Vertebral Fragility Fractures (VFF)-Who, when and how to operate

Related factors of severe osteoporotic vertebral compression fracture and clinical outcomes of percutaneous kyphoplasty: A retrospective study

BACKGROUND

Osteoporosis is the most common disease in postmenopausal women and the elderly, which can lead to vertebral compression fracture.

OBJECTIVE

To investigate the related factors of severe osteoporotic vertebral compression fracture (SOVCF) and evaluate the long-term outcomes of percutaneous kyphoplasty (PKP) for treating SOVCF through comparison with mild OVCF (MOVCF).

METHODS

From September 2015 to March 2019, 294 osteoporotic vertebral compression fracture (OVCF) patients treated with PKP were analyzed. Compression of the anterior margin of the fractured vertebral body beyond 2/3 of the original height was defined as SOVCF. Baseline data, clinical and imaging findings before and after surgery and at the last follow-up were recorded. Numerical Rating Scale (NRS) was used to evaluate low back pain, the Oswestry Disability Index (ODI) was used to evaluate activity of daily life. Anterior vertebral height (AVH) and local kyphosis angle (LKA) was used to evaluate radiographic outcomes. During the follow-up, patients with recurrent back pain were examined by MRI to identify new fractures and the incidence of adjacent vertebral fracture (AVF) was recorded. Age, sex, body mass index (BMI), dual energy X-ray absorptiometry based T value, duration of symptom, history of trauma, steroid use, and fracture site were collected for univariate logistic regression analysis Variables with a P-value of less than 0.05 were then included in multivariate analysis to determine the related factors for SOVCF.

RESULTS

Logistic regression analysis indicated that longer duration of symptom (OR = 1.109, 95%CI: 1.038-1.185, P= 0.002), lower T value (OR = 0.332, 95%CI: 0.139-0.763, P= 0.001), and steroid use (OR = 31.294, 95%CI: 1.020-960.449, P= 0.049) were related factors of SOVCF. Compared with the MOVCF group, the SOVCF group had longer operation time (57.3 ± 13.51 minutes vs 44.9 ± 8.13 minutes, P< 0.001), more radiation exposure (39.9 ± 7.98 times vs 25.5 ± 4.01 times, P< 0.001), and higher cement leakage rate (55.81% vs 18.73%, P< 0.001). At the last follow-up, the SOVCF group had higher NRS (2.28 ± 0.85 vs 1.30 ± 0.71, P< 0.001), and ODI (16.23 ± 4.43 vs 12.88 ± 3.34, P< 0.001). After operation and at the last follow-up, the SOVCF group had higher LKA and lower AVH (all P< 0.05). The AVF rate at the last follow-up was higher in the SOVCF group at the last follow-up (4.78% vs 18.60%, P< 0.001).

CONCLUSION

Lower T value, longer duration of disease, and steroid use were related factors of SOVCF. Compared with MOVCF, PKP for SOVCF had longer operation time, more radiation exposure, and higher cement leakage rate, and the long-term outcomes were worsen.

Analysis of Prognostic Factors in Osteoporotic Patients Who Were Treated with Percutaneous Vertebroplasty for Refracture After Vertebral Augmentation

OBJECTIVE

To retrospectively analyze prognostic factors in osteoporotic patients who treated with percutaneous vertebroplasty for refracture after vertebral augmentation.

METHODS

A retrospective analysis was performed of 61 patients with refractures after vertebral augmentation who received percutaneous vertebroplasty treatment again from January 2019 to December 2021. Based on the presence of back pain at the last follow-up, 17 patients were placed in the pain group, and 44 patients were placed in the pain-free group. The following covariates were reviewed: age; bone mineral density; bone cement dosage; bone cement leakage; body mass index; and rate of anterior vertebral height (AVH) loss in the target before surgery, 1 week after surgery, and at last follow-up. Patients were assessed using visual analogue scale score and Oswestry Disability Index.

RESULTS

Binary logistic regression analysis revealed that the rate of AVH loss after surgery was associated with postoperative back pain. According to the receiver operating characteristic curve analysis, the area under the curve of AVH loss rate at 1 week after surgery was 0.6845, and the cutoff value was 0.18; the area under the curve of AVH loss rate at the last follow-up was 0.7306, and the cutoff value was 0.2815. Kaplan-Meier survival analysis showed that patients with lower AVH loss rates had lower incidence of postoperative back pain and better prognosis.

CONCLUSIONS

Occurrence of postoperative back pain was strongly associated with AVH loss after surgery. Patients with a lower rate of AVH loss had a lower incidence of postoperative back pain and a better prognosis.

The associations between short-term exposure to ambient particulate matter and hospitalizations for osteoporotic fracture in Hangzhou: a time-stratified case-crossover study

Our results suggested that short-term exposure to particulate matter (PM) might increase the risks of hospitalizations for osteoporotic fractures. Government should protect its citizens by putting in place policies to reduce unhealthy emissions and air pollution.

INTRODUCTION

Osteoporotic fractures are accompanied by high rates of disability and mortality. PM has been linked with many health outcomes. However, few studies focus on the association of short-term exposure to ambient PM and osteoporotic fractures.

METHODS

Data on daily mean air pollution, meteorological factors, and hospitalizations for osteoporotic fractures were collected from Hangzhou, China, 2020-2021. A time-stratified case-crossover design with extended Cox proportional hazards regression was applied to assess the associations between PM and osteoporotic fractures.

RESULTS

Short-term exposure to PM significantly increased the risks of hospitalizations for osteoporotic fractures at cumulative lag days. Per 10 μg/m3 increased in PM2.5 (PM with an aerodynamic diameter ≤ 2.5 μm), PMC (PM with an aerodynamic diameter between 2.5 μm and 10 μm), and PM10 (PM with an aerodynamic diameter ≤ 10 μm) were associated with 5.65% (95% confidence intervals (CIs): 1.29, 10.19), 3.19% (0.11, 6.36), and 2.45% (0.57, 4.37) increase in hospitalizations for osteoporotic fractures, respectively. Significant PM-osteoporotic fracture associations were only observed in females and people aged over 65 years old. For the season, the estimates of PM on hospitalizations for osteoporotic fractures were 6.30% (95% CIs: 1.62, 11.20) in the cold season vs. 2.16% (95% CIs: - 4.62, 9.42) in the warm season for per 10 μg/m3 increase of PM2.5, and 0.99 (95% CIs: - 2.69, 4.80) vs. 6.72% (95% CIs: 0.68, 13.13) for PMC.

CONCLUSIONS

Our study showed PM was positively linked with the risk of osteoporotic fractures. Females and people aged over 65 years old were more susceptible to PM. The adverse impacts of PM2.5 in the cold season and PMC in the warm season were worthy of special attention.

Pharmacological options for pain control in patients with vertebral fragility fractures

This review considers the evidence base and current knowledge for pharmacological treatment options that are available for pain control in patients with vertebral fractures sustained after a low trauma incident. Due care needs to be taken when considering prescribed options for pain control. The decision should be based on first establishing whether the presentation is one of acute severe pain at the time of a new vertebral fragility fracture incident or whether the complaint is one of the debilitating, longer term chronic back pain syndrome, accompanied by a clinical suspicion of a possible new fracture. The article also presents currently debated questions in this important area of clinical and patient care and will be of interest to the readership worldwide.

Kyphoplasty for Elderly Patients With Vertebral Compression Fractures-Do We Save Lives? Mortality Rates Analysis Comparison in a Long-Term Follow-Up Cohort

STUDY DESIGN

Retrospective cohort.

OBJECTIVES

We aimed to compare a large cohort of patients with vertebral compression fractures (VCF) treated in 2 centers using different protocols (conservative vs BKP) and compare mortality rates on a long-term follow-up.

METHODS

Retrospective cohort held in 2 medical centers (W and AH). All patients admitted with VCF from November 2008 to January 2015 were enrolled in the study. Exclusion criteria were patients admitted with non-osteoporotic pathological fractures (such as metastatic or MM).

RESULTS

Our study included 208 patients treated for VCF, 127 were treated with BKP (88 females, 69.3%) and 81 were treated conservatively (59 females, 72.8%). Patients from Centre W were older and frailer compared to the patients from AH center (Average age 75.12 ± 11.16 vs 69.13 ± 9.61 years and Frailty score of 0.16 ± 0.1 vs 0.12 ± 0.1 respectively, T-test, p < 0.01 for both). Hazard ratios (HR) for age, female gender and frailty were significant for increased mortality, frailty had the highest HR of 182.42 (CI 29.05-1145.33, p < 0.01). Multivariate Cox model was fitted and after accounting for Gender, Age and Frailty, no significant difference was found between the 2 medical centers mortality rates (p = 0.59), thus no difference in mortality rates between BKP and conservative treatment in our study.

CONCLUSION

long-term follow-up following BKP treatment for VCF did not show a reduced mortality rate compared to conservative treatment after accounting for frailty, age and gender. Frailty was the most important factor in predicting mortality. Further RCTs are needed to compare the quality of life differences between the 2 treatment strategies.

The Covid 19 Pandemic Effect on the Epidemiology of Thoracolumbar Fractures Presenting to the Emergency Department in Patients Above 65 years Old

Introduction

Studies investigating the Covid-19 Pandemic’s orthopedic aspects are accumulating, including reports on a 10-33% decrease in hip fracture incidence alongside shorter times to surgery. Osteoporotic vertebral compression fractures (VCF) have not yet been discussed. This study evaluated the effect of the Covid-19 pandemic’s first wave on VCF in the elderly.

Method

A retrospective cohort of elderly patients diagnosed with VCF between 2018-19 (Pre-Covid-19 pandemic) to 2020.

Results

The cohort included 172 patients above 65 years with VCF during 2018-2020. Patients’ age and gender were similar between the two study groups. We found a higher proportion of high-energy VCF during 2020 (10.5% vs 6.7%). Incidence of recurrent fractures was 7.5 times higher during 2020 (5.3% vs .7%, P =.06), and significantly higher rates of Ankylosing Spondylitis or Diffuse Idiopathic Skeletal Hyperostosis in 2020 (7.9% vs 1.5%, P=.04). VCF ED admission rates were similar, with 60% treated conservatively. Admitted patients underwent more surgeries in 2020 (66.7% vs 60%, P =.71) and a tendency towards Precoutaneus Balloon Kyphoplasty (BKP) + fixation compared with BKP alone (15.8% in 2020 vs 7.5% in 2018-19, P =.29). RR for BKP + fixation vs BKP alone was 1.95, suggesting higher odds for a more complex surgery during the Covid-19 pandemic. The complication rate was significantly higher during 2020 (18.4% vs 3.7%, P <.001). Admission length was slightly longer during 2020 (12.2 days vs 9.9 days, P = .27), and time to surgery was marginally longer, 6.25 vs 5.3 days (P = .55). Many patients chose home over institutional rehabilitation during the Covid-19 pandemic (72.2% vs 58.8%).

Conclusion

The Covid-19 pandemic did not alter VCF incidence, but patients’ characteristics changed, affecting admissions, institutional rehabilitation, and a tendency towards complex surgery rather than BKP alone. It is still unclear if Covid-19 will remain an issue in the upcoming years, but its impact and lessons are still worthwhile.

Spinal Orthoses Prescription for Vertebral Fragility Fractures by Italian Physical and Rehabilitation Medicine Physicians: The SPIN-VER Survey

Vertebral fragility fractures (VFFs) are the most common type of osteoporotic fractures, related to pain and disability. In this scenario, physical and rehabilitative medicine (PRM) physicians prescribe a patient-tailored rehabilitation plan, including spinal orthoses. However, there is a high heterogeneity in the clinical indications of spinal orthoses. Thus, the aim of this survey was to investigate common clinical practice in terms of the prescription of spinal orthoses. This nationwide cross-sectional survey recruited Italian PRM physicians commonly involved in the management of patients with VFFs. One hundred twenty-six PRM physicians completed the survey. The results showed that most PRM physicians prescribe spinal orthoses in outpatients suffering from VFFs (n = 106; 83.9%). The most prescribed spinal orthosis for acute VFF patients was the three-point rigid orthosis (n = 64; 50.8%), followed by the semirigid thoraco-lumbar orthosis (n: 20; 15.9%). However, most PRM physicians prescribed dynamic orthoses in outpatients with chronic VFFs (n = 66; 52.4%). Albeit that a correct management of VFFs is mandatory to improve pain and reduce disability, our findings highlighted uncertainty in the type of spinal orthosis prescription in both the acute and chronic VFF phase. Therefore, high-quality research trials are warranted to provide clear recommendations for the correct clinical management of VFF.

Management of hospitalised osteoporotic vertebral fractures

Management of hospitalised osteoporotic vertebral fracture patients was explored across all major trauma orthopaedic hospitals in Ireland. Findings, based on a survey of orthopaedic doctors and physiotherapists, indicate a lack of standardised clinical care pathways. This study will inform development of clinical audit mechanisms and health service development for this large and growing fracture population in both Ireland and internationally.

PURPOSE

To explore the management of hospitalised vertebral fragility fracture (VFF) patients in Ireland.

METHODS

A cross-sectional survey of orthopaedic doctors (specialist registrar level) and physiotherapists was conducted across all hospitals with major orthopaedic trauma units in Ireland. Data were analysed using descriptive statistics in SPSS (V24).

RESULTS

Responses were achieved from 100% (n = 16) of the hospitals (42 individual physiotherapists and 47 orthopaedic doctors). Conservative management was usual with both orthopaedic doctors (n = 37, 79%) and physiotherapists (n = 40, 96%) reporting prescription of bracing as common practice despite a lack of underpinning evidence. A majority (87%) of the doctors believed osteoporosis medications should commence prior to discharge from the acute setting, but 68% did not agree that responsibility for coordination and delivery of bone health assessment and fracture risk management rested with them. A majority (72%) of physiotherapists reported an absence or were unsure regarding existence of fracture liaison services. 73% of physiotherapists reported prescribing an inpatient or home (78%) exercise programme, including mobility, strength and balance exercise though detail on dose and adherence remain unknown. Wide variance in referral patterns to multi-disciplinary team (MDT) members existed although 79% of orthopaedic doctors supported an MDT approach.

CONCLUSION

Clinical care pathways for the hospitalised VFF population lack standardisation in Ireland. Key challenges reported by orthopaedic doctors and physiotherapists relate to pain management, osteoporosis medication prescription, clarity on indications for bracing and a lack of fracture liaison services. Clinical guidelines, defined clinical care pathways and high-quality clinical research trials are required for VFF management.