Chronic Vertebral Compression Fractures Research Articles

Improved Detection Accuracy of Chronic Vertebral Compression Fractures by Integrating Height Loss Ratio and Deep Learning Approaches

Objectives: This study aims to assess the limitations of the height loss ratio (HLR) method and introduce a new approach that integrates a deep learning (DL) model to enhance vertebral compression fracture (VCF) detection performance. Methods: We conducted a retrospective study on 589 patients with chronic VCFs. We compared four different methods: HLR-only, DL-only, a combination of HLR and DL for positive VCF, and a combination of HLR and DL for negative VCF. The models were evaluated using dice similarity coefficient, sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC). Results: The combined method (HLR + DL, positive) demonstrated the best performance with an AUROC of 0.968, sensitivity (94.95%), and specificity (90.59%). The HLR-only and the HLR + DL (negative) also showed strong discriminatory power, with AUROCs of 0.948 and 0.947, respectively. The DL-only model achieved the highest specificity (95.92%) but exhibited lower sensitivity (82.83%). Conclusions: Our study highlights the limitations of the HLR method in detecting chronic VCFs and demonstrates the improved performance of combining HLR with DL models.

Bone Scintigraphy for Guidance of Targeted Treatment of Vertebral Compression Fractures.

Background: Vertebral compression fractures (VCFs) are prevalent in the elderly population and might be the source of back pain if they are fresh and yet unhealed. In many cases, it is a diagnostic challenge to differentiate fresh VCFs from healed united fractures, which retain similar radiographic characteristics but no longer generate pain. This information is crucial for appropriate management. The aim of this study was to evaluate the role of bone scintigraphy (BS) in identifying fresh VCFs appropriate for targeted treatment when compared to the findings of Computerized Tomography (CT). Methods: We retrospectively reviewed 190 patients with back pain suspected to stem from a recent VCF that underwent both a CT and a BS and compared the imaging patterns per vertebra. Results: The studies were concordant in the majority of cases (95.5%), diagnosing 84.4% normal vertebrae, 6.4% acute VCFs, and 4.7% chronic VCFs. However, in 37 patients, 45 occult acute VCFs were only detected on BS and not on CT. Multivariate logistic regression analysis revealed that these patients were older and had lower bone density compared to the rest of the study population. Additionally, 40 patients had acute VCFs visible on CT, but with no increased or low intensity uptake on BS. These cases were associated with a shorter time period between trauma and BS, a higher prevalence of male patients, and a higher bone density. Acute VCFs with no increased uptake or low levels of uptake were found only within the first six days of the trauma. Conclusions: BS detects radiologically occult fractures and can differentiate if a radiographically evident VCF is indeed clinically active, guiding possible treatment options. To avoid missing acute VCFs, BS should be performed six days or more after the injury.

Percutaneous vertebroplasty: efficacy in the management of pain related to acute vertebral compression fractures.

Historically, both acute and chronic vertebral compression fractures (VCF) have been managed with vertebral augmentation procedures such as percutaneous vertebroplasty (VP). Recently, however, the trend has shifted to manage VCF pharmacotherapeutically. This study aims to determine if VP is effective for managing pain related to acute VCF (≤12 weeks). This study retrospectively surveyed 8 of 15 patients that underwent VP at Middlemore Hospital between 2018 and 2021. All had VCF aged ≤12 weeks, and presence of increased bone marrow signal on magnetic resonance imaging (MRI). The survey reviewed pain levels (via numeric score), opiate analgesia dispensation, and mobility levels pre- and post-procedure. Results showed post-procedure improvement in pain levels in 75% of individuals, which were maintained over the two- and four-week marks. There was an improvement in mobility in 75% of patients at 4 weeks, and 66% had decreased dispensation or complete cessation of opioid analgesia 4 weeks post procedure. This study shows that VP correlates with overall improvement in pain scores, opiate use and mobility in the sample group with VCF aged ≤12 weeks. Hopefully the results of this study will encourage physicians to consider vertebroplasty as a method of achieving adequate analgesia in this demographic of patients.

Differentiation of acute and chronic vertebral compression fractures using conventional CT based on deep transfer learning features and hand-crafted radiomics features

BackgroundWe evaluated the diagnostic efficacy of deep learning radiomics (DLR) and hand-crafted radiomics (HCR) features in differentiating acute and chronic vertebral compression fractures (VCFs).MethodsA total of 365 patients with VCFs were retrospectively analysed based on their computed tomography (CT) scan data. All patients completed MRI examination within 2 weeks. There were 315 acute VCFs and 205 chronic VCFs. Deep transfer learning (DTL) features and HCR features were extracted from CT images of patients with VCFs using DLR and traditional radiomics, respectively, and feature fusion was performed to establish the least absolute shrinkage and selection operator. The MRI display of vertebral bone marrow oedema was used as the gold standard for acute VCF, and the model performance was evaluated using the receiver operating characteristic (ROC).To separately evaluate the effectiveness of DLR, traditional radiomics and feature fusion in the differential diagnosis of acute and chronic VCFs, we constructed a nomogram based on the clinical baseline data to visualize the classification evaluation. The predictive power of each model was compared using the Delong test, and the clinical value of the nomogram was evaluated using decision curve analysis (DCA).ResultsFifty DTL features were obtained from DLR, 41 HCR features were obtained from traditional radiomics, and 77 features fusion were obtained after feature screening and fusion of the two. The area under the curve (AUC) of the DLR model in the training cohort and test cohort were 0.992 (95% confidence interval (CI), 0.983-0.999) and 0.871 (95% CI, 0.805-0.938), respectively. While the AUCs of the conventional radiomics model in the training cohort and test cohort were 0.973 (95% CI, 0.955-0.990) and 0.854 (95% CI, 0.773-0.934), respectively. The AUCs of the features fusion model in the training cohort and test cohort were 0.997 (95% CI, 0.994-0.999) and 0.915 (95% CI, 0.855-0.974), respectively. The AUCs of nomogram constructed by the features fusion in combination with clinical baseline data were 0.998 (95% CI, 0.996–0.999) and 0.946 (95% CI, 0.906–0.987) in the training cohort and test cohort, respectively. The Delong test showed that the differences between the features fusion model and the nomogram in the training cohort and the test cohort were not statistically significant (P values were 0.794 and 0.668, respectively), and the differences in the other prediction models in the training cohort and the test cohort were statistically significant (P < 0.05). DCA showed that the nomogram had high clinical value.ConclusionThe features fusion model can be used for the differential diagnosis of acute and chronic VCFs, and its differential diagnosis ability is improved when compared with that when either radiomics is used alone. At the same time, the nomogram has a high predictive value for acute and chronic VCFs and can be a potential decision-making tool to assist clinicians, especially when a patient is unable to undergo spinal MRI examination.

Evaluation of the role of vertebral augmentation in chronic vertebral compression fractures: A retrospective study

ObjectivesVertebral augmentation is recommended for acute or subacute vertebral compression fractures (VCFs); few studies claim its usefulness in chronic VCFs also. Use of radionuclide imaging may improvise identification of chronic VCFs that may benefit from vertebral augmentation; hence we have evaluated efficacy of vertebral augmentation procedures in chronic VCFs with incomplete fracture healing suggested either by MRI or Tc99m- MDP bone scan. Materials and MethodsPatients with chronic osteoporotic VCFs (>12 weeks) during the period of June 2013 to June 2019 were included in this retrospective study; patients with evidence of incomplete fracture healing either by MRI or bone scan imaging with Tc 99m-MDP underwent vertebroplasty or kyphoplasty. Primary outcome measure was patient’s pain score measured by numerical rating scale (NRS); secondary outcome measures were patient’s disability assessed by Roland Morris Disability questionnaire (RDQ); quality of life assessed by Quality of life questionnaire of European Foundation of Osteoporosis (QUALLEFO) and analgesic usage. P ​< ​0.050 was considered as significant. Results34 patients were enrolled for the study with median fracture age of 36 months. The median NRS pain scores, RDQ scores, QUALEFFO scores and analgesic usage were significantly reduced at all-time points as compared to the baseline value over the follow up period of 1 year after vertebral augmentation procedure (P ​< ​0.050). Cement leakage was seen in 5 patients (15%). ConclusionVertebral augmentation procedures provided significant improvements in pain scores, disability and quality of life in patients of chronic osteoporotic VCFs with median fracture age of 36 months.

Radiographic assessment of acute vs chronic vertebral compression fractures.

Distinguishing between acute and chronic vertebral compression fractures typically requires advanced imaging techniques such as magnetic resonance imaging (MRI). Recognizing specific radiographic findings associated with fracture acuity may improve the accuracy of radiographic assessment. Patients with compression fractures that had both radiographic and MRI studies of the lumbar spine within a 30-day time frame were retrospectively reviewed. MRI studies were used to determine compression fracture acuity. Radiographs were interpreted by a separate group of radiologists blinded to the MRI results. Radiographic findings of endplate osteophyte, subendplate density, subendplate cleft, and subendplate cyst were recorded as was the overall impression of fracture acuity. Sensitivity and specificity for radiographic reporting of acute fracture were 0.52 (95% CI: 0.42, 0.61) and 0.95 (95% CI: 0.93, 0.97) respectively. For chronic fractures, the sensitivity and specificity were 0.52 (95% CI: 0.41, 0.63) and 0.94 (95% CI: 0.92, 0.96). The radiographic presence of a subendplate cleft increased the odds of a fracture being acute by a factor of 1.75 (95% CI: 1.09, 2.81; P = 0.0202). The radiographic presence of subendplate density increased the odds of a fracture being acute by a factor of 1.78 (95% CI: 1.21, 2.63; P = 0.0037). The presence of an endplate osteophyte or subendplate cyst was not significantly associated with fracture acuity. Radiographs are relatively insensitive in distinguishing between acute and chronic lumbar compression fractures but the presence of a subendplate cleft or subendplate density increases the likelihood that a given fracture is acute.

Prediction of the Acuity of Vertebral Compression Fractures on CT Using Radiologic and Radiomic Features

To develop and validate prediction models to differentiate acute and chronic vertebral compression fractures based on radiologic and radiomic features on CT. This study included acute and chronic compression fractures in patients who underwent both spine CT and MRI examinations. For each fractured vertebra, three CT findings ([1] cortical disruption, [2] hypoattenuating cleft or sclerotic line, and [3] relative bone marrow attenuation) were assessed by two radiologists. A radiomic score was built from 280 radiomic features extracted from non-contrast-enhanced CT images. Weighted multivariable logistic regression analysis was performed to build a radiologic model based on CT findings and an integrated model combining the radiomic score and CT findings. Model performance was evaluated and compared. Models were externally validated using an independent test cohort. A total to 238 fractures (159 acute and 79 chronic) in 122 patients and 58 fractures (39 acute and 19 chronic) in 32 patients were included in the training and test cohorts, respectively. The AUC of the radiomic score was 0.95 in the training and 0.93 in the test cohorts. The AUC of the radiologic model was 0.89 in the training and 0.83 in the test cohorts. The discriminatory performance of the integrated model was significantly higher than the radiologic model in both the training (AUC, 0.97; p<0.01) and the test (AUC, 0.95; p=0.01) cohorts. Combining radiomics with radiologic findings significantly improved the performance of CT in determining the acuity of vertebral compression fractures.

Fast kilovoltage (KV)-switching dual-energy CT virtual noncalcium technique using different reconstruction kernels for identifying acute and chronic vertebral compression fractures.

To investigate whether different reconstruction kernels (STND V.S. BONE) affect the diagnostic performance of dual-energy CT virtual noncalcium technique (VNCa) for identifying acute and chronic vertebral compression fractures (VCFs). This retrospective study included 31 consecutive patients with 79 VCFs who underwent both a dual-energy CT and a 3-T MR examination of the spine between August 2018 and March 2019. MR images served as the reference standard. Two independent and blinded radiologists evaluated all vertebral bodies for the presence of abnormal edema on color-coded overlay VNCa images. Two additional radiologists performed a quantitative analysis on VNCa images by calculating water content of vertebral bodies. Receiver operating characteristic curve (ROC) analysis was conducted. Area under the curve (AUC) was calculated. MR imaging depicted 44 edematous and 35 nonedematous VCFs. In visual analysis, the AUCSTND and AUCBONE were 0.932 and 0.943. In quantitative analysis, water content results were significantly different between vertebrae with and without bone marrow edema on MR (P < 0.001). And the AUCSTND and AUCBONE were 0.851 and 0.850 respectively. Visual and quantitative analysis of dual-energy CT VNCa technique had excellent diagnostic performance for identifying acute and chronic compression fractures; different reconstruction kernels did not matter.

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

Hydroxyapatite (HAP) is the main component of bone mineral. The utility of using HAP-water decomposition technique with fast kilovoltage (KV)-switching dual-energy computed tomography (DECT) to detect abnormal edema in vertebral compression fractures (VCFs) has not been widely reported. A total of 31 consecutive patients with 80 VCFs who underwent DECT and magnetic resonance imaging (MRI) of the spine were retrospectively enrolled in our study between October 2018 and January 2019. VCFs in MR examinations served as the standard of reference. Two radiologists blindly and independently evaluated color-coded overlay virtual nonhydroxyapatite (VNHAP) images for the presence of abnormal edema. The inter-reader agreement, specificity, sensitivity, accuracy, and predictive values of VNHAP images for edema detection were calculated. The diagnostic accuracy of two readers was compared using McNemar's test. Two additional radiologists performed a quantitative analysis on VNHAP images, receiver operating characteristic (ROC) curve analysis was conducted, and the threshold was calculated. MRI depicted 45 edematous and 35 nonedematous VCFs. For visual analysis, the VNHAP technique showed a sensitivity of 93.3%, a specificity of 97.1%, a positive predictive value (PPV) of 97.7%, a negative predictive value (NPV) of 91.9%, and an accuracy of 95.0%. The inter-reader agreement was almost perfect (k=0.90). The diagnostic accuracy of the two readers showed no significant differences in the assessment of VNHAP images (P=1.00). Significant differences in CT numbers between vertebrae with and without bone marrow edema were found by quantitative analysis (P<0.01). The area under the curve (AUC) of the VNHAP images was estimated to be 0.917. The threshold of 1,003.2 mg/cm3 yielded a sensitivity of 88.9% and a specificity of 82.9% for the differentiation of fresh and old VCFs. Fast KV-switching DECT HAP-water decomposition technique had excellent diagnostic performance for identifying acute and chronic VCFs in visual and quantitative analyses.

Radiologic Evaluation of Chronic Vertebral Compression Fractures and Role of Vertebral Augmentation.

The literature has classified chronic vertebral compression fractures (VCF) as those still "symptomatic" four or more months after onset. Pain is regarded as the predominant chronic symptom; however, radiologic changes are important in evaluating fracture progression. This review examines a series of patients with chronic fractures and both persistence of spinal pain combined with radiologic changes, such as worsening collapse, spinal angulation, the development of vertebral edema and clefts, as well as the development of new fractures at adjacent spinal levels. In patients with clear progressive radiologic changes in addition to pain, vertebral augmentation on an average of 9.3 months after injury was effective in reducing the pain and stabilizing these more chronic osteoporotic fractures. A comparison of the pre- and post-procedure visual analog scale score (VAS) indicated an average of 66% reduction in pain. There are several reasons for the development of chronic symptomatic fractures. Most commonly, interventional treatment is delayed in a patient already diagnosed with VCF after a long period of conservative treatment, yet pain persists, or the initial clinical and radiologic evaluation misses the fracture, leading to a delay in diagnosis and treatment. In this report, management in these patients and the role of late vertebral augmentation for chronic symptomatic fractures is clarified based on the findings of various radiologic changes seen on both initial and follow-up radiologic studies.

Vertebral augmentation with the SpineJack® in chronic vertebral compression fractures with major kyphosis

Osteoporotic vertebral compression fractures (OVCFs) are an important health issue for which minimally invasive techniques are a feasible treatment. The SpineJack® (Vexim) is an intravertebral expandable system designed to improve the correction of the structural modifications caused by OVCFs. Its ability to stabilise and reduce OVCFs at the acute phase being already well established, we sought to evaluate the feasibility of vertebral augmentation with the SpineJack® in chronic kyphotic OVCFs. All consecutive patients treated with the SpineJack® were prospectively included if they met the following criteria: (1) OVCF considered unstable (grade A3 according to Magerl's classification). (2) Local kyphotic angle ≥ 20°. (3) OVCF older than 6 weeks. (4) Back pain with visual analogue scale (VAS) ≥ 4. Nineteen consecutive patients (16 women [84.2%] and 3 men [15.8%]; mean age 73.2 ± 8.2 years) were included. Treatment was performed after a mean delay of 5.8 months ± 2.9 (range 1.5-12). Median visual analogue scale significantly improved from 7 preoperatively (IQR 6-9) to 2 (IQR 1-5) at 6 months (p < 0.01). Significant kyphosis reduction (i.e. ≥ 30%) was obtained in 94.7% of cases. Secondary adjacent level fractures (SALFs) were noted in 21.1% of cases and were correlated with the importance of the kyphosis reduction. Vertebral augmentation with the SpineJack® is feasible and seems able to correct major structural deformities in chronic OVCFs. SALFs were noted in a substantial amount of cases. Preventive adjacent vertebroplasty might be useful in patients with several risk factors for SALFs. • Vertebral augmentation with SpineJack® is effective to correct major structural deformities e.g. height loss and kyphosis. • Successful reduction is reachable with SpineJack® in chronic (older than 6 weeks) OVCFs. • Aggressive reduction of major kyphosis might promote SALFs and complementary adjacent vertebroplasties prevent their occurrence.

Bone marrow fat quantification of osteoporotic vertebral compression fractures: comparison of multi-voxel proton MR spectroscopy and chemical-shift gradient-echo MR imaging

Only a few studies have used in/opposed phase method for a quantitative evaluation of fat fraction in the spine. To compare multivoxel proton MR spectroscopy and chemical-shift gradient-echo MR imaging for bone marrow fat quantification in vertebral compression fractures (VCF). Vertebral marrow fat quantification in fifteen patients was measured at 3.0-T. Multi-voxel proton spectroscopy (MRS) and in/opposed-phase MR imaging using a fat map build with a triple-echo gradient-echo sequence was used. All the patients had benign vertebral collapse. Bone marrow fat content was evaluated by both techniques in compressed (acute or chronic) and in non-compressed vertebrae. The percentage of fat fraction measured by the triple-echo sequence was well correlated with those calculated by MRS (r(2) = 0.85; P < 10(-4)). There was a significant decrease of fat fraction in acute VCF versus both chronic VCF (P < 10(-9)) and non-fractured vertebrae (P < 10(-7)). There was no significant difference in fat fraction evaluated by both techniques between non-fractured vertebrae and chronic VCF. We have validated the in/opposed phase method compared with MRS for vertebral bone marrow fat quantification. The fat mapping using a triple-echo gradient-echo sequence allows distinguishing acute and chronic benign VCF.

Percutaneous vertebroplasty for the treatment of osteoporotic vertebral compression fractures

In a prospective study between August 2002 and August 2005, we studied the quantitative clinical and radiological outcome 36 months after percutaneous vertebroplasty for intractable type-II osteoporotic vertebral compression fractures which had been unresponsive to conservative treatment for at least eight weeks. We also examined the quality of life (QoL). The clinical follow-up involved the use of a pain intensity numerical rating scale (PI-NRS, 0 to 10), the Short-Form 36 (SF-36) QoL questionnaire and an anamnestic questionnaire before and at seven days (PI-NRS only), and one, three, 12 and 36 months post-operatively. A total of 30 consecutive patients received percutaneous vertebroplasty for 62 vertebral compression fractures with a mean time between fracture and treatment of 7.7 months (2.2 to 39). An immediate, significant and lasting reduction in the average and worst back pain was found, represented by a decrease of 3.1 and 2.7 points after seven days and 3.1 and 2.8 points after 36 months, respectively (p < 0.00). Comparison of the pre- and post-vertebroplasty scores on the various SF-36 domains showed an ultimate significant increase in six of eight domains and both summary scores. Asymptomatic leakage of cement was found in 47 of 58 (81%) of treated vertebrae. Two minor complications occurred, an asymptomatic pulmonary cement embolism and a cement spur along the needle track. Percutaneous vertebroplasty in the treatment of chronic vertebral compression fractures results in an immediate, significant and lasting reduction in back pain, and overall improvement in physical and mental health.

Acute versus chronic vertebral compression fractures treated with kyphoplasty: early results

Background context Kyphoplasty, a minimally invasive technique for fracture reduction and stabilization, has been shown to reduce pain and restore vertebral body height in patients with vertebral compression fractures (VCFs). Analyses comparing treatment outcomes of acute versus chronic VCFs have not yet been reported. Purpose To assess whether kyphoplasty results in better clinical outcome and fracture reduction in patients with either acute or chronic VCFs. Study design A prospective, consecutive cohort study of patients who underwent kyphoplasty between March 2000 and December 2001 to treat osteoporotic VCFs that were either less than 10 weeks old (acute) or more than 4 months old (chronic). Fifteen subacute fractures (treated 10 to 16 weeks after fracture) were excluded from analyses. Patient sample Eighty-six VCFs in 47 patients (35 female and 12 male) were treated during 55 kyphoplasty procedures. Mean patient age was 74 years (range, 47 to 91). Methods Clinical outcomes were determined by comparison of preoperative and postoperative data from patient-reported indexes (pain assessment, pain medication usage and Oswestry Disability Index for Back Pain). Radiographs were assessed as to percent vertebral collapse, vertebral height restoration and local kyphosis correction. Results By 2 weeks after surgery, 90% of acute and 87% of chronic fractures were associated with pain relief. Narcotic usage decreased and Oswestry scores improved in almost all patients. Mean vertebral body height significantly improved after kyphoplasty (acute: 58% to 86% of estimated normal vertebral height, p<.001; chronic: 56% to 79% of estimated normal vertebral height, p<.001). Restoration to 89% or greater estimated normal vertebral height was achieved in 60% of acute fractures and 26% of chronic fractures. In addition, more acute fractures were reducible (greater than 80% restoration of height lost) compared with chronic fractures (p = .01). After kyphoplasty, less than 10% correction of height lost occurred in 8% of acute fractures and 20% of chronic fractures. Local kyphosis significantly improved after kyphoplasty (mean local Cobb angle: acute, 15 to 8 degrees, p<.001; chronic, 15 to 10 degrees, p<.001). Conclusion Fracture reduction was best achieved in acute fractures. Symptomatic chronic fractures may also remain candidates for kyphoplasty because pain relief and improvement in patient function are reliable and some kyphosis correction can still be achieved in many of these patients.