Establishment and Verification of a Predictive Nomogram for New Vertebral Compression Fracture Occurring after Bone Cement Injection in Middle-Aged and Elderly Patients with Vertebral Compression Fracture

What Risk Factors Are Associated With Recurrent Osteoporotic Vertebral Compression Fractures After Percutaneous Vertebral Augmentation? A Meta-analysis

BACKGROUND

Osteoporotic vertebral compression fracture (OVCF) has been extensively treated clinically using percutaneous vertebral augmentation (PVA), which includes percutaneous kyphoplasty and percutaneous vertebroplasty. Postoperative refracture is a common complication after PVA, but the associated factors and specific mechanisms behind these fractures are not entirely clear.

QUESTIONS/PURPOSES

In a systematic review and meta-analysis, we asked: What factors were associated with increased or decreased odds of refracture after PVA for OVCF?

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines, we conducted a comprehensive search of the Cochrane Library, PubMed, Web of Science, and Embase for the time period from database inception to August 31, 2024 (which also was when we last searched). We included case-control studies in which participants were patients with OVCF and were treated with PVA, grouped into refracture versus non-refracture groups based on the presence or absence of refracture. We excluded studies published on preprint servers, conference reports, case reports, and systematic reviews or meta-analyses. We collected 2398 records in the database. After excluding studies that were duplicates and did not meet the inclusion criteria, we included 22 studies involving 7132 participants, 75% (5368) of whom were women, with a mean age of 76 years for patients in the refracture group and 74 years for patients in the non-refracture group. Quality assessment was performed using the Newcastle-Ottawa Scale, with which we assessed three aspects of the study; the mean ± SD score for the included studies was 7.3 ± 0.7 of 9 total (on this scale, higher scores are better), representing generally high study quality. The determination of heterogeneity relied on I2 and chi-square test, and we used a random-effects model when the I2 was > 50% and p ≤ 0.05; otherwise, a fixed-effects model was chosen. According to the Egger test and trim and fill method, publication bias did not significantly affect most of our results.

RESULTS

The combined results showed that older age (mean difference 2.24 [95% confidence interval (CI) 1.25 to 3.23]; p < 0.001), lower bone mineral density (BMD) (standardized mean difference [SMD] -0.72 [95% CI -0.99 to -0.45]; p < 0.001), greater preoperative AP vertebral height ratio (SMD 0.26 [95% CI 0.07 to 0.45]; p = 0.01), greater preoperative kyphotic angle (KA) (SMD 0.47 [95% CI 0.10 to 0.83]; p = 0.01), bone cement leakage (OR 1.39 [95% CI 1.05 to 1.84]; p = 0.02), multivertebral fractures (OR 3.58 [95% CI 2.53 to 5.07]; p < 0.001), smoking (OR 1.53 [95% CI 1.16 to 2.02]; p = 0.003), use of glucocorticoids (OR 3.18 [95% CI 2.09 to 4.84]; p < 0.001), and previous osteoporotic vertebral fracture (OR 2.55 [95% CI 1.58 to 4.13]; p < 0.001) were associated with increased odds of refractures after surgery. Use of antiosteoporosis therapy was associated with a decreased odds of postoperative refracture (OR 0.39 [95% CI 0.24 to 0.64]; p < 0.001).

CONCLUSION

Based on the results of our meta-analysis, surgeons can identify those who are more likely to have refracture by knowing basic information about their patients preoperatively, such as advanced age, lower BMD, greater preoperative AP ratio, greater preoperative KA, and the presence of multivertebral fractures or previous osteoporotic vertebral fracture. Also, intraoperative reduction of bone cement leakage and postoperative counseling of patients to quit smoking, reduce glucocorticoid use, and administration of antiosteoporosis therapy were used to reduce the probability of refracture. The association between some factors and refracture is uncertain, such as BMI and thoracolumbar fracture, and further studies are needed.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Risk factors for new vertebral fractures after percutaneous vertebroplasty or percutaneous kyphoplasty in the treatment of osteoporotic vertebral compression fractures

Object

This study aims to conduct a prospective analysis of patients with osteoporotic vertebral compression fractures (OVCF) who underwent percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP), and further analyze the risk factors for new vertebral fracture following treatment.

Methods

A prospective study was conducted from November 2020 to March 2022 at the First Hospital of Longyan City to select patients with OVCF who underwent treatment in the Department of Spinal Surgery. Data collection during the follow-up period focused on various factors that could potentially be associated with new vertebral fractures after PVP/PKP procedures. Patients were divided into two groups based on whether they experienced new vertebral fractures within two years after discharge: the new fracture group (n = 186) and the non-fracture group (n = 64), and statistical analysis was conducted accordingly.

Results

All cases were followed up for 12 to 24 months, with an average of 14.7 months. Differential analysis revealed that age, diabetes, hemoglobin (HB), total protein (TP), serum albumin (ALB), b-C-terminal telopeptide of type I collage (β-CTX), 25-hydroxyvitamin D (25-OH-D3), number of fractured vertebrae, bone mineral density (BMD), regular exercise after discharge, anti-osteoporosis treatment after discharge, cross-sectional area (CSA), and fatty degeneration ratio (FDR) were associated with new vertebral fractures (all P < 0.05). Multivariate analysis showed that age (OR = 1.519, P = 0.032), diabetes (OR = 3.273, P = 0.048), and FDR (OR = 1.571, P = 0.027) were positively associated with the occurrence of new vertebral fractures, while bone mineral density (OR = 0.108, P = 0.044), 25-OH-D3 (OR = 0.871, P = 0.032), CSA (OR = 0.564, P = 0.009), regular postoperative exercise (OR = 0.259, P = 0.025), and osteoporosis treatment (OR = 0.291, P = 0.045) were negatively associated with the occurrence of new vertebral fractures.

Conclusion

Patients with osteoporosis fractures who are older, have poor glycemic control, lower bone mineral density, lower levels of 25-OH-D3, weaker paraspinal muscles, and higher fat infiltration are at increased risk of new vertebral fractures after undergoing PKP/PVP. On the other hand, maintaining regular physical activity and adhering to osteoporosis treatment can help prevent new vertebral fractures.

Analysis of Risk Factors for Augmented Vertebral Refracture After Percutaneous Kyphoplasty in Osteoporotic Vertebral Compression Fractures

Objectives: The aim of this study was to investigate the incidence of vertebral refractures following percutaneous kyphoplasty (PKP) and to explore risk factors for augmented vertebral refractures, thereby assisting spinal surgeons in clinical practice. Methods: We analyzed the records of 495 patients with single-segment osteoporotic vertebral compression fractures (OVCFs) who were treated with single-entry PKP at our institution from March 2016 to August 2022. Univariate analysis, binary logistic regression, and ROC curve analysis were performed to determine potential risk factors, independent risk factors, and discrimination ability. Results: A total of 168 patients were included in the study, with a median follow-up duration of 7.00 months. In total, 143 patients did not experience vertebral refracture after surgery, while 25 patients did, including 22 augmented vertebral fractures and 3 adjacent vertebral compression refractures. The correction rate of the Cobb angle (p < 0.001; OR = 1.070) and postoperative anti-osteoporosis treatment (p = 0.002; OR = 0.021) were independently associated with augmented vertebral refracture. The ROC curves showed that these variables demonstrated satisfactory predictive values for augmented vertebral refracture. Conclusions: A high degree of restoration of the Cobb angle was the factor contributing to vertebral refracture after PKP. Conversely, postoperative anti-osteoporosis treatment was observed to be a protective factor against subsequent vertebral refracture.

Prediction of new vertebral compression fracture within 3 years after percutaneous vertebroplasty for osteoporotic vertebral compression fracture: Establishment and validation of a nomogram prediction model

New vertebral compression fractures (NVCF) are common in patients with osteoporotic vertebral compression fractures (OVCF) who have undergone percutaneous vertebroplasty (PVP). We sought to develop a nomogram prediction model for better identification and prevention of NVCF within 3 years after PVP in patients with OVCF. The demographic, clinical, and imaging data of patients who underwent PVP for OVCF between January 2010 and December 2019 were reviewed. Multivariate logistic regression analysis was used to screen for risk factors for NVCF within 3 years after PVP. A nomogram prediction model was then developed and validated to visually predict NVCF. The samples in the model were randomly divided into training and validation sets at a ratio of 7:3. Twenty-seven percent of patients experienced NVCF in other segments within 3 years after PVP. Older age, lower bone mineral density (BMD), smoking, lack of anti-osteoporosis therapy, and postoperative trauma were risk factors for NVCF. The area under the receiver operating characteristic curve suggested good discrimination of this model: training set (0.781, 95% confidence interval: 0.731-0.831) and validation set (0.786, 95% confidence interval: 0.708-0.863). The calibration curve suggested good prediction accuracy between the actual and predicted probabilities in the training and validation sets. The DCA results suggested that, when the probability thresholds were 0.0452-08394 and 0.0336-0.7262 in the training and validation set, respectively, patients can benefit from using this model to predict NVCF within 3 years after PVP. In conclusion, this nomogram prediction model that included five risk factors (older age, lower BMD, smoking, postoperative minor trauma, and lack of anti-osteoporosis treatment can effectively predict NVCF within 3 years after PVP. Postoperative smoking cessation, standard anti-osteoporosis treatment, and reduction in incidental minor trauma are necessary and effective means of reducing the incidence of NVCF.

Biomechanical study of different bone cement distribution on osteoporotic vertebral compression Fracture-A finite element analysis

Purpose

This study aimed to compare the biomechanical effects of different bone cement distribution methods on osteoporotic vertebral compression fractures (OVCF).

Patients and methods

Raw CT data from a healthy male volunteer was used to create a finite element model of the T12-L2 vertebra using finite element software. A compression fracture was simulated in the L1 vertebra, and two forms of bone cement dispersion (integration group, IG, and separation group, SG) were also simulated. Six types of loading (flexion, extension, left/right bending, and left/right rotation) were applied to the models, and the stress distribution in the vertebra and intervertebral discs was observed. Additionally, the maximum displacement of the L1 vertebra was evaluated.

Results

Bone cement injection significantly reduced stress following L1 vertebral fractures. In the L1 vertebral body, the maximum stress of SG was lower than that of IG during flexion, left/right bending, and left/right rotation. In the T12 vertebral body, compared with IG, the maximum stress of SG decreased during flexion and right rotation. In the L2 vertebral body, the maximum stress of SG was the lowest under all loading conditions. In the T12-L1 intervertebral disc, compared with IG, the maximum stress of SG decreased during flexion, extension, and left/right bending and was basically the same during left/right rotation. However, in the L1-L2 intervertebral discs, the maximum stress of SG increased during left/right rotation compared with that of IG. Furthermore, the maximum displacement of SG was smaller than that of IG in the L1 vertebral bodies under all loading conditions.

Conclusions

SG can reduce the maximum stress in the vertebra and intervertebral discs, offering better biomechanical performance and improved stability than IG.

Fatty Infiltration of Multifidus Muscles: An Easily Overlooked Risk Factor for the Severity of Osteoporotic Vertebral Fractures

OBJECTIVES

Osteoporotic vertebral fractures (OVFs) are a critical public health concern requiring urgent attention, and severe OVFs impose substantial health and economic burdens on patients and society. Analysis of the risk factors for severe OVF is imperative to actively prevent the occurrence of this degenerative disorder. This study aimed to investigate the risk factors associated with the severity of OVF, with a specific focus on changes in the paraspinal muscles.

METHODS

A total of 281 patients with a first-time single-level acute OVF between January 2016 and January 2023 were enrolled in the study. Clinical and radiological data were collected and analyzed. The cross-sectional area (CSA) and degree of fatty infiltration (FI) of the paraspinal muscles, including the multifidus muscles (MFMs), erector spinae muscles (ESMs), and psoas major muscles (PSMs), were measured by magnetic resonance imaging (MRI) of the L4/5 intervertebral discs. According to the classification system of osteoporotic fractures (OF classification) and recommended treatment plan, OVFs were divided into a low-grade OF group and a high-grade OF group. Univariate and multivariate logistic regression analyse s were performed to identify risk factors associated with the severity of OVF.

RESULTS

Ninety-eight patients were included in the low-grade OF group, and 183 patients were included in the high-grade OF group. Univariate analysis revealed a significantly higher incidence of a high degree of FI of MFMs (OR = 1.71, p = 0.002) and ESMs (OR = 1.56, p = 0.021) in the high-grade OF group. Further multivariate logistic regression analysis demonstrated that a high degree of FI of the MFMs (OR = 1.71, p = 0.002) is an independent risk factor for the severity of OVF.

CONCLUSION

A high degree of FI of the MFMs was identified as an independent risk factor for the severity of OVF. Decreasing the degree of FI in the MFMs might lower the incidence of the severity of OVF, potentially reducing the necessity for surgical intervention in OVF patients.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Development and validation of a nomogram for predicting new vertebral compression fractures after percutaneous kyphoplasty in postmenopausal patients

BACKGROUND

Postmenopausal women face a heightened risk of developing new vertebral compression fractures (NVCFs) following percutaneous kyphoplasty (PKP) for osteoporotic vertebral compression fractures (OVCFs). This study aimed to develop and validate a visual nomogram model capable of accurately predicting NVCF occurrence post-PKP to optimize treatment strategies and minimize occurrence.

METHODS

This retrospective study included postmenopausal women diagnosed with OVCF who underwent PKP at the Affiliated Hospital of Shandong University of Traditional Chinese Medicine between January 2016 and January 2021. Patient data, including basic information, surgical details, imaging records, and laboratory findings, were collected. The patients were categorized into two groups based on NVCF occurrence within 2 years post-PKP: the NVCF group and the non-NVCF group. Following the utilization of least absolute shrinkage and selection operator (LASSO) regression for feature selection, a nomogram was constructed. Model differentiation, calibration, and clinical applicability were evaluated using receiver operating characteristic (ROC), calibration, and decision (DCA) curve analyses.

RESULTS

In total, 357 patients were included in the study. LASSO regression analysis indicated that cement leakage, poor cement diffusion, and endplate fracture were independent predictors of NVCF. The nomogram demonstrated excellent predictive accuracy and clinical applicability.

CONCLUSIONS

This study used LASSO regression to identify three independent predictors of NVCF and developed a predictive model that could effectively predict NVCF occurrence in postmenopausal women. This simple prediction model can support medical decision-making and is feasible for clinical practice.