The Incidence of New Vertebral Fractures Following Vertebral Augmentation: A Meta-Analysis of Randomized Controlled Trials

A Real-world Study of Denosumab For Reducing Refracture Risk after Percutaneous Vertebral Augmentation

OBJECTIVE

To investigate the use of anti-osteoporotic agents and refracture incidence in patients with osteoporotic vertebral compression fracture (OVCF) following percutaneous vertebral augmentation (PVA) and to evaluate the real-world treatment of patients using denosumab following PVA. This study aims to provide spine surgeons with empirical insights derived from real-world scenarios to enhance the management of bone health in OVCF patients.

METHODS

This retrospective cohort study was based on data from the MarketScan and Optum databases from the USA. Female patients aged 55-90 years who underwent PVA for OVCF between January 2013 and March 2020 were included and followed up from the day after surgery. Patients who received at least one dose of denosumab were included in the denosumab cohort and were further divided into the on-treatment and off-treatment groups according to whether they received a second dose of denosumab, with follow-up beginning on the index day (225 days after the first denosumab dose). In this study, the off-treatment group was considered as the control group. Refracture incidence after PVA, the proportion of patients using anti-osteoporotic agents in the total study population, and refracture incidence after the index day in the denosumab cohort were analyzed.

RESULTS

A total of 13,451 and 21,420 patients from the MarketScan and Optum databases, respectively, were included. In the denosumab cohort, the cumulative incidence of clinical osteoporotic fractures within 3 years after the index day was significantly lower in the on-treatment group than in the off-treatment group (MarketScan database: 23.0% vs 39.0%, p = 0.002; Optum database: 28.2% vs 40.0%, p = 0.023). The cumulative incidence of clinical vertebral fractures was also lower in the on-treatment group than in the off-treatment group, with a significant difference in the MarketScan database (14.4% vs 25.5%, p = 0.002) and a numerical difference was found in the Optum database (20.2% vs 27.5%, p = 0.084).The proportion of patients using anti-osteoporotic agents was low at 6 months postoperatively, with only approximately 7% using denosumab and 13%-15% taking oral bisphosphonates.

CONCLUSION

Postmenopausal women have a high refracture rate and a low proportion of anti-osteoporotic drug use after PVA. Continued denosumab treatment after PVA is associated with a lower risk of osteoporotic and clinical vertebral fractures. Therefore, denosumab may be a treatment option for patients with osteoporosis after PVA.

Association between opportunistic vertebral bone density measurements and new vertebral fractures after percutaneous vertebral cementoplasty: a case-control study

OBJECTIVES

To study the relationship between opportunistic CT bone density measurements and the occurrence of new vertebral fractures after percutaneous vertebral cementoplasty (PVC) of osteoporotic vertebral compression fractures (OVCF).

METHODS

A prospective analysis of retrospective data of 275 patients with OVCF treated by PVC between 2014 and 2019 with a clinico-radiological follow-up one year after treatment was conducted. Opportunistic bone density measurements were obtained at the trabecular bone of the L1 or an adjacent vertebra in Hounsfield units performed on the preoperative CT study. These density measurements values ​​were then compared between patients with and without new OCVF and in various population subgroups.

RESULTS

There were 275 patients included, with 53 (19%) presenting a new OCVF and 24 (9%) developing a fracture cascade. The median opportunistic density measurements ​​in patients with recurrent OCVF were lower than those without (median 52[40.5]) HU and 77[49] HU)(p < 0.00001). Among the patients with new OVCF the median opportunistic density measurements in patients with fracture cascades were also lower than those without (44 HU and 62 HU, respectively) (p < 0.0096). Patients with density measurements under 61 HU were 3.6 times more likely to present recurrent fractures and those with density under 54 HU were 9.8 times more likely to develop a fracture cascade. The 36 HU threshold yielded a high specificity (90-91%) for the prediction of recurrent fractures and fracture cascade but with low sensitivity (respectively 26% and 37%).

CONCLUSION

Low opportunistic vertebral density measurements are associated with a higher risk of OVCF and fracture cascades after PVC.

KEY POINTS

• Low opportunistic density measurements are associated with a higher risk of OVCF and fracture cascades after PVC. • Measuring bone density before performing a PVC could help predict the risk of new vertebral fracture after treatment • Patient management could be adapted according to bone density.

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.

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.

Vertebral fractures cascade: potential causes and risk factors

We performed a study to identify potential causes and risk factors of vertebral fracture cascade. Vertebral fracture cascade is a severe clinical event in patients with bone fragility. Only half of patients have an identified cause of secondary osteoporosis.

INTRODUCTION

Vertebral fracture (VF) is the most common osteoporotic fracture, and a strong risk factor of subsequent VFs leading to VF cascade (VFC). We prompted a study to identify potential causes and risk factors of VFC.

METHODS

VFC observations were collected retrospectively between January 2016 and April 2017. VFC was defined as an occurrence of at least three VFs within 1 year.

RESULTS

We included in 10 centers a total of 113 patients with VFC (79.6% of women, median age 73, median number of VFs in the cascade, 5). We observed 40.5% and 30.9% of patients with previous major fractures and a previous VF, respectively, and 68.6% with densitometric osteoporosis; 18.9% of patients were currently receiving oral glucocorticoids and 37.1% in the past. VFC was attributed by the physician to postmenopausal osteoporosis in 54% of patients. A secondary osteoporosis associated with the VFC was diagnosed in 52 patients: glucocorticoid-induced osteoporosis (25.7%), non-malignant hemopathies (6.2%), alcoholism (4.4%), use of aromatase inhibitors (3.6%), primary hyperparathyroidism (2.7%), hypercorticism (2.7%), anorexia nervosa (2.7%), and pregnancy and lactation-associated osteoporosis (1.8%). A total of 11.8% of cases were reported following a vertebroplasty procedure. A total of 31.5% patients previously received an anti-osteoporotic treatment. In six patients, VFC occurred early after discontinuation of an anti-osteoporotic treatment, in the year after the last dose effect was depleted: five after denosumab and one after odanacatib.

CONCLUSION

The results of this retrospective study showed that only half of VFC occurred in patients with a secondary cause of osteoporosis. Prospective studies are needed to further explore the determinants of this severe complication of osteoporosis.

The Efficacy and Safety of Vertebral Augmentation: A Second ASBMR Task Force Report

Vertebral augmentation is among the current standards of care to reduce pain in patients with vertebral fractures (VF), yet a lack of consensus regarding efficacy and safety of percutaneous vertebroplasty and kyphoplasty raises questions on what basis clinicians should choose one therapy over another. Given the lack of consensus in the field, the American Society for Bone and Mineral Research (ASBMR) leadership charged this Task Force to address key questions on the efficacy and safety of vertebral augmentation and other nonpharmacological approaches for the treatment of pain after VF. This report details the findings and recommendations of this Task Force. For patients with acutely painful VF, percutaneous vertebroplasty provides no demonstrable clinically significant benefit over placebo. Results did not differ according to duration of pain. There is also insufficient evidence to support kyphoplasty over nonsurgical management, percutaneous vertebroplasty, vertebral body stenting, or KIVA®. There is limited evidence to determine the risk of incident VF or serious adverse effects (AE) related to either percutaneous vertebroplasty or kyphoplasty. No recommendation can be made about harms, but they cannot be excluded. For patients with painful VF, it is unclear whether spinal bracing improves physical function, disability, or quality of life. Exercise may improve mobility and may reduce pain and fear of falling but does not reduce falls or fractures in individuals with VF. General and intervention-specific research recommendations stress the need to reduce study bias and address methodological flaws in study design and data collection. This includes the need for larger sample sizes, inclusion of a placebo control, more data on serious AE, and more research on nonpharmacologic interventions. Routine use of vertebral augmentation is not supported by current evidence. When it is offered, patients should be fully informed about the evidence. Anti-osteoporotic medications reduce the risk of subsequent vertebral fractures by 40-70%. © 2018 American Society for Bone and Mineral Research.

Effect of Teriparatide on Subsequent Vertebral Fractures after Instrumented Fusion Surgery for Osteoporotic Vertebral Fractures with Neurological Deficits

STUDY DESIGN

Retrospective case review.

PURPOSE

To assess the incidence and effect of teriparatide (TP) on subsequent vertebral fractures following a long-instrumented fusion surgery for osteoporotic vertebral fractures (OVFs).

OVERVIEW OF LITERATURE

TP treatment may be a useful strategy for patients with OVFs treated with a long-instrumented surgery.

METHODS

Overall, 47 patients who underwent long-instrumented fusion surgery (≥3 levels) for OVFs with neurological deficits between 2010 and 2013 were enrolled. The mean age of the subjects was 76 years; the study population comprised 20 males and 27 females. The mean follow-up duration was 23 months. The average of fused vertebrae was 4.9. TP was used for 19 patients who comprised the TP group. The incidence of subsequent VFs was estimated with Kaplan-Meier analyses and compared between the TP and non-TP groups using the log-rank test. Risk factors were evaluated using a Cox proportional hazards model.

RESULTS

A total of 38% (18/47 cases) of the subjects were identified with subsequent VFs. There were no significant differences in the age, sex, fused levels, presence of prevalent fractures, and correction loss of the two groups. The occurrence of subsequent VFs was lower in the TP group than in the non-TP group (16% vs. 54%, p=0.014). The log-rank test revealed that the TP treatment significantly reduced the risk of subsequent VFs (p=0.048). A Cox proportional hazards model revealed that preoperative TP treatment is only a protective factor of subsequent VFs after instrumented fusion surgery for OVFs (hazard ratio, 0.281; p=0.047).

CONCLUSIONS

In this retrospective study, pre- and postoperative TP treatment significantly reduced the incidence of subsequent VFs after instrumented fusion surgery for OVFs. A prospective randomized study is warranted to determine the efficacy of TP treatments.

Complications of percutaneous vertebroplasty: An analysis of 1100 procedures performed in 616 patients

Percutaneous vertebroplasty (PVP) is a minimally invasive procedure widely used for the treatment of pain due to vertebral fractures of different origins-osteoporotic, traumatic, or neoplastic. PVP is minimally invasive, but the complications are not rare; however, they are in most cases not significant clinically. The most frequent is cement leakage, which can occur onto veins, paravertebral soft tissue, into the intervertebral disk, or to the spinal canal, affecting foraminal area or epidural space. We analyzed results of treatment and complications of vertebroplasty performed with the use of polimethylomethylacrylate cement (PMMA) on 1100 vertebrae, with a special regard to the severity of complication and eventual clinical manifestation. One thousand one hundred PVP were analyzed, performed in 616 patients. There were 468 (76%) women and 148 men (24%), 24 to 94-year old, mean age 68 years. From 1100 procedures, 794 treated osteporotic and 137 fractures due to malignant disease, 69 PVP were made in traumatic fractures. One hundred patients had painful vertebral hemangiomas. Seven hundred twenty-six (66%) lesions were in thoracic, and 374 (34%) in lumbar area. Results of treatment were assessed using 10 cm Visual Analogue Scale (VAS) 12 hours after surgery, 7 days, 30 days, and then each 6 months, up to 3 years. Before surgery all patients had significant pain 7 to 10 in VAS scale, mean 8.9 cm. Twelve  hours after surgery 602 (97.7%) reported significant relief of pain, with mean VAS of 2,3 cm. Local complications occurred in 50% of osteoporotic, 34% of neoplastic, 16% of traumatic fractures, and 2% of vertebral hemangiomas. The most common was PMMA leakage into surrounding tissues-20%; paravertebral vein embolism-13%; intradiscal leakage-8%; and PMMA leakage into the spinal canal-0.8%. Results of treatment did not differ between patients with and without any complications. From 104 patients who had chest X-ray or CT study performed after surgery, pulmonary embolism was noted in 2 patients, but without any clinical symptoms. Only 1 patient-with PMMA leakage into the spinal canal required surgical decompression In conclusion, PVP is effective in decreasing the level of pain in compression vertebral fractures. Complications occur in almost half of the patients but in more than 95% of them do not produce any clinical symptoms.