Early vertebroplasty associated with a lower risk of mortality and respiratory failure in aged patients with painful vertebral compression fractures: a population-based cohort study in Taiwan

Kyphoplasty is associated with reduced mortality risk for osteoporotic vertebral compression fractures: a systematic review and meta-analysis

BACKGROUND

Vertebral augmentation, such as vertebroplasty (VP) or kyphoplasty (KP), has been utilized for decades to treat OVCFs; however, the precise impact of this procedure on reducing mortality risk remains a topic of controversy. This study aimed to explore the potential protective effects of vertebral augmentation on mortality in patients with osteoporotic vertebral compression fractures (OVCFs) using a large-scale meta-analysis.

MATERIALS AND METHODS

Cochrane Library, Embase, MEDLINE, PubMed and Web of Science databases were employed for literature exploration until May 2023. The hazard ratios (HRs) and 95% confidence intervals (CIs) were utilized as a summary statistic via random-effect models. Statistical analysis was executed using Review Manager 5.3 software.

RESULTS

After rigorous screening, a total of five studies with substantial sample sizes were included in the quantitative meta-analysis. The total number of participants included in the study was an 2,421,178, comprising of 42,934 cases of vertebral augmentation and 1,991,244 instances of non-operative management. The surgical intervention was found to be significantly associated with an 18% reduction in the risk of mortality (HR 0.82; 95% CI 0.78, 0.85). Subgroup analysis revealed a remarkable 71% reduction in mortality risk following surgical intervention during short-term follow-up (HR 0.29; 95% CI 0.26, 0.32). Furthermore, KP exhibited a superior and more credible decrease in the risk of mortality when compared to VP treatment.

CONCLUSIONS

Based on a comprehensive analysis of large samples, vertebral augmentation has been shown to significantly reduce the mortality risk associated with OVCFs, particularly in the early stages following fractures. Furthermore, it has been demonstrated that KP is more reliable and effective than VP in terms of mitigating mortality risk.

Mortality among older adults with osteoporotic vertebral fracture

We evaluated whether older adults who received kyphoplasty had reduced risk of mortality compared to those who did not. In unmatched analyses, those receiving kyphoplasty were at reduced risk of death but after matching on age and medical complications, patients who received kyphoplasty were at increased risk of death.

PURPOSE

In previous observational studies, kyphoplasty for treatment of osteoporotic vertebral fractures has been associated with decreased mortality compared to conservative management. The purpose of this research was to determine whether older adults who received kyphoplasty had reduced risk of mortality compared to matched patients who did not.

METHODS

Retrospective cohort study of US Medicare enrollees with osteoporotic vertebral fractures between 2017-2019 comparing patients who underwent kyphoplasty to those who did not. We identified 2 control groups a priori: 1) non-augmented patients who met inclusion criteria (group 1); 2) propensity-matched patients on demographic and clinical variables (group 2). We then identified additional control groups using matching for medical complications (group 3) and age + comorbidities (group 4). We calculated hazard ratios (HRs) and 95% confidence intervals (95% CIs) associated with mortality.

RESULTS

A total of 235,317 patients (mean (± standard deviation) age 81.1 ± 8.3 years; 85.8% female) were analyzed. In the primary analyses, those who received kyphoplasty were at reduced risk of death compared to those who did not: adjusted HR (95% CI) in group 1 = 0.84 (0.82, 0.87); and in group 2 = 0.88 (0.85, 0.91). However, in post hoc analyses, patients who received kyphoplasty were at increased risk of death: adjusted HR (95% CI) in group 3 = 1.32 (1.25, 1.41) and 1.81 (1.58, 2.09) in group 4.

CONCLUSION

An apparent benefit of kyphoplasty on mortality among patients with vertebral fractures was not present after rigorous propensity matching, illustrating the importance of comparing similar individuals when evaluating observational data.

Early Interventional Treatments for Patients with Cancer Pain: A Narrative Review

Between 10% and 20% of patients with cancer-related pain cannot achieve adequate control following the three-step ladder guidelines by the World Health Organization. Therefore, a "fourth step", including interventional approaches, has been suggested for those cases. Systematic reviews support the early use of interventional procedures to treat refractory cancer pain, control symptoms and prevent opioid dose escalation. There is strong evidence of the efficacy of celiac plexus or splanchnic neurolysis, vertebroplasty, kyphoplasty and intrathecal drug delivery. Those procedures have been found to be associated with a decrease in the symptom burden and opioid consumption, improved quality of life, and suggested as having a potentially positive impact on survival. Several studies have recommended using specific interventional techniques at earlier stages, possibly even when opioid treatment is first being considered. Conversely, leaving these options as a last analgesic resource might not be advisable since the burden these procedures might impose on too ill patients is significant. The objective of this review was to collect the available evidence published on the use of interventional treatments for refractory cancer pain with a particular interest in comparing early versus late indications. The results of the search demonstrated a very low number and quality of articles particularly addressing this question. This scarce number of evidence precluded performing a systematic analysis. A detailed and narrative description of the potential benefits of integrating interventional techniques into clinical guidelines at the early stages of the disease is provided.

Advances in Animal Models for Studying Bone Fracture Healing

Fracture is a common traumatic injury that is mostly caused by traffic accidents, falls, and falls from height. Fracture healing is a long-term and complex process, and the mode of repair and rate of healing are influenced by a variety of factors. The prevention, treatment, and rehabilitation of fractures are issues that urgently need to be addressed. The preparation of the right animal model can accurately simulate the occurrence of fractures, identify and observe normal and abnormal healing processes, study disease mechanisms, and optimize and develop specific treatment methods. We summarize the current status of fracture healing research, the characteristics of different animal models and the modeling methods for different fracture types, analyze their advantages and disadvantages, and provide a reference basis for basic experimental fracture modeling.

Three generations of treatments for osteoporotic vertebral fractures: what is the evidence?

The management of vertebral compression fractures (VCFs) is based on conservative treatment and minimally invasive vertebral augmentation procedures. However, the role of vertebral augmentation is now being questioned by clinical trials and extensive studies. The aim of this review is to report the most relevant evidences on effectiveness, safety, and indications of the currently available vertebral augmentation techniques. Conservative treatment with bracing is effective in reducing acute but it has no effect on segmental kyphosis progression and pseudoarthrosis can occur. Percutaneous vertebroplasty (PV) was the first vertebral augmentation technique to be proposed for the treatment of VCFs. Two blinded and randomized clinical trials compared PV to a sham procedure and no significant differences in terms of efficacy were reported. More recent studies have suggested that PV can still benefit patients with acute VCFs and severe pain at onset. Balloon kyphoplasty (BK) was developed to improve the segmental alignment restoring the height of collapsed vertebrae. BK allows similar pain relief and disability improvement, as well as greater kyphosis correction compared to PV, moreover BKP seems to reduce cement leakage. Vertebral body stenting (VBS) and the KIVA system are third generation techniques of vertebral augmentation. VBS aims to increase the effectiveness in restoring the segmental alignment, while the KIVA system can prevent cement leakage. These techniques are effective and safe, even if their superiority to BK has yet to be proven by studies with a high level of evidence.

Association of early vertebroplasty with risk of hip replacement: A nationwide population-based cohort study in Taiwan

Studies show that vertebral fractures could predict the risk of hip fractures. We aimed to evaluate the potential benefits of whether the timing of vertebroplasty (VP) for vertebral fracture associated with the risk of hip fracture for hip replacement.We identified 142,782 patients from the Taiwan National Health Insurance Database with thoracolumbar vertebral fracture (International Classification of Diseases, Ninth Revision, Clinical Modification:805.2-805.9) who were followed up from 2000 to 2013. These patients were divided into those who underwent VP (VP group) (International Classification of Diseases, Ninth Revision, Clinical Modification : 78.49) within 3 months and those who did not (non-VP group). After adjusting for the confounding factors, the Cox proportional hazards analysis was used to estimate the effect of early VP on reducing the risk of hip fracture. The difference in the risk of hip replacement, between the VP group and non-VP group was estimated using the Kaplan-Meier method with the log-rank test.In the 14-year follow-up, the cumulative incidence rate of hip replacement in the VP group was lower than that in the non-VP group (0.362% and 0.533%, respectively, long-rank P < .001). There was a significant difference between the 2 groups since the first-year follow-up.Our study showed that early VP performed to avoid progression of the kyphotic changes following thoracolumbar vertebral fracture may reduce the risk of hip fracture. These results, obtained from retrospective data, indicate that a prospective study is warranted.

Mortality Outcomes of Vertebral Augmentation (Vertebroplasty and/or Balloon Kyphoplasty) for Osteoporotic Vertebral Compression Fractures: A Systematic Review and Meta-Analysis

Background Osteoporotic vertebral compression fractures (OVCFs) are prevalent, with associated morbidity and mortality. Vertebral augmentation (VA), defined as either vertebroplasty and/or balloon kyphoplasty (BKP), is a minimally invasive surgical treatment to reduce pain and further collapse and/or renew vertebral body height by introducing bone cement into fractured vertebrae. Nonsurgical management (NSM) for OVCF carries inherent risks. Purpose To summarize the literature and perform a meta-analysis on the mortality outcomes of patients with OVCF treated with VA compared with those in patients treated with NSM. Materials and Methods A single researcher performed a systematic literature review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, or PRISMA, guidelines. Online scientific databases were searched in April 2018 for English-language publications. Included studies investigated mortality in patients with OVCF with VA as the primary intervention and NSM as the comparator. A meta-analysis was performed for studies that reported hazard ratios (HRs) and 95% confidence intervals (CIs). HR was used as a summary statistic and was random-effect-models tested. The χ² test was used to study heterogeneity between trials, and the I² statistic was calculated to estimate variation across studies. Results Of the 16 included studies, eight reported mortality benefits in VA, seven reported no mortality difference, and one reported mixed results. Seven studies were included in a meta-analysis examining findings in more than 2 million patients with OVCF (VA = 382 070, NSM = 1 707 874). The pooled HR comparing VA to NSM was 0.78 (95% CI: 0.66, 0.92; P = .003), with mortality benefits across 2- and 5-year periods (HR = 0.70, 95% CI: 0.69, 0.71, P < .001; and HR = 0.79, 95% CI: 0.62, 0.9999, P = .05; respectively). Balloon kyphoplasty provided mortality benefits over vertebroplasty, with HRs of 0.77 (95% CI: 0.77, 0.78; P < .001) and 0.87 (95% CI: 0.87, 0.88; P < .001), respectively. Conclusion In a meta-analysis of more than 2 million patients, those with osteoporotic vertebral compression fractures who underwent vertebral augmentation were 22% less likely to die at up to 10 years after treatment than those who received nonsurgical treatment. © RSNA, 2020 See also the editorial by Jennings in this issue.

Chronic obstructive pulmonary disease combined with vertebral compression fracture increases the risk of temporomandibular disorder: A population-based cohort study

Vertebral compression fracture (VCF) is a common comorbidity of chronic obstructive pulmonary disease (COPD), and the coexistence of COPD and temporomandibular disorder (TMD) has been clinically noted. The present study aimed to investigate whether VCF increases the risk of TMD in patients with COPD.With a follow-up period of 15 years, this retrospective, population-based longitudinal cohort study enrolled sex- and age-matched COPD patients with and without VCF (1:3) who were identified from Taiwan's National Health Insurance Research Database from 2000 to 2015. Multivariate Cox regression analysis was performed to determine the risk of TMD in COPD patients with and without VCF. The cumulative risk of TMD between groups was estimated using Kaplan-Meier analysis.The risk factors for TMD in patients with COPD were VCF, osteoporosis, and winter season. The COPD with VCF group was more likely to develop TMD (adjusted hazard ratio = 3.011, P < .001) than the COPD without VCF group after adjustment for sex, age, variables, and comorbidities. In the subgroup analysis, the COPD with VCF group had a higher risk of TMD than the COPD without VCF group in almost all stratifications.COPD patients with VCF are at a higher risk of developing TMD. Clinicians taking care of patients with COPD should be aware of the occurrence of TMD as a comorbidity.

Vertebroplasty and Kyphoplasty for Osteoporotic Vertebral Fractures: What Are the Latest Data?

Osteoporotic vertebral compression fractures frequently result in significant morbidity and health care resource use. For patients with severe and disabling pain, vertebral augmentation (vertebroplasty and kyphoplasty) is often considered. Although vertebroplasty was introduced >30 years ago, there are conflicting opinions regarding the role of these procedures in the treatment of osteoporotic vertebral compression fractures. This review article updates clinicians on the published prospective randomized controlled data, including the most recent positive trials that followed initial negative trials in 2009. Analysis of multiple national claim datasets has also provided further insight into the utility of these procedures. Finally, we considered the recent recommendations of national organizations and medical societies that advise on the use of vertebral augmentation procedures for osteoporotic vertebral compression fractures.