decrease in appendicular and trunk relative SMM index did not statistically affect abnormal spinal sagittal alignment.

Conclusions

BES was associated with changes in spinal sagittal alignment; however, SMM, which is often used for diagnosing sarcopenia, did not affect spinal sagittal alignment.

Presence or absence of adjacent vertebral fractures has no effect on long-term global alignment and quality of life in patients with osteoporotic vertebral fractures treated with balloon kyphoplasty

BACKGROUND

Global sagittal malalignment after osteoporotic vertebral fracture is correlated with decreased quality of life. Balloon kyphoplasty promotes short-term global alignment, but long-term correction is difficult in patients with such fractures. Adjacent vertebral fracture is one of the major complications of balloon kyphoplasty. We investigated the correlation of the incidence of adjacent vertebral fracture with the loss of global alignment correction after balloon kyphoplasty.

METHODS

Forty patients were enrolled in this retrospective study. Adjacent vertebral fracture occurred in 17 patients. Sagittal vertical axis, the angle between the two vertebrae above and below the balloon kyphoplasty site (local alignment angle), and the vertebral kyphotic angle at the kyphoplasty site were measured pre- and post-operatively. Clinical results were assessed.

RESULTS

There were no significant differences between the sagittal vertical axis before and after balloon kyphoplasty in groups with (+) or without (-) adjacent vertebral fracture. Local alignment angles decreased soon after balloon kyphoplasty, but increased during follow-up in both groups. Vertebral kyphotic angles decreased significantly soon after balloon kyphoplasty in both groups; although this increased significantly in the adjacent vertebral fracture (-) group, but not in the adjacent vertebral fracture (+) group, during follow-up. Correction loss of alignment was found in both adjacent vertebral fracture (+) and (-) groups, attributed to adjacent vertebral fracture in the former and re-collapse of the balloon kyphoplasty site in the latter. No significant differences in clinical results were observed between the groups, although these were strongly correlated with sagittal vertical axis before balloon kyphoplasty.

CONCLUSIONS

The adjacent vertebral fracture (+) and (-) groups exhibited similar correction loss of alignment and improved quality of life. The presence or absence of adjacent vertebral fractures had no effect on long-term global alignment and patient quality of life.

Relationship between lumbopelvic discordance and locomotive syndrome in a middle-aged community-living population: The Yakumo study

BACKGROUND

Locomotive syndrome (LS) affects the quality and activities of daily living. Although spinal sagittal balance influences LS, no report elucidated the relationship between LS risk and lumbopelvic discordance. This study aimed to investigate the relationship between lumbopelvic discordance and LS in a middle-aged community.

METHODS

The subjects (n = 135) were divided into three groups based on the LS risk stage, which was evaluated through spinopelvic sagittal alignment and lumbopelvic mismatch prevalence (Pelvic incidence-Lumbar lordosis >10°:PI-LL mismatch).Then, the subjects were divided into two groups (lumbopelvic matched and mismatched groups) and analyzed based on the demographic data, physical test, stabilometry, and body pain using the visual analog scale.

RESULTS

There were 76, 37 and 22 subjects in stages 0, 1, and 2, respectively. The pelvic incidence-lumbar lordosis (PI-LL) mismatched group had a higher prevalence in LS risk stage 2 than in LS risk stage 0. The prevalence of PI-LL mismatch was significantly different among the groups. Post hoc test revealed the differences in spinopelvic alignment among the stages. In each LS risk stage, the degree of PI-LL was significantly higher in stage 2 than that in stages 0 and 1. On comparing the PI-LL matched (n = 67) and mismatched groups (n = 68) with a stabilometer, the envelopment area tracing by the movement of the center of pressure and locus length/second was greater in the PI-LL mismatched group than that in the PI-LL matched group with/without eyes opened.

CONCLUSIONS

The prevalence of LS risk stage 2 was more frequently observed in the PI-LL mismatched group. The degree of PI-LL was evaluated through the LS risk stages. Physical dysfunction in the PI-LL mismatched group was related to trunk imbalance based on stabilometry. These findings will help manage LS and PI-LL mismatched subjects.

Determination of Any Correlation between Sagittal Spinopelvic Configuration and Progressive Collapse of Acute Osteoporotic Compression Spine Fractures: A Retrospective Radiological Analysis

Study Design

A retrospective cohort study.

Purpose

The aim of this study was to determine any correlations between spinopelvic configuration and progressive collapse following acute osteoporotic compression spine fractures.

Overview of Literature

Few studies have investigated the risk factors for progressive osteoporotic compression spine fractures. However, the correlation between the spinopelvic configuration, which is a crucial to optimize the management of lumbar degenerative diseases, and progressive collapse following acute osteoporotic compression spine fractures was not analyzed.

Methods

We retrospectively identified all patients treated for thoracolumbar fractures in Assaf Harofe Medical Center between January 2008 and July 2013. Pelvic incidence (PI), sacral slope (SS), and pelvic tilt (PT) were measured for the pelvic parameters. For each patient, we classified the fracture according to the AOSpine Thoracolumbar Spine Injury Classification System. Height loss was measured initially and at a minimum of 3-month follow-up. The difference between initial and final height loss was documented as height loss difference.

Results

The study included 124 patients comprised 86 women and 38 men. The mean patient age was 69±9.6 years. The mean length of follow-up was 14±15 months. No significant effect of the PI, PT, and SS angles on the vertebral fracture level (p>0.05) was found. Similarly, no significant relationship between the PI, PT, and SS angle and the fracture type according to the AO classification (p>0.05) was found. There was no correlation between PI, PT, and SS angles and initial height loss, final height loss and height loss difference (p>0.05)

Conclusions

The spinopelvic configuration represented by the PI, PT, and SS angle does not influence progressive collapse following acute osteoporotic compression spine fractures.

Local Mechanical Environment and Spinal Trabecular Volumetric Bone Mineral Density Measured by Quantitative Computed Tomography: A Study on Lumbar Lordosis

OBJECTIVE

There have been some reports on the association between spinal balance parameters and regional bone mineral density (BMD), but the results are controversial. The purpose of this study is to evaluate the relationship between spinopelvic parameters and regional volumetric BMDs (vBMDs) measured by quantitative computed tomography (QCT) in the lumbosacral region of patients undergoing lumbar fusion surgery.

METHODS

The data of consecutive patients undergoing posterior lumbar spinal fusion with preoperative computed tomography was reviewed. QCT measurements were conducted in L1-S1 vertebral trabecular bone. The associations between spinopelvic sagittal parameters and vBMDs were evaluated. Multivariate analyses adjusted with age, gender, race, and body mass index were conducted with vBMD as the response variable.

RESULTS

A total of 144 patients were included in the final analyses. Mean age (± standard deviation) was 65.4 ± 11.8 years. Mean vBMD in L1 (± standard deviation) was 118.3 ± 37.4 mg/cm³. After adjusting by cofactors, lumbar lordosis was negatively associated with vBMDs in all levels from L1 to L5 (% regression coefficients and adjusted R² values: L1, -0.438, 0.268; L2, -0.556, 0.296; L3, -0.608, 0.362; L4, -0.554, 0.228; L5, -0.424, 0.194), but not in S1. Sacral slope was negatively associated with vBMD only at L4 (% coefficient, -0.588; R², 0.208). Other parameters were not significantly associated with vBMDs at any levels.

CONCLUSIONS

Higher lumbar lordosis was associated with lower vBMDs in all lumbar spine levels. Our results suggest that BMD is affected not only by metabolic factors but also by the mechanical environment. Further longitudinal studies are needed to elucidate this effect of vBMD on clinical outcomes.

Factors Predicting the Surgical Risk of Osteoporotic Vertebral Compression Fractures

The aim of our study was to investigate the association between global spinal alignment, spinopelvic parameters, and outcomes of osteoporotic vertebral compression fractures (OVCF). Patients with vertebral compression fractures seen at our hospital between October 2017 and November of 2018 with a bone mineral density (BMD) T-score < -2.5 were recruited for the study. Surgical intervention was performed after eight weeks of conservative treatment depending on clinical symptoms and the willingness of patients. Spinopelvic and sagittal alignment parameters were compared between patients who had surgery and those that did not. Seventy-nine patients were included in the study. Twenty-five patients (31.6%, mean age: 73.28 ± 9.78 years) received surgery, and 54 (68.3%, mean age: 73 ± 8.58 years) conservative treatment only. Pelvic tilt, pelvic incidence, and local kyphotic angle were statistically different between the groups (all p < 0.05). A sagittal vertical axis ≥ 50 mm, distance between the C7 plumb line and the center of the fractured vertebra (DSVA) ≥ 60 mm, pelvic incidence outside of the range of 44 to 62°), and pelvic tilt ≥ 27° were associted with the need for surgical intervention. Measurement of spinopelvic parameters can predict the need for surgery in patients with OVCF.

Estradiol Replacement Timing and Obesogenic Diet Effects on Body Composition and Metabolism in Postmenopausal Macaques

Whether hormone replacement therapy has beneficial metabolic effects in postmenopausal women remains controversial because of between-study differences in menopausal duration, estrogen formulations, and diet. Additionally, animal studies have not reflected the typical human obesogenic, Western-style diet (WSD). In this study, we determined the effects of immediate 17β-estradiol (ImE) or delayed 17β-estradiol treatment on weight and metabolism parameters in old ovo-hysterectomized rhesus macaques consuming a WSD over a 30-month period. The placebo and ImE groups exhibited progressive gains in weight and fat mass, which ImE initially attenuated but did not prevent. Progression of insulin resistance (IR) was lessened by ImE compared with placebo under both fasting and IV glucose-stimulated conditions, plateauing in all groups between 24 and 30 months. Consequently, relative euglycemia was maintained through lower stimulated insulin levels with ImE than with placebo. Bone mineral density decreased in the placebo group but was maintained in the ImE group, whereas bone mineral content was unaffected by placebo and increased with ImE. Daily activity was reduced while macaques consumed a WSD and was not affected by ImE. Over time, total cholesterol, triglyceride, very-low-density cholesterol, high-density lipoprotein cholesterol (HDL-C), non-HDL-C, and IL-8 levels increased or trended upward in all animals, with only the change in HDL-C affected by ImE. Delayed estrogen treatment (months 24 to 30) had no significant impact on body composition or glucometabolic parameters. In summary, detrimental WSD-induced changes in body composition and metabolism were only temporarily ameliorated by ImE, with the important exception of glucose homeostasis, which benefited from E replacement even as body composition worsened.

Global sagittal alignment in elderly patients with osteoporosis and its relationship with severity of vertebral fracture and quality of life

We compared global sagittal alignment and quality of life in osteoporotic patients with and without vertebral compression fracture (VCF) and determined its relationship with VCF severity. The findings revealed osteoporotic patients with VCF showed decreased quality of life and worse global sagittal alignment, which was significantly associated with VCF severity.

INTRODUCTION

The aim of this study was to compare the global sagittal alignment and quality of life in elderly osteoporotic patients with and without vertebral compression fracture (VCF), and to investigate the relationship between global sagittal alignment and severity of VCF.

METHODS

A consecutive series of 72 female patients with osteoporosis aged over 60 years and 31 age-matched females without osteoporosis were prospectively enrolled. The patients were divided into VCF and non-VCF group. Patient's clinical demography, nature of VCF, and bone mineral density (BMD) were also recorded. Spinal deformity index was used to evaluate severity of VCF. EOS® biplanar imaging system was then used to evaluate global sagittal parameters: T1 pelvic angle (TPA) and global sagittal angle (GSA). In addition, quality of life was assessed with self-reported questionnaires: the Oswestry Disability Index (ODI) and Short-form 12 (SF-12).

RESULTS

Osteoporotic patients and controls were found to be significantly different in terms of TPA, GSA, and BMD. And in patients with VCF, they were found to have significantly higher TPA and GSA. TPA and GSA were significantly correlated with SF-12 and ODI. The number of VCF and SDI significantly correlated with global sagittal alignment. Using regression analysis, parameters significantly associated with abnormal global alignment were the number of VCF (OR = 1.13) and SDI (OR = 1.84).

CONCLUSION

Osteoporotic patients with VCF showed worse global sagittal alignment and decreased quality of life. The number and severity of VCF had a negative influence on global sagittal balance, which indicates that poorer sagittal global alignment may imply worse quality of life and more severe VCF.