Malignant Compression Fractures Research Articles

Value of 18F-FDG-PET/CT radiomics combined with clinical variables in the differential diagnosis of malignant and benign vertebral compression fractures

BackgroundVertebral compression fractures (VCFs) are common clinical problems that arise from various reasons. The differential diagnosis of benign and malignant VCFs is challenging. This study was designed to develop and validate a radiomics model to predict benign and malignant VCFs with 18F-fluorodeoxyglucose-positron emission tomography/computed tomography (18F-FDG-PET/CT).ResultsTwenty-six features (9 PET features and 17 CT features) and eight clinical variables (age, SUVmax, SUVpeak, SULmax, SULpeak, osteolytic destruction, fracture line, and appendices/posterior vertebrae involvement) were ultimately selected. The area under the curve (AUCs) of the radiomics and clinical–radiomics models were significantly different from that of the clinical model in both the training group (0.986, 0.987 vs. 0.884, p < 0.05) and test group (0.962, 0.948 vs. 0.858, p < 0.05), while there was no significant difference between the radiomics model and clinical–radiomics model (p > 0.05). The accuracies of the radiomics and clinical–radiomics models were 94.0% and 95.0% in the training group and 93.2% and 93.2% in the test group, respectively. The three models all showed good calibration (Hosmer–Lemeshow test, p > 0.05). According to the decision curve analysis (DCA), the radiomics model and clinical–radiomics model exhibited higher overall net benefit than the clinical model.ConclusionsThe PET/CT-based radiomics and clinical–radiomics models showed good performance in distinguishing between malignant and benign VCFs. The radiomics method may be valuable for treatment decision-making.

Differentiation of benign versus malignant indistinguishable vertebral compression fractures by different machine learning with MRI-based radiomic features.

To explore an optimal machine learning (ML) model trained on MRI-based radiomic features to differentiate benign from malignant indistinguishable vertebral compression fractures (VCFs). This retrospective study included patients within 6weeks of back pain (non-traumatic) who underwent MRI and were diagnosed with benign and malignant indistinguishable VCFs. The two cohorts were retrospectively recruited from the Affiliated Hospital of Qingdao University (QUH) and Qinghai Red Cross Hospital (QRCH). Three hundred seventy-six participants from QUH were divided into the training (n = 263) and validation (n = 113) cohort based on the date of MRI examination. One hundred three participants from QRCH were used to evaluate the external generalizability of our prediction models. A total of 1045 radiomic features were extracted from each region of interest (ROI) and used to establish the models. The prediction models were established based on 7 different classifiers. These models showed favorable efficacy in differentiating benign from malignant indistinguishable VCFs. However, our Gaussian naïve Bayes (GNB) model attained higher AUC and accuracy (0.86, 87.61%) than the other classifiers in validation cohort. It also remains the high accuracy and sensitivity for the external test cohort. Our GNB model performed better than the other models in the present study, suggesting that it may be more useful for differentiating indistinguishable benign form malignant VCFs. • The differential diagnosis of benign and malignant indistinguishable VCFs based on MRI is rather difficult for spine surgeons or radiologists. • Our ML models facilitate the differential diagnosis of benign and malignant indistinguishable VCFs with improved diagnostic efficacy. • Our GNB model had the high accuracy and sensitivity for clinical application.

Percutaneous mesh-container-plasty versus percutaneous kyphoplasty in the treatment of malignant thoracolumbar compression fractures: a retrospective cohort study.

This study aimed to compare the clinical and radiological results of percutaneous mesh-container-plasty versus percutaneous kyphoplasty in the treatment of malignant thoracolumbar compression fractures. Patients with malignant thoracolumbar compression fractures treated in a single tertiary care center between January 2011 and December 2020 were retrospectively reviewed and included in the study. Ninety-four patients who were diagnosed by pathological biopsy were divided into 2 groups according to the type of surgical treatment: the percutaneous kyphoplasty group (50 patients: 24 male, 26 female; mean age=73.02 ± 7.79 years) and the percutaneous mesh-container-plasty group (44 patients: 21 male, 23 female; mean age=74.68 ± 7.88 years). The epidemiological data, surgical outcomes, and clinical and radiological features were compared between the 2 groups. Cement leakage, height restoration, deformity correction, and cement distribution were calculated from the radiographs. The visual analog scale, Oswestry disability index, Karnofsky performance scale scores, and short-form 36 health survey domains role physi cal and bodily pain were calculated preoperatively, immediately, and 1 year postoperatively. The visual analog scale score improved from 5 (range=4-6) preoperatively to 2 (range=2-3) immediately postoperatively in the percutaneous kyphoplasty group and from 5 (range=4-6) preoperatively to 2 (range=2-2) immediately postoperatively in the percutane ous mesh-container-plasty group; there was a significant difference between the 2 groups (P=.018). Although Oswestry disability index, Karnofsky performance scale, short-form 36 health survey domains bodily pain and role physical significantly improved in both groups after surgery compared to the preoperative period, there was no significant difference between the 2 groups (P > .05). The mean cost in the percutaneous kyphoplasty group was lower than that in the percutaneous mesh-container-plasty group (5563 ± 439 vs. 6569 ± 344 thousand dollars, P < .05). There was no difference between the cement volume in the 2 groups, and cement distribution in the percutaneous mesh-container-plasty group was higher than that in the percutaneous kyphoplasty group (44.30% ± 10.25% vs. 32.54% ± 11.76%, P < .05). Cement leakage was found to be lesser in the percutaneous mesh-container-plasty group (7/44) than in the percutane ous kyphoplasty group (18/50, P < .05). There were no statistically significant differences in the recovery of vertebral body height and improvement of segmental kyphosis between the 2 groups (P > .05). Percutaneous kyphoplasty and percutaneous mesh-container-plasty both have significant abilities in functional recovery, height restoration, and segment kyphosis improvement in treating malignant thoracolumbar compression fractures. Percutaneous mesh container-plasty may be better able to relieve pain, inhibit cement leakage, and improve cement distribution than percutaneous kypho plasty. However, percutaneous mesh-container-plasty requires a relatively longer procedure and is more expensive than percutaneous kyphoplasty. Level III, Therapeutic Study.

Vessel-Plasty Using Bone-Filling Mesh Container for Treatment of Malignant Severe Compression Fractures in Cervical Vertebrae.

ObjectiveTo evaluate the feasibility, safety, and efficacy of vessel-plasty using bone-filling mesh container (BFMC) for malignant severe compression fractures of cervical vertebra.MethodsThis study prospectively recruited fifteen consecutive patients (eight men, seven women; mean age, 57.4 years) with severe malignant compression fractures of cervical vertebrae for vessel-plasty. Procedure duration, incidence of cement leakage and other complications, pain relief and improvement of neck function were analyzed. Pain was assessed using a visual analog scale (VAS) and function by the neck disability index (NDI), with scores recorded before the procedure and at 3 days and 1, 3, 6 and 12 months after the procedure.ResultsA total of 16 vertebrae were treated. All vertebrae had destruction of bone in more than one place as well as broken bone walls. Mean procedure duration was 42.9±13.6 minutes. Bone cement leakage occurred in two vertebrae without any symptoms. No procedure-related complications occurred. Mean VAS and NDI declined from 7.1 ± 1.4 and 63.6 ± 16.3, respectively, before the procedure to 3.5 ± 1.1 and 37.4 ± 11.0, respectively, at three days after the procedure (P < 0.01). CT images at three months after the procedure confirmed that there were no cases of refractures at the treated or adjacent levels, recurrence of vertebral collapse and mobilization of bone cement block.ConclusionVessel-plasty using BFMC appears to be effective and safe for malignant severe compression fractures in cervical vertebrae. It is effective in stabilizing vertebral body, relieving pain.

Evaluation and outcome of percutaneous vertebroplasty for multilevel osteoporotic and malignant vertebral fractures (more than two)

BackgroundPercutaneous vertebroplasty (PV) is now a popular technique used to augment and stabilize the vertebral body fracture and to reduce pain as well. AimThe aim of the study is to evaluate the outcome of percutaneous vertebroplasty of multilevel osteoporotic and malignant fractures (more than two). Study designThis is a retrospective clinical case series study. Patients and methodsThis study was conducted on 30 patients with multilevel osteoporotic and malignant compression fractures (more than two). Visual analogue scale (VAS) was used to evaluate the functional outcome. All patients were treated using percutaneous vertebroplasty. They were followed for 6 months postoperatively. ResultsThe functional state of all patients improved after percutaneous vertebroplasty. According to the visual analogue scale (VAS), the preoperative VAS score was (8.43 ± 1.19). Immediate postoperative VAS was (3.07 ± 1.20) and after six months it dropped to (1.13 ± 0.67). There was a significant improvement of pain (p < 0.001). Asymptomatic leakage in the disc space was reported in two patients. A single case of pulmonary embolism was reported who complained of dyspnea. This patient was admitted to ICU and managed with proper medications with satisfactory results. ConclusionsMultilevel PV is proved to be a safe, cost effective and successful procedure that could reduce pain significantly and improve patient’s mobility.

Differentiation between benign and malignant vertebral compression fractures using qualitative and quantitative analysis of a single fast spin echo T2-weighted Dixon sequence

ObjectivesTo determine and compare the qualitative and quantitative diagnostic performance of a single sagittal fast spin echo (FSE) T2-weighted Dixon sequence in differentiating benign and malignant vertebral compression fractures (VCF), using multiple readers and different quantitative methods.MethodsFrom July 2014 to June 2020, 95 consecutive patients with spine MRI performed prior to cementoplasty for acute VCFs were retrospectively included. VCFs were categorized as benign (n = 63, mean age = 76 ± 12 years) or malignant (n = 32, mean age = 63 ± 12 years) with a best valuable comparator as a reference. Qualitative analysis was independently performed by four radiologists by categorizing each VCF as either benign or malignant using only the image sets provided by FSE T2-weighted Dixon sequences. Quantitative analysis was performed using two different regions of interest (ROI1-2) and three methods (signal drop, fat fraction (FF) from ROIs, FF maps). Diagnostic performance was compared using ROC curves analyses. Interobserver agreement was assessed using kappa statistics and intraclass correlation coefficients (ICC).ResultsThe qualitative diagnostic performance ranged from area under the curve (AUC) = 0.97 (95% CI: 0.91–1.00) to AUC = 0.99 (95% CI: 0.95–1.0). The quantitative diagnostic performance ranged from AUC = 0.82 (95% CI: 0.73–0.89) to AUC = 0.97 (95% CI: 0.91–0.99). Pairwise comparisons showed no statistical difference in diagnostic performance (all p > 0.0013, Bonferroni-corrected p < 0.0011). All five cases with disagreement among the readers were correctly diagnosed at quantitative analysis using ROI2. Interobserver agreement was excellent for both qualitative and quantitative analyses.ConclusionsA single FSE T2-weighted Dixon sequence can be used to differentiate benign and malignant VCF with high diagnostic performance using both qualitative and quantitative analyses, which can provide complementary information.Key Points• Qualitative analysis of a single FSE T2-weighted Dixon sequence yields high diagnostic performance and excellent observer agreement for differentiating benign and malignant compression fractures.• The same FSE T2-weighted Dixon sequence allows quantitative assessment with high diagnostic performance.• Quantitative data can readily be extracted from the FSE T2-weighted Dixon sequence and may provide complementary information to the qualitative analysis, which may be useful in doubtful cases.

Efficacy of Percutaneous Vertebroplasty in the Treatment of Malignant and Benign Vertebral Fractures: Single-Center Experiences

AbstractPercutaneous vertebroplasty (PVP) is a method used for vertebral stabilization and pain treatment. This study was performed to demonstrate the efficacy of PVP in treatment of malignant and benign vertebral compression fractures (VCFs). The study was conducted on 45 cases with a total of 106 VCFs. The mean age of the patients was 62.4 years (37–86 years). The vertebral fractures were classified according to Genant’s Classification. Pain was rated using the visual analog scale (VAS). VAS scores were recorded before and after PVP operations. A total of 58 vertebrae (54.8%) were treated via a bipedicular approach, and 48 vertebrae (45.2%) were treated via a unilateral transpedicular approach with the help of biplane imaging and under anesthesia. L1 vertebra (19.8%) fractures and Grade III fractures (46.3%) were more common. Vertebral collapse was the most common cause of malignancy (53.8%). The mean VAS score was measured to be 8.39 before the VP operations and 2.05 after the VP operations. The VAS score dropped to 2.3 through the unipedicular approach and to 1.84 through the bipedicular approach. The decrease in pain due to VP was statistically significant (p &lt; 0.001). There was no statistically significant difference between the unipedicular and bipedicular approaches in terms of pain relief (p&gt; 0.05). Some patients (18.8%) had complications. PVP is a highly therapeutic method for pain relief in case of pain secondary to malignant or benign vertebral fractures.

Role of Diffusion-Weighted and Chemical Shift Magnetic Resonance Imaging in Differentiation of Benign and Malignant Spinal Fractures

Atraumatic spinal compression fractures are common clinical problem. Differentiating benign osteoporotic fractures from pathological fractures due to malignant/metastatic lesions affects the management and prognoses in patients with known extraspinal malignancy. The objective of the research was to assess the role of conventional magnetic resonance imaging sequences with diffusion-weighted imaging and chemical-shift imaging in differentiating benign and malignant acute spinal compression fractures.&#x0D; Materials and Methods. The study included 40 patients with acute spinal compression fractures. Patients were evaluated using magnetic resonance imaging with diffusion-weighted imaging and chemical-shift imaging to differentiate benign etiology from malignant one. The results obtained were compared with histopathological follow-up for 6 months for definite clinical diagnoses.&#x0D; Results. No significant difference was noted in signal characteristics of benign and malignant fractures on T1, T2 and short-tau inversion recovery. However, posterior element involvement, soft tissue component and post-contrast enhancement were seen more frequently in malignant fractures (p&lt;0.05). On diffusion-weighted images, 77.8% of malignant fractures were hyperintense and 59.1% of benign fractures were hypointense (p&lt;0.05). The mean apparent diffusion coefficient value was 0.81 ± 0.19 for malignant and 1.24 ± 0.24 for benign fractures (p&lt;0.5). The mean signal intensity ratio for malignant fractures was 0.91 ± 0.125, whereas the signal intensity ratio for benign fractures was 0.64 ± 0.096 (p&lt;0.001).&#x0D; Conclusions. Signal characteristics on T1, T2 and short-tau inversion recovery sequences do not differentiate benign from malignant fractures; however, posterior element involvement, soft tissue and post contrast enhancement help in differentiating the etiology. Diffusion-weighted imaging and apparent diffusion coefficient values, as well as using chemical shift imaging further improve the diagnostic accuracy of magnetic resonance imaging.

177. Vertebral height restoration following painful vertebral compression fracture: an international multicenter experience using spine jack

BACKGROUND CONTEXT Currently, there is no standard of care regarding the management of osteoporotic, malignant or traumatic vertebral compression fractures (VCFs). It is unclear which clinical parameters constitute sufficient indication for proceeding beyond conservative treatment. The criteria for surgical intervention are also not well defined. Recently, the SpineJack (Stryker, Kalamazoo, MI, USA) implantable device for the reduction of VCFs has gained FDA clearance for marketing in the United States. To date, there have not been any large reports describing early use cases, outcomes, or adverse events with SpineJack in the United States. Of immediate relevance is the use of the device in cases of osteoporotic compression fractures (for which it is FDA approved) and malignant compression fractures (for which it is not). The present study is a retrospective analysis of the largest international multicenter registry for vertebral augmentation using SpineJack. PURPOSE To review the efficacy of vertebral height restoration for painful VCFs using the SpineJack implantable device in a large international sample of real-world cases. STUDY DESIGN/SETTING Retrospective analysis is conducted utilizing a multicenter retrospective registry comprised of 180 patients who underwent vertebral augmentation using SpineJack in the United States and Europe. PATIENT SAMPLE The inclusion criteria of this study encompass any patient who underwent vertebral augmentation in whom the SpineJack device was used for the treatment of painful osteoporotic, malignant, or traumatic VCFs. OUTCOME MEASURES Primary outcomes measures include: (1) vertebral height restoration (mm), (2) change in NRS pain score, (3) rate of adjacent level fractures, and (3) rate of serious adverse events (SAEs). Secondary outcome measures include: (1) change in kyphotic angle, and (2) change in opioid utilization. METHODS Case enrollment began in August 2019. Pre- and postprocedural pain was recorded using the Numeric Rating Scale (NRS). Functional recovery is measured using the Oswestry Disability Index, and change in opioid utilization postprocedurally is measured in morphine equivalent units. Vertebral height is measured at the anterior vertebral body on pre- and postprocedural imaging. Loss of vertebral height due to VCF is calculated using prefracture imaging when available, or the average of vertebral height at the adjacent levels above and below the VCF. In a preliminary analysis of 27 cases, local kyphotic angle is measured as the angle of intersection between planes drawn along the superior and inferior endplates of the affected vertebrae. Final analysis will include segmental kyphotic angle, measured by the method of cobb utilizing the superior endplate of the level above the fracture and the inferior endplate of the level below. Follow-up for all outcome measures in conducted in the immediate postoperative period, 1 month, 3 months and 6 months after the procedure. RESULTS Case enrollment is schedule to close in August 2020. In a preliminary analysis of 27 patients who underwent vertebral augmentation with SpineJack at 34 separate levels, patients experienced an average vertebral height recovery of 74% (loss of 30±19% to 13±25% post procedurally). Local kyphotic angle was reduced by an average of 50% (7.5±7.5° to 4.0±5.3° post procedurally). 33% of patients (n=9) achieved complete restoration of prefracture vertebral height. 49% of patients achieved pain reduction (NRS decrease >50%) within the first 24 hours post-operatively. There were no SAEs or adjacent level fractures in this prelimary cohort, and the rate of opioid utilization remained unchaged in the immediate postoperative period. CONCLUSIONS The present study presents real-world evidence for the safety and efficacy of SpineJack as used in six centers in the United States and Europe. Preliminary results suggest excellent vertebral height restoration and reduction in local kyphotic angle. There were no SAEs or adjacent level fractures. FDA DEVICE/DRUG STATUS SpineJack (Not approved for this indication)

Percutaneous vertebroplasty of the cervical spine performed via a posterior trans-pedicular approach.

Percutaneous vertebroplasty (PV) of the cervical spine has been traditionally performed with a trans-oral or antero-lateral approach. The posterior trans-pedicular approach (PTPA) has been sporadically reported. Therefore, the aim of this study is to retrospectively assess the technical feasibility, safety, and clinical outcomes of cervical PV performed with a PTPA. All consecutive patients undergoing PV in cervical levels with PTPA (under general anesthesia and computed tomography [CT] guidance) from January 2008 to November 2019 were identified. The following data were collected: patients' demographics; indication for PV; vertebral level features; procedure-related variables; and clinical outcomes including complications and pain relief. Thirty-two patients (18 females, 14 males; mean age 61.1 ± 13.2 years, range 36-88) were included accounting for 36 vertebrae. Three vertebrae (3/36, 8%) were referred due to an underlying traumatic fracture, the remaining (33/36, 92%) due to a painful lytic tumor. Technical success was 97% (35/36 levels). Mean time required to deploy the trocar was 23 ± 11 min (range 7-60). Extra-vertebral asymptomatic cement leakage was observed in 3/35 (9%) vertebral levels. One patient (1/32, 3%) developed an acute cardiogenic pulmonary edema requiring admission in the intensive care unit; another patient (1/32, 3%) developed localized infection to the skin entry site, which was managed conservatively. At 1-month follow-up, the mean pain in the study population was 1.0 ± 1.1 (range 0-4/10) vs 6.2 ± 1.4 (range 4-9/10) at baseline (p < 0.05). Cervical PV performed via a CT-guided PTPA is technically feasible, safe, and results in effective pain relief. • Percutaneous vertebroplasty (PV) is a well-established technique for the treatment of benign and malignant compression fractures. • Common PV approaches used for cervical vertebrae include the trans-oral, antero-lateral, lateral, and sporadically the posterior trans-pedicular approach. • Retrospective analysis of our 11-year experience with the posterior trans-pedicular approach used for cervical vertebrae proved that such approach was safe and effective.

Vertebral augmentation with spinal implants: third-generation vertebroplasty.

This article is to review the different types of vertebral augmentation implants recently becoming available for the treatment of benign and malignant spinal compression fractures. After a detailed description of the augmentation implants, we review the available clinical data. We will conclude with a summary of the advantages and disadvantages of vertebral implants and how they can affect the future treatment options of compression fractures.

Less PMMA Injection as an Independent Factor for Poor Neurologic Recovery in Malignant Vertebral Compression Fractures With Symptoms of Neurologic Compression Following Percutaneous Vertebroplasty

Background: Recent years, percutaneous vertebroplasty (PVP) has gained wide clinical acceptance as an effective treatment option for patients with intractable pain related to compression fractures of the spine. But little is known about PVP for spinal malignant lesions with epidural involvement in patients with neurologic deficit. Aim: To evaluate the efficacy of PVP for malignant vertebral compression fractures with symptoms of neurologic compression following percutaneous vertebroplasty (PVP), and evaluate the predictive factors for poor outcomes following PVP. Methods: Forty-three patients with malignant vertebral compression fractures with symptoms of neurologic compression were treated with PVP. Patients were classified into 2 groups according to the American Spinal Injury Association (ASIA) impairment scale at the last follow-up. Data were collected and the patients followed-up at 1, 3, 6 and 12 months and yearly after the procedure. Univariate and multivariate analysis was performed to evaluate factors predictive of poor neurologic compression symptoms recovery. Results: PVP were successful in all patients. Full recovery from (n = 2) or improvement of (n = 16) neurologic compression symptoms were achieved in 18 patients (Group A), and no improvement of neurologic compression symptoms in 25 patients (Group A). Univariate analysis showed more PMMA leakage ( P = 0.038) and less PMMA volume injection ( P &lt; 0.001) was associated with the poor symptoms of neurologic compression recovery, and multivariate analysis showed that less PMMA volume injection ( P = 0.004) was an independent predictor for poor symptom of neurologic compression recovery. Conclusion: Our results indicated PVP should not be served as an effective treatment of malignant compression fractures with symptoms of neurologic compression, and less PMMA volume injection was an independent predictor of poor symptom of neurologic compression recovery.

Diagnostic Performance of In-Phase and Opposed-Phase Chemical-Shift Imaging for Differentiating Benign and Malignant Vertebral Marrow Lesions: A Meta-Analysis.

The purpose of this study was to assess the diagnostic performance of in-phase and opposed-phase chemical-shift imaging (CSI) for differentiating benign and malignant vertebral bone marrow lesions (BMLs). The PubMed and EMBASE databases were searched for diagnostic accuracy studies comparing conventional gradient-echo CSI or the Dixon method for differentiating benign and malignant vertebral BMLs with histopathologic or best-value comparator results. Methodologic quality was assessed with the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Bivariate modeling and hierarchical summary ROC (HSROC) modeling were performed to evaluate the diagnostic performance of CSI. For heterogeneity exploration, we performed meta-regression analyses. Twelve studies including 663 lesions of 591 patients were included. CSI showed a pooled sensitivity of 0.92 (95% CI, 0.84-0.96), pooled specificity of 0.89 (95% CI, 0.81-0.93), and HSROC AUC of 0.95 (95% CI, 0.93-0.97) for differentiating benign from malignant vertebral BMLs. The corresponding values for differentiating benign from malignant compression fractures were 0.96 (95% CI, 0.81-0.99), 0.89 (95% CI, 0.83-0.93), and 0.93 (95% CI, 0.91-0.95). In meta-regression analysis, minimum TR (< 100 ms), flip angle (< 50°), and Dixon method tended to have higher specificity. Study population, slice thickness (< 5 mm), minimum TE (< 2.3 ms), flip angle (< 50°), and blinding also significantly affected heterogeneity (p < 0.05). In-phase and opposed-phase CSI has excellent diagnostic performance for differentiating benign and malignant vertebral BMLs. CSI with a short TR, small flip angle, and Dixon method is recommended for more accurate diagnosis as specificity increases.

Kyphoplasty patient-centered outcomes via questionnaire.

To assess patient centered outcomes among adults with compression fractures treated by kyphoplasty. A 3-question survey was administered via telephone to patients who had a kyphoplasty procedure performed from 2008-2011. One hundred fifty-one patients completed the telephone satisfaction survey. Of these, 95.4% of respondents said the procedure was tolerable, 82.8% had full or partial pain relief and 66.2% would have the procedure again. Large randomized and observational evidence support the use of kyphoplasty in osteoporotic and malignant compression fractures. Based on our survey, patients believe kyphoplasty is a tolerable procedure that produces full or partial pain relief and would undergo the procedure again if needed.

ADC as a useful diagnostic tool for differentiating benign and malignant vertebral bone marrow lesions and compression fractures: a systematic review and meta-analysis.

To assess the sensitivity and specificity of quantitative assessment of the apparent diffusion coefficient (ADC) for differentiating benign and malignant vertebral bone marrow lesions (BMLs) and compression fractures (CFs) METHODS: An electronic literature search of MEDLINE and EMBASE was conducted. Bivariate modelling and hierarchical summary receiver operating characteristic modelling were performed to evaluate the diagnostic performance of ADC for differentiating vertebral BMLs. Subgroup analysis was performed for differentiating benign and malignant vertebral CFs. Meta-regression analyses according to subject, study and diffusion-weighted imaging (DWI) characteristics were performed. Twelve eligible studies (748 lesions, 661 patients) were included. The ADC exhibited a pooled sensitivity of 0.89 (95% confidence interval [CI] 0.80-0.94) and a pooled specificity of 0.87 (95% CI 0.78-0.93) for differentiating benign and malignant vertebral BMLs. In addition, the pooled sensitivity and specificity for differentiating benign and malignant CFs were 0.92 (95% CI 0.82-0.97) and 0.91 (95% CI 0.87-0.94), respectively. In the meta-regression analysis, the DWI slice thickness was a significant factor affecting heterogeneity (p < 0.01); thinner slice thickness (< 5 mm) showed higher specificity (95%) than thicker slice thickness (81%). Quantitative assessment of ADC is a useful diagnostic tool for differentiating benign and malignant vertebral BMLs and CFs. • Quantitative assessment of ADC is useful in differentiating vertebral BMLs. • Quantitative ADC assessment for BMLs had sensitivity of 89%, specificity of 87%. • Quantitative ADC assessment for CFs had sensitivity of 92%, specificity of 91%. • The specificity is highest (95%) with thinner (< 5 mm) DWI slice thickness.

Differentiation of Acute Osteoporotic and Malignant Vertebral Fractures by Quantification of Fat Fraction With a Dixon MRI Sequence.

The purpose of this study was to differentiate malignant compression fractures from acute osteoporotic compression fractures of the spine by use of a Dixon MRI sequence to quantify fat fraction (FF). Forty-four vertebral compression fractures were assessed with turbo spin-echo T1-weighted and six-echo Dixon sequences for FF quantification at 3-T MRI. The fractures were divided into malignant compression fractures (n = 24) and acute osteoporotic compression fractures (n = 20). Two radiologists independently measured quantitative parameters from ROIs in the fractures, including the T1 signal intensity of the fracture, the FF of the fracture, and the FF ratio (fracture FF divided by normal marrow FF). The mean values of the parameters were compared between the two groups, interobserver reliability between two radiologists was assessed, ROC curves were analyzed, and logistic regression analysis was performed. The fracture FF and FF ratio of malignant compression fractures were significantly lower than those of acute osteoporotic compression fractures (fracture FF, 2.73% vs 14.36% [p < 0.001]; FF ratio, 0.05 vs 0.22 [p < 0.001]). There was no difference in T1 signal intensity of the fracture. The ROC AUC of fracture FF was 0.98 and of FF ratio was 0.95. In logistic regression analysis, fracture FF remained a significant variable that could be used to independently differentiate malignant from acute osteoporotic compression fractures (odds ratio, 0.33; p < 0.005). FF and FF ratio obtained from FF maps obtained with a six-echo Dixon MRI sequence may be useful for differentiating acute osteoporotic compression fractures from malignant compression fractures.

Clinical Experience Using a Remote Control Injection System in Vertebroplasty: Feasibility, Safety, and Cement Leakage of Osteoporotic and Malignant Compression Fractures.

A retrospective study. Cement leakage is a frequent occurrence in vertebroplasty and is also the main source of complications. Continuous radiographic evaluation is mandatory to detect cement leakage during injecting cement into the vertebral body, while the operator is subjected to x-ray radiation exposure. The aim of this study was to evaluate the feasibility and safety of vertebroplasty performed on patients and operators for the treatment of osteoporotic and malignant vertebral compression fractures using a remote control injection system. Institutional review board approval was obtained for this retrospective study. Clinical charts and postoperative radiographs were obtained for 74 patients (114 levels) who underwent vertebroplasty. The study group included 46 cases (71 levels) of benign osteoporotic fractures and 28 cases (43 levels) of different malignant metastatic lesions. Under fluoroscopic guidance, cement was injected using a remote control injection system, while the operator was standing outside the radiation field. The location and degree of leakage at each treated level were recorded. Cement leakage rate reached 47.4% across all treated levels. No severe leakage in any location was observed. A total of 35 leakages were detected in 71 levels and 24 leakages were detected in 43 levels in the benign and malignant fracture group, respectively. The overall rate of cement leakages and the location of the leakages were not statistically different between the benign and malignant fracture group (P=0.60, P=0.45). With the operator standing outside the radiation field to inject cement, the radiation dose to operators was avoided during cement injection. Vertebroplasty using a remote control injection system was feasible and safe in treatment of osteoporotic and malignant compression fractures. The cement injection system had potential benefits to decrease the leakage rate in treating malignant fractures and eliminate injection dose to operators under lateral fluoroscopic monitoring.

Response to: Role of Transpedicular Percutaneous Vertebral Biopsy for Diagnosis of Pathology in Vertebral Compression Fractures

Study design Retrospective observational study. Purpose To identify the role of percutaneous vertebral biopsy in histopathological diagnosis of vertebral compression fractures and to identify the frequency of unexpected malignancy in vertebral compression fractures. Overview of literature Vertebral compression fractures are common in the Indian population. Magnetic resonance imaging and nuclear imaging have some limitations in the diagnosis of definitive pathology of vertebral compression fractures. Therefore, histological confirmation is necessary for definitive diagnosis and to plan appropriate management for patient. Methods A retrospective observational study was conducted involving 84 patients who underwent percutaneous vertebral biopsy between 2010 and 2014. We performed C-arm guided percutaneous transpedicular core vertebral biopsy of vertebral compression fractures under combination of local anesthesia and intravenous conscious sedation. Results Sufficient biopsy material was obtained in 79 of the 84 cases. In the other five cases, biopsy material was not sufficient for reporting. Out of the 79 cases, osteoporotic pathology was detected in 69 patients, malignancy was detected in 8 patients and no pathology was found in 2 patients. Two patients with distant metastases to vertebra were identified. Primary spinal malignancy was detected in 6 patients (1 unsuspected plasmacytoma, 5 diagnosed malignancy preoperatively). So, the frequency of unsuspected malignancy of this study was 1.19% (1/84). None of the patients had any complications. Conclusions C-arm guided percutaneous transpedicular vertebral biopsy is useful in obtaining definitive histopathological diagnosis of vertebral compression fractures, especially in differentiating malignant and non-malignant vertebral compression fractures and helping plan appropriate management of patients. The rate of unexpected malignancy in vertebral compression fracture was 1.19%.

Benign Versus Malignant Vertebral Compression, Chemical Shift MR Imaging, Is It Useful?

Objectives: The aim of this study was to evaluate the diagnostic accuracy of chemical shift imaging in vertebral compression. Patients and Methods: Forty-nine patients with vertebral compression with suspected malignancy or history of trauma were included in this study. MR imaging of the spine with standard conventional MR sequences and additional chemical shift imaging was done with 1.5 Tesla MR Unit. Regions of interest (ROI) were placed on the abnormal marrow of compressed vertebrae both on the opposed phase and on the matching in phase images and signal intensity (SI) ratio values (SI out-phase/SI-in phase) were calculated. Results: Forty-nine patients had 68 spine lesions, consisting of 49 benign and 19 malignant fractures. Student t test, receiver operating characteristic (ROC) analysis and interclass correlation test were used statistically. Mean SI ratio of benign vertebral compression (0. 68 ± 0.29, range 0.13 - 1.53) was significantly lower than malignant SI ratio values (1.06 ± 0.10, range 0.96 - 1.35). With student t-test, there was significant difference between benign compressions compared to malignant compressions (P < 0.001). Receiver operating characteristic (ROC) curve analysis was used to determine the optimal cut off value in malignant and benign lesion definition. The optimal SI ratio cut off value was found to be 0.96 for separating benign and malignant vertebral compression. The area under the curve (AUC) value was observed as 0.92 (95% confidence interval [CI] = 0.86 - 0.99). According to that cutoff value, sensitivity was 100% (95% CI = 82.35% - 100%) and the specificity was 86% (95% CI = 72.76% - 94.06%). Interobserver reliability was studied with intraclass correlation and results were statistically significant with intraclass correlation coefficient (ICC) as 0.85 (P < 0.05). Conclusions: There is significant difference in signal values between benign and malignant compression fractures in chemical shift MR imaging. Chemical shift MR imaging has much additive data to conventional MRI in vertebral compression.

Differentiation of acute osteoporotic from malignant vertebral compression fractures with conventional MRI and diffusion MR imaging

AimTo evaluate the role of using a single shot spin echoplanar DW sequence (SSSEP-DWI) compared to conventional MRI and contrast enhanced T1WI in differentiation between vertebral osteoporotic fractures and malignant compression fractures. The sensitivity and specificity of (SSSEP-DWI) will also be calculated. Patients and methodsSixty-eight acute vertebral compression fractures in 41 patients were imaged using conventional MRI, fat suppressed contrast enhanced T1WI and DW sequence on a 1.5T MR machine. Quantitative assessment of the abnormal signal intensity was done by measuring apparent diffusion coefficients (ADCs). Also, the areas of abnormal signal intensity were compared to adjacent normal marrow. ResultsWe had 38 benign fractures, and 30 malignant fractures. Post contrast enhancement showed sensitivity of 92% and specificity of 70% for malignant compression fractures. The hyperintense signal on DWI has 89% PPV for malignancy, while the sensitivity and specificity were 86% and 91% respectively. The mean ADC for malignant fractures was significantly lower than those of osteoporotic fractures (p=0.0002). ConclusionsSSSEP-DWI is a reliable adjunct parameter that supports conventional MRI in differentiating benign and malignant vertebral fractures.