Prevalence of Frailty in Patients with Osteoporotic Vertebral Compression Fracture and Its Association with Numbers of Fractures

The Evolution of Risk Assessment in Spine Surgery: A Narrative Review

BACKGROUND

Risk assessment is critically important in elective and high-risk interventions, particularly spine surgery. This narrative review describes the evolution of risk assessment from the earliest instruments focused on general surgical risk stratification, to more accurate and spine-specific risk calculators that quantified risk, to the current era of big data.

METHODS

The PubMed and SCOPUS databases were queried on October 11, 2023 using search terms to identify risk assessment tools (RATs) in spine surgery. A total of 108 manuscripts were included after screening with full-text review using the following inclusion criteria: 1) study population of adult spine surgical patients, 2) studies describing validation and subsequent performance of preoperative RATs, and 3) studies published in English.

RESULTS

Early RATs provided stratified patients into broad categories and allowed for improved communication between physicians. Subsequent risk calculators attempted to quantify risk by estimating general outcomes such as mortality, but then evolved to estimate spine-specific surgical complications. The integration of novel concepts such as invasiveness, frailty, genetic biomarkers, and sarcopenia led to the development of more sophisticated predictive models that estimate the risk of spine-specific complications and long-term outcomes.

CONCLUSIONS

RATs have undergone a transformative shift from generalized risk stratification to quantitative predictive models. The next generation of tools will likely involve integration of radiographic and genetic biomarkers, machine learning, and artificial intelligence to improve the accuracy of these models and better inform patients, surgeons, and payers.

Osteoporosis Evaluation and Management in Spine Surgery

Osteoporosis is a global health problem affecting over 200 million people worldwide and 54 million adults in the United States. Approximately half of all postmenopausal women will have an osteoporosis-related fracture during their lifetime. In the United States, the direct medical cost related to osteoporosis is expected to exceed $25 billion by 2025. Management of osteoporosis in vertebral fractures and elective spine surgery is of the utmost concern, given the high prevalence of osteoporosis in the general population and the increased risk of complication in this population. New pharmacologic treatment options such as anabolic medications and diagnostic tools including Hounsfield unit measurements on routine computed tomography scans are available to orthopaedic and spinal surgeons to help best manage this condition. This review serves as an update to diagnosis, management, and treatment of patients with osteoporosis undergoing spinal surgery.

Risk Factors for Undergoing Surgical Intervention for Vertebral Compression Fractures: An Analysis of 703,499 Patients

BACKGROUND

Vertebral compression fractures (VCFs) are typically treated nonoperatively but can be treated with either kyphoplasty or vertebroplasty when indicated. The decision to treat patients with/without surgical intervention is dependent on the severity of deformity and patient risk profile. The aims of this study were to: 1) compare baseline patient demographics, 2) identify risk factors of patients undergoing operative vs. nonoperative management, and 3) identify patient-specific risk factors associated with postoperative readmissions.

METHODS

This retrospective database study used patient information from January 1st, 2010, to October 31st, 2021. Cohorts were identified by patients diagnosed with VCFs through International Classification of Disease, Ninth Revision (ICD-9), ICD-10 codes, identifying those undergoing kyphoplasty/vertebroplasty via Current Procedural Terminology codes. The 2 research domains utilized in this investigation were baseline demographic profiles of patients who underwent kyphoplasty or vertebroplasty for treatment of VCFs, and those who underwent nonoperative management served as the control cohort.

RESULTS

Of the 703,499 patients diagnosed with VCFs, 76,126 patients (10.8%) underwent kyphoplasty or vertebroplasty within 90 days of diagnosis of a VCF. Univariate analysis demonstrated female sex was associated with increased risk of undergoing surgical management for VCF (P < 0.0001). Several comorbidities were significantly associated with increased rates of readmission including hypertension, tobacco use, coronary artery disease, and chronic obstructive pulmonary disease (P < 0.0001 for all).

CONCLUSIONS

This study highlights specific comorbidities that are significantly associated with higher rates of kyphoplasty or vertebroplasty for the treatment of thoracolumbar wedge compression fractures and increased risk for 90-day postoperative hospital readmission.

Exploring the association between Frailty Index and low back pain in middle-aged and older Chinese adults: a cross-sectional analysis of data from the China Health and Retirement Longitudinal Study (CHARLS)

OBJECTIVES

This study explored the association between the Frailty Index (FI) and low back pain (LBP) in middle-aged and older Chinese adults. We hypothesised that a higher FI correlates with increased LBP prevalence.

DESIGN

Cross-sectional analysis.

SETTING

The study used data from the China Health and Retirement Longitudinal Study (CHARLS) across various regions of China.

PARTICIPANTS

The analysis included 6375 participants aged 45 and above with complete LBP and FI data from the CHARLS for 2011, 2013 and 2015. We excluded individuals under 45, those with incomplete LBP data, participants with fewer than 30 health deficit items and those missing covariate data.

OUTCOME MEASURES

We constructed an FI consisting of 35 health deficits. Logistic multivariable regression examined the relationship between FI and LBP, using threshold analysis to identify inflection points. Sensitivity analyses were performed to ensure the robustness of the findings.

RESULTS

Of the participants, 27.2% reported LBP. A U-shaped association was observed between FI and LBP, with the highest quartile (Q4, FI ≥0.23) showing more than a twofold increased risk of LBP (OR=2.90, 95% CI: 2.45-3.42, p<0.001). Stratified analysis showed a significant association in participants under 60, particularly in the lowest FI quartile (OR=1.43, 95% CI: 1.14 to 1.79). Sensitivity analysis upheld the robustness of the primary results.

CONCLUSIONS

The findings suggest a complex relationship between frailty and LBP, highlighting the need for early screening and tailored interventions to manage LBP in this demographic. Further research is necessary to understand the mechanisms of this association and to validate the findings through longitudinal studies.

Prognostic nutritional index and modified frailty index, independent risk factors for recompression in elderly patients with osteoporotic vertebral compression fractures

BACKGROUND

To identify some clinical and laboratory independent risk factors for postoperative recompression among elderly osteoporotic vertebral compression fractures (OVCF) patients.

METHODS

A retrospective analysis was conducted on 287 elderly OVCF patients after percutaneous vertebroplasty (PVP). Relevant risk factors for recompression were screened and further analyzed through multivariate logistic regression.

RESULTS

Within postoperative 1 year, recompression had occurred in 72 patients, with an incidence of 25.1% (72/287). Multivariate logistic analysis indicated that mean spinal BMD <  - 2.85 (OR: 4.55, 95%CI 2.22-9.31, P < 0.001), ODI ≥ 68.05% (OR: 6.78, 95%CI 3.16-14.55, P < 0.001), PNI score < 43.1 (OR: 2.81, 95%CI 1.34-5.82, P = 0.005), and mFI score ≥ 0.225 (OR: 8.30, 95%CI 3.14-21.95, P < 0.001) were four distinct risk factors that independently contributed to postoperative recompression.

CONCLUSIONS

Spinal BMD, ODI, PNI and mFI independently predict recompression in OVCF patients after PVP treatment.

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.

Finite element analysis of vertebroplasty in the osteoporotic T11-L1 vertebral body: Effects of bone cement formulation

Vertebral compression fractures are one of the most severe clinical consequences of osteoporosis and the most common fragility fracture afflicting 570 and 1070 out of 100,000 men and women worldwide, respectively. Vertebroplasty (VP), a minimally invasive surgical procedure that involves the percutaneous injection of bone cement, is one of the most efficacious methods to stabilise osteoporotic vertebral compression fractures. However, postoperative fracture has been observed in up to 30% of patients following VP. Therefore, this study aims to investigate the effect of different injectable bone cement formulations on the stress distribution within the vertebrae and intervertebral discs due to VP and consequently recommend the optimal cement formulation. To achieve this, a 3D finite element (FE) model of the T11-L1 vertebral body was developed from computed tomography scan data of the spine. Osteoporotic bone was modeled by reducing the Young's modulus by 20% in the cortical bone and 74% in cancellous bone. The FE model was subjected to different physiological movements, such as extension, flexion, bending, and compression. The osteoporotic model caused a reduction in the average von Mises stress compared with the normal model in the T12 cancellous bone and an increment in the average von Mises stress value at the T12 cortical bone. The effects of VP using different formulations of a novel injectable bone cement were modeled by replacing a region of T12 cancellous bone with the materials. Due to the injection of the bone cement at the T12 vertebra, the average von Mises stresses on cancellous bone increased and slightly decreased on the cortical bone under all loading conditions. The novel class of bone cements investigated herein demonstrated an effective restoration of stress distribution to physiological levels within treated vertebrae, which could offer a potential superior alternative for VP surgery as their anti-osteoclastogenic properties could further enhance the appeal of their fracture treatment and may contribute to improved patient recovery and long-term well-being.

Double Vertebrae Kümmell Disease: Five Cases Report and Literature Review

Kümmell disease (KD) is a complication of osteoporotic vertebral compression fractures. There is a lot of literature on KD, but the reported cases are all single vertebrae. This study reports five double vertebrae KD cases (10 levels) and discusses the possible underlying mechanisms with a literature review. One hundred and thirty vertebrae KD were diagnosed from 2074 osteoporotic vertebral compression fractures patients treated in our hospital between 2015 and 2019. These vertebrae KD were divided into two groups, one-level vertebrae KD (n = 125) and double-level KD (n = 5). The diagnosis of KD is mainly based on the signs of intravertebral vacuum cleft on X-ray or CT scan. Double vertebrae KD cases were classified by using the KD staging system. The analysis was performed on KD to compare age, gender, femoral neck bone mineral density of femoral neck (BMD), vertebrae distribution, Cobb angle, and visual analog scale (VAS) between one-level KD and double-level by t-tests, Welch's t-test, or hypothesis testing. The mean age of the participants in the one-level KD group was 78.69 years, while the mean age in the double-level KD group was 82.4 years. The difference was statistically significant (t = 3.66, p = 0.0004). There were 89 females and 36 males in the one-level KD group, while the double-level KD group had five females and no males. The femoral neck BMD was significantly different between the two groups, with the one-level KD group having a mean BMD of -2.75 and the double-level KD group having a mean BMD of -4.2 (t = 2.99, p= 0.0061). The vertebrae distribution was different between the groups, with the one-level KD group having vertebrae from T7 to L4 and the double-level KD group having vertebrae from T11 to L1. The Cobb angle was also significantly different between the groups, with the one-level KD group having a mean angle of 20.58 and the double-level KD group having a mean angle of 31.54 (t = 6.22, p = 0.0001). Finally, the VAS scores were similar between the two groups, with the one-level KD group having a mean score of 8.63 and the double-level KD group having a mean score of 8.8 (t = 1.35, p = 0.1790). It is concluded that double vertebrae Kümmell disease has special clinical significance due to its potential to cause greater spinal instability and deformity, increased risk of neurological symptoms, more complex surgical management, and greater risk of complications.

From research to daily clinical practice: implementation of orthogeriatric co-management in the trauma ward

Introduction

Evidence strongly suggests that orthogeriatric co-management improves patient outcomes in frail older patients with a fracture, but evidence regarding how to implement this model of care in daily clinical practice is scarce. In this paper, we first describe the implementation process and selection of implementation strategies for an orthogeriatric co-management program in the traumatology ward of the University Hospitals Leuven in Belgium. Second, we report the results of a multi-method feasibility study. This study (1) measures the fidelity towards the program's core components, (2) quantifies the perceived feasibility and acceptability by the healthcare professionals, and (3) defines implementation determinants.

Methods

Implementation strategies were operationalized based on the Expert Recommendations for Implementing Change (ERIC) guidelines. In the feasibility study, fidelity towards the core components of the program was measured in a group of 15 patients aged 75 years and over by using electronic health records. Feasibility and acceptability as perceived by the involved healthcare professionals was measured using a 15-question survey with a 5-point Likert scale. Implementation determinants were mapped thematically based on seven focus group discussions and two semi-structured interviews by focusing on the healthcare professionals' experiences.

Results

We observed low fidelity towards completion of a screening questionnaire to map the premorbid situation (13%), but high fidelity towards the other program core components: multidimensional evaluation (100%), development of an individual care plan (100%), and systematic follow-up (80%). Of the 50 survey respondents, 94% accepted the program and 62% perceived it as feasible. Important implementation determinants were feasibility, awareness and familiarity, and improved communication between healthcare professionals that positively influenced program adherence.

Conclusions

Fidelity, acceptability, and feasibility of an orthogeriatric co-management program were high as a result of an iterative process of selecting implementation strategies with intensive stakeholder involvement from the beginning.

Clinical trial registration

[https://www.isrctn.com/ISRCTN20491828], International Standard Randomised Controlled Trial Number (ISRCTN) Registry: [ISRCTN20491828]. Registered on October 11, 2021.

Geriatric spine fractures - Demography, changing trends, challenges and special considerations: A narrative review

The aim of this manuscript was to summarize the demography and changing trends of geriatric spinal injuries and to enumerate the challenges and special considerations in the care of geriatric spinal injuries. PubMed, Scopus and Embase databases were searched for literature on geriatric spine fractures using MeSH terms 'aged', 'aged, 80 and over', 'elderly', 'spinal fracture/epidemiology', spinal fracture/therapy∗' and keywords pertaining to the same. The search results were screened for appropriate articles and reviewed. There is a high community prevalence of elderly vertebral fractures ranging from 18% to as high as 51%. The proportion of older patients among the spinal injured is rising as well. There is a higher chance of missing spinal injuries in the elderly and clinical guidelines may not be applicable to this patient group. Classification and surgical treatment are different from younger adult counterparts as the elderly osteoporotic spine behaves differently biomechanically. There is a high incidence of respiratory complications both for surgically and conservatively managed groups. Older age generally is associated with a higher complication rate including mortality.

Biomechanical Comparison and Three-Dimensional Analysis of Cement Distribution Patterns for Different Pedicle Screw Designs

The purpose of this study to explore strategies for reducing cement leakage during cement-augmented pedicle screw fixation, we compared the cement distribution patterns and biomechanical strengths of different types of cement-augmented fenestrated screws and traditional cement-augmented techniques. We compared five screw groups in this study: (1) Cannulated screws (Cann); (2) distal one-hole screws (D1); (3) distal two-hole screws (D2); (4) middle two-hole screws (M2); and (5) traditional screws with a traditional cement injection technique (Trad). The screws were inserted into cancellous bone blocks using a controlled, adequate cement injection pressure (1.6–2.0 kg), and an appropriate cement viscosity. Center to screw tip distance, three-dimensional distribution, and pull-out strength for cement were compared between groups. The average distance between the cement center and the screw tip was highest in the M2 group, suggesting a higher risk of cement leakage into the spinal canal. The Trad group had the highest migration distance in the z-axis, also reflecting a higher risk of leakage into the spinal canal. The D1 group had the highest pull-out strength ( $253\pm 48.82\text{N}$ and $797\pm 58.31\text{N}$ ) in bone blocks representing different degrees of osteoporosis, and the D2 group had the second highest pull-out strength in the severe osteoporosis model. Overall, D1 screws appeared to be the best option for optimizing biomechanical function and minimizing the risk of cement leakage into the spinal canal in patients with osteoporotic bone undergoing spinal surgery.

Study on Risk Factors of Primary Non-traumatic OVCF in Chinese Elderly and a Novel Prediction Model

Objective

Prevention of fragility fractures is one of the public health priorities worldwide, whilst the incidence of osteoporotic vertebral compression fractures (OVCF) continues to rise and lacks the corresponding accurate prediction model. This study aimed to screen potential causes and risk factors for primary non‐traumatic osteoporotic vertebral compression fractures (NTOVCF) in the elderly by characterizing a patient population with NTOVCF and comparing it with a population of osteoporotic patients.

Methods

Between January 2013 and January 2022, 208 elderly patients with unequivocal evidence of bone fragility manifested as painful NTOVCF were enrolled, and compared with 220 patients with osteoporosis and no fractures. The demographic data, bone turnover markers, blood routine, serum biochemical values, and radiological findings were investigated. Differences between the fracture and non‐fracture groups were analyzed, and variables significant in univariate analysis and correlation analysis were included in the logistic analysis to build the risk prediction model for osteoporotic vertebral fractures. Univariate analysis using student's t‐tests for continuous variables or a chi‐squared test for categorical variables was conducted to identify risk factors.

Results

No significant differences were revealed regarding age, gender, BMI, smoking, alcohol consumption, blood glucose, propeptide of type I procollagen (P1NP), and N‐terminal middle segment osteocalcin (N‐MID) (P > 0.05). Parathyroid Hormone (PTH), 25(OH)D, serum albumin (ALB), hemoglobin (HB), bone mineral density (BMD), and cross‐sectional area (CSA) of the paraspinal muscle in the fracture group were significantly lower than those in the control group; however, b‐C‐terminal telopeptide of type I collagen (β‐CTX), total cholesterol (TC), high‐density lipoprotein cholesterol (HDL‐C), non‐prostatic acid phosphatase (NACP), and fatty degeneration ratio (FDR) were significantly higher than those in the control group (P < 0.05). Logistic regression analysis showed that ALB, HB, CSA, and BMD were negatively correlated with NTOVCF, while β‐CTX, HDL‐C, NACP, and FDR were positively correlated with NTOVCF.

Conclusion

Decreased physical activity, anemia, hypoproteinemia, imbalances in bone metabolism, abnormal lipid metabolism, and degenerative and decreased muscle mass, were all risk factors for OVCF in the elderly, spontaneous fractures may be the consequence of cumulative declines in multiple physiological systems over the lifespan. Based on this risk model, timely detection of patients with high OVCF risk and implementation of targeted preventive measures is expected to improve the effect of fracture prevention.

Experimental validation of a subject-specific finite element model of lumbar spine segment using digital image correlation

Pathologies such as cancer metastasis and osteoporosis strongly affect the mechanical properties of the vertebral bone and increase the risk of fragility fractures. The prediction of the fracture risk with a patient-specific model, directly generated from the diagnostic images of the patient, could help the clinician in the choice of the correct therapy to follow. But before such models can be used to support any clinical decision, their credibility must be demonstrated through verification, validation, and uncertainty quantification. In this study we describe a procedure for the generation of such patient-specific finite element models and present a first validation of the kinematics of the spine segment. Quantitative computed tomography images of a cadaveric lumbar spine segment presenting vertebral metastatic lesions were used to generate the model. The applied boundary conditions replicated a specific experimental test where the spine segment was loaded in compression-flexion. Model predictions in terms of vertebral surface displacements were compared against the full-field experimental displacements measured with Digital Image Correlation. A good agreement was obtained from the local comparison between experimental data and simulation results (R² > 0.9 and RMSE% <8%). In conclusion, this work demonstrates the possibility to apply the developed modelling pipeline to predict the displacement field of human spine segment under physiological loading conditions, which is a first fundamental step in the credibility assessment of these clinical decision-support technology.

Effects of transitional care based on the social support theory for older patients with osteoporotic vertebral compression fractures: A quasi-experimental trial

OBJECTIVES

This study aimed to investigate the effects of transitional care (TC) programs on the health outcomes of discharged older patients with osteoporotic vertebral compression fractures (OVCFs).

METHODS

A total of 160 older patients were recruited from two campuses of a public teaching hospital in China. Patients were grouped according to the campus to which they were admitted. The TC programs commenced one day before discharge and lasted 6 months after discharge. Repeated-measures analysis of variance was used to analyse the effects of the TC programs.

RESULTS

The TC programs improved the discharge of older patients with OVCF in their activities of daily living (ADLs), pain levels and social support, and decreased fracture recurrence rates.

CONCLUSIONS

This study provides evidence of concurrent clinical improvements and health outcomes in discharged older patients with OVCFs from the effects of TC programs based on social support theory.

Vertebral fractures at hospitalization predict impaired respiratory function during follow-up of COVID-19 survivors

PURPOSE

Morphometric vertebral fractures (VFs) have been recently reported as an important component of the endocrine phenotype of COVID-19 and emerging data show negative respiratory sequelae at long-term follow-up in COVID-19 survivors. The aim of this study was to evaluate the impact of VFs on respiratory function in COVID-19 survivors.

METHODS

We included patients referred to our Hospital Emergency Department and re-evaluated during follow-up. VFs were detected on lateral chest X-rays on admission using a qualitative and semiquantitative assessment and pulmonary function tests were obtained by Jaeger-MasterScreen-Analyzer Unit 6 months after discharge.

RESULTS

Fifty patients were included. Median age was 66 years and 66% were males. No respiratory function data were available at COVID-19 diagnosis. VFs were detected in 16 (32%) patients. No differences between fractured and non-fractured patients regarding age and sex were observed. Although no difference was observed between VF and non-VF patient groups in the severity of pneumonia as assessed by Radiological-Assessment-of-Lung-Edema score at admission, (5 vs. 6, p = 0.69), patients with VFs were characterized as compared to those without VFs by lower Forced Vital Capacity (FVC, 2.9 vs. 3.6 L, p = 0.006; 85% vs. 110% of predicted, respectively, p = 0.001), Forced Expiratory Volume 1st s (FEV1, 2.2 vs. 2.8 L, p = 0.005; 92% vs. 110% of predicted, respectively, p = 0.001) and Diffusing Capacity of the Lungs for Carbon Monoxide (DLCO 5.83 vs. 6.98 mmol/min/kPa, p = 0.036, 59% vs. 86.3% of predicted, respectively, p = 0.043) at 6-month follow up.

CONCLUSIONS

VFs, expression of the endocrine phenotype of the disease, appear to influence medium-term impaired respiratory function of COVID-19 survivors which may significantly influence their recovery. Therefore, our findings suggest that a VFs assessment at baseline may help in identifying patients needing a more intensive respiratory follow-up and patients showing persistent respiratory impairment without evidence of pulmonary disease may benefit from VFs assessment to preventing the vicious circle of further fractures and respiratory deterioration.

Which frailty scales for patients with adult spinal deformity are feasible and adequate? A systematic review

BACKGROUND CONTEXT

Frailty as a concept is not yet fully understood, and is not the same as comorbidity. It is associated with an increased risk of adverse events and mortality after surgery, which makes its preoperative assessment significant. Despite its relevance, it still remains unclear which scales are appropriate for use in patients with spinal pathology.

PURPOSE

To evaluate the feasibility and measurement properties of frailty scales for spine patients, specifically with adult spinal deformity (ASD), and to propose adequate scales for primary triage to prevent surgery in too frail patients and for preoperative assessment to modify patients' condition and surgical plans.

STUDY DESIGN/SETTING

Systematic review.

METHODS

Systematic search was performed between 2010 and 2021 including terms relating to spinal disorders, frailty scales, and methodological quality. Characteristics of the studies and frailty scales and data describing relation to treatment outcomes were extracted. The risk of bias was determined with the QAREL score.

RESULTS

Of the 1993 references found, 88 original studies were included and 23 scales were identified. No prospective interventional study was found where the preoperative frailty assessment was implemented. Predictive value of scales for surgical outcomes varied, dependent on spinal disorders, type of surgeries, patients' age and frailty at baseline, and outcomes. Seventeen studies reported measurement properties of eight scales but these studies were not free of bias. In 30 ASD studies, ASD-Frailty Index (ASD-FI, n=14) and 11-item modified Frailty Index (mFI-11, n=11) were most frequently used. These scales were mainly studied in registry studies including young adult population, and carry a risk of sample bias and make their validity in elderly population unclear. ASD-FI covers multidisciplinary concepts of frailty with 40 items but its feasibility in clinical practice is questionable due to its length. The Risk Analysis Index, another multidisciplinary scale with 14 items, has been implemented for preoperative assessment in other surgical domains and was proven to be feasible and effective in interventional prospective studies. The FRAIL is a simple questionnaire with five items and its predictive value was confirmed in prospective cohort studies in which only elderly patients were included.

CONCLUSIONS

No adequate scale was identified in terms of methodological quality and feasibility for daily practice. Careful attention should be paid when choosing an adequate scale, which depends on the setting of interest (eg triage or preoperative work-up). We recommend to further study a simple and predictive scale such as FRAIL for primary triage and a comprehensive and feasible scale such as Risk Analysis Index for preoperative assessment for patients undergoing spine surgery, as their adequacy has been shown in other medical domains.

Diagnosis and Management of Vertebral Compression Fracture

Vertebral compression fractures are the most common complication of osteoporosis, with 700,000 cases reported every year in the United States. Vertebral compression fractures typically present with abrupt-onset low back pain with or without a history of trauma, although more than two-thirds are detected incidentally. Diagnosis is confirmed using plain radiographs, while computed tomography and magnetic resonance imaging may be required to evaluate for a malignant cause or if there are neurological deficits on examination. Magnetic resonance imaging is also the modality of choice to determine if the fracture is acute vs chronic in nature. Patients can be managed with a combination of nonsurgical modalities including medications, bracing, and physical therapy, although when indicated, kyphoplasty or vertebroplasty may be considered to provide symptom relief.

Hospital Frailty Risk Score predicts adverse events in older patients with vertebral compression fractures: Analysis of data in a nationwide in-patient database in Japan

AIMS

This study investigated the usefulness of frailty for predicting adverse events in patients with vertebral compression fractures (VCFs) during hospitalization using data obtained from the Japanese health insurance system.

METHODS

This retrospective cohort study of patients with VCFs aged ≥65 years was conducted using a nationwide database in Japan. We examined the relationships between frailty risk, classified using the Hospital Frailty Risk Score (HFRS), in-hospital mortality, and complications such as pressure ulcers and pneumonia. Multivariate logistic regression analysis was used to estimate the association between the HFRS and the outcomes of patients with VCFs.

RESULTS

In this study, the data of 30 980 in-patients with VCFs were analyzed. Of these patients, 76.8%, 21.3%, and 1.9% had low, intermediate, and high risks of frailty, respectively. The higher the risk of frailty, the higher the rate of in-hospital mortality and the occurrence of all complications (P < 0.001 for trend). An intermediate risk of frailty was independently associated with in-hospital mortality (odds ratio [OR], 1.421; P < 0.001), whereas a high risk of frailty did not show statistical significance (OR, 1.385; P = 0.150). Each frailty risk was independently associated with the occurrence of all complications during hospitalization.

CONCLUSIONS

The HFRS, which can assess the risk of frailty based on routinely collected medical records, was predictive of adverse events in older patients with VCFs based on a nationwide database in Japan. Future studies need to assess approaches to preventing adverse events in frail VCF patients. Geriatr Gerontol Int 2022; ••: ••-••.

The first reported fracture liaison service (FLS) for vertebral fractures in China: is muscle the missing gap?

Fracture liaison services (FLS) have been implemented worldwide, but we present one of the first reported experiences in China. Only 1 out of 226 patients had a secondary fracture within 1 year. This serves as a platform to improving solutions and decreasing imminent fractures for future use nationwide in China.

INTRODUCTION

Fracture liaison services (FLS) have been implemented worldwide but we present one of the first reported experiences in China. Vertebral fragility fracture is one of the earliest fracture to occur. The objective of this study was to implement a dedicated fracture service to decrease imminent fractures for future use nationwide in China.

METHODS

Patients 50 years or older with a recent vertebral compression fracture were recruited. All patients were offered investigation with DXA scan and blood taking. Treatment was provided with calcium and vitamin D supplements and denosumab injections. The primary outcome was the imminent fracture rate or the re-fracture rate occurring within 2 years of the initial one. Secondary outcomes were bone mineral density (BMD), treatment initiation, adherence to drug, compliance to follow-up, falls, mortality, pain, quality of life, pain-related disability with Roland-Morris Disability Questionnaire (RMDQ), and Oswestry Disability Index (ODI).

RESULTS

Two hundred twenty-six patients (n = 226) were analyzed. 0.4% (n = 1) had an imminent fracture within 2 years. 11.1% (n = 25) had a fall within 2 years, in which 1 resulted in a major osteoporotic fracture. 7.1% died (n = 16) within the 2-year time period. 97.8% (n = 221) underwent BMD investigation with an initial DXA scan. One hundred percent (n = 226) had treatment initiation and were prescribed with Denosumab injections. 89.8% (n = 203) were compliant and showed complete adherence to drug therapy over the 2 years. Pain, quality of life, and disability were significantly improved.

CONCLUSION

This is the first reported fracture liaison service for vertebral fracture patients reported in China. Future FLS should incorporate muscle and sarcopenic assessments as a routine, and also research on novel interventions in this area would significantly improve patient outcomes.

Association Among Geriatric Nutritional Risk Index and Functional Prognosis in Elderly Patients with Osteoporotic Vertebral Compression Fractures

BACKGROUND

Osteoporotic vertebral compression fractures (OVCF) are common among the elderly, and malnutrition has also been identified as a poor prognostic factor in elderly patients with fractures. However, the relationship between nutrition status and functional prognosis in OVCF is unclear. The aim of this study was to investigate the association between nutritional status using geriatric nutritional risk index (GNRI), activities of daily living (ADL), and fall after fracture in patients with OVCF.

METHODS

The clinical information of 187 conservatively treated OVCF patients was retrospectively examined. This information included: age, sex, body mass index, total number of drugs used for treatment at admission, bone mineral density, use of drugs for osteoporosis, fracture type, comorbidity severity, nutritional status, Barthel Index (BI), and fall after OVCF. Subjects were divided into two groups according to their GNRI. Propensity score matching was used to confirm factors affecting BI and falls after OVCF.

RESULTS

Sixty-eight patients (36.4%) presented with malnutrition at fracture. According to multiple linear regression analysis, GNRI positively affected BI gain (β = 0.283, 95% confidence interval [CI] - 122.2 to - 0.706, p = 0.001). Furthermore, on logistic regression analysis, fall after OVCF was associated with GNRI (odds ratio = 0.896, 95% CI 0.832-0.964, p = 0.003).

CONCLUSIONS

Malnutrition in elderly OVCF patients decreases the acquisition of ADL and increases fall risk. Improvement of nutritional status during OVCF treatment may lead to improvement of ADL and prevention of falls.

Health-Related Quality of Life in Patients With Different Diseases Measured With the EQ-5D-5L: A Systematic Review

Background: The EQ-5D-5L is a generic preference-based questionnaire developed by the EuroQol Group to measure health-related quality of life (HRQoL) in 2005. Since its development, it has been increasingly applied in populations with various diseases and has been found to have good reliability and sensitivity. This study aimed to summarize the health utility elicited from EQ-5D-5L for patients with different diseases in cross-sectional studies worldwide.

Methods: Web of Science, MEDLINE, EMBASE, and the Cochrane Library were searched from January 1, 2012, to October 31, 2019. Cross-sectional studies reporting utility values measured with the EQ-5D-5L in patients with any specific disease were eligible. The language was limited to English. Reference lists of the retrieved studies were manually searched to identify more studies that met the inclusion criteria. Methodological quality was assessed with the Agency for Health Research and Quality (AHRQ) checklist. In addition, meta-analyses were performed for utility values of any specific disease reported in three or more studies.

Results: In total, 9,400 records were identified, and 98 studies met the inclusion criteria. In the included studies, 50 different diseases and 98,085 patients were analyzed. Thirty-five studies involving seven different diseases were included in meta-analyses. The health utility ranged from 0.31 to 0.99 for diabetes mellitus [meta-analysis random-effect model (REM): 0.83, (95% CI = 0.77–0.90); fixed-effect model (FEM): 0.93 (95% CI = 0.93–0.93)]; from 0.62 to 0.90 for neoplasms [REM: 0.75 (95% CI = 0.68–0.82); FEM: 0.80 (95% CI = 0.78–0.81)]; from 0.56 to 0.85 for cardiovascular disease [REM: 0.77 (95% CI = 0.75–0.79); FEM: 0.76 (95% CI = 0.75–0.76)]; from 0.31 to 0.78 for multiple sclerosis [REM: 0.56 (95% CI = 0.47–0.66); FEM: 0.67 (95% CI = 0.66–0.68)]; from 0.68 to 0.79 for chronic obstructive pulmonary disease [REM: 0.75 (95% CI = 0.71–0.80); FEM: 0.76 (95% CI = 0.75–0.77)] from 0.65 to 0.90 for HIV infection [REM: 0.84 (95% CI = 0.80–0.88); FEM: 0.81 (95% CI = 0.80–0.82)]; from 0.37 to 0.89 for chronic kidney disease [REM: 0.70 (95% CI = 0.48–0.92; FEM: 0.76 (95% CI = 0.74–0.78)].

Conclusions: EQ-5D-5L is one of the most widely used preference-based measures of HRQoL in patients with different diseases worldwide. The variation of utility values for the same disease was influenced by the characteristics of patients, the living environment, and the EQ-5D-5L value set.

Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42020158694.

Effect of multi-platform extended care on postoperative self-efficacy and quality of life in patients with osteoporotic vertebral compressive fracture

OBJECTIVES

This study analyzed the effect of multi-platform extended care on postoperative self-efficacy and quality of life in patients with osteoporotic vertebral compressive fracture (OVCF).

METHODS

162 OVCF patients who underwent percutaneous vertebroplasty (PVP) or percutanous kyphoplasty (PKP) surgery in our hospital from January 2018 to June 2019 were classified into a control group (n=78) and an observation group (n=84) based on the admission time. The control group was given conventional health guidance and follow-up by telephone, and the observation group got multi-platform extended care. The postoperative incidence of re-fracture, Oswestry dysfunction index (ODI) before and after intervention, self-efficacy and quality of life were compared between the two groups.

RESULTS

Incidence of re-fracture in the observation group was higher than that of the control group (P<0.05). The ODI scores of the two groups 3, 6, and 12 months after operation were lower than those on discharge (P<0.05), and the observation group had lower OD scores than the control group 6 and 12 months after operation (P<0.05). The self-efficacy scores of the two groups 6 months after discharge were higher than that on discharge (P<0.05), and the index in the observation group was higher than that of the control group (P<0.05). In addition, the scores of all dimensions of quality of life in two groups 6 months of discharge were higher than those on discharge (P<0.05), and the scores in the observation group were higher than those of the control group (P<0.05).

CONCLUSION

Multi-platform extended care can effectively reduce the risk of postoperative re-fracture in OVCF patients, facilitate the improvement of patients' lumbar function, self-efficacy, and quality of life, and improve the prognosis of patients, which is worthy of clinical promotion.

The Impact of Frailty on Spine Surgery: Systematic Review on 10 years Clinical Studies

Frailty is a condition characterized by a high vulnerability to low-power stressor. Frailty increases with age and is associated with higher complications and mortality. Several indexes have been used to quantify frailty. Spine diseases, both degenerative and oncologic, frequently require surgery which is related to complications and mortality. Aim of the present systematic review was to collect the most frequently used frailty indexes in clinics to predict surgical outcomes in patients affected by spine diseases, taking into account gender differences. Three databases were employed, and 29 retrospective clinical studies were included in this systematic review. The identified spine pathologies were primary and metastatic spine tumors, adult spine deformity (ASD), degenerative spine disease (DSD), cervical deformity (CD) and other pathologies that affected lumbar spine or multiple spine levels. Eleven indexes were identified: modified Frailty Index (mFI), Adult spinal deformity frailty index (ASD-FI), mFI-5, Metastatic Spinal Tumor Frailty Index (MSTFI), Fried criteria, Cervical deformity frailty index (CD-FI), Spinal tumor frailty index (STFI), Frailty Phenotype criteria (FP), Frailty Index (FI), FRAIL scale and Modified CD-FI (mCD-FI). All these indexes correlated well with minor and major postoperative complications, mortality and length of stay in hospital. Results on gender differences and frailty are still conflicting, although few studies show that women are more likely to develop frailty and more complications in the post-operative period than men. This systematic review could help the surgeon in the adoption of frailty indexes, before the operation, and in preventing complications in frail patients.

Low back pain is closely associated with frailty but not with sarcopenia: Cross-sectional study of rural Japanese community-dwelling older adults

AIM

We speculated that low back pain, which is the most common ailment in older adults, is associated with frailty and/or sarcopenia and contributes to the progression of either condition. Our objective was to evaluate the relationship between low back pain, sarcopenia and frailty in rural Japanese community-dwelling older adults.

METHODS

We recruited 730 participants aged ≥65 years who underwent a comprehensive health examination between November 2016 and December 2018. The Oswestry Disability Index (ODI) was used to assess low back pain quantitatively, and scores were compared for the frail groups determined by the Japanese version of Cardiovascular Health Study, and the sarcopenia groups as determined by the Asian Working Group for Sarcopenia 2019.

RESULTS

Among 730 participants, the prevalence of low back pain was 57.8%. There were significant differences in the ODI scores between the robust, prefrail and frail groups (P < 0.001). In contrast, there were no significant differences in the ODI scores among the robust, low appendicular skeletal muscle and sarcopenia groups. Logistic regression analysis showed that the prevalence of low back pain and the ODI scores were significantly associated with frailty after adjustment for age, sex and body mass index (odds ratio 3.41, 95% confidence interval 1.39-8.39, P = 0.008, and odds ratio 1.06, 95% confidence interval 1.04-1.09, P < 0.001, respectively).

CONCLUSIONS

To the best of our knowledge, this study is the first to show the close association between low back pain and frailty, and suggests that not only the decline in physical function but also neuropsychiatric factors, including chronic pain, constitute a vicious cycle of frailty in community-dwelling older adults. Geriatr Gerontol Int 2021; 21: 54-59.

Helicobacter pylori Related Diseases and Osteoporotic Fractures (Narrative Review)

Osteoporosis (OP) and osteoporotic fractures (OFs) are common multifactorial and heterogenic disorders of increasing incidence. Helicobacter pylori (H.p.) colonizes the stomach approximately in half of the world's population, causes gastroduodenal diseases and is prevalent in numerous extra-digestive diseases known to be associated with OP/OF. The studies regarding relationship between H.p. infection (HPI) and OP/OFs are inconsistent. The current review summarizes the relevant literature on the potential role of HPI in OP, falls and OFs and highlights the reasons for controversies in the publications. In the first section, after a brief overview of HPI biological features, we analyze the studies evaluating the association of HPI and bone status. The second part includes data on the prevalence of OP/OFs in HPI-induced gastroduodenal diseases (peptic ulcer, chronic/atrophic gastritis and cancer) and the effects of acid-suppressive drugs. In the next section, we discuss the possible contribution of HPI-associated extra-digestive diseases and medications to OP/OF, focusing on conditions affecting both bone homeostasis and predisposing to falls. In the last section, we describe clinical implications of accumulated data on HPI as a co-factor of OP/OF and present a feasible five-step algorithm for OP/OF risk assessment and management in regard to HPI, emphasizing the importance of an integrative (but differentiated) holistic approach. Increased awareness about the consequences of HPI linked to OP/OF can aid early detection and management. Further research on the HPI-OP/OF relationship is needed to close current knowledge gaps and improve clinical management of both OP/OF and HPI-related disorders.

Normal tissue complication probability of vertebral compression fracture after stereotactic body radiotherapy for de novo spine metastasis

OBJECTIVE

Stereotactic body radiotherapy (SBRT) for spine metastases is associated with post-treatment vertebral compression fracture (VCF). The purpose of this study is to identify clinical and radiation planning characteristics that predict post-SBRT VCF through a novel normal tissue complication probability (NTCP) analysis.

METHODS

Patients with de novo spine metastases treated with SBRT between 2009 and 2018 at a single institution were included. Those who had surgical stabilization or radiation to the same site prior to SBRT were excluded. VCF was defined as new development or progression of existing vertebral body height loss not attributable to tumor growth. Probit NTCP models were constructed and fitted using a maximum likelihood approach. A multivariate proportional hazard model was used to estimate time to VCF using the Fine and Gray method.

RESULTS

Three hundred and two vertebral segments from 193 patients were treated with a median dose of 24 Gy in 3 fractions (range 15-30 Gy in 1-5 fractions). With a median follow up of 13.9 months, local control was 89.3% at 1 year. A total of 26 SBRT-induced VCFs were observed, with 1 and 2-year cumulative incidences of 4.6% and 6.7%. NTCP modeling demonstrated a steep response of VCF risk to the dose to 80% and 50% volume of the planning target volume (PTV D80% and D50%), but not maximum dose or dose to 1 cc or 10% of PTV. D80% of 25 Gy and D50% of 28 Gy in 3 fractions corresponded to 10% VCF risk. On multivariate analysis, lower body mass index (HR 0.90 per unit increase, p = 0.04), total spinal instability neoplastic score (SINS, HR 2.44 unstable vs stable, p = 0.04), and PTV D80% (HR 1.11 for every Gy increase, p = 0.003) were associated with increased VCF risk.

CONCLUSIONS

SBRT provides excellent tumor control for spinal metastases and is associated with low rate of VCF in our cohort. NTCP modeling suggests that the larger volume of spine receiving lower doses are more closely associated with post-SBRT VCF than high dose regions. Under current target delineation methods, common SBRT regimens such as 24 Gy in 2 fractions or 27 Gy in 3 fractions may be inherently associated with VCF risk of 10% or greater. Consensus contouring guidelines should be reevaluated to minimize the volume of irradiated spine in light of these new data.

Effects of rosuvastatin and zoledronic acid in combination on the recovery of senile osteoporotic vertebral compression fracture following percutaneous vertebroplasty

Objectives

This study analyzed the effects of rosuvastatin and zoledronic acid in combination on patient recovery following percutaneous vertebroplasty (PVP) that was performed to treat senile osteoporotic vertebral compression.

Methods

Senile patients with osteoporotic vertebral compression fracture (n = 120) were included in this retrospective study, and they were classified into two groups. Those in the control group (n = 60) were treated with PVP + caltrate and those in the observation group (n = 60) received this treatment with combined zoledronic acid and rosuvastatin. Between-group comparisons were made at both pre- and post-treatment regarding bone density, type I procollagen peptide (CTX) and bone-specific alkaline phosphatase (BAP) levels, visual analog scale (VAS) score, Oswestry Disability Index (ODI) score, and adjacent centrum refracture.

Results

Bone density was higher and BAP and CTX levels as well as ODI and VAS scores were lower at post-treatment in the observation group compared with the control group. The refracture rate in the observation group was lower compared with the control group.

Conclusion

Treatment with a combination of rosuvastatin and zoledronic acid following PVP can improve the condition of senile osteoporotic vertebral compression fracture and patient’s functional status, and it can also alleviate pain.

Percutaneous cement augmentation in the treatment of osteoporotic vertebral fractures (OVFs) in the elderly: a systematic review

Purpose

A systematic review, to study treatment effects for osteoporotic vertebral fractures (OVFs) in the elderly including all available evidence from controlled trials on percutaneous cement augmentation.

Methods

Primary studies, published up to December, 2019, were searched in PubMed and the Cochrane Library. Selected were all prospective controlled studies including patients > 65 years of age and reporting on at least one main outcome. Main outcomes were pain, disability and quality of life (QOL) 1 day post-intervention and at 6 months postoperatively. Excluded were meta-analyses or reviews, retrospective or non-controlled studies, case studies, patients’ groups with neoplastic and/or traumatic fractures and/or neurologically compromised patients.

Results

Eighteen studies comprising 2165 patients (n = 1117 percutaneous cement augmentation, n = 800 conservative treatment (CT), n = 248 placebo) with a mean follow-up of up to 12 months were included. Pooled results showed significant pain relief in favor of percutaneous cement augmentation compared to CT, direct postoperative and at 6 months follow-up. At 6 months, a significant difference was observed for functional disability scores in favor of percutaneous cement augmentation. When comparing percutaneous cement augmentation to placebo, no significant differences were observed.

Conclusion

This review incorporates all current available evidence (RCTs and non-RCTs) on the efficacy of percutaneous cement augmentation in the treatment of OVFs in the elderly. Despite methodological heterogeneity of the included studies, this review shows overall significant sustained pain relief and superior functional effect in the short- and long term for percutaneous cement augmentation compared to conservative treatment.

Graphic abstract

These slides can be retrieved under Electronic Supplementary Material.

Efficacy of calcitonin for treating acute pain associated with osteoporotic vertebral compression fracture: an updated systematic review

Objective

Acutely painful osteoporotic vertebral compression fractures are associated with hospitalization and mortality in older adults. Calcitonin may be an alternative to opioid or nonopioid analgesia for treating acute compression fracture pain in emergency and primary care settings. This review summarizes pain, function, and adverse events associated with calcitonin.

Methods

We searched MEDLINE, EMBASE, The Cochrane Library, clinical trials registries, and reference lists of included studies. Eligible studies evaluated the effect of synthetic calcitonins (salmon, eel, and human) on pain scores in adults ≥60 years old with a recent atraumatic compression fracture. Two reviewers screened studies, extracted data, and allocated bias in duplicate. A random effects meta-analysis evaluated standard mean difference (SMD) and heterogeneity (I2).

Results

Of 1,198 articles screened, 11 were included (9 in the meta-analysis). Treatment lasted from 14 days to 6 months. Pain was lower in the salmon calcitonin group (100–200 IU IM or NAS, daily) than the control group with high certainty of evidence at week 1 (SMD, -1.54; 95% confidence interval [CI], -2.02 – -1.06; I2 = 52%), representing a number needed to treat of two. The analgesic efficacy of salmon calcitonin at 4 weeks was unclear due to substantial heterogeneity. There was low certainty evidence that calcitonin did not increase the overall risk of adverse events, including nausea and vomiting (risk ratio, 2.10; 95% CI, 0.87–5.08; I2 = 47%).

Conclusions

Calcitonin is beneficial and appears safe for treating acute pain associated with compression fractures. Further studies may improve the certainty of evidence.

[Hybrid stabilization and geriatric complex treatment of type A spinal fractures]

Approximately 200,000 spinal fractures occur each year in Germany. The decimated stability of the vertebra often leads to type A fractures with a substantial influence by osteoporosis. A mobility preserving and gentle treatment has clear advantages compared to conservative treatment. The hybrid stabilization as a combination of minimally invasive dorsal stabilization and vertebral augmentation has become an established method. In the period from July 2014 to June 2015 a total of 205 spinal operations were documented. In the group of very old patients more than 80% were treated for a geriatric type A vertebral fracture, 24 with hybrid stabilization, 5 by percutaneous bisegmental, 22 by kyphoplasty stabilization and 13 by percutaneous polysegmental procedures. Furthermore, these 4 groups were also considered with respect to the treatment in geriatric trauma centers (GTC). The 4 forms of treatment achieved a mean remuneration of 11,238.77 €. For the individual treatment form of kyphoplasty there was an increase in the remuneration of 4276.54 €, when patients undergo geriatric complex treatment and the remuneration is according to the diagnosis-related groups (DRG) classification I34Z. In the field of operative treatment of geriatric vertebral fractures, the augmentative procedures of kyphoplasty and vertebroplasty are well-established but an injury-related involvement of adjacent spinal segments and continuity fractures are frequent occurrences so that a bisegmental hybrid stabilization is advantageous. In addition, the perioperative stress in hybrid stabilization is only negligibly longer so that hybrid stabilization and geriatric complex treatment can be recommended as the new standard in spinal surgery for the treatment of type A fractures in aged patients.

Association of Dietary Niacin Intake With Incident Hip Fracture, BMD, and Body Composition: The Cardiovascular Health Study

Interest in niacin has increased in the setting of reports suggesting that niacin plays a role in diseases of aging. No study to date has examined the association of dietary niacin intake with multiple skeletal health parameters including bone mineral density (BMD), hip fractures, and body composition, and none have included both African American and white men and women. Participants included 5187 men and women ≥65 years from the Cardiovascular Health Study (CHS). Mean daily dietary niacin intake was 32.6 mg, with quartiles 1 through 4 defined as 3.6 to 21.8 mg/day, 21.9 to 30.2 mg/day, 30.3 to 40.9 mg/day, and 41.0 to 102.4 mg/day, respectively. Risk of incident hip fracture per 10 mg increment of daily dietary niacin intake was estimated using proportional hazards models. During a median follow-up of 13 years, 725 participants had an incident hip fracture. In models adjusted for demographic and clinical characteristics and diet, dietary niacin intake was significantly associated with an increased risk of hip fractures (hazard ratio [HR] 1.12; 95% CI, 1.01 to 1.24) with spline models suggesting a U-shaped association. In post hoc analyses, both the lowest (HR 1.31; 95% CI, 1.04 to 1.66) and highest (HR 1.53; 95% CI, 1.20 to 1.95) quartiles of niacin intake were associated with an increased risk of incident hip fracture versus quartiles 2 and 3. There was a trend for a significant inverse association of dietary niacin intake with hip BMD (p = 0.06), but no significant association with total body BMD or any body composition measures. In this cohort of elderly, community-dwelling African American and white men and women, both high and low dietary niacin intakes were associated with a significantly increased risk of subsequent hip fracture, suggesting a possible U-shaped association. By comparison, dietary niacin may have an inverse linear association with hip BMD. © 2018 American Society for Bone and Mineral Research.

Hybrid stabilization of unstable osteoporotic thoracolumbar vertebral body fractures: clinical and radiological outcome after a mean of 4 years

PURPOSE

The aim of this study was to evaluate midterm results after hybrid stabilization of unstable osteoporotic fractures of the thoracolumbar junction.

METHODS

This retrospective study was performed at a level I trauma center. A total of 113 patients aged 61 and older were stabilized using hybrid stabilization consisting of short-segmental posterior instrumentation and augmentation of the fractured vertebral body after suffering an unstable osteoporotic vertebral body fracture at the thoracolumbar spine. All patients were treated by hybrid stabilization. The primary outcome parameters were the ODI score and loss of reduction. Secondary radiological outcome parameters were the sagittal alignment parameters.

RESULTS

Seventy-two women and 41 men (74.6 ± 6.8 years) were included. Sixty-nine patients (61%) were re-evaluated after a mean of 48 months. Seventeen patients have died during the follow-up period (15%). A total of five in-patient complications were documented (4.4%). Additionally, 12 patients (17.4%) suffered from further osteoporotic vertebral body fractures affecting vertebral bodies of different levels. The average ODI score at the final follow-up was 29.9 (± 22.0). Thereby, 66.6% of all patients had low to moderate limitations. The average regional sagittal loss of reduction was 7.4% (± 5.6%). Loss of reduction was below 10° in 78% of the patients. There were statistically significant correlations between the loss of reduction and the ODI score, pelvic incidence and latest Cobb angle, and between the ODI scores and the lumbar lordosis.

CONCLUSIONS

The majority of patients had low or moderate limitations and low to moderate reduction loss. Thereby, high loss of reduction correlated directly with inferior outcomes. These slides can be retrieved under Electronic Supplementary Material.