Risk Factors for Recollapse of the Augmented Vertebrae After Percutaneous Vertebral Augmentation: A Systematic Review and Meta-Analysis

Establishing a nomogram to predict refracture after percutaneous kyphoplasty by logistic regression

Introduction

Several studies have examined the risk factors for post-percutaneous kyphoplasty (PKP) refractures and developed many clinical prognostic models. However, no prior research exists using the Random Forest (RF) model, a favored tool for model development, to predict the occurrence of new vertebral compression fractures (NVCFs). Therefore, this study aimed to investigate the risk factors for the occurrence of post-PKP fractures, compare the predictive performance of logistic regression and RF models in forecasting post-PKP fractures, and visualize the logistic regression model.

Methods

We collected clinical data from 349 patients who underwent PKP treatment at our institution from January 2018 to December 2021. Lasso regression was employed to select risk factors associated with the occurrence of NVCFs. Subsequently, logistic regression and RF models were established, and their predictive capabilities were compared. Finally, a nomogram was created.

Results

The variables selected using Lasso regression, including bone density, cement distribution, vertebral fracture location, preoperative vertebral height, and vertebral height restoration rate, were included in both the logistic regression and RF models. The area under the curves of the logistic regression and RF models were 0.868 and 0.786, respectively, in the training set and 0.786 and 0.599, respectively, in the validation set. Furthermore, the calibration curve of the logistic regression model also outperformed that of the RF model.

Conclusion

The logistic regression model provided better predictive capabilities for identifying patients at risk for post-PKP vertebral fractures than the RF model.

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.

Vertebral compression fractures managed with brace: risk factors for progression

PURPOSE

The aim of this study is to identify risk factors for vertebral compression fracture (VCF) progression in patients treated conservatively with a brace. Then, a case-control study was designed.

METHODS

All patients over 50 years old with diagnosis of thoracic or lumbar VCF (T5 to L5) in absence of underlying oncological process, treated conservatively with brace, and consecutively attended at our department from January 2017 to June 2021 were retrospectively selected for analysis. Patients missed for follow-up or dead during the first 3 months of follow-up were excluded.

RESULTS

Five hundred and eighty-two consecutive patients were recorded. Incomplete follow-up excluded 74 patients and other 19 died in the first three months after diagnosis, so 489 cases were finally analyzed. Median follow-up was 21 (IQR 13;30) weeks. Increased collapse of the vertebral body was found in 29.9% of VCFs with a median time to progression of 9 (IQR 7;13) weeks. Male gender (OR 1.6), type A3 fracture of the AOSpine classification (OR 2.7), thoracolumbar junction location (OR 1.7), and incorrect use of the brace (OR 3.5) were identified as independent risk factors for progression after multivariable analysis.

CONCLUSION

Male gender, type A3 fracture of the AOSpine classification, thoracolumbar junction location, and incorrect use of the brace were identified as independent risk factors for VCF progression, which resulted in worse pain control, when treated with brace. Thus, other treatments such as percutaneous vertebral augmentation could be considered to avoid progression in selected cases, since collapse rate has been demonstrated lower with these procedures.

Therapeutic Efficacy and Safety of Percutaneous Curved Vertebroplasty in Osteoporotic Vertebral Compression Fractures: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis is aimed to provide higher quality evidence regarding the efficacy and safety between PCVP and PVP/KP in OVCFs. We searched the Cochrane Library, PubMed, Web of Science, and Embase databases for all randomized controlled trials (RCTs) and observational studies (cohort or case-control studies) that compare PCVP to PVP/KP for OVCFs. The Cochrane Collaboration's Risk of Bias Tool and Newcastle-Ottawa Scale (NOS) were used to evaluate the quality of the RCTs and non-RCTs, respectively. Meta-analysis was performed using RevMan 5.4 software. A total of seven articles consisting of 562 patients with 593 diseased vertebral bodies were included. Statistically significant differences were found in the postoperative visual analog scale (VAS) at 1 day (MD = -0.11; 95% CI: [-0.21 to -0.01], p = 0.03), but not at 3 months (MD = -0.21; 95% CI: [-0.41-0.00], p = 0.05) or 6 months (MD = 0.03; 95% CI: [-0.13-0.20], p = 0.70). There was no statistically significant difference in postoperative Oswestry disability index (ODI) at 1 day (MD = -0.28; 95% CI: [-0.62-0.05], p = 0.10), 3 months (MD = -1.52; 95% CI: [-3.11-0.07], p = 0.06), or 6 months (MD = 0.18; 95% CI: [-0.13-0.48], p = 0.25). Additionally, there were no statistically significant differences in Cobb angle (MD = 0.30; 95% CI: [-1.69-2.30], p = 0.77) or anterior vertebral body height (SMD = -0.01; 95% CI: [-0.26-0.23], p = 0.92) after surgery. Statistically significant differences were found in surgical time (MD = -8.60; 95% CI: [-13.75 to -3.45], p = 0.001), cement infusion volume (MD = -0.82; 95% CI: [-1.50 to -0.14], P = 0.02), and dose of fluoroscopy (SMD = -1.22; 95% CI: [-1.84 to -0.60], p = 0.0001) between curved and noncurved techniques, especially compared to bilateral PVP. Moreover, cement leakage showed statistically significant difference (OR = 0.40; 95% CI: [0.27-0.60], p < 0.0001). Compared with PVP/KP, PCVP is superior for pain relief at short-term follow-up. Additionally, PCVP has the advantages of significantly lower surgical time, radiation exposure, bone cement infusion volume, and cement leakage incidence compared to bilateral PVP, while no statistically significant difference is found when compared with unilateral PVP or PKP. In terms of quality of life and radiologic outcomes, the effects of PCVP and PVP/KP are not significantly different. Overall, this meta-analysis reveals that PCVP was an effective and safe therapy for patients with OVCFs.

A nomogram for predicting the risk of new vertebral compression fracture after percutaneous kyphoplasty

BACKGROUND

New vertebral compression fractures (NVCFs) are common adverse events in percutaneous kyphoplasty (PKP). The present study aimed to investigate the risk factors for NVCFs in patients after PKP and to construct a nomogram for the prediction of the risk of re-fracture.

METHODS

We retrospectively analyzed the medical records of patients after PKP surgery between January 2017 and December 2020. Patients were divided into an NVCF group (n = 225) and a control group (n = 94) based on the presence or absence of NVCFs, respectively, at follow-up within 2 years after surgery. Lasso regression was used to screen for risk factors for re-fracture. Based on the results, a Lasso-logistic regression model was developed, and its prediction performance was evaluated using receiver operating characteristic curves, calibration, and decision curve analysis. The model was visualized, and a nomogram was constructed.

RESULTS

A total of eight potential predictors were obtained from Lasso screening. Advanced age, low body mass index, low bone mineral density, lack of anti-osteoporosis treatment, low preoperative vertebral body height, vertebral body height recovery ≥ 2, cement leakage, and shape D (lack of simultaneous contact of bone cement with the upper and lower plates) were included in the logistic regression model.

CONCLUSIONS

A nomogram for predicting postoperative NVCF in PKP was developed and validated. This model can be used for rational assessment of the magnitude of the risk of developing NVCFs after PKP, and can help orthopedic surgeons make clinical decisions aimed at reducing the occurrence of NVCFs.

Comparison of unilateral and bilateral percutaneous kyphoplasty for the treatment of osteoporotic vertebral compression fractures associated with scoliosis

To assess the clinical and radiographic effectiveness of unilateral and bilateral percutaneous kyphoplasty (PKP) in the treatment of osteoporotic vertebral compression fractures (OVCF) associated with scoliosis, 52 patients with OVCF associated with scoliosis who underwent PKP were retrospectively analysed. The patients were divided into the unilateral PKP group (n=26) and the bilateral PKP group (n=26). The operation time, bone cement injection volume and frequency of intraoperative fluoroscopy were recorded and compared between the groups. Additionally, visual analogue scale (VAS) and Oswestry disability index (ODI) scores, as well as postoperative complications, including bone cement leakage and adjacent vertebral fractures, were also assessed. The operation time, bone cement injection volume and intraoperative fluoroscopy frequency were significantly lower in the unilateral compared with the bilateral group (P<0.001). The VAS score, ODI score, average vertebral body height and kyphotic angle (KA) were improved after surgery in each group with no difference in these clinical parameters between the two groups both before and after surgery. Furthermore, the proportion of cases with bone cement leakage in the unilateral group was significantly lower compared with that in the bilateral group (P<0.05). During the follow-up, there were three cases (11.5%) in the unilateral group and two cases (7.7%) in the bilateral group who suffered adjacent vertebral fractures, but there was no statistically significant difference between the two groups (P>0.05). For treating patients with OVCF accompanied by scoliosis, both unilateral and bilateral PKP could effectively relieve the acute back pain and correct the KA. However, unilateral PKP presents more advantages, such as a short operation duration and reduced intraoperative fluoroscopy frequency and bone cement leakage.

Effect of different bone cement distributions in percutaneous kyphoplasty on clinical outcomes for osteoporotic vertebral compression fractures: A retrospective study

Osteoporotic fractures and their complications are becoming increasingly harmful to the elderly. This study aimed to evaluate the clinical results of connected or unconnected bilateral cement after bilateral percutaneous kyphoplasty (PKP) in patients with osteoporotic vertebral compression fractures (OVCF). The clinical data of 217 patients with single-segment OVCF were retrospectively collected. Patients were allocated into 2 groups according to the bilateral bone cement in the vertebrae was connected or unconnected after surgery. The surgery-related indexes of the 2 groups were compared, including operation time; bone cement injection volume; contact situation between bone cement and the upper and lower endplates of the vertebral body; visual analogue scale (VAS) scores before surgery, 1 week and 1 year after surgery; Oswestry disability index (ODI) before surgery, 1 week and 1 year after surgery; local kyphosis angle (LKA) before surgery, 1 week and 1 year after surgery; postoperative vertebral body height at 1 week and 1 year after surgery; vertebral body height restoration rate (HRR) at 1 week and 1 year after surgery. The follow-up results of all patients were recorded. The postoperative VAS, ODI, vertebral body height, LKA and other indexes of the 2 groups were significantly improved compared with those before the operation (P < .05), and there was no significant difference between the 2 groups (P > .05). At the same time, there were no significant difference in vertebral body HRR and bone cement leakage rate between the 2 groups (P > .05). X-ray examination showed that 21 of 217 patients (21/217, 9.8%) had a refracture of the injured vertebral body, including 16 cases (16/121, 13.2%) in the unconnected group and 5 cases (5/96, 5.2%) in the connected group (P < .05). Adjacent vertebrae fractures occurred in 25 cases (25/217, 11.5%), while 19 cases (19/121, 15.7%) were in the unconnected group and 6 cases (6/96, 6.3%) were in the connected group (P < .05). PKP has a good therapeutic effect on OVCF no matter whether the bilateral bone cement is connected or not. However, if the bilateral cement inside the vertebra was connected, the risk of recollapse of the injured vertebrae and the new fracture of adjacent vertebrae could be reduced.

Correlation analysis of larger side bone cement volume/vertebral body volume ratio with adjacent vertebral compression fractures during vertebroplasty

OBJECTIVE

To investigate the correlation analysis of larger side bone cement volume/vertebral body volume ratio (LSBCV/VBV%) with adjacent vertebral compression fracture (AVCF) in percutaneous vertebroplasty (PVP) for osteoporotic vertebral compression fracture (OVCF).

METHODS

A retrospective analysis of 245 OVCF patients who underwent PVP treatment from February 2017 to February 2021, including 85 males and 160 females. The age ranged from 60 to 92 years, with a mean of (70.72 ± 7.03) years. According to whether AVCF occurred after surgery, they were divided into 38 cases in the AVCF group (fracture group) and 207 cases in the no AVCF group (non-fracture group). The correlation between gender, age, bone mineral density (BMD), body mass index (BMI), thoracolumbar segment fracture, bone cement disc leakage, LSBCV, bone cement volume (BCV), VBV, LSBCV/VBV ratio (LSBCV/VBV%), and BCV/VBV% and AVCF were analyzed in both groups. Risk factors for AVCF after PVP were analyzed by multifactorial logistic regression, and then the receiver operating characteristic curves (ROC curves) were plotted to identify the critical value of LSBCV/VBV%.

RESULTS

38 patients (15.5%) developed AVCF postoperatively. Univariate analysis showed that BMD, bone cement disc leakage, LSBCV, and LSBCV/VBV% were risk factors for AVCF after PVP (P<0.05), while gender, age, BMI, thoracolumbar segment fracture, BCV, VBV, and BCV/VBV% were not significantly different in both groups (P>0.05). Multifactorial logistic regression analysis revealed that BMD, bone cement disc leakage, and LSBCV/VBV% were independent risk factors for AVCF after PVP (P<0.05). According to the ROC curve, the LSBCV/VBV% had an area under the curve of 71.6%, a sensitivity and specificity of 89.5% and 51.7%, respectively, and a critical value of 13.82%.

CONCLUSION

BMD, bone cement disc leakage and LSBCV/VBV% are independent risk factors for AVCF after PVP. With LSBCV/VBV at 13.82%, the incidence of AVCF significantly increased.

Biomechanical CT-computed bone strength predicts the risk of subsequent vertebral fracture

Following primary fractures and percutaneous kyphoplasty (PKP), patients have a high risk of incurring a subsequent vertebral fracture (SVF). Given that SVF is a consequence of mechanical deterioration of the vertebra, we sought to examine whether vertebral strength derived from QCT-based finite element analysis (i.e., BCT) can predict the risk of SVF. Sixty-six patients who underwent PKP were categorized into two groups: control or non-SVF group (age: 70 ± 7 years; n = 40) and SVF group (age: 69 ± 8 years; n = 26). BCT was performed on L4 or L3 vertebrae to noninvasively measure vertebral strength. Vertebral strength was also estimated based upon the geometry and material properties of the vertebra. Additionally, trabecular volumetric bone mineral density (vBMD) and L1 Hounsfield unit (HU) were measured. t-Test, χ² test or Mann Whitney U test were used to compare differences in these parameters between the two groups. The predictive abilities of BCT strength and other measured parameters were evaluated using the receiver operating characteristic (ROC) analysis. Results showed no significant difference in either vBMD or L1 HU between the control and SVF groups (p > 0.05), whereas BCT-computed and estimated vertebral strength values were significantly reduced by 33 % and 24 % for the SVF group relative to the non-SVF group, respectively. ROC curve indicated that BCT strength had the largest area under the curve, compared to other parameters. These results suggest that BCT-computed vertebral strength may serve as a surrogate for assessing risk of SVF.

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.

The effects of biomechanical factors on adjacent vertebral compression fractures after percutaneous kyphoplasty: a propensity score matching analysis

Adjacent vertebral compression fracture (AVCF) is the primary factor affecting satisfaction after PKP surgery. In addition to osteoporosis, certain structural characteristics of the vertebral body itself also increase their risk. The purpose of this study was to explore the impact of biomechanical changes on AVCF after balancing other factors.

INTRODUCTION

As a routine treatment of OVCF, the postoperative refracture of PKP is a serious problem. The aim of our study was to explore the impact of lumbar biomechanical changes on the risk of AVCF. A propensity score matching was performed to balance the interference of osteoporosis, which is the primary risk factor of AVCF.

METHODS

A retrospective, single-center case-control study was performed. From September 2013 to March 2020, 1752 patients were enrolled, and AVCF was assessed in 80 of these patients. A propensity score matching (PSM) analysis was performed, and 5 potential confounding factors were matched (age, BMI, number of fractured vertebral bodies, fracture region, and HDL). The preoperative and postoperative radiological factors were measured in the matched cohort of 48 pairs. A conditional logistic regression analysis to adjust the comparative risks.

RESULTS

The preoperative wedge angle and its postoperative recovery of the AVCF group were significantly higher than that of the non-AVCF group. The local kyphosis of the fractured vertebral body between the two groups was similar, but the recovery in the AVCF group was slightly higher than that in the non-AVCF group. The preoperative and postoperative relative anterior height (RAH) of the fractured vertebral body was familiar in two groups, so was the recovery of RAH. The preoperative spino-sacral angle (SSA) was significantly higher in the AVCF group than in the non-AVCF group. The preoperative wedge angle was identified as the only significant risk factor for AVCF in the multivariate analysis.

CONCLUSION

In conclusion, a larger preoperative fracture vertebral wedge angle is a risk factor for AVCF. For such high-risk patients, surgeons should be cautious about surgical decisions. The postoperative active measures and tailored surveillance should be attached to great importance as well.

A Three-Dimensional Cement Quantification Method for Decision Prediction of Vertebral Recompression after Vertebroplasty

Objective

Proposing parameters to quantify cement distribution and increasing accuracy for decision prediction of vertebroplasty postoperative complication.

Methods

Finite element analysis was used to biomechanically assess vertebral mechanics (n = 51) after percutaneous vertebroplasty (PVP) or kyphoplasty (PKP). The vertebral space was divided into 27 portions. The numbers of cement occupied portions and numbers of cement-endplate contact portions were defined as overall distribution number (oDN) and overall endplate contact number (oEP), respectively. And cement distribution was parametrized by oDN and oEP. The determination coefficients of vertebral mechanics and parameters (R 2) can validate the correlation of proposed parameters with vertebral mechanics.

Results

oDN and oEP were mainly correlated with failure load (R 2 = 0.729) and stiffness (R 2 = 0.684), respectively. oDN, oEP, failure load, and stiffness had obvious difference between the PVP group and the PKP group (P < 0.05). The regional endplate contact number in the front column is most correlated with vertebral stiffness (R 2 = 0.59) among all regional parameters. Cement volume and volume fraction are not dominant factors of vertebral augmentation, and they are not suitable for postoperative fracture risk prediction.

Conclusions

Proposed parameters with high correlation on vertebral mechanics are promising for clinical utility. The oDN and oEP can strongly affect augmented vertebral mechanics thus is suitable for postoperative fracture risk prediction. The parameters are beneficial for decision-making process of revision surgery necessity. Parametrized methods are also favorable for surgeon's preoperative planning. The methods can be inspirational for clinical image recognition development and auxiliary diagnosis.

Establishment and Validation of a Nomogram for the Risk of New Vertebral Compression Fractures After Percutaneous Vertebroplasty in Patients With Osteoporotic Vertebral Compression Fractures: A Retrospective Study

Purpose

New vertebral compression fractures(NVCFs) after minimally invasive surgery in patients with osteoporotic vertebral compression fracture (OVCF) is a challenging issue worldwide. Predicting the occurrence of NVCFs is key to addressing such questions. Therefore, we aimed to investigate the risk factors for patients who developed NVCFs after undergoing surgical treatment and establish a nomogram model to reduce the occurrence of NVCFs.

Methods

This study is a retrospective analysis that collected the general characteristics and surgical features of patients who underwent surgical treatment at 2 central institutions between January 2017 and December 2020. Patients were divided into training and testing sets based on the presence or absence of NVCFs. Independent risk factors for NVCFs were obtained in the training set of patients, and then a nomogram model was constructed. Internal and external validation of the nomogram model was performed using the consistency index (C index), receiver operating characteristic curve(ROC), calibration curves, and decision curve analysis (DCA).

Results

A total of 562 patients were included in this study. Patients from the first center were used for nomogram construction and internal validation, and patients from the second center were used as an external validation population. Multivariate regression analysis showed that age, Hounsfield unit (Hu) value, cement leakage, and thoracolumbar (TL) junction fracture were independent risk factors for NVCFs after minimally invasive surgery. The C index was .85, and the validation of internal and external validation shows that the predicted values of the established model is in good agreement with the actual values.

Conclusions

In this study, 4 independent risk factors were obtained by regression analysis, and a nomogram model was constructed to guide clinical work. The application of this model can help surgeons to make more accurate judgments to prevent the occurrence of NVCFs.

Can facet joint block be a complementary or alternative therapeutic option for patients with osteoporotic vertebral fractures: a meta-analysis

Background

Recently facet joint block has been increasingly used to relief the residual pain after vertebral augmentation, but whether it can be a complementary or alternative to vertebral augmentation remain largely unknown. Thus, we conducted this meta-analysis to determine the effect of facet joint block in the treatment of osteoporotic vertebral compression fractures (OVCF).

Methods

Following PRISMA statement, a comprehensive literature search through Embase, PubMed, Web of Science, Wanfang Data, China National Knowledge Infrastructure and Chinese BioMedical Literature Database was performed to identify relevant studies. Studies comparing vertebral augmentation combined with facet joint block (combined therapy) with vertebral augmentation, and studies comparing facet joint block with vertebral augmentation were analyzed, respectively.

Results

A total of 10 studies were included. There were seven studies comparing combined therapy with vertebral augmentation, the results showed combined therapy was associated with significantly lower visual analog scale (VAS) scores on postoperative day 1, 7, month 1, 3, and lower oswestry disability index (ODI) scores on postoperative day 1, 7, and month 3. There were three studies comparing facet joint block with vertebral augmentation, the results demonstrated vertebral augmentation only provided better analgesia in month 1 after surgery, but it was associated with a higher incidence of refracture.

Conclusions

Current evidence suggested facet joint block might be considered as a complementary to vertebral augmentation in the treatment of OVCF, but it might not be effectively used as an alternative therapy.

Analysis of risk factors related to the re-fracture of adjacent vertebral body after PKP

BACKGROUND

This study aims to investigate the risk factors of vertebral re-fracture after percutaneous kyphoplasty (PKP) for osteoporosis vertebral compression fracture (OVCF), and to provide reference for clinical prevention.

MATERIAL AND METHODS

A retrospective analysis was performed on 228 OVCF patients admitted on November 6, 2013, solstice, December 14, 2018, which met the inclusion criteria. There were 35 males and 193 females, with a male-to-female ratio of 3:20, and an age of 61-89 years. All patients were treated with PKP surgery with complete clinical data, and the rate of re-fracture was calculated according to whether re-fracture occurred after surgery, divided into the re-fracture group (24 cases) and the non-refracture group (204 cases). May be associated with subsequent fracture factors (gender, age, number of surgical segment vertebral body, whether with degenerative scoliosis, whether to fight osteoporosis) into a single-factor research, then the single-factor analysis was statistically significant risk factors for multiple logistic regression analysis, further defined after PKP holds the vertebral body fracture independent risk factors. Survival analysis was performed using the time of vertebral re-fracture after PKP as the end time of follow-up, the occurrence of re-fracture after PKP as the endpoint event, and the presence or absence of degenerative lateral curvature as a variable factor.

RESULTS

All 228 vertebroplasty patients were followed up for a period of 1.8 to 63.6 months. The mean follow-up time was (28.8 ± 15.6) months, and the re-fracture rate was 10.5%. There were statistically significant differences between the re-fracture group and the non-refracture group in age, number of operative vertebral bodies, whether there was a combination of degenerative scoliosis and whether there was anti-osteoporosis treatment (P < 0.05). The results of univariate logistic regression analysis after excluding the mutual influence of various factors showed that the number of vertebral bodies and the group with lateral curvature might be the risk factors for PKP re-fracture after surgery. The above possible risk factors were included in multiple logistic regression analysis to show whether there were independent risk factors for scoliosis and vertebral re-fracture. Survival analysis showed that the mean survival time was 42.1 months, the P value was 0.00, and the mean 95% confidence interval was (34.4-49.7 months), indicating that the combination of degenerative lateral bending might be related to the occurrence of re-fracture.

CONCLUSIONS

Combined scoliosis is an independent risk factor for re-fracture after OVCF laminoplasty and a possible risk factor for re-fracture after surgery.

Does prophylactic vertebral augmentation reduce the refracture rate in osteoporotic vertebral fracture patients: a meta-analysis

PURPOSE

In order to prevent the recurrent fracture after vertebral augmentation, the concept of prophylactic vertebral augmentation has been proposed, but its efficacy is still controversial. This study aimed to determine the efficacy of prophylactic vertebral augmentation for prevention of refracture in osteoporotic vertebral fracture patients.

METHODS

Following PRISMA guidelines, a literature search was performed using PubMed, Embase and Web of Science databases for relevant studies published until February 2021. A meta-analysis of randomized controlled trials and retrospective controlled trials comparing prophylactic group versus nonprophylactic group was conducted. The primary outcome was the incidence of new vertebral compression fracture (VCF), and secondary outcomes were incidence of adjacent vertebral fracture (AVF) and remote vertebral fracture (RVF).

RESULTS

A total of 6 studies encompassing 618 patients were included in the meta-analysis. The incidence of new VCF was reported in all six studies, and the result showed no significant difference between the two groups (OR: 0.509; 95% CI: 0.184-1.409). Four studies provided data on the incidence of AVF, and it was revealed that there was no significant difference between the two groups (OR: 0.689; 95% CI: 0.109-4.371). In view of the incidence of RVF, prophylactic group also did not differ significantly compared with nonprophylactic group (OR: 0.535; 95% CI: 0.167-1.709).

CONCLUSIONS

The current evidence suggested that prophylactic vertebral augmentation might not be appropriate to diminish the risk of new VCF. Therefore, there is a need to investigate the mechanism of refracture and explore other preventive regimens to reduce the risk.

Risk of New Fractures in Vertebroplasty for Multiple Myeloma. A Retrospective Study

OBJECTIVE

Vertebroplasty is a percutaneous minimally invasive procedure indicated for vertebral collapse pain treatment. Among the known complications of the procedure is the augmented risk of new vertebral fractures. There are no specific studies in this patient population describing the risk of new vertebral fractures after vertebroplasty. This study analyzed risk factors associated with new vertebral fractures after vertebroplasty in patients with multiple myeloma.

METHODS

Observational retrospective study in patients with multiple myeloma. The data collection took place from January 1, 2010, to December 30, 2017, at the National Cancer Institute. Clinical data and procedural variables such as cement volume, cement leaks, fracture level, number of treated vertebrae, pedicular disease, and cement distribution pattern, with two years follow-up, were analyzed with the Wilcoxon test, and a logistic regression model was used to identify risk factors related to new vertebral fractures. A confidence interval of 95% was used for analysis.

RESULTS

At one-year follow-up, 30% of fractures were reported after vertebroplasty, most of them at low thoracic and lumbar level (50% adjacent level). Vertebroplasty was most commonly performed at the thoracolumbar and lumbar area. We demonstrated a 70.7% median numerical rating scale reduction at one-year follow-up; a significant decrease in opioid consumption occurred only during the first month.

CONCLUSIONS

Pedicle involvement, disc leakage, cement volume, thoracolumbar and lumbar level, and number of treated vertebrae by intervention are important risk factors when performing vertebroplasty. Prospective randomized studies are needed to evaluate these factors in this specific population.

Predictive risk factors for recollapse of cemented vertebrae after percutaneous vertebroplasty: A meta-analysis

BACKGROUND

As one of the most common complications of osteoporosis, osteoporotic vertebral compression fracture (OVCF) increases the risk of disability and mortality in elderly patients. Percutaneous vertebroplasty (PVP) is considered to be an effective, safe, and minimally invasive treatment for OVCFs. The recollapse of cemented vertebrae is one of the serious complications of PVP. However, the risk factors associated with recollapse after PVP remain controversial.

AIM

To identify risk factors for the recollapse of cemented vertebrae after PVP in patients with OVCFs.

METHODS

A systematic search in EMBASE, MEDLINE, the Cochrane Library, and PubMed was conducted for relevant studies from inception until March 2020. Studies investigating risk factors for the recollapse of cemented vertebrae after PVP without additional trauma were selected for analysis. Odds ratios (ORs) or standardized mean differences with 95% confidence interval (CI) were calculated and heterogeneity was assessed by both the chi-squared test and the I-squared test. The methodological quality of the included studies was assessed according to the Newcastle-Ottawa Scale.

RESULTS

A total of nine case-control studies were included in our meta-analysis comprising 300 cases and 2674 controls. The significant risk factors for the recollapse of cemented vertebrae after PVP in OVCF patients were fractures located at the thoracolumbar junction (OR = 2.09; 95%CI: 1.30 to 3.38; P = 0.002), preoperative intravertebral cleft (OR = 2.97; 95%CI: 1.93 to 4.57; P < 0.00001), and solid lump distribution pattern of the cement (OR = 3.11; 95%CI: 1.91 to 5.07; P < 0.00001). The analysis did not support that age, gender, lumbar bone mineral density, preoperative visual analogue scale score, injected cement volume, intradiscal cement leakage, or vertebral height restoration could increase the risk for cemented vertebra recollapse after PVP in OVCFs.

CONCLUSION

This meta-analysis suggests that thoracolumbar junction fractures, preoperative intravertebral cleft, and solid lump cement distribution pattern are associated with the recollapse of cemented vertebrae after PVP in OVCF patients.

Current Concepts in the Management of Osteoporotic Vertebral Fractures: A Narrative Review

Vertebral fractures are the most common type of osteoporotic fracture and can increase morbidity and mortality. To date, the guidelines for managing osteoporotic vertebral fractures (OVFs) are limited in quantity and quality, and there is no gold standard treatment for these fractures. Conservative treatment is considered the primary treatment option for OVFs and includes pain relief through shortterm bed rest, analgesics, antiosteoporotic drugs, exercise, and braces. Studies on vertebral augmentation (VA) including vertebroplasty and kyphoplasty have been widely reported, but there is still debate and controversy regarding the effectiveness of VA when compared with conservative treatment, and the routine use of VA for OVF is not supported by current evidence. Although most OVFs heal well, approximately 15%-35% of patients with unstable fractures, chronic intractable back pain, severely collapsed vertebra (leading to neurological deficits and kyphosis), or chronic pseudarthrosis frequently require surgery. Given that there is no single technique for optimizing surgical outcomes in OVFs, tailored surgical techniques are needed. Surgeons need to pay attention to advances in osteoporotic spinal surgery and should be open to novel thoughts and techniques. Prevention and management of osteoporosis is the key element in reducing the risk of subsequent OVFs. Bisphosphonates and teriparatide are mainstay drugs for improving fracture healing in OVF. The effects of bisphosphonates on fracture healing have not been clinically evaluated. The intermittent administration of teriparatide significantly enhanced spinal fusion and fracture healing and reduced mortality risk. Based on the current literature, there is still a lack of standard management strategies for OVF. There is a need for greater efforts through multimodal approaches including conservative treatment, surgery, osteoporosis treatment, and drugs that promote fracture healing to improve the quality of the guidelines.

Application of Titanium Alloy 3D-Printed Artificial Vertebral Body for Stage III Kümmell's Disease Complicated by Neurological Deficits

Purpose

The current study aimed to compare the clinical and radiographic results of the 3D-printed artificial vertebral body (3DP-AVB) and titanium mesh cage (TMC) for the treatment of Kümmell’s disease (KD) complicated by neurological deficits.

Patients and Methods

From January 2014 to July 2018, 28 consecutive patients diagnosed with KD and nerve injuries in our department were treated by posterior vertebral column resection and internal fixation. The patients were divided into two groups (3DP-AVB group and TMC group) based on the different anterior column reconstruction implants. Clinical and radiographic parameters were used to evaluate the outcomes.

Results

The two groups achieved excellent clinical and radiographic results 1 month after surgery with no significant difference (P>0.05), while 3DP-AVB group showed better outcomes compared with TMC group during the follow-up after 6 months (P<0.05). The risk of subsidence in 3DP-AVB group was lower than that in TMC group (41.6% vs 87.5%, P<0.05), and severe subsidence (≥5 mm) was correlated with the recurrence of back pain and bad daily life function. No significant difference was found in the improvement of neurological function between the two groups (P>0.05). The blood loss and operation time in 3DP-AVB group were significantly less than both in TMC group (P<0.05).

Conclusion

The lower incidence of cage subsidence, with a better long-term efficacy in maintaining the height of the fused segment, relieving back pain, and improving daily life function indicates that the 3DP-AVB may be a superior alternative for KD with neurological deficits.

Creation of a planned or central-clefted puncture combined with a second puncture during vertebroplasty to treat osteoporotic vertebral compression fractures with large clefts

BACKGROUND

Cemented vertebrae frequently re-fracture after vertebroplasty to treat osteoporotic vertebral compression fractures (OVCFs) with large clefts. We compared the efficacy of planned and central-clefted puncture, both followed by a second puncture, as treatments for OVCFs with large clefts.

METHODS

We retrospectively studied 38 patients. 18 of whom underwent planned puncture (group A) and 20 central-clefted puncture (group B). A second puncture was performed when the initially injected cement was restricted to the cleft. We recorded a visual analog scale (VAS) pain scores, vertebral kyphotic angles (KAs), and compression ratios (CRs) preoperatively and at 2 days and 6 months postoperatively. We recorded the cement dispersion patterns and complications.

RESULTS

Second punctures succeeded in 15/18 and 7/20 patients of groups A and B, respectively. At 2 days postoperatively, the VAS score, KA, and CR were significantly better than the preoperative values (P < 0.01); no significant difference was found between the two groups (P > 0.05). At the 6-month follow-up, all scores were poorer than at 2 days postoperatively (all P < 0.05), significantly more so in group B than group A (P < 0.05). Significant differences in terms of the cement dispersion patterns, and the cemented vertebral re-fracture and cement leakage rates, were observed between the two groups (all P < 0.05).

CONCLUSION

The two-puncture techniques were initially effective when treating large-clefted OVCFs. However, compared to the central-clefted puncture, the planned puncture improved the success rate of the second puncture, allowed better cement dispersion, and reduced the incidence of vertebral re-fracture during follow-up.

Risk factors of cemented vertebral refracture after percutaneous vertebral augmentation: a systematic review and meta-analysis

To evaluate the risk factors of cemented vertebral refracture after percutaneous vertebral augmentation (PVA) for patients with osteoporotic vertebral compression fractures (OVCFs). We performed a literature search on cemented vertebral refracture after PVA using the PubMed, EMBASE, and Cochrane Library medical databases. The clinical data, including literature information, basic patient information, observational factors, and interventional factors, were extracted by two authors. The pooled results and related heterogeneity of each factor between the refracture group and the non-refracture group were evaluated using Review Manager software 5.35. A total of 3185 patients from 10 studies were included, with 195 patients in the refracture group and 2990 patients in the non-refracture group. The mean follow-up duration was 18.9 months. According to the meta-analysis, age, low bone marrow density (BMD), intravertebral cleft (IVC), high anterior vertebral height (AVH) restoration/high Cobb angle restoration, and low cement dose were the risk factors of cemented vertebral refracture after PVA. Our results showed that age, low BMD, IVC, high AVH restoration, high Cobb angle restoration, and low cement dose were the risk factors for cemented vertebral refracture after PVA.

Prophylactic Percutaneous Kyphoplasty Treatment for Nonfractured Vertebral Bodies in Thoracolumbar for Osteoporotic Patients

Purpose

The occurrence of new vertebral compression fractures (VCFs) is a common complication after percutaneous kyphoplasty (PKP). Secondary VCFs after PKP occur predominantly in the thoracolumbar segment (T11 to L2). Prophylactic injections of cement into vertebral bodies in order to reduce new VCFs have rarely been reported. The main purpose of this study was to investigate whether prophylactically injecting cement into a nonfractured vertebral body at the thoracolumbar level (T11-L2) could reduce the occurrence of new VCFs.

Methods

From July 2011 to July 2018, PKP was performed in 86 consecutive patients with osteoporotic vertebral compression fractures (OVCFs) in the thoracolumbar region (T11-L2). All patients selected underwent PKP because of existing OVCFs (nonprophylactic group). Additionally, 78 consecutive patients with fractured vertebrae in the thoracolumbar region (T11-L2) with OVCFs underwent PKP and received prophylactic injections of cement into their nonfractured vertebrae in the thoracolumbar region (T11-L2) (prophylactic group). The visual analog scale (VAS) scores and incidence of new VCFs after PKP were compared between the two groups.

Results

The mean VAS scores improved from 8.00 ± 0.79 preoperatively to 1.62 ± 0.56 at the last follow-up in the nonprophylactic group and improved from 8.17 ± 0.84 to 1.76 ± 0.34 in the prophylactic group (P > 0.05). In the nonprophylactic group, 21 of 86 patients (24.4%) developed new VCFs within one year after PKP, of whom 15 patients (71.4%) developed VCFs within 3 months. In the prophylactic group, 8 of 78 patients (10.3%) developed new VCFs within one year, and 6 of these 8 patients (75%) developed new VCFs within 3 months. The incidence of new VCFs was significantly higher in the nonprophylactic group than that in the prophylactic group at one year (P = 0.018), but there were no statistically significant differences at three months (P = 0.847).

Conclusions

Prophylactic injections of cement into nonfractured (T11-L2) vertebral bodies reduced the incidence of secondary VCFs after PKP in patients with OVCFs, but there was no significant difference in local back pain (VAS) scores between the two groups.

Risk factors of adjacent segmental fractures when percutaneous vertebroplasty is performed for the treatment of osteoporotic thoracolumbar fractures

The study aimed to analyze the radiographic and magnetic resonance imaging (MRI) findings that might predict the risk for adjacent segmental fractures (ASFs) when percutaneous vertebroplasty (PV) is used for the treatment of osteoporotic thoracolumbar fractures (OTFs). A total of 92 OTFs patients who underwent PV between January 2013 and January 2015 were retrospectively reviewed. The visual analog scale (VAS), Oswestry-Disability Index (ODI) and radiolographic measurements were assessed. The VAS and ODI scores improved significantly at the final follow-up (FU) compared with the preoperation scores. Compared with the preoperative values, the fractured body alignment (FBA) significantly improved at the 3-month FU and the final FU, but the adjacent segment alignment (ASA) and thoracolumbar alignment (TLA) did not improve. According to the correlation analysis, the final FU TLA and the final FU ASA were correlated with the preoperative FBA, ASA, and TLA on plain radiography and were highly correlated on MRI. However, the final FU FBA was not correlated with the preoperative FBA, ASA, or TLA on plain radiography or MRI (P > 0.05). The ASFs were correlated with the 3-month FU TLA (r = 0.6044, P = 0.0037) and the final FU TLA (r = 0.5699, P = 0.007) on plain radiography, and the final TLA was more correlated with the preoperative FBA, ASA, and TLA on MRI than on plain radiography. In conclusion, the preoperative ASA and TLA on MRI were risk factors associated with ASFs in OTFs treated with PV.

Posterior Fixation Combined with Vertebroplasty or Vertebral Column Resection for the Treatment of Osteoporotic Vertebral Compression Fractures with Intravertebral Cleft Complicated by Neurological Deficits

Purpose

The aim of the current study was to evaluate the relative benefits of posterior fixation combined with vertebroplasty (PFVP) or vertebral column resection (PVCR) for osteoporotic vertebral compression fractures (OVCFs) with intravertebral cleft (IVC) complicated by neurological deficits.

Methods

From June 2010 to January 2015, 45 consecutive patients suffering OVCFs with IVC and spinal cord injuries were treated with PFVP or PVCR in our department. The visual analogue scale (VAS) score, anterior vertebral height (AVH), posterior vertebral height (PVH), local kyphotic angle (LKA), and neurologic function were evaluated and compared, and the operative duration, blood loss, and complications were also recorded.

Results

They all achieved excellent pain relief, vertebral height recovery, and kyphosis correction one month after surgery, and no significant differences existed between the two groups. No significant differences were observed between the 1-month postoperative and final follow-up VAS, AVH, and LKA values in the PVCR group (P > 0.05), while AVH and LKA worsened in the PFVP group at the final follow-up (P < 0.05). Similarly, the initial improvements in VAS scores decreased over time (P < 0.05). Neurologic function improved in both groups, and no significant differences were observed between the 2 groups either preoperatively or postoperatively (P > 0.05). The blood loss and operative duration were significantly lower in the PFVP group than those in the PVCR group (P < 0.05).

Conclusion

Compared with PVCR, PFVP had equivalent short-term clinical outcomes with less blood loss and operative duration which can be very beneficial for treating elderly patients with extreme comorbidities in this condition. However, based on the long-term efficacy of pain relief, vertebral height maintenance, and deformity correction, PVCR is a more reasonable choice.

Outcomes of vertebroplasty in osteoporotic vertebral fractures with limited indication

INTRODUCTION

Vertebroplasty has been shown to be effective for improving quality of life and pain of osteoporotic vertebral fractures (OVF) without neurological deficit and not susceptible to conservative treatment. It is advisable to perform them on recent fractures with 50% crush and without the involvement of the canal, although there are no standard recommendations. In some cases these limits are exceeded. We analyse the outcomes of percutaneous vertebroplasty (PVP) in OVF with relative/limit indication.

MATERIALS AND METHODS

Retrospective analysis of 88 patients (126 fractures) who underwent surgery by PVP; 95/126 were osteoporotic fractures. Thirty-four cases (35%) were included in the relative indication group, with at least one of the following: canal involvement,>50% collapse, and>12 months of evolution of the fracture. The rest of the cases were included in the standard indication group. We performed clinical-radiological follow-up, collected intraoperative data on techniques and complications, occurrence of leaks, postoperative clinical improvement (according to VAS), new adjacent fractures, and satisfaction.

RESULTS

Most fractures were between D11-L2 (66%) with 6-8 months follow-up. No significant differences were observed regarding clinical improvement in either group. A higher percentage of leaks were detected in the relative indication group, 44% in comparison to 29.5% in the standard indication group, without statistical significance. All leakages were asymptomatic. There were 3new OVF after PVP in the relative indication group and 4in the standard group, without statistically significant differences.

DISCUSSION AND CONCLUSIONS

The use of cement in OVF with relative indication led to the same clinical benefit in our sample as those with standard indication. A higher number of leakages occurred in the relative indication group with no clinical consequences or adjacent fractures.

Kyphosis and canal compromise due to refracturing of an L1 cemented vertebra managed with posterior surgery alone

Background:

An already cemented vertebral body rarely refractures and its occurrence may be signaled by the reappearance of pain and/or significant vertebral collapse/kyphosis resulting in canal compromise and neurological deterioration.

Case Description:

An 81-year-old male originally underwent an L1 kyphoplasty for an osteoporotic compression fracture. Nine months later, he presented with the late onset of recurrent collapse of the cemented vertebral body, leading to pain, kyphosis, and canal compromise. Surgery warranted total L1 corpectomy, reconstruction of the anterior column, and a posterior fixation through a purely posterior approach (posterior vertebral column resection [pVCR]).

Conclusion:

Here, we presented the safety/efficacy of utilizing a purely posterior approach (e.g., including L1 corpectomy, reconstruction of the anterior column, and posterior fusion: pVCR) in the management of a repeated fracture of a cemented L1 vertebra resulting in kyphosis and canal compromise.

12-Month Teriparatide Treatment Reduces New Vertebral Compression Fractures Incidence And Back Pain And Improves Quality Of Life After Percutaneous Kyphoplasty In Osteoporotic Women

Purpose

Define the effectiveness of teriparatide (TPTD) treatment on reducing the incidence of new vertebral compression fractures (NVCFs) and back pain and improving quality of life after percutaneous kyphoplasty (PKP).

Methods

Two years of clinical follow-up data from primary osteoporotic women who had experienced initial osteoporotic vertebral compression fractures (OVCFs) and received PKP plus 12-month TPTD (n=113) or basic treatment (BT) of calcium and vitamin D supplements (n=208) were retrospectively collected. The risk of NVCFs over each 6-month period in the TPTD group was evaluated and compared with the BT group using a logistic regression. Health-related quality of life (HRQoL, EQ-5D questionnaire), back pain [100 mm visual analog scale (VAS)] and bone mineral density (BMD) of the spine were analyzed using linear mixed models for repeated measures (LMMRM).

Results

Logistic regression analysis adjusting for baseline characteristics showed that patients in the TPTD group had a lower risk of NVCFs compared with those receiving BT during the final three observation intervals (6-12 months, OR=0.189, 95% CI=0.030-0.681, p=0.046; 12-18 months, OR=0.009, 95% CI=0.0001-0.111, p=0.001; 18-24 months, OR=0.024, 95% CI=0.0009-0.264, p=0.009, respectively). Significant improvements in adjusted EQ-5D and back pain VAS scores were identified in the TPTD group compared with the BT group, and this improvement was sustained for at least 12 months after teriparatide treatment was discontinued (both p<0.001). The BMD of the spine also showed a higher T-value in the TPTD group compared with the BT group (p<0.001).

Conclusion

In routine clinical practice, for patients with OVCFs who receive the PKP procedure, TPTD treatment may be a preferable subsequent therapy because of its ability to reduce the incidence of NVCFs and sustain a high quality of life and back pain alleviation.

The methods for inserting lumbar bicortical pedicle screws from the anatomical perspective of the prevertebral great vessels

BACKGROUND

At present, bicortical pedicle screws (BPSs) are not used clinically because they carry the potential risk of damaging the prevertebral great vessels (PGVs). The authors observed the anatomical relationship between the PGVs and simulated BPSs at different transverse screw angles (TSAs), exploring the insertion method of the BPS.

METHODS

Computed tomography angiography (CTA) images from 65 adults were collected. A total of 4-5 TSAs of the BPSs were simulated on the left and right sides of L1-L5 (L1-L3: 0°, 5°, 10°, 15°; L4-L5: 0°, 5°, 10°, 15°, 20°). There were three types of distances from the anterior vertebral cortex (AVC) to the PGVs (D_AVC-PGV); D_{AVC-PGV < 0.50 cm}, D_{AVC-PGV ≥ 0.50 cm}, and D_AVC-PGV↑; these distances represented close, distant, and noncontact PGV, respectively.

RESULTS

The ratio of every type of PGV was calculated, and the appropriate TSA of the BPS was recommended. In L1, the recommended left TSA of the BPS was 0°, and the ratio of the close PGV was 7.69%, while the recommended right TSA was 0°-10°, and the ratio of the close PGV was 1.54-4.62%. In L2, the recommended left TSA of the BPS was 0° and the ratio of the close PGV was 1.54%, while the recommended right TSA was 0°-15° and the ratio of the close PGV was 3.08-9.23%. In L3, the recommended left TSA was 0°-5°, and the ratio of the close PGV was 1.54-4.62%. In L4, the recommended left TSA was 0°, and the ratio of the close PGV was 4.62%. BPS use was not recommended on the right side of either L3 or L4 or on the either side of L5.

CONCLUSIONS

From the anatomical perspective of the PGVs, BPSs were not suitable for insertion into every lumbar vertebra. Furthermore, the recommended methods for inserting BPSs were different in L1-L4.

Factors Predicting the Surgical Risk of Osteoporotic Vertebral Compression Fractures

The aim of our study was to investigate the association between global spinal alignment, spinopelvic parameters, and outcomes of osteoporotic vertebral compression fractures (OVCF). Patients with vertebral compression fractures seen at our hospital between October 2017 and November of 2018 with a bone mineral density (BMD) T-score < -2.5 were recruited for the study. Surgical intervention was performed after eight weeks of conservative treatment depending on clinical symptoms and the willingness of patients. Spinopelvic and sagittal alignment parameters were compared between patients who had surgery and those that did not. Seventy-nine patients were included in the study. Twenty-five patients (31.6%, mean age: 73.28 ± 9.78 years) received surgery, and 54 (68.3%, mean age: 73 ± 8.58 years) conservative treatment only. Pelvic tilt, pelvic incidence, and local kyphotic angle were statistically different between the groups (all p < 0.05). A sagittal vertical axis ≥ 50 mm, distance between the C7 plumb line and the center of the fractured vertebra (DSVA) ≥ 60 mm, pelvic incidence outside of the range of 44 to 62°), and pelvic tilt ≥ 27° were associted with the need for surgical intervention. Measurement of spinopelvic parameters can predict the need for surgery in patients with OVCF.

Intervertebral Bridging Ossification After Percutaneous Kyphoplasty in Osteoporotic Vertebral Compression Fractures

BACKGROUND

Percutaneous kyphoplasty (PKP) is effective in treating osteoporotic vertebral compression fractures (OVCFs). Intervertebral bridging ossification can sometimes be detected after surgery, but studies related to its formation mechanism and its influence on outcome are few.

CASE DESCRIPTION

We reviewed patients' radiologic images and found 7 patients in whom intervertebral bridging ossification developed after PKP. Their personal and clinical information was recorded. The 7 patients had an average age of 63.43 ± 4.79 years. Injured levels included L1 (1 patients) and L2 (1 patient). GeneX and PMMA cement were respectively applied. Both the Cobb angle and the VAS scores were significantly improved after surgery, but all surgical vertebrae showed recollapse combined with larger Cobb angle at the last follow-up visits. In 1 patient the new-onset T11 fracture developed 29 months after surgery.

CONCLUSIONS

We deemed that spinal degeneration, mechanical instability, bone cement, and fracture pattern are all potential promoting factors for intervertebral bridging ossification. Solid bridging ossification may increase local spinal stability, but it also increases the risk of adjacent vertebral fractures.

Improved biomechanics of two alternative kyphoplasty cementation methods limit vertebral recollapse

The clinical efficacy of vertebral cement augmentation for compression fractures (VCFs) remains undetermined. Recent studies have shown that refracture and progression of deformity may occur after augmentation with significant clinical consequences. Vertebral body height loss following kyphoplasty has also been observed with cyclic loading. We hypothesized that height loss is partly due to lack of cement fill past the margin of cancellous bone created by balloon expansion with subsequent failure under load. The biomechanical characteristics of two alternative cementation techniques were compared to standard kyphoplasty in cyclically loaded cadaveric VCF constructs. Sectioned osteoporotic thoracolumbar cadaveric spines were compressed to 75% of anterior vertebral height. Specimens were then allocated to standard kyphoplasty, balloon pressurization (BP), with reinflation of the balloon after 50% cement injection, or endplate post (EP), with perforation of the cavity rim using an articulating curette prior to injection. Following cementation, each specimen was preconditioned and loaded over 100,000 cycles. All techniques improved vertebral height (p's < 0.005). The EP and BP techniques provided greater cement fill than the standard technique (p's ≤ 0.01). Normalized vertebral height loss following 100,000 cycles was reduced with the EP technique versus standard kyphoplasty (p < 0.04). Height loss was inversely correlated with cement fill (p < 0.03). No vertebral recollapse occurred with the EP technique in blinded radiographic analysis. Statement of clinical significance: The EP technique demonstrated improved biomechanical characteristics versus the standard technique in cadaveric osteoporotic VCF constructs with decreased recollapse following cementation. This technique may have increased efficacy in cases when kyphoplasty more substantially improves vertebral body height. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:3225-3230, 2018.

Percutaneous Vertebral Augmentation for Osteoporotic Vertebral Compression Fracture in the Midthoracic Vertebrae (T5-8): A Retrospective Study of 101 Patients with 111 Fractured Segments

OBJECTIVE

Data reporting percutaneous vertebroplasty (PVP) or percutaneous balloon kyphoplasty (PKP) application to the midthoracic vertebrae remain limited. This study aimed to summarize our experiences and explore the efficacy and safety of PVP or PKP in dealing with osteoporotic vertebral compression fracture (OVCF) in the midthoracic vertebrae.

METHODS

Patients receiving PVP or PKP for midthoracic OVCF in our institution from January 2015 to January 2018 were retrospectively enrolled. All patients were grouped according to cement augmentation procedure types, surgical approaches, and puncture routes. All patients underwent a postoperative follow-up of 2-36 months. Visual analog scale (VAS) and ECOG Scale of Performance Status scores were evaluated pre- and postoperatively. Cement distribution and rate of cement leakage were assessed by radiographs. Associations of these variables and clinical scores and radiographic indices were analyzed.

RESULTS

A total of 101 consecutive patients with 111 fractured centrums were enrolled. Both VAS and ECOG Scale of Performance Status scores of all patients decreased significantly after the operation, and progressively decreased at the final follow-up. The cement distribution of the bipedicular group was significantly better than the unipedicular group, but the total leakage rate of the former (71.7%) was significantly higher than the latter (43.1%). The rate of epidural cement leakage in the PKP group (5.4%) was significantly lower than that of the PVP group (20.3%), whereas the left puncture group (28.6%) was significantly higher than that of the right puncture group (2.7%).

CONCLUSIONS

PKP and a bipedicular approach can help improve cement distribution and reduce the epidural cement leakage rate and therefore should be preferred over PVP or a unipedicular approach in OVCF of the midthoracic vertebrae.

Coronal Imaging Changes Associated with Recollapse of Injured Vertebrae After Percutaneous Vertebroplasty or Percutaneous Kyphoplasty Treatment for Osteoporotic Thoracolumbar Fracture

OBJECTIVE

To observe coronal imaging changes associated with recollapse of injured vertebrae after percutaneous vertebroplasty or percutaneous kyphoplasty for osteoporotic thoracolumbar fracture (OTLF).

METHODS

Fifty-four cases were retrospectively divided into 2 groups according to the Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation (AO/ASIF) classification of thoracolumbar fracture: group A, type A1 fracture (n = 26); group B, type A3.1 fracture (n = 28). Visual analog scale, Oswestry Disability Index, local scoliotic Cobb angle, and coronal wedge angle of the injured vertebrae were observed preoperatively, on postoperative day 3, and at final follow-up.

RESULTS

The average follow-up time was 19.17 ± 6.30 months. At final follow-up, the visual analog scale score and the Oswestry Disability Index score were significantly greater in group B than in group A (both P < 0.05). At final follow-up, loss of correction of scoliotic Cobb angle and coronal wedge angle was significantly higher in group B than in group A (P < 0.05).

CONCLUSIONS

Percutaneous vertebroplasty or percutaneous kyphoplasty was effective in both type A1 and type A3.1 OTLF. However, coronal imaging changes after percutaneous vertebroplasty or percutaneous kyphoplasty were more obvious in type A3.1 OTLF than in type A1. Moreover, clinical outcomes in type A3.1 OTLF were slightly inferior to those in type A1.