Acute Osteoporotic Vertebral Fractures Research Articles

Surgical management of lower limb radiculopathy following acute singe-level osteoporotic vertebral fracture of lower lumbar spine in geriatric patient: a retrospective study

BackgroundRadiculopathy of the lower limb after acute osteoporotic vertebral fractures (OVFs) in the lower lumbar spine is uncommon in geriatric patients. Moreover, surgical intervention is generally recommended in patients who are irresponsive to conservative treatment. Determining an optimum surgical strategy is challenging considering the poor general condition of this population. Thus, herein, we established an algorithm for surgically managing this clinical scenario, hoping to provide a reference for making a surgical decision.MethodsWe retrospectively studied patients who suffered from new-onset radiculopathy of the lower limb after acute single-level OVFs in the lower lumbar spine and eventually underwent surgical intervention at our department. Information on the demographics, bone quality, AO spine classification of the vertebral fracture, pre-existing degenerative changes, including foraminal stenosis and lumbar disc herniation, and surgical intervention type was collected. Additionally, clinical outcomes, including preoperative and postoperative visual analog scale (VAS) scores for back and leg pain, Oswestry disability index (ODI), and MacNab criterion for response to surgery, were evaluated.ResultsFrom September 2019 to December 2021, a total of 22 patients with a mean age of 68.59 ± 9.74 years were analyzed. The most involved vertebra was L5 (54.5%), followed by L4 (27.3%) and L3 (18.2%). Among the 22 patients, 15 (68.2%) were diagnosed with the A1 type fracture of AO classification, and among them, 11 (73.3%) were characterized by the collapse of the inferior end plate (IEP). Three patients (13.6%) suffered from A2-type fractures, whereas four patients (18.2%) suffered from A3-type fractures. Pre-existing degenerative changes were observed in 12 patients (54.5%) of the patients. A total of 16 patients (72.7%) were treated by percutaneous kyphoplasty (PKP). Additionally, three patients underwent posterior instrumentation and fusion, two patients underwent a secondary endoscopic foraminoplasty, and one patient underwent a secondary radiofrequency ablation. The mean follow-up period was 17.42 ± 9.62 months. The mean VAS scores for leg and back pain and ODI decreased significantly after the surgery (P < 0.05). The total satisfaction rate at the last follow-up was 90.9% per the Macnab criterion.ConclusionPatients with OVFs in the IEP are predisposed to suffer from radiculopathy of the lower limb. PKP alone or in combination with other minimally invasive surgical strategies is safe and effective in treating stable fractures. Additionally, aggressive surgical intervention should be considered in patients with unstable fractures or severe foraminal encroachment.

Paralumbar Spine Disease as a Cause of Low Back Pain in Older Adults.

Introduction Low back pain (LBP) is a major contributor to decreases in the ability to perform activities of daily living (ADL) in older adults. Paralumbar spine disease (PLSD) is a common cause of LBP. We aimed to investigate the causes of LBP, including PLSD, among older adults. Methods Among 744 consecutive patients with LBP, 75 patients (10.1%) aged >80 years (25 males and 50 females) were included. The average patient age was 83.9 years. All patients were evaluated using lumbar magnetic resonance imaging (MRI) and radiography to diagnose the causes of LBP. PLSD was diagnosed based on clinical symptoms, palpation, and the effects of the block. Results Eleven patients (11/75, 14.7%) had acute osteoporotic vertebral fractures. Twenty-eight of the remaining 64 patients exhibited decreased LBP with oral medication, and six (6/75, 8.0%) exhibited lumbar spinal canal stenosis on MRI. PLSD was suspected in 19 of the remaining 30 cases based on clinical symptoms and palpation. Blocks were effective in 16 patients with PLSD, which involved superior cluneal nerve entrapment (SCN-E) in eight patients (10.7%), middle cluneal nerve entrapment (MCN-E) in nine patients (12.0%), sacroiliac joint (SIJ) pain in five patients (6.7%), and gluteus medius muscle (GMeM) pain in three patients (4.0%). The average numerical rating scale (NRS) scores for pain changed from 7.5 ± 1.5 before treatment to 1.3 ± 0.9 at discharge (p < 0.05). Conclusion Osteoporotic acute vertebral fracture (14.7%) was identified as the cause of LBP in older adults. Block therapy for PLSD may aid in the diagnosis and treatment of non-specific LBP.

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

Osteoporotic vertebral fractures (OVFs) are a critical public health concern requiring urgent attention, and severe OVFs impose substantial health and economic burdens on patients and society. Analysis of the risk factors for severe OVF is imperative to actively prevent the occurrence of this degenerative disorder. This study aimed to investigate the risk factors associated with the severity of OVF, with a specific focus on changes in the paraspinal muscles. A total of 281 patients with a first-time single-level acute OVF between January 2016 and January 2023 were enrolled in the study. Clinical and radiological data were collected and analyzed. The cross-sectional area (CSA) and degree of fatty infiltration (FI) of the paraspinal muscles, including the multifidus muscles (MFMs), erector spinae muscles (ESMs), and psoas major muscles (PSMs), were measured by magnetic resonance imaging (MRI) of the L4/5 intervertebral discs. According to the classification system of osteoporotic fractures (OF classification) and recommended treatment plan, OVFs were divided into a low-grade OF group and a high-grade OF group. Univariate and multivariate logistic regression analyse s were performed to identify risk factors associated with the severity of OVF. Ninety-eight patients were included in the low-grade OF group, and 183 patients were included in the high-grade OF group. Univariate analysis revealed a significantly higher incidence of a high degree of FI of MFMs (OR = 1.71, p = 0.002) and ESMs (OR = 1.56, p = 0.021) in the high-grade OF group. Further multivariate logistic regression analysis demonstrated that a high degree of FI of the MFMs (OR = 1.71, p = 0.002) is an independent risk factor for the severity of OVF. A high degree of FI of the MFMs was identified as an independent risk factor for the severity of OVF. Decreasing the degree of FI in the MFMs might lower the incidence of the severity of OVF, potentially reducing the necessity for surgical intervention in OVF patients.

Constructing a Deep Learning Radiomics Model Based on X-ray Images and Clinical Data for Predicting and Distinguishing Acute and Chronic Osteoporotic Vertebral Fractures: A Multicenter Study

To construct and validate a deep learning radiomics (DLR) model based on X-ray images for predicting and distinguishing acute and chronic osteoporotic vertebral fractures (OVFs). A total of 942 cases (1076 vertebral bodies) with both vertebral X-ray examination and MRI scans were included in this study from three hospitals. They were divided into a training cohort (n=712), an internal validation cohort (n=178), an external validation cohort (n=111), and a prospective validation cohort (n=75). The ResNet-50 model architecture was used for deep transfer learning (DTL), with pre-training performed on RadImageNet and ImageNet datasets. DTL features and radiomics features were extracted from lateral X-ray images of OVFs patients and fused together. A logistic regression model with the least absolute shrinkage and selection operator was established, with MRI showing bone marrow edema as the gold standard for acute OVFs. The performance of the model was evaluated using receiver operating characteristic curves. Eight machine learning classification models were evaluated for their ability to distinguish between acute and chronic OVFs. The Nomogram was constructed by combining clinical baseline data to achieve visualized classification assessment. The predictive performance of the best RadImageNet model and ImageNet model was compared using the Delong test. The clinical value of the Nomogram was evaluated using decision curve analysis (DCA). Pre-training resulted in 34 and 39 fused features after feature selection and fusion. The most effective machine learning algorithm in both DLR models was Light Gradient Boosting Machine. Using the Delong test, the area under the curve (AUC) for distinguishing between acute and chronic OVFs in the training cohort was 0.979 and 0.972 for the RadImageNet and ImageNet models, respectively, with no statistically significant difference between them (P=0.235). In the internal validation cohort, external validation cohort, and prospective validation cohort, the AUCs for the two models were 0.967 vs 0.629, 0.886 vs 0.817, and 0.933 vs 0.661, respectively, with statistically significant differences in all comparisons (P<0.05). The deep learning radiomics nomogram (DLRN) was constructed by combining the predictive model of RadImageNet with clinical baseline features, resulting in AUCs of 0.981, 0.974, 0.895, and 0.902 in the training cohort, internal validation cohort, external validation cohort, and prospective validation cohort, respectively. Using the Delong test, the AUCs for the fused feature model and the DLRN in the training cohort were 0.979 and 0.981, respectively, with no statistically significant difference between them (P=0.169). In the internal validation cohort, external validation cohort, and prospective validation cohort, the AUCs for the two models were 0.967 vs 0.974, 0.886 vs 0.895, and 0.933 vs 0.902, respectively, with statistically significant differences in all comparisons (P<0.05). The Nomogram showed a slight improvement in predictive performance in the internal and external validation cohort, but a slight decrease in the prospective validation cohort (0.933 vs 0.902). DCA showed that the Nomogram provided more benefits to patients compared to the DLR models. Compared to the ImageNet model, the RadImageNet model has higher diagnostic value in distinguishing between acute and chronic OVFs. Furthermore, the diagnostic performance of the model is further improved when combined with clinical baseline features to construct the Nomogram.

Analysis of Potential Risk Factors for Cement Leakage into Paraspinal Veins after Vertebroplasty for Acute Osteoporotic Vertebral Fractures Based on a 3D Reconstruction Technique: A Retrospective Matched Case-Control Study.

Pulmonary embolism, cardiac embolism, and even cerebral embolism due to paraspinal vein leakage (PVL) are increasingly reported, and their risk factors need to be adequately investigated for prevention. To this end, this study investigated the correlation of the distribution and morphological characteristics of fracture lines with the occurrence of PVL after percutaneous vertebroplasty (PVP), which has not been previously reported. Patients with acute single-segment thoracolumbar osteoporotic vertebral compression fractures (OVCFs) treated with PVP at our institution from January 2019 to July 2022 were selected for a matched case-control study. The case and control groups included those with and without PVL, respectively, matched at a 1:1 ratio based on general clinical characteristics. Additionally, fracture map and heatmap analysis was performed in both groups. In addition to the general clinical characteristics, the vertebral height ratio, puncture angle, delivery rate, and indexes were assessed via the three-dimensional CT reconstruction fracture line mapping technique, namely, the distribution of fracture lines, fracture line length, main fracture line shape, location of fracture line involvement, and number of fracture line branches, were compared between the two groups. The Wilcoxon rank-sum test, t tests, analysis of variance, and conditional logistic regression were used for statistical analysis. Among 658 patients with OVCFs, 54 who did and 54 who did not develop PVL were included in this study. Significant differences in the puncture angle, fracture line distribution (MR-1, ML-2, MM-2, MR-2, ML-3, MM-3, LL-1, LM-1, LL-2, LM-2), fracture line involvement of the posterior wall, total fracture line length, and main fracture line length were found between the two groups (p < 0.05). Logistic univariate analysis showed significant differences in the puncture angle, fracture line distribution (MR-1, ML-2, MM-2, MR-2, ML-3, MM-3, LL-1, LL-2, LM-2, LL-3), total fracture line length, main fracture line length, and fracture line involvement of the posterior wall between the two groups (p < 0.05). Logistic multifactorial analysis showed that the fracture line distribution (UR-3, ML-3, LM-2, LR-2) and main fracture line length were independent risk factors for the development of PVL in both groups. In addition, the fracture maps and heatmaps showed a greater degree of fracture line encapsulation and more extensive involvement in the middle and lower regions of the vertebral body in the PVL group than in the control group. Through a three-dimensional computed tomography reconstruction-based fracture line mapping technique, this study revealed for the first time that the distribution of fracture lines (UR-3, ML-3, LM-2, LR-2) and main fracture line length were independent risk factors for PVL after PVP in patients with acute single-segment thoracolumbar OVCFs. In addition, we hypothesized that the fracture line-vein traffic branch that may appear within 2 weeks after injury in acute OVCF patients may be one of the mechanisms influencing the above potential independent risk factors associated with PVL.

The Impact of Controlling Nutritional Status (CONUT) score on functional prognosis in hospitalized elderly patients with acute osteoporotic vertebral fractures

BackgroundNutritional status, which is associated with osteoporosis and muscle weakness is considered an important factor in the management of acute osteoporotic vertebral fracture (AOVF). However, few reports have investigated the nutritional status of hospitalized patients with AOVF and the impact of malnutrition on their functional prognosis. This study aimed to evaluate the nutritional status of hospitalized elderly patients with AOVF using the Controlling Nutritional Status (CONUT) score and to determine the usefulness of the CONUT score in predicting their functional prognosis.MethodsThe CONUT score on admission was retrospectively calculated for 134 hospitalized elderly patients (mean age 83 ± 7.6 years, 66% female) with AOVF who received conservative treatment between 2017 and 2020. Functional outcome was assessed by comparing ambulatory ability before the onset of AOVF and upon discharge. Patients were divided into two groups: CONUT-high ( ≥ 4) and CONUT-low ( ≤ 3), according to receiver operating characteristic (ROC) analysis to predict decline in ambulatory ability upon discharge. Logistic regression analysis was performed to obtain odds ratios (OR) and 95% confidence intervals (CI) of the relationships between the nutritional status and ambulatory ability. The discriminative power of the CONUT score was then compared with other nutritional assessment tools such as the Geriatric Nutritional Risk Index (GNRI) and prognostic nutritional index (PNI) by ROC analysis.Results81% of hospitalized patients with an AOVF were malnourished at the time of admission. The CONUT-high group had a significantly higher rate of decline in ambulatory ability (P < 0.001) than the CONUT-low group. Logistic regression analysis revealed the CONUT score ( ≥ 4) as an independent risk factor for a decline in ambulatory ability (OR 3.44, 95% CI 1.61–7.37, P = 0.0014). ROC analysis showed that the area under the curve (AUC) for the CONUT score (AUC = 0.724) was significantly greater than that for the GNRI (AUC = 0.624, P = 0.021) and PNI (AUC = 0.636, P = 0.0008).ConclusionsThis study showed that 81% of hospitalized elderly patients with AOVFs were malnourished and that the CONUT score was a useful predictive factor of functional prognosis.

Predictive Factors for Sustained Pain after (sub)acute Osteoporotic Vertebral Fractures. Combined Results from the VERTOS II and VERTOS IV Trial

PurposeOsteoporotic vertebral compression fractures are treated conservatively or in selected cases with percutaneous vertebroplasty (PV). The purpose of this retrospective analysis is to determine predictive factors for a high visual analogue scale (VAS) pain score after conservative, sham or PV and is based on previously published randomized trials.MethodsThe VERTOS II compared conservative versus PV, and VERTOS IV compared sham versus PV treatment. The conservative group received pain medication. The sham and PV group received subcutaneous lidocaine/bupivacaine. In addition, the PV group received cementation, which was simulated in the sham group. Nineteen different predictors of high (≥ 5) versus low (< 5) VAS pain score at 12 months were investigated.Results20.7% of patients in the PV group demonstrated a VAS ≥ 5 at the 12-month, compared to 40.1% in the conservative or sham group, with a significant difference (χ2(1) = 15.26, p < 0.0001, OR = 2.57, 95% CI = 1.59 to 4.15). In the subgroup analysis, we detected five predictors for the risk of high pain scores (VAS ≥ 5 after 12 months follow-up), namely: female, baseline VAS > 8, long-term baseline pain, mild/severe Genant and new fractures.ConclusionsStatistically significant more patients had a high pain score at 12 months in the sham and conservative group when compared with the PV group. Five predictors were identified for sustained high local back pain, regardless of the received treatment. Patients with moderate fracture deformity were less likely to have high pain scores at 12 months if they received PV than if they had sham or conservative therapy.

The Acute VertEbRal AugmentaTion (AVERT) study: protocol for a randomised controlled, feasibility trial of spinal medial branch nerve block in hospitalised older patients with vertebral fragility fractures

IntroductionVertebral fragility fractures (VFFs) are the most common type of osteoporotic fracture found in older people, resulting in increasing morbidity and excess mortality. These fractures can cause significant pain, requiring...

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

This review aims to search for up-to-date information on epidemiology, natural course, and preventive measures of osteoporotic spine fractures. 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 are presented. 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 VAS-scores ≥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 X-ray 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. 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.

Prediction of acute versus chronic osteoporotic vertebral fracture using radiomics-clinical model on CT

PurposeThis paper aims to use radiomics-clinical analysis based on CT imaging to distinguish between acute and chronic osteoporotic vertebral fractures. MethodA total of 147 patients who underwent both dual-energy X-ray absorptiometry (DEXA), CT and MRI of the spine were analyzed retrospectively. The patients were assigned to either a training cohort (n = 103) or a validation cohort (n = 44). The radiomics model and combined nomogram model were established by multivariate logistic regression analysis. The predictive performance was assessed with receiver operating characteristic (ROC) curve. ResultsFourteen radiomic features based on spine CT images were constructed to distinguish acute versus chronic osteoporotic vertebral fractures, and its differentialperformance was good with an area under the curve (AUC) of 0.90 (95% CI, 0.84–0.95) in the training cohort and 0.82 (95% CI, 0.69–0.94) in the validation cohort. Based on the radiomic signature and clinical fracture line feature, a combined nomogram was developed and showed excellent differential ability with highest AUC of 0.93 (95 %CI,0.88–0.98) in the training cohort and 0.86 (95 %CI,0.73–0.98) in the validation cohort, which performed better than the clinical model significantly only. ConclusionsA quantitative nomogram based on clinical fracture line feature and radiomic features of CT images can be used to distinguish acute and chronic osteoporotic vertebral fractures with excellent predictive ability, which can be served as a potential decision support tool to assist clinicians in evaluating the phase of vertebral fractures timely, especially in situation where spine MRI was not available for patient.

Early mobilization reduces the medical care cost and the risk of disuse syndrome in patients with acute osteoporotic vertebral fractures

Study designA retrospective observational study. PurposeTo compare two conservative treatments for acute osteoporotic vertebral fractures (OVFs). Overview of literatureSeveral studies have reported conservative treatments for OVFs in terms of using a brace, rehabilitation, and bed rest. However, there is no consensus about the conservative treatment for OVFs. MethodsWe evaluated 68 patients with acute OVF treated in our hospital from 2007 to 2011. Thirty-four patients treated in prolonged bed rest (PBR) regimen underwent rehabilitation wearing a Jewett’s brace after three weeks of bed rest. In contrast, the other 34 patients underwent rehabilitation wearing a Jewett’s brace as soon as possible, which we called a stir-up (SU) regimen. We compared two treatment groups for medical costs, hospital length of stay (LOS), pain according to the numeric rating scale (NRS), the activities of daily living (ADL), and imaging studies. ResultsThe average hospital LOS was significantly shorter in patients treated by the SU regimen, which resulted in the medical costs reduction. There was no significant difference in the NRS through 6 months between the two groups. Although many patients in both groups experienced at least one level reduction in ADL at 6 months after the injury, patients in the SU group tended to maintain their pre-injury ADL, which almost agrees with past reports. In terms of imaging studies, patients in the PBR group showed milder vertebral compression rate over time. Pseudoarthrosis occurred in 2 patients in the SU group, who presented with mild pain, which had little influence on their daily lives. ConclusionWe compared two conservative treatments for OVFs. Early rehabilitation was useful treatment for OVFs to minimize the risk for disuse syndrome, maintain pre-injury ADL status, and reduce the medical costs.

Relationship between Vertebral Instability and the Cross-Sectional Area of Lumbar Muscles in Postmenopausal Acute Osteoporotic Vertebral Fractures.

Introduction Vertebral instability (VI) in osteoporotic vertebral fractures (OVFs) varies from mild to severe. The relationship between the VI of OVFs and independent factors, such as bone mineral density (BMD) and lumbar muscle volume, is unclear. This study aimed to investigate whether BMD and the cross-sectional area (CSA) of lumbar muscles are related to VI in OVFs. Methods On the basis of the thoracolumbar lateral radiographs of 95 acute OVFs in postmenopausal women (mean age 80.6 years; range: 64-103 years), supine and standing vertebral collapse rates (CRsp and CRst, respectively) were determined. Subsequently, VI was defined as follows: VI=CRst−CRsp. Using axial T2-weighted magnetic resonance imaging (MRI), CSA of the psoas major, erector spinae, and multifidus muscles at the L3/4 intervertebral disc level were measured. The BMD of the lumbar spine and proximal femur (total hip) was measured for all participants using dual-energy X-ray absorptiometry. The patients were classified into group 1 (VI <20%) and group 2 (VI ≥20%). Results We observed a negative correlation between VI and CSA of the erector spinae muscle (r=−0.3962, P<0.0001). No significant correlations were observed between VI and BMD. The CSA of the erector spinae muscle in group 2 was significantly lower than that in group 1 (P=0.0002). No significant difference in the BMD or the CSA of the psoas major or multifidus muscles was observed between the two groups. A multivariable analysis of factors of VI was performed. Both age (odds ratio [OR], 1.099; 95% confidence interval [CI], 1.015-1.189; P=0.020) and the CSA of the erector spinae (OR, 0.996; 95% CI, 0.993-0.999; P=0.020) were significant predictors of high VI. Conclusions Although the severity of OVFs was related to the CSA of the erector spinae muscle, it was not associated with BMD.

Risk factors for subsequent vertebral fracture after acute osteoporotic vertebral fractures.

To investigate the incidence and characteristics of subsequent vertebral fracture after osteoporotic vertebral fractures (OVFs) and identify risk factors for subsequent vertebral fractures. This post-hoc analysis from a prospective randomized multicenter trial included 225 patients with a 48-week follow-up period. Differences between the subsequent and non-subsequent fracture groups were analyzed. Of the 225 patients, 15 (6.7%) had a subsequent fracture during the 48-week follow-up. The annual incidence of subsequent vertebral fracture after fresh OVFs in women aged 65-85years was 68.8 per 1000 person-years. Most patients (73.3%) experienced subsequent vertebral fractures within 6months. At 48weeks, European Quality of Life-5 Dimensions, the Japanese Orthopedic Association Back Pain Evaluation Questionnaire pain-related disorder, walking ability, social life function, and lumbar function scores were significantly lower, while the visual analog scale (VAS) for low back pain was higher in patients with subsequent fracture. Cox proportional hazards analysis showed that a VAS score ≥ 70 at 0weeks was an independent predictor of subsequent vertebral fracture. After adjustment for history of previous fracture, there was a ~ 67% reduction in the risk of subsequent vertebral fracture at the rigid-brace treatment. Women with a fresh OVF were at higher risk for subsequent vertebral fracture within the next year. Severe low back pain and use of soft braces were associated with higher risk of subsequent vertebral fractures. Therefore, when treating patients after OVFs with these risk factors, more attention may be needed for the occurrence of subsequent vertebral fractures. III.

Dixon or DWI – Comparing the utility of fat fraction and apparent diffusion coefficient to distinguish between malignant and acute osteoporotic vertebral fractures

PurposeTo compare fat fraction (FF) and apparent diffusion coefficient (ADC) as discriminators distinguishing malignant from acute/subacute osteoporotic vertebral fractures. Method1.5 T MRIs of 42 malignant and 27 acute/subacute osteoporotic vertebral fractures (38 patients) were retrospectively reviewed. Two readers independently classified fractures as malignant or osteoporotic based on conventional imaging morphology. Diagnostic reader confidence was rated as confident or not confident. FF was derived from axial T1 gradient-echo 2-point Dixon MRI. ADC maps were calculated from axial b50 and b900 images. Both readers independently performed ROI measurements of mean FF and ADC of the same fractured vertebrae. FF and ADC values, corresponding ROC curves and optimized cut-off value performance were compared. Inter-reader agreement was analysed by calculation of intraclass correlation coefficients (ICCs). A p-value < 0.05 was deemed significant. ResultsMean FF and ADC were significantly lower in malignant (9.5 % and 1.05 × 10−3 mm²/s) compared to osteoporotic fractures (32 % and 1.34 × 10−3 mm²/s, all p < 0.001). The optimal cut-off FF was 11.5 %, detecting malignant fractures with 86 %/89 % sensitivity/specificity. The optimal ADC cut-off of 1.04 × 10−3 mm/s² yielded 62 %/96 % sensitivity/specificity. FF AUC (0.93) was significantly larger than ADC AUC (0.82, p = 0.03). In the subgroup of nine cases reported with low expert reader confidence, the optimized cut-off specificities of FF (83 %) and ADC (83 %) exceeded reader specificity (50 %). There was excellent inter-reader agreement for mean FF (ICC = 0.99) and good agreement for mean ADC (ICC = 0.86) measurements. ConclusionFF and ADC can improve reader specificity to distinguish between malignant and acute or subacute osteoporotic vertebral fractures. As single discriminator, FF was superior to ADC.

Predictors of residual low back pain after acute osteoporotic compression fracture

BackgroundStudies on the clinical and radiographic risk factors for the residual low back pain beyond 6 months after osteoporotic vertebral fractures (OVFs) are lacking. Hence, this study aimed to characterize a patient population with residual low back pain 48 weeks after acute OVFs and to identify the risk factors associated with residual low back pain. MethodsThis prospective multicenter study included 166 female patients aged 65–85 years with acute one-level OVFs. We defined the residual low back pain as visual analog scale (VAS) for low back pain ≥3.5 at 48 weeks in this study, as VAS score ≥3.5 is used to describe moderate or severe pain. Thus, outcome and risk factor analyses were performed by comparing patients with VAS scores <3.5 and ≥ 3.5. In the radiographic analysis, the anterior vertebral body compression percentage was measured at 0, 12, and 48 weeks. Magnetic resonance imaging (MRI) was performed at enrollment and 48 weeks. ResultsOf the 166 patients analyzed, 58 complained of residual low back pain at 48 weeks after OVFs. At 0 weeks, the VAS score was significantly higher, and the JOABPEQ mental health score and anterior vertebral body compression percentage were significantly lower in patients with persistent pain 48 weeks after OVFs. The independent risk factors in the acute phase for persistent pain 48 weeks after OVFs were a high VAS score, MRI T2 fluid-intensity image pattern, and a lower anterior vertebral body compression percentage. ConclusionsSevere low back pain, MRI T2 fluid-intensity image pattern, and severe vertebral body collapse in the acute phase were significant risk factors for residual low back pain 48 weeks after OVFs. Patients with acute OVFs who have these risk factors should be carefully monitored for the possible development of residual chronic low back pain.

Changes in magnetic resonance imaging signal intensity in predicting complications during acute phase osteoporotic vertebral fractures

PurposeTo demonstrate prediction of complications in osteoporotic vertebral fractures with magnetic resonance imaging (MRI) changes over time. MethodsMRI signal intensities in osteoporotic vertebral fractures were investigated according to the interval between onset and imaging as follows: 0–10 days (early), 11–20 days (middle), and 21–30 days (later). ResultsThe diffuse low pattern rates were 52%, 84%, and 95% and 20%, 24%, and 52% in the early, middle, and later periods on T1-WI and T2-WI, respectively. ConclusionsThe diffuse low pattern increased with time. The MRI prediction of complications depends on the time phase.

Bracing for Acute and Subacute Osteoporotic Compression Fractures: A Systematic Review of the Literature

Many treatment options for osteoporotic vertebral fractures are available. However, limited and variable findings have been reported on the efficacy of the individual therapies. The objective of the present study was to systematically review the reported data for evidence of efficacy of spinal orthoses for osteoporotic vertebral fractures. A systematic review of the PubMed database was performed. Two reviewers evaluated the studies found for eligibility. Randomized controlled trails (RCTs) and prospective nonrandomized, prospective single-arm, and retrospective comparative studies of the treatment of acute osteoporotic vertebral fractures with spinal orthoses were included. A total of 16 studies were included: 5 RCTs, 6 nonrandomized prospective comparative studies, 1 retrospective case-control study, and 4 prospective single-arm studies. Of the 16 studies, 4 (3 single-arm studies and 1 nonrandomized study) provided low-quality evidence that bracing, with or without bedrest, was safe. Also, 1 nonrandomized and 1 single-arm study provided low-quality evidence that bracing improved pain and disability. In addition, 4 studies demonstrated that the use of a rigid brace was equivalent to the use of a soft brace or no brace (2 high-quality RCTs, 2 nonrandomized studies, 1 low-quality RCT). Two nonrandomized and one case-control study demonstrated a benefit of kyphoplasty compared with bracing alone (all low quality). Two RCTs had provided low-quality evidence that bracing was superior to no brace and one nonrandomized study provided low-quality evidence that a dynamic brace was superior to rigid orthosis. Limited evidence has suggested the safety of spinal orthoses for the treatment of osteoporotic compression fractures. At present, compelling evidence is not available to suggest that a rigid brace is superior to a soft brace or no brace. Kyphoplasty might be of benefit for select patients.

Vertebral mobility is a valuable indicator for predicting and determining bone union in osteoporotic vertebral fractures: a conventional observation study

BackgroundConservative treatments for osteoporotic vertebral fractures (OVFs) have not been standardized, and criteria for determining bone union have not been established. To determine bone union, we have adopted a cutoff value of 1.0 mm for vertebral mobility (V-mobility), defined as the difference in anterior vertebral height (Ha) between lateral radiographs taken in weight-bearing and non-weight-bearing positions. The present study aimed to investigate the usefulness of V-mobility for determining bone union and predicting bone union at 6 months after OVF onset.MethodsThe study included 54 acute OVFs from T11 to L3 in 53 patients (12 males, 41 females; mean age 82 years; age range 55–97 years) who were hospitalized at ≤ 3 weeks after OVF onset. Vertebral deformity (V-deformity) and V-mobility were evaluated in accordance with Ha on lateral radiographs taken in the sitting position (SIT), lateral decubitus position (DEC), and supine position (SUP). OVFs showing V-mobility of ≤ 1.0 mm between SIT and DEC radiographs and no intravertebral cleft on DEC radiograph were defined as semi-union, while those showing V-mobility of ≤ 1.0 mm between SIT and SUP radiographs and no intravertebral cleft on SUP radiograph were defined as bone union. We calculated the bone union rates including semi-unions associated with V-mobility cutoff values of 1.0 mm, 1.5 mm, and 2.0 mm and estimated cutoff values for V-mobility at 5 weeks after OVF onset to predict bone union at 6 months after OVF onset.ResultsThe cumulative number of bone unions including semi-unions was more influenced by the different V-mobility cutoff values in Ha for determining bone union in the earlier period compared with the later period in the time course of OVF. Receiver-operating characteristic curve analyses revealed that V-mobility cutoff value of 2.1 mm in Ha between SIT and DEC radiographs at 5 weeks after OVF had moderate accuracy for predicting bone union including semi-union at 6 months after OVF. The mean V-deformity value on SIT radiographs did not progress significantly.ConclusionV-mobility in the early stage after OVF can predict bone union at 6 months after OVF and is a useful quantitative indicator for determining bone union.

Risk Factors of Nonunion After Acute Osteoporotic Vertebral Fractures: A Prospective Multicenter Cohort Study.

Prospective cohort study. To characterize a patient population with nonunion after acute osteoporotic vertebral fractures (OVFs) and compare the union and nonunion groups to identify risk factors for nonunion. While OVFs are the most common type of osteoporotic fracture, the predictive value of a clinical assessment for nonunion at 48 weeks after OVF has not been extensively studied. This prospective multicenter cohort study included female patients aged 65 to 85 years with acute one-level osteoporotic compression fractures. In the radiographic analysis, the anterior vertebral body compression percentage was measured at 0, 12, and 48 weeks. Magnetic resonance imaging (MRI) was performed at enrollment and at 48 weeks to confirm the diagnosis and union status. The patient-reported outcome measures included scores on the European Quality of Life-5 Dimensions (EQ-5D), a visual analogue scale for low back pain, and the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) at 0, 12, and 48 weeks. In total, 166 patients completed the 12-month follow-up, 29 of whom had nonunion. Patients with nonunion at 48 weeks after OVF had lower EQ-5D and JOABPEQ walking ability, social life function, mental health, and lumbar function scores than those with union at 48 weeks after injury. The independent risk factors for nonunion after OVF in the acute phase were a diffuse low type pattern on T1-weighted MRI and diffuse low and fluid type patterns on T2-weighted MRI. The anterior vertebral body compression percentage and JOABPEQ social life function scores were independent risk factors at 12 weeks. A diffuse low type pattern on T1-weighted MRI and diffuse low and fluid type patterns on T2-weighted MRI were independent risk factors for nonunion in the acute phase. Patients who have acute OVFs with these risk factors should be carefully monitored for nonunion. 2.

Which anatomic structures are responsible for the reduction loss after hybrid stabilization of osteoporotic fractures of the thoracolumbar spine?

IntroductionHybrid stabilization is an accepted therapy strategy for unstable osteoporotic thoracolumbar fractures. However, a moderate reduction loss has been reported and it remains unclear which anatomic structure is responsible for the reduction loss.MethodsThis retrospective study was performed at a level I trauma center. Patients aged 61 and older were stabilized using hybrid stabilization after suffering acute and unstable osteoporotic vertebral body fractures at the thoracolumbar spine. Posterior stabilization was done short-segmental and minimal invasive with cement-augmentation of all pedicle screws. The minimum follow-up has been 2 years. The outcome parameters were the reduction loss and the relative loss of height of both intervertebral discs adjacent to the fractured vertebral body, the fractured vertebral body and a reference disc (intervertebral disc superior of the stabilization) between the postoperative and latest lateral radiographs. Additionally, implant positioning and loosening was analyzed.Results29 mainly female (72%) patients (73.3 ± 6.0 years) were included. Fractures consisted of 26 incomplete burst fractures and 3 complete burst fractures of the thoracolumbar junction (Th11 – L2: 86%) and the midlumbar spine. The mean follow-up time was 36 months (range: 24–58 months). The mean reduction loss was 7.7° (range: 1–25). The relative loss of heights of both intervertebral discs adjacent to the fractured vertebral body, the reference disc, and the central vertebral body were significant. Thereby, the relative loss of the superior disc height was significant higher compared to the reference disc. Additionally, only the relative loss of central vertebral body height and reduction loss correlated significantly. There were no signs of implant loosening in any patient.ConclusionsThe mean reduction loss was moderate 3 years after hybrid stabilization of unstable osteoporotic vertebral fractures of the thoracolumbar spine. A significant loss of both adjacent disc heights and the central vertebral body was seen, with the highest loss in the superior adjacent disc significantly outranging the reference disc. The superior adjacent intervertebral disc and the central part of the fractured vertebral body seem to be responsible for the majority of reduction loss.