Identifying osteoporotic vertebral fracture

Reduction of material groups for vertebral bone finite element simulation: cross comparison of grouping methods

In patient-specific biomechanical modeling, the process of image-to-mesh-material mapping is important, and various strategies have been explored for assigning the number of groups of unique material properties to the mesh. This study aims to cross-compare different grouping strategies to identify the minimum number of unique groups necessary for accurately calculating the fracture load of vertebral bones. We analyzed 12 vertebral specimens by experimentally determining the biomechanical fracture load and acquiring corresponding CT scans. After geometry extraction and meshing, we applied commonly used fixed-value strategies for reducing the number of unique groups, such as Modulus Gaping and Percentual Thresholding. Additionally, we introduced a patient-specific adaptive grouping method based on K-means clustering, which allowed us to maintain a consistent number of groups of unique material properties across the study. A total of 204 simulations were performed, achieving a potential 98% reduction in the number of individual material parameters while maintaining a strong correlation with experimental results when utilizing Percentual Thresholding or Adaptive Clustering, compared to Modulus Gaping. The findings demonstrate the feasibility of significantly reducing simulation complexity while maintaining the accuracy of patient-specific models that strongly correlate with experimental results. This reduction enables efficient processing of patient-specific biomechanical models derived from image data, offering potential benefits for clinicians, particularly in resource-constrained settings.

Correlation study of multiple inflammatory indices and vertebral compression fracture: A cross-sectional study

Background

Vertebral compression fractures (VCFs) are prevalent in patients with osteoporosis and pose significant health risks. Although chronic low-grade inflammation plays a crucial role in the pathogenesis of osteoporosis, the relationship between various inflammatory indices and the occurrence of fractures remains unclear.

Objective

This study aims to evaluate the correlation between multiple inflammatory indices, neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), systemic immune-inflammatory index (SII), and systemic inflammatory response index (SIRI), and VCFs, to explore the significance of these indices in clinical application.

Methods

Clinical data of 310 patients diagnosed with osteoporosis from November 2020 to June 2023 in the hospital were collected. The general conditions between fracture and non-fracture groups were described. Spearman analysis and binary logistic regression analysis were used to assess the relationship between inflammatory indices and VCFs. Receiver operating characteristic curve was used to evaluate the diagnostic efficacy of these inflammatory indices for VCFs.

Results

VCFs were diagnosed in 43.55 % of patients with osteoporosis. NLR(ρ = 0.169, P=0.003), MLR(ρ = 0.293, P<0.001), SII(ρ = 0.126, P=0.027), and SIRI(ρ = 0.273, P<0.001) were positively correlated with the occurrence of VCFs. NLR(OR=1.480, 95 %CI 1.114 ∼ 1.966, P=0.007), MLR(multiplied by 100, OR=1.048, 95 %CI 1.011 ∼ 1.087, P=0.011), and SIRI(OR=3.327, 95 %CI 1.510 ∼ 7.330, P=0.003) were independent risk factors for VCFs, hip bone mineral density (BMD) (OR=0.011, 95 %CI 0.001 ∼ 0.151, P=0.001) was an independent protective factor for VCFs. MLR(AUC 0.671, 95 % CI=0.610 ∼ 0.732, P <0.001) had relatively high clinical diagnostic efficacy.

Conclusion

The neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), and systemic inflammatory response index (SIRI) are independent risk factors for vertebral compression fractures.

Diagnostic Value of Hounsfield Units for Osteoporotic Thoracolumbar Vertebral Non-Compression Fractures in Elderly Patients with Low-Energy Injuries

Background

Thoracolumbar vertebral fractures are common pathological fractures caused by osteoporosis in the elderly. These fractures are challenging to detect. This study aimed to evaluate the diagnostic value of Hounsfield units for osteoporotic thoracolumbar vertebral non-compression fractures in elderly patients with low-energy fractures.

Methods

The retrospective case-control study included elderly patients diagnosed with osteoporotic thoracolumbar vertebral fractures and non-fractured patients who underwent computed tomography examinations for lumbar vertebra issues during July 2017 and June 2020.

Results

This study included 216 patients with fractures (38 males and 178 females; average age: 77.28±8.68 years) and 124 patients without fractures (21 males and 103 females; average age: 75.35±9.57 years). The difference in Hounsfield units of the target (intermediate) vertebral body significantly differed between the two groups (54.74 ± 21.84 vs 5.86 ± 5.14; p<0.001). The ratios of Hounsfield units were also significantly different between the two groups (1.38 ± 1.60 vs 0.13 ± 0.23; p<0.001). The cut-off value for the difference in Hounsfield units to detect osteoporotic spine fractures was 25.35, with high sensitivity (98.5%), specificity (99.9%), and the area under the curve (AUC) (0.999, 95% CI: 0.999-1). The cut-off value for the odds ratio of Hounsfield units was 0.260, with high sensitivity (99.1%), specificity (92.7%), and AUC (0.970, 95% CI: 0.949-0.992).

Conclusion

The difference between Hounsfield units and the odds ratio of Hounsfield units might help diagnose osteoporotic thoracolumbar vertebral non-compression fractures in elderly patients with low-energy fractures.

For older women, the majority of hip fragility fractures and radiographic vertebral fragility fractures occur among the densitometrically osteoporotic population: a literature analysis

It has been frequently cited that 'the majority of fragility fractures (FF) occur at non-osteoporotic bone mineral density (BMD)'. For the reports with T-score measured around the time of a hip fracture, we conducted a systematic literature search in December 2022, and resulted in 10 studies with five for Caucasian women and five for East Asian women. Femoral neck (FN) T-score was reported in five Caucasian studies and three East Asian studies, three of five Caucasian studies had a mean T-score ≤-2.5, and one study had the majority of their patients measuring a mean T-score ≤-2.5. All three East Asian studies reported a mean FN T-score ≤-2.7. Total hip T-score was reported in two Caucasian studies and three East Asian studies, the two Caucasian studies both had a mean T-score ≤-2.5, and all three East Asian studies had a mean T-score ≤-2.6. A new literature search conducted in April 2024 results in additional three studies, with results being consistent with the data described above. A trend was noted that 'younger' patients suffer from hip fractures at a 'higher' T-score. For the highly cited articles where the notion the majority of FF occur at non-osteoporotic BMD was derived from, authors reported prospective epidemiological studies where BMD was not measured at the timepoint of hip fracture, instead, BMD was measured at the study baseline. These epidemiological studies suggest that >50% of hip fractures likely occur in women with an osteoporotic FN or hip T-score. However, a pattern was seen that older men suffer from hip fracture at a notably higher T-score than older women. For the cases of radiographic vertebral FF, despite varying criteria being used to classify these FFs, the majority of female patients had spine densitometric osteoporosis. Literature shows, compared with the cases of hip fracture, distal forearm fracture occurs at a 'younger' age and 'higher' BMD, suggesting distal forearm fracture is more likely associated with a 'higher' trauma energy level.

Deep learning-driven diagnosis of multi-type vertebra diseases based on computed tomography images

Background

Osteoporotic vertebral compression fractures (OVCFs) are the most common type of fragility fracture. Distinguishing between OVCFs and other types of vertebra diseases, such as old fractures (OFs), Schmorl's node (SN), Kummell's disease (KD), and previous surgery (PS), is critical for subsequent surgery and treatment. Combining with advanced deep learning (DL) technologies, this study plans to develop a DL-driven diagnostic system for diagnosing multi-type vertebra diseases.

Methods

We established a large-scale dataset based on the computed tomography (CT) images of 1,051 patients with OVCFs from Luhe Hospital and used data of 46 patients from Xuanwu Hospital as alternative hospital validation dataset. Each patient underwent one examination. The dataset contained 11,417 CT slices and 19,718 manually annotated vertebrae with diseases. A two-stage DL-based system was developed to diagnose five vertebra diseases. The proposed system consisted of a vertebra detection module (VDModule) and a vertebra classification module (VCModule).

Results

The training and testing dataset for the VDModule consisted of 9,135 and 3,212 vertebrae, respectively. The VDModule using the ResNet18-based Faster region-based convolutional neural network (R-CNN) model achieved an area under the curve (AUC), false-positive (FP) rate, and false-negative (FN) rate of 0.982, 1.52%, and 1.33%, respectively, in the testing dataset. The training dataset for VCModule consisted of 14,584 and 47,604 diseased and normal vertebrae, respectively. The testing dataset consisted of 4,489 and 15,122 diseased and normal vertebrae, respectively. The ResNet50-based VCModule achieved an average sensitivity and specificity of 0.919 and 0.995, respectively, in diagnosing four kinds of vertebra diseases except for SN in the testing dataset. In the alternative hospital validation dataset, the ResNet50-based VCModule achieved an average sensitivity and specificity of 0.891 and 0.989, respectively, in diagnosing four kinds of vertebra diseases except for SN.

Conclusions

Our proposed DL system can accurately diagnose four vertebra diseases and has strong potential to facilitate the accurate and rapid diagnosis of vertebral diseases.

Development and usability of a decision aid to initiate anti-osteoporosis medication treatment in patients visiting the fracture liaison service with a recent fracture

This study describes the development of a decision aid (DA), aimed at supporting patients in their decision whether to start anti-osteoporosis medication. People with recent fractures or osteoporosis and health professionals were supportive of the DA initiative. An experimental study been started to assess (cost-)effectiveness of the DA.

PURPOSE

At fracture liaison services (FLS), patients with a recent fracture ánd osteoporosis or a prevalent vertebral fracture are advised to start anti-osteoporosis medication (AOM). This study describes the development of a decision aid (DA) to support patients and healthcare providers (HCPs) in their decision about whether to start AOM.

METHODS

The DA was developed according to International Patient Decision Aid Standards (IPDAS). A systematic procedure was chosen including scope, design, prototype development, and alpha testing. A previously developed DA for women with osteoporosis was used as a basis. Furthermore, input from literature searches, the Dutch guideline on management of osteoporosis, and from people with a fracture or osteoporosis was used. The updated DA was evaluated during alpha testing.

RESULTS

The DA facilitates the decision of patients whether to initiate AOM treatment and provides information on fractures and osteoporosis, general risk factors that increase the likelihood of a subsequent fracture, the role of lifestyle, personalized risk considerations of a subsequent fracture with and without AOM treatment, and AOM options and their characteristics in an option grid. Alpha testing with 15 patients revealed that patient preferences and needs were adequately presented, and several suggestions for improvement (e.g. adding more specific information, simplifying terminology, improving icon use) were accounted for. Participants from the alpha testing recommended use of the DA during outpatient visits.

CONCLUSION

Professionals and persons with osteoporosis were supportive of the proposed DA and its usability. The DA could help in a shared decision-making process between patients and HCPs.

Calcium phosphate cement promotes the stability of osteoporotic lumbar pedicle screw by enhancer-injecters with different number of holes

BACKGROUNDS

This study aimed to compare whether Calcium phosphate cement (CPC) promotes the stability of osteoporotic lumbar pedicle screw by enhancer-injecters with different number of holes.

METHODS

Through a self-designed bone cement injection device, the pedicle screw canal was strengthened with calcium phosphate bone cement, and divided into 4-hole group, 6-hole group, 8-hole group, straight pore group and the control group. The screw was inserted into the mechanical test module, the Maximum insertion torque and Maximum axial pull-out strength were recorded, and the distribution of calcium phosphate bone cement was analyzed by CT and X-ray. The data results were analyzed using SPSS19.0 statistical software package.

RESULTS

The distribution of bone cement in different reinforcement groups was different and showed regularity. The bone cement in the 4-hole group was roughly located in the head 1/3 of the screw, the 6-hole group was located in the middle 1/3 of the screw, and the 8-hole group was located in the caudal 1/3 of the screw. Compared with the control group, the maximum axial pull-out force of screws in the lateral hole and full screw tunnel reinforcement group was significantly increased. There was no significant difference between the 4-hole, 6-hole and straight pore groups. There was no difference in the screw-in torque between the reinforcement groups, and they all increased significantly compared with the control group, and the difference was statistically significant. After the screw was pulled out, the interface between the bone cement and the polyurethane material was fractured, and a tight package was formed with the screw.

CONCLUSIONS

Enhancer syringes with different hole numbers combined with CPC bone cement injection can significantly increase the maximum screw pull-out force. The 8-hole group has a smaller pull-out force and is relatively prone to leakage of reinforcing material, which lacks safety in use. The local reinforcement of 4-hole and 6-hole sheath can play a similar role to that of total nail tunnel reinforcement.

Outpatient minimally invasive spine surgeries during the COVID-19 pandemic - A retrospective analysis of 164 consecutive cases

Objective

To share our surgical experiences of minimally invasive cervical and lumbar procedures for patients who suffered from non-fatal motor vehicle accidents (MVAs) in the ambulatory surgery centers (ASCs) during the coronavirus disease 2019 (COVID-19) pandemic.

Methods

Anterior cervical discectomy and fusion (ACDF), anterior lumbar interbody fusion (ALIF), minimally invasive laminotomy and discectomy (MILD), percutaneous endoscopic laser-assisted discectomy (PELD) and percutaneous kyphoplasty (PK) were performed on carefully selected patients.

Results

From January 2020 to December 2021, our group performed 164 cases on 153 patients involving 249 intervertebral disc (IVD) levels. Of these, 116 cases (70.73%) on 114 patients (74.51%) were cervical, 48 cases (29.27%) were lumbar (including 8 PK cases). Eight patients had both cervical and lumbar procedures in a single anesthetic session (SAS) and were discharged on the same day. One hundred and six ACDF cases (92.17%) were at the C4-C5 and C5-C6 levels, which comprised of 146 (76.04%) IVDs. Of the 40 non-PK lumbar cases, 38 (95.0%) were at L4 to S1 lumbar levels. Six of these cases (15.0%) involved 2 lumbar levels. In contrast, 6 out of 8 kyphoplasties (75.0%) involved lower thoracic/higher lumbar vertebral columns (T11 to L2) and 2 were at the lower lumbar L4 level.

Conclusions

We successfully and safely performed various cervical and lumbar spine surgeries in the ASCs amid COVID-19 pandemic and all patients achieved the same-day discharge (SDD). In the non-fatal MVAs, mid-lower cervical (C4 to C6) and lower lumbar (L4 to S1) IVDs were the most affected levels.

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

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

Improved fracture risk prediction by adding VFA-identified vertebral fracture data to BMD by DXA and clinical risk factors used in FRAX

Vertebral fracture (VF) is a strong predictor of subsequent fracture. In this study of older women, VF, identified by dual-energy X-ray absorptiometry (DXA) vertebral fracture assessment (VFA), were associated with an increased risk of incident fractures and had a substantial impact on fracture probability, supporting the utility of VFA in clinical practice.

PURPOSE

Clinical and occult VF can be identified using VFA with dual-energy X-ray absorptiometry (DXA). The aim of this study was to investigate to what extent VFA-identified VF improve fracture risk prediction, independently of bone mineral density (BMD) and clinical risk factors used in FRAX.

METHODS

A total of 2852 women, 75-80 years old, from the prospective population-based study SUPERB cohort, were included in this study. At baseline, BMD was measured by DXA, VF diagnosed by VFA, and questionnaires used to collect data on risk factors for fractures. Incident fractures were captured by X-ray records or by diagnosis codes. An extension of Poisson regression was used to estimate the association between VFA-identified VF and the risk of fracture and the 5- and 10-year probability of major osteoporotic fracture (MOF) was calculated from the hazard functions for fracture and death.

RESULTS

During a median follow-up of 5.15 years (IQR 4.3-5.9 years), the number of women who died or suffered a MOF, clinical VF, or hip fracture was 229, 422, 160, and 124, respectively. A VFA-identified VF was associated with an increased risk of incident MOF (hazard ratio [HR] = 1.78; 95% confidence interval [CI] 1.46-2.18), clinical VF (HR = 2.88; 95% [CI] 2.11-3.93), and hip fracture (HR = 1.67; 95% [CI] 1.15-2.42), adjusted for age, height, and weight. For women at age 75 years, a VFA-identified VF was associated with 1.2-1.4-fold greater 10-year MOF probability compared with not taking VFA into account, depending on BMD.

CONCLUSION

Identifying an occult VF using VFA has a substantial impact on fracture probability, indicating that VFA is an efficient method to improve fracture prediction in older women.

Nature-Inspired Unconventional Approaches to Develop 3D Bioceramic Scaffolds with Enhanced Regenerative Ability

Material science is a relevant discipline in support of regenerative medicine. Indeed, tissue regeneration requires the use of scaffolds able to guide and sustain the natural cell metabolism towards tissue regrowth. This need is particularly important in musculoskeletal regeneration, such as in the case of diseased bone or osteocartilaginous regions for which calcium phosphate-based scaffolds are considered as the golden solution. However, various technological barriers related to conventional ceramic processing have thus far hampered the achievement of biomimetic and bioactive scaffolds as effective solutions for still unmet clinical needs in orthopaedics. Driven by such highly impacting socioeconomic needs, new nature-inspired approaches promise to make a technological leap forward in the development of advanced biomaterials. The present review illustrates ion-doped apatites as biomimetic materials whose bioactivity resides in their unstable chemical composition and nanocrystallinity, both of which are, however, destroyed by the classical sintering treatment. In the following, recent nature-inspired methods preventing the use of high-temperature treatments, based on (i) chemically hardening bioceramics, (ii) biomineralisation process, and (iii) biomorphic transformations, are illustrated. These methods can generate products with advanced biofunctional properties, particularly biomorphic transformations represent an emerging approach that could pave the way to a technological leap forward in medicine and also in various other application fields.

Vertebral compression fractures: Still an unpredictable aspect of osteoporosis

Vertebral compression fracture is a hallmark of osteoporosis (OP) and by far the most prevalent fragility fracture. It is well proven that patients who develop a vertebral compression fracture are at substantial risk for additional fractures. Diagnosis is based on adequate clinical evaluation, imaging, and laboratory tests. The imaging of OP and fragility fractures includes conventional radiology to evaluate spinal fractures, bone mineral density (BMD) testing by dual energy x-ray densitometry, quantitative computerized tomography, magnetic resonance imaging, bone scintigraphy (if necessary), and ultrasound. Screening and treatment of individuals with high risk of osteoporotic fracture are cost-effective, but approximately two-thirds of the vertebral compression fractures (VCF) that occur each year are not accurately diagnosed and, therefore, not treated. Evaluation of VCFs, even though they may be asymptomatic, seems essential to health-related and/or clinical research on OP.

Craniocervical instability associated with rheumatoid arthritis: a case report and brief review

Rheumatoid arthritis (RA) is an autoimmune disease that affects the synovial tissue which lines joints and tendons. The craniocervical junction is made up exclusively of synovial joints and ligaments and especially vulnerable to the inflammatory process of RA. The chronic inflammation of RA leads to loss of ligamentous restriction and erosion of the bony structures and results in craniocervical instability (CCI). This is a case report of an 80-year-old woman who had been diagnosed with seropositive RA two decades ago presented with head dropping and losing balance while walking for several months. Radiographic images of the cervical spine showed RA-related features of instability in the form of atlantoaxial instability, cranial settling and subaxial subluxation. Since physical therapy and acupuncture previously failed to provide a substantial, long-lasting outcome, the patient sought chiropractic care for her condition. The chiropractic regimen consisted of upper thoracic spine mobilization/adjustment, electrical muscle stimulation of the cervical extensors, home exercises and neck bracing. She regained substantial neck muscle strength, gaze angle and walking balance following a 4-month chiropractic treatment, although cervical kyphosis persisted. The current study aims to provide basic knowledge of CCI associated with RA and ability to modify a treatment program to accommodate the needs of patients with coexisting red flags.

Nanotechnological approach and bio-inspired materials to face degenerative diseases in aging

The aging of the world population is increasingly claimed as an alarming situation, since an ever-raising number of persons in advanced age but still physically active is expected to suffer from invalidating and degenerative diseases. The impairment of the endogenous healing potential provoked by the aging requires the development of more effective and personalized therapies, based on new biomaterials and devices able to direct the cell fate to stimulate and sustain the regrowth of damaged or diseased tissues. To obtain satisfactory results, also in cases where the cell senescence, typical of the elderly, makes the regeneration process harder and longer, the new solutions have to possess excellent ability to mimic the physiological extracellular environment and thus exert biomimetic stimuli on stem cells. To this purpose, the "biomimetic concept" is today recognized as elective to fabricate bioactive and bioresorbable devices such as hybrid osteochondral scaffolds and bioactive bone cements closely resembling the natural hard tissues and with enhanced regenerative ability. The review will illustrate some recent results related to these new biomimetic materials developed for application in different districts of the musculoskeletal system, namely bony, osteochondral and periodontal regions, and the spine. Further, it will be shown how new bioactive and superparamagnetic calcium phosphate nanoparticles can give enhanced results in cardiac regeneration and cancer therapy. Since tissue regeneration will be a major demand in the incoming decades, the high potential of biomimetic materials and devices is promising to significantly increase the healing rate and improve the clinical outcomes even in aged patients.

[Physical rehabilitation of patients with osteoporosis]

Osteoporosis is one of the most common diseases, which along with cardiovascular pathology, diabetes mellitus and oncological diseases has a leading place in the structure of morbidity and mortality of the population. The combination of pharmacological and non-pharmacological methods is fundamental for the treatment and prevention of osteopenia and osteoporosis. This article presents rehabilitation methods that are of great importance for improving the functioning of the musculoskeletal system, the quality of life of patients with osteoporosis. Physical rehabilitation is aimed at stopping the destruction of bone tissue, strengthening it, eliminating pain, reducing stress from the affected areas and restoring the normal function of joints and bones. The proposed types of physical activity not only increase bone strength and strengthen muscle mass, but also reduce the risk of falling - a leading cause of osteoporotic fractures. Exercise programs designed for patients with osteoporosis should include strength and exercise exercises, as well as exercises for flexibility, posture correction, coordination of movements and balance. Training should be regular, varied and of a certain duration. The article considers the advantages and disadvantages of each type of activity.

Is Breast Size Related to Prevalent Thoracic Vertebral Fracture? A Cross-Sectional Study

Large breasts may increase the likelihood of thoracic vertebral fractures by increasing the mechanical loading of the spine. We examined breast size as a factor associated with prevalent thoracic vertebral fractures, also considering its relationship with thoracic kyphosis and upper back extensor muscle endurance. Using a cross-sectional study, the design measurements collected were thoracic vertebral fractures (≥20% loss in vertebral body height on lateral radiograph), breast size (bra size converted to an ordinal breast size score), BMD (g/cm² averaged femoral neck, DXA), upper back extensor muscle endurance (isometric chest raise test), body composition (DXA), thoracic kyphosis (radiograph), and upper back pain (numerical rating scale). Correlations and multivariable logistic regression examined relationships between characteristics and their association with vertebral fracture. Participants were 117 healthy postmenopausal women. The 17 (15%) women with ≥1 thoracic vertebral fracture had larger breast size (mean difference [MD]: 2.2 sizes; 95% CI, 0.6 to 3.8 sizes), less upper back extensor muscle endurance (MD: -38.6 s; 95% CI, -62.9 to -14.3 s), and greater thoracic kyphosis (MD: 7.3°; 95% CI, 1.7° to 12.8°) than those without vertebral fracture. There were no between group differences in age, height, weight, and BMD. Breast size (r = -0.233, p = 0.012) and thoracic kyphosis (r = -0.241, p = 0.009) correlated negatively with upper back extensor muscle endurance. Breast size was unrelated to thoracic kyphosis (r = 0.057, p = 0.542). A (final) multivariable model containing breast size (OR 1.85; 95% CI, 1.10 to 3.10) and thoracic kyphosis (OR 2.04; 95%CI, 1.12 to 3.70) explained 18% of the variance in vertebral fracture. Breast size had a significant, but weak relationship with vertebral fracture (R ² = 0.10), which was independent of BMD and unrelated to thoracic kyphosis. Further work is needed to confirm larger breast size as a risk factor for vertebral fracture. © 2020 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Increase in the Number of Bone Marrow Osteoclast Precursors at Different Skeletal Sites, Particularly in Long Bone and Jaw Marrow in Mice Lacking IL-1RA

Recently, it was shown that interleukin-1β (IL-1β) has diverse stimulatory effects on different murine long bone marrow osteoclast precursors (OCPs) in vitro. In this study, interleukin-1 receptor antagonist deficient (Il1rn^-/-) and wild-type (WT) mice were compared to investigate the effects of enhanced IL-1 signaling on the composition of OCPs in long bone, calvaria, vertebra, and jaw. Bone marrow cells were isolated from these sites and the percentage of early blast (CD31^hi Ly-6C^-), myeloid blast (CD31⁺ Ly-6C⁺), and monocyte (CD31^- Ly-6C^hi) OCPs was assessed by flow cytometry. At the time-point of cell isolation, Il1rn^-/- mice showed no inflammation or bone destruction yet as determined by histology and microcomputed tomography. However, Il1rn^-/- mice had an approximately two-fold higher percentage of OCPs in long bone and jaw marrow compared to WT. Conversely, vertebrae and calvaria marrow contained a similar composition of OCPs in both strains. Bone marrow cells were cultured with macrophage colony stimulating factor (M-CSF) and receptor of NfκB ligand (RANKL) on bone slices to assess osteoclastogenesis and on calcium phosphate-coated plates to analyze mineral dissolution. Deletion of Il1rn increased osteoclastogenesis from long bone, calvaria, and jaw marrows, and all Il1rn^-/- cultures showed increased mineral dissolution compared to WT. However, osteoclast markers increased exclusively in Il1rn^-/- osteoclasts from long bone and jaw. Collectively, these findings indicate that a lack of IL-1RA increases the numbers of OCPs in vivo, particularly in long bone and jaw, where rheumatoid arthritis and periodontitis develop. Thus, increased bone loss at these sites may be triggered by a larger pool of OCPs due to the disruption of IL-1 inhibitors.

Fast kilovoltage (KV)-switching dual-energy computed tomography hydroxyapatite (HAP)-water decomposition technique for identifying bone marrow edema in vertebral compression fractures

Background

Hydroxyapatite (HAP) is the main component of bone mineral. The utility of using HAP-water decomposition technique with fast kilovoltage (KV)-switching dual-energy computed tomography (DECT) to detect abnormal edema in vertebral compression fractures (VCFs) has not been widely reported.

Methods

A total of 31 consecutive patients with 80 VCFs who underwent DECT and magnetic resonance imaging (MRI) of the spine were retrospectively enrolled in our study between October 2018 and January 2019. VCFs in MR examinations served as the standard of reference. Two radiologists blindly and independently evaluated color-coded overlay virtual nonhydroxyapatite (VNHAP) images for the presence of abnormal edema. The inter-reader agreement, specificity, sensitivity, accuracy, and predictive values of VNHAP images for edema detection were calculated. The diagnostic accuracy of two readers was compared using McNemar's test. Two additional radiologists performed a quantitative analysis on VNHAP images, receiver operating characteristic (ROC) curve analysis was conducted, and the threshold was calculated.

Results

MRI depicted 45 edematous and 35 nonedematous VCFs. For visual analysis, the VNHAP technique showed a sensitivity of 93.3%, a specificity of 97.1%, a positive predictive value (PPV) of 97.7%, a negative predictive value (NPV) of 91.9%, and an accuracy of 95.0%. The inter-reader agreement was almost perfect (k=0.90). The diagnostic accuracy of the two readers showed no significant differences in the assessment of VNHAP images (P=1.00). Significant differences in CT numbers between vertebrae with and without bone marrow edema were found by quantitative analysis (P<0.01). The area under the curve (AUC) of the VNHAP images was estimated to be 0.917. The threshold of 1,003.2 mg/cm³ yielded a sensitivity of 88.9% and a specificity of 82.9% for the differentiation of fresh and old VCFs.

Conclusions

Fast KV-switching DECT HAP-water decomposition technique had excellent diagnostic performance for identifying acute and chronic VCFs in visual and quantitative analyses.

Thoracic kyphosis assessment in postmenopausal women: an examination of the Flexicurve method in comparison to radiological methods

The Flexicurve ruler is an alternative method to radiographs for measuring thoracic kyphosis (curvature), but it is not certain that it is comparable. This study shows that Flexicurve can estimate radiographic vertebral centroid angles with less error than Cobb angles but that its accuracy would be inadequate for most clinical purposes.

INTRODUCTION

The Flexicurve ruler provides a non-radiological method of measuring thoracic kyphosis (TK) that has moderately strong correlations with the gold-standard radiographic Cobb angle method, while consistently underestimating the TK angle. Cobb angles can include measurement errors that may contribute to poor agreement, particularly in older populations. The vertebral centroid angle could be a better radiographic reference method for the validation of Flexicurve. Using two separate radiographic measurements of TK, we examined the validity of Flexicurve. We aimed to ascertain the level of agreement between measures and to empirically explore reasons for between-method differences.

METHODS

TK angles determined using Flexicurve and radiographic Cobb and vertebral centroid methods were compared using data from 117 healthy postmenopausal women (mean (SD) age 61.4 (7.0) years). Bland and Altman plots were used to assess differences between methods. Age, bone mineral density and body mass index were examined as characteristics that might explain any differences.

RESULTS

Flexicurve angles were scaled prior to analysis. There was no statistically significant difference between angles produced by Flexicurve and vertebral centroid methods (MD - 2.16°, 95%CI - 4.35° to 0.03°) although differences increased proportionally with TK angles. Flexicurve angles were significantly smaller than radiographic Cobb angles and depending on the scaling method used, systematic error ranged between - 2.48° and - 5.19°. Age accounts for some of the differences observed (R² < 0.08, p < 0.005).

CONCLUSIONS

TK measured using the Flexicurve shows better agreement with the radiographic vertebral centroid method, but inaccuracy of the Flexicurve increases with increasing angle of kyphosis.

Upper back pain in postmenopausal women and associated physical characteristics

The physical characteristics of postmenopausal women that are associated with upper back pain are not well-understood. The aim of this cross-sectional study was to identify the physical characteristics associated with presence and severity of upper back pain in healthy postmenopausal women. Self-reported upper back pain presence (within the previous month) and severity (numerical rating scale) were examined against the physical characteristics: height; weight; body mass index; breast size; breast ptosis; upper back extensor muscle endurance (isometric chest raise test); head, shoulder and upper back posture (photogrammetry); thoracic extension mobility (photogrammetry); bone mineral density (dual-energy x-ray absorptiometry (DXA)); body composition (DXA); and thoracic kyphosis, thoracic osteoarthritis and thoracic vertebral fracture (all radiography). A multivariable logistic regression model, adjusted for age, was built using physical characteristics with a significant univariate association with upper back pain. Censored Tobit regression, adjusted for age, was used to examine each physical characteristic against upper back pain severity. Postmenopausal women (n = 119) with a mean (SD) age of 61.4 (7.0) years participated in the study. After adjusting for age, the physical characteristics independently associated with upper back pain were: height (OR: 0.50, 95% CI: 0.31–0.79); and upper back extensor muscle endurance (OR: 0.46, 95%CI: 0.28–0.75). This model explained 31% of the variance in upper back pain (p<0.001). After adjusting for age, being taller and having better upper back extensor muscle endurance were associated with lower odds for upper back pain. After adjusting for age, differences in upper back pain severity were explained by upper back extensor muscle endurance (p = <0.001) and lean mass (p = 0.01). Conclusion: As a modifiable physical characteristic of postmenopausal women with upper back pain, upper back extensor muscle endurance is worth considering clinically.

Impact of mild and moderate/severe vertebral fractures on physical activity: a prospective study of older women in the UK

Little is known about the long-term impact of vertebral fractures on physical activity. There is also uncertainty over the clinical significance of mild vertebral fracture. We showed that women with moderate/severe but not mild vertebral fracture do less walking duration and housework than those without fracture after 5.4 years of follow-up.

INTRODUCTION

Little is known about the long-term impact of vertebral fractures on physical activities. There is also uncertainty over the clinical significance of mild fracture. Therefore, the aim of this study was to evaluate the prospective association between vertebral fracture and future physical activity.

METHODS

This is a 5-year prospective study of a mixed community and secondary care cohort of women aged > 50 from the UK. Vertebral fractures were identified at baseline on radiographs or DXA-based Vertebral Fracture Assessment by a Quantitative Morphometric approach and defined as moderate/severe (≥ 25% height decrease) or mild (20-24.9% height decrease). Physical activity data were collected 5.4 years later by self-completion questionnaires. Multivariable logistic regression was used to determine the association between presence of fracture and various physical activities while adjusting for potential confounders.

RESULTS

Two hundred eighty-six women without, 58 with mild, and 69 with moderate/severe fracture were recruited. Those with mild and moderate/severe fracture were older than women without fracture and had more concomitant diseases at baseline. At 5.4 years follow-up, women with moderate/severe fracture self-reported shorter walking duration compared to those without fracture, even after adjusting for potential confounders (OR 2.96, 95%CI 1.11-7.88, P = 0.030). No independent association was seen between the presence of mild fractures and reduced physical activity at follow-up.

CONCLUSION

This is the first study of older women from the UK that explored the prospective association between vertebral fracture and physical activity duration. Moderate/severe fractures were associated with reduced walking duration. Mild fractures had no impact on future physical ability.

Quantitative imaging techniques for the assessment of osteoporosis and sarcopenia

Bone and muscle are two deeply interconnected organs and a strong relationship between them exists in their development and maintenance. The peak of both bone and muscle mass is achieved in early adulthood, followed by a progressive decline after the age of 40. The increase in life expectancy in developed countries resulted in an increase of degenerative diseases affecting the musculoskeletal system. Osteoporosis and sarcopenia represent a major cause of morbidity and mortality in the elderly population and are associated with a significant increase in healthcare costs. Several imaging techniques are currently available for the non-invasive investigation of bone and muscle mass and quality. Conventional radiology, dual energy X-ray absorptiometry (DXA), computed tomography (CT), magnetic resonance imaging (MRI) and ultrasound often play a complementary role in the study of osteoporosis and sarcopenia, depicting different aspects of the same pathology. This paper presents the different imaging modalities currently used for the investigation of bone and muscle mass and quality in osteoporosis and sarcopenia with special emphasis on the clinical applications and limitations of each technique and with the intent to provide interesting insights into recent advances in the field of conventional imaging, novel high-resolution techniques and fracture risk.

Vertebral fractures and their association with health-related quality of life, back pain and physical function in older women

Studies investigating prevalent vertebral fracture (VF) diagnosed using densitometry-based VF assessment (VFA) and associations with physical function, assessed by performance-based measures, are lacking. In this population-based study of 1027 older women, we found that prevalent VF, identified by VFA, was associated with inferior physical health, back pain and inferior physical function.

PURPOSE

Several studies have investigated the associations between health-related quality of life (HRQL) and back pain with prevalent VF, detected by spine radiographs, but just a few have been population-based and have used vertebral fracture assessment (VFA) for diagnosing VF. The aims of this study were to investigate associations between prevalent VF, detected by VFA, with HRQL, back pain and physical function, and investigate if also mild VFs were associated with these clinical parameters.

METHODS

One thousand twenty-seven women aged 75-80 years participated in this population-based cross-sectional study. VF was identified by VFA using dual-energy X-ray absorptiometry. HRQL was assessed by SF-12, back pain during the past 12 months using a questionnaire, and physical function was tested with one leg standing (OLS), Timed Up and Go (TUG), walking speed, 30-s chair stand test and maximum grip strength.

RESULTS

Physical health (Physical Component Summary, PCS), derived from SF-12, was worse (43.5 ± 11.3 vs. 46.2 ± 10.5, p < 0.001) and back pain more frequent in women with any VF than in women without (69.0 vs. 59.9%, p = 0.008). PCS and physical function (OLS, 30-s chair stand test), were significantly worse for mild VF compared to no VF (43.8 ± 10.9 vs. 46.2 ± 10.5, p < 0.001, 12.7 ± 9.9 vs. 15.3 ± 10.4 s, p = 0.038, 10.7 ± 3.2 vs. 11.4 ± 3.4 times, p = 0.021, respectively). In multivariable adjusted linear regression models, VF prevalence was associated with PCS (β = - 0.079, p = 0.007), TUG (β = 0.067, p = 0.021), walking speed (β = - 0.071, p = 0.009) and 30-s chair stand test (β = - 0.075, p = 0.012).

CONCLUSIONS

In conclusion, prevalent VF, diagnosed by VFA, was associated with inferior physical health, back pain and inferior physical function, indicating VFA is useful for diagnosing clinically relevant vertebral fractures. Also, mild VF was associated with inferior physical health and inferior physical function.

Identifying osteoporotic vertebral endplate and cortex fractures

Osteoporosis is the most common metabolic bone disease, and vertebral fractures (VFs) are the most common osteoporotic fracture. A single atraumatic VF may lead to the diagnosis of osteoporosis. Prevalent VFs increase the risk of future vertebral and non-vertebral osteoporotic fracture independent of bone mineral density (BMD). The accurate and clear reporting of VF is essential to ensure patients with osteoporosis receive appropriate treatment. Radiologist has a vital role in the diagnosis of this disease. Several morphometrical and radiological methods for detecting osteoporotic VF have been proposed, but there is no consensus regarding the definition of osteoporotic VF. A vertebra may fracture yet not ever result in measurable changes in radiographic height or area. To overcome these difficulties, algorithm-based qualitative approach (ABQ) was developed with a focus on the identification of change in the vertebral endplate. Evidence of endplate fracture (rather than variation in vertebral shape) is the primary indicator of osteoporotic fracture according to ABQ criteria. Other changes that may mimic osteoporotic fractures should be systemically excluded. It is also possible that vertebral cortex fracture may not initially occur in endplate. Particularly, vertebral cortex fracture can occur in anterior vertebral cortex without gross vertebral deformity (VD), or fractures deform the anterior vertebral cortex without endplate disruption. This article aims to serve as a teaching material for physicians or researchers to identify vertebral endplate/cortex fracture (ECF). Emphasis is particularly dedicated to identifying ECF which may not be associated apparent vertebral body collapse. We believe a combined approach based on standardized radiologic evaluation by experts and morphometry measurement is the most appropriate approach to detect and classify VFs.

Percutaneous vertebral augmentation in fragility fractures-indications and limitations

INTRODUCTION

There is still no general consensus about the management of osteoporotic vertebral fractures. Recommendations depend on type of fracture, grade of instability, bone quality, and general conditions of the patient. Spontaneous fractures may be considered to be treated different compared to cases with high-velocity trauma.

METHODS

According to the DVO, patients without trauma should first be treated conservatively. However, there is no more strict time protocol of 3 or 6 week conservative treatment before operations may be indicated. Surgical criteria are not yet distinctly defined. For highly unstable fractures (type B and C according to the AO Spine Classification), posterior instrumentation with cement augmented screws and as long construct, respectively, is adequate. Current literature has been analysed for diagnostic and therapeutic protocols.

RESULTS

There is no clear operative concept for burst fractures and classic osteoporotic fractures with dynamic ongoing sintering. Percutaneous vertebral augmentation showed to prevent the fractures from ongoing kyphotic deformity and the patients from painful immobilization. Indications and results of classical vertebroplasty and kyphoplasty have been discussed intensively in the literature. Further development included special injection techniques, cements with different viscosities and stenting systems to reach more stable constructs and avoid typical complications, such as cement extrusion.

CONCLUSIONS

This review reports upon indications and limitations of percutaneous vertebral augmentation and the potential development of classifications and therapeutic algorithms.

Classifying thoracolumbar fractures: role of quantitative imaging

This article describes different types of vertebral fractures that affect the thoracolumbar spine and the most relevant contributions of the different classification systems to vertebral fracture management. The vertebral fractures types are based on the three columns model of Denis that includes compression, burst, flexion-distraction and fracture-dislocation types. The most recent classifications systems of these types of fractures are reviewed, including the Thoracolumbar Injury Classification and Severity score (TLICS) and the Arbeitsgemeinschaft für Osteosynthesefragen Spine Thoracolumbar Injury Classification and Severity score (AOSpine-TLICS). Correct classification requires a quantitative imaging approach in which several measurements determine TLICS or AOSpine-TLICS grade. If the TLICS score is greater than 4, or the AOSpine-TLICS is greater than 5, surgical management is indicated. In this review, the most important imaging findings and measurements on radiography, multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) are described. These include degree of vertebral wedging and percentage of vertebral height loss in compression fractures, degree of interpedicular distance widening and spinal canal stenosis in burst fractures, and the degree of vertebral translation or interspinous widening in more severe fractures types, such as flexion-distraction and fracture-dislocation. These findings and measurements are illustrated with schemes and cases of our archives in a didactic way.

Acute vertebral fracture after spinal fusion: a case report illustrating the added value of single-source dual-energy computed tomography to magnetic resonance imaging in a patient with spinal Instrumentation

Magnetic resonance imaging (MRI) is degraded by metal-implant-induced artifacts when used for the diagnostic assessment of vertebral compression fractures in patients with instrumented spinal fusion. Dual-energy computed tomography (DECT) offers a promising supplementary imaging tool in these patients. This case report describes an 85-year-old woman who presented with a suspected acute vertebral fracture after long posterior lumbar interbody fusion. This is the first report of a vertebral fracture that showed bone marrow edema on DECT; however, edema was missed by an MRI STIR sequence owing to metal artifacts. Bone marrow assessment using DECT is less susceptible to metal artifacts than MRI, resulting in improved visualization of vertebral edema in the vicinity of fused vertebral bodies.

Osteoporosis Imaging in the Geriatric Patient

Given the expected rapid growth of the geriatric world population (=individuals aged >65 years) to 1.3 billion by 2050, age-related diseases such as osteoporosis and its sequelae, osteoporotic fractures, are on the rise. Areal bone mineral density (aBMD) by dual-energy X-ray absorptiometry (DXA) is the current gold standard to diagnose osteoporosis, to assess osteoporotic fracture risk, and to monitor treatment-induced BMD changes. However, most fragility fractures occur in patients with normal or osteopenic aBMD, indicating that factors beyond BMD impact bone strength. Recent developments in DXA technology such as TBS, VFA, and hip geometry analysis are now available to assess some of these non-BMD parameters from the DXA image. This review will discuss the use of DXA and DXA-assisted technologies and their respective advantages and disadvantages. Special attention is given to if and how each method is indicated in the geriatric population, and the latest ISCD 2015 guidelines have been incorporated.