Clinical and radiological subsequent fractures after vertebral augmentation for treating osteoporotic vertebral compression fractures: a meta-analysis

A Real-world Study of Denosumab For Reducing Refracture Risk after Percutaneous Vertebral Augmentation

OBJECTIVE

To investigate the use of anti-osteoporotic agents and refracture incidence in patients with osteoporotic vertebral compression fracture (OVCF) following percutaneous vertebral augmentation (PVA) and to evaluate the real-world treatment of patients using denosumab following PVA. This study aims to provide spine surgeons with empirical insights derived from real-world scenarios to enhance the management of bone health in OVCF patients.

METHODS

This retrospective cohort study was based on data from the MarketScan and Optum databases from the USA. Female patients aged 55-90 years who underwent PVA for OVCF between January 2013 and March 2020 were included and followed up from the day after surgery. Patients who received at least one dose of denosumab were included in the denosumab cohort and were further divided into the on-treatment and off-treatment groups according to whether they received a second dose of denosumab, with follow-up beginning on the index day (225 days after the first denosumab dose). In this study, the off-treatment group was considered as the control group. Refracture incidence after PVA, the proportion of patients using anti-osteoporotic agents in the total study population, and refracture incidence after the index day in the denosumab cohort were analyzed.

RESULTS

A total of 13,451 and 21,420 patients from the MarketScan and Optum databases, respectively, were included. In the denosumab cohort, the cumulative incidence of clinical osteoporotic fractures within 3 years after the index day was significantly lower in the on-treatment group than in the off-treatment group (MarketScan database: 23.0% vs 39.0%, p = 0.002; Optum database: 28.2% vs 40.0%, p = 0.023). The cumulative incidence of clinical vertebral fractures was also lower in the on-treatment group than in the off-treatment group, with a significant difference in the MarketScan database (14.4% vs 25.5%, p = 0.002) and a numerical difference was found in the Optum database (20.2% vs 27.5%, p = 0.084).The proportion of patients using anti-osteoporotic agents was low at 6 months postoperatively, with only approximately 7% using denosumab and 13%-15% taking oral bisphosphonates.

CONCLUSION

Postmenopausal women have a high refracture rate and a low proportion of anti-osteoporotic drug use after PVA. Continued denosumab treatment after PVA is associated with a lower risk of osteoporotic and clinical vertebral fractures. Therefore, denosumab may be a treatment option for patients with osteoporosis after PVA.

The Closer Vicinity to Treated Vertebrae in Percutaneous Vertebroplasty, the Higher Rate of New Vertebral Compression Fractures at Follow-up

OBJECTIVE

To investigate whether risk of new vertebral compression fractures (NVCFs) was associated with vicinity to treated vertebrae in percutaneous vertebroplasty (PVP) for osteoporotic vertebral compression fractures (OVCFs).

METHODS

All OVCF (T6-L5) patients treated with PVP between January 2016 and December 2020 were retrospectively reviewed. Vicinity to treated vertebrae was defined as the number of vertebrae between an untreated and its closest treated level. The closest treated level was chosen as reference vertebra. Clinical, radiologic, and surgical parameters were compared between groups of reference vertebrae for each vicinity NVCF.

RESULTS

In total, 1348 patients with 1592 fractured and 14,584 normal vertebrae were enrolled. NVCF was identified in 20.1% (271 of 1348) patients in 2.2% (319 of 14584) vertebrae in a mean follow-up time of 24.3 ± 11.9 months. Rate of NVCF in vicinity 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11 level were 4.6% (130 of 2808), 2.4% (62 of 2558), 1.8% (42 of 2365), 1.5% (31 of 2131), 1.3% (23 of 1739), 1.3% (17 of 1298), 0.8% (7 of 847), 0.9% (4 of 450), 0.8% (2 of 245), 0.9% (1 of 117), and 0% (0 of 26), respectively. Rate of NVCF in vicinity 1 level was significantly higher than that in vicinity 2, 3, 4, 5, 6, 7, 8, and 9 level, respectively. However, compared to reference vertebrae for vicinity 1 NVCF, any clinical, radiologic, or surgical parameters were not significantly different in those for vicinity 2, 3, and 4 NVCF, respectively.

CONCLUSIONS

The closer vicinity to treated vertebrae in PVP, the higher rate of NVCF at follow-up. However, any clinical, radiologic, or surgical parameters might not matter in this phenomenon of vicinity-related NVCF.

Vertebral compression fractures: pain relief, progression and new fracture rate comparing vertebral augmentation with brace

BACKGROUND

Osteoporotic vertebral compression fracture (VCF) is the third most frequent fragility fracture in the world. Conservative treatment, vertebroplasty, and kyphoplasty are all recognized therapies. However, diagnostic and therapeutic recommendations must be more consistent when comparing clinical guidelines. This study aims to compare the efficacy of vertebral augmentation therapy and conservative management for treating VCFs, the risk of subsequent complications, and the length of hospital stay.

METHOD

All patients over 50 years old with a diagnosis of thoracic or lumbar VCF without underlying oncological process, treated conservatively or surgically, and consecutively attended at our department from January 2017 to June 2021 were retrospectively selected for analysis. Patients who missed follow-up or died during the first three months were excluded.

RESULTS

A total of 573 cases were selected for analysis. Most patients were treated conservatively (85.3%). Both groups were homogenous regarding epidemiological and clinical features. The median time elapsed to achieve pain relief was significantly lower in the surgical cohort (4.5 vs. 10 weeks, p < 0.001), and the proportion of patients reporting pain at the first outpatient visit was also significantly lower with a vertebral augmentation procedure (p = 0.004). The new fracture rate and the adjacent level rate did not differ significantly when comparing both treatments, whereas the progression of the diagnosed fracture was more frequent in the conservative group (4.8% vs. 29.7%; p < 0.001). The median hospital stay was significantly lower in the conservative group (3 vs. 10 days; p < 0.001).

CONCLUSION

Surgical treatment (vertebroplasty/kyphoplasty) of VCFs was associated with sooner pain relief without an increased risk of new or adjacent fractures. Moreover, the progression of treated fractures was significantly lower in the surgical cohort. The only unfavorable aspect was the more extended hospital stay compared with the conservative treatment group.

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.

Percutaneous Kyphoplasty Versus Percutaneous Vertebroplasty for Neurologically Intact Osteoporotic Kümmell's Disease: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

Percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) are minimally invasive techniques widely used for the treatment of neurologically intact osteoporotic Kümmell's disease (KD), but which treatment is preferable remains controversial. Therefore, this study aimed to shed light on this issue.

METHODS

Six databases were searched for all relevant studies based on the PRISMA guidelines. Two investigators independently conducted a quality assessment, extracted the data and performed all statistical analyses.

RESULTS

Eight studies encompassing 438 neurologically intact osteoporotic KD patients met the inclusion criteria. Compared to PVP, PKP was associated with greater improvement in the short- and long-term Cobb angle [SMD = -0.37, P = 0.007; SMD = -0.34, P = 0.012], short-term anterior vertebral height [SMD = 0.43, P = 0.003] and long-term middle vertebral height [SMD = 0.57, P = 0.012] and a lower cement leakage rate [SMD = 0.50, P = 0.003] but produced more consumption (cement injection volume, operative time, fluoroscopy times, intraoperative blood loss and operation cost). However, there were no differences between the 2 procedures in the short- and long-term VAS and ODI scores, long-term anterior vertebral height, overall complications or new vertebral fractures.

CONCLUSIONS

Both procedures are equally effective for neurologically intact KD in terms of the clinical outcomes, with the exception of a lower cement leakage risk and better radiographic improvement for PKP but greater resource consumption. Based on the evidence available, good clinical judgment should be exercised in the selection of patients for these procedures.

Subsequent fractures after vertebroplasty in osteoporotic vertebral fractures: a meta-analysis

Percutaneous vertebroplasty (VP) provides substantial benefit to patients with painful osteoporotic vertebral compression fractures (OVCF). However, the reoccurrence of vertebral fracture after VP is a major concern. The purpose of this study is to conduct a meta-analysis on the incidence of subsequent fractures after VP in patients with OVCF. PubMed and EMBASE were searched. In addition, we scrutinized the reference list of all relevant articles to supplement the database search. We included original articles reporting on new fracture rates after VP in OVCF patients. Subsequent fracture rates were pooled across studies using a random-effects meta-analysis. Thirty-nine studies with a total of 8047 participants from 12 countries were included in this meta-analysis. Patients' age ranged from 64.2 to 94.6 years (reported by 31 studies). The median follow-up was 21 months (36 studies). Pooled estimate for subsequent fractures after VP was 23.4% (95% CI, 19.8-27.2%; I² = 93.0%, p < 0.01). New fractures after VP in 54.6% of cases occurred in the vertebral bodies adjacent to the treated vertebra (95% CI, 49.0-60.1%; I² = 66.0%, p < 0.01). A significant proportion of patients undergoing VP for OVCF experience new fractures after treatment, most of which are developed in the vertebral bodies adjacent to the treated vertebra.

Clinical correlation between osteoporotic thoracolumbar vertebral compression fractures and lumbar spondylolisthesis

PURPOSE

This study was to explore the clinical correlation between osteoporosis thoracolumbar vertebral compression fracture (thoracolumbar OVCF) and lumbar spondylolisthesis (LS).

METHODS

In total, 208 patients with thoracolumbar OVCF (fracture group) and 250 elderly patients with osteoporosis (non-fracture group) were retrospectively analyzed. The incidence of LS was compared between the two groups. At the same time, 75 cases of elderly patients with osteoporosis were selected, including 25 patients with isthmic spondylolisthesis (IS group), 25 patients with degenerative spondylolisthesis (DS group), and 25 patients without LS (non-LS group). All patients underwent full-length spine anteroposterior and lateral X-ray, and the spinal pelvic imaging parameters were collected for comparison.

RESULTS

The incidence of LS in the fracture group (10.1%, 21/208) was significantly higher than that in the non-fracture group (4.8%, 12/250); the difference was statistically significant (χ² = 4.763, P = 0.029). The incidence of trauma in the fracture group (51.0%, 106/208) was significantly higher than that in the non-fracture group (13.6%, 34/250); the difference was statistically significant (χ² = 74.673, P = 0.000). The LS (OR = 2.273, 95% CI = 1.030-5.017, P = 0.042) and trauma (OR = 6.622, 95% CI = 4.203-10.432, P = 0.000) were independently associated with thoracolumbar OVCF. There were significant differences in pelvic incidence (PI), sacral slope (SS), lumbar lordosis (LL), thoracolumbar kyphosis (TLK), and thoracic kyphosis (TK) among the IS, DS, and non-LS groups (P < 0.05). Among them, PI, SS, LL, TLK, and TK of the IS group and the DS group were significantly higher than those of the non-LS group (P < 0.05).

CONCLUSIONS

Patients with LS are more likely to suffer from OVCF in the future, and LS is one of the important risk factors for secondary OVCF.