Advancements in osteoporotic spine fixation

Treatment Strategies in the Osteoporotic Spine

This article reviews the appropriate assessment and management of osteoporotic compression fractures and discusses the implications of osteoporosis on initial patient evaluation, medical optimization for surgery, selection of instrumentation, and surgical technique. Adverse outcomes associated with osteoporosis are discussed. Failure to appropriately evaluate, optimize, and treat spine patients with osteoporotic bone can lead to disastrous complications. Weakened bone can lead to implant failure through cage subsidence and screw pullout, as well as, peri-implant fractures, failure of deformity correction, and proximal kyphosis. These risks must be taken into account when considering operative interventions in these patients.

Pushing the Limits of Minimally Invasive Spine Surgery-From Preoperative to Intraoperative to Postoperative Management

The introduction of minimally invasive surgery ushered in a new era of spine surgery by minimizing the undue iatrogenic injury, recovery time, and blood loss, among other complications, of traditional open procedures. Over time, technological advancements have further refined the care of the operative minimally invasive spine patient. Moreover, pre-, and postoperative care have also undergone significant change by way of artificial intelligence risk stratification, advanced imaging for surgical planning and patient selection, postoperative recovery pathways, and digital health solutions. Despite these advancements, challenges persist necessitating ongoing research and collaboration to further optimize patient care in minimally invasive spine surgery.

Design of a new detachable pedicle screw based on medical optical imaging inspection to improve osteoporosis and enhance vertebral body revision effect

Osteoporosis is a common bone disease that often leads to difficulty in vertebrae revision. Traditional pedicle screws are often complicated to operate and have poor visibility during implantation. A new detachable pedicle screw is needed to improve the revision effect. The aim of this study was to design a new detachable pedicle screw based on medical optical imaging to improve the outcome of vertebral revision in osteoporosis, and to improve operational feasibility and visibility. In this study, the parameters related to the degree of osteoporosis were obtained by optical imaging detection of the osteoporotic vertebral body. Then a new detachable pedicle screw was designed according to the test results to improve the effect of vertebral body revision. By preparing and optimizing the material and structure of the screw, it is ensured that it has sufficient mechanical strength and stability. Finally, the visibility and operability of the improved screw during implantation were verified by medical optical imaging. Compared with traditional screws, the new detachable pedicle screw can improve the vertebral body revision in the case of osteoporosis. The optical imaging test results show that the new screw has good visibility and maneuverability, providing more accurate guidance and positioning for the vertebral body revision operation.

Posterolateral Instrumented Fusion in Elderly Patients With a Single Osteoporotic Vertebral Fracture: Evaluation of Health-Related Quality of Life

Introduction Treatment of osteoporotic vertebral fractures (OVFs) is a factor that affects the quality of life and should be considered during management. In patients with a single OVF and neurologic deficit, surgical procedures aiming at neural decompression with instrumented fusion should be considered in elderly individuals. Posterolateral instrumented fusion (PLF) constitutes a largely performed fusion surgery for patients featuring indications for fusion surgery. The aim of this study was to determine the safety, effectiveness, and impact on health-related quality of life (HRQoL) of PLF surgery in elderly patients diagnosed with a single OVF. Methods This study was conducted at Interbalkan European Medical Center, Thessaloniki, Greece. Eighty (80) consecutive individuals with OVFs were subjected to PLF and recruited in this prospectively designed non-randomized study. Clinical evaluation was performed preoperatively and postoperatively at particular chronic intervals at one, three, six, and 12 months and two years. The assessment was conducted via the standardized Visual Analogue Scale (VAS) and Short-Form 36 (SF-36) Medical Health Survey Questionnaire for pain and HRQoL, respectively. Results No major perioperative complications were observed. All parameters of SF-36 presented significant improvement over the entire follow-up period with VAS scores reaching a plateau at six months. Depicted improvement of these parameters proves the beneficial role of PLF in elderly patients who suffered from a single OVF with or without referable neurological deficit. Conclusion OVFs have a significant impact on the quality of life of elderly patients, and surgical treatment with PLF with or without decompression can lead to functional recovery, pain relief, and HRQoL amelioration. Our results demonstrated that the outcomes of PLF in the surgical treatment of these patients are remarkably favorable, demonstrating the safety and efficacy of the technique.

Increased stability due to symmetric cement volume in augmented pedicle screws? A biomechanical study

Pedicle screw instrumentation has become "state of the art" in surgical treatment of many spinal disorders. Loosening of pedicle screws due to poor bone mineral density is a frequent complication in osteoporotic patients. As prevalence of osteoporosis and spinal disorders are increasing with an aging demographic, optimizing the biomechanical properties of pedicle screw constructions and therefore outcome after spinal surgery in osteoporotic patients is a key factor in future surgical therapy. Therefore, this biomechanical study investigated the stability of polymethylmethacrylate (PMMA)-augmented pedicle screw-rod constructions under a deviating distribution of PMMA applied to the instrumentation in osteoporotic human cadaveric vertebrae. We showed that PMMA-augmented pedicle screw-rod constructions tend to be more stable than those with non-augmented pedicle screws. Further, there appears to be a larger risk of screw loosening in unilateral augmented pedicle screws than in non-augmented, therefore a highly asymmetrically distributed PMMA should be avoided.

The Use of Intraoperative CT Hounsfield Unit Values for the Assessment of Bone Quality in Patients Undergoing Lumbar Interbody Fusion

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVE

To evaluate the accuracy of intraoperatively measured computed tomography (CT) Hounsfield unit (HU) values by comparison with preoperative CT HU values and to compare the radiation exposure between preoperative and intraoperative CT scans.

METHODS

HU values of lumbar vertebrae were measured and compared between preoperative and intraoperative CT scans in patients undergoing lumbar interbody fusion. In patient group one, Canon CT scanners were used preoperatively and the AIRO CT scanner was used intraoperatively. In patient group two, Canon CT scanners were used preoperatively and the O-arm Cone Beam CT (CBCT) scanner was used intraoperatively. In a subgroup analysis of patient group one, radiation by means of CT Dose Index (CTDI) was compared between Canon and AIRO CT scanners.

RESULTS

In the first patient group, a total of 250 vertebrae were analysed in 74 patients showing a strong Pearson correlation of >.94 between pre- and intraoperative HU values. Bland-Altman analysis indicated consistency and equivalence with a bias of 3.9 and 95% limits of agreement from -27.17 to 34.97 when comparing all pre- and intraoperative HU values of L1-5. In the second patient group, a total of 27 vertebrae were analysed in 10 patients showing weak Pearson correlation and Bland-Altman analysis indicated no equivalence. CTDI did not differ between Canon and AIRO CT scanners.

CONCLUSION

Correct and reliable CT HU measurement as mandatory key factor for the intraoperative assessment of bone quality and robotic-assisted surgery is feasible with intraoperative AIRO CT imaging without increase of radiation exposure.

The Cortical Bone Trajectory Screw Technique Assisted by the Mazor Renaissance Robotic System as a Salvage Strategy for Failed Lumbar Spine Surgery: Technical Note and Case Series

Purpose

The objective of this study was to describe the Mazor Renaissance robotic system-assisted CBT (cortical bone trajectory) screw technique as a salvage strategy for failed lumbar spine surgery.

Patients and Methods

Between January 2018 and June 2022, 7 patients underwent salvage surgery with the CBT screw fixation technique assisted by the Mazor Renaissance robot system in our institution. Intraoperative observations were recorded for blood loss, duration of operation, and fluoroscopy time. Complications related to CBT screws were also recorded. The accuracy of CBT screws was recorded in accordance with the modified Gertzbein-Robbins classification. The JOA (Japanese Orthopedic Association) score for low back pain was used to evaluate surgical outcomes.

Results

A total of 26 CBT screws were placed in 7 patients, including 4 females and 3 males. Three patients underwent ASD (adjacent segment disease) and four patients underwent lumbar union failure with loose or compromised PSs (pedicle screws). The mean operation time was 129.29 ± 32.97 minutes, the mean blood loss was 180 ± 52.60 mL, and the mean intraoperative fluoroscopy time was 14.29 ± 3.15 s. All screws were clinically acceptable according to the Gertzbein-Robbins classification. There were no complications related to CBT screws in any of the cases. The JOA scores for low back pain of all patients were significantly improved at the final follow-up.

Conclusion

The CBT screw fixation technique supplemented the traditional PS fixation technique, which can be performed as a salvage strategy for failed lumbar spine surgery and achieved good clinical results. The spinal robot was very helpful in evaluating pedicle size and determining CBT screw direction, especially in a previously instrumented lumbar pedicle.

Cement-augmented pedicle screw for thoracolumbar degenerative diseases with osteoporosis: a systematic review and meta-analysis

BACKGROUND

Cement-augmentation pedicle screws have been widely used in spinal internal fixation surgery combined with osteoporosis in recent years, which can significantly improve the fixation strength, but compared with conventional methods, whether it has more advantages is still inconclusive of evidencebased medicine. To systematically evaluate the efficacy and safety of cement-augmented pedicle screw in the treatment of thoracolumbar degenerative diseases with osteoporosis.

METHODS

We searched PubMed, Embase, and Cochrane Library for studies published from the establishment of the database up until June 2023. We included studies that concerning the cement-augmented pedicle screw and the traditional pedicle screw placement for thoracolumbar degenerative diseases with osteoporosis. We excluded repeated publication, researches without full text, incomplete information or inability to conduct data extraction and animal experiments, case report, reviews and systematic reviews. STATA 15.1 software was used to analyze the data.

RESULTS

A total of 12 studies were included in this meta-analysis. The sample size of patients were totally 881, of which, 492 patients in cement-augmented screw group and 389 patients in conventional screw group. Meta-analysis results showed that Japanese Orthopaedic Association (JOA) score (WMD = 1.69, 95% CI 1.15 to 2.22), intervertebral space height (WMD = 1.66, 95% CI 1.03 to 2.29) and post-operation fusion rate (OR = 2.80, 95% CI 1.49 to 5.25) were higher in the cement-augmented screw group than those in the conventional screw group. Operation time was longer in the cement-augmented screw group than that in the conventional screw group (WMD = 15.47, 95% CI 1.25 to 29.70). Screw loosening rate was lower in the cement-augmented screw group than those in the conventional screw group (OR = 0.13, 95% CI 0.07 to 0.22). However, hospitalization time, intraoperative blood loss and Visual analog scale (VAS) score were not significantly different between the two groups (P > 0.05).

CONCLUSION

Compared with conventional pedicle screw placement, cement-augmented pedicle screw is more effective in the treatment of osteoporotic thoracolumbar degenerative disease by improving fusion rate and interbody height, reducing the incidence of screw loosening, and elevating long-term efficacy.

Screw Osteointegration-Increasing Biomechanical Resistance to Pull-Out Effect

Spinal disorders cover a broad spectrum of pathologies and are among the most prevalent medical conditions. The management of these health issues was noted to be increasingly based on surgical interventions. Spinal fixation devices are often employed to improve surgery outcomes, increasing spinal stability, restoring structural integrity, and ensuring functionality. However, most of the currently used fixation tools are fabricated from materials with very different mechanical properties to native bone that are prone to pull-out effects or fail over time, requiring revision procedures. Solutions to these problems presently exploited in practice include the optimal selection of screw shape and size, modification of insertion trajectory, and utilization of bone cement to reinforce fixation constructs. Nevertheless, none of these methods are without risks and limitations. An alternative option to increasing biomechanical resistance to the pull-out effect is to tackle bone regenerative capacity and focus on screw osteointegration properties. Osteointegration was reportedly enhanced through various optimization strategies, including use of novel materials, surface modification techniques (e.g., application of coatings and topological optimization), and utilization of composites that allow synergistic effects between constituents. In this context, this paper takes a comprehensive path, starting with a brief presentation of spinal fixation devices, moving further to observations on how the pull-out strength can be enhanced with existing methods, and further focusing on techniques for implant osteointegration improvement.

New Research Progress of Modified Bone Cement Applied to Vertebroplasty

Percutaneous vertebroplasty and percutaneous kyphoplasty are effective methods to treat acute osteoporotic vertebral compression fractures that can quickly provide patients with pain relief, prevent further height loss of the vertebral body, and help correct kyphosis. Many clinical studies have investigated the characteristics of bone cement. Bone cement is a biomaterial injected into the vertebral body that must have good biocompatibility and biosafety. The optimization of the characteristics of bone cement has become of great interest. Bone cement can be mainly divided into 3 types: polymethyl methacrylate, calcium phosphate cement, and calcium sulfate cement. Each type of cement has its own advantages and disadvantages. In the past 10 years, the performance of bone cement has been greatly improved via different methods. The aim of our review is to provide an overview of the current progress in the types of modified bone cement and summarize the key clinical findings.

Geriatric spine fractures - Demography, changing trends, challenges and special considerations: A narrative review

The aim of this manuscript was to summarize the demography and changing trends of geriatric spinal injuries and to enumerate the challenges and special considerations in the care of geriatric spinal injuries. PubMed, Scopus and Embase databases were searched for literature on geriatric spine fractures using MeSH terms 'aged', 'aged, 80 and over', 'elderly', 'spinal fracture/epidemiology', spinal fracture/therapy∗' and keywords pertaining to the same. The search results were screened for appropriate articles and reviewed. There is a high community prevalence of elderly vertebral fractures ranging from 18% to as high as 51%. The proportion of older patients among the spinal injured is rising as well. There is a higher chance of missing spinal injuries in the elderly and clinical guidelines may not be applicable to this patient group. Classification and surgical treatment are different from younger adult counterparts as the elderly osteoporotic spine behaves differently biomechanically. There is a high incidence of respiratory complications both for surgically and conservatively managed groups. Older age generally is associated with a higher complication rate including mortality.

Craniocaudal toggling increases the risk of screw loosening in osteoporotic vertebrae

BACKGROUND AND OBJECTIVE

Screw loosening remains a prominent problem for osteoporotic patients undergoing pedicle screw fixation surgeries but its underlying mechanisms are not fully understood. This study sought to examine the interactive effect of craniocaudal or axial cyclic loading (toggling) and osteoporosis on screw fixation.

METHODS

QCT-based finite element models of normal (n = 7; vBMD = 156 ± 13 mg/cm³) and osteoporotic vertebrae (n = 7; vBMD = 72 ± 6 mg/cm³) were inserted with pedicle screws and loaded with or without craniocaudal toggling. Among them, a representative normal vertebra (age: 55; BMD: 140 mg/cm³) and an osteoporotic vertebra (age: 64; BMD: 79 mg/cm³) were also loaded with or without axial toggling. The individual and interactive effects of craniocaudal toggling and osteoporosis on screw fixation strength (the force when the pull-up displacement of the screw head reached 1 mm) and bone tissue failure (characterized by equivalent plastic strain) were examined by repeated measure ANOVA.

RESULTS

A significant interactive effect between craniocaudal toggling and osteoporosis on screw fixation strength was detected (p = 0.008). Specifically, craniocaudal toggling led to a marked decrease in the fixation strength (68%, p < 0.05) and stiffness (83%, p < 0.05) only in the osteoporotic vertebrae but had no effect on screw fixation strength and stiffness of the normal vertebrae (p > 0.05). Likewise, most of the bone tissues around the screw in the osteoporotic vertebrae yielded following craniocaudal toggling whereas this result was not seen in the normal vertebrae. The axial toggling had no significant effect on bone tissue failure as well as pedicle screw fixation in normal or osteoporotic vertebrae.

CONCLUSIONS

Craniocaudal toggling substantially reduces the screw fixation strength of the osteoporotic vertebrae by progressively increasing tissue failure around the screw, and therefore may contribute to the higher rates of screw loosening in osteoporotic compared to normal patients, whereas axial toggling is not a risk factor for pedicle screw loosening in normal or osteoporotic patients.

USE OF THE uCentrum SYSTEM IN THE SURGICAL TREATMENT OF DISEASES OF THE VERTEBRAL SPINE

ABSTRACT Objectives: Evaluate the treatment outcome and the performance of the uCentum spinal fixation system in treating traumatic, degenerative, and tumoral diseases of the spine. Methods: This is a therapeutic study to investigate treatment outcomes and level of evidence III, including twenty-three adult patients of both sexes undergoing surgical treatment of degenerative (13 patients), traumatic (04 patients), or tumor diseases (06 patients). Patients were prospectively evaluated using clinical parameters: pain (visual analog scale), clinical and functional assessment questionnaires (SF-36, Oswestry and Roland-Morris), and radiological criteria (arthrodesis consolidation, loosening, breakage or deformation of the implants). Results: Twenty patients were followed for a period of 01 month to 12 month (mean 6,5±7,77). Three patients died due to complications unrelated to the primary disease (traumatic brain injury, septicemia, and lung tumor). Improvements were observed in clinical parameters and scores of the evaluation questionnaires used. No implant-related complications (breakage, loosening, deformation) were observed. Conclusion: the uCentum fixation system showed great versatility for performing the surgical treatment, allowing the performance of open, percutaneous procedures, the introduction of acrylic cement inside the implants, and conversion of polyaxial screws into monoaxial screws intraoperatively. Level of Evidence III; Therapeutic Studies - Investigating the Results of Treatment.

Management of Osteoporotic Vertebral Fracture: Review Update 2022

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.

Hounsfield unit for assessing asymmetrical loss of vertebral bone mineral density and its correlation with curve severity in adolescent idiopathic scoliosis

Background

Low bone mass concomitantly occurs in patients with adolescent idiopathic scoliosis (AIS) and can persist until skeletal maturity. The purpose of this study was to assess the asymmetrical loss of vertebral bone mineral density (vBMD) and its correlation with curve severity in patients with AIS using Hounsfield unit (HU) values measured from computed tomography scans.

Methods

A total of 93 AIS patients were retrospectively recruited. The HU values of the vertebral body (VB-HU) and pedicle screw trajectory (PST-HU) were measured from four vertebrae above (Apex − 4) to four below (Apex + 4) the apical vertebra (Apex) of the major curve. The VB-HU and PST-HU at the upper end vertebra, Apex, and lower end vertebra within the concave and convex sides of the major and minor curves and stable vertebrae were obtained.

Results

A significant correlation was found between the Cobb angle and VB-HU at the periapical levels of the major curve. VB-HU and PST-HU at periapical levels were significantly greater within the concavity than the convexity of both major and minor curves. The asymmetric ratios of VB-HU and PST-HU were significantly correlated with the major curve Cobb angle, peaked at the apex, and gradually diminished from the apex to the end vertebrae. The asymmetrical loss of vBMD aggravated with the progression of curve severity, presenting as VB-HU, significantly decreased within the convexity and insignificantly decreased within the concavity of the major curve.

Conclusion

The asymmetrical loss of vBMD was associated with the progression of curve severity in AIS. For patients with severe AIS, the distraction of the pedicle screws at the concave side should be a priority in correcting the major curve, and supplemental anchors and larger-sized screws should be placed within the convex side around the apex of the major curve to reduce the risk of screw loosening after surgery.

Prevention of Compression Fracture in Osteoporosis Patients under Minimally Invasive Trans-Foraminal Lumbar Interbody Fusion with Assistance of Bone-Mounted Robotic System in Two-Level Degenerative Lumbar Disease

Background and Objectives: Minimally invasive spine surgery reduces destruction of the paraspinal musculature and improves spinal stability. Nevertheless, screw loosening remains a challenging issue in osteoporosis patients receiving spinal fixation and fusion surgery. Moreover, adjacent vertebral compression fracture is a major complication, particularly in patients with osteoporosis. We assessed long-term imaging results to investigate the outcomes of osteoporosis patients with two-level degenerative spine disease receiving minimally invasive surgery with the assistance of a robotic system. Materials and Methods: We retrospectively analyzed consecutive osteoporosis patients who underwent minimally invasive surgery with the assistance of a robotic system at our institution during 2013–2016. All patients were diagnosed with osteoporosis according to the World Health Organization criteria. All patients were diagnosed with two levels of spinal degenerative disease, including L34, L45, or L5S1. The study endpoints included screw-loosening condition, cage fusion, and vertebral body heights of the adjacent, first fixation segment, and second fixation segments before and after surgery, including the anterior, middle, and posterior third parts of the vertebral body. Differences in vertebral body heights before and after surgery were evaluated using the F-test. Results: Nineteen consecutive osteoporosis patients were analyzed. A lower rate of screw loosening was observed in osteoporosis patients in our study. There were no significant differences between the preoperative and postoperative vertebral body heights, including adjacent and fixation segments. Conclusions: According to our retrospective study, we report that minimally invasive surgery with the assistance of a robotic system provided better screw fixation, a lower rate of screw loosening, and a lesser extent of vertebral compression fracture after spinal fixation and fusion surgery in osteoporosis patients.

Case Report: Spinal Stabilization Surgery Using a Novel Custom-Made Titanium Fixation System for the Spinal Instability Caused by Vertebral Malformation in a Dog

A 2-year-old Maltese was presented with wobbly gait of the pelvic limbs. Based on imaging examinations, a diagnosis of congenital malformation at T5–T8 and severe kyphosis causing spinal cord compression at T6–T7 was made. Dorsal laminectomy and stabilization of T6 and T7 vertebrae were performed. As the size of the vertebrae was small and they were severely deformed, novel custom-made titanium implants were used for spinal stabilization. Clinical signs were resolved 2 weeks after surgery. Although radiographic examination 373 days after surgery showed slight loosening of implants, post-operative course remained uneventful. This report describes the use of novel custom-made titanium implants for spinal fixation surgery in a dog.

Safety and efficacy of cement augmentation with fenestrated pedicle screws for tumor-related spinal instability

OBJECTIVE

Achieving rigid spinal fixation can be challenging in patients with cancer-related instability, as factors such as osteopenia, radiation, and immunosuppression adversely affect bone quality. Augmenting pedicle screws with cement is a strategy to overcome construct failure. This study aimed to assess the safety and efficacy of cement augmentation with fenestrated pedicle screws in patients undergoing posterior, open thoracolumbar surgery for spinal metastases.

METHODS

A retrospective review was performed for patients who underwent surgery for cancer-related spine instability from 2016 to 2019 at the Massachusetts General Hospital. Patient demographics, surgical details, radiographic characteristics, patterns of cement extravasation, complications, and prospectively collected Patient-Reported Outcomes Measurement Information System Pain Interference and Pain Intensity scores were analyzed using descriptive statistics. Logistic regression was performed to determine factors associated with cement extravasation.

RESULTS

Sixty-nine patients underwent open posterior surgery with a total of 502 cement-augmented screws (mean 7.8 screws per construct). The median follow-up period for those who survived past 90 days was 25.3 months (IQR 10.8-34.6 months). Thirteen patients (18.8%) either died within 90 days or were lost to follow-up. Postoperative CT was performed to assess the instrumentation and patterns of cement extravasation. There was no screw loosening, pullout, or failure. The rate of cement extravasation was 28.9% (145/502), most commonly through the segmental veins (77/145, 53.1%). Screws breaching the lateral border of the pedicle but with fenestrations within the vertebral body were associated with a higher risk of leakage through the segmental veins compared with screws without any breach (OR 8.77, 95% CI 2.84-29.79; p < 0.001). Cement extravasation did not cause symptoms except in 1 patient who developed a symptomatic thoracic radiculopathy requiring decompression. There was 1 case of asymptomatic pulmonary cement embolism. Patients experienced significant pain improvement at the 3-month follow-up, with decreases in Pain Interference (mean change 15.8, 95% CI 14.5-17.1; p < 0.001) and Pain Intensity (mean change 28.5, 95% CI 26.7-30.4; p < 0.001).

CONCLUSIONS

Cement augmentation through fenestrated pedicle screws is a safe and effective option for spine stabilization in the cancer population. The risk of clinically significant adverse events from cement extravasation is very low.

Current Concepts in the Management of Osteoporotic Vertebral Fractures: A Narrative Review

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.