Osteoporotic compression fractures of the spine; current options and considerations for treatment

Conservative Treatments in the Management of Acute Painful Vertebral Compression Fractures: A Systematic Review and Network Meta-Analysis

Importance

Osteoporotic vertebral compression fractures (VCFs) frequently cause substantial pain and reduced mobility, posing a major health problem. Despite the critical need for effective pain management to restore functionality and improve patient outcomes, the value of various conservative treatments for acute VCF has not been systematically investigated.

Objective

To assess and compare different conservative treatment options in managing acute pain related to VCF.

Data Sources

On May 16, 2023, 4 databases-PubMed, Embase, Scopus, and CINAHL-were searched. In addition, a gray literature search within Scopus and Embase was also conducted.

Study Selection

Included studies were prospective comparative and randomized clinical trials that assessed conservative treatments for acute VCF.

Data Extraction and Synthesis

Data extraction and synthesis were performed by 2 authors according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Network Meta-Analyses recommendations. A frequentist graph-theoretical model and a random-effects model were applied for the meta-analysis.

Main Outcomes and Measures

Primary outcomes were short-term (4 weeks) pain during activity and long-term (latest available follow-up) nonspecified pain in patients with acute VCF.

Results

The study included 20 trials, encompassing 2102 patients, and evaluated various interventions for managing VCF. Calcitonin (standardized mean difference [SMD], -4.86; 95% CI, -6.87 to -2.86) and nonsteroidal anti-inflammatory drugs (NSAIDs; SMD, -3.94; 95% CI, -7.30 to -0.58) were beneficial regarding short-term pain during activity compared with placebo. For long-term nonspecific pain management, bisphosphonates were associated with inferior pain outcomes compared with daily (SMD, 1.21; 95% CI, 0.11 to 2.31) or weekly (SMD, 1.13; 95% CI, 0.05 to 2.21) administration of teriparatide, with no treatment being superior to NSAIDs. The qualitative analysis of adverse events highlighted that typical adverse events associated with these medications were observed.

Conclusions and Relevance

NSAIDs and teriparatide may be the preferred treatment options for pain management in acute osteoporotic VCF. Although calcitonin also proved to be beneficial, its safety profile and potential adverse effects restrict its widespread application. The limited evidence on braces and analgesics underscores the urgent need for future research.

Prognostic Factors Associated with Poor Treatment Outcomes After Balloon Kyphoplasty in Elderly Patients Aged ≥81 years

OBJECTIVE

Balloon kyphoplasty (BKP) is an effective procedure for osteoporotic vertebral compression fractures; however, there is limited data regarding its outcomes in patients aged ≥81 years. This study investigated the treatment outcomes and prognostic factors for BKP in this age group.

METHODS

A retrospective analysis was conducted on 115 patients with osteoporotic vertebral compression fracture undergoing single-level BKP after failed conservative treatment, classified into the <81 years (n=70) and ≥81 years (n=45) groups. Surgical results were evaluated as good outcomes (independent indoors 1 year postoperatively) and poor outcomes, followed by univariate and multivariate analyses to determine prognostic factors correlating with these outcomes.

RESULTS AND CONCLUSION

The majority of patients (<81 years: 85.7%; ≥81 years: 73.3%) had a good degree of independence at 1 year postoperatively, which was comparable in both groups. Further analysis of patients aged ≥81 years showed that longer duration from onset to surgery, more subsequent vertebral fractures, and lower preoperative body mass index were correlated with poorer outcomes postoperatively, and low body mass index, time from onset to surgery, and female sex were independent risk factors for these outcomes (area under the receiver operating characteristics curve: 0.91).

Magnesium malate-modified calcium phosphate bone cement promotes the repair of vertebral bone defects in minipigs via regulating CGRP

Active artificial bone substitutes are crucial in bone repair and reconstruction. Calcium phosphate bone cement (CPC) is known for its biocompatibility, degradability, and ability to fill various shaped bone defects. However, its low osteoinductive capacity limits bone regeneration applications. Effectively integrating osteoinductive magnesium ions with CPC remains a challenge. Herein, we developed magnesium malate-modified CPC (MCPC). Incorporating 5% magnesium malate significantly enhances the compressive strength of CPC to (6.18 ± 0.49) MPa, reduces setting time and improves disintegration resistance. In vitro, MCPC steadily releases magnesium ions, promoting the proliferation of MC3T3-E1 cells without causing significant apoptosis, proving its biocompatibility. Molecularly, magnesium malate prompts macrophages to release prostaglandin E2 (PGE2) and synergistically stimulates dorsal root ganglion (DRG) neurons to synthesize and release calcitonin gene-related peptide (CGRP). The CGRP released by DRG neurons enhances the expression of the key osteogenic transcription factor Runt-related transcription factor-2 (RUNX2) in MC3T3-E1 cells, promoting osteogenesis. In vivo experiments using minipig vertebral bone defect model showed MCPC significantly increases the bone volume fraction, bone density, new bone formation, and proportion of mature bone in the defect area compared to CPC. Additionally, MCPC group exhibited significantly higher levels of osteogenesis and angiogenesis markers compared to CPC group, with no inflammation or necrosis observed in the hearts, livers, or kidneys, indicating its good biocompatibility. In conclusion, MCPC participates in the repair of bone defects in the complex post-fracture microenvironment through interactions among macrophages, DRG neurons, and osteoblasts. This demonstrates its significant potential for clinical application in bone defect repair.

Augmented Central Pain Processing Occurs after Osteoporotic Vertebral Compression Fractures and Is Associated with Residual Back Pain after Percutaneous Vertebroplasty

STUDY DESIGN

A retrospective analysis.

PURPOSE

To investigate the occurrence of central sensitization (CS) in patients with osteoporotic vertebral compression fractures (OVCFs) and identify the association between CS and residual back pain (RBP).

OVERVIEW OF LITERATURE

RBP is a vexing complication that affects 6.3%-17.0% of patients with OVCFs who underwent percutaneous vertebroplasty (PVP). Given the negative effect of RBP on patients' psychological and physiological statuses, efforts to preoperatively select patients who are at risk for RBP development have a high priority to offer additional treatment and minimize this complication.

METHODS

Preoperatively, all 160 patients with OVCFs underwent pressure-pain threshold (PPT), temporal summation (TS), conditioned pain modulation (CPM), and imaging assessments. Pain intensity and pain-related disability were evaluated before and after PVP.

RESULTS

Preoperatively, patients with OVCFs had lower PPTs in both local pain and pain-free areas and lower CPM and higher TS in pain-free areas than healthy participants (p<0.05). Unlike patients with acute fractures, patients with subacute/chronic OVCFs showed higher TS with or without lower CPM in the pain-free area compared with healthy participants (p<0.05). Postoperatively, RBP occurred in 17 of 160 patients (10.6%). All preoperative covariates with significant differences between the RBP and non-RBP groups were subjected to multivariate logistic regression, showing that intravertebral vacuum cleft, posterior fascia edema, numeric rating pain scale scores for low back pain at rest, and TS were independently associated with RBP (p<0.05).

CONCLUSIONS

Augmented central pain processing may occur in patients with OVCFs, even in the subacute stage, and this preexisting CS may be associated with RBP. Preoperative assessment of TS in pain-free areas may provide additional information for identifying patients who may be at risk of RBP development, which may be beneficial for preventing this complication.

An Automated Vertebrae Localization, Segmentation, and Osteoporotic Compression Fracture Detection Pipeline for Computed Tomographic Imaging

Osteoporosis is the most common chronic metabolic bone disease worldwide. Vertebral compression fracture (VCF) is the most common type of osteoporotic fracture. Approximately 700,000 osteoporotic VCFs are diagnosed annually in the USA alone, resulting in an annual economic burden of ~$13.8B. With an aging population, the rate of osteoporotic VCFs and their associated burdens are expected to rise. Those burdens include pain, functional impairment, and increased medical expenditure. Therefore, it is of utmost importance to develop an analytical tool to aid in the identification of VCFs. Computed Tomography (CT) imaging is commonly used to detect occult injuries. Unlike the existing VCF detection approaches based on CT, the standard clinical criteria for determining VCF relies on the shape of vertebrae, such as loss of vertebral body height. We developed a novel automated vertebrae localization, segmentation, and osteoporotic VCF detection pipeline for CT scans using state-of-the-art deep learning models to bridge this gap. To do so, we employed a publicly available dataset of spine CT scans with 325 scans annotated for segmentation, 126 of which also graded for VCF (81 with VCFs and 45 without VCFs). Our approach attained 96% sensitivity and 81% specificity in detecting VCF at the vertebral-level, and 100% accuracy at the subject-level, outperforming deep learning counterparts tested for VCF detection without segmentation. Crucially, we showed that adding predicted vertebrae segments as inputs significantly improved VCF detection at both vertebral and subject levels by up to 14% Sensitivity and 20% Specificity (p-value = 0.028).

Vertebral fracture severity assessment on anteroposterior radiographs with a new semi-quantitative technique

We developed a new tool to assess the severity of osteoporotic vertebral fracture using radiographs of the spine. Our technique can be used in patient care by helping to stratify patients with osteoporotic vertebral fractures into appropriate treatment pathways. It can also be used for research purposes.

PURPOSE

The aim of our study was to propose a semi-quantitative (SQ) grading scheme for osteoporotic vertebral fracture (OVF) on anteroposterior (AP) radiographs.

METHODS

On AP radiographs, the vertebrae are divided into right and left halves, which are graded (A) vertical rectangle, (B) square, (C) traverse rectangle, and (D) trapezoid; whole vertebrae are graded (E) transverse band or (F) bow-tie. Type A and B were compared with normal and Genant SQ grade 1 OVF, Type C and D with grade 2 OVF, and Type E and F with grade 3 OVF. Spine AP radiographs and lateral radiographs of 50 females were assessed by AP radiographs SQ grading. After training, an experienced board-certified radiologist and a radiology trainee assessed the 50 AP radiographs.

RESULTS

The height-to-width ratio of the half vertebrae varied 1.32-1.48. On lateral radiographs, 84 vertebrae of the 50 patients had OVFs (38 grade 1, 24 grade 2, and 22 grade 3). On AP radiographs, the radiologist correctly assigned 84.2%, 91.7%, and 77.2% and the trainee correctly assigned 68.4%, 79.2%, and 81.8% of grade 1, 2, and 3 OVFs, respectively. Compared with lateral radiographs, the radiologist had a weighted Kappa of 0.944 including normal vertebrae and 0.883 not including normal vertebrae, while the corresponding Kappa values for the trainee were 0.891 and 0.830, respectively.

CONCLUSION

We propose a new semi-quantitative grading system for vertebral fracture severity assessment on AP spine radiographs.

Management of the Geriatric Trauma Patient

With a rapidly aging worldwide population, the care of geriatric trauma patients will be at the forefront of every career in Trauma and Acute Care Surgery. The unique intersection of advanced age, comorbidities, frailty, and physiologic changes presents a challenge in the care of elderly injured patients. It is well established that increasing age is associated with higher mortality and worse outcomes after injury, but it is also clear that there is room for improvement in the management of this special patient population.

Assessment of Cement Leakage in Decompressed Percutaneous Kyphoplasty

Symptomatic osteoporotic compression fractures are commonly addressed through vertebroplasty and kyphoplasty. However, cement leakage poses a significant risk of neurological damage. We introduced "aspiration percutaneous kyphoplasty", also known as "decompressed kyphoplasty", as a method to mitigate cement leakage and conducted a comparative analysis with high viscosity cement vertebroplasty. We conducted a retrospective study that included 136 patients with single-level osteoporotic compression fractures. Among them, 70 patients underwent high viscosity cement vertebroplasty, while 66 patients received decompressed percutaneous kyphoplasty with low-viscosity cement. Comparison parameters included cement leakage rates, kyphotic angle alterations, and the occurrence of adjacent segment fractures. The overall cement leakage rate favored the decompressed kyphoplasty group (9.1% vs. 18.6%), although statistical significance was not achieved (p = 0.111). Nonetheless, the risk of intradiscal leakage significantly reduced in the decompressed kyphoplasty cohort (p = 0.011), which was particularly evident in cases lacking the preoperative cleft sign on X-rays. Kyphotic angle changes and the risk of adjacent segment collapse exhibited similar outcomes (p = 0.739 and 0.522, respectively). We concluded that decompressed kyphoplasty demonstrates efficacy in reducing intradiscal cement leakage, particularly benefiting patients without the preoperative cleft sign on X-rays by preventing intradiscal leakage.

Comparison between percutaneous short-segment fixation and percutaneous vertebroplasty in treating Kummell's disease: A minimum 2-year follow-up retrospective study

BACKGROUND

Percutaneous kyphoplasty (PKP) or percutaneous short-segment fixation (PSSF) is often used to treat Kummell's disease. However, it is not clear which treatment is better for patients.

OBJECTIVE

To retrospectively compare the clinical efficacy of PVP and PSSF for the treatment of Kummell's disease.

METHOD

60 patients were involved in this research and the period of follow-up was at least 2 years. 27 of them were treated with PVP (Group I) and the rest who received PSSF (Group II). The visual analog scale (VAS) and radiographic indexes of each participant had been measured preoperatively as well as 1 week, 3 months, and 2 years postoperatively. Additionally, the Oswestry Disability Index (ODI) scores were assessed at the last time point.

RESULTS

Comparing the two groups, no statistical significance was found among all parameters preoperatively. The time of operations and blood loss is less in Group I. At each time point after operation, the imaging indices in Group II are lower (P< 0.05). One week after treatments, the VAS scores are lower in Group I, and similarly, 3 months are the same (P< 0.05), while VAS are similar at the last time point. In the aspect of ODI scores, they are lower in Group II during long-term follow-up.

CONCLUSION

For the treatment of Kummell's disease, both PVP and PSSF have been found to be effective. PVP can provide rapid pain relief with a shorter operation time. However, in cases with severe kyphosis deformity, PSSF should be given priority.

Comparison between unilateral and bilateral percutaneous kyphoplasty in the treatment of osteoporotic vertebral compression fracture: A meta‑analysis and systematic review

The present study collected retrospective research data and compared the safety and efficacy of unilateral and bilateral percutaneous puncture kyphoplasty for the treatment of vertebral fractures caused by osteoporosis, to guide the selection of clinical surgical methods. In the present meta-analysis, PubMed, Embase and the Cochrane Library were searched from the establishment of the databases to March 2023. Studies that reported differences in the efficacy and safety between the unilateral and bilateral approaches in the treatment of osteoporotic vertebral compression fractures were included in the analysis. Duplicate published studies, unpublished studies, studies with incomplete data, animal experiments, literature reviews and systematic studies were excluded from the analysis. All data were processed using STATA 15.1 statistical software. The pooled results demonstrated that there were no significant differences between the unilateral and bilateral approaches in the visual analog scores, Oswestry disability index, height restoration rate or incidence of cement leakage. However, the post-kyphotic angle of the unilateral approach was significantly lower than that of the bilateral approach (standardized mean difference, -0.41; 95% confidence interval, -0.68 to -0.14; P=0.003). Furthermore, the pooled results demonstrated that the unilateral approach required less operative time and a lower volume of injected cement, which is safer for elderly patients who are more likely to have underlying diseases.

Comparative Efficacy of Surgical Interventions for Osteoporotic Vertebral Compression Fractures: A Systematic Review and Network Meta-analysis

OBJECTIVE

We aimed to comprehensively compare surgical methods for osteoporotic vertebral compression fracture (OVCF) using systematic review and network meta-analysis to understand their effectiveness and outcomes, as current research provides limited overviews.

METHODS

We followed PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines, preregistering our protocol with PROSPERO. We analyzed Englishpublished randomized controlled trials (RCTs) on adults with OVCFs that evaluated pain intensity or functionality using tools like visual analogue scale (VAS) or Oswestry Disability Index (ODI). Exclusions included non-RCTs, malignancy-related fractures, and certain interventions. Using the RoB 2 tool, we assessed bias and visualized results with Robvis. Our primary outcome was pain intensity, with secondary outcomes including disability, new fractures, and cement leakage. Results were synthesized using Stata/MP.

RESULTS

Thirty-four RCTs from 10 countries, totaling 4,384 patients, were analyzed. Shortterm VAS indicated kyphoplasty with facet joint injection (KIJ) as the top treatment at 87.7%, while unipedicular kyphoplasty (UKP) led to long-term at 74.9%. Short-term ODI favored vertebroplasty with facet joint injection (VIJ) at 98.4%, with kyphoplasty (KP) leading longterm at 66.0%. All surgical techniques were superior to conservative treatment. Vertebral augmentation devices reported the fewest new fractures and curved vertebroplasty had the least cement leakage. SUCRA (surface under the cumulative ranking) analyses suggested UKP and VIJ as top choices for postoperative pain relief, with VIJ excelling in postoperative disability improvement.

CONCLUSION

Our analysis evaluates 12 OVCF interventions, underscoring KIJ for short-term pain relief and VIJ and UKP for long-term efficacy. Notably, VIJ stands out in disability outcomes, emphasizing the need for comprehensive OVCF management.

Pain Management in Osteoporosis

The most prevalent metabolic bone disease, osteoporosis, is characterized by a decrease in bone mineral density and alterations to the bone's microstructure, both of which can result in fragility fractures. It affects a significant section of the population. Acute or chronic pain from these fractures is typical in elderly adults with other coexisting conditions. Since the antiresorptive medication only partially reduces pain, other analgesics are required for effective pain management. NSAIDs or selective COX-2 inhibitors can reduce acute pain, but persistent neuropathic pain is difficult to manage with these drugs. Opioids have their adverse effects and safety concerns, although they can be used to address acute or chronic pain. Hence, a multifaceted approach is to be implemented, including pharmacological and nonpharmacological therapy and surgical treatment in a selected number of cases. This chapter briefly describes the etiology of pain, its mechanism, and pain management in osteoporotic patients.

Machine-learning-based approach for nonunion prediction following osteoporotic vertebral fractures

PURPOSE

An osteoporotic vertebral fracture (OVF) is a common disease that causes disabilities in elderly patients. In particular, patients with nonunion following an OVF often experience severe back pain and require surgical intervention. However, nonunion diagnosis generally takes more than six months. Although several studies have advocated the use of magnetic resonance imaging (MRI) observations as predictive factors, they exhibit insufficient accuracy. The purpose of this study was to create a predictive model for OVF nonunion using machine learning (ML).

METHODS

We used datasets from two prospective cohort studies for OVF nonunion prediction based on conservative treatment. Among 573 patients with acute OVFs exceeding 65 years in age enrolled in this study, 505 were analyzed. The demographic data, fracture type, and MRI observations of both studies were analyzed using ML. The ML architecture utilized in this study included a logistic regression model, decision tree, extreme gradient boosting (XGBoost), and random forest (RF). The datasets were processed using Python.

RESULTS

The two ML algorithms, XGBoost and RF, exhibited higher area under the receiver operating characteristic curves (AUCs) than the logistic regression and decision tree models (AUC = 0.860 and 0.845 for RF and XGBoost, respectively). The present study found that MRI findings, anterior height ratio, kyphotic angle, BMI, VAS, age, posterior wall injury, fracture level, and smoking habit ranked as important features in the ML algorithms.

CONCLUSION

ML-based algorithms might be more effective than conventional methods for nonunion prediction following OVFs.

A Comparison of Outcomes between the Wiltse Approach with Pedicle Screw Fixation and the Percutaneous Pedicle Screw Fixation for Multi-Segmental Thoracolumbar Fractures

OBJECTIVE

Multi-segmental thoracolumbar fracture (MSF) generally refers to fractures occurring in two or more segments of the thoracolumbar spine. With the development of minimally invasive concept, there is little research on its application in the field of MSF. The purpose of this study is to compare two minimally invasive surgical techniques and determine which one is more suitable for treating patients with neurologically intact MSF.

METHODS

We retrospectively analyzed the clinical data of 49 MSF patients with intact nerves who were admitted from January 2017 to February 2019. Among them, 25 cases underwent percutaneous pedicle screw fixation (PPSF), and 24 cases underwent Wiltse approach pedicle screw fixation (WAPSF). The operation time, number of fixed segments, blood loss, length of incision, postoperative ambulation time, accuracy of pedicle screw placement, facet joint violation (FJV), number of C-arm exposures, as well as pre- and postoperative visual analogue scale (VAS), Oswestry disability index (ODI), local Cobb's angle (LCA), and percentage of anterior vertebral body height (PAVBH) were recorded for both groups. Paired sample t-test was used for intra-group comparison before and after surgery while independent sample t-test was used for inter-group comparison.

RESULTS

The differences in the number of fixed segments, intraoperative bleeding, postoperative bed time, accuracy rate of pedicle screw placement, VAS, and ODI between the two groups were not statistically significant (p > 0.05). However, the operative time and total surgical incision length were significantly shorter in the WAPSF group than in the PPSF group (p < 0.05), and the FJV was significantly higher in the PPSF group than in the WAPSF group (p < 0.05). Also, the PPSF group received more intraoperative fluoroscopy (p < 0.05). The result of LCA and PAVBH in the WAPSF group were significantly better than in the PPSF group (p < 0.05).

CONCLUSIONS

Both PPSF and WAPSF were found to be safe and effective in the treatment of MSF without neurological deficits through our study. However, considering radiation exposure, FJV, vertebral height restoration, correction of kyphosis, and learning curve, WAPSF may be a better choice for neurologically intact MSF.

Opportunistic CT Screening-Machine Learning Algorithm Identifies Majority of Vertebral Compression Fractures: A Cohort Study

Vertebral compression fractures (VCF) are common in patients older than 50 years but are often undiagnosed. Zebra Medical Imaging developed a VCF detection algorithm, with machine learning, to detect VCFs from CT images of the chest and/or abdomen/pelvis. In this study, we evaluated the diagnostic performance of the algorithm in identifying VCF. We conducted a blinded validation study to estimate the operating characteristics of the algorithm in identifying VCFs using previously completed CT scans from 1200 women and men aged 50 years and older at a tertiary-care center. Each scan was independently evaluated by two of three neuroradiologists to identify and grade VCF. Disagreements were resolved by a senior neuroradiologist. The algorithm evaluated the CT scans in a separate workstream. The VCF algorithm was not able to evaluate CT scans for 113 participants. Of the remaining 1087 study participants, 588 (54%) were women. Median age was 73 years (range 51-102 years; interquartile range 66-81). For the 1087 algorithm-evaluated participants, the sensitivity and specificity of the VCF algorithm in diagnosing any VCF were 0.66 (95% confidence interval [CI] 0.59-0.72) and 0.90 (95% CI 0.88-0.92), respectively, and for diagnosing moderate/severe VCF were 0.78 (95% CI 0.70-0.85) and 0.87 (95% CI 0.85-0.89), respectively. Implementing this VCF algorithm within radiology systems may help to identify patients at increased fracture risk and could support the diagnosis of osteoporosis and facilitate appropriate therapy. © 2023 Amgen, Inc. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Comparison of unilateral and bilateral percutaneous kyphoplasty for the treatment of osteoporotic vertebral compression fractures associated with scoliosis

To assess the clinical and radiographic effectiveness of unilateral and bilateral percutaneous kyphoplasty (PKP) in the treatment of osteoporotic vertebral compression fractures (OVCF) associated with scoliosis, 52 patients with OVCF associated with scoliosis who underwent PKP were retrospectively analysed. The patients were divided into the unilateral PKP group (n=26) and the bilateral PKP group (n=26). The operation time, bone cement injection volume and frequency of intraoperative fluoroscopy were recorded and compared between the groups. Additionally, visual analogue scale (VAS) and Oswestry disability index (ODI) scores, as well as postoperative complications, including bone cement leakage and adjacent vertebral fractures, were also assessed. The operation time, bone cement injection volume and intraoperative fluoroscopy frequency were significantly lower in the unilateral compared with the bilateral group (P<0.001). The VAS score, ODI score, average vertebral body height and kyphotic angle (KA) were improved after surgery in each group with no difference in these clinical parameters between the two groups both before and after surgery. Furthermore, the proportion of cases with bone cement leakage in the unilateral group was significantly lower compared with that in the bilateral group (P<0.05). During the follow-up, there were three cases (11.5%) in the unilateral group and two cases (7.7%) in the bilateral group who suffered adjacent vertebral fractures, but there was no statistically significant difference between the two groups (P>0.05). For treating patients with OVCF accompanied by scoliosis, both unilateral and bilateral PKP could effectively relieve the acute back pain and correct the KA. However, unilateral PKP presents more advantages, such as a short operation duration and reduced intraoperative fluoroscopy frequency and bone cement leakage.

Risk Factors for Hidden Blood Loss Associated with Vertebroplasty or Kyphoplasty for Osteoporotic Vertebral Compression Fracture: A Systematic Review and Meta-Analysis

OBJECTIVE

Hidden blood loss (HBL), as a perioperative complication of percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP), affects the quality of life of older adults with poor health status, but it is often ignored by clinical surgeons. The purpose of this study was to discuss the risk factors for perioperative HBL through meta-analysis.

METHODS

We systematically searched PubMed, Embase, Cochrane Library, Web of Science, Scopus, Google Scholar, Chinese National Knowledge Infrastructure, and Wan Fang from establishment of the database to September 2022. All eligible studies regarding risk factors for HBL after PVP or PKP were included. Heterogeneity was assessed using the χ2 test and I2 statistic percentages. If I2 >50% or P < 0.1, the random-effect model was used; otherwise, the fixed-effect model was used. Data were analyzed with Revman 5.4 and Stata 16.0.

RESULTS

Eleven studies involving 1506 patients were included and the average HBL of PKP and PVP was 278.57 mL and 276.12mL. The results showed that bone cement leakage (P < 0.0001), thoracic vertebra (P < 0.00001), bilateral surgical approach (P = 0.0008), ≥2 fracture segments (P < 0.00001), vertebral body height loss rate (≥1/3) (P < 0.00001), and vertebral body height restoration rate (≥1/3) (P < 0.00001) were risk factors for increased HBL. Diabetes (P = 0.12) and hypertension (P = 0.52) were not significantly associated with HBL.

CONCLUSIONS

The findings of this meta-analysis suggested that fracture level, surgical approach, number of fracture levels, cement leakage, vertebral height loss and restoration rate were significant risk factors for HBL, which had certain guiding significance for clinical surgeons to take reasonable measures to deal with this complication.

Indirect Decompression of Osteoporotic Vertebral Compression Fracture Using Intraoperative Motor Evoked Potential Monitoring-Guided Ligamentotaxis

Osteoporotic vertebral compression fractures have become common in aging societies and can lead to a decreased quality of life with severe back pain and neurological deficits. Traditional direct decompression and stabilization surgeries can produce sufficient decompression and provide good results. However, after surgical treatment, some elderly patients with numerous chronic diseases often experience severe postoperative complications owing to the long surgery duration and massive bleeding. Therefore, to prevent perioperative morbidity, other surgical methods that simplify the surgical process and reduce the operation time are required. Herein, we describe a case of indirect decompression using ligamentotaxis and sequential anabolic agents. To examine their effectiveness during surgery, we monitored intraoperative motor-evoked potentials. The patient's neurological symptoms improved postoperatively. After the operation, the anabolic agent "romosozumab" was injected monthly to treat osteoporosis, prevent additional fractures, and accelerate posterolateral fusion. On serial follow-up, the anterior body height of the fractured vertebra improved significantly, demonstrating the importance of osteoporosis treatment using anabolic agents. Indirect decompression surgery may have early effects, whereas sequential anabolic agent use may consolidate the long-term effects of surgical treatment.

Benign vs malignant vertebral compression fractures with MRI: a comparison between automatic deep learning network and radiologist's assessment

OBJECTIVE

To test the diagnostic performance of a deep-learning Two-Stream Compare and Contrast Network (TSCCN) model for differentiating benign and malignant vertebral compression fractures (VCFs) based on MRI.

METHODS

We tested a deep-learning system in 123 benign and 86 malignant VCFs. The median sagittal T1-weighted images (T1WI), T2-weighted images with fat suppression (T2WI-FS), and a combination of both (thereafter, T1WI/T2WI-FS) were used to validate TSCCN. The receiver operator characteristic (ROC) curve was analyzed to evaluate the performance of TSCCN. The accuracy, sensitivity, and specificity of TSCCN in differentiating benign and malignant VCFs were calculated and compared with radiologists' assessments. Intraclass correlation coefficients (ICCs) were tested to find intra- and inter-observer agreement of radiologists in differentiating malignant from benign VCFs.

RESULTS

The AUC of the ROC plots of TSCCN according to T1WI, T2WI-FS, and T1WI/T2WI-FS images were 99.2%, 91.7%, and 98.2%, respectively. The accuracy of T1W, T2WI-FS, and T1W/T2WI-FS based on TSCCN was 95.2%, 90.4%, and 96.2%, respectively, greater than that achieved by radiologists. Further, the specificity of T1W, T2WI-FS, and T1W/T2WI-FS based on TSCCN was higher at 98.4%, 94.3%, and 99.2% than that achieved by radiologists. The intra- and inter-observer agreements of radiologists were 0.79-0.85 and 0.79-0.80 for T1WI, 0.65-0.72 and 0.70-0.74 for T2WI-FS, and 0.83-0.88 and 0.83-0.84 for T1WI/T2WI-FS.

CONCLUSION

The TSCCN model showed better diagnostic performance than radiologists for automatically identifying benign or malignant VCFs, and is a potentially helpful tool for future clinical application.

CLINICAL RELEVANCE STATEMENT

TSCCN-assisted MRI has shown superior performance in distinguishing benign and malignant vertebral compression fractures compared to radiologists. This technology has the value to enhance diagnostic accuracy, sensitivity, and specificity. Further integration into clinical practice is required to optimize patient management.

KEY POINTS

• The Two-Stream Compare and Contrast Network (TSCCN) model showed better diagnostic performance than radiologists for identifying benign vs malignant vertebral compression fractures. • The processing of TSCCN is fast and stable, better than the subjective evaluation by radiologists in diagnosing vertebral compression fractures. • The TSCCN model provides options for developing a fully automated, streamlined artificial intelligence diagnostic tool.

ACR Appropriateness Criteria® Management of Vertebral Compression Fractures: 2022 Update

Vertebral compression fractures (VCFs) can have a variety of etiologies, including trauma, osteoporosis, or neoplastic infiltration. Osteoporosis related fractures are the most common cause of VCFs and have a high prevalence among all postmenopausal women with increasing incidence in similarly aged men. Trauma is the most common etiology in those >50 years of age. However, many cancers, such as breast, prostate, thyroid, and lung, have a propensity to metastasize to bone, which can lead to malignant VCFs. Indeed, the spine is third most common site of metastases after lung and liver. In addition, primary tumors of bone and lymphoproliferative diseases such as lymphoma and multiple myeloma can be the cause of malignant VCFs. Although patient clinical history could help raising suspicion for a particular disorder, the characterization of VCFs is usually referred to diagnostic imaging. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Biomechanical evaluation of a novel tri-blade titanium implantable vertebral augmentation device

BACKGROUND CONTEXT

Titanium implantable vertebral augmentation device (TIVAD) are regarded as having potential in the treatment of vertebral compression fractures (VCFs). However, improper design in current TIVADs results in the inability to effectively restore VCF height and maintain stability. There is still an unmet clinical need for improvement.

PURPOSE

The authors tested a newly developed a TIVAD (Tri-blade fixed system) that can provide enough endplate collapse support to restore the vertebral body height in a safe retraction mechanism for VCFs using minimally invasive surgery (MIS).

STUDY DESIGN

The performed biomechanical tests included blade expansion force, lifetime of cement embedded and vertebral height restoration efficiency of porcine osteoporosis VCFs for its feasibility.

METHODS

A cylinder with 3 surface cuts that form blades that can be expanded into a conical space was designed (Tri-blade fixed system). The 3 blades can be expanded outward with angles between blades as 105°/ 105°/150° for lower left/lower right/upper arms, respectively that reach 15mm in height and 14.8 mm in width. A frame was specifically designed to measure the contact force using force sensing resistors during blade expansion. The Tri-blade fixed system was embedded into a cement block to perform fatigue testing under 2000N pressure (5*10⁶ cycles) for understanding the device lifetime limitation. The Tri-blade system was then inserted into porcine osteoporosis VCFs to examine the vertebral height restoration efficiency.

RESULTS

The average maximum contact force for the top, bottom left and right blades were 299.0N, 283.5N and 279.3N, respectively with uniformly outward expansion forces. The fatigue test found that there were no obvious cracks or damage to the cement block. The porcine osteoporosis vertebral body at the anterior, middle, and posterior heights can be restored to 21.9%, 12.6% and 6.4%, respectively.

CONCLUSIONS

This study developed a novel TIVAD with conical shape that can provide a more stable structure with sufficient/uniform expansion force, passing the fatigue test with bone cement and high effective in vertebral height restoration tests for porcine osteoporosis VCFs.

CLINICAL SIGNIFICANCE

The new 3D Tri-blade TIVAD may offer a new treatment option for VCFs.

Porous titanium microsphere kyphoplasty for augmentation treatment of osteoporotic vertebral fractures: Technical report and case series

Background

Vertebral augmentation procedures (VAPs) are used in cases of persistent and unresponsive pain in patients with vertebral compression fractures (VCFs). Although VAPs are considered a safe procedure providing quick pain relief and improved physical function, some postoperative complications can occur, for example, bone cement leakage. The material used in this procedure is almost exclusively polymethyl methacrylate (PMMA), which appears to lack biological activity and osteointegration capabilities. In this study, we introduce a new filling system consisting of cannulas preloaded with titanium microspheres, which stabilizes and consolidates the structure of the vertebral body in treating VCFs after the performance of the kyphoplasty procedure.

Methods

We report a retrospective case series of six patients affected by osteoporotic vertebral fractures with worsening back pain, neurologic impairment, and failed conservative treatment who underwent the VAP at our institute, for which the SPHEROPLAST [MT ORTHO s.r.l., Aci Sant'Antonio (CT), Italy] system was used.

Results

The patients had failed an average conservative trial of 3.9 weeks before they presented to us with neurodeficit. There were two men and four women with a mean age of 74.5 years. The average hospital stay was 2 days. There were no reported perioperative complications related to cement injection, such as intraoperative hypoxia, hypotension, pulmonary embolization, myocardial infarction, neurovascular or viscera injury, or death. The VAS score significantly decreased from a mean preoperative of 7.5 (range 6-19) to 3.8 (range 3-5) immediately after surgery and 1.8 (range 1-3).

Conclusion

We report the first clinical results in a series of six patients treated for VCF using the microsphere system after analyzing the clinical results produced by, and the complications that arose from, this new device. In patients with VCF, the VAP using titanium microspheres appears to be a feasible and safe procedure with a low risk of material leakage.

Role of metabolic equivalent between calcium intake and vertebral fractures: a cross-sectional study of NHANES 2013-2014

BACKGROUND

This study was to analyze the association of calcium intake and metabolic equivalent (MET) with vertebral fractures, and to explore the role of MET between calcium intake and vertebral fractures.

METHOD

This cross-sectional study used data from the National Health and Nutrition Examination Surveys (NHANES) 2013-2014. The study involved individuals aged ≥ 50 years old with complete information on vertebral fracture, calcium intake, and physical activity. Vertebral fracture assessment is obtained using dual-energy x-ray absorptiometry to perform a lateral scan of the thoracolumbar spine. Calcium intake included total nutrient intake and total dietary supplements. The total MET is the sum of the METs for each activity (Vigorous/ moderate work-related activities, walking or bicycling for transportation and vigorous/ moderate recreational activities). Univariate and multivariate logistic regression analyses were utilized to investigate the effect of calcium intake, MET, and their combined effect on vertebral fracture.

RESULTS

A total of 766 participants were included in the analysis, and 54 participants had vertebral fractures. The median calcium intake and MET were 8.43 mcg and 280.00, respectively. Multivariate results showed that neither calcium intake nor MET as continuous or categorical variables was significantly associated with vertebral fractures. MET < 160 and calcium intake ≥ 670 mg group was associated with the decreased risks of vertebral fracture [odds ratio (OR) = 0.47, 95% confidence interval (CI): 0.26-0.83, P = 0.032] after adjusting for age, race, energy, total femur bone mineral density (BMD), and femoral neck BMD. In the group of MET < 160, increased calcium intake was associated with a reduced risk of vertebral fracture, with a decreased OR value. In the group of MET ≥ 160, increased calcium intake was associated with an increased risk of vertebral fracture, with an increased OR value.

CONCLUSION

The combination of MET < 160 and calcium intake ≥ 670 mg was associated with decreased risks of vertebral fractures. There may be an interaction between calcium intake and MET on vertebral fracture risk.

Absolute Bed Rest Duration of 3 Days for Osteoporotic Vertebral Fractures: A Retrospective Study

STUDY DESIGN

Retrospective case-control study.

PURPOSE

To reduce unnecessary absolute bed rest (ABR), this study sought to determine the optimal aimed length of ABR in older patients getting conservative treatment for osteoporotic vertebral fractures (OVFs).

OVERVIEW OF LITERATURE

OVFs are quite common in elderly patients. ABR is a vital part of conservative treatment for OVFs, although the length of ABR may increase patient. No recommendations regarding how long ABR should last.

METHODS

This study was conducted in 134 patients with OVFs initially treated conservatively. The patients were split into two groups: 3-day and 7-day ABR. From the time of injury to 1, 4, and 12 weeks after injury, compression rate (CR) and local kyphotic angle (LKA) were assessed and compared between the two groups. Any complications such as pneumonia, deep vein thrombosis, delirium, and urinary tract infection known to be related to ABR were examined based on the electronic medical record.

RESULTS

Forty-four patients underwent ABR for 3 days and 90 underwent ABR for 7 days. There was no significant difference in CR and LKA between the two groups at the time of injury versus 1, 4, and 12 weeks after injury. The patients were divided into two groups: those who received a 3-day ABR and those who received a 7-day ABR. CR and LKA were measured and compared between the two groups from the time of damage to 1, 4, and 12 weeks after injury. The ABR-related complication rate was 43.4% in the 7-day ABR group and 22.7% in 3-day ABR group (p=0.02). The duration of hospital stay was significantly shorter in the 3-day ABR group (12.8 days) than in the 7-day group (16 days) (p=0.01).

CONCLUSIONS

Considering radiological outcomes, prognosis, complications, patient convenience, and economic impact, a 3-day ABR period is appropriate for the conservative treatment of OVFs.

Cement augmentation for treatment of high to mid-thoracic osteoporotic compression fractures, high-viscosity cement percutaneous vertebroplasty versus balloon kyphoplasty

Whilst the majority of the literature suggests that balloon kyphoplasty (BKP) can relieve pain associated with vertebral compression fractures (VCFs), evidence of high-viscosity cement (HVC) vertebroplasty (VP) or low viscosity cement (LVC) BKP for the treatment of VCFs at the levels of high and mid-thoracic vertebrae remains limited. The purpose of this study was to identify the different outcomes between HVC VP and LVC BKP used to repair high (T4-6) and mid (T7-9)-thoracic VCFs. A total of 114 patients with painful collapsed single-level vertebrae at high to mid-thoracic level who had undergone HVC VP or LVC BKP at a single tertiary medical center was reviewed retrospectively. All patients were divided into the HVC VP group (n = 72) and the LVC BKP group (n = 42). Clinical outcomes including demographic data and visual analogue scale (VAS) were compared. Radiographic data were collected preoperatively, postoperatively, and at final follow-up. More volume (ml) of cement injection was seen in the LVC BKP group (4.40 vs. 3.66, p < 0.001). The operation time (minutes) of the HVC VP group was significantly less than that of the LVC BKP group (33.34 vs. 39.05, p = 0.011). Leakage rate of cement was also fewer in the HVC VP group (26/72 vs. 27/42, p = 0.004). Compared with preoperative data, the VAS was improved after surgery in both groups. The LVC BKP group corrected more middle vertebral body height and local kyphosis angle than the HVC VP group. The outcomes of LVC BKP were not superior to that of HVC VP. HVC VP might be a good alternative to LVC BKP in the treatment of osteoporotic VCFs in high to mid-thoracic spine.

A Worldwide Bibliometric Analysis of Published Literature on Osteoporosis Vertebral Compression Fracture

Background

With the aging population growth in the world, the prevalence of osteoporotic vertebral compression fracture (OVCF) is rapidly increasing and receiving widespread attention. Although there are numerous articles on the topic, the research status and hotspot analysis are unclear.

Objective

The goal of this study is to identify trends in the OVCF field and to analyze the most highly cited original articles published in the Web of Science Index on OVCF using bibliometric analysis.

Methods

All OVCF data were obtained from the Web of Science Core Collection, and the number of citations, institutions, journals, countries, and years of publication in this field were visually analyzed using VOSviewer, the bibliometrics online analysis platform, and Excel software. Simultaneously, the top 100 most cited articles were extracted and analyzed.

Results

A total of 756 publications were related to OVCF were included from 1900 to 2022. In recent years, the number of articles on OVCF significantly increased. They are mainly from 41 countries/regions and 202 journals, led by China and the United States. Among all countries, China had the most significant contribution on OVCF (n = 363), and it also was cited most often (n = 3337). The institution with the most articles was Soochow University (n = 40). Osteoporosis International was the journal with most studies and has published 50 on this field. The journal of Spine was cited most often (n = 1968). The most productive periods were from 2016 to 2020, which received 294 articles and 4868 citations. After the analysis, the “vertebroplasty” and “kyphoplasty” of OVCF have been the most common research hotspots.

Conclusion

This study represents an updated bibliometric analysis of OVCF. The aim is to identify current research hotspots and future trends to guide clinicians and researchers in this field.

Incidence and Risk Factors for Complications and Mortality After Vertebroplasty or Kyphoplasty in the Osteoporotic Vertebral Compression Fracture-Analysis of 1,932 Cases From the American College of Surgeons National Surgical Quality Improvement

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

The purpose was to investigate the incidence of and risk factors for complications associated with vertebroplasty (VP) or kyphoplasty (KP) for osteoporotic vertebral compression fracture (OVCF) using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.

METHODS

A cohort of patients undergoing VP/KP was constructed from the 2011-2013 ACS-NSQIP dataset using Current Procedural Terminology (CPT) codes. The incidences of minor complications (i.e. urinary tract infection, pneumonia, renal insufficiency, superficial infection, wound dehiscence), major complications (i.e. reoperation, deep vein thrombosis, pulmonary embolism, sepsis, dialysis, cardiac arrest, deep infection, stroke), and mortality within 30 days post-surgery were investigated, and their risk factors were assessed using logistic regression modeling.

RESULTS

Of 1932 patients undergoing VP/KP, 166 (8.6%) experienced a complication, including minor complications in 53 (2.7%), major complications in 95 (4.9%), and death in 40 (2.1%). Multivariate logistic regression analysis indicated that the adjusted odds ratios (95% confidence interval [CI]) of mortality was significantly associated with ASA 4: 16.604 (1.956-140.959) and increased creatinine (≥ 1.3 mg/dL): 3.494 (1.128-10.823). History of chronic obstructive pulmonary disease was associated with minor complications. Increased WBC count and hypoalbuminemia (<3.0 g/dL) were also associated with major complications.

CONCLUSIONS

The major complication and mortality rates associated with VP/KP were 4.9% and 2.1% respectively, higher than previous reports. Increased creatinine and ASA 4 were independently associated with mortality after VP/KP. Therefore, cautious monitoring and counseling is needed for elderly, patients with preexisting kidney disease or ASA 4 undergoing VP/KP.

Managements of osteoporotic vertebral compression fractures: A narrative review

Osteoporotic vertebral compression fractures (OVCFs) are the most common fragility fracture and significantly influence the quality of life in the elderly. Currently, the literature lacks a comprehensive narrative review of the management of OVCFs. The purpose of this study is to review background information, diagnosis, and surgical and non-surgical management of the OVCFs. A comprehensive search of PubMed and Google Scholar for articles in the English language between 1980 and 2021 was performed. Combinations of the following terms were used: compression fractures, vertebral compression fractures, osteoporosis, osteoporotic compression fractures, vertebroplasty, kyphoplasty, bisphosphonates, calcitonin, and osteoporosis treatments. Additional articles were also included by examining the reference list of articles found in the search. OVCFs, especially those that occur over long periods, can be asymptomatic. Symptoms of acute OVCFs include pain localized to the mid-line spine, a loss in height, and decreased mobility. The primary treatment regimens are pain control, medication management, vertebral augmentation, and anterior or posterior decompression and reconstructions. Pain control can be achieved with acetaminophen or nonsteroidal anti-inflammatory drugs for mild pain or opioids and/or calcitonin for moderate to severe pain. Bisphosphonates and denosumab are the first-line treatments for osteoporosis. Vertebroplasty and kyphoplasty are reserved for patients who have not found symptomatic relief through conservative methods and are effective in achieving pain relief. Vertebroplasty is less technical and cheaper than kyphoplasty but could have more complications. Calcium and vitamin D supplementation can have a protective and therapeutic effect. Management of OVCFs must be combined with multiple approaches. Appropriate exercises and activity modification are important in fracture prevention. Medication with different mechanisms of action is a critical long-term causal treatment strategy. The minimally invasive surgical interventions such as vertebroplasty and kyphoplasty are reserved for patients not responsive to conservative therapy and are recognized as efficient stopgap treatment methods. Posterior decompression and fixation or Anterior decompression and reconstruction may be required if neurological deficits are present. The detailed pathogenesis and related targeted treatment options still need to be developed for better clinical outcomes.

Restoration in Vertebral Compression Fractures (VCF): Effectiveness Evaluation Based on 3D Technology

There are few studies about anatomical reduction of the fractured vertebral body before stabilization for treatment of vertebral compression fracture (VCF). Although restoration on vertebral height has been useful, the reduction of fractured endplates is limited. The vertebra is part of a joint, and vertebral endplates must be treated like other weight-bearing joint to avoid complications. The aim of this study was to evaluate the feasibility of anatomic reduction of vertebral compression fracture, in different bone conditions, fracture types, and ages (VCF). Under methodological point of view, we followed different steps: first was the placement of two expandable titanium implants just below the fracture. Later, to push the fractured endplates into a more anatomical position, the implants were expanded. Finally, with the implants perfectly positioned, PMMA cement was injected to avoid any loss of correction. To evaluate the effectiveness of this procedure in anatomical fracture reduction, a method based on 3D CT reconstructions was developed. In this paper, we have developed the procedure in three case studies. In all of them, we were able to demonstrate the efficacy of this procedure to reduce the VCF. The percentage of correction of the kyphotic angle varied range between 49% and 62% with respect to the value after the fracture preoperative value. This was accompanied by a reduction of the pain level on the VAS scale around 50%. In conclusion, this novel approach to the vertebral fracture treatment (VCF) associated with 3D assessment have demonstrated the possibility of reducing the vertebral kyphosis angle and the vertebral endplate fractures. However, given the few cases presented, more studies are necessaries to confirm these results.

High viscosity bone cement vertebroplasty versus low viscosity bone cement vertebroplasty in the treatment of mid-high thoracic vertebral compression fractures

BACKGROUND CONTEXT

As science and technology have advanced, novel bone cements with numerous formulated ingredients have greatly evolved and been commercialized for vertebroplasty. Recently, viscosity has been a focus to achieve better clinical outcomes and fewer complications. Meanwhile, the experience in the treatment of mid (T7-9) to high (T4-6) thoracic vertebral compression fractures is limited.

PURPOSE

The objective of this study was to identify the different outcomes between high-viscosity bone cement (HVBC) and low-viscosity bone cement (LVBC) used to repair mid (T7-9)- and high (T4-6)- thoracic vertebral compression fractures.

STUDY DESIGN/SETTING

This study was a single-center, retrospective cohort study PATIENT SAMPLE: A consecutive series of 107 patients with a total of 144 vertebrae was included.

OUTCOME MEASURES

The anterior vertebral height (AVH), middle vertebral height (MVH), posterior vertebral height (PVH), local kyphotic angle (KA), Cobb angle (CA), and other associated parameters were evaluated radiologically at several time points-preoperative, surgery day 0, postoperative day 1, and 6-month follow-up. Pain evaluation was assessed by using a visual analog scale (VAS) before and 6 months after the procedure.

METHODS

The patients were divided into two groups according to the viscosity of the bone cement used, and plain film and magnetic resonance imaging (MRI) of the vertebrae were used to calculate parameters. The patient characteristics; bone cement brand; changes in AVH, MVH, PVH, KA, CA, and VAS; and complications of each patient were recorded and then analyzed.

RESULTS

Both groups showed increased vertebral body height, corrected KA, and CA after vertebroplasty. There were no significant differences between the HVBC and LVBC groups (ΔAVH: 2.19±2.60 vs. 2.48±3.09, p=.555; ΔMVH: 1.25±3.15 vs. 1.89±2.58, p=.192; ΔKA: -5.46±4.58 vs -5.37±4.47, p=.908; and ΔCA: -4.22±4.23 vs. -4.56±5.17, p=.679). There were significant preoperative to postoperative and preoperative to follow-up changes in AVH (HVBC, p=.012 and .046, respectively; LVBC, p=.001 and .015, respectively); a significant preoperative to postoperative change in MVH (HVBC, p=.045; LVBC, p=.001); and significant preoperative to postoperative and preoperative to follow-up changes in KA and CA (KA: HVBC, p=0.000 and .003, respectively; LVBC, p=.000 and .000, respectively; CA: HVBC, p=.017 and .047, respectively; LVBC, p=.006 and .034, respectively). The volume of cement injected was significantly higher with HVBC (3.66±1.36 vs. 3.11±1.53, p=.024), and the use of HVBC was associated fewer cases with cement leakage (26 vs. 45, p=.002). Furthermore, there was no difference between the groups in the incidence of adjacent fracture. Both groups showed an improved VAS score at follow-up, with statistically greater improvement in the HVBC group (2.40±1.53 vs. 3.07±1.69, p=.014). Moreover, significantly fewer patients with a VAS score ≥ 3 were found in the HVBC group (22 vs. 39, p=.004) CONCLUSIONS: HVBC and LVBC are safe and effective to treat mid-to-high level thoracic vertebral compression fractures. Compared with LVBC, HVBC shows less cement leakage, a greater injection volume, and better postoperative pain relief.

Spinous Process Fractures in Osteoporotic Vertebral Fractures: A Cross-Sectional Study

Introduction

The purpose of this study was to assess radiological features and clinical scores of osteoporotic vertebral fracture (OVF) accompanied by spinous process fracture (SPF).

Methods

We included painful patients with single-level OVF with intravertebral cleft. SPF was detected using magnetic resonance imaging (MRI) and/or computed tomography (CT). The plain radiographs of the vertebral fractures were evaluated based on the wedging angle of the fractured vertebrae and vertebral instability. We investigated the clinical parameters of age, gender, visual analog scale (VAS) score for low back pain (LBP), Oswestry Disability Index (ODI), and the period from the onset of acute fracture.

Results

MRI and/or CT indicated among 195 patients of OVF with LBP, 41 patients (20.5%) had SPFs. SPFs were observed one level above the fractured vertebral body in 35 patients (85.4%) and at the same level as the fractured vertebral body in 6 patients (14.6%). The prevalence of vertebral fracture of thoracic spine in the SPF-positive group was significantly greater than that in the SPF-negative group. There were no significant differences in age, gender, VAS, ODI, the time period from the onset of acute LBP, wedging angle, and vertebral instability between the presence or absence of SPFs.

Conclusions

SPFs occurred in 20.5% of patients with OVF and LBP. In addition, SPFs often occurred one level above the fractured vertebra, and SPFs with OVF tended to be located in the thoracic spine.

Hospital Frailty Risk Score predicts adverse events in older patients with vertebral compression fractures: Analysis of data in a nationwide in-patient database in Japan

AIMS

This study investigated the usefulness of frailty for predicting adverse events in patients with vertebral compression fractures (VCFs) during hospitalization using data obtained from the Japanese health insurance system.

METHODS

This retrospective cohort study of patients with VCFs aged ≥65 years was conducted using a nationwide database in Japan. We examined the relationships between frailty risk, classified using the Hospital Frailty Risk Score (HFRS), in-hospital mortality, and complications such as pressure ulcers and pneumonia. Multivariate logistic regression analysis was used to estimate the association between the HFRS and the outcomes of patients with VCFs.

RESULTS

In this study, the data of 30 980 in-patients with VCFs were analyzed. Of these patients, 76.8%, 21.3%, and 1.9% had low, intermediate, and high risks of frailty, respectively. The higher the risk of frailty, the higher the rate of in-hospital mortality and the occurrence of all complications (P < 0.001 for trend). An intermediate risk of frailty was independently associated with in-hospital mortality (odds ratio [OR], 1.421; P < 0.001), whereas a high risk of frailty did not show statistical significance (OR, 1.385; P = 0.150). Each frailty risk was independently associated with the occurrence of all complications during hospitalization.

CONCLUSIONS

The HFRS, which can assess the risk of frailty based on routinely collected medical records, was predictive of adverse events in older patients with VCFs based on a nationwide database in Japan. Future studies need to assess approaches to preventing adverse events in frail VCF patients. Geriatr Gerontol Int 2022; ••: ••-••.

Healing of Vertebral Compression Fractures in the Elderly after Percutaneous Vertebroplasty-An Analysis of New Bone Formation and Sagittal Alignment in a 3-Year Follow-Up

BACKGROUND

Vertebral compression fractures, resulting in significant pain and disability, commonly occur in elderly osteoporotic patients. However, the current literature lacks long-term follow-up information related to image parameters and bone formation following vertebroplasty.

PURPOSE

To evaluate new bone formation after vertebroplasty and the long-term effect of vertebroplasty.

METHODS

A total of 157 patients with new osteoporotic compression fractures who underwent vertebroplasty were retrospectively analyzed. The image parameters, including wedge angles, compression ratios, global alignment, and new bone formation, were recorded before and after vertebroplasty up to three years postoperatively.

RESULTS

The wedge angle improved and was maintained for 12 months. The compression ratios also improved but gradually deteriorated during the follow-up period. New bone formation was found in 40% of the patients at 36 months, and the multivariate analysis showed that this might have been related to the correction of the anterior compression ratio.

CONCLUSIONS

Vertebroplasty significantly restored the wedge angles and compression ratios up to one year postoperatively, and new bone formation was noted on plain radiographs, which increased over time. Last, the restoration of vertebral parameters may contribute to new bone formation.

Cumulative Incidence and Factors Associated with Subsequent Vertebral Compression Fractures: A Nationwide Population-based Study

OBJECTIVE

Patients who experience vertebral compression fractures are vulnerable to subsequent vertebral compression fractures (SVCFs). The purpose of this nationwide population-based study was to determine the age-specific cumulative incidence and factors associated with SVCFs in South Korea.

METHODS

Diagnostic codes, medical costs, and comorbid diseases in patients who had a vertebral compression fracture in 2011 and 2012 were collected from the National Health Insurance Service database of South Korea from 2007 to 2018. Demographic data, mortality rate, medical cost, and frequency of vertebroplasty or kyphoplasty were compared between patients with an initial fracture (IF) and those with a subsequent fracture (SF).

RESULTS

The cumulative incidence of SVCFs over 4 years was 24.4% and increased rapidly within a few months after the IF. In 2011, SVCFs occurred in 17,004 patients, and the incidence rate per 100,000 people was 113.6 (84.9 in men vs. 138.5 in women). The odds ratio (OR) of SVCFs in units of 10 years was the highest in women in their 60s, at 2.89. However, in men in their 70s, the OR was the highest, at 2.51. The rates of vertebroplasty or kyphoplasty, medical expenses, and mortality rate were significantly higher in the SF group than in the IF group (p < 0.01).

CONCLUSION

The age-specific cumulative incidence of SVCFs per 100,000 people was 113.6. SVCFs were more frequent among women, the elderly, and patients who underwent vertebroplasty or kyphoplasty. Women in their 60s or above and men in their 70s or above were at highest risk.

A novel extraction method enhanced the osteogenic and anti-osteoporosis effect of tea extract without any hepatotoxicity in ovariectomized rats

Tea (Camellia sinensis) has several reported health benefits, including that on bone health attributed to catechins of which the most abundant is epigallocatechin-3-gallate (EGCG). However, several preclinical and clinical studies raise safety concerns about EGCG in tea extract causing acute liver failure. Tea also contains kaempferol, albeit scanty, and it has hepatoprotective and osteogenic effects. Here, we utilized a novel extraction procedure of acid hydrolysis to enhance the osteogenic effect of tea extract while reducing its hepatotoxicity. The resultant extract (USKECSE) has a ~40-fold increase in kaempferol and a 2.5-fold reduction in EGCG content compared with the hydroethanolic extract (USCSE). In a female Sprague Dawley (SD) rat femur osteotomy model, USKECSE (100 mg/kg) but not USCSE promoted bone regeneration. In a rat postmenopausal osteoporosis model induced by bilateral ovariectomy (OVX), USKECSE through an osteogenic mechanism maintained bone mass, strength, and microarchitecture to the levels of ovary-intact rats with no hepatotoxic effect. After a single oral dose (100 mg/kg) of USKECSE to adult rats, kaempferol was detectable for 48 hours, suggesting its significant absorption and distribution in plasma. Peak kaempferol concentration in plasma (C_max) was 483 ng/ml (2 μM), and at this concentration, kaempferol induces osteoblast differentiation. USKECSE had no genotoxicity, and its safety index assessed by preclinical toxicity studies, including safety pharmacology, was >20-fold. Taken together, we report a novel extraction process that enhanced the osteogenicity and concomitantly reduced hepatotoxicity of tea extract with significant kaempferol bioavailability and a favorable systemic safety profile. Based on these data, we propose assessing the USKECSE effect for postmenopausal osteoporosis treatment.

Association Between Overweight Sarcopenic Population and Acute Vertebral Osteoporotic Compression Fractures in Females: Retrospective, Cross-Sectional Study

Background: This study aimed to determine whether the prevalence of acute vertebral osteoporotic compression fractures (VOCF) in the elderly population is related to the distribution of muscles and fat in the human body. Methods: Data of acute VOCF and non-VOCF patients presenting at our institution between January 2018 and May 2020 were analyzed. Patients aged 65 years and older, who underwent body composition test and dual-energy X-ray absorptiometry at the same time were enrolled. After applying exclusion criteria, patients were divided into four groups: normal, sarcopenia without obesity, obesity without sarcopenia, and sarcopenic obesity. Body mass index ≥25 kg/m2 was considered obesity, and sarcopenia was defined as skeletal muscle index lower than 7.0 kg/m2 in males and 5.4 kg/m2 in females. The VOCF rate was analyzed between the groups. Discussion: A total of 461 patients were included, of whom 103 were males. Among them, 163 (35.36%) had normal body composition, 151 (32.75%) had sarcopenia without obesity, 110 (23.86%) had obesity without sarcopenia, and 37 (8.03%) had sarcopenic obesity. The sarcopenic obesity group had the highest rate of acute VOCF (37.8%), which was statistically significant. Specifically, females with sarcopenic obesity and sarcopenia without obesity had significantly higher acute VOCF rates compared to those with normal body compositions. Multivariate analysis showed that sarcopenic obesity was significantly associated with acute VOCF rate overall, as well as in females. Conclusion: Sarcopenic obesity is strongly associated with acute VOCF, especially in females, and it could be an essential criterion for the prevention of acute VOCF.

Much lower prevalence and severity of radiographic osteoporotic vertebral fracture in elderly Hong Kong Chinese women than in age-matched Rome Caucasian women: a cross-sectional study

INTRODUCTION

Many earlier studies reported that East Asians and Caucasians have similar radiographic osteoporotic vertebral fracture (OVF) prevalence. Since elderly Chinese's osteoporotic hip fracture prevalence is half (or less than half) of that of their age-match Caucasians, we hypothesize that elderly Chinese's OVF prevalence could be only half, or even less than half, of that of their age-match Caucasians.

MATERIALS

Age-matched (mean: 74.1 years; range: 65-87 years) elderly women's radiographs (T4-L5) were from two OVF population-based epidemiological studies conducted in Hong Kong (n = 200) and in Rome (n = 200). All radiographs were double read by one reader in Hong Kong and one reader in Rome. Radiological osteoporotic vertebral deformity (ROVD) classification included no ROVD (grade 0), and ROVDs with < 20%, 20 ~ 25%, ≥ 25% ~ 1/3, ≥ 1/3 ~ 40%, ≥ 40% ~ 2/3, and ≥ 2/3 height loss (grade 1 ~ 6) as well as endplate/cortex fracture (ECF). Spinal deformity index (SDI) was calculated with each vertebra assigned a score of 0, 0.5, 1, 1.5, 2, 2.5, and 3 for no ROVD or ROVDs grade 1 ~ 6.

RESULTS

Seventy-seven (38.5%) Chinese subjects and 123 Italian subjects (61.5%) had ROVD respectively (p < 0.0001). Chinese subjects had ECF in 52 (26%) cases involving 100 vertebrae, while Italian subjects had ECF in 93 (47%) cases involving 230 vertebrae. ROVDs in Italian subjects tended to be more severe (total and mean SDI: 454.5 and 3.71 for Italian, and 212 and 2.72 for Chinese, p < 0.05), more likely to be multiple, more likely to have severe and collapsed grades. The slope of the relationship between age vs. SDI was steeper for the Italian subjects than for the Chinese subjects, suggesting ROVD severity developed faster for aging Italian subjects. A trend suggested earlier onset of ROVD among Italian.

CONCLUSION

OVFs in Chinese women tend to be less common, less severe, and less likely to have multiple fractures.

Advances in the application of mesenchymal stem cells, exosomes, biomimetic materials, and 3D printing in osteoporosis treatment

Owing to an increase in the aging population, osteoporosis has become a severe public health concern, with a high prevalence among the elderly and postmenopausal adults. Osteoporosis-related fracture is a major cause of morbidity and mortality in elderly and postmenopausal adults, posing a considerable socioeconomic burden. However, existing treatments can only slow down the process of osteoporosis, reduce the risk of fractures, and repair fractures locally. Therefore, emerging methods for treating osteoporosis, such as mesenchymal stem cell transplantation, exosome-driving drug delivery systems, biomimetic materials, and 3D printing technology, have received increasing research attention, with significant progress. Mesenchymal stem cells (MSCs) are pluripotent stem cells that can differentiate into different types of functional cells. Exosomes play a key role in regulating cell microenvironments through paracrine mechanisms. Bionic materials and 3D printed scaffolds are beneficial for the reconstruction and repair of osteoporotic bones and osteoporosis-related fractures. Stem cells, exosomes, and biomimetic materials represent emerging technologies for osteoporosis treatment. This review summarizes the latest developments in these three aspects.

Investigation of Preoperative Traction Followed by Percutaneous Kyphoplasty Combined with Percutaneous Cement Discoplasty for the Treatment of Severe Thoracolumbar Osteoporotic Vertebral Compression Fractures

Objective

To evaluate the feasibility, clinical efficacy and imaging results of preoperative traction (PT) followed by percutaneous kyphoplasty (PKP) combined with percutaneous cement discoplasty (PCD) for treating severe thoracolumbar osteoporotic vertebral compression fractures (OVCFs).

Methods

A total of 13 patients with severe thoracolumbar OVCFs treated by PT followed by PKP combined with PCD were enrolled. General information, PT time, operation time, postoperative hospital stay, perioperative complications, visual analog scale (VAS) score, Oswestry disability index (ODI) score, local kyphosis angle, intervertebral angle (IVA), anterior vertebral height (AVH) and posterior vertebral height (PVH) were recorded.

Results

The average VAS score at admission was 7.4±3.5, decreased to 4.3±1.7 after PT and 2.3±0.7 three days after operation, and 1.5±0.9 at last follow-up. The average ODI score was 73.7±21.4 before operation, decreased to 26.6±9.3 three days after operation and 13.7±7.1 at last follow-up. Compared to VAS and ODI scores at admission, these at the third day after operation and last follow-up were significantly different. At admission, the IVA was 3.4°±6.8°, the disc height was 5.7±1.2mm, the AVH was 10.7±3.2mm, and the PVH was 25.7±4.2 mm, which, after PT, changed to 8.1°±7.3°, 8.6±2.6mm, 18.5±2.8mm, and 26.2±7.1mm, respectively, and the differences were significant. The average kyphotic angle was 43.4°±17.8° at admission, and decreased to 26.3°±6.7° after PT, 17.5°±8.4° three days after operation and 19.1°±10.3° at last follow-up, and the differences were significant.

Conclusion

PT followed by PKP combined with PCD for the treatment of severe thoracolumbar OVCFs was an effective and simple procedure with satisfactory short-term clinical outcomes by relieving pain and improving kyphosis.

A Pilot Study of Radiculopathy Following Osteoporotic Vertebral Fracture in Elderly Patients: An Algorithmic Approach to Surgical Management

Background: Osteoporotic vertebral compression fractures (OVCF) due to severe and refractory back pain or neurological complications require surgical treatment. In this study, patients with radiculopathy due to foraminal stenosis following OVCF were surgically managed by performing transforaminal full-endoscopic lumbar foraminoplasty and/or discectomy (FELFD). Methods: From May 2015 to November 2019, fifteen patients underwent transforaminal FELFD. Patient data, Charlson comorbidity index (CCI), and American Society of Anesthesiologists (ASA) score were collected. Clinical outcomes, including pre- and postoperative Visual Analog Scale (VAS) scores for back and leg pain, Oswestry Disability Index (ODI), and MacNab criteria of response to surgical treatment, were evaluated. Results: Mean of age, bone mineral density (T-score), CCI, ASA, and follow-up duration were 69.5 ± 6.6 years, −2.6 ± 0.8, 5.2 ± 2.3, 2.4 ± 0.5, and 24.5 ± 8.8 months, respectively. Mean VAS for leg pain significantly decreased from 6.9 ± 0.8 preoperatively to 2.9 ± 1.1 (P < .05). Mean ODI decreased from 39.9 ± 3.2 preoperatively to 19.3 ± 4.6 postoperatively (P < .05). The satisfaction rate is 86.7% (based on Macnab criteria), showed six patients had excellent outcomes and seven had good outcomes. Conclusions: Transforaminal FELFD is an effective treatment option for patients with radiculopathy due to lumbar OVCF, including those with severe osteoporosis and elderly patients.

Effects of vitamin D supplementation on the functional outcome in patients with osteoporotic vertebral compression fracture and vitamin D deficiency

BACKGROUND

In osteoporotic vertebral compression fractures, supplementation using vitamin D preparations and maintenance of blood vitamin D level within the normal range are necessary for proper fracture union, enhancement of muscle strength, and maintenance of body balance. The purpose of this study is to investigate the effects of vitamin D supplementation on blood vitamin D level, pain relief, union time, and functional outcome in patients with osteoporotic vertebral compression fracture and vitamin D deficiency.

METHODS

One hundred thirty patients who were deficient in blood vitamin D level and had osteoporotic vertebral compression fracture were divided into supplementation group and non-supplementation group. Initially, 3 months, 6 months, and 12 months after the injury, radiographs were taken to assess fracture union, and questionnaires were evaluated to evaluate the functional outcome and quality of life.

RESULTS

The mean age of the 130 patients (36 males and 94 females) was 74.75 ± 7.25 years. There were no statistically significant differences in initial severity of low back pain, functional outcome, and quality of life between the insufficient group and the deficient group (all p values were > 0.05). There was no significant time-by-group interaction between the supplementation group and the non-supplementation group (p = 0.194). In terms of SF-36 physical component score, there was no significant time-by-group interaction between the supplementation group and the non-supplementation group (p = 0.934).

CONCLUSIONS

Fracture union was achieved in all patients regardless of serum vitamin D level, and there were significant improvements in severity of low back pain, functional outcome, and quality of life over 12 months in patients with osteoporotic vertebral compression fracture. Short-term vitamin D supplementation of patients with osteoporotic vertebral compression fracture and deficiency of vitamin D did not result in significant differences in fracture union status, functional outcome, and quality of life between the supplementation groups and the non-supplementation groups of patients.

The effects of bone morphogenetic protein 2 and thrombopoietin treatment on angiogenic properties of endothelial cells derived from the lung and bone marrow of young and aged, male and female mice

With an aging world population, there is an increased risk of fracture and impaired healing. One contributing factor may be aging-associated decreases in vascular function; thus, enhancing angiogenesis could improve fracture healing. Both bone morphogenetic protein 2 (BMP-2) and thrombopoietin (TPO) have pro-angiogenic effects. The aim of this study was to investigate the effects of treatment with BMP-2 or TPO on the in vitro angiogenic and proliferative potential of endothelial cells (ECs) isolated from lungs (LECs) or bone marrow (BMECs) of young (3-4 months) and old (22-24 months), male and female, C57BL/6J mice. Cell proliferation, vessel-like structure formation, migration, and gene expression were used to evaluate angiogenic properties. In vitro characterization of ECs generally showed impaired vessel-like structure formation and proliferation in old ECs compared to young ECs, but improved migration characteristics in old BMECs. Differential sex-based angiogenic responses were observed, especially with respect to drug treatments and gene expression. Importantly, these studies suggest that NTN1, ROBO2, and SLIT3, along with angiogenic markers (CD31, FLT-1, ANGPT1, and ANGP2) differentially regulate EC proliferation and functional outcomes based on treatment, sex, and age. Furthermore, treatment of old ECs with TPO typically improved vessel-like structure parameters, but impaired migration. Thus, TPO may serve as an alternative treatment to BMP-2 for fracture healing in aging owing to improved angiogenesis and fracture healing, and the lack of side effects associated with BMP-2.

Independent Living 1 Year After Balloon Kyphoplasty for Osteoporotic Vertebral Compression Fracture

BACKGROUND

The prevalence of osteoporotic vertebral compression fracture (OVCF) is increasing. The indications for and efficacy of balloon kyphoplasty (BKP) are controversial. We sought to identify predictors of outcome after BKP in patients with OVCF.

METHODS

Between January 2001 and December 2019, 152 patients underwent BKP for painful OVCFs at our institution. This study included 115 patients who were followed for >12 months, and their data were retrospectively analyzed. With regard to the degree of independent living 1 year after BKP, patients were divided into a good outcome group (composed of patients who could independently go indoors) and a poor outcome group. We analyzed factors associated with outcome and subsequent OVCF.

RESULTS

Mean age of patients was 77.9 years, 58.2% were female, 81% had a good outcome, and 19% had a poor outcome. Univariable analysis revealed significant differences in age, bone mineral density, preoperative vertebral body decompression rate, body mass index (BMI), preoperative Japanese Orthopaedic Association score, preoperative modified Rankin Scale score, and subsequent OVCF. Multivariable logistic analysis showed that low BMI (odds ratio 1.415, 95% confidence interval 1.06-1.87, P = 0.046) and subsequent OVCF (odds ratio 0.13, 95% confidence interval 0.02-0.69, P = 0.044) were independent risk factors. The incidence of subsequent OVCF was also lower among patients with higher BMI (odds ratio 0.83, 95% confidence interval 0.72-0.95, P = 0.001).

CONCLUSIONS

BMI and subsequent OVCF are the most influential predictors of independent living 1 year after BKP for OVCF.

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.

Clinical effect of a novel transpedicular reducer for reduction and bone grafting combined with pedicle screw fixation for thoracolumbar burst fractures

BACKGROUND

Short-segment transpedicular screw fixation is a common method for the treatment of thoracolumbar burst fractures (TBFs),but this technique has many problems. Therefore,the purpose of this article is to observe and evaluate the clinical efficacy of a novel transpedicular reducer that we designed for fractured vertebral body reduction and bone grafting in the treatment of TBFs.

METHODS

From July 2018 to November 2020, 70 cases of TBFs were included. Thirty-five patients were treated with the novel transpedicular reducer for reduction and bone grafting combined with pedicle screw fixation (observation group), and 35 patients were treated with short-segment transpedicular screw fixation (control group). Before the operation, after reduction, and 3 days, 3 months,and 12 months after the operation, the two groups were assessed, and compared with respect to the anterior and middle heights of the injured vertebrae, the ratios of the anterior and middle heights of the injured vertebral body to the respective heights of the adjacent uninjured vertebral bodies (AVBHr and MVBHr, respectively), and the Cobb angle of the patients. We compared the pain VAS score and quality of life GQOL-74 score at the last follow-up. Finally,we evaluated the distribution of bone grafts and bone healing 12 months after the operation.

RESULTS

The anterior height, middle height, AVBHr, MVBHr, and Cobb angle of the injured vertebral body in the observation after reduction, and 3 days, 3 months and 12 months post-operatively were compared with those of the injured vertebral body before operation. All of these parameters were improved, and the difference was statistically significant (p < 0.05). These parameters in the observation group at the above time points were significantly better than thoes in the control group at the corresponding time points (p < 0.05). The VAS scores at the last follow-up were significantly better than those of the control group (p < 0.05), but the GQOL-74 score differences were not statistically significant (p > 0.05). The observation group showed no obvious defects on CT at 12 months after the operation, and the bone healing was good.

CONCLUSION

The novel transpedicular reducer for reduction and bone grafting combined with pedicle screw fixation for TBFs has good clinical efficacy.

Minimally Invasive Short-Segment Anteroposterior Surgery for Thoracolumbar Osteoporotic Fractures with Canal Compromise: A Prospective Study with a Minimum 2-Year Follow-up

Study Design

A prospective study with a minimum follow-up of 24 months.

Purpose

This study aimed to evaluate the results of minimally invasive anteroposterior surgery for osteoporotic vertebral fractures (OVFs) associated with bony spinal canal compromise in elderly patients.

Overview of Literature

There is a recent increase in the incidence of osteoporosis with OVFs, causing an increasing burden on medical systems.

Methods

The study included 47 patients, of whom 45 completed a minimum of 24-month follow-up. The inclusion criteria were OVF types 3 and 4 according to the osteoporotic fracture classification in patients aged ≥65 years with bony stenosis. The surgical management consisted of anterior corpectomy and decompression using a thoracoscopic or mini-laparotomy approach, together with posterior percutaneous cement-augmented short-segment fixation. Self-reported outcome measures included Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) in the preoperative phase and regular follow-up at a minimum of 24 months. Radiological measures included segmental lordosis, dual-energy X-ray absorptiometry for osteoporosis assessment, and radiological fracture healing.

Results

There were 33 patients with lumbar fracture and 12 patients with thoracic fracture. Thirteen patients had preoperative neurological deficits. The mean age was 77.4±8.3 years. The mean preoperative VAS score was 8.12±1.5, and the mean ODI score was 24.4±8.2. The mean preoperative sagittal Cobb angle was 6.3°±4.2° kyphosis. The mean operative time was 220.3±55.5 minutes, with a mean blood loss of 360.75±200.6 mL. After a mean follow-up of 32.6±6.4 months, the mean VAS significantly improved to 2.3, and the ODI to 12. Only three patients still had a partial neurological deficit. The mean final sagittal Cobb angle was significantly better, with 12.5°±4.3° of lordosis.

Conclusions

Short-segment percutaneous fixation with cement augmentation combined with minimally invasive anterior decompression and corpectomy is a less invasive and safe approach in elderly patients with OVF and canal compromise.

Improving osteoporotic vertebral deformity detection on chest frontal view radiograph by adjusted X-ray beam positioning

Purpose

In clinics, chest frontal view radiograph (CFR) is often taken for patients suspected of respiratory diseases and for assessing the heart and big vessels. CFR can be utilised to opportunistically detect osteoporotic vertebral fracture (OVF). However, for standard CFR, the site of highest OVF prevalence, i.e., the thoracolumbar junction, is usually 'off-centre' to the X-ray beam focus. This study tested the hypothesis that, if a CRF is taken with approximately two vertebrae lower than the standard X-ray beam positioning, the visualization of thoraco-lumbar junction can be much improved.

Materials

Four hospitals (A, B, C, D) provided 101 elderly women's digital CFRs with standard filming (28, 20, 24, and 21 cases respectively). Eighty four elderly female patients were prospectively recruited from hospitals-A and B, who were consecutive patients referred for chest radiograph with indications other than spine disorders. For theses prospective CFRs, the focus of X-ray beam was adjusted from towards vertebra T6 to towards T8, and standard lateral radiographs were obtained for reference. Visibility of spine and detectability of OVF were assessed on the CFRs. OVF was diagnosed based on chest lateral radiograph (CLR) after excluding other potential causes both radiographically and clinically.

Results

For standardly filmed CFR, spine readability was similar among those from Hospitals-A, B, and C, while performed less well for those from Hospital-D. With the prospective cases from Hospitals-A and B, spines readable to vertebra L1 level or lower increased from 48.2% for standard filming to 80.7% for adjusted filming. Spines with 'blurry' labelling decreased from 35.7% for standard filming to 15.7% for adjusted filming. For the 84 prospective cases, 42.9% (36/84) of the patients had OVF, and 26 cases of CLR positive cases were detected as having vertebral deformity on CFR. For minimal OVF cases (<20% height loss), 38% (5/13) were detected on CFR. Among 22 cases with apparent OVF (≥20% height loss), two cases were missed on CFR. False positivity was labelled in five cases, among them four cases had 'burry' spines.

Conclusion

CFR can help opportunistically detect OVF, which can be further improved if X-ray beam is adjusted to towards vertebra T8 instead of towards vertebra T6.

The translational potential of this article

This study confirms that CFR can help detect OVF opportunistically, and the visibility of the mid/lower thoracic spine and thoracolumbar junction can be much improved after minor adjustment of X-ray beam positioning. This study also suggests high positive rate of OVF in elderly Chinese female patients indicated for chest radiograph. Radiologists should be trained and sensitized in vertebral deformity identification on CFR as the clinical management can be improved by opportunistic detection of OVF.

[Clinical application of an improved classification system of Kümmell's disease]

OBJECTIVE

To report an improved classification system of Kümmell's disease and its clinical application.

METHODS

Based on CT and MRI, an improved classification system of Kümmell's disease was proposed in terms of the integrity of sagittal endplate, the integrity of posterior wall of vertebral body, and the degree of vertebral compression. Between January 2011 and March 2018, the improved classification system was used to evaluate and guide the treatment of 78 patients with Kümmell's disease. There were 13 males and 65 females. The mean age was 69.1 years (range, 54-85 years). The mean disease duration was 4.0 months (range, 1-8 months). The mean T value of bone mineral density was -3.66 (range, -3.86- -3.34).The fractures located at thoracic vertebrae in 47 cases and lumbar vertebrae in 31 cases. According to the modified classification system of Kümmell's disease, there were 11 cases of type A1, 13 cases of type A2, 2 cases of type A3, 10 cases of type B1, 18 cases of type B2, 4 cases of type B3, 4 cases of type C1, 5 cases of type C2, and 11 cases of type C3. According to the classification results, the patients of types A and B were treated with percutaneous kyphoplasty (PKP), while the patients of type C were treated with PKP or intra- vertebral fixation according to the degree of vertebral reduction. Visual analogue scale (VAS) score and Oswestry Disability Index (ODI) were used to evaluate clinical efficacy. The heights of the anterior, middle, and posterior edges of the vertebrae and the Cobb angle were measured to evaluate the reduction of the injured vertebrae and the improvement of kyphosis deformity. The complications were recorded.

RESULTS

The statistical analysis showed that the improved classification system has good consistency. All patients were followed up 12-36 months (mean, 24.3 months). The heights of anterior, middle, and posterior edges of the vertebrae, Cobb angle, VAS score, and ODI of all types of patients at last follow-up showed significant differences when compared with those before operation ( P<0.05). After operation, 4 patients of type A2 had different degree of vertebral height loss; 2 patients of type B2, 3 patients of type C1, and 2 patients of type C2 developed asymptomatic bone cement leakage during PKP; 2 patients of type B3 and 3 patients of type C2 underwent percutaneous internal fixation and vertebral augmentation due to bone cement loosening.

CONCLUSION

The modified classification system of Kümmell's disease can be used to guide treatment of Kümmell's disease, but the number of clinical application cases is limited, and further application and observation are needed.