Black DM, Cummings SR, Karpf DB, Cauley JA, Thompson DE, Nevitt MC, Bauer DC, Genant HK, Haskell WL, Marcus R, Ott SM, Torner JC, Quandt SA, Reiss TF, Ensrud KE.
Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Fracture Intervention Trial Research Group.
Lancet. 1996 Dec 7;348(9041):1535-41. doi: 10.1016/s0140-6736(96)07088-2.
Abstract/Text
BACKGROUND: Previous studies have shown that alendronate can increase bone mineral density (BMD) and prevent radiographically defined (morphometric) vertebral fractures. The Fracture Intervention Trial aimed to investigate the effect of alendronate on the risk of morphometric as well as clinically evident fractures in postmenopausal women with low bone mass.
METHODS: Women aged 55-81 with low femoral-neck BMD were enrolled in two study groups based on presence or absence of an existing vertebral fracture. Results for women with at least one vertebral fracture at baseline are reported here. 2027 women were randomly assigned placebo (1005) or alendronate (1022) and followed up for 36 months. The dose of alendronate (initially 5 mg daily) was increased (to 10 mg daily) at 24 months, with maintenance of the double blind. Lateral spine radiography was done at baseline and at 24 and 36 months. New vertebral fractures, the primary endpoint, were defined by morphometry as a decrease of 20% (and at least 4 mm) in at least one vertebral height between the baseline and latest follow-up radiograph. Non-spine clinical fractures were confirmed by radiographic reports. New symptomatic vertebral fractures were based on self-report and confirmed by radiography.
FINDINGS: Follow-up radiographs were obtained for 1946 women (98% of surviving participants). 78 (8.0%) of women in the alendronate group had one or more new morphometric vertebral fractures compared with 145 (15.0%) in the placebo group (relative risk 0.53 [95% Cl 0.41-0.68]). For clinically apparent vertebral fractures, the corresponding numbers were 23 (2.3%) alendronate and 50 (5.0%) placebo (relative hazard 0.45 [0.27-0.72]). The risk of any clinical fracture, the main secondary endpoint, was lower in the alendronate than in the placebo group (139 [13.6%] vs 183 [18.2%]; relative hazard 0.72 [0.58-0.90]). The relative hazards for hip fracture and wrist fracture for alendronate versus placebo were 0.49 (0.23-0.99) and 0.52 (0.31-0.87). There was no significant difference between the groups in numbers of adverse experiences, including upper-gastrointestinal disorders.
INTERPRETATION: We conclude that among women with low bone mass and existing vertebral fractures, alendronate is well tolerated and substantially reduces the frequency of morphometric and clinical vertebral fractures, as well as other clinical fractures.
Mori S, Soen S, Hagino H, Nakano T, Ito M, Fujiwara S, Kato Y, Tokuhashi Y, Togawa D, Endo N, Sawaguchi T; Committee for Vertebral Fracture Evaluation.
Justification criteria for vertebral fractures: year 2012 revision.
J Bone Miner Metab. 2013 May;31(3):258-61. doi: 10.1007/s00774-013-0441-1. Epub 2013 Apr 26.
Abstract/Text
Justification Criteria for Vertebral Fractures 2012 version was made based on new clinical findings. Major differences in this version compared to the 1996 version are inclusion of the semiquantitative method (SQ), statements to improve considerations during radiographic analysis, and the need for more detailed evaluation by MRI.
Horii C, Asai Y, Iidaka T, Muraki S, Oka H, Tsutsui S, Hashizume H, Yamada H, Yoshida M, Kawaguchi H, Nakamura K, Akune T, Tanaka S, Yoshimura N.
Differences in prevalence and associated factors between mild and severe vertebral fractures in Japanese men and women: the third survey of the ROAD study.
J Bone Miner Metab. 2019 Sep;37(5):844-853. doi: 10.1007/s00774-018-0981-5. Epub 2019 Jan 3.
Abstract/Text
Vertebral fracture (VF) is a common osteoporotic fracture, while its epidemiology varies according to regions and ethnicities, little is known about it in Japan. Using whole-spine radiographs from a population-based cohort study, the Research on Osteoarthritis/Osteoporosis Against Disability study 3rd survey performed in 2012-2013, we estimated the sex- and age-specific prevalence of VF in the Japanese. Genant's semiquantitative method (SQ) was used to define VF; SQ ≥ 1 as VF, SQ = 1 as mild VF, SQ≥ 2 as severe VF. We also revealed accurate site-specific prevalence, and associated factors with mild and severe VF. The participants were 506 men [mean age 66.3 years, standard deviation (SD):13.0] and 1038 women (mean age 65.3 years, SD: 12.6). The prevalence of VF in participants aged under 40, in their 40s, 50s, 60s, 70s, and ≥ 80 years was 17.4, 7.9, 18.5, 25.6, 26.3, and 41.5%, respectively, in men, and 2.9%, 2.4%, 7,3, 10.3, 27.1, and 53.0%, respectively, in women. Men had a significantly higher prevalence of mild VF (21.2%) than women (10.0%, p < 0.001); whereas, severe VF was significantly more prevalent in women (9.1%) than in men (4.7%, p = 0.003). VF was distributed with 2 peaks regarding site; one large peak at the thoracolumbar region, and another at the middle thoracic lesion. Low back pain and decreased walking ability were independently associated with severe VF, but not with mild VF, after adjustment for participant characteristics. Decreased walking ability was associated with multiple VFs in women, but not in men.
Horii C, Iidaka T, Muraki S, Oka H, Asai Y, Tsutsui S, Hashizume H, Yamada H, Yoshida M, Kawaguchi H, Nakamura K, Akune T, Oshima Y, Tanaka S, Yoshimura N.
The cumulative incidence of and risk factors for morphometric severe vertebral fractures in Japanese men and women: the ROAD study third and fourth surveys.
Osteoporos Int. 2022 Apr;33(4):889-899. doi: 10.1007/s00198-021-06143-7. Epub 2021 Nov 19.
Abstract/Text
UNLABELLED: This population-based cohort study with a 3-year follow-up revealed that the annual incidence rates of vertebral fracture (VF) and severe VF (sVF) were 5.9%/year and 1.7%/year, respectively. The presence of mild VF at the baseline was a significant risk factor for incident sVF in participants without prevalent sVF.
INTRODUCTION: This study aimed to estimate the incidence of morphometric vertebral fracture (VF) and severe VF (sVF) in men and women and clarify whether the presence of a mild VF (mVF) increases the risk of incident sVF.
METHODS: Data from the population-based cohort study, entitled the Research on Osteoarthritis/Osteoporosis Against Disability (ROAD) study, were analyzed. In total, 1190 participants aged ≥ 40 years (mean age, 65.0 ± 11.2) years completed whole-spine lateral radiography both at the third (2012-2013, baseline) and fourth surveys performed 3 years later (2015-2016, follow-up). VF was defined using Genant's semi-quantitative (SQ) method: VF as SQ ≥ 1, mVF as SQ = 1, and sVF as SQ ≥ 2. Cumulative incidence of VF and sVF was estimated. Multivariate logistic regression analyses were performed to evaluate risk factors for incident sVF.
RESULTS: The baseline prevalence of mVF and sVF were 16.8% and 6.0%, respectively. The annual incidence rates of VF and sVF were 5.9%/year and 1.7%/year, respectively. The annual incidence rates of sVF in participants without prevalent VF, with prevalent mVF, and with prevalent sVF were 0.6%/year, 3.8%/year, and 11.7%/year (p < 0.001), respectively. Multivariate logistic regression analyses in participants without prevalent sVF showed that the adjusted odds ratios for incident sVF were 4.12 [95% confident interval 1.85-9.16] and 4.53 [1.49-13.77] if the number of prevalent mVF at the baseline was 1 and ≥ 2, respectively.
CONCLUSIONS: The annual incidence rates of VF and sVF were 5.9%/year and 1.7%/year, respectively. The presence of prevalent mVF was an independent risk factor for incident sVF.
© 2021. International Osteoporosis Foundation and National Osteoporosis Foundation.
Tsukutani Y, Hagino H, Ito Y, Nagashima H.
Epidemiology of fragility fractures in Sakaiminato, Japan: incidence, secular trends, and prognosis.
Osteoporos Int. 2015 Sep;26(9):2249-55. doi: 10.1007/s00198-015-3124-z. Epub 2015 May 19.
Abstract/Text
UNLABELLED: We investigated the incidence of fragility fractures from 2010 to 2012 in Sakaiminato, Japan. The incidence rates of limb fractures in Sakaiminato were lower than in Caucasian populations but had increased relative to data obtained in Japan in the 1990s. Clinical vertebral fractures occurred at higher rates in Sakaiminato than in Caucasian populations.
INTRODUCTION: To elucidate the incidence and prognosis of fragility fractures in Sakaiminato, Japan.
METHODS: A survey of all hip, distal radius, proximal humerus, and clinical vertebral fractures was performed from 2010 to 2012 in patients aged 50 or older in Sakaiminato city, Tottori prefecture, Japan. The age- and gender-specific incidence rates (per 100,000 person-years) were calculated based on the population of Sakaiminato city each year. The incidence rates of hip, distal radius, and proximal humerus fractures were compared with previous reports. We conducted a follow-up study assessing patients within 1 year following their initial treatment at two Sakaiminato hospitals.
RESULTS: The age-adjusted incidence rates in population aged 50 years or older (per 100,000 person-years) of hip, distal radius, proximal humerus, and clinical vertebral fractures were, respectively, 217, 82, 26, and 412 in males and 567, 432, 96, and 1229 in females. Age-specific incidence rates of hip, distal radius, and proximal humerus fractures all increased since the 1990s. Our study also revealed that anti-osteoporotic pharmacotherapy was prescribed 1 year post-fracture at rates of 29, 20, 30, and 50 % for patients with hip, distal radius, proximal humerus, and clinical vertebral fractures, respectively.
CONCLUSIONS: The incidence rates of limb fractures in Sakaiminato were substantially lower than Caucasian populations in northern Europe but had increased relative to data obtained in Japan in the 1990s. Unlike upper and lower limb fractures, clinical vertebral fractures occurred at higher rates in our study population than in other Asian and North European countries.
Deyo RA, Rainville J, Kent DL.
What can the history and physical examination tell us about low back pain?
JAMA. 1992 Aug 12;268(6):760-5.
Abstract/Text
Toyoda H, Takahashi S, Hoshino M, Takayama K, Iseki K, Sasaoka R, Tsujio T, Yasuda H, Sasaki T, Kanematsu F, Kono H, Nakamura H.
Characterizing the course of back pain after osteoporotic vertebral fracture: a hierarchical cluster analysis of a prospective cohort study.
Arch Osteoporos. 2017 Sep 23;12(1):82. doi: 10.1007/s11657-017-0377-5. Epub 2017 Sep 23.
Abstract/Text
UNLABELLED: This study demonstrated four distinct patterns in the course of back pain after osteoporotic vertebral fracture (OVF). Greater angular instability in the first 6 months after the baseline was one factor affecting back pain after OVF.
PURPOSE: Understanding the natural course of symptomatic acute OVF is important in deciding the optimal treatment strategy. We used latent class analysis to classify the course of back pain after OVF and identify the risk factors associated with persistent pain.
METHODS: This multicenter cohort study included 218 consecutive patients with ≤ 2-week-old OVFs who were enrolled at 11 institutions. Dynamic x-rays and back pain assessment with a visual analog scale (VAS) were obtained at enrollment and at 1-, 3-, and 6-month follow-ups. The VAS scores were used to characterize patient groups, using hierarchical cluster analysis.
RESULTS: VAS for 128 patients was used for hierarchical cluster analysis. Analysis yielded four clusters representing different patterns of back pain progression. Cluster 1 patients (50.8%) had stable, mild pain. Cluster 2 patients (21.1%) started with moderate pain and progressed quickly to very low pain. Patients in cluster 3 (10.9%) had moderate pain that initially improved but worsened after 3 months. Cluster 4 patients (17.2%) had persistent severe pain. Patients in cluster 4 showed significant high baseline pain intensity, higher degree of angular instability, and higher number of previous OVFs, and tended to lack regular exercise. In contrast, patients in cluster 2 had significantly lower baseline VAS and less angular instability.
CONCLUSIONS: We identified four distinct groups of OVF patients with different patterns of back pain progression. Understanding the course of back pain after OVF may help in its management and contribute to future treatment trials.
Katzman WB, Vittinghoff E, Kado DM, Lane NE, Ensrud KE, Shipp K.
Thoracic kyphosis and rate of incident vertebral fractures: the Fracture Intervention Trial.
Osteoporos Int. 2016 Mar;27(3):899-903. doi: 10.1007/s00198-015-3478-2. Epub 2016 Jan 18.
Abstract/Text
SUMMARY: Biomechanical analyses support the theory that thoracic spine hyperkyphosis may increase risk of new vertebral fractures. While greater kyphosis was associated with an increased rate of incident vertebral fractures, our analysis does not show an independent association of kyphosis on incident fracture, after adjustment for prevalent vertebral fracture. Excessive kyphosis may still be a clinical marker for prevalent vertebral fracture.
INTRODUCTION: Biomechanical analyses suggest hyperkyphosis may increase risk of incident vertebral fracture by increasing the load on vertebral bodies during daily activities. We propose to assess the association of kyphosis with incident radiographic vertebral fracture.
METHODS: We used data from the Fracture Intervention Trial among 3038 women 55-81 years of age with low bone mineral density (BMD). Baseline kyphosis angle was measured using a Debrunner kyphometer. Vertebral fractures were assessed at baseline and follow-up from lateral radiographs of the thoracic and lumbar spine. We used Poisson models to estimate the independent association of kyphosis with incident fracture, controlling for age and femoral neck BMD.
RESULTS: Mean baseline kyphosis was 48° (SD = 12) (range 7-83). At baseline, 962 (32%) participants had a prevalent fracture. There were 221 incident fractures over a median of 4 years. At baseline, prevalent fracture was associated with 3.7° greater average kyphosis (95% CI 2.8-4.6, p < 0.0005), adjusting for age and femoral neck BMD. Before adjusting for prevalent fracture, each 10° greater kyphosis was associated with 22% increase (95% CI 8-38%, p = 0.001) in annualized rate of new radiographic vertebral fracture, adjusting for age and femoral neck BMD. After additional adjustment for prevalent fracture, estimated increased annualized rate was attenuated and no longer significant, 8% per 10° kyphosis (95% CI -4 to 22%, p = 0.18).
CONCLUSIONS: While greater kyphosis increased the rate of incident vertebral fractures, our analysis does not show an independent association of kyphosis on incident fracture, after adjustment for prevalent vertebral fracture. Excessive kyphosis may still be a clinical marker for prevalent vertebral fracture.
van der Jagt-Willems HC, de Groot MH, van Campen JP, Lamoth CJ, Lems WF.
Associations between vertebral fractures, increased thoracic kyphosis, a flexed posture and falls in older adults: a prospective cohort study.
BMC Geriatr. 2015 Mar 28;15:34. doi: 10.1186/s12877-015-0018-z. Epub 2015 Mar 28.
Abstract/Text
BACKGROUND: Vertebral fractures, an increased thoracic kyphosis and a flexed posture are associated with falls. However, this was not confirmed in prospective studies. We performed a prospective cohort study to investigate the association between vertebral fractures, increased thoracic kyphosis and/or flexed posture with future fall incidents in older adults within the next year.
METHODS: Patients were recruited at a geriatric outpatient clinic. Vertebral fractures were evaluated on lateral radiographs of the spine with the semi-quantitative method of Genant; the degree of thoracic kyphosis was assessed with the Cobb angle. The occiput-to-wall distance was used to determine a flexed posture. Self-reported falls were prospectively registered by monthly phone contact for the duration of 12 months.
RESULTS: Fifty-one older adults were included; mean age was 79 years (SD = 4.8). An increased thoracic kyphosis was independently associated with future falls (OR 2.13; 95% CI 1.10-4.51). Prevalent vertebral fractures had a trend towards significancy (OR 3.67; 95% CI 0.85-15.9). A flexed posture was not significantly associated with future falls.
CONCLUSION: Older adults with an increased thoracic kyphosis are more likely to fall within the next year. We suggest clinical attention for underlying causes. Because patients with increased thoracic curvature of the spine might have underlying osteoporotic vertebral fractures, clinicians should be aware of the risk of a new fracture.
Miyakoshi N, Kasukawa Y, Sasaki H, Kamo K, Shimada Y.
Impact of spinal kyphosis on gastroesophageal reflux disease symptoms in patients with osteoporosis.
Osteoporos Int. 2009 Jul;20(7):1193-8. doi: 10.1007/s00198-008-0777-x. Epub 2008 Oct 23.
Abstract/Text
SUMMARY: Spinal kyphosis has been speculated to participate in the increased frequency of gastroesophageal reflux disease (GERD) in patients with osteoporosis. The present study provides further evidence that increases in lumbar kyphosis and number of vertebral fractures represent very important risk factors for GERD in patients with osteoporosis.
INTRODUCTION: Osteoporosis and spinal kyphosis have been speculated to participate in the increased frequency of gastroesophageal reflux disease (GERD). The present study examined whether GERD in patients with osteoporosis is affected by spinal factors including spinal kyphosis in the presence of oral pharmacotherapies.
METHODS: Subjects comprised 112 patients with osteoporosis (mean age, 78 years) who responded to the Frequency Scale for Symptoms of GERD (FSSG) questionnaire, regardless of complaints. Relationships between total FSSG score and number of vertebral fractures, angles of kyphosis, use of bisphosphonates and nonsteroidal anti-inflammatory drugs (NSAIDs), and total number of oral medicines per day were evaluated. Logistic regression identified factors associated with GERD.
RESULTS: Bisphosphonates and NSAIDs did not affect total FSSG score. Total FSSG score showed significant positive correlations with total number of medicines (r = 0.283, p = 0.0025), angle of lumbar kyphosis (r = 0.576, p = 0.0001), and numbers of thoracic vertebral fractures (r = 0.214, p = 0.0232) and lumbar vertebral fractures (r = 0.471, p < 0.0001). Angle of lumbar kyphosis and number of lumbar vertebral fractures were identified by multivariate analysis as indices affecting the presence of GERD.
CONCLUSION: Increases in angle of lumbar kyphosis and number of lumbar vertebral fractures may represent very important risk factors for GERD in osteoporotic patients.
日本整形外科学会骨粗鬆症委員会 骨粗鬆症性椎体骨折診療マニュアルワーキンググループ編. 骨粗鬆症性椎体骨折診療マニュアル. 日整会誌. 2020;94(10):882-906.
Han CS, Hancock MJ, Downie A, Jarvik JG, Koes BW, Machado GC, Verhagen AP, Williams CM, Chen Q, Maher CG.
Red flags to screen for vertebral fracture in people presenting with low back pain.
Cochrane Database Syst Rev. 2023 Aug 24;8(8):CD014461. doi: 10.1002/14651858.CD014461.pub2. Epub 2023 Aug 24.
Abstract/Text
BACKGROUND: Low back pain is a common presentation across different healthcare settings. Clinicians need to confidently be able to screen and identify people presenting with low back pain with a high suspicion of serious or specific pathology (e.g. vertebral fracture). Patients identified with an increased likelihood of having a serious pathology will likely require additional investigations and specific treatment. Guidelines recommend a thorough history and clinical assessment to screen for serious pathology as a cause of low back pain. However, the diagnostic accuracy of recommended red flags (e.g. older age, trauma, corticosteroid use) remains unclear, particularly those used to screen for vertebral fracture.
OBJECTIVES: To assess the diagnostic accuracy of red flags used to screen for vertebral fracture in people presenting with low back pain. Where possible, we reported results of red flags separately for different types of vertebral fracture (i.e. acute osteoporotic vertebral compression fracture, vertebral traumatic fracture, vertebral stress fracture, unspecified vertebral fracture).
SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search date was 26 July 2022.
SELECTION CRITERIA: We considered primary diagnostic studies if they compared results of history taking or physical examination (or both) findings (index test) with a reference standard test (e.g. X-ray, magnetic resonance imaging (MRI), computed tomography (CT), single-photon emission computerised tomography (SPECT)) for the identification of vertebral fracture in people presenting with low back pain. We included index tests that were presented individually or as part of a combination of tests.
DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data for diagnostic two-by-two tables from the publications or reconstructed them using information from relevant parameters to calculate sensitivity, specificity, and positive (+LR) and negative (-LR) likelihood ratios with 95% confidence intervals (CIs). We extracted aspects of study design, characteristics of the population, index test, reference standard, and type of vertebral fracture. Meta-analysis was not possible due to heterogeneity of studies and index tests, therefore the analysis was descriptive. We calculated sensitivity, specificity, and LRs for each test and used these as an indication of clinical usefulness. Two review authors independently conducted risk of bias and applicability assessment using the QUADAS-2 tool.
MAIN RESULTS: This review is an update of a previous Cochrane Review of red flags to screen for vertebral fracture in people with low back pain. We included 14 studies in this review, six based in primary care, five in secondary care, and three in tertiary care. Four studies reported on 'osteoporotic vertebral fractures', two studies reported on 'vertebral compression fracture', one study reported on 'osteoporotic and traumatic vertebral fracture', two studies reported on 'vertebral stress fracture', and five studies reported on 'unspecified vertebral fracture'. Risk of bias was only rated as low in one study for the domains reference standard and flow and timing. The domain patient selection had three studies and the domain index test had six studies rated at low risk of bias. Meta-analysis was not possible due to heterogeneity of the data. Results from single studies suggest only a small number of the red flags investigated may be informative. In the primary healthcare setting, results from single studies suggest 'trauma' demonstrated informative +LRs (range: 1.93 to 12.85) for 'unspecified vertebral fracture' and 'osteoporotic vertebral fracture' (+LR: 6.42, 95% CI 2.94 to 14.02). Results from single studies suggest 'older age' demonstrated informative +LRs for studies in primary care for 'unspecified vertebral fracture' (older age greater than 70 years: 11.19, 95% CI 5.33 to 23.51). Results from single studies suggest 'corticosteroid use' may be an informative red flag in primary care for 'unspecified vertebral fracture' (+LR range: 3.97, 95% CI 0.20 to 79.15 to 48.50, 95% CI 11.48 to 204.98) and 'osteoporotic vertebral fracture' (+LR: 2.46, 95% CI 1.13 to 5.34); however, diagnostic values varied and CIs were imprecise. Results from a single study suggest red flags as part of a combination of index tests such as 'older age and female gender' in primary care demonstrated informative +LRs for 'unspecified vertebral fracture' (16.17, 95% CI 4.47 to 58.43). In the secondary healthcare setting, results from a single study suggest 'trauma' demonstrated informative +LRs for 'unspecified vertebral fracture' (+LR: 2.18, 95% CI 1.86 to 2.54) and 'older age' demonstrated informative +LRs for 'osteoporotic vertebral fracture' (older age greater than 75 years: 2.51, 95% CI 1.48 to 4.27). Results from a single study suggest red flags as part of a combination of index tests such as 'older age and trauma' in secondary care demonstrated informative +LRs for 'unspecified vertebral fracture' (+LR: 4.35, 95% CI 2.92 to 6.48). Results from a single study suggest when '4 of 5 tests' were positive in secondary care, they demonstrated informative +LRs for 'osteoporotic vertebral fracture' (+LR: 9.62, 95% CI 5.88 to 15.73). In the tertiary care setting, results from a single study suggest 'presence of contusion/abrasion' was informative for 'vertebral compression fracture' (+LR: 31.09, 95% CI 18.25 to 52.96).
AUTHORS' CONCLUSIONS: The available evidence suggests that only a few red flags are potentially useful in guiding clinical decisions to further investigate people suspected to have a vertebral fracture. Most red flags were not useful as screening tools to identify vertebral fracture in people with low back pain. In primary care, 'older age' was informative for 'unspecified vertebral fracture', and 'trauma' and 'corticosteroid use' were both informative for 'unspecified vertebral fracture' and 'osteoporotic vertebral fracture'. In secondary care, 'older age' was informative for 'osteoporotic vertebral fracture' and 'trauma' was informative for 'unspecified vertebral fracture'. In tertiary care, 'presence of contusion/abrasion' was informative for 'vertebral compression fracture'. Combinations of red flags were also informative and may be more useful than individual tests alone. Unfortunately, the challenge to provide clear guidance on which red flags should be used routinely in clinical practice remains. Further research with primary studies is needed to improve and consolidate our current recommendations for screening for vertebral fractures to guide clinical care.
Copyright © 2023 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
北米脊椎外科学会（NASS）：Diagnosis and Treatment of Adults with Osteoporotic Vertebral Compression Fractures.
Jin H, Ma X, Liu Y, Yin X, Zhu J, Wang Z, Fan W, Jin Y, Pu J, Zhao J, Liu M, Liu P.
Back Pain-Inducing Test, a Novel and Sensitive Screening Test for Painful Osteoporotic Vertebral Fractures: A Prospective Clinical Study.
J Bone Miner Res. 2020 Mar;35(3):488-497. doi: 10.1002/jbmr.3912. Epub 2019 Dec 4.
Abstract/Text
To detect painful vertebral fractures (VFs) in back pain populations at risk of osteoporosis, we designed a physical examination test (the Back Pain-Inducing Test [BPIT]) that included three movements: lying supine, rolling over, and sitting up. If back pain is induced during any of these movements, the result is defined as positive, thereby establishing a presumptive diagnosis of painful VFs. Pain severity is quantified using a self-reported numerical rating scale (NRS). The presence or absence of painful VFs is verified by whole-spine magnetic resonance imaging (MRI), the gold standard for final diagnosis. According to the standards for reporting diagnostic accuracy, a real-world, prospective, and observational study was performed on 510 back pain patients (enrolled from a single institute) at risk of osteoporosis. The sensitivity, specificity, and accuracy of the BPIT for identifying painful VFs were 99.1% (95% CI, 97.5% to 99.8%), 67.9% (95% CI, 60.4% to 74.5%), and 89.0%, respectively. The positive and negative predictive values were 86.6% (95% CI, 82.9% to 89.6%) and 97.4% (95% CI, 92.6% to 99.3%), respectively. Cutoff NRS scores for lying supine, rolling over, and sitting up were 3, 0, and 2, respectively. The corresponding area under the receiver operating characteristic curves (AUROCs) of each movement was 0.898 (95% CI, 0.868 to 0.922), 0.884 (95% CI, 0.854 to 0.911), and 0.910 (95% CI, 0.882 to 0.933), respectively. Although the high prevalence of VFs in the enrolled cohort partially limits the external validity of the predictive value in the general population, we conclude that the BPIT is potentially effective for detecting painful VFs in back pain populations at risk of osteoporosis. This test may be used as a stratification tool in decision-making on subsequent imaging procedures: a negative BPIT rules out painful VFs and indicates that an MRI should be spared, whereas a positive BPIT means that an MRI is necessary and is likely to identify painful VFs. © 2019 American Society for Bone and Mineral Research.
© 2019 American Society for Bone and Mineral Research.
Langdon J, Way A, Heaton S, Bernard J, Molloy S.
Vertebral compression fractures--new clinical signs to aid diagnosis.
Ann R Coll Surg Engl. 2010 Mar;92(2):163-6. doi: 10.1308/003588410X12518836440162. Epub 2009 Dec 7.
Abstract/Text
INTRODUCTION: Acute osteoporotic vertebral compression fractures are common and usually managed conservatively. However, a significant number will remain symptomatic, causing significant pain with considerable associated morbidity and mortality. These fractures can be effectively treated with cement augmentation. However, it is impossible to distinguish between an acute and a chronic healed fracture on plain radiographs. The definitive investigation is a magnetic resonance scan. The aim of this paper is to describe and evaluate two new clinical signs to help in the diagnosis of symptomatic fractures. A prospective study of 83 patients with suspected acute osteoporotic vertebral compression fractures was carried out. All patients had a full clinical assessment, which included closed-fist percussion of their spine and asking the patient to lie supine on the examination couch. All patients had a MRI scan.
RESULTS: The closed-fist percussion sign had a sensitivity of 87.5% and a specificity of 90%. The supine sign had a sensitivity of 81.25% and a specificity of 93.33%.
CONCLUSIONS: These tests will enable the practitioner to predict more accurately which patients have an acute fracture, guiding referral for further imaging.
Siminoski K, Jiang G, Adachi JD, Hanley DA, Cline G, Ioannidis G, Hodsman A, Josse RG, Kendler D, Olszynski WP, Ste Marie LG, Eastell R.
Accuracy of height loss during prospective monitoring for detection of incident vertebral fractures.
Osteoporos Int. 2005 Apr;16(4):403-10. doi: 10.1007/s00198-004-1709-z. Epub 2004 Aug 11.
Abstract/Text
Vertebral fractures are the most common type of osteoporotic fracture, but more than two-thirds remain undetected. We have examined the relationship between height loss and the development of new vertebral fractures to determine whether there is a height loss threshold that has useful clinical accuracy to detect new fractures. We studied 985 postmenopausal women with osteoporosis in the placebo arms of the Vertebral Efficacy with Risedronate Therapy studies. Height was measured annually for 3 years using a wall-mounted stadiometer. New fractures were determined using quantitative and semi-quantitative radiographic morphometry. The relationship between height loss over three years and the number of new vertebral fractures was: height loss (cm) = 0.95 x number of new vertebral fractures-0.4 cm (r = 0.33). The odds ratio for the development of a new fracture increased up to 20.6 (95% confidence interval, 9.3, 45.8) when height loss was greater than 4.0 cm. At a threshold of > 2.0 cm height loss over 3 years, sensitivity was 35.5% for detecting new vertebral fractures and specificity was 93.6%. These findings show that there is a strong relationship between the amount of height loss and the risk of a new vertebral fracture. While there is no cut-off that can reliably rule in a new fracture, height loss of < or = 2.0 cm over 1-3 years has acceptable accuracy for ruling out an incident fracture.
Green AD, Colón-Emeric CS, Bastian L, Drake MT, Lyles KW.
Does this woman have osteoporosis?
JAMA. 2004 Dec 15;292(23):2890-900. doi: 10.1001/jama.292.23.2890.
Abstract/Text
CONTEXT: Although recent US Preventive Services Task Force guidelines recommend bone densitometry for all women older than 65 years, identifying younger women at increased risk for osteoporosis and women with occult vertebral fractures remains a clinical challenge. We investigated whether physical signs are useful as a screening tool either for early referral to bone densitometry or for occult spinal fractures.
OBJECTIVE: To review the accuracy and precision of physical examination findings for the diagnosis of osteopenia, osteoporosis, or spinal fracture.
DATA SOURCES: We conducted a MEDLINE search for articles published from 1966 through August 2004, manually reviewed bibliographies, consulted 4 clinical skills textbooks, and contacted experts in the field.
STUDY SELECTION: Studies were included if they contained adequate original data on the accuracy or precision of physical examination for diagnosing osteopenia, osteoporosis, or spinal fracture. Two authors screened abstracts found by the search. Fourteen of 191 full articles reviewed met inclusion criteria.
DATA EXTRACTION: Two authors independently abstracted data from the included studies. Disagreements were resolved by discussion.
DATA SYNTHESIS: No single maneuver is sufficient to rule in or rule out osteoporosis or spinal fracture without further testing. The following yielded the greatest positive likelihood ratios (LR+): weight less than 51 kg, LR+, 7.3 (95% confidence interval [CI], 5.0-10.8); tooth count less than 20, LR+, 3.4 (95% CI, 1.4-8.0); rib-pelvis distance less than 2 finger breadths, LR+, 3.8 (95% CI, 2.9-5.1); wall-occiput distance greater than 0 cm, LR+, 4.6 (95% CI, 2.9-7.3), and self-reported humped back, LR+, 3.0 (95% CI, 2.2-4.1).
CONCLUSIONS: In patients who do not meet current bone mineral density screening recommendations, several convenient examination maneuvers, especially low weight, can significantly change the pretest probability of osteoporosis and suggest the need for earlier screening. Wall-occiput distance greater than 0 cm and rib-pelvis distance less than 2 fingerbreadths suggest the presence of occult spinal fracture.
Tsujio T, Nakamura H, Terai H, Hoshino M, Namikawa T, Matsumura A, Kato M, Suzuki A, Takayama K, Fukushima W, Kondo K, Hirota Y, Takaoka K.
Characteristic radiographic or magnetic resonance images of fresh osteoporotic vertebral fractures predicting potential risk for nonunion: a prospective multicenter study.
Spine (Phila Pa 1976). 2011 Jul 1;36(15):1229-35. doi: 10.1097/BRS.0b013e3181f29e8d.
Abstract/Text
STUDY DESIGN: Prospective multicenter study.
OBJECTIVE: To identify radiographic or magnetic resonance (MR) images of fresh vertebral fractures that can predict a high risk for delayed union or nonunion of osteoporotic vertebral fractures (OVFs).
SUMMARY OF BACKGROUND DATA: Vertebral body fractures are the most common fractures in osteoporosis patients. Conservative treatments are typically chosen for OVFs, and associated back pain generally subsides within several weeks with residual persistent deformity of the vertebral body. In some patients, OVF healing is impaired and correlated with prolonged back pain. However, assessments such as plain radiograph or MR images taken during the early phase to predict high risks for nonunions of OVFs and/or poor prognoses have not been identified.
METHODS: A total of 350 OVF patients from 25 institutes were enrolled in this clinical study. Plain radiograph and MR images of the OVFs were routinely taken at enrollment at the respective institutes. The findings on the plain radiograph and MR images were classified after enrollment in the study. All the patients were treated conservatively without any surgical intervention. After a 6-month follow-up, the patients were classified into two groups, a union group and a nonunion group, depending on the presence of an intravertebral cleft on plain radiograph or MR images. The associations of the images from the first visit with those of the corresponding nonunions at the 6-month follow-up were analyzed by multivariate logistic regression to elucidate specific image characteristics that may predict a high risk for nonunion of OVFs.
RESULTS: Forty-eight patients (49 vertebrae) among the 350 patients (363 vertebrae) were classified as nonunions, indicating a nonunion incidence of 13.5% for conventional conservative treatments for OVFs. The statistical analyses revealed that a vertebral fracture in the thoracolumbar spine, presence of a middle-column injury, and a confined high intensity or a diffuse low intensity area in the fractured vertebrae on T2-weighted MR images were significant risk factors for nonunion of OVFs.
CONCLUSION: The results of this study revealed significant relationships between plain radiograph and MR images of acute phase OVFs and the incidence of nonunion. As these risk factors are defined more clearly and further validated, they may become essential assessment tools for determining subsequent OVF treatments. Patients with one or more of the earlier-described risk factors for nonunion should be observed carefully and provided with more intensive treatments.
Matsumoto T, Hoshino M, Tsujio T, Terai H, Namikawa T, Matsumura A, Kato M, Toyoda H, Suzuki A, Takayama K, Takaoka K, Nakamura H.
Prognostic factors for reduction of activities of daily living following osteoporotic vertebral fractures.
Spine (Phila Pa 1976). 2012 Jun 1;37(13):1115-21. doi: 10.1097/BRS.0b013e3182432823.
Abstract/Text
STUDY DESIGN: Prospective cohort study.
OBJECTIVE: To elucidate the prognostic factors indicating reduced activities of daily living (ADL) at the time of the 6-month follow-up after osteoporotic vertebral fracture (OVF).
SUMMARY OF BACKGROUND DATA: OVF has severe effects on ADL and quality of life (QOL) in elderly patients and leads to long-term deteriorations in physical condition. Many patients recover ADL with acceleration of bony union and spinal stability, but some experience impaired ADL even months after fracture. Identifying factors predicting reduced ADL after OVF may prove valuable.
METHODS: Subjects in this prospective study comprised 310 OVF patients from 25 institutes. All patients were treated conservatively without surgery. Pain, ADL, QOL, and other factors were evaluated on enrollment and at 6 months. ADL were evaluated using the criteria of the Japanese long-term care insurance system to evaluate the degree of independence. We defined reduced ADL as a reduction of at least single grade at 6 months after fracture and investigated factors predicting reduced ADL after OVF, using uni- and multivariate regression analysis.
RESULTS: ADL were reduced at 6 months after OVF in 66 of 310 patients (21.3%). In univariate analysis, age more than 75 years (P = 0.044), female sex (P = 0.041), 2 or more previous spine fractures (P = 0.009), presence of middle column injury (P = 0.021), and lack of regular exercise before fracture (P = 0.001) were significantly associated with reduced ADL. In multivariate analysis, presence of middle column injury (odds ratio [OR], 2.26; P = 0.022) and lack of regular exercise before fracture (OR, 2.49; P = 0.030) were significantly associated with reduced ADL.
CONCLUSION: These results identified presence of middle column injury of the vertebral body and lack of regular exercise before fracture as prognostic factors for reduced ADL. With clarification and validation, these risk factors may provide crucial tools for determining subsequent OVF treatments. Patients showing these prognostic factors should be observed carefully and treated with more intensive treatment options.
Muratore M, Ferrera A, Masse A, Bistolfi A.
Osteoporotic vertebral fractures: predictive factors for conservative treatment failure. A systematic review.
Eur Spine J. 2018 Oct;27(10):2565-2576. doi: 10.1007/s00586-017-5340-z. Epub 2017 Oct 13.
Abstract/Text
PURPOSE: To analyze clinical, radiographic and magnetic resonance findings that might predict risk of complications and conservative treatment failure of osteoporotic vertebral fractures.
METHODS: The authors conducted a systematic review of observational studies, collecting data on osteoporotic vertebral fracture and complications like vertebral collapse, kyphosis, pseudoarthrosis, and neurologic deficit. MeSH items such as 'spinal fracture/radiology,' 'spinal fracture/complications,' 'spinal fracture/diagnosis' were used. PRISMA statement criteria were applied, and the risk of bias was classified as low, medium, high, following the Newcastle-Ottawa Quality Assessment Scale (NOS).
RESULTS: Eleven cohort studies, either retrospective or prospective, met the eligibility criteria and were included in the review. Major risk factors that were statistically predictive of the following complications were as follows; (1) vertebral collapse: presence of intravertebral cleft, MR T1-WI 'total type fractures' and T2-WI 'hypointense-wide-type'. (2) Pseudoarthrosis (nonunion): middle-column damage, thoracolumbar vertebrae involvement, MR T2-WI confined high-intensity pattern and diffuse low intensity pattern. (3) Kyphotic deformity: thoracolumbar fracture and superior endplate fracture. (4) Neurologic impairment: a retropulsed bony fragment occupying more than 42% of the sagittal diameter of the spinal canal and a change of more than 15° in vertebral wedge angle on lateral dynamic radiography.
CONCLUSIONS: Shape and level of the fracture were risk factors associated with the progression of collapse, pseudoarthrosis, kyphotic deformity and neurologic impairment. MRI findings were often related to the failure of conservative treatment. If prognosis can be predicted at the early fracture stage, more aggressive treatment options, rather than conservative ones, might be considered.
Takahashi S, Hoshino M, Takayama K, Iseki K, Sasaoka R, Tsujio T, Yasuda H, Sasaki T, Kanematsu F, Kono H, Toyoda H, Nakamura H.
Time course of osteoporotic vertebral fractures by magnetic resonance imaging using a simple classification: a multicenter prospective cohort study.
Osteoporos Int. 2017 Feb;28(2):473-482. doi: 10.1007/s00198-016-3737-x. Epub 2016 Aug 30.
Abstract/Text
UNLABELLED: This study revealed the time course of osteoporotic vertebral fracture by magnetic resonance imaging using a simple classification. Signal changes were associated with the compression degree and mobility of the fractured vertebral body. This classification showed sufficient reliability in categorizing magnetic resonance imaging findings of osteoporotic vertebral fractures.
INTRODUCTION: Magnetic resonance imaging (MRI) is useful in diagnosing osteoporotic vertebral fractures (OVFs). This study investigated the time course of OVFs by MRI using a simple classification.
METHODS: This multicenter cohort study was performed from 2012 to 2015. Consecutive patients with ≤2-week-old OVFs were enrolled in 11 institutions. MRI was performed at enrollment and at 1-, 3-, 6-, and 12-month follow-up. Signal changes on T1-weighted imaging (T1WI), T2WI, and short τ inversion recovery (STIR) were classified according to signal intensity. Height and angular motion of vertebral bodies were also measured.
RESULTS: The 6-month follow-up was completed by 153 patients. At enrollment, fractured vertebrae signal changes were 43 % diffuse and 57 % confined low on T1WI; on T2WI, 56, 24, and 5 % were confined low, high, and diffuse low, respectively; on STIR, 100 % were high. On T1WI, diffuse low remained most common (90 % at 1 month and 60 % at 3 months) until 6 and 12 months, when most were confined low (54 and 52 %, respectively). On T2WI, confined low remained most common (decreasing to 41 % at 12 months). On STIR, high signal change was shown in 98, 87, and 64 % at 3, 6, and 12 months, respectively. At 3, 6, and 12 months, diffuse low signal change was associated with significantly lower vertebral height, and high signal change was associated with significantly greater angular motion.
CONCLUSIONS: MRI signal changes were associated with the compression degree and angular motion of fractured vertebrae. This classification showed sufficient reliability in categorizing MRI findings of OVFs.
Hoshino M, Tsujio T, Terai H, Namikawa T, Kato M, Matsumura A, Suzuki A, Takayama K, Takaoka K, Nakamura H.
Impact of initial conservative treatment interventions on the outcomes of patients with osteoporotic vertebral fractures.
Spine (Phila Pa 1976). 2013 May 15;38(11):E641-8. doi: 10.1097/BRS.0b013e31828ced9d.
Abstract/Text
STUDY DESIGN: Prospective multicenter study.
OBJECTIVE: To examine whether initial conservative treatment interventions for osteoporotic vertebral fractures (OVF) influence patient outcomes.
SUMMARY OF BACKGROUND DATA: OVFs have been described as stable spinal injuries and, in most cases, are managed well with conservative treatment. However, systematic treatments for OVF have not been clearly established.
METHODS: A total of 362 patients with OVF (59 males and 303 females; mean age, 76.3 yr) from 25 institutes were enrolled in this clinical study. All the patients were treated conservatively without any surgical interventions. The patient outcomes were evaluated 6 months after the fractures on the basis of Short Form-36 (SF-36) physical component summary (PCS) and mental component summary (MCS), activities of daily living (the Japanese long-term care insurance system), back pain (visual analogue scale), cognitive status (mini-mental state examination), and vertebral collapse, which were used as response variables. Furthermore, brace type, hospitalization, bisphosphonates after injury, and painkillers after injury were explanatory variables for the treatment interventions. To evaluate the independent effects of treatment interventions on patient outcomes, we performed multivariate logistic regression analyses and obtained odds ratios that were adjusted for the potential confounding effects of age, sex, level of fracture, presence of middle-column injury, pain visual analogue scale at enrollment, mini-mental state examination score at enrollment, and previous use of steroids.
RESULTS: There was no significant difference for treatment intervention factors including brace type, hospitalization, bisphosphonates after injury, and painkillers after injury. For adjusting factors, the presence of middle-column injury was significantly associated with SF-36 PCS ≤ 40, reduced activities of daily living, prolonged back pain, and vertebral collapse. Female sex and advanced age were associated with SF-36 PCS ≤ 40. Low mini-mental state examination scores at enrollment were associated with SF-36 PCS ≤ 40 and reduced activities of daily living. The previous use of steroids was associated with SF-36 MCS ≤ 40, prolonged back pain, and vertebral collapse. No other examined variables were significant risk factors for patient outcomes.
CONCLUSION: These results showed that treatment intervention factors did not affect patient outcomes 6 months after OVF. Middle-column injury was a significant risk factor for both clinical and radiological outcomes. In the future, establishing systematic treatments for cases with middle-column injuries is needed.
LEVEL OF EVIDENCE: 2.
Hasegawa K, Homma T, Uchiyama S, Takahashi H.
Vertebral pseudarthrosis in the osteoporotic spine.
Spine (Phila Pa 1976). 1998 Oct 15;23(20):2201-6. doi: 10.1097/00007632-199810150-00011.
Abstract/Text
STUDY DESIGN: Radiologic and operative findings of intravertebral cleft in the osteoporotic spine were investigated and the pathomechanism discussed.
OBJECTIVES: To clarify the pathologic features of the intravertebral cleft.
SUMMARY OF BACKGROUND DATA: Intravertebral "vacuum" cleft is one of the common radiographic findings in the osteoporotic spine. It is thought that the cleft is a rare lesion of an ununited fracture, or pseudarthrosis. Evidential findings of the disease, however, have never been reported.
METHODS: Simple bone grafting was performed in five cases (average age, 76.8 years) of thoracolumbar intravertebral cleft in osteoporotic spine in patients who had been suffering from prolonged pain of the back or leg. Preoperative radiologic evaluation using flexion-extension radiograph and magnetic resonance imaging was performed in all patients. At operation, the cleft and the components of the structure were macroscopically and microscopically observed. The fluid content in the cleft was biochemically analyzed.
RESULTS: In all patients, preoperative flexion-extension radiographs showed intravertebral instability at the location of the clefts that indicated gas density in three cases and water density in two cases. Magnetic resonance imaging showed that, for the most part, the cleft was low intensity on the T1-weighted image and high intensity on the T2-weighted scans, regardless of the radiographic findings. At operation, abnormal movement was observed at the cleft of the affected body, which was covered with hypertrophic membrane. The serous fluid within the cleft was aspirated before the excision of soft tissue. The thick membrane was excised and showed that the cleft was lined by smooth fibrocartilaginous tissue and the great degree of motion between the fracture ends that is consistent with the pathologic appearance of pseudarthrosis.
CONCLUSIONS: The unstable cleft in the affected vertebral body of the osteoporotic spine with magnetic resonance findings of low intensity on the T1-weighted scans and high intensity on the T2-weighted scans suggests that the cleft is a false joint lined by fibrocartilaginous tissue with notable movement consistent with pseudarthrosis.
Yasuda H, Hoshino M, Tsujio T, Terai H, Namikawa T, Kato M, Matsumura A, Suzuki A, Takayama K, Takahashi S, Nakamura H.
Difference of clinical course between cases with bone union and those with delayed union following osteoporotic vertebral fractures.
Arch Osteoporos. 2017 Dec 28;13(1):3. doi: 10.1007/s11657-017-0411-7. Epub 2017 Dec 28.
Abstract/Text
UNLABELLED: In this prospective multicenter study of osteoporotic vertebral fractures (OVFs), delayed union of OVF at 6-month follow-up caused prolonged pain, QOL impairment, ADL impairment, cognitive status deterioration, and vertebral collapse progression.
PURPOSE: Delayed union following osteoporotic vertebral fracture displayed as an intravertebral cleft on plain X-rays was reported to be a factor for prolonged severe pain. However, the difference of clinical course between bone union and delayed union cases still remains unclear. The purpose of this study was to identify how OVF delayed union following conventional conservative treatment influences the clinical course with a prospective multicenter study.
METHODS: A total of 324 OVF patients from 25 institutes in Osaka, Japan, were included in the study. At the 6-month follow-up after initial visit to each institute, the patients were classified into bone union and delayed union groups based on plain X-ray findings. The outcome assessments included a VAS for back pain, SF-36 for quality of life (QOL), severity of bed-ridden state for activities of daily living (ADL), MMSE for cognitive functions, and degree of vertebral collapse on plain X-rays.
RESULTS: Overall, 280 patients were included into the union group and 44 into the delayed union group. The VAS score at 6 months was significantly worse in the delayed union group (p = 0.01). The scores for the SF-36 scales of physical functioning and bodily pain at 6 months were significantly lower in the delayed union group (p = 0.019, p = 0.01, respectively). The percentage of nearly or completely bed-ridden patients was significantly higher in the delayed union group. The percentage of newly developed cognitive impairment was significantly higher in the delayed union group (p = 0.02). Progression of vertebral collapse during the 6-month follow-up was more pronounced in the delayed union group (p < 0.01).
CONCLUSION: The present results revealed that delayed union following OVF causes prolonged pain, QOL impairment, ADL impairment, cognitive status deterioration, and vertebral collapse progression.
Takahashi S, Hoshino M, Takayama K, Iseki K, Sasaoka R, Tsujio T, Yasuda H, Sasaki T, Kanematsu F, Kono H, Toyoda H, Nakamura H.
Predicting delayed union in osteoporotic vertebral fractures with consecutive magnetic resonance imaging in the acute phase: a multicenter cohort study.
Osteoporos Int. 2016 Dec;27(12):3567-3575. doi: 10.1007/s00198-016-3687-3. Epub 2016 Jun 25.
Abstract/Text
UNLABELLED: This study demonstrated the predictive values of radiological findings for delayed union after osteoporotic vertebral fractures (OVFs). High-signal changes on T2WI were useful findings.
INTRODUCTION: The purpose of the present study is to determine predictive radiological findings for delayed union by magnetic resonance imaging (MRI) and plain X-rays at two time points in the acute phase of OVFs.
METHODS: This multicenter cohort study was performed from 2012 to 2015. A total of 218 consecutive patients with OVFs ≤2 weeks old were enrolled. MRIs and plain X-rays were performed at the time of enrollment and at 1- and 6-month follow-ups. Signal changes on T1-weighted imaging (T1WI) were classified as diffuse low-, confined low-, or no-signal change; those on T2WI were classified as high (similar to the intensity of cerebrospinal fluid), confined low-, diffuse low-, or no-signal change. The angular motion of the fractured vertebral body was measured with X-rays.
RESULTS: A total of 153 patients completed the 6-month follow-up. A high-signal change on T2WI was most useful in predicting delayed union. Sensitivity, specificity, and positive predictive values were 53.3, 87.8, and 51.6 % at enrollment and 65.5, 84.8, and 51.4 % at the 1-month follow-up, respectively. The positive predictive value increased to 62.5 % with observation of high- or diffuse low-signal changes at both enrollment and the 1-month follow-up. The cutoff value of vertebral motion was 5 degrees. Sensitivity and specificity at enrollment were 52.4 and 74.1 %, respectively.
CONCLUSIONS: This study demonstrated the radiological factors predicting delayed union after an OVF. T2 high-signal changes showed the strongest association with delayed union. Consecutive MRIs were particularly useful as a differential tool to predict delayed union following OVFs.
Wakao N, Sakai Y, Watanabe T, Osada N, Sugiura T, Iida H, Ozawa Y, Murotani K.
Spinal pseudoarthrosis following osteoporotic vertebral fracture: prevalence, risk factors, and influence on patients' activities of daily living 1 year after injury.
Arch Osteoporos. 2023 Mar 29;18(1):45. doi: 10.1007/s11657-023-01236-8. Epub 2023 Mar 29.
Abstract/Text
PURPOSE: To investigate the prevalence and risk factors and influence of pseudoarthrosis on activities of daily living (ADL) of patients with osteoporotic vertebral fracture (OVF).
METHODS: Spinal pseudoarthrosis is defined as the presence of a cleft in the vertebral body on a lateral X-ray image in the sitting position at 1 year after admission. Of the total 684 patients treated for OVF between January 2012 and February 2019 at our institution, 551 patients (mean age, 81.9 years; a male-to-female ratio, 152:399) who could be followed up to 1 year were included in this study. Prevalence, risk factors, and influence of pseudoarthrosis on the ADL of patients as well as fracture type and location were investigated. Pseudoarthrosis was set as the objective variable. Total bone mineral density, skeletal muscle mass index, sex, age, history of osteoporosis treatment, presence of dementia, vertebral kyphosis angle, fracture type (presence of posterior wall injury), degree of independence before admission, history of steroid use, albumin level, renal function, presence of diabetes, and diffuse idiopathic skeletal hyperostosis were set as explanatory variables for multivariate analysis of the influence of pseudoarthrosis on the walking ability and ADL independence before and 1 year after OVF.
RESULTS: In total, 54 (9.8%) patients were diagnosed with pseudarthrosis 1 year after injury (mean age, 81.3 ± 6.5 years; male-to-female ratio, 18:36). BKP was performed in nine patients who did not develop pseudoarthrosis after 1 year. In the multivariate analysis, only the presence of posterior wall injury was significantly correlated with the presence of pseudoarthrosis (OR = 2.059, p = 0.039). No significant difference was found between the pseudarthrosis group and the non-pseudarthrosis group in terms of walking ability and ADL independence at 1 year.
CONCLUSIONS: The prevalence of pseudoarthrosis following OVF was 9.8%, and its risk factor was posterior wall injury. The BKP group was not included in the pseudoarthrosis group, which may have led to an underestimation of the prevalence of pseudoarthrosis. The prevalence, risk factors, and influence of spinal pseudoarthrosis on patients' ADL following osteoporotic vertebral fracture (OVF) were investigated. Pseudoarthrosis occurs in 9.8% 1 year after the injury in patients with OVF. Posterior wall injury was the risk factor of pseudoarthrosis.
© 2023. The Author(s).
Belanger TA, Rowe DE.
Diffuse idiopathic skeletal hyperostosis: musculoskeletal manifestations.
J Am Acad Orthop Surg. 2001 Jul-Aug;9(4):258-67. doi: 10.5435/00124635-200107000-00006.
Abstract/Text
Diffuse idiopathic skeletal hyperostosis (DISH) is a common disorder of unknown etiology that is characterized by back pain and spinal stiffness. There may be mild pain if ankylosis has occurred. The condition is recognized radiographically by the presence of "flowing" ossification along the anterolateral margins of at least four contiguous vertebrae and the absence of changes of spondyloarthropathy or degenerative spondylosis. Even in patients who present with either lumbar or cervical complaints, radiographic findings are almost universally seen on the right side of the thoracic spine. Thus, radiographic examination of this area is critical when attempting to establish a diagnosis of DISH. The potential sequelae of hyperostosis in the cervical and lumbar spine include lumbar stenosis, dysphagia, cervical myelopathy, and dense spinal cord injury resulting from even minor trauma. There may be a delay in diagnosis of spinal fractures in a patient with DISH because the patient often has a baseline level of spinal pain and because the injury may be relatively trivial. The incidence of delayed neurologic injury due to such fractures is high as a result of unrecognized instability and subsequent deterioration. Extraspinal manifestations are also numerous and include an increased risk of heterotopic ossification after total hip arthroplasty. Prophylaxis to prevent heterotopic ossification may be indicated for these patients.
Westerveld LA, Verlaan JJ, Oner FC.
Spinal fractures in patients with ankylosing spinal disorders: a systematic review of the literature on treatment, neurological status and complications.
Eur Spine J. 2009 Feb;18(2):145-56. doi: 10.1007/s00586-008-0764-0. Epub 2008 Sep 13.
Abstract/Text
The ankylosed spine is prone to fracture after minor trauma due to its changed biomechanical properties. Although many case reports and small series have been published on patients with ankylosing spondylitis (AS) suffering spine fractures, solid data on clinical outcome are rare. In advanced diffuse idiopathic skeletal hyperostosis (DISH), ossification of spinal ligaments also leads to ankylosis. The prevalence of AS is stable, but since DISH may become more widespread due to its association with age, obesity and type 2 diabetes mellitus, a systematic review of the literature was conducted to increase the current knowledge on treatment, neurological status and complications of patients with preexisting ankylosed spines sustaining spinal trauma. A literature search was performed to obtain all relevant articles concerning the outcome of patients with AS or DISH admitted with spinal fractures. Predefined parameters were extracted from the papers and pooled to study the effect of treatment on neurological status and complications. Ninety-three articles were included, representing 345 AS patients and 55 DISH patients. Most fractures were localized in the cervical spine and resulted from low energy impact. Delayed diagnosis often occurred due to patient and doctor related factors. On admission 67.2% of the AS patients and 40.0% of the DISH patients demonstrated neurologic deficits, while secondary neurological deterioration occurred frequently. Surgical or nonoperative treatment did not alter the neurological prospective for most patients. The complication rate was 51.1% in AS patients and 32.7% in DISH patients. The overall mortality within 3 months after injury was 17.7% in AS and 20.0% in DISH. This review suggests that the clinical outcome of patients with fractures in previously ankylosed spines, due to AS or DISH, is considerably worse compared to the general trauma population. Considering the potential increase in prevalence of DISH cases, this condition may render a new challenge for physicians treating spinal injuries.
Baba H, Maezawa Y, Kamitani K, Furusawa N, Imura S, Tomita K.
Osteoporotic vertebral collapse with late neurological complications.
Paraplegia. 1995 May;33(5):281-9. doi: 10.1038/sc.1995.64.
Abstract/Text
This paper describes 27 patients who had a spinal fracture and underwent an anterior or a posterior spinal decompression, with or without spinal instrumentation, for late neurological compromise secondary to post-traumatic vertebral collapse associated with osteoporosis. Five males and 22 females were studied, with an average follow-up of 3.7 years. The patients developed delayed neurological compromise due to osteoporotic vertebral collapse 1 month to 1.5 years following insignificant spinal fractures. Abnormal hypermobility at the collapsed spinal level with gradual retropulsion of fracture fragments into the spinal canal appeared to contribute to late paralysis. This pathology is treated surgically either anteriorly or posteriorly, but we recommend transpedicular posterolateral decompression and stabilization with a screw-rod construct because of technical ease and minimum invasion.
Kim DY, Lee SH, Jang JS, Chung SK, Lee HY.
Intravertebral vacuum phenomenon in osteoporotic compression fracture: report of 67 cases with quantitative evaluation of intravertebral instability.
J Neurosurg. 2004 Jan;100(1 Suppl Spine):24-31. doi: 10.3171/spi.2004.100.1.0024.
Abstract/Text
OBJECT: The objectives of this study were to: 1) describe the incidence and clinical features of intravertebral vacuum phenomenon (IVVP) in a relatively large number of cases; 2) quantitatively evaluate intravertebral instability and determine the factors affecting instability; and 3) evaluate the efficacy of percutaneous vertebroplasty in the treatment of this phenomenon.
METHODS: A retrospective review was conducted of the records of 67 patients with IVVP among 652 consecutive cases of osteoporotic compression fracture. Comparisons between the IVVP group and a control group, a stable group, and an unstable group were conducted. Percutaneous vertebroplasty was performed in all patients. There were 67 patients (10.3%) in whom there were 70 vacuum phenomena of the intravertebral space. Intravertebral vacuum phenomena occurred predominantly in the thoracolumbar junction (81%) and in patients with a longer duration of symptoms (10.6 +/- 9.8 months) compared with the control group. Of 59 vertebrae for which flexion-extension radiographs were available, 26 vertebrae were categorized as stable and 33 as unstable. Twenty-one vertebrae (64%) had undergone compression fracture in the unstable group compared with nine (35%) compression fractures in the stable group. There were 28 (85%) fractures of the wedged vertebrae in the unstable group compared with 16 (61%) fractures in wedged vertebrae in the stable group. Percutaneous vertebroplasty was performed with successful clinical outcome.
CONCLUSIONS: Intravertebral vacuum phenomenon is more common than has been previously appreciated. The results of this study indicate that biomechanics, not ischemic or avascular theory, may play an important role in pathogenesis of this phenomenon. Percutaneous vertebroplasty was found to be a minimally invasive and effective procedure for the treatment of IVVP.
Hoshino M, Nakamura H, Terai H, Tsujio T, Nabeta M, Namikawa T, Matsumura A, Suzuki A, Takayama K, Takaoka K.
Factors affecting neurological deficits and intractable back pain in patients with insufficient bone union following osteoporotic vertebral fracture.
Eur Spine J. 2009 Sep;18(9):1279-86. doi: 10.1007/s00586-009-1041-6. Epub 2009 May 31.
Abstract/Text
The purpose of this study was to examine factors affecting the severity of neurological deficits and intractable back pain in patients with insufficient bone union following osteoporotic vertebral fracture (OVF). Reports of insufficient union following OVF have recently increased. Patients with this lesion have various degrees of neurological deficits and back pain. However, the factors contributing to the severity of these are still unknown. A total of 45 patients with insufficient union following OVF were included in this study. Insufficient union was diagnosed based on the findings of vertebral cleft on plain radiography or CT, as well as fluid collection indicating high-intensity change on T2-weighted MRI. Multivariate logistic regression analysis was performed to determine the factors contributing to the severity of neurological deficits and back pain in the patients. Age, sex, level of fracture, duration after onset of symptoms, degree of local kyphosis, degree of angular instability, ratio of occupation by bony fragments, presence or absence of protrusion of flavum, and presence or absence of ossification of the anterior longitudinal ligament (OALL) in the adjacent level were used as explanatory variables, while severity of neurological deficits and back pain were response variables. On multivariate analysis, factors significantly affecting the severity of neurological deficits were angular instability of more than 15 degrees [adjusted odds ratio (OR), 9.24 (95% confidence interval, CI 1.49-57.2); P < 0.05] and ratio of occupation by bony fragments in the spinal canal of more than 42% [adjusted OR 9.23 (95%CI 1.15-74.1); P < 0.05]. The factor significantly affecting the severity of back pain was angular instability of more than 15 degrees [adjusted OR 14.9 (95%CI 2.11-105); P < 0.01]. On the other hand, presence of OALL in the adjacent level reduced degree of back pain [adjusted OR 0.14 (95%CI 0.03-0.76); P < 0.05]. In this study, pronounced angular instability and marked posterior protrusion of bony fragments in the canal were factors affecting neurological deficits. In addition, marked angular instability was a factor affecting back pain. These findings are useful in determining treatment options for patients with insufficient union following OVF.
Takahashi S, Terai H, Hoshino M, Tsujio T, Kato M, Toyoda H, Suzuki A, Tamai K, Yabu A, Nakamura H.
Machine-learning-based approach for nonunion prediction following osteoporotic vertebral fractures.
Eur Spine J. 2023 Nov;32(11):3788-3796. doi: 10.1007/s00586-022-07431-4. Epub 2022 Oct 21.
Abstract/Text
PURPOSE: An osteoporotic vertebral fracture (OVF) is a common disease that causes disabilities in elderly patients. In particular, patients with nonunion following an OVF often experience severe back pain and require surgical intervention. However, nonunion diagnosis generally takes more than six months. Although several studies have advocated the use of magnetic resonance imaging (MRI) observations as predictive factors, they exhibit insufficient accuracy. The purpose of this study was to create a predictive model for OVF nonunion using machine learning (ML).
METHODS: We used datasets from two prospective cohort studies for OVF nonunion prediction based on conservative treatment. Among 573 patients with acute OVFs exceeding 65 years in age enrolled in this study, 505 were analyzed. The demographic data, fracture type, and MRI observations of both studies were analyzed using ML. The ML architecture utilized in this study included a logistic regression model, decision tree, extreme gradient boosting (XGBoost), and random forest (RF). The datasets were processed using Python.
RESULTS: The two ML algorithms, XGBoost and RF, exhibited higher area under the receiver operating characteristic curves (AUCs) than the logistic regression and decision tree models (AUC = 0.860 and 0.845 for RF and XGBoost, respectively). The present study found that MRI findings, anterior height ratio, kyphotic angle, BMI, VAS, age, posterior wall injury, fracture level, and smoking habit ranked as important features in the ML algorithms.
CONCLUSION: ML-based algorithms might be more effective than conventional methods for nonunion prediction following OVFs.
© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.
Inose H, Kato T, Ichimura S, Nakamura H, Hoshino M, Togawa D, Hirano T, Tokuhashi Y, Ohba T, Haro H, Tsuji T, Sato K, Sasao Y, Takahata M, Otani K, Momoshima S, Yuasa M, Hirai T, Yoshii T, Okawa A.
Risk Factors of Nonunion After Acute Osteoporotic Vertebral Fractures: A Prospective Multicenter Cohort Study.
Spine (Phila Pa 1976). 2020 Jul 1;45(13):895-902. doi: 10.1097/BRS.0000000000003413.
Abstract/Text
STUDY DESIGN: Prospective cohort study.
OBJECTIVE: To characterize a patient population with nonunion after acute osteoporotic vertebral fractures (OVFs) and compare the union and nonunion groups to identify risk factors for nonunion.
SUMMARY OF BACKGROUND DATA: While OVFs are the most common type of osteoporotic fracture, the predictive value of a clinical assessment for nonunion at 48 weeks after OVF has not been extensively studied.
METHODS: This prospective multicenter cohort study included female patients aged 65 to 85 years with acute one-level osteoporotic compression fractures. In the radiographic analysis, the anterior vertebral body compression percentage was measured at 0, 12, and 48 weeks. Magnetic resonance imaging (MRI) was performed at enrollment and at 48 weeks to confirm the diagnosis and union status. The patient-reported outcome measures included scores on the European Quality of Life-5 Dimensions (EQ-5D), a visual analogue scale for low back pain, and the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) at 0, 12, and 48 weeks.
RESULTS: In total, 166 patients completed the 12-month follow-up, 29 of whom had nonunion. Patients with nonunion at 48 weeks after OVF had lower EQ-5D and JOABPEQ walking ability, social life function, mental health, and lumbar function scores than those with union at 48 weeks after injury. The independent risk factors for nonunion after OVF in the acute phase were a diffuse low type pattern on T1-weighted MRI and diffuse low and fluid type patterns on T2-weighted MRI. The anterior vertebral body compression percentage and JOABPEQ social life function scores were independent risk factors at 12 weeks.
CONCLUSION: A diffuse low type pattern on T1-weighted MRI and diffuse low and fluid type patterns on T2-weighted MRI were independent risk factors for nonunion in the acute phase. Patients who have acute OVFs with these risk factors should be carefully monitored for nonunion.
LEVEL OF EVIDENCE: 2.
Inose H, Hirai T, Yoshii T, Kimura A, Takeshita K, Inoue H, Maekawa A, Endo K, Miyamoto T, Furuya T, Nakamura A, Mori K, Kanbara S, Imagama S, Seki S, Matsunaga S, Okawa A.
Predictors for quality of life improvement after surgery for degenerative cervical myelopathy: a prospective multi-center study.
Health Qual Life Outcomes. 2021 May 19;19(1):150. doi: 10.1186/s12955-021-01789-7. Epub 2021 May 19.
Abstract/Text
BACKGROUND: Degenerative cervical myelopathy (DCM) can significantly impair a patient's quality of life (QOL). In this study, we aimed to identify predictors associated with QOL improvement after surgery for DCM.
METHODS: This study included 148 patients who underwent surgery for DCM. The European QOL-5 Dimension (EQ-5D) score, the Japanese Orthopedic Association for the assessment of cervical myelopathy (C-JOA) score, and the Nurick grade were used as outcome measures. Radiographic examinations were performed at enrollment. The associations of baseline variables with changes in EQ-5D scores from preoperative to 1-year postoperative assessment were investigated using a multivariable linear regression model.
RESULTS: The EQ-5D and C-JOA scores and the Nurick grade improved after surgery (P < 0.001, P < 0.001, and P < 0.001, respectively). Univariable analysis revealed that preoperative EQ-5D and C-JOA scores were significantly associated with increased EQ-5D scores from preoperative assessment to 1 year after surgery (P < 0.0001 and P = 0.045). Multivariable regression analysis showed that the independent preoperative predictors of change in QOL were lumbar lordosis (LL), sacral slope (SS), and T1 pelvic angle (TPA). According to the prediction model, the increased EQ-5D score from preoperatively to 1 year after surgery = 0.308 - 0.493 × EQ-5D + 0.006 × LL - 0.008 × SS + 0.004 × TPA.
CONCLUSIONS: Preoperative LL, SS, and TPA significantly impacted the QOL of patients who underwent surgery for DCM. Less improvement in QOL after surgery was achieved in patients with smaller LL and TPA and larger SS values. Patients with these risk factors may therefore require additional support to experience adequate improvement in QOL.
Funayama T, Tatsumura M, Fujii K, Ikumi A, Okuwaki S, Shibao Y, Koda M, Yamazaki M; the Tsukuba Spine Group.
Therapeutic Effects of Conservative Treatment with 2-Week Bed Rest for Osteoporotic Vertebral Fractures: A Prospective Cohort Study.
J Bone Joint Surg Am. 2022 Oct 19;104(20):1785-1795. doi: 10.2106/JBJS.22.00116. Epub 2022 Aug 24.
Abstract/Text
This article was updated on October 19, 2022, because of previous errors, which were discovered after the preliminary version of the article was posted online. On page 1787, in the legend for Figure 2, the sentence that had read "The vertebral collapse rate (in %) was defined as 1 - (A/P) × 100, and vertebral instability (in %) was defined as the difference in vertebral collapse rate between the loaded and non-loaded images." now reads "The vertebral collapse rate (in %) was defined as (1 - [A/P]) × 100, and vertebral instability (in %) was defined as the difference in vertebral collapse rate between the loaded and non-loaded images." On page 1788, in the section entitled "Data Collection," the sentence that had read "The vertebral collapse rate (in %) was defined as 1 - (anterior vertebral wall height/posterior vertebral wall height) × 100, and vertebral instability (in %) was defined as the difference in vertebral collapse rate between the loaded and non-loaded images 9 ." now reads "The vertebral collapse rate (in %) was defined as (1 - [anterior vertebral wall height/posterior vertebral wall height]) × 100, and vertebral instability (in %) was defined as the difference in vertebral collapse rate between the loaded and non-loaded images 9 ." Finally, on page 1791, in Table IV, the footnote for the "Primary outcome" row that had read "N = 113 in the rest group and 99 in the no-rest group." now reads "N = 116 in the rest group and 108 in the no-rest group."
Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.
Esses SI, McGuire R, Jenkins J, Finkelstein J, Woodard E, Watters WC 3rd, Goldberg MJ, Keith M, Turkelson CM, Wies JL, Sluka P, Boyer KM, Hitchcock K.
The treatment of symptomatic osteoporotic spinal compression fractures.
J Am Acad Orthop Surg. 2011 Mar;19(3):176-82. doi: 10.5435/00124635-201103000-00007.
Abstract/Text
This clinical practice guideline is based on a series of systematic reviews of published studies on the treatment of symptomatic osteoporotic spinal compression fractures. Of 11 recommendations, one is strong; one, moderate; three, weak; and six, inconclusive. The strong recommendation is against the use of vertebroplasty to treat the fractures; the moderate recommendation is for the use of calcitonin for 4 weeks following the onset of fracture. The weak recommendations address the use of ibandronate and strontium ranelate to prevent additional symptomatic fractures, the use of L2 nerve root blocks to treat the pain associated with L3 or L4 fractures, and the use of kyphoplasty to treat symptomatic fractures in patients who are neurologically intact.
Pieroh P, Spiegl UJA, Völker A, Märdian S, von der Höh NH, Osterhoff G, Heyde CE; Spine Section of the German Society for Orthopaedics and Trauma.
Spinal Orthoses in the Treatment of Osteoporotic Thoracolumbar Vertebral Fractures in the Elderly: A Systematic Review With Quantitative Quality Assessment.
Global Spine J. 2023 Apr;13(1_suppl):59S-72S. doi: 10.1177/21925682221130048.
Abstract/Text
STUDY DESIGN: Systematic review.
OBJECTIVES: Spinal orthoses are frequently used to non-operatively treat osteoporotic vertebral fractures (OVF), despite the available evidence is rare. Previously systematic reviews were carried out, presenting controversial recommendations. The present study aimed to systematic review the recent and current literature on available evidence for the use of orthoses in OVF.
METHODS: A systematic review was conducted using PubMed, Medline, EMBASE and CENTRAL databases. Identified articles including previous systematic reviews were screened and selected by three authors. The results of retrieved articles were presented in a narrative form, quality assessment was performed by two authors using scores according to the study type.
RESULTS: Thirteen studies (n = 5 randomized controlled trials, n = 3 non- randomized controlled trials and n = 5 prospective studies without control group) and eight systematic reviews were analyzed. Studies without comparison group reported improvements in pain, function and quality of life during the follow-up. Studies comparing different types of orthoses favor non-rigid orthoses. In comparison to patients not wearing an orthosis three studies were unable to detect beneficial effects and two studies reported about a significant improvement using an orthosis. In the obtained quality assessment, three studies yielded good to excellent results. Previous reviews detected the low evidence for spinal orthoses but recommended them.
CONCLUSION: Based on the study quality and the affection of included studies in previous systematic reviews a general recommendation for the use of a spinal orthosis when treating OVF is not possible. Currently, no superiority for spinal orthoses in OVF treatment was found.
Kato T, Inose H, Ichimura S, Tokuhashi Y, Nakamura H, Hoshino M, Togawa D, Hirano T, Haro H, Ohba T, Tsuji T, Sato K, Sasao Y, Takahata M, Otani K, Momoshima S, Tateishi U, Tomita M, Takemasa R, Yuasa M, Hirai T, Yoshii T, Okawa A.
Comparison of Rigid and Soft-Brace Treatments for Acute Osteoporotic Vertebral Compression Fracture: A Prospective, Randomized, Multicenter Study.
J Clin Med. 2019 Feb 6;8(2). doi: 10.3390/jcm8020198. Epub 2019 Feb 6.
Abstract/Text
While bracing is the standard conservative treatment for acute osteoporotic compression fracture, the efficacy of different brace treatments has not been extensively studied. We aimed to clarify and compare the preventive effect of the different brace treatments on the deformity of the vertebral body and other clinical results in this patient cohort. This multicenter nationwide prospective randomized study included female patients aged 65⁻85 years with acute one-level osteoporotic compression fractures. We assigned patients within four weeks of injury to either a rigid-brace treatment or a soft-brace treatment. The main outcome measure was the anterior vertebral body compression percentage at 48 weeks. Secondary outcome measures included scores on the European Quality of Life-5 Dimensions (EQ-5D), visual analog scale (VAS) for lower back pain, and the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ). A total of 141 patients were assigned to the rigid-brace group, whereas 143 patients were assigned to the soft-brace group. There were no statistically significant differences in the primary outcome and secondary outcome measures between groups. In conclusion, among patients with fresh vertebral compression fractures, the 12-week rigid-brace treatment did not result in a statistically greater prevention of spinal deformity, better quality of life, or lesser back pain than soft-brace.
Inose H, Kato T, Ichimura S, Nakamura H, Hoshino M, Togawa D, Hirano T, Tokuhashi Y, Ohba T, Haro H, Tsuji T, Sato K, Sasao Y, Takahata M, Otani K, Momoshima S, Takahashi K, Yuasa M, Hirai T, Yoshii T, Okawa A.
Risk factors for subsequent vertebral fracture after acute osteoporotic vertebral fractures.
Eur Spine J. 2021 Sep;30(9):2698-2707. doi: 10.1007/s00586-021-06741-3. Epub 2021 Jan 30.
Abstract/Text
PURPOSE: To investigate the incidence and characteristics of subsequent vertebral fracture after osteoporotic vertebral fractures (OVFs) and identify risk factors for subsequent vertebral fractures.
METHODS: This post-hoc analysis from a prospective randomized multicenter trial included 225 patients with a 48-week follow-up period. Differences between the subsequent and non-subsequent fracture groups were analyzed.
RESULTS: Of the 225 patients, 15 (6.7%) had a subsequent fracture during the 48-week follow-up. The annual incidence of subsequent vertebral fracture after fresh OVFs in women aged 65-85 years was 68.8 per 1000 person-years. Most patients (73.3%) experienced subsequent vertebral fractures within 6 months. At 48 weeks, European Quality of Life-5 Dimensions, the Japanese Orthopedic Association Back Pain Evaluation Questionnaire pain-related disorder, walking ability, social life function, and lumbar function scores were significantly lower, while the visual analog scale (VAS) for low back pain was higher in patients with subsequent fracture. Cox proportional hazards analysis showed that a VAS score ≥ 70 at 0 weeks was an independent predictor of subsequent vertebral fracture. After adjustment for history of previous fracture, there was a ~ 67% reduction in the risk of subsequent vertebral fracture at the rigid-brace treatment.
CONCLUSION: Women with a fresh OVF were at higher risk for subsequent vertebral fracture within the next year. Severe low back pain and use of soft braces were associated with higher risk of subsequent vertebral fractures. Therefore, when treating patients after OVFs with these risk factors, more attention may be needed for the occurrence of subsequent vertebral fractures.
LEVEL OF EVIDENCE: III.
© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH, DE part of Springer Nature.
Iwamae M, Takahashi S, Terai H, Tamai K, Hoshino M, Kobayashi Y, Umano M, Sasaki R, Uematsu M, Katsuda H, Shimada N, Nakamura H.
Is orthotic treatment beneficial for fresh osteoporotic vertebral fractures? A propensity score matching study.
Spine J. 2024 Dec;24(12):2343-2355. doi: 10.1016/j.spinee.2024.08.002. Epub 2024 Aug 13.
Abstract/Text
BACKGROUND CONTEXT: Orthotic treatment is a common option for the conservative treatment of osteoporotic vertebral fractures (OVF). However, there is insufficient evidence of its clinical benefit.
PURPOSE: To investigate the effectiveness of orthotic treatment for OVF.
STUDY DESIGN/SETTING: Retrospective cohort study with data from two prospective studies.
PATIENT SAMPLE: This study included 160 patients with fresh OVF enrolled in 2012 and 2020 prospective cohort studies.
OUTCOME MEASURES: The visual analog scale (VAS) score for low back pain was used for clinical outcomes, and radiographic parameters included the percent height of the vertebra and angular change of the vertebral body. Moreover, the occurrence of secondary vertebral fractures was followed-up over time.
METHODS: The patients were divided into brace and no-brace groups and were matched according to propensity score for age, sex, anterior percent height at the initial examination, and presence of old OVFs. Hazard ratio for the cumulative incidence of secondary vertebral fractures with and without bracing were calculated and analyzed using the generalized Wilcoxon test. In addition, the brace group was divided into soft and rigid brace groups and compared with the no-brace group.
RESULTS: Each group had 61 cases after propensity score matching. There were no significant differences in the VAS improvement for low back pain and the change in percent height of the anterior and posterior walls from initial examination to 6 months after injury (p=.87, p=.39 and p=.14, respectively, mixed-effect models). Meanwhile, the mean angular change of fractured vertebrae was 4.3° / 3.2° initially and 1.2° / 2.5° at 6 months (the brace group / no-brace group, respectively; p=.007, mixed-effect models). A significant difference was also observed between the rigid brace group and the no-brace group (p=.008, mixed effect models). The incidence of secondary vertebral fractures was 1.6% / 11.4% at 1 month, indicating a significant difference (the brace group / no-brace group, respectively; p=.028). The hazard ratio for the cumulative incidence of secondary fractures due to orthotic treatment was 0.47 (95% confidence interval 0.20-1.09, p=.054).
CONCLUSIONS: Although orthotic treatment for fresh OVF did not relieve pain, it might contribute to the stabilization of the fractured vertebra, especially using a rigid brace. Moreover, it might influence a reduction of the imminent vertebral fracture risk immediately after the onset of OVF.
CLASSIFICATIONS: Clinical study.
Copyright © 2024 Elsevier Inc. All rights reserved.
Gregson CL, Armstrong DJ, Bowden J, Cooper C, Edwards J, Gittoes NJL, Harvey N, Kanis J, Leyland S, Low R, McCloskey E, Moss K, Parker J, Paskins Z, Poole K, Reid DM, Stone M, Thomson J, Vine N, Compston J.
UK clinical guideline for the prevention and treatment of osteoporosis.
Arch Osteoporos. 2022 Apr 5;17(1):58. doi: 10.1007/s11657-022-01061-5. Epub 2022 Apr 5.
Abstract/Text
UNLABELLED: The National Osteoporosis Guideline Group (NOGG) has revised the UK guideline for the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women, and men age 50 years and older. Accredited by NICE, this guideline is relevant for all healthcare professionals involved in osteoporosis management.
INTRODUCTION: The UK National Osteoporosis Guideline Group (NOGG) first produced a guideline on the prevention and treatment of osteoporosis in 2008, with updates in 2013 and 2017. This paper presents a major update of the guideline, the scope of which is to review the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women, and men age 50 years and older.
METHODS: Where available, systematic reviews, meta-analyses and randomised controlled trials were used to provide the evidence base. Conclusions and recommendations were systematically graded according to the strength of the available evidence.
RESULTS: Review of the evidence and recommendations are provided for the diagnosis of osteoporosis, fracture-risk assessment and intervention thresholds, management of vertebral fractures, non-pharmacological and pharmacological treatments, including duration and monitoring of anti-resorptive therapy, glucocorticoid-induced osteoporosis, and models of care for fracture prevention. Recommendations are made for training; service leads and commissioners of healthcare; and for review criteria for audit and quality improvement.
CONCLUSION: The guideline, which has received accreditation from the National Institute of Health and Care Excellence (NICE), provides a comprehensive overview of the assessment and management of osteoporosis for all healthcare professionals involved in its management. This position paper has been endorsed by the International Osteoporosis Foundation and by the European Society for the Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases.
© 2022. The Author(s).
Blattert TR, Schnake KJ, Gonschorek O, Gercek E, Hartmann F, Katscher S, Mörk S, Morrison R, Müller M, Partenheimer A, Piltz S, Scherer MA, Ullrich BW, Verheyden A, Zimmermann V; Spine Section of the German Society for Orthopaedics and Trauma.
Nonsurgical and Surgical Management of Osteoporotic Vertebral Body Fractures: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU).
Global Spine J. 2018 Sep;8(2 Suppl):50S-55S. doi: 10.1177/2192568217745823. Epub 2018 Sep 7.
Abstract/Text
STUDY DESIGN: Prospective clinical cohort study (data collection); expert opinion (recommendation development).
OBJECTIVES: Treatment options for nonsurgical and surgical management of osteoporotic vertebral body fractures are widely differing. Based on current literature, the knowledge of the experts, and their classification for osteoporotic fractures (OF classification) the Spine Section of the German Society for Orthopaedics and Trauma has now introduced general treatment recommendations.
METHODS: a total of 707 clinical cases from 16 hospitals were evaluated. An OF classification-based score was developed to guide in the option of nonsurgical versus surgical management. For every classification type, differentiated treatment recommendations were deduced. Diagnostic prerequisites for reproducible treatment recommendations were defined: conventional X-rays with consecutive follow-up images (standing position whenever possible), magnetic resonance imaging, and computed tomography scan. OF classification allows for upgrading of fracture severity during the course of radiographic follow-up. The actual classification type is decisive for the score.
RESULTS: A score of less than 6 points advocates nonsurgical management; more than 6 points recommend surgical management. The primary goal of treatment is fast and painless mobilization. Because of expected comorbidities in this age group, minimally invasive procedures are being preferred. As a general rule, stability is more important than motion preservation. It is mandatory to restore the physiological loading capacity of the spine. If the patient was in a compensated unbalanced state at the time of fracture, reconstruction of the individual prefracture sagittal profile is sufficient. Instrumentation technique has to account for compromised bone quality. We recommend the use of cement augmentation or high purchase screws. The particular situations of injuries with neurological impairment; necessity to fuse; multiple level fractures; consecutive and adjacent fractures; fractures in ankylosing spondylitis are being addressed separately.
CONCLUSIONS: The therapeutic recommendations presented here provide a reliable and reproducible basis to decide for treatment choices available. However, intermediate clinical situations remain with a score of 6 points allowing for both nonsurgical and surgical options. As a result, individualized treatment decisions may still be necessary. In the next step, the recommendations presented will be further evaluated in a multicenter controlled clinical trial.
Hoshino M, Takahashi S, Yasuda H, Terai H, Watanabe K, Hayashi K, Tsujio T, Kono H, Suzuki A, Tamai K, Ohyama S, Toyoda H, Dohzono S, Kanematsu F, Hori Y, Nakamura H.
Balloon Kyphoplasty Versus Conservative Treatment for Acute Osteoporotic Vertebral Fractures With Poor Prognostic Factors: Propensity Score Matched Analysis Using Data From Two Prospective Multicenter Studies.
Spine (Phila Pa 1976). 2019 Jan 15;44(2):110-117. doi: 10.1097/BRS.0000000000002769.
Abstract/Text
STUDY DESIGN: A multicenter, prospective, single-arm, intervention study.
OBJECTIVE: The aim of this study was to investigate efficacy of balloon kyphoplasty (BKP) for acute osteoporotic vertebral fractures (OVFs) in patients with poor prognostic factors.
SUMMARY OF BACKGROUND DATA: The indications for BKP remain unclear. Characteristic magnetic resonance imaging (MRI) findings (high-intensity or diffuse low-intensity area in fractured vertebrae on T2-weighted images) were reportedly predictive of delayed union.
METHODS: This study enrolled 106 patients with poor prognostic MRI findings who underwent BKP within 2 months after injury, and 116 controls with acute OVFs and the same poor prognostic factors who underwent conservative treatment. Patients were propensity score matched in a logistic regression model adjusted for age, sex, number of baseline old fractures, and fracture level. The primary outcome was reduction in activities of daily living (ADLs) at 6 months after fracture, and the secondary outcomes were improvement in short-form (SF)-36 subscales, back pain visual analog scale (VAS) score, and vertebral body deformity.
RESULTS: A decrease in ADLs occurred in 5.6% of patients in the BKP group and 25.6% of patients in the conservative treatment group (P < 0.001). The SF-36 vitality subscale score improved by 26.9 ± 25.9 points in the BKP group and 14.5 ± 29.4 points in the control group (P = 0.03). The VAS pain score improved by 43.4 ± 34.4 in the BKP group and 52.2 ± 29.8 in the control group (P = 0.44). The vertebral body wedge angle improved by 5.5 ± 6.2° in the BKP group and -6.3 ± 5.0° in the control group (P < 0.0001). The percent vertebral body height improved by 15.2 ± 19.2% in the BKP group and -20.6 ± 14.2% in the control group (P < 0.0001).
CONCLUSION: ADLs, quality of life, and vertebral deformity showed greater improvement with BKP intervention for acute OVF with poor prognostic factors than with conservative treatment at 6 months after injury. Our treatment strategy uses BKP intervention according to the presence or absence of poor prognostic MRI findings.
LEVEL OF EVIDENCE: 4.
Takahashi S, Hoshino M, Terai H, Toyoda H, Suzuki A, Tamai K, Watanabe K, Tsujio T, Yasuda H, Kono H, Sasaoka R, Dohzono S, Hayashi K, Ohyama S, Hori Y, Nakamura H.
Differences in short-term clinical and radiological outcomes depending on timing of balloon kyphoplasty for painful osteoporotic vertebral fracture.
J Orthop Sci. 2018 Jan;23(1):51-56. doi: 10.1016/j.jos.2017.09.019. Epub 2017 Oct 4.
Abstract/Text
BACKGROUND: Balloon kyphoplasty or vertebroplasty is widely performed as a surgical intervention for osteoporotic vertebral fracture (OVF) and the effects have been investigated in many previous studies. However, the influence of the timing of the procedure on patient outcomes has not been studied formally. The purpose of this study was to investigate differences in the surgical outcomes of OVFs according to the timing of balloon kyphoplasty.
METHODS: This was a multicenter cohort study. Participants comprised 72 consecutive patients who underwent balloon kyphoplasty between January 2012 and January 2016. Patients were analyzed in two groups according to the timing of kyphoplasty after onset (Early group: ≤2 months; Late group: >2 months). Follow-up continued for more than 6 months.
RESULTS: A total of 72 patients were effectively analyzed. Of these, 27 (38%) patients underwent kyphoplasty within 2 months after symptom onset. The Late group showed greater angular motion of fractured vertebrae (p = 0.005) and compression of anterior vertebral height (p = 0.001) before surgery. Final outcomes adjusted for age and preoperative outcome showed lower visual analog scale (VAS) scores for low back pain in the Early group than in the Late group (19.9 vs. 30.4, p = 0.049). Final relative anterior vertebral height and kyphotic angle were more preserved in the Early group than in the Late group (p = 0.002 and p = 0.020, respectively), although absolute differences were not significant.
CONCLUSIONS: Vertebral height and kyphotic angle before and after balloon kyphoplasty were greater in patients who underwent kyphoplasty within 2 months after onset, and the VAS score for low back pain at final follow-up was better. Our results support kyphoplasty within 2 months.
Copyright © 2017 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
Minamide A, Maeda T, Yamada H, Murakami K, Okada M, Enyo Y, Nakagawa Y, Iwasaki H, Tsutsui S, Takami M, Nagata K, Hashizume H, Yukawa Y, Schoenfeld AJ, Simpson AK.
Early versus delayed kyphoplasty for thoracolumbar osteoporotic vertebral fractures: The effect of timing on clinical and radiographic outcomes and subsequent compression fractures.
Clin Neurol Neurosurg. 2018 Oct;173:176-181. doi: 10.1016/j.clineuro.2018.07.019. Epub 2018 Jul 30.
Abstract/Text
OBJECTIVE: Osteoporotic vertebral body fractures (OVFs) represent a significant medical and socioeconomic burden. There is ongoing debate concerning the role of cement augmentation versus conservative management, but we are increasingly recognizing the longer-term effects of kyphotic vertebral alignment on functional outcomes, pain, and subsequent fracture rates. The purpose of this study was to determine the effect of timing of intervention with percutaneous balloon kyphoplasty (BKP) for OVF on clinical and radiographic outcomes.
PATIENTS AND METHODS: 51 patients (mean age, 75.5 years) who underwent BKP for OVF were analyzed. Patients were divided into two groups based on timing of BKP: early (<4 weeks) or late (>4 weeks). Multiple factors were assessed preoperatively and throughout follow up and compared between groups using bivariate testing, including: focal kyphosis, subsequent vertebral fracture, and low back pain.
RESULTS: This was a retrospective sub-group analysis. There were 32 patients in the early group and 19 patients in the late group. There was no significant difference in preoperative bone density between groups. Mean follow-up was 1.2 years. Local kyphosis at final follow-up was significantly greater in the late group (-28.4°) than in the early group (-9.5°; p < 0.001). There was no significant difference in local kyphosis between preoperative measurement and final follow-up in the early (p = 0.741) or late cohort (p = 0.794). Patients treated with early BKP demonstrated significantly better LBP scores (p < 0.05) and a lower rate of subsequent vertebral fracture (p < 0.05).
CONCLUSION: BKP is able to prevent progressive collapse and kyphosis after OVF, but not effectively restore alignment, and as a result, patients who undergo early BKP (<4 weeks) demonstrate better alignment, better LBP scores, and reduced rates of subsequent fracture at an average of 1.2 years following treatment.
Copyright © 2018 Elsevier B.V. All rights reserved.
Seah SJ, Yeo MH, Tan JH, Hey HWD.
Early cement augmentation may be a good treatment option for pain relief for osteoporotic compression fractures: a systematic review and meta-analysis.
Eur Spine J. 2023 May;32(5):1751-1762. doi: 10.1007/s00586-023-07658-9. Epub 2023 Mar 25.
Abstract/Text
PURPOSE: The incidence of osteoporotic compression fractures (VCFs) have been rising over the past decades. Presently, vertebral cement augmentation procedures such as balloon kyphoplasty and vertebroplasty are common treatments allowing pain relief and functional recovery. However, there is controversy on whether different timeframes for cement augmentation affects clinical outcomes. Hence, this study aimed to compare pain relief and complication rates between early versus late cement augmentation.
METHODS: A comprehensive systematic review of PubMed, EMBASE, Scopus and Cochrane Library was conducted, identifying studies that compared early versus late cement augmentation for VCFs. As the definitions of "early" and "late" phases across studies are heterogenous, we established the cut-off between early and late phase as intervals to accommodate as many studies as possible for analysis. We conducted two separate analyses with different cut-off intervals and included studies that reported interventions within these respective time intervals. In analysis 1, we included studies which grouped patients into "early" and "late" group based on a cut-off time frame of 2-4 weeks. On the other hand, in analysis 2, we included studies which grouped patients into "early" and "late" groups based on a cut-off time frame of 6-8 weeks. Meta-analysis was conducted via random-effect models, comparing outcomes of interest between early and late groups.
RESULTS: Eleven studies were included. The total cohort size was 712 and 775 patients in analysis 1 and 2 respectively. Mean follow-up was 12.9 ± 3.7 months and 11 ± 0.6 months respectively. VAS change at final follow-up was significantly greater in the early group for both analyses. (MD = - 0.66, p = 0.01; and MD = - 1.18, p < 0.005 respectively). There was no significant difference in post-operative absolute VAS score, number of cement leakage, number of adjacent compression fractures and local kyphotic angle, for both analyses. Patients in both groups experienced reductions in VAS score that exceeded the minimum clinically important difference.
CONCLUSION: Both early and late timeframes for cement augmentation offered significant improvement in pain relief, with similar post-operative absolute pain score, kyphotic angle, cement leakage and adjacent vertebral fractures. Early surgery may offer substantial pain relief in patients presenting with pain as early as < 2-4 weeks of VCFs.
© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.
McGraw JK, Cardella J, Barr JD, Mathis JM, Sanchez O, Schwartzberg MS, Swan TL, Sacks D; SIR Standards of Practice Committee.
Society of Interventional Radiology quality improvement guidelines for percutaneous vertebroplasty.
J Vasc Interv Radiol. 2003 Jul;14(7):827-31. doi: 10.1016/s1051-0443(07)60242-5.
Abstract/Text
Takahashi S, Hoshino M, Yasuda H, Hori Y, Ohyama S, Terai H, Hayashi K, Tsujio T, Kono H, Suzuki A, Tamai K, Toyoda H, Dohzono S, Sasaoka R, Kanematsu F, Nakamura H.
Development of a scoring system for predicting adjacent vertebral fracture after balloon kyphoplasty.
Spine J. 2019 Jul;19(7):1194-1201. doi: 10.1016/j.spinee.2019.02.013. Epub 2019 Mar 1.
Abstract/Text
BACKGROUND CONTEXT: The incidence of adjacent vertebral fracture (AVFs) is reported to be 10%-38% after balloon kyphoplasty. However, no reports have established a system for prediction of AVF occurrence.
PURPOSE: To establish a scoring system for predicting AVF occurrence after balloon kyphoplasty for osteoporotic vertebral fractures (OVFs).
DESIGN: A prospective cohort study.
PATIENT SAMPLE: Consecutive elderly patients aged 65 years and older who underwent balloon kyphoplasty for OVFs within 2 months after the onset.
OUTCOME MEASURES: AVF was confirmed by X-ray.
METHODS: From 2015 to 2017, 116 consecutive patients from 10 participating hospitals who underwent balloon kyphoplasty were enrolled in this study. Prior to study enrollment, each patient underwent plain X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) of the thoracic and lumbar spine. Severity of pain was subjectively assessed using a visual analog scale (VAS) based on the average level of back pain that the patient had experienced in the preceding week. After enrollment, subjects underwent balloon kyphoplasty. Quality of life was evaluated using SF-36. Patients were followed up for at least 6 months.
RESULTS: Of the 116 patients enrolled, 109 patients with all the required data at the time of enrolment and the 6-month follow-up were included in the study. A total of 32 patients (29%) showed AVFs within the 6-month follow-up. No significant differences were observed in each clinical outcome at 6-month follow-up, although higher VAS score for back pain at 1-month follow-up was observed in the AVF group (37.5) than in the non-AVF group (20.8, p<.001). Wedge angle of vertebrae before surgery was greater in the AVF group (21.6°) than in the non-AVF group (15.7°, p<.001). The change in wedge angle between pre- and postsurgery was greater in the AVF group than in the non-AVF group, whereas the change in local kyphosis was not significantly different. The multiple logistic regression model showed increased odds ratio (OR) of thoracic or thoracolumbar spine, old OVF presence, >25° kyphosis before surgery, and >10°correction for AVF. Based on this result, a simple scoring system for predicting AVF occurrence was developed. The total AVF score was calculated as the sum of the individual scores, which varied from 0 to 6. All patients with 5-6 points sustained AVF.
CONCLUSIONS: More severe wedge angle before surgery, correction degree, old OVF presence, and thoracolumbar level were predictive factors for AVF. All patients with AVF risk score of 5 or more showed AVF. This information may aid preoperative risk assessment, informed shared decision-making, and consideration of potential alternative management strategies.
Copyright © 2019 Elsevier Inc. All rights reserved.
Halvachizadeh S, Stalder AL, Bellut D, Hoppe S, Rossbach P, Cianfoni A, Schnake KJ, Mica L, Pfeifer R, Sprengel K, Pape HC.
Systematic Review and Meta-Analysis of 3 Treatment Arms for Vertebral Compression Fractures: A Comparison of Improvement in Pain, Adjacent-Level Fractures, and Quality of Life Between Vertebroplasty, Kyphoplasty, and Nonoperative Management.
JBJS Rev. 2021 Oct 25;9(10). doi: 10.2106/JBJS.RVW.21.00045. Epub 2021 Oct 25.
Abstract/Text
BACKGROUND: Osteoporotic vertebral fractures (OVFs) have become increasingly common, and previous nonrandomized and randomized controlled trials (RCTs) have compared the effects of cement augmentation versus nonoperative management on the clinical outcome. This meta-analysis focuses on RCTs and the calculated differences between cement augmentation techniques and nonsurgical management in outcome (e.g., pain reduction, adjacent-level fractures, and quality of life [QOL]).
METHODS: A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, and the following scientific search engines were used: MEDLINE, Embase, Cochrane, Web of Science, and Scopus. The inclusion criteria included RCTs that addressed different treatment strategies for OVF. The primary outcome was pain, which was determined by a visual analog scale (VAS) score; the secondary outcomes were the risk of adjacent-level fractures and QOL (as determined by the EuroQol-5 Dimension [EQ-5D] questionnaire, the Oswestry Disability Index [ODI], the Quality of Life Questionnaire of the European Foundation for Osteoporosis [QUALEFFO], and the Roland-Morris Disability Questionnaire [RDQ]). Patients were assigned to 3 groups according to their treatment: vertebroplasty (VP), kyphoplasty (KP), and nonoperative management (NOM). The short-term (weeks), midterm (months), and long-term (>1 year) effects were compared. A random effects model was used to summarize the treatment effect, including I2 for assessing heterogeneity and the revised Cochrane risk-of-bias 2 (RoB 2) tool for assessment of ROB. Funnel plots were used to assess risk of publication bias. The log of the odds ratio (OR) between treatments is reported.
RESULTS: After screening of 1,861 references, 53 underwent full-text analysis and 16 trials (30.2%) were included. Eleven trials (68.8%) compared VP and NOM, 1 (6.3%) compared KP and NOM, and 4 (25.0%) compared KP and VP. Improvement of pain was better by 1.31 points (95% confidence interval [CI], 0.41 to 2.21; p < 0.001) after VP when compared with NOM in short-term follow-up. Pain effects were similar after VP and KP (midterm difference of 0.0 points; 95% CI, -0.25 to 0.25). The risk of adjacent-level fractures was not increased after any treatment (log OR, -0.16; 95% CI, -0.83 to 0.5; NOM vs. VP or KP). QOL did not differ significantly between the VP or KP and NOM groups except in the short term when measured by the RDQ.
CONCLUSIONS: This meta-analysis provides evidence in favor of the surgical treatment of OVFs. Surgery was associated with greater improvement of pain and was unrelated to the development of adjacent-level fractures or QOL. Although improvements in sagittal balance after surgery were poorly documented, surgical treatment may be warranted if pain is a relevant problem.
LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
Copyright © 2021 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.
Fribourg D, Tang C, Sra P, Delamarter R, Bae H.
Incidence of subsequent vertebral fracture after kyphoplasty.
Spine (Phila Pa 1976). 2004 Oct 15;29(20):2270-6; discussion 2277. doi: 10.1097/01.brs.0000142469.41565.2a.
Abstract/Text
STUDY DESIGN: A retrospective review of charts and radiographs of all consecutive patients who underwent kyphoplasty at the authors' center from the initial procedure in September 2000 to the end of the collection period in July 2002.
SUMMARY OF BACKGROUND DATA: The best available natural history data would suggest that after experiencing an osteoporotic vertebral compression fracture, patients have a 19% incidence of subsequent fracture in the following year when no surgical intervention is performed. When kyphoplasty is performed, there are conflicting data regarding the incidence of subsequent fracture, ranging anywhere from 3 to 29%. These fractures occur at adjacent levels between 30 and 90% of the time, with no clear explanation for the wide variation in the results of three different studies. There are biomechanical data to suggest that injection of cement does increase the stiffness of the treated vertebra and that this increases strain on adjacent vertebrae, especially in forward bending.
METHODS: A database was created containing patient age, gender, height, weight, medication history, comorbidities, fracture levels, and pain level before and after surgery. Subsequent fractures were confirmed with radiographs and MRI. Statistical analysis was performed.
RESULTS: Thirty-eight patients (10 men and 28 women) were treated for 47 levels initially. L1 and L2 were the most common level of fracture managed initially. The gender, smoking and medication history, location of fracture, and number of fracture levels of the patients did not correlate with the risk of subsequent fracture. Over the follow-up period (average, 8 months), 10 patients sustained 17 subsequent fractures. Eight patients sustained fractures in the first 2 months after the index procedure, all with at least one fracture at an adjacent level. Of the 17 subsequent fractures, there were nine at the adjacent-above levels, four at adjacent-below levels, and four at remote levels. The remote fractures occurred at significantly greater time intervals after the index procedure (P < 0.001).
CONCLUSION: This study demonstrated a higher rate of subsequent fracture after kyphoplasty compared with natural history data for untreated fractures. Most of these occurred at an adjacent level within 2 months of the index procedure. After this 2-month period, there were only occasional subsequent fractures, which occurred at remote levels. This confirms biomechanical studies showing that cement augmentation places additional stress on adjacent levels. Patients with an increase in back pain after kyphoplasty should be evaluated carefully for subsequent adjacent fractures, especially during the first 2 months after the index procedure.
Kado DM, Lui LY, Ensrud KE, Fink HA, Karlamangla AS, Cummings SR; Study of Osteoporotic Fractures.
Hyperkyphosis predicts mortality independent of vertebral osteoporosis in older women.
Ann Intern Med. 2009 May 19;150(10):681-7. doi: 10.7326/0003-4819-150-10-200905190-00005.
Abstract/Text
BACKGROUND: Excessive kyphosis may be associated with earlier mortality, but previous studies have not controlled for clinically silent vertebral fractures, which are a known mortality risk factor.
OBJECTIVE: To determine whether hyperkyphosis predicts increased mortality independent of vertebral fractures.
DESIGN: Prospective cohort study.
SETTING: Four clinical centers in Baltimore County, Maryland; Portland, Oregon; Minneapolis, Minnesota; and the Monongahela Valley, Pennsylvania.
PATIENTS: 610 women, age 67 to 93 years, from a cohort of 9704 women recruited from community-based listings between 1986 and 1988.
MEASUREMENTS: Kyphosis was measured by using a flexicurve. Prevalent radiographic vertebral fractures at baseline were defined by morphometry, and mortality was assessed during an average follow-up of 13.5 years.
RESULTS: In age-adjusted models, each SD increase in kyphosis carried a 1.14-fold increased risk for death (95% CI, 1.02 to 1.27; P = 0.023). After adjustment for age and other predictors of mortality, including such osteoporosis-related factors as low bone density, moderate and severe prevalent vertebral fractures, and number of prevalent vertebral fractures, women with greater kyphosis were at increased risk for earlier death (relative hazard per SD increase, 1.15 [CI, 1.01 to 1.30]; P = 0.029). On stratification by prevalent vertebral fracture status, only women with prevalent fractures were at increased mortality risk from hyperkyphosis, independent of age, self-reported health, smoking, spine bone mineral density, number of vertebral fractures, and severe vertebral fractures (relative hazard per SD increase, 1.58 [CI, 1.06 to 2.35]; P = 0.024).
LIMITATION: The study population included only white women.
CONCLUSION: In older women with vertebral fractures, hyperkyphosis predicts an increased risk for death, independent of underlying spinal osteoporosis and the extent and severity of vertebral fractures.
PRIMARY FUNDING SOURCE: National Institute of Arthritis and Musculoskeletal and Skin Diseases and National Institute on Aging.
