Incidence Of Vertebral Compression Fractures Research Articles

FRI677 Analysis Of Characteristics Associated With Osteoporosis In Solid Organ Transplant Recipients - Results Of Phoenix VA Based Quality Improvement Project

Abstract Disclosure: T. Shah: None. K. Vinales: None. Introduction: Solid organ transplants are increasingly performed for multiple end-stage organ failures, that increase longevity and quality of life, but can be complicated with osteoporosis, which is associated with increased morbidity and mortality. Determining the risk factors, diagnostic and treatment related characteristics will facilitate improvement in care of patients with this condition. Design: This was part of a quality improvement project at single institution to identify male veterans, 65 years and older, who were at risk for or osteoporosis. In this analysis, we focused on those with solid-organ transplant who developed post-transplant osteoporosis over the past 10 years. Various parameters were obtained, along with the most recent DXA scan, quantifying the T-scores at various sites, trabecular bone score (TBS) and treatment modalities. Results: From initial cohort of male veterans at risk for osteoporosis (n=1676), 26 (1.5%) were identified as post-transplant osteoporosis. Baseline characteristics (mean±SD) included: age = 72.9±3.0 years-old, BMI =26.0±3 kg/m2. 26.9% patients were noted to have history of smoking, while 7.6% had rheumatoid arthritis, 65% had history of diabetes mellitus, 54% were noted to be on prednisone as part of post-transplant immunosuppression regimen with dosages varying between 5-10mg daily. 61.5% of patients had GERD, whereas 57.1% were treated with proton pump inhibitors and H2-blockers. Analysis of DXA parameters revealed the lowest T-score average to be -1.88±0.5 with 88% having low BMD at the femoral neck site. Average TBS in the group was noted to be 1.37±0.1, while vertebral compression fractures were noted in 21% of these patients. Only 76% of patients were on osteoporosis treatment, where 65% were treated with Alendronate, 25% were treated with Denosumab and 20% with Zolendronic acid. Sub group analysis based on the solid organ transplanted reported liver transplant in 46%, renal transplant in 30%, lung transplant in 15%, heart transplant in 7% of the patients. Patients in the liver transplant group had a lower TBS of 1.26 (vs. 1.46 in the renal, 1.45 in the heart and 1.33 in the lung transplant groups). Incidence of vertebral compression fractures was highest in this subgroup and noted in 27% patients. Notably 25% of liver transplant were diagnosed with osteoporosis solely based on presence of vertebral compression fractures. Conclusion: Our quality improvement study highlights the fact that lowest DEXA scan T-scores are most commonly found at the femoral neck site in solid organ transplant recipients and high incidence of fragility fractures. Thorough assessment for vertebral fractures should be routinely incorporated while evaluating DXA scans in post-transplant osteoporosis cases, especially recipients of liver transplants as vertebral compression fractures can be the sole determinant of osteoporosis in this group of patients. Presentation: Friday, June 16, 2023

Incidence and Mortality of Vertebral Compression Fracture Among All Age Groups: A Nationwide, Population-based Study in the Republic of Korea

BACKGROUND: Although several studies have examined the epidemiological features of vertebral compression fractures (VCF) among elderly patients, few studies have reported the epidemiology of VCF among younger individuals. OBJECTIVE: To examine trends in the incidence and mortality of VCF in both the old (>= 65 years) and young (< 65 years) age groups. This study aimed to investigate the incidence and mortality of VCF among all age groups in Korea. STUDY DESIGN: Population-based cohort study. SETTING: A nationwide, population-based setting. METHODS: Using the Korean National Health Insurance database, which has complete population coverage, we identified patients diagnosed with VCF between 2005 to 2018. Differences in incidence, survival and mortality were compared across groups using Kaplan-Meier analysis and Cox regression for all age groups and both genders. RESULTS: We identified a total of 742,993 VCF patients and the annual incidence was 140.09/100,000 individuals. Although the incidence of VCF was significantly higher in the older age compared to younger age group (556.38/100,000 vs. 44.09/100,000 individuals), the mortality rate ratio for VCF patients was higher among younger compared to older individuals (old: 1.59 vs. young: 2.87). In our multivariable-adjusted analysis, the hazard ratio for multiple fractures, traumatic injury and osteoporosis were higher in patients aged < 65 years compared to patients aged >= 65 years, suggesting that the impact of these clinical variables on mortality is more significant in the younger age group. LIMITATION: A limitation of this study was its lack of information on clinical features, such as disease severity and laboratory data. The precise cause of death of VCF patients could not be confirmed from the study database. CONCLUSIONS: The mortality rate ratio and hazard ratio were significantly higher among younger patients with VCF, indicating the need for further research on VCF in younger age groups. KEY WORDS: Cohort study; hazard ratio; incidence; mortality; mortality rate; mortality rate ratio; population-based cohort study; vertebral compression fracture

The incidence of vertebral compression fractures and spinal instability in newly diagnosed multiple myeloma patients

BackgroundMultiple myeloma (MM) is a hematologic malignancy, characterized by clonal proliferation of plasma cells in the bone marrow. These plasma cell proliferations frequently result in scattered osteolytic bone lesions and extensive skeletal destruction. Myeloma bone lesions are frequently located in the spine, and are associated with debilitating bone pain and an increased rate of pathologic fractures and mortality. The aim of this study was to investigate the incidence of vertebral compression fractures (VCFs) and spinal instability in patients with MM. Patients and methodsNewly diagnosed patients with MM with computed tomography (CT) scans of the spine within three months of diagnosis were identified through an electronic patient database. Clinical baseline data were manually extracted from the patient charts. Fractured levels were graded on CT scans following the Genant grading system, and spinal instability was assessed through the Spinal Instability Neoplastic Score (SINS). ResultsA total of 385 patients with 6289 eligible vertebrae were eligible for inclusion. The mean age at diagnosis was 67 years, and 60% were male. At least one VCF was present in 180 patients (47%). A quarter of fractures were classified as severe. The incidence of fractures increased with more advanced disease stages, and men were more likely to have a fracture than women. ConclusionsOur data show that 47% of MM patients present with one or more VCFs at the onset of their disease, of which 20% were classified as unstable, meaning a surgical consultation is recommended.

P121: PREVALENCE OF VERTEBRAL COMPRESSION FRACTURE AND HYPOVITAMINOSIS D IN CHILDREN WITH THALASSEMIA MAJOR

Background: Thalassemia major has various complications that can increase morbidity and mortality. Osteoporosis is a common complication in thalassemia major and has a multifactorial pathogenesis. Osteoporosis can cause vertebral compression fractures and lead to disability. In TIF recommendation, a DEXA-scan is used to measure bone density in thalassemia patients. However, most patients in Indonesia could not afford the DEXA-scan examination because it is not covered by insurance. The 2019 ISCD Pediatric Positions Task Forces stated that the diagnosis of pediatric osteoporosis included the presence of a nontraumatic vertebral compression fracture (VF), without the need for BMD criteria. In Indonesia, there has been no study for the prevalence of hypovitaminosis D and vertebral compression fractures in children with thalassemia major and its correlation. Objective: To describe the prevalence of VF and hypovitaminosis D in children with thalassemia major. Methods: A cross-sectional study design was conducted in children with thalassemia major aged 7–18 years at the Thalassemia Center at Cipto Mangunkusumo National Hospital. Detection and evaluation techniques for vertebral fractures were using plain radiograph from Siemens Healthineers – Ysio Max – X-ray. The classification is based on Global Consensus Recommendations on Prevention and Management of Nutritional Rickets, whereas <30 nmol/L or <12 ng/mL are deficient, 30–50 nmol/L or 12–20 ng/mL are insufficient. Results: This study obtained 165 subjects (50,1% boys, 66% homozygous beta-thalassemia). Fifty-two subjects (31,5%) have VF, and three of them have both thoracal and lumbar fractures. The most common sites of VF were lumbar five and thoracic 11–12. The youngest subject who has VF is seven years old. Osteopenia was found in 67,3% of patients. There were no subjects with fractures who had complaints of pain or a history of previous trauma. Vitamin D levels [25(OH)D] were measured in 122 subjects, and hypovitaminosis D occurred in 77,9% of the subject (32,8% deficiency, 45,1% insufficiency). Our study found no significant relationship between vitamin D levels on the incidence of vertebral compression fractures (p>0,05). Conclusion: To our knowledge, this is the highest prevalence of VF among various studies that have been conducted. Vertebral X-ray is beneficial to detect bone density from osteopenia to fracture in children with thalassemia major. Hypovitaminosis D is common in thalassemia, requiring regular vitamin D administration. Further research is needed to consider the other contributing factors.

Clinical and dosimetric risk factors for vertebral compression fracture after single-fraction stereotactic body radiation therapy for spine metastases

ObjectivesThis analysis was performed to evaluate the incidence of vertebral compression fracture (VCF) and determine the contributing factors for VCF in patients undergoing single-fraction stereotactic body radiotherapy (SBRT) for spinal bone metastases (SBM). MethodsA retrospective review of medical records was conducted for patients undergoing SBRT for SBM at our institution between January 2010 and December 2018. Patients who had undergone neither pre-SBRT surgical excision nor post-SBRT prophylactic fixation were included. The effects of clinical and dosimetric parameters were analyzed with respect to VCF risk. The following dosimietric parameters of the planning target volume (PTV) were calculated: mean/minimum/maximum dose, radiation dose to 10–90% volume, and irradiated volume receiving more than 10–25 Gy (PTV_V10 – 25 Gy). ResultsAmong 163 patients (179 vertebrae), 21 (12.8%) experienced VCF. The 1-year and 2-year VCF rates were 12.1% and 13.2%, respectively. Among dosimetric parameters, PTV_V15 Gy was the most significant for VCF prediction. In a univariate analysis, breast or prostate primary, no vertebral body collapse, and PTV_V15 Gy ≤42 cm3 were significantly associated with a lower incidence rate of VCF. In a multivariate analysis, PTV_V15 Gy was the only significant factor for VCF risk. The 1-year VCF rate was 3.8% in patients with PTV_V15 Gy ≤42 cm3, while it was 22.1% in those with PTV_V15 Gy > 42 cm3 (p < 0.01). ConclusionsSBRT-related VCF was found in 12% of patients in our institution. The PTV_V15 Gy is a significant factor for VCF prediction.

Outcomes and Toxicity of Single- And Multi-Fraction Spine Radiosurgery for Three or More Vertebral Bodies

Spine radiosurgery is an accepted standard treatment for vertebral body metastases and is traditionally restricted to one or two consecutive vertebral bodies due to toxicity concerns with larger volumes. Thus, the outcomes and toxicity of radiosurgery to a larger volume of three or more vertebral bodies are poorly characterized. We sought to describe our single-institution experience of treating patients with radiosurgery to three or more consecutive vertebral bodies. An IRB-approved retrospective review of our prospectively maintained radiosurgery database was performed. Inclusion criteria were men and women receiving single- or multi-fraction spine radiosurgery to three or more consecutive vertebral bodies with at least one month of follow-up. We recorded outcome data such as local control, overall survival, and pain response. Local progression was defined as radiologic progression, recurrent pain in the treatment field, or a vertebral body metastasis in the body adjacent to the treatment volume. Pain scores (scored 0-10) in the treated area were evaluated within one month before treatment and in longer follow-up. Average change in pain score after treatment was reported. Karnofsky performance status (KPS) was also evaluated within one month before treatment and in follow up. KPS was based on debilitation from tumors at the treated site. Toxicity endpoints of interest were radiation myelopathy and vertebral body fracture. 32 patients were identified (18 male, 14 female), and 35 total sites were treated. Median age of patient at time of SRS treatment was 59. Median dose in single fraction was 1300cGy (range: 800-1800cGy), and median dose in multiple fractions was 2400cGy (range: 1800-3000cGy). 21% of patients had cervical spine metastases, 55% with thoracic spine metastases, and 24% with lumbar spine metastases, with primary tumor sites including colon, breast, thymus, pelvis, lung, mammary gland, kidney, thyroid, nasopharynx, rhabdomyosarcoma, bone, schwannoma, and vulva. 14/32 (43%) patients had epidural or paraspinal soft tissue components of their disease. The six-month local control rate was 77%. The one-year survival rate was 49%. Average change in pain score was -.5 (range: -7-+4, st dev ±2.55). Median pre-treatment KPS was 90%, and median post-treatment KPS was 80%, with 7/32 (22%) patients having a decline in 20% or greater, and 2/32 (6.2%) patient having an improvement of 20% or greater. Incidence of vertebral compression fracture was 4/32 (12.5%), and radiation myelopathy was 0/32 (0%). Treatment of patients with radiosurgery to three or more consecutive vertebral body metastases is well tolerated. For the majority of treated patients, single- or multi-fraction radiosurgery provides durable local control, modest pain relief, preserved quality of life, and low rates of severe toxicity.

Treating Vertebral Compression Fractures: Establishing the Appropriate Diagnosis, Preoperative Considerations, Treatment Techniques, Postoperative Follow-Up and General Guidelines for the Treatment of Patients With Symptomatic Vertebral Compression Fractures

Vertebral compression fractures (VCFs) result from either trauma or a pathologic process that weakens the bone by conditions such as osteoporosis or tumor. The incidence of VCFs has been rising over the last few decades in accordance with the aging population. These fractures can result in severe pain, physical limitation and disability, as well as increased morbidity and mortality. Patients with VCFs are optimally treated by accurate and early diagnosis and treatment. An effective method to treat these fractures is percutaneous vertebral augmentation, which is a set of minimally invasive procedures that stabilizes osseous fractures, provides immediate pain relief, and improves quality of life. Vertebral augmentation procedures include vertebroplasty, kyphoplasty, and vertebral augmentation with implants. Each of these techniques is described in general terms in this article. The ideal candidate for vertebral augmentation is a patient with a symptomatic fracture seen on cross-sectional imaging in which nonsurgical management has failed and has positive signs on physical examination with no absolute contraindication. This procedure should be done with the appropriate equipment and personnel in a facility designed for this purpose. After the procedure, the patient should undergo the appropriate follow-up to ensure optimal recovery. Additionally, it is essential that the patient receives appropriate therapy for the underlying disorder that predisposed them to the vertebral fracture.

Efficacy and safety of different fractions in stereotactic body radiotherapy for spinal metastases: A systematic review.

BackgroundIn the treatment of spinal metastases, stereotactic body radiotherapy (SBRT) delivers precise, high‐dose radiation to the target region while sparing the spinal cord. A range of doses and fractions had been reported; however, the optimal prescribed scheme remains unclear.MethodsTwo reviewers performed independent literature searches of the PubMed, EMBASE, Cochrane Database, and Web of Science databases. Articles were divided into one to five fractions groups. The Methodological Index for Non‐randomized Studies (MINORS) was used to assess the quality of studies. Local control (LC) and overall survival (OS) were presented for the included studies and a pooled value was calculated by the weighted average.ResultsThe 38 included studies comprised 3,754 patients with 4,731 lesions. The average 1‐year LCs for the one to five fractions were 92.7%, 84.6%, 86.8%, 82.6%, and 80.6%, respectively. The average 1‐year OS for the one to five fractions were 53.0%, 70.4%, 60.1%, 48%, and 80%, respectively. The 24 Gy/single fraction scheme had a higher 1‐year LC (98.1%) than those of 24 Gy/two fractions (85.4%), 27 Gy/three fractions (84.9%), and 24 Gy/three fractions (89.0%). The incidence of vertebral compression fracture was 10.3%, with 10.7% in the single‐fraction group and 10.1% in the multi‐fraction group. The incidence of radiation‐induced myelopathy was 0.19%; three and two patients were treated with single‐fraction and multi‐fraction SBRT, respectively. The incidence of radiculopathy was 0.30% and all but one patient were treated with multi‐fraction SBRT.ConclusionsSBRT provided satisfactory efficacy and acceptable safety for spinal metastases. Single‐fraction SBRT demonstrated a higher local control rate than those of the other factions, especially the 24 Gy dose. The risk of vertebral compression fracture (VCF) was slightly higher in single‐fraction SBRT and more patients developed radiculopathy after multi‐fraction SBRT.

Local control and vertebral compression fractures following stereotactic body radiotherapy for spine metastases

PurposeWe aimed to retrospectively assess the incidence of vertebral compression fractures (VCF), examine clinicopathologic factors potentially associated with VCF, and evaluate treatment response in patients who received stereotactic body radiotherapy (SBRT) for spine metastases (spMets). Methods and MaterialsWe identified 78 patients with 125 spMets at baseline and subsequent assessments. Patients received SBRT doses of 16 or 18 Gy. Patients with pre-existing VCF and co-existing local progression were excluded. Spine instability neoplastic score (SINS) was used for spMets categorization. Response to SBRT and VCF were assessed according to the Positron Emission tomography Response Criteria In Solid Tumors (PERCIST) and Genant scores, respectively. Kaplan–Meier analyses were used to assess local control of disease and vertebral compression fracture-free survival (FFS). ResultsWe treated 103 cases with single spMets and 11 cases involving double spMets with SBRT. Progressive disease was reported in 3.2% and 8.2% of the cases in the first and last PET/CT reports, respectively. The distribution of treatment response in the remaining patients was: complete response in 30.6% of patients, partial response in 47.1% of patients, and stable disease in 22.3% of patients in the first PET/CT; complete response in 62.3% of patients, partial response in 16.7% of patients, and stable disease in 21% of patients at the last monitoring. Local failures were observed in 15 (12%) of cases. Median SINS was 5 (range: 1−13); majority of patients in our cohort (70.4%) were categorized as stable according to SINS, five (4%) patients had Grade 3 VCF at a median time of 16 months after SBRT (range: 2−22 months), and 60% of VCF occurred after an interval of at least 12 months after SBRT. No bisphosphonate usage was significantly associated with VCF (r = −0.204; p = 0.022). Median FFS was 21 months. Univariate analyses indicated that female gender (p < 0.001), bisphosphonate use (p = 0.005), >6 months of bisphosphonates use (p = 0.002), and the lowest vertebral body collapse score (p = 0.023) were associated with higher FFS. Female gender (p = 0.007), >6 months of bisphosphonates usage (p = 0.018), and the lowest vertebral body collapse score (p = 0.044) retained independent significance. ConclusionsThis study demonstrated that spine SBRT with doses of 16–18 Gy promises good local control of disease with acceptable VCF rates. Lowest vertebral body collapse score, female gender, and >6 months of bisphosphonate use were significantly associated with longer FFS.

ASYMPTOMATIC VERTEBRAL COMPRESSION FRACTURES IN POSTMENOPAUSAL WOMEN WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that most commonly occurs in women. Improved treatments for SLE have led to a substantial increase in the life expectancy of patients, so the problems of complications of both the disease itself and its therapy have come to be top priority. The most common complications of SLE among the musculoskeletal system lesions are osteoporosis and related vertebral compression fractures (VCFs). However, only one third of these fractures has clinical manifestations and causes the patient to seek medical advice. More VCFs remain undetected because they have no or scarce symptoms. The question of the influence of various factors (gender, age, menopause, etc.) on the incidence of VCFs in patients with SLE remains open. It should be expected that in postmenopausal women with SLE, the incidence of VCFs may be considerably higher than that in the population. Objective : to determine the frequency of and to evaluate the role of various factors in the development of asymptomatic vertebral fractures in postmenopausal women with SLE (a retrospective study). Subjects and methods . A total of 86 postmenopausal women (mean age, 59±7.9 years) with a diagnosis of SLE, which met the 2012 Systemic Lupus Collaborating Clinics (SLICC) criteria, were examined. The mean duration of the disease and menopause was 15±8.3 and 12.8±7 years, respectively. All the patients with SLE were treated with glucocorticoids (GC) at a dose of 15±5 mg/day calculated with reference to prednisolone for more than 12 months (mean, 159.7±90.9 months) and had a low disease activity (the mean SLEDAI-2K score was 5.1±3.9). The ACR damage index for SLE averaged 5.5±2.6. All the patients underwent vertebral fracture assessment (VFA) using a Hologic Explorer bone densitometer to identify VCFs in the thoracic and lumbar spine. The anterior, middle, and posterior heights of ТhIV–LV, and the height of each vertebra as well as the underlying vertebra were calculated and compared. If the differences in the anterior, middle, or posterior vertebral heights were >20–25%, this deformation was regarded as VCFs. Bone mineral density (BMD) in the hip and spine was measured with an X-ray bone densitometer. Results. VFA revealed VCFs in 40 (46.5%) patients with SLE; these were detected for the first time in 22 (55%) patients since they had no significant clinical manifestations. VCFs happened most commonly in the mid-thoracic spine (ThVI–IX). All the patients with asymptomatic VCFs had a fracture of only one vertebra. The patients with VCFs had a longer duration of SLE and menopause, more frequently received cytostatic therapy, and had a higher cumulative dose and a longer duration of GC therapy. They also had a higher damage index and lower BMD values in LI–IV than patients without VCFs (p 0.05). Conclusion. The detection rate for VCFs is nearly 50% in postmenopausal women with SLE, and about every two VCFs remain undetected. The long duration of SLE, menopause, and GC treatment, a high cumulative dose, a high damage index and low BMD values in LI–IV were associated with VCFs. VFA is an effective screening method to detect asymptomatic VCFs.

Percutaneous vertebroplasty in Moroccan patients with vertebral compression fractures.

Incidence of vertebral compression fractures (VCFs) is increasing due to the increase in human life expectancy and prevalence of osteoporosis. Percutaneous vertebroplasty (PVP) has become a widely used alternative treatment for symptomatic VCFs refractory to medical therapy. It is a minimally invasive technique involving injection most frequently of polymethylmethacrylate (PMMA) directly into the vertebral body through the pedicles. Percutaneous vertebroplasty yields good results in terms of early vertebral stabilization and prompt pain relief. This study describes the experience of the Department of Neurosurgery at Ibn Sina University Hospital (Rabat, Morocco) and assesses short and long term clinical and radiological outcomes and complications of vertebroplasty in a retrospective assessment of 36 vertebral compression fractures in 35 patients (16 men and 19 women subjects) who had been treated with vertebroplasty from November 2006 to December 2014.

Outcome of percutaneous balloon kyphoplasty in vertebral compression fractures.

Background:Incidence of vertebral compression fractures (VCFs) is increasing due to increase in human life expectancy and prevalence of osteoporosis. Vertebroplasty had been traditional treatment for pain, but it neither attempts to restore vertebral body height nor eliminates spinal deformity and is associated with a high rate of cement leakage. Balloon kyphoplasty involves introduction of inflatable balloon into the fractured body of vertebra for elevation of the end-plates prior to fixation of the fracture with bone cement. This study evaluates short term functional and radiological outcomes of balloon kyphoplasty. The secondary aim is to explore short-term complications of the procedure.Materials and Methods:A retrospective study of 199 kyphoplasty procedures in 135 patients from March 2009 to March 2012 were evaluated with short form-36 (SF-36) score, visual analogue scale (VAS), detailed neurological and radiological evaluations. The mean followup was 18 months (range 12–20 months). Statistical analysis including paired sample t-test was done with statistical package for social sciences.Results:Statistically significant improvements in SF-36 (from 34.29 to 48.53, an improvement of 14.24, standard deviation (SD) - 20.08 P < 0.0001), VAS (drop of 4.49, from 6.74 to 2.24, SD - 1.44, P < 0.0001), percentage restoration of lost vertebral height (from 30.62% to 16.19%, improvement of 14.43%, SD - 15.37, P < 0.0001) and kyphotic angle correction (from 17.41° to 10.59°, improvement of 6.82, SD - 7.26°, P < 0.0001) were noted postoperatively. Six patients had cement embolism, 65 had cement leak and three had adjacent level fracture which required repeat kyphoplasty later. One patient with history of ischemic heart disease had cardiac arrest during the procedure. No patients had neurological deterioration in the followup period.Conclusions:Kyphoplasty is a safe and effective treatment for VCFs. It improves physical function, reduces pain and corrects kyphotic deformity.

Vertebral compression fractures after spine irradiation using conventional fractionation in patients with metastatic colorectal cancer.

PurposeTo evaluate the risk of vertebral compression fracture (VCF) after conventional radiotherapy (RT) for colorectal cancer (CRC) with spine metastasis and to identify risk factors for VCF in metastatic and non-metastatic irradiated spines.Materials and MethodsWe retrospectively reviewed 68 spinal segments in 16 patients who received conventional RT between 2009 and 2012. Fracture was defined as a newly developed VCF or progression of an existing fracture. The target volume included all metastatic spinal segments and one additional non-metastatic vertebra adjacent to the tumor-involved spines.ResultsThe median follow-up was 7.8 months. Among all 68 spinal segments, there were six fracture events (8.8%) including three new VCFs and three fracture progressions. Observed VCF rates in vertebral segments with prior irradiation or pre-existing compression fracture were 30.0% and 75.0% respectively, compared with 5.2% and 4.7% for segments without prior irradiation or pre-existing compression fracture, respectively (both p < 0.05). The 1-year fracture-free probability was 87.8% (95% CI, 78.2-97.4). On multivariate analysis, prior irradiation (HR, 7.30; 95% CI, 1.31-40.86) and pre-existing compression fracture (HR, 18.45; 95% CI, 3.42-99.52) were independent risk factors for VCF.ConclusionThe incidence of VCF following conventional RT to the spine is not particularly high, regardless of metastatic tumor involvement. Spines that received irradiation and/or have pre-existing compression fracture before RT have an increased risk of VCF and require close observation.

Robot-Assisted Vertebral Body Augmentation

Retrospective. To assess radiation exposure time during robot-guided vertebral body augmentation compared with other published findings. Rising incidence of vertebral compression fractures in the aging population result in widespread use of vertebral body cement augmentation with significant radiation exposure to the surgeon, operating room staff, and patient. Radiation exposure leads to higher cancer rates among orthopedic and spine surgeons and patients. Thirty-three patients with 60 vertebral compression fractures underwent robot-guided vertebral body augmentation performed by 2 surgeons simultaneously injecting cement at 2 levels under pulsed fluoroscopy. The age of patients was in the range from 29 to 92 (mean, 67 yr). One to 6 vertebrae were augmented per case (average 2). Twenty-five patients had osteoporotic fractures and 8 had pathological fractures. Robotic guidance data included execution rate, accuracy of guidance, total surgical time, and time required for robotic guidance. Radiation-related data included the average preoperative computed tomographic effective dose, radiation time for calibration, registration, placement of Kirschner wires, and total procedure radiation time. Radiation time per level and surgeon's exposure were calculated. Kyphoplasty was performed in 15 patients (1 sacroplasty), vertebroplasty in 13, and intravertebral expanding implants in 5. The average preoperative computed tomographic effective dose was 50 mSv (18-81). Average operative time was 118 minutes (49-350). Mean robotic guidance took 36 minutes. Average operative radiation time was 46.1 seconds per level (33-160). Average exposure time of the surgeons and the operating room staff per augmented level was 37.6 seconds. The execution rate was 99%, with an accuracy of 99%. Two complications (hemothorax and superficial wound infection) occurred. The radiation exposure of the surgeon and the operating room staff in a series of robot-assisted vertebral body augmentation was 74% lower than published results on fluoroscopy guidance and approximately 50% lower than the literature on navigated augmentation. 4.

Use of vertebroplasty to prevent proximal junctional fractures in adult deformity surgery: a biomechanical cadaveric study

Background contextVertebral compression fractures at the proximal junction are common complications of long spinal fusion surgeries that can contribute to the development of proximal junctional kyphosis or proximal junctional failure. To our knowledge, no biomechanical studies have addressed the effect of vertebral augmentation at the proximal junction. PurposeTo evaluate the effectiveness of prophylactic vertebroplasty in reducing the incidence of vertebral compression fractures at the proximal junction after a long spinal fusion in a cadaveric spine model. Study designBiomechanical cadaveric study. MethodsWe divided 18 cadaveric spine specimens into three groups of six spines each: a control group, a group treated with one-level prophylactic vertebroplasty at the upper instrumented vertebra, and a group treated with two-level prophylactic vertebroplasty at the upper instrumented vertebra and the supra-adjacent vertebra. In all spines, the pedicles were instrumented from L5 to T10. Using eccentric axial loading, the specimens were then compressed until failure. Failure was defined as a precipitous decrease in load with increasing compression. The effect of augmentation on load-to-failure was checked using linear regression. The effect of augmentation on incidence of adjacent fractures was checked using logistic regression. Differences at the level of p<.05 were considered significant. KyphX cement introducer was donated by Kyphon, and the pedicle screws were donated by DePuy. ResultsFractures occurred in 12 of 18 specimens: five in the control group, six in the one-level group, and only one in the two-level group; these differences were statistically significant. ConclusionsProphylactic vertebroplasty at the upper instrumented level and its supra-adjacent vertebra reduced the incidence of junctional fractures after long posterior spinal instrumentation in this axially loaded cadaveric model. Additional studies are necessary to determine if these results are translatable to clinical practice.

Incidence and Risk Factors for Vertebral Compression Fractures From Spine Stereotactic Body Radiation Therapy: Results of a Large Institutional Series

There is a paucity of data regarding the incidence of and risk factors associated with the development of vertebral compression fractures (VCF) post-spine stereotactic body radiation therapy (sSBRT). Patients who underwent sSBRT, typically for spine metastases, were included in an IRB-approved database. Gender, consult KPS, epidural disease, thecal sac compression, histology, spine tumor location, VCF, pre-existing VCF, and dosimetric factors (prescription dose, target volume, maximum target dose) were retrospectively collected. Pain relief post-sSBRT was prospectively collected using the Brief Pain Inventory. These factors were correlated to the development of new VCF or the progression of a pre-existing VCF. Survival was calculated using Kaplan-Meier analysis and Cox proportional hazards modeling was utilized to evaluate the association between the clinical factors and the occurrence of VCF. A total of 507 treatments (348 patients) were included in this study. Median KPS, follow-up, and prescription dose were 80 (range, 30-100), 8 months (range, 1-72), and 15 Gy in one fraction (range, 7-18), respectively. Fifty-seven percent of patients were prior smokers whereas only 9% were actively smoking. The reasons for treatment were pain (73%), pain and neurological deficit (13%), asymptomatic (10%), and only neurological deficit (3%). Renal cell carcinoma (24%), lung cancer (14%), and breast cancer (11%) were the most common histologies. Multiple myeloma accounted for 7.3% of treatments. Fifty-nine percent, 32%, and 9% of tumors were located in the cervical/thoracic, lumbar, and sacral spine, respectively. Some patients received prior external beam radiation therapy (26%), sSBRT (4%), surgery (21%) and kyphoplasty (5%). Pre-existing VCF was present in 31% of treatments. Actuarial survival, radiographic control and pain control at 6/12 months were 71%/55%, 74%/64% and 82%/ 75%, respectively. Progression of a pre-existing VCF or development of a new VCF occurred in 15% of treatments. Univariate analysis demonstrated that prior smoking (HR 1.7, p = 0.04), current smoking (HR 1.9, p = 0.03), pain as a reason for treatment (HR 15.4, p < 0.01), lumbar vs sacral spine (HR 4.8, p = 0.03) and pre-existing VCF (HR 5.7, p < 0.01) were predictors of VCF. Multivariate analysis showed that only pre-existing VCF (HR 5.6, p < 0.01) and pain as a reason for treatment (HR 14.9, p < 0.01) were significant predictors of VCF. In our series of over 500 treatments, the incidence of VCF was low (15%). Important predictors of VCF were pre-existing VCF, pain as the reason for treatment, smoking, as well as lumbar spine location. This data shows that the rate of VCF is acceptable at sSBRT doses up to 16 Gy in one fraction.

Risk Factors of Subsequent Vertebral Compression Fractures After Vertebroplasty

To elucidate the risk factors for a subsequent vertebral compression fracture following percutaneous vertebroplasty, we analyzed the potential predictors of vertebral compression fractures adjacent to or remote from fractures previously treated with percutaneous vertebroplasty. This is a retrospective cohort study. A major concern after percutaneous vertebroplasty in patients with osteoporosis is the occurrence of subsequent vertebral compression fractures in the untreated vertebral bodies. The risk factors for the development of subsequent vertebral compression fractures after percutaneous vertebroplasty are unclear. Two hundred four consecutive patients underwent percutaneous vertebroplasty for acute vertebral compression fractures between January 2007 and December 2008. Forty-nine patients were excluded. Subsequent vertebral compression fractures were diagnosed by bone edema changes on magnetic resonance imaging. Patient's demographic data were used for univariate and multivariable binary logistic regression analyses. Forty-three (27.7%) of the 155 patients had subsequent vertebral compression fractures within 2 years of percutaneous vertebroplasty, with 21 (48.8%) of these patients having fractures detected within 3 months. Adjacent vertebral compression fractures tended to occur sooner, although not significantly (log-rank test, P = 0.112). On multivariate analyses, only the T-score of bone mineral density was significantly associated with subsequent vertebral compression fractures (P < 0.0001; odds ratio = 0.27; 95% confidence interval, 0.15-0.49). The only risk factor significantly associated with subsequent vertebral compression fractures following percutaneous vertebroplasty was a low bone mineral density T-score. Patients with lower bone mineral density have a higher incidence of vertebral compression fractures and thus need more intensive clinical and radiological follow-up.

Does alendronate disturb the healing process of posterior lumbar interbody fusion? A prospective randomized trial

Bisphosphonate medications are widely used for the treatment of osteoporosis, but they might disturb the healing process of spinal fusion. The object of this prospective randomized controlled study was to evaluate the effect of bisphosphonate medication on spinal fusion through radiographic, clinical, and biological assessments. A total of 40 patients with osteoporosis who were candidates for single-level posterior lumbar interbody fusion were randomly assigned to the alendronate group (alendronate sodium 35 mg/week) or the control group (vitamin D, alfacalcidol 1 μg/day). Pedicle screw fixation and carbon polyetheretherketone cages were used for all the patients. Bone graft material was prepared as a mixture of local bone and β-tricalcium phosphate in a ratio of 2:1. Functional radiography and CT scans were used to evaluate fusion status and cage subsidence. The incidence of vertebral compression fractures (VCFs) occurring after surgery (subsequent VCFs) was assessed by means of MR imaging. Bridging bone formation was graded into 3 categories: Grade A (bridging bone through bilateral cages), Grade B (bridging bone through a unilateral cage), or Grade C (incomplete bony bridging). A solid fusion was defined as less than 5° of angular motion in flexion-extension radiographs and the presence of bridging bone through the cage (Grade A or B). Clinical outcome was evaluated by means of the Oswestry Disability Index. Bone metabolic markers (serum bone alkaline phosphatase, serum and urine Type I collagen cross-linked N-telopeptides) were measured to investigate the biological effects of alendronate on spinal fusion. Bridging bone formation (Grade A or B) was more frequently observed in the alendronate group at all postoperative assessment periods. At 1-year postoperative follow-up, a solid fusion was achieved in 95% of the patients in the alendronate group and 65% of those in the control group. Cage subsidence (> 2 mm) was observed in 5% of the alendronate group and 29% of the control group. No vertebral fractures were observed in the alendronate group, whereas 24% of patients in the control group showed subsequent VCFs. There was no statistically significant between-groups difference in clinical outcomes, but poor clinical results in the control group were associated with pseudarthrosis and subsequent VCFs. Biochemical analysis of bone turnover demonstrated that alendronate inhibited bone resorption from the early phase of the fusion process and also suppressed bone formation after 6 months postoperatively. Favorable mechanical circumstances provided by alendronate overcame its detrimental biological effect on the healing process of spinal fusion. The authors recommend that osteoporosis patients undergoing spinal fusion take bisphosphonates throughout the postoperative period.

Importance of Sagittal Spinal Alignment for the Prevention of Vertebral Fracture Cascade

Physiological spinal curvature plays an important role in absorbing axial stress onto spinal column, and its modification has been shown to increase the incidence of vertebral compression fracture (VCF). The fact that VCF itself increases the risk of subsequent fracture propels physicians to predict the risk of first VCF, and evaluation of sagittal spinal alignment might be helpful in this scope.

Vertebroplasty with self-locking hexagonal metal implants shows comparable primary and secondary stiffness to PMMA cement augmentation techniques in a biomechanical vertebral compression fracture model

With the growing incidence of vertebral compression fractures in elderly patients having a fair overall health condition, minimal-invasive treatment techniques are getting in focus of surgical therapy. Cement augmentation is widely performed and its complications and mechanical limitations are well described. Implants avoiding the side effects of cement augmentation while reaching the same level of stability would be desirable. The primary and secondary stability of a new augmentation method with self-locking hexagonal metal implants were investigated and compared with the performance of established augmentation options. 18 fresh-frozen human spinal specimens (Th12-L2/L3-L5) were tested with pure moments of 7.5 Nm in a six-degree-of-freedom spine simulator to investigate primary and secondary stability of three augmentation techniques: (1) vertebroplasty, (2) PMMA filled cavity and (3) hexagonal metal implants. An increasing three-step cyclic loading model was included. Elastic displacement and height loss under loading did not show significant differences between the three test groups. Investigation of primary and secondary stability evenly demonstrated comparable results for all techniques indicating an insufficiency to stabilise the fracture with higher load cycles. The newly introduced method for augmentation with the metal implant Spine Pearls achieved comparable results to bone cement based techniques in a biomechanical in vitro study. Midterm and longterm reduction preservation and ingrowth of the implants have to be proven in further studies.