Pathological Vertebral Fractures Research Articles

Osteoporotic Vertebral Compression Fractures: Medical, Social Aspects, Clinical Picture, Treatment and Medical Rehabilitation. A Review

INTRODUCTION. Osteoporosis is one of the most common metabolic skeletal diseases in the world, which is characterized by a decrease in bone tissue strength and an increased risk of fractures with minimal trauma, including pathological vertebral compression fractures (VCFs). VCFs are accompanied by a decrease in the quality of life of patients with osteoporosis due to a pronounced pain syndrome, sleep problems, decreased motor and social activity, a high risk of falls and fractures, the development of pathological spinal deformities, decreased lung capacity and increased number of comorbid diseases. In this regard, timely treatment and medical rehabilitation in patients with osteoporosis and VCFs are of particular importance to restore functionality, reduce the risk of developing new fractures, disability and death.
 MAIN CONTENT OF THE REVIEW. The literature review is the analysis of 7 domestic and 49 foreign literary sources, which was used to describe the prevalence, medical and social significance and clinical picture of osteoporotic VCFs. It provides data on modern methods of drug and non-drug treatment of patients with VCFs. The effectiveness and limitations of the use of physical therapy methods in the rehabilitation of patients with pathological spinal fractures are described in detail.
 CONCLUSION. It is concluded that VCFs pose a significant healthcare burden due to their high prevalence and negative impact on the quality of life of older patients with osteoporosis. Osteoporotic VCFs lead to the development of severe back pain, limited mobility, spinal deformities, loss of height and permanent disability. An effective strategy for the treatment and rehabilitation of patients with osteoporotic VCFs should include the use analgesics, orthotics, correction of nutritional deficiency, elimination of vitamin D and calcium deficiency, modern methods of physical therapy, fall prevention and timely prescription of effective drugs for pathogenetic therapy of osteoporosis to reduce the risk of pathological fractures in the future and ensure a high level of functioning and of the quality of life.

Impact of metastatic epidural spinal cord compression (MESCC) and pathological vertebral compression fracture (pVCF) in neurological and survival prognosis

BackgroundMetastatic epidural spinal cord compression (MESCC) and pathological vertebral compression fractures (pVCF) are the most serious debilitating morbidities of spine metastases (SpMs) causing devastating neurological damages. The respective impact of these two metastasis-spreading entities on survival and on neurological damage is debated. MethodsA French prospective cohort study collected 279 consecutive patients presenting with SpMs between January 2017 and 2021. We compared 174 patients with MESCC and 105 patients with pVCF. ResultsThe median Overall Survival (OS) for the MESCC group was 13.4 months (SD 1.5) vs 19.2 months (SD 2.3) for pVCF patients (p = 0.085). Sixty-five patients (23.3 %) were operated on: 49/65 (75.4 %) in the MESCC group and 16/65 (15.2 %) in the pVCF group, p < 0.0001. At 6 months FU, in the MESCC group, 21/44 (45.4 %) of non-ambulatory patients at onset improved to ambulatory status (Frankel D-E) vs 10/13 (76.9 %) in the pVCF group (p = 0.007). In multivariable analysis with the Cox proportional hazard model, good ECOG-PS and SINS Score 7–12 [HR: 6.755, 95 % CI 2.40–19.00; p = 0.001] were good prognostic factors for preserved ambulatory neurological status. However, SpMs diagnosed synchronously with the primary tumor [HR: 0.397, 95 % CI 0.185–0.853; p = 0.018] and MESCC [HR: 0.058, 95 % CI 0.107–0.456; p = 0.007] were independent risk factors for impaired neurological function. ConclusionContrary to pVCF, MESCC causes neurological damage. Nevertheless, neurological recovery remains possible. MESCC and pVCF have no impact on survival. The management of MESCC remains to be clarified and optimized to reduce neurological damage.

Efficacy and risk of osteonecrosis of the jaw for pamidronate, zoledronic acid, and denosumab in comparison to alendronate in multiple myeloma patients

Background Approximately 70% of multiple myeloma patients develop pathologic fractures. Osteoclast inhibitors can provide reduction in vertebral fractures with an increased risk of osteonecrosis of the jaw (ONJ). ONJ associated with currently used osteoclast inhibitors causes significant morbidity, often from delayed diagnosis and ineffective treatment. Methods The TriNetX Diamond Network was used to create patient cohorts for each medication: alendronate, pamidronate, zoledronic acid, and denosumab. All patients had a diagnosis of multiple myeloma as identified by International Classification of Disease–10 (ICD-10) code C90.0. Pamidronate, zoledronic acid, and denosumab were each compared to alendronate for 5-year incidence of pathologic vertebral fracture (ICD-10 M48.50XA) and development of ONJ. Results The 5-year risk of pathologic vertebral fracture was not statistically different between alendronate versus pamidronate, zoledronic acid, and denosumab. However, the 5-year risk of ONJ was significantly higher for both zoledronic acid and denosumab (relative risk 4.85 and 2.9, respectively). Conclusion This study shows that fracture reduction risk is comparable for all four treatments in multiple myeloma patients, but ONJ risk is lowest for alendronate and pamidronate. Overall, these data support the continued use of pamidronate and alendronate in multiple myeloma patients.

Retrospective Review of 181 Patients with Pathologic Vertebral Compression Fractures

Background: Compression fractures are often associated with lower energy trauma and may occur in the setting of abnormal bone health associated with genetic disorders and endocrine disorders, neoplastic disease, infection, and inflammatory disorders. There is no significant series in the literature describing the prevalence or etiology of pathologic pediatric compression fractures.Methods: IRB-approved retrospective study was performed at a tertiary children's hospital from 2012-2022. Patients <18 years old diagnosed with atraumatic vertebral compression fractures were included and reviewed for demographics, underlying diagnosis/comorbidity, presentation, mobility, deformities, imaging data, treatments, and outcomes.Results: 181 patients (54% Male) were included with mean age 14.17 years and follow-up of 20 months. A compression fracture was the presenting symptom of an underlying diagnosis in 32% of patients, and 21% of patients received an MRI to distinguish between metastatic disease and benign fractures. Primary osteoporosis was the cause in 15% and secondary osteoporosis was in 65% of patients; most commonly due to immunosuppressants (46%) and acute lymphoblastic leukemia (ALL) (10%). Primary lesions were the etiology in 20% of patients. There was a median of 3 fractures per patient, mostly of the midthoracic (82%) and thoracolumbar spine (51%). Radiographs revealed wedge fractures in 82%, biconcave fractures in 22%, and vertebra plana in 12%. Patients were managed with observation (46%), bracing (31%), bisphosphonates (31%), and fusions (4%). By last follow-up, there was a higher proportion of patients who developed scoliosis or became wheelchair-bound. Overall, there was a 16% mortality rate which was mostly associated with cancer.Conclusion: Overall, 32% of patients presented with a compression fracture as the presenting symptom of an underlying disease. Pathologic vertebral compression fractures in children frequently occurred due to immunosuppressants, ALL, and metastatic disease. The fractures were most often wedge morphology in the thoracolumbar and mid-thoracic regions of the spine. MRIs may be useful for distinguishing between benign fractures and malignancy.Levels of Evidence: Level IV Key Concepts•Pathologic Vertebral Compression Fractures occur commonly in children with primary or secondary osteoporosis or due to primary site lesions, such as metastases.•Patients often have multiple fractures about the thoracolumbar and mid-thoracic regions of the spine.•Wedge and biconcave fractures were the most common fracture type at presentation and indicated an underlying disease not previously known in one-third of patients.•MRI is useful for distinguishing between benign fractures and malignancy as the etiology of the fracture.

Novel Intrafraction Motion Tracking During Postoperative Spine Stereotactic Irradiation for a Patient With Carbon Fiber Fixation Hardware

Carbon-fiber reinforced (CFR) polyetheretherketone hardware is an alternative to traditional metal hardware used for spinal fixation surgeries before postoperative radiation therapy for patients with spinal metastases. CFR hardware's radiolucency decreases metal artifact, improving visualization and accuracy of treatment planning. We present the first clinical use and proof of principle of CFR spinal hardware with tantalum markers used for successful tracking of intrafraction motion (IM) using Varian TrueBeam IMR (Intrafraction Motion Review) software module during postoperative spine stereotactic radiation. A 63-year-old woman with history of endometrial cancer presented with acute back pain. Imaging demonstrated pathologic T12 vertebral fracture with cord compression. She underwent T12 vertebrectomy with circumferential decompression and posterior instrumented T10-L2 fusion at our facility using CFR-polyetheretherketone hardware with tantalum screw markers followed by postoperative stereotactic body radiation therapy to 3000 cGy in 5 fractions delivered to T11-T12. Tantalum screw markers were used for IMR tracking. During irradiation, 260 kV images were acquired, and IMR software was able to identify and track markers. During the entire treatment, the IM motions were less than 3 mm. This is the first presented case of CFR spinal hardware with tantalum markers used for successful IMR tracking of IM during daily spine stereotactic treatment. Future work will be needed to improve workflow and create a spine-specific IMR protocol.

Pathophysiology and treatment of pain in multiple myeloma

Most patients with multiple myeloma (MM) suffer from chronic pain of varying degrees of intensity at every stage of the natural disease process. Osteolytic bone lesions are one of the most common complications of MM. The bone disease visualized by PET/CT and MRI affects up to 90% of newly diagnosed MM patients, increasing the risk of the development of skeletal-related events. Pathological fractures and spinal cord compression occur in 17% and 6% of patients, respectively. Bone pain is explained by an increase in pressure in the bone marrow, the release of chemical mediators by myeloma plasma cells, and the occurrence of microcracks in the bones, indirectly to a violation of local metabolism. Management of myeloma bone disease includes anti-myeloma chemotherapy and radiotherapy, antiresorptive therapy with bisphosphonates or denosumab, and direct pharmacological pain correction. Patients with pathological vertebral fractures and without spinal cord compression should be considered for vertebroplasty or kyphoplasty. The use of proteasome inhibitors and monoclonal antibodies for the treatment of MM is associated with a risk of herpes simplex virus (HSV) and varicella-zoster virus (VZV) reactivation. The result of the healing of herpetic eruptions in some patients will be the development of postherpetic neuralgia, manifested by excruciating pain for months or years. Moreover, the treatment with proteasome inhibitor bortezomib is often associated with the development of long-term persistent peripheral neuropathy, often complicated by pain. According to their neurobiological and clinical features, pain is classified into nociceptive, neuropathic, and functional. Bone pain is nociceptive and for postherpetic and chemotherapy-induced neuropathy, the neuropathic component is more significant. Opioids are the drugs of choice for moderate to severe nociceptive pain, while anticonvulsants and antidepressants are the most commonly used adjuvants for neuropathic pain. This review summarizes information on the pathophysiology of various types of pain syndrome in patients with MM, as well as on modern approaches to the prevention and treatment of complications. The issues of the pharmacology of opioid analgesics are discussed. The review concludes with data from a clinical trial of a new domestic non-opioid μ1-opioid receptor agonist Tafalgin, considered a real alternative to narcotic analgesics.

Percutaneous Vertebral Reconstruction (PVR) Technique of Pathological Compression Fractures: An Innovative Combined Treatment of Microwave Ablation, Bilateral Expandable Titanium SpineJack Implants Followed by Vertebroplasty.

(1) Background: to retrospectively evaluate safety and efficacy of combined microwave ablation (MWA) and bilateral expandable titanium SpineJack (SJ) implants followed by vertebroplasty (VP) for the treatment of painful thoracolumbar pathological vertebral compression fracture. (2) Methods: from July 2017 to October 2022, twenty-eight patients (13 women and 15 men; mean age 68 ± 11 years) with a history of primary neoplasm and thirty-six painful vertebral metastases with vertebral compression fracture underwent combined MWA and bilateral expandable titanium SpineJack implants with vertebroplasty. We analyzed safety through complications rate, and efficacy through vertebral height restoration and pain decrease, evaluated using a visual analogue scale (VAS), and Functional Mobility Scale (FMS), and local tumor control. Contrast-enhanced CT scans were performed at 1, 3, and 6 months and a contrast-enhanced spine MRI at 6 months after the procedure. (3) Results: Technical success rate was 100%. No procedure-related major complications or death occurred. Vertebral height restoration was observed in 22 levels (58%), with a mean anterior height restoration of 2.6 mm ± 0.6 and a mean middle height restoration of 4.4 mm ± 0.6 (p < 0.001). Mean VAS score of pain evaluation on the day before treatment was 6.3 ± 1.5 (range 4-9). At the 6-month evaluation, the median VAS score for pain was 0.4 ± 0.6 (range 0-2) with a mean reduction of 93.65% (6.8 ± 0.7 vs. 0.4 ± 0.6; p < 0.000) compared with baseline evaluation. Contrast-enhanced CT scans were performed at 1, 3, and 6 months and a contrast-enhanced spine MRI was performed at 6 months after the procedure, showing no local recurrence, implant displacement, or new fractures in the treated site. (4) Conclusions: combined microwave ablation and bilateral expandable titanium SpineJack implants with vertebroplasty is a safe and effective procedure for the treatment of pathological compressive vertebral fractures. The vertebral stabilization achieved early and persistent pain relief, increasing patient mobility, improving recovery of walking capacity, and providing local tumor control.

Management of Pathological Thoracolumbar Vertebral Fractures in Patients With Multiple Myeloma: Multidisciplinary Recommendations

Mutlidisciplinary consensus recommendations for patients suffering from multiple myeloma (MM) involvement of the spinal column by the Spine Section of the German Association of Orthopaedic and Trauma Surgeons. To provide a comprehensive multidisciplinary diagnostic and therapeutic approach and to summarize the current literature on the management of pathological thoracolumbar vertebral fractures in patients with multiple myeloma. Multidisciplinary recommendations using a classical consensus process provided by radiation oncologists, medical oncologists, orthopaedic- and trauma surgeons. A narrative literature review of the current diagnostic and treatment strategies was conducted. Treatment decision has to be driven by a multidisciplinary team of oncologists, radiotherapists and spine surgeons. When considering surgery in MM patients, differing factors compared to other secondary spinal lesions have to be included into the decision process: probable neurological deterioration, the stage of the disease and prognosis, patient's general condition, localization and number of the lesions as well as patient's own wishes or expectations. Aiming to improve quality of life, the major goal of surgical treatment is to preserve mobility by reducing pain, secure neurological function and stability. The goal of surgery is primarily to improve quality of life by restoring stability and neurological function. Interventions with an increased risk of complications due to MM-associated immunodeficiency must be avoided whenever feasible to allow early systemic treatment. Hence, treatment decisions should be based on a multidisciplinary team that considers patient's constitution and prognosis.

Neurosurgical management of vertebral lesions in pediatric chronic recurrent multifocal osteomyelitis: patient series.

Chronic recurrent multifocal osteomyelitis (CRMO) is a rare pediatric autoinflammatory disorder involving 2 or more inflammatory bone lesions separated in time and space associated with pathological vertebral fractures. There are no current guidelines for the role of pediatric spine surgeons in the management of this condition. The authors demonstrate the importance of close and early involvement of neurosurgeons in caring for patients with CRMO with vertebral involvement. Fifty-six pediatric patients with clinical and radiographic evidence of CRMO were identified and clinical, radiographic, laboratory, and histopathological data were reviewed. All were evaluated via Jansson and Bristol CRMO diagnostic criteria. Ten had radiographic evidence of vertebral involvement (17.9%). Nine of these had multifocal disease. Five patients had multiple vertebrae affected. Six patients were evaluated for possible surgical intervention and one required intervention due to vertebra plana leading to a progressive kyphotic deformity and significant spinal canal stenosis. In conjunction with management by the primary pediatric rheumatology team using nonsteroidal anti-inflammatory drugs, disease-modifying anti-rheumatic drugs, immunotherapies, and bisphosphonates, given the risk of pathological fractures and potential resulting long-term neurological deficits, the authors recommend close monitoring and management by pediatric spine surgeons for any patient with CRMO with vertebral lesions.

Imaging features of chronic recurrent multifocal osteomyelitis (CRMO) involving the vertebral column of a lemur with subsequent paraplegia due to pathological fractures

A seven-year-old, female ring-tailed lemur was referred for progressive non-ambulatory paraplegia. A computed tomographic (CT) scan of the whole body revealed multifocal lytic lesions involving multiple vertebrae and several pathological vertebral fractures. Necropsy and histopathology identified pyogranulomatous osteomyelitis. The imaging and histopathological findings resemble chronic recurrent multifocal osteomyelitis described in human medicine.

Editorial

Editorial

Evaluation of Load-To-Strength Ratios in Metastatic Vertebrae and Comparison With Age- and Sex-Matched Healthy Individuals.

Vertebrae containing osteolytic and osteosclerotic bone metastases undergo pathologic vertebral fracture (PVF) when the lesioned vertebrae fail to carry daily loads. We hypothesize that task-specific spinal loading patterns amplify the risk of PVF, with a higher degree of risk in osteolytic than in osteosclerotic vertebrae. To test this hypothesis, we obtained clinical CT images of 11 cadaveric spines with bone metastases, estimated the individual vertebral strength from the CT data, and created spine-specific musculoskeletal models from the CT data. We established a musculoskeletal model for each spine to compute vertebral loading for natural standing, natural standing + weights, forward flexion + weights, and lateral bending + weights and derived the individual vertebral load-to-strength ratio (LSR). For each activity, we compared the metastatic spines’ predicted LSRs with the normative LSRs generated from a population-based sample of 250 men and women of comparable ages. Bone metastases classification significantly affected the CT-estimated vertebral strength (Kruskal–Wallis, p < 0.0001). Post-test analysis showed that the estimated vertebral strength of osteosclerotic and mixed metastases vertebrae was significantly higher than that of osteolytic vertebrae (p = 0.0016 and p = 0.0003) or vertebrae without radiographic evidence of bone metastasis (p = 0.0010 and p = 0.0003). Compared with the median (50%) LSRs of the normative dataset, osteolytic vertebrae had higher median (50%) LSRs under natural standing (p = 0.0375), natural standing + weights (p = 0.0118), and lateral bending + weights (p = 0.0111). Surprisingly, vertebrae showing minimal radiographic evidence of bone metastasis presented significantly higher median (50%) LSRs under natural standing (p < 0.0001) and lateral bending + weights (p = 0.0009) than the normative dataset. Osteosclerotic vertebrae had lower median (50%) LSRs under natural standing (p < 0.0001), natural standing + weights (p = 0.0005), forward flexion + weights (p < 0.0001), and lateral bending + weights (p = 0.0002), a trend shared by vertebrae with mixed lesions. This study is the first to apply musculoskeletal modeling to estimate individual vertebral loading in pathologic spines and highlights the role of task-specific loading in augmenting PVF risk associated with specific bone metastatic types. Our finding of high LSRs in vertebrae without radiologically observed bone metastasis highlights that patients with metastatic spine disease could be at an increased risk of vertebral fractures even at levels where lesions have not been identified radiologically.

Spinal Cord Compression as a First Presentation of Polystotic Brown Tumor: A Case Report and Review of Imaging Features

Despite the fact that brown tumor is the hallmark of hyperparathyroidism, it is very rarely observed at present due to early laboratory detection of elevated parathyroid hormone level. The unusual occurrence of this entity in everyday practice is a concern not only for patients, but also for physicians, as it can be mistaken for other lytic bone lesions. If the full continuum of clinical, laboratory and radiological findings is considered, a diagnosis can easily be made. Herein, we report a case of polystotic brown tumor presenting with thoracic cord compression secondary to vertebral pathological fracture.

Spinal Fusion in Pediatric Patients With Low Bone Density: Defining the Value of DXA.

Children with medical complexity are at increased risk of low bone mineral density (BMD) and complications after spinal fusion compared with idiopathic scoliosis patients. Our aim was to compare treatments and outcomes of children with medical complexity undergoing spinal fusion in those who had dual-energy x-ray absorptiometry (DXA) scans versus those who did not in an effort to standardize the workup of these patients before undergoing spinal surgery. We conducted a retrospective review of patients with low BMD who underwent spinal fusion at a tertiary care pediatric hospital between 2004 and 2016. We consulted with a pediatric endocrinologist to create standard definitions for low BMD to classify each subject. Regardless of DXA status, all patients were given a clinical diagnosis of osteoporosis [at least 2 long bone or 1 vertebral pathologic fracture(s)], osteopenia (stated on radiograph or by the physician), or clinically low bone density belonging to neither category. The last classification was used for patients whose clinicians had documented low bone density not meeting the criteria for osteoporosis or osteopenia. Fifty-nine patients met the criteria, and 314 were excluded for insufficient follow-up and/or not meeting a diagnosis definition. BMD Z -scores compare bone density ascertained by DXA to an age-matched and sex-matched average. Patients who had a DXA scan were also given a DXA diagnosis of low bone density (≤-2 SD), slightly low bone density (-1.0 to -1.9 SD), or neither (>-1.0 SD) based on the lowest BMD Z -score recorded. Fifty-nine patients were analyzed. Fifty-four percent had at least 1 DXA scan preoperatively. Eighty-one percent of DXA patients received some form of treatment compared with 52% of non-DXA patients ( P =0.03). Patients referred for DXA scans were more likely to be treated for low BMD, although there is no standardized system in place to determine which patients should get scans. Our research highlights the need to implement clinical protocols to optimize bone health preoperatively. Level II-retrospective prognostic study.

Fabrication of Radio-Opaque and Macroporous Injectable Calcium Phosphate Cement.

The aim of this work was the development of injectable radio-opaque and macroporous calcium phosphate cement (CPC) to be used as a bone substitute for the treatment of pathologic vertebral fractures. A CPC was first rendered radio-opaque by the incorporation of zirconium dioxide (ZrO2). In order to create macroporosity, poly lactic-co-glycolic acid (PLGA) microspheres around 100 μm were homogeneously incorporated into the CPC as observed by scanning electron microscopy. Physicochemical analyses by X-ray diffraction and Fourier transform infrared spectroscopy confirmed the brushite phase of the cement. The mechanical properties of the CPC/PLGA cement containing 30% PLGA (wt/wt) were characterized by a compressive strength of 2 MPa and a Young's modulus of 1 GPa. The CPC/PLGA exhibited initial and final setting times of 7 and 12 min, respectively. Although the incorporation of PLGA microspheres increased the force necessary to inject the cement and decreased the percentage of injected mass as a function of time, the CPC/PLGA appeared fully injectable at 4 min. Moreover, in comparison with CPC, CPC/PLGA showed a full degradation in 6 weeks (with 100% mass loss), and this was associated with an acidification of the medium containing the CPC/PLGA sample (pH of 3.5 after 6 weeks). A cell viability test validated CPC/PLGA biocompatibility, and in vivo analyses using a bone defect assay in the caudal vertebrae of Wistar rats showed the good opacity of the CPC through the tail and a significant increased degradation of the CPC/PLGA cement a month after implantation. In conclusion, this injectable CPC scaffold appears to be an interesting material for bone substitution.

Cranial and vertebral osteosarcoma commonly has T2 signal heterogeneity, contrast enhancement, and osteolysis on MRI: A case series of 35 dogs.

Magnetic resonance imaging (MRI) is commonly used to evaluate the central nervous system (CNS) in dogs; however, published studies describing the MRI appearance of cranial and vertebral osteosarcoma are scarce. In this multicenter, retrospective, case series study, MRI studies of 35 dogs with cranial or vertebral osteosarcoma were prospectively scored by consensus of two veterinary radiologists. Recorded characteristics were location, signal intensity (compared to gray matter), homogeneity, contrast enhancement, margin delineation, local invasion, osteolysis, osteosclerosis, zone of transition, periosteal proliferation, pathological fracture, meningeal/CNS involvement, and presence of metastatic disease. Locations included the parietal bone (n=1), occipital bone (n=2), or cervical (n=5), thoracic (n=17), lumbar (n=7), or sacral vertebrae (n=3). Common features included signal heterogeneity in T2-weighted (T2W) images (n=35), contrast enhancement (in all 34 dogs with postcontrast MRI), osteolysis (n=34), compression of the CNS or cauda equina (n=33), an associated soft tissue mass (n=33), a long zone of transition (n=30), osteosclerosis (n=28), signal isointensity to normal-appearing gray matter in T1-weighted images (T1W, n=26), and T2W hyperintensity of adjacent brain or spinal cord (n=23). Other findings included periosteal proliferation (n=18), meningeal contrast enhancement (n=17), T1W and T2W hypointense foci in the soft tissue mass (n=14), invasion into adjacent bones (n=10), pathological vertebral fractures (n=7), regional lymphadenopathy (n=6), skip metastases (n=2), lung nodule (n=1), diaphragmatic nodule (n=1), and brain invasion (n=1). Contrast enhancement was typically strong and heterogeneous. Magnetic resonance imaging features of cranial and vertebral osteosarcoma were analogous to those previously reported for other imaging modalities. Osteosarcoma should be a differential diagnosis for compressive, contrast-enhancing, osteolytic lesions of the cranium or vertebrae.

Clinical application of a modified percutaneous vertebroplasty instrument in vertebral body biopsy in adults

BackgroundPercutaneous vertebroplasty (PVP) has been widely used to treat vertebral pathological fractures in recent decades, and the modified PVP instrument is very suitable for percutaneous biopsy of diseases promoting vertebral bone destruction. The purpose of this study was to evaluate the relevance of the clinical application of the modified PVP instrument in computed tomography-guided (CT-guided) biopsies of the vertebral body.MethodsRetrospective analysis of clinical data obtained by percutaneous biopsy using a modified PVP outer shell of a bone filler device (OSBF) from 161 patients presenting vertebral body destruction was conducted. The rate of correctly performed biopsy diagnosis was evaluated from three aspects: imaging performance, histological type, and vertebral segment.ResultsThe results of 149 biopsy cases were consistent with the final clinical diagnosis. From those cases, 92 were diagnosed as vertebral body metastasis, 45 cases presented primary spinal tumors and tumor-like changes, 7 cases presented vertebral body infections, and 5 cases displayed normal bones or fractures. From the remaining 12 patients, whose biopsy results were inconsistent with the final clinical diagnosis, 4 presented vertebral metastases, 4 displayed primary vertebral tumors, and 4 presented vertebral infections. The diagnostic rate of the modified PVP OSBF biopsy was 92.5%. The rate of correct biopsy diagnosis for vertebral metastases was 95.8%. The rate of correct diagnosis of primary vertebral tumors and tumor-like biopsy was 91.8%, and the rate of correct diagnosis for vertebral infectious diseases was 63.6%.ConclusionThe modified PVP OSBF allows obtaining more lesion tissue, in multiple directions and multiple angles, during the biopsy of vertebral bones presenting destructive lesions. The technique displays appropriate safety and high diagnostic accuracy and presents a desirable reference value for the preoperative diagnosis of diseases that yield vertebral bone destruction, especially for vertebral tumor lesions.

Radiotherapy alleviates spinal cord compression caused by solitary bone plasmacytoma: A case report.

Introduction and importanceSolitary bone plasmacytoma (SBP) is a hematopoietic malignancy occurring in bone tissue, which often causes bone destruction at the site of the lesion. When the lesion occurs in the spine and causes spinal stenosis and compression of the spinal cord, surgery is performed as an adjuvant treatment before radiotherapy.Case presentationA 36-year-old patient suffered from neck, shoulder and upper limbs pain for 3 weeks and the symptom worsened for 3 days after exercise. CT and MRI examination of the neck after emergency admission revealed C5 vertebral pathological fracture with associated spinal stenosis and spinal cord compression. PET-CT indicated a hypermetabolic soft tissue mass in the C5–6 vertebral body. Granulomatous lesions (tuberculosis) were considered, but neoplastic lesions were not ruled out. The primary diagnosis was cervical fracture caused by tuberculosis. Finally, a needle biopsy was performed at the lesion site and a diagnosis of SBP was made. Radiotherapy was immediately followed and the spinal cord compression was relieved a month later. After 6 months of follow-up, she is now in stable condition with no neck pain or neurological impairment.ConclusionFor patients with SPB resulting in pathological fracture of the cervical vertebra with spinal stenosis and compression of the spinal cord, forgoing surgery and undergoing radiation therapy alone may be an option.

Моделювання варіантів транспедикулярної фіксації грудного відділу хребта при резекції одного-трьох хребців

Актуальність. Патологічні переломи хребців є найбільшим ускладненням пухлинного процесу. Застосування додаткової внутрішньої фіксації металевими імплантатами значно покращує результати лікування й скорочує строки реабілітації хворих. Використання транспедикулярних пристроїв забезпечує стабільну фіксацію й стабільність сегментів хребта навіть при максимальному ступені його нестабільності. Мета: визначення оптимального варіанта протяжності заднього спондилодезу при паліативному та радикальному хірургічному лікуванні пухлин хребта. Матеріали та методи. Для вивчення можливостей стабілізації за допомогою транспедикулярної фіксації при резекції одного-трьох хребців провели експериментальні випробування на препаратах хребта свині. Використовували препарати сегментів грудного відділу хребта від Th3 до Th12 хребців. Вивчали 3 групи моделей: з одним резектованим хребцем Th6, з двома — Th5-Th6 і з трьома — Th5-Th7. Результати. Виявлено, що при резекції одного хребця в грудному відділі хребта транс-педикулярна фіксація за схемами 111х111, 101х101 та 011х110 має однакову ефективність. При резекції двох хребців найкращі стабілізуючі можливості мала конструкція за схемою 111хх111, схеми 101хх101 та 011хх110 показали доволі непогану фіксуючу здатність. При резекції трьох хребців грудного відділу хребта найбільш стабільну фіксацію показала схема 111ххх111. Схема фіксації 001ххх100 виявилась нестабільною при всіх видах резекції хребців. Висновки. Експериментальні дослідження транспедикулярної фіксації при радикальному хірургічному лікуванні пухлин хребта, який включає резекцію одного-трьох хребців, показали, що конструкція відповідає вимогам фіксації, коли кріплення відбувається не менше ніж за два верхніх та два нижніх хребці (можна через один), при резекції трьох хребців найбільш стабільною є конструкція з кріпленням за три верхні та три нижні хребці (без пропусків). Система кріплення за один хребець виявилася неспроможною майже при всіх видах резекції.

Predictive factors, preventive implications, and personalized surgical strategies for bone metastasis from lung cancer: population-based approach with a comprehensive cancer center-based study.

Bone metastasis (BM) and skeletal-related events (SREs) happen to advanced lung cancer (LC) patients without warning. LC-BM patients are often passive to BM diagnosis and surgical treatment. It is necessary to guide the diagnosis and treatment paradigm for LC-BM patients from reactive medicine toward predictive, preventive, and personalized medicine (PPPM) step by step. Two independent study cohorts including LC-BM patients were analyzed, including the Surveillance, Epidemiology, and End Results (SEER) cohort (n = 203942) and the prospective Fudan University Shanghai Cancer Center (FUSCC) cohort (n = 59). The epidemiological trends of BM in LC patients were depicted. Risk factors for BM were identified using a multivariable logistic regression model. An individualized nomogram was developed for BM risk stratification. Personalized surgical strategies and perioperative care were described for FUSCC cohort. The BM incidence rate in LC patients grew (from 17.53% in 2010 to 19.05% in 2016). Liver metastasis was a significant risk factor for BM (OR = 4.53, 95% CI = 4.38-4.69) and poor prognosis (HR = 1.29, 95% CI = 1.25-1.32). The individualized nomogram exhibited good predictive performance for BM risk stratification (AUC = 0.784, 95%CI = 0.781-0.786). Younger patients, males, patients with high invasive LC, and patients with other distant site metastases should be prioritized for BM prevention. Spine is the most common site of BM, causing back pain (91.5%), pathological vertebral fracture (27.1%), and difficult walking (25.4%). Spinal surgery with personalized spinal reconstruction significantly relieved pain and improved daily activities. Perioperative inflammation, immune, and nutrition abnormities warrant personalized managements. Radiotherapy needs to be recommended for specific postoperative individuals. The presence of liver metastasis is a strong predictor of LC-BM. It is recommended to take proactive measures to prevent BM and its SREs, particularly in young patients, males, high invasive LC, and LC with liver metastasis. BM surgery and perioperative management are personalized and required. In addition, adjuvant radiation following separation surgery must also be included in PPPM-guided management. The online version contains supplementary material available at 10.1007/s13167-022-00270-9.