A new technique for stabilization of injuries at C2-C3 in young children

BACKGROUND

Reported surgical treatment for injuries and instabilities of the paediatric cervical spine most commonly involves posterior fusion with internal fixation, usually posterior wiring.

PURPOSE

To present a new simple technique of stabilization without fusion of the upper cervical spine of young children.

STUDY DESIGN

A technical report.

METHODS

Detailed description of the surgical procedure carried out for stabilizing an unstable flexion-distraction injury in a 23 month-old toddler, with severe head injury and pneumothorax is presented.

RESULTS

A rare unstable flexion-distraction injury in the upper cervical spine of a toddler was successfully treated with a posterior Number 2 Vicryl (polyglactin 910) suture fixation, with good healing of the ligaments and endplates, without fusion. Preservation of motion was achieved without obvious instability at 63 months post-surgery.

CONCLUSIONS

In selected cases of cervical spine injuries in the young paediatric population, a limited approach to the injured spinal segments and simple stabilization using suitable degradable sutures, can provide sufficient stability until healing occurs.

ADVANTAGES

fusion is avoided, growth disturbances are prevented and spinal motion maintained.

[Correlation analysis of cement leakage with volume ratio of intravertebral bone cement to vertebral body and vertebral body wall incompetence in percutaneous vertebroplasty for osteoporotic vertebral compression fractures]

OBJECTIVE

To investigate the risk factors of cement leakage in percutaneous vertebroplasty (PVP) for osteoporotic vertebral compression fracture (OVCF).

METHODS

Between March 2011 and March 2012, 98 patients with single level OVCF were treated by PVP, and the clinical data were analyzed retrospectively. There were 13 males and 85 females, with a mean age of 77.2 years (range, 54-95 years). The mean disease duration was 43 days (range, 15-120 days), and the mean T score of bone mineral density (BMD) was -3.8 (range, -6.7- -2.5). Bilateral transpedicular approach was used in all the patients. The patients were divided into cement leakage group and no cement leakage group by occurrence of cement leakage based on postoperative CT. Single factor analysis was used to analyze the difference between 2 groups in T score of BMD, operative level, preoperative anterior compression degree of operative vertebrae, preoperative middle compression degree of operative vertebrae, preoperative sagittal Cobb angle of operative vertebrae, preoperative vertebral body wall incompetence, cement volume, and volume ratio of intravertebral bone cement to vertebral body. All relevant factors were introduced to logistic regression analysis to analyze the risk factors of cement leakage.

RESULTS

All procedures were performed successfully. The mean operation time was 40 minutes (range, 30-50 minutes), and the mean volume ratio of intravertebral bone cement to vertebral body was 24.88% (range, 7.84%-38.99%). Back pain was alleviated significantly in all the patients postoperatively. All patients were followed up with a mean time of 8 months (range, 6-12 months). Cement leakage occurred in 49 patients. Single factor analysis showed that there were significant differences in the volume ratio of intravertebral bone cement to vertebral body and preoperative vertebral body wall incompetence between 2 groups (P < 0.05), while no significant difference in T score of BMD, operative level, preoperative anterior compression degree of operative vertebrae, preoperative middle compression degree of operative vertebrae, preoperative sagittal Cobb angle of operative vertebrae, and cement volume (P > 0.05). The logistic regression analysis showed that the volume ratio of intravertebral bone cement to vertebral body (P < 0.05) and vertebral body wall incompetence (P < 0.05) were the risk factors for occurrence of cement leakage.

CONCLUSION

The volume ratio of intravertebral bone cement to vertebral body and vertebral body wall incompetence are risk factors of cement leakage in PVP for OVCF. Cement leakage is easy to occur in operative level with vertebral body wall incompetence and high volume ratio of intravertebral bone cement to vertebral body.

The relationship between the Spine Deformity Index, biochemical parameters of bone metabolism and vascular calcifications: results from the Epidemiological VERtebral FRACtures iTalian Study (EVERFRACT) in dialysis patients

BACKGROUND

The Spine Deformity Index (SDI) is a measure of vertebral fractures (VFs), providing information on both their number and severity.

METHODS

We evaluated the relationships between SDI and clinical, biochemical and arterial calcification parameters in 387 hemodialysis (HD) patients. VFs, assessed by quantitative vertebral morphometry, and vascular calcifications were identified in the same lateral spinal X-ray. To improve the detection of fracture severity, we created a corrected SDI (c-SDI), by dividing SDI for the number of VFs. We assessed routine biochemistry, bone-Gla-protein (BGP), undercaboxylated BGP (ucBGP), and matrix-Gla-protein (MGP).

RESULTS

VFs prevalence was 55.3%. HD patients with a SDI >1 were more frequently males (p<0.05), and had lower BGP (p<0.01). Patients with a c-SDI >1 had higher LDL-cholesterol (p<0.05) and lower ucBGP (p<0.05) and MGP (p<0.05). Calcifications of the abdominal aorta (AAoC) were more frequent in patients with SDI >1 (p<0.05) and with c-SDI >1 (p<0.05). Multivariate logistic regression showed that male sex (OR 1.86, CI 1.20-2.91), age (OR 1.03, CI 1.01-1.05) and albumin ≥3.5 g/dL (OR 0.54, CI 0.31-0.93) were predictors of a SDI >1. Age (OR 1.05, CI 1.03-1.07), LDL-cholesterol (OR 1.74, CI 1.04-2.92) and ucBGP (OR 0.35, CI 0.18-0.70) were associated with c-SDI >1.

CONCLUSIONS

We conclude that the severity of VFs was associated with age, atherogenic factors and bone metabolism markers.

Detective value of historical height loss and current height/knee height ratio for prevalent vertebral fracture in Japanese postmenopausal women

Vertebral fracture (VFx) is associated with various co-morbidities and increased mortality. In this paper, we have studied the detective value of height loss for VFx using two indices; historical height loss (HHL) which is the difference between the maximal height, and the current height (CH), and CH/knee height (KH) ratio. One-hundred and fifty-one postmenopausal women visiting the outpatient clinic of orthopaedics were studied for their CH, self-reported maximal height, KH, and radiographically diagnosed VFx number(s). VFx was present in 41.1 % of the subjects. Multiple regression analyses revealed that the number of prevalent fractures was a significant predictor of HHL and CH/KH ratio. Receiver operator characteristic curve analysis has shown that for HHL, the area under the curve (AUC) with their 95 %CI in the parentheses was 0.84 (0.77, 0.90), 0.88 (0.83, 0.94), and 0.91 (0.86, 0.96) for ≥ 1, ≥ 2, and ≥ 3 fractures, respectively. For the presence of ≥ 1 VFx, the cut-off value was 4.0 cm (specificity 79 %; sensitivity 79 %). Regarding the CH/KH ratio, AUC was 0.73 (0.65, 0.82), 0.85 (0.78, 0.93), and 0.91 (0.86, 0.96) for ≥ 1, ≥ 2, and ≥ 3 fractures, respectively. For the presence of ≥ 1 VFx, the cut-off value was 3.3 (specificity 47 %; sensitivity 91 %). Both cut-off values for HHL and CH/KH ratio had high negative predictivity across the wide range of theoretical VFx prevalence. Thus, HHL and CH/KH were both good detectors of VFx. Our data would be the basis to determine the cut-off value for the screening or case finding of subjects with VFx.

Changes in bone mineral density, bone turnover markers, and vertebral fracture risk reduction with once weekly teriparatide

OBJECTIVE

We aimed to evaluate the surrogacy of bone mineral density and bone turnover markers for incident vertebral fracture using data from 237 patients treated with once weekly 56.5 μg teriparatide or placebo.

METHODS

This analysis was conducted using data from the Teriparatide Once-Weekly Efficacy Research trial, a randomized, double-blind, placebo-controlled trial for patients with severe osteoporosis in Japan. A total of 237 subjects (placebo group, n = 130; teriparatide group, n = 107) were assessed at baseline and at 72 weeks. Main outcome measures included estimation of the treatment effects of once weekly teriparatide on vertebral fracture risk reduction using percentage changes in lumbar bone mineral density and bone turnover markers.

RESULTS

The percentage change in lumbar bone mineral density was 6.69% in the teriparatide group compared with 0.28% in the placebo group (p < 0.01). One incident vertebral fracture occurred in the teriparatide group compared with 16 in the placebo group. The unadjusted and adjusted hazard ratios of the teriparatide group compared with the placebo group were 0.07 (95% confidence interval: 0.01 to 0.56) and 0.64 (95% confidence interval: 0.06 to 6.36), respectively. The proportion of treatment effect explained by changes in lumbar bone mineral density was 83% (Freedman's method) and 66% (Chen's method). There were no notable changes in hazard ratios if we adjusted for bone turnover markers.

CONCLUSIONS

Most of the vertebral fracture risk reduction with once weekly 56.5 μg teriparatide is explained by changes in lumbar bone mineral density rather than changes in bone turnover markers.

Vertebral microarchitecture and fragility fracture in men: a TBS study

INTRODUCTION

Although osteoporosis is considered a disease of women, 25% of the individuals with osteoporosis are men. BMD measurement by DXA is the gold standard used to diagnose osteoporosis and assess fracture risk. Nevertheless, BMD does not take into account alterations of microarchitecture. TBS is an index of bone microarchitecture extracted from the spine DXA. Previous studies have reported the ability of the spine TBS to predict osteoporotic fractures in women. This is the first case-controlled study in men to evaluate the potential diagnostic value of TBS as a complement to bone mineral density (BMD), by comparing men with and without fractures.

METHODS

To be eligible for this study, subjects had to be non-Hispanic US white men aged 40 and older. Furthermore, subjects were excluded if they have or have had previously any treatment or illness that may influence bone metabolism. Fractured subjects were included if the presence of at least one fracture was confirmed. Cases were matched for age (±3 years) and BMD (±0.04 g/cm(2)) with three controls. BMD and TBS were first retrospectively evaluated at AP spine (L1-L4) with a Prodigy densitometer (GE-Lunar, Madison, USA) and TBS iNsight® (Med-Imaps, France) in Lausanne University Hospital blinded from clinical outcome. Inter-group comparisons were undertaken using Student's t-tests or Wilcoxon signed rank tests. Odds ratios were calculated per one standard deviation decrease as well as areas under the receiver operating curve (AUC).

RESULTS

After applying inclusion/exclusion criteria, a group of 180 male subjects was obtained. This group consists of 45 fractured subjects (age=63.3±12.6 years, BMI=27.1±4.2 kg/m(2)) and 135 control subjects (age=62.9±11.9 years, BMI=26.7±3.9 kg/m(2)) matched for age (p=0.86) and BMD (p=0.20). A weak correlation was obtained between TBS and BMD and between TBS and BMI (r=0.27 and r=-0.28, respectively, p<0.01). Subjects with fracture have a significant lower TBS compared to control subjects (p=0.013), whereas no differences were obtained for BMI, height and weight (p>0.10). TBS OR per standard deviation is 1.55 [1.09-2.20] for all fracture type. When considering vertebral fracture only TBS OR reached 2.07 [1.14-3.74].

CONCLUSION

This study showed the potential use of TBS in men. TBS revealed a significant difference between fractured and age- and spine BMD-matched nonfractured subjects. These results are consistent with those previously reported on for men of other nationalities.

Pathomechanism of intravertebral clefts in osteoporotic compression fractures of the spine

BACKGROUND CONTEXT

Intravertebral cleft (IVC) associated with vertebral collapse is not uncommon in osteoporotic compression fracture. However, the pathomechanism of IVC is poorly understood. Bone ischemia is indicated in the current hypothesis.

PURPOSE

To clarify the pathomechanism of IVC in delayed posttraumatic vertebral collapse, referred to as Kummell's disease.

STUDY DESIGN

Magnetic resonance (MR) angiography and histology of segmental arteries and vertebral bodies in delayed posttraumatic vertebral collapse were investigated.

PATIENT SAMPLE

All elderly patients admitted to the authors' spine clinic of tertiary referral center for a 105-month period.

OUTCOME MEASURES

All imaging tests including plain radiographs, computed tomography, and MR angiography were reviewed by authors using a double-blind method. All operations were performed by one experienced surgeon. The statistical data were analyzed using SPSS program.

METHODS

Evaluations using MR angiography and computed tomography were performed in 22 patients. Twelve of the 22 patients underwent corpectomy and anterior interbody fusion. At operation, segmental artery and bone surrounding IVC were harvested and microscopically evaluated.

RESULTS

Magnetic resonance angiography showed occlusions of bilateral segmental arteries in nine of 22 patients. Seven patients had unilateral occlusion. In six patients, no occlusion was seen. Microscopically, the left segmental arteries of three patients were completely obstructed by thrombosis. Histologic examination of necrotic bone showed fragile trabecular bone and sparse osteocytes.

CONCLUSIONS

The findings of thrombosis of the segmental arteries of the vertebral body with IVC could suggest a mechanism by which IVC is formed, and the progressive collapse may develop following osteoporotic spinal fracture.

Anesthetic management of acute cervical spinal cord injury in pregnancy

The incidence of traumatic spinal cord injury is 11,000 per year, with 55% of the injuries occurring between the age of 16 and 33, 18% of these in women of reproductive age. Diagnostic and early spinal decompression along with maintaining the mean arterial pressure to improve spinal cord perfusion and a high progesterone level in pregnancy for its neuroprotective and anti-inflammatory effect have the leading role in neurological recovery and clinical outcome. We present a case of a patient in the 17th week of pregnancy who sustained luxation fracture of the C5 and C6 vertebrae and tetraplegia as passenger in a road accident. The early operative treatment and appropriate anesthetic procedure resulted in good clinical outcome with complete neurological recovery.

[Justification criteria for vertebral fractures ; year 2012 revision]

Justification Criteria for Vertebral Fractures 2012 version was made based on new clinical findings. Major differences in this version compared to the 1996 version are 1) inclusion of the semi quantitative method (SQ) , 2) statements to improve considerations during radiographic analysis, and 3) the need for more detailed evaluation by MRI. New Justification Criteria aims that the treatment of vertebral fracture in both fracture and osteoporosis is properly performed in daily clinical practice.

Preventive effects of conservative treatment with short-term teriparatide on the progression of vertebral body collapse after osteoporotic vertebral compression fracture

The progression of fractured vertebral collapse is not rare after a conservative treatment of vertebral compression fracture (VCF). Teriparatide has been shown to directly stimulate bone formation and improve bone density, but there is a lack of evidence regarding its use in fracture management. Conservative treatment with short-term teriparatide is effective for decreasing the progression of fractured vertebral body collapse.

INTRODUCTION

Few studies have reported on the prevention of collapsed vertebral body progression after osteoporotic VCF. Teriparatide rapidly enhances bone formation and increases bone strength. This study evaluated preventive effects of short-term teriparatide on the progression of vertebral body collapse after osteoporotic VCF.

METHODS

Radiographs of 68 women with single-level osteoporotic VCF at thoracolumbar junction (T11-L2) were reviewed. Among them, 32 patients were treated conservatively with teriparatide (minimum 3 months) (group I), and 36 were treated with antiresorptive (group II). We measured kyphosis and wedge angle of the fractured vertebral body, and ratios of anterior, middle, and posterior heights of the collapsed body to posterior height of a normal upper vertebra were determined. The degree of collapse progression was compared between two groups.

RESULTS

The progression of fractured vertebral body collapse was shown in both groups, but the degree of progression was significantly lower in group I than in group II. At the last follow-up, mean increments of kyphosis and wedge angle were significantly lower in group I (4.0° ± 4.2° and 3.6° ± 3.6°) than in group II (6.8° ± 4.1° and 5.8° ± 3.5°) (p = 0.032 and p = 0.037). Decrement percentages of anterior and middle border height were significantly lower in group I (9.6 ± 10.3 and 7.4 ± 7.5 %) than in group II (18.1 ± 9.7 and 13.8 ± 12.2 %) (p = 0.001 and p = 0.025), but not in posterior height (p = 0.086).

CONCLUSIONS

In female patients with single-level osteoporotic VCF at the thoracolumbar junction, short-term teriparatide treatment did not prevent but did decrease the progression of fractured vertebral body collapse.

Efficacy of the dynamic radiographs for diagnosing acute osteoporotic vertebral fractures

We investigated the efficacy of dynamic radiographs for diagnosing acute osteoporotic vertebral fractures (OVFs) compared with supine radiographs or sitting radiographs alone. Evaluation of the dynamic radiographs was superior to the other evaluations. Dynamic radiographs provide a convenient and useful method of diagnosing acute OVFs.

INTRODUCTION

Identifying acute OVFs on plain radiographs is difficult. We studied a new approach to identify acute OVFs on the basis of fracture mobility.

METHODS

We performed a retrospective radiographic analysis of 472 acute OVFs (<3 weeks after onset), which were diagnosed on the basis of magnetic resonance imaging of T5 through L5 (a total of 5,239 vertebrae). Supine lateral radiographs were compared with sitting lateral radiographs to determine the presence or absence of mobility. Vertebrae showing changes in the vertebral body height were diagnosed as acute OVFs. We analyzed the diagnostic accuracy on the basis of comparative supine and sitting lateral radiographs and compared it with that of radiographs obtained in the supine or the sitting position alone.

RESULTS

Of the 472 acute OVFs diagnosed, 313 (66 %) exhibited vertebral mobility on supine lateral and sitting lateral radiographs. Correct diagnoses of acute OVFs or no acute OVFs were made in 4,883 vertebrae. There were 159 unreadable OVFs (3 %), and 197 previous OVFs (4 %) were misdiagnosed as acute OVFs. The sensitivity was 66 % and the specificity was 96 %. Evaluation of the mobility of acute OVFs in the supine and the sitting position was superior to evaluation using radiographs in either the supine or the sitting position alone.

CONCLUSIONS

Dynamic radiographs provide a convenient way to identify acute OVFs.

The associations between QCT-based vertebral bone measurements and prevalent vertebral fractures depend on the spinal locations of both bone measurement and fracture

We examined how spinal location affects the relationships between quantitative computed tomography (QCT)-based bone measurements and prevalent vertebral fractures. Upper spine (T4-T10) fractures appear to be more strongly related to bone measures than lower spine (T11-L4) fractures, while lower spine measurements are at least as strongly related to fractures as upper spine measurements.

INTRODUCTION

Vertebral fracture (VF), a common injury in older adults, is most prevalent in the mid-thoracic (T7-T8) and thoracolumbar (T12-L1) areas of the spine. However, measurements of bone mineral density (BMD) are typically made in the lumbar spine. It is not clear how the associations between bone measurements and VFs are affected by the spinal locations of both bone measurements and VF.

METHODS

A community-based case-control study includes 40 cases with moderate or severe prevalent VF and 80 age- and sex-matched controls. Measures of vertebral BMD, strength (estimated by finite element analysis), and factor of risk (load:strength ratio) were determined based on QCT scans at the L3 and T10 vertebrae. Associations were determined between bone measures and prevalent VF occurring at any location, in the upper spine (T4-T10), or in the lower spine (T11-L4).

RESULTS

Prevalent VF at any location was significantly associated with bone measures, with odds ratios (ORs) generally higher for measurements made at L3 (ORs = 1.9-3.9) than at T10 (ORs = 1.5-2.4). Upper spine fracture was associated with these measures at both T10 and L3 (ORs = 1.9-8.2), while lower spine fracture was less strongly associated (ORs = 1.0-2.4) and only reached significance for volumetric BMD measures at L3.

CONCLUSIONS

Closer proximity between the locations of bone measures and prevalent VF does not strengthen associations between bone measures and fracture. Furthermore, VF etiology may vary by region, with VFs in the upper spine more strongly related to skeletal fragility.

Downregulated interleukin 37 expression associated with aggravation of intervertebral disc degeneration

Interleukin 37 (IL-37) is an anti-inflammatory cytokine which was proven to be associated with several diseases characterized with excessive-inflammation. The pathologic process of Intervertebral disc degeneration (IVDD) is also companied by uncurbed inflammation, many cytokines were reported presenting in the process. However, there is little IL-37 related knowledge in IVDD up to now. The aim of this study was to investigate whether IL-37 expression in degenerative intervertebral disc (IVD) is different from that in non-degenerative disc and to evaluate the relationship between IL-37 expression, overexpression of pro-inflammatory cytokines and development of degeneration. Human nucleus pulposus samples were obtained from patients with disc degenerative disease and vertebra fractures undergoing discectomy and fusion. Subsequently, expression of IL-37 was assessed by real-time quantitative polymerase chain reaction (RT-PCR) and western blotting. Gene expression level was measured for IL-1α, IL-1β, IL-6, IL-16, TNF-α, TGF-β1 and Smad3. Degree of degeneration was evaluated for MRI with modified Pfirrmann grading system. The results showed that IL-37 had a decreased expression in degenerative samples compared to that in normal samples both at mRNA and protein level. Instead, significant elevated gene expression of IL-1β, IL-16, TNF-α, TGF-β1 and Smad3 were detected in degenerative samples. High correlations were observed between IL-37, IL-1β, IL-16, TGF-β1, Smad3 and degeneration degree of IVD. Downregulation of IL-37 expression appeared to result in overexpression of pro-inflammatory cytokines, such as IL-1β and IL-16, in degenerative IVD and may be a contributor involved in the progression of IVDD.

Red flags to screen for malignancy and fracture in patients with low back pain: systematic review

OBJECTIVE

To review the evidence on diagnostic accuracy of red flag signs and symptoms to screen for fracture or malignancy in patients presenting with low back pain to primary, secondary, or tertiary care.

DESIGN

Systematic review.

DATA SOURCES

Medline, OldMedline, Embase, and CINAHL from earliest available up to 1 October 2013.

INCLUSION CRITERIA

Primary diagnostic studies comparing red flags for fracture or malignancy to an acceptable reference standard, published in any language.

REVIEW METHODS

Assessment of study quality and extraction of data was conducted by three independent assessors. Diagnostic accuracy statistics and post-test probabilities were generated for each red flag.

RESULTS

We included 14 studies (eight from primary care, two from secondary care, four from tertiary care) evaluating 53 red flags; only five studies evaluated combinations of red flags. Pooling of data was not possible because of index test heterogeneity. Many red flags in current guidelines provide virtually no change in probability of fracture or malignancy or have untested diagnostic accuracy. The red flags with the highest post-test probability for detection of fracture were older age (9%, 95% confidence interval 3% to 25%), prolonged use of corticosteroid drugs (33%, 10% to 67%), severe trauma (11%, 8% to 16%), and presence of a contusion or abrasion (62%, 49% to 74%). Probability of spinal fracture was higher when multiple red flags were present (90%, 34% to 99%). The red flag with the highest post-test probability for detection of spinal malignancy was history of malignancy (33%, 22% to 46%).

CONCLUSIONS

While several red flags are endorsed in guidelines to screen for fracture or malignancy, only a small subset of these have evidence that they are indeed informative. These findings suggest a need for revision of many current guidelines.

Scaling relations between trabecular bone volume fraction and microstructure at different skeletal sites

In this study, we investigated the scaling relations between trabecular bone volume fraction (BV/TV) and parameters of the trabecular microstructure at different skeletal sites. Cylindrical bone samples with a diameter of 8mm were harvested from different skeletal sites of 154 human donors in vitro: 87 from the distal radius, 59/69 from the thoracic/lumbar spine, 51 from the femoral neck, and 83 from the greater trochanter. μCT images were obtained with an isotropic spatial resolution of 26μm. BV/TV and trabecular microstructure parameters (TbN, TbTh, TbSp, scaling indices (< > and σ of α and αz), and Minkowski Functionals (Surface, Curvature, Euler)) were computed for each sample. The regression coefficient β was determined for each skeletal site as the slope of a linear fit in the double-logarithmic representations of the correlations of BV/TV versus the respective microstructure parameter. Statistically significant correlation coefficients ranging from r=0.36 to r=0.97 were observed for BV/TV versus microstructure parameters, except for Curvature and Euler. The regression coefficients β were 0.19 to 0.23 (TbN), 0.21 to 0.30 (TbTh), -0.28 to -0.24 (TbSp), 0.58 to 0.71 (Surface) and 0.12 to 0.16 (<α>), 0.07 to 0.11 (<αz>), -0.44 to -0.30 (σ(α)), and -0.39 to -0.14 (σ(αz)) at the different skeletal sites. The 95% confidence intervals of β overlapped for almost all microstructure parameters at the different skeletal sites. The scaling relations were independent of vertebral fracture status and similar for subjects aged 60-69, 70-79, and >79years. In conclusion, the bone volume fraction-microstructure scaling relations showed a rather universal character.

Unstable atlas fracture treatment by anterior plate C1-ring osteosynthesis using a transoral approach

STUDY DESIGN

A retrospective study was conducted to evaluate anterior plate fixation of unstable atlas fractures using a transoral approach.

OBJECTIVE

To further investigate the safety and efficacy of this surgical technique, as there is currently a paucity of available data. While most atlas fractures can be managed by external immobilization with favorable results, surgery is usually preferable in highly unstable cases. Surgical stabilization is most commonly achieved using a posterior approach with fixation of C1-C2 or C0-C2, but these techniques usually result in loss of joint function and cannot fully stabilize anterior arch fractures of the atlas. Although a transoral approach circumvents these issues, only nine cases were described in the literature to our knowledge.

METHODS

Twenty patients with unstable atlas fractures were treated with this technique during a 6-year period. Screw and plate placement, bone fusion, and integrity of spinal cord and vertebral arteries were assessed via intraoperative and follow-up imaging. Neurologic function, range of motion, strength, pain levels, and signs of infection were assessed clinically upon follow-up.

RESULTS

There were no incidents of screw loosening or breakage, plate displacement, spinal cord injury, or vertebral artery injury. A total of 20 plates were placed and all 40 screws were inserted into the atlas lateral masses. CT scans demonstrated that two screws were placed too close to the vertebral artery canal, but without clinical consequences. Imaging demonstrated that bone fusion was achieved in all cases by 6 months postoperatively, without intervertebral instability. No plate-related complications were observed in any patients during the follow-up period.

CONCLUSIONS

C1 anterior plate fixation using a transoral approach appears to be a safe, reliable, and function-preserving surgical method for the management of unstable atlas fractures. For this type of fracture, a transoral approach with anterior fixation should be considered as an alternative to posterior approaches or conservative treatments.

Bone quality, as measured by trabecular bone score, in patients with primary hyperparathyroidism

OBJECTIVE

In primary hyperparathyroidism (PHPT), vertebral fractures (VFx) occur regardless of bone mineral density (BMD) and may depend on decreased bone quality. Trabecular bone score (TBS) is a texture measurement acquired during a spinal dual-energy X-ray absorptiometry (DXA). Recently, TBS has been proposed as an index of bone micro-architecture.

DESIGN

We studied 92 PHPT patients (74 females, age 62.1±9.7 years) and 98 control subjects. In all patients at baseline, in 20 surgically treated patients and in 10 conservatively treated patients after 24 months, TBS, spinal (lumbar spine (LS)) and femoral (total hip (TH) and femoral neck (FN)) BMD were assessed by DXA and VFx by spinal radiograph.

RESULTS

PHPT patients had lower TBS (-2.39±1.8) and higher VFx prevalence (43.5%) than controls (-0.98±1.07 and 8.2% respectively, both P<0.0001). TBS was associated with VFx (odds ratio 1.4, 95% CI 1.1-1.9, P=0.02), regardless of LS-BMD, age, BMI and gender, and showed a better compromise between sensitivity (75%) and specificity (61.5%) for detecting VFx than LS-BMD, TH-BMD and FN-BMD (31 and 75%, 72 and 44.2%, and 64 and 65% respectively). In surgically treated patients, TBS, LS-BMD, TH-BMD and FN-BMD increased (+47±44.8,+29.2±34.1,+49.4±48.7 and +30.2±39.3% respectively, all P<0.0001). Among patients treated conservatively, TBS decreased significantly in those (n=3) with incident VFx (-1.3±0.3) compared with those without (-0.01±0.9, P=0.048), while BMD changes were not statistically different (LS 0.3±1.2 vs -0.8±0.9 respectively, P=0.19; TH 0.4±0.8 vs -0.8±1.4 respectively, P=0.13 and FN 0.4±0.9 vs -0.8±1.4 respectively, P=0.14).

CONCLUSIONS

In PHPT, bone quality, as measured by TBS, is reduced and associated with VFx and improves after surgery.

Percutaneous vertebroplasty: Technique and results in 192 procedures

Percutaneous vertebroplasty with acrylic cement (usually polymethylmethacrylate) consists of injecting cement into vertebral bodies weakened by osseous lesions. The objective of this procedure is to obtain an analgesic effect by mechanical stabilization in destructive lesions of the spine. The three major indications are aggressive vertebral hemangiomas, severe or refractory pain related to osteoporotic vertebral fractures, and malignant vertebral tumors. Complications are infrequent, but occur essentially in patients with vertebral malignant tumors. We present our experience with 148 patients that underwent 192 percutaneous PMMA vertebroplasties for the treatment of painful osteoporotic compression fractures (76 patients, 105 vertebral levels), hemangiomas (31 patients, 43 vertebral levels) and neoplasms (31 patients, 43 vertebral levels). In a vast majority of appropriately selected cases and especially in osteoporotic cases, vertebroplasty constitutes a relatively simple procedure with a very high rate of success.

Percutaneous vertebral augmentation assisted by PEEK implant in painful osteolytic vertebral metastasis involving the vertebral wall: experience on 40 patients

BACKGROUND

Vertebral metastases are associated with significant pain, disability, and morbidity. Open surgery for fracture stabilization is often inappropriate in this cancer population due to a poor risk-benefit profile, particularly if life expectancy is short. Vertebroplasty and kyphoplasty are appealing adjunctive procedures in patients with malignancy for alleviation of intractable pain. However, these patients have a higher risk of serious complications, notably cement extravasation.

STUDY DESIGN

We prospectively evaluated clinical results of polyetheretherketone (PEEK) implant (Kiva) assisted vertebroplasty performed in malignant painful osteolytic lesions at risk for cement extravasation due to vertebral wall involvement.

SETTING

Department of Interventional Radiology, Institute for Cancer Research and Treatment, Candiolo, Turin, Italy

METHODS

Forty patients (22 women; mean age 66.8 ± 12.4), suffering from a painful spine malignancy with vertebral wall involvement not responding to conventional therapies and without surgical indications, underwent vertebral augmentation with Kiva intravertebral implant for pain palliation. The procedure was performed with moderate sedation and local anesthesia under combined digital fluoroscopy and computed tomography guidance. After the coil-shaped PEEK implant was deployed within the vertebral lesion, bone cement was injected under continuous digital fluoroscopic control. Patients were discharged from the hospital the next procedural day. The Visual Analog Scale (VAS) for pain, Oswestry Disability Index (ODI), analgesic requirement, and use of external brace support were evaluated to determine efficacy. The primary end-point was safety and efficacy at one month after the procedure. However, all the patients were scheduled to be followed-up at month 3, 6, and every 6 months thereafter. Follow-up was prospectively evaluated in all patients after Kiva with clinical interviews. The Institution's Internal Review Board approved this study.

RESULTS

Median pre-treatment VAS of 10 (range 6 - 10) significantly (P < 0.001) dropped to one (range 0 - 3), with all patients achieving a clinically relevant benefit on pain at one month. Differences in pre- and post-treatment analgesic therapy were significant (P < 0.001). All patients no longer use an external brace after Kiva. In 7 out of 43 (16.3%) treated vertebrae a bone cement leakage was detected.

LIMITATIONS

This is a not randomized study. Participants were limited to 40 patients.

CONCLUSION

The Kiva System potentially represents a novel and effective minimally invasive treatment option for patients suffering from severe pain due to osteolytic vertebral metastases.

[Influence on adjacent lumbar bone density after strengthening of T12, L1 segment vertebral osteoporotic compression fracture by percutaneous vertebroplasty and percutaneous kyphoplasty]

OBJECTIVE

To observe the influence on adjacent lumbar bone density after strengthening of T12, L1 segment vertebral osteoporotic compression fracture by percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) in postmenopausal female.

METHODS

Between January 2008 and June 2011, 59 patients with T12, L1 segment thoracolumbar osteoporotic compression fracture were treated with PVP in 29 cases (PVP group) and PKP in 30 cases (PKP group), who were in accordance with the inclusion and exclusion criteria. No significant difference was found in gender, duration of menopause, disease druation, causes of injury, fractured vertebral body, and vertebral fracture classification between 2 groups (P > 0.05). The kyphosis Cobb angle of surgical area was measured at preoperation, 1 week after operation, and last follow-up; the lower three lumbar spine bone mineral density (BMD) of the surgical area, the femoral neck BMD, and body mass index (BMI) of patients were measured at perioperative period and last follow-up to find out the statement of anti-osteoporosis; FRAX online tools were used to evaluate the probability of major osteoporotic fracture and hip fracture of the next 10 years.

RESULTS

The average follow-up was 25.5 months (range, 12-48 months) in 2 groups. There was significant difference in kyphosis Cobb angle of T12, L1 between preoperation and last follow-up in 2 groups (P < 0.05); the Cobb angle of PKP group was significantly less than that of PVP group at 1 week after operation and last follow-up (P < 0.05). No significant difference was found in BMI between 2 groups, and between perioperative period and last follow-up in the same group (P > 0.05). The lower three lumbar spine BMD of the surgical area and its T value at last follow-up was improved significantly when compared with BMD at perioperative period (P < 0.05); there was no significant difference in the lower three lumbar spine BMD and its T value between 2 groups at perioperative period (P > 0.05), but significant difference was found between two groups at last follow-up (P < 0.05). Difference was not significant in the femoral neck BMD and its T value between 2 groups, and between perioperative period and last follow-up in the same group (P > 0.05). The probability of major osteoporotic fracture and hip fracture of the next 10 years was not significantly different between 2 groups and between perioperative period and last follow-up in the same group (P > 0.05).

CONCLUSION

The increased BMD of adjacent lumbar spine can improve the strength of the vertebral body and reduce the incidence of adjacent vertebral fracture in patients with T12, L1 segment vertebral osteoporotic compression fracture after PVP/PKP, and PKP is superior to PVP increasing BMD of adjacent lumbar spine.

Influence of non-traumatic thoracic and lumbar vertebral fractures on sagittal spine alignment assessed by radiation-free spinometry

Due to missing indications for specific diagnostics, the majority of non-symptomatic vertebral fractures are not diagnosed. This study shows the ability of radiation-free spinometry to assess sagittal spine parameters to raise suspicion for new non-traumatic thoracic and lumbar vertebral fractures and indicate specific diagnostics.

INTRODUCTION

The primary aim of this study was to investigate the accuracy of radiation-free spinometry to predict new non-traumatic vertebral fractures (VF) by the assessment of thoracic kyphosis (TK), lumbar lordosis (LL), and trunk inclination.

METHODS

Three hundred sixty-one patients (278 females and 83 males; age, 67.0 ± 8.6 years) were enrolled. In 86 women and 24 men, at least one non-traumatic VF was confirmed by radiography, MRI, and/or CT. Spinometry (video rasterstereography) was used to assess TK, LL, and trunk inclination. Receiver operating characteristic (ROC) and multivariate logistic regression analyses were performed to test the influence of age, sex, number, location, and grade of fractures on sagittal spine alignment.

RESULTS

TK, LL, and trunk inclination were associated with advancing age (p < 0.05). Patients with prevalent thoracic and lumbar VFs showed increased TK (p < 0.001), decreased LL (p < 0.001), and increased trunk inclination (p < 0.001) in comparison to patients without VFs. ROC analysis revealed that the combination of TK and LL presented with the best predictive accuracy to raise suspicion for new grade 2 or grade 3 VFs in the thoracic and the lumbar spine (AUC, 0.752-0.771). Odds ratio (OR) showed an increased risk for VFs with increased TK (OR, 1.05-1.11; p < 0.001) and LL (1.05-1.07; p < 0.001) in specified regions of interest. A TK <50° (sensitivity, 88-100 %; specificity, 23-25 %) and LL (78-92 %; 24-27 %) were considered as appropriate cutoffs for future screening.

CONCLUSION

Spinometry showed better predictive accuracy than historical height loss. Severe changes of TK and LL may help to raise suspicion of new VFs radiation-free and indicate proper diagnostics, such as radiographs, MRI, or CT.

Neurologic recovery according to the spinal fracture patterns by Denis classification

PURPOSE

Although Denis classification is considered as one of most clinically useful schemes for the evaluation of spinal fracture, there is little documentation on the relationship between fracture pattern and the neurologic recovery. The purpose is to evaluate the correlation between the fracture patterns according to Denis classification and neurologic recovery.

MATERIALS AND METHODS

The 38 patients (26 men and 12 women) in this series had an average follow-up of 47.1 months, and they were all managed surgically. Denis classification had been used prospectively to determine the fracture morphology. Frankel Scale and American Spinal Injury Association Spinal Cord Injury Assessment Form [American Spinal Injury Association (ASIA) score] were obtained before surgery, after surgery and at the final follow-up.

RESULTS

The common injuries making neurologic deterioration were burst fracture and fracture-dislocation. The degree of neurologic deficits seen first and at the final follow-up was more severe in fracture-dislocation than burst fracture. The neurologic recovery was not different between burst fracture and fracture-dislocation, assessed by Frankel grading and ASIA scoring system. The neurologic recovery evaluated by ASIA score was not different between the lumbar and thoracic spinal fracture. The neurologic recovery assessed by Frankel grade was greater in the lumbar spinal fractures in than the thoracic spinal fractures.

CONCLUSION

The severity of initial and the final follow-up neurologic deficits were correlated with the fracture patterns according to Denis classification, but the neurologic recovery was not correlated.

Justification criteria for vertebral fractures: year 2012 revision

Justification Criteria for Vertebral Fractures 2012 version was made based on new clinical findings. Major differences in this version compared to the 1996 version are inclusion of the semiquantitative method (SQ), statements to improve considerations during radiographic analysis, and the need for more detailed evaluation by MRI.

Quantitative vertebral morphometry based on parametric modeling of vertebral bodies in 3D

Quantitative vertebral morphometry (QVM) was performed by parametric modeling of vertebral bodies in three dimensions (3D).

INTRODUCTION

Identification of vertebral fractures in two dimensions is a challenging task due to the projective nature of radiographic images and variability in the vertebral shape. By generating detailed 3D anatomical images, computed tomography (CT) enables accurate measurement of vertebral deformations and fractures.

METHODS

A detailed 3D representation of the vertebral body shape is obtained by automatically aligning a parametric 3D model to vertebral bodies in CT images. The parameters of the 3D model describe clinically meaningful morphometric vertebral body features, and QVM in 3D is performed by comparing the parameters to their statistical values. Thresholds and parameters that best discriminate between normal and fractured vertebral bodies are determined by applying statistical classification analysis.

RESULTS

The proposed QVM in 3D was applied to 454 normal and 228 fractured vertebral bodies, yielding classification sensitivity of 92.5% at 7.5% specificity, with corresponding accuracy of 92.5% and precision of 86.1%. The 3D shape parameters that provided the best separation between normal and fractured vertebral bodies were the vertebral body height and the inclination and concavity of both vertebral endplates.

CONCLUSION

The described QVM in 3D is able to efficiently and objectively discriminate between normal and fractured vertebral bodies and identify morphological cases (wedge, (bi)concavity, or crush) and grades (1, 2, or 3) of vertebral body fractures. It may be therefore valuable for diagnosing and predicting vertebral fractures in patients who are at risk of osteoporosis.

Imaging technologies for assessment of skeletal health in men

Conventional radiography can detect most fractures, evaluate their healing, and visualize characteristic skeletal abnormalities for some metabolic bone diseases. Dual-energy X-ray absorptiometry (DXA) is used to measure areal bone mineral density (BMD) in order to diagnose osteoporosis, estimate fracture risk, and monitor changes in BMD over time. Vertebral fracture assessment by DXA can diagnose vertebral fractures with less ionizing radiation, greater patient convenience, and lower cost than conventional radiography. Quantitative computed tomography (QCT) measures volumetric BMD separately in cortical and trabecular bone compartments. High resolution peripheral QCT and high resolution magnetic resonance imaging are noninvasive research tools that assess the microarchitecture of bone. The use of these technologies and others has been associated with special challenges in men compared with women, provided insights into differences in the pathogenesis of osteoporosis in men and women, and enhanced understanding of the mechanisms of action of osteoporosis treatments.