Satoshi Mori, Satoshi Soen, Hiroshi Hagino, Tetsuo Nakano, Masako Ito, Saeko Fujiwara, Yoshiharu Kato, Yasuaki Tokuhashi, Daisuke Togawa, Naoto Endo, Takeshi Sawaguchi, 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.
D M Black, S R Cummings, D B Karpf, J A Cauley, D E Thompson, M C Nevitt, D C Bauer, H K Genant, W L Haskell, R Marcus, S M Ott, J C Torner, S A Quandt, T F Reiss, K E Ensrud
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.
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.
Abstract/Text
BACKGROUND: Although vertebral fractures are very common among elderly Caucasian women, no studies have compared the prevalence to that among Asian populations. Any observed differences in prevalence might lead to the identification of important environmental and/or genetic factors. We therefore compared the prevalence of vertebral fractures among US Caucasians to native Japanese and Japanese immigrants in Hawaii using a standardized approach.
METHODS: Spinal radiographs of women aged > 50 years were obtained from native Japanese in Hiroshima, Japanese-Americans in Hawaii, and North American Caucasians in Minnesota between 1982 and 1991. Fractures were defined as vertebral heights > 3 standard deviations (SD) below the vertebra-specific mean.
RESULTS: Compared to Japanese-Americans, odds ratios (OR) and 95% confidence intervals (CI) for prevalent vertebral fractures were 1.8 (95% CI: 1.3-2.5) for native Japanese women and 1.5 (95% CI: 1.1-2.1) for Minnesota Caucasians. The OR tended to be higher when comparing the prevalence of two or more fractures per person: OR = 3.2 (95% CI: 2.0-5.3) for native Japanese and OR = 1.9 (95% CI: 1.2-3.2) for Minnesota Caucasians. Similar results were observed for native Japanese using a fracture definition of > or = 4 SD below the mean, but the OR for Caucasians was reduced to 1.2 (95% CI: 0.6-2.3).
CONCLUSION: The observation that, among these three populations, hip fracture incidence is lowest but spine fracture prevalence is greatest among native Japanese suggests that different risk factors may be responsible.
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.
Hiromitsu Toyoda, Shinji Takahashi, Masatoshi Hoshino, Kazushi Takayama, Kazumichi Iseki, Ryuichi Sasaoka, Tadao Tsujio, Hiroyuki Yasuda, Takeharu Sasaki, Fumiaki Kanematsu, Hiroshi Kono, Hiroaki Nakamura
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
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.
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.
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.
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.
K Siminoski, G Jiang, J D Adachi, D A Hanley, G Cline, G Ioannidis, A Hodsman, R G Josse, D Kendler, W P Olszynski, L-G Ste Marie, R Eastell
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.
Amanda D Green, Cathleen S Colón-Emeric, Lori Bastian, Matthew T Drake, Kenneth W Lyles
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.
Tadao Tsujio, Hiroaki Nakamura, Hidetomi Terai, Masatoshi Hoshino, Takashi Namikawa, Akira Matsumura, Minori Kato, Akinobu Suzuki, Kazushi Takayama, Wakaba Fukushima, Kyoko Kondo, Yoshio Hirota, Kunio Takaoka
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.
Tomiya Matsumoto, Masatoshi Hoshino, Tadao Tsujio, Hidetomi Terai, Takashi Namikawa, Akira Matsumura, Minori Kato, Hiromitsu Toyoda, Akinobu Suzuki, Kazushi Takayama, Kunio Takaoka, Hiroaki Nakamura
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.
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.
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.
Hiroyuki Yasuda, Masatoshi Hoshino, Tadao Tsujio, Hidetomi Terai, Takashi Namikawa, Minori Kato, Akira Matsumura, Akinobu Suzuki, Kazushi Takayama, Shinji Takahashi, Hiroaki Nakamura
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
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.
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.
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.
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.
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.
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.
Tsuyoshi Kato, Hiroyuki Inose, Shoichi Ichimura, Yasuaki Tokuhashi, Hiroaki Nakamura, Masatoshi Hoshino, Daisuke Togawa, Toru Hirano, Hirotaka Haro, Tetsuro Ohba, Takashi Tsuji, Kimiaki Sato, Yutaka Sasao, Masahiko Takahata, Koji Otani, Suketaka Momoshima, Ukihide Tateishi, Makoto Tomita, Ryuichi Takemasa, Masato Yuasa, Takashi Hirai, Toshitaka Yoshii, Atsushi Okawa
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.
Masatoshi Hoshino, Shinji Takahashi, Hiroyuki Yasuda, Hidetomi Terai, Kyoei Watanabe, Kazunori Hayashi, Tadao Tsujio, Hiroshi Kono, Akinobu Suzuki, Koji Tamai, Shoichiro Ohyama, Hiromitsu Toyoda, Sho Dohzono, Fumiaki Kanematsu, Yusuke Hori, Hiroaki Nakamura
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.
Shinji Takahashi, Masatoshi Hoshino, Hidetomi Terai, Hiromitsu Toyoda, Akinobu Suzuki, Koji Tamai, Kyoei Watanabe, Tadao Tsujio, Hiroyuki Yasuda, Hiroshi Kono, Ryuichi Sasaoka, Sho Dohzono, Kazunori Hayashi, Shoichiro Ohyama, Yusuke Hori, Hiroaki Nakamura
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.
Akihito Minamide, Takahiro Maeda, Hiroshi Yamada, Kimihide Murakami, Motohiro Okada, Yoshio Enyo, Yukihiro Nakagawa, Hiroshi Iwasaki, Shunji Tsutsui, Masanari Takami, Keiji Nagata, Hiroshi Hashizume, Yasutsugu Yukawa, Andrew J Schoenfeld, Andrew K Simpson
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.
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.
