Vertebroplasty For Osteoporotic Vertebral Fractures Research Articles

Investigation of preoperative asymptomatic bacteriuria as a risk factor for postvertebroplasty infection.

Postvertebroplasty infection (PVI) is a catastrophic complication after vertebroplasty (VP). Although the urinary tract has been considered as a source of infectious pathogens, whether asymptomatic bacteriuria (ASB) is a risk factors for PVI remains unknown. This retrospective study included 716 patients (207 males; 509 females) treated with VP for osteoporotic vertebral fractures in a single medical center between May 2015 and December 2019. Clinical symptoms, urinalysis results, and culture data were collected preoperatively to identify patients with ASB. The primary outcome was PVI at the index level during follow-up. Demographic data and laboratory test results were compared between the PVI and non-PVI groups. The mean age of the cohort was 78.6 ± 9.6 (range, 63-106). The prevalence of ASB was 14.1%, with female predominance (63.4%). The overall PVI rate was 1.26% (9/716). The PVI group had more patients with ASB (4/9, 44.4%) than did the non-PVI group (97/707, 13.7%) (p = 0.027). The rate of ASB treatment was similar between the PVI and non-PVI groups (25% vs. 23.7%, respectively). No case of PVI was caused by the urine culture pathogen. Multivariate analysis identified the following risk factors for PVI: ASB (odds ratio [OR], 5.61; 95% CI, 1.14-27.66; p = 0.034), smoking (OR, 16.26; 95% CI, 2.58-102.65; p = 0.003), and malignancy (OR 7.27; 95% CI, 1.31-40.31; p = 0.023). ASB was not uncommon among patients admitted for VP and should be considered a marker of relatively poor host immunity. Preoperative ASB, a history of malignancy, and smoking were identified as significant risk factors for PVI.

Efficacy and safety of percutaneous vertebroplasty for osteoporotic vertebral compression fractures

Background Osteoporotic vertebral compression fractures constitute a major concern in elderly population who may not tolerate conservative treatment. Although percutaneous vertebroplasty is an alternative minimally invasive procedure that is commonly used nowadays, there is still debate about its efficacy. The study aim is to provide short term experience about efficacy of vertebroplasty for osteoporotic vertebral fractures. Methods Thirty five patients were treated by percutaneous vertebroplasty (the intervention group). The visual analog scale before the intervention (pre VAS), one week after the intervention (post VAS 1), at three months (post VAS 2) after the intervention were compared at each time point with the control group (35 patients). The oswestry disability index before (pre ODI) and three months after the procedure (post ODI) were assessed. The control group received the optimal medical treatment and a regular physiotherapy program for three months. Results Both conservative and vertebroplasty group showed significant improvement in the VAS/ODI with time. With vertebroplasty, the improvement is faster and statistically significant compared with conservative group. There were statistically significant differences between both groups concerning post VAS 1, post VAS 2 and post ODI as the P values were 0.00 in all relationships. Conclusion Patients with osteoporotic compression fractures who were treated with percutaneous vertebroplasty experienced considerable clinical improvement in comparison with those who received the conservative management.

Subsequent fractures after vertebroplasty in osteoporotic vertebral fractures: a meta-analysis.

Percutaneous vertebroplasty (VP) provides substantial benefit to patients with painful osteoporotic vertebral compression fractures (OVCF). However, the reoccurrence of vertebral fracture after VP is a major concern. The purpose of this study is to conduct a meta-analysis on the incidence of subsequent fractures after VP in patients with OVCF. PubMed and EMBASE were searched. In addition, we scrutinized the reference list of all relevant articles to supplement the database search. We included original articles reporting on new fracture rates after VP in OVCF patients. Subsequent fracture rates were pooled across studies using a random-effects meta-analysis. Thirty-nine studies with a total of 8047 participants from 12 countries were included in this meta-analysis. Patients' age ranged from 64.2 to 94.6years (reported by 31 studies). The median follow-up was 21months (36 studies). Pooled estimate for subsequent fractures after VP was 23.4% (95% CI, 19.8-27.2%; I2 = 93.0%, p < 0.01). New fractures after VP in 54.6% of cases occurred in the vertebral bodies adjacent to the treated vertebra (95% CI, 49.0-60.1%; I2 = 66.0%, p < 0.01). A significant proportion of patients undergoing VP for OVCF experience new fractures after treatment, most of which are developed in the vertebral bodies adjacent to the treated vertebra.

Outcomes of vertebroplasty in osteoporotic vertebral fractures with limited indication

IntroductionVertebroplasty has been shown to be effective for improving quality of life and pain of osteoporotic vertebral fractures (OVF) without neurological deficit and not susceptible to conservative treatment. It is advisable to perform them on recent fractures with 50% crush and without the involvement of the canal, although there are no standard recommendations. In some cases these limits are exceeded. We analyse the outcomes of percutaneous vertebroplasty (PVP) in OVF with relative/limit indication. Materials and methodsRetrospective analysis of 88 patients (126 fractures) who underwent surgery by PVP; 95/126 were osteoporotic fractures. Thirty-four cases (35%) were included in the relative indication group, with at least one of the following: canal involvement, >50% collapse, and >12 months of evolution of the fracture. The rest of the cases were included in the standard indication group. We performed clinical-radiological follow-up, collected intraoperative data on techniques and complications, occurrence of leaks, postoperative clinical improvement (according to VAS), new adjacent fractures, and satisfaction. ResultsMost fractures were between D11-L2 (66%) with 6–8 months follow-up. No significant differences were observed regarding clinical improvement in either group. A higher percentage of leaks were detected in the relative indication group, 44% in comparison to 29.5% in the standard indication group, without statistical significance. All leakages were asymptomatic. There were 3 new OVF after PVP in the relative indication group and 4 in the standard group, without statistically significant differences. Discussion and ConclusionsThe use of cement in OVF with relative indication led to the same clinical benefit in our sample as those with standard indication. A higher number of leakages occurred in the relative indication group with no clinical consequences or adjacent fractures.

Vertebroplasty in Osteoporotic Vertebral Fractures: Technical Considerations and Complications

Vertebroplasty in Osteoporotic Vertebral Fractures: Technical Considerations and Complications

Response to: Risk Factors for Cement Loosening after Vertebroplasty for Osteoporotic Vertebral Fracture with Intravertebral Cleft: A Retrospective Analysis.

Response to: Risk Factors for Cement Loosening after Vertebroplasty for Osteoporotic Vertebral Fracture with Intravertebral Cleft: A Retrospective Analysis.

Preoperative Risk Factor of Postoperative Early Adjacent Vertebral Fracture after Vertebroplasty for Osteoporotic Vertebral Fracture

Preoperative Risk Factor of Postoperative Early Adjacent Vertebral Fracture after Vertebroplasty for Osteoporotic Vertebral Fracture

Cochrane in CORR®: Percutaneous Vertebroplasty for Osteoporotic Vertebral Compression Fracture.

Importance of the TopicOsteoporotic vertebral fractures can occur without trauma, and cause pain and disability related to decreased mobility [14]. As the North American population ages in the coming decade, osteoporotic vertebral fractures will become more burdensome on patients and healthcare syst

Risk Factors for Cement Loosening after Vertebroplasty for Osteoporotic Vertebral Fracture with Intravertebral Cleft: A Retrospective Analysis.

Study DesignRetrospective case-control study.PurposeTo evaluate the primary outcomes and radiographic results of percutaneous vertebroplasty (PVP) in patients with singlelevel osteoporotic vertebral fracture (OVF) with intravertebral cleft (IVC) to identify the risk factors for cement loosening after PVP.Overview of LiteraturePVP is a widely accepted method for managing painful OVF; however, cement loosening occasionally occurs with poor outcomes.MethodsThis retrospective study involved 195 patients treated with PVP for single-level OVF with IVC. Six months thereafter, the primary outcomes were evaluated using the Visual Analog Scale (VAS) for back pain and the modified Oswestry Disability Index. Computed tomography was conducted to detect cement loosening. Possible risk factors, such as age, sex, wedging angle, intravertebral instability, Parkinson’s disease, spinous process fracture, ankylosing spinal hyperostosis, split vertebrae, and adjacent intervertebral vacuum, were assessed.ResultsForty-nine patients (25%) experienced cement loosening 6 months after PVP. The mean VAS scores were significantly higher in patients with cement loosening than in those without (50 vs. 26 mm, respectively; p <0.01). Cement loosening was closely associated with intravertebral instability (odds ratio [OR], 1.20; 95% confidence interval [CI], 1.04–1.40; p =0.015), Parkinson’s disease (OR, 54.31; 95% CI, 4.47–659.53; p =0.002), spinous process fracture (OR, 7.11; 95% CI, 1.65–30.60; p =0.009), and split vertebrae (OR, 11.59; 95% CI, 1.64–82.02; p =0.014).ConclusionsPatients with cement loosening experienced worse back pain than those without cement loosening. The important risk factors that influenced cement loosening after PVP were high intravertebral instability, Parkinson’s disease, spinous process fracture, and split vertebrae.

Bone Regeneration of Osteoporotic Vertebral Body Defects Using Platelet-Rich Plasma and Gelatin β-Tricalcium Phosphate Sponges.

The objective of the present study was to investigate the effect of platelet-rich plasma (PRP) combined with gelatin β-tricalcium phosphate (β-TCP) sponge on bone generation in a lumbar vertebral body defect of ovariectomized rat. After creating critical-size defects in the center of the anterior vertebral body, the defects were filled with the following materials: (1) no material (control group), (2) gelatin β-TCP sponge with PRP (PRP sponge group), and (3) gelatin β-TCP sponge with phosphate-buffered saline (PBS sponge group). Microcomputed tomography and histological evaluation were performed immediately after surgery and at 4, 8, and 12 weeks to assess bone regeneration. Biomechanical test was also performed at postoperative week 12. In the PRP sponge group, both imaging and histological examination showed that visible osteogenesis was first induced and additional growth of bone tissue was observed in the transplanted sponge, compared with the PBS sponge group. There was no negative effect of either PRP sponge or PBS sponge transplantation on bone tissue generation around the periphery of the defect. Biomechanical test showed increased stiffness of the affected vertebral bodies in the PRP sponge group. These results indicate that PRP-impregnated gelatin β-TCP sponge is effective for facilitating bone regeneration in lumbar vertebral bone defect under osteoporotic condition. PRP combined with gelatin β-TCP sponges could be potentially useful for developing a new approach to vertebroplasty for osteoporotic vertebral fracture.

What are the predictors of clinical success after percutaneous vertebroplasty for osteoporotic vertebral fractures?

Osteoporotic vertebral fractures are responsible for acute pain and disability that may persist for more than 2 months. We wanted to identify predicting factors for mid-term outcome after vertebroplasty. We included consecutive patients who underwent vertebroplasty for fragility fractures with persistent and intense pain between January 2014-June 2016. Outcome was assessed by an independent clinician after 1 month using a standardized questionnaire. Patients were classified as having either a favorable or a poor outcome. Presence of an intravertebral cleft and bone oedema mean signal intensity was assessed by an independent radiologist blinded to the clinical data. Pre-intervention clinical or radiological factors were analysed as predictors for outcome. In the 78 included patients (females 71%, age 75 ± 8.3 years), 61.5% had a favourable outcome. When vertebroplasty was performed within 2 months after fracture, the outcome was favourable in 19 patients (39.6%) and poor in five (16.7%; estimate for favourable outcome: OR = 4.1, 95% CI 1.2-13.8, p = 0.021). Absence of intravertebral cleft on pre-intervention imaging was also a predictor of favourable outcome (OR = 3.7, 95% CI 1.2-11.8, p = 0.024). On pre-intervention MRI, vertebral body oedema intensity signal did not influence the outcome. In patients with persistent and intense pain after an osteoporotic vertebral fracture, early intervention and absence of intravertebral cleft were predictors of favourable outcome at 1 month after vertebroplasty. • Performing vertebroplasty within 2 months following a fragility fracture increases success rate. • Presence of an intravertebral cleft at baseline is a predictor of poor mid-term outcome. • A pre-intervention MRI should be performed to ascertain the indication of vertebroplasty.

Application of unilateral multiple channels approach in percutaneous vertebroplasty for osteoporotic vertebral fractures.

This study aimed to investigate the application valuable of percutaneous vertebroplasty (PVP) with unilateral multiple channels approach in osteoporotic vertebral fractures patients. A retrospective review was conducted on 685 consecutive patients with osteoporotic vertebral fracture from March 2003 to October 2012. Among them, 82 cases were given PVP procedure by unilateral multiple channels approach. The timing of surgery, bone cements injection, and complications were analyzed. By using the X-ray film, the distribution of cement was detected and scored. The visual analogue scale (VAS) score and Oswestry disability index (ODI) system were used to evaluate the pain relief and improvement of daily activity function after operation. The excellent and good rate of cement distribution was 98.8% (98/99).Before surgery, the VAS score was 2.5±0.43. After surgery, the VAS score was significantly decreased to 2.0±0.33 at 1 h. Before surgery, ODI was 40.94±2.72.ODI was significantly decreased at 1 month after surgery (9.64±2.60) and at the final follow-up (7.77±2.15). No spine or nerve injury, bone cement leakage, pulmonary embolism, pneumothorax, bleeding or infection occurred intraoperatively. Thus, the PVP with unilateral multiple channels approach effectively relieve the pain and improve the functional activity, without occurrence of complications.

P178 - Risk Factors Predicting Cement Loosening after Percutaneous Vertebroplasty for Osteoporotic Vertebral Fracture with Intravertebral Cleft: A Retrospective Analysis

BACKGROUND CONTEXT: Percutaneous vertebroplasty (PVP) is an efficient procedure to treat painful osteoporotic vertebral fracture (OVF) with intravertebral cleft. However, cement loosening occurs occasionally with poor outcome.

Percutaneous Vertebroplasty in Osteoporotic Vertebral Fractures Using a Combination of CT Fluoroscopy and Conventional Lateral Fluoroscopy

Percutaneous Vertebroplasty in Osteoporotic Vertebral Fractures Using a Combination of CT Fluoroscopy and Conventional Lateral Fluoroscopy

Risk factors for recollapse of the augmented vertebrae after percutaneous vertebroplasty for osteoporotic vertebral fractures with intravertebral vacuum cleft.

To determine risk factors related to recollapse of the augmented vertebrae after percutaneous vertebroplasty (PVP) for osteoporotic vertebral compression fractures (OVCFs) with intravertebral vacuum cleft (IVC).Fifty-two patients treated with PVP for single OVCFs with the IVC were retrospectively reviewed. The follow-up period was at least 2 years. Vertebral height loss ≥15% or kyphotic angle ≥10° at the final follow-up in relation to the immediately postoperative values were adopted as a definition of recollapse of the augmented vertebrae. Correlation analysis and multiple logistic regression analyses were performed to elucidate the related clinical or radiological factors for recollapse of the augmented vertebrae including age, gender, bone mineral density, preoperative fracture severity, locations of IVC sign, distribution patterns of polymethylmethacrylate (PMMA), reduction rate, and reduction angle.Assuming the increase of height loss more than 15% as a criterion of recollapse, only cleft filling pattern of PMMA in the IVC area was a significant risk factor for recollapse of the augmented vertebrae (P < 0.01). Assuming ≥10° progression of kyphotic angle as a criterion, cleft filling pattern of PMMA and higher values of reduction angle was as 2 significant risk factors for recollapse of the augmented vertebrae (P < 0.01). No significant difference was found in other clinical and radiological factors (P > 0.05).Cleft filling pattern of PMMA and higher values of reduction angle may play an important role in inducing recollapse of the augmented vertebrae after PVP for OVCFs with the IVC. Careful observation of patients with these conditions is necessary to prevent deterioration of their clinical course.

Risk factors of adjacent vertebral collapse after percutaneous vertebroplasty for osteoporotic vertebral fracture in postmenopausal women.

BackgroundRecently percutaneous vertebroplasty (PVP) was frequently performed for treatment of osteoporotic vertebral fractures (VFs). It is widely accepted that new compression fractures tend to occur adjacent to the vertebral bodies, typically within a month after PVP. To determine the risk factors among several potential predictors for de novo VFs following PVP in patients with osteoporosis.MethodsWe retrospectively screened the clinical results of 88 patients who had been treated by PVP. Fifteen cases were excluded due to non-union. Of the remaining 73 patients, 19 (26.0 %) later returned with pain due to a new vertebral compression fracture. One patient with a non-adjacent fracture and 2 patients with adjacent factures occurring 3 months later were excluded from the study. The 9 male patients were excluded to avoid gender bias. Ultimately, we divided the 61 remaining postmenopausal female patients (mean age: 78.9 years) into the collapse group (14 patients) who had experienced adjacent vertebral collapse after PVP and the non-collapse group (47 patients) who had not. Logistic regression analysis was performed to identify the risk factors for new VFs after PVP.ResultsAll 14 cases of adjacent VF occurred within the first month after surgery. The collapse group had significantly advanced age, higher urinary N-terminal cross-linking telopeptide of type I collagen, and lower lumbar and hip bone mineral density (BMD) scores as compared with the non-collapse group. The odds ratios for age, lumbar, total hip, femoral neck, and trochanteric BMD were 4.5, 8.2, 4.5, 7.2, and 9.6, respectively. Positive likelihood ratios suggested that age more than 85 years, lumbar BMD less than 0.700 [−2.6SD], total hip BMD less than 0.700 [−1.8SD], neck BMD less than 0.600 [−2.1], and trochanter BMD less than 0.600 conferred an elevated risk of adjacent VF.ConclusionsOur study revealed that advanced age and decreased lumbar and hip BMD scores most strongly indicated a risk of adjacent VF following PVP.

A case of percutaneous vertebroplasty for osteoporotic vertebral fracture with bladder rectum failure

A case of percutaneous vertebroplasty for osteoporotic vertebral fracture with bladder rectum failure

Controversial issues in kyphoplasty and vertebroplasty in osteoporotic vertebral fractures.

Kyphoplasty (KP) and vertebroplasty (VP) have been successfully employed for many years for the treatment of osteoporotic vertebral fractures. The purpose of this review is to resolve the controversial issues raised by the two randomized trials that claimed no difference between VP and SHAM procedure. In particular we compare nonsurgical management (NSM) and KP and VP, in terms of clinical parameters (pain, disability, quality of life, and new fractures), cost-effectiveness, radiological variables (kyphosis correction and vertebral height restoration), and VP versus KP for cement extravasation and complications profile. Cement types and optimal filling are analyzed and technological innovations are presented. Finally unipedicular/bipedicular techniques are compared. Conclusion. VP and KP are superior to NSM in clinical and radiological parameters and probably more cost-effective. KP is superior to VP in sagittal balance improvement and cement leaking. Complications are rare but serious adverse events have been described, so caution should be exerted. Unilateral procedures should be pursued whenever feasible. Upcoming randomized trials (CEEP, OSTEO-6, STIC-2, and VERTOS IV) will provide the missing link.

Letter to the Editor: Is There Really No Benefit of Vertebroplasty for Osteoporotic Vertebral Fractures? A Meta-analysis

To the Editor We read with interest the article by Shi et al. [9] published in your journal that addresses the controversial topic of percutaneous vertebroplasty (PVP) using meta-analysis of selected literature. The authors’ conclusion [9] appears to contradict Recommendation 8 of the American Academy of Orthopaedic Surgeons (AAOS) “Clinical Practice Guideline (CPG) on the Treatment of Symptomatic Osteoporotic Spinal Compression Fractures” [2]. We would like to address the differences between their analysis and that done by the AAOS CPG Workgroup. Although the meta-analysis process was similar in both reviews, some methodologic aspects differ. AAOS established a priori content based inclusion and exclusion criteria for study selection [2]. It is unclear how Shi et al. determined which articles to include. The AAOS Workgroup excluded three studies that they included [1, 4, 8] for poor study design description and for not being the best available evidence. A study is not the best available evidence if there are at least two studies of higher quality that measure the same outcomes; high quality studies are unlikely to be overturned by future evidence. Three studies in the current review [5, 7, 11] were published after the AAOS CPG was completed, but would not have changed our recommendation. Only three studies were mutually included [3, 6, 10]. Both reviews show no difference between sham treatments and PVP [2, 9]. There is disagreement in outcomes between nonoperative therapy and PVP, a comparison not made in randomized controlled studies because of inherent bias. The AAOS considered the magnitude of treatment effects by using statistical significance in the context of minimal clinically important improvements (MCII). The MCII is the smallest change that is important to patients; it controls for statistically significant treatment effects that are too small to matter. Shi et al. appear to incorporate only statistics. They rely heavily on the results of PVP that measure subjective outcomes and, in their conclusion, diminish the validity of comparing PVP with nonoperative treatment [9]. The meta-analysis by Shi et al. offers a different conclusion on the benefits of PVP than does the AAOS guideline. The methodology used by the AAOS is substantially more rigorous and transparent. Additional studies used in the Shi et al. analysis either do not meet our inclusion criteria standards or their weakened quality would exclude them in the AAOS analysis. We believe the AAOS’s use of MCII is preferred over the use of straight statistical comparisons used by Shi et al. PVP versus sham surgery is the gold standard of comparisons, and these results are not contradicted. It is understandable that physicians would want to validate a procedure that they believe works. For this to occur, high-quality studies using appropriate outcome measures will have to show a difference greater than the MCII.

Reply to Letter to the Editor: Is There Really No Benefit of Vertebroplasty for Osteoporotic Vertebral Fractures? A Meta-analysis

We appreciate the interest in our meta-analysis by the American Academy of Orthopaedic Surgeons (AAOS). Some of the points in the letter addressed limitations of our meta-analysis [7]. We included four trials which were not included in the AAOS guideline 2010 [1, 4, 6, 8], of which two were randomized controlled trials and the other two were prospective nonrandomized controlled trails. In addition to two Level I trials, there were three Level II trials in the AAOS guideline that had the same quality as these four trials. Dr. Jevsevar and his colleagues commented in their letter that “A study is not the best available evidence if there are at least two studies of higher quality that measure the same outcomes”, a point with which we concur. However, these two sham-control trials [3, 5] had some limitations: (1) Although both trials questioned the effect of PVP, there was still a trend toward a better outcome with PVP. (2) There was a large proportion of patients declining to enroll and high crossover rate raising the question of whether they had enough subjects. (3) These two trials included acute and chronic fractures; is there no difference between acute and chronic fractures? Our analysis suggested the difference might influence the results. Further, our meta-analysis added other outcomes. For example, PVP did not increase the risk of recurrent fractures and some inclusion criteria might influence the result (eg, bone edema of vertebral fracture observed on MR images). Our review attempted to include all the available prospective evidence and was comprehensive. The AAOS guideline was based on more stringent selection criteria but eliminated some evidence. In addition, one new RCT has been published comparing PVP and conservative therapy [2] that concluded PVP achieved faster pain relief. We believe the AAOS guideline on treatment of symptomatic osteoporotic spinal compression fractures will face more challenges and we look forward to the findings of further investigations.