Management of Osteoporotic Vertebral Fracture: Review Update 2022

The Effects of Longer Use of Teriparatide on Clinical and Radiographic Outcomes after Spinal Fusion in Geriatric Patients

Background: Teriparatide is an anabolic agent for osteoporosis and is believed to improve the bone healing process. Previous studies showed that teriparatide could enhance not only fracture healing but also spine fusion. It has been reported that use of teriparatide could promote the spine fusion process and decrease mechanical complications. However, there was no consensus regarding optimal treatment duration. The purpose of this study was to compare surgical outcomes between short-duration and long-duration teriparatide treatment after lumbar fusion surgery in elderly patients. Materials and Methods: All consecutive patients older than 60 years who underwent 1-level lumbar fusion surgery for degenerative diseases between January 2015 and December 2019 were retrospectively reviewed. Based on the duration of teriparatide treatment (daily subcutaneous injection of 20 µg teriparatide), patients were subdivided into two groups: a short-duration (SD) group (<6 months) and a long-duration (LD) group (≥6 months). Mechanical complications, such as screw loosening, cage subsidence, and adjacent vertebral fractures, were investigated. Postoperative 1-year union rate was also evaluated on computed tomography. Clinical outcomes were recorded using visual analog scale (VAS) and Oswestry Disability Index (ODI). Between-group differences for these radiographic and clinical outcomes were analyzed. Results: Ninety-one patients were reviewed in this study, including sixty patients in the SD group and thirty-one patients in the LD group. Their mean age was 72.3 ± 6.2 years, and 79 patients were female. Mean T-score was -3.3 ± 0.8. Cage subsidence (6.7% vs. 3.2%), screw loosening (28.3% vs. 35.5%), and adjacent vertebral fracture (6.7% vs. 9.7%) were not significantly different between the SD and LD groups. Union rate at 1-year postoperative was 65.0% in the SD group and 87.1% in the LD group (p = 0.028). Both groups showed improvement in VAS and ODI after surgery. However, the differences of VAS from preoperative to 6 months and 1 year postoperative were significantly higher in the LD group. Conclusions: Longer teriparatide treatment after lumbar fusion surgery resulted in a higher union rate at 1-year postoperative than the shorter treatment. Also, it could be more beneficial for clinical outcomes.

Prevalent morphometric vertebral fractures as a risk factor for subsequent clinical vertebral fractures after shortfusion surgery in older Japanese women with degenerative spondylolisthesis

STUDY DESIGN

A retrospective cohort study using the Kaplan-Meier method with propensity-score matching.

PURPOSE

To evaluate whether the presence of prevalent morphometric vertebral fractures (VFs) poses a risk for subsequent clinical VFs after short-fusion surgery in women aged ≥60 years with degenerative spondylolisthesis.

OVERVIEW OF LITERATURE

VFs are common osteoporotic fractures and are associated with a low quality of life. Subsequent VFs are a complication of instrumented fusion in patients with degenerative lumbar disorders. Thus, risk factors for subsequent VFs after fusion surgery must be analyzed. Population-based studies have suggested that prevalent morphometric VFs led to a higher incidence of subsequent VFs in postmenopausal women; however, no studies have investigated whether prevalent morphometric VFs are a risk factor for subsequent VFs after fusion surgery in patients with degenerative spondylolisthesis.

METHODS

The study enrolled a total of 237 older female patients: 50 and 187 patients had prevalent morphometric VFs (VF [+] group) and nonprevalent morphometric VFs (VF [-] group), respectively. The time to subsequent clinical VFs after fusion surgery was compared between the two groups using the Kaplan-Meier method. Moreover, 40 and 80 patients in the VF (+) and VF (-) groups, respectively, were analyzed and matched by propensity scores for age, follow-up duration, surgical procedure, number of fused segments, body mass index, and number of patients treated for osteoporosis.

RESULTS

Kaplan-Meier analysis indicated that the VF (+) group had a higher incidence of subsequent clinical VFs than the VF (-) group, and Cox regression analysis showed that the presence of prevalent morphometric VFs was an independent risk factor for subsequent clinical VFs before matching. Kaplan-Meier analysis demonstrated comparable results after matching.

CONCLUSIONS

The presence of prevalent morphometric VFs may be a risk factor for subsequent clinical VFs in older women with degenerative spondylolisthesis who underwent short-fusion surgery.

Weight changes after smoking cessation affect the risk of vertebral fractures: a nationwide population-based cohort study

BACKGROUND CONTEXT

Smoking cessation reduces the risk of vertebral and hip fractures but usually increases body weight. Since underweight is known as a risk factor for vertebral fractures, smoking cessation is considered to have a protective effect on vertebral fractures. However, the actual effect of weight change after smoking cessation on the risk of vertebral fractures remains uncertain.

PURPPOSE

This study aimed to assess the risk of vertebral fractures among individuals who reported smoking cessation with a specific focus on changes in body weight.

STUDY DESIGN

Retrospective cohort study based on nationwide health insurance database.

PATIENT SAMPLE

Participants were from nationwide biennial health checkups between 2007 and 2009 conducted by the Korean National Health Insurance Service. Participants were followed up from 2010 to 2018 to find incidence of newly developed vertebral fractures.

OUTCOME MEASURES

The incidence rate was defined as the incidence rate (IR) per 1,000 person-years (PY). Cox proportional regression analysis was used to analyze the risk of vertebral fracture to determine the hazard ratio (HR) associated with the incidence of vertebral fractures based on smoking status and weight changes.

METHODS

Based on their self-reported questionnaires, the participants were classified into three groups: current smokers, quitters, and nonsmokers. The quitter was defined as an individual who were smokers in 2007 and ceased smoking in 2009. Individuals with smoking cessation were categorized according to the weight change between baseline and 2 years prior: weight maintenance (-5∼5 % of weight change), weight loss (<-5 % of weight change), and weight gain (>5 % of weight change). We used Cox proportional hazards analysis to determine the hazard ratio (HR) associated with the incidence of vertebral fractures based on smoking status and temporal weight change over 2 years.

RESULTS

This study evaluated 913,805 eligible participants, of whom 672,858 were classified as nonsmokers, 34,143 as quitters, and 206,804 as current smokers. Among quitters, 2,372 (6.9%) individuals had weight loss, and 7,816 (22.9%) had weight gain over 2 years. About 23,952 (70.2%) individuals maintained their weight over 2 years. The overall risk of vertebral fractures was significantly higher in quitters (adjusted HR [aHR]=1.110, 95% confidence interval [CI] 1.013-1-216) than in nonsmokers, but it was lower than in current smokers (aHR=1.197, 95%CI 1.143-1.253), regardless of weight change after smoking cessation. However, individuals who experienced weight loss after smoking cessation exhibited a notably higher risk of vertebral fractures than current smokers (aHR=1.321, 95%CI 1.004-1.461). In the female population, weight gain after smoking cessation was associated with a higher risk of vertebral fractures (aHR = 1.470, 95%CI 1.002-2.587) than in current female smokers.

CONCLUSIONS

Maintaining weight after smoking cessation may mitigate the risk of vertebral fractures. Weight loss after smoking cessation adversely affects the protective effects of smoking cessation on vertebral fractures in the general population.

Transpedicular Intravertebral Cage Augmentation Using Expandable Cage in Kummell Disease: Technical Note and Case Series

OBJECTIVE

To demonstrate the surgical techniques for transpedicular intravertebral cage augmentation (TPICA) using an expandable cage for Kummell disease, which requires posterior surgical stabilization, and provide the preliminary surgical outcomes.

METHODS

Six consecutive patients undergoing TPICA surgery using an expandable cage with a minimum 6-month follow-up were evaluated. Radiographic analysis to evaluate the local kyphosis angle, restoration ratio of anterior vertebral height of the index vertebra, and clinical outcomes including the Oswestry Disability Index, EuroQol 5-dimension instrument, and visual analog scale for back and leg pain, were compared between the preoperative and final follow-ups.

RESULTS

All patients showed improvements in all clinical outcomes and were able to walk independently without support at the last follow-up. In radiographic evaluation, the mean preoperative restoration ratio of anterior vertebral height was 41.2 ± 15.6%, which increased postoperatively to 70.3 ± 20.5% (1.70 times) and 62.4 ± 20.0% at the last follow-up (1.51 times). The mean preoperative local kyphosis angle was 10.5 ± 14.8 and was corrected to 6.0 ± 10.0 at the last follow-up. A slight loss of correction was observed between the postoperative period and the last follow-up; however, there was no clinical significance.

CONCLUSIONS

Expandable cages in TPICA may allow easier surgical manipulation for cage insertion around the pedicle entrance, minimizing damage to the fractured vertebral body's end plates while achieving satisfactory height restoration compared to static cages, and may also provide wider indications for TPICA surgery.

Paravertebral Nerve Block for Procedural Pain in Percutaneous Vertebroplasty

OBJECTIVES

This study aimed to unidimensionally measure procedural pain at each percutaneous vertebroplasty (PVP) stage and evaluate the effectiveness of paravertebral nerve block (PVNB) in reducing procedural pain.

METHODS

A retrospective study of prospectively collected data was conducted on 66 patients who underwent PVP for osteoporotic vertebral compression fractures. The patients were divided into 2 groups: group A (fluoroscopic-guided PVNB; 5 cm 3 of 0.75% ropivacaine on each side) and group B (local anesthesia). To investigate procedural pain associated with PVP, the visual analog scale score was assessed at each surgical stage: before the incision (stage 1), transpedicular approach (stage 2), and polymethylmethacrylate cement injection (stage 3). After the procedure, patients were asked about their surgical experience and satisfaction using the Iowa Satisfaction with Anesthesia Scale. Periprocedural complications were also recorded.

RESULTS

A total of 63 patients (78.65 y of age) were finally enrolled: 30 from group A and 33 from group B. In both groups, a significant ≥2-point increase in procedural pain was observed during PVP compared with that during stage 1 ( P < 0.001). In stages 2 and 3, the pain intensity was significantly lower in group A ( P < 0.001). Upon discharge, the visual analog scale score improved in all groups; however, the Iowa Satisfaction with Anesthesia Scale score was significantly higher in group A ( P < 0.001). There was no difference in periprocedural complications between the two groups ( P = 0.743).

CONCLUSION

PVP causes significant procedural pain, and PVNB is a potentially effective modality for enhancing patient satisfaction and reducing procedural pain.

Dynamic spinal orthoses self-reported effects in patients with back pain due to vertebral fragility fractures: A multi-center prospective cohort study

BACKGROUND

Vertebral fragility fractures (VFFs) commonly result from low bone mass and microarchitecture deterioration of bone tissue. spinal orthoses are common non-pharmacological options for managing vertebral fracture pain. However, the effects of spinal orthoses on pain, physical functioning, and quality of life (QoL) are still debated.

OBJECTIVE

This survey aimed to investigate the patients-reported outcomes of a dynamic spinal orthosis prescribed in the routine clinical practice of VFFs management.

METHODS

This multi-center national-wide prospective cohort study assessed older patients (aged > 60 years) diagnosed with acute VFFs and prescribed with a dynamic spinal orthosis (Spinfast®). A survey questionnaire was realized and included sections on patient characterization, osteoporosis characterization, spinal orthosis, clinical outcomes, pain medications, and osteoporosis medications. The questionnaire was administered at baseline and after three months. A total of 68 patients completed the questionnaire at three months. Most patients had one or two VFFs and were treated with pain medications and osteoporosis medications. Compliance and tolerability of the spinal orthosis were assessed, and clinical outcomes such as pain intensity, physical functioning, and QoL were measured.

RESULTS

The results showed no significant differences in outcomes between age subgroups. Italian physical medicine and rehabilitation physicians were commonly involved in the management of VFFs patients. Sixty-six patients completed the questionnaire. The results showed that pain intensity, physical functioning and QoL improved after three months of spinal orthosis wearing (p< 0.0001).

CONCLUSION

The correct management of VFFs is mandatory to improve pain and reduce disability, and our findings suggested a positive role of dynamic spinal orthosis to improve the comprehensive management of VFFs patients. However, high-quality research trials are warranted to provide clear recommendations for the correct clinical management of VFF.

Role of biophysical stimulation in multimodal management of vertebral compression fractures

Raised life expectancy and aging of the general population are associated with an increased concern for fragility fractures due to factors such as osteoporosis, reduced bone density, and an higher risk of falls. Among these, the most frequent are vertebral compression fractures (VCF), which can be clinically occult. Once the diagnosis is made, generally thorough antero-posterior and lateral views of the affected spine at the radiographs, a comprehensive workup to assess the presence of a metabolic bone disease or secondary causes of osteoporosis and bone frailty is required. Treatment uses a multimodal management consisting of a combination of brace, pain management, bone metabolism evaluation, osteoporosis medication and has recently incorporated biophysical stimulation, a noninvasive technique that uses induced electric stimulation to improve bone recovery through the direct and indirect upregulation of bone morphogenic proteins, stimulating bone formation and remodeling. It contributes to the effectiveness of the therapy, promoting accelerated healing, supporting the reduction of bed rest and pain medications, improving patients' quality of life, and reducing the risk to undergo surgery in patients affected by VCFs. Therefore, the aim of this review is to outline the fundamental concepts of multimodal treatment for VCF, as well as the present function and significance of biophysical stimulation in the treatment of VCF patients.

Assessing bone mineral density in non-weight bearing regions of the body: a texture analysis approach using abdomen and pelvis computed tomography Hounsfield units-a cross-sectional study

Background

Highlighting a gap in comprehending bone microarchitecture's intricacies using dual-energy X-ray absorptiometry (DXA), this study aims to bridge this chasm by analyzing texture in non-weight bearing regions on axial computed tomography (CT) scans. Our goal is to enrich osteoporosis patient management by enhancing bone quality and microarchitecture insights.

Methods

Conducted at Busan Medical Center from March 1, 2013, to August 30, 2022, 1,320 cases (782 patients) were screened. After applying exclusion criteria, 458 samples (296 patients) underwent bone mineral density (BMD) assessment with both CT and DXA. Regions of interest (ROIs) included spine pedicle's maximum trabecular area, sacrum Zone 1, superior/inferior pubic ramus, and femur's greater/lesser trochanters. Texture features (n=45) were extracted from ROIs using gray-level co-occurrence matrices. A regression model predicted BMD, spotlighting the top five influential texture features.

Results

Correlation coefficients ranged from 0.709 (lowest for total femur BMD) to 0.804 (highest for femur intertrochanter BMD). Mean squared error (MSE) values were also provided for lumbar and femur BMD/bone mineral content (BMC) metrics. The most influential texture features included contrast_32, correlation_32_v, and three other metrics.

Conclusions

By melding traditional DXA and CT texture analysis, our approach presents a comprehensive bone health perspective, potentially revolutionizing osteoporosis diagnostics.

Predictive factors for conversion from conservatively to surgically treatment osteoporotic thoracolumbar compression fractures based on sagittal parameters and magnetic resonance imaging features

PURPOSE

To investigate the relationship between sagittal plane characteristics of the spinal column and conservative treatment failure in acute osteoporotic spinal fractures (OSFs).

METHODS

As a retrospective study of single-institute data, thoracolumbar OSF patients with similar propensities in terms of location of fractures and results of bone mineral density were analyzed. Among them, 43 patients (group I) who needed reconstructive surgical interventions and 39 patients (group II) who obtained successful treatment through conservative care were included. General demographic data, radiographic features of fractures, and magnetic resonance imaging (MRI) features of fractures were analyzed. To investigate the relationship between global sagittal alignment of the spine and occurrence of delayed complication following OSFs, radiological sagittal parameters were analyzed.

RESULTS

The number of cases requiring reconstructive surgery was significantly higher when the index vertebra showed diffuse or mid-portion bone marrow changes in MRI. In terms of sagittal parameters, pelvic incidence (group I 59.1° ± 11.9°, group II 54.6° ± 9.8°) and thoracolumbar angle (group I 26.5° ± 14.1°, group II 17.4° ± 11.2°) were significantly higher in group I. Logistic regression analysis showed that higher pelvic incidence (OR 1.09, 95% CI 1.01-1.18, p value < 0.05) and higher thoracolumbar angle (OR 1.09, 95% CI 1.02-1.17, p value < 0.05) were significant risk factors for delayed complications requiring reconstructive surgery following OSFs.

CONCLUSION

Delayed complications requiring reconstructive surgery following OSFs are related to sagittal plane parameters of the spine such as high pelvic incidences, in addition to previously known radiographic characteristics of fractures.

A Randomized Controlled Trial of Vertebral Body Decompression Procedure Versus Conservative Treatment for Painful Vertebral Compression Fracture

Background: Traditional treatment modalities for vertebral compression fractures (VCFs) include bed rest, pain medications, muscle relaxants, back braces, and physical therapy. In cases where conservative treatment proves ineffective, a new procedure called core decompression of the vertebral body is explored. Core decompression of the vertebral body has the potential to lower and stabilize the intraosseous pressure, resulting in enhanced blood circulation, which contributes to pain reduction. In this trial, we evaluated the efficacy of core decompression of the vertebral body in patients with painful VCFs compared with conventional conservative treatment. Methods: This prospective randomized controlled trial was conducted at a tertiary education hospital between June 2017 and May 2020. The participants were randomly assigned in a 1:1 ratio to one of two treatment groups: the core decompression group and the conservative treatment group. The primary outcome measure was the visual analog scale (VAS) pain score of the back 3 months after the procedure. Secondary outcome measures included the Oswestry Disability Index (ODI) for lumbar disabilities, the European Quality of Life-5 Dimensions (EQ-5D) score for quality of life, and radiographic outcomes such as changes in compression rate. Results: All patients underwent the assigned intervention (48 core decompression and 50 conservative treatments). At both 1 month and 3 months, there were no significant differences between the core decompression group and conservative treatment group in VAS pain score (adjusted treatment effect: -0.1 and 2.0; 95% confidence interval [CI]: -7.5 to 7.3 and -5.6 to 9.6; p = 0.970 and p = 0.601, respectively). In addition, there were no significant inter-group differences in ODI and EQ-5D scores throughout the follow-up period (p = 0.917 and 0.704, respectively). Conclusion: Core decompression of the vertebral body did not demonstrate any significant improvement in pain and disability compared to conventional conservative treatment.

[Osteoporotic vertebral body fractures]

The number of osteoporotic fractures of the spine is increasing. These fractures are associated with elevated morbidity and mortality. This article provides an overview of the special features of these fractures, the diagnostic procedure, their classification, and the conservative and surgical treatment options. For the mostly elderly patients, it is important to treat the underlying disease and to address associated problems such as frailty and sarcopenia. To meet this growing medical and socio-economic challenge, a holistic interdisciplinary and interprofessional treatment approach is required.

Application of Escherichia coli-Derived Recombinant Human Bone Morphogenic Protein-2 to Unstable Spinal Fractures

(1) Background: Recently, Escherichia coli-derived recombinant human bone morphogenetic protein-2 (E. coli-derived rhBMP-2) has been increasingly applied to different types of spinal surgeries and reported to achieve successful fusion. This pilot study aimed to evaluate the clinical efficacy and safety of rhBMP-2 in patients undergoing posterior instrumented fusions for unstable spinal fractures. (2) Methods: This study included ten consecutive patients undergoing spinal surgery using E. coli-derived rhBMP-2 with more than one year of follow-up. Radiologic outcomes were compared, including the average fracture healing period, local kyphosis correction, and clinical outcomes between preoperative and the last follow-up. (3) Results: The average time of radiographic union was 99.9 ± 45.4 (62-192) days, with an average use of 5.2 ± 3.9 months of anabolic agents. Radiologic parameters such as anterior vertebral height and vertebral wedge angle were significantly corrected postoperatively and at the last follow-up. Clinical outcomes other than leg pain were significantly improved after the surgery. In addition, four patients with preoperative neurologic deficits showed improved neurologic status. (4) Conclusions: Combined with the anabolic agents, applying E. coli-derived rhBMP-2 to the fractured vertebral body could be an effective surgical treatment for unstable spinal fractures. Further trials are needed to validate this result.

Assessing Bone Mineral Density in Weight-Bearing Regions of the Body through Texture Analysis of Abdomen and Pelvis CT Hounsfield Unit

Objective: This study aimed to develop a novel method for opportunistically screening osteoporosis by measuring bone mineral density (BMD) from CT images. We addressed the limitations of commercially available software and introduced texture analysis using Hounsfield units (HU) as an alternative approach. Methods: A total of 458 samples (296 patients) were selected from a dataset of 1320 cases (782 patients) between 1 March 2013, and 30 August 2022. BMD measurements were obtained from the ilium, femoral neck, intertrochanteric region of both femurs, and L1-L5 and sacrum spine body. The region of interest (ROI) for each patient's CT scan was defined as the maximum trabecular area of the spine body, ilium, femoral neck, and femur intertrochanter. Using gray-level co-occurrence matrices, we extracted 45 texture features from each ROI. Linear regression analysis was employed to predict BMD, and the top five influential texture features were identified. Results: The linear regression (LR) model yielded correlation coefficients (R-squared values) for total lumbar BMD, total lumbar BMC, total femur BMD, total femur BMC, femur neck BMD, femur neck BMC, femur intertrochanter BMD, and femur intertrochanter BMC as follows: 0.643, 0.667, 0.63, 0.635, 0.631, 0.636, 0.68, and 0.68, respectively. Among the 45 texture features considered, the top five influential factors for BMD prediction were Entropy, autocorrelate_32, autocorrelate_32_volume, autocorrelate_64, and autocorrelate_64_volume.

Exploring the Paradox of Bone Mineral Density in Type 2 Diabetes: A Comparative Study Using Opportunistic Chest CT Texture Analysis and DXA

BACKGROUND

This study aimed to validate the application of CT texture analysis in estimating Bone Mineral Density (BMD) in patients with Type 2 Diabetes (T2D) and comparing it with the results of dual-energy X-ray absorptiometry (DXA) in a normative cohort.

METHODS

We analyzed a total of 510 cases (145 T2D patients and 365 normal patients) from a single institution. DXA-derived BMD and CT texture analysis-estimated BMD were compared for each participant. Additionally, we investigated the correlation among 45 different texture features within each group.

RESULTS

The correlation between CT texture analysis-estimated BMD and DXA-derived BMD in T2D patients was consistently high (0.94 or above), whether measured at L1 BMD, L1 BMC, total hip BMD, or total hip BMC. In contrast, the normative cohort showed a modest correlation, ranging from 0.66 to 0.75. Among the 45 texture features, significant differences were found in the Contrast V 64 and Contrast V 128 features in the normal group.

CONCLUSION

In essence, our study emphasizes that the clinical assessment of bone health, particularly in T2D patients, should not merely rely on traditional measures, such as DXA BMD. Rather, it may be beneficial to incorporate other diagnostic tools, such as CT texture analysis, to better comprehend the complex interplay between various factors impacting bone health.

When Should Spinal Surgery Be Considered for Spinal Metastasis from Non-Small Cell Lung Cancer?-Propensity Score Matched Study between Surgery with Radiotherapy and Radiotherapy Alone

(1) Background: Although metastatic spine disease is increasing, the debate on therapeutic modality remains due to the heterogeneity of tumors and patients. This study aims to evaluate the efficacies of surgery and risk factors for patients' survival from potentially unstable spinal metastasis of non-small cell lung cancer; (2) Methods: Twenty-two patients undergoing surgery and radiotherapy (group I) were compared with 22 patients undergoing radiotherapy alone (group II) using propensity score matching in a 1-to-1 format. Clinical outcomes included the performance status and ambulatory status. In addition, independent risk factors for patients' survival were evaluated, including the molecular targeted therapy for mutations; (3) Results: deterioration in neurologic status was only observed in group II compared to group I (22.7% vs. 0%, p-value = 0.018). In addition, five patients in the surgery group showed improved Frankel grades. Regarding the patients' survival, a smoking history of more than ten pack-years (hazard ratio (HR) = 12.18), worse performance status (HR = 6.86), and absence of mutations (HR = 3.39) were the independent risk factors; (4) Conclusions: Spinal surgery with radiotherapy could have advantages for improving the neurologic status including ambulation for potentially unstable spine due to metastasis. Thus, surgery should be considered for patients with a longer life expectancy resulting from better performance status and use of the targeted therapy.

Comparison of unilateral and bilateral percutaneous kyphoplasty for the treatment of osteoporotic vertebral compression fractures associated with scoliosis

To assess the clinical and radiographic effectiveness of unilateral and bilateral percutaneous kyphoplasty (PKP) in the treatment of osteoporotic vertebral compression fractures (OVCF) associated with scoliosis, 52 patients with OVCF associated with scoliosis who underwent PKP were retrospectively analysed. The patients were divided into the unilateral PKP group (n=26) and the bilateral PKP group (n=26). The operation time, bone cement injection volume and frequency of intraoperative fluoroscopy were recorded and compared between the groups. Additionally, visual analogue scale (VAS) and Oswestry disability index (ODI) scores, as well as postoperative complications, including bone cement leakage and adjacent vertebral fractures, were also assessed. The operation time, bone cement injection volume and intraoperative fluoroscopy frequency were significantly lower in the unilateral compared with the bilateral group (P<0.001). The VAS score, ODI score, average vertebral body height and kyphotic angle (KA) were improved after surgery in each group with no difference in these clinical parameters between the two groups both before and after surgery. Furthermore, the proportion of cases with bone cement leakage in the unilateral group was significantly lower compared with that in the bilateral group (P<0.05). During the follow-up, there were three cases (11.5%) in the unilateral group and two cases (7.7%) in the bilateral group who suffered adjacent vertebral fractures, but there was no statistically significant difference between the two groups (P>0.05). For treating patients with OVCF accompanied by scoliosis, both unilateral and bilateral PKP could effectively relieve the acute back pain and correct the KA. However, unilateral PKP presents more advantages, such as a short operation duration and reduced intraoperative fluoroscopy frequency and bone cement leakage.

Radiological Factors Associated with Bisphosphonate Treatment Failure and Their Impact on Fracture Healing in Postmenopausal Women with Osteoporotic Vertebral Fractures

(1) Background: Bisphosphonate treatment failure is one of the most difficult clinical problems for patients with osteoporosis. This study aimed to analyze the incidence of bisphosphonate treatment failure, associated radiological factors, and effect of fracture healing in postmenopausal women with osteoporotic vertebral fractures (OVFs). (2) Methods: A total of 300 postmenopausal patients with OVFs who were prescribed bisphosphonate were retrospectively analyzed and divided into two groups according to the treatment response: response (n = 116) and non-response (n = 184) groups. The radiological factors and the morphological patterns of OVFs were included in this study. (3) Results: The initial BMD values of the spine and femur in the non-response group were significantly lower than those in the response group (all Ps < 0.001). The initial BMD value of the spine (odd ratio = 1.962) and the fracture risk assessment tool (FRAX) hip (odd ratio = 1.32) showed statistical significance in logistic regression analysis, respectively (all Ps < 0.001). (4) Conclusions: The bisphosphonate non-responder group showed a greater decrease in BMD over time than the responder group. The initial BMD value of the spine and the FRAX hip could be considered radiological factors influencing bisphosphonate non-response in the postmenopausal patients with OVFs. The failure of bisphosphonate treatment for osteoporosis has a possible negative on the fracture healing process in OVFs.

Risk of fracture according to temporal changes of low body weight changes in adults over 40 years: a nationwide population-based cohort study

BACKGROUND

Low body weight is associated with an increased risk of fractures. However, the effect of temporal changes in the low body weight status on the risk of fracture remains unknown. This study aimed to evaluate the relationships between temporal changes in low body weight status and the risk of fractures in adults over the age of 40 years.

METHODS

This study included data on adults over 40 years old who underwent two biannual consecutive general health examinations between January 1, 2007 and December 31, 2009 extracted from the National Health Insurance Database, a large nationwide population database. Fracture cases in this cohort were monitored from the time of the last health examination to the end of the designated follow-up period (from January 1, 2010 to December 31, 2018) or the participant's death. Fractures were defined as any fracture resulting in hospitalization or outpatient treatment claim after the date of general health screening. The study population was then separated into four groups based on the temporal changes in low body weight status as follows: low body weight to low body weight (L-to-L), low body weight to non-low body weight (L-to-N), non-low body weight to low body weight (N-to-L), and non-low body weight to non-low body weight (N-to-N). The hazard ratios (HRs) for new fractures, depending on weight changes over time, were calculated using Cox proportional hazard analysis.

RESULTS

Adults in the L-to-L, N-to-L, and L-to-N groups had a substantially increased risk of fractures after multivariate adjustment (HR, 1.165; 95% confidence interval [CI], 1.113-1.218; HR, 1.193; 95% CI, 1.131-1.259; and HR, 1.114; 95% CI, 1.050-1.183, respectively). Although the adjusted HR was greater in participants who changed into having a low body weight, followed by those with consistently low body weight, those with low body weight remained to have an elevated risk of fracture independent of weight fluctuation. Elderly men (aged over 65 years), high blood pressure, and chronic kidney disease were significantly associated with an increase in fractures (p < 0.05).

CONCLUSION

Individuals aged over 40 years with low body weight, even after regaining normal weight, had an increased risk of fracture. Moreover, having a low body weight after having a normal body weight increased the risk of fractures the most, followed by those with consistently low body weight.

Underweight and risk of fractures in adults over 40 years using the nationwide claims database

We aimed to investigate how underweight affects the incidence of fractures, as well as the influence of cumulative, longitudinal periods of low body mass index (BMI) and changes in body weight on fracture development. Data on adults aged 40-year and over who had three health screenings between January 1, 2007, and December 31, 2009 were used to determine the incidence of new fractures. The hazard ratios (HRs) for new fractures depending on BMI, total cumulative number of underweight, and weight change over time were calculated using Cox proportional hazard analysis. In this study, 15,955 (2.8%) of the 561,779 adults were diagnosed with fractures more than once over three health examinations. The fully adjusted HR for fractures in underweight individuals was 1.173 (95% Confidence interval [CI] 1.093-1.259). Underweight individuals diagnosed only once, twice, or three times had an adjusted HR of 1.227 (95%CI 1.130-1.332), 1.174 (95%CI 1.045-1.319), and 1.255 (95%CI 1.143-1.379), respectively. Although the adjusted HR was higher in adults who consistently had underweight (HR; 1.250 [95%CI 1.146-1.363]), those with underweight had an increased risk of fractures regardless of weight change (HR; 1.171 [95%CI 1.045-1.312], and 1.203[95%CI 1.075-1.346]). Underweight is a risk factor for fractures in adults over the age of 40 years, even if they returned to normal weight.

Effect of Lumbar Spinal Stenosis on Treatment of Osteoporosis: Comparison of Three Oral Bisphosphonate Therapies

(1) Background: Lumbar spinal stenosis (LSS) causes uncomfortable neuropathic symptoms, which can negatively affect osteoporosis. The aim of this study was to investigate the effect of LSS on bone mineral density (BMD) in patients treated with one of three oral bisphosphonates (ibandronate, alendronate and risedronate) for initially diagnosed osteoporosis. (2) Methods: We included 346 patients treated with oral bisphosphonates for three years. We compared annual BMD T-scores and BMD increases between the two groups according to symptomatic LSS. The therapeutic efficacies of the three oral bisphosphonates in each group were also evaluated. (3) Results: Annual and total increases in BMD were significantly greater in group I (osteoporosis) compared to group II (osteoporosis + LSS). The total increase in BMD for three years was significantly greater in the ibandronate and alendronate subgroups than that in the risedronate subgroup (0.49 vs. 0.45 vs. 0.25, p < 0.001). Ibandronate showed a significantly greater increase in BMD than that of risedronate in group II (0.36 vs. 0.13, p = 0.018). (4) Conclusions: Symptomatic LSS may interfere with the increase in BMD. Ibandronate and alendronate were more effective in treating osteoporosis than risedronate. In particular, ibandronate was more effective than risedronate in patients with both osteoporosis and LSS.