Management of vertebral compression fracture in general practice: BEACH program

Incidence of Sacroiliac Joint Pain Following Lumbar Fractures: A Retrospective-Cohort Study

BACKGROUND

Sacroiliac joint (SIJ) pain commonly affects patients with low back pain and can arise from traumatic and degenerative causes. However, the incidence of SIJ pain following lumbar fractures is not well understood.

METHODS

TriNetX, a national network of deidentified patient records, was retrospectively queried. The lumbar fracture cohort included 239,199 adults, while the no lumbar fracture group included 6,975,046 adults. Following a propensity-score match based on demographics and risk factors for SIJ, there were 239,197 patients in each cohort. The incidence of SIJ pain and clinical outcomes were analyzed from 1 day to 1 year following the index event. Moreover, the location and type of single-level lumbar fractures were reported. The incidence of SIJ pain for single-level fractures was compared using a χ2 goodness-of-fit.

RESULTS

The lumbar fracture cohort was more likely to develop SIJ pain at 3 months (odds ratio [OR]: 5.3, 95% confidence interval [CI]: 4.8-5.9), 6 months (OR: 4.4, 95% CI: 4.1-4.8), and 1 year (OR: 3.9, 95% CI: 3.6-4.2) postfracture. Among single-level lumbar fractures, the incidence of SIJ pain at 1 month (P = 0.005), 6 months (P = 0.010), and 1 year (P = 0.003) varied significantly, with the highest incidence in the L5 cohort.

CONCLUSIONS

Our findings suggest that lumbar fractures are a risk factor for developing SIJ pain. Moreover, the incidence of SIJ pain is greater following an L5 fracture than an L1 fracture. Further investigation is warranted to determine how the type and treatment of lumbar fractures affects the incidence of SIJ pain.

A Comparative Study on the Treatment of Osteoporotic Vertebral Compression Fractures With Early Ambulation and at Least 1 Week of Absolute Bed Rest

Objective

This study aimed to determine whether absolute bed rest (ABR) is essential for the conservative treatment of osteoporotic vertebral compression fractures (OVCFs).

Methods

This study included 115 patients diagnosed with OVCFs. The patients in group A were allowed to ambulate as soon as possible, while those in group B underwent ABR for at least 1 week. X-ray images at baseline and 1 week, 2 weeks, 1 month, 3 months, and 6 months after trauma were obtained from both groups for assessment. In each group, ABR-related complications including constipation, indigestion, Foley catheter insertion, urinary tract infection, cough/sputum, dizziness, and neurasthenia were investigated.

Results

In both groups, the compression rates, Cobb angles, and visual analog scale scores did not differ significantly at baseline and the first, second, third, fourth, and fifth follow-ups. In terms of constipation, indigestion, dizziness, and neurasthenia, group A reported a significantly higher complication rate than group B (p<0.05).

Conclusion

The prognosis did not differ significantly between patients who underwent ABR for at least 1 week and those who started walking as soon as possible. The incidence of complications due to ABRs was lower in the early ambulatory group. Therefore, it may be helpful to start walking as early as possible during the conservative treatment of OVCFs.

Complications and healthcare utilization in commercially-insured osteoporotic vertebral compression fracture patients: a comparison of kyphoplasty versus propensity-matched controls

BACKGROUND CONTEXT

Osteoporotic vertebral fractures (OVFs) can lead to severe pain and reduced function and quality-of-life, but the strength of evidence for treatments remains low, particularly in younger populations.

PURPOSE

To determine whether patients with OVFs who received kyphoplasty had different patterns of healthcare utilization compared to propensity-matched patients who did not receive vertebral augmentation.

DESIGN

Observational cohort study.

PATIENT SAMPLE

We identified patients with OVFs from 2007 to 2018 in the IBM MarketScan Commercial Claims and Encounters Databases who received kyphoplasty and compared them to propensity-matched controls who did not receive vertebral augmentation (either kyphoplasty or vertebroplasty).

OUTCOME MEASURES

Major medical complications within 30 days, fills of opioids from 1-week through 1-month postaugmentation, and spine-related gross covered payments from 3-days postkyphoplasty through 1-year post-OVF.

METHODS

We used logistic regression to obtain odds ratios (ORs) and 95% confidence intervals (95% CIs) to compare binary outcomes and median analysis to compare continuous outcomes.

RESULTS

Of the 15,197 OVF patients identified, 1,969 (13%) received kyphoplasty and 1,928 (98%) of these were propensity matched to nonaugmented controls. We did not observe differences in the odds of major medical complications within 30 days (adjusted OR [95% CI]: 1.0 [0.6, 1.8]) but patients who received kyphoplasty were more likely to have filled opioid medications within 30 days (adjusted OR [95% CI]: 1.3 [1.1, 1.5]) and had greater spine-related gross covered payments (kyphoplasty median [95% CI]: $1,340 [$240, $4,850]; nonaugmented: $7,870 [$7,480, $8,270]; adjusted difference in medians [95% CI]: $260 [$190, $2,050]).

CONCLUSIONS

In this cohort of patients <65 years, receipt of kyphoplasty was associated with greater likelihood of opioid fills and somewhat greater spine-related gross covered payments, but no difference in major medical complications. In this retrospective study of administrative data, we did not detect advantages of treatment with kyphoplasty compared with nonaugmentation for any of our outcomes.

Association between timing of kyphoplasty and opioid prescribing risk after vertebral fracture

OBJECTIVE

Approximately 550,000 Americans experience vertebral fracture annually, and most receive opioids to treat the resulting pain. Kyphoplasty of the fractured vertebra is a procedural alternative that may mitigate risks of even short-term opioid use. While reports of kyphoplasty's impact on pain scores are mixed, no large-scale data exist regarding opioid prescribing before and after the procedure. This study was conducted to determine whether timing of kyphoplasty following vertebral fracture is associated with duration or intensity of opioid prescribing.

METHODS

This retrospective cohort study used 2001-2014 insurance claims data from a single, large private insurer in the US across multiple care settings. Patients were adults with vertebral fractures who were prescribed opioids and underwent balloon-assisted kyphoplasty within 4 months of fracture. Opioid overdose risk was stratified by prescribed average daily morphine milligram equivalents using CDC guidelines. Filled prescriptions and risk categories were evaluated at baseline and 90 days following kyphoplasty.

RESULTS

Inclusion criteria were met by 7119 patients (median age 77 years, 71.7% female). Among included patients, 3505 (49.2%) were opioid naïve before fracture. Of these patients, 31.1% had new persistent opioid prescribing beyond 90 days after kyphoplasty, and multivariable logistic regression identified kyphoplasty after 8 weeks as a predictor (OR 1.34, 95% CI 1.02-1.76). For patients previously receiving opioids, kyphoplasty > 4 weeks after fracture was associated with persistently elevated prescribing risk (OR 1.84, 95% CI 1.23-2.74).

CONCLUSIONS

New persistent opioid prescribing occurred in nearly one-third of patients undergoing kyphoplasty after vertebral fracture, although early treatment was associated with a reduction in this risk. For patients not naïve to opioids before fracture diagnosis, early kyphoplasty was associated with less persistent elevation of opioid overdose risk. Subsequent trials must compare opioid use by vertebral fracture patients treated via operative (kyphoplasty) and nonoperative (ongoing opioid) strategies before concluding that kyphoplasty lacks value, and early referral for kyphoplasty may be appropriate to avoid missing a window of efficacy.

Toxicity of the acetyl-para-aminophenol group of medicines to intact intervertebral disc tissue cells

The present study aimed to investigate the effects of paracetamol, an analgesic and antipyretic that is used in emergency departments and neurosurgery departments for postoperative pain management on intervertebral disc tissue. Paracetamol-treated human primary cell cultures and untreated cell cultures were compared using molecular analyses. Cell proliferation and gene expression were statistically analyzed. Cell proliferation was suppressed on days 10 (P=0.05) and 20 (P<0.05) in the paracetamol-treated groups. Gene expression of chondroadherin, matrix metalloproteinase (MMP)-7, MMP-13 and MMP-19 was higher in the paracetamol-treated samples while gene expression of Cartilage Oligomeric Matrix Protein and interleukin-1β was lower (P<0.05). Paracetamol, which appears innocuous compared with many analgesics, may increase the expression of MMPs, which serve a significant role in catabolic reactions and suppress the proliferation of intact intervertebral disc tissue cells.

Management of hospitalised osteoporotic vertebral fractures

Management of hospitalised osteoporotic vertebral fracture patients was explored across all major trauma orthopaedic hospitals in Ireland. Findings, based on a survey of orthopaedic doctors and physiotherapists, indicate a lack of standardised clinical care pathways. This study will inform development of clinical audit mechanisms and health service development for this large and growing fracture population in both Ireland and internationally.

PURPOSE

To explore the management of hospitalised vertebral fragility fracture (VFF) patients in Ireland.

METHODS

A cross-sectional survey of orthopaedic doctors (specialist registrar level) and physiotherapists was conducted across all hospitals with major orthopaedic trauma units in Ireland. Data were analysed using descriptive statistics in SPSS (V24).

RESULTS

Responses were achieved from 100% (n = 16) of the hospitals (42 individual physiotherapists and 47 orthopaedic doctors). Conservative management was usual with both orthopaedic doctors (n = 37, 79%) and physiotherapists (n = 40, 96%) reporting prescription of bracing as common practice despite a lack of underpinning evidence. A majority (87%) of the doctors believed osteoporosis medications should commence prior to discharge from the acute setting, but 68% did not agree that responsibility for coordination and delivery of bone health assessment and fracture risk management rested with them. A majority (72%) of physiotherapists reported an absence or were unsure regarding existence of fracture liaison services. 73% of physiotherapists reported prescribing an inpatient or home (78%) exercise programme, including mobility, strength and balance exercise though detail on dose and adherence remain unknown. Wide variance in referral patterns to multi-disciplinary team (MDT) members existed although 79% of orthopaedic doctors supported an MDT approach.

CONCLUSION

Clinical care pathways for the hospitalised VFF population lack standardisation in Ireland. Key challenges reported by orthopaedic doctors and physiotherapists relate to pain management, osteoporosis medication prescription, clarity on indications for bracing and a lack of fracture liaison services. Clinical guidelines, defined clinical care pathways and high-quality clinical research trials are required for VFF management.

Decreased physical health-related quality of life-a persisting state for older women with clinical vertebral fracture

In a population-based study of older Swedish women, we investigated if clinical vertebral fracture was associated with lower health-related quality of life (HRQoL) and determined whether the association remained over time. Clinical vertebral fracture was associated with lower HRQoL and the effect persisted for up to 18.9 years.

INTRODUCTION

Vertebral fractures are often associated with back pain and reduced physical function, which might result in isolation and depression. As a result, women with vertebral fractures often have lower health-related quality of life (HRQoL), but during what time frame the decrease lingers is unclear. Therefore, the aim of this study was to investigate if clinical vertebral fracture and hip fracture were associated with lower HRQoL and to determine whether the associations remained over time.

METHODS

Vertebral fracture assessments (VFA) were performed using dual-energy X-ray absorptiometry. Data regarding prior fractures, medications, medical history, and physical activity was collected using a questionnaire. Self-rated physical HRQoL was assessed using the 12-Item Short-Form Health Survey (SF-12). Women with clinical vertebral fractures were divided into tertiles according to time since fracture onset and their HRQoL was compared with non-fractured women.

RESULTS

In a population-based cross-sectional study of 3028 women aged 77.8 ± 1.63 (mean ± SD), a total of 130 (4.3%) women reported at least one clinical vertebral fracture. Women with a clinical vertebral fracture, divided into tertiles (T1-T3) depending on time since the fracture occurred, had lower HRQoL (T1: 36.3 ± 10.8; T2: 41.0 ± 9.94; and T3:41.6 ± 11.4) than women without fracture (46.2 ± 10.6; p < 0.001). Using linear regression analysis, clinical vertebral fracture was associated with reduced physical HRQoL for up to 18.9 years, independently of covariates (age, height, weight, smoking, prior stroke, mental HRQoL, grip strength, and lumbar spine BMD).

CONCLUSIONS

Clinical vertebral fracture was associated with lower self-rated physical HRQoL, for up to 18.9 years after time of fracture.

Vertebral fragility fractures - How to treat them?

Approximately 20% of men and women aged 50 years or older will present with a vertebral fragility fracture - a prevalence that steadily increases with age. The condition may be associated with severe pain and disability, significant reductions in overall quality of life, mobility, social participation, sleep quality and increased fear for the future. There is, however, no current consensus on what constitutes the best management of symptomatic vertebral fractures. Moreover, evidence supporting common treatment approaches is scarce and often of poor quality. The lack of adequate management of VFF and associated osteoporosis and the burden of this condition to patient and society are estimated to increase substantially in coming years as recurrent, disabling episodes are set to occur. This chapter will address these issues, including a discussion on existing care pathways for vertebral fragility fractures, and an overview of the evidence supporting recommendations of the main international clinical practice guidelines.