Vertebral Compression Fracture Post Spine Stereotactic Body Radiotherapy: The Role of Vertebral Endplate

PURPOSE/OBJECTIVE(S)

Maintaining hydrostatic pressure -via Pascal's Principle- between vertebral bodies is essential to decrease the chance of vertebral compression fracture (VCF). Vertebral endplates (EP) play an essential role in this matter through maintaining the mechanical environment as well as the proper nutrition of avascular discs. The purpose of this study is to establish the correlation of VCF with disrupted EP by tumor involvement.

MATERIALS/METHODS

A retrospective analysis of de novo spine metastases treated with stereotactic body radiotherapy (SBRT) between 2013-2019. Patients (pts) with previous surgical intervention were excluded. VCF defined as new or progression of existing loss of vertebral body height. The vertebral EP region defined in relation to the vertebral body as superior EP vs inferior EP. Kaplan-Meier curves used to analyze the variables. A multivariate proportional hazard model used to assess the risk of all covariates.

RESULTS

A total of 111 pts were treated with SBRT with a median dose of 27 Gy (10-35 Gy). Median follow-up was 18 months (1.2-107). The median age was 60 years (24-87) and 59 were males (53%) and 52 were females (47%). The median body mass index (BMI) was 27 kg/m2 (16-47). Almost 9 pts diagnosed with osteoporosis prior radiation. Twelve pts received prolonged steroids. Twenty pts received bisphosphonate and 8 pts received denosumab. The median PTV was 50cc (8-465) and median Conformity Index was 1.05 (0.42-1.4). Almost 75% of pts received >95% of the dose covering 100% of the PTV. The most common histopathologies were renal cell carcinoma (25%), lung (13%) and breast (11%). Most of the pts (77%) had SINS score of 7 or less. 48 pts (43%) had either superior or inferior EP disruption secondary to the tumor at the time of radiation. Twenty pts (18%) had both superiorly and inferiorly disrupted EP. Around 20 pts (18%) developed VCF. The median time to VCF was 5.2 months (1.1-57.4). The one-year cumulative incidence of VCF was 18%. The 1-year cumulative incidence of VCF with either superiorly and/or inferiorly disrupted EP was 29% vs 6%, p value <0.001. The 1-year cumulative incidence of VCF with both superiorly and inferiorly disrupted EP was 57% vs 7% (p value <0.001). The median time to VCF was earlier in pts with both disrupted EP (2.4 months vs 5.7 months, p value <0.05). Other risk factors like SINS score of >7 and local recurrence (LR) associated with higher risk of VCF. On multivariate analysis, LR (HR 8.2 [CI 2.4-28, p- value <0.001]), tumor disrupting the EP (HR 4.5 [CI 1.3-16, p-value<0.018]) and SINS score of seven and above (HR 1.7 [CI 1.3-2.25, p-value <0.001]) correlated with the VCF risk.

CONCLUSION

In this retrospective analysis, tumor disrupting the EP, disease recurrence and high SINS score increased the risk of VCF. Cement augmentation either prophylactically or immediately following SBRT is currently being studied in a prospective trial within our institution.

The effects of gender and menstrual phase on carbohydrate utilization during acute cold exposure

OBJECTIVE

The purpose of this study was to evaluate the effects of gender and menstrual cycle on the percent of carbohydrate (CHO) utilized during cold water immersion (20 degrees C). Previous research has suggested that males and females utilize CHO differently during submaximal exercise. This study examined whether this differential response is replicated during a submaximal elevation in metabolism, as demonstrated during thermogenesis (i.e., shivering during acute cold exposure).

METHODS

Male and female subjects between the ages of 18 and 30 years were recruited for this study. Female subjects underwent the experimental trial once during the follicular phase and once during the luteal phase of their menstrual cycle. Subjects were immersed to the first thoracic vertebra until esophageal temperature reached 36.5 degrees C or for a maximum preocclusion period of 40 minutes. Peripheral temperature homeostasis via cuff occlusion (right arm and left leg) took place for 10 minutes, after which the pressure cuffs were released (postocclusion) and the subjects remained in the water for an additional 10 minutes. The following variables were measured: respiratory exchange ratio, percent of CHO utilization, and oxygen consumption (Vo2).

RESULTS

Analysis of variance demonstrated no significant difference between genders or phases of the menstrual cycle in respiratory exchange ratio, percent CHO utilization, or Vo2 during cold water immersion. A significant difference was observed between men and women for absolute Vo2.

CONCLUSIONS

These data suggest that although men and women differ with respect to absolute aerobic metabolism, this distinction does not cause a differential response with respect to substrate utilization during acute cold exposure.