Single-level vertebral kyphoplasty is not associated with an increased risk of symptomatic secondary adjacent osteoporotic vertebral compression fractures: a matched case-control analysis

[Current surgical treatment concepts for traumatic fractures of the thoracic and lumbar spine with osteoporotic bone substance]

Osteoporosis-related vertebral fractures are among the most frequent fracture entities in geriatric patients. They are associated with far-reaching individual and socioeconomic consequences. Adequate diagnostics and treatment are therefore essential. The osteoporotic fracture (OF) score is a central element in determining the right treatment. Although the majority of fractures can be healed with conservative treatment, a change of treatment should be considered in good time in cases of failure. Isolated cement augmentation procedures are particularly suitable for reducing pain in primarily stable osteoporotic vertebral fractures with a preserved framework structure (OF types 1-3) and a largely intact posterior edge. Dorsal cement-augmented stabilization with cementing of the fractured vertebral body leads to good results in unstable OF types 3 and 4 fractures. Dorsoventral procedures with cement-augmented internal fixator from the dorsal side and vertebral body replacement from the ventral side play a more subordinate role. Purely ventral procedures should be avoided in this patient group.

Biomechanical Comparisons between One- and Two-Compartment Devices for Reconstructing Vertebrae by Kyphoplasty

BACKGROUND

This biomechanical in vitro study compared two kyphoplasty devices for the extent of height reconstruction, load-bearing capacity, cement volume, and adjacent fracture under cyclic loading.

METHODS

Multisegmental (T11-L3) specimens were mounted into a testing machine and subjected to compression, creating an incomplete burst fracture of L1. Kyphoplasty was performed using a one- or two-compartment device. Then, the testing machine was used for a cyclic loading test of load-bearing capacity to compare the two groups for the amount of applied load until failure and subsequent adjacent fracture.

RESULTS

Vertebral body height reconstruction was effective for both groups but not statistically significantly different. After cyclic loading, refracture of vertebrae that had undergone kyphoplasty was not observed in any specimen, but fractures were observed in adjacent vertebrae. The differences between the numbers of cycles and of loads were not statistically significant. An increase in cement volume was strongly correlated with increased risks of adjacent fractures.

CONCLUSION

The two-compartment device was not substantially superior to the one-compartment device. The use of higher cement volume correlated with the occurrence of adjacent fractures.

Treatment and Outcome of Osteoporotic Thoracolumbar Vertebral Fractures With Anterior or Posterior Tension Band Failure (OF 5): Short-Term Results From the Prospective EOFTT Multicenter Study

STUDY DESIGN

Subgroup analysis of a multicenter prospective cohort study.

OBJECTIVE

To analyse surgical strategies applied to osteoporotic thoracolumbar osteoporotic fracture (OF) 5 injuries with anterior or posterior tension band failure and to assess related complications and clinical outcome.

METHODS

A multicenter prospective cohort study (EOFTT) was conducted at 17 spine centers including 518 consecutive patients who were treated for an osteoporotic vertebral fracture (OVF). For the present study, only patients with OF 5 fractures were analysed. Outcome parameters were complications, Visual Analogue Scale (VAS), Oswestry Disability Questionnaire (ODI), Timed Up & Go test (TUG), EQ-5D 5L, and Barthel Index.

RESULTS

In total, 19 patients (78 ± 7 years, 13 female) were analysed. Operative treatment consisted of long-segment posterior instrumentation in 9 cases and short-segment posterior instrumentation in 10 cases. Pedicle screws were augmented in 68 %, augmentation of the fractured vertebra was performed in 42%, and additional anterior reconstruction was done in 21 %. Two patients (11 %) received short-segment posterior instrumentation without either anterior reconstruction or cement-augmentation of the fractured vertebra. No surgical or major complications occurred, but general postoperative complications were observed in 45%. At a follow-up of mean 20 ± 10 weeks (range, 12 to 48 weeks), patients showed significant improvements in all functional outcome parameters.

CONCLUSIONS

In this analysis of patients with type OF 5 fractures, surgical stabilization was the treatment of choice and lead to significant short-term improvement in terms of functional outcome and quality of life despite a high general complication rate.

Chronologically clustered osteoporotic vertebral compression fractures: Analysis of a case series

AIM

To provide quality care to older adults, healthcare professionals should be aware that osteoporotic vertebral compression fractures (OVCFs) might occur sequentially in the same patient, involving different vertebral bodies, each separated by short intervals. This situation is called chronologically clustered OVCFs (CCOVCF).

METHODS

A total of 40 patients with CCOVCFs (index cohort) were retrospectively analyzed, and compared with 40 patients having only one OVCF (comparison cohort). All fractures were treated with percutaneous balloon kyphoplasty.

RESULTS

In the index cohort, the number of patients having the second, third, fourth and fifth OVCF events within 3 months were 40, 15, five and two, respectively. Recurring pain or seemingly non-stop pain were the major reasons why new OCVFs were found. The average interval between pain relief provided by percutaneous balloon kyphoplasty and radiographic diagnosis of new OVCFs was significantly longer than that between pain relief and a new episode of disabling pain (26.7 ± 16.8 vs 16.4 ± 15.8 days, P < 0.0001), reflecting how shortly new OCVFs occurred after successful surgery, and how often they were neglected. The mean T-score of the index cohort was significantly lower than that of the comparison cohort (-3.66 ± 0.79 vs -3.17 ± 0.80, P = 0.01).

CONCLUSIONS

CCOVCFs make a patient seem constantly in pain, despite repeated admissions and operations. Recurrent symptoms after an effective procedure should be taken as a warning that a new OCVF might have occurred, even if only a few days apart. Advanced osteoporosis is a significant risk factor for CCOVCFs. Geriatr Gerontol Int 2023; 23: 44-49.

Biomechanical CT-computed bone strength predicts the risk of subsequent vertebral fracture

Following primary fractures and percutaneous kyphoplasty (PKP), patients have a high risk of incurring a subsequent vertebral fracture (SVF). Given that SVF is a consequence of mechanical deterioration of the vertebra, we sought to examine whether vertebral strength derived from QCT-based finite element analysis (i.e., BCT) can predict the risk of SVF. Sixty-six patients who underwent PKP were categorized into two groups: control or non-SVF group (age: 70 ± 7 years; n = 40) and SVF group (age: 69 ± 8 years; n = 26). BCT was performed on L4 or L3 vertebrae to noninvasively measure vertebral strength. Vertebral strength was also estimated based upon the geometry and material properties of the vertebra. Additionally, trabecular volumetric bone mineral density (vBMD) and L1 Hounsfield unit (HU) were measured. t-Test, χ² test or Mann Whitney U test were used to compare differences in these parameters between the two groups. The predictive abilities of BCT strength and other measured parameters were evaluated using the receiver operating characteristic (ROC) analysis. Results showed no significant difference in either vBMD or L1 HU between the control and SVF groups (p > 0.05), whereas BCT-computed and estimated vertebral strength values were significantly reduced by 33 % and 24 % for the SVF group relative to the non-SVF group, respectively. ROC curve indicated that BCT strength had the largest area under the curve, compared to other parameters. These results suggest that BCT-computed vertebral strength may serve as a surrogate for assessing risk of SVF.

Timing of symptomatic subsequent vertebral compression fracture associated with different demographic factors

BACKGROUND

Symptomatic subsequent vertebral compression fracture (VCF; SVCF) is a common complication associated with poor outcomes. Accumulating evidence shows that demographic factors and incidences of symptomatic SVCFs differ during different periods after the primary vertebroplasty (VP).

PURPOSE

To investigate the incidence and demographic factors of symptomatic SVCFs after the primary VP in different periods using registry data in the Taiwan National Health Insurance Research Database.

METHODS

This retrospective cohort study included 28,343 patients aged ≥ 50 years with painful VCF treated with VP from 2002 to 2016. Symptomatic SVCF was defined as SVCF requiring another VP or re-admission. During the 2-year follow-up, 1955 patients received subsequent VP while 1,407 were readmitted. Cox proportional hazard models were used to compare the risks of subsequent VP or readmission.

RESULTS

The cumulative incident rate of subsequent VP and re-hospitalization was 0.87 [95% confidence interval (CI), 0.82 ~ 0.92] and 0.62 (95% CI, 0.58 ~ 0.66) per 100 person-months, respectively, within the first 6 months after the primary VP, and it decreased over time. A multiple Cox regression model showed that age, osteopenia or osteoporosis, Charlson comorbidity index (CCI) were significant independent risk factors of subsequent VP or readmission within the first 6 months.

CONCLUSIONS

This study demonstrated that the incidence of symptomatic SVCF peaked in the first 6 months after the primary VP. Age, osteoporosis or osteopenia, and CCI were determined to be risk factors in the first 6 months, but only osteoporosis or osteopenia and CCI were risk factors thereafter.

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.

Risk factors of new vertebral compression fracture after percutaneous vertebroplasty or percutaneous kyphoplasty

BACKGROUND

New vertebral compression fracture (VCF) may occur in patients who underwent percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP) for osteoporotic vertebral compression fracture (OVCF). However, the risk factors of new VCF remain controversial. The research aimed to analyze the risk factors of new VCF after PVP or PKP.

METHODS

From August 2019 to March 2021, we retrospectively analyzed the patients who underwent PVP or PKP for OVCF at our institution. Age, gender, body mass index (BMI), smoking, drinking, hypertension, diabetes, fracture location, surgical method, Hounsfield unit (HU) value, preoperative degree of anterior vertebral compression (DAVC), bisphosphonates, bone cement volume, bone cement leakage, and cement distribution were collected. The risk factors were obtained by univariate and multivariate analysis of the data.

RESULTS

A total of 247 patients were included in the study. There were 23 patients (9.3%) with new VCF after PVP or PKP. Univariate analysis showed that age (p < 0.001), BMI (p = 0.002), fracture location (p = 0.030), and a low HU value (p < 0.001) were significantly associated with new VCF after PVP or PKP. A low HU value was an independent risk factor for new VCF after PVP or PKP obtained by multivariate regression analysis (OR = 0.963; 95% CI, 0.943-0.984, p = 0.001).

CONCLUSIONS

In this study, a low HU value was an independent risk factor of new VCF after PVP or PKP.

Systematic Review and Meta-Analysis of 3 Treatment Arms for Vertebral Compression Fractures: A Comparison of Improvement in Pain, Adjacent-Level Fractures, and Quality of Life Between Vertebroplasty, Kyphoplasty, and Nonoperative Management

BACKGROUND

Osteoporotic vertebral fractures (OVFs) have become increasingly common, and previous nonrandomized and randomized controlled trials (RCTs) have compared the effects of cement augmentation versus nonoperative management on the clinical outcome. This meta-analysis focuses on RCTs and the calculated differences between cement augmentation techniques and nonsurgical management in outcome (e.g., pain reduction, adjacent-level fractures, and quality of life [QOL]).

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, and the following scientific search engines were used: MEDLINE, Embase, Cochrane, Web of Science, and Scopus. The inclusion criteria included RCTs that addressed different treatment strategies for OVF. The primary outcome was pain, which was determined by a visual analog scale (VAS) score; the secondary outcomes were the risk of adjacent-level fractures and QOL (as determined by the EuroQol-5 Dimension [EQ-5D] questionnaire, the Oswestry Disability Index [ODI], the Quality of Life Questionnaire of the European Foundation for Osteoporosis [QUALEFFO], and the Roland-Morris Disability Questionnaire [RDQ]). Patients were assigned to 3 groups according to their treatment: vertebroplasty (VP), kyphoplasty (KP), and nonoperative management (NOM). The short-term (weeks), midterm (months), and long-term (>1 year) effects were compared. A random effects model was used to summarize the treatment effect, including I2 for assessing heterogeneity and the revised Cochrane risk-of-bias 2 (RoB 2) tool for assessment of ROB. Funnel plots were used to assess risk of publication bias. The log of the odds ratio (OR) between treatments is reported.

RESULTS

After screening of 1,861 references, 53 underwent full-text analysis and 16 trials (30.2%) were included. Eleven trials (68.8%) compared VP and NOM, 1 (6.3%) compared KP and NOM, and 4 (25.0%) compared KP and VP. Improvement of pain was better by 1.31 points (95% confidence interval [CI], 0.41 to 2.21; p < 0.001) after VP when compared with NOM in short-term follow-up. Pain effects were similar after VP and KP (midterm difference of 0.0 points; 95% CI, -0.25 to 0.25). The risk of adjacent-level fractures was not increased after any treatment (log OR, -0.16; 95% CI, -0.83 to 0.5; NOM vs. VP or KP). QOL did not differ significantly between the VP or KP and NOM groups except in the short term when measured by the RDQ.

CONCLUSIONS

This meta-analysis provides evidence in favor of the surgical treatment of OVFs. Surgery was associated with greater improvement of pain and was unrelated to the development of adjacent-level fractures or QOL. Although improvements in sagittal balance after surgery were poorly documented, surgical treatment may be warranted if pain is a relevant problem.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Osteoporotic mid-thoracic vertebral body fractures: what are the differences compared to fractures of the lumbar spine?-a systematic review

Purpose

The aim of this systematically review is to detect differences between fractures located at the mid-thoracic spine compared to fractures of the thoracolumbar junction (TLJ) and the lumbar spine in osteoporotic vertebral body fractures.

Methods

This review is based on articles retrieved by a systematic search in the PubMed and Web of Science database for publications regarding osteoporotic fractures of the thoracolumbar spine with respect to the fracture location. Differences in prevalence, cause of fracture, fracture healing, and outcomes between the mid-thoracic spine and the TLJ and the lumbar spine were considered.

Results

Altogether, 238 articles could be retrieved from the literature search. A total of 222 articles were excluded. Thus, 16 remaining original articles were included in this systematic review comprising the topics prevalence, bone mineral density and regional blood flow, biomechanics, subsequent fractures, and outcome, respectively. The overall level of evidence of the vast majority of studies was moderate to low.

Conclusion

Several differences between osteoporotic fractures of the mid-thoracic spine compared to the TLJ and the lumbar spine could be identified. Thereby, osteoporotic mid-thoracic fractures seem to be particularly more related to frailty without a history of traumatic injury compared to osteoporotic fractures of the TLJ and the lumbar spine. Additionally, the presence of severe mid-thoracic fractures predicts subsequent fractures of the hip. In contrast, subsequent fractures of the spine are less likely.

Risk Factors for Cement Leakage and Adjacent Vertebral Fractures in Kyphoplasty for Osteoporotic Vertebral Fractures

PURPOSE

Cement leakage and adjacent vertebral fractures are not uncommon after percutaneous augmentation. However, conclusive identification of risk factors for postprocedural complications remains elusive. The anticipation of leakage and successive fractures through the identification of risk factors will help physicians better inform patients of potential complications and establish procedural refinements key to risk reduction. The aim of this retrospective study was to summarize available reports of the risk factors for cement leak and adjacent vertebral fracture in or after kyphoplasty for osteoporotic vertebral compression fractures.

METHODS

A total of 102 cases of bilateral percutaneous kyphoplasty (PKP), performed between January 2014 and December 2016, were retrospectively reviewed. Each case surveyed in this review included a minimum 1-year follow-up and data on age, sex, bone mineral density, Visual Analog Scale score, preoperative compression rate, kyphotic angle, treatment time, the volume of cement, and the intactness of the vertebral posterior wall (computed tomography scan) were collected. Pearson χ test and independent samples test were used to determine the relative risk factors of cement leak and adjacent vertebral fracture in patient subsets.

RESULTS

Diabetic status and alteration in the Cobb angle after PKP exhibited a statistically significant correlation with the incidence of new adjacent vertebral fracture (group B) (P<0.05). In addition, the integrity of vertebral walls (P=0.001) and the volume of injected cement (P=0.026) significantly boosted the potential risk of cement leakage (P<0.05), although these variables did not associate with the adjacent fracture. Additional examined variables, including age, sex, Visual Analog Scale scores, number of fractures were not significantly associated with leakage or adjacent vertebral fracture risk.

CONCLUSIONS

Diabetes and the alteration of the Cobb angle following PKP are factors positively related to the occurrence of postoperative adjacent vertebral fractures. It is also demonstrated that the integrity of vertebral walls and average volumes of injected cement are the possible risk factors of cement leakage while performing the PKP.

[Hounsfield units as a measure of bone density-applications in spine surgery]

Despite today's good diagnostic and therapeutic options for osteoporosis, the number of unidentified cases is very high and therapy is therefore usually inadequate. Frequently, the diagnosis of osteoporosis is made only after the occurrence of a fracture. The reason for this, apart from the costs incurred as well as the additional radiation exposure of the diagnostics, is certainly the limited availability of dual energy X‑ray absorptiometry (DEXA) as well as quantitative computed tomography (q-CT). In search of an alternative technique, Hounsfield units (HU) of the clinical CT examination proved to be ground-breaking: the results of previous investigations demonstrated a reliable correlation between the T values of the DEXA measurement and the HU of the same vertebral body. Due to the widespread use of clinical CT scans of the thorax and the abdomen for a variety of indications, it is expected that the number of unidentified cases of osteoporosis can be significantly reduced-without additional costs and radiation exposure associated with osteoporosis screening. In addition to osteoporosis diagnostics, the calculated HU may also provide better preoperative planning as well as predicting the further course of the disease. Thus, the risk for vertebral body fractures, screw loosening and cage sintering after ventral fusion operations can be sufficiently predicted. In this way, preoperative modifications to the surgical procedure can be made to reduce the risk of implant failure.