Prospective and Multicenter Evaluation of Outcomes for Quality of Life and Activities of Daily Living for Balloon Kyphoplasty in the Treatment of Vertebral Compression Fractures: The EVOLVE Trial

CT-based vertebral three-dimensional Hounsfield unit can predict the new vertebral fracture after percutaneous vertebral augmentation in postmenopausal women: a retrospective study

BACKGROUND

Vertebral Hounsfield unit (HU) were regarded as a new way to predict fragility fracture. However, HU values were measured in a single plane, which is not accurate for the entire vertebral body. This study aimed to create a new CT-based metric for assessing bone mineral density, three-dimensional Hounsfield unit value (3D-HU), and to evaluate its effect in independently predicting new vertebral fracture (NVF) after percutaneous vertebral augmentation (PVA) in postmenopausal women.

METHODS

This study reviewed female patients with osteoporotic vertebral compression fracture (OVCF) who were treated at our hospital. Patients were divided into NVF and control groups according to whether they had NVF. 3D-HU of the L1-4 vertebrae was measured using preoperative computed tomography (CT) scanning of the lumbar spine. Demographics, procedure-related data, and radiological data were collected. Pearson correlation test was used to determine the correlation between 3D-HU and BMD T-score. The independent risk factors of NVF were determined by multivariate logistic regression analyses. Receiver operating characteristic curve (ROC) was used to evaluate the predictive performance of 3D-HU.

RESULTS

This study involved 349 postmenopausal women who were treated with PVA between January 2017 and August 2022. Among them, 61 people suffered the NVF following PVA. The mean 3D-HU was 40.64 ± 22.43 in the NVF group and 79.93 ± 25.69 in the without NVF group (p < 0.001). Multivariate analysis showed that lower 3D-HU (OR = 0.927; 95%CI = 0.906-0.945; p < 0.001) was the only independent predictor of NVF following PVA. The predictive accuracy of 3D-HU was 87.7%, which was higher than that of the HU value (82.3%), and it was highly positively correlated with BMD T-score (r = 0.628, p < 0.001).

CONCLUSIONS

Lower 3D-HU was significantly associated with NVF following PVA in postmenopausal women. In addition, vertebral 3D-HU had better predictive power than HU values. 3D-HU assessment prior to PVA may provide insight into a patient' s risk for NVF.

Efficacy and safety of vertebral augmentation techniques in patients with osteoporotic vertebral compression fractures: A single center, retrospective, observational study

Background

Back pain secondary to osteoporotic vertebral compression fractures (OVCF) is a common global health problem that is frequently overlooked. For some patients, conservative management (CM) is inadequate to treat the pain associated with OVCF. This subset of patients are often candidates for interventional vertebral augmentation techniques (VAT). Multiple studies have shown significant pain reduction, height restoration, reduction in hospitalization time, morbidity and mortality in patients treated with VAT as compared with those patients treated with CM. This study examines if the previously published trials are consistent with outcomes in a real-world cohort of patients in interventional pain practices following VAT.

Objectives

The purpose of this retrospective databased analysis was to further investigate the efficacy and safety of percutaneous vertebral augmentation techniques in patients suffering from osteoporotic vertebral compression fractures in our center.

Study design

Retrospective study.

Setting

A single-center study.

Patients and methods

We have included data from a total of 42 patients (26 females, 16 males) with diagnosis of OVCF that received VAT at our center between January 2023 and June 2024. Efficacy data included pre-procedure, 2-week, 1-month and 3-month follow-up numerical rating scale (NRS) pain scores when available.

Results

The mean pain score using NRS was 7.5 (n = 45), 3.24 (n = 44), 3.65 (n = 21) and 2.7 (n = 15) at pre-procedure, 2-week, 1-month and 3-month follow-up (P < 0.001), respectively. At the 2-week follow up, 44 %, 16 %, 20 % and 13 % of patients (n = 45) had NRS pain score reduction between 76 and 100 %, 51-75 %, 26-50 % and 0-25 % (P ≤ 0.05), respectively. At the 1-month follow-up visit, 24 %, 33 %, 14.3 % and 24 % of patients (n = 21) had NRS pain score reduction between 76 and 100 %, 51-75 %, 26-50 % and 0-25 % (P ≤ 0.05), respectively. At the 3-month follow-up visit, 60 %, 6.7 %, 6.7 % and 20 % of patients (n = 15) had NRS pain score reduction between 76 and 100 %, 51-75 %, 26-50 % and 0-25 % (P ≤ 0.05), respectively. This indicates significant differences in NRS pain scores across the different time points. There was a high dropout rate at the 3-month follow up visit most likely due to patient's pain improving post procedure.

Limitations

This was a single-center retrospective study with a small sample size and relatively short follow-up time.

Conclusion

VAT are effective and safe procedures for patients suffering from OCVF. However, proceduralists must be aware of patient-specific risk factors to prevent possible complications.

Developing predictive models for residual back pain after percutaneous vertebral augmentation treatment for osteoporotic thoracolumbar compression fractures based on machine learning technique

BACKGROUND

Machine learning (ML) has been widely applied to predict the outcomes of numerous diseases. The current study aimed to develop a prognostic prediction model using machine learning algorithms and identify risk factors associated with residual back pain in patients with osteoporotic vertebrae compression fracture (OVCF) following percutaneous vertebroplasty (PVP).

METHODS

A total of 863 OVCF patients who underwent PVP surgery were enrolled and analyzed. One month following surgery, a Visual Analog Scale (VAS) score of ≥ 4 was deemed to signify residual low back pain following the operation and patients were grouped into a residual pain group and pain-free group. The optimal feature set for both machine learning and statistical models was adjusted based on a 2000-resample bootstrap-based internal validation via an exhaustive search. The area under the curve (AUC), classification accuracy, sensitivity, and specificity of each model were then calculated to evaluate the predictive performance of each model.

RESULTS

In our current study, two main findings were observed: (1) Compared with statistical models, ML models exhibited superior predictive performance, with SVM demonstrating the highest prediction accuracy; (2) several variables were identified as the most predictive factors by both the machine learning and statistical models, including bone cement volume, number of fractured vertebrae, facet joint violation, paraspinal muscle degeneration, and intravertebral vacuum cleft.

CONCLUSION

Overall, the study demonstrated that machine learning classifiers such as SVM can effectively predict residual back pain for patients with OVCF following PVP while identifying associated predictors in a multivariate manner.

Effectiveness of ultra-early balloon kyphoplasty at one year after osteoporotic vertebral fracture

INTRODUCTION

Balloon kyphoplasty (BKP) for osteoporotic vertebral fracture (OVF) has been reported to maintain quality of life (QOL). This study aimed to investigate the effectiveness of ultra-early BKP performed within two weeks of injury (ultra-early group) to cases after two to four weeks post-injury (early group) and over four weeks (conventional group), assessing radiographic assessment such as subsequent fracture etc, questionarre such as QOL and back pain-related activities of daily living (ADL) one year after surgery.

METHODS

Ninety cases of OVF treated with BKP (23 males, 67 females, average age 78.0 years) were included. Radiographic assessments were examined and QOL parameters (SF-36 and EQ-5D-5L) and back pain-related ADL (ODI score) were assessed using self-administered questionnaires before and one year after surgery. Analysis of Variance (ANOVA) was used to compare changes in evaluation parameters among 3 groups. When significant differences were detected, post-hoc multiple comparisons were performed using the Steel-Dwass test.

RESULTS

The mean follow-up duration was 16.6 months. The ultra-early group consisted of 29 cases (10 males, 19 females, average age 77.0 years), the early group consisted of 39 (6 males, 33 females, average age 79.3 years), while the conventional group consisted of 22 cases (7 males, 15 females, average age 80.0 years). There was no significant difference in the preoperative score of SF-36, EQ-5D-5L, and ODI score. At the 1 year follow up, presence of subsequent fracture was significantly difference among 3 groups (3.4 % vs. 10.3 % vs. 31.8 %) (ANOVA, p < 0.05). Moreover, subsequent Steel-Dwass multiple comparisons also revealed that ultra-early group showed significantly less subsequent fracture compared to the conventional group (p < 0.05). Furthermore, Significant differences were observed in the changes of bodily pain in SF-36, EQ-5D-5L and ODI among 3 groups (ANOVA, p < 0.05). Steel-Dwass multiple comparisons also revealed that ultra-early group showed significantly greater improvement in EQ-5D-5L compared to the early group and conventional group (p < 0.05). ODI scores in ultra-early group also showed greater recover compared to the conventional group (p < 0.005).

CONCLUSIONS

Ultra early BKP within two weeks of OVF demonstrates effectiveness for less complication such as subsequent fracture, QOL and back pain-related ADL one year post-surgery, enabling early return to society.

Vertebroplasty and kyphoplasty in the management of osteoporotic vertebral compression fractures in elderly individuals: evaluation of the health-related quality of life

Aim of this study is to investigate the safety, efficacy and impact on Health-Related Quality of Life (HRQoL) of Vertebroplasty (VP) and Kyphoplasty (KP) in the management of Osteoporotic Vertebral Compression Fractures (OVCFs) in elderly individuals. VP and KP represent Minimally Invasive Vertebral Augmentation (MIVA) procedures that are increasingly implemented for surgical treatment of OVCFs in recent years. These interventions have been associated with minimal traumatization and intraoperative hemorrhage, considerable analgesic effect and rapid postoperative recovery. Seventy-seven (77) consecutive individuals with OVCFs were subjected to VP/KP and recruited in this prospectively designed non-randomized study. Clinical evaluation was performed preoperatively and postoperatively at particular chronic intervals at 1, 6 weeks and at 3, 6, 12 months and 2 years. Assessment was conducted via the standardized Visual Analogue Scale (VAS) and Short-Form 36 (SF-36) Medical Health Survey Questionnaire for pain and HRQoL, respectively. No perioperative complications were observed. All studied indices were demonstrated to present a statistically significant amelioration following overall analysis. Pain intensity measured by the VAS score was depicted to be significantly reduced during the first 3 months, but continuous improvement of all indices of SF-36 and VAS was demonstrated to reach a plateau at 6 months, featuring no further clinical improvement.VP and KP represent safe and efficient options for interventional treatment of OVCFs in elderly and oldest-old patients, improving self-reported symptoms of pain as well as overall HRQoL.

Incidence and risk factors of adjacent vertebral fracture after percutaneous vertebroplasty or kyphoplasty in postmenopausal women: a retrospective study

Adjacent vertebral fracture (AVF) is a serious complication of percutaneous vertebroplasty (PVP) or kyphoplasty (PKP) for osteoporotic vertebral compression fracture (OVCF). This study aimed to explore the incidence and risk factors of AVF following PVP or PKP in postmenopausal women. The incidence of AVF was determined by spinal radiographic examinations. The potential risk factors of AVF were identified by univariate analysis, followed by multivariate logistic regression analyses to determine the independent risk factors. In total, 674 postmenopausal women who were treated with PVP or PKP from December 2019 to February 2022 were enrolled in the study. Among them, 58 (8.61%) women experienced an AVF following PVP or PKP. After adjusting for confounding factors, BMI (OR [95% CI] 0.863 [0.781-0.952]; p = 0.003), previous history of OVCF (OR [95% CI] 1.931 [1.044-3.571]; p = 0.036), and Hounsfield unit (HU) value (OR [95% CI] 0.979 [0.967-0.990]; p < 0.001) were found to be independent risk factors of AVF following PVP or PKP in postmenopausal women. The ROC analysis revealed that the BMI and HU thresholds were 21.43 and 65.15, respectively. In conclusion, the incidence of AVF was 8.61%. BMI, previous history of OVCF and HU value were independent risk factors of AVF following PVP or PKP in postmenopausal women.

Incidence and risk factors of subsequent vertebral fracture following percutaneous vertebral augmentation in postmenopausal women

PURPOSE

Subsequent vertebral fracture (SVF) is a severe advent event of percutaneous vertebral augmentation (PVA). However, the incidence and risk factors of SVF following PVA for OVCF in postmenopausal women remain unclear. This research aims to investigative the incidence and risk factors of SVF after PVA for OVCF in postmenopausal women.

METHODS

Women who underwent initial PVA for OVCF between August 2019 and December 2021 were reviewed. Univariate logistic regression analysis was performed to identify possible risk factors of SVF, and independent risk factors were determined by multivariate logistic regression.

RESULTS

A total of 682 women after menopause were enrolled in the study. Of these women, 100 cases had an SVF after PVA, with the incidence of 14.66%. Univariate logistic regression analysis demonstrated that age (p = 0.001), body mass index (BMI) (p < 0.001), steroid use (p = 0.008), history of previous vertebral fracture (p < 0.001), multiple vertebral fracture (p = 0.033), postoperative wedge angle (p = 0.003), and HU value (p < 0.001) were significantly correlated with SVF following PVA. Furthermore, BMI (OR [95%CI] = 0.892 [0.825 - 0.965]; p = 0.004), steroid use (OR [95%CI] = 3.029 [1.211 - 7.574]; p = 0.018), history of previous vertebral fracture (OR [95%CI] = 1.898 [1.148 - 3.139]; p = 0.013), postoperative wedge angle (OR [95%CI] = 1.036 [1.004 - 1.070]; p = 0.028), and HU value (OR [95%CI] = 0.980 [0.971 - 0.990]; p < 0.001) were identified as independent risk factors of SVF after PVA by multivariate logistic regression analysis.

CONCLUSIONS

The incidence of SVF following PVA for OVCF in postmenopausal women was 14.66%. BMI, steroid use, history of previous vertebral fracture, postoperative wedge angle, and HU value were independent risk factors of SVF after PVA for OVCF in postmenopausal women.

[Vertebral fractures combined with prolonged activated partial prothrombin time: A case report]

With the development of modern medical standards, autoimmune diseases and their associated successive osteoporosis have received increasing attention in recent years. Patients with autoimmune diseases, due to the characteristics of the disease and the prolonged use of glucocorticoid hormone therapy, may affect the bone formation and bone absorption of the patient, followed by severe successive osteoporosis, thereby increasing the risk of osteoporotic vertebral fractures. Vertebral compression fractures of the spine are common fracture types in patients with osteoporotic fractures. Osteoporosis is a common complication after glucocorticoid therapy in patients with autoimmune diseases. Percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) are minimally invasive operation and are commonly used surgical methods for the treatment of osteoporotic vertebral compression fractures. However, due to the operation of spinal puncture during the operation, there are serious surgical risks such as bone cement leakage, spinal epidural hemorrhage, subdural hemorrhage, and subarachnoid hemorrhage in both PVP and PKP. As a result, it is necessary to evaluate the patient' s body before surgery carefully, especially in the case of blood coagulation. This article reports a case of autoimmune disease patient admitted to Peking University People' s Hospital due to lumbar 4 vertebral compression fracture combined with Sjögren' s syndrome. The patient' s preoperative examination showed that the activated partial thromboplastin time (APTT) was significantly prolonged. After completing the APTT extended screening experiment and lupus anticoagulant factor testing, the multi-disciplinary team (MDT) of Peking University People' s Hospital jointly discussed the conclusion that the patient' s test results were caused by an abnormal self-immunity anti-copulant lupus (LAC). Based on the results of the laboratory examination, the patient was considered to be diagnosed with combined antiphospholipid syndrome (APS). For such patients, compared with the patient' s tendency to bleed, we should pay more attention to the risk of high blood clotting in the lower limbs of the patient, pulmonary clots and so on. With timely anti-coagulation treatment, the patient safely passed the peripheral period and was successfully discharged from the hospital. Therefore, for patients with autoimmune diseases with prolonged APTT in the perioperative period, doctors need to carefully identify the actual cause and carry out targeted treatment in order to minimize the risk of surgical and perioperative complications and bring satisfactory treatment results to the patients.

Percutaneous kyphoplasty through unilateral puncture on the convex side for the treatment of painful osteoporotic vertebral compression fracture with scoliosis

PURPOSE

To assess the clinical safety, accuracy, and efficacy of percutaneous kyphoplasty (PKP) surgery using an enhanced method of unilateral puncture on the convex side for the treatment of painful osteoporotic vertebral compression fractures (P-OVCF) with scoliosis.

METHODS

Clinical and radiographic data of P-OVCF patients with scoliosis who underwent PKP via unilateral puncture on the convex side from January 2018 to December 2021 were retrospectively analyzed. This technique's detailed surgical steps and tips were described. The local kyphosis angle (LKA), scoliosis Cobb angle (SCA), and local scoliosis Cobb angle (LSCA) were measured using X-ray and compared at pre-operation, post-operation, and the last follow-up. The width of pedicle (POW), inner inclination angle (IIA), lateral distance (LD), and puncture course length (PCL) were measured on the axial computed tomography image and compared between two sides. Postoperative computed tomography was employed to evaluate the condition of cement distribution and puncture. Clinical outcomes were evaluated using the Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) for back pain (BP).

RESULTS

Thirty-six patients, 23 women and 13 men, with an average age of 76.31 ± 6.28 years were monitored for 17.69 ± 4.70 months. The median surgical duration of single vertebrae was 35 min. The volume of bone cement for single vertebrae was 3.81 ± 0.87 ml and the proportion of sufficient cement distribution of the patients was 97.22. LKA was considerably improved from pre-operation to post-operation and sustained at the last follow-up. SCA and LSCA were not significantly modified between these three-time points. IIA, PCL, and LD were lower on the convex side than on the concave side. POW was considerably wider on the convex side. The ODI and VAS-BP scores were significantly improved after surgery and sustained during the follow-up.

CONCLUSIONS

Combining with the proper assessment of the pre-injured life status of patients, PKP surgery using unilateral puncture on the convex side for the treatment of P-OVCF with scoliosis can achieve safe, excellent clinical, and radiographic outcomes.

A Deep-Learning Model for Diagnosing Fresh Vertebral Fractures on Magnetic Resonance Images

BACKGROUND

The accurate diagnosis of fresh vertebral fractures (VFs) was critical to optimizing treatment outcomes. Existing studies, however, demonstrated insufficient accuracy, sensitivity, and specificity in detecting fresh fractures using magnetic resonance imaging (MRI), and fall short in localizing the fracture sites.

METHODS

This prospective study comprised 716 patients with fresh VFs. We obtained 849 Short TI Inversion Recovery (STIR) image slices for training and validation of the AI model. The AI models employed were yolov7 and resnet50, to detect fresh VFs.

RESULTS

The AI model demonstrated a diagnostic accuracy of 97.6% for fresh VFs, with a sensitivity of 98% and a specificity of 97%. The performance of the model displayed a high degree of consistency when compared to the evaluations by spine surgeons. In the external testing dataset, the model exhibited a classification accuracy of 92.4%, a sensitivity of 93%, and a specificity of 92%.

CONCLUSIONS

Our findings highlighted the potential of AI in diagnosing fresh VFs, offering an accurate and efficient way to aid physicians with diagnosis and treatment decisions.

The Effect of Kyphoplasty on Opioid Use in Patients With Vertebral Compression Fractures

Objective The primary objective of this study was to assess opioid use in the 90 days following kyphoplasty (KP) compared to the period between compression fracture and KP. Methods All patients aged 50-85 who underwent KP following a newly diagnosed vertebral compression fracture (VCF) at a large, urban academic medical center between January 1st, 2015, and January 1st, 2023, were screened for inclusion. Patients were excluded if they had an opioid prescription in the month prior to the compression fracture, had a history of malignancy, or underwent concomitant or other surgical procedures in the 90 days following KP. Opioid measures, including the prescribed amount of morphine milliequivalents (MME) per day, number of opioid days, and total MME (MME per day x number of opioid days), in addition to numerical rating scale (NRS) pain scores, were analyzed pre- and post-KP. Results A total of 27 patients met the eligibility criteria, with a mean age of 69.7 and 59.2% being female. Sixteen patients (59%) had received an opioid prescription between compression fracture and KP (opioid group). The median differences pre- and post-KP in prescribed MMEs per day, number of opioid days, and total MMEs were 17.7 (p=.0009), 11.0 (p=.0004), and 232.5 (p<.0001), respectively. There was a significant difference in NRS pain scores in both the opioid group (6.25, p<.0001) and the non-opioid group (4.36, p<.0001) pre- and post-KP. Conclusion Our findings suggest that KP may be associated with a reduction in both opioid use and pain scores in opioid-naïve patients with VCFs. Larger studies that directly compare KP to conservative management are needed to fully assess the impact of KP on opioid and pain outcome measures.

Lateral Lumbar Interbody Fusion within Three-level for Patients with Neurological Symptoms due to Vertebral Fragility Fractures in the Lumbar Spine

There is a lack of agreement on whether minimally invasive lateral lumbar intervertebral fusion (LLIF) is a suitable treatment option for vertebral fragility fractures (VFFs). Hence, we sought to evaluate the efficacy and safety of LLIF in the management of VFF with neurological deficits in the lumbar spine. Between April 2015 and March 2020, we conducted a retrospective observational study of patients with VFF treated with three-level or less LLIF. The participants had previously received conservative treatment but had not been able to control their neurological symptoms. To assess the outcomes of the LLIF procedures, the patients were followed up for a minimum of 1 year. Clinical and radiological results, which include the timing and location of the bony fusion, were analyzed. The study involved 19 patients with 23 vertebral fracture levels. The residual height of the fractured vertebra was found to be 57.0 ± 12.3% of the height of the adjacent level. The mean Japanese Orthopedic Association score significantly improved postoperatively. Postoperative radiological parameters were significantly maintained at 1 year, and lumbar lordosis was maintained at the last follow-up (45.0 ± 26.7). In total 31 LLIF levels, bone fusion was observed in four levels at 6 months postoperatively, in 16 levels at 1 year, and in 23 levels at the last follow-up. The facet joint had the highest bony fusion location. LLIF within three levels can be safely performed in certain VFF cases with sufficient residual vertebral height.

Risk Factors for Residual Back Pain After PVP Treatment for osteoporotic Thoracolumbar Compression Fractures: A Retrospective Cohort Study

OBJECTIVES

To explore the risk factors of residual back pain after percutaneous vertebroplasty (PVP) in patients with osteoporotic vertebral compression fracture (OVCF).

METHODS

We retrospectively reviewed the records of 675 patients with OVCF treated with PVP from January 2015 to January 2020. Postoperative back pain intensity was assessed by the VAS score. Residual back pain was defined as the presence of postoperative moderate-severe pain (average VAS score≥4), and the variables included patient characteristics, baseline symptoms, imaging data and operation-related factors. Risk factors were identified with univariate and multivariate logistic regression analysis.

RESULTS

Residual back pain occurred in 46 of the 675 patients included in the study, with an incidence rate of 6.8%. Multivariate logistic regression analysis showed that low Pre-BMD (OR = 3.576, P = 0.041), multiple vertebral fractures (OR = 2.795, P = 0.026), posterior fascia injury (OR = 4.083, P = 0.032), cement diffusion volume rate <0.2 (OR = 3.507, P = 0.013), facet joint violation (OR = 11.204, P < 0.001), and depression (OR = 3.562, P = 0.035) were positively correlated with residual back pain after PVP.

CONCLUSIONS

Low pre-BMD (pre-bone mineral density), multiple vertebral fractures, posterior fascia injury, cement diffusion volume rate <0.2, facet joint violation and depression were the independent risk factors of residual back pain after PVP.

Vertebral augmentation: an overview

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

Case report: Basivertebral nerve block during vertebral augmentation: an alternative approach to intraprocedural pain management

Osteoporotic compression fractures can be treated with vertebral augmentation. Since intraprocedural pain is common during vertebral body endplate manipulation, these procedures are often performed with conscious sedation or general anesthesia. Research has shown that vertebral endplates are innervated by the basivertebral nerve (BVN), which has been successfully targeted via radiofrequency ablation to treat chronic vertebrogenic lower back pain. With this physiology in mind, we evaluated if temporary BVN block would provide sufficient analgesia so that patients could forego sedation during percutaneous vertebral augmentation. Ten patients with single-level vertebral compression fractures were selected. Prior to balloon augmentation, temporary intraosseous BVN block was achieved using 2% lidocaine injection. All ten patients successfully completed their procedure without intraprocedural sedative or narcotic medications, and without significant deviation from baseline vital signs. Temporary BVN block can be used as intraprocedural anesthesia in select patients who may be poor candidates for general anesthesia or conscious sedation.

Advances in Animal Models for Studying Bone Fracture Healing

Fracture is a common traumatic injury that is mostly caused by traffic accidents, falls, and falls from height. Fracture healing is a long-term and complex process, and the mode of repair and rate of healing are influenced by a variety of factors. The prevention, treatment, and rehabilitation of fractures are issues that urgently need to be addressed. The preparation of the right animal model can accurately simulate the occurrence of fractures, identify and observe normal and abnormal healing processes, study disease mechanisms, and optimize and develop specific treatment methods. We summarize the current status of fracture healing research, the characteristics of different animal models and the modeling methods for different fracture types, analyze their advantages and disadvantages, and provide a reference basis for basic experimental fracture modeling.

Elevated Red Blood Cell Distribution Width Is Associated with Poor Prognosis in Fractured Patients Admitted to Intensive Care Units

OBJECTIVES

Red blood cell distribution width (RDW) with prognosis in various infectious diseases. For fractured patients admitted to the intensive care units (ICU), an accurate and fast appraisal is essential. To investigate the association between RDW and prognosis in fractured patients admitted to the ICU utilizing the MIMIC-III database.

METHODS

A retrospective cohort from the MIMIC III database from 2001 and 2012 was constructed. RDW and other information were collected with in-hospital mortality as the primary outcome and 90-day mortality and hospital and intensive care unit (ICU) length of stay (LOS) as secondary outcomes. Univariate and multivariate logistic regression models with propensity score inverse probability of treatment weighting (IPTW) were used to investigate the prognostic value of RDW. A nomogram was built with significant prognostic factors to predict in-hospital mortality, and the performance of the nomogram was evaluated and compared with other severity assessment scores. Subgroup analysis was also conducted.

RESULTS

A total of 2721 fracture patients admitted to the ICU were identified. After IPTW, the group with higher RDW was significantly associated with elevated in-hospital mortality (odds ratio [OR]: 1.68, 95% confidence interval [CI]: 1.19-2.37), 90-day mortality (OR: 1.39, 95% CI: 1.04-1.86), prolonged hospital LOS (OR: 1.25, 95% CI: 1.03-1.50), and ICU LOS significantly (OR: 1.26, 95% CI: 1.05-1.53) in the multivariate logistics model. The nomogram showed optimal discriminative ability and predictive accuracy with an area under the receiver operating characteristic curve of 0.77.

CONCLUSION

RDW independently predicted in-hospital mortality, 90-day mortality, and hospital and ICU LOS in fractured patients admitted to ICU. The nomogram including RDW could also be a promising tool with potential clinical benefits.

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

Introduction

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

Objective

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

Methods

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

Results

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

Conclusion

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

Multidisciplinary Care of a Vertebral Fracture in a Patient with Hematopoietic Stem Cell Transplant: Safety Appropriateness in Interventional Pain Management and Rehabilitation Considerations

Bone loss leading to fragility fracture is a highly prevalent late effect in hematopoietic stem-cell transplant patients, who are affected 8–9 times more than the general population, particularly for vertebral compression fractures. Spinal interventions such as lumbar epidural steroid injections and vertebral augmentation may be helpful for providing pain relief and improved function, quality of life and return to ambulation. However, interventional procedures should be approached with caution in these patients. Our study found that there is a paucity of scientific studies addressing the risks of spinal injections in these patients and there is no absolute recommendation specific to spinal injections in patients receiving immunosuppressive agents or who have a history of solid organ or hematopoietic stem cell transplant. It is imperative to consider proper timing of the intervention to minimize risks while optimizing the benefits of the intervention combined with a well-defined post-transplant rehabilitation plan. Moreover, the decision to proceed with spinal interventions should be done case by case and with caution. Therefore, this article reports the case of a multidisciplinary treatment for a vertebral compression fracture in a patient with a hematopoietic stem-cell transplant, in particular discussing safety appropriateness in interventional pain management and rehabilitation considerations for this condition in this patient population.

Changes in T2 Relaxation Time Mapping of Intervertebral Discs Adjacent to Vertebrae after Kyphoplasty Correlate with the Physical Clinical Outcome of Patients

(1) Background: To assess whether clinical outcomes correlate with tissue changes in the intervertebral discs (IVDs) after kyphoplasty as treatment for vertebral fractures, quantitative MRI was applied. (2) Methods: Quantitative T2 mapping acquired in a 3 T MRI scanner of the thoracolumbar spine was performed in 20 patients two years after kyphoplasty. The IVDs adjacent and nonadjacent to the treated vertebrae were divided into six regions of interest (ROI), which were further categorised into inner (ROI 2–5) and outer (ROI 1 and 6) parts of the IVDs, and the T2 values were analysed. T2 values of adjacent discs were correlated with the items of questionnaires evaluating the clinical outcome (i.e., 36-Item Short Form Survey). (3) Results: Lower T2 values in adjacent IVDs correlated with poorer physical outcome two years after kyphoplasty. The inner part of the IVDs adjacent to treated vertebrae showed statistically significant lower T2 values in segments L2/L3 and L3/L4 compared to nonadjacent ones. Patients with lower T2 values showed more pain and physical limitations in everyday life. (4) Conclusions: Quantitative T2 mapping can detect IVD degeneration in patients after kyphoplasty and correlates with the physical outcome. This technique could help to gain better insights into alterations in tissue composition following kyphoplasty and the consequences for the patients’ quality of life.

Better vertebrae remodeling in pediatric spinal eosinophilic granuloma patients treated with kyphoplasty and short-term posterior instrumentation: A minimal two-year follow-up with historical controls

OBJECTIVE

To assess the validity and safety of kyphoplasty combined with short-term posterior instrumentation to treat children with vertebrae plana due to eosinophilic granuloma (EG).

PATIENTS AND METHODS

Clinical data of EG patients, who received kyphoplasty and short-term instrumentation from March 2019 to March 2020, were retrospectively reviewed. The recovery of diseased vertebrae was assessed and compared with historical case data.

RESULTS

Nine patients with EG had received kyphoplasty and short-term posterior instrumentation. The mean age at initial treatment was 66.7 months old (range, 28-132 months). The average number of follow-up months was 26.7. (range, 24-30 months).Four and 5 cases presented with thoracic and lumbar vertebral destruction, respectively. Under Garg's classification, 7 and 2 cases were classified as Grade IIA and IIB, respectively. The average diseased vertebral heights at 1-year and 2-year after surgery were significantly higher than the preoperative heights. The average percentages of diseased vertebral heights to references at 1-year and 2-year after surgery were 72.0% and 86.0%, respectively. The average percentage of diseased vertebral heights to the references at 2-year after surgery was significantly higher than that of the historical cases at the same time. No minor or major adverse events were observed.

CONCLUSIONS

Transpedicular balloon kyphoplasty for the direct restoration of vertebrae plana seems feasible and safe in combination with short-term posterior instrumentation. Better short-time vertebrae remodeling was observed 2 years after surgery. Active surgical treatment is suggested for children who have vertebrae plana as a result of EG in order to maintain the ability to recover vertebral height.

Risk factors of new vertebral compression fracture after percutaneous vertebroplasty or percutaneous kyphoplasty

BACKGROUND

New vertebral compression fracture (VCF) may occur in patients who underwent percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP) for osteoporotic vertebral compression fracture (OVCF). However, the risk factors of new VCF remain controversial. The research aimed to analyze the risk factors of new VCF after PVP or PKP.

METHODS

From August 2019 to March 2021, we retrospectively analyzed the patients who underwent PVP or PKP for OVCF at our institution. Age, gender, body mass index (BMI), smoking, drinking, hypertension, diabetes, fracture location, surgical method, Hounsfield unit (HU) value, preoperative degree of anterior vertebral compression (DAVC), bisphosphonates, bone cement volume, bone cement leakage, and cement distribution were collected. The risk factors were obtained by univariate and multivariate analysis of the data.

RESULTS

A total of 247 patients were included in the study. There were 23 patients (9.3%) with new VCF after PVP or PKP. Univariate analysis showed that age (p < 0.001), BMI (p = 0.002), fracture location (p = 0.030), and a low HU value (p < 0.001) were significantly associated with new VCF after PVP or PKP. A low HU value was an independent risk factor for new VCF after PVP or PKP obtained by multivariate regression analysis (OR = 0.963; 95% CI, 0.943-0.984, p = 0.001).

CONCLUSIONS

In this study, a low HU value was an independent risk factor of new VCF after PVP or PKP.

Does time-to-surgery affect mortality in patients with acute osteoporotic vertebral compression fractures?

Introduction

Osteoporotic vertebral compression fractures (VCFs) are common. An increase in mortality associated with osteoporotic VCFs has been well documented. The purpose of this study was to assess the impact of time to surgery on 1-year survival in patients with osteoporotic vertebral compression fractures.

Methods

In a retrospective cohort study with prospective mortality follow-up, consecutive patients aged ≥ 60 years who had operative treatment of a low-energy fracture of a thoracolumbar vertebra and had undergone surgical stabilization between January 2015 and December 2018 were identified from our institutional database. By chart review, additional information on hospitalization time, comorbidities (expressed as ASA - American Society of Anesthesiologists Scale), complications and revision surgery was obtained. Time-to-surgery was defined as the time between admission and surgery. Mortality data was assessed by contacting the patients by phone, mail or the national social insurance database.

Results

Two hundred sixty patients (mean age 78 years, SD 7 years, range, 60 to 93; 172 female) were available for final analysis. Mean follow-up was 40 months (range, 12 to 68 months). Fifty-nine patients (22.7%) had died at final follow-up and 27/260 patients (10.4%) had died within 1 year after the surgery. Time-to-surgery was not different for patients who died within 1 year after the surgery and those who survived (p = .501). In-hospital complications were seen in 40/260 (15.4%) patients. Time-to-surgery showed a strong correlation with hospitalization time (Pearson’s r = .614, p < .001), but only a very weak correlation with the time spent in hospital after the surgery (Pearson’s r = .146, p = .018).

Conclusions

In contrast to patients with proximal femur factures, time-to-surgery had no significant effect on one-year mortality in geriatric patients with osteoporotic vertebral compression fractures. Treatment decisions for these fractures in the elderly should be individualized.

Interventional Procedures for Vertebral Diseases: Spinal Tumor Ablation, Vertebral Augmentation, and Basivertebral Nerve Ablation-A Scoping Review

Low back pain is consistently documented as the most expensive and leading cause of disability. The majority of cases have non-specific etiologies. However, a subset of vertebral diseases has well-documented pain generators, including vertebral body tumors, vertebral body fractures, and vertebral endplate injury. Over the past two decades, specific interventional procedures targeting these anatomical pain generators have been widely studied, including spinal tumor ablation, vertebral augmentation, and basivertebral nerve ablation. This scoping review summarizes safety and clinical efficacy and discusses the impact on healthcare utilization of these interventions. Vertebral-related diseases remain a top concern with regard to prevalence and amount of health care spending worldwide. Our study shows that for a subset of disorders related to the vertebrae, spinal tumor ablation, vertebral augmentation, and basivertebral nerve ablation are safe and clinically effective interventions to decrease pain, improve function and quality of life, and potentially reduce mortality, improve survival, and overall offer cost-saving opportunities.

Systematic Review and Meta-Analysis of 3 Treatment Arms for Vertebral Compression Fractures: A Comparison of Improvement in Pain, Adjacent-Level Fractures, and Quality of Life Between Vertebroplasty, Kyphoplasty, and Nonoperative Management

BACKGROUND

Osteoporotic vertebral fractures (OVFs) have become increasingly common, and previous nonrandomized and randomized controlled trials (RCTs) have compared the effects of cement augmentation versus nonoperative management on the clinical outcome. This meta-analysis focuses on RCTs and the calculated differences between cement augmentation techniques and nonsurgical management in outcome (e.g., pain reduction, adjacent-level fractures, and quality of life [QOL]).

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, and the following scientific search engines were used: MEDLINE, Embase, Cochrane, Web of Science, and Scopus. The inclusion criteria included RCTs that addressed different treatment strategies for OVF. The primary outcome was pain, which was determined by a visual analog scale (VAS) score; the secondary outcomes were the risk of adjacent-level fractures and QOL (as determined by the EuroQol-5 Dimension [EQ-5D] questionnaire, the Oswestry Disability Index [ODI], the Quality of Life Questionnaire of the European Foundation for Osteoporosis [QUALEFFO], and the Roland-Morris Disability Questionnaire [RDQ]). Patients were assigned to 3 groups according to their treatment: vertebroplasty (VP), kyphoplasty (KP), and nonoperative management (NOM). The short-term (weeks), midterm (months), and long-term (>1 year) effects were compared. A random effects model was used to summarize the treatment effect, including I2 for assessing heterogeneity and the revised Cochrane risk-of-bias 2 (RoB 2) tool for assessment of ROB. Funnel plots were used to assess risk of publication bias. The log of the odds ratio (OR) between treatments is reported.

RESULTS

After screening of 1,861 references, 53 underwent full-text analysis and 16 trials (30.2%) were included. Eleven trials (68.8%) compared VP and NOM, 1 (6.3%) compared KP and NOM, and 4 (25.0%) compared KP and VP. Improvement of pain was better by 1.31 points (95% confidence interval [CI], 0.41 to 2.21; p < 0.001) after VP when compared with NOM in short-term follow-up. Pain effects were similar after VP and KP (midterm difference of 0.0 points; 95% CI, -0.25 to 0.25). The risk of adjacent-level fractures was not increased after any treatment (log OR, -0.16; 95% CI, -0.83 to 0.5; NOM vs. VP or KP). QOL did not differ significantly between the VP or KP and NOM groups except in the short term when measured by the RDQ.

CONCLUSIONS

This meta-analysis provides evidence in favor of the surgical treatment of OVFs. Surgery was associated with greater improvement of pain and was unrelated to the development of adjacent-level fractures or QOL. Although improvements in sagittal balance after surgery were poorly documented, surgical treatment may be warranted if pain is a relevant problem.

LEVEL OF EVIDENCE

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

A deep-learning model for identifying fresh vertebral compression fractures on digital radiography

OBJECTIVES

To develop a deep-learning (DL) model for identifying fresh VCFs from digital radiography (DR), with magnetic resonance imaging (MRI) as the reference standard.

METHODS

Patients with lumbar VCFs were retrospectively enrolled from January 2011 to May 2020. All patients underwent DR and MRI scanning. VCFs were categorized as fresh or old according to MRI results, and the VCF grade and type were assessed. The raw DR data were sent to InferScholar Center for annotation. A DL-based prediction model was built, and its diagnostic performance was evaluated. The DeLong test was applied to assess differences in ROC curves between different models.

RESULTS

A total of 1877 VCFs in 1099 patients were included in our study and randomly divided into development (n = 824 patients) and test (n = 275 patients) datasets. The ensemble model identified fresh and old VCFs, reaching an AUC of 0.80 (95% confidence interval [CI], 0.77-0.83), an accuracy of 74% (95% CI, 72-77%), a sensitivity of 80% (95% CI, 77-83%), and a specificity of 68% (95% CI, 63-72%). Lateral (AUC, 0.83) views exhibited better performance than anteroposterior views (AUC, 0.77), and the best performance among respective subgroupings was obtained for grade 3 (AUC, 0.89) and crush-type (AUC, 0.87) subgroups.

CONCLUSION

The proposed DL model achieved adequate performance in identifying fresh VCFs from DR.

KEY POINTS

• The ensemble deep-learning model identified fresh VCFs from DR, reaching an AUC of 0.80, an accuracy of 74%, a sensitivity of 80%, and a specificity of 68% with the reference standard of MRI. • The lateral views (AUC, 0.83) exhibited better performance than anteroposterior views (AUC, 0.77). • The grade 3 (AUC, 0.89) and crush-type (AUC, 0.87) subgroups showed the best performance among their respective subgroupings.

Exploration of percutaneous vertebroplasty in the treatment of osteoporotic vertebral compression fracture as day surgery: a retrospective study

BACKGROUND

The purpose of this retrospective study was to evaluate and compare the clinical outcomes of patients underwent PVP for OVCF as day surgery with the outcomes of patients managed as traditional inpatients.

METHODS

According to the selection criteria, patients who underwent PVP for single-segment thoracolumbar OVCF were included retrospectively in the day surgery procedure (DSP) group and the traditional inpatient procedure (TIP) group between April 2018 and September 2019. The visual analog scale score (VAS) and Oswestry Disability Index (ODI) score were recorded preoperatively and 1 day, 1 week, 1 month, 3 months, 6 months, and 12 months after surgery. Duration of hospital stay, preoperative waiting time, hospital cost, and postoperative complications were recorded and analyzed.

RESULTS

A total of 335 patients (53 in DSP group; 282 in TIP group) were enrolled and completed 12-month follow-up. The mean duration of hospital stay, the mean preoperative waiting time, and the mean hospital costs were significant lower in the DSP group. The postoperative VAS and ODI scores in both groups were significantly improved after surgery. Moreover, both VAS and ODI scores at each follow-up stage were also significantly lower than the previous follow-up stage. However, the ODI score in the DSP group was significantly lower at 1-day, 1-week, 1-month, and 3-month follow-up, respectively. For cement leakage and secondary vertebral compression fractures, there was no statistical difference between the two groups.

CONCLUSIONS

We suggest that PVP for OVCFs in day surgery procedure is worthy of wide application.

Efficacy and Safety of Balloon Kyphoplasty for Pathological Vertebral Fractures in Patients with Hematological Malignancies in Our Institution

Objective Patients with hematological malignancies, particularly those with multiple myeloma, often suffer from pathological vertebral compression fractures (VCFs). Consequent and significant spinal pain and paralysis impair the activities of daily living and quality of life and delay subsequent chemotherapy. Balloon kyphoplasty (BKP), which is less invasive than conventional therapies, is a type of percutaneous vertebroplasty in which cement is injected into the broken vertebrae to stabilize the spinal column. The present study assessed the effect of BKP on hematological tumors. Methods We retrospectively analyzed five myeloma patients and one lymphoma patient who underwent BKP for pathological VCFs in our institution. Results The median age was 74 years old. The spinal operation level ranged from T2 to L4. BKP was performed at the diagnosis in two cases, after first-line chemotherapy in one case, and after subsequent chemotherapy in three cases. After approximately 1 month, the patients' average Eastern Cooperative Oncology Group performance status score rapidly improved from 3.2 to 1.3. The numeric rating scale score decreased from 8.8 to 2.0, and the Karnofsky Performance Status score increased from 35 to 75. No severe complications were observed. All patients became able to walk unassisted and underwent early subsequent chemotherapy. Conclusion BKP can be a safe and effective treatment option for pathological VCFs in patients with hematological malignancies and allows for rapid induction with subsequent chemotherapy.

Kyphoplasty versus percutaneous posterior instrumentation for osteoporotic vertebral fractures with posterior wall injury: a propensity score matched cohort study

Background

Osteoporotic vertebral fractures (OVFs) that present with posterior wall cortical injury pose a higher risk for instability. Surgical management includes standard cement augmentation techniques like balloon kyphoplasty (BKP) or percutaneous posterior instrumentation with pedicle screws (PS) or both. Neither treatment has yet demonstrated superiority, and posterior cement leakage is of special concern in these fractures.

Methods

At a single tertiary care center, 25 patients with 32 OVFs with posterior wall injury treated with percutaneous instrumentation and cement augmentation (PS group) were retrospectively included and matched (1:1) using propensity scores to 25 patients with 29 OVFs with posterior wall injury treated with standalone BKP (BKP group) from 2010 to 2018. Our primary study aim identified 30-day morbidity rates using a 4-point grading system by comparing BKP with and without percutaneous instrumentation with PS for the treatment of OVFs with posterior wall injury. Our secondary aims evaluated cement leakage, radiographic results, surgical time, length of stay (LOS), pain relief, and subsequent fractures.

Results

Overall 30-day morbidity was 34% and did not differ between groups (24% BKP vs. 44% PS groups, P=0.136). Most complications were mild (82.4%), requiring no interventions beyond drug treatment. In the PS group, a trend towards more mild complications was observed (16% vs. 40%, P=0.059). Moderate and severe complications affected 17.6% of all morbidity cases and were comparable between groups. Asymptomatic cement leakage into the spinal canal was noted in 2 (8%) BKP patients and symptomatic pulmonary cement embolism in 1 (4.8%) PS patient. Compared with baseline, all radiographic parameters significantly improved in both groups. In the BKP group, mean surgical times (52±32.9 vs. 164.9±48.4 minutes, P<0.001) and LOS (4.3±2.5 vs. 7±2.9 days, P<0.001) were significantly shorter, and use of opioids at discharge was significantly lower (52% vs. 84%, P=0.015). At 3-month follow-up, no differences between groups were seen in back pain, use of opioids, and occurrence of subsequent OVFs. Follow-up averaged 8.4 months.

Conclusions

Standalone BKP may be a viable option for the treatment of OVFs even in the presence of posterior wall cortical injury.

[Minimally invasive stabilization of thoracolumbar osteoporotic fractures]

BACKGROUND

Minimally invasive stabilization of thoracolumbar osteoporotic fractures (OF) in neurologically intact patients is well established. Various posterior and anterior surgical techniques are available. The OF classification and OF score are helpful for defining the indications and choice of operative technique.

OBJECTIVE

This article gives an overview of the minimally invasive stabilization techniques, typical complications and outcome.

MATERIAL AND METHODS

Selective literature search and description of surgical techniques and outcome.

RESULTS

Vertebral body augmentation alone can be indicated in painful but stable fractures of types OF 1 and OF 2 and to some extent for type OF 3. Kyphoplasty has proven to be an effective and safe procedure with a favorable clinical outcome. Unstable fractures and kyphotic deformities (types OF 3-5) should be percutaneously stabilized from posterior. The length of the pedicle screw construct depends on the extent of instability and deformity. Bone cement augmentation of the pedicle screws is indicated in severe osteoporosis but increases the complication rate. Restoration of stability of the anterior column can be achieved through additional vertebral body augmentation or rarely by anterior stabilization. Clinical and radiological short and mid-term results of the stabilization techniques are promising; however, the more invasive the surgery, the more complications occur.

CONCLUSION

Minimally invasive stabilization techniques are safe and effective. The specific indications for the individual procedures are guided by the OF classification and the individual clinical situation of the patient.

Vertebral fragility fractures: clinical and radiological results of augmentation and fixation-a systematic review of randomized controlled clinical trials

AIM

To assess the outcome of augmentation techniques, i.e., percutaneous vertebroplasty (PVP), balloon kyphoplasty (BKP), vertebral body stenting (VBS) and fixation techniques in the management of vertebral fragility fractures (VFFs).

METHODS

OVID-MEDLINE®, EMBASE, Cochrane Library, SCOPUS, Springer Link, Web of Science, Google Scholar and PubMed were searched from January 2009 to February 2019 to identify relevant studies. The methodological qualities of the studies were evaluated and relevant data were extracted.

RESULTS

Thirteen randomized controlled trials, recruiting 1963 patients, were included. PVP, compared with conservative management (CM), showed a greater pain relief and an improved vertebral body height (VBH) restoration. Moreover, PVP revealed superior to a sham procedure for pain relief in acute VFFs. BKP, compared with CM, rapidly reduces pain and improves quality of life without increasing the risk of additional VFFs. BKP, compared with PVP, has fewer cement leakage rates and is more effective in VBH restoration. BKP should also be preferred to VBS, since it is associated with less material-related complications. Pedicle screw fixation associated with PVP, compared with PVP alone, revealed effective in preventing secondary VFFs.

CONCLUSIONS

BKP showed better clinical and radiological outcomes compared with CM and PVP. BKP revealed as effective as VBS in VBH restoration with less material-related complications.

Current Concepts in the Management of Vertebral Compression Fractures

PURPOSE OF REVIEW

This comprehensive review of current concepts in the management of vertebral compression fractures is a manuscript of vertebral augmentation literature of risk factors, clinical presentation, and management. The objective of this review is to compare outcomes between multiple augmentation techniques and ongoing discussions of effectiveness of vertebral augmentation procedures.

RECENT FINDINGS

Vertebral compression fractures (VCFs) are a prevalent disease affecting approximately 1.5 million US adults annually. VCFs can cause severe physical limitations, including back pain, functional disability, and progressive kyphosis of the thoracic spine that ultimately results in decreased appetite, poor nutrition, impaired pulmonary function, and spinal cord compression with motor and sensory deficits. The deconditioning that affects patients with vertebral compression fractures leads to mortality at a far higher rate than age-matched controls. The management of vertebral compression fractures has been extensively discussed with opponents arguing in favor or restricting conservative management and against augmentation, while proponents argue in favor of augmentation. The literature is well established in reference to the effects on mortality when patients undergo treatment with vertebral augmentation; in over a million patients with vertebral compression fractures treated with vertebral augmentation as compared with patients treated with non-surgical management, the patients receiving augmentation performed well with a decrease in morbidity and mortality. Summary of the literature review shows that understanding the risk factors, appropriate clinical evaluation, and management strategies are crucial. Analysis of the evidence shows, based on level I and II studies, balloon kyphoplasty had significantly better and vertebroplasty tended to have better pain reduction compared with non-surgical management. In addition, balloon kyphoplasty tended to have better height restoration than vertebroplasty.

Usefulness of Fat Suppression Magnetic Resonance Imaging of Osteoporotic Vertebral Fractures in Preventing Subsequent Fractures After Kyphoplasty

BACKGROUND

Preoperative magnetic resonance imaging with fat suppression (FS-MRI) is useful to detect bone marrow edema in osteoporotic vertebral fractures (OVFs) and thus can improve diagnostic accuracy and influence surgical strategy for percutaneous augmentation. The role of preoperative FS-MRI in preventing subsequent fractures after balloon kyphoplasty has not been investigated in initially subclinical fractures or fractures without obvious morphologic changes.

METHODS

From January 2010 to December 2017, 214 consecutive patients underwent balloon kyphoplasty for painful OVFs. We defined 2 groups based on preoperative imaging (100 patients had preoperative FS-MRI and 114 patients had no MRI) and then compared baseline and surgical characteristics. The primary end point was incidence of subsequent fractures within 12 months after treatment.

RESULTS

The 214 patients underwent kyphoplasty of 414 vertebrae. Comparing FS-MRI with no-MRI groups, spontaneous fractures occurred significantly more (58% vs. 26.3%; P < 0.001) and fractures were more often multilevel (≥ 4 levels) (15% vs. 2.6%; P = 0.001), respectively. Overall incidence of subsequent vertebral fractures was 25.7% (32% in FS-MRI, 20.2% in no-MRI groups; P = 0.048). Average time to diagnosis of subsequent fractures did not differ between the 2 groups (9.3 FS-MRI vs. 11.5 weeks no-MRI; P = 0.411). Age ≥80 years at the time of balloon kyphoplasty was associated with a higher odds ratio (2.3) for subsequent fractures within 12 months (P = 0.039).

CONCLUSIONS

Surgical treatment according to preoperative FS-MRI did not reduce occurrence of subsequent OVFs and did not prolong fracture-free intervals within 12 months after kyphoplasty.

Clinical comparison between a percutaneous hydraulic pressure delivery system and balloon tamp system using high-viscosity cement for the treatment of osteoporotic vertebral compression fractures

OBJECTIVES

Osteoporotic vertebral compression fractures (OVCFs) affect the elderly population, especially postmenopausal women. Percutaneous kyphoplasty is designed to treat painful vertebral compression fractures for which conservative therapy has been unsuccessful. High-viscosity cement can be injected by either a hydraulic pressure delivery system (HPDS) or a balloon tamp system (BTS). Therefore, the purpose of this study was to compare the safety and clinical outcomes of these two systems.

METHODS

A random, multicenter, prospective study was performed. Clinical and radiological assessments were carried out, including assessments of general surgery information, visual analog scale, quality of life, cement leakage, and height and angle restoration.

RESULTS

Using either the HPDS or BTS to inject high-viscosity cement effectively relieved pain and improved the patients' quality of life immediately, and these effects lasted at least two years. The HPDS using high-viscosity cement reduced cost, surgery time, and radiation exposure and showed similar clinical results to those of the BTS. In addition, the leakage rate and the incidence of adjacent vertebral fractures after the HPDS treatment were reduced compared with those after treatment using the classic vertebroplasty devices. However, the BTS had better height and angle restoration abilities.

CONCLUSIONS

The percutaneous HPDS with high-viscosity cement has similar clinical outcomes to those of traditional procedures in the treatment of vertebral fractures in the elderly. The HPDS with high-viscosity cement is better than the BTS in the treatment of mild and moderate OVCFs and could be an alternative method for the treatment of severe OVCFs.

ISASS Policy 2018-Vertebral Augmentation: Coverage Indications, Limitations, and/or Medical Necessity

The ISASS Policy Statement on vertebral augmentation has the objectives to provide a background and an update with the latest clinical evidence for the international spine community. A SpineLine Panel Review (2010) appropriately recommended an exploration of "the seeming disconnect between the conclusions of … two [Level I] PRCT's and previous experience and data" regarding vertebral augmentation. ISASS responded by supporting a comprehensive meta-analysis to help frame a cogent historical analysis of vertebral augmentation. This ISASS Policy 2018 is based on a thorough literature search for relevant studies, including systematic reviews and meta-analyses, that are subjected to thorough quality appraisal for the purpose of informing public opinion and decision making. Given the abundance of high-quality information, ISASS can confidently advocate that there is strong support for vertebral augmentation in the treatment of symptomatic vertebral compression fractures.

Comparative efficacy and tolerability of three treatments in old people with osteoporotic vertebral compression fracture: a network meta-analysis and systematic review

PURPOSE

The question which kind of methods is most suitable for treating the old people for osteoporotic vertebral compression fracture is still discussed and pairwise meta-analyses cannot get hierarchies of these treatments. Our aim is to integrate the evidence to provide hierarchies of the comparative efficacy measured by the change of VAS (Visual Analogue Scale) and tolerability measured by incidence of new fractures and risk of all-cause discontinuation on three treatments (percutaneous vertebroplasty (PVP)、balloon kyphoplasty (BK) and conservative treatment (CT)).

METHODS

We performed a Bayesian-framework network meta-analysis of randomized controlled trials (RCTs) to compare three treatments for the old people with osteoporotic vertebral compression fracture. The eligible RCTs were identified by searching Amed, British Nursing Index, Embase, Pubmed, the Cochrane Central Register of Controlled Trials (CENTRAL), Google scholar, SIGLE, the National Technical Information Service, the National Research Register (UK) and the Current Controlled Trials databases. Data from three outcomes (e.g. VAS, risk of all-cause discontinuation and incidence of new fractures) were independently extracted by two authors.

RESULTS

A total of five RCTs were finally included into this article. PVP and BK significantly decreased VAS when compared with CT. BK had a significantly lower risk of all-cause discontinuation contrast to CT. Three treatments (BK, PVP and CT) had no significant differences in the incidence of new fractures.

CONCLUSIONS

PVP may be the best way to relieve pain, CT might lead to the lowest incidence of new fractures and BK might had the lowest risk of all-cause discontinuation in old people with osteoporotic vertebral compression fracture. More large-scale and longer duration of follow-up studies are needed.