Risk Of Compression Fractures Research Articles

Dosimetric Analysis of Local Failure Outcomes and Vertebral Compression Fracture Risk in Single-Fraction Spine Stereotactic Radiosurgery for Metastatic Sarcoma

Sarcoma spinal metastases (SSM) are particularly difficult to manage given their poor response rates to chemotherapy and their inherent radioresistance. We sought to analyze dosimetric parameters impacting local failure and vertebral compression fracture outcomes in a homogenously treated cohort of patients with SSM treated with single-fraction spine stereotactic radiosurgery (SSRS). A retrospective review was conducted on a cohort of patients with SSM treated with definitive SSRS at a single tertiary institution. 16-24 Gy was delivered to the GTV and 16 Gy uniformly to the CTV. Kaplan-Meier analysis was conducted to assess time to local failure (LF). The log-rank test was utilized to examine group differences. Patients were censored at time of last follow-up or death. Cox proportionate hazards modeling was used to determine hazard ratios (HR) and their respective 95% confidence intervals (CI). A total of 66 patients with 96 lesions underwent SSRS for SSM. Median follow-up was 17 months (IQR 8-28). Median age was 55 years (IQR 41-63). The most common histological subtype was leiomyosarcoma (41%) followed by liposarcoma (9%). 81 lesions received 24 Gy to the GTV, 12 received 18 Gy and 3 received 16 Gy. Median GTV and CTV volume was 13.6cc (IQR 5-27) and 51.6cc (IQR 30-80) respectively. 27% of patients had Bilsky 1b or greater disease. 16 of 96 lesions demonstrated progression representing a crude local failure rate of 17% with median time to failure of 8 months (IQR 5-18). The 1-year actuarial progression free survival (PFS) was 89% with a median PFS of 13 months (IQR 16-63). Median overall survival (OS) was 15 months (IQR 8-28) from SSRS. 8% of patients developed vertebral compression fractures at a median of 13 months post SSRS (IQR 7-25). Every 1 Gy increase in GTV minimum dose (DMin) across the range (5.8-25cc) was associated with a reduced risk of local failure (HR = 0.875 [95% CI 0.787-0.974], p = 0.01). Stratifying thresholds for GTV DMin, a local control benefit was seen as low as 12 Gy and higher (HR = 0.329 [95% CI 0.11-0.97, p = 0.044) with a significantly greater magnitude benefit seen at 14 Gy (HR = 0.267 [95% CI 0.09-0.77, p = 0.014) and above 15 Gy (HR = 0.091 [95% CI 0.03-0.41], p = 0.0018). There were no other queried variables besides GTV Dmin associated with local control including: GTV: volume, mean, Dmax, D90, CTV: volume, Dmin, Dmean, Dmax, or D90. There was an increased risk of VCF with increasing CTV DMean (HR = 2.4 [95% CI 1.4-4.1], p = 0.002) and CTV D90 (HR = 2.2 [95% CI 1.2-4.0], p = 0.01); however, no association with GTV parameters. This study represents one of the most homogenously treated and the largest cohorts of patients with sarcoma spinal metastases treated with single-fraction SSRS. Despite inherent radioresistance, SSRS confers durable and high rates of local control in SSM without unexpected long-term toxicity rates. Increasing GTV minimum dose is significantly associated with superior local control with no corresponding increased risk of VCF.

Fatty infiltration of the multifidus muscle independently increases osteoporotic vertebral compression fracture risk

BackgroundVertebral compression fractures decrease daily life activities and increase economic and social burdens. Aging decreases bone mineral density (BMD), which increases the incidence of osteoporotic vertebral compression fractures (OVCFs). However, factors other than BMD can affect OVCFs. Sarcopenia has been a noticeable factor in the aging health problem. Sarcopenia, which involves a decrease in the quality of the back muscles, influences OVCFs. Therefore, this study aimed to evaluate the influence of the quality of the multifidus muscle on OVCFs.MethodsWe retrospectively studied patients aged 60 years and older who underwent concomitant lumbar MRI and BMD in the university hospital database, with no history of structurally affecting the lumbar spine. We first divided the recruited people into a control group and a fracture group according to the presence or absence of OVCFs, and further divided the fracture group into an osteoporosis BMD group and an osteopenia BMD group based on the BMD T-score of -2.5. Using images of lumbar spine MRI, the cross-sectional area and percentage of muscle fiber (PMF) of the multifidus muscle were obtained.ResultsWe included 120 patients who had visited the university hospital, with 45 participants in the control group and 75 in the fracture group (osteopenia BMD: 41, osteoporosis BMD: 34). Age, BMD, and the psoas index significantly differed between the control and fracture groups. The mean cross-sectional area (CSA) of multifidus muscles measured at L4-5 and L5-S1, respectively, did not differ among the control, P-BMD, and O-BMD groups. On the other hand, the PMF measured at L4-5 and L5-S1 showed a significant difference among the three groups, and the value of the fracture group was lower than that of the control group. Logistic regression analysis showed that the PMF value, not the CSA, of the multifidus muscle at L4-5 and L5-S1 affected the risk of OVCFs, with and without adjusting for other significant factors.ConclusionsHigh percentage of fatty infiltration of the multifidus muscle increases the spinal fracture risk. Therefore, preserving the quality of the spinal muscle and bone density is essential for preventing OVCFs.

Impact Of the Covid-19 Pandemic on The Prevalence of Thoracolumbar Vertebral Compression Fractures in Elderly People

Covid-19 had a profound effect on many parts of life during 2020. Our country, much like the majority of other nations across the globe, saw a Covid-19 epidemic, a wave reaching its height from the middle of March through April of 2020. This brought about significant difficulties for our civilization in a variety of spheres, including the medical, social, and economic spheres. On February 27th, the first patient in our country to be diagnosed with Covid-19 was identified. Objective: To evaluate the Covid-19 effect on the prevalence of thoracolumbar vertebral compression fractures in elderly people. Methods: A total of 172 individuals with vertebral compression fractures (VCF) were above the age of 65 years. The age and gender of the patients were comparable across the two research groups. Only those people who exhibited symptoms for less than four weeks were taken into account. We analyzed every patient's medical records and obtained all essential data, including demographics (gender, age, and compression fracture risk factors), fracture mechanism, and location of the fracture. Results: In 2020, we observed a greater percentage of high-energy VCF (10.5% versus 6.7%). In 2020, there were 7.5 times more recurrent fractures and the proportion of Ankylosing Spondylitis was much higher. Similar admission rates to VCF ED were observed, with 60% receiving conservative care. The number of procedures performed on admitted patients increased in 2020 (66.7% vs. 60%, P =.71), and PBK plus fixation tended to be more common in 2020 compared to 2018-19 (15.8% versus 7.5%, P =.29). In the Covid-19 epidemic, the RR for BKP Plus fixation vs. BKP alone was 1.95, indicating increased risks for difficult operation. In 2020, there were significantly more complications (18.4% vs 3.7%, P.001). Time to surgery also increased somewhat in 2020, from 6.25 days to 5.3 days (P =.55), and admission duration increased marginally (12.2 days vs. 9.9 days, P =.27). Most of the patients choose home treatment over inpatient care during the Covid-19 pandemic (72.2% vs. 58.8%). Conclusions: The frequency of VCF did not vary as a result of the Covid-19 pandemic; nevertheless, the features of patients did change, which had an effect on hospitalizations, institutional rehabilitative services, and a predilection for extensive surgery as opposed to BKP alone. Although it is not yet known whether or not COVID-19 will continue to be a problem in the years to come, the effects and lessons it has provided are still valuable.

Epidemiological and clinical characteristics analysis of 681 cases of thoracolumbar osteoporotic vertebral compression fractures

To investigate the epidemiological and clinical characteristics of patients with thoracolumbar osteoporotic vertebral compression fracture (OVCF) treated by percutaneous vertebroplasty (PVP). The clinical and imaging data of 681 patients with thoracolumbar OVCF treated with PVP between January 2017 and December 2021 were collected. The epidemiological and clinical characteristics of the patients with thoracolumbar OVCF in single center were summarized from the aspects of demographic distribution (mainly including gender, age), fracture characteristic analysis [including pathological segments, bone mineral density, and body mass index (BMI)], and operation related results (including the distribution of unilateral and bilateral puncture and bone cement injection, postoperative effectiveness analysis and refracture). Of the 681 patients, 134 (19.68%) were male and 547 (80.32%) were female, with a male-to-female ratio of 1∶4.08. The age ranged from 53 to 105 years, with an average of 75.3 years. The age group of 60-90 years old had the largest number of patients (91.04%); the high incidence age group of men was 70-90 years old (13.95%), and that of women was 60-80 years old (72.98%). A total of 836 vertebrae were involved, and the morbidity of thoracolumbar vertebrae (T 11-L 1) was the highest (56.34%, 471/836). The main type of fracture was compression fracture (92.58%, 774/836) and Kümmell disease (7.42%, 62/836). There were 489 cases (71.81%) of osteoporosis, including 66 males and 423 females, with a male-to-female ratio of 1∶6.42. There was significant difference in distribution of bone mineral density between male and female groups ( Z=-5.810, P<0.001). BMI showed 206 cases (30.25%) of underweight, 347 (50.95%) cases of normal, 58 cases (8.52%) of overweight, 42 cases (6.17%) of obese, and 28 cases (4.11%) of extremely obese. The difference in BMI distribution between male and female groups was significant ( Z=-2.220, P=0.026). Of 836 vertebral bodies, 472 (56.46%) were punctured unilaterally and 364 (43.54%) bilaterally. Most of the vertebral bodies (49.88%, 417/836) were injected with 5.0-6.9 mL bone cement, and most of them were distributed in thoracolumbar and lumbar vertebral bodies (T 11-L 3). The visual analogue scale (VAS) score and Oswestry disability index (ODI) of patients with unilateral puncture and bilateral puncture significantly improved at 6 months after operation ( P<0.001), and also the difference was significant between the two groups in the difference of pre- and post-operation ( P<0.001). There were 628 cases (92.22%) with the first occurrence of OVCF, and 53 cases (7.78%) with two or more times of OVCF, all of which were female patients, and 26 cases (49.06%) occurred in the adjacent segment of the previous PVP operation. Female were more than male in OVCF patients. Thoracolumbar vertebral body has the highest morbidity. Patients with low BMI are more likely to have osteoporosis, and patients with high BMI have a higher risk of compression fracture. The amount of bone cement injected through bilateral puncture was greater than that through unilateral puncture.

Reconstruction Using an Osteofasciocutaneous Fibula Free Flap for a Distal Tibial Defect in Refractory Chronic Osteomyelitis: A Case Report

The fibular free flap (FFF) is an option used for tibial defect reconstruction in post-traumatic chronic osteomyelitis (PCOM). However, as the tibia is a weight-bearing bone, there exists a risk of compression fracture risk after FFF. This complicates reconstructing distal tibial defects adjacent to the articular cartilage. We report a successful case of reconstruction using FFF for a bone defect adjacent to the distal tibial articular surface in refractory PCOM. The patient was a 73-year-old woman with refractory PCOM in the right distal tibia secondary to a tibial fracture from a traffic accident that occurred 28 years ago. After bone debridement, the tibial bone defect was 8 cm in length, and its distal margin was located 0.5 cm above the articular surface of the tibiotalar joint. Tibial bone and soft tissue defects were reconstructed using a contralateral FFF consisting of an 8-cm fibula bone and a 14×5-cm-sized skin paddle. After 2 months, an Ilizarov apparatus was applied and maintained for 3 months. After 6 months, she started weight-bearing. The follow-up period was 15 months. Imaging studies revealed bone block union. The patient displayed no difficulty in ambulation and had no additional infections or flap necrosis.

Focal osteoporosis defect is associated with vertebral compression fracture prevalence in a bone mineral density-independent manner.

IntroductionFocal osteoporosis defect has shown a high association with the bone fragility and osteoporotic fracture prevalence. However, no routine computed tomography (CT)‐based vertebral focal osteoporosis defect measurement and its association with vertebral compression fracture (VCF) were discussed yet. This study aimed to develop a routine CT‐based measurement method for focal osteoporosis defect quantification, and to assess its association with the VCF prevalence.Materials and MethodsA total of 205 cases who underwent routine CT scanning, were retrospectively reviewed and enrolled into either the VCF or the control group. The focal bone mineral content loss (focal BMC loss), measured as the cumulated demineralization within bone void space, was proposed for focal osteoporosis defect quantification. Its scan‐rescan reproducibility and its correlation with trabecular bone mineral density (BMD) and apparent microarchitecture parameters were evaluated. The association between focal BMC loss and the prevalence of VCF was studied by logistic regression.ResultsThe measurement of focal BMC loss showed high reproducibility (RMSSD = 0.011 mm, LSC = 0.030 mm, ICC = 0.97), and good correlation with focal bone volume fraction (r = 0.79, P < 0.001), trabecular bone separation (r = 0.76, P < 0.001), but poor correlation with trabecular BMD (r = 0.37, P < 0.001). The focal BMC loss was significantly higher in the fracture group than the control (1.03 ± 0.13 vs. 0.93 ± 0.11 mm; P < 0.001), and was associated with prevalent VCF (1.87, 95% CI = 1.31–2.65, P < 0.001) independent of trabecular BMD level.DiscussionAs a surrogate measure of focal osteoporosis defect, focal BMC Loss independently associated with the VCF prevalence. It suggests that focal osteoporosis defect is a common manifestation that positively contributed to compression fracture risk and can be quantified with routine CT using focal BMC Loss.

Rehabilitation Principles in Bone Metastasis

Metastatic bone disease is often associated with a decline in function and overall quality of life. Pain and musculoskeletal events are contributors to decrease mobility and independence.4, 5, 6, 7 In cases where there is neurological involvement, such as in patients with cord compression syndrome, it can be associated with neurogenic bowel and bladder. The role of cancer rehabilitation providers is to improve the overall health-related quality of life and their function and independence. Rehabilitation interventions, including aerobic and resistant exercise prescription, are associated with positive physical and self-reported outcomes with a low rate of adverse events.4 Low impact aerobic activity has been wildly studied in patients with bone metastasis and has been found to be safe.4,9 Rehabilitation physicians focus on designing a rehabilitation and exercise plan that improves the patient's physical function while keeping in mind the necessary precautions to prevent musculoskeletal events. Activity modification and physical activity that prevents the axial loading of the spine can improve the core musculature of patients with spine involvement while decreasing the risk of compression fractures of the vertebral bodies.21 Furthermore, patients who have undergone surgical interventions as part of the treatment of metastatic bone disease frequently present an acute functional decline. Rehabilitation providers are vital in evaluating these functional impairments and developing a comprehensive rehabilitation plan in the appropriate setting (inpatient vs home vs outpatient).26 Overall, patients with metastatic bone disease present with functional impairments that put them at risk for immobility-related complications. Rehabilitation interventions, such as exercise, are safe and effective in improving immobility complications, decreasing caregiver burden, and improving overall quality of life.4,7,9,26

Complication Trends and Costs of Surgical Management in 11,086 Osteoporotic Patients Receiving Lumbar Fusion.

Retrospective cohort study. The aim of this study was to compare different aspects of fusion surgery in patients with osteoporosis with regard to graft subtype and surgical approach. Osteoporosis and chronic lower back pain are common in elderly populations and significantly increase the risk of compression fractures within the spine. Using the 2016-2017 National Readmission Database we identified 11,086 osteoporotic patients who received lumbar fusion using ICD-10 coding. Information regarding biologic graft type and surgical approach was collected. Patients were stratified by number of levels fused. Perioperative complications were collected at 30-, 90-, and 180-day follow-up intervals. Statistical analysis included univariate testing and multivariate regression modeling, controlling for patient demographics and comorbidities. Patients receiving single-level fusion with autologous grafts had higher rates of hardware failure (P = 0.00014) at 30-day follow-up and 90-day follow-up (P < 0.0001) and higher rates of lumbar vertebral fractures at 90-day follow-up (P = 0.045) compared to those treated with nonautologous grafts. Patients receiving lumbar fusion with anterior and posterior approaches had no difference in readmission or infection rates, but the anterior approach was associated with a higher cost. In this study, osteoporotic patients treated with autologous grafts had higher rates of complications compared to those treated with nonautologous grafts. Anterior and posterior approaches had similar complication rates; however, the anterior approach was associated with a higher total cost.Level of Evidence: 4.

Vertebral bone quality score predicts fragility fractures independently of bone mineral density

BACKGROUND Current evidence suggests that dual energy X-ray absorptiometry (DXA) scans –conventional method defining osteoporosis – is underutilized and, when used, may underestimate patient risk for skeletal fragility. It has recently been suggested that other imaging modalities may better estimate bone quality, such as the MRI-based vertebral bone quality (VBQ) score, previously associated with vertebral compression fracture risk in patients with spine metastases. PURPOSE To evaluate whether VBQ score is predictive of fragility fractures in a population with pre-existing low bone density and at high-risk for fracture. STUDY DESIGN/SETTING Retrospective single-center cohort. PATIENT SAMPLE Patients followed at a metabolic bone clinic for osteopenia/osteoporosis. OUTCOME MEASURES Radiographically-documented new- onset fragility fracture. METHODS Patients with a DXA and MRI scans at the time of consultation and ≥2-year follow-up were included. Details were gathered about patient demographics, health history, current medication use, and serological studies of kidney function and bone turnover. For each patient, VBQ score was calculated using T1-weighted lumbar MRI images. Univariable and multivariable analyses were used to identify the independent predictors of a new fragility fracture. To support the construct validity of VBQ, patient VBQ scores were compared to those in a cohort of 45 healthy adults. RESULTS Seventy-two (39.1%) study participants suffered fragility fractures, the occurrence of which was associated with higher VBQ score (3.50 vs 3.01; p<0.001), chronic glucocorticoid use (30.6% vs 15.2%; p=0.014), and a history of prior fragility fracture (36.1% vs 21.4%; p=0.030). Mean VBQ score across all patients in the study cohort was significantly higher than the mean VBQ score in the healthy controls (p<0.001). In multivariable analysis, new-onset fracture was independently associated with history of prior fracture (OR=6.94; 95% CI [2.48–19.40]; p<0.001), higher VBQ score (OR=2.40 per point; [1.30–4.44]; p=0.003), higher BMI (OR=1.09 per kg/m 2 ; [1.01–1.17]; p- 0.03), and chronic glucocorticoid use (OR=2.89; [1.03–8.17]; p=0.043). Notably, DXA bone mineral density (BMD) was not found to be significantly predictive of new-onset fractures in the multivariable analysis (p=0.081). CONCLUSION Here we demonstrate the novel, MRI-derived VBQ score is both an independent predictor of fragility fracture in at-risk patients and a superior predictor of fracture risk than DXA-measured BMD. Given the frequency with which MRIs are obtained by patients undergoing spine surgery consultation, we believe the VBQ score could be a valuable tool for estimating bone quality in order to optimize the management of these patients. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. Current evidence suggests that dual energy X-ray absorptiometry (DXA) scans –conventional method defining osteoporosis – is underutilized and, when used, may underestimate patient risk for skeletal fragility. It has recently been suggested that other imaging modalities may better estimate bone quality, such as the MRI-based vertebral bone quality (VBQ) score, previously associated with vertebral compression fracture risk in patients with spine metastases. To evaluate whether VBQ score is predictive of fragility fractures in a population with pre-existing low bone density and at high-risk for fracture. Retrospective single-center cohort. Patients followed at a metabolic bone clinic for osteopenia/osteoporosis. Radiographically-documented new- onset fragility fracture. Patients with a DXA and MRI scans at the time of consultation and ≥2-year follow-up were included. Details were gathered about patient demographics, health history, current medication use, and serological studies of kidney function and bone turnover. For each patient, VBQ score was calculated using T1-weighted lumbar MRI images. Univariable and multivariable analyses were used to identify the independent predictors of a new fragility fracture. To support the construct validity of VBQ, patient VBQ scores were compared to those in a cohort of 45 healthy adults. Seventy-two (39.1%) study participants suffered fragility fractures, the occurrence of which was associated with higher VBQ score (3.50 vs 3.01; p<0.001), chronic glucocorticoid use (30.6% vs 15.2%; p=0.014), and a history of prior fragility fracture (36.1% vs 21.4%; p=0.030). Mean VBQ score across all patients in the study cohort was significantly higher than the mean VBQ score in the healthy controls (p<0.001). In multivariable analysis, new-onset fracture was independently associated with history of prior fracture (OR=6.94; 95% CI [2.48–19.40]; p<0.001), higher VBQ score (OR=2.40 per point; [1.30–4.44]; p=0.003), higher BMI (OR=1.09 per kg/m 2 ; [1.01–1.17]; p- 0.03), and chronic glucocorticoid use (OR=2.89; [1.03–8.17]; p=0.043). Notably, DXA bone mineral density (BMD) was not found to be significantly predictive of new-onset fractures in the multivariable analysis (p=0.081). Here we demonstrate the novel, MRI-derived VBQ score is both an independent predictor of fragility fracture in at-risk patients and a superior predictor of fracture risk than DXA-measured BMD. Given the frequency with which MRIs are obtained by patients undergoing spine surgery consultation, we believe the VBQ score could be a valuable tool for estimating bone quality in order to optimize the management of these patients.

Vertebral bone quality score predicts fragility fractures independently of bone mineral density

BackgroundCurrent evidence suggests that dual-energy x-ray absorptiometry (DXA) scans, the conventional method defining osteoporosis, is underutilized and, when used, may underestimate patient risk for skeletal fragility. It has recently been suggested that other imaging modalities may better estimate bone quality, such as the magnetic resonance imaging (MRI)-based vertebral bone quality (VBQ) score which also may assess vertebral compression fracture risk in patients with spine metastases. PurposeTo evaluate whether VBQ score is predictive of fragility fractures in a population with pre-existing low bone density and at high-risk for fracture. Study Design/SettingRetrospective single-center cohort. Patient SamplePatients followed at a metabolic bone clinic for osteopenia and/or osteoporosis. Outcome MeasuresRadiographically-documented new-onset fragility fracture. MethodsPatients with a DXA and MRI scans at the time of consultation and ≥2-year follow-up were included. Details were gathered about patient demographics, health history, current medication use, and serological studies of kidney function and bone turnover. For each patient, VBQ score was calculated using T1-weighted lumbar MRI images. Univariable and multivariable analyses were used to identify the independent predictors of a new fragility fracture. To support the construct validity of VBQ, patient VBQ scores were compared to those in a cohort of 45 healthy adults. ResultsSeventy-two (39.1%) study participants suffered fragility fractures, the occurrence of which was associated with higher VBQ score (3.50 vs. 3.01; p<.001), chronic glucocorticoid use (30.6% vs. 15.2%; p=.014), and a history of prior fragility fracture (36.1% vs. 21.4%; p=.030). Mean VBQ score across all patients in the study cohort was significantly higher than the mean VBQ score in the healthy controls (p<.001). In multivariable analysis, new-onset fracture was independently associated with history of prior fracture (OR=6.94; 95% confidence interval [2.48–19.40]; p<.001), higher VBQ score (OR=2.40 per point; [1.30–4.44]; p=.003), higher body mass index (OR=1.09 per kg/m²; [1.01–1.17]; p=.03), and chronic glucocorticoid use (OR=2.89; [1.03–8.17]; p=0.043). Notably, DXA bone mineral density (BMD) was not found to be significantly predictive of new-onset fractures in the multivariable analysis (p=.081). ConclusionsHere we demonstrate the novel, MRI-derived VBQ score is both an independent predictor of fragility fracture in at-risk patients and a superior predictor of fracture risk than DXA-measured BMD. Given the frequency with which MRIs are obtained by patients undergoing spine surgery consultation, we believe the VBQ score could be a valuable tool for estimating bone quality in order to optimize the management of these patients.

T-score differences and nonprogression in lumbar vertebrae as predictors of vertebral fractures.

In case of a vertebral fracture, the area of the vertebrae decreases with a concomitant increase in BMD, as assessed by a DXA scanning. Furthermore, a vertebral fracture may disrupt the normal increase in vertebral body area from L1 to L4 (nonprogression). We aimed to examine associations between T-score difference and nonprogression of vertebral area and vertebral fractures. We identified 100 patients with 1 or more fractures in L1-L4 and 106 patients without fractures. All patients had undergone a DXA scan and a lumbar spine X-ray. In fracture patients, we recorded T-score difference between the fractured vertebra and the adjacent vertebra, and whether the fractured vertebra was smaller than the one above (nonprogression). In nonfracture patients, the greatest positive T-score difference was recorded, and nonprogression was present if vertebral area did not increase successively from L1 to L4. With a T-score difference ≥1SD odds ratio for fracture was 1.30 (0.74-2.29). Sensitivity and specificity were 0.40 and 0.66, respectively. With T-score difference ≥1.5SD, odds ratio for fracture was 2.26 (1.08-4.73). Sensitivity and specificity were 0.24 and 0.88, respectively. Nonprogression was very common in the no-fracture group (38%), while only 23% of X-ray verified fractures had nonprogression. A randomly found T-score difference ≥1.5SD between adjacent vertebrae on a DXA scan is associated with a small increased risk of compression fracture. Nonprogression is very common in patients without fractures.

Soft Tissue and Bony Injuries Attributed to the Practice of Yoga: A Biomechanical Analysis and Implications for Management

ObjectiveTo analyze injuries that were directly associated with yoga practice and identify specific poses that should be avoided in patients with osteopenia or osteoporosis. Patients and MethodsWe retrospectively reviewed the medical records of patients with injuries that were primarily caused by yoga. Patients were seen from January 1, 2006, through December 31, 2018. Injuries were categorized into 3 groups: (1) soft tissue injury, (2) axial nonbony injury, and (3) bony injury. Patients underwent evaluation and were counseled to modify exercise activity. ResultsWe identified 89 patients for inclusion in the study. Within the soft tissue group, 66 patients (74.2%) had mechanical myofascial pain due to overuse. Rotator cuff injury was seen in 6 (6.7%), and trochanteric bursopathy was observed in 1 (1.1%). In the axial group, exacerbation of pain in degenerative joint disease (46 patients [51.7%]) and facet arthropathy (n=34 [38.2%]) were observed. Radiculopathy was seen in 5 patients (5.6%). Within the bony injury category, kyphoscoliosis was seen on imaging in 15 patients (16.9%). Spondylolisthesis was present in 15 patients (16.9%). Anterior wedging was seen in 16 (18.0%), and compression fractures were present in 13 (14.6%). The poses that were most commonly identified as causing the injuries involved hyperflexion and hyperextension of the spine. We correlated the kinesiologic effect of such exercises on specific musculoskeletal structures. ConclusionYoga potentially has many benefits, but care must be taken when performing positions with extreme spinal flexion and extension. Patients with osteopenia or osteoporosis may have higher risk of compression fractures or deformities and would benefit from avoiding extreme spinal flexion. Physicians should consider this risk when discussing yoga as exercise.

Oligometastatic Disease State Is Associated with Improved Local Control in Patients Undergoing 3 or 5 Fraction Spine Stereotactic Body Radiotherapy

Stereotactic body radiotherapy (SBRT) is an increasingly utilized treatment modality for patients with spine metastases. The objective of our study was to describe the local control (LC) outcomes with 3 or 5 fraction SBRT to the spine and identify predictors for improved LC. We retrospectively reviewed outcomes of patients treated with SBRT for vertebral body metastases. No patients had prior surgical intervention or spinal cord compression. All patients were treated with 3 (median dose 27 Gy; range 24-30 Gy) or 5 fraction (median dose 35 Gy, range 25-40 Gy) SBRT. The Kaplan-Meier method and SPINO criteria were used to determine LC. Patients were classified as having an oligometastatic disease state (< 5 systemic metastases) or polymetastatic disease state (≥ 5 metastases). Univariate analysis (UVA) was performed using the log-rank test to predict for clinical factors associated with LC. Multivariable analysis (MVA) was conducted using the cox proportional hazards model and included all covariates with p < 0.1 on UVA. Predictors of compression fracture were also evaluated using logistic regression. We included 56 patients with a total of 64 distinct SBRT targets. Median follow-up time was 9 months. Fifteen targets and 49 targets were treated with 3 and 5 fractions, respectively. Thirteen patients (20%) had prior radiotherapy to the SBRT area. Twenty-one patients (33%) had an oligometastatic disease state. One year LC was 82% (100% for 3 fraction, 77% for 5 fraction, p = 0.11). On UVA, polymetastases (1 year LC 76% vs. 100%; p = 0.038), prior radiotherapy to the SBRT target (65% vs. 87%; p = 0.041), and inclusion of greater than 2 vertebral levels in the target (63% vs. 86%; p < 0.01) were associated with worse LC. Male sex (84% vs. 87%; p = 0.091) had a trend toward worse LC at one year. Pseudoprogression occurred in 3 patients (5%) and was not associated with LC on UVA (p = 0.470). On MVA, patients with a polymetastatic state (hazard ratio 21.3, 95% confidence interval 1.21-373.73; p = 0.036) and prior radiotherapy to the SBRT target (HR 7.01, 95% confidence interval 1.46-33.6; p = 0.015) had worse LC. Sex and number of treated vertebral levels were not statistically significant (p = 0.395 and p = 0.233, respectively). Eight patients had grade 1 toxicity, and 1 patient had grade 2 toxicity. Vertebral body compression fractures occurred in 11 (17%) patients. Five fractions was associated with a higher risk of compression fracture (22% versus 0%, p=0.044), while increasing biologically effective dose (p = 0.110) and prior radiotherapy (p = 0.328) were not associated with an increased risk of compression fracture. LC of vertebral body metastases is encouraging with 3 or 5 fraction SBRT. Our study is hypothesis-generating in that patients with an oligometastatic disease state appear to have improved LC following SBRT, suggesting there may be a biologic advantage with local therapy in this group of patients not seen in patients with polymetastatic disease.

Local Control and Vertebral Compression Fracture Risk for a Novel Simultaneous Integrated Boost Technique in Stereotactic Spine Radiosurgery

Local Control and Vertebral Compression Fracture Risk for a Novel Simultaneous Integrated Boost Technique in Stereotactic Spine Radiosurgery

Non traumatic fractures of the lumbar spine and seizures: case report

Abstract Injury-induced seizures may appear clinically asymptomatic and can be easily monitored by the absence of trauma and post-ictal impairment of consciousness. Patients with epilepsy have a higher risk of compression fractures, leading to serious musculoskeletal injuries, this type of non-traumatic compression fractures of the spine secondary to seizures are rare lesions, and is produced by the severe contraction of the paraspinal muscles that can achieve the thoracic spine fracture. Seizures induced lesions may appear clinically asymptomatic and can be easily monitored by the absence of trauma and post-ictal impairment of consciousness. We present a case report.

Percutaneous Vertebroplasty for Pathological Vertebral Compression Fractures Secondary to Multiple Myeloma--Medium-Term and Long-Term Assessment of Pain Relief and Quality of Life.

In patients with multiple myeloma (MM) there is ahigh risk of compression fractures of the spine. In the majority of cases, the method of treatment is percutaneous vertebroplasty (PV) or kyphoplasty (PK). The number of studies verifying their efficacy in MM is still relatively small. The aim of this study has been to assess medium- and long-term pain relief as well as improvement in the quality of life (QL) after PV in MM cases. There was aprospective group of 34 MM cases in which atotal of 131 vertebral bodies were augmented by means of PV. It was possible to follow up 22patients who agreed to take part in the assessment. Their level of daily activity and the level of pain were assessed using the Oswestry Back Pain scale and avisual analogue scale (VAS) before PV and at alater date (medium-term follow up was amean of 10months after the last operation). Five out of eight cases in which 4.5-5years had elapsed since the first PV were tested again (long-term follow-up). Relief of pain and improvement of QL, assessed amean of 10months after PV, proved to be statistically significant. On the average, pain decreased by 4.7 points as measured on the VAS scale and the average improvement in the QL measured on the Oswestry scale was 27.7%. There were no neurological or general complications. After 4.5-5years, there has not been any significant change in the level of pain relief or the improvement in the QL in the 5cases in which long-term assessment was possible. In MM cases, PV is asimple, effective and safe method for the treatment of vertebral infiltration and compression fractures, giving permanent long-term pain relief and concomitant improvement in the QL.

Intermediate strain rate behaviour of cancellous bone: Links between microstructural and mechanical properties

Relationships between the micro-architecture description of cancellous bone, obtained from medical imaging, and its mechanical properties can be used to assess the compression fracture risk at high and low strain rate. This study extends the rupture prediction to the intermediate strain rate regime. The micro-architecture description was obtained with a CT-scan, for which geometry, topology, connectivity and anisotropy parameters were computed and compared to mechanical identified parameters in order to confirm their usefulness. Three strain rates were investigated: 1/s, 10/s and 100/s using two different devices: a Wedge-Bar apparatus and a conventional split Hopkinson pressure bar implemented with a Cone-in-Tube striker and a tandem momentum trap. This setup provides a constant strain rate loading with routine specimen recovery allowing the fracture zone to be investigated. This study reveals that a transition in the response behaviour occurred in the intermediate regime and confirms the significant porous organization influence through the regimes.

High-dose Radiotherapy Using Helical Tomotherapy for Vertebral Metastasis: Early Clinical Outcomes and Cord Dose Specification

For several decades, radiotherapy has been widely used to treat metastatic vertebral tumors. This study was designed to assess the feasibility and early clinical outcomes of high-dose radiotherapy to treat such tumors, using helical tomotherapy. Between June 2009 and December 2011, 51 sites in 36 patients were treated with high-dose radiotherapy using helical tomotherapy for vertebral metastasis. Treatment outcomes and dosimetric analyses of spinal cord were retrospectively evaluated. Median follow-up was 11.5 months (range, 6-34.6) for surviving patients. The median total dose and the number of fractions in the primary helical tomotherapy arm were 2700 cGy and 3 fractions, respectively. Actuarial 6-month local control rates were 85.7%, and symptomatic vertebral compression fractures developed in five patients after a median of 4.2 (range, 2.9-5.7) months. Among 13 patients with 19 metastatic sites who showed pre-treatment impairment in neurologic function, five patients (with seven sites) in whom symptoms were mild showed improvement in neuronal function. The median pre-treatment pain visual analog scale score of 7 decreased to a median of 3 after helical tomotherapy (P < 0.001) at a median of 1 month (range, 0.5-3.2) of follow-up. No significant morbidity developed during follow-up except for one grade 3 esophagitis. The use of helical tomotherapy to treat metastatic vertebral tumors appears to be both safe and reliable in terms of local tumor control and early pain relief. Local progression and the risk of compression fracture in patients with pre-existing spinal instability remain the principal factors of limiting improved clinical and functional outcomes. Optimal dose-fractionation schemes and appropriate patient selection are required to achieve better outcomes with high-dose radiotherapy using helical tomotherapy.

Prediction of compression fracture risk of lumbar vertebra using a X-ray CT-based finite element method

Prediction of compression fracture risk of lumbar vertebra using a X-ray CT-based finite element method

Vertebral Compression Fractures in Patients with Chronic Lymphocytic Leukemia: Incidence and Risk Factors

AbstractAbstract 4586 Introduction:Patients with chronic lymphocytic leukemia (CLL) have infiltrative bone marrow changes in vertebral bodies on radiographic studies. Whether CLL is associated with an increased risk of compression fracture and/or osteoporosis in correlation with the burden or duration of the disease has not been studied. For this purpose, we performed a retrospective case-control study. Methods:After obtaining Institutional Review Board approval, we reviewed the records of CLL patients managed in our centers with watchful waiting from diagnosis until treatment. Data on demographic, clinical and laboratory variables, radiographic findings and treatment were collected. Presence of osteoporosis and compression fractures was ascertained from physician evaluation notes, bone densitometry studies and/or computed tomography (CT) scan results prior to initiation of chemotherapy. CLL cases were matched by age, sex and body mass index (BMI) at 1:2 ratio to healthy controls derived from a local Family Practice database. Cox regression models were used for the evaluation of hazard ratios (HR) and 95% confidence intervals (CI) for factors associated with compression fractures in patients with CLL undergoing a watchful waiting approach. Results:Among 96 CLL cases included in the analysis there were 48% women, 10% current and 34% former smokers. The median age was 71 years (range, 44–99), median BMI 26 (18–50) and median follow up time 2.9 years (0–22, with the last follow up between 2003 and 2012). The median absolute lymphocyte count (ALC) was 40,850/mm3 (5,700–969,000/mm3), mean hemoglobin 12.4 g/dL (+/− 2.2 g/dL), lactate dehydrogenase 202 IU/L (+/− 95 IU/L), 25-OH-vitamin D 30.7 ng/mL (+/− 12.3 ng/mL). Staging CT scans were available in 68% of cases, but bone density scans only in 13% (2% men, 24% women). Chemotherapy was started in 41% of patients after a median time of 2.4 years from diagnosis.Osteoporosis and osteopenia were each recorded in 12% of patients while a vertebral compression fracture was present in 7%. With marked differences in the availability of evaluation tests (e.g. bone density, p<0.001) and length of period of observation between CLL cases and matched controls, there was no significant difference in the odds of compression fracture (odds ratio 1.0, 95%CI 0.32–2.84, p=1.0).In the time-to-event analysis, the rate of compression fracture occurrence was 1.7% per year (95%CI 0.8–3.6%). Compression fractures in CLL patients were associated with underlying osteoporosis or osteopenia (HR 12.8, 95%CI 1.5–109, p=0.004), ALC over 100,000/mm3 (HR 5.1, 95%CI 1.1–23.7, p=0.04) and anemia, defined as hemoglobin less than 12 g/dL (HR 8.9, 95%CI 1.1–74, P=0.01, Fig.1). Conclusions:CLL patients managed with watchful waiting may be at risk of vertebral compression fractures proportional to the burden of disease. Further prospective research may delineate potential role for screening for osteoporosis and prevention of osteoporosis and vertebral fractures in this population. [Display omitted] Disclosures:No relevant conflicts of interest to declare.