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

The Value of Cerebral Blood Volume Derived from Dynamic Susceptibility Contrast Perfusion MRI in Predicting IDH Mutation Status of Brain Gliomas-A Systematic Review and Meta-Analysis

Background: Dynamic susceptibility contrast perfusion MRI (DSC-MRI) is a promising non-invasive examination to predict histological and molecular characteristics of brain gliomas. However, the diagnostic accuracy of relative cerebral blood volume (rCBV) is heterogeneously reported in the literature. This systematic review and meta-analysis aims to assess the diagnostic accuracy of mean rCBV derived from DSC-MRI in differentiating Isocitrate Dehydrogenase (IDH)-mutant from IDH-wildtype gliomas. Methods: A comprehensive literature search was conducted in PubMed, Web of Science, and EMBASE up to January 2025, following PRISMA guidelines. Eligible studies reported mean CBV values in treatment-naïve gliomas with histologically confirmed IDH status. Pooled estimates of standardized mean differences (SMDs), diagnostic odds ratios (DOR), and area under the receiver-operating characteristic curve (AUC) were computed using a random-effects model. Heterogeneity was assessed via I2 statistic. Meta-regression analyses were also performed. Results: An analysis of 18 studies (n = 1733) showed that mean rCBV is significantly lower in IDH-mutant gliomas (SMD = -0.86; p < 0.0001). The pooled AUC was 0.80 (95% CI, 0.75-0.90), with moderate sensitivity and specificity. Meta-regression revealed no significant influence of DSC-MRI acquisition parameters, although a flip angle showed a trend toward significance (p = 0.055). Conclusions: Mean rCBV is a reliable imaging biomarker for IDH mutation status in gliomas, demonstrating good diagnostic performance. However, heterogeneity in acquisition parameters and post-processing methods limits generalizability of results. Future research should focus on standardizing DSC-MRI protocols.

Cement-Augmented Pedicle Screw Fixation in Patients with Osteoporosis : Safety, Efficacy and Complications

Cement-augmented pedicle screw instrumentation is a widely accepted method for managing osteoporotic fractures, but it carries inherent risks, particularly related to cement leakage and embolism. This study aimed to analyze a clinical case of complications following cement fixation and provide a detailed review of relevant literature. A 70-year-old patient underwent transpedicular screw instrumentation from L2-L4 with polymethyl methacrylate augmentation, which resulted in cement leakage into the spinal canal and subsequent pulmonary embolism. After revision surgery and conservative treatment for the embolism, the patient's condition stabilized, demonstrating that conservative measures can be effective in managing cement embolism. To complement this case, a comprehensive literature review was conducted to explore the causes, prevention, and treatment of complications related to cement augmentation. The findings support that while cement-augmented pedicle screw instrumentation remains a leading technique for osteoporotic fractures, the associated risks are manageable with proper treatment protocols. This study holds practical significance for healthcare professionals by highlighting both the risks and solutions associated with cement fixation, thus contributing to improved patient outcomes and the development of standardized treatment guidelines.

Computed Tomography-Based Sarcopenia and Pancreatic Cancer Survival-A Comprehensive Meta-Analysis Exploring the Influence of Definition Criteria, Prevalence, and Treatment Intention

Background: Sarcopenia has been associated with poor outcomes in pancreatic cancer (PC). However, published results are heterogeneous in terms of study design, oncological outcomes, and sarcopenia measurements. This meta-analysis aims to evaluate the impact of computed tomography (CT)-based sarcopenia on overall survival (OS) and progression-free survival (PFS) in patients with PC, considering potential confounders such as the CT-based method and thresholds used to define sarcopenia, as well as treatment intention. Methods: We systematically searched databases for observational studies reporting hazard ratios (HRs) for OS and PFS in PC patients stratified by CT-based sarcopenia status. Random-effects models were used to calculate pooled crude and adjusted HRs (cHRs and aHRs, respectively), with subgroup analyses based on sarcopenia measurement methods, cutoff values, sarcopenia prevalence, and treatment intention. Heterogeneity was assessed using the I2 and τ2 statistics, and publication bias was evaluated using funnel plots and Egger's test. Results: Data from 48 studies were included. Sarcopenia was significantly associated with worse OS (pooled cHR = 1.58, 95% CI: 1.38-1.82; pooled aHR = 1.39, 95% CI: 1.16-1.66) and worse PFS (pooled cHR = 1.55, 95% CI: 1.29-1.86; pooled aHR = 1.31, 95% CI: 1.11-1.55). Subgroup analyses revealed significantly different, stronger associations in studies using stricter sarcopenia cutoffs (<50 cm2/m2 for males) and in patients undergoing curative treatments. Heterogeneity was substantial across analyses (I2 > 67%), but with generally low τ2 values (0.01-0.25). Egger's test indicated potential publication bias for OS (p < 0.001), but no significant bias was observed for PFS (p = 0.576). Conclusions: Sarcopenia determined by CT is an independent predictor of poor OS and PFS in PC, but this association varies depending on the cutoff used for its definition as well as on the treatment intention. Therefore, its routine assessment in clinical practice could provide valuable prognostic information, but future research should focus on standardizing sarcopenia assessment methods.

Percutaneous vertebroplasty by two-step fluoroscopy: a treatment for osteoporotic compression fractures of thoracic vertebrae in older adults

OBJECTIVE

This study aimed to evaluate the clinical efficacy of percutaneous vertebroplasty (PVP) performed with a two-step fluoroscopy technique for treating thoracic osteoporotic vertebral compression fractures (OVCFs) in older patients.

METHODS

A retrospective analysis was conducted on clinical and imaging data from 48 patients diagnosed with thoracic OVCFs, who underwent treatment with percutaneous vertebroplasty(PVP) utilizing a two-step fluoroscopy technique at Yangquan First People's Hospital between January 2019 and January 2022. The study assessed the clinical efficacy of this procedure by analyzing Visual Analog Scale(VAS) scores, Cobb angle values, and vertebral height measurements before surgery and at 2 days, 3 months, 6 months, and 12 months postoperatively.

RESULTS

Before treatment, the mean VAS score of patients was 7.5 ± 0.6. Subsequently, at 2 days, 3 months, 6 months, and 12 months after the procedure, these mean scores decreased to 2.3 ± 0.6, 2.2 ± 0.5, 2.2 ± 0.4, and 2.0 ± 0.3, respectively. This decline was statistically significant (P < 0.05) compared to the preoperative VAS score. The preoperative Cobb angle was 12.1° ± 0.9°, and the Cobb angle values at the corresponding time points were 12.2° ± 0.8°, 12.3° ± 1.1°, 12.3° ± 1.0°, and 12.2° ± 0.9°. Initially, the mean height of the vertebral body in these patients was 17.38 ± 1.56 mm. Postoperatively, at 2 days, 3 months, 6 months, and 12 months, these values were 19.30 ± 1.81 mm, 19. 12 ± 1.60 mm, 19.00 ± 1.45 mm, and 19.00 ± 1.20 mm, respectively. No significant difference was observed between postoperative and preoperative Cobb angle and vertebral height (P > 0.05).

CONCLUSION

Percutaneous vertebroplasty using a two-step fluoroscopy method not only has the therapeutic effect of traditional surgical methods, reducing pain from thoracic vertebral compression fractures in the elderly and enhancing their quality of life and mobility, but also streamlines the intraoperative fluoroscopy procedure. This method stand as an effective approach for managing osteoporotic compression fractures of the thoracic vertebrae in elderly.

Impact of Cement Distribution on the Efficacy of Percutaneous Vertebral Augmentation for Osteoporotic Fractures: Assessment with an MRI-Based Reference Marker

BACKGROUND

No studies have evaluated the impact of the cement distribution as classified on the basis of the fracture bone marrow edema area (FBMEA) in magnetic resonance imaging (MRI) on the efficacy of percutaneous vertebral augmentation (PVA) for acute osteoporotic vertebral fractures.

METHODS

The clinical data of patients with acute, painful, single-level thoracolumbar osteoporotic fractures were retrospectively analyzed. The bone cement distribution on the postoperative radiograph was divided into 4 types according to the distribution of the FBMEA on the preoperative MRI. The primary outcomes were the postoperative visual analog scale (VAS) for pain and Oswestry Disability Index (ODI) scores. Cement leakage, adjacent vertebral fractures (an important concern in complications after vertebroplasty and a subset of new fractures), and recollapse of the treated vertebra were also evaluated.

RESULTS

A total of 128 patients, 80.5% of whom were female, were included and had follow-up for 24 months. The mean patient age (and standard deviation) was 74.2 ± 8.6 years. The cement distribution was classified as Type I in 18 patients, Type II in 26, Type III in 46, and Type IV in 38. At the primary time point (6 months), there was a significant difference in the ODI score favoring the Type-III and Type-IV groups compared with the Type-I and Type-II groups (adjusted 95% confidence interval [CI]: Type I versus Type II, -2.40 to 4.50; Type I versus Type III, 1.35 to 7.63; Type I versus Type IV, 1.27 to 7.92; Type II versus Type III, 0.67 to 6.21; Type II versus Type IV, 0.63 to 6.46; adjusted p < 0.0083), whereas no significant differences were found between the 4 groups in the VAS pain score. The Type-II and Type-IV groups had a higher incidence of cement leakage, and the Type-III and Type-IV groups had a lower incidence of vertebral recollapse.

CONCLUSIONS

An adequate distribution of bone cement is advantageous for functional improvement, short-term pain relief, and a lower rate of vertebral recollapse. The FBMEA appears to be a feasible reference marker for evaluating the performance of the PVA procedure.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Factors Influencing the Development of Metachronous Fractures in Patients with Osteoporotic Vertebral Fractures Treated with Conservative Management or Vertebroplasty

Objectives: We aimed to analyze potential predictors for the development of metachronous fractures (MFs) after osteoporotic vertebral fractures (OVFs), with particular focus on radiological variables obtained at initial X-rays and computed tomography (CT) examinations, treatment applied (conservative management [CM] versus percutaneous vertebroplasty [PV]), and fractures located at the thoracolumbar junction (T11-L2). Methods: We conducted a two-center, observational retrospective study, including patients with single-level OVFs treated with CM or VP. We collected socio-demographic, radiological and treatment-related variables. We performed descriptive and contrastive bivariate analyses based on the presence of MFs and univariate and multivariate logistic regression analyses to obtain adjusted and crude odds ratios (aOR and cOR, respectively) for predicting MFs. Finally, we performed receiver-operating characteristic (ROC) curve analyses to determine the discriminative power of the models obtained. Results: Of the 90 patients included, 20 (22.2%) developed one or more MFs (15 in CM and 5 in PV groups, respectively; p = 0.037). The treatment group (aOR for PV, 0.087; 95%CI, 0.015-0.379), presence of intravertebral cleft (aOR, 5.62; 95%CI, 1.84-19.2) and difference in posterior height loss between X-rays and CT (aOR, 0.926; 95%CI, 0.856-0.992) were identified as significant predictors for MFs, while Genant's numerical classification showed a trend toward significance (aOR, 1.97; 95%CI, 0.983-4.19; p = 0.064). A multivariate model combining these four variables showed optimal fitting and correctly discriminated over 80% of cases (AUC, 0.828; 95%CI, 0.725-0.930). Factors associated with MFs in thoracolumbar junction OVFs were intravertebral cleft, CM, posterior height loss in CT, and DGOU OF3 fractures. Conclusions: The presence of intravertebral cleft, a difference in posterior height loss between X-rays and CT equal to or lower than 2.4%, higher grades of Genant's numerical classification, and application of CM instead of PV are predictors of MFs. These findings improve our understanding of the factors involved in the development of MFs, but they need to be validated prospectively.

Comparative study between unilateral and bilateral extrapedicular approaches for osteoporotic vertebral compression fractures: A retrospective study

OBJECTIVE

Percutaneous vertebroplasty (PVP) is a primary treatment for osteoporotic vertebral compression fractures (OVCF). Historically, surgeons preferred a bilateral approach for PVP; however, this approach may impose greater financial strain on patients. This retrospective study examines the efficacy of the unilateral approach compared to the bilateral approach.

METHODS

A total of193 patients were categorized into Group A (unilaterally extrapedicular approach) and Group B (bilateral approach) based on the operative method. Efficacy was evaluated using perioperative indicators, follow-up results, and imaging evaluation results.

RESULTS

Out of the 193 patients involved, 169 were eligible for analysis. All patients completed follow-up visits lasting 49-70 months. Compared to Group B, Group A exhibited significantly shorter operation time, puncture duration, amount of bone cement injected, and number of X-ray fluoroscopies (P < 0.05). While initial pain reduction, as measured by the visual analog scale and Oswestry Disability Index scores, was lower in Group A, the difference between the groups narrowed by the final follow-up. At the final imaging follow-up, no statistically significant differences were observed between the two groups regarding the relative height of the injured vertebral bodies and local Cobb angle measurements.

CONCLUSIONS

This technique holds the potential for accelerated patient rehabilitation and reduced hospitalization expenses, presenting a promising treatment option for OVCF patients.

Percutaneous Vertebroplasty versus Nonoperative Treatment of Osteoporotic Vertebral Fractures: A Meta-Analysis of Randomized Controlled Trials

Osteoporotic vertebral fractures frequently result in pain and decreased quality of life (QoL). The management of these fractures remains a topic of debate. Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we analyzed randomized controlled trials comparing percutaneous vertebroplasty (PV) with non-operative treatment (non-OT). The outcomes of interest included pain, QoL, cement leakage, and new osteoporotic vertebral fractures after 1 year. Compared to non-OT regarding pain relief, PV yielded significant improvement at 1-2 weeks, 1 month, 6 months (standard mean difference [SMD] = -0.67 (6/14; 95% confidence interval [CI]: -1.29 to -0.06; I2 = 92%, random effects) and 1 year (mean difference = -1.07 (4/14; 95% CI: -1.97 to -0.18; I2 = 97%, random effects). For QoL, notable improvements were observed at 1 week (standard mean difference = -2.10 (5/14; 95% CI: -3.77 to -0.42; I2 = 98%, random effects) and 3 months (mean difference = -1.58 (4/14; 95% CI: -3.07 to -0.09; I2 = 96%, random effects), with 1 month, 6 months and 1 year being inconclusive. A cement leakage rate of 42% (10/14; 95% CI: 25% to 59%; I2 = 99%, random effects) was found. Further, PV did not significantly heighten the risk of new fractures within a year (odds ratio = 1.26 (6/14; 95% CI: 0.63 to 2.53; I2 = 74%, random effects). PV emerges as a promising intervention for specific time intervals regarding pain relief, especially in the extended-term analysis, and QoL, especially in the short-term analysis, compared to non-OT. However, clinicians must consider cement leakage risks. Heterogeneity among studies underscores careful patient selection.

Prevalence of Sarcopenia Determined by Computed Tomography in Pancreatic Cancer: A Systematic Review and Meta-Analysis of Observational Studies

Introduction: Sarcopenia, a condition characterized by a loss of skeletal muscle mass, is increasingly recognized as a significant factor influencing patient outcomes in pancreatic cancer (PC). This systematic review and meta-analysis aimed to estimate the prevalence of sarcopenia in patients with PC using computed tomography and to explore how different measurement methods and cut-off values impact such prevalence. Materials and Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a comprehensive search of PubMed, Web of Science, and EMBASE databases was performed, identifying 48 observational studies involving 9063 patients. Results: The overall pooled prevalence of sarcopenia was 45% (95% CI, 40-50%), but varied significantly by the method used: 47% when measured with the skeletal muscle index and 33% when assessed with the total psoas area. In addition, in studies using SMI, sarcopenia prevalence was 19%, 45%, and 57% for cutoff values <40 cm2/m2, 40-50 cm2/m2, and >50 cm2/m2, respectively. Moreover, the prevalence was higher in patients receiving palliative care (50%) compared to those treated with curative intent (41%). High heterogeneity was observed across all analyses, underscoring the need for standardized criteria in sarcopenia assessment. Conclusions: Our findings highlight the substantial variability in sarcopenia prevalence, which could influence patient outcomes, and stress the importance of consensus in measurement techniques to improve clinical decision making and research comparability.

A Comparative Analysis of International Classification Systems to Predict the Risk of Collapse in Single-Level Osteoporotic Vertebral Fractures

INTRODUCTION

Various classifications for osteoporotic vertebral fractures (OVFs) have been introduced to enhance patient care and facilitate clinical communication. However, there is limited evidence of their effectiveness in predicting vertebral collapse, and very few studies have compared this association across different classification systems. This study aims to investigate the association between OVF categories, according to the most widely used classification systems, and vertebral collapse.

PATIENTS AND METHODS

A retrospective single-center study was conducted involving patients diagnosed with acute OVFs at the emergency department of a tertiary-level academic hospital with a minimum follow-up of 6 months. Vertebral fractures were independently classified by two radiologists according to several classification systems, including those proposed by Genant, Sugita, the German Society for Orthopedics and Trauma (DGOU), and the AO Spine. Associations between vertebral collapse and OVF classification systems were analyzed using bivariate and logistic regression analyses.

RESULTS

This study included 208 patients (82.7% females; mean age of 72.6 ± 9.2 years). The median follow-up time was 15 months, with L1 being the most common fracture site (47.6%). The most frequent OVF types observed, according to Genant's morphological, Genant's quantitative, Sugita 's, DGOU's, and AO Spine's classifications, were biconcave (50%), grade 0.5 (47.6%), bow-shaped (61.5%), OF2 (74%), and A1 (61.5%), respectively. All classifications, except for Genant's quantitative system, were significantly associated with vertebral collapse in bivariate analyses. Logistic regression analyses showed a significant association (p = 0.002) between the AO Spine classification and vertebral collapse, with 85.7% of A4 fractures developing collapse on follow-up.

CONCLUSIONS

The AO Spine classification showed the highest predictive capacity for vertebral collapse. Specifically, A4 fracture types showed a very high risk of vertebral collapse, confirming the need for non-conservative management of these fractures. Further multicentric and prospective studies are warranted to confirm these findings.

Enhancing percutaneous kyphoplasty efficacy in elderly osteoporotic fractures through optimal cement filling ratio

Objective

To explore the appropriate bone cement filling ratio in percutaneous kyphoplasty (PKP) for the treatment of osteoporotic vertebral compression fractures (OVCF).

Methods

Clinical and radiological data from 150 OVCF patients treated with PKP were retrospectively analyzed. Patients were categorized into three groups based on bone cement filling ratio: low (<0.4), medium (0.4-0.6), and high (>0.6) filling ratio groups. The clinical characteristics (age, gender, BMI, etc.) and related study data (bone cement leakage and its location, pre/post-operative Visual Analogue Scale (VAS), pre/post-operative Oswestry Disability Index (ODI), vertebral height restoration, kyphotic Cobb angle, etc.) among the three groups were compared using statistical software to compare to identify the most appropriate cement filling ratio.

Results

The 0.4-0.6 group presented a lower cement leakage rate compared to the >0.6 group, and there were no significant differences in pre-operative VAS, post-operative day 2 VAS, post-operative month 1 VAS, and pre-operative ODI (p>0.05). However, significant differences were observed in post-operative month 3 VAS (p=0.002), post-operative day 2 ODI (p=0.002), post-operative month 1 ODI (p<0.001), and post-operative month 3 ODI (p<0.001). The "0.4-0.6" group showed better pain improvement and functional recovery compared with the ">0.6" group at the 3-month follow-up. While presenting the best vertebral height restoration, the ">0.6" group also exhibited the greatest variability. Additionally, no significant difference in Cobb angle changes was observed among the groups.

Conclusion

A bone cement filling ratio of 0.4-0.6 in PKP treatment for OVCF strikes a favorable balance between complication reduction and positive patient outcomes, warranting it as an optimal filling volume.

Efficacy of radiofrequency in lumbar facet joint pain: a systematic review and meta-analysis of placebo-controlled randomized controlled trials

BACKGROUND

Lumbar facet joint pain (LFJP) is one of the main causes of chronic low back pain (LBP) and can be treated using radiofrequency (RF) sensory denervation. The aim of this work is to analyze the efficacy of RF in LFJP through a systematic review and meta-analysis of randomized controlled trials (RCTs) with placebo control.

MATERIALS AND METHODS

A systematic search was conducted in the Medline (PubMed), Scopus, Web of Science databases, and the Cochrane Central Register of Controlled Trials (CENTRAL). The variables of interest were pain, functional status, quality of life (QoL), and global perceived effect (GPE) measured at different time intervals: short (< 3 months), medium (> 3 and < 12 months), and long term (> 12 months).

RESULTS

Eight RCTs with placebo control were included. RF showed significant benefits over placebo in pain relief in the short (MD - 1.01; 95% CI - 1.98 to -0.04; p = 0.04), medium (MD - 1.42; 95% CI - 2.41 to - 0.43; p = 0.005), and long term (MD - 1.12; 95% CI - 1.57 to - 0.68; p < 0.001), as well as improvement in functional disability in the short (SMD - 0.94; 95% CI - 1.73 to - 0.14; p = 0.02) and long term (SMD - 0.74; 95% CI - 1.09 to - 0.39; p < 0.001). No statistically significant differences were observed in QoL or quantitative GPE, but benefits for RF were observed in dichotomous GPE in the medium (OR 0.19; 95% CI 0.07-0.52; p = 0.001) and long term (OR 0.22; 95% CI 0.06-0.78; p = 0.02). Subgroup analyses showed more benefits for RF in LBP < 1 year in the short term and in RCTs that did not require performing an MRI for patient selection.

CONCLUSIONS

RF demonstrated significant improvement in pain and functionality, but the benefits in terms of QoL and GPE are inconclusive. Future clinical trials should investigate the long-term effects of RF, its impact on quality of life, and define appropriate criteria for patient selection.

Implementation of a Specific Set of Intraoperative C-Arm Fluoroscopy Terminologies in Percutaneous Vertebroplasty

OBJECTIVE

Percutaneous vertebroplasty (PVP) is currently the primary minimally invasive surgical approach for treating vertebral compression fractures caused by senile osteoporosis. The current existing problem is the lack of research on the application of a specific set of intraoperative C-arm fluoroscopy terminologies in PVP. Therefore, the purpose of this study is to explore the use of a specific set of intraoperative C-arm fluoroscopic terminologies in PVP in order to increase fluoroscopy accuracy, decrease fluoroscopy frequencies and ray protection, and minimize operation times through rapid preoperative training of surgeons and radiographers.

METHODS

Spine surgeons and radiographers with at least 5 years of experience from nine different hospitals were randomly selected for a series of specialized intraoperative C-arm fluoroscopy terminology training between October 2018 and December 2021. Before and after the training, they were surveyed using a five-point Likert scale to statistically compare their knowledge of the terminology. Simultaneously, 190 PVP cases completed by these surgeons and radiographers before and after the training were chosen for comparison and analysis of fluoroscopy times, effective fluoroscopy rate, fluoroscopy time, repeated puncture rate, and other indicators before and after receiving specialized terminology training. Two-sample tests were mainly used to investigate differences in answers between surgeons and radiographers.

RESULTS

After the training, there was a notable improvement in the fluency of intraoperative communication between professional spine surgeons and radiographers. By comparing the indicators of pre-training with post-training, the effective anteroposterior fluoroscopy rate increased from 46.5% to 75.7%; the effective lateral fluoroscopy rate increased from 59.8% to 76.9%. Moreover, a notable decrease in communication barriers, fluoroscopy frequencies, fluoroscopy time, and the rate of repeated punctures, and a notable increase in the effective fluoroscopy rate was observed.

CONCLUSION

Smooth intraoperative communication between professional spine surgeons and radiographers can significantly lower the communication barrier, reduce the fluoroscopy frequencies and time, the rate of repeated puncture, and increase the effective fluoroscopy rate, all of which are important in improving the fluoroscopy in PVP.

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.

Vertebral augmentation: an overview

Vertebral compression fractures (VCFs) are a common pathologic process seen in 30-50% of individuals over the age of 50 years. Historically, VCFs were first treated with nonsurgical management while vertebral augmentation was reserved for severe cases resulting in deformity or significant disability. Current treatment algorithms based on established appropriateness criteria have changed recommendations towards supporting early vertebral augmentation for the VCFs causing the most clinically difficulty and taking into account the degree of vertebral body height loss, kyphotic deformity, and the degree of clinical progression. Percutaneous vertebroplasty (PVP) involves injecting primarily polymethacrylate (PMMA) bone cement directly into the cancellous bone of the vertebral body. There is recent literature showing the effectiveness of PVP including data comparing vertebroplasty to sham treatment. Vertebroplasty evolved into balloon kyphoplasty (BKP) where a balloon is first inserted into the vertebral body to create a cavity and reduce the fracture followed by an injection of bone cement. Both PVP and BKP have been shown to be significantly more effective at treatment of VCFs compared to nonsurgical management. The benefits shown in the literature have been demonstrated randomized control trials, cohort matched trials, post-market trials, registries, and many other data sources with approximately 250 manuscripts produced per year dedicated to the topic of vertebral augmentation.

The American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain

Introduction

Painful lumbar spinal disorders represent a leading cause of disability in the US and worldwide. Interventional treatments for lumbar disorders are an effective treatment for the pain and disability from low back pain. Although many established and emerging interventional procedures are currently available, there exists a need for a defined guideline for their appropriateness, effectiveness, and safety.

Objective

The ASPN Back Guideline was developed to provide clinicians the most comprehensive review of interventional treatments for lower back disorders. Clinicians should utilize the ASPN Back Guideline to evaluate the quality of the literature, safety, and efficacy of interventional treatments for lower back disorders.

Methods

The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations. Experts from the fields of Anesthesiology, Physiatry, Neurology, Neurosurgery, Radiology, and Pain Psychology developed the ASPN Back Guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Scopus, and meeting abstracts to identify and compile the evidence (per section) for back-related pain. Search words were selected based upon the section represented. Identified peer-reviewed literature was critiqued using United States Preventive Services Task Force (USPSTF) criteria and consensus points are presented.

Results

After a comprehensive review and analysis of the available evidence, the ASPN Back Guideline group was able to rate the literature and provide therapy grades to each of the most commonly available interventional treatments for low back pain.

Conclusion

The ASPN Back Guideline represents the first comprehensive analysis and grading of the existing and emerging interventional treatments available for low back pain. This will be a living document which will be periodically updated to the current standard of care based on the available evidence within peer-reviewed literature.

Management of Osteoporotic Vertebral Fracture: Review Update 2022

A vertebral fracture is the most common type of osteoporotic fracture. Osteoporotic vertebral fractures (OVFs) cause a variety of morbidities and deaths. There are currently few "gold standard treatments" outlined for the management of OVFs in terms of quantity and quality. Conservative treatment is the primary treatment option for OVFs. The treatment of pain includes short-term bed rest, analgesic medication, anti-osteoporotic medications, exercise, and a brace. Numerous reports have been made on studies for vertebral augmentation (VA), including vertebroplasty and kyphoplasty. There is still debate and controversy about the effectiveness of VA in comparison with conservative treatment. Until more robust data are available, current evidence does not support the routine use of VA for OVF. Despite the fact that the majority of OVFs heal without surgery, 15%-35% of patients with an unstable fracture, persistent intractable back pain, or severely collapsed vertebra that causes a neurologic deficit, kyphosis, or chronic pseudarthrosis frequently require surgery. Because no single approach can guarantee the best surgical outcomes, customized surgical techniques are required. Surgeons must stay current on developments in the osteoporotic spine field and be open to new treatment options. Osteoporosis management and prevention are critical to lowering the risk of future OVFs. Clinical studies on bisphosphonate's effects on fracture healing are lacking. Teriparatide was intermittently administered, which dramatically improved spinal fusion and fracture healing while lowering mortality risk. According to the available literature, there are no standard management methods for OVFs. More multimodal approaches, including conservative and surgical treatment, VA, and medications that treat osteoporosis and promote fracture healing, are required to improve the quality of the majority of guidelines.

Healthcare Disparities in Interventional Radiology

Racial, ethnic, and sex-based healthcare disparities have been documented for the past several decades. Nonetheless, disparities remain firmly entrenched in our care delivery systems, with multiple contributing factors, including patient interactions with care providers, systemic barriers to access, and socioeconomic determinants of health. Interventional radiology is also subject to these drivers of health inequity. In this review, documented disparities for the most common conditions being addressed by interventional radiologists are summarized; their magnitude is quantified where relevant, and underlying drivers are identified. Specific examples are provided to illustrate how medical, cultural, and socioeconomic factors interact to produce unequal outcomes. By outlining known disparities and common contributors, this review aims to motivate future efforts to mitigate them.

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.

Effect of cement distribution type on clinical outcome after percutaneous vertebroplasty for osteoporotic vertebral compression fractures in the aging population

Objective

The study aimed to investigate the effect of the type of bone cement distribution on clinical outcomes following percutaneous vertebroplasty (PVP) for osteoporotic vertebral compression fractures (OVCF) in the elderly.

Methods

Retrospective analysis of 160 patients diagnosed with OVCF who underwent PVP treatment from March 2018 to December 2020. Based on the kind of postoperative bone cement distribution, bone cement was classified as types I, II, III, IV, and V. Visual Analog Scale (VAS), Oswestry Disability Index (ODI), Cobb angle, anterior vertebral height ratio, refracture rate of injured vertebrae, and incidence of adjacent vertebral fractures were compared for the five types before and after three days, and one year of operation.

Results

VAS and ODI at three days and one year postoperative were significantly lower than those preoperative (P < 0.05) for all five distribution types. VAS and ODI for types I, II, and III were lower at one year postoperatively than for types IV and V (P < 0.05). There was no significant difference in Cobb angle and anterior vertebral body height ratio between preoperative and three days postoperative groups (P < 0.05); however, there were significant differences between three days and one-year postoperative and preoperative groups (P < 0.05). Following one year of surgery, the Cobb angle and the anterior vertebral height ratio of types IV and V were significantly different from those of types I, II, and III (P < 0.05), and there was a statistically significant difference between types IV and V (P < 0.05). In terms of the incidence of injured vertebral refractures and adjacent vertebral fractures, the evenly distributed types I, II, and III were significantly lower than the unevenly distributed types IV and V, and the incidence of type V was higher (P < 0.05).

Conclusions

The clinical efficacy of cement distribution following PVP of types I, II, and III is better than that of types IV and V, which can better relieve pain with long-lasting efficacy and minimize the occurrence of refractures of injured vertebrae and adjacent vertebral body fractures.

Is the incidence of sandwich vertebral fracture higher than that of ordinary adjacent vertebral fracture after PKP?

OBJECTIVE

To compare the incidence of fracture between sandwich vertebra and ordinary adjacent vertebra after percutaneous kyphoplasty (PKP).

METHOD

We analyzed 225 consecutive patients with osteoporotic vertebral compression fractures who underwent PKP between January 2016 and December 2020 at our medical institution. The sandwich vertebrae was located between 2 cement-augmented vertebra and was followed for at least 12 months. The clinical data of patients with sandwich vertebra and ordinary adjacent vertebra were recorded, and the incidence of postoperative fracture between sandwich vertebra and ordinary adjacent vertebra was compared.

RESULTS

The mean continuous follow-up time was 31.30 ± 18.04 months in patients with sandwich vertebra and 25.85 ± 7.96 months in patients with ordinary adjacent vertebra. It should be noted that the incidence of sandwich vertebral fractures was 10.00%, which was not statistically higher than 3.26% for ordinary adjacent vertebral fractures. However, a significant difference was observed in the cement volume of single vertebral body, procedure time, and bleeding.

CONCLUSION

Although the volume of cement in a single vertebral body is less and the procedure time and bleeding are more, the incidence of sandwich vertebral fracture is not higher than that of ordinary adjacent vertebral body.