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Yang DD, Li Y, Tian JY, Li Y, Liu J, Liu YS, Cao XW, Liu C. MRI-based vertebral bone quality score as a novel bone status marker of patients with adolescent idiopathic scoliosis. Sci Rep 2024; 14:12518. [PMID: 38822099 PMCID: PMC11143181 DOI: 10.1038/s41598-024-63426-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 05/29/2024] [Indexed: 06/02/2024] Open
Abstract
To investigate the application of MRI-based vertebral bone quality (VBQ) score in assessing bone mineral density (BMD) for patients with adolescent idiopathic scoliosis (AIS). We reviewed the data of AIS patients between January 2021 and October 2023 with MRI, whole-spine plain radiographs, quantitative computed tomography (QCT) and general information. VBQ score was calculated using T1-weighted MRI. Univariate analysis was applied to present the differences between variables of patients with normal BMD group (QCT Z-score > - 2.0) and low BMD group (QCT Z-score ≤ - 2.0). The correlation between VBQ score and QCT Z-score was analyzed with Pearson correlation test. A multivariate logistic regression model was used to determine the independent factors related to low BMD. Receiver operating characteristic curve (ROC) was drawn to analyze the diagnostic performance of VBQ score in distinguishing low BMD. A total of 136 AIS patients (mean age was 14.84 ± 2.10 years) were included, of which 41 had low BMD. The low BMD group had a significantly higher VBQ score than that in normal group (3.48 ± 0.85 vs. 2.62 ± 0.62, P < 0.001). The VBQ score was significantly negative correlated with QCT Z score (r = - 0.454, P < 0.001). On multivariate analysis, VBQ score was independently associated with low BMD (OR: 4.134, 95% CI 2.136-8.000, P < 0.001). The area under the ROC curve indicated that the diagnostic accuracy of the VBQ score for predicting low BMD was 81%. A sensitivity of 65.9% with a specificity of 88.4% could be achieved for distinguishing low BMD by setting the VBQ score cutoff as 3.18. The novel VBQ score was a promising tool in distinguishing low BMD in patients with AIS and could be useful as opportunistic assessment for screening and complementary evaluation to QCT before surgery.
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Affiliation(s)
- Dan-Dan Yang
- Radiology Department, The Third People's Hospital of Chengdu, No. 82 Qinglong Road, Qingyang District, Chengdu, 610031, Sichuan, China
| | - Yi Li
- Radiology Department, The Third People's Hospital of Chengdu, No. 82 Qinglong Road, Qingyang District, Chengdu, 610031, Sichuan, China
| | - Jiang-Yu Tian
- Radiology Department, The Third People's Hospital of Chengdu, No. 82 Qinglong Road, Qingyang District, Chengdu, 610031, Sichuan, China
| | - Ya Li
- Radiology Department, The Third People's Hospital of Chengdu, No. 82 Qinglong Road, Qingyang District, Chengdu, 610031, Sichuan, China
| | - Jian Liu
- Radiology Department, The Third People's Hospital of Chengdu, No. 82 Qinglong Road, Qingyang District, Chengdu, 610031, Sichuan, China
| | - Yun-Song Liu
- Radiology Department, The Third People's Hospital of Chengdu, No. 82 Qinglong Road, Qingyang District, Chengdu, 610031, Sichuan, China
| | - Xin-Wen Cao
- Radiology Department, The Third People's Hospital of Chengdu, No. 82 Qinglong Road, Qingyang District, Chengdu, 610031, Sichuan, China
| | - Chuan Liu
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, West China Second University Hospital, Sichuan University, No. 20 Renmin South Road, Wuhou District, Chengdu, 610044, Sichuan, China.
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Williamson TK, Koslosky EJ, Lebovic J, Owusu-Sarpong S, Tretiakov P, Mir J, Dave P, Schoenfeld AJ, Diebo BG, Koller H, Lafage R, Lafage V, Passias PG. Lower Hounsfield Units at the Planned Lowest Instrumented Vertebra is an Independent Risk Factor for Complications Following Adult Cervical Deformity Surgery. Clin Spine Surg 2024:01933606-990000000-00317. [PMID: 38809280 DOI: 10.1097/bsd.0000000000001647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 04/29/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND The association of Hounsfield units (HU) and junctional pathologies in adult cervical deformity (ACD) surgery has not been elucidated. OBJECTIVE Assess if the bone mineral density of the LIV, as assessed by HUs, is prognostic for the risk of complications after ACD surgery. STUDY DESIGN/SETTING Retrospective cohort study. METHODS HUs were measured on preoperative CT scans. Means comparison test assessed differences in HUs based on the occurrence of complications, linear regression assessed the correlation of HUs with risk factors, and multivariable logistic regression followed by a conditional inference tree derived a threshold for HUs based on the increased likelihood of developing a complication. RESULTS In all, 107 ACD patients were included. Thirty-one patients (29.0%) developed a complication (18.7% perioperative), with 20.6% developing DJK and 11.2% developing DJF. There was a significant correlation between lower LIVs and lower HUs (r=0.351, P=0.01), as well as age and HUs at the LIV. Age did not correlate with change in the DJK angle (P>0.2). HUs were lower at the LIV for patients who developed a complication and an LIV threshold of 190 HUs was predictive of complications (OR: 4.2, [1.2-7.6]; P=0.009). CONCLUSIONS Low bone mineral density at the lowest instrumented vertebra, as assessed by a threshold lower than 190 Hounsfield units, may be a crucial risk factor for the development of complications after cervical deformity surgery. Preoperative CT scans should be routinely considered in at-risk patients to mitigate this modifiable risk factor during surgical planning. LEVEL OF EVIDENCE Level-III.
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Affiliation(s)
- Tyler K Williamson
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
- Departments of Orthopaedic Surgery, University of Texas Health San Antonio, San Antonio, TX
| | - Ezekial J Koslosky
- Departments of Orthopaedic Surgery, University of Texas Health San Antonio, San Antonio, TX
| | - Jordan Lebovic
- Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, NY
| | | | - Peter Tretiakov
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Jamshaid Mir
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Pooja Dave
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital/Harvard Medical Center, Boston, MA
| | - Bassel G Diebo
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University Medical Center, Providence, RI
| | - Heiko Koller
- Department of Orthopaedic Surgery, Paracelsus Medical University, Salzburg, Austria
| | - Renaud Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Virginie Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Peter G Passias
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
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Huang W, Gong Z, Zheng C, Chen Y, Ma X, Wang H, Jiang J. Preoperative Assessment of Bone Density Using MRI-Based Vertebral Bone Quality Score Modified for Patients Undergoing Cervical Spine Surgery. Global Spine J 2024; 14:1238-1247. [PMID: 36321883 PMCID: PMC11289558 DOI: 10.1177/21925682221138261] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
STUDY DESIGN Diagnostic accuracy study. OBJECTIVES Previous studies have reported the clinical application of the Vertebral Bone Quality (VBQ) scores for assessing bone density in operative lumbar spine patients. We aim to explore whether the method could be modified and applicable for patients undergoing cervical spine surgery. METHODS Adult patients receiving cervical spine surgery for degenerative diseases between September 2020 and March 2022 with non-contrast T1-weighted MRI and DEXA were included. Correlation between cervical VBQ scores and DEXA T-scores was analyzed using Pearson's correlation. Student's t test was used to present the discrepancy between the VBQ of patients with normal bone density (T ≥ -1.0) and patients with osteopenia/osteoporosis (T < -1.0). Statistical significance was set at P < .05. RESULTS Eighty-three patients (20 patients with T ≥ -1.0 vs 63 patients with T < -1.0 ) were included. Significant difference was found between the cervical VBQ between groups (2.99 ± .79 vs 3.80 ± .81, P < .001). Interclass correlation coefficient for inter-rater reliability was .82 (95% CI: .70-.93) and .91(95% CI: .84-.97) for intra-rater reliability. The area under the ROC curve was .78 (95% CI: .65-.90). The DEXA T-score of the femoral neck, total hip and the lowest DEXA T-score were found to be significantly correlated with the cervical VBQ score according to Pearson correlation analysis (P < .001). CONCLUSIONS This is the first study to apply the VBQ method to assess the bone density in preoperative cervical spine patients. Cervical VBQ scores were significantly correlated with DEXA T-score. With an overall accuracy of .78, the radiation-free and cost-effective method could be a potential tool for screening patients with osteopenia and osteoporosis before surgery.
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Affiliation(s)
- Weibo Huang
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Zhaoyang Gong
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Chaojun Zheng
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Yu Chen
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaosheng Ma
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Hongli Wang
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Jianyuan Jiang
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
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Nishida K, Park H, Ogiri M, Rossi A. Clinical and Economic Outcomes of Patients with Osteoporosis Undergoing Spine Fusion Surgery in Japan. Spine Surg Relat Res 2024; 8:163-170. [PMID: 38618219 PMCID: PMC11007240 DOI: 10.22603/ssrr.2023-0175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 09/02/2023] [Indexed: 04/16/2024] Open
Abstract
Introduction Spinal fusion surgery with instrumentation is a treatment of choice for many spinal disorders; however, there is little data related to factors associated with early and late outcomes, especially among patients with poor bone quality (e.g., osteoporosis). We conducted this study to characterize the epidemiology and outcomes of patients undergoing spinal fusion surgery with instrumentation in Japan, especially in patients with poor bone quality and those needing additional fixation methods. Methods This retrospective observational study used real-world health insurance claims data from the Japanese Medical Data Vision. Adult patients undergoing an index spinal fusion procedure from April 1, 2010, to September 30, 2017, with procedural details, length of stay (LOS), total in-hospital costs, spine-related reoperation, all-cause readmission, and postoperative complications recorded. Data were summarized descriptively overall, by osteoporosis status, and additional fixation method used, and were analyzed in bivariate analyses. Multivariate logistic and linear regressions were used to explore associations between covariates and variables of interest. Results A total of 22,932 patients (mean age, 67.3 years; 51.2% male) met the study criteria and were included. A total of 5,288 (23.0%) patients had osteoporosis, and 2,507 (10.9%) needed additional fixation methods; these patients were older, more frequently female, and had higher Elixhauser comorbidity index scores. Osteoporosis and additional fixation use were also associated with longer LOS, higher hospital costs, and higher rates of complications. Conclusions Patients with osteoporosis and those needing additional fixation methods have a higher risk for procedural and postoperative complications, reoperation, longer LOS, and higher total hospital costs.
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Affiliation(s)
- Kotaro Nishida
- Department of Orthopedic Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - HyeJin Park
- Health Economics and Market Access, Johnson & Johnson Medical, Seoul, Republic of Korea
| | - Mami Ogiri
- Health Economics and Market Access, Johnson & Johnson Medical J.J.K.K., Tokyo, Japan
| | - Anne Rossi
- Health Economics and Market Access, Johnson & Johnson Medical, Socresby, Australia
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Razzouk J, Ramos O, Scolieri J, Bouterse A, Cabrera A, Shin D, Brandt Z, Carter D, Wycliffe N, Cheng W, Danisa O. Correlations among Cervical, Thoracic, and lumbar Hounsfield Unit measurements for assessment of bone mineral density. J Clin Neurosci 2024; 120:23-28. [PMID: 38171097 DOI: 10.1016/j.jocn.2023.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/11/2023] [Accepted: 12/30/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVE Bone mineral density assessment using Hounsfield Unit (HU) currently depends upon the availability of computed tomography (CT) of the lumbar spine. The primary aim of this study was to evaluate the associations among HU measurements of the cervical (CHU), thoracic (THU), and lumbar (LHU) spine. The secondary aim of this study was to analyze the influence of patient demographic and anthropometric characteristics on HU measurements. METHODS Radiographic records of 165 patients who underwent CT of the cervical, thoracic, and lumbar spine were retrieved. The CHU, THU, and LHU were calculated by obtaining the mean signal intensity from the medullary portions of C3-C7, T8-T12, and L1-L4 vertebral bodies. RESULTS Mean CHU, THU, and LHU values were 266.26 ± 88.69, 165.57 ± 55.06, and 166.45 ± 51.38. Significant differences of 100.69, 99.81, and 0.88 were observed between CHU and THU (p <.001), CHU and LHU (p <.001), and THU and LHU (p =.023). Correlations of 0.574, 0.488, and 0.686 were observed between CHU and THU (p <.001), CHU and LHU (p <.001), and THU and LHU (p <.001). No differences in HU based on sex, age, height, weight, or ethnicity were observed. Multivariate regression models demonstrated R2 values of 0.770 - 0.790 (p <.001) in prediction of LHU. CONCLUSIONS Hounsfield Unit measurements derived from the cervical and thoracic spine correlate with the validated lumbar Hounsfield Unit. Hounsfield Unit measurements do not vary based on sex, ethnicity, age, height, or weight.
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Affiliation(s)
- Jacob Razzouk
- School of Medicine, Loma Linda University, Loma Linda, CA, United States
| | - Omar Ramos
- Department of Orthopaedic Surgery, Twin Cities Spine Center, Minneapolis, MN, United States
| | - Juliette Scolieri
- Department of Orthopaedic Surgery, Loma Linda University, Loma Linda, CA, United States
| | - Alex Bouterse
- School of Medicine, Loma Linda University, Loma Linda, CA, United States
| | - Andrew Cabrera
- School of Medicine, Loma Linda University, Loma Linda, CA, United States
| | - David Shin
- School of Medicine, Loma Linda University, Loma Linda, CA, United States
| | - Zachary Brandt
- School of Medicine, Loma Linda University, Loma Linda, CA, United States
| | - Davis Carter
- School of Medicine, Loma Linda University, Loma Linda, CA, United States
| | - Nathaniel Wycliffe
- Department of Radiology, Loma Linda University, Loma Linda, CA, United States
| | - Wayne Cheng
- Division of Orthopaedic Surgery, Jerry L Pettis Memorial Veterans Hospital, Loma Linda, CA, United States
| | - Olumide Danisa
- Department of Orthopaedic Surgery, Loma Linda University, Loma Linda, CA, United States.
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Hochreiter B, Selman F, Calek AK, Kriechling P, Götschi T, Grubhofer F, Wieser K, Bouaicha S. Why is female gender associated with poorer clinical outcomes after reverse total shoulder arthroplasty? J Shoulder Elbow Surg 2023; 32:2355-2365. [PMID: 37276918 DOI: 10.1016/j.jse.2023.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/19/2023] [Accepted: 04/24/2023] [Indexed: 06/07/2023]
Abstract
INTRODUCTION There is a lack of gender-specific research after reverse total shoulder arthroplasty (RTSA). Although previous studies have documented worse outcomes in women, a more thorough understanding of why outcomes may differ is needed. We therefore asked: (1) Are there gender-specific differences in preoperative and postoperative clinical scores, complications, surgery-related parameters, and demographics? (2) Is female gender an independent risk factor for poorer clinical outcomes after RTSA? (3) If so, why is female gender associated with poorer outcomes after RTSA? MATERIALS AND METHODS Between 2005 and 2019, 987 primary RTSAs were performed in our institution. After exclusion criteria were applied, data of 422 female and 271 male patients were analyzed. Clinical outcomes (absolute/relative Constant Score [a/rCS] and Subjective Shoulder Value [SSV]), complications (intra- and/or postoperative fracture, loosening), surgery-related parameters (indication, implant-related characteristics), and demographics (age, gender, body mass index, and number of previous surgeries) were evaluated. Preoperative and postoperative radiographs were analyzed (critical shoulder angle, deltoid-tuberosity index, reverse shoulder angle, lateralization shoulder angle, and distalization shoulder angle). RESULTS Preoperative clinical scores (aCS, rCS, SSV, and pain level) and postoperative clinical outcomes (aCS and rCS) were significantly worse in women. However, the improvement between preoperative and postoperative outcomes was significantly higher in female patients for rCS (P = .037), internal rotation (P < .001), and regarding pain (P < .001). Female patients had a significantly higher number of intraoperative and postoperative fractures (24.9% vs. 11.4%, P < .001). The proportion of female patients with a deltoid-tuberosity index <1.4 was significantly higher than males (P = .01). Female gender was an independent negative predictor for postoperative rCS (P = .047, coefficient -0.084) and pain (P = .017, coefficient -0.574). In addition to female sex per se being a predictive factor of worse outcomes, females were significantly more likely to meet 2 of the 3 most significant predictive factors: (1) significantly worse preoperative clinical scores and (2) higher rate of intra- and/or postoperative fractures. CONCLUSIONS Female sex is a very weak, but isolated, negative predictive factor that negatively affects the objective clinical outcome (rCS) after RTSA. However, differences did not reach the minimal clinically important difference, and it is not a predictor for the subjective outcome (SSV). The main reason for the worse outcome in female patients seems to be a combination of higher preoperative disability and higher incidence of fractures. To improve the outcome of women, all measures that contribute to the reduction of perioperative fracture risk should be used.
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Affiliation(s)
- Bettina Hochreiter
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.
| | - Farah Selman
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Anna-Katharina Calek
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Philipp Kriechling
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Tobias Götschi
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Florian Grubhofer
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Karl Wieser
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Samy Bouaicha
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Pan TY, Chang CC, Chen HT, Tsou HK, Lin YC, Hsu CH. Effectiveness of Teriparatide for Spine Fusion in Osteoporotic Patient: A Systematic Review and Meta-Analysis of Comparative Studies. World Neurosurg 2023; 179:8-17. [PMID: 37479030 DOI: 10.1016/j.wneu.2023.07.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 07/12/2023] [Indexed: 07/23/2023]
Abstract
OBJECTIVE Our goal was to assess teriparatide's (TP) effectiveness in improving radiographic and functional outcomes after spinal fusion surgery. This meta-analysis included randomized controlled trials (RCTs) and comparative cohort studies. The findings provide valuable insights and guidance for surgeons treating osteoporotic patients undergoing spinal fusion surgery. METHODS We conducted a systematic review to assess TP's efficacy in spinal fusion surgery for osteoporosis. Through thorough selection, data extraction, and quality assessment, we employed network meta-analysis to evaluate radiographic outcomes (fusion rate, screw loosening, vertebral fracture) and changes in bone mineral density measured by Hounsfield units. Functional outcomes were assessed using the Oswestry Disability Index scales. Our study aims to comprehensively understand TP's impact and effectiveness in spinal fusion surgery. RESULTS A total of 868 patients were included in the analysis. All patients underwent thoracolumbar internal fixation fusion surgery and were divided into following 2 groups: the TP treatment group and the control group. The results revealed significant differences in radiological outcomes. The fusion rate showed a significant difference, as well as screw loosening, and bone mineral density measured in Hounsfield units. However, there was no significant difference in vertebral fracture. The TP group demonstrated favorable effects with statistical significance. In terms of functional outcomes, there was no significant difference in the assessment of Oswestry Disability Index scores between the 2 treatment groups. CONCLUSIONS The meta-analysis demonstrated that the TP group exhibited significantly better outcomes, particularly in radiological measures, when compared to the control group. The use of TP in spinal fusion surgery shows promise in reducing postoperative complications and providing overall benefits.
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Affiliation(s)
- Tao-Yin Pan
- Minimally invasive spine and joint center, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan, Republic of China
| | - Chien-Chun Chang
- Minimally invasive spine and joint center, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan, Republic of China; Department of Leisure Industry Management, National Chin-Yi University of Technology, Taichung, Taiwan, Republic of China; Department of Orthopaedic, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan, Republic of China.
| | - Hsien-Te Chen
- Department of Orthopaedic Surgery, China Medical University Hospital, China Medical University, Taichung, Taiwan, Republic of China; Spine Center, China Medical University Hospital, China Medical University, Taichung, Taiwan, Republic of China; Department of Sport Medicine, College of Health Care, China Medical University, Taichung, Taiwan, Republic of China
| | - Hsi-Kai Tsou
- Functional Neurosurgery Division, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China; Department of Rehabilitation, Jen-Teh Junior College of Medicine, Nursing and Management, Miaoli County, Taiwan, Republic of China; Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan, Republic of China
| | - Ying-Chao Lin
- School of Medicine, Tzu Chi University, Hualien, Taiwan, Republic of China; Department of Neurological Institute, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taiwan, Republic of China
| | - Chin-Hsien Hsu
- Department of Leisure Industry Management, National Chin-Yi University of Technology, Taichung, Taiwan, Republic of China
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Jin D, Zheng H, Yuan H. Exploring the Possibility of Measuring Vertebrae Bone Structure Metrics Using MDCT Images: An Unpaired Image-to-Image Translation Method. Bioengineering (Basel) 2023; 10:716. [PMID: 37370647 DOI: 10.3390/bioengineering10060716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/05/2023] [Accepted: 06/08/2023] [Indexed: 06/29/2023] Open
Abstract
Bone structure metrics are vital for the evaluation of vertebral bone strength. However, the gold standard for measuring bone structure metrics, micro-Computed Tomography (micro-CT), cannot be used in vivo, which hinders the early diagnosis of fragility fractures. This paper used an unpaired image-to-image translation method to capture the mapping between clinical multidetector computed tomography (MDCT) and micro-CT images and then generated micro-CT-like images to measure bone structure metrics. MDCT and micro-CT images were scanned from 75 human lumbar spine specimens and formed training and testing sets. The generator in the model focused on learning both the structure and detailed pattern of bone trabeculae and generating micro-CT-like images, and the discriminator determined whether the generated images were micro-CT images or not. Based on similarity metrics (i.e., SSIM and FID) and bone structure metrics (i.e., bone volume fraction, trabecular separation and trabecular thickness), a set of comparisons were performed. The results show that the proposed method can perform better in terms of both similarity metrics and bone structure metrics and the improvement is statistically significant. In particular, we compared the proposed method with the paired image-to-image method and analyzed the pros and cons of the method used.
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Affiliation(s)
- Dan Jin
- Department of Radiology, Peking University Third Hospital, Beijing 100191, China
| | - Han Zheng
- School of Traffic and Transportation, Beijing Jiaotong University, Beijing 100044, China
| | - Huishu Yuan
- Department of Radiology, Peking University Third Hospital, Beijing 100191, China
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Soliman MAR, Aguirre AO, Kuo CC, Ruggiero N, Khan A, Ghannam MM, Rho K, Jowdy PK, Mullin JP, Pollina J. A Novel Cervical Vertebral Bone Quality Score Independently Predicts Cage Subsidence After Anterior Cervical Diskectomy and Fusion. Neurosurgery 2023; 92:779-786. [PMID: 36729684 DOI: 10.1227/neu.0000000000002269] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 09/23/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Surgeons can preoperatively assess bone quality using dual-energy X-ray absorptiometry or computed tomography; however, this is not feasible for all patients. Recently, a MRI-based scoring system was used to evaluate the lumbar spine's vertebral bone quality. OBJECTIVE To create a similar MRI-based scoring system for the cervical spine (C-VBQ), correlate C-VBQ scores with computed tomography-Hounsfield units (HU), and evaluate the utility of this scoring system to independently predict cage subsidence after single-level anterior cervical diskectomy and fusion (ACDF). METHODS Demographic, procedure-related, and radiographic data were collected for patients. Pearson correlation test was used to determine the correlation between C-VBQ and HU. Cage subsidence was defined as ≥3 mm loss of fusion segmental height. A multivariate logistic regression model was built to determine the correlation between potential risk factors for subsidence. RESULTS Of 59 patients who underwent single-level ACDF, subsidence was found in 17 (28.8%). Mean C-VBQ scores were 2.22 ± 0.36 for no subsidence levels and 2.83 ± 0.38 ( P < .001) for subsidence levels. On multivariate analysis, a higher C-VBQ score was significantly associated with subsidence (odds ratio = 1.85, 95% CI = 1.39-2.46, P < .001) and was the only significant independent predictor of subsidence after ACDF. There was a significant negative correlation between HU and C-VBQ (r 2 = -0.49, P < .001). CONCLUSION We found that a higher C-VBQ score was significantly associated with cage subsidence after ACDF. Furthermore, there was a significant negative correlation between C-VBQ and HU. The C-VBQ score may be a valuable tool for assessing preoperative bone quality and independently predicting cage subsidence after ACDF.
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Affiliation(s)
- Mohamed A R Soliman
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
- Department of Neurosurgery, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Alexander O Aguirre
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
| | - Cathleen C Kuo
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
| | - Nicco Ruggiero
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
| | - Asham Khan
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - Moleca M Ghannam
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - Kyungduk Rho
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - Patrick K Jowdy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - Jeffrey P Mullin
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - John Pollina
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
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Lee JW, Kim HC, Kim SI, Min HK, Ha KY, Park HY, Cho CH, Sung HS, Lim JH, Kim YH. Effects of bone cement augmentation for uppermost instrumented vertebra on adjacent disc segment degeneration in lumbar fusions. World Neurosurg 2023; 171:e31-e37. [PMID: 36528321 DOI: 10.1016/j.wneu.2022.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 11/03/2022] [Accepted: 11/04/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE We investigated the long-term effects of bone cement-augmented instrumentation in multilevel lumbar fusions in a retrospective cohort study. The use of cement-augmented screws is one of the techniques used to reduce early mechanical failure in treating multilevel lumbar fusion, especially in the elderly. However, little information is available regarding the long-term effects. METHODS A total of 51 patients who had undergone ≥3 levels of lumbar fusion were divided into two groups according to the use of bone cement-augmented screw fixation involving the upper instrumented vertebra: 22 patients in the cement-augmented group (group I) and 29 patients in the non-cement-augmented group (group II). Analysis of radiographic adjacent disc segment degeneration (ASD) revealed patients with lumbosacral fusion with a similar degree of osteoporosis. Radiologic ASD was defined as progression of >2 UCLA (University of California, Los Angeles) grades at 2 years postoperatively. Other sagittal parameters and the preoperative magnetic resonance imaging Pfirrmann grades at the adjacent levels, possibly related to ASD, were also analyzed. RESULTS No significant differences were present in the preoperative demographic and radiographic parameters between the 2 groups. However, the postoperative kyphotic changes at 3 months were greater for the non-cement-augmented group. In terms of the long-term effects, the incidence of radiologic ASD (group I, n = 20 [95.2%]; vs group II, n = 15 [53.6%]) was significantly higher in the cement-augmented group. Logistic regression analysis of radiologic ASD, including other clinical and radiologic parameters, postoperative pelvic incidence-lumbar lordosis mismatch (odds ratio, 5.201; 95% confidence interval, 1.123-24.090; P = 0.035), and cement augmentation (odds ratio, 20.193; 95% confidence interval, 2.195-185.729; P = 0.008) showed a significant correlation with the development of radiologic ASD at 2 years postoperatively. CONCLUSIONS Although bone cement-augmented screw implantation can prevent kyphotic deformation at the proximal junction of upper instrumented vertebra in the early postoperative stages of multilevel lumbar fusion, a careful selection of patients is required because of possibly accelerated degeneration of adjacent segments.
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Affiliation(s)
- Jae-Won Lee
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Hun-Chul Kim
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Sang-Il Kim
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Hyung-Ki Min
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Kee-Yong Ha
- Department of Orthopedic Surgery, Kyung-Hee University Hospital at Gangdong, Seoul, Korea
| | - Hyung-Youl Park
- Department of Orthopedic Surgery, Eunpyeong St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Chang-Hee Cho
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Hoon-Seok Sung
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Jae-Hak Lim
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Young-Hoon Kim
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea.
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11
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Jang HD, Kim EH, Lee JC, Choi SW, Kim HS, Cha JS, Shin BJ. Management of Osteoporotic Vertebral Fracture: Review Update 2022. Asian Spine J 2022; 16:934-946. [PMID: 36573301 PMCID: PMC9827207 DOI: 10.31616/asj.2022.0441] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 12/08/2022] [Indexed: 12/29/2022] Open
Abstract
A vertebral fracture is the most common type of osteoporotic fracture. Osteoporotic vertebral fractures (OVFs) cause a variety of morbidities and deaths. There are currently few "gold standard treatments" outlined for the management of OVFs in terms of quantity and quality. Conservative treatment is the primary treatment option for OVFs. The treatment of pain includes short-term bed rest, analgesic medication, anti-osteoporotic medications, exercise, and a brace. Numerous reports have been made on studies for vertebral augmentation (VA), including vertebroplasty and kyphoplasty. There is still debate and controversy about the effectiveness of VA in comparison with conservative treatment. Until more robust data are available, current evidence does not support the routine use of VA for OVF. Despite the fact that the majority of OVFs heal without surgery, 15%-35% of patients with an unstable fracture, persistent intractable back pain, or severely collapsed vertebra that causes a neurologic deficit, kyphosis, or chronic pseudarthrosis frequently require surgery. Because no single approach can guarantee the best surgical outcomes, customized surgical techniques are required. Surgeons must stay current on developments in the osteoporotic spine field and be open to new treatment options. Osteoporosis management and prevention are critical to lowering the risk of future OVFs. Clinical studies on bisphosphonate's effects on fracture healing are lacking. Teriparatide was intermittently administered, which dramatically improved spinal fusion and fracture healing while lowering mortality risk. According to the available literature, there are no standard management methods for OVFs. More multimodal approaches, including conservative and surgical treatment, VA, and medications that treat osteoporosis and promote fracture healing, are required to improve the quality of the majority of guidelines.
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Affiliation(s)
- Hae-Dong Jang
- Department of Orthopaedic Surgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Eung-Ha Kim
- Department of Orthopaedic Surgery, Dongkang Hospital, Ulsan, Korea
| | - Jae Chul Lee
- Department of Orthopaedic Surgery, Soonchunhyang University Seoul Hospital, Seoul, Korea,Corresponding author: Jae Chul Lee Department of Orthopaedic Surgery, Soonchunhyang University Seoul Hospital, 59 Daesagwan-ro, Yongsan-gu, Seoul 04401, Korea Tel: +82-32-621-5114, Fax: +82-32-621-5018, E-mail:
| | - Sung-Woo Choi
- Department of Orthopaedic Surgery, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Hak Soo Kim
- Department of Orthopaedic Surgery, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Joong-Suk Cha
- Department of Orthopaedic Surgery, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Byung-Joon Shin
- Department of Orthopaedic Surgery, Soonchunhyang University Seoul Hospital, Seoul, Korea
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12
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Jain N, Labaran L, Phillips FM, Khan SN, Jain A, Kebaish KM, Hassanzadeh H. Prevalence of Osteoporosis Treatment and Its Effect on Post-Operative Complications, Revision Surgery and Costs After Multi-Level Spinal Fusion. Global Spine J 2022; 12:1119-1124. [PMID: 33334188 PMCID: PMC9210228 DOI: 10.1177/2192568220976560] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To study the prevalence of pre-operative osteoporosis treatment, and its effect on risk of ORC, revision surgery and costs in osteoporotic patients undergoing ≥3-level spinal fusion for degenerative pathology. METHODS Patients and procedures of interest were included using International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) coding. Our outcome measures were ORC at 1-year post-operatively and included instrumentation complications, pathological fracture, and revision surgery. Kaplan-Meier survival curves and Cox proportional hazards analysis was done to study the effect of osteoporosis treatment on risk of ORC. RESULTS We included a total of 849 patients with documented osteoporosis undergoing ≥3-level spinal fusion. White (85.6%), female (82.7%), and 60-79 years of age (79.9%) was the most common demographic. Of entire cohort, 121(14.3%) were on osteoporosis treatment prior to spinal fusion. Of treated patients, 52/121 (43.0%) had continued prescriptions at 1 year post-operatively. Treated patients and not-treated patients had 1-year ORC incidence of 9.1% and 15.0%, respectively. The average 1-year reimbursement/patient for managing ORC was $3,053 (treated) and $21,147 (not-treated). On adjusted cox analysis, pre-operative osteoporosis treatment was associated with a lower risk of ORC (HR: 0.53, 95% CI: 0.28-0.99, p = 0.04). CONCLUSIONS Pre-operative osteoporosis treatment is associated with lower risk of ORC and revision surgery at 1-year after ≥3-level spinal fusion. There is a low incidence of osteoporosis treatment prior to spinal fusion, and subsequently a low rate of treatment continuation after surgery. These findings highlight the need for heightened awareness, patient education and management of osteoporosis before elective multi-level spinal fusion.
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Affiliation(s)
- Nikhil Jain
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA
| | - Lawal Labaran
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA
| | - Frank M. Phillips
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
| | - Safdar N. Khan
- Department of Orthopaedic Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Amit Jain
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Khaled M. Kebaish
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Hamid Hassanzadeh
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA,Hamid Hassanzadeh, Department of Orthopaedic Surgery, University of Virginia, 400 Ray C. Hunt Dr, Charlottesville, VA 22903, USA.
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13
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In Response to a Letter to the Editor. Spine (Phila Pa 1976) 2022; 47:E467-E468. [PMID: 35193999 DOI: 10.1097/brs.0000000000004321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Zhou J, Yuan C, Liu C, Liu M, Zhou L, Wang J. Assessment of vertebral bone mineral density and stand-alone oblique lumbar interbody fusion for adjacent segment disease and primary lumbar degenerative diseases. J Orthop Surg (Hong Kong) 2022; 30:10225536221091846. [PMID: 35410526 DOI: 10.1177/10225536221091846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To evaluate the vertebral bone mineral density and the value of stand-alone oblique lumbar interbody fusion (SA OLIF) for the management of single-level adjacent segment disease (ASD) and primary lumbar degenerative diseases. PATIENTS AND METHODS Seventy-eight patients undergoing single-level SA OLIF was divided into index surgery group (n = 36) or revision surgery group (n = 42) at single center. The vertebral body Hounsfield units (HU) value was measured to assess bone mineral density of operated level by the preoperative CT. The following data were retrospectively collected and compared between the two groups: demographic, surgical data, clinical results, and complications. RESULTS No differences were found between the two groups in surgical data. The fusion segment HU values in the revision group were significantly higher than that in the index group (147.4 ± 35.3 vs 129.2 ± 38.4 p = .033). There were significant differences while comparing fusion segment HU values to L1-L4 horizontal plane (147.4 ± 35.3 vs 126.1 ± 28.4, p = .000) and L1 (147.4 ± 35.3 vs 126.8 ± 26.2, p = .000) in revision group, meanwhile, no statistically significant difference was observed in index group (p > .05). The cage subsidence was observed in the revision group (n = 2) and index group (n = 9) (p = .045). The patients with cage subsidence had significantly lower vertebral HU values. CONCLUSION SA OLIF is valid alternative to the traditional posterior approach in the management of ASD with good clinical outcomes at short-term follow-up. Increased HU values of fusion segment may play a role in the management of ASD by SA OLIF.
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Affiliation(s)
- Jing Zhou
- Department of Orthopaedic Surgery, Affiliated Xinqiao Hospital, 105785The Third Military Medical University, Chongqing, China
| | - Chao Yuan
- Department of Orthopaedic Surgery, Affiliated Xinqiao Hospital, 105785The Third Military Medical University, Chongqing, China
| | - Chao Liu
- Department of Orthopaedic Surgery, Affiliated Xinqiao Hospital, 105785The Third Military Medical University, Chongqing, China
| | - Minghan Liu
- Department of Orthopaedic Surgery, Affiliated Xinqiao Hospital, 105785The Third Military Medical University, Chongqing, China
| | - Lei Zhou
- Department of Orthopaedic Surgery, Affiliated Xinqiao Hospital, 105785The Third Military Medical University, Chongqing, China
| | - Jian Wang
- Department of Orthopaedic Surgery, Affiliated Xinqiao Hospital, 105785The Third Military Medical University, Chongqing, China
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Mierke A, Ramos O, Macneille R, Chung JH, Wycliffe N, Cheng W, Danisa OA. Intra- and inter-observer reliability of the novel vertebral bone quality score. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:843-850. [PMID: 34984535 DOI: 10.1007/s00586-021-07096-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 11/21/2021] [Accepted: 12/18/2021] [Indexed: 12/11/2022]
Abstract
PURPOSE To assess the intra- and inter-observer reliability of the novel vertebral bone quality (VBQ) scoring system. METHODS Four orthopedic surgery residents at various levels of training (PGY1-4) evaluated 100 noncontrast, T1-weighted MRIs of the lumbar spine. VBQ was calculated as quotient of the median of L1-L4 average signal intensity (SI) and the L3 cerebral spinal fluid (CSF) SI, as described by Ehresman et al. All measurements were repeated 2 weeks later. We performed a stratified analysis based on patient history of instrumentation, pathology, and MRI manufacturer/magnet strength to determine their effect on VBQ reliability. Spinal pathologies included compression fracture, burst fracture, vertebral osteomyelitis, epidural abscess, or neoplasm. The interclass correlation coefficient (ICC) two-way mixed model on absolute agreement was used to analyze inter-rater and intra-rater reliability. ICC less than 0.40 was considered poor, 0.40-0.59 as fair, 0.60-0.74 as good, and greater than 0.75 as excellent. RESULTS Intra-observer reliability was excellent (≥ 0.75) for all four observers. When stratified by history of spinal instrumentation or spinal pathology, all raters showed excellent intra-observer reliability except one (0.71 and 0.69, respectively). When stratified by MRI manufacturer, intra-observer reliability was ≥ 0.75 for all raters. Inter-observer reliability was excellent (0.91) and remained excellent (≥ 0.75) when stratified by history of spinal instrumentation, spinal pathology, or MRI-manufacturer. CONCLUSIONS VBQ scores from spine lumbar MRIs demonstrate excellent intra-observer and inter-observer reliability. These scores are reliably reproduced in patients regardless of previous instrumentation, spinal pathology, or MRI manufacturer/magnetic field strength.
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Affiliation(s)
- Alex Mierke
- Department of Orthopaedic Surgery, Loma Linda University Health, Loma Linda Drive, Suite 213, 11406, Loma Linda, CA, United States of America.
| | - Omar Ramos
- Department of Orthopaedic Surgery, Loma Linda University Health, Loma Linda Drive, Suite 213, 11406, Loma Linda, CA, United States of America
| | - Rhett Macneille
- Department of Orthopaedic Surgery, Loma Linda University Health, Loma Linda Drive, Suite 213, 11406, Loma Linda, CA, United States of America
| | - Jun Ho Chung
- Department of Orthopaedic Surgery, Loma Linda University Health, Loma Linda Drive, Suite 213, 11406, Loma Linda, CA, United States of America
| | - Nathaniel Wycliffe
- Department of Orthopaedic Surgery, Loma Linda University Health, Loma Linda Drive, Suite 213, 11406, Loma Linda, CA, United States of America
| | - Wayne Cheng
- Division of Orthopaedic Surgery, Jerry L. Pettis VA Medical Center, Loma Linda, CA, United States of America
| | - Olumide A Danisa
- Department of Orthopaedic Surgery, Loma Linda University Health, Loma Linda Drive, Suite 213, 11406, Loma Linda, CA, United States of America
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Somma T, DE Rosa A, Mastantuoni C, Esposito F, Meglio V, Romano F, Ricciardi L, DE Divitiis O, DI Somma C. Multidisciplinary management of osteoporotic vertebral fractures. An overview. Minerva Endocrinol (Torino) 2021; 47:189-202. [PMID: 34881854 DOI: 10.23736/s2724-6507.21.03515-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Vertebral fractures represent the most frequent complication associated with osteoporosis. Patients harboring a vertebral fracture complain physical impairment including low back pain and spine balance alteration, i.e., kyphosis, leading to subsequent systemic complication, with an increase in morbidity and mortality risk. Different strategies are available in the management of osteoporotic vertebral fractures: medical therapy acts as a prevention strategy while surgical vertebral augmentation procedures, when correctly indicated, aim to reduce pain and to restore the physiological vertebral height. Considering the growing prevalence and incidence of this condition and its socio-economic burden, prevention, diagnosis and treatment of osteoporotic vertebral fractures are of utmost importance. Our aim is to review the current strategies for the management of osteoporotic vertebral fractures providing an integrated multidisciplinary endocrinological, radiological and neurosurgical point of view.
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Affiliation(s)
- Teresa Somma
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Andrea DE Rosa
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Naples, Italy -
| | - Ciro Mastantuoni
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Felice Esposito
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Vincenzo Meglio
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Fiammetta Romano
- Unit of Endocrinology, Department of Clinical Medicine and Surgery, Federico II University Medical School, Naples, Italy
| | - Luca Ricciardi
- Neurosurgery, Department NESMOS, Sapienza University of Rome, Rome, Italy
| | - Oreste DE Divitiis
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Carolina DI Somma
- Unit of Endocrinology, Department of Clinical Medicine and Surgery, Federico II University Medical School, Naples, Italy
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Zhou J, Yuan C, Liu C, Zhou L, Wang J. Hounsfield unit value on CT as a predictor of cage subsidence following stand-alone oblique lumbar interbody fusion for the treatment of degenerative lumbar diseases. BMC Musculoskelet Disord 2021; 22:960. [PMID: 34789220 PMCID: PMC8600787 DOI: 10.1186/s12891-021-04833-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 10/31/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND To investigate the correlation between vertebral Hounsfield unit (HU) values and cage subsidence in patients treated with stand-alone (SA) OLIF. METHODS A retrospective review of collected data was performed on 76 patients who underwent SA OLIF. We utilized the HU value for lumbar bone mineral density (BMD) obtained on preoperative CT. The vertebral HU values of patients with subsidence were compared to those without subsidence. The correlation between cage subsidence and clinical score was investigated. RESULTS Sixteen patients (21.1%) had at least radiographic evidence of interbody cage subsidence. The average cage subsidence was 2.5 ± 1.3 mm (range 0.9-4.8 mm). There were no significant differences in sex, BMI, preoperative diagnoses, or fused level (p > 0.05); however, there were significant differences between the cage subsidence group and the nonsubsidence group in age, average of the lowest T-score, and average HU value, including for the L1 vertebrae, L1-L4 horizontal plane, and L1-L4 sagittal plane (p < 0.05). The average HU value of the L1-L4 horizontal plane showed a more predictable AUC of 0.909 (95% CI, 0.834-0.984; P < 0.001) compared with the average of the lowest T-score following an AUC of 0.791 (95% CI, 0.674-0.909; P < 0.001). Based on logistic regression analysis, the average HU value of the L1-L4 horizontal plane (OR, 0.912; 95% CI, 0.861-0.966; P = 0.002) was an independent factor influencing cage subsidence. CONCLUSIONS Patients with lower average HU values of the lumbar vertebrae are at a much higher risk of developing cage subsidence after SA OLIF. Measurement of preoperative HU values on preexisting CT scans could be rapid, simple and feasible.
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Affiliation(s)
- Jing Zhou
- Department of Orthopaedic Surgery, Affiliated Xinqiao Hospital, Army Medical University, No.183, Xinqiao Street, Shapingba District, Chongqing, 400037, People's Republic of China
| | - Chao Yuan
- Department of Orthopaedic Surgery, Affiliated Xinqiao Hospital, Army Medical University, No.183, Xinqiao Street, Shapingba District, Chongqing, 400037, People's Republic of China
| | - Chao Liu
- Department of Orthopaedic Surgery, Affiliated Xinqiao Hospital, Army Medical University, No.183, Xinqiao Street, Shapingba District, Chongqing, 400037, People's Republic of China
| | - Lei Zhou
- Department of Orthopaedic Surgery, Affiliated Xinqiao Hospital, Army Medical University, No.183, Xinqiao Street, Shapingba District, Chongqing, 400037, People's Republic of China
| | - Jian Wang
- Department of Orthopaedic Surgery, Affiliated Xinqiao Hospital, Army Medical University, No.183, Xinqiao Street, Shapingba District, Chongqing, 400037, People's Republic of China.
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周 晶, 周 蕾, 刘 超, 袁 超, 王 建. [CT value of vertebral body predicting Cage subsidence after stand-alone oblique lumbar interbody fusion]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2021; 35:1449-1456. [PMID: 34779172 PMCID: PMC8586776 DOI: 10.7507/1002-1892.202105058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 09/13/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To investigate the correlation between CT value and Cage subsidence in patients with lumbar degenerative disease treated with stand-alone oblique lumbar interbody fusion (OLIF). METHODS The clinical data of 35 patients with lumbar degenerative diseases treated with stand-alone OLIF between February 2016 and October 2018 were retrospectively analyzed. There were 15 males and 20 females; the age ranged from 29 to 81 years, with an average of 58.4 years. There were 39 operative segments, including 32 cases of single-segment, 2 cases of double-segment, and 1 case of three-segment. Preoperative lumbar CT was used to measure the CT values of the axial position of L 1 vertebral body, the axial and sagittal positions of L 1-4 vertebral body, surgical segment, and the axial position of upper and lower vertebral bodies as the bone mineral density index, and the lowest T value was recorded by dual-energy X-ray absorptiometry. The visual analogue scale (VAS) and Oswestry disability index (ODI) scores were recorded before operation and at last follow-up. At last follow-up, the lumbar interbody fusion was evaluated by X-ray films of the lumbar spine and dynamic position; the lumbar lateral X-ray film was used to measure the subsidence of the Cage, and the patients were divided into subsidence group and nonsubsidence group. The univariate analysis on age, gender, body mass index, lowest T value, CT value of vertebral body, disease type, and surgical segment was performed to initially screen the influencing factors of Cage subsidence; further the logistic regression for multi-factor analysis was used to screen fusion independent risk factors for Cage subsidence. The receiver operating characteristic (ROC) curve and area under curve (AUC) were used to analyze the CT value and the lowest T value to predict the Cage subsidence. Spearman correlation analysis was used to determine the correlation between Cage subsidence and clinical results. RESULTS All the 35 patients were followed up 27-58 months, with an average of 38.7 months. At last follow-up, the VAS and ODI scores were significantly decreased when compared with preoperative scores ( t=32.850, P=0.000; t=31.731, P=0.000). No recurrent lower extremity radiculopathy occurred and no patient required revision surgery. Twenty-seven cases (77.1%) had no Cage subsidence (nonsubsidence group); 8 cases (22.9%) had at least radiographic evidence of Cage subsidence, the average distance of Cage subsidence was 2.2 mm (range, 1.1-4.2 mm) (subsidence group). At last follow-up, there was 1 case of fusion failure both in the subsidence group and the nonsubsidence group, there was no significant difference in the interbody fusion rate (96.3% vs. 87.5%) between two groups ( P=0.410). Univariate analysis showed that the CT value of vertebral body (L 1 axial position, L 1-4 axial and sagittal positions, surgical segment, and upper and lower vertebral bodies axial positions) and the lowest T value were the influencing factors of Cage subsidence ( P<0.05). According to ROC curve analysis, compared with AUC of the lowest T value [0.738, 95% CI (0.540, 0.936)], the AUC of the L 1-4 axis CT value was 0.850 [95% CI (0.715, 0.984)], which could more effectively predict Cage subsidence. Multivariate analysis showed that the CT value of L 1-4 axis was an independent risk factor for Cage subsidence ( P<0.05). CONCLUSION The CT value measurement of the vertebral body based on lumbar spine CT before stand-alone OLIF can predict the Cage subsidence. Patients with low CT values of the lumbar spine have a higher risk of Cage subsidence. However, the Cage subsidence do not lead to adverse clinical results.
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Affiliation(s)
- 晶 周
- 中国人民解放军陆军军医大学第二附属医院骨科(重庆 400037)Department of Orthopedics, the First Affiliated Hospital of the Army Military Medical University, Chongqing, 400037, P.R.China
| | - 蕾 周
- 中国人民解放军陆军军医大学第二附属医院骨科(重庆 400037)Department of Orthopedics, the First Affiliated Hospital of the Army Military Medical University, Chongqing, 400037, P.R.China
| | - 超 刘
- 中国人民解放军陆军军医大学第二附属医院骨科(重庆 400037)Department of Orthopedics, the First Affiliated Hospital of the Army Military Medical University, Chongqing, 400037, P.R.China
| | - 超 袁
- 中国人民解放军陆军军医大学第二附属医院骨科(重庆 400037)Department of Orthopedics, the First Affiliated Hospital of the Army Military Medical University, Chongqing, 400037, P.R.China
| | - 建 王
- 中国人民解放军陆军军医大学第二附属医院骨科(重庆 400037)Department of Orthopedics, the First Affiliated Hospital of the Army Military Medical University, Chongqing, 400037, P.R.China
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Jin D, Zheng H, Zhao Q, Wang C, Zhang M, Yuan H. Generation of Vertebra Micro-CT-like Image from MDCT: A Deep-Learning-Based Image Enhancement Approach. Tomography 2021; 7:767-782. [PMID: 34842849 PMCID: PMC8628970 DOI: 10.3390/tomography7040064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/05/2021] [Accepted: 11/09/2021] [Indexed: 11/26/2022] Open
Abstract
This paper proposes a deep-learning-based image enhancement approach that can generate high-resolution micro-CT-like images from multidetector computed tomography (MDCT). A total of 12,500 MDCT and micro-CT image pairs were obtained from 25 vertebral specimens. Then, a pix2pixHD model was trained and evaluated using the structural similarity index measure (SSIM) and Fréchet inception distance (FID). We performed subjective assessments of the micro-CT-like images based on five aspects. Micro-CT and micro-CT-like image-derived trabecular bone microstructures were compared, and the underlying correlations were analyzed. The results showed that the pix2pixHD method (SSIM, 0.804 ± 0.037 and FID, 43.598 ± 9.108) outperformed the two control methods (pix2pix and CRN) in enhancing MDCT images (p < 0.05). According to the subjective assessment, the pix2pixHD-derived micro-CT-like images showed no significant difference from the micro-CT images in terms of contrast and shadow (p > 0.05) but demonstrated slightly lower noise, sharpness and trabecular bone texture (p < 0.05). Compared with the trabecular microstructure parameters of micro-CT images, those of pix2pixHD-derived micro-CT-like images showed no significant differences in bone volume fraction (BV/TV) (p > 0.05) and significant correlations in trabecular thickness (Tb.Th) and trabecular spacing (Tb.Sp) (Tb.Th, R = 0.90, p < 0.05; Tb.Sp, R = 0.88, p < 0.05). The proposed method can enhance the resolution of MDCT and obtain micro-CT-like images, which may provide new diagnostic criteria and a predictive basis for osteoporosis and related fractures.
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Affiliation(s)
- Dan Jin
- Department of Radiology, Peking University Third Hospital, Beijing 100191, China; (D.J.); (Q.Z.); (C.W.); (M.Z.)
| | - Han Zheng
- School of Traffic and Transportation, Beijing Jiaotong University, Beijing 100044, China;
| | - Qingqing Zhao
- Department of Radiology, Peking University Third Hospital, Beijing 100191, China; (D.J.); (Q.Z.); (C.W.); (M.Z.)
| | - Chunjie Wang
- Department of Radiology, Peking University Third Hospital, Beijing 100191, China; (D.J.); (Q.Z.); (C.W.); (M.Z.)
| | - Mengze Zhang
- Department of Radiology, Peking University Third Hospital, Beijing 100191, China; (D.J.); (Q.Z.); (C.W.); (M.Z.)
| | - Huishu Yuan
- Department of Radiology, Peking University Third Hospital, Beijing 100191, China; (D.J.); (Q.Z.); (C.W.); (M.Z.)
- Correspondence:
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Althoff AD, Kamalapathy P, Vatani J, Hassanzadeh H, Li X. Osteoporosis is associated with increased minor complications following single level ALIF and PSIF: an analysis of 7,004 patients. JOURNAL OF SPINE SURGERY 2021; 7:269-276. [PMID: 34734131 DOI: 10.21037/jss-21-29] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 07/13/2021] [Indexed: 11/06/2022]
Abstract
Background Osteoporosis is a prevalent disease that predisposes patients to fracture and additional post-operative complications, potentially contributing to decreased quality of life. The objective of the current study is to (I) characterize the demographic trends of individuals with osteoporosis undergoing single level posterior spine instrumentation and fusion (PSIF) and anterior lumbar interbody fusion (ALIF); (II) determine the association between osteoporosis and postoperative complications; (III) identify whether the use of bone strengthening medications is associated with improved outcomes. Methods A retrospective review of the Mariner Claims Database was conducted on patients undergoing single level ALIF (CPT 22558) and PSIF (CPT 22840) between 2011 and 2017. Diagnosis of osteoporosis (CPT 77080, CPT 77801, CPT 77082) included a bone density scan within two years of surgery. Patients with osteoporosis were 1:1 matched to controls. Patients taking bone enhancing medications prior to surgery were compared to those that did not take medications. Multivariable logistic regression analyses were performed to evaluate post-operative complication risk factors. Results 3,502 patients with diagnosed osteoporosis underwent ALIF and PSIF, of which 788 (22.5%) were treated with supplemental medication. Diagnosis of osteoporosis was associated with an increased risk of pulmonary embolism [1.1% vs. 0.4%, odds ratio (OR) 2.48, 95% confidence interval (CI): 1.36-4.53, P=0.003] and minor complications (16.7% vs. 12.9%, OR 1.15, 95% CI: 1.01-1.30, P=0.039). Revision rates two-years post-operatively were not significantly different between patients with osteoporosis and matched controls (P>0.05). There were no differences in outcomes between osteoporotic patients who received medications and those who did not receive medication (P>0.05). Conclusions Osteoporosis is common in a nationally-representative Medicare database cohort. Pre-operative diagnosis of osteoporosis is associated with increased minor complications following ALIF and PSIF. Pre-operative osteoporosis treatment is not associated with a significant difference in post-operative outcomes. The current study can guide pre-operative counseling in this cohort.
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Affiliation(s)
- Alyssa D Althoff
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA
| | - Pramod Kamalapathy
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA
| | - Jasmine Vatani
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Hamid Hassanzadeh
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA
| | - Xudong Li
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA
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21
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Zhang D, Gao X, Ding W, Cui H. Predictors and Correlative Factors for Low Back Pain after Long Fusion Arthrodesis in Patients with Adult Scoliosis. Adv Ther 2021; 38:3803-3815. [PMID: 34037959 DOI: 10.1007/s12325-021-01763-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 04/27/2021] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Low back pain (LBP) still exists at the follow-up visit in some cases after long fusion arthrodesis for adult scoliosis. However, few available studies have elaborated the reasons and factors associated with this symptom. Therefore, the aim of the current study was to identify the correlative factors and predictors of postoperative LBP after long fusion arthrodesis and provide evidence to improve the surgical strategy. METHODS Seventy-nine patients with adult scoliosis who underwent long fusion arthrodesis were divided into a group with no or mild LBP (NLBP group) and one with moderate or severe LBP (MLBP group) according to the average Oswestry Dability Index (ODI) at the last follow-up visit. The Japanese Orthopaedic Association (JOA) score, ODI and complications were used to evaluate clinical outcomes. %Fat infltration area (%FIA), sagittal and coronal parameters were recorded to evaluate radiological outcomes. Multivariate logistic regression analysis was conducted to identify the predictors and correlative factors for postoperative LBP. RESULTS Thirty-three patients (41.77%) with ODI (30.06% ± 6.92%) higher than the average at the last follow-up were divided into the MLBP group, while the rest (58.23%) with last follow-up ODI (13.26% ± 5.31%) lower than the average were divided into the NLBP group. In multivariate logistic regression, the preoperative sagittal vertical axis (SVA) (P < 0.001), %FIA (P = 0.003) and osteoporosis (P = 0.016) were identified to be predictors and last follow-up SVA (P < 0.001), last follow-up lumbar lordosis (LL) (P = 0.031) and adjacent segment degeneration (ASD) (P = 0.043) were identified as correlative factors. The receiver-operating characteristic (ROC) curve showed satisfactory accuracy in preoperative SVA (P < 0.001) and %FIA (P < 0.001) to predict postoperative LBP. CONCLUSION Postoperative LBP after long fusion arthrodesis for adult scoliosis was common. Postoperative LBP was associated with increased SVA and decreased LL and ASD. Preoperative SVA > 3.54 cm, %FIA > 24.82% and osteoporosis showed good accuracy to predict the postoperative symptoms. Optimal surgical methods should be used for patients with these factors to decrease the incidence and degree of postoperative LBP.
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Affiliation(s)
- Di Zhang
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
| | - Xianda Gao
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
| | - Wenyuan Ding
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
| | - Huixian Cui
- Department of Anatomy, Hebei Medical University, No. 361 Zhongshan East Road, Shijiazhuang, 050017, China.
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Moverman MA, Menendez ME, Mahendraraj KA, Polisetty T, Jawa A, Levy JC. Patient risk factors for acromial stress fractures after reverse shoulder arthroplasty: a multicenter study. J Shoulder Elbow Surg 2021; 30:1619-1625. [PMID: 33038496 DOI: 10.1016/j.jse.2020.09.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 09/07/2020] [Accepted: 09/21/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Despite the growing recognition of acromial stress fractures (ASFs) after reverse total shoulder arthroplasty (RTSA), most of the current data are derived from single-center studies with limited generalizability. This multicenter study investigated the incidence of ASFs after RTSA and identified preoperative patient characteristics associated with their occurrence. METHODS Using 2 institutional registries from different regions of the United States, we identified 1479 patients undergoing either primary or revision RTSA between 2013 and 2018 with minimum 3-month follow-up. ASFs were defined as radiographic evidence of an acromial or scapular spine fracture with clinical symptoms (eg, tenderness over the acromion or scapular spine). Multivariable logistic regression was performed to identify preoperative patient factors associated with the development of ASFs. RESULTS Overall, 54 (3.7%) patients were diagnosed with an ASF after RTSA. Patient-related factors independently associated with the development of an ASF included female sex (odds ratio [OR], 2.21 reference: male; 95% confidence interval [CI], 1.03-4.74; P < .05), rheumatoid arthritis (OR, 2.30; 95% CI, 1.02-5.16; P < .05), osteoporosis (OR, 2.55; 95% CI, 1.24-5.21; P < .05), a diagnosis of degenerative joint disease with rotator cuff tear (OR, 4.74 reference: degenerative joint disease without rotator cuff tear; 95% CI, 1.84-12.23; P < .05), and fracture malunion/nonunion (OR, 5.21; 95% CI, 1.20-22.76; P < .05). CONCLUSIONS The non-negligible percentage of ASFs that occur after RTSA is associated with the diagnoses of rotator cuff dysfunction and chronic fracture sequelae in female patients with suboptimal bone health. This information can be used to counsel patients and set expectations about potential setbacks in recovery.
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Affiliation(s)
- Michael A Moverman
- Department of Orthopaedic Surgery, New England Baptist Hospital, Tufts University School of Medicine, Boston, MA, USA
| | - Mariano E Menendez
- Department of Orthopaedic Surgery, New England Baptist Hospital, Tufts University School of Medicine, Boston, MA, USA
| | - Kuhan A Mahendraraj
- Department of Orthopaedic Surgery, New England Baptist Hospital, Tufts University School of Medicine, Boston, MA, USA; Boston Sports and Shoulder Center, Waltham, MA, USA
| | - Teja Polisetty
- Department of Orthopaedics, Holy Cross Orthopaedic Institute, Fort Lauderdale, FL, USA
| | - Andrew Jawa
- Department of Orthopaedic Surgery, New England Baptist Hospital, Tufts University School of Medicine, Boston, MA, USA; Boston Sports and Shoulder Center, Waltham, MA, USA.
| | - Jonathan C Levy
- Department of Orthopaedics, Holy Cross Orthopaedic Institute, Fort Lauderdale, FL, USA
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Mei J, Song X, Guan X, Wu D, Wang J, Liu Q. Postoperative bisphosphonate do not significantly alter the fusion rate after lumbar spinal fusion: a meta-analysis. J Orthop Surg Res 2021; 16:284. [PMID: 33926494 PMCID: PMC8082634 DOI: 10.1186/s13018-021-02444-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 04/22/2021] [Indexed: 11/13/2022] Open
Abstract
Background To evaluate the effect of postoperative BP treatment on improving the fusion rate after lumbar spinal fusion surgery by performing a meta-analysis of randomized controlled trials (RCTs) and other comparative cohort studies. Methods A comprehensive search of PubMed, EMBASE, the Web of Science, and the Cochrane Central Register of Controlled Trials was performed for RCTs and other comparative cohort studies on the effect of BP treatment on improving the fusion rate after lumbar spinal fusion surgery. The primary outcome measures were the number of patients with bone formation grades A, B, and C at 12 months of follow-up; fusion rates at 12 and 24 months of follow-up; vertebral compression fracture (VCF) at 12 and 24 months of follow-up; pedicle screw loosening at 24 months of follow-up; and cage subsidence, the Oswestry disability index (ODI), and the visual analogue score (VAS) at 12 months of follow-up. The final search was performed in July 2020. Results Seven studies with 401 patients were included. Compared with the placebo, BP treatment did not significantly alter the number of patients with bone formation grades A, B, and C, or the VAS at the 12-month follow-up or the fusion rates at the 12- and 24-month follow-ups. In addition, compared with the placebo, BPs significantly reduced the risks of VCF at the 12- and 24-month follow-ups, pedicle screw loosening at the 24-month follow-up, and cage subsidence and the ODI at the 12-month follow-up. Conclusions Postoperative BPs do not clearly improve bone formation and the fusion rate, but they reduce VCF, cage subsidence, and loosening of pedicle screws after lumbar fusion surgery compared with the control treatment.
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Affiliation(s)
- Jun Mei
- Shanxi Medical University, Taiyuan, China.,Shanxi Bethune Hospital, Shanxi Academy of Medical Science, No. 99, Longcheng Street, Taiyuan, 030032, Shanxi Province, China
| | - Xiaoxu Song
- Shanxi Bethune Hospital, Shanxi Academy of Medical Science, No. 99, Longcheng Street, Taiyuan, 030032, Shanxi Province, China
| | - Xiaoming Guan
- Shanxi Bethune Hospital, Shanxi Academy of Medical Science, No. 99, Longcheng Street, Taiyuan, 030032, Shanxi Province, China
| | - Dou Wu
- Shanxi Bethune Hospital, Shanxi Academy of Medical Science, No. 99, Longcheng Street, Taiyuan, 030032, Shanxi Province, China
| | | | - Qiang Liu
- Shanxi Bethune Hospital, Shanxi Academy of Medical Science, No. 99, Longcheng Street, Taiyuan, 030032, Shanxi Province, China.
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Elarjani T, Warner T, Nguyen K, Nguyen S, Urakov TM. Quantifying Bone Quality Using Computed Tomography Hounsfield Units in the Mid-sagittal View of the Lumbar Spine. World Neurosurg 2021; 151:e418-e425. [PMID: 33892163 DOI: 10.1016/j.wneu.2021.04.051] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Computed tomography Hounsfield unit (HU) is an alternative tool to the dual energy x-ray absorptiometry scan T-score to quantify the bone quality. DEXA scan can overestimate the bone mineral density. We studied the correlation of the vertebral mid-axial and mid-sagittal HU to the T-score. METHODS We retrospectively reviewed the electronic medical records of patients who underwent dual energy x-ray absorptiometry and computed tomography scans within 1 year. Age, sex, mid-axial and mid-sagittal HU, and T-score were collected and statistically analyzed. RESULTS We identified 100 patients with computed tomography of the L1-L4. There were 80 female and 20 male patients. The average age was 60.25 years (±12.54 years). Nineteen patients were diagnosed with degenerative spine disease. There were 56 patients with a normal T-score, 33 with osteopenia, and 11 with osteoporosis. The average HU for the mid-sagittal view was 163 (±59) for L1, 159 (±62) for L2, 151 (±59) for L3, and 150 (±62) for L4. The mid-axial and mid-sagittal HU were positively correlated to the DEXA T-score (P < 0.001). The HU was 177 (95% CI: 160-194) for normal T-scores, 132 (120-143) for T-scores indicating osteopenia, and 106 (88-124) for T-scores indicating osteoporosis (P < 0.001). Post hoc analysis showed no difference between osteopenia and osteoporosis (P = 0.46). CONCLUSIONS Mid-sagittal HU is positively correlated to the T-score, similar to the mid-axial HU. Therefore, it can be used to acquire a general overview of the bone quality before spinal instrumentation.
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Affiliation(s)
- Turki Elarjani
- Department of Neurological Surgery, University of Miami MILLER School of Medicine, Miami, Florida, USA.
| | - Tyler Warner
- Department of Neurological Surgery, University of Miami MILLER School of Medicine, Miami, Florida, USA
| | - Kimanh Nguyen
- Department of Neurological Surgery, University of Miami MILLER School of Medicine, Miami, Florida, USA
| | - Stephanie Nguyen
- Department of Neurological Surgery, University of Miami MILLER School of Medicine, Miami, Florida, USA
| | - Timur M Urakov
- Department of Neurological Surgery, University of Miami MILLER School of Medicine, Miami, Florida, USA
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25
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Fiani B, Newhouse A, Sarhadi KJ, Arshad M, Soula M, Cathel A. Special Considerations to Improve Clinical Outcomes in Patients with Osteoporosis Undergoing Spine Surgery. Int J Spine Surg 2021; 15:386-401. [PMID: 33900998 PMCID: PMC8059385 DOI: 10.14444/8050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Osteoporosis is a condition that is commonly encountered, with increasing diagnosis by the medical community with the aging population. Osteoporosis leaves patients susceptible to fragility fractures in the vertebrae and is also associated with degenerative changes, both of which may require intervention from a spine surgeon. The goal of this review is to concisely outline special nonoperative adjuncts, as well as preoperative, intraoperative, and postoperative considerations of osteoporotic patients undergoing spine intervention. METHODS A literature analysis was completed for this narrative review. A database search of PubMed and Google Scholar was conducted using "osteoporosis" combined with "spine," "spine surgery," and "spinal fusion" without exclusion based on publication date. Articles were screened to exclude duplicate articles and screened for their full text and English language availability. RESULTS The database search yielded recent publications from which the narrative review was completed. CONCLUSIONS Preoperatively, screening is traditionally completed with dual-energy x-ray absorptiometry (DEXA). Pharmacological therapy modalities currently include teriparatide, raloxifene, denosumab, bisphosphonates, and calcitonin. In order to prevent operative complications associated with osteoporosis, surgeons have found success in increasing the diameter and the length of pedicle screws, limiting pedicle tapping, achieving bicortical or even tricortical purchase, augmenting with polymethyl methacrylate, using iliosacral stabilization, preventing positive sagittal balance, and using adequate fusion products when necessary. Postoperatively, it is important to implant a care plan that includes adequate pain control and necessary care, and to understand risks associated with falls may increase risk of postoperative fragility fractures as well as instrumentation displacement. At this time there are no recommendations in regard to bracing in the postoperative setting. CLINICAL RELEVANCE This review article outlines the most current evidence-based medicine with regard to considerations in spine surgery of the osteoporotic patient, and aims to bring about new questions to be investigated in that paradigm.
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Affiliation(s)
- Brian Fiani
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, California
| | - Alexander Newhouse
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
| | | | - Mohammad Arshad
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, California
| | - Marisol Soula
- New York University School of Medicine, New York University, New York, New York
| | - Alessandra Cathel
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, California
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Arlt H, Besschetnova T, Ominsky MS, Fredericks DC, Lanske B. Effects of systemically administered abaloparatide, an osteoanabolic PTHrP analog, as an adjuvant therapy for spinal fusion in rats. JOR Spine 2021; 4:e1132. [PMID: 33778406 PMCID: PMC7984001 DOI: 10.1002/jsp2.1132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 10/26/2020] [Accepted: 11/04/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Abaloparatide is a parathyroid hormone receptor agonist that increases bone formation and reduces vertebral and nonvertebral fracture risk in women with postmenopausal osteoporosis. Animal studies indicate abaloparatide stimulates vertebral bone formation and enhances bony bridging and biomechanical stability of fracture calluses. AIMS The current study is evaluating the potential utility for abaloparatide as an adjunct therapy for spinal fusions. MATERIAL AND METHODS The effects of 14 or 28 days of daily subcutaneous injections of abaloparatide (20 μg/kg/d) or vehicle were evaluated in 32 male Sprague-Dawley rats starting 1 day after noninstrumented posterolateral fusion (PLF) with bone autograft. Fusion mass microarchitecture was analyzed by micro-computed tomography (micro-CT) and serum markers of bone formation and bone resorption were evaluated. Motion segments were scored in a blinded manner as fused or unfused by postmortem radiography and manual palpation. RESULTS Abaloparatide-treated rats showed higher bone formation (serum osteocalcin) at day 14 and 28 compared with vehicle controls, without increases in the bone resorption marker serum TRACP-5b. Micro-CT showed greater trabecular number in fusion masses from the abaloparatide group vs vehicle controls at day 14. Manual palpation and radiography indicated no fusions in either group at day 14, whereas 25% of vehicle-treated rats and 50% of abaloparatide-treated rats had bilateral fusion at day 28. DISCUSSION AND CONCLUSION In summary, this rat PLF model showed that abaloparatide treatment was associated with higher levels of the bone formation marker osteocalcin, improved fusion mass architecture, and a non- significant 2-fold higher fusion rate compared with vehicle.
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Affiliation(s)
- Heike Arlt
- Research & DevelopmentRadius Health, Inc.WalthamMassachusettsUSA
| | | | | | - Douglas C. Fredericks
- Department of Orthopedics and RehabilitationUniversity of Iowa Hospitals and ClinicsIowa CityIowaUSA
| | - Beate Lanske
- Research & DevelopmentRadius Health, Inc.WalthamMassachusettsUSA
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Assessing underlying bone quality in spine surgery patients: a narrative review of dual-energy X-ray absorptiometry (DXA) and alternatives. Spine J 2021; 21:321-331. [PMID: 32890786 DOI: 10.1016/j.spinee.2020.08.020] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 08/15/2020] [Accepted: 08/29/2020] [Indexed: 02/06/2023]
Abstract
Poor bone quality and low bone mineral density (BMD) have been previously tied to higher rates of postoperative mechanical complications in patients undergoing spinal fusion. These include higher rates of proximal junctional kyphosis, screw pullout, pseudoarthrosis, and interbody subsidence. For these reasons, accurate preoperative assessment of a patient's underlying bone quality is paramount for all elective procedures. Dual-energy X-ray absorptiometry (DXA) is currently considered to be the gold standard for assessing BMD. However, a growing body of research has suggested that in vivo assessments of BMD using DXA are inaccurate and have, at best, moderate correlations to postoperative mechanical complications. Consequently, there have been investigations into using alternative methods for assessing in vivo bone quality, including using computed tomography (CT) and magnetic resonance imaging (MRI) volumes that are commonly obtained as part of surgical evaluation. Here we review the data regarding the accuracy of DXA for the evaluation of spine bone quality and describe the alternative imaging modalities currently under investigation.
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28
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Jang HD, Kim EH, Lee JC, Choi SW, Kim K, Shin BJ. Current Concepts in the Management of Osteoporotic Vertebral Fractures: A Narrative Review. Asian Spine J 2020; 14:898-909. [PMID: 33373513 PMCID: PMC7788360 DOI: 10.31616/asj.2020.0594] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 11/24/2020] [Indexed: 12/14/2022] Open
Abstract
Vertebral fractures are the most common type of osteoporotic fracture and can increase morbidity and mortality. To date, the guidelines for managing osteoporotic vertebral fractures (OVFs) are limited in quantity and quality, and there is no gold standard treatment for these fractures. Conservative treatment is considered the primary treatment option for OVFs and includes pain relief through shortterm bed rest, analgesics, antiosteoporotic drugs, exercise, and braces. Studies on vertebral augmentation (VA) including vertebroplasty and kyphoplasty have been widely reported, but there is still debate and controversy regarding the effectiveness of VA when compared with conservative treatment, and the routine use of VA for OVF is not supported by current evidence. Although most OVFs heal well, approximately 15%-35% of patients with unstable fractures, chronic intractable back pain, severely collapsed vertebra (leading to neurological deficits and kyphosis), or chronic pseudarthrosis frequently require surgery. Given that there is no single technique for optimizing surgical outcomes in OVFs, tailored surgical techniques are needed. Surgeons need to pay attention to advances in osteoporotic spinal surgery and should be open to novel thoughts and techniques. Prevention and management of osteoporosis is the key element in reducing the risk of subsequent OVFs. Bisphosphonates and teriparatide are mainstay drugs for improving fracture healing in OVF. The effects of bisphosphonates on fracture healing have not been clinically evaluated. The intermittent administration of teriparatide significantly enhanced spinal fusion and fracture healing and reduced mortality risk. Based on the current literature, there is still a lack of standard management strategies for OVF. There is a need for greater efforts through multimodal approaches including conservative treatment, surgery, osteoporosis treatment, and drugs that promote fracture healing to improve the quality of the guidelines.
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Affiliation(s)
- Hae-Dong Jang
- Department of Orthopaedic Surgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Eung-Ha Kim
- Department of Orthopaedic Surgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Jae Chul Lee
- Department of Orthopaedic Surgery, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Sung-Woo Choi
- Department of Orthopaedic Surgery, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Kyungbum Kim
- Department of Orthopaedic Surgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Byung-Joon Shin
- Department of Orthopaedic Surgery, Soonchunhyang University Seoul Hospital, Seoul, Korea
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Sallent I, Capella-Monsonís H, Procter P, Bozo IY, Deev RV, Zubov D, Vasyliev R, Perale G, Pertici G, Baker J, Gingras P, Bayon Y, Zeugolis DI. The Few Who Made It: Commercially and Clinically Successful Innovative Bone Grafts. Front Bioeng Biotechnol 2020; 8:952. [PMID: 32984269 PMCID: PMC7490292 DOI: 10.3389/fbioe.2020.00952] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 07/23/2020] [Indexed: 12/11/2022] Open
Abstract
Bone reconstruction techniques are mainly based on the use of tissue grafts and artificial scaffolds. The former presents well-known limitations, such as restricted graft availability and donor site morbidity, while the latter commonly results in poor graft integration and fixation in the bone, which leads to the unbalanced distribution of loads, impaired bone formation, increased pain perception, and risk of fracture, ultimately leading to recurrent surgeries. In the past decade, research efforts have been focused on the development of innovative bone substitutes that not only provide immediate mechanical support, but also ensure appropriate graft anchoring by, for example, promoting de novo bone tissue formation. From the countless studies that aimed in this direction, only few have made the big jump from the benchtop to the bedside, whilst most have perished along the challenging path of clinical translation. Herein, we describe some clinically successful cases of bone device development, including biological glues, stem cell-seeded scaffolds, and gene-functionalized bone substitutes. We also discuss the ventures that these technologies went through, the hindrances they faced and the common grounds among them, which might have been key for their success. The ultimate objective of this perspective article is to highlight the important aspects of the clinical translation of an innovative idea in the field of bone grafting, with the aim of commercially and clinically informing new research approaches in the sector.
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Affiliation(s)
- Ignacio Sallent
- Regenerative, Modular & Developmental Engineering Laboratory, National University of Ireland Galway, Galway, Ireland
- Science Foundation Ireland Centre for Research in Medical Devices (CÚRAM), National University of Ireland Galway, Galway, Ireland
| | - Héctor Capella-Monsonís
- Regenerative, Modular & Developmental Engineering Laboratory, National University of Ireland Galway, Galway, Ireland
- Science Foundation Ireland Centre for Research in Medical Devices (CÚRAM), National University of Ireland Galway, Galway, Ireland
| | - Philip Procter
- Division of Applied Materials Science, Department of Engineering Sciences, Uppsala University, Uppsala, Sweden
- GPBio Ltd., Shannon, Ireland
| | - Ilia Y. Bozo
- Histograft LLC, Moscow, Russia
- Federal Medical Biophysical Center of FMBA of Russia, Moscow, Russia
| | - Roman V. Deev
- Histograft LLC, Moscow, Russia
- I.I. Mechnikov North-Western State Medical University, Saint Petersburg, Russia
| | - Dimitri Zubov
- State Institute of Genetic & Regenerative Medicine NAMSU, Kyiv, Ukraine
- Medical Company ilaya, Kyiv, Ukraine
| | - Roman Vasyliev
- State Institute of Genetic & Regenerative Medicine NAMSU, Kyiv, Ukraine
- Medical Company ilaya, Kyiv, Ukraine
| | | | | | - Justin Baker
- Viscus Biologics LLC, Cleveland, OH, United States
| | | | - Yves Bayon
- Sofradim Production, A Medtronic Company, Trévoux, France
| | - Dimitrios I. Zeugolis
- Regenerative, Modular & Developmental Engineering Laboratory, National University of Ireland Galway, Galway, Ireland
- Science Foundation Ireland Centre for Research in Medical Devices (CÚRAM), National University of Ireland Galway, Galway, Ireland
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Cheng SH, Kuo YJ, Chen C, Kang YN. Effects of teriparatide and bisphosphonate on spinal fusion procedure: A systematic review and network meta-analysis. PLoS One 2020; 15:e0237566. [PMID: 32870946 PMCID: PMC7462270 DOI: 10.1371/journal.pone.0237566] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 07/14/2020] [Indexed: 01/11/2023] Open
Abstract
Background Giving patients anti-osteoporotic agents peri-operatively is a well-accepted strategy to increase fusion rate and prevent complications. The purpose of this study was to investigate effectiveness of teriparatide and bisphosphonate on fusion surgery of thoracic and lumbar spine. Methods We searched EMBASE and PubMed for randomized clinical trials (RCTs) and prospective comparative studies using teriparatide or bisphosphonate in peri-operative spinal fusion surgery. Our synthesized data of fusion rate, Oswestry disability index (ODI), and adverse event in contrast-based network meta-analysis. Pooled results were presented in risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI). Results Our search hit eight RCTs and three prospective studies with 676 patients receiving spinal surgery. Pooled result showed that teriparatide+Denosumab leads to significantly higher fusion rate than placebo (RR, 2.84; 95% CI: 1.22 to 6.60) and bisphosphonate (RR, 2.59; 95% CI: 1.13 to 5.96). We did not observe significant finding among placebo, teriparatide, and bisphosphonate in the two network models. Conclusion This is the first network meta-analysis providing an overview of the use of teriparatide and bisphosphonate for spinal fusion surgery. Teriparatide treatments are worth to be consider for spinal fusion surgery.
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Affiliation(s)
- Shih-Hao Cheng
- Department of Orthopedics, Wan Fang Hospital, Taipei Medical University, Taipei, Republic of China (Taiwan)
- Department of Orthopedics, Cheng Hsin General Hospital, Taipei, Republic of China (Taiwan)
| | - Yi-Jie Kuo
- Department of Orthopedics, Wan Fang Hospital, Taipei Medical University, Taipei, Republic of China (Taiwan)
- Department of Orthopedic Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Republic of China (Taiwan)
| | - Chiehfeng Chen
- Department of Public Health, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Republic of China (Taiwan)
- Cochrane Taiwan, Taipei Medical University, Taipei, Republic of China (Taiwan)
- Division of Plastic Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Republic of China (Taiwan)
- Evidence-Based Medicine Center, Wan Fang Hospital, Taipei Medical University, Taipei, Republic of China (Taiwan)
| | - Yi-No Kang
- Cochrane Taiwan, Taipei Medical University, Taipei, Republic of China (Taiwan)
- Evidence-Based Medicine Center, Wan Fang Hospital, Taipei Medical University, Taipei, Republic of China (Taiwan)
- Research Center of Big Data and Meta-Analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Republic of China (Taiwan)
- Institute of Health Policy & Management, College of Public Health, National Taiwan University, Taipei, Republic of China (Taiwan)
- * E-mail:
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Anderson PA, Kadri A, Hare KJ, Binkley N. Preoperative bone health assessment and optimization in spine surgery. Neurosurg Focus 2020; 49:E2. [PMID: 32738805 DOI: 10.3171/2020.5.focus20255] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 05/13/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The purpose of this investigation was to characterize the bone health in preoperative spine surgery patients. This information will provide a framework to understand the needs and methods for providing bone health optimization in elective spine surgery patients. METHODS A retrospective study of 104 patients undergoing bone health optimization was performed. Patients were selected based on risk factors identified by the surgeon and suspected compromised bone health. Evaluation included history and examination, laboratory investigations, and bone mineral density (BMD) at 3 sites (femoral neck, lumbar spine, and radius). Patients' bone status was classified using WHO criteria and expanded criteria recommended by the National Osteoporosis Foundation (NOF). The 10-year Fracture Risk Assessment Tool (FRAX) scores of the hip and major osteoporotic fracture (MOF) were calculated with and without femoral neck BMD, with spine BMD, and with the trabecular bone score (TBS). Antiresorptive and anabolic agents were provided in accordance with meeting NOF criteria for treatment of osteoporosis. RESULTS The mean patient age was 69.0 years, and 81% of patients were female. The mean historical height loss was 5.6 cm, and 54% of patients had a history of fracture. Secondary osteoporosis due to chronic renal failure, inflammatory arthritis, diabetes, and steroid use was common (51%). The mean 25-hydroxy vitamin D was 42.4 ng/ml and was normal in 81% of patients, with only 4 patients being deficient. The mean T-scores were -2.09 (SD 0.71) of the femoral neck, -0.54 (1.71) of the lumbar spine, and -1.65 (1.38) of the distal radius. These were significantly different. The 10-year FRAX MOF score was 20.7%, and that for hip fracture was 6.9% using the femoral neck BMD and was not significantly different without the use of BMD. The FRAX risk-adjusted score using the lumbar spine BMD and TBS was significantly lower than that for the hip. Osteoporosis was present in 32.1% according to WHO criteria compared with 81.6% according to NOF criteria. Antiresorptive medications were recommended in 31 patients and anabolic medications in 44 patients. CONCLUSIONS Surgeons can reliably identify patients with poor bone health by using simple criteria, including historical height loss, history of fracture, comorbidities associated with osteoporosis, analysis of available imaging, and calculation of FRAX score without BMD. High-risk patients should have BMD testing and bone health assessment. In patients with osteoporosis, a comprehensive preoperative bone health assessment is recommended and, if warranted, pharmacological treatment should be started.
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Affiliation(s)
- Paul A Anderson
- 1Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison; and
| | - Aamir Kadri
- 1Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison; and
| | - Kristyn J Hare
- 1Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison; and
| | - Neil Binkley
- 2University of Wisconsin School of Medicine and Public Health, Osteoporosis Clinical Research Program, Madison, Wisconsin
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Bettag C, Abboud T, von der Brelie C, Melich P, Rohde V, Schatlo B. Do we underdiagnose osteoporosis in patients with pyogenic spondylodiscitis? Neurosurg Focus 2020; 49:E16. [DOI: 10.3171/2020.5.focus20267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 05/14/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVEPyogenic spondylodiscitis affects a fragile patient population. Surgical treatment in cases of instability entails instrumentation, and loosening of this instrumentation is a frequent occurrence in pyogenic spondylodiscitis. The authors therefore attempted to investigate whether low bone mineral density (BMD)—which is compatible with the diagnosis of osteoporosis—is underdiagnosed in patients with pyogenic spondylodiscitis. How osteoporosis was treated and how it affected implant stability were further analyzed.METHODSCharts of patients who underwent operations for pyogenic spondylodiscitis were retrospectively reviewed for clinical data, prior medical history of osteoporosis, and preoperative CT scans of the thoracolumbar spine. In accordance with a previously validated high-fidelity opportunistic CT assessment, average Hounsfield units (HUs) in vertebral bodies of L1 and L4 were measured. Based on the validation study, the authors opted for a conservative cutoff value for low BMD, being compatible with osteoporosis ≤ 110 HUs. Baseline and outcome variables, including implant failure and osteoporosis interventions, were entered into a multivariate logistic model for statistical analysis.RESULTSOf 200 consecutive patients who underwent fusion surgery for pyogenic spondylodiscitis, 64% (n = 127) were male and 66% (n = 132) were older than 65 years. Seven percent (n = 14) had previously been diagnosed with osteoporosis. The attenuation analysis revealed HU values compatible with osteoporosis in 48% (95/200). The need for subsequent revision surgery due to implant failure showed a trend toward an association with estimated low BMD (OR 2.11, 95% CI 0.95–4.68, p = 0.067). Estimated low BMD was associated with subsequent implant loosening (p < 0.001). Only 5% of the patients with estimated low BMD received a diagnosis and pharmacological treatment of osteoporosis within 1 year after spinal instrumentation.CONCLUSIONSRelying on past medical history of osteoporosis is insufficient in the management of patients with pyogenic spondylodiscitis. This is the first study to identify a substantially missed opportunity to detect osteoporosis and to start pharmacological treatment after surgery for prevention of implant failure. The authors advocate for routine opportunistic CT evaluation for a better estimation of bone quality to initiate diagnosis and treatment for osteoporosis in these patients.
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Affiliation(s)
- Christoph Bettag
- 1Department of Neurosurgery, Georg-August University of Göttingen; and
| | - Tammam Abboud
- 1Department of Neurosurgery, Georg-August University of Göttingen; and
| | | | - Patrick Melich
- 1Department of Neurosurgery, Georg-August University of Göttingen; and
- 2Department of Neurosurgery, University Hospital Cologne, Germany
| | - Veit Rohde
- 1Department of Neurosurgery, Georg-August University of Göttingen; and
| | - Bawarjan Schatlo
- 1Department of Neurosurgery, Georg-August University of Göttingen; and
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Thompson JC, Wanderman N, Anderson PA, Freedman BA. Abaloparatide and the Spine: A Narrative Review. Clin Interv Aging 2020; 15:1023-1033. [PMID: 32636617 PMCID: PMC7334019 DOI: 10.2147/cia.s227611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 04/23/2020] [Indexed: 11/23/2022] Open
Abstract
Osteoporosis is a common and debilitating condition characterized by diminished bone mass and architecture leading to bone fragility. Antiresorptive medicines like bisphosphonates (and less commonly denosumab) are the typical first-line agents for the medical treatment of osteoporosis. However, newer anabolic agents have been shown to improve bone mass and architecture, as well as reduce fracture risk, to a greater degree than traditional antiresorptive therapies. Teriparatide (human recombinant parathyroid hormone (PTH) 1–34, Forteo, Ely Lilly, Indianapolis, IN), which was the first in class to be approved in the United States, is the most widely used anabolic osteoporosis medicine and has shown significant benefit over traditional antiresorptive therapies. However, abaloparatide (synthetic parathyroid-related peptide (PTHrP), Tymlos, Radius Health, Waltham, MA), the second drug in this family, has recently become available for use. In this narrative review, we review the mechanism, effects, and benefits of abaloparatide compared to alternative treatments as well as discuss the current literature in regard to its effect on osteoporosis-related complications in the spine.
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Affiliation(s)
| | - Nathan Wanderman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Paul A Anderson
- Department of Orthopaedic Surgery, Department of Orthopedics Surgery & Rehabilitation, University of Wisconsin, Madison, WI 53705-2281, USA
| | - Brett A Freedman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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Ehresman J, Schilling A, Pennington Z, Gui C, Chen X, Lubelski D, Ahmed AK, Cottrill E, Khan M, Redmond KJ, Sciubba DM. A novel MRI-based score assessing trabecular bone quality to predict vertebral compression fractures in patients with spinal metastasis. J Neurosurg Spine 2020; 32:499-506. [PMID: 31860825 DOI: 10.3171/2019.9.spine19954] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 09/30/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Vertebral compression fractures (VCFs) in patients with spinal metastasis can lead to destabilization and often carry a high risk profile. It is therefore important to have tools that enable providers to predict the occurrence of new VCFs. The most widely used tool for bone quality assessment, dual-energy x-ray absorptiometry (DXA), is not often available at a patient's initial presentation and has limited sensitivity. While the Spinal Instability Neoplastic Score (SINS) has been associated with VCFs, it does not take patients' baseline bone quality into consideration. To address this, the authors sought to develop an MRI-based scoring system to estimate trabecular vertebral bone quality (VBQ) and to assess this system's ability to predict the occurrence of new VCFs in patients with spinal metastasis. METHODS Cases of adult patients with a diagnosis of spinal metastasis, who had undergone stereotactic body radiation therapy (SBRT) to the spine or neurosurgical intervention at a single institution between 2012 and 2019, were retrospectively reviewed. The novel VBQ score was calculated for each patient by dividing the median signal intensity of the L1-4 vertebral bodies by the signal intensity of cerebrospinal fluid (CSF). Multivariable logistic regression analysis was used to identify associations of demographic, clinical, and radiological data with new VCFs. RESULTS Among the 105 patients included in this study, 56 patients received a diagnosis of a new VCF and 49 did not. On univariable analysis, the factors associated with new VCFs were smoking status, steroid use longer than 3 months, the SINS, and the novel scoring system-the VBQ score. On multivariable analysis, only the SINS and VBQ score were significant predictors of new VCFs and, when combined, had a predictive accuracy of 89%. CONCLUSIONS As a measure of bone quality, the novel VBQ score significantly predicted the occurrence of new VCFs in patients with spinal metastases independent of the SINS. This suggests that baseline bone quality is a crucial factor that requires assessment when evaluating these patients' conditions and that the VBQ score is a novel and simple MRI-based measure to accomplish this.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Majid Khan
- 3Radiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Kadri A, Binkley N, Hare KJ, Anderson PA. Bone Health Optimization in Orthopaedic Surgery. J Bone Joint Surg Am 2020; 102:574-581. [PMID: 31977823 DOI: 10.2106/jbjs.19.00999] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Osteoporosis is associated with adverse orthopaedic surgical outcomes. Bone health optimization is a preoperative intervention intended to reduce the likelihood of postoperative complications. We aimed to characterize a patient cohort referred for bone health optimization to test the hypothesis that poor bone quality is common in orthopaedic surgery and that many such patients meet guidelines for osteoporosis treatment. METHODS This retrospective study evaluated 124 patients referred for bone health optimization who were ≥50 years of age and candidates for arthroplasty or thoracolumbar surgery. The Fracture Risk Assessment Tool (FRAX) risk factors and dual x-ray absorptiometry (DXA) results were collected. When available, opportunistic computed tomographic (CT) imaging and the trabecular bone score were evaluated. The World Health Organization (WHO) diagnostic and National Osteoporosis Foundation (NOF) treatment guidelines were applied. RESULTS All patients were referred by their orthopaedic surgeon; their mean age was 69.2 years, 83% of patients were female, 97% were Caucasian, and 56% had sustained a previous fracture. The mean historical height loss (and standard deviation) was 5.3 ± 3.3 cm for women and 6.0 ± 3.6 cm for men. The mean lowest T-score of the hip, spine, or wrist was -2.43 ± 0.90 points in women and -2.04 ± 0.81 points in men (p < 0.08). Osteoporosis (T-score of ≤-2.5 points) was present in 45% of women and 20% of men; only 3% of women and 10% of men had normal bone mineral density. Opportunistic CT scans identified 60% of patients as likely having osteoporosis. The trabecular bone score identified 34% of patients with degraded bone microarchitecture and 30% of patients with partially degraded bone microarchitecture. The NOF threshold for osteoporosis treatment was met in 91% of patients. Treatment was prescribed in 75% of patients (45% anabolic therapy and 30% antiresorptive therapy). CONCLUSIONS Osteoporosis, degraded bone microarchitecture, prior fracture, and elevated fracture risk were common. Given the high prevalence of impaired bone health in this cohort, we believe that bone health screening, including FRAX assessment, should be considered in selected patients undergoing orthopaedic surgery as part of the preoperative optimization for all adults who are ≥50 years of age. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Aamir Kadri
- Department of Orthopedics & Rehabilitation (A.K., K.J.H., and P.A.A.), and the Osteoporosis Clinical Research Program (N.B.), University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Gupta A, Upadhyaya S, Patel A, Fogel HA, Cha T, Schwab J, Bono C, Hershman S. DEXA sensitivity analysis in patients with adult spinal deformity. Spine J 2020; 20:174-180. [PMID: 31479779 DOI: 10.1016/j.spinee.2019.08.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 08/20/2019] [Accepted: 08/26/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND Adult spinal deformity (ASD) is a debilitating condition that commonly requires surgical intervention. However, ASD patients may also present with osteoporosis, predisposing them to surgical complications and failure of instrumentation. As a result, proper detection of low bone mineral density (BMD) is critical in order to ensure proper patient care. Typically dual-energy x-ray absorptiometry (DEXA) scans are performed on the hip and spine. Unfortunately, in ASD patients, the latter is often inaccurate PURPOSE: In this study, we consider the value of obtaining a forearm DEXA scan in addition to a hip scan in patients suffering from ASD and osteoporosis in order to accurately detect low BMD. STUDY DESIGN Retrospective study. PATIENT SAMPLE Patient data between 2016 and 2018 from a single academic medical center was utilized. Two hundred eighty-six patients met the initial search criteria. OUTCOME MEASURES No outcomes measures related to self-reporting, physiology, or functionality were evaluated in this study. Primary outcome measures analyzed included T-scores across various anatomic locations and diagnoses relating to low bone density (ie, osteopenia and osteoporosis). METHODS This retrospective study examines patients that underwent DEXA studies between 2016 and 2018 and were previously diagnosed with both osteoporosis and adult spinal deformity. For each patient, age, gender, body mass index, and smoking history were noted, as well as whether there was long-term prednisone use. T-scores from both the forearm and hip were recorded and analyzed. Diagnoses from hip DEXA scans were compared with those obtained from forearm scans to identify which region was more sensitive in detecting low BMD. From this data, the frequency of a missed diagnosis, due to reliance on hip or spine T-scores for detection of low BMD, was extrapolated. No external funding source was received in support of this study. RESULTS Two hundred eighty-six patients matched the initial search criteria. Only 68% had one T-score value. However, 24.8% of patients had data for both the hip and forearm, whereas 7.1% had data for the forearm, hip, and spine. Among the 85 patients with more than one anatomical site of study, the forearm was more sensitive than the hip in its ability to detect osteopenia or osteoporosis 41.2% of the time. A two-tailed t test showed no statistically significant difference between hip T-scores and forearm T-scores. However, for more than 17% of patients, the forearm allowed clinicians to detect osteoporosis or osteopenia in a setting where using only the hip data would have missed such a diagnosis. CONCLUSIONS Clinicians need to ensure they survey at least two locations when conducting DEXA studies before precluding a diagnosis of osteopenia or osteoporosis. All ASD patients being evaluated for low bone density should receive DEXA scans that survey at least the hip and the forearm. Misdiagnoses can be costly in the setting of ASD. They occur frequently when only a single hip scan is relied upon to assess BMD.
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Affiliation(s)
- Anmol Gupta
- Icahn School of Medicine at Mount Sinai, NY, USA; Department of Orthopedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
| | - Shivam Upadhyaya
- Department of Orthopedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
| | - Anuj Patel
- Department of Orthopedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
| | - Harold A Fogel
- Department of Orthopedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
| | - Thomas Cha
- Department of Orthopedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
| | - Joseph Schwab
- Department of Orthopedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
| | - Chris Bono
- Department of Orthopedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
| | - Stuart Hershman
- Department of Orthopedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA.
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