Percutaneous vertebroplasty for subacute and chronic painful osteoporotic vertebral compression fractures can safely be undertaken in the first year after the onset of symptoms

The Closer Vicinity to Treated Vertebrae in Percutaneous Vertebroplasty, the Higher Rate of New Vertebral Compression Fractures at Follow-up

OBJECTIVE

To investigate whether risk of new vertebral compression fractures (NVCFs) was associated with vicinity to treated vertebrae in percutaneous vertebroplasty (PVP) for osteoporotic vertebral compression fractures (OVCFs).

METHODS

All OVCF (T6-L5) patients treated with PVP between January 2016 and December 2020 were retrospectively reviewed. Vicinity to treated vertebrae was defined as the number of vertebrae between an untreated and its closest treated level. The closest treated level was chosen as reference vertebra. Clinical, radiologic, and surgical parameters were compared between groups of reference vertebrae for each vicinity NVCF.

RESULTS

In total, 1348 patients with 1592 fractured and 14,584 normal vertebrae were enrolled. NVCF was identified in 20.1% (271 of 1348) patients in 2.2% (319 of 14584) vertebrae in a mean follow-up time of 24.3 ± 11.9 months. Rate of NVCF in vicinity 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11 level were 4.6% (130 of 2808), 2.4% (62 of 2558), 1.8% (42 of 2365), 1.5% (31 of 2131), 1.3% (23 of 1739), 1.3% (17 of 1298), 0.8% (7 of 847), 0.9% (4 of 450), 0.8% (2 of 245), 0.9% (1 of 117), and 0% (0 of 26), respectively. Rate of NVCF in vicinity 1 level was significantly higher than that in vicinity 2, 3, 4, 5, 6, 7, 8, and 9 level, respectively. However, compared to reference vertebrae for vicinity 1 NVCF, any clinical, radiologic, or surgical parameters were not significantly different in those for vicinity 2, 3, and 4 NVCF, respectively.

CONCLUSIONS

The closer vicinity to treated vertebrae in PVP, the higher rate of NVCF at follow-up. However, any clinical, radiologic, or surgical parameters might not matter in this phenomenon of vicinity-related NVCF.

Analysis of adjacent vertebral fracture after percutaneous vertebroplasty: do radiological or surgical features matter?

PURPOSE

To report the incidence and risk factors of adjacent vertebral fracture (AVF) after percutaneous vertebroplasty (PVP) in patients with osteoporotic vertebral compression fractures (OVCFs). We focused to investigate effect of radiological or surgical features on AVF.

METHODS

All patients with OVCFs who were treated with PVP between January 2016 and December 2019 were retrospectively reviewed. Patients were followed up at least 12 months after procedure according to treatment protocol. AVF was defined as postoperatively recurrent intractable back pain and subsequently presence of fracture on magnetic resonance imaging (MRI) in adjacent levels. Clinical, radiological, and surgical factors potentially affecting occurrence of AVF were recorded and analyzed using univariate and multivariate analysis.

RESULTS

Totally, 1077 patients with 1077 fractured vertebrae who underwent PVP were enrolled in the study, after inclusion and exclusion criteria were met. Mean follow-up time was 24.3 ± 11.9 months (range, 12-59 months). AVF was identified in 98 (9.1%) patients. Univariate analysis showed that seven significant factors related to AVF were older age, non-traumatic fracture, cortical disruption on anterior wall, cortical disruption on lateral wall, basivertebral foramen, type-B leakage and type-C leakage. In multivariate analysis, two clinical factors, older age (P = 0.031) and non-traumatic fracture (P = 0.002), were significantly associated with AVF. However, any radiological or surgical factor did not reach significance in final model analysis.

CONCLUSIONS

Incidence of AVF after PVP in patients with OVCFs was 9.1% (98/1077). Older age and non-traumatic fracture were two clinical risk factors for AVF. Neither radiological nor surgical feature was significantly correlated with AVF.

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

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

Evaluation of the role of vertebral augmentation in chronic vertebral compression fractures: A retrospective study

Objectives

Vertebral augmentation is recommended for acute or subacute vertebral compression fractures (VCFs); few studies claim its usefulness in chronic VCFs also. Use of radionuclide imaging may improvise identification of chronic VCFs that may benefit from vertebral augmentation; hence we have evaluated efficacy of vertebral augmentation procedures in chronic VCFs with incomplete fracture healing suggested either by MRI or Tc99m- MDP bone scan.

Materials and Methods

Patients with chronic osteoporotic VCFs (>12 weeks) during the period of June 2013 to June 2019 were included in this retrospective study; patients with evidence of incomplete fracture healing either by MRI or bone scan imaging with Tc 99m-MDP underwent vertebroplasty or kyphoplasty. Primary outcome measure was patient's pain score measured by numerical rating scale (NRS); secondary outcome measures were patient's disability assessed by Roland Morris Disability questionnaire (RDQ); quality of life assessed by Quality of life questionnaire of European Foundation of Osteoporosis (QUALLEFO) and analgesic usage. P ​< ​0.050 was considered as significant.

Results

34 patients were enrolled for the study with median fracture age of 36 months. The median NRS pain scores, RDQ scores, QUALEFFO scores and analgesic usage were significantly reduced at all-time points as compared to the baseline value over the follow up period of 1 year after vertebral augmentation procedure (P ​< ​0.050). Cement leakage was seen in 5 patients (15%).

Conclusion

Vertebral augmentation procedures provided significant improvements in pain scores, disability and quality of life in patients of chronic osteoporotic VCFs with median fracture age of 36 months.

Factors Contributing to Residual Low Back Pain after Osteoporotic Vertebral Fractures

Although osteoporotic vertebral fractures (OVFs) are the most common type of osteoporotic fracture, few reports have investigated the factors contributing to residual low back pain in the chronic phase after OVFs by using radiographic evaluation. We examined the contribution of nonunion, vertebral deformity, and thoracolumbar alignment to the severity of residual low back pain post-OVF. This post hoc analysis of a prospective randomized study included 195 patients with a 48-week follow-up period. We investigated the associations between radiographic variables with the visual analog scale (VAS) scores for low back pain at 48 weeks post-OVF using a multiple linear regression model. Univariate analysis revealed that analgesic use, the local angle on magnetic resonance imaging, anterior vertebral body compression percentage on X-ray, and nonunion showed a significant association with VAS scores for low back pain. Multiple regression analysis produced the following equation: VAS for low back pain at 48 weeks = 15.49 + 0.29 × VAS for low back pain at 0 weeks + (with analgesics: +8.84, without analgesics: −8.84) + (union: −5.72, nonunion: −5.72). Among local alignment, thoracolumbar alignment, and nonunion, nonunion independently contributed to residual low back pain at 48 weeks post-OVF. A treatment strategy that reduces the occurrence of nonunion is desirable.

Effect of Surgical Timing on the Refracture Rate after Percutaneous Vertebroplasty: A Retrospective Analysis of at Least 4-Year Follow-Up

Introduction

The effect of surgical timing on vertebral refracture rate and mortality remains elusive after percutaneous kyphoplasty (PKP) or percutaneous vertebroplasty (PVP), and we aim to assess the impact of surgical timing on vertebral refracture rate and mortality in patients undergoing percutaneous vertebroplasty.

Methods

We did a retrospective cohort study of patients who underwent PKP or PVP because of osteoporotic vertebral compression fracture (OVCF) between April 1, 2014 and March 31, 2016. The primary outcome measure was the incidence of vertebral refracture. Secondary outcomes included the mortality and chronic back pain.

Results

The rate of vertebral refracture was significantly lower in early surgical timing group than that in late surgical timing group (HR 2.415, 95% CI 1.318–4.427; P = 0.004). We found that the bone mineral density (BMD) was only the risk factor to increase the vertebral refracture rate after vertebroplasty (P = 0.001). In addition, there was similar mortality between the two groups (15.7% in early surgical timing group versus 10% in late surgical timing group). Male patients (27.3%, 12/44) had higher mortality compared to female patients (10.6%, 20/189), while the mortality was higher in patients with cerebral infarction (25%, 3/12) than those without cerebral infarction (12.1%, 17/140).

Conclusions

Surgical timing significantly affects the vertebral refracture rate after PKP or PVP, which is also influenced by BMD. The mortality after the surgery is not affected by the surgical timing, but gender and cerebral infarction may be the risk factors of mortality.

Inhibition of CDK1 attenuates neuronal apoptosis and autophagy and confers neuroprotection after chronic spinal cord injury in vivo

Chronic spinal cord injury (CSCI) results from progressive compression of the spinal cord over time. A variety of factors cause CSCI, and its exact pathogenesis is unknown. Cyclin-dependent kinase 1 (CDK1) is closely related to the apoptosis pathway, but no CSCI-related studies on CDK1 have been conducted. In this study, the role of CDK1 in CSCI was explored in a rat model. The CSCI model was established by screw compression using the cervical anterior approach for twelve weeks. The neurological function of the rats was evaluated using the neurological severity scores (NSS) and motor evoked potentials (MEPs). Pathological changes in spinal cord tissue were observed by hematoxylin-eosin (HE) staining, and Nissl staining was performed to assess the survival of motor neurons in the anterior horn of the spinal cord. Changes in autophagy and apoptosis in anterior horn of spinal cord tissue were detected using transmission electron microscopy and the terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay, respectively. The expression levels of glial fibrillary acidic protein (GFAP), ionized calcium-binding adaptor (IBA) and choline acetyltransferase (CHAT) in the anterior horn were determined using immunohistochemistry assays to investigate astrocytes, microglia and motor neurons, respectively, in the anterior horn. Western blot assays were used to detect the expression levels of CDK1, Bcl-2, Bax, Caspase 3, LC3 and Beclin1. Changes in the expression of CDK1, LC3 and Beclin1 were also observed using immunohistochemistry. The results indicated that CSCI resulted in neuronal injury and a decrease in the NSS. In the CSCI model group, anterior horn astrocytes and microglia were activated, and motor neurons were decreased. Neuronal apoptosis was promoted, and the number of autophagic vacuoles was elevated. Rats treated with the CDK1 shRNA lentivirus exhibited better NSS, more surviving motor neurons, and fewer apoptotic neurons than the model rats. The occurrence of autophagy and the expression of proapoptotic and autophagy-related proteins were lower in the CDK1 shRNA group than the model group. In conclusion, CDK1 downregulation suppressed the activation of anterior horn astrocytes and microglia, promoted motor neuron repair, and inhibited neurons apoptosis and autophagy to promote the recovery of motor function after spinal cord injury.

When to perform vertebroplasty? A retrospective analysis from a single center and a review of the literature

BACKGROUND AND AIM

To establish an optimal timing for vertebroplasty in order to obtain a clinically important pain reduction and improving quality of live in patients with osteoporotic or traumatic vertebral fractures.

METHODS

This study includes 22 vertebroplasty procedures performed from October 2018 to July 2020 in 21 patients with traumatic or osteoporotic vertebral fractures (19 female, two men; age between 53 and 89 years). All treatments were executed under fluoroscopic guidance using 11 or 13 G needle through transpedicular or costovertebral unilateral approach. Each patient underwent conscious sedation, continuously monitored by an anesthesiologist. Preoperative MRI images, obtained by 3T or 1.5T MRI scanner, always showed bone marrow edema. The VAS scale and Roland Morris disability questionnaire (RMdq) were administered to patients before and after the treatment to evaluate pain and life quality.

RESULTS

7 patients were treated in the first month after the injury, one was treated twice; 8 patients in the second month, 6 in the third. We observed a reduction of: 5.5 points in the vas scale, 10.3 in the RMdq in the first month; 5.6 points vas, 11.6 points RMdq in the second month; 4 points vas and 9.75 points RMdq in the third month.

CONCLUSIONS

This study demostrated that, in our preliminary experience, vertebroplasty has the best outcome if performed at 2 months from injury.

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.

A Review and Clinical Perspective of the Impact of Osteoporosis on the Spine

Introduction

Osteopenia and osteoporosis are common conditions in the United States. The health consequences of low bone density can be dire, from poor surgical outcomes to increased mortality rates following a fracture.

Significance

This article highlights the impact low bone density has on spine health in terms of vertebral fragility fractures and its adverse effects on elective spine surgery. It also reviews the clinical importance of bone health assessment and optimization.

Results

Vertebral fractures are the most common fragility fractures with significant consequences related to patient morbidity and mortality. Additionally, a vertebral fracture is the best predictor of a subsequent fracture. These fractures constitute sentinel events in osteoporosis that require further evaluation and treatment of the patient's underlying bone disease. In addition to fractures, osteopenia and osteoporosis have deleterious effects on elective spine surgery from screw pullout to fusion rates. Adequate evaluation and treatment of a patient's underlying bone disease in these situations have been shown to improve patient outcomes.

Conclusion

With an increased understanding of the prevalence of low bone mass and its consequences as well an understanding of how to identify these patients and appropriately intervene, spine surgeons can effectively decrease the rates of adverse health outcomes related to low bone mass.

ACR Appropriateness Criteria® Management of Vertebral Compression Fractures

Vertebral compression fractures (VCFs) have various causes, including osteoporosis, neoplasms, and acute trauma. As painful VCFs may contribute to general physical deconditioning, management of painful VCFs has the potential for improving quality of life and preventing superimposed medical complications. Various imaging modalities can be used to evaluate a VCF to help determine the etiology and guide intervention. The first-line treatment of painful VCFs has been nonoperative or conservative management as most VCFs show gradual improvement in pain over 2 to 12 weeks, with variable return of function. There is evidence that vertebral augmentation (VA) is associated with better pain relief and improved functional outcomes compared to conservative therapy for osteoporotic VCFs. A multidisciplinary approach is necessary for the management of painful pathologic VCFs, with management strategies including medications to affect bone turnover, radiation therapy, and interventions such as VA and percutaneous thermal ablation to alleviate symptoms. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Early versus late percutaneous kyphoplasty for treating osteoporotic vertebral compression fracture: A retrospective study

OBJECTIVE

Osteoporotic vertebral compression fracture (OVCF) is a common disease in the aged population that can greatly affect the quality of life. Percutaneous kyphoplasty (PKP) has become a mainstream approach for treating OVCF, but the optimal surgical timing for treating OVCF with PKP remains controversial. In the current study, we retrospectively studied patients with OVCF that underwent PKP, and aimed to find out whether surgical timing could affect the clinical and radiological outcomes.

PATIENTS AND METHODS

We retrospectively studied 62 patients who underwent PKP for OVCF. Patients were divided into 2 groups based on the timing of PKP: operation within 4 weeks (group A) and operation later than 4 weeks (group B). VAS, ODI, height of fracture vertebra, restored height rate, local kyphosis angle and complications were assessed preoperatively and throughout the follow-up.

RESULTS

There were 36 cases (58 fracture vertebra) in the group A and 26 cases (40 fracture vertebra) in the group B. There was no significant difference between the two groups regarding to the demographic data before surgery. In terms of the VAS and ODI, no statistical difference was observed before operation, after operation and at the 6th month follow-up between the two groups. The HRR after operation and at the 6^th month follow-up in the group A was 17.5 ± 5.3% and 10.5 ± 3.7%, and that in the group B was 7.2 ± 3.2% and 3.6 ± 1.1%, and there is significant difference between the two groups (p < 0.05). The LKA (preoperatively / post-operatively / 6th month follow-up) was -12.7°, -7.3°, -11.4° in the group A and -17.6°, -14.4°, -16.1° in the group B. There was significant difference between the two groups at all the time points for local kyphosis angle (p < 0.01), with a lower rate of subsequent vertebral fracture in the group A (p < 0.05).

CONCLUSION

Both surgical timings of PKP showed similar outcomes in terms of the VAS and ODI. Early PKP could result in better restoration of vertebral body height and reduced rate of subsequent fracture compared to late PKP.

Vertebral Fragility Fractures (VFF)-Who, when and how to operate

Vertebral Fragility Fractures (VFF) are common and lead to pain, long term disability and increased mortality. Most patients will have mild to moderate pain symptoms and can be managed conservatively. However, patients with severe pain who have minimal or no pain relief with potent analgesia, or who only achieve adequate pain relief with high doses of morphine based analgesia which results in significant adverse events, should be considered for vertebral augmentation. Ideally, for vertebral augmentation, patients should present within four months of the fracture (onset of acute pain) and have at least 3 weeks of failure of conservative treatment although early intervention may be more appropriate for hospitalised patients, who tend to be older, more frail and likely to be less tolerant to the adverse effects of conservative treatment. The Cardiovascular and Interventional Radiological Society of Europe (CIRSE) recommends Percutaneous Vertebroplasty as the first line surgical augmentation technique for VFF in older people, which has been shown to improve pain symptoms, allow early restoration of functional mobility and may reduce the risk of further vertebral collapse. CIRSE recommends percutaneous Balloon Kyphoplasty as second line treatment in VFF, although the optimal indication is for acute traumatic vertebral fractures (less than 7-10 days) in younger people. Assessment and treatment of underlying osteoporosis is important to reduce the risk of further fractures in older people with VFF.

Vertebroplasty and Return to Work for Thoracolumbar Fractures Within the Workers' Compensation Population

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Analyze efficacy of vertebroplasty and its affect on return to work (RTW) in a workers' compensation (WC) population SUMMARY OF BACKGROUND DATA.: Vertebroplasty remains a controversial treatment modality for vertebral compression fractures (VCFs). No studies have analyzed use of vertebroplasty in the clinically distinct WC population.

METHODS

A total of 371 Ohio WC subjects were identified who sustained VCFs and were treated with either vertebroplasty or conservative medical therapy between 1993 and 2013 using Current Procedural Terminology procedural and International Classification of Diseases, Ninth Revision diagnosis codes. Subjects with a prior smoking history, prior thoracolumbar surgery or comorbidities, or underwent decompression and/or fusion within 3 months after injury were excluded. Forty-six subjects had undergone vertebroplasty within 1 year of injury and were therefore included in the vertebroplasty group. The remaining 325 subjects received spinal orthosis and formed the control group. The primary outcomes were whether subjects returned to work at early and late time points. Early RTW was defined as returning to work within 3 months and remaining at work for more than 6 months of the following year. Late RTW was defined as returning to work within 2 years and remaining at work for more than 6 months of the following year. Secondary outcomes included opioid use, all-cause mortality, and additional VCFs.

RESULTS

Approximately 37% (17/46) of vertebroplasty group made an early RTW, compared with 35.4% (115/325) of control group (P = 0.835). Regarding late RTW, only 54.3% (25/46) of vertebroplasty group made a sustainable RTW, compared with 70.8% (230/325) of subjects in control group (P = 0.025). In addition, the vertebroplasty group was associated with significantly higher postoperative opioid use.

CONCLUSION

Vertebroplasty may not be an effective treatment modality for VCFs in the WC population when RTW is the primary goal.

LEVEL OF EVIDENCE

3.

Trends in vertebroplasty and kyphoplasty after thoracolumbar osteoporotic fracture: A large database study from 2005 to 2012

PURPOSE

The aim of our study was to investigate the trends and incidence of vertebral augmentation procedures (VAPs) in treating osteoporotic vertebral compression fractures.

RESULTS

In total, 118,074 patients were analyzed. The overall incidence of VAPs was 15.2%. The incidence of VAPs was significantly higher in those 75-79 years old (20.4%), significantly higher in females than males (15.6% versus 14.9%), and most commonly performed in the South (17.7%).

CONCLUSION

There was a decline in the frequency of these procedures since 2008, but physicians are still performing these procedures, albeit at a much lower frequency than before 2009.

Percutaneous vertebral body augmentation: an updated review

There are many medical conditions like osteoporosis, tumor, or osteonecrosis that weaken the structural strength of the vertebral body and prone it to fracture. Percutaneous vertebral augmentation that is usually applied by polymethylmethacrylate is a relatively safe, effective, and long lasting procedure commonly performed in these situations. In this paper, we updated a review of biomechanics, indications, contraindications, surgical techniques, complications, and overall prognosis of these minimally invasive spinal procedures.

Risks and benefits of percutaneous vertebroplasty or kyphoplasty in the management of osteoporotic vertebral fractures

Vertebral fracture (VF) is the most common osteoporotic fracture and is associated with high morbidity and mortality. Conservative treatment combining antalgic agents and rest is usually recommended for symptomatic VFs. The aim of this paper is to review the randomized controlled trials comparing the efficacy and safety of percutaneous vertebroplasty (VP) and percutaneous balloon kyphoplasty (KP) versus conservative treatment. VP and KP procedures are associated with an acceptable general safety. Although the case series investigating VP/KP have all shown an outstanding analgesic benefit, randomized controlled studies are rare and have yielded contradictory results. In several of these studies, a short-term analgesic benefit was observed, except in the prospective randomized sham-controlled studies. A long-term analgesic and functional benefit has rarely been noted. Several recent studies have shown that both VP and KP are associated with an increased risk of new VFs. These fractures are mostly VFs adjacent to the procedure, and they occur within a shorter time period than VFs in other locations. The main risk factors include the number of preexisting VFs, the number of VPs/KPs performed, age, decreased bone mineral density, and intradiscal cement leakage. It is therefore important to involve the patients to whom VP/KP is being proposed in the decision-making process. It is also essential to rapidly initiate a specific osteoporosis therapy when a VF occurs (ideally a bone anabolic treatment) so as to reduce the risk of fracture. Randomized controlled studies are necessary in order to better define the profile of patients who likely benefit the most from VP/KP.