Vertebral Fractures: Clinical Importance and Management

Geometric determinants of the mechanical behavior of image-based finite element models of the intervertebral disc

The intervertebral disc is an important structure for load transfer through the spine. Its injury and degeneration have been linked to pain and spinal fractures. Disc injury and spine fractures are associated with high stresses; however, these stresses cannot be measured, necessitating the use of finite element (FE) models. These models should include the disc's complex structure, as changes in disc geometry have been linked to altered mechanical behavior. However, image-based models using disc-specific structures have yet to be established. This study describes a multiphasic FE modeling approach for noninvasive estimates of subject-specific intervertebral disc mechanical behavior based on medical imaging. The models (n = 22) were used to study the influence of disc geometry on the predicted global mechanical response (moments and forces), internal local disc stresses, and tractions at the interface between the disc and the bone. Disc geometry was found to have a strong influence on the predicted moments and forces on the disc (R2 = 0.69-0.93), while assumptions regarding the side curvature (bulge) of the disc had only a minor effect. Strong variability in the predicted internal disc stresses and tractions was observed between the models (mean absolute differences of 5.1%-27.7%). Disc height had a systematic influence on the internal disc stresses and tractions at the disc-to-bone interface. The influence of disc geometry on mechanics highlights the importance of disc-specific modeling to estimate disc injury risk, loading on the adjacent vertebral bodies, and the mechanical environment present in disc tissues.

Distal junctional failure after corrective surgery without pelvic fixation for thoracolumbar junctional kyphosis due to osteoporotic vertebral fracture

BACKGROUND

Thoracolumbar junctional kyphosis (TLJK) due to osteoporotic vertebral fracture (OVF) negatively impacts patients' quality of life. The necessity of pelvic fixation in corrective surgery for TLJK due to OVF remains controversial. This study aimed to: 1) evaluate the surgical outcomes of major corrective surgery for thoracolumbar junctional kyphosis due to osteoporotic vertebral fracture, and 2) identify the risk factors for distal junctional failure to identify potential candidates for pelvic fixation.

METHODS

Patients who underwent surgical correction (fixed TLJK>40°, OVF located at T11-L2, the lowermost instrumented vertebra at or above L5) were included. Sagittal vertical axis, pelvic tilt, pelvic incidence, thoracic kyphosis, lumbar lordosis (L1-S1), local kyphosis, and lower lumbar lordosis (L4-S1) were assessed. Proximal and distal junctional kyphosis (P/DJK) and failures (P/DJF) were evaluated. Pre/postoperative spinopelvic parameters were compared between DJF and non-DJF patients.

RESULTS

Thirty-one patients (mean age: 72.3 ± 7.9 years) were included. PJK was observed in five patients (16.1%), while DJK in 11 (35.5%). Twelve cases (38.7%) were categorized as failure. Among the patients with PJK, there was only one patient (20%) categorized as PJF and required an additional surgery. Contrary, all of eleven patients with DJK were categorized as DJF, among whom six (54.5%) required additional surgery for pelvic fixation. In comparisons between DJF and non-DJF patients, there was no significant difference in pre/postoperative LK (pre/post, p = 0.725, p = 0.950). However, statistically significant differences were observed in the following preoperative alignment parameters: SVA (p = 0.014), LL (p = 0.001), LLL (p = 0.006), PT (p = 0.003), and PI-LL (p < 0.001).

CONCLUSIONS

Spinopelvic parameters, which represent the compensatory function of lumbar hyperlordosis and pelvic retroversion, have notable impacts on surgical outcomes in correction surgery for TLJK due to OVF. Surgeons should consider each patient's compensatory function when choosing a surgical approach.

Osteoporotic vertebral fractures: Natural history and impact

Osteoporosis, and the consequences derived from it, such as fragility fractures, constitute a growing public health problem. Suffering from a fracture of this nature is the main risk factor for suffering a new fracture. It is documented that vertebral compression fractures lead to significant morbidity and mortality, in the short and long term, as well as other complications, such as sagittal imbalance and hyperkyphosis of the segment. However, we have not found documentation that analyzes the medium and long-term consequences of these injuries, assessing the type of treatment used, and the economic impact they represent. The purpose of this review is to analyze the main recent literature on the subject and make a breakdown of the consequences of these fractures in various spheres, such as economic, quality of life, sagittal balance and radiographic parameters, pain or mortality; as well as a brief analysis of epidemiology and natural history. CONCLUSION: Osteoporotic fractures constitute an emerging problem, both in the medical and economic fields. The consequences and sequelae on the patient are multiple and although surgical options offer good long-term results, it is necessary to properly select the patient, through multidisciplinary teams, to try to minimize potential complications.

Obesity Is Associated with Asymptomatic Vertebral Fractures: A Yakumo Study

(1) Background: Patients with primary vertebral fracture (VF) are at high risk of re-fracture and mortality. However, approximately two-thirds of patients with VFs receive minimal clinical attention. (2) Methods: The current study aimed to investigate the factors associated with asymptomatic VFs in middle-aged and elderly individuals who underwent resident health examinations. (3) Results: The current study included 217 participants aged > 50 years. VFs were diagnosed based on lateral radiographic images using Genant's semiquantitative (SQ) method. The participants were divided into non-VF (N; SQ grade 0) and asymptomatic VF (F; SQ grades 1-3) groups. Data on body composition, blood tests, quality of life measures, and radiographic parameters were assessed. A total of 195 participants were included in the N group (mean age, 64.8 ± 7.8 years), and 22 were in the F group (mean age, 66.1 ± 7.9 years). The F group had a significantly higher body mass index (BMI), body fat percentage (BF%), and proportion of patients with knee osteoarthritis (KOA) than the N group. The F group had a significantly higher knee joint pain visual analog scale (VAS) score and painDETECT score than the N group. Logistic regression analysis showed that BF% was associated with asymptomatic VFs. (4) Conclusions: Middle-aged and elderly individuals with asymptomatic VF presented with high BMIs, BF%, and incidence of KOA.

The Dutch multidisciplinary guideline osteoporosis and fracture prevention, taking a local guideline to the international arena

BACKGROUND

In 2018, a grant was provided for an evidence-based guideline on osteoporosis and fracture prevention based on 10 clinically relevant questions.

METHODS

A multidisciplinary working group was formed with delegates from Dutch scientific and professional societies, including representatives from the patient's organization and the Dutch Institute for Medical Knowledge. The purpose was to obtain a broad consensus among all participating societies to facilitate the implementation of the updated guideline.

RESULTS

Novel recommendations in our guideline are as follows: - In patients with an indication for DXA of the lumbar spine and hips, there is also an indication for VFA. - Directly starting with anabolic drugs (teriparatide or romosozumab) in patients with a very high fracture risk; - Directly starting with zoledronic acid in patients 75 years and over with a hip fracture (independent of DXA); - Directly starting with parenteral drugs (denosumab, teriparatide, zoledronic acid) in glucocorticoid-induced osteoporosis with very high fracture risk; - A lifelong fracture risk management, including lifestyle, is indicated from the start of the first treatment.

CONCLUSION

In our new multidisciplinary guideline osteoporosis and fracture prevention, we developed 5 "relatively new statements" that are all a crucial step forward in the optimization of diagnosis and treatment for fracture prevention. We also developed 5 flowcharts, and we suppose that this may be helpful for individual doctors and their patients in daily practice and may facilitate implementation.

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.

Regional Variations in the Intra- and Intervertebral Trabecular Microarchitecture of the Osteoporotic Axial Skeleton with Reference to the Direction of Puncture

BACKGROUND

Trabeculae in vertebral bodies are unequally distributed within the cervical spine (CS), the thoracic spine (TS), and lumbar spine (LS). Such structures are also unequally distributed within the individual vertebrae. Exact knowledge of the microstructure of these entities could impact our understanding and treatment of fractures caused by osteoporosis and possibly improve surgical approaches. Appropriate investigations could help clarify the pathomechanisms of different forms of osteoporotic vertebral fractures, as well as different changes in morphological findings like the trabecular bone score (TBS). In the present study, we applied punctures to the craniocaudal and ventrocaudal directions and obtained cylinders of cancellous bone from the central portions and marginal regions of cervical vertebrae 5 and 6, thoracic vertebrae 8 and 12, and lumbar vertebrae 1 and 3. We systematically analyzed these samples to determine the bone volume fraction, trabecular thickness, separation, connectivity density, degree of anisotropy, and structure model index.

METHODS

Using an 8-gauge Jamshidi needle, we obtained samples from three quadrants (Q I: right margin; Q II: central; Q III: left margin) in the frontal and transverse plane and prepared these samples with a moist cloth in a 1.5 mL Eppendorf reaction vessel. The investigations were performed on a micro-CT device (SKYSCAN 1172, RJL Micro & Analytic Company, Karlsdorf-Neuthard, Germany). All collected data were analyzed using the statistical software package SPSS (version 24.0, IBM Corp., Armonk, NY, USA). Student's t test, the Wilcoxon-Mann-Whitney test, the Chi-squared test, and univariate analysis were used for between-group comparisons. The selection of the test depended on the number of investigated groups and the result of the Shapiro-Wilk test of normal distribution. In the case of statistically significant results, a post hoc LSD test was performed.

RESULTS

In total, we obtained 360 bone samples from 20 body donors. The craniocaudal puncture yielded data of similar magnitudes for all investigated parameters in all three quadrants, with the highest values observed in the CS. Comparisons of the ventrodorsal and craniocaudal microstructure revealed a significantly lower trabecular density and a significantly higher degree of anisotropy in the craniocaudal direction.

CONCLUSIONS

The results presented different distributions and behaviors of trabecular density, with lower density in the mid-vertebral region over the entire breadth of the vertebrae. Reduced trabecular density caused a higher degree of anisotropy and was, therefore, associated with a lower capacity to sustain biomechanical loads. Fractures in fish vertebrae were easily explained by this phenomenon. The different changes in these structures could be responsible, in part, for the changes in the TBS determined using dual-energy X-ray absorptiometry. These results confirm the clinical relevance of the TBS.

Characterizing Bone Phenotypes Related to Skeletal Fragility Using Advanced Medical Imaging

PURPOSE OF REVIEW

Summarize the recent literature that investigates how advanced medical imaging has contributed to our understanding of skeletal phenotypes and fracture risk across the lifespan.

RECENT FINDINGS

Characterization of bone phenotypes on the macro-scale using advanced imaging has shown that while wide bones are generally stronger than narrow bones, they may be more susceptible to age-related declines in bone strength. On the micro-scale, HR-pQCT has been used to identify bone microarchitecture phenotypes that improve stratification of fracture risk based on phenotype-specific risk factors. Adolescence is a key phase for bone development, with distinct sex-specific growth patterns and significant within-sex bone property variability. However, longitudinal studies are needed to evaluate how early skeletal growth impacts adult bone phenotypes and fracture risk. Metabolic and rare bone diseases amplify fracture risk, but the interplay between bone phenotypes and disease remains unclear. Although bone phenotyping is a promising approach to improve fracture risk assessment, the clinical availability of advanced imaging is still limited. Consequently, alternative strategies for assessing and managing fracture risk include vertebral fracture assessment from clinically available medical imaging modalities/techniques or from fracture risk assessment tools based on clinical risk factors. Bone fragility is not solely determined by its density but by a combination of bone geometry, distribution of bone mass, microarchitecture, and the intrinsic material properties of bone tissue. As such, different individuals can exhibit distinct bone phenotypes, which may predispose them to be more vulnerable or resilient to certain perturbations that influence bone strength.

Exploring the terminological validity of 'chronic pain' nursing diagnosis: A retrospective descriptive study using nursing diaries

AIM

The aim of this study is to generate empirical evidence, drawing from clinical records, with the goal of elevating the level of evidence supporting the nursing diagnosis (ND) of 'chronic pain'.

BACKGROUND

Chronic pain is a prevalent condition that affects all age groups. Patients often feel disbelieved about their pain perception, leading to adverse psychological effects, difficulty accessing healthcare and poor rehabilitation outcomes.

DESIGN

Retrospective descriptive study. Standards for Reporting Diagnostic Accuracy Studies guidelines were followed in this study.

METHODS

Data were extracted from Electronic Health Records (EHR) of patients admitted to the University Hospital of Perugia, Italy, between March 2016 and December 2022. The study sample comprised individuals without a specific medical diagnosis or high-risk population. Out of 1,048,565 EHR, 43,341 clinical-nursing diaries with the keyword 'pain' were identified, from which 283 clinical-nursing notes were selected based on a keyword-based retrieval technique and diagnostic definition for further analysis.

RESULTS

Our study findings support the diagnostic descriptors of the 'chronic pain' ND in clinical-nursing diaries. We observed the presence of 9 out of 11 defining characteristics, 7 out of 10 related factors, 4 out of 8 at-risk populations and 11 out of 17 associated conditions.

CONCLUSIONS

The study validated diagnostic criteria for chronic pain and proposed 'haematological pathology' as a new associated condition. The findings were presented to the Diagnosis Development Committee of NANDA-International for further review. However, limitations of the study prompted the need for further analysis using natural language processing and artificial neural network techniques. As a result, a new research direction using artificial intelligence (AI) tools was initiated.

RELEVANCE TO CLINICAL PRACTICE

The study validates diagnostic descriptors for chronic pain and proposes future directions in semantic analysis and AI tools, aiming to enhance clinical practice and decision-making in nursing care.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Evaluation of bone density and hand grip strength in the course of drug treatment for osteoporosis : A real-world study

BACKGROUND

The aim of this clinical investigation was to assess the physical performance in osteoporotic patients undergoing drug treatment (DT) for years by measuring hand grip strength (HGS) and bone mineral density (BMD). A further aim was to detect the time until the occurrence of vertebral fractures (VF) and influencing factors.

MATERIAL AND METHODS

The investigation comprised 346 persons (276 women, 70 men) aged on average 66.9 ± 10.7 years with confirmed osteoporosis (OP). Over a mean period of 1384 ± 727 days, OP was assessed every 2 years, including a bone densitometry by dual X‑ray absorptiometry and HGS measurement. In subgroups OP patients were analyzed with and without a bone density (BMD) increase, and with and without VFs.

RESULTS

Under DT, calcium and vitamin D substitution, the median T‑score improved in the entire group from -3.2 to -3.1 standard deviations (SD; p = 0.002). HGS was reduced (median) from 26 kg to 24 kg (p < 0.001). The median interval until the occurrence of VF was 2652 days (95% confidence interval [CI] 1825.2-3478.8 days) and 1461 days (95% CI 1246.5-1675.5, p < 0.001) in those with and without a BMD increase, respectively.

DISCUSSION

Guideline-based DT improves bone density and causes a longer interval without VF. The HGS falls independent of BMD. The association between bone and muscle in patients with a deterioration of the musculoskeletal system is known as osteosarcopenia. Early muscle exercises would be meaningful in this setting.

Radiology reporting of incidental osteoporotic vertebral fragility fractures present on CT studies: results of UK national re-audit

AIM

To describe a UK-wide re-audit of the 2019 Royal College of Radiologists (RCR) audit evaluating patient-related data and organisational infrastructure in the radiological reporting of vertebral fragility fractures (VFFs) on computed tomography (CT) studies and to assess the impact of a series of RCR interventions, initiated to raise VFF awareness, on reporting practice and outcomes.

MATERIALS AND METHODS

Patient specific and organisational questionnaires largely replicated those utilised in 2019. The patient questionnaire involved retrospective analysis of between 50 and 100 consecutive, non-traumatic CT studies which included the thoracolumbar spine. All RCR radiology audit leads were invited to participate. Data collection commenced from 1 April 2022.

RESULTS

Data were supplied by 129/194 (67%) departments. One thousand five hundred and eighty-six of 7,316 patients (21.7%) had a VFF on auditor review. Overall improvements were demonstrated in key initial/provisional reporting results; comment on spine/bone (93.2%, 14.4% improvement, p<0.0002); fracture severity assessment (34.7%, 8.5% improvement, p=0.0007); use of recommended terminology (67.8%, 7.5% improvement, p=0.0034); recommendations for further management (11.7%, 9.1% improvement, p<0.0002).

CONCLUSIONS

The 2022 national re-audit confirms improvements in diagnostic performance and practice in VFF reporting. Continuing work is required to build on this improvement and to further embed best practice.

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.

New Insights in the Pathophysiology, Epidemiology, and Response to Treatment of Osteoporotic Vertebral Fractures

CONTEXT

Vertebral fractures (VFs) make up an important but challenging group of fractures often caused by osteoporosis. Osteoporotic fractures pose unique diagnostic challenges in generally requiring imaging for diagnosis. The objective of this narrative mini-review is to provide an overview of these recent advances in our knowledge of VF pathophysiology and epidemiology with particular focus on endocrine diseases, prevention, and treatment.

EVIDENCE ACQUISITION

We searched PubMed on May 23, 2022, for studies of VFs in humans. Results were limited to papers available as full-text publications in English, published from 2020 and onward. This yielded 3457 citations. This was supplemented by earlier publications selected to add context to the recent findings.

EVIDENCE SYNTHESIS

Studies addressed VF risk in hyperthyreosis, hyperparathyroidism, acromegaly, Cushing syndrome, primary aldosteronism, and diabetes. For pharmaceutical treatment, new studies or analyses were identified for romosozumab and for weekly teriparatide. Several studies, including studies in the immediate pipeline, were intervention studies with vertebroplasty or kyphoplasty, including combination with stem cells or pharmaceuticals.

CONCLUSIONS

Endocrinologists should be aware of the high likelihood of osteoporotic VFs in patients with endocrine diseases. Though licensed treatments are able to substantially reduce the occurrence of VFs in patients with osteoporosis, the vast majority of recent or ongoing randomized controlled trials in the VF area focus on advanced invasive therapy of the fracture itself.

A Randomized Controlled Trial of Vertebral Body Decompression Procedure Versus Conservative Treatment for Painful Vertebral Compression Fracture

Background: Traditional treatment modalities for vertebral compression fractures (VCFs) include bed rest, pain medications, muscle relaxants, back braces, and physical therapy. In cases where conservative treatment proves ineffective, a new procedure called core decompression of the vertebral body is explored. Core decompression of the vertebral body has the potential to lower and stabilize the intraosseous pressure, resulting in enhanced blood circulation, which contributes to pain reduction. In this trial, we evaluated the efficacy of core decompression of the vertebral body in patients with painful VCFs compared with conventional conservative treatment. Methods: This prospective randomized controlled trial was conducted at a tertiary education hospital between June 2017 and May 2020. The participants were randomly assigned in a 1:1 ratio to one of two treatment groups: the core decompression group and the conservative treatment group. The primary outcome measure was the visual analog scale (VAS) pain score of the back 3 months after the procedure. Secondary outcome measures included the Oswestry Disability Index (ODI) for lumbar disabilities, the European Quality of Life-5 Dimensions (EQ-5D) score for quality of life, and radiographic outcomes such as changes in compression rate. Results: All patients underwent the assigned intervention (48 core decompression and 50 conservative treatments). At both 1 month and 3 months, there were no significant differences between the core decompression group and conservative treatment group in VAS pain score (adjusted treatment effect: -0.1 and 2.0; 95% confidence interval [CI]: -7.5 to 7.3 and -5.6 to 9.6; p = 0.970 and p = 0.601, respectively). In addition, there were no significant inter-group differences in ODI and EQ-5D scores throughout the follow-up period (p = 0.917 and 0.704, respectively). Conclusion: Core decompression of the vertebral body did not demonstrate any significant improvement in pain and disability compared to conventional conservative treatment.

The adult with low back pain: causes, diagnosis, imaging features and management

Low back pain is the leading cause of disability worldwide. This article highlights the importance of succinct history taking and a thorough clinical examination when managing a patient with lower back pain in hospital. Furthermore, it encourages the clinician to consider the pertinent causes of low back pain such as age-related degeneration, malignancy, trauma, infection and seronegative inflammatory spondyloarthropathies, and looks at the diagnosis, imaging features and key management options which are available in secondary care.

[Osteoporotic vertebral body fractures]

The number of osteoporotic fractures of the spine is increasing. These fractures are associated with elevated morbidity and mortality. This article provides an overview of the special features of these fractures, the diagnostic procedure, their classification, and the conservative and surgical treatment options. For the mostly elderly patients, it is important to treat the underlying disease and to address associated problems such as frailty and sarcopenia. To meet this growing medical and socio-economic challenge, a holistic interdisciplinary and interprofessional treatment approach is required.

Incident vertebral fracture and longitudinal BMD change in Chinese postmenopausal women with early CKD: Peking Vertebral Fracture Study

Early chronic kidney disease (CKD) and non-CKD individuals had similar morphometric vertebral fracture (mVF) incidence and longitudinal bone mineral density (BMD) change. CKD did not modify the association between BMD and incident mVF status. Patients with a higher baseline BMD had a higher longitudinal BMD loss in early CKD.

PURPOSE

The aim of this 5-year longitudinal cohort study was to compare the risk of incident morphometric vertebral fracture (mVF) and longitudinal bone mineral density (BMD) change between individuals with early chronic kidney disease (CKD) and those without CKD.

METHODS

A total of 869 Chinese postmenopausal women were enrolled in the study. Serum creatinine levels were assessed using standard methods, and estimated glomerular filtration rate (eGFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation. Incident mVF was confirmed through lateral radiographs of the thoracolumbar spine. BMDs at the lumbar spine (LS) and femoral neck (FN) were measured using dual-energy X-ray absorptiometry. CKD was defined based on eGFR values: 60-89 mL/min/1.73m2 for stage 2 (n = 511) and 30-59 mL/min/1.73m2 for stage 3 (n = 92). The non-CKD group included individuals with an eGFR greater than or equal to 90 mL/min/1.73m2.

RESULTS

The incidence of mVF was not statistically different between individuals with early CKD and those without CKD (4.1% in non-CKD, 6.3% in CKD stage 2, and 7.6% in CKD stage 3; p = 0.348). Neither eGFR nor CKD status was significantly associated with incident mVF in the multivariate logistic regression analysis. Baseline BMD T-scores were negatively associated with incident mVF (LS T-score, OR = 0.603, 95% CI = 0.468-0.777; FN T-score, OR = 0.511, 95% CI = 0.350-0.746). No evidence of interaction between BMD T-scores and CKD status were identified (p = 0.284-0.785) . The differences in longitudinal BMD changes between non-CKD and CKD groups were comparable (FN BMD: -6.31 ± 7.20% in non-CKD, -5.07 ± 8.20% in CKD stage 2, and -4.49 ± 8.40% in CKD stage 3, p = 0.556; LS BMD: -1.38 ± 8.18% in non-CKD, -0.32 ± 7.14% in CKD stage 2, and 1.5 ± 6.97% in CKD stage 3, p = 0.406). Individuals with a higher baseline FN BMD showed a greater longitudinal FN BMD loss (r = -0.185, p < 0.001) .

CONCLUSIONS

Our study revealed that early CKD was not associated with an increased risk of incident mVF or greater longitudinal BMD loss. Moreover, CKD did not modify the association between BMD and the risk of incident mVF, suggesting that the management and prevention of fractures in early CKD should be approached similarly to those without CKD. Measurement of BMD appears to be crucial for predicting incident mVF risk and longitudinal bone loss in early CKD.

Similarities and Differences in the Management of Patients with Osteoporotic Vertebral Fractures and Those with Rebound-Associated Vertebral Fractures Following Discontinuation of Denosumab

Rebound-associated vertebral fractures (RVFx) following denosumab discontinuation are typically multiple, are commonly associated with acute sharp pain, increase the risk of imminent fractures, and are pathogenetically different from common osteoporotic vertebral fractures (VFx). A clinically relevant question is whether patients with RVFx should be managed differently from patients with osteoporotic VFx. To address this question, we performed a systematic search of the PubMed database, and we reviewed current evidence on the optimal management of patients with RVFx. For pain relief of patients with RVFx, potent analgesics, often opioids, are essential. Information on the effectiveness of braces in these patients is scarce. Vertebroplasty and kyphoplasty are strongly contraindicated as they confer a substantial risk for new VFx. Exercise may be helpful, but again evidence is lacking. In contrast to patients with osteoporotic VFx, in whom initial treatment with bone-forming agents is recommended, patients with RVFx should initiate treatment with potent antiresorptives. To summarize, patients who have sustained RVFx following denosumab discontinuation are at a very high risk for new fractures, especially VFx. The management of such patients requires a multidisciplinary approach that should not be restricted to pain relief and administration of antiosteoporotic medication, but should also include back protection, early mobilization, and appropriate exercise.

Using Artificial Intelligence to Diagnose Osteoporotic Vertebral Fractures on Plain Radiographs

Osteoporotic vertebral fracture (OVF) is a risk factor for morbidity and mortality in elderly population, and accurate diagnosis is important for improving treatment outcomes. OVF diagnosis suffers from high misdiagnosis and underdiagnosis rates, as well as high workload. Deep learning methods applied to plain radiographs, a simple, fast, and inexpensive examination, might solve this problem. We developed and validated a deep-learning-based vertebral fracture diagnostic system using area loss ratio, which assisted a multitasking network to perform skeletal position detection and segmentation and identify and grade vertebral fractures. As the training set and internal validation set, we used 11,397 plain radiographs from six community centers in Shanghai. For the external validation set, 1276 participants were recruited from the outpatient clinic of the Shanghai Sixth People's Hospital (1276 plain radiographs). Radiologists performed all X-ray images and used the Genant semiquantitative tool for fracture diagnosis and grading as the ground truth data. Accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were used to evaluate diagnostic performance. The AI_OVF_SH system demonstrated high accuracy and computational speed in skeletal position detection and segmentation. In the internal validation set, the accuracy, sensitivity, and specificity with the AI_OVF_SH model were 97.41%, 84.08%, and 97.25%, respectively, for all fractures. The sensitivity and specificity for moderate fractures were 88.55% and 99.74%, respectively, and for severe fractures, they were 92.30% and 99.92%. In the external validation set, the accuracy, sensitivity, and specificity for all fractures were 96.85%, 83.35%, and 94.70%, respectively. For moderate fractures, the sensitivity and specificity were 85.61% and 99.85%, respectively, and 93.46% and 99.92% for severe fractures. Therefore, the AI_OVF_SH system is an efficient tool to assist radiologists and clinicians to improve the diagnosing of vertebral fractures. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Examination and Scientific Analysis of Thoracic Vertebral Fractures

Background Thoracic vertebral fractures are clinically important due to their association with the thoracic spinal cord and the potential to cause devastating neurological injury. Using the National Electronic Injury Surveillance System (NEISS) data, this study investigated fracture patterns to understand associated factors to improve prevention strategies. We explored different factors associated with thoracic vertebral fractures to improve our understanding of preventative strategies and patient care standards, focusing on spatial distribution, sex-age dynamics, and location of injury. Methodology This retrospective, cross-sectional study examines thoracic vertebral fractures across diverse age groups from 2013 to 2022, utilizing the NEISS database from the U.S. Consumer Product Safety Commission. Inclusion criteria based on specific terms related to thoracic fractures were employed. Descriptive statistics illustrated fracture distribution by age groups and associated products. Statistical analyses, including chi-square tests and multivariate logistic regressions, were conducted to explore associations between fracture occurrence, locations, products, age, and gender. Results The analysis of thoracic vertebral fractures by location and associated products yielded several statistically significant findings. Notably, the prevalence of fractures at home (39.67%) was significantly higher than in other locations, and these differences in fracture distribution were statistically significant (χ² = 7.34, p < 0.001). Among the associated products, ladders (10.46%) emerged as the most frequent product associated with fractures. Multivariate logistic regression analysis showed that the age groups of 41-50, 51-60, and 61-70 had increased odds of fractures with adjusted odds ratios (AORs) of 1.08 (95% confidence interval (CI) = 1.04-1.42, p < 0.05), 1.21 (95% CI = 1.13-1.56, p < 0.001), and 1.17 (95% CI = 1.08-1.39, p < 0.001), respectively. The likelihood of thoracic vertebral fractures did not significantly differ between males and females (AOR = 1.12, 95% CI = 0.87-1.53, p = 0.262). Fracture distribution by age groups and products indicated increasing ladder-related fractures within the 41-50 age group and 51-60 age group. Football-related fractures peaked within the 21-30 age group. Fracture distribution patterns for bicycles had increased prevalence within the 11-20 and 21-30 age groups, and football-related fractures in younger age groups. Conclusions This study analyzed factors associated with thoracic vertebral fractures, showing the significance of targeted preventative interventions, such as earlier screening, physical therapy, and nutritional status assessment, in the setting of significant location and age-related susceptibilities. The observed patterns of injury provide a foundation for future research to elucidate the underlying mechanisms between different environments and the likelihood of injury to improve preventive strategies.

Red flags to screen for vertebral fracture in people presenting with low back pain

BACKGROUND

Low back pain is a common presentation across different healthcare settings. Clinicians need to confidently be able to screen and identify people presenting with low back pain with a high suspicion of serious or specific pathology (e.g. vertebral fracture). Patients identified with an increased likelihood of having a serious pathology will likely require additional investigations and specific treatment. Guidelines recommend a thorough history and clinical assessment to screen for serious pathology as a cause of low back pain. However, the diagnostic accuracy of recommended red flags (e.g. older age, trauma, corticosteroid use) remains unclear, particularly those used to screen for vertebral fracture.

OBJECTIVES

To assess the diagnostic accuracy of red flags used to screen for vertebral fracture in people presenting with low back pain. Where possible, we reported results of red flags separately for different types of vertebral fracture (i.e. acute osteoporotic vertebral compression fracture, vertebral traumatic fracture, vertebral stress fracture, unspecified vertebral fracture).

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 26 July 2022.

SELECTION CRITERIA

We considered primary diagnostic studies if they compared results of history taking or physical examination (or both) findings (index test) with a reference standard test (e.g. X-ray, magnetic resonance imaging (MRI), computed tomography (CT), single-photon emission computerised tomography (SPECT)) for the identification of vertebral fracture in people presenting with low back pain. We included index tests that were presented individually or as part of a combination of tests.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data for diagnostic two-by-two tables from the publications or reconstructed them using information from relevant parameters to calculate sensitivity, specificity, and positive (+LR) and negative (-LR) likelihood ratios with 95% confidence intervals (CIs). We extracted aspects of study design, characteristics of the population, index test, reference standard, and type of vertebral fracture. Meta-analysis was not possible due to heterogeneity of studies and index tests, therefore the analysis was descriptive. We calculated sensitivity, specificity, and LRs for each test and used these as an indication of clinical usefulness. Two review authors independently conducted risk of bias and applicability assessment using the QUADAS-2 tool.

MAIN RESULTS

This review is an update of a previous Cochrane Review of red flags to screen for vertebral fracture in people with low back pain. We included 14 studies in this review, six based in primary care, five in secondary care, and three in tertiary care. Four studies reported on 'osteoporotic vertebral fractures', two studies reported on 'vertebral compression fracture', one study reported on 'osteoporotic and traumatic vertebral fracture', two studies reported on 'vertebral stress fracture', and five studies reported on 'unspecified vertebral fracture'. Risk of bias was only rated as low in one study for the domains reference standard and flow and timing. The domain patient selection had three studies and the domain index test had six studies rated at low risk of bias. Meta-analysis was not possible due to heterogeneity of the data. Results from single studies suggest only a small number of the red flags investigated may be informative. In the primary healthcare setting, results from single studies suggest 'trauma' demonstrated informative +LRs (range: 1.93 to 12.85) for 'unspecified vertebral fracture' and 'osteoporotic vertebral fracture' (+LR: 6.42, 95% CI 2.94 to 14.02). Results from single studies suggest 'older age' demonstrated informative +LRs for studies in primary care for 'unspecified vertebral fracture' (older age greater than 70 years: 11.19, 95% CI 5.33 to 23.51). Results from single studies suggest 'corticosteroid use' may be an informative red flag in primary care for 'unspecified vertebral fracture' (+LR range: 3.97, 95% CI 0.20 to 79.15 to 48.50, 95% CI 11.48 to 204.98) and 'osteoporotic vertebral fracture' (+LR: 2.46, 95% CI 1.13 to 5.34); however, diagnostic values varied and CIs were imprecise. Results from a single study suggest red flags as part of a combination of index tests such as 'older age and female gender' in primary care demonstrated informative +LRs for 'unspecified vertebral fracture' (16.17, 95% CI 4.47 to 58.43). In the secondary healthcare setting, results from a single study suggest 'trauma' demonstrated informative +LRs for 'unspecified vertebral fracture' (+LR: 2.18, 95% CI 1.86 to 2.54) and 'older age' demonstrated informative +LRs for 'osteoporotic vertebral fracture' (older age greater than 75 years: 2.51, 95% CI 1.48 to 4.27). Results from a single study suggest red flags as part of a combination of index tests such as 'older age and trauma' in secondary care demonstrated informative +LRs for 'unspecified vertebral fracture' (+LR: 4.35, 95% CI 2.92 to 6.48). Results from a single study suggest when '4 of 5 tests' were positive in secondary care, they demonstrated informative +LRs for 'osteoporotic vertebral fracture' (+LR: 9.62, 95% CI 5.88 to 15.73). In the tertiary care setting, results from a single study suggest 'presence of contusion/abrasion' was informative for 'vertebral compression fracture' (+LR: 31.09, 95% CI 18.25 to 52.96).

AUTHORS' CONCLUSIONS

The available evidence suggests that only a few red flags are potentially useful in guiding clinical decisions to further investigate people suspected to have a vertebral fracture. Most red flags were not useful as screening tools to identify vertebral fracture in people with low back pain. In primary care, 'older age' was informative for 'unspecified vertebral fracture', and 'trauma' and 'corticosteroid use' were both informative for 'unspecified vertebral fracture' and 'osteoporotic vertebral fracture'. In secondary care, 'older age' was informative for 'osteoporotic vertebral fracture' and 'trauma' was informative for 'unspecified vertebral fracture'. In tertiary care, 'presence of contusion/abrasion' was informative for 'vertebral compression fracture'. Combinations of red flags were also informative and may be more useful than individual tests alone. Unfortunately, the challenge to provide clear guidance on which red flags should be used routinely in clinical practice remains. Further research with primary studies is needed to improve and consolidate our current recommendations for screening for vertebral fractures to guide clinical care.

Adjusting FRAX Estimates of Fracture Probability Based on a Positive Vertebral Fracture Assessment

Importance

FRAX is the most widely used and validated fracture risk prediction tool worldwide. Vertebral fractures, which are an indicator of subsequent osteoporotic fractures, can be identified using dual-energy x-ray absorptiometry (DXA) vertebral fracture assessment (VFA).

Objective

To assess the calibration of FRAX and develop a simple method for improving FRAX-predicted fracture probability in the presence of VFA-identified fracture.

Design, Setting, and Participants

This prognostic study analyzed the DXA and VFA results of all individuals who underwent a VFA between March 31, 2010, and March 31, 2018, who were included in the Manitoba Bone Mineral Density Registry. These individuals were randomly assigned to either the development cohort or validation cohort. A modified algorithm-based qualitative approach was used by expert readers to code VFAs as positive (≥1 vertebral fractures detected) or negative (0 vertebral fracture detected). Statistical analysis was conducted from August 7, 2022, to May 22, 2023.

Exposures

FRAX scores for major osteoporotic fracture (MOF) and hip fracture were calculated with or without VFA results.

Main Outcomes and Measures

Incident fractures and death were ascertained using linked population-based health care provincial data. Cumulative incidence curves for MOF and hip fracture were constructed, including competing mortality, to predict the 10-year observed risk of fracture. The observed probability was compared with FRAX-predicted fracture probability with and without VFA results and recalibrated FRAX from derived multipliers.

Results

The full cohort of 11 766 individuals was randomly allocated to the development cohort (n = 7854; 7349 females [93.6%]; mean [SD] age, 75.7 [6.8] years) or the validation cohort (n = 3912; 3713 females [94.9%]; mean [SD] age, 75.5 [6.9] years). Over a mean (SD) observation time of 3.8 (2.3) years, with the longest observation at 7.5 years, FRAX was well calibrated in subgroups with negative VFA results. For individuals without a prior clinical fracture but with a positive VFA result, the 10-year FRAX-predicted MOF probability was 16.3% (95% CI, 15.7%-16.8%) without VFA information and 23.4% (95% CI, 22.7%-24.1%) with VFA information. The observed 10-year probabilities were 26.9% (95% CI, 26.0%-27.8%) and 11.2% (95% CI, 10.3%-12.1%), respectively, resulting in recalibration multipliers of 1.15 (95% CI, 0.87-1.43) for MOF and 1.31 (95% CI, 0.75-1.87) for hip fracture. For individuals with a prior clinical fracture and a positive VFA result, the 10-year FRAX-predicted probabilities were 25.0% (95% CI, 24.2%-25.7%) for MOF and 9.3% (95% CI, 8.7%-10.0%) for hip fracture. The observed 10-year probabilities were 38.1% (95% CI, 37.0%-39.1%) for MOF and 16.4% (95% CI, 15.4%-17.4%) for hip fracture, resulting in a recalibration multiplier of 1.53 (95% CI, 1.10-1.96) for MOF and 1.76 (95% CI, 1.17-2.35) for hip fracture. Good calibration (>0.90) was confirmed using the derived multipliers in the validation cohort.

Conclusions and Relevance

Results of this prognostic study suggest that FRAX underestimated fracture risk in patients with VFA-identified fractures. Simple multipliers could recover FRAX calibration in individuals with VFA-identified fractures.

Percutaneous lordoplasty for the treatment of severe osteoporotic vertebral compression fractures with kyphosis

Objective

The study aimed to explore the safety and effectiveness of percutaneous lordoplasty (PLP) in the treatment of severe osteoporotic vertebral compression fracture (OVCF).

Methods

Included in this prospective study were patients with single-segment acute severe OVCF who were treated with PLP in our institution from July 2016 to October 2019. Patients' back pain and quality of life were assessed using the visual analog scale (VAS) and SF-36 scores. Lateral X-ray radiography of the spine was performed to measure the vertebral height, vertebral kyphotic angle, and segmental kyphotic angle, and to evaluate the outcome of fracture reduction and kyphotic correction. Intra-and postoperative complications were recorded.

Results

Of the 51 included patients, 47 patients were followed up for 12 months. The VAS score decreased from preoperative 7.33 ± 1.92 to postoperative 1.76 ± 0.85 at the 12th month (p < 0.05), and the SF-36 score increased from preoperative 79.50 ± 9.22 to postoperative 136.94 ± 6.39 at the 12th month (p < 0.05). During the 1-year follow-up period, the anterior height of the vertebral body increased significantly from preoperative 10.49 ± 1.93 mm to 19.33 ± 1.86 mm (p < 0.05); the posterior height of the vertebral body increased insignificantly from preoperative 22.23 ± 2.36 mm to 23.05 ± 1.86 mm (p > 0.05); the vertebral kyphotic angle decreased significantly from preoperative 18.33° ± 11.49° to 8.73° ± 1.21° (p < 0.05); and the segmental kyphotic angle decreased significantly from preoperative 24.48° ± 4.64° to 11.70° ± 1.34° (p < 0.05). During the 1-year follow-up period, there was no significant difference in the radiologic parameters, VAS scores, and SF-36 scores, between the 1st day and the 12th month of post-operation (P > 0.05). No nerve damage occurred in any of the cases. Intraoperative cement leakage occurred in six cases, and the fracture of the adjacent vertebral body occurred in one case.

Conclusion

PLP can well reduce the risk of fracture and achieve good kyphotic correction and may prove to be a safe, cost-effective and minimally invasive alternative option for the treatment of severe OVCF with kyphotic deformity.

Risk Factors for the Occurrence and Severity of Vertebral Fractures in Inflammatory Bowel Disease Patients: A Nationwide Population-Based Cohort Study

BACKGROUND

The risk of vertebral fractures is increased in inflammatory bowel disease (IBD) patients. However, whether the severity of vertebral fractures differs between IBD patients and the general population, or between patients with Crohn's disease (CD) and ulcerative colitis (UC), is unknown.

METHODS

We investigated risk factors associated with the occurrence and severity of vertebral fractures in IBD patients using The National Healthcare Insurance Service (NHIS) database. We defined the patients who underwent vertebroplasty or kyphoplasty after being diagnosed with a vertebral fracture as having a severe vertebral fracture than those with only diagnosis codes.

RESULTS

From 2008 to 2018, there were 33,778 patients with IBD (24,370 UC patients and 9,408 CD patients) and 101,265 patients in the reference population. The incidence rate ratio of vertebral fractures in the IBD patients was 1.27 per 1,000 person-years (95% confidence interval [CI], 1.26-1.27). The risk of vertebral fracture was higher in CD and UC patients than in the matched reference group (hazard ratio [HR], 1.59; 95% CI, 1.31-1.92; P < 0.001 and HR, 1.26; 95% CI, 1.14-1.41; P < 0.001, respectively). In a multivariate analysis, the occurrence of vertebral fracture was associated with CD (HR, 1.31; 95% CI, 1.08-1.59; P = 0.006), older age (CD: HR, 1.09; 95% CI, 1.08-1.09; P < 0.001 and UC: HR, 1.09; 95% CI, 1.08-1.09; P < 0.001), female sex (CD: HR, 1.81; 95% CI, 1.63-2.01; P < 0.001 and UC: HR, 2.02; 95% CI, 1.83-2.22; P < 0.001), high Charlson Comorbidity Index (CCI) score (CD: HR, 1.42; 95% CI, 1.23-1.63; P < 0.001 and UC: HR, 1.46; 95% CI, 1.29-1.65, P < 0.001), and long-term steroid use (CD: HR, 3.71; 95% CI, 2.84-3.37; P < 0.001 and UC: HR, 3.88; 95% CI, 3.07-4.91; P < 0.001). The severity of vertebral fractures was associated with IBD (CD: HR, 1.82; 95% CI, 1.17-2.83; P = 0.008 and UC: HR, 1.49; 95% CI, 1.17-1.89; P < 0.001) and older age (HR, 1.06; 95% CI, 1.05-1.07; P < 0.001).

CONCLUSION

Vertebral fractures occur frequently and more severely in IBD patients, particularly those with CD. Therefore, we suggest monitoring of bone density, regular vitamin D supply, and reducing the use of corticosteroids to prevent vertebral fractures in IBD patients who are older, female, or have comorbidities.

Hormones and Aging: An Endocrine Society Scientific Statement

Multiple changes occur across various endocrine systems as an individual ages. The understanding of the factors that cause age-related changes and how they should be managed clinically is evolving. This statement reviews the current state of research in the growth hormone, adrenal, ovarian, testicular, and thyroid axes, as well as in osteoporosis, vitamin D deficiency, type 2 diabetes, and water metabolism, with a specific focus on older individuals. Each section describes the natural history and observational data in older individuals, available therapies, clinical trial data on efficacy and safety in older individuals, key points, and scientific gaps. The goal of this statement is to inform future research that refines prevention and treatment strategies in age-associated endocrine conditions, with the goal of improving the health of older individuals.

Discovery of potential biomarkers for osteoporosis diagnosis by individual omics and multi-omics technologies

INTRODUCTION

Global aging has made osteoporosis an increasingly serious public health problem. Osteoporotic fractures seriously affect the quality of life of patients and increase disability and mortality rates. Early diagnosis is important for timely intervention. The continuous development of individual- and multi-omics methods is helpful for the exploration and discovery of biomarkers for the diagnosis of osteoporosis.

AREAS COVERED

In this review, we first introduce the epidemiological status of osteoporosis and then describe the pathogenesis of osteoporosis. Furthermore, the latest progress in individual- and multi-omics technologies for exploring biomarkers for osteoporosis diagnosis is summarized. Moreover, we clarify the advantages and disadvantages of the application of osteoporosis biomarkers obtained using the omics method. Finally, we put forward valuable views on the future research direction of diagnostic biomarkers of osteoporosis.

EXPERT OPINION

Omics methods undoubtedly provide greatly contribute to the exploration of diagnostic biomarkers of osteoporosis; however, in the future, the clinical validity and clinical utility of the obtained potential biomarkers should be thoroughly examined. In addition, the improvement and optimization of the detection methods for different types of biomarkers and standardization of the detection process guarantee the reliability and accuracy of the detection results.

Regional variations in the intra- and intervertebral trabecular microarchitecture of the osteoporotic axial skeleton

Trabecular structures in vertebral bodies are unequally distributed in the cervical, thoracic and lumbar spine, and also within individual vertebrae. Knowledge of the microstructure of these entities could influence our comprehension and treatment of osteoporotic fractures, and even surgical procedures. Appropriate investigations may clarify the pathomechanisms of various osteoporotic fractures (fish, wedge-shaped, and flat vertebrae). We obtained three cancellous bone cylinders from the centers and margins of cervical vertebra 3 to lumbar vertebra 5, and investigated these in regard of bone volume fraction, trabecular thickness, separation, trabecular number, trabecular bone pattern factor, connectivity density, and degree of anisotropy. Using a Jamshidi needle^®, we obtained samples from three quadrants (QI: right-sided edge, QII: central, QIII: left-sided edge) of 242 prepared vertebrae, and investigated these on a micro-CT device. In all, 726 bone samples were taken from eleven body donors. Bone volume fraction, trabecular thickness, and the degree of anisotropy were significantly lower in QII than in QI and QIII. Trabecular pattern factor, however, was significantly higher in QII than in QI and QIII. The results helped to explain fish vertebrae. Wedge fractures and flat vertebrae are most likely caused by the complex destruction of trabecular and cortical structures. The higher bone volume fraction in the cervical spine compared to the thoracic and lumbar spine accounts for the small number of fractures in the cervical spine. The marked trabecular pattern factor in the center of thoracic and lumbar vertebrae could be a reason for the surgeon to use different screw designs for individual vertebrae.

Intravoxel Incoherent Motion Factors Affecting Collapse and Nonunion of Osteoporotic Vertebral Fracture

STUDY DESIGN

Longitudinal study.

OBJECTIVES

Intravoxel incoherent motion (IVIM), a magnetic resonance imaging (MRI) scanning technique that applies diffusion-weighted imaging (DWI), is effective for the quantitative assessment of malignant tumors of the vertebral bone. We hypothesized that IVIM parameters of vertebral bodies are associated with the prognosis of osteoporotic vertebral fracture (OVF). We aimed to explore the relationships between IVIM parameters for vertebral collapse and non-union after OVF and calculate the cut-off values of these parameters for vertebral collapse and non-union.

METHODS

A total of 150 patients with acute OVF (150 women; mean age: 79.1 ± 7.4 years) were included and treated conservatively with bracing. MRI was performed at the time of injury. IVIM parameters, such as apparent diffusion coefficient (ADC), molecular diffusion coefficient (D), and perfusion-related diffusion (D*) were recorded. The patients were classified into 3 groups: low-collapse (height loss of ≤50%), high-collapse (height loss of >50%), and non-union. We compared ADC, D, and D* among the low-collapse, high-collapse, and non-union groups and performed a receiver operating characteristic (ROC) curve analysis to determine the boundary values of the high-collapse and non-union groups.

RESULTS

The low-collapse, high-collapse, and non-union groups had no significant differences in ADC and D. However, D* differed significantly among the 3 groups. ROC analysis revealed cut-off values of 19.0 × 10-3 mm2/s and 12.3 × 10-3 mm2/s for the high-collapse and non-union groups, respectively.

CONCLUSIONS

D* is a significant prognostic indicator for high-collapse and non-union groups with OVF. This suggests that D* should be considered when assessing OVF.

Effects of resistance and balance exercises for athletic ability and quality of life in people with osteoporotic vertebral fracture: Systematic review and meta-analysis of randomized control trials

Purpose

This study aimed to use meta-analysis to determine the impact of resistance and balance training on athletic ability and quality of life for patients with osteoporotic vertebral fracture (OVF).

Methods

This study followed the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) criteria for systematic reviews and meta-analyzes. The PubMed, Web of science, Cochrane, Embase, and CNKI databases were searched for randomized controlled trials (RCTs) up to September 2022. The search strategy was related to the intervention measures, population, and results, and was structured around the search terms: “Exercise,” “Osteoporotic vertebral fracture,” and “activities of function.” Two reviewers strictly implemented the inclusion and exclusion criteria. Subgroup analyzes of age and training duration were performed for the main outcomes.

Results

We included 12 RCTs (n = 1,289) of resistance and balance training in patients with OVF. Compared with controls, the intervention group showed improvements on the Quality of Life Questionnaire issued by the European Foundation for Osteoporosis, visual analog pain scale, Timed Up and Go, falls efficacy scale international (FES-I), kyphosis, and functional reach. On subgroup analysis, the effect was more significant when training continued &gt;10 weeks.

Conclusion

Resistance and balance exercise training improved function and balance, and reduced fall risk in patients with OVF. We recommend resistance and balance training for at least 10 weeks. Future multicenter, large sample trials are needed for more reliable conclusions.

Spinal Metastasis Causing Dropped Head Syndrome in the Chiropractic Office: A Case Report

Dropped head syndrome is a rare disorder involving an inability to hold the head upright. It may be caused by a variety of neuromuscular disorders and occasionally by pathological vertebral fractures. A 79-year-old man presented to a chiropractor with a two-year history of gradual-onset chin-on-chest posture and increased thoracic kyphosis, which had failed to respond to physical therapy. The chiropractor ordered whole spine computed tomography which revealed extensive mixed lytic and sclerotic changes and multiple thoracic compression fractures suggestive of metastasis. The chiropractor promptly referred the patient to an oncologist, who performed a biopsy confirming prostate adenocarcinoma. The patient's health deteriorated, and he expired three weeks later. This case highlights that chiropractors should be aware that patients may present to their office with symptoms related to undiagnosed cancer, such as spinal deformity and dropped head syndrome. Chiropractors should order advanced imaging when patients have red flag signs or symptoms (e.g., older age, progressive symptoms despite care) and refer to an oncologist when clinical features or testing are suggestive of metastasis.

Body composition, trabecular bone score and vertebral fractures in subjects with Klinefelter syndrome

BACKGROUND

Klinefelter syndrome (KS) frequently causes skeletal fragility characterized by profound alterations in bone microstructure with increased risk of fractures. Increased body fat mass associated with decreased body lean mass are frequent features of KS with possible detrimental effects on skeletal health. In this cross-sectional study, we evaluated the associations between body composition parameters, vertebral fractures (VFs) and trabecular bone score (TBS) in adult subjects with KS.

METHODS

Seventy-one adult males (median age 41 years, range 18-64) with 47, XXY KS were consecutively enrolled by two Endocrinology and Andrology Units (IRCCS Humanitas Research Hospital in Milan and ASST Spedali Civili in Brescia). Dual-energy X-ray absorptiometry (DXA) was performed to assess bone mineral density (BMD) at lumbar spine, femoral neck and total hip, TBS and body composition. Prevalence of VFs was assessed by quantitative morphometry on lateral spine X-rays.

RESULTS

VFs were detected in 14 patients (19.7%), without significant association with low BMD (p = 0.912). In univariate logistic regression analysis, VFs were significantly associated with truncal/leg fat ratio (OR 2.32 per tertile; 95% CI 1.05-5.15; p = 0.038), whereas impaired TBS (detected in 23.4% of subjects) was associated with older age at study entry (p = 0.001) and at diagnosis of disease (p = 0.015), body mass index (BMI; p = 0.001), waist circumference (p = 0.007), fat mass index (FMI; p < 0.001), FMI/lean mass index (LMI) ratio (p = 0.001). Prevalence of VFs was not significantly different between subjects with impaired TBS as compared to those with normal TBS (26.7 vs. 18.4%; p = 0.485). Skeletal end-points were not significantly associated with duration of testosterone replacement therapy and serum testosterone and 25hydroxyvitamin D values.

CONCLUSION

Body composition might influence bone quality and risk of VFs in subjects with KS.

Litigation involving sports-related spinal injuries: a comprehensive review of reported legal claims in the United States in the past 70 years

BACKGROUND CONTEXT

Sports-related spinal injuries can be catastrophic in nature. Athletes competing in collision sports (eg, football) may be particularly prone to injury given the high-impact nature of these activities. Due to the oftentimes profound impact of sports-related spinal injuries on health and quality-of-life, they are also associated with a substantial risk of litigation. However, no study to date has assessed litigation risks associated with sports-related spinal injuries. A better understanding of the risk factors surrounding these legal claims may provide insights into injury prevention and other strategies to minimize litigation risks. In addition, it may allow the spine surgeon to better recognize the health, socioeconomic, and legal challenges faced by this patient population.

PURPOSE

To provide a comprehensive assessment of reported legal claims involving sports-related spinal injuries, including a comparative analysis of legal outcomes between collision and non-collision sports. To discuss strategies to prevent sports-related spinal injuries and minimize litigation risks.

STUDY DESIGN/SETTING

Retrospective review.

PATIENT SAMPLE

Athletes experiencing spinal injuries during sports.

OUTCOME MEASURES

Outcomes included verdict outcome (defendant vs. plaintiff), legal claims, injuries sustained, clinical symptoms, and award payouts.

METHODS

The legal research database Westlaw Edge (Thomson Reuters) was queried for legal claims brought in the United States from 1950 to 2021 involving sports-related spinal injuries. Verdict or settlement outcomes were collected as well as award payouts, time to case closure, case year, and case location. Demographic data, including type of sport (ie collision vs. non-collision sport) and level of play were obtained. Legal claims, spinal injuries sustained, and clinical symptoms were also extracted. Furthermore, the nature of injury, injured spinal region, and treatment pursued were collected. Descriptive statistics were reported for all cases and independent-samples t-tests and chi-square tests were used to compare differences between collision and non-collision sports.

RESULTS

Of the 840 cases identified on initial search, 78 met our criteria for in-depth analysis. This yielded 62% (n=48) defendant verdicts, 32% (n=25) plaintiff verdicts, and 6% (n=5) settlements, with a median inflation-adjusted award of $780,000 (range: $5,480-$21,585,000) for all cases. The most common legal claim was negligent supervision (n=38, 46%), followed by premises liability (n=23, 28%), and workers' compensation/no fault litigation (n=10, 12%). The most common injuries sustained were vertebral fractures (n=34, 44%) followed by disc herniation (n=14, 18%). Most cases resulted in catastrophic neurological injury (n=37, 49%), either paraplegia (n=6, 8%) or quadriplegia (n=31, 41%), followed by chronic/refractory pain (n=32, 43%). Non-collision sport cases had a higher percentage of premises liability claims (41% vs. 11%, p=.006) and alleged chronic/refractory pain (53% vs. 28%, p=.04). Conversely, collision sport cases had a higher proportion of workers' compensation/no fault litigation (23% vs. 4%, p=.03) and cases involving disc herniation (29% vs. 9%, respectively; p=.04).

CONCLUSION

Sports-related spinal injuries are associated with multiple and complex health, socioeconomic, and legal consequences, with median inflation-adjusted award payouts nearing $800,000 per case. In our cohort, the most commonly cited legal claims were negligent supervision and premises liability, emphasizing the need for prevention guidelines for safe sports practice, especially in non-professional settings. Cases involving athletes participating in non-collision sports were significantly associated with claims citing chronic/refractory pain, highlighting the importance of long-term care in severely injured athletes.

Should vertebral fracture assessment be performed in Fracture Liaison Service patients with non-vertebral fracture?

Prior non-vertebral fractures, except of the ankle, are associated with increased likelihood of vertebral fracture. As knowledge of vertebral fracture presence may alter care, vertebral fracture assessment (VFA) is indicated in patients with prior fracture.

INTRODUCTION

Vertebral fractures are often unappreciated. It was recently advocated that all Fracture Liaison Service (FLS) patients have densitometric VFA performed. We evaluated the likelihood of vertebral fracture identification with VFA in patients with prior fracture using the Manitoba Bone Density database. METHODS : VFA was performed in patients with T-scores below - 1.5 and age 70 + (or younger with height loss or glucocorticoid use) obtaining bone densitometry in Manitoba from 2010 to 2018. Those with prior clinical vertebral fracture, pathologic fracture, or uninterpretable VFA were excluded. Vertebral fractures were identified using the modified ABQ method. Health records were assessed for non-vertebral fracture (excluding head, neck, hand, foot) diagnosis codes unassociated with trauma prior to DXA. Multivariable odds ratios (ORs) for vertebral fracture were estimated without and with adjustment for age, sex, body mass index, ethnicity, area of residence, income level, comorbidity score, diabetes mellitus, falls in the last year, glucocorticoid use, and lowest BMD T-score.

RESULTS

The study cohort consisted of 12,756 patients (94.4% women) with mean (SD) age 75.9 (6.8) years. Vertebral fractures were identified in 1925 (15.1%) overall. Vertebral fractures were significantly more likely (descending order) in those with prior pelvis, hip, humerus, other sites, and forearm, but not ankle fracture. There was modest attenuation with covariate adjustment but statistical significance was maintained.

CONCLUSIONS

Prior hip, humerus, pelvis, forearm, and other fractures are associated with an increased likelihood of previously undiagnosed vertebral fracture, information useful for risk stratification and monitoring. These data support recommending VFA in FLS patients who are age 70 + with low BMD.

A novel classification of cement distribution patterns based on plain radiographs associated with cement filling rate and relevance to the clinical results of unipedicle vertebroplasty

INTRODUCTION

Cement distribution pattern following unipedicle percutaneous vertebroplasty (UVP) for osteoporotic vertebral compression fractures (OVCFs) has been reported in association with clinical results. The present retrospective study aimed to classify the bone cement distribution types following UVP and investigate the differences in clinical efficacy and related complications.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of the patients with single-segment OVCFs who underwent UVP. Cement distribution patterns were divided into the diffuse, block, double band, and single band types according to the plain radiographs and further by cement filling rate (CFR) based on a three-dimension reconstruction of post-operative CT. The cutoff values of CFR were > 34% for the diffuse, block between 34 and 20%, and each band of the double or single band < 20%. Clinical efficacy and related complications were compared among the four cement distribution types 24 h after the operation and the last follow-up.

RESULTS

A total of 155 patients with an average follow-up time of 20.3 months were included. The diffuse type included 26 patients; block, 87; double band, 18; and single band, 24. The VAS and ODI after operation improved significantly in all four groups. The diffuse and block types had similar clinical results. The clinical outcomes in the single band group were the poorest at the last follow-up. The patients with single band type also had the highest rates of body re-collapse and revision surgery for the index level.

CONCLUSION

Diffuse and block groups can better maintain the height of the vertebral body and reduce the risk of vertebral body recompression. The single band has the poorest results, and intraoperative immediate contralateral vertebroplasty was highly recommended.

[Impact of osteoporosis on physical performance parameters of middle-aged and elderly individuals-a cross-sectional study]

BACKGROUND

Osteoporosis (OP) in the elderly is accompanied by reduced muscle mass and reduced muscle strength, also known as sarcopenia. This results in functional limitations and a high risk of falls and injuries. The determination of physical performance parameters such as grip strength and trunk strength on the one hand, and balance abilities on the other, provide information about the individual's general neuromuscular condition and serve as an indicator of physical performance in the elderly. The extent to which previous osteoporotic vertebral fractures (VFs) restrict an individual's physical performance has not been adequately investigated yet.

MATERIAL AND METHODS

In total, 118 persons, with a mean age of 71.5 ± 9 years, participated in the clinical trial (ethics committee approval number A2020-0041). Patients were divided into an OP group (58 patients) and a control group (CG; 60 patients). OP patients with (VFs) and without vertebral fractures (0VFs) were viewed separately in the subgroup analysis. Data concerning physical status, including hand grip strength (HGS), the chair-rising test (CRT), tandem stance (TS), tandem gait (TG), and single-leg stance (SLS) were available for all patients. All data were analyzed using SPSS, Version 23.0.

RESULTS

No significant difference (p > 0.05) was registered between the OP and CG groups with regard of HGS, CRT, TG, TS, and SLS. In the subgroup analysis, OP patients with VFs had a lower HGS than OP patients without 0 VFx (VFs 24.3 ± 10.2 kg vs. 0 VFs 29.7 ± 9.5 kg, p = 0.026). TS was maintained longer by OP patients 0 VFs (VFs 7.8 ± 3.2 s vs. 0 VFs 9.5 ± 1.8 s, p = 0.008). The latter were also able to maintain their balance in TG over more numerous steps (VFs 4.8 ± 3.0 vs. 0 VFs 6.7 ± 2.4, p = 0.011). In a regression analysis, body size, gender, and age were shown to be independent factors influencing HGS (p < 0.001).

CONCLUSION

Patient age, constitution, and gender have a relevant influence on HGS, with baseline conditions after diagnosed OP at comparable levels in this age group. In a subgroup of OP patients with VFs, there is a close relationship between bone and muscle with an increasing deterioration of the musculoskeletal system. For prophylaxis of osteosarcopenia, early training seems reasonable.

Pharmacological options for pain control in patients with vertebral fragility fractures

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

Association between testosterone levels and bone mineral density in females aged 40-60 years from NHANES 2011-2016

Growing evidence indicates that testosterone is a conspicuous marker for assessing male bone mineral density (BMD). However, research regarding testosterone levels and BMD is sparse and controversial for females. Hence, we aimed to investigate the association between testosterone levels and BMD among adult females aged 40–60 years in the United States. In this cross-sectional study, all participants were part of the National Health and Nutrition Examination Survey (2011–2016). A weighted general linear model was used to estimate the association between testosterone levels and lumbar BMD. Age, race, income level, education level, body mass index (BMI), blood urea nitrogen (BUN) level, serum uric acid (UA) level, serum calcium (Ca) level, serum phosphorus (P) level, the use of oral contraceptive pills, the use of hormone replacement therapy (HRT), smoking status, drinking status, and the use of corticosteroids were adjusted using a weighted multiple regression model. Subgroup analyses were performed using the same regression model. We included 2198 female participants in the study, and testosterone levels were positively associated with lumbar BMD after adjusting for all the covariates (β = 1.12, 95% CI 0.31, 1.93). In subgroup analyses, the associations in the fourth quartile of testosterone levels were stronger for the participants aged 40–50 years old (quartile 4, β = 42.92, 95% CI 7.53, 78.30 vs. quartile 1) and 50 to 60-year-old (quartile 4, β = 32.41, 95% CI 0.14, 64.69 vs. quartile 1). Similar results were found in other subgroups, including subgroups for race (Non-Hispanic Black, Other), income level (income ≤ 1.3, income > 3.5), education level (college or higher), BMI > 25 kg/m², BUN levels ≤ 20 mg/dL, UA levels ≤ 6 mg/dL, Ca levels ≤ 10.1 mg/dL, P levels ≤ 5 mg/dL, drinking status, never smoker, never taking birth control pills, and HRT user. There was no interaction among the covariates in the association between lumbar BMD and testosterone levels (P for interaction > 0.05). In US adult females aged 40–60 years, the testosterone level was a positive predictor of the lumbar BMD after adjusting for covariates.

Study on Risk Factors of Primary Non-traumatic OVCF in Chinese Elderly and a Novel Prediction Model

Objective

Prevention of fragility fractures is one of the public health priorities worldwide, whilst the incidence of osteoporotic vertebral compression fractures (OVCF) continues to rise and lacks the corresponding accurate prediction model. This study aimed to screen potential causes and risk factors for primary non‐traumatic osteoporotic vertebral compression fractures (NTOVCF) in the elderly by characterizing a patient population with NTOVCF and comparing it with a population of osteoporotic patients.

Methods

Between January 2013 and January 2022, 208 elderly patients with unequivocal evidence of bone fragility manifested as painful NTOVCF were enrolled, and compared with 220 patients with osteoporosis and no fractures. The demographic data, bone turnover markers, blood routine, serum biochemical values, and radiological findings were investigated. Differences between the fracture and non‐fracture groups were analyzed, and variables significant in univariate analysis and correlation analysis were included in the logistic analysis to build the risk prediction model for osteoporotic vertebral fractures. Univariate analysis using student's t‐tests for continuous variables or a chi‐squared test for categorical variables was conducted to identify risk factors.

Results

No significant differences were revealed regarding age, gender, BMI, smoking, alcohol consumption, blood glucose, propeptide of type I procollagen (P1NP), and N‐terminal middle segment osteocalcin (N‐MID) (P > 0.05). Parathyroid Hormone (PTH), 25(OH)D, serum albumin (ALB), hemoglobin (HB), bone mineral density (BMD), and cross‐sectional area (CSA) of the paraspinal muscle in the fracture group were significantly lower than those in the control group; however, b‐C‐terminal telopeptide of type I collagen (β‐CTX), total cholesterol (TC), high‐density lipoprotein cholesterol (HDL‐C), non‐prostatic acid phosphatase (NACP), and fatty degeneration ratio (FDR) were significantly higher than those in the control group (P < 0.05). Logistic regression analysis showed that ALB, HB, CSA, and BMD were negatively correlated with NTOVCF, while β‐CTX, HDL‐C, NACP, and FDR were positively correlated with NTOVCF.

Conclusion

Decreased physical activity, anemia, hypoproteinemia, imbalances in bone metabolism, abnormal lipid metabolism, and degenerative and decreased muscle mass, were all risk factors for OVCF in the elderly, spontaneous fractures may be the consequence of cumulative declines in multiple physiological systems over the lifespan. Based on this risk model, timely detection of patients with high OVCF risk and implementation of targeted preventive measures is expected to improve the effect of fracture prevention.

The Difference of Disease Injury and Postoperative Recovery in the Occupational Characteristics of Thoracolumbar Fracture Patients: A Retrospective Study

Objectives

Understanding the occupational characteristics of patients is not only related to patients' life and health, but also conducive to improving their happiness. However, there were no studies that had been conducted on the relationship between occupation characteristic and postoperative recovery in patients with spinal fractures. The purpose of this study was to explore the relationship between the occupation characteristics of patients with thoracolumbar fracture and the characteristics of disease injury, treatment, and recovery so as to reduce the incidence and improve postoperative rehabilitation.

Methods

Patients (n = 719) with thoracolumbar fractures were recruited. Patients were grouped according to the characteristic of occupations: unemployed group (n = 299), white‐collar worker group (n = 20), and blue‐collar worker group (n = 400). Data were collected, including the characteristics, injury and treatment information, and the recovery records for 1 year after operation. One‐way ANOVA analysis, χ² test, and binary logistic regression analysis was used to explore the relationship among these factors.

Results

Male, high‐falling injuries and single segment injury (mainly T 11, T 12 and L2) were common in patients with thoracolumbar fractures, especially in the blue‐collar worker group (70.8%, 78.3%, and 85.4%). Compared with the unemployed group, the patients in the white‐collar worker group and blue‐collar worker group had a higher proportion of young patients, a higher height and weight, a lesser rate of hypertension or diabetes. One week after injury, 73.4% of patients underwent surgery, with the blue‐collar worker group accounted for the largest proportion. One month after surgery, 77.1% of patients were able to get out of bed, with the white‐collar worker group accounted for the largest proportion. In the postoperative recovery information, patients in the blue‐collar worker group were more likely to have severe low back pain (OR = 2.023, 95% CI: 1.440‐2.284) and pain‐disturbed sleep (OR = 2.287, 95% CI: 1.585‐3.299) than those who in the unemployed group.

Conclusions

Blue‐collar workers, with a high risk of thoracolumbar fracture, have a higher incidence of low back leg pain and pain‐disturbed sleep in the recovery after thoracolumbar fracture surgery, and this requires more attention.

Risk factors of refracture after a fragility fracture in elderly

The study examined the risk factors of recurrent fragility fractures in elderly. Female and older age increased the risk of refracture. Older age at the first fracture also resulted in shorter time to the second fracture. The prevention program should be emphasized.

PURPOSE

The study examined the characteristics of the fragility fractures and refractures and the factors affecting the incidence and duration to the second fragility fracture.

METHODS

The retrospective cohort study reviewed electronic medical records from Nan Provincial Public Health Office, Thailand. Patients aged ≥ 60 years with fragility fractures (hip, wrist, vertebra, and proximal humerus) from low-energy injuries between 1 January 2009 and 31 December 2018 were included. The characteristics of the first and second fractures and the factors that had effect on refracture incidence and duration were investigated.

RESULTS

Among 4322 patients, 306 patients (7%) had subsequent fragility fractures. Risk factors of refracture included female (adjusted odd ratio 1.79, 95%CI 1.304-2.467) and older age at the first fracture (adjusted odd ratio 1.016, 95%CI 1.003-1.029). Factor resulted in shorter time to second fracture was older age at the first fracture (β-coefficient - 0.96, 95%CI - 1.4-(- 0.5)). Any type of the first fracture resulted in similar risk and duration to subsequent fracture. Half (48%) and two-third (65%) of the second fractures occurred within 3 and 4 years, respectively.

CONCLUSION

Female and older age were risk factors of subsequent fragility fracture. Older age resulted in shorter time to the second fracture. Refracture prevention program should be initiated in patients with any type of first fragility fracture and should be continued for at least 3-4 years.

Forward Bending in Supine Test: Diagnostic Accuracy for Acute Vertebral Fragility Fracture

Despite its high incidence rate, vertebral fragility fracture (VFF) is frequently underdiagnosed due to the absence of marked symptoms. This study evaluated the diagnostic accuracy of our suggested physical examinations and compared them with that of plain radiographs. Patients over 65 years of age with sudden back pain within the preceding 3 weeks were enrolled. Physical examinations in three different positions and a closed-fist percussion test were performed, and the presence of VFF was evaluated through confirmatory radiographic tools. We assessed the diagnostic accuracy of each physical examination and compared them with the interpretation of plain radiographs and examined the patient-reported pain locations based on the VFF level. A total of 179 patients were enrolled. The forward bending in supine (FB-SU) test demonstrated superior diagnostic values (sensitivity: 90.6%, specificity: 71.2%), which outperformed those of plain radiographs (sensitivity: 68.9%, specificity: 71.9%). The location of patient-reported pain was generally close to or lower than the index fracture level. FB-SU showed the highest diagnostic accuracy and was more valuable than plain radiographs in diagnosing acute VFF. FB-SU is a simple and affordable screening test. If positive, physicians should highly suspect VFF even when based on vague evidence of acute fracture provided by plain radiographs.

Progression of Vertebral Fractures in Patients with Adrenocortical Carcinoma Undergoing Mitotane Therapy

CONTEXT

Patients with adrenocortical carcinoma (ACC) are frequently on mitotane therapy for a long time period. The drug exerts adrenolytic activity requiring glucocorticoid supplementation, which can be potentially detrimental for bone.

OBJECTIVE

To explore whether mitotane with/without chemotherapy is associated with an increased proportion of morphometric vertebral fractures (VFs) in ACC patients. Secondary objectives were proportion of patients with VF progression, or worsening of the spinal deformity index (SDI) during mitotane therapy; and to explore predictive factors of VF progression and a prognostic role of VF progression.

METHODS

Multicenter, retrospective cohort study of patients with ACC who received mitotane alone or in association to chemotherapy, recruited from January 2010 to January 2020 in 2 reference centers in Italy and France.

RESULTS

A significant increase in the frequency of VFs before and after mitotane therapy was seen both in Italian (28.3% vs 47.8%, P = .04) and French (17.8% vs 35.6%, P = .04) series. VF progression was observed in 39.1%, and 28.9% of patients, respectively. Baseline VFs and increased patient body mass index, but not the dose of cortisol supplementation, showed an independent association with VF progression at multivariate analysis. Among the 72 advanced ACC patients, progression of VFs was associated with a poorer survival.

CONCLUSION

The administration of mitotane with/without chemotherapy in ACC patients impairs bone health independently from cortisol supplementation. Appropriate preventive measures to decrease the fracture risk should be implemented in these patients.

Ground truth generalizability affects performance of the artificial intelligence model in automated vertebral fracture detection on plain lateral radiographs of the spine

BACKGROUND CONTEXT

Computer-aided diagnosis with artificial intelligence (AI) has been used clinically, and ground truth generalizability is important for AI performance in medical image analyses. The AI model was trained on one specific group of older adults (aged≧60) has not yet been shown to work equally well in a younger adult group (aged 18-59).

PURPOSE

To compare the performance of the developed AI model with ensemble method trained with the ground truth for those aged 60 years or older in identifying vertebral fractures (VFs) on plain lateral radiographs of spine (PLRS) between younger and older adult populations.

STUDY DESIGN/SETTING

Retrospective analysis of PLRS in a single medical institution.

OUTCOME MEASURES

Accuracy, sensitivity, specificity, and interobserver reliability (kappa value) were used to compare diagnostic performance of the AI model and subspecialists' consensus between the two groups.

METHODS

Between January 2016 and December 2018, the ground truth of 941 patients (one PLRS per person) aged 60 years and older with 1101 VFs and 6358 normal vertebrae was used to set up the AI model. The framework of the developed AI model includes: object detection with You Only Look Once Version 3 (YOLOv3) at T0-L5 levels in the PLRS, data pre-preprocessing with image-size and quality processing, and AI ensemble model (ResNet34, DenseNet121, and DenseNet201) for identifying or grading VFs. The reported overall accuracy, sensitivity and specificity were 92%, 91% and 93%, respectively, and external validation was also performed. Thereafter, patients diagnosed as VFs and treated in our institution during October 2019 to August 2020 were the study group regardless of age. In total, 258 patients (339 VFs and 1725 normal vertebrae) in the older adult population (mean age 78±10.4; range, 60-106) were enrolled. In the younger adult population (mean age 36±9.43; range, 20-49), 106 patients (120 VFs and 728 normal vertebrae) were enrolled. After identification and grading of VFs based on the Genant method with consensus between two subspecialists', VFs in each PLRS with human labels were defined as the testing dataset. The corresponding CT or MRI scan was used for labeling in the PLRS. The bootstrap method was applied to the testing dataset.

RESULTS

The model for clinical application, Digital Imaging and Communications in Medicine (DICOM) format, is uploaded directly (available at: http://140.113.114.104/vght_demo/svf-model (grading) and http://140.113.114.104/vght demo/svf-model2 (labeling). Overall accuracy, sensitivity and specificity in the older adult population were 93.36% (95% CI 93.34%-93.38%), 88.97% (95% CI 88.59%-88.99%) and 94.26% (95% CI 94.23%-94.29%), respectively. Overall accuracy, sensitivity and specificity in the younger adult population were 93.75% (95% CI 93.7%-93.8%), 65.00% (95% CI 64.33%-65.67%) and 98.49% (95% CI 98.45%-98.52%), respectively. Accuracy reached 100% in VFs grading once the VFs were labeled accurately. The unique pattern of limbus-like VFs, 43 (35.8%) were investigated only in the younger adult population. If limbus-like VFs from the dataset were not included, the accuracy increased from 93.75% (95% CI 93.70%-93.80%) to 95.78% (95% CI 95.73%-95.82%), sensitivity increased from 65.00% (95% CI 64.33%-65.67%) to 70.13% (95% CI 68.98%-71.27%) and specificity remained unchanged at 98.49% (95% CI 98.45%-98.52%), respectively. The main causes of false negative results in older adults were patients' lung markings, diaphragm or bowel airs (37%, n=14) followed by type I fracture (29%, n=11). The main causes of false negatives in younger adults were limbus-like VFs (45%, n=19), followed by type I fracture (26%, n=11). The overall kappa between AI discrimination and subspecialists' consensus in the older and younger adult populations were 0.77 (95% CI, 0.733-0.805) and 0.72 (95% CI, 0.6524-0.80), respectively.

CONCLUSIONS

The developed VF-identifying AI ensemble model based on ground truth of older adults achieved better performance in identifying VFs in older adults and non-fractured thoracic and lumbar vertebrae in the younger adults. Different age distribution may have potential disease diversity and implicate the effect of ground truth generalizability on the AI model performance.

Trends in opioid use following balloon kyphoplasty or vertebroplasty for the treatment of vertebral compression fractures

This retrospective analysis of insurance claims evaluated real-world trends in prescription fills among patients treated with balloon kyphoplasty (N = 6,656) or vertebroplasty (N = 2,189) following diagnosis of vertebral compression fracture. Among those with evidence of opioid use, nearly half of patients discontinued or reduced prescription fills relative to pre-operative levels.

INTRODUCTION

Vertebral compression fractures (VCF) are associated with debilitating pain, spinal misalignment, increased mortality, and increased healthcare-resource utilization in elderly patients. This study evaluated the effect of balloon kyphoplasty (BKP) or vertebroplasty (VP) on post-procedure opioid prescription fills and payer costs in patients with VCF.

METHODS

This was a retrospective analysis of a large, nationally representative insurance-claims database. Clinical characteristics, opioid prescription patterns, and payer costs for subjects who underwent either BKP or VP to treat VCF were evaluated beginning 6 months prior to surgery through 7-month follow-up that included a 30-day, postoperative medication washout. Patient demographics, changes in opioid utilization, and payer costs were analyzed.

RESULTS

A total of 8,845 patients met eligibility criteria (75.3% BKP and 24.7% VP) with a mean of age 77 and 74% female. Among the 75% of patients who used opioids, 48.7% of patients discontinued opioid medication and 8.4% reduced prescription fills versus preoperative baseline. Patients who reduced or discontinued prescriptions exhibited a decrease in all-cause payer costs relative to pre-intervention levels, which was a significantly greater change relative to patients with no change, increase, or new start of opioids.

CONCLUSIONS

Interventional treatment for VCF was associated with decreased or discontinued opioid prescription fills and reduced payer costs in follow-up in a significant proportion of the study population. Reduction of opioid-based harms may represent a previously unrecognized benefit of vertebral augmentation for VCF, especially in this elderly and medically fragile population.

The cumulative incidence of and risk factors for morphometric severe vertebral fractures in Japanese men and women: the ROAD study third and fourth surveys

This population-based cohort study with a 3-year follow-up revealed that the annual incidence rates of vertebral fracture (VF) and severe VF (sVF) were 5.9%/year and 1.7%/year, respectively. The presence of mild VF at the baseline was a significant risk factor for incident sVF in participants without prevalent sVF.

INTRODUCTION

This study aimed to estimate the incidence of morphometric vertebral fracture (VF) and severe VF (sVF) in men and women and clarify whether the presence of a mild VF (mVF) increases the risk of incident sVF.

METHODS

Data from the population-based cohort study, entitled the Research on Osteoarthritis/Osteoporosis Against Disability (ROAD) study, were analyzed. In total, 1190 participants aged ≥ 40 years (mean age, 65.0 ± 11.2) years completed whole-spine lateral radiography both at the third (2012-2013, baseline) and fourth surveys performed 3 years later (2015-2016, follow-up). VF was defined using Genant's semi-quantitative (SQ) method: VF as SQ ≥ 1, mVF as SQ = 1, and sVF as SQ ≥ 2. Cumulative incidence of VF and sVF was estimated. Multivariate logistic regression analyses were performed to evaluate risk factors for incident sVF.

RESULTS

The baseline prevalence of mVF and sVF were 16.8% and 6.0%, respectively. The annual incidence rates of VF and sVF were 5.9%/year and 1.7%/year, respectively. The annual incidence rates of sVF in participants without prevalent VF, with prevalent mVF, and with prevalent sVF were 0.6%/year, 3.8%/year, and 11.7%/year (p < 0.001), respectively. Multivariate logistic regression analyses in participants without prevalent sVF showed that the adjusted odds ratios for incident sVF were 4.12 [95% confident interval 1.85-9.16] and 4.53 [1.49-13.77] if the number of prevalent mVF at the baseline was 1 and ≥ 2, respectively.

CONCLUSIONS

The annual incidence rates of VF and sVF were 5.9%/year and 1.7%/year, respectively. The presence of prevalent mVF was an independent risk factor for incident sVF.

Utility of upright radiographs in traumatic thoracolumbar fracture management

Background

It is common practice to use a combination approach of computed tomography (CT) scan followed by upright radiographs when assessing traumatic thoracolumbar (TL) vertebral fractures. The purpose of this study was to determine the clinical utility of upright spine radiographs in the setting of traumatic TL fracture management. Our null hypothesis is that upright TL radiographs rarely change management of acute vertebral fractures.

Methods

A retrospective study was performed on patients with an initial plan of non-operative management for a TL fracture between January 2014 and June 2020 at a single Level 1 trauma center. Patients were followed from time of initial consult to either conversion to surgery (operative) or last available outpatient follow up imaging (non-operative). Lateral kyphotic angle of the fractured vertebra and anterior vertebral body height% loss on initial CT, first upright radiograph, and endpoint upright radiograph imaging were measured. Measurements were compared between and within operative and non-operative groups using t-tests and Mann-Whitney U tests when appropriate. P-values ≤ 0.05 were considered statistically significant.

Results

The study included 70 patients with an average age of 54 years and 37 (52.9%) were women. Six (8.6%) of 70 patients had a change from non-operative to operative management based on upright radiographs. The mean (standard deviation) change in degrees of kyphosis from CT scan to first X-ray was 4.6 (7.0) in the non-operative group and 11.5 (8.1) in the operative group (P = 0.03). Delta degrees of kyphosis from CT scan to endpoint X-ray was 6.4 (9.0) and 16.2 (6.2) in the non-operative and operative groups, respectively (P = 0.01). In the operative group, mean degrees of kyphosis increased from 1.6 (7.6) in initial CT to 13.1 (8.9) in first X-ray (P = 0.02). First X-ray mean anterior body height% loss was 37.5 (17.6) and 53.2 (16.1) in the non-operative and operative groups, respectively (P = 0.04).

Conclusions

Upright radiographs are useful in guiding traumatic vertebral fracture management decisions. Larger studies are needed to determine the degree of change in kyphosis between CT and first standing radiograph that is suggestive of operative management.

Trial registration number and date of registration

Not applicable.

Osteoporotic vertebral fractures: radiologic diagnosis, clinical and radiologic factors affecting surgical decision making: WFNS Spine Committee Recommendations

With the varied literature on osteoporotic vertebral fracture that may predispose to diagnostic and management dilemma, it is timely to evaluate and streamline the evidence. The aim of this review is to create recommendations on osteoporotic vertebral fractures regarding radiologic diagnosis, and clinical and radiological factors affecting surgical decision making. A computerized literature search was done using PubMed, Google scholar and Cochrane Database of Systematic Reviews from 2010 to 2020. For radiologic diagnosis, the keywords "osteoporotic vertebral fractures" and "radiologic diagnosis" were used yielding 394 articles (19 relevant articles). For clinical and radiological factors affecting surgical decision making, the keywords "osteoporotic vertebral fractures", "radiologic diagnosis", and "surgery" were used yielding 568 articles (25 relevant articles). All pertinent data were reviewed, and consensus statements were obtained in two virtual separate consensus meetings of the World Federation of Neurosurgical Societies (WFNS) Spine committee. The statements were voted and yielded positive or negative consensus using the Delphi method. This review summarizes the WFNS Spine Committee recommendations on the radiologic diagnosis, and clinical and radiological factors affecting surgical decision making of osteoporotic vertebral fractures.

Epidemiology, natural course, and preventive measures of osteoporotic vertebral fractures: WFNS Spine Committee Recommendations

INTRODUCTION

This review aims to search for up-to-date information on epidemiology, natural course, and preventive measures of osteoporotic spine fractures.

EVIDENCE ACQUISITION

We reviewed the literature of the last ten years using keywords "natural course and osteoporotic vertebral fractures", "epidemiology and osteoporotic vertebral fractures" and "prevention and osteoporotic vertebral fractures." We then discussed the search results to reach an agreement in two consensus meetings on January and February 2021 of the World Federation of Neurosurgical Societies (WFNS) Spine Committee. Finally, we utilized the Delphi method to administer the questionnaire to preserve a high degree of validity. We summarized seven papers on the natural course, 15 articles on epidemiology, and 84 papers on preventing osteoporotic vertebral fractures. Finally, the consensus results after voting is presented.

EVIDENCE SYNTHESIS

Natural course of acute osteoporotic vertebral fractures is benign; many patients may have sufficient pain relief during the first three months with conservative treatment. At the end of one year of conservative treatment, 40% may still have pain with VASscores ≥4. Since the populations are aging, the incidence of OVF continues to rise. Although the prevalence varies across the globe, the highest rates are from North America and some countries of Asia. Preventive treatment of OVF must involve an active lifestyle, adequate nutrition, prevention of immobilization with physical therapy, and pharmacological therapy. Oral calcium and vitamin D are first-line interventions to prevent the bone mass loss, especially in postmenopausal women. There are many pharmacological treatment options; the decision must be made by fracture risk assessment (clinical factors + BMD + BMI) alone or along with DXA (dual-energy Xray absorptiometry) or history of previous fragility fractures. The indication of one respect to the others is based on patient preference, compliance, and risk of discontinuation related to adverse events and administration method.

CONCLUSIONS

The incidence of osteoporotic vertebral fractures increases with age and other factors. The natural course shows that most patients benefit from conservative therapy without any surgical intervention during the first three months. Preventive measures must include active lifestyle, adequate nutrition, prevention of immobilization with physical therapy, oral calcium, and vitamin D intake, and pharmacological therapy after fracture risk assessment.