Management of acute osteoporotic vertebral fractures: a nonrandomized trial comparing percutaneous vertebroplasty with conservative therapy

Appropriate Use Criteria for Osteoporotic Compression Fractures

BACKGROUND CONTEXT

There is a lack of consensus regarding optimal indications for treatment of patients with osteoporotic vertebral fractures. An opportunity exists to improve outcomes if these indications can be clarified.

PURPOSE

The purpose of the North American Spine Society (NASS) Appropriate Use Criteria (AUC) was to determine the appropriate (i.e. reasonable) multidisciplinary treatment recommendations for patients with osteoporotic vertebral fractures across a spectrum of more common clinical scenarios.

STUDY DESIGN

A Modified Delphi process.

PATIENT SAMPLE

Modified consensus based guideline OUTCOME MEASURES: Final rating for treatment recommendations as either "Appropriate", "Uncertain", or "Rarely Appropriate" based on the median final rating among the raters.

METHODS

The methodology was based on the AUC development process established by the Research AND Development (RAND) Corporation. The topic of osteoporotic vertebral compression fracture was selected by NASS for its Clinical Practice Guideline development (CPG). In conjunction, the AUC committee determined key modifiers and adapted the standard definitions developed by the CPG with minimal modifications. A literature search and evidence analysis performed by the CPG were reviewed by the AUC work group. A separate multidisciplinary rating group was assembled. Clinical scenarios were generated based on a matrix of the modifiers, to rate the appropriateness of medical management, cement augmentation, or surgery. Based on the literature, provider experience, and group discussion, each scenario was scored on a nine-point scale on two separate occasions: once without discussion and again following discussion of the initial responses. The median rating for each scenario and level of agreement was then used to determine final indications as rarely appropriate with agreement (1 - 3), uncertain or disagreement (4-6), or appropriate with agreement (7-9). Consensus was not mandatory.

RESULTS

Medical management was appropriate across all scenarios. Cement augmentation was rarely appropriate in 60% of scenarios and uncertain or disagreement in 35% of scenarios. In the 5% of scenarios rated as appropriate with agreement for cement augmentation, high pain scores, acute duration, and simple fracture pattern were always present. Surgery was appropriate in 35% of scenarios and strongly influenced by instability and stenosis with neurological findings. Surgery was rarely appropriate in 18%, and uncertain or disagreement in 47% of scenarios.

CONCLUSIONS

Multidisciplinary appropriate treatment criteria for osteoporotic vertebral fractures were generated based on the RAND methodology. This document provides comprehensive evidence-based recommendations for evaluation and treatment of osteoporotic vertebral fractures. The document in its entirety will be found on the NASS website (https://www.spine.org/Research-Clinical-Care/Quality-Improvement/Appropriate-Use-Criteria).

Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of adults with osteoporotic vertebral compression fractures

BACKGROUND CONTEXT

The North American Spine Society's (NASS) Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Adults with Osteoporotic Vertebral Compression Fractures features evidence-based recommendations for diagnosing and treating adult patients with osteoporotic vertebral compression fractures. The guideline is intended to reflect contemporary treatment concepts for osteoporotic vertebral compression fractures as reflected in the highest quality clinical literature available on this subject as of September 2020.

PURPOSE

The purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with osteoporotic vertebral compression fractures. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition.

STUDY DESIGN

This is a guideline summary review.

METHODS

This guideline is the product of NASS' Clinical Practice Guidelines Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with a medical librarian. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guideline was submitted to an internal and external peer review process and ultimately approved by the NASS Board of Directors.

RESULTS

Twenty-nine clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature.

CONCLUSIONS

The evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with osteoporotic vertebral compression fractures. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at http://www.spine.org/guidelines.

Treatment Strategies in the Osteoporotic Spine

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

Risk factors for nonunion of osteoporotic vertebral compression fracture: a case‒control study

BACKGROUND

Early assessment of the risk of nonunion in osteoporotic vertebral compression fracture (OVCF) is beneficial to early clinical decision making. However, a comprehensive understanding of the risk factors for OVCF nonunion is lacking.

METHODS

We conducted a case-control study to investigate risk factors for OVCF nonunion. Patients who underwent surgery for nonunited OVCFs between January 2011 and December 2021 were eligible for inclusion as cases. Patients with successful OVCF healing confirmed by MRI over the same period were identified as controls. Patient demographics, comorbidities, and fasting blood test data were extracted for analysis.

RESULTS

A total of 201 patients with nonunited OVCFs and 1044 controls were included to evaluate the risk factors for nonunited OVCFs. There were statistically significant differences in sex, age, number of patients with hypertension, number of patients on bed rest after OVCF and T-score of BMD between the two groups. Logistic regression showed that female patients had a higher risk of OVCF nonunion than male patients and that smoking, drinking, diabetes, and hypertension were risk factors for nonunion of OVCFs, while bed rest and spinal support were protective factors against nonunion of OVCFs. We also found that age, BMD, FBG, and β-CTX were positively correlated with nonunited OVCFs, and that HGB and 1,25-(OH)2VitD3 level were negatively correlated with nonunited OVCFs.

CONCLUSION

Smoking, drinking, diabetes and hypertension were risk factors for nonunion of OVCFs, while bed rest and spinal support were protective factors against nonunion of OVCFs. Age, BMD, FBG and β-CTX were positively correlated with nonunited OVCFs, while HGB and 1,25-(OH)2VitD3 level were negatively correlated with nonunited OVCFs. Based on the results of our study, we suggest that bed rest or spinal support for at least 3 consecutive weeks is necessary to reduce the risk of OVCFs nonunion.

Early Vertebroplasty for Severely Painful Acute Osteoporotic Compression Fractures: A Critical Review of the Literature

Vertebroplasty has emerged over the last 30 years as a common treatment for painful osteoporotic vertebral fractures. Patient selection and the time at which vertebroplasty is offered to the patient varies between centres and regions. Vertebroplasty has been studied in comparison to placebo intervention in five blinded trials. One such trial showed more benefit from vertebroplasty than placebo when the procedure was mostly performed within 3 weeks of fracture onset. Others showed no additional benefit from vertebroplasty compared to placebo when it was performed later in the natural history of the fracture. In this review, we examine data from blinded and open label randomised studies of vertebroplasty for evidence relating specifically to the use of early vertebroplasty for patients with severely painful acute osteoporotic fractures.

Analysis of the most influential publications on vertebral augmentation for treating osteoporotic vertebral compression fracture: A review

This study aimed to analyze the most influential publications on vertebral augmentation for treating osteoporotic vertebral compression fracture. The Web of Science database was searched using the key words "percutaneous vertebroplasty," "percutaneous kyphoplasty," "balloon kyphoplasty," "vertebroplasty," "kyphoplasty," and "vertebral augmentation." The top 100 publications were arranged by citations per year and descriptively and visually analyzed. The top 100 publications were cited 25,482 times, with an average of 14.4 citations per paper per year. The corresponding authors of the publications represented 17 nations, with most authors being American (46 authors). Thirty-two journals were involved, with SPINE issuing the most publications (24 papers of the 100). Clinical research (73 of the 100 papers) outnumbered basic studies (14 papers) and systematic reviews (13 papers), and the most publications were published between 2000 and 2004. Co-citation analysis of the key words indicated that the top 5 focus areas were "complication," "balloon kyphoplasty," "vertebral compression fracture," "biomechanics," and "calcium phosphate cement." The top 3 keywords with the strongest citation bursts were "compression fracture," "cement," and "balloon kyphoplasty." The keywords with persistent strong citation bursts are "balloon kyphoplasty" and "augmentation." There are still contrary opinions about vertebral augmentation; new research should be conducted with more deliberate design and longer follow-up.

Difference in the Cobbs Angle Between Standing and Supine Position as a Prognostic Factor After Vertebral Augmentation in Osteoporotic Vertebral Compression Fractures

Objective

We retrospectively analyzed patients with osteoporotic vertebral compression fracture (OVCF) undergoing vertebral augmentation to compare the Cobb angle changes in the supine and standing positions and the clinical outcomes.

Methods

We retrospectively extracted the data of OVCF patients who underwent vertebral augmentation. Back pain was assessed using a visual analogue scale (VAS). Supine and standing radiographs were assessed before treatment to determine the Cobb angle and compression ratio. Receiver operating characteristic curve analysis was performed to determine the optimal cutoff to predict favorable outcomes after vertebral augmentation.

Results

A total of 249 patients were included. We observed a statistically significant increase in the VAS score change with increasing Cobb angle and compression ratio (p < 0.001), and multivariate logistic regression analysis showed that a difference in the Cobb angle (odds ratio [OR], 1.27) and compression ratio (OR, 1.12) were the independent risk factors for predicting short-term favorable outcomes after vertebral augmentation. In addition, we found that the difference in the Cobb angle (OR, 1.05) was the only factor for predicting midterm favorable outcomes after vertebral augmentation. The optimal cutoff value of the difference in the Cobb angle for predicting midterm favorable outcomes was 35.526°.

Conclusion

We found that the midterm clinical outcome after vertebral augmentation was better when there was a difference of approximately 35% or more in the Cobb angle between the standing and supine positions. Surgeons should pay attention to the difference in the Cobb angle depending on the posture when deciding to perform vertebral augmentation in patients with OVCFs.

Value of MRI in assessing back pain after thoracolumbar osteoporotic vertebral compression fractures and discussion on the underlying mechanisms by tissue biopsy

PURPOSE

The specific radiological feature of osteoporotic vertebral compression fractures (OVCFs) is bone marrow oedema (BME) on magnetic resonance imaging (MRI). However, the relationship between BME and back pain (BP) is unclear. We investigated the value of MRI in assessing BP and discussed the relevant mechanisms by tissue biopsy.

METHODS

One hundred nineteen patients with thoracolumbar OVCFs were included in this study. We divided all patients into two groups: the low-oedema group (BME ≤ 75%) and the high-oedema group (BME > 75%). To reduce the error generated in the acute phase of fracture, we separately analysed patients in phases I (within one month) and II (more than one month). We compared the differences between the groups using the Mann-Whitney U test and investigated the correlations using Spearman's correlation test.

RESULTS

The degree of BP was significantly correlated with BME (p < 0.001; p < 0.001) and fibrous tissue content (p = 0.006; p = 0.035) in both phases. Further, the fibrous tissue content in the low-oedema group (12.49 ± 7.37%; 15.25 ± 13.28%) was significantly lower than that in the high-oedema group (25.68 ± 20.39%, p = 0.014; 23.92 ± 14.61%, p = 0.022) in both phases. The lamellar bone content was significantly correlated with BP (p = 0.021) in phase II.

CONCLUSIONS

BME signals on MRI can accurately predict the degree of BP, and the main mechanisms are related to the stimulation of fibrous tissue.

The Rates of Cement Leakage Following Vertebroplasty in Osteoporotic versus Metastatic Disease

Introduction  Percutaneous vertebroplasty is used for symptomatic osteoporotic fractures and osteolytic neoplasms. We performed a retrospective study to analyze the pattern of leaks in the two cohorts.

Material and Methods  Vertebroplasties performed over a 7-year period at a tertiary orthopaedic center were included in the study and divided into osteoporotic and neoplastic groups. The incidence and pattern of cement leaks in each group were documented and analyzed.

Results  There were 75 leaks of a cohort of 211 vertebroplasties with a relatively equal proportion in osteoporotic and neoplastic groups. The incidence of discal leaks was comparable between the two groups. Lateral and posterior leaks were more common in the neoplastic group.

Conclusion  We report the incidence and type of leaks in osteoporotic and neoplastic groups. Understanding the fracture pattern and preoperative management are both essential in preventing cement leakage. Using highly viscous cement or allowing the cement to harden prior to injection, with use of low pressure, decreases the risk and incidence of cement leakage.

Efficacy and safety of percutaneous vertebroplasty for osteoporotic vertebral compression fractures

Background

Osteoporotic vertebral compression fractures constitute a major concern in elderly population who may not tolerate conservative treatment. Although percutaneous vertebroplasty is an alternative minimally invasive procedure that is commonly used nowadays, there is still debate about its efficacy. The study aim is to provide short term experience about efficacy of vertebroplasty for osteoporotic vertebral fractures.

Methods

Thirty five patients were treated by percutaneous vertebroplasty (the intervention group). The visual analog scale before the intervention (pre VAS), one week after the intervention (post VAS 1), at three months (post VAS 2) after the intervention were compared at each time point with the control group (35 patients). The oswestry disability index before (pre ODI) and three months after the procedure (post ODI) were assessed. The control group received the optimal medical treatment and a regular physiotherapy program for three months.

Results

Both conservative and vertebroplasty group showed significant improvement in the VAS/ODI with time. With vertebroplasty, the improvement is faster and statistically significant compared with conservative group. There were statistically significant differences between both groups concerning post VAS 1, post VAS 2 and post ODI as the P values were 0.00 in all relationships.

Conclusion

Patients with osteoporotic compression fractures who were treated with percutaneous vertebroplasty experienced considerable clinical improvement in comparison with those who received the conservative management.

Impact of Multifidus Muscle Atrophy on the Occurrence of Secondary Symptomatic Adjacent Osteoporotic Vertebral Compression Fractures

To assess the potential influence of multifidus atrophy and fatty degeneration on the incidence of adjacent vertebral compression fractures within one year after the index fracture. In a retrospective cohort study, patients who underwent surgery for an OVCF were identified and baseline characteristics, fracture patterns and the occurrence of secondary adjacent fractures within one year were obtained by chart review. Multifidus muscle atrophy and fatty degeneration were determined on preoperative MRI or CT scans. In this analysis of 191 patients (mean age 77 years, SD 8, 116 female), OF type 3 was the most common type of OVCF (49.2%). Symptomatic adjacent OVCFs within one year after index fracture were observed in 23/191 patients (12%) at mean 12, SD 12 weeks (range 1-42 weeks) postoperatively. The mean multifidus muscle area was 264, SD 53 mm² in patients with an adjacent vertebral fracture and 271, SD 92 mm² in patients without a secondary fracture (p = 0.755). Mean multifidus fatty infiltration was graded Goutallier 2.2, SD 0.6 in patients with an adjacent fracture and Goutallier 2.2, SD 0.7 in patients without an adjacent fracture (p = 0.694). Pre-existing medication with corticosteroids was associated with the occurrence of an adjacent fracture (p = 0.006). Multifidus area and multifidus fatty infiltration had no significant effect on the occurrence of adjacent vertebral fractures within one year after the index fracture. Patients with a pre-existing medication with corticosteroids were more likely to sustain an adjacent fracture.

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.

Numerical Comparison of Restored Vertebral Body Height after Incomplete Burst Fracture of the Lumbar Spine

BACKGROUND AND OBJECTIVES

Vertebral compression fracture is a major health care problem worldwide due to its direct and indirect negative influence on health-related quality of life and increased health care costs. Although a percutaneous surgical intervention with balloon kyphoplasty or metal expansion, the SpineJack, along with bone cement augmentation has been shown to efficiently restore and fix the lost vertebral height, 21-30% vertebral body height loss has been reported in the literature. Furthermore, the effect of the augmentation approaches and the loss of body height on the biomechanical responses in physiological activities remains unclear. Hence, this study aimed to compare the mechanical behavior of the fractured lumbar spine with different restored body heights, augmentation approaches, and posterior fixation after kyphoplasty using the finite element method. Furthermore, different augmentation approaches with bone cement and bone cement along with the SpineJack were also considered in the simulation.

MATERIALS AND METHODS

A numerical lumbar model with an incomplete burst fracture at L3 was used in this study. Two different degrees of restored body height, namely complete and incomplete restorations, after kyphoplasty were investigated. Furthermore, two different augmentation approaches of the fractured vertebral body with bone cement and SpineJack along with bone cement were considered. A posterior instrument (PI) was also used in this study. Physiological loadings with 400 N + 10 Nm in four directions, namely flexion, extension, lateral bending, and axial rotation, were applied to the lumbar spine with different augmentation approaches for comparison.

RESULTS

The results indicated that both the bone cement and bone cement along with the SpineJack could support the fractured vertebral body to react similarly with an intact lumbar spine under identical loadings. When the fractured body height was incompletely restored, the peak stress in the L2-L3 disk above the fractured vertebral body increased by 154% (from 0.93 to 2.37 MPa) and 116% (from 0.18 to 0.39 MPa), respectively, in the annular ground substance and nucleus when compared with the intact one. The use of the PI could reduce the range of motion and facet joint force at the implanted levels but increase the facet joint force at the upper level of the PI.

CONCLUSIONS

In the present study, complete restoration of the body height, as possible in kyphoplasty, is suggested for the management of lumbar vertebral fractures.

Trends and regional variation in vertebroplasty and kyphoplasty in Switzerland: a population-based small area analysis

Regional variation in procedure use often reflects the uncertainty about the risks and benefit of procedures. In Switzerland, regional variation in vertebroplasty and balloon kyphoplasty rates was high, although the variation declined between 2013 and 2018. Substantial parts of the variation remained unexplained, and likely signal unequal access and differing physician opinion.

PURPOSE

To assess trends and regional variation in percutaneous vertebroplasty (VP) and balloon kyphoplasty (BKP) use across Switzerland.

METHODS

We conducted a population-based analysis using patient discharge data from all Swiss acute care hospitals for 2013-2018. We calculated age/sex-standardized mean procedure rates and measures of variation across VP/BKP-specific hospital areas (HSAs). We assessed the influence of potential determinants of variation using multilevel regression models with incremental adjustment for demographics, cultural/socioeconomic, health, and supply factors.

RESULTS

We analyzed 7855 discharges with VP/BKP from 31 HSAs. The mean age/sex-standardized procedure rate increased from 16 to 20/100,000 persons from 2013 to 2018. While the variation in procedure rates across HSAs declined, the overall variation remained high (systematic component of variation from 56.8 to 6.9 from 2013 to 2018). Determinants explained 52% of the variation.

CONCLUSIONS

VP/BKP procedure rates increased and regional variation across Switzerland declined but remained at a high level. A substantial part of the regional variation remained unexplained by potential determinants of variation.

Vertebroplasty for osteoporotic vertebral fracture

Appropriate care of patients with a recent painful osteoporotic vertebral fracture (VF) requires immobilisation, analgesics and spinal orthoses. Some VFs are however responsible for disabling pain and prolonged bed rest. In this context, vertebroplasty techniques have been proposed with a large benefit in case series and open-label randomised studies, but lack efficacy in three among four double-blind randomised studies. The objectives of the treatment of a recent painful VF are to relieve pain and to preserve mechanical conditions. With this in mind, we report an experts’ opinion paper on the indications for vertebroplasty and research agenda for clinical studies.

Survival analysis and risk factors of new vertebral fracture after vertebroplasty for osteoporotic vertebral compression fracture

BACKGROUND CONTEXT

Although risk factors of new adjacent vertebral fracture (AVF) and remote vertebral fracture (RVF) after vertebroplasty may differ, research on this topic is lacking.

PURPOSE

To determine the natural course of new vertebral fractures after vertebroplasty for osteoporotic vertebral compression fracture (OVCF) and to analyze each risk factor for understanding the incidence of AVF and RVF.

STUDY DESIGN

Retrospective cohort study.

PATIENT SAMPLE

The study subjects included 205 patients who received vertebroplasty for OVCF and were followed-up for at least 1-year.

OUTCOME MEASURES

Data on factors that could affect the occurrence of vertebral fractures, such as age, body mass index, and bone density, were collected from the patients' medical records. Fracture pattern, fracture location, sagittal imbalance, degree of segmental kyphosis after vertebroplasty, cement distribution, and cement leakage were radiologically examined.

METHODS

xDuring the follow-up period, any newly developed vertebral fractures were identified. We analyzed whether the time of occurrence differed between AVF and RVF by performing a survival analysis and each risk factor separately.

RESULTS

New vertebral fractures occurred in 47 patients (22.9%) after vertebroplasty, AVF occurred in 21 patients (10.2%), and RVF occurred in 26 patients (12.7%). The onset time of AVF was 6.2±1.8 months after vertebroplasty, showing a significant difference from that of RVF, which was 15.2±1.8 months (p<.001). In the univariate analysis, the risk factors of AVF included severe osteoporosis (T-score<-3.0), vertebroplasty in the thoracolumbar junction, sagittal imbalance, and segmental kyphosis angle >15° (p=0.029, p=0.033, p=0.001, and p=0.021, respectively). The risk factors of RVF included severe osteoporosis (T-score <-3.0) and sagittal imbalance (p=0.013 and p=0.004). In the multivariate analysis, the risk factors of AVF included vertebroplasty in the thoracolumbar junction and sagittal imbalance (hazard ratio=3.34, p=0.032 and hazard ratio=4.05, p=0.008), and those of RVF included only sagittal imbalance (hazard ratio=2.66, p=0.024).

CONCLUSON

After vertebroplasty for OVCF, a significant difference in the meantime of occurrence was found; it took 6 months for AVF and 15 months for RVF to develop. Vertebroplasty in the thoracolumbar junction was identified as a risk factor for AVF, whereas sagittal imbalance was a risk factor of both AVF and RVF.

The Impact of Bone Mineral Density on Bone Metabolism and the Fracture Healing Process in Elderly Chinese Patients With Osteoporotic Vertebral Compression Fractures

BACKGROUND

The aim of this study was to investigate the effect of bone mineral density (BMD) on bone histomorphological parameters and bone turnover markers (BTMs) following osteoporotic vertebral compression fracture (OVCF) and to determine the correlation between BMD and the percentage of middle height compression during the healing process.

METHODS

A total of 206 patients with OVCFs were included in this study. Bone biopsy specimens were acquired during surgery. Blood samples were obtained to determine the serum concentrations of BTMs. The patients were divided into 2 groups according to BMD.

RESULTS

The concentrations of N-terminal propeptide of type I collagen (PINP) in the T-score ≤ -2.5 group (50.92 ± 12.78 ng/ml) were significantly lower than those in the T-score > -2.5 group (68.75 ± 28.66 ng/ml, p = 0.025) 3-6 mo after fracture. Moreover, the volume of necrotic bone in the T-score ≤ -2.5 group (15.15 ± 5.44%) was higher than that (1.67 ± 0.79%, p < 0.001) in the T-score > -2.5 group during the same period. BMD was statistically correlated with cancellous bone content (R_S = 0.761, p <0.001), PMHC (R_S = 0.85, p < 0.001), fibrous tissue volume (R_S = -0.376, p < 0.001), and necrotic bone content (R_S = -0.487, p < 0.001).

CONCLUSIONS

The healing process of OVCFs in the setting of low bone mass frequently occurs in the presence of decreased bone formation abilities, severe vertebral body height loss and a large amount of necrotic bone.

Vertebroplasty Increases the Incidence Of New Vertebral Compression Fractures Compared To Conservative Management

Background Vertebral osteoporotic fractures are a major cause of morbidity and disability among the elderly population.

This study sought to compare the incidence of new vertebral fractures in patients treated by vertebroplasty with that of those managed conservatively, while also assessing the potential risk factors contributing to the occurrence of these fractures.

Materials and Methods The details of a total of 121 eligible subjects with radiologically proven osteoporotic vertebral fractures were retrieved from our archive between January 2010 and September 2019 and divided, based on the treatment method, into percutaneous vertebroplasty (PVP) (n = 60) and nonsurgical treatment (n = 61). The included subjects’ clinical data, demographic profiles, and imaging findings on plain radiography, CT, and MRI scans performed at baseline and within 24 months following treatment were reviewed and documented.

Results The difference in the incidence of new fractures was statistically significant (p = 0.001), with rates of 70% (n = 32) in the vertebroplasty group and 30% (n = 14) in the conservatively treated cases reported at a median follow-up time point of approximately 4 months. The presence of liver disease (p = 0.037), a history of transplantation (p = 0.003), the use of steroids (p = 0.023), a low-bone mineral density (BMD) score (p = 0.023), and a higher number of fractures on baseline imaging (p = 0.013) were associated with a greater risk of subsequent vertebral fractures.

Conclusions The incidence of acute fractures after PVP is higher than that among patients treated conservatively. Decision-making regarding the adoption of this intervention should take into consideration the risk factors leading to a greater risk of subsequent vertebral fractures, such as a higher number of fractures at baseline imaging, low-BMD score, patient comorbidities, and steroid use.

The 100 Most-Cited Papers in Traumatic Injury of the Spine

Background

Traumatic injury to the spine can be a complex diagnostic and therapeutic entity often with devastating consequences. Outside of the isolated vertebral column injury costs; annual costs associated with spinal cord injury (SCI) are estimated to exceed $9.7 billion.

Objective

To identify the 100 most-cited articles on spine trauma.

Methods

The Thomson Reuters Web of Science citation indexing service was queried. The articles were sorted by times cited in descending order. Two independent reviewers reviewed the article titles and abstracts to identify the top 100 most-cited articles.

Results

The top 100 articles were found to be cited between 108 (articles #99-100) and 1595 times (article #1). The most-cited basic science article was cited 340 times (#12 on the top 100 list). The oldest article on the top 100 list was from 1953 and most recent from 2012. The number of patients, when applicable, in a study ranged from 9 (article #34) to 34,069 (article #5). Top 100 articles were published in 41 different journals with a wide range of specialities and fields most commonly multidisciplinary. Basic science research encompassed 34 of the 100 articles on the list.

Conclusions

We present the 100 most-cited articles in spinal trauma with emphases on important contributions from both basic science and clinical research across a wide range of authors, specialties, patient populations, and countries. Recognizing some of the most important contributions in the field of spinal trauma may provide insight and guide future work.

Percutaneous Vertebroplasty and Facet Blocking for Treating Back Pain Caused by Osteoporotic Vertebral Compression Fracture

Methods

Clinical and radiological data of 204 patients were reviewed. The patients were divided into Group A (PVP alone) and Group B (PVP and FB combined therapy) according to treatments. Back pain was evaluated with Visual Analog Scale (VAS) and Oswestry Disability Index (ODI). The operation, fluoroscopic exposure time, and bone cement leakage were recorded. The χ² test, Student's t-test, and repeated measures analysis of variance were used to compare the differences between the two groups.

Results

There were 125 patients in Group A and 79 patients in Group B. Their baseline characteristics were similar (P > 0.05). The mean VAS scores of Group A and Group B were 7.03 and 7.21 at admission, 4.7 and 3.2 at 1 day after operation, 4.0 and 3.0 at 3 months, and 2.2 and 2.2 at 12 months after operation, respectively. The mean ODI scores of Group A and Group B were 30.9 and 29.8 at admission, 17.6 and 17.7 at 3 months, and 10.5 and 10.9 at 12 months after operation, respectively. The mean operation time and fluoroscopic exposure time of Group A (35.6 minutes and 7.2 seconds, respectively) was significantly shorter than that of Group B (45.7 minutes and 11.7 seconds, respectively, P < 0.01). The incidence of bone cement leakage and new fractures after operation did not have statistically significant difference between groups.

Conclusion

PVP and FB combined therapy could provide better pain relief than PVP alone in short term after operation in patients with OVCFs associated back pains.

Clinical and radiological subsequent fractures after vertebral augmentation for treating osteoporotic vertebral compression fractures: a meta-analysis

PURPOSE

This study aimed to identify all relevant randomized controlled trials (RCT) and prospective non-RCTs to further investigate whether percutaneous vertebral augmentation (PVA) was associated with clinical and radiological subsequent fractures on unoperated levels.

METHODS

We systematically searched PubMed, EMBASE, Cochrane library, Google Scholar, web of science, and ClinicalTrial.gov from the establishment of the database to January 2020. All eligible studies comparing subsequent fractures after PVA with those after conservative treatment (CT) were incorporated. The pooled risk ratio (RR) with its 95% confidence intervals (95% CIs) was used. Heterogeneity, sensitivity, and publication bias analyses were performed.

RESULTS

In all, 32 studies were included in the study: 82/512 patients (16.02%) and 58/433 patients (13.39%) had clinical subsequent fractures in the PVA group and CT group, respectively. No significant differences were observed between the two groups [RR = 1.22, 95% CI 0.70-2.12, P = 0.49]. Further, 175/837 patients (20.91%) in the PVA group and 160/828 patients (19.32%) in the CT group had radiological subsequent fractures. No significant difference was observed between groups [RR = 0.91, 95% CI 0.71-2.12, P = 1.16]. Further, no statistical difference was observed on subgroup analysis between RCTs and non-RCTs or PVP and PKP.

CONCLUSION

Our systematic review revealed that subsequent fractures on unoperated levels were not associated with PVA, regardless of whether they were clinical or radiological subsequent fractures.

Additional Magnetic Resonance or Nuclear Scintigraphy Imaging Influences Approach to Vertebral Augmentation: A Single Institution Experience

STUDY DESIGN

Retrospective review.

OBJECTIVE

To ascertain impact of preprocedural magnetic resonance imaging (MRI) or nuclear medicine Tc99m-DMP scintigraphy on the treatment plan when compared with plain films and/or computed tomography prior to vertebral augmentation procedures.

SUMMARY OF BACKGROUND DATA

Over 1 million vertebral compression fractures (VCFs) occur in the United States annually with over 150,000 individuals hospitalized each year. Physical examination and history are essential to the workup of VCFs, but imaging remains necessary for confirming the diagnosis. VCFs can be imaged with various modalities and there is limited data on the comparative effectiveness of different imaging modalities.

METHODS

Six hundred fifty consecutive patients treated with vertebral augmentation at a single institution between May of 2013 and April of 2018 were reviewed. Preprocedure imaging of the spine obtained within 30 days prior to the procedure were reviewed. Preprocedure imaging results were cross-referenced against the levels treated by vertebral augmentation to determine whether there was a change in the levels treated after receiving an MRI or NM imaging study.

RESULTS

Three hundred sixty-three patients had adequate imaging for inclusion. One hundred fifty-four of these 363 patients (42.4%) had an alteration of their treatment plan based upon the MR or NM imaging. Fewer vertebral levels were treated in 33, different levels were treated in 41, and more levels were treated in 80 patients.

CONCLUSION

MRI or nuclear medicine bone scan imaging prior to vertebral augmentation altered the location and number of levels treated in a large percentage of patients, adding specificity to treatment over findings on radiographs or computed tomography alone.

LEVEL OF EVIDENCE

3.

Changes of Bone Turnover Markers and Bone Tissue Content After Severe Osteoporotic Vertebral Compression Fracture

Background

The incidence of osteoporotic vertebral fractures (OVCFs) has increased significantly in recent years. In order to assess osteoporotic fracture healing process, it is necessary to study the characteristics after this type of vertebral fracture. However, there are few researches on fracture healing process in severe OVCFs. We aim to investigate the histological healing process and the kinetics of bone turnover markers following severe OVCFs.

Material/Methods

There were 149 patients with severe OVCFs included in this study. Fasting blood samples were obtained to detect bone turnover markers levels. A transpedicular bone biopsy was performed to collect bone biopsy specimens during vertebroplasty surgery. Stratification of healing process was performed: stage I (1–3 days), stage II (4–10 days), stage III (11–20 days), stage IV (21–30 days), stage V (1–3 months), stage VI (3–6 months).

Results

Quantitative analysis of bone histomorphometry showed that a large amount of necrotic bone tissue was observed in stage VI (12.92±3.66%). Bone turnover markers showed the concentration of β-isomerized C-terminal telopeptide (β-CTX) which reflects activity in osteoclast continued to increase in stage VI (0.9±0.33 ng/mL). These results differed from previous reports of other type vertebral fractures.

Conclusions

Bone histomorphometric analysis and bone turnover markers showed that severe osteoporotic vertebral compression fractures often associated with delayed union and nonunion during the healing process.

Deterioration of Cortical and Trabecular Microstructure Identifies Women With Osteopenia or Normal Bone Mineral Density at Imminent and Long-Term Risk for Fragility Fracture: A Prospective Study

More than 70% of women sustaining fractures have osteopenia or "normal" bone mineral density (BMD). These women remain undetected using the BMD threshold of -2.5 SD for osteoporosis. As microstructural deterioration increases bone fragility disproportionate to the bone loss producing osteopenia/normal BMD, we hypothesized that the structural fragility score (SFS) of ≥70 units, a measure capturing severe cortical and trabecular deterioration, will identify these women. Distal radial images were acquired using high-resolution peripheral quantitative tomography in postmenopausal French women, mean age 67 years (range 42-96 years); 1539 women were followed for 4 years (QUALYOR) and 561 women followed for 8 years (OFELY). Women with osteopenia or normal BMD accounted for ~80% of fractures. Women ≥70 years, 29.2% of the cohort, accounted for 39.2% to 61.5% of fractures depending on follow-up duration. Women having fractures had a higher SFS, lower BMD, and a higher fracture risk assessment score (FRAX) than women remaining fracture-free. In each BMD category (osteoporosis, osteopenia, normal BMD), fracture incidence was two to three times higher in women with SFS ≥70 than <70. In multivariable analyses, associations with fractures remained for BMD and SFS, not FRAX. BMD was no longer, or weakly, associated with fractures after accounting for SFS, whereas SFS remained associated with fracture after accounting for BMD. SFS detected two-to threefold more women having fractures than BMD or FRAX. SFS in women with osteopenia/normal BMD conferred an odds ratio for fracture of 2.69 to 5.19 for women of any age and 4.98 to 12.2 for women ≥70 years. Receiver-operator curve (ROC) analyses showed a significant area under the curve (AUC) for SFS, but not BMD or FRAX for the women ≥70 years of age. Targeting women aged ≥70 years with osteopenia indicated that treating 25% using SFS to allocate treatment conferred a cost-effectiveness ratio < USD $21,000/QALY saved. Quantifying microstructural deterioration complements BMD by identifying women without osteoporosis at imminent and longer-term fracture risk. © 2019 American Society for Bone and Mineral Research.

Early vertebroplasty within 3 weeks of fracture for acute painful vertebral osteoporotic fractures: subgroup analysis of the VAPOUR trial and review of the literature

BACKGROUND

VAPOUR found vertebroplasty (V) more effective than placebo (P) in patients with severe pain and fracture duration less than 6 weeks. Exploratory analysis suggested that benefits were concentrated in the subgroup of patients with fractures ≤ 3-week duration. This difference may account for the three negative blinded trials that included few patients within this fracture time frame.

PURPOSE

To assess the safety and efficacy of early vertebroplasty for acute painful vertebral osteoporotic fractures within 3 weeks of fracture onset in the VAPOUR study.

METHODS

Spearman's rank log coefficients were calculated to reassess the relationship of pain reduction from vertebroplasty and fracture duration in the VAPOUR trial. We more fully report baseline and outcome data in patients with fractures ≤ 3-week duration.

RESULTS

There were 46V and 47P patients with fractures ≤ 3-week duration. Baseline characteristics were similar. In total, 86 patients (41V, 45P) completed the 14-day questionnaire. The proportion of patients with reduction in pain from severe (NRS ≥ 7/10 was an inclusion requirement) to mild (NRS < 4) at 14 days was 21 (51%) V-group and 9 (20%) in the P-group (between-group difference 31 percentage points, 95% CI 12-50; p = 0.002). Early vertebroplasty provided greater reductions in mean NRS pain and Roland-Morris Disability.

CONCLUSION

Analysis of this patient subgroup from the VAPOUR trial, in the context of other randomised trial evidence, suggests clinically significant benefits from early vertebroplasty if performed within 3 weeks of fracture. These slides can be retrieved from Electronic Supplementary Material.

Poly(methyl methacrylate) bone cement composited with mineralized collagen for osteoporotic vertebral compression fractures in extremely old patients

To examine the clinical effects of a new bone cement composed of poly(methyl methacrylate) (PMMA) and mineralized collagen (MC) compared with pure PMMA bone cement in treating osteoporotic vertebral compression fractures (OVCFs) in patients aged over 80. In all, 32 cases using pure PMMA bone cement and 31 cases using MC-modified PMMA (MC-PMMA) bone cement for OVCFs between June 2014 and March 2016 were screened as PMMA group and MC-PMMA group, respectively, with an average age of over 80. The operation duration, intraoperative blood loss, hospital stay, oswestry disability index (ODI), visual analogue scale (VAS), anterior vertebral height (AVH), intermediate vertebral height (IVH) and posterior vertebral height (PVH) of injured vertebrae, vertebral computed tomography value, re-fracture rate of adjacent vertebrae, correction rate of spinal kyphotic angle and wedge-shaped vertebra angle and surgical complications were compared between the two groups. In the early post-operative period, the VAS, ODI, AVH and IVH in MC-PMMA group were comparable to those in the traditional PMMA group. Moreover, the MC-PMMA group showed better effects compared with the PMMA group 12 months after surgery. Thus, this new bone cement has superior clinic effects in the long term.

Percutaneous vertebroplasty versus non-operative treatment for osteoporotic vertebral compression fractures: a meta-analysis of randomized controlled trials

PURPOSE

Osteoporotic vertebral compression fractures (OVCFs) are common in the elderly population and are often treated using percutaneous vertebroplasty (PVP). However, the effectiveness of PVP reported by various randomized controlled trials (RCTs) is inconclusive. This study aimed to analyze, from published literature, the efficacy and safety of PVP for OVCFs.

METHODS

A search was conducted in Medline, EMBASE, and Cochrane Libraries since their respective inception on January 1, 2019, for RCTs of OVCFs treated with PVP compared with non-operative treatment. The primary outcomes were pain relief at 1 to 2 weeks, 1 to 3 months, and 6 to 12 months. The secondary outcome was the rate of occurrence of new vertebral fractures. Meta-analysis was performed using a random effect model.

RESULTS

A total of 13 RCTs comprising 1624 patients were included. For the blinded studies, statistical differences were found between PVP and the sham injection group for the 3 primary outcomes in the subgroup of the Vertebroplasty for Acute Painful Osteoporotic fractURes (VAPOUR) trial. Although pain scores were similar between the PVP group and the sham injection group for the VAPOUR trial at each period, the effect size of PVP increased over time. For the open-label studies, PVP significantly reduced pain at all time points. The risk of new vertebral fractures was similar between the PVP groups and control groups.

CONCLUSIONS

Application of PVP was effective and safe only in patients with acute OVCFs having persistent and severe pain. No benefits were recorded, among patients with older fractures or those bearing non-severe symptoms.

Risk factors of neurological deficit and pulmonary cement embolism after percutaneous vertebroplasty

Background

The risk factors, incidence, and clinical management of pulmonary cement embolism and neurological deficit during percutaneous vertebroplasty (PVP) were evaluated.

Methods

Three thousand one hundred and seventy-five patients with symptomatic osteoporotic vertebral compression fractures (OVCFs) treated with PVP were retrospectively reviewed in a single institution. Clinical parameters such as age, gender, number of fractures, and time from fracture to vertebroplasty were recorded at the time of surgery. Image and surgical parameters including the amount of cement, the vertebral level, uni- or bipedicle surgical approach, and leakage pattern were recorded.

Results

Type-C leakage, including paraspinal (25%), intradiscal (26%), and posterior (0.7%) leakage, was more common than type-B (11.4%) and type-S leaks (4.9%). Cement leakage into the spinal canal (type-C posterior) occurred in 26 patients (0.7%), and four patients needed surgical decompression. Three in nine patients with leakage into thoracic spine needed decompressive surgery, but only one of 17 patients into lumbar spine needed surgery (p < 0.01). Age, gender, number of fractures, and time from fracture to vertebroplasty were not risk factors of pulmonary cement embolism or neurological deficit. The risk factor of pulmonary cement embolism was higher volume of PMMA injected (p < 0.001) and risk factor of neurological deficit was type-C posterior cement leakage into thoracic spine. The incidence of pulmonary cement embolism was significantly high in the volume of PMMA injected (PMMA injection < 3.5 cc: 0%; 3.5–7.0 cc: 0.11%; > 7.0 cc: 0.9%; p < 0.01) which needed postoperative oxygen support.

Conclusions

Cement leakage is relatively common but mostly of no clinical significance. Percutaneous vertebroplasty in thoracic spine and high amount of PMMA injected should be treated with caution in clinical practice.

Percutaneous kyphoplasty assisted with/without mixed reality technology in treatment of OVCF with IVC: a prospective study

Background

The purpose of this study was to assess the clinical outcome of percutaneous kyphoplasty (PKP) assisted with mixed reality (MR) technology in treatment of osteoporotic vertebral compression fracture (OVCF) with intravertebral vacuum cleft (IVC).

Method

Forty cases of OVCF with IVC undergoing PKP were randomized into a MR technology-assisted group (group A) and a traditional C-arm fluoroscopy group (group B). Both groups were performed PKP and evaluated by VAS scores, ODI scores, radiological evidence of vertebral body height, and kyphotic angle (KA) at pre-operation and post-operation. The volume of injected cement, fluoroscopy times, and operation time were recorded. And cases of non-PMMA-endplates-contact(NPEC) in radiological evidence was also recorded postoperatively. The clinical outcomes and complications were evaluated afterwards. All patients received 10 to 14 months follow-up, with an average of 12 months.

Result

This MR-assisted group (group A) acquired more about the amount of the polymethyl methacrylate (PMMA) injection and postoperative vertebral height and less about postoperative KA, fluoroscopy times, and operation time compared with the control group (group B) (P < 0.05). The VAS scores and ODI scores in both groups have improved, but more significantly in group A (P < 0.05). Also, more cases achieve both-endplates-touching of cement in group A (P < 0.05). And there are less of the loss of vertebral height, KA, and occurrence of re-collapse of the vertebra in group A during the follow-up (P < 0.05).

Conclusion

PKP assisted with MR technology can accurately orientate the position of IVC area, which can be augmented by the balloon leading to more satisfied vertebral height improvement, cement diffusion, and pain relief.

Trial registration

ClinicalTrials.gov Identifier: NCT03959059. Registered 25 September 2016.

Can Three Months of Teriparatide Be One of Treatment Options for Osteoporotic Vertebral Compression Fracture Patients?

Objective

Osteoporosis is one of the most common causes of vertebral compression fractures (VCFs). Teriparatide, a recombinant human parathyroid hormone, is the first anabolic agent for the treatment of osteoporosis. The aim of this study was to determine whether 3 months of teriparatide could be effective for patients with osteoporotic VCF at the thoracolumbar spine.

Methods

We reviewed 25 patients with thoracolumbar osteoporotic compression fractures between July 2012 and October 2016 who could be followed up for more than 1 year. Patients were divided into 2 groups depending on the use of teriparatide: 14 patients received teriparatide through subcutaneous injection (group I) and 11 patients did not receive teriparatide (group II). Demographic data, bone mineral density, hospitalization period, changes in the visual analogue scale (VAS) score, body mass index, and medical history such as smoking, alcohol, diabetes, and steroid usage were reviewed. Radiographs were also reviewed to evaluate vertebral body compression percentages and kyphotic angles.

Results

Overall changes of VAS score between injury and follow-up were statistically improved in both groups at 2 to 3 weeks post-injury. However, difference in VAS improvement at a specific time between the 2 groups was not statistically significant. Overall kyphotic angle and compression percentage between injury and follow-up time were increased in group II than those in group I, although the difference between the 2 groups was not statistically significant.

Conclusion

Three-month of teriparatide did not show protective effects on progression of fractured vertebral body collapse or kyphotic changes in patients with osteoporosis.

Navigation for Tubular Decompression of the L5 Nerve Root Ganglion after Cement Leakage via a Wiltse Approach

Osteoporotic vertebral fractures are a widespread problem in the elderly population. In experienced hands, treatment procedures are safe and can be done in a minimally invasive fashion. Nevertheless, in rare cases, severe complications may occur. We present a case report of cement leakage after vertebroplasty of L5 compressing the nerve root with neurological signs and radiculopathy. An 86-year-old female patient was introduced to our department with severe L5 nerve root radiculopathy and a foot flexion paresis after vertebroplasty of L5. Computed tomography (CT) of the lumbar spine revealed extraforaminal extravasation of cement around the nerve root causing significant compression. The patient underwent surgical revision using spinal navigation for skin incision, retractor placing, and verification of the cement extravasation. The cement plombage was removed, and the patient improved immediately. Sufficient decompression of the nerve root after cement leakage can be achieved using a spinal navigation setup in combination with intraoperative CT.

The safety and efficacy of percutaneous vertebroplasty for patients over 90 years old

OBJECTIVE

To retrospectively analyze the safety and efficacy of percutaneous vertebroplasty (PVP) for patients aged 90 or over.

MATERIALS AND METHODS

We analyzed 130 consecutive patients with osteoporotic vertebral fractures who underwent a first-time PVP between May 2015 and September 2017 at our institution. We divided them into the elder patient group aged 90 years or over (n = 21) and the younger patient group under 90 years (n = 109). We compared the two groups' background, treatments, and outcomes using univariate analyzes and the log rank test.

RESULTS

A significant difference was observed in dementia (19% in the younger group vs. 48% in the elder group, p < 0.01). No significant difference was revealed in the procedure time or the rate of complications. The post-PVP mobility function and the pain level were significantly improved compared to before PVP in both groups (p < 0.01 each). No significant differences were observed between the two groups in the recurrence of vertebral fracture after treatment (17% vs. 14%) or the 1-year survival rate (79% vs. 86%), respectively.

CONCLUSION

The results of our analyzes suggested that a PVP can safely and effectively contribute to pain relief as well as the restoration of ambulation for patients aged 90 or over.

Medial Branch Block Versus Vertebroplasty for 1-Level Osteoporotic Vertebral Compression Fracture: 2-Year Retrospective Study

OBJECTIVE

Percutaneous vertebroplasty (VP) and medial branch block (MBB) are used to treat osteoporotic vertebral compression fractures (VCF). We compared the clinical outcomes, radiologic changes, and economic results of MBB with those of VP in treating osteoporotic VCFs.

METHODS

A total of 164 patients with 1-level osteoporotic VCF were reviewed retrospectively. The clinical outcomes were measured with a visual analogue scale (VAS) and the Oswestry Disability Index (ODI). To compare economic costs between groups, total hospital costs at the last follow-up day were calculated.

RESULTS

The patients were divided into 2 groups: 72 patients in the conservative group treated by MBB (MBB group) and 92 patients in the group who underwent VP (VP group). The VAS and ODI scores improved significantly within postoperative week 1 in the VP group compared with the MBB group. However, the VAS and ODI scores did not differ between the groups after 1 postoperative year. After 2 years of follow-up, 14 new fractures occurred in the VP group and 3 in the MBB group. The improvement in compression ratio was statistically greater in the VP group than in the MBB group. However, after 2 years the radiologic changes between groups did not differ statistically. After the final follow-up visits, the hospital costs were significantly lower in the MBB group.

CONCLUSIONS

After 2 years of follow-up, VP and MBB both had similar efficacy in terms of pain relief and radiologic changes. MBB was more cost effective than VP. Thus, MBB alone can be a possible alternative to VP in patients with 1-level osteoporotic VCFs.

Safety and results of image-guided vertebroplasty with elastomeric polymer material (elastoplasty)

Background

Image-guided elastoplasty is an innovative method for percutaneous vertebral augmentation with a silicone elastomeric material. Our aim was to evaluate its technical success, safety and efficacy as well as the rate of secondary fractures.

Methods

Nineteen patients (13 women and 6 men, age 72 ± 10 years, mean ± standard deviation) underwent elastoplasty between 2010 and 2016. A total of 33 vertebrae were treated. A total of 2–6 mL of silicone-based elastomeric polymer material (VK100) was used. Visual analogue scale (VAS) and Oswestry disability index (ODI) pain scores were used.

Results

In all cases, it was possible to complete the procedure (technical success 100%). No major complications occurred. In 6/19 (31.5%) patients, asymptomatic leakage of the material was observed during the procedure. Full pain recovery was obtained in 18/19 (94%) patients. One patient with a painful angioma did not experience any change in symptoms. VAS and ODI were significantly reduced after the procedure, from 7.9 ± 1.1 to 0.7 ± 1.4 and from 79.6 ± 12% to 9.9 ± 14% respectively (p < 0.001 for both comparisons). After vertebroplasty, 14 of 15 patients (93%) removed the brace and 16/19 (84%) completely stopped using any drugs for pain relief (p < 0.001 for both pre-procedure versus post-procedure comparisons). At a mean follow-up time of 26.5 ± 28.1 months (median 8.7 months, range 6–69 months), no secondary fracture occurred.

Conclusion

Taking into consideration the relatively small sample size, image-guided elastoplasty seems to be a safe procedure providing effective pain control over time.

Vertebral Augmentation is Superior to Nonoperative Care at Reducing Lower Back Pain for Symptomatic Osteoporotic Compression Fractures: A Meta-Analysis

STUDY DESIGN

This is a systematic review and meta-analysis.

OBJECTIVE

This study's goal was to (i) assess the clinical outcomes with and without vertebral augmentation (VA) for osteoporotic vertebral compression fractures (VCFs) with versus without correlating signs and symptoms; and (ii) acute (symptoms <3 mo duration) and subacute VCFs (3-6 mo duration) versus chronic VCFs (>6 mo).

SUMMARY OF BACKGROUND DATA

Previously, a randomized controlled trial in the New England Journal of Medicine concluded that vertebroplasty for osteoporotic VCFs provided no clinical benefit over sham surgery. However, the VCFs examined had no clinical correlation with symptom, physical examination, or imaging (magnetic resonance imaging/bone scan) findings. Nonetheless, the randomized controlled trial resulted in a reduction in VA performed in the United States. Currently, no consensus exists on VA versus nonoperative care for symptomatic VCFs (SVFs).

MATERIALS AND METHODS

A literature search was conducted for studies on VA and conservative management for VCFs. Meta-analysis was performed using the random-effects model. The primary outcome was improvement in lower back pain visual analog score. SVFs were defined as radiographic VCF with clinical correlation. Radiographic-alone VCF (RVF) was defined as radiographic VCF without clinical correlation.

RESULTS

Thirteen studies totaling 1467 patients with minimum 6-month follow-up were found. Pain reduction was greater with VA over conservative management for SVFs (P<0.000001) and equivalent for RVFs (P=0.22). Subanalysis for acute/subacute SVFs and chronic SVFs showed that VA was superior to nonoperative care (P=0.0009 and 0.04, respectively). No difference was observed in outcomes between VA and nonoperative care for chronic RVF (P=0.22).

CONCLUSIONS

VA is superior to nonoperative care in reducing lower back pain for osteoporotic VCFs with correlating signs and symptoms. VA had no benefit over nonoperative care for chronic VCFs that lacked clinical correlation. Lower back pain has many etiologies and patients should be clinically assessed before recommending VA.

Single-level vertebral kyphoplasty is not associated with an increased risk of symptomatic secondary adjacent osteoporotic vertebral compression fractures: a matched case-control analysis

This matched case-control study compared the rate of symptomatic adjacent-level vertebral compression fractures (VCF) within 1 year in patients operatively treated with kyphoplasty to a control group of non-operatively treated VCFs. The adjacent-level fracture rate did not show a significant difference between groups.

PURPOSE

To compare the rate of new symptomatic adjacent-level fractures within 1 year after an isolated osteoporotic vertebral compression fracture (VCF) treated by either kyphoplasty or non-operative treatment.

METHODS

Patients aged ≥ 50 years with an isolated, fresh, and symptomatic osteoporotic VCF who were treated by kyphoplasty were compared to patients of similar age, gender, vertebral segment, and bone mineral density who were treated non-operatively (n = 98). A matched case-control analysis was conducted by retrospective chart review, and the rate of new adjacent-level symptomatic vertebral fractures, defined as occurring within two segments of the index fracture, within the first year was determined.

RESULTS

Ninety-eight patients (66 female, aged 73.5, SD 9.7 years) were analyzed in this matched case-control study. The adjacent fracture rate within 1 year was not different between the kyphoplasty group and the non-operative group (20.4 vs 18.4%; McNemar, p = 1.0). The time to a new adjacent fracture after the index fracture was significantly shorter in the kyphoplasty (7, SD 8 weeks) versus non-operative group (22, SD 13 weeks).

CONCLUSIONS

Patients with osteoporotic VCFs treated with kyphoplasty did not show an increased rate of additional symptomatic adjacent-level VCFs when compared to a non-operative control group matched for age, gender, fracture level, and bone mineral density.

LEVEL OF EVIDENCE

Level III.

Cadaveric device-injected very high-viscosity cement during vertebroplasty

Introduction:

Cement extravasation during vertebroplasty (VP) is the most commonly reported complication. Cement viscosity is considered the single most important predictor of the risk of extravasation. Certainly, injecting high-viscosity cement (HVC) is difficult to utilize in real practice. We invented a new device capable of injecting high-viscosity with ease and at a distance to avoid radiation. The aim of this study is to confirm the efficacy and safety of the new device on cadaveric vertebrae.

Methodology:

A 126 osteoporotic vertebral bodies were harvested from cadavers. Eighty vertebrae were included in the study. Computer-randomization software was used to allocate specimens over two main groups, Conventional VP and New Device. Both groups were further subdivided into two subgroups; high-viscosity and low-viscosity. A custom device was used on each vertebra to induce a compression fracture.

Results:

Injecting HVC was associated with a lower leakage volume compared with low-viscosity cement. HVC was associated with no leakage into the spinal canal. It was also associated with a low incidence of vascular extravasation (P < 0.001). The mean volume of cement leakage in the low-viscosity group was 0.23 and 0.15 cc, for the Conventional VP and New Device, respectively. In both groups, the most common site for leakage was the vertebral end plate, which was exhibited more in the low-viscosity group (71.5%) compared with the high-viscosity group (42.5%). The preset target amount of cement to be injected was reached in 99% of the time when injecting HVC with the New Device, compared with 62% using the Conventional VP. In both groups, there was no correlation between the amount of cement injected and the amount of leakage.

Conclusion:

The new device is capable of injecting HVC easily, with a lower incidence of cement leakage. It also minimized the risk of radiation exposure to the surgeon.

Nonfusion Intracorporeal Enhancement System for the Treatment of Osteoporotic Vertebral Compression Fractures-Preliminary Clinical Result of a Novel Technique

OBJECTIVE

This study sought to determine whether implantation of a newly designed nonfusion intracorporeal enhancement (NICE) system is an effective and safe way to treat osteoporotic vertebral compression fracture (OVCF).

METHODS

Thirteen patients with OVCF (10 women, 3 men; mean age 69 years, T11-L4) were included. From June 2014 to June 2016, all patients were treated with the NICE system. The clinical and radiologic results were evaluated preoperatively, postoperatively, and at 24 months follow-up based on the visual analog scale and the Oswestry Disability Index, radiography, magnetic resonance imaging, and computed tomography (height of fractured body and kyphosis Cobb angle).

RESULTS

There was a significant improvement in pain intensity (visual analog scale score decreased from 8.3 preoperatively to 2.2 postoperatively, and decreased to 1.5 twenty-four months postoperatively). Also, a significant reduction was observed in that the mean Oswestry Disability Index decreased from 71.9% preoperatively to 17.6% after 24 months. The mean Cobb angle had a significant improvement, which decreased from 6.6° preoperatively to 1.3° postoperatively and then decreased to 1.2° after 24 months. Height of fractured body improved significantly from 66.4% to 86.5% and slightly decreased to 82.4% after 24 months. No specific complications were identified to be associated with this technique.

CONCLUSIONS

With a low complication rate, the clinical midterm results are satisfactory. The treatment of symptomatic OVCF with the NICE system is a safe and effective procedure.

Glass -polyalkenoate cement: An alternative material for kyphoplasty in osteoporotic vertebral compression fractures - An ex vivo study

Adjacent vertebral body fracture is described as a risk after vertebroplasty and kyphoplasty. It may be true that this phenomenon is caused precisely because of the frequently used polymethylmethacrylate cement (PMMA), which shows a higher level of stiffness than bone material and may ultimately lead to shifting stress levels within the entire spine. The goal of the present study was to evaluate and compare the pressure distribution in the endplate of human vertebrae after kyphoplasty with PMMA and aluminum-free glass-polyalkenoate cement (gpc). For the present study, 8 fresh frozen human cadaveric vertebral bodies from the thoracolumbar junction were used. All vertebrae were augmented transpedicularly on one side with gpc and on the other side with PMMA. A loading of 600 N, 800 N and 1000 N was applied. In the data processing an individual region of interest (roi) was generated for each vertebra. The following parameters were determined for each roi: maximum force [N], maximum pressure [kPa], mean pressure [kPa], roi area [cm²]. We found significantly higher mean pressure values in the areas of the vertebrae augmented with PMMA, compared to the ones after augmentation with gpc (p = 0.012) when applying 1000 N. In the groups with lower forces there were no statistical relevant differences. The pressure distribution shows an advantage for gpc. A material, which does not create load concentration onto the cranial and caudal vertebral surface, could have major advantages concerning the risk of adjacent vertebral fractures. Thus the results of the 1000 N loading protocol suggest gpc being a possible alternative to ordinary PMMA cement, regarding its influence on stiffness in kyphoplasty. These and other general aspects like incorporation should be addressed and elaborated more detailed in further studies.

Correlation analysis between the magnetic resonance imaging characteristics of osteoporotic vertebral compression fractures and the efficacy of percutaneous vertebroplasty: a prospective cohort study

Background

To explore the relationship between the magnetic resonance imaging (MRI) characteristics of osteoporotic vertebral compression fractures (OVCFs) and the efficacy of percutaneous vertebroplasty (PVP).

Methods

A prospective study was conducted to analyze the clinical and imaging data of 93 patients with OVCFs treated via PVP. A visual analogue scale (VAS), the Oswestry Disability Index (ODI), and the Medical Outcomes Study(MOS) 36-Item short-form health survey (SF-36) were completed before surgery as well as 1 day and 1, 6, and 12 months after surgery. In addition, postoperative complications were recorded. According to the degree and ranges of bone marrow edema on MRI, the patients were divided into three groups: the mild (group A), moderate (group B), and severe (group C) bone marrow edema groups. Pain and dysfunction scores were compared across the three groups of patients before surgery as well as 1 day and 1, 6, and 12 months after surgery.

Results

The VAS, ODI, and SF-36 scores showed significant differences (P < 0.05) before and after surgery among the three groups. The ODI and SF-36 scores were significantly different (P < 0.05) at 1 day and 1 month after surgery among the three groups. Groups A and B showed significantly better pain relief than group C. Group B experienced better pain relief than group A. These results indicate that PVP was associated with better pain relief effects among patients with a greater extent of bone marrow edema. The edema ranges of the vertebral fractures were negatively correlated with the postoperative VAS and ODI scores 1 month after surgery, whereas the ranges were positively correlated with postoperative SF-36 scores 1 month after surgery.

Conclusions

PVP is an effective treatment for OVCFs. Better outcomes were observed among patients with severe or moderate bone marrow edema rather than those with mild bone marrow edema. A greater degree of pain relief after PVP was correlated with faster recovery of the postoperative function. However, this correlation gradually became weak over time and disappeared 6 months after surgery. Therefore, PVP should be an option for early stage OVCFs, especially among patients with bone marrow edema signs on MRI.

Efficacy of Vertebral Augmentation for Vertebral Compression Fractures: A Review of Meta-Analyses

Introduction

Vertebral compression fracture incidence is rising with the growth of the geriatric population and is one of the leading disabilities in healthcare. However, the literature is conflicted on the benefits of vertebral augmentation versus nonoperative care for these fractures. The purpose of the current study was to perform a review of all meta-analyses in the literature comparing vertebral augmentation to nonoperative care and descriptively report the results.

Methods

A review of all meta-analyses evaluating trials of vertebral augmentation compared with nonoperative care was performed. The primary outcome studied was pain. Secondary outcomes were quality of life (QoL) metrics and functional outcomes.

Results

Ten studies met the inclusion criteria. Besides two sham procedure studies, the remaining literature concluded that vertebral augmentation was superior to nonoperative care for reducing back pain. The reporting of secondary outcomes, such as QoL metrics and functional outcomes, was heterogeneous among the studies. Studies that reported these secondary outcomes, however, did identify some early benefit in vertebral augmentation.

Conclusions

The current literature suggests vertebral augmentation is more effective in improving pain outcomes compared with nonoperative management. While more studies are needed to conclusively assess vertebral augmentation's efficacy in improving functional outcome and QoL, the meta-analyses surveyed here suggest that at least some benefit exists when assessing these two outcomes.

Difference of clinical course between cases with bone union and those with delayed union following osteoporotic vertebral fractures

In this prospective multicenter study of osteoporotic vertebral fractures (OVFs), delayed union of OVF at 6-month follow-up caused prolonged pain, QOL impairment, ADL impairment, cognitive status deterioration, and vertebral collapse progression.

PURPOSE

Delayed union following osteoporotic vertebral fracture displayed as an intravertebral cleft on plain X-rays was reported to be a factor for prolonged severe pain. However, the difference of clinical course between bone union and delayed union cases still remains unclear. The purpose of this study was to identify how OVF delayed union following conventional conservative treatment influences the clinical course with a prospective multicenter study.

METHODS

A total of 324 OVF patients from 25 institutes in Osaka, Japan, were included in the study. At the 6-month follow-up after initial visit to each institute, the patients were classified into bone union and delayed union groups based on plain X-ray findings. The outcome assessments included a VAS for back pain, SF-36 for quality of life (QOL), severity of bed-ridden state for activities of daily living (ADL), MMSE for cognitive functions, and degree of vertebral collapse on plain X-rays.

RESULTS

Overall, 280 patients were included into the union group and 44 into the delayed union group. The VAS score at 6 months was significantly worse in the delayed union group (p = 0.01). The scores for the SF-36 scales of physical functioning and bodily pain at 6 months were significantly lower in the delayed union group (p = 0.019, p = 0.01, respectively). The percentage of nearly or completely bed-ridden patients was significantly higher in the delayed union group. The percentage of newly developed cognitive impairment was significantly higher in the delayed union group (p = 0.02). Progression of vertebral collapse during the 6-month follow-up was more pronounced in the delayed union group (p < 0.01).

CONCLUSION

The present results revealed that delayed union following OVF causes prolonged pain, QOL impairment, ADL impairment, cognitive status deterioration, and vertebral collapse progression.

Characterizing the course of back pain after osteoporotic vertebral fracture: a hierarchical cluster analysis of a prospective cohort study

This study demonstrated four distinct patterns in the course of back pain after osteoporotic vertebral fracture (OVF). Greater angular instability in the first 6 months after the baseline was one factor affecting back pain after OVF.

PURPOSE

Understanding the natural course of symptomatic acute OVF is important in deciding the optimal treatment strategy. We used latent class analysis to classify the course of back pain after OVF and identify the risk factors associated with persistent pain.

METHODS

This multicenter cohort study included 218 consecutive patients with ≤ 2-week-old OVFs who were enrolled at 11 institutions. Dynamic x-rays and back pain assessment with a visual analog scale (VAS) were obtained at enrollment and at 1-, 3-, and 6-month follow-ups. The VAS scores were used to characterize patient groups, using hierarchical cluster analysis.

RESULTS

VAS for 128 patients was used for hierarchical cluster analysis. Analysis yielded four clusters representing different patterns of back pain progression. Cluster 1 patients (50.8%) had stable, mild pain. Cluster 2 patients (21.1%) started with moderate pain and progressed quickly to very low pain. Patients in cluster 3 (10.9%) had moderate pain that initially improved but worsened after 3 months. Cluster 4 patients (17.2%) had persistent severe pain. Patients in cluster 4 showed significant high baseline pain intensity, higher degree of angular instability, and higher number of previous OVFs, and tended to lack regular exercise. In contrast, patients in cluster 2 had significantly lower baseline VAS and less angular instability.

CONCLUSIONS

We identified four distinct groups of OVF patients with different patterns of back pain progression. Understanding the course of back pain after OVF may help in its management and contribute to future treatment trials.