Reduction In Vertebral Body Height Research Articles

Surgery versus conservative management of stable thoracolumbar fracture: the PRESTO feasibility RCT.

There is informal consensus that simple compression fractures of the body of the thoracolumbar vertebrae between the 10th thoracic vertebra and the second lumbar vertebra without neurological complications can be managed conservatively and that obvious unstable fractures require surgical fixation. However, there is a zone of uncertainty about whether surgical or conservative management is best for stable fractures. To assess the feasibility of a definitive randomised controlled trial comparing surgical fixation with initial conservative management of stable thoracolumbar fractures without spinal cord injury. External randomised feasibility study, qualitative study and national survey. Three NHS hospitals. A feasibility randomised controlled trial using block randomisation, stratified by centre and type of injury (high- or low-energy trauma) to allocate participants 1 : 1 to surgery or conservative treatment; a costing analysis; a national survey of spine surgeons; and a qualitative study with clinicians, recruiting staff and patients. Adults aged ≥ 16 years with a high- or low-energy fracture of the body of a thoracolumbar vertebra between the 10th thoracic vertebra and the second lumbar vertebra, confirmed by radiography, computerised tomography or magnetic resonance imaging, with at least one of the following: kyphotic angle > 20° on weight-bearing radiographs or > 15° on a supine radiograph or on computerised tomography; reduction in vertebral body height of 25%; a fracture line propagating through the posterior wall of the vertebra; involvement of two contiguous vertebrae; or injury to the posterior longitudinal ligament or annulus in addition to the body fracture. Surgical fixation: open spinal surgery (with or without spinal fusion) or minimally invasive stabilisation surgery. Conservative management: mobilisation with or without a brace. Recruitment rate (proportion of eligible participants randomised). Twelve patients were randomised (surgery, n = 8; conservative, n = 4). The proportion of eligible patients recruited was 0.43 (95% confidence interval 0.24 to 0.63) over a combined total of 30.7 recruitment months. Of 211 patients screened, 28 (13.3%) fulfilled the eligibility criteria. Patients in the qualitative study (n = 5) expressed strong preferences for surgical treatment, and identified provision of information about treatment and recovery and when and how they are approached for consent as important. Nineteen surgeons and site staff participated in the qualitative study. Key themes were the lack of clinical consensus regarding the implementation of the eligibility criteria in practice and what constitutes a stable fracture, alongside lack of equipoise regarding treatment. Based on the feasibility study eligibility criteria, 77% (50/65) and 70% (46/66) of surgeons participating in the survey were willing to randomise for high- and low-energy fractures, respectively. Owing to the small number of participants, there is substantial uncertainty around the recruitment rate. A definitive trial is unlikely to be feasible currently, mainly because of the small number of patients meeting the eligibility criteria. The recruitment and follow-up rates were slightly lower than anticipated; however, there is room to increase these based on information gathered and the support within the surgical community for a future trial. Development of consensus regarding the population of interest for a trial. Current Controlled Trials ISRCTN12094890. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 62. See the NIHR Journals Library website for further project information.

Bone-vessels relationships: association between calcifications of the iliac arteries with vertebral fractures in hemodialysis patients – results from the VIKI study

Abstract Background Vascular calcification and fragility fractures are common age-related disorders, associated with high morbidity and mortality especially in end-stage renal disease. Skeletal disorders occur in dialysis patients. Few studies have provided data on the prevalence of vertebral fractures (VF) and their association with large artery calcifications. Purpose We evaluated the relationship of iliac arteries calcifications (IACs) and abdominal aorta calcifications (AACs) with the risk for VFs in hemodialysis (HD) patients. Methods The VIKI Study is a cross-sectional study involving 387 HD patients from 18 Italian dialysis centers, assessing demographic, clinical and biochemical data in such patients. Biochemical data included bone health markers such as vitamin K levels, vitamin K-dependent proteins, vitamin 25(OH)D, alkaline phosphatase, parathormone, calcium, phosphate, Bone Gla Protein and Matrix Gla Protein. The presence of VF, IACs and AACs were determined through standardized radiograms of the spine. A >20% reduction of vertebral body height was considered a VF. We quantified vascular calcifications by measuring the length of calcium deposits along the abdominal arteries, classifying the degree of severity for the IACs and AACs with a specific score (mild: 0.1–3 cm; moderate: 3.1–5 cm; and severe >5 cm) previously validated for AACs. Results The prevalence of IACs was 56.1%, and of AACs 80.6%. After adjusting for confounding variables, the presence of IACs was associated with 73% higher odds of VF (p=0.028), whereas we found no association (p=0.294) for AACs. The presence of IACs associated with VF irrespective of calcification severity. Patients with IACs had lower levels of the vitamin K2, menaquinone 7 (0.99 vs 1.15 ng/ml; p=0.003), and deficiency of this marker became greater when adjusting for triglyceride levels (0.57 vs 0.87 ng/ml; p<0.001). Conclusions The presence of IACs, regardless of their extent, appears to be a clinically relevant risk factor for VFs. The association is further enhanced by including vitamin K, a main player in bone and vascular health, in the model. Prospective studies are needed to confirm these findings both in chronic kidney disease patients and in the general population. Funding Acknowledgement Type of funding sources: None.

The Vessels-Bone Axis: Iliac Artery Calcifications, Vertebral Fractures and Vitamin K from VIKI Study.

Vascular calcification and fragility fractures are associated with high morbidity and mortality, especially in end-stage renal disease. We evaluated the relationship of iliac arteries calcifications (IACs) and abdominal aortic calcifications (AACs) with the risk for vertebral fractures (VFs) in hemodialysis patients. The VIKI study was a multicenter cross-sectional study involving 387 hemodialysis patients. The biochemical data included bone health markers, such as vitamin K levels, vitamin K-dependent proteins, vitamin 25(OH)D, alkaline phosphatase, parathormone, calcium, and phosphate. VF, IACs and AACs was determined through standardized spine radiograms. VF was defined as >20% reduction of vertebral body height, and VC were quantified by measuring the length of calcium deposits along the arteries. The prevalence of IACs and AACs were 56.1% and 80.6%, respectively. After adjusting for confounding variables, the presence of IACs was associated with 73% higher odds of VF (p = 0.028), whereas we found no association (p = 0.294) for AACs. IACs were associated with VF irrespective of calcification severity. Patients with IACs had lower levels of vitamin K2 and menaquinone 7 (0.99 vs. 1.15 ng/mL; p = 0.003), and this deficiency became greater with adjustment for triglycerides (0.57 vs. 0.87 ng/mL; p < 0.001). IACs, regardless of their extent, are a clinically relevant risk factor for VFs. The association is enhanced by adjusting for vitamin K, a main player in bone and vascular health. To our knowledge these results are the first in the literature. Prospective studies are needed to confirm these findings both in chronic kidney disease and in the general population.

Effect of the metastatic defect on the structural response and failure process of human vertebrae: An experimental study

BackgroundPathologic vertebral fractures are associated with intractable pain, loss of function and high morbidity in patients with metastatic spine disease. However, the failure mechanisms of vertebrae with lytic defects and the failed vertebrae's ability to retain load carrying capacity remain unclear. MethodsEighteen human thoracic and lumbar vertebrae with simulated uncontained bone defects were tested under compression-bending loads to failure. Failure was defined as 50% reduction in vertebral body height. The vertebrae were allowed to recover under load and re-tested to failure using the initial criteria. Repeated measure ANOVA was used to test for changes in strength and stiffness parameters. FindingsVertebral failure occurred via buckling and fracture of the cortex around the defect, followed by collapse of the defect region. Compared to the intact vertebrae, the failed vertebrae exhibited a significant loss in compressive strength (59%, p<0.001), stiffness (53%, p<0.05) and flexion (70%, p<0.01) strength. Significant reduction in anterior-posterior shear (strength (63%, p<0.01) and stiffness (67%, p<0.01)) and lateral bending strength (134%, p<0.05) were similarly recorded. In the intact vertebrae, apart from flexion strength (r2=0.63), both compressive and anterior-posterior shear strengths were weakly correlated with their stiffness parameters (r2=0.24 and r2=0.31). By contrast, in the failed vertebrae, these parameters were strongly correlated, (r2=0.91, r2=0.86, and r2=0.92, p<0.001 respectively). InterpretationFailure of the vertebral cortex at the defect site dominated the initiation and progression of vertebral failure with the vertebrae failing via a consolidation process of the vertebral bone. Once failed, the vertebrae showed remarkable loss of load carrying capacity.

Myeloma Presenting as Paraparesis: A Case Report

Aim: To highlight the need to consider multiple myeloma as a probable diagnosis while evaluating a patient presenting with paraparesis and backache. Presentation of Case: A 55 year old woman presented to a hospital in Calabar, Nigeria with complaints of low back pain and progressive difficulty in walking for three months. There was associated constipation and weight loss. She had received two units of whole blood prior to presentation on account of severe anaemia. Physical examination revealed marked cachexia, pallor, dehydration and oral candidiasis. There was bilateral lower extremity weakness and exaggerated deep tendon reflexes. Investigation revealed anaemia, elevated erythrocyte sedimentation rate, hypoalbuminemia and increased serum globulin. Corrected serum calcium and uric acid were also elevated. Radiographic studies revealed generalized osteopenia and gross reduction in vertebral body height of T6, T9, T11 and L2 with lytic lesions on the ribs and skull. She was managed with blood transfusions and cycles of systemic chemotherapy comprising of vincristine, adriamycin and dexamethasone and referred for radiotherapy. Discussion: This case posed a diagnostic challenge. The presenting complaints suggested a compressive myelopathy which is more commonly caused by tuberculosis in our setting. Other considerations were benign or malignant tumours, HTLV-1 associated myelopathy/tropical spastic paraparesis (HAM/TSP) and neurolathyrism. Conclusion: In the evaluation of a patient with paraparesis and backache, multiple Case Study British Journal of Medicine & Medical Research, 4(15): 3016-3021, 2014 3017 myeloma should be considered. Failure to investigate for multiple myeloma will lead to delays in diagnosis and treatment. Early diagnosis can be made by demonstrating M proteins in either serum or urine, and showing more than 10% of these malignant plasma cells in the bone marrow.

Sub-NOAEL amounts of vinclozolin and xenoestrogens target rat chondrogenesis in vivo

Several endocrine disrupting compounds (EDC) elicit skeletal dysgenesis at pharmacological doses. We have investigated the impact of doses below the "No Observed Adverse Effect" (NOAEL) for vinclozolin (V), an anti-androgenic fungicide, alone or associated with xenoestrogens (Genistein, G and bisphenol-A, BPA). V, G, BPA and their combinations were administered orally to female Wistar rats during gestation and lactation. F1 and F2 offspring were investigated for skeletal anomalies at post-natal days 30, 110 (d30, d110). Skeletal development was monitored by measuring caudal vertebrae and long bones dimensions by X-ray micro-CT-scan. A significant increase in Inter Transverse Apophysis (ITA) distance at the upper head of caudal vertebrae, associated with a reduction in vertebral body height was observed in treated F1 females, but not males. Histometrical analysis of vertebral body growth plate cartilage was performed on serial sections of caudal vertebrae. F1 females but not males showed a diminution in growth plate thickness, with greater impact on the hypertrophic zone. All effects were maximal at d30. Effects on ITA width persisted until d110 while effects on growth plate disappeared. These effects were essentially vinclozolin or BPA-dependent. F2 animals were not affected. Our data suggest that vinclozolin and xenoestrogens act as cartilage developmental disruptors. We suggest that present NOAEL values for these compounds, and EDC at large, might be reconsidered using gestational exposure models. Finally, micro CT-scan appears a valuable non-invasive technique to detect EDC effects on live fauna.

Prevalence and risk factors of vertebral fracture in female Japanese patients with systemic lupus erythematosus

Objective We examined the prevalence and risk factors of vertebral fracture in female Japanese patients with systemic lupus erythematosus (SLE).Methods We performed lateral radiographs of the thoracic and lumbar spine and bone mineral density (BMD) measurements and collected demographic, lifestyle, clinical, and treatment characteristics of 52 SLE patients. Vertebral fractures were defined as a >20 % reduction of vertebral body height. Odds ratios (ORs) and their 95 % confidence intervals (CIs) were computed to assess the strength of associations between vertebral fractures and selected factors among SLE patients.Results At least one vertebral fracture was detected in 50 % of SLE patients. A history of previous bone fracture was significantly associated with an increased risk of vertebral fractures among SLE patients (adjusted OR = 14.8, 95 % CI = 1.62–134; P = 0.017). Daily use of tea or coffee was marginally associated with a decreased risk of vertebral fractures among SLE patients (adjusted OR = 0.11, 95 % CI = 0.01–1.01; P = 0.051).Conclusion The high prevalence of vertebral fracture in SLE patients (50 %) indicates that we need to assess the lateral spine radiograph in more female Japanese SLE patients regardless of BMD and use of corticosteroids, although additional studies are warranted to confirm the findings suggested in this study.

Type 2 Diabetes is Associated with Vertebral Fractures in a Sample of Clinic- and Hospital-Based Latinos

Latinos are the fastest growing ethnic population in the United States and type 2 diabetes is a major health burden in this population, but little effort has been made to study the prevalence of diabetic vertebral fragility in Latinos. We performed a cross-sectional study to determine vertebral fracture prevalence in a hospital-based population of South Texas residents (N = 296). We defined fractures in X-rays as a >20% reduction in vertebral body height. Numerous variables were recorded, including age, body mass index, indicators of diabetes management and others. 71% of the sample (N = 296) was Latino. The prevalence of vertebral fracture was increased in diabetic subjects relative to non-diabetic subjects (diabetic 27.9%, non-diabetic 13.8%) and, regardless of sex and diabetics status, decreased in Latinos relative to non-Latinos (Latino 16.7%, non-Latino 26.4%). These data suggest that vertebral fractures may be a growing concern for diabetic Latinos as well as diabetics of any racial/ethnic background.

Early diagnosis of vertebral fractures.

Vertebral fractures are a common clinical entity, caused by trauma or related to osteoporosis (benign). Their recognition is especially important in the post-menopausal female population but also important is their differentiation from pathological (malignant) fractures (1). A vertebral fracture is evidenced by vertebral body deformity or reduction in vertebral body height beyond a certain threshold value in the absence of bone discontinuity. For prognosis and treatment it is extremely important to recognize the cause of the fracture. In contrast to fractures that occur in other locations, vertebral fractures often go unrecognized in the acute phase as the pain may be transient and radiographic and evaluation of the spine may be difficult (2). Objective measurement of the vertebral deformity provides invaluable information to the interpreting physician and helps grade fracture severity. The recognition and diagnosis of vertebral fractures can be performed using additional diagnostic tools.

Prevalence and risk factors of vertebral fracture in female Japanese patients with systemic lupus erythematosus

We examined the prevalence and risk factors of vertebral fracture in female Japanese patients with systemic lupus erythematosus (SLE). We performed lateral radiographs of the thoracic and lumbar spine and bone mineral density (BMD) measurements and collected demographic, lifestyle, clinical, and treatment characteristics of 52 SLE patients. Vertebral fractures were defined as a >20% reduction of vertebral body height. Odds ratios (ORs) and their 95% confidence intervals (CIs) were computed to assess the strength of associations between vertebral fractures and selected factors among SLE patients. At least one vertebral fracture was detected in 50% of SLE patients. A history of previous bone fracture was significantly associated with an increased risk of vertebral fractures among SLE patients (adjusted OR = 14.8, 95% CI = 1.62-134; P = 0.017). Daily use of tea or coffee was marginally associated with a decreased risk of vertebral fractures among SLE patients (adjusted OR = 0.11, 95% CI = 0.01-1.01; P = 0.051). The high prevalence of vertebral fracture in SLE patients (50%) indicates that we need to assess the lateral spine radiograph in more female Japanese SLE patients regardless of BMD and use of corticosteroids, although additional studies are warranted to confirm the findings suggested in this study.

Vitamin K, vertebral fractures, vascular calcifications, and mortality: VItamin K Italian (VIKI) dialysis study

Vitamin K (vitamin K1 or phylloquinone and vitamin K2, a series of menaquinones [MKs]) is involved in the production of bone and matrix amino acid γ-carboxy-glutamic acid (Gla) proteins, regulating bone and vascular calcification. Low vitamin K concentrations are associated with increased risks of fractures and vascular calcification, and frequent complications in hemodialysis patients. We carried out an observational study to establish the prevalence of vitamin K deficiency and to assess the relationship between vitamin K status, vertebral fractures, vascular calcification, and survival in 387 patients on hemodialysis for ≥1 year. We determined plasma levels of vitamin K compound, bone-Gla-protein, matrix-Gla-protein, and routine biochemistry. Vertebral fractures (reduction in vertebral body height by ≥20%) and aortic and iliac calcifications were also investigated in a spine (D(5) -L(4)) radiograph. Three-year patient survival was analyzed. Important proportions of patients had deficiency of MK7 (35.4%), vitamin K1 (23.5%), and MK4 (14.5%). A total of 55.3% of patients had vertebral fractures, 80.6% had abdominal aorta calcification, and 56.1% had iliac calcification. Vitamin K1 deficiency was the strongest predictor of vertebral fractures (odds ratio [OR], 2.94; 95% confidence interval [CI], 1.38-6.26). MK4 deficiency was a predictor of aortic calcification (OR, 2.82; 95% CI, 1.14-7.01), whereas MK5 deficiency actually protected against it (OR, 0.38; 95% CI, 0.15-0.95). MK7 deficiency was a predictor of iliac calcification (OR, 1.64; 95% CI, 1.03-2.60). The presence of vertebral fractures was also a predictor of vascular calcifications (OR, 1.76; 95% CI, 1.00-3.08). Increased alkaline phosphatase and C reactive protein (CRP), age, and cerebrovascular events were predictors of mortality. Our study suggests that the vitamin K system may be important for preserving bone mass and avoiding vascular calcification in hemodialysis patients, pointing out a possible role of vitamin K in bone and vascular health. Based on our results, we suggest that the general population should also be studied for vitamin K deficiency as a possible cause of both vertebral fractures and vascular calcification.

Severity of vertebral fracture and risk of hip fracture: a nested case–control study

Severe vertebral fractures strongly predicted subsequent hip fracture in this population-based study. Such high-risk patients should be provided with clinical evaluation and care for osteoporosis. Vertebral fractures are commonly osteoporotic and known to predict hip fracture. The aim of this study was to evaluate associations between the severity of vertebral fractures and the risk of subsequent hip fracture. Chest radiographs were obtained of 7,095 Finnish men and women aged 30years or over in the Mini-Finland Health Survey in 1978-1980. Record linkage to the National Hospital Discharge Register identified 182 subjects from the survey who had subsequently been hospitalized for primary treatment of hip fracture by the end of 1994. A nested case-control setting was adopted, where three controls individually matched for age, gender, and place of residence were drawn for 169 subjects with hip fracture from the same cohort. Baseline vertebral fractures were identified at levels T3 to T12, and their morphology was categorized to mild, moderate, or severe according to Genant's classification. Severe vertebral fracture (>40% reduction in vertebral body height) strongly predicted hip fracture. After controlling for education, physical activity, smoking, alcohol consumption, and self-rated general health, the adjusted relative odds was 12.06 (95% confidence interval, 3.80-38.26). Mild to moderate fracture grades and the number of compressed vertebral bodies showed no prediction for hip fracture. The presence of a severe vertebral fracture in the thoracic spine strongly predicts subsequent hip fracture. Such high-risk patients should be clinically evaluated and provided with care for osteoporosis and measures to reduce the risk of falling as required.

Lumbar bone density. Risk factor for vertebral fractures in women

The direct connections between a reduction in bone density and an increase in the incidence of fractures with increasing age is well known. When interpreting bone density measurements the attending physician is confronted with an overlap of false-positive and false-negative parameters, as is also the case with biochemical data. Aim of this study was to determine, in addition to bone density, a fracture threshold, i.e. a value for bone density with maximal sensitivity and specificity, in a representative cohort of women. 534 healthy women (mean age 60.9 +/- 8.07, range 40-83 years), seen in an out-patient osteological clinic between 1993 and 1996 were included. After full biochemical investigation to exclude a metabolic bone disease, bone density (LBD) of the lumbar vertebrae 1-5 and the number of vertebral body fractures were documented, together with age and menopausal status. LBD was measured by quantitative computed tomography (qCT), results being analysed with the Wilcoxon 2-sample test and logistic regression and assessed by receiver operating characteristics (ROC) analysis. None of the women with a qCT value over 111 mg/cc had evidence of vertebral fractures. Those with values under 60 mg/cc had at least one vertebral fracture (defined as at least 15% reduction in vertebral body height). There was a highly significant negative correlation between age and LBD (r = -0.56; P < 0.0001), as well as between LBD and the number of fractured vertebrae (r = -0.58, P < 0.0001). But there was no longer any correlation between age and number of vertebral body fractures once allowance was made for LBD (r = 0.001, not significant). The least overlap of false-positive and false-negative values was at an LBD with qCT values of 102 mg/cc. LBD is the determining variable for fracture risk independent of age. Despite an overlap of false-positive and false-negative LBD values, the probability of fractures can be predicted from bone mineral content.

Platyspondyly in treated beta-thalassemia

Flattening of the vertebral bodies with a platyspondyly appearance is described in 14 patients selected for evaluation of short stature from 106 patients affected by thalassemia major, who received an intensive transfusion regimen combined with continuous chelation therapy. The vertebral body height/width ratio was decreased at the level of all the investigated tracts, namely, cervical and/or dorsal and/or lumbar. The flattening of the vertebral bodies may be due to suppression of intramedullary hematopoiesis by a high transfusion regimen. The reduced intravertebral pressure due to disturbed hemopoiesis could cause weight-bearing and other biological stresses to provoke a reduction in vertebral body height.