Percutaneous cement augmentation for osteoporotic vertebral fractures

EFFECTIVENESS AND SAFETY OF SPINEJACK SYSTEM IN THE MANAGEMENT OF VERTEBRAL FRAGILITY FRACTURES: A SYSTEMATIC REVIEW

Introduction: The SpineJackⓇ (SJ) system received FDA clearance in 2018, therefore this device is currently available to perform kyphoplasty in osteoporotic vertebral fractures. This study aims to assess the outcome of the SJ system in the management of vertebral fragility fractures (VFFs).

Evidence Acquisition and Synthesis: OVID-MEDLINEⓇ, EMBASE, Cochrane Library, SCOPUS, Springer Link, Web of Science, Google Scholar and PubMed were searched from January 2015 to November 2021 to identify relevant studies. The methodological qualities of the studies were evaluated, and relevant data were extracted.

Seven clinical trials, recruiting 644 patients with 690 VFFs were included. Although PVP, balloon kyphoplast (BKP) and SJ showed comparable effectiveness in back pain relief in patients with VFFs, SJ showed a faster and higher pain relief and a better quality of life, compared with the other two augmentation techniques. Moreover, patients treated with SJ, compared with PVP and BKP, showed a better vertebral body height (VBH) restoration and kyphotic correction; these findings were confirmed also at long-term follow-up. Asymptomatic cement leakage and adjacent level fractures (ALFs) were observed in patients treated with SJ, but with a lower incidence compared with PVP and BKP.

Conclusions: This systematic review shows that SJ has an excellent risk/benefit profile and is more effective than the other augmentation techniques in VBH restoration and kyphotic correction. These findings correlate with a better postoperative quality of life.

Treatment progress of spinal metastatic cancer: a powerful tool for improving the quality of life of the patients

Spinal metastasis is a common secondary malignant tumor of the bone, often resulting in spinal cord and nerve root compression, leading to obvious pain and related compression symptoms. This condition has a high incidence and mortality rate. The treatment approach for most patients with spinal metastasis is primarily palliative. Consultation with a multidisciplinary team is widely accepted as a comprehensive treatment approach for patients with spinal metastases. With advancements in research and technology, the evaluation and treatment of spinal metastatic cancer are continuously evolving. This study provides an overview of surgical treatment, minimally invasive treatment, and radiotherapy for spinal metastatic cancer and also analyzes the clinical effects, advantages, and current limitations associated with various treatment approaches.

Prediction model of adjacent vertebral compression fractures after percutaneous kyphoplasty: a retrospective study

OBJECTIVES

The purpose of this study was to develop a prediction model to assess the risk of adjacent vertebral compression fractures (AVCFs) after percutaneous kyphoplasty (PKP) surgery.

DESIGN

A retrospective chart review.

SETTING AND PARTICIPANTS

Patients were collected from the Quzhou People's Hospital, from March 2017 to May 2019. Patients were included if they suffered from osteoporotic vertebral compression fractures (OVCFs), underwent PKP surgery and were followed up for 2 years.

INTERVENTIONS

None.

METHODS

This was a retrospective cohort study of all PKP surgery procedures of the thoracic, lumbar and thoracolumbar (TL) spine that have been performed for OVCF from 1 March 2017 up to 1 May 2019. The least absolute shrinkage and selection operator (LASSO) regression model was used to optimise feature selection for the AVCF risk model. Multivariable logistic regression analysis was applied to build a predicting model incorporating the feature selected in the LASSO regression model. The C-index, calibration plot and decision curve analysis were applied to assess this model.

RESULTS

Gender, age, the number of surgical vertebrae, cement volume, bone mineral density, diabetes, hypertension, bone cement leakage, duration of anti-osteoporosis treatment after surgery and TL junction were identified as predictors. The model displayed good discrimination with a C-index of 0.886 (95% CI 0.828-0.944) and good calibration. High C-index value of 0.833 could still be reached in the interval validation. Decision curve analysis showed that the AVCF nomogram was clinically useful when intervention was decided at the AVCF possibility threshold of 1%.

CONCLUSIONS

This study developed a clinical prediction model to identify the risk factors for AVCF after PKP surgery, and this tool is of great value in sharing surgical decision-making among patients consulted before surgery.

TRIAL REGISTRATION NUMBER

researchregistry7716.

Correlation Analysis between Residual Pain after Vertebral Augmentation and the Diffusion Distribution of Bone Cement: A Retrospective Cohort Study

Objective

To explore the influence and potential factors of the bone cement dispersion state on residual pain after vertebral augmentation.

Methods

The cases included in this retrospective cohort study were patients treated with vertebral augmentation (VA) for osteoporotic vertebral compression fractures (OVCFs) between July 2018 and June 2021. According to the type of cement diffusion distribution, the patients were divided into a sufficient diffusion group (Group A) and an insufficient diffusion group (Group B). The differences in the baseline data, visual analog scale (VAS), Oswestry disability index score (ODI), injured vertebral height (IVH), and local kyphosis angle (LKA) between the two groups were analyzed. Assessments were performed preoperatively on the 2nd day postoperation and at the last follow-up. The imaging data of injured vertebrae were accurately reconstructed by a GE AW4.7 workstation, and the differences in the vertebral body volume, bone cement volume, and bone cement volume ratio were compared between the groups.

Result

After screening, 36 patients were included. (1) The postoperative VAS and ODI scores of the two groups were significantly improved compared with the preoperative scores. (2) On the 2nd day postoperation and the last follow-up, the VAS and ODI scores of Group A were significantly different from those of Group B, and Group A outperformed Group B. (3) The IVH and LKA of the two groups were improved after the operation, and no significant difference was found between the groups. (4) Significant differences were found in the bone cement volume and bone cement volume ratio between the groups, and Group A was larger than Group B.

Conclusions

Sufficient bone cement diffusion can reduce residual pain after vertebral augmentation.

Expression of lncRNA MALAT1 through miR-144-3p in Osteoporotic Tibial Fracture Rats and Its Effect on Osteogenic Differentiation of BMSC under Traction

Objective

To investigate the expression of lncRNA MALAT1 and miR-144-3p in osteoporotic (OP) tibial fracture rats and analyze their targeting relationship and effects on the osteogenic differentiation of bone marrow mesenchymal stem cells (BMSC) under traction.

Methods

The OP tibial fracture model was established, and the rats were divided into a sham group and a model group. The tibial tissue of these rats was taken. BMSC of cultured rats with good growth was purchased and grouped according to the presence or absence of transfection of si-MALAT1 and miR-144-3p-mimic. The expression of MALAT1 and miR-144-3p in each group was detected. The bioinformatics website and double luciferase were used to predict the targeting relationship between MALAT1 and miR-144-3p and to detect the expression of genes related to bone differentiation (collagen I, osteocalcin (OCN), osteopontin (OPN), and alkaline phosphatase (ALP)) of each component, and ALP staining and AR staining were used to detect the formation of BMSC calcium nodules.

Results

The levels of ALP and TRAP in the model group were higher than that in the sham group (P < 0.05). qRT-PCR results showed that the relative expression level of MALAT1 in the model group was higher than that in the sham group, and the relative expression level of miR-144-3p was lower than that in the sham group (P < 0.05). MALAT1 has a targeting relationship with miR-144-3p. qRT-PCR results showed that the relative expression level of MALAT1 in the tension-MSC group was higher than the MSC group, and the relative expression level of miR-144-3p was lower than the MSC group (P < 0.05). The expressions of collagen I, OCN, OPN, and ALP proteins in the si-MALAT1 group were higher than those of the si-NC group (P < 0.05). The results of ALP staining showed that BMSCs of the si-MALAT1 group had stronger osteogenic differentiation capacity and higher ALP activity than those of the si-NC group. The results of AR staining showed that compared with the si-NC group, the mineralization degree of cells in the si-MALAT1 group was higher, the number of calcium nodules was more, and the cells were more deeply stained. The expressions of collagen I, OCN, OPN, and ALP proteins in the miR-144-3p-mimic group were higher than the mimic-NC group (P < 0.05). ALP staining results showed that BMSCs in the miR-144-3p-mimic group had strong osteogenic differentiation capacity and high ALP activity compared with the mimic-NC group. The results of AR staining showed that, compared with the mimic-NC group, the mineralization degree of cells in the miR-144-3p-mimic group was higher, the number of calcium nodules was more and the cells were more deeply stained.

Conclusion

In the OP rat model with the tibial fracture, the expression of MALAT1 is upregulated and that of miR-144-3p is downregulated. MALAT1 has a targeting relationship with miR-144-3p, and downregulation of MALAT1 and upregulation of miR-144-3p can promote the osteogenic differentiation of BMSC under traction.

Clinical Therapy of Metastatic Spinal Tumors

Metastatic spinal tumors (MST) have high rates of morbidity and mortality. MST can destroy the vertebral body or compress the nerve roots, resulting in an increased risk of pathological fractures and intractable pain. Here, we elaborately reviewed the currently available therapeutic options for MST according to the following four aspects: surgical management, minimally invasive therapy (MIT), radiation therapy, and systemic therapy. In particular, these aspects were classified and introduced to show their developmental process, clinical effects, advantages, and current limitations. Furthermore, with the improvement of treatment concepts and techniques, we discovered the prevalent trend toward the use of radiation therapy and MIT in clinic therapies. Finally, the future directions of these treatment options were discussed. We hoped that along with future advances and study will lead to the improvement of living standard and present status of treatment in patients with MST.

Comparison of morbidity and mortality of hip and vertebral fragility fractures: Which one has the highest burden?

Objectives

Hip fragility fractures were regarded as one of the most severe, but recent papers report on the underestimated burden of vertebral compression fractures. This study aims to compare morbidity and mortality of hip and vertebral fragility fractures in patients treated in the same setting.

Methods

Patients aged ≥50 years with hip fracture, and those with vertebral fracture presenting to our hospital between January 2014 and January 2017 were included. Patients were evaluated 1 year after their index fracture. SF-36 scores, mortality, and institutionalization are then recorded. Patients were divided into 2 groups: hip fractures and vertebral fractures.

Results

There were 106 and 90 patients respectively evaluated in hip and vertebral fracture groups at 1 year. Patients in both groups were comparable for age, sex, comorbidities and neuropsychiatric condition (P > 0.05). At 1 year follow-up, SF-36 showed better averages in all 8 scales in hip fracture group compared to vertebral fracture group. Mortality in the hip fracture group reached 32.1% compared to 10% for the vertebral fracture group (P < 0.01). Fifteen patients were institutionalized in the hip fracture group compared to 18 patients in the vertebral fracture group (P > 0.05).

Conclusions

When comparing patients treated in the same setting, hip fracture is associated with significantly increased mortality than vertebral fracture; however, the latter is associated with more morbidity.

Vertebral fragility fractures: clinical and radiological results of augmentation and fixation-a systematic review of randomized controlled clinical trials

AIM

To assess the outcome of augmentation techniques, i.e., percutaneous vertebroplasty (PVP), balloon kyphoplasty (BKP), vertebral body stenting (VBS) and fixation techniques in the management of vertebral fragility fractures (VFFs).

METHODS

OVID-MEDLINE^®, EMBASE, Cochrane Library, SCOPUS, Springer Link, Web of Science, Google Scholar and PubMed were searched from January 2009 to February 2019 to identify relevant studies. The methodological qualities of the studies were evaluated and relevant data were extracted.

RESULTS

Thirteen randomized controlled trials, recruiting 1963 patients, were included. PVP, compared with conservative management (CM), showed a greater pain relief and an improved vertebral body height (VBH) restoration. Moreover, PVP revealed superior to a sham procedure for pain relief in acute VFFs. BKP, compared with CM, rapidly reduces pain and improves quality of life without increasing the risk of additional VFFs. BKP, compared with PVP, has fewer cement leakage rates and is more effective in VBH restoration. BKP should also be preferred to VBS, since it is associated with less material-related complications. Pedicle screw fixation associated with PVP, compared with PVP alone, revealed effective in preventing secondary VFFs.

CONCLUSIONS

BKP showed better clinical and radiological outcomes compared with CM and PVP. BKP revealed as effective as VBS in VBH restoration with less material-related complications.

Risk factors of adjacent segmental fractures when percutaneous vertebroplasty is performed for the treatment of osteoporotic thoracolumbar fractures

The study aimed to analyze the radiographic and magnetic resonance imaging (MRI) findings that might predict the risk for adjacent segmental fractures (ASFs) when percutaneous vertebroplasty (PV) is used for the treatment of osteoporotic thoracolumbar fractures (OTFs). A total of 92 OTFs patients who underwent PV between January 2013 and January 2015 were retrospectively reviewed. The visual analog scale (VAS), Oswestry-Disability Index (ODI) and radiolographic measurements were assessed. The VAS and ODI scores improved significantly at the final follow-up (FU) compared with the preoperation scores. Compared with the preoperative values, the fractured body alignment (FBA) significantly improved at the 3-month FU and the final FU, but the adjacent segment alignment (ASA) and thoracolumbar alignment (TLA) did not improve. According to the correlation analysis, the final FU TLA and the final FU ASA were correlated with the preoperative FBA, ASA, and TLA on plain radiography and were highly correlated on MRI. However, the final FU FBA was not correlated with the preoperative FBA, ASA, or TLA on plain radiography or MRI (P > 0.05). The ASFs were correlated with the 3-month FU TLA (r = 0.6044, P = 0.0037) and the final FU TLA (r = 0.5699, P = 0.007) on plain radiography, and the final TLA was more correlated with the preoperative FBA, ASA, and TLA on MRI than on plain radiography. In conclusion, the preoperative ASA and TLA on MRI were risk factors associated with ASFs in OTFs treated with PV.

Outcomes of vertebroplasty in osteoporotic vertebral fractures with limited indication

INTRODUCTION

Vertebroplasty has been shown to be effective for improving quality of life and pain of osteoporotic vertebral fractures (OVF) without neurological deficit and not susceptible to conservative treatment. It is advisable to perform them on recent fractures with 50% crush and without the involvement of the canal, although there are no standard recommendations. In some cases these limits are exceeded. We analyse the outcomes of percutaneous vertebroplasty (PVP) in OVF with relative/limit indication.

MATERIALS AND METHODS

Retrospective analysis of 88 patients (126 fractures) who underwent surgery by PVP; 95/126 were osteoporotic fractures. Thirty-four cases (35%) were included in the relative indication group, with at least one of the following: canal involvement,>50% collapse, and>12 months of evolution of the fracture. The rest of the cases were included in the standard indication group. We performed clinical-radiological follow-up, collected intraoperative data on techniques and complications, occurrence of leaks, postoperative clinical improvement (according to VAS), new adjacent fractures, and satisfaction.

RESULTS

Most fractures were between D11-L2 (66%) with 6-8 months follow-up. No significant differences were observed regarding clinical improvement in either group. A higher percentage of leaks were detected in the relative indication group, 44% in comparison to 29.5% in the standard indication group, without statistical significance. All leakages were asymptomatic. There were 3new OVF after PVP in the relative indication group and 4in the standard group, without statistically significant differences.

DISCUSSION AND CONCLUSIONS

The use of cement in OVF with relative indication led to the same clinical benefit in our sample as those with standard indication. A higher number of leakages occurred in the relative indication group with no clinical consequences or adjacent fractures.

Exercise or manual physiotherapy compared with a single session of physiotherapy for osteoporotic vertebral fracture: three-arm PROVE RCT

BACKGROUND

A total of 25,000 people in the UK have osteoporotic vertebral fracture (OVF). Evidence suggests that physiotherapy may have an important treatment role.

OBJECTIVE

The objective was to investigate the clinical effectiveness and cost-effectiveness of two different physiotherapy programmes for people with OVF compared with a single physiotherapy session.

DESIGN

This was a prospective, adaptive, multicentre, assessor-blinded randomised controlled trial (RCT) with nested qualitative and health economic studies.

SETTING

This trial was based in 21 NHS physiotherapy departments.

PARTICIPANTS

The participants were people with symptomatic OVF.

INTERVENTIONS

Seven sessions of either manual outpatient physiotherapy or exercise outpatient physiotherapy compared with the best practice of a 1-hour single session of physiotherapy (SSPT).

MAIN OUTCOME MEASURES

Outcomes were measured at 4 and 12 months. The primary outcomes were quality of life and muscle endurance, which were measured by the disease-specific QUALEFFO-41 (Quality of Life Questionnaire of the European Foundation for Osteoporosis - 41 items) and timed loaded standing (TLS) test, respectively. Secondary outcomes were (1) thoracic kyphosis angle, (2) balance, evaluated via the functional reach test (FRT), and (3) physical function, assessed via the Short Physical Performance Battery (SPPB), 6-minute walk test (6MWT), Physical Activity Scale for the Elderly, a health resource use and falls diary, and the EuroQol-5 Dimensions, five-level version.

RESULTS

A total of 615 participants were enrolled, with 216, 203 and 196 randomised by a computer-generated program to exercise therapy, manual therapy and a SSPT, respectively. Baseline data were available for 613 participants, 531 (86.6%) of whom were women; the mean age of these participants was 72.14 years (standard deviation 9.09 years). Primary outcome data were obtained for 69% of participants (429/615) at 12 months: 175 in the exercise therapy arm, 181 in the manual therapy arm and 173 in the SSPT arm. Interim analysis met the criteria for all arms to remain in the study. For the primary outcomes at 12 months, there were no significant benefits over SSPT of exercise [QUALEFFO-41, difference -0.23 points, 95% confidence interval (CI) -3.20 to 1.59 points; p = 1.000; and TLS test, difference 5.77 seconds, 95% CI -4.85 to 20.46 seconds; p = 0.437] or of manual therapy (QUALEFFO-41, difference 1.35 points, 95% CI -1.76 to 2.93 points; p = 0.744; TLS test, difference 9.69 seconds (95% CI 0.09 to 24.86 seconds; p = 0.335). At 4 months, there were significant gains for both manual therapy and exercise therapy over SSPT in the TLS test in participants aged < 70 years. Exercise therapy was superior to a SSPT at 4 months in the SPPB, FRT and 6MWT and manual therapy was superior to a SSPT at 4 months in the TLS test and FRT. Neither manual therapy nor exercise therapy was cost-effective relative to a SSPT using the threshold of £20,000 per quality-adjusted life-year. There were no treatment-related serious adverse events.

CONCLUSIONS

This is the largest RCT to date assessing physiotherapy in participants with OVFs. At 1 year, neither treatment intervention conferred more benefit than a single 1-hour physiotherapy advice session. The focus of future work should be on the intensity and duration of interventions to determine if changes to these would demonstrate more sustained effects.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN49117867.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 44. See the NIHR Journals Library website for further project information.

Percutaneous fixation of thoracolumbar vertebral fractures

Surgical treatment of patients with thoracolumbar vertebral fracture without neurological deficit is still controversial.

Management of vertebral fracture with percutaneous fixation was first reported in 2004.

Advantages of percutaneous fixation are: less tissue dissection; decreased post-operative pain; decreased bleeding and operative time (depending on the steep learning curve); better screw positioning with fluoroscopy compared with an open freehand technique; and a decreased infection rate.

The limitations of percutaneous fixation of vertebral fractures include increased radiation exposure to the patient and the surgeon, together with the steep learning curve for this technique.

Adding a screw at the level of the fractured vertebra has the advantages of incorporating fewer motion segments with less operative time and bleeding. This also increases the axial, sagittal and torsional stiffness of the construct.

Percutaneous fixation alone without grafting is sufficient for treating type A and B1 (AO classification) thoracolumbar fractures with satisfactory results concerning kyphosis reduction when compared with open instrumentation and fusion and with open fixation.

Type C and B2 fractures (ligamentous injuries) should undergo fusion since the ligamentous healing is mechanically weak, increasing the risk of instability.

This review offers a detailed description of percutaneous screw insertion and discusses the advantages and disadvantages.

Cite this article: EFORT Open Rev 2018;3:604-613. DOI: 10.1302/2058-5241.3.170026.

Anterolateral Cervical Kyphoplasty for Metastatic Cervical Spine Lesions

Study Design

Retrospective case series.

Purpose

To evaluate the clinical and radiological efficacy of anterolateral kyphoplasty for cervical spinal metastasis.

Overview of Literature

Although the spine is the third most common site of tumor metastasis, the cervical spine is the least commonly affected (incidence, 10%–15%). Surgical decompression is highly challenging because of the proximity of neural and vascular elements. Kyphoplasty for cervical spine metastasis has been described in small case reports with promising results.

Methods

Retrospective analysis of a prospective collected single-center spine metastasis database was done for cervical kyphoplasty cases. Data pertaining to age, sex, primary tumor diagnosis, modified Tokuhashi score, Spinal Instability Neoplastic Score (SINS), preoperative Visual Analog Scale (VAS) score, and analgesic medication were extracted. Postoperative data included VAS score at postoperative day 1, duration of hospitalization, self-reported functional outcome, and VAS score at the last follow-up.

Results

Eleven patients (mean age, 62.5 years) with cervical spine metastases were treated with 15-level kyphoplasty. Mean Tokuhashi score was 8.1, and mean SINS was 7.85. Mean preoperative pain score was 7.1, and 82% of patients used opioid analgesics. Mean total bleeding volume was 100 mL. Mean complication-free length of stay was 2.6 days with a decrease in postoperative pain (VAS score=2.8, p <0.05). There was a 56% decrease in opioid dosage and the number of consumed analgesics (1.09, p =0.004). Eighty-two percent of the patients reported excellent improvement at the last follow-up self-assessment.

Conclusions

To our knowledge, this case series represents the largest series of vertebral augmentation using balloon kyphoplasty for cervical spinal metastasis. This technique is associated with low postoperative complications as well as significant decrease in pain, use of opioids, and length of hospital stay. The main indications for vertebral kyphoplasty are lytic lesions of the cervical spine, painful lesions refractory to medical treatment, SINS score of 6–10, and absence of posterior wall defect.