Percutaneous vertebroplasty versus non-operative treatment for osteoporotic vertebral compression fractures: a meta-analysis of randomized controlled trials

Gusongan capsule enhances osteogenic differentiation to mitigate bone loss in ovariectomized rats via the TLR2/NF-κB pathway

BACKGROUND

Osteoporosis (OP) is a metabolic bone disease characterized by reduced bone mass and impaired bone microstructure, leading to an increased risk of fractures. In this context, the Gusongan (GSA) capsule has gained recognition for its osteogenic potential.

PURPOSE

This study sought to examine the therapeutic effects of GSA capsule on OP and to elucidate the molecular mechanisms underpinning its osteoprotective properties.

METHODS

An OP model was established in female Sprague-Dawley rats through bilateral ovariectomy (OVX), followed by gavage administration of varying doses of GSA capsule. The study included the control, OVX model, and positive control (alendronate) groups. Bone mineral density (BMD) and serum biomarkers of rats were analyzed using micro-computed tomography (micro-CT) and enzyme-linked immunosorbent assay (ELISA). RNA sequencing (RNA-seq)- and network pharmacology-based analyses were conducted to identify potential molecular targets. Additionally, in vitro experiments were performed to evaluate the impacts of GSA capsule on the osteogenic differentiation of bone marrow mesenchymal stem cells (BMSCs) and the TLR2/NF-κB pathway.

RESULTS

Micro-CT analysis demonstrated that GSA capsule treatment markedly improved BMD, trabecular number (Tb.N), and bone volume/total volume (BV/TV), while reducing trabecular separation (Tb.Sp) (p< 0.05). ELISA results further revealed that GSA capsule diminished serum levels of bone Gla protein (BGP), bone alkaline phosphatase (BALP), and tartrate-resistant acid phosphatase (TRACP) in OVX rats (p< 0.05), suggesting an inhibitory effect on bone resorption and turnover. RNA-seq- and network pharmacology-based analyses highlighted the downregulation of key factors in the TLR2/NF-κB pathway in BMSCs following GSA capsule treatment. Furthermore, GSA capsule enhanced BALP activity and mineralized nodule formation in BMSCs (p< 0.05). In vitro investigations corroborated that GSA capsule downregulated TLR2 and NF-κB p65 levels and fostered the expression of osteogenic genes, including COL1A1, RUNX2, and OPN (p< 0.05).

CONCLUSION

This study highlighted that GSA capsule attenuated inflammation and augmented osteogenic differentiation of BMSCs by targeting the TLR2/NF-κB pathway. These molecular mechanisms contributed to enhanced BMD and bone microarchitecture in OVX rats, suggesting the therapeutic potential of GSA capsule in OP management.

Appropriate Use Criteria for Osteoporotic Compression Fractures

BACKGROUND CONTEXT

There is a lack of consensus regarding optimal indications for treatment of patients with osteoporotic vertebral fractures. An opportunity exists to improve outcomes if these indications can be clarified.

PURPOSE

The purpose of the North American Spine Society (NASS) Appropriate Use Criteria (AUC) was to determine the appropriate (i.e. reasonable) multidisciplinary treatment recommendations for patients with osteoporotic vertebral fractures across a spectrum of more common clinical scenarios.

STUDY DESIGN

A Modified Delphi process.

PATIENT SAMPLE

Modified consensus based guideline OUTCOME MEASURES: Final rating for treatment recommendations as either "Appropriate", "Uncertain", or "Rarely Appropriate" based on the median final rating among the raters.

METHODS

The methodology was based on the AUC development process established by the Research AND Development (RAND) Corporation. The topic of osteoporotic vertebral compression fracture was selected by NASS for its Clinical Practice Guideline development (CPG). In conjunction, the AUC committee determined key modifiers and adapted the standard definitions developed by the CPG with minimal modifications. A literature search and evidence analysis performed by the CPG were reviewed by the AUC work group. A separate multidisciplinary rating group was assembled. Clinical scenarios were generated based on a matrix of the modifiers, to rate the appropriateness of medical management, cement augmentation, or surgery. Based on the literature, provider experience, and group discussion, each scenario was scored on a nine-point scale on two separate occasions: once without discussion and again following discussion of the initial responses. The median rating for each scenario and level of agreement was then used to determine final indications as rarely appropriate with agreement (1 - 3), uncertain or disagreement (4-6), or appropriate with agreement (7-9). Consensus was not mandatory.

RESULTS

Medical management was appropriate across all scenarios. Cement augmentation was rarely appropriate in 60% of scenarios and uncertain or disagreement in 35% of scenarios. In the 5% of scenarios rated as appropriate with agreement for cement augmentation, high pain scores, acute duration, and simple fracture pattern were always present. Surgery was appropriate in 35% of scenarios and strongly influenced by instability and stenosis with neurological findings. Surgery was rarely appropriate in 18%, and uncertain or disagreement in 47% of scenarios.

CONCLUSIONS

Multidisciplinary appropriate treatment criteria for osteoporotic vertebral fractures were generated based on the RAND methodology. This document provides comprehensive evidence-based recommendations for evaluation and treatment of osteoporotic vertebral fractures. The document in its entirety will be found on the NASS website (https://www.spine.org/Research-Clinical-Care/Quality-Improvement/Appropriate-Use-Criteria).

Precooling storage of bone cement in percutaneous vertebroplasty for osteoporotic vertebral compression fracture

PURPOSE

This study aimed to investigate the effect of precooling storage of bone cement in percutaneous vertebroplasty(PVP) for the patients with osteoporotic vertebral compression fracture (OVCF).

METHODS

A total of 207 OVCF patients who underwent PVP were included in this study. Two different storage methods for the bone cement were randomly utilized: an operating room (NT group, 23 °C) and a refrigerator (PC group, 4 °C). Clinical outcomes were evaluated using the visual analog scale (VAS) and Oswestry Disability Index (ODI) scores. In addition, radiographic evaluations were performed using anterior vertebral height and Cobb angle.

RESULTS

The time of cement infusion was 10.8 ± 2.1 min in the PC group, which was significantly longer compared to the NT group (6.9 ± 1.8 min)(P < 0.0001). However, the postoperative VAS score was lower in the PC group than the NT group (P < 0.0001). Moreover, compared to the NT group, the cement distribution score and rate of cement touching both upper and lower vertebral endplates were higher in the PC group (P < 0.0001 and = 0.037, respectively). Additionally, the anterior vertebral height was higher in the PC group compared to the NT group at both the 2-day postoperative assessment and the final follow-up (P = 0.046 and 0.026, respectively). Lastly, the rates of cement leakage and re-compression were lower in the PC group (P = 0.016 and 0.034, respectively) compared with the NT group.

CONCLUSION

Precooling storage of bone cement may prolong manipulation time in percutaneous vertebroplasty, optimize pain relief for patients, and mitigate the risk of bone cement leakage and re-compression.

TRIAL REGISTRATION

Trial registration number: ChiCTR2400092330. Retrospective registration date: 14/11/2024 ( www.chictr.org.cn ).

A biomechanical investigation comparing a novel bone cement bridging screw system with conventional treatment methods for Kummell's disease

Based on the characteristics of Kummell's disease (KD) and related anatomical structures of the thoracolumbar spine, a novel bone cement screw system has been designed to effectively avoid the cement loosening and displacement. This experiment aimed to assess the biological effects of the novel bone cement screw system in KD on fresh cadaveric thoracolumbar spine specimens, thereby discussing its potential application value and providing a foundation for clinical implementation. This study employed a total of 50 fresh female adult cadaver specimens. Each specimen underwent extraction of the T12 to L2 segment followed by the creation of an artificial KD model at the L1 segment and subsequent establishment of five distinct types of bone cement repair models. Model A represents the percutaneous vertebroplasty (PVP) model, Model B combines PVP with unilateral percutaneous pediculoplasty (PPP), Model C combines PVP with bilateral PPP, Model D introduces the novel bone cement screw combined with unilateral PVP, and Model E combines the novel screw with bilateral PVP, each group consists of 10 specimens. Subsequently, the six-axis spine robot was employed to execute cement three-dimensional biomechanical strength tests in six directions, including anterior flexion and posterior extension, left and right lateral bending, as well as left and right rotation. The novel bone cement screw, whether used unilaterally or bilaterally in combination with the PVP model, exhibits significantly reduced bone cement mobility and superior biomechanical stability during anterior flexion, posterior extension, left lateral bending, and right lateral bending (P<0.05).No significant differences were observed among the five models under both left and right rotation (P > 0.05).When comparing the novel bone cement screw combined with PVP unilaterally and bilaterally, no statistically significant difference was observed in the stability of bone cement across all six directions of motion (P>0.05). To conclude, this novel bone cement bridging screw system exhibits superior biomechanical stability compared to commonly used treatments. Furthermore, both unilateral and bilateral implementations of the novel bone cement screw system yield without significant differences observed. These findings present a reliable and innovative approach for clinical management of KD.

Early kyphoplasty in the elderly patient

Prevalence of vertebral compression fractures is over 30 % in the elderly population. The ideal treatment for these fractures remains a subject of debate. The objective in this study is to compare the clinical outcomes of early kyphoplasty and conservative treatment in vertebral compression fractures.

MATERIALS AND METHODS

Observational retrospective study of 50 consecutive patients with acute vertebral compression fracture (25 patients treated by kyphoplasty and 25 treated by conservative therapy). Number and location of the fractures, radiographic assessment (Beck Index), symptoms duration, pain intensity (Visual Analog Scale -VAS), patient's functional capacity (Oswestry Disability Index - ODI) and analgesic use and dose were analysed. Both groups were followed for 1 year.

RESULTS

Most of the patients in the sample were women with a mean age of 80,5 years old, both groups being comparable in age and sex (p=1 and p=1 respectively). The mean ASA score for kyphoplasty vs conservative was 2.6 vs 2.5 (p 0,54). VAS at initial diagnosis 8,50 vs 8,80 (p 0,405). VAS two months after initiation of the treatment 4,40 vs 2,40 (p 0,028), and VAS at one year follow-up was 1,80 vs 1,30 (p 0,216). ODI mean scores conservative vs kyphoplasty at initial diagnosis were 69,79 vs 74 (p 0,87) and two months later 31,60 vs15,40 (p 0,03). The mean Beck Index at the diagnosis conservative vs kyphoplasty was 59,20 % vs 61,50 % (p 0,68) and after 1 year 51,80 % vs 57,40 % (p 0,45). In the kyphoplasty group only 1 patient had to be hospitalised during 24 h. Cement leakage was detected in 2 patients without clinical repercussion. In the conservative group 5 patients had home help during their recovery and 3 went to nursing homes.

CONCLUSION

Kyphoplasty is a minimally invasive surgical procedure with hardly any complications. It offers a faster and greater pain relief to elderly patients than conservative treatment. Early treatment with kyphoplarty allows patients to walk in a short time (early wandering) after the fracture. This treatment avoids long periods of rest and loss of muscle mass. It is a surgical procedure that should be considered as part of the initial therapeutic choices for osteoporotic vertebral fractures.

LEVEL OF EVIDENCE

IV.

Pain Intervention for Osteoporotic Compression Fracture, From Physical Therapy to Surgery: A Literature Review

Osteoporotic vertebral compression fractures (OVCF) significantly contribute to increased morbidity and mortality in aging populations. When adjusted for age, South Korea has the highest global prevalence of OVCF, with rates of 544 per 100,000 men and 1,575 per 100,000 women. Moreover, patients with OVCF are at a heightened risk of additional fractures, with the risk of new vertebral fractures being up to 5-fold higher. Therefore, in treating patients with OVCF, it is essential to address the current symptoms and take preventive measures against further fractures. Although pharmacological treatment is crucial, it may be insufficient for all patients with OVCF, with more severe cases often requiring physical therapy or surgical intervention. This review aimed to explore effective physical therapy methods for patients with OVCF and summarize surgical techniques for high-risk older patients with various underlying conditions.

In vivo evaluation of hyaluronic acid-polyethylene glycol amended PMMA bone cement for orthopaedic application

The utilization of polymethyl methacrylate (PMMA) bone cement is employed for the purpose of stabilizing fractured vertebral bodies. The existence of a mechanical imbalance in hard polymethylmethacrylate (PMMA) bone cement has the potential to increase the likelihood of a fracture occurring in the neighbouring vertebral body. In order to reduce potential difficulties, the primary goal of this study is to investigate the potential benefits of increasing PMMA bone cement's bioactivity and lowering its elastic modulus. The incorporation of a 10% volume fraction of hyaluronic acid (HyA) and polyethylene glycol (PEG) into the bone cement led to an improvement in the bioactivity and decreasing of elastic modulus of polymethylmethacrylate (PMMA). The integration of HyPE gel phase presents several advantages over pure PMMA bone cement, including enhanced setting parameters, improved degradability, and increased biocompatibility. The gel phase is additionally accountable for a reduction in the elastic modulus of polymethylmethacrylate (PMMA) bone cement. In addition, the existence of a porous structure that arises from the degradation of the HyPE gel phase delivers a significant amount of room, thereby enhancing the process of bone regeneration when implanted in the femur of rabbits. The utilization of HyPE in PMMA has been shown through comprehensive µ-CT analysis to enhance bone formation, thereby promoting osteointegration at the implantation site. Furthermore, the histological analysis demonstrated the existence of osteogenic activity in the PMMA polyethylene glycol supplemented with 10% HyA and 10% PEG after a 2-month period subsequent to implantation.

Rheological Analysis and Evaluation of Measurement Techniques for Curing Poly(Methyl Methacrylate) Bone Cement in Vertebroplasty

Vertebroplasty is a minimally invasive surgical procedure used to treat vertebral fractures, which conventionally involves injecting poly(methyl methacrylate) (PMMA) bone cement into the fractured vertebra. A common risk associated with vertebroplasty is cement leaking out of the vertebra during the injection, which may occur due to a lack of understanding of the complex flow behavior. Therefore, experiments to quantify the cement's flow properties are necessary for understanding and proper handling of the bone cement. In this study, we aimed to characterize the behavior of PMMA bone cement in its curing stages to obtain parameters that govern the flow behavior during injection. We used rotational and oscillatory rheometry for our measurements, as well as a custom-made injector setup that replicated a typical vertebroplasty setting. Our results showed that the complex viscoelastic behavior of bone cement is significantly affected by deformations and temperature. We found that the results from rotational tests, often used for characterizing the bone cement, are susceptible to measurement artifacts caused by wall slip and "ridge"-like formations in the test sample. We also found the Cox-Merz rule to be conditionally valid, which affects the use of oscillatory tests to obtain the shear-thinning characteristics of bone cement. Our findings identify important differences in the measured flow behavior of PMMA bone cement when assessed by different rheological methods, an understanding that is crucial for its risk-free usage in downstream medical applications.

Is the interspinous process device safe and effective in elderly patients with lumbar degeneration? A systematic review and meta-analysis of randomized controlled trials

BACKGROUND CONTEXT

Lumbar spinal stenosis is one of the most common diseases affecting the elderly that is characterized by the narrowing of the spinal canal and peripheral neural pathways which may cause back pain and neurogenic intermittent claudication in affected patients. Recently, as an alternative treatment between conservative therapy and decompression surgery, interspinous process device (IPD) such as X-stop, Coflex, DIAM, Aperius, Wallis, etc., has gained enough popularity.

PURPOSE

The purpose of this study was to evaluate the efficacy and safety of IPD in the treatment of degenerative lumbar spinal stenosis compared with decompression surgery.

STUDY DESIGN

This study was a systematic review and meta-analysis of randomized controlled trials.

PATIENT SAMPLE

555 patients' samples were collected for this study.

OUTCOME MEASURES

The Visual Analogue Scale and the Oswestry Disability Index were analyzed, as well as the Zurich Claudication Questionnaire For efficacy evaluation. Complication and reoperation rate was utilized for the assessment of safety.

METHODS

A comprehensive literature search was performed through Pubmed, EMBASE, Web of Science, and Cochrane Library until October 2023. Among the studies meeting the eligible criteria, any study in which IPD was utilized in the treatment of degenerative lumbar spinal stenosis was included in the current review. For efficacy evaluation, the Visual Analogue Scale and the Oswestry Disability Index were analyzed, as well as the Zurich Claudication Questionnaire. Complication and reoperation rates were utilized for the assessment of safety.

RESULTS

Five randomized controlled trials with 555 patients were included. There were no significant differences in VAS leg pain (SMD - 0.08, 95% CI - 0.32 to 0.15) and back pain (SMD 0.09, 95%CI-0.27 to 0.45), ODI scores (MD 1.08, 95% CI - 11.23 to 13.39) and ZCQ physical function (MD-0.09, 95% CI-0.22 to 0.05) for IPD compared with decompression surgery. In terms of ZCQ symptom severity (MD - 0.22, 95% CI - 0.27 to - 016), decompression surgery showed superior to the IPD. As for complications (RR 1.08, 95% CI 0.36 to 3.27), the IPD had no advantages compared to decompression surgery, whereas inferior to it in reoperation rate (RR 2.58, 95% CI 1.67 to 3.96).

CONCLUSIONS

This systematic review and meta-analysis indicated no superiority in the clinical outcome for IPD compared with decompression surgery. However, more clinical studies are warranted to determine the efficacy and safety of IPD.

Robot-assisted percutaneous vertebroplasty for osteoporotic vertebral compression fracture treatment and risk factor screening for postoperative refracture

Osteoporotic vertebral compression fracture (OVCF) is a serious complication of osteoporosis, and percutaneous vertebroplasty (PVP) is a major therapeutic method for OVCF. This study aimed to evaluate the clinical efficacy and postoperative complications of robot-assisted targeted PVP for the treatment of OVCF. The data from 202 OVCF patients were analyzed in this study, including 72 cases received traditional PVP (PVP group), 68 cases received robot-assisted PVP (R-PVP group), and 62 cases underwent robot-assisted PVP combined with targeted plugging (R-PVP + TP group). The fluoroscopic exposure conditions, operative duration, lengths of stay, postoperative bone cement leakage, refracture, Visual Analog Scale (VAS) score, and Oswestry Disability Index (ODI) score were obtained and compared between the three groups. The Kaplan-Meier method and logistic regression model were adopted to screen the risk factors related with postoperative refracture. R-PVP and R-PVP + TP group had significantly reduced fluoroscopic frequency and radiation dose, and reduced cement leakage compared with PVP group. R-PVP + TP not only showed more obvious advantages in these aspects, but also had a lower probability of postoperative refracture. In addition, BMD, fracture vertebral distribution, cement leakage, and surgery methods were independent related with refracture. All the results demonstrated robot assistance could improve the application of PVP in the treatment of OVCF, and robot-assisted PVP combined with targeted plugging showed significantly reduced fluoroscopic exposure, bone cement leakage, and rate of postoperative refracture. BMD, fracture vertebral distribution, cement leakage, and operation methods were identified as four risk factors for the onset of refracture after PVP.

Effect of different cement distribution in bilateral and unilateral Percutaneous vertebro plasty on the clinical efficacy of vertebral compression fractures

BACKGROUND

The ramifications of osteoporotic fractures and their subsequent complications are becoming progressively detrimental for the elderly population. This study evaluates the clinical ramifications of postoperative bone cement distribution in patients with osteoporotic vertebral compression fractures (OVCF) who underwent both bilateral and unilateral Percutaneous Vertebroplasty (PVP).

OBJECTIVE

The research aims to discern the influence of bone cement distribution on the clinical outcomes of both bilateral and unilateral Percutaneous Vertebroplasty. The overarching intention is to foster efficacious preventive and therapeutic strategies to mitigate postoperative vertebral fractures and thereby enhance surgical outcomes.

METHODS

A comprehensive evaluation was undertaken on 139 patients who received either bilateral or unilateral PVP in our institution between January 2018 and March 2022. These patients were systematically classified into three distinct groups: unilateral PVP (n = 87), bilateral PVP with a connected modality (n = 29), and bilateral PVP with a disconnected modality (n = 23). Several operational metrics were juxtaposed across these cohorts, encapsulating operative duration, aggregate hospital expenses, bone cement administration metrics, VAS (Visual Analogue Scale) scores, ODI (Oswestry Disability Index) scores relative to lumbar discomfort, postoperative vertebral height restitution rates, and the status of the traumatized and adjacent vertebral bodies. Preliminary findings indicated that the VAS scores for the January and December cohorts were considerably reduced compared to the unilateral PVP group (P = 0.015, 0.032). Furthermore, the recurrence of fractures in the affected and adjacent vertebral structures was more pronounced in the unilateral PVP cohort compared to the bilateral PVP cohorts. The duration of the procedure (P = 0.000) and the overall hospitalization expenses for the unilateral PVP group were markedly lesser than for both the connected and disconnected bilateral PVP groups, a difference that was statistically significant (P = 0.015, P = 0.024, respectively). Nevertheless, other parameters, such as the volume of cement infused, incidence of cement spillage, ODI scores for lumbar discomfort, post-surgical vertebral height restitution rate, localized vertebral kyphosis, and the alignment of cement and endplate, did not exhibit significant statistical deviations (P > 0.05).

CONCLUSION

In juxtaposition with unilateral PVP, the employment of bilateral PVP exhibits enhanced long-term prognostic outcomes for patients afflicted with vertebral compression fractures. Notably, bilateral PVP significantly curtails the prevalence of subsequent vertebral injuries. Conversely, the unilateral PVP cohort is distinguished by its abbreviated operational duration, minimal invasiveness, and reduced overall hospitalization expenditures, conferring it with substantial clinical applicability and merit.

Preoperative Prediction of New Vertebral Fractures after Vertebral Augmentation with a Radiomics Nomogram

The occurrence of new vertebral fractures (NVFs) after vertebral augmentation (VA) procedures is common in patients with osteoporotic vertebral compression fractures (OVCFs), leading to painful experiences and financial burdens. We aim to develop a radiomics nomogram for the preoperative prediction of NVFs after VA. Data from center 1 (training set: n = 153; internal validation set: n = 66) and center 2 (external validation set: n = 44) were retrospectively collected. Radiomics features were extracted from MRI images and radiomics scores (radscores) were constructed for each level-specific vertebra based on least absolute shrinkage and selection operator (LASSO). The radiomics nomogram, integrating radiomics signature with presence of intravertebral cleft and number of previous vertebral fractures, was developed by multivariable logistic regression analysis. The predictive performance of the vertebrae was level-specific based on radscores and was generally superior to clinical variables. RadscoreL2 had the optimal discrimination (AUC ≥ 0.751). The nomogram provided good predictive performance (AUC ≥ 0.834), favorable calibration, and large clinical net benefits in each set. It was used successfully to categorize patients into high- or low-risk subgroups. As a noninvasive preoperative prediction tool, the MRI-based radiomics nomogram holds great promise for individualized prediction of NVFs following VA.

Early Vertebroplasty for Severely Painful Acute Osteoporotic Compression Fractures: A Critical Review of the Literature

Vertebroplasty has emerged over the last 30 years as a common treatment for painful osteoporotic vertebral fractures. Patient selection and the time at which vertebroplasty is offered to the patient varies between centres and regions. Vertebroplasty has been studied in comparison to placebo intervention in five blinded trials. One such trial showed more benefit from vertebroplasty than placebo when the procedure was mostly performed within 3 weeks of fracture onset. Others showed no additional benefit from vertebroplasty compared to placebo when it was performed later in the natural history of the fracture. In this review, we examine data from blinded and open label randomised studies of vertebroplasty for evidence relating specifically to the use of early vertebroplasty for patients with severely painful acute osteoporotic fractures.

Similarities and Differences in the Management of Patients with Osteoporotic Vertebral Fractures and Those with Rebound-Associated Vertebral Fractures Following Discontinuation of Denosumab

Rebound-associated vertebral fractures (RVFx) following denosumab discontinuation are typically multiple, are commonly associated with acute sharp pain, increase the risk of imminent fractures, and are pathogenetically different from common osteoporotic vertebral fractures (VFx). A clinically relevant question is whether patients with RVFx should be managed differently from patients with osteoporotic VFx. To address this question, we performed a systematic search of the PubMed database, and we reviewed current evidence on the optimal management of patients with RVFx. For pain relief of patients with RVFx, potent analgesics, often opioids, are essential. Information on the effectiveness of braces in these patients is scarce. Vertebroplasty and kyphoplasty are strongly contraindicated as they confer a substantial risk for new VFx. Exercise may be helpful, but again evidence is lacking. In contrast to patients with osteoporotic VFx, in whom initial treatment with bone-forming agents is recommended, patients with RVFx should initiate treatment with potent antiresorptives. To summarize, patients who have sustained RVFx following denosumab discontinuation are at a very high risk for new fractures, especially VFx. The management of such patients requires a multidisciplinary approach that should not be restricted to pain relief and administration of antiosteoporotic medication, but should also include back protection, early mobilization, and appropriate exercise.

Risk assessment for sandwich vertebral fractures in the treatment of osteoporosis vertebral compression fractures using two methods of bone cement reinforcement

PURPOSE

Bone cement augmentation surgery includes percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP). In this study, we aimed to investigate the risk of sandwich vertebral fractures in the treatment of osteoporotic vertebral compression fractures via PVP and PKP.

METHODS

We performed a retrospective analytical study and included 61 patients with osteoporotic vertebral compression fractures who underwent PVP and PKP at the Spinal Surgery Department of The Second Hospital of Liaocheng Affiliated with Shandong First Medical University from January 2019 to January 2022. These patients were divided into the following two groups by simple random sampling: group A (N = 30) underwent PVP treatment and group B (N = 31) underwent PKP treatment. The surgical time, fluoroscopy frequency, visual analog scale (VAS) score, amount of bone cement, the leakage rate of bone cement in intervertebral space, Cobb angle, and the incidence of fractures in both groups of sandwich vertebral were recorded after 1 year of follow-up.

RESULTS

No statistically significant difference was found in terms of surgical time, fluoroscopy frequency, and VAS score between the two groups (P > 0.05). However, a statistically significant difference was found in terms of the amount of bone cement, the leakage rate of bone cement intervertebral space, Cobb angle, and the incidence of vertebral body fractures in both groups (P < 0.05). The amount of bone cement, the leakage rate of bone cement in intervertebral space, Cobb angle, and sandwich vertebral fractures were higher in Group A than in Group B.

CONCLUSIONS

When PVP and PKP were performed to treat osteoporotic vertebral compression fractures, the sandwich vertebral exhibited a risk of fracture. PVP exhibited a greater relative risk than PKP, which may be due to the relatively larger amount of bone cement, higher rate of bone cement leakage in the intervertebral space, and larger Cobb angle.

Development and validation of a machine learning model to predict imminent new vertebral fractures after vertebral augmentation

BACKGROUND

Accurately predicting the occurrence of imminent new vertebral fractures (NVFs) in patients with osteoporotic vertebral compression fractures (OVCFs) undergoing vertebral augmentation (VA) is challenging with yet no effective approach. This study aim to examine a machine learning model based on radiomics signature and clinical factors in predicting imminent new vertebral fractures after vertebral augmentation.

METHODS

A total of 235 eligible patients with OVCFs who underwent VA procedures were recruited from two independent institutions and categorized into three groups, including training set (n = 138), internal validation set (n = 59), and external validation set (n = 38). In the training set, radiomics features were computationally retrieved from L1 or adjacent vertebral body (T12 or L2) on T1-w MRI images, and a radiomics signature was constructed using the least absolute shrinkage and selection operator algorithm (LASSO). Predictive radiomics signature and clinical factors were fitted into two final prediction models using the random survival forest (RSF) algorithm or COX proportional hazard (CPH) analysis. Independent internal and external validation sets were used to validate the prediction models.

RESULTS

The two prediction models were integrated with radiomics signature and intravertebral cleft (IVC). The RSF model with C-indices of 0.763, 0.773, and 0.731 and time-dependent AUC (2 years) of 0.855, 0.907, and 0.839 (p < 0.001 for all) was found to be better predictive than the CPH model in training, internal and external validation sets. The RSF model provided better calibration, larger net benefits (determined by decision curve analysis), and lower prediction error (time-dependent brier score of 0.156, 0.151, and 0.146, respectively) than the CPH model.

CONCLUSIONS

The integrated RSF model showed the potential to predict imminent NVFs following vertebral augmentation, which will aid in postoperative follow-up and treatment.

Vertebral Augmentation in Spine Surgery

Vertebral augmentation has been a well-studied adjunct percutaneous procedure in spine surgery. Cement augmentation has been used in the treatment of compression fractures through kyphoplasties or vertebroplasties. Historically, data have shown no difference between treating compression fractures conservatively versus with percutaneous cement augmentation procedures. Recent literature has shown improvement in patient outcomes and increase in mobility with percutaneous cement augmentation procedures. Cement augmentation has been used in treating patients with spinal column fractures in higher energy trauma. Cement augmentation has shown to have a reduction in local kyphosis, improved pain, and significant height restoration of the anterior column in patients with burst fractures. Augmentation has been used in spinal deformity surgery, specifically to attempt to reduce the risk of proximal junctional kyphosis and to decrease the risk of screw pullout with cement augmented fenestrated screws in patients with osteoporosis. In pathologic compression fractures, cement augmentation is a safe, viable intervention to improve pain control in these patients. This review will go into the new advances of vertebral augmentation and indications for use in treatment today.

A Preliminary Study on the Morphological Changes of an NiTi-Shaped Memory Alloy Stent in the Vertebral Body

OBJECTIVE

At present, the most commonly used filler polymethyl methacrylate (PMMA) has the disadvantages of monomer toxicity, heat and leakage, and cannot be applied in young people. Therefore, finding a minimally invasive and good tissue-compatible alternative material has been a research hotspot in spine surgery in recent years. The aim of this study is to explore whether the memory alloy stent can avoid the complications of bone cement or not.

METHODS

Four non-adjacent vertebral bodies of the thoracic and lumbar spine in the 18 10-month-old pigs were selected as the surgical site and were randomly divided into the scaffold group and the bone cement group. The memory alloy scaffold and PMMA (polymethyl methacrylate) bone cement were placed via percutaneous puncture, and intraoperative fluoroscopy and micro-CT were used to observe the changes in the height of scaffolds and bone cement in the vertebral body immediately, 6 weeks, and 12 weeks after operation, the microstructural parameters of the bone trabeculae (bone volume fraction, bone surface volume ratio, bone trabeculae number) were also measured.

RESULTS

The memory alloy stent could expand in the vertebral body, and its height gradually increased with time; additionally, the height of the bone cement mass did not change with time (p = 0.00). New bone trabeculae could grow into the scaffold along the gap, and the volume fraction of bone, the volume ratio of bone surface area, and the number of bone trabeculae increased gradually (p = 0.00). However, the volume fraction of bone, the volume ratio of bone surface area, and the number of trabeculae in the cement block decreased gradually (p = 0.00).

CONCLUSIONS

Memory alloy scaffolds have dynamic expansion characteristics in vivo, which can effectively avoid the complications of bone cement. Thus, it is beneficial to explore this minimally invasive treatment for vertebral compression fractures.

Correlation Analysis between Residual Pain after Vertebral Augmentation and the Diffusion Distribution of Bone Cement: A Retrospective Cohort Study

Objective

To explore the influence and potential factors of the bone cement dispersion state on residual pain after vertebral augmentation.

Methods

The cases included in this retrospective cohort study were patients treated with vertebral augmentation (VA) for osteoporotic vertebral compression fractures (OVCFs) between July 2018 and June 2021. According to the type of cement diffusion distribution, the patients were divided into a sufficient diffusion group (Group A) and an insufficient diffusion group (Group B). The differences in the baseline data, visual analog scale (VAS), Oswestry disability index score (ODI), injured vertebral height (IVH), and local kyphosis angle (LKA) between the two groups were analyzed. Assessments were performed preoperatively on the 2nd day postoperation and at the last follow-up. The imaging data of injured vertebrae were accurately reconstructed by a GE AW4.7 workstation, and the differences in the vertebral body volume, bone cement volume, and bone cement volume ratio were compared between the groups.

Result

After screening, 36 patients were included. (1) The postoperative VAS and ODI scores of the two groups were significantly improved compared with the preoperative scores. (2) On the 2nd day postoperation and the last follow-up, the VAS and ODI scores of Group A were significantly different from those of Group B, and Group A outperformed Group B. (3) The IVH and LKA of the two groups were improved after the operation, and no significant difference was found between the groups. (4) Significant differences were found in the bone cement volume and bone cement volume ratio between the groups, and Group A was larger than Group B.

Conclusions

Sufficient bone cement diffusion can reduce residual pain after vertebral augmentation.

A Worldwide Bibliometric Analysis of Published Literature on Osteoporosis Vertebral Compression Fracture

Background

With the aging population growth in the world, the prevalence of osteoporotic vertebral compression fracture (OVCF) is rapidly increasing and receiving widespread attention. Although there are numerous articles on the topic, the research status and hotspot analysis are unclear.

Objective

The goal of this study is to identify trends in the OVCF field and to analyze the most highly cited original articles published in the Web of Science Index on OVCF using bibliometric analysis.

Methods

All OVCF data were obtained from the Web of Science Core Collection, and the number of citations, institutions, journals, countries, and years of publication in this field were visually analyzed using VOSviewer, the bibliometrics online analysis platform, and Excel software. Simultaneously, the top 100 most cited articles were extracted and analyzed.

Results

A total of 756 publications were related to OVCF were included from 1900 to 2022. In recent years, the number of articles on OVCF significantly increased. They are mainly from 41 countries/regions and 202 journals, led by China and the United States. Among all countries, China had the most significant contribution on OVCF (n = 363), and it also was cited most often (n = 3337). The institution with the most articles was Soochow University (n = 40). Osteoporosis International was the journal with most studies and has published 50 on this field. The journal of Spine was cited most often (n = 1968). The most productive periods were from 2016 to 2020, which received 294 articles and 4868 citations. After the analysis, the “vertebroplasty” and “kyphoplasty” of OVCF have been the most common research hotspots.

Conclusion

This study represents an updated bibliometric analysis of OVCF. The aim is to identify current research hotspots and future trends to guide clinicians and researchers in this field.

Novel Radiomics-Clinical Model for the Noninvasive Prediction of New Fractures After Vertebral Augmentation

PURPOSE

To investigate the noninvasive prediction model for new fractures after percutaneous vertebral augmentation (PVA) based on radiomics signature and clinical parameters.

METHODS

Data from patients who were diagnosed with osteoporotic vertebral compression fracture (OVCF) and treated with PVA in our hospital between May 2014 and April 2019 were retrospectively analyzed. Radiomics features were extracted from T1-weighted magnetic resonance imaging (MRI) of the T11-L5 segments taken before PVA. Different radiomics models was developed by using linear discriminant analysis (LDA), multilayer perceptron (MLP), and stochastic gradient descent (SGD) classifiers. A nomogram was constructed by integrating clinical parameters and Radscore that calculated by the best radiomics model. The model performance was quantified in terms of discrimination, calibration and clinical usefulness.

RESULT

Four clinical parameters and 16 selected radiomics features were used for model development. The clinical model showed poor discrimination capability with area under the curves (AUCs) yielding of 0.522 in the training dataset and 0.517 in the validation dataset. The LDA, MLP and SGD classifier-based radiomics model had achieved AUCs of 0.793, 0.810, and 0.797 in the training dataset, and 0.719, 0.704, and 0.725 in the validation dataset, respectively. The nomogram showed the best performance with AUCs achieving 0.810 and 0.754 in the training and validation datasets, respectively. The decision curve analysis demonstrated the net benefit of the nomogram was higher than that of other models.

CONCLUSION

Our findings indicate that combining clinical features with radiomics features from pre-augmentation T1-weighted MRI can be used to develop a nomogram that can predict new fractures in patients after PVA.

Safety and Efficacy of Bone Cement (Spinofill®) for Vertebroplasty in Patients with Osteoporotic Compression Fracture : A Preliminary Prospective Study

Objective

Although several commercialized bone cements are used during percutaneous vertebroplasty (PVP) for patients with osteoporotic vertebral compression fracture (OVCF), there are no reports using domestic products from South Korea. In this study, we investigated the safety and efficacy of Spinofill^® (Injecta Inc., Gunpo, Korea), a new polymethyl methacrylate product.

Methods

A prospective, single-center, and single-arm clinical trial of 30 participants who underwent PVP using Spinofill^® for painful thoracolumbar OVCF was performed with 6-months follow-up. Clinical and surgical outcomes included the Visual analog scale (VAS), Korean-Oswestry disability index (K-ODI), and Odom’s criteria, complication rate, and recurrence rate. Radiological outcomes were evaluated by measuring the findings of postoperative computed tomography and simple radiograph.

Results

The pain of VAS (from 8.95±1.05 to 4.65±2.06, p<0.001) and the life quality based on K-ODI (from 33.95±5.84 to 25.65±4.79, p<0.001) improved significantly, and successful patient satisfaction were achieved in 20 patients (66.7%) 1 day after surgery. These immediate improvements were maintained or more improved during the follow-up. There was no surgery- or product-related complications, but OVCF recurred in two patients (6.7%). Favorable cement interdigitation was reported in 24 patients (80.0%), and extra-vertebral cement leakage was reported in 13 patients (43.0%). The mean vertebral height ratio (from 60.49%±21.97% to 80.07%±13.16%, p<0.001) and segmental kyphotic angle (from 11.46°±8.50° to 7.79°±6.08°, p=0.002) improved one day after surgery. However, these short-term radiological findings somewhat regressed at the end.

Conclusion

The overall outcomes of PVP using Spinofill^® were as favorable as those of other conventionally used products.

Biomechanical Analysis of Different Internal Fixation Combined with Different Bone Grafting for Unstable Thoracolumbar Fractures in the Elderly

This research was developed to accurately evaluate the unstable fractures of thoracolumbar before and after surgery and discuss the treatment timing and methods. Three-dimensional (3D) finite element method was adopted to construct the T₁₂-L₅ segment model of human body. The efficiency of percutaneous kyphoplasty (PKP) and percutaneous vertebroplasty (PVP), two commonly used internal fixation procedures, was retrospectively compared. A total of 150 patients with chest fracture who received PKP or PVP surgery in our hospital, and 104 patients with the same symptoms who received conservative treatment were collected and randomly rolled into PVP group (75 cases), PKP group (75 cases), and control group (104 cases). Visual analog scale (VAS) score and Oswestry disability index (ODI) of patients were collected before and after surgery and 2, 12, and 24 months after surgery. Then, the anterior and central height of the patient's cone and the kyphosis angle were calculated by X-ray. Lumbar minimally invasive fusion system and lumbar pedicle screw rod system were established by computer-aided design (CAD), and the biomechanical characteristics were analyzed. The results showed that there was no substantial difference in VAS score and ODI score between PKP and PVP (P > 0.05), but they were higher than those of the control group (P < 0.05). The anterior edge and middle height of vertebra in the two groups were higher than those in control group (P < 0.05), and the increase in PKP group was more substantial (P < 0.05). The kyphosis of the two groups was smaller than that of the control group (P < 0.05), and the decrease of the kyphosis of the PKP group was more substantial (P < 0.05). In summary, the thoracolumbar segment model established by 3D finite element method was an effective model, and it was verified on patients that both PKP and PVP could achieve relatively satisfactory efficacy. The implantation of the new internal fixation system had no obvious effect on the lumbar movement. This work provided a novel idea and method for the treatment of senile thoracolumbar unstable fracture, as well as experimental data of biomechanics for the operation of senile unstable fracture.

Percutaneous Cement-Augmented Screws Short Fixation for the treatment of Severe Osteoporotic Vertebral Burst Fractures

OBJECTIVE (BACKGROUND)

This study aims to evaluate the therapeutic reliability of posterior percutaneous cement-augmented screws short fixation(PASF) in patients with severe osteoporotic vertebral burst fractures(OVBFs).

METHODS

Single-level OVBFs with an anterior vertebral body height(VBH) reduction equal or superior to 60% were included. A frailty index was employed for preoperative frailty assessment. Back pain and related disability were assessed through the VAS scale and Oswestry low-back pain disability index(ODI), being administered at injury time, preoperative, postoperative, twelfth-month and last patient follow-up evaluations. The main radiological outcomes were represented by Cobb angle(CA) and anterior vertebral body compression percentage(AVBC%), being measured at injury time, preoperative, postoperative and twelfth-month examinations. Among the others, the incidence of cement leakages and hardware failures was assessed.

RESULTS

Thirty-three patients met the inclusion criteria. All patients resulted frail(76%) or semi-frail(24%). Significant VBH restoration and segmental kyphosis improvement after PASF was documented (AVBC%:-40(-43;-37) VS -67(-70;-65), P = 0.0001; CA: 10(8-12) VS 24(23-26), P = 0.0001). The mean VAS and ODI scores documented optimal and long-enduring pain relief and related disability reduction after PASF (VAS: 2(2-3) VS 8(7-8), P = 0.0001; ODI: 22(17-26) VS 64(60-69), P = 0.0001). Only one cement leakage (3%), asymptomatic, occurred. After a mean follow-up of 33 months, no early/late hardware failures were reported.

CONCLUSIONS

The clinical and radiological results of this study suggest that PASF could be a safe and effective treatment option for severe OVBFs when conservative treatments failed.

Healing of Vertebral Compression Fractures in the Elderly after Percutaneous Vertebroplasty-An Analysis of New Bone Formation and Sagittal Alignment in a 3-Year Follow-Up

BACKGROUND

Vertebral compression fractures, resulting in significant pain and disability, commonly occur in elderly osteoporotic patients. However, the current literature lacks long-term follow-up information related to image parameters and bone formation following vertebroplasty.

PURPOSE

To evaluate new bone formation after vertebroplasty and the long-term effect of vertebroplasty.

METHODS

A total of 157 patients with new osteoporotic compression fractures who underwent vertebroplasty were retrospectively analyzed. The image parameters, including wedge angles, compression ratios, global alignment, and new bone formation, were recorded before and after vertebroplasty up to three years postoperatively.

RESULTS

The wedge angle improved and was maintained for 12 months. The compression ratios also improved but gradually deteriorated during the follow-up period. New bone formation was found in 40% of the patients at 36 months, and the multivariate analysis showed that this might have been related to the correction of the anterior compression ratio.

CONCLUSIONS

Vertebroplasty significantly restored the wedge angles and compression ratios up to one year postoperatively, and new bone formation was noted on plain radiographs, which increased over time. Last, the restoration of vertebral parameters may contribute to new bone formation.

Trends and regional variation in vertebroplasty and kyphoplasty in Switzerland: a population-based small area analysis

Regional variation in procedure use often reflects the uncertainty about the risks and benefit of procedures. In Switzerland, regional variation in vertebroplasty and balloon kyphoplasty rates was high, although the variation declined between 2013 and 2018. Substantial parts of the variation remained unexplained, and likely signal unequal access and differing physician opinion.

PURPOSE

To assess trends and regional variation in percutaneous vertebroplasty (VP) and balloon kyphoplasty (BKP) use across Switzerland.

METHODS

We conducted a population-based analysis using patient discharge data from all Swiss acute care hospitals for 2013-2018. We calculated age/sex-standardized mean procedure rates and measures of variation across VP/BKP-specific hospital areas (HSAs). We assessed the influence of potential determinants of variation using multilevel regression models with incremental adjustment for demographics, cultural/socioeconomic, health, and supply factors.

RESULTS

We analyzed 7855 discharges with VP/BKP from 31 HSAs. The mean age/sex-standardized procedure rate increased from 16 to 20/100,000 persons from 2013 to 2018. While the variation in procedure rates across HSAs declined, the overall variation remained high (systematic component of variation from 56.8 to 6.9 from 2013 to 2018). Determinants explained 52% of the variation.

CONCLUSIONS

VP/BKP procedure rates increased and regional variation across Switzerland declined but remained at a high level. A substantial part of the regional variation remained unexplained by potential determinants of variation.

Establishment and validation of a nomogram and web calculator for the risk of new vertebral compression fractures and cement leakage after percutaneous vertebroplasty in patients with osteoporotic vertebral compression fractures

PURPOSE

The aim of this work was to investigate the risk factors for cement leakage and new-onset OVCF after Percutaneous vertebroplasty (PVP) and to develop and validate a clinical prediction model (Nomogram).

METHODS

Patients with Osteoporotic VCF (OVCF) treated with PVP at Liuzhou People's Hospital from June 2016 to June 2018 were reviewed and met the inclusion criteria. Relevant data affecting bone cement leakage and new onset of OVCF were collected. Predictors were screened using univariate and multi-factor logistic analysis to construct Nomogram and web calculators. The consistency of the prediction models was assessed using calibration plots, and their predictive power was assessed by tenfold cross-validation. Clinical value was assessed using Decision curve analysis (DCA) and clinical impact plots.

RESULTS

Higher BMI was associated with lower bone mineral density (BMD). Higher BMI, lower BMD, multiple vertebral fractures, no previous anti-osteoporosis treatment, and steroid use were independent risk factors for new vertebral fractures. Cement injection volume, time to surgery, and multiple vertebral fractures were risk factors for cement leakage after PVP. The development and validation of the Nomogram also demonstrated the predictive ability and clinical value of the model.

CONCLUSIONS

The established Nomogram and web calculator (https://dr-lee.shinyapps.io/RefractureApp/) (https://dr-lee.shinyapps.io/LeakageApp/) can effectively predict the occurrence of cement leakage and new OVCF after PVP.

Percutaneous vertebroplasty versus conservative treatment and placebo in osteoporotic vertebral fractures: meta-analysis and critical review of the literature

OBJECTIVES

To assess the current evidence regarding the efficacy of percutaneous vertebroplasty (PVP) over conservative treatment (CT) and placebo in osteoporotic vertebral fractures (OVFs) by performing a meta-analysis of randomized controlled trials (RCTs).

MATERIALS AND METHODS

A systematic search was conducted on PubMed, EMBASE, and Cochrane databases. The main outcomes were pain relief, improvement of functional disability, and quality of life at different time points: short-term (1-2 weeks), medium-term (1-3 months), and long-term (≥ 6 months). Subgroup analyses based on time from fracture onset and sham procedure were also performed.

RESULTS

A total of 14 RCTs were included in the meta-analysis. PVP showed significant benefits over CT in all outcomes, but slight-to-none clear differences over placebo. Subgroup analyses revealed that PVP performed in fractures < 6 weeks provided superior short-term pain relief than the control group (p = .02), and better quality of life in the medium-term (p = .03) and long-term (p = .006). Placebo based on infiltrating the skin alone was significantly inferior to PVP at most time points in all outcomes, but no significant differences between PVP and placebo were found when the sham procedure consisted of infiltrating both the skin and periosteum.

CONCLUSIONS

PVP showed significant advantages over CT in terms of efficacy, but benefits were more limited when compared to placebo. In addition, benefits of PVP are more prominent in recent OVFs. Differences in the sham procedure or criteria regarding patient's selection/allocation seem to be the main causes of disparity in previous RCTs.

KEY POINTS

• Previous RCTs showed significant advantages of PVP over CT in terms of efficacy, but benefits were more limited when compared to placebo. • Differences in patient allocation or in the sham procedure might explain the lack of benefits of PVP versus placebo found in previous RCTs. • Despite controversial opinions, PVP should be offered to patients with OVFs as an alternative option to conservative treatment.

Association Between Bone Cement Augmentation and New Vertebral Fractures in Patients with Osteoporotic Vertebral Compression Fractures: A Systematic Review and Meta-Analysis

PURPOSE

To investigate the association between bone cement augmentation and new vertebral fractures (VF) in patients with osteoporotic vertebral compression fractures (OVCFs).

METHODS

A literature search of PubMed, EMBASE, and the Cochrane Library was conducted from 1987 to December 31, 2020, to identify randomized controlled trials that compared bone cement augmentation with non-bone cement treatments in patients with OVCFs. The clinical incidence of new VF and the risk of new adjacent vertebral fractures (AVF) after treatment were calculated. The indexes of the risk ratio or odds ratio, and 95% confidence intervals were determined with RevMan 5.2 software.

RESULTS

A total of 13 randomized controlled trials involving 1949 participants were included in the final quantitative analysis. There was no significant association between bone cement augmentation and the clinical incidence of new VF during the 6-month and 12-month follow-ups or the whole follow-up period. However, there was a significantly lower clinical incidence of new VF in patients who received bone cement augmentation compared with non-bone cement treatments during 24 months or more of follow-up. Pooled data from the relevant trials demonstrated that the risk of new AVF in bone cement augmentation was significantly higher than that in non-bone cement treatments.

CONCLUSIONS

Although the use of bone cement augmentation in OVCFs significantly increased the risk of new AVF compared with non-bone cement treatments, it was not significantly associated with a higher clinical incidence of new VF.

Is Kummell's Disease a Misdiagnosed and/or an Underreported Complication of Osteoporotic Vertebral Compression Fractures? A Pattern of the Condition and Available Treatment Modalities

This narrative review provides the outcomes of minimally invasive surgery (MIS) and describes the available conservative treatment options for patients with osteoporotic vertebral compression fractures (OVCFs) that have risk factors for Kummell's disease (KD). It aims to explore the evidence, emphasize the possible therapy complications, and aims to propose the most efficient clinical strategies for maintaining a good overall condition of individuals who may suffer from neurological deficits from a late-diagnosed OVCF complication. The secondary objective is to sum up the diagnostic particularities concerning individuals prone to OVCFs and KD, as the major risk factor for developing these severe conditions remains osteoporosis. Findings of our narrative review are based on the results found in PubMed, Embase, and Google Scholar from the beginning of their inception to December 2020, described independently by two authors. All of the studies included in the review focus on reporting the following treatment methods: conservative methods, vertebroplasty, kyphoplasty, targeted percutaneous vertebroplasty, frontal and side-opening cannula vertebroplasty, SpineJack, bone-feeling mesh container treatment, and the difference in the cement viscosity used (high vs. low) and the approach used (unilateral vs. bilateral). The comparison of randomized control trials (RCTs) as well as prospective and retrospective case series showed a comparable efficacy of kyphoplasty and vertebroplasty, and described cement-augmented screw fixation and the SpineJack system as effective and safe. Although it should be noted that several studies revealed inconsistent results in regards to the efficacy of using back braces and analgesics in patients who had vertebral fractures that were overlooked or not enrolled in any active surveillance program to track the patient's deterioration immediately. Nevertheless there are non-standardized guidelines for treating patients with OVCFs and their complications already established. Using these guidelines, a treatment plan can be planned that takes into consideration the patients' comorbidities and susceptibilities. However, the primary approach remains the management of osteoporosis and that is why prophylaxis and prevention play a crucial role. These measures reduce the risk of disease progression. Unfortunately, in the majority of cases these measures are not taken into account and KD develops.

Vertebral augmentation reduces the 12-month mortality and morbidity in patients with osteoporotic vertebral compression fractures

OBJECTIVES

To investigate the 12-month all-cause mortality and morbidity in patients with osteoporotic vertebral compression fractures (OVCFs) undergoing vertebroplasty/balloon kyphoplasty (VP/BKP) versus non-surgical management (NSM).

METHODS

Following a Medline and EMBASE search for English language articles published from 2010 to 2019, 19 studies reporting on mortality and morbidity after VP/BKP in patients with OVCFs were selected. The 12-month timeline was set due to the largest amount of data availability at such time interval. Estimates for each study were reported as odds ratios (OR) along with 95% confidence intervals (CI) and p values. Fixed or random-effects meta-analyses were performed. All tests were based on a two-sided significance level of 0.05.

RESULTS

Pooled OR across 5 studies favored VP/BKP over NSM in terms of 12-month all-cause mortality (OR: 0.81 [95% CI: 0.46-1.42]; p = .46). Pooled OR across 11 studies favored VP/BKP over NSM in terms of 12-month all-cause morbidity (OR: 0.64 [95% CI: 0.31-1.30]; p = .25). Sub-analysis of data dealing with 12-month infective morbidity from any origin confirmed the benefit of VP/BKP over NSM (OR: 0.23 [95% CI, 0.02-2.54]; p = .23).

CONCLUSION

Compared to NSM, VP/BKP reduces the 12-month risk of all-cause mortality and morbidity by 19% and 36%, respectively. Moreover, VP/BKP reduces by 77% the 12-month risk of infection from any origin.

KEY POINTS

• Compared to non-surgical management, vertebral augmentation reduces the 12-month risk of all-cause mortality by 19% and all-cause morbidity by 36%. • Vertebral augmentation reduces the 12-month risk of infection morbidity from any origin by 77%.

Treatment of osteoporotic vertebral fractures

Osteoporosis is a public health problem that is contributing to an increasing number of osteoporotic vertebral fractures. The aim of this lecture is to summarize the current state of knowledge about osteoporotic fractures by answering five questions. 1/How does the spine typically age and how is osteoporosis diagnosed? Various normal aging processes will gradually modify the vertebral column (static, dynamic, bone quality). Osteoporosis is diagnosed through a DEXA scan. 2/How is an osteoporotic fracture evaluated clinically and radiologically? Magnetic resonance imaging is the preferred modality for making the diagnosis and selecting the most appropriate treatment. 3/What are the treatment options for an osteoporotic fracture? The options are conservative treatment, conventional surgery, and minimally invasive techniques (cementoplasty, percutaneous instrumentation). 4/Which fractures should be treated, and which technique should be used? The choice is clear when neurological deficits are present, although the indications are less firm when there is no deficit. The treatment can be conservative (back brace) if the fracture is non-displaced and minimally painful, vertebroplasty if the fracture is painful and shows hyperintensity on T2-STIR sequences, vertebral expansion if the radiological deformity worsens along with symptoms. 5/What are the technical challenges and complications related to the presence of osteoporosis when treating vertebral fractures surgically? The reduced bone stock increases the risk of poor implant hold and postoperative mechanical complications (adjacent fracture, junctional kyphosis). Technical solutions have been developed (augmented screw fixation, transitional zone) to limit their impact. It is essential to know and master these techniques, and their indications. Treatment of the osteoporosis itself is crucial. Level of evidence V; Expert opinion.

Comparison Between Hyperextension and Neutral Positions for Vertebroplasty and Kyphoplasty: Which is Best for Osteoporotic Vertebral Compression Fractures?

Purpose

This study aimed to compare the demographic features (including total cost), surgical effects, radiographic parameters, and complications of kyphoplasty (KP) and vertebroplasty (VP) in the hyperextension (HP) and neutral positions (NP) and to assess their efficacy and cost-effectiveness for treating single-level osteoporotic vertebral compression fractures (OVCF).

Patients and Methods

This was a retrospective analysis of 245 consecutive patients who underwent KP or VP from February 2018 to February 2019 with observation on postoperative day 2 and at the one-year follow-up. The first 122 patients (86 KP and 36 VP cases) were treated in the neutral position, and the remaining 123 in the hyperextension position (90 VP and 33 KP cases). Back pain and impact on daily life were evaluated. Cobb’s angle and the ratio of the anterior (AR) and middle vertebral (MR) bodies were the main radiographic parameters. The chi-square test, one-way analysis of variance (ANOVA), repeated measurement ANOVA, and post hoc tests (Bonferroni adjustments) were used for statistical analysis.

Results

There were no significant differences in the demographic features, operation time, or rate of re-fracture at the one-year follow-up among the groups. The rate of cement leakage was significantly lower in the HPVP group than in the NPKP group. The total cost was significantly lower in the VP groups than in the KP groups. At the one-year follow-up, back pain was significantly lower in the HPVP group than in the NPKP group. The Oswestry Disability Index, Cobb’s angle, AR, and MR in the HPVP group were similar to those in the NPKP and HPKP groups, but better than those in the NPVP group.

Conclusion

HPVP can achieve better pain relief, and similar disability scores, Cobb’s angle, AR and MR recovery, with a lower total cost, compared with NPKP. HPVP is the most economically efficacious treatment for OVCF.

A novel and convenient method to evaluate bone cement distribution following percutaneous vertebral augmentation

A convenient method to evaluate bone cement distribution following vertebral augmentation is lacking, and therefore so is our understanding of the optimal distribution. To address these questions, we conducted a retrospective study using data from patients with a single-segment vertebral fracture who were treated with vertebral augmentation at our two hospitals. Five evaluation methods based on X-ray film were compared to determine the best evaluation method and the optimal cement distribution. Of the 263 patients included, 49 (18.63%) experienced re-collapse of treated vertebrae and 119 (45.25%) experienced new fractures during follow-up. A 12-score evaluation method (kappa value = 0.652) showed the largest area under the receiver operating characteristic curve for predicting new fractures (0.591) or re-collapse (0.933). In linear regression with the 12-score method, the bone cement distribution showed a negative correlation with the re-collapse of treated vertebra, but it showed a weak correlation with new fracture. The two prediction curves intersected at a score of 10. We conclude that an X-ray-based method for evaluation of bone cement distribution can be convenient and practical, and it can reliably predict risk of new fracture and re-collapse. The 12-score method showed the strongest predictive power, with a score of 10 suggesting optimal bone cement distribution.

Comparison of targeted percutaneous vertebroplasty and traditional percutaneous vertebroplasty for the treatment of osteoporotic vertebral compression fractures in the elderly

Objective

To investigate the clinical effect of precise puncture and low-dose bone cement in percutaneous vertebroplasty (PVP).

Methods

Sixty patients with osteoporotic vertebral compression fracture (OVCFs) who were treated with PVP in our hospital from July 2018 to June 2019. These included patients were divided into group A (N = 30) and group B (N = 30). Group A has punctured to the fracture area accurately and injected with a small dose of bone cement, the group B was injected with a conventional dose of bone cement. The operation time, the amount of bone cement injection, the number of X-rays, the VAS scores, the leakage rate of bone cement, and the incidence of adjacent vertebral fractures were compared between the two groups.

Result

The operation time, fluoroscopic times, and bone cement volume in group A are less than that in group B (P < 0.05). Patients in group A had a lower incidence of cement leakage and adjacent vertebral fracture than that in patients in group B. There was no significant difference in postoperative pain relief between the two groups.

Conclusions

Precise puncture and injection of small doses of bone cement can reduce the number of X-ray fluoroscopy, operation time, amount of bone cement injection, reduce the rate of bone cement leakage and the incidence of adjacent vertebral fractures, which is a safe and effective surgical approach for the treatment for the aged with OVCFs.

Posterior short segment fixation including the fractured vertebra combined with kyphoplasty for unstable thoracolumbar osteoporotic burst fracture

BACKGROUND

Various studies have described the efficacy and safety of the treatment for unstable thoracolumbar osteoporotic burst fracture, however, there is still no consensus on the optimal treatment regimen. The aim of this study was to evaluate the clinical and radiographic results of posterior short segment fixation including the fractured vertebra (PSFFV) combined with kyphoplasty (KP) for unstable thoracolumbar osteoporotic burst fracture.

METHODS

Forty-three patients with unstable thoracolumbar osteoporotic burst fracture underwent PSFFV combined with KP from January 2015 to December 2017 were analyzed retrospectively. Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) was used to evaluate the clinical outcome, radiological parametres including local kyphotic Cobb angle, percentage of the anterior, middle and posterior height of the fractured vertebra were measured and compared pre-operation, post-operation and at final follow-up.

RESULTS

All patients underwent surgery successfully and with an average follow-up of 19.2 ± 6.7 months (rang 15-32). The VAS decreased from 7.1 ± 2.3 pre-operation to 1.6 ± 0.4 at the final follow-up (p < 0.05). The ODI decreased from 83.1 ± 10.5 pre-operation to 19.2 ± 7.3 (P < 0.05) at the final follow-up. The correction of local kyphotic angle was 16.9° ± 5.3° (p < 0.05), and the loss of correction was 3.3° ± 2.6° (p > 0.05), the correction of anterior vertebral height was 30.8% ± 8.6% (p < 0.05), and the loss of correction was 4.5% ± 3.9% (p > 0.05), the correction of middle vertebral height was 26.4% ± 5.8% (p < 0.05), and the loss of correction was 2.0% ± 1.6% (p > 0.05), the correction of posterior vertebral height was 9.4% ± 6.9% (p < 0.05), and the loss of correction was 1.6% ± 1.3% (p > 0.05). Two cases of screw pullout and 8 cases of cement leakage were observed, but without clinical consequence.

CONCLUSIONS

PSFFV combined with KP is a reliable and safe procedure with satisfactory clinical and radiological results for the treatment of unstable thoracolumbar osteoporotic burst fracture.

Effect of Preoperative Zoledronic Acid Administration on Pain Intensity after Percutaneous Vertebroplasty for Osteoporotic Vertebral Compression Fractures

Introduction

This study aimed to compare and analyze the effect of preoperative zoledronic acid (ZOL) administration on pain intensity after percutaneous vertebroplasty (PVP) for osteoporotic vertebral compression fracture (OVCF).

Methods

The study included 242 patients with OVCFs who underwent PVP in our hospital between January 2015 and June 2018. The patients were randomly assigned to either a ZOL group (n = 121) or a control group (n = 121). The patients in the ZOL group were treated preoperatively with intravenous infusion of 5 mg ZOL. Those in the control group were treated without ZOL. All the patients were followed up for 1 year.

Results

No statistically significant differences in age, sex, weight, and body mass index (BMI) were found between the two groups. During the follow-up period, the visual analog scale score and Oswestry dysfunction index score in the ZOL group were lower than those in the control group. The bone mineral density at 6 or 12 months after treatment was significantly higher and the levels of the bone metabolism markers were significantly lower in the ZOL group than in the control group (P < 0.05 for both). Two patients in the treatment group had new vertebral fractures, whereas 13 patients in the control group had new vertebral fractures, which translate to recompression vertebral fracture incidence rates of 1.7% and 10.7%, respectively. The incidence rate of mild adverse reactions was significantly higher in the ZOL group than in the control group, but all the cases were endurable.

Conclusion

Intravenous infusion of ZOL before PVP can effectively reduce postoperative pain intensity, reduce bone loss, increase bone density, reduce the risk of refracture, and improve patient quality of life.

Therapeutic effect of percutaneous vertebroplasty and nonoperative treatment on osteoporotic vertebral compression fracture: A randomized controlled trial protocol

BACKGROUND

Osteoporosis and related complications have been increasing with the aging population. Osteoporotic vertebral compression fractures (OVCFs) are the most common among all osteoporotic fractures. The purpose of this study was performed to compare the efficiency and safety of vertebroplasty versus conservative treatment for acute OVCFs.

METHODS

The conduct of this study followed the Declaration of Helsinki principles and the reporting of this study adhered to the Consolidated Standards of Reporting Trials guidelines for randomized controlled trials. Written informed consent was obtained from every participant. Participants were randomly assigned (1:1) to receive either vertebroplasty or control group. The primary outcome was pain relief at 1 month and 1 year, measured with a Visual Analogue Scale score. The secondary outcomes were Roland-Morris Disability Questionnaire, short form score, European Quality of Life-5 Dimensions, and postoperative complications.

RESULTS

We hypothesize that vertebroplasty will provide a rapid decrease of pain and an early return to daily life activities compared with the control group.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry5624).

Thorned heart. Description of a near-fatal cardiac embolism after percutaneous Vertebroplasty

Cement extravasation is a rather common complication of vertebroplasty, which can be observed in up to 30-40% of patients undergoing this procedure, further associated with venous leakage occurring in up to 24% of cases. Pulmonary embolism may eventually develop once the cement migrates within the pulmonary artery, and is the most common complication of cement extravasation (involving ~4.6% of patients). Intra-cardiac cement embolism is considerably less frequent, but is a potentially fatal complication, mostly managed with cardiac surgery. We describe here a rare case of near-fatal cardiac cement embolism, with a large fragment perforating the right ventricle and reaching the pericardium, who presented to the Emergency Department (ED) for syncope. The patient, who displayed this severe complication after a vertebroplasty procedure performed for osteoporotic compression fracture, needed cardiac surgery.

MicroRNA-505 is involved in the regulation of osteogenic differentiation of MC3T3-E1 cells partially by targeting RUNX2

Objective

Evidence suggests that microRNAs (miRNAs) regulate the expression of genes involved in bone metabolism. This study aimed to investigate the role of miR-505 in the osteogenic differentiation of MC3T3-E1 cells.

Methods

We performed miRNA sequencing to identify differentially expressed miRNAs between MC3T3-E1 cells treated with osteogenic induction medium (OIM) and control cells. Bioinformatics analysis was performed by using the TargetScan and miRDB databases. The expression of miR-505 in MC3T3-E1 cells was detected during osteogenic differentiation. After transfection with miR-505 mimic or miR-505 inhibitor, MC3T3-E1 cells were induced to differentiate into osteoblasts, and the expression of osteogenic differentiation markers (Runt-related transcription factor 2 (RUNX2), alkaline phosphatase (ALP), osteopontin (OPN), osteocalcin (OCN), and osterix (OSX)) was detected.

Results

miR-505 was the most downregulated miRNA among the differentially expressed miRNAs. The RUNX2 gene was identified as a potential target of miR-505 using the target prediction program. miR-505 expression was downregulated during osteogenic differentiation of MC3T3-E1 cells. The expression of osteogenic marker genes was inhibited in MC3T3-E1 cells after transfection with miR-505. However, the expression of osteogenic marker genes was upregulated after transfection with miR-505 inhibitor.

Conclusion

This study is the first to report miR-505 could bind to the RUNX2 gene and thus regulate partly the dysfunction of osteoblasts differentiation, which is expected to be targets for the treatment of osteoporosis.

Early vertebroplasty within 3 weeks of fracture for acute painful vertebral osteoporotic fractures: subgroup analysis of the VAPOUR trial and review of the literature

BACKGROUND

VAPOUR found vertebroplasty (V) more effective than placebo (P) in patients with severe pain and fracture duration less than 6 weeks. Exploratory analysis suggested that benefits were concentrated in the subgroup of patients with fractures ≤ 3-week duration. This difference may account for the three negative blinded trials that included few patients within this fracture time frame.

PURPOSE

To assess the safety and efficacy of early vertebroplasty for acute painful vertebral osteoporotic fractures within 3 weeks of fracture onset in the VAPOUR study.

METHODS

Spearman's rank log coefficients were calculated to reassess the relationship of pain reduction from vertebroplasty and fracture duration in the VAPOUR trial. We more fully report baseline and outcome data in patients with fractures ≤ 3-week duration.

RESULTS

There were 46V and 47P patients with fractures ≤ 3-week duration. Baseline characteristics were similar. In total, 86 patients (41V, 45P) completed the 14-day questionnaire. The proportion of patients with reduction in pain from severe (NRS ≥ 7/10 was an inclusion requirement) to mild (NRS < 4) at 14 days was 21 (51%) V-group and 9 (20%) in the P-group (between-group difference 31 percentage points, 95% CI 12-50; p = 0.002). Early vertebroplasty provided greater reductions in mean NRS pain and Roland-Morris Disability.

CONCLUSION

Analysis of this patient subgroup from the VAPOUR trial, in the context of other randomised trial evidence, suggests clinically significant benefits from early vertebroplasty if performed within 3 weeks of fracture. These slides can be retrieved from Electronic Supplementary Material.

Update on Symptomatic Treatment of Acute Vertebral Compression Fracture

The vertebral column is the most common site of osteoporotic fracture in older individuals and in those using long-term glucocorticoids. Vertebral compression fracture leads to significant morbidities such as acute and chronic pain, spinal deformities and neurological complications, resulting in reduced mobility and quality of life. As a previous vertebral compression fracture is a strong risk factor for further fragility fractures and mortality, it should be treated appropriately. This article reviews the management of osteoporotic vertebral compression fracture and provides evidence-based treatment options.