Vertebral Compression Fractures: Evaluation and Management

Incidence of and Risk Factors for Neurological Deficits Associated With Percutaneous Vertebral Augmentation

Study DesignRetrospective cohort study.ObjectivesTo investigate the incidence of neurological deficits associated with percutaneous vertebral augmentation (PVA) surgery and to identify related risk factors.MethodsWe performed a retrospective analysis of the clinical data of patients who underwent PVA surgery at our institution between 2017 and 2022. A range of clinical parameters, including age, sex, fracture cause, fracture segment, number of vertebrae treated, surgical approach and surgical method, were collected.ResultsThis study included a total of 1847 patients, including 422 (22.8%) men and 1425 (77.2%) women, with a total of 2319 diseased vertebrae. The mean age of the patients was 70.71 ± 8.80 years, with 211 (11.4%) patients aged under 60 years and 1636 (88.6%) patients aged over 60 years. Forty-six (2.5%) patients, accounting for 67 diseased vertebrae, were treated for tumors, whereas the remaining 1801 (97.5%) patients underwent surgery for fractures. Four hundred seventy-eight (20.6%) vertebrae underwent unilateral puncture, and the remaining 1841 (79.4%) vertebrae underwent bilateral puncture. Percutaneous vertebroplasty was performed on 1781 (76.8%) vertebrae, whereas percutaneous kyphoplasty was chosen for the remaining 538 (23.2%) vertebrae. Postoperative X-ray evaluations were conducted on the treated vertebrae, revealing that 403 (17.4%) vertebrae experienced polymethylmethacrylate (PMMA) leakage. Among the 1847 patients, 6 (7 diseased vertebrae) experienced nerve injuries postoperatively, and the incidence of neurological deficits after PVA surgery was 0.32%. Four of the 6 patients had nerve injuries due to PMMA leakage, and the other 2 patients had failed punctures. There was no statistically significant difference in terms of neurological complication rates according to patient age, sex, fracture segment, number of vertebrae treated, surgical approach or surgical method. However, the incidence of neurological complications was greater for patients with neoplastic fractures who underwent PVA surgery than for those with osteoporotic fractures.ConclusionsPVA is an effective minimally invasive procedure for treating osteoporotic and neoplastic vertebral fractures. However, PVA can lead to serious neurological deficits. The incidence of neurological deficits associated with PVA surgery is 0.32%. Compared with patients with osteoporotic fractures, patients with neoplastic vertebral fractures who undergo PVA have a greater risk of neurological complications.

Appropriate Use Criteria for Osteoporotic Compression Fractures

BACKGROUND CONTEXT

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

PURPOSE

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

STUDY DESIGN

A Modified Delphi process.

PATIENT SAMPLE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Fast kilovoltage peak-switching dual-energy computed tomography water-hydroxyapatite decomposition for detecting vertebral compression fracture-related bone marrow edema: a comparison with magnetic resonance imaging

Background

Dual-energy computed tomography (DECT) material decomposition techniques have been reported to be effective for identifying acute and chronic vertebral compression fractures (VCFs) as compared with magnetic resonance imaging (MRI). However, a quantitative evaluation of the consistency of the bone marrow edema (BME) region depicted by DECT with that delineated by MRI has not been reported. This study thus aimed to qualitatively and quantitatively assess the fast kilovoltage peak (kVp)-switching DECT water-hydroxyapatite (HAP) decomposition technique in detecting traumatic BME in patients with VCFs and compare it to MRI.

Methods

A total of 195 consecutive patients who underwent both spinal DECT and MRI within 3 days from each other were retrospectively enrolled. All vertebral bodies were blindly evaluated for the presence of traumatic BME on water-HAP images. Water concentration was measured in all vertebral bodies, and the maximum area of BME was measured in the edematous ones. An experienced radiologist blindly evaluated the presence of BME on fluid-sensitive MR images, which served as the reference, and calculated the maximum area of BME. One-way analysis of variance with post hoc pairwise comparisons (Tamhane's T2 at P<0.05) was used to compare water concentrations among acute VCFs, chronic VCFs, and normal vertebrae. Receiver operating characteristic (ROC) curve analysis was conducted to predict acute VCFs. Bland-Altman analysis was performed to evaluate the consistency of the maximum area of BME measured on DECT and MRI.

Results

In the visual analysis of acute VCFs, water-HAP images had an overall sensitivity of 97.1%, a specificity of 99.7%, and an accuracy of 99.4%. Water concentration differed significantly between acute and chronic VCFs and between acute VCFs and normal vertebrae (P<0.001), but it did not differ significantly between chronic VCFs and normal vertebrae (P=0.998). ROC curve analysis yielded an area under the curve of 0.989, and the optimal threshold of 991.4 mg/cm3 yielded a 94.9% sensitivity and a 90.3% specificity in identifying edematous vertebral bodies. Bland-Altman plots indicated that all mean differences in the maximum area of BME measured on DECT and MRI were nearly zero (P>0.05), with most differences having a standard deviation within 1.96.

Conclusions

The fast kVp-switching DECT water-HAP decomposition technique had an excellent diagnostic performance in distinguishing acute VCFs from chronic ones. The depicted areas of BME on DECT and MRI were highly similar.

Enhancing fracture risk indication: The impact of bone load index and muscle fat infiltration on vertebral compression fracture

PURPOSE

This study aims to identify risk factors for vertebral compression fracture and enhance the ability to indicate fracture risk.

METHODS

A retrospective collection of clinical and imaging data was conducted for patients with vertebral compression fractures and control subjects who underwent quantitative computed tomography scans. Stepwise logistic regression analysis was employed to identify variables associated with fractures, constructing both unadjusted model and adjusted model.

RESULTS

Compared with the non-fracture group, the fracture group showed significant differences in weight, body mass index (BMI), bone mineral density (BMD), vertebral cross-sectional area, paraspinal muscle area and right psoas major muscle fat area (all P < 0.05). Adjusted characteristics analyzed by stepwise logistic regression indicated that bone load index (BLI) (OR = 3.19, P = 0.041), paraspinal muscle fat infiltration (PMFI) (OR = 2.27, P = 0.039), and right psoas major muscle fat infiltration (RPMFI) (OR = 1.08, P = 0.005) were independent risk factors for vertebral fractures. Interaction analysis revealed a positive interaction between BLI and PMFI (OR = 1.95, P = 0.008) as well as RPMFI (OR = 1.53, P = 0.045). Compared with the unadjusted model, the diagnostic performance of the adjusted model was significantly improved (training set IDI: 19.5 %, validation set IDI: 18.4 %, P < 0.001). Correlation analysis demonstrated significant associations between BMD (r = -0.353, P = 0.002), BLI (r = 0.631, P < 0.001), PMFI (r = 0.412, P < 0.001), RPMFI (r = 0.513, P < 0.001), and the degree of vertebral compression.

CONCLUSION

Under conditions of bone maladaptive loading and muscle degeneration, vertebral bodies may become more susceptible to external forces, increasing the risk of vertebral compression fracture.

Radiomics Based on Multimodal magnetic resonance imaging for the Differential Diagnosis of Benign and Malignant Vertebral Compression Fractures

OBJECTIVES

Recent studies have indicated that radiomics may have excellent performance and clinical application prospects in the differential diagnosis of benign and malignant vertebral compression fractures (VCFs). However, multimodal magnetic resonance imaging (MRI)-based radiomics model is rarely used in the differential diagnosis of benign and malignant VCFs, and is limited to lumbar. Herein, this study intends to develop and validate MRI radiomics models for differential diagnoses of benign and malignant VCFs in patients.

METHODS

This cross-sectional study involved 151 adult patients diagnosed with VCF in The First Affiliated Hospital of Soochow University in 2016-2021. The study was conducted in three steps: (i) the original MRI images were segmented, and the region of interest (ROI) was marked out; (ii) among the extracted features, those features with Pearson's correlation coefficient lower than 0.9 and the top 15 with the highest variance and Lasso regression coefficient less than and more than 0 were selected; (iii) MRI images and combined data were studied by logistic regression, decision tree, random forest and extreme gradient boosting (XGBoost) models in training set and the test set (ratio of 8:2), respectively; and the models were further verified and evaluated for the differential diagnosis performance. The evaluated indexes included area under receiver (AUC) of operating characteristic curve, accuracy, sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and 95% confidence intervals (CIs). The AUCs were used to assess the predictive performance of different machine learning modes for benign and malignant VCFs.

RESULTS

A total of 1144 radiomics features, and 14 clinical features were extracted. Finally, 12 radiomics features were included in the radiomics model, and 12 radiomics features with 14 clinical features were included in the combined model. In the radiomics model, the differential diagnosis performance in the logistic regression model with the AUC of 0.905 ± 0.026, accuracy of 0.817 ± 0.057, sensitivity of 0.831 ± 0.065, and negative predictive value of 0.813 ± 0.042, was superior to the other three. In the combined model, XGBoost model had the superior differential diagnosis performance with specificity (0.979 ± 0.026) and positive predictive value (0.971 ± 0.035).

CONCLUSION

The multimodal MRI-based radiomics model performed well in the differential diagnosis of benign and malignant VCFs, which may provide a tool for clinicians to differentially diagnose VCFs.

[Translated article] Truths and myths about augmentation techniques in the treatment of fragility fractures

The main event of osteoporosis is fragility fractures. Vertebral compression fractures are the most commonly fragility fracture related to osteoporosis. Our goal is to review the available literature to confirm or deny concepts learned about spinal cementation and adapt our clinical practice according to scientific evidence. In the complex world of spine surgery, constant innovations seek to improve the quality of life of patients. Among these, vertebral augmentation has emerged as an increasingly popular technique, but often shrouded in myths and misunderstandings. In this systematic review, we will thoroughly explore the truths behind vertebral augmentation, unravelling common myths and providing a clear insight into this technique. As specialists in the field, it is crucial to understand the reality surrounding these interventions to offer our patients the best possible information and make informed decisions.

Deep learning-based automated high-accuracy location and identification of fresh vertebral compression fractures from spinal radiographs: a multicenter cohort study

Background

Digital radiography (DR) is a common and widely available examination. However, spinal DR cannot detect bone marrow edema, therefore, determining vertebral compression fractures (VCFs), especially fresh VCFs, remains challenging for clinicians.

Methods

We trained, validated, and externally tested the deep residual network (DRN) model that automated the detection and identification of fresh VCFs from spinal DR images. A total of 1,747 participants from five institutions were enrolled in this study and divided into the training cohort, validation cohort and external test cohorts (YHDH and BMUH cohorts). We evaluated the performance of DRN model based on the area under the receiver operating characteristic curve (AUC), feature attention maps, sensitivity, specificity, and accuracy. We compared it with five other deep learning models and validated and tested the model internally and externally and explored whether it remains highly accurate for an external test cohort. In addition, the influence of old VCFs on the performance of the DRN model was assessed.

Results

The AUC was 0.99, 0.89, and 0.88 in the validation, YHDH, and BMUH cohorts, respectively, for the DRN model for detecting and discriminating fresh VCFs. The accuracies were 81.45% and 72.90%, sensitivities were 84.75% and 91.43%, and specificities were 80.25% and 63.89% in the YHDH and BMUH cohorts, respectively. The DRN model generated correct activation on the fresh VCFs and accurate peak responses on the area of the target vertebral body parts and demonstrated better feature representation learning and classification performance. The AUC was 0.90 (95% confidence interval [CI] 0.84-0.95) and 0.84 (95% CI 0.72-0.93) in the non-old VCFs and old VCFs groups, respectively, in the YHDH cohort (p = 0.067). The AUC was 0.89 (95% CI 0.84-0.94) and 0.85 (95% CI 0.72-0.95) in the non-old VCFs and old VCFs groups, respectively, in the BMUH cohort (p = 0.051).

Conclusion

In present study, we developed the DRN model for automated diagnosis and identification of fresh VCFs from spinal DR images. The DRN model can provide interpretable attention maps to support the excellent prediction results, which is the key that most clinicians care about when using the model to assist decision-making.

Truths and myths about augmentation techniques in the treatment of fragility fractures

The main event of osteoporosis is fragility fractures. Vertebral compression fractures are the most commonly fragility fracture related to osteoporosis. Our goal is to review the available literature to confirm or deny concepts learned about spinal cementation and adapt our clinical practice according to scientific evidence. In the complex world of spine surgery, constant innovations seek to improve the quality of life of patients. Among these, vertebral augmentation has emerged as an increasingly popular technique, but often shrouded in myths and misunderstandings. In this systematic review, we will thoroughly explore the truths behind vertebral augmentation, unraveling common myths and providing a clear insight into this technique. As specialists in the field, it is crucial to understand the reality surrounding these interventions to offer our patients the best possible information and make informed decisions.

Comparison of the efficacy and safety of unilateral and bilateral approach kyphoplasty in the treatment of osteoporotic vertebral compression fractures: A meta-analysis

OBJECTIVES

The study aimed to compare the efficacy and safety of unilateral versus bilateral percutaneous kyphoplasty (PKP) in treating osteoporotic vertebral compression fractures.

MATERIALS AND METHODS

Adhering to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, three English-language databases were systematically reviewed: PubMed, Web of Science, and the National Library of Medicine. The search was conducted between their inception and January 1, 2023. Studies that were replications or that used regression analysis were excluded. Randomized controlled trials and cohort studies that met the criteria were included, and a meta-analysis was performed.

RESULTS

The mean follow-up duration was 17.9±9.7 months for the unilateral group and 18.4±8.3 months for the bilateral group. Eight randomized controlled trials and four cohort studies were included, comprising a total of 1,391 patients (499 males, 697 females; 195 cases did not report sex; mean age: 70.9 years; range, 45 to 82 years). Of these patients, 710 underwent the unilateral surgical approach and 681 the bilateral approach. The meta-analysis revealed that the long-term VAS was marginally higher in the unilateral PKP group (mean difference [MD]=0.09; 95% confidence interval [CI]: 0.06-0.13; p<0.001). The unilateral group also demonstrated a greater recovery rate in the postoperative kyphosis angle (MD=2.27; 95% CI: 0.67-3.87; p=0.006), shorter operation duration (MD=18.56 min; 95% CI: 8.96-28.17; p<0.001), and a lower bone cement dosage (MD=1.20 mL; 95% CI: 0.39-2.01; p=0.004).

CONCLUSION

Unilateral PKP appears equally effective as bilateral PKP for treating osteoporotic vertebral compression fractures but with advantages in terms of procedure time, cement use, and pain reduction.

Circulating miR-107 as a diagnostic biomarker of osteoporotic vertebral compression fracture increases bone formation in vitro and in vivo

AIMS

This study aimed to examine the key circulating miRNAs in the plasma of patients with osteoporotic vertebral compression fracture and assess their potential role as diagnostic biomarkers and explore their function in vitro and in vivo.

METHODS

Weighted gene co-expression network analysis (WGCNA) was applied to identify hub miRNAs for subsequent analysis. The candidate miRNAs were tested using plasma from 144 patients and the results were applied to construct receiver operating characteristic (ROC) curves to assess their diagnostic value. In addition, the function of the target microRNA was validated in MC3T3-E1 cells, human bone marrow-derived mesenchymal stromal cells (BMSCs), and an ovariectomized (OVX) mouse model.

KEY FINDINGS

Seven modules were obtained by WGCNA analysis. The expression levels of circulating miR-107 in the red module were significantly lower in osteoporotic patients than in healthy controls. In addition, miR-107 provided discrimination with an AUC > 85 % by ROC analyses to differentiate women osteoporosis patients from healthy controls and differentiate women osteoporotic patients with vertebral compression fractures from osteoporotic patients without vertebral compression fractures. In vitro experiments revealed that miR-107 levels were increased in osteogenically induced MC3T3-E1 cells and BMSCs and transfection with synthetic miR-107 could promote bone formation. Lastly, the bone parameters were improved by miR-107 upregulation in OVX mice.

SIGNIFICANCE

Our findings show that circulating miR-107 plays an essential role in facilitating osteogenesis and may be a useful diagnostic biomarker and therapeutic target in osteoporosis.

Chronologically clustered osteoporotic vertebral compression fractures: Analysis of a case series

AIM

To provide quality care to older adults, healthcare professionals should be aware that osteoporotic vertebral compression fractures (OVCFs) might occur sequentially in the same patient, involving different vertebral bodies, each separated by short intervals. This situation is called chronologically clustered OVCFs (CCOVCF).

METHODS

A total of 40 patients with CCOVCFs (index cohort) were retrospectively analyzed, and compared with 40 patients having only one OVCF (comparison cohort). All fractures were treated with percutaneous balloon kyphoplasty.

RESULTS

In the index cohort, the number of patients having the second, third, fourth and fifth OVCF events within 3 months were 40, 15, five and two, respectively. Recurring pain or seemingly non-stop pain were the major reasons why new OCVFs were found. The average interval between pain relief provided by percutaneous balloon kyphoplasty and radiographic diagnosis of new OVCFs was significantly longer than that between pain relief and a new episode of disabling pain (26.7 ± 16.8 vs 16.4 ± 15.8 days, P < 0.0001), reflecting how shortly new OCVFs occurred after successful surgery, and how often they were neglected. The mean T-score of the index cohort was significantly lower than that of the comparison cohort (-3.66 ± 0.79 vs -3.17 ± 0.80, P = 0.01).

CONCLUSIONS

CCOVCFs make a patient seem constantly in pain, despite repeated admissions and operations. Recurrent symptoms after an effective procedure should be taken as a warning that a new OCVF might have occurred, even if only a few days apart. Advanced osteoporosis is a significant risk factor for CCOVCFs. Geriatr Gerontol Int 2023; 23: 44-49.

Pharmacological options for pain control in patients with vertebral fragility fractures

This review considers the evidence base and current knowledge for pharmacological treatment options that are available for pain control in patients with vertebral fractures sustained after a low trauma incident. Due care needs to be taken when considering prescribed options for pain control. The decision should be based on first establishing whether the presentation is one of acute severe pain at the time of a new vertebral fragility fracture incident or whether the complaint is one of the debilitating, longer term chronic back pain syndrome, accompanied by a clinical suspicion of a possible new fracture. The article also presents currently debated questions in this important area of clinical and patient care and will be of interest to the readership worldwide.

Multidisciplinary management of osteoporotic vertebral fractures. An overview

Vertebral fractures represent the most frequent complication associated with osteoporosis. Patients harboring a vertebral fracture complain physical impairment including low back pain and spine balance alteration, i.e., kyphosis, leading to subsequent systemic complication, with an increase in morbidity and mortality risk. Different strategies are available in the management of osteoporotic vertebral fractures: medical therapy acts as a prevention strategy while surgical vertebral augmentation procedures, when correctly indicated, aim to reduce pain and to restore the physiological vertebral height. Considering the growing prevalence and incidence of this condition and its socio-economic burden, prevention, diagnosis and treatment of osteoporotic vertebral fractures are of utmost importance. Our aim is to review the current strategies for the management of osteoporotic vertebral fractures providing an integrated multidisciplinary endocrinological, radiological and neurosurgical point of view.

"Outcome of thoracolumbar compression fractures following non-operative treatment"

Axial compressive/flexion moderate forces on the anterior spinal elements may cause vertebral compression fractures (VCF), compromising the anterior column of the spine, reducing vertebral body height and leading to characteristic wedge-shaped deformity. 60% to 75% of VCFs are located in the thoracolumbar junction (T12 - L2) due to mechanical forces upon the transition from the relatively fixed thoracic to the relatively mobile lumbar spine. Compression force spinal fractures vary in literature according to the classification system in use, resulting in controversial treatment options. Type A fracture patterns of AO classification are eligible for non-operative treatment provided the posterior complex is intact and there are no neurologic complications. That includes both simple compressive and burst fractures. The aim of this study is to investigate the long-term consequences of non-operative treated compressive thoracolumbar fractures regarding posttraumatic deformity, chronic back pain, and functional status. A retrospective study of 75 patients with stable (compressive and burst type A AO) spinal fractures of the thoracolumbar spine (T12-L2) without neurological symptoms and treated non-operatively was conducted. Post traumatic regional kyphosis, Visual Analogue Scale (VAS) and the Oswestry Disability Index (ODI) were used to evaluate deformity progression, pain and alteration of the quality of life during follow up. There was no significant correlation between magnitude of posttraumatic regional kyphosis, sex, pain score and disability index. Statistically significant correlation between patients age and disability index was revealed.