Pre-existing Vertebral Compression Fractures Research Articles

Risk Factors for Adjacent Vertebral Fractures Following Cement Vertebroplasty: The Clinical Significance of Multiple Preexisting Vertebral Compression Fractures.

A retrospective cohort study. The study retrospectively analyzed the factors associated with the development of adjacent vertebral fractures. Adjacent vertebral fractures (AVF) may occur following cement vertebroplasty, and several risk factors have been reported with controversies. A total of 123 patients, with a mean age of 79.2 years, who underwent single-level vertebroplasty were included in the investigation. We systematically collected data encompassing baseline demographics, osteoporosis parameters, surgical details, radiologic measurements, and Hounsfield unit (HU) values in the lumbar spine. Subsequently, univariable, followed by multivariable logistic regression analyses, were employed to identify the risk factors of AVFs. Thirty of 123 patients had AVFs within 6 months following vertebroplasty. The AVF group exhibited a higher percentage of multiple preexisting vertebral compression fractures (P=0.006), a greater volume of injected cement (P=0.032), and a more pronounced reduction in local kyphosis (P=0.007). Multivariable logistic regression analysis revealed multiple preexisting vertebral compression fractures and a reduction in local kyphosis exceeding 8 degrees were independent risk factors for AVFs (P=0.008 and 0.003, respectively), with odds ratios of 3.78 (95% confidence interval: 1.41-10.12) and 4.16 (95% CI: 1.65-10.50), respectively. Subgroup analysis showed that patients with multiple preexisting vertebral compression fractures (VCFs) had significantly lower bone mineral density Z-score, T-score, and HU values compared with those without preexisting VCFs (P<0.05). Conversely, there were no significant differences in T-score or HU values between patients with no VCFs and those with a single VCF. This study demonstrated that both bone strength and local alignment are key factors associated with adjacent vertebral fractures. Specifically, having multiple preexisting vertebral compression fractures and a reduction in local kyphosis exceeding 8 degrees are independent risk factors. The presence of more than one previous vertebral compression fracture serves as a significant clinical indicator of advanced bone density reduction in patients with osteoporosis, offering a quick and straightforward method for identifying high-risk patients. Patients exhibiting these risk factors should be monitored more closely for favorable clinical outcomes. Level III-retrospective nonexperimental study.

Fracture rate after conventional external beam radiation therapy to the spine in multiple myeloma patients

Background ContextConventional external beam radiation therapy (cEBRT) is used in multiple myeloma (MM) to treat severe pain, spinal cord compression, and disease-related bone disease. However, radiation may be associated with an increased risk of vertebral compression fractures (VCFs), which could substantially impair survival and quality of life. Additionally, the use of the Spinal Instability Neoplastic Score (SINS) in MM is debated in MM. PurposeTo determine the incidence of VCFs after cEBRT in patients with MM and to assess the applicability of the SINS score in the prediction of VCFs in MM. Study DesignRetrospective multicenter cohort study. Patient SampleMM patients with spinal myeloma lesions who underwent cEBRT between January 2010 and December 2021. Outcome MeasuresFrequency of new or progressed VCFs and subdistribution hazard ratios for potentially associated factors. MethodsPatient and treatment characteristics were manually collected from the patients’ electronic medical records. Computed tomography (CT) scans from before and up to 3 years after the start of radiation were used to score radiographic variables at baseline and at follow-up. Multivariable Fine and Gray competing risk analyses were performed to evaluate the diagnostic value of the SINS score to predict the postradiation VCF rate. ResultsA total of 127 patients with 427 eligible radiated vertebrae were included in this study. The mean age at radiation was 64 years, and 66.1% of them were male. At the start of radiation, 57 patients (44.9%) had at least one VCF. There were 89 preexisting VCFs (18.4% of 483 vertebrae). Overall, 39 of 127 patients (30.7%) reported new fractures (number of vertebrae (n)=12) or showed progression of existing fractures (n=36). This number represented 11.2% of all radiated vertebrae. Five of the 39 (12.8%) patients with new or worsened VCFs received an unplanned secondary treatment (augmentation [n=2] or open surgery [n=3]) within 3 years. Both the total SINS score (SHR 1.77; 95% confidence interval (CI) 1.54–2.03; p<.001) and categorical SINS score (SHR 10.83; 95% CI 4.20–27.94; p<.001) showed an independent association with higher rates of new or progressed VCFs in adjusted analyses. The use of bisphosphonates was independently associated with a lower rate of new or progressed VCFs (SHR 0.47 [95% CI 0.24–0.92; p=.027]). ConclusionsThis study demonstrated that new or progressed VCFs occurred in 30.7% of patients within 3 years, in a total of 11.2% of vertebrae. The SINS score was found to be independently associated with the development or progression of VCFs and could thus be applied in MM for fracture prediction and possibly prevention.

Vertebral compression fracture after stereotactic ablative radiotherapy in patients with oligometastatic bone lesions from hepatocellular carcinoma.

Stereotactic ablative radiotherapy (SABR) is popularly used to treat bone metastasis. Despite its efficacy, adverse events, including vertebral compression fracture (VCF), are frequently observed. Here, we investigated VCF risk after SABR for oligometastatic vertebral bone metastasis from hepatocellular carcinoma. A total of 84 patients with 144 metastatic bone lesions treated at three institutions between 2009 and 2019 were retrospectively reviewed. The primary endpoint was VCF development, either new or progression of a pre-existing VCF. VCFs were assessed using the spinal instability neoplastic score (SINS). Among 144 spinal segments, 26 (18%) had pre-existing VCF and 90 (63%) had soft tissue extension. The median biologically effective dose (BED) was 76.8Gy. VCF developed in 14 (12%) of 118 VCF-naïve patients and progressed in 20 of the 26 with pre-existing VCF. The median time to VCF development was 6months (range, 1-12months). The cumulative incidence of VCF at 12months with SINS class I, II and III was 0%, 26% and 83%, respectively (p<0.001). Significant factors for VCF development were pre-existing VCF, soft tissue extension, high BED, and SINS class in univariate analysis, and pre-existing VCF in multivariate analysis. Of the six components of SINS, pain, type of bone lesion, spine alignment, vertebral body collapse, and posterolateral involvement were identified as predictors of VCF development. SABR for oligometastatic vertebral bone lesions from HCC resulted in a substantial rate of new VCF development and pre-existing VCF progression. Pre-existing VCF was significant risk factor for VCF development, which require special attention in patient care. Patients with SINS class III should be considered surgical treatment rather than upfront SABR.

Patterns Of Failure After Single Fraction Stereotactic Ablative Radiotherapy (SAbR) With A Simultaneous Integrated Boost (SIB) In The Treatment Of De Novo Spinal Metastases

In spine SAbR, the International Spine Radiosurgery Consortium Consensus Guidelines recommend targeting both the gross tumor volume (GTV) and clinical target volume (CTV) to a single total dose of 16-24 Gy (Cox et al. IJROBP, 2012). However, it is unclear if such a high dose to the CTV is necessary for local control. We hypothesize that a lower dose is sufficient for control of microscopic disease and may decrease risk of toxicity, such as vertebral compression fracture (VCF). This study reports outcomes and analyzes patterns of failure after spine SAbR using a novel dose painting SIB technique. An IRB-approved, retrospective review was performed of 156 de novo spine metastases from 138 patients treated with single-fraction SAbR using a SIB approach from 2014-2019. The most commonly prescribed GTV and CTV doses were 20 Gy (range, 16-25 Gy) and 14 Gy (range, 12-20 Gy), respectively. Pre-existing VCF was present in 19% of cases, and prophylactic vertebroplasty after SAbR was performed in 22% of cases. Competing risk analysis was used to calculate cumulative incidences of local failure (LF) and VCF, with death as a competing risk. LF and VCF were assessed on follow up imaging with VCF defined as new or progression of pre-existing fracture after SAbR. Overall survival (OS) was estimated with Kaplan Meier analysis. Patterns of failure were examined in detail, and all ‘in-field’ failures were further subclassified as failure in the high-dose GTV area alone, low-dose CTV area alone, or in both the low- and high-dose areas. Median follow-up was 11 months. The 1- and 2-year cumulative incidence of LF was 10.7% and 22.6%, respectively, with a median time to LF of 4 months. OS was 68.3% at 1 year and 46.6% at 2 years, with median survival of 23 months. The 1- and 2-year cumulative incidence of VCF was 13.8% and 19.8%, respectively. There were 24 local failures in total. Of these, 18 (75%) were in-field, 5 (21%) were marginal/epidural, and 2 (4%) were outside the treated area. Of the in-field failures, 3 recurred only in the high-dose GTV area, 5 recurred only in the low-dose CTV area, and 12 were equivocal, with recurrence in both the low- and high-dose areas. For those who failed only in the low-dose area, the median isodose line at which failure occurred was 73% or 14.6 Gy (range, 70-95%). Single fraction spine SAbR using a dose painting SIB technique results in good overall local control and low rates of VCF. The patterns of local failure suggest that although rare overall, in-field failures are most common, with the majority of these occurring in the lower dose CTV. It is plausible that some of these failures may have been prevented with higher doses, at the risk of higher toxicity. Further study is needed to compare outcomes with the SIB technique described above to those with standard single-dose spine SAbR.

Vertebral Fractures Following Stereotactic Body Radiotherapy for Spine Oligometastases: A Multi-institutional Analysis of Patient Outcomes

AimsStereotactic body radiotherapy (SBRT) is a locally ablative therapy used for the treatment of patients with spine metastases. However, it is associated with higher rates of vertebral compression fractures (VCF) than conventionally fractionated palliative radiotherapy. The purpose of this study was to determine the rate of VCF following spine SBRT and to identify the risk factors associated with this outcome. Materials and methodsWe retrospectively reviewed patients treated at two Australian institutions from January 2015 to March 2019. Descriptive statistics were used to assess patient, tumour and treatment factors. The Log-rank test and Cox proportional hazards model were applied in univariate and multivariable analyses to identify factors associated with VCF, local control and overall survival. ResultsWe evaluated 113 spinal segments from 84 patients, with a median follow-up time of 11.9 months. The median dose and fractionation utilised was 30 Gy in three fractions (67.3%), with a single-fraction rate of 0.9%. The median Spinal Instability Neoplastic Score (SINS) of the lesions was 4/18, with most (84.1%) being SINS stable, scoring between 0 and 6. Five VCFs were observed (three progression of pre-existing fractures and two de novo), a cumulative VCF risk of 4.4%. Four of five fractures occurred within the first year after treatment, with a median time to VCF of 9.2 months. A pre-existing VCF (P = 0.011) was associated with subsequent fracture on multivariable analysis, whereas all VCF segments displayed lytic disease appearance. All fractures were managed conservatively with analgesia, without requirement for subsequent surgical intervention. ConclusionSBRT to spine metastases is safe with respect to VCF, with rates around the lower limit observed in similar studies. Knowledge of factors that predispose to post-treatment fracture, such as pre-existing compression, lytic vertebral disease and SINS >6 will aid in the counselling and selection of patients for this therapy.

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.

Volumetric Dosimetry Analysis of Vertebral Compression Fracture Risk Following Spine Stereotactic Body Radiation Therapy

Spine stereotactic body radiotherapy (SBRT) has offered improved tumor response and palliation in treating spinal metastases. However, risk of vertebral compression fracture (VCF) following spine SBRT has been reported in 15-20% of patients. Dose per fraction has been found to be an important risk factor for the development of VCF. However, vertebral body dosimetry and its effect on risk for VCF is unknown. We performed detailed volumetric analysis of vertebral body dosimetry and its association with VCF. We utilized our institutional database to identify eligible patients for this study. We included patients who underwent single fraction spine SBRT who had at least a one month follow-up. Exclusion criteria included patients with sacral involvement, prior in-field spine SBRT treatment as well hardware at the site of spine SBRT. We identified 44 consecutive treatments that met criteria for inclusion. The primary outcome was de novo or progression of VCF. Each treated vertebral body was contoured using the simulation CT. Dosimetric endpoints included mean dose, maximum dose, minimum dose, percentage of vertebral body receiving >18 Gy, > 20 Gy, and >22 Gy. Dosimetric endpoints were correlated with the occurrence of VCF using the Wilcoxon rank-sum test. Eighty-four spinal segments (10 cervical, 49 thoracic, 25 lumbar) from 44 treatments were included in the analysis. Ten segments (12%) had either a new VCF or progression of pre-existing VCF. Median treatment dose was 16 Gy (range, 14-18 Gy). Median follow-up was 13 months (range, 1-23). The average mean vertebral body dose for spinal segments that developed VCF was 19.0 Gy vs. 17.5 Gy for spinal segments without VCF (p=0.21). The average maximum/minimum vertebral body dose was 21.6 Gy/12.0 Gy for spinal segments with VCF and 20.6 Gy/10.6 Gy for spinal segments without VCF (p=0.33). The average proportion of vertebral body receiving >18 Gy, >20 Gy and >22 Gy for spinal segments with VCF/without VCF was 70.5%/56.7% (p=0.26), 29.7%/22.5% (p=0.62), 8.7%/6.7% (p=0.27), respectively. None of the patients in this series required kyphoplasty and there were no grade ≥2 toxicities. This study is suggestive that spinal segments that developed VCF had higher maximum and minimum dose as well as a greater proportion of the vertebral body receiving >18 Gy in a single fraction. Although not significant in our small series, our findings corroborate previous studies that show that doses >18 Gy per fraction to the vertebral body increase the risk for developing a VCF. Our data further adds that the proportion of vertebral body receiving >18 Gy may also be an important predictor for the development of VCF. Given small patient numbers, additional data is required to further establish this relationship.

Stereotactic ablative body radiotherapy for spinal metastasis from hepatocellular carcinoma: its oncologic outcomes and risk of vertebral compression fracture.

Spinal metastases from hepatocellular carcinoma (HCC) require high-dose irradiation for durable pain and tumor control. Stereotactic ablative body radiotherapy (SABR) enables the delivery of high-dose radiation. However, but vertebral compression fracture (VCF) can be problematic. The aim of his study is to evaluate the outcome and risk of VCF after SABR for spinal metastasis from HCC. We retrospectively reviewed 33 lesions in 42 spinal segments from 29 patients who received SABR with 1 fraction (16-20 Gy), or 3 fractions (18-45 Gy) from September 2009 to January 2015. The 1-year local control (LC) rate was 68.3%. Radiographic grade of cord compression (RGCC) was the only independent prognostic factor associated with LC (P = 0.007). The 1-year ultimate LC rate including the outcome of salvage re-irradiation was 87.2%. The pain response rate was 73.3% according to the categories of the International Bone Metastases Consensus Group. The 1-year VCF-free rate was 71.5%. Pre-existing VCF (P < 0.001) and only-lytic change (P = 0.017) were associated with a higher post-SABR VCF rate. One-third of post-SABR VCFs required interventions. SABR for spinal metastases from HCC provided efficacious LC, especially for lesions with RGCC ≤ II, and showed effective and durable pain relief. As VCF after SABR occurred frequently for vertebral segments with pre-existing VCF and only-lytic change, early preventive vertebroplasty is considerable for those high-risk vertebral segments.

Clinical outcome of vertebral compression fracture after single fraction spine radiosurgery for spinal metastases.

Vertebral compression fracture (VCF) occurs after stereotactic body radiation therapy (SBRT) for spine metastasis. Recently, single fraction radiosurgery (sfSRS) is used more frequently. The aim of this study is to determine the clinical outcome of VCF after sfSRS. Spinal instability neoplastic score (SINS) criteria were used to retrospectively score 143 consecutive vertebral segments in 79 patients treated with SRS. Follow-up MRI, pain, and neurologic assessments obtained every 3-6months. Pain also scored at 7, 14, and 30days after sfSRS. Follow up was 16±18months ±SD, range 3-78. Long-term radiographic control occurred in 94% of cases. Pain improvement resulted within 7days in 100% of cases with severe pain and sustained long-term in 95%. VCF occurred in 21% of segments: 30% were de novo VCF. The overall 1year fracture free probability (1yFFP) was 76%. Pre-existing VCF resulted in higher probability to progress: 1yFFP 90 versus 60%. Symptoms presented in 6% of cases with de novo VCF and 39% with progressive. The former were treated with vertebral augmentation (VA), the latter with open surgery. Surgery/VA prior to SRS did not change risk of progressive VCF. Univariate but not multivariate analysis identified histology (colorectal), pre-existing VCF, and pain (severe) as significant predictors of VCF. In conclusion, sfSRS compares favourably to SBRT for radiographic and pain control with similar VCF risk. Patients with pre-existing VCF have a higher probability to progress, become symptomatic, and require surgery. These results may help discussing risk and benefits with patients undergoing sfSRS for spinal metastasis and developing new treatment algorithms.

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.

Clinical Features of Percutaneous Hemivertebroplasty in Patients with Osteoporotic Vertebral Compression Fractures

Objective: Unilateral percutaneous vertebroplasty is a widely accepted treatment for osteoporotic vertebral compression fractures (VCFs). However, bone cement may fail to fill both hemivertebra from the single needle. We assessed the radiographic and clinical outcome of hemivertebroplasty (HVP) and evaluated the factors that affect subsequent VCFs after HVP. Methods: Fifty two patients who underwent HVP were reviewed. VCFs were identified based on clinical and radiological findings. The patients were grouped into two groups : 1) no subsequent VCFs, 2) subsequent VCFs. We evaluated the association between age, sex, body mass index (BMI) and bone mineral density (BMD) and subsequent VCFs. We also assessed the impact of location, type and grade of fracture, endplate fracture, burst fracture, bone cement volume on subsequent VCFs. We analyzed the compression ratio, wedge angle, kyphotic angle, and visual analogue scale (VAS) score in both groups. Results: There were no significant differences in age, gender, BMI, and BMD between two groups. No significant differ ence was also found in pre-existing VCF, location, type and grading of fracture, endplate fracture, burst fracture, amount of bone cement, and radiological findings such as compression ratio, wedge angle, and kyphotic angle between two groups. The final mean VAS scores of patients with or without subsequent VCFs were 3.11 and 4.02, respectively. Conclusion: No major risk factors for the subsequent VCFs after HVP were found. However, we identified adjacent frac tures, refractures, and remote fractures after HVP in chronological order. Therefore, long-term follow-up is necessary to evaluate the effectiveness of HVP to osteoporotic VCFs. (Korean J Neurotrauma 2013;9:17-22)

Vertebral compression fracture risk after stereotactic body radiotherapy for spinal metastases

The aim of this study was to identify potential risk factors for and determine the rate of vertebral compression fracture (VCF) after intensity-modulated, near-simultaneous, CT image-guided stereotactic body radiotherapy (SBRT) for spinal metastases. The study group consisted of 123 vertebral bodies (VBs) in 93 patients enrolled in prospective protocols for metastatic disease. Data from these patients were retrospectively analyzed. Stereotactic body radiotherapy consisted of 1, 3, or 5 fractions for overall median doses of 18, 27, and 30 Gy, respectively. Magnetic resonance imaging studies, obtained at baseline and at each follow-up, were evaluated for VCFs, tumor involvement, and radiographic progression. Self-reported average pain levels were scored based on the 11-point (0-10) Brief Pain Inventory both at baseline and at follow-up. Obesity was defined as a body mass index ≥ 30. The median imaging follow-up was 14.9 months (range 1-71 months). Twenty-five new or progressing fractures (20%) were identified, and the median time to progression was 3 months after SBRT. The most common histologies included renal cancer (36 VBs, 10 fractures, 10 tumor progressions), breast cancer (20 VBs, 0 fractures, 5 tumor progressions), thyroid cancer (14 VBs, 1 fracture, 2 tumor progressions), non-small cell lung cancer (13 VBs, 3 fractures, 3 tumor progressions), and sarcoma (9 VBs, 2 fractures, 2 tumor progressions). Fifteen VBs were treated with kyphoplasty or vertebroplasty after SBRT, with 5 procedures done for preexisting VCFs. Tumor progression was noted in 32 locations (26%) with 5 months' median time to progression. At the time of noted fracture progression there was a trend toward higher average pain scores but no significant change in the median value. Univariate logistic regression showed that an age > 55 years (HR 6.05, 95% CI 2.1-17.47), a preexisting fracture (HR 5.05, 95% CI 1.94-13.16), baseline pain and narcotic use before SBRT (pain: HR 1.31, 95% CI 1.06-1.62; narcotic: HR 2.98, 95% CI 1.17-7.56) and after SBRT (pain: HR 1.34, 95% CI 1.06-1.70; narcotic: HR 3.63, 95% CI 1.41-9.29) were statistically significant predictors of fracture progression. On multivariate analysis an age > 55 years (HR 10.66, 95% CI 2.81-40.36), a preexisting fracture (HR 9.17, 95% CI 2.31-36.43), and baseline pain (HR 1.41, 95% CI 1.05-1.9) were found to be significant risks, whereas obesity (HR 0.02, 95% CI 0-0.2) was protective. Stereotactic body radiotherapy is associated with a significant risk (20%) of VCF. Risk factors for VCF include an age > 55 years, a preexisting fracture, and baseline pain. These risk factors may aid in the selection of which spinal SBRT patients should be considered for prophylactic vertebral stabilization or augmentation procedures. Clinical trial registration no.: NCT00508443.

Repeated and Multiple New Vertebral Compression Fractures After Percutaneous Transpedicular Vertebroplasty

A retrospective study to detect patients with new-onset compression fractures following vertebroplasty. To investigate the characteristics and associated risk factors of new-onset vertebral compression fractures after vertebroplasty. Percutaneous vertebroplasty is a well-established technique for treating osteoporotic compression fractures. Short-term results are promising, but longer-term studies have suggested a possible accelerated failure rate in the adjacent vertebral body. METHODS.: We retrospectively reviewed patients with osteoporotic compression fractures from January 2000 to June 2006. The patients received percutaneous vertebroplasty with bone cement augmentation. Long-term follow-up radiographically identified the occurrence of vertebral fracture (minimum follow-up 24 months) after an initial vertebral fracture. In 852 patients (1131 vertebrae), 58.8% to 63.8% of new compression fractures after vertebroplasty were adjacent compression fractures. Adjacent fractures occurred much sooner than nonadjacent fractures; (71.9 +/- 71.8 days vs. 286.8 +/- 232.8 days, P < 0.001). In patients who experienced vertebral compression fractures 2 or more times, older age, lower baseline bone mineral density (BMD), and more pre-existing vertebral compression fractures were demonstrated in this study (P < 0.005). The gender and amount of cemented polymethyl methacrylate were not statistically different between Groups A (1 vertebral compression fracture) and B (vertebral compression fracture > or =2 times). New-onset vertebral compression fractures occurred repeatedly within a few years after vertebroplasty. New-onset adjacent-level fractures occurred sooner and were more predominate than nonadjacent level fractures. The results of this study suggest that older patient age, lower baseline BMD, and more pre-existing vertebral fractures were found to be risk factors for multiple vertebral compression fractures.

The Risk of New Osteoporotic Vertebral Compression Fractures in the Year after Percutaneous Vertebroplasty

To prospectively assess the incidence, location, and possible causative mechanisms of new vertebral compression fractures (VCFs) in 66 symptomatic patients with osteoporotic VCFs treated with percutaneous vertebroplasty (PV) and to study the relation between new VCFs and back pain symptoms. Sixty-six patients with 102 painful symptomatic VCFs were treated with PV. All patients had baseline total spinal magnetic resonance (MR) imaging. Follow-up MR imaging was performed at 3, 6, and 12 months to locate new VCFs. Visual analog scales for pain and pain medication consumption were used to assess clinical outcomes. The following characteristics were compared in patients with new VCFs after PV versus patients without new VCFs: patient age, sex, presence of secondary osteoporosis, bone mineral density, number of preexisting VCFs, shape and grade of VCFs, type of bone cement used for PV, volume of injected cement, and cement leakage in intervertebral disc spaces. Sixteen of 66 patients had 26 new VCFs during 1 year of follow-up after PV. Most new VCFs occurred within 3 months of PV, half of new VCFs appeared in levels adjacent to treated levels, and half of the new VCFs were symptomatic. The presence of more than two preexisting VCFs was the only independent risk factor for the development of a new VCF. New VCFs occurred after PV in 24% of patients. Half of new VCFs occurred in levels adjacent to treated levels and half were symptomatic. The presence of more than two preexisting VCFs was the only independent risk factor for the development of a new VCF.