��������������� ����� � ��������������� ���������� ��� ��������� (�� ������� C����-����������)

To retrospectively assess the prevalence and clinical outcomes of unreported vertebral compression fractures at abdominal computed tomography (CT). This HIPAA-compliant study had institutional review board approval; the need for informed consent was waived for this retrospective analysis. A total of 2041 consecutive adult patients (1640 women, 401 men; age range, 19-94 years) underwent both abdominal multidetector CT and dual-energy x-ray absorptiometry (DXA) within 6 months of each other between 2000 and 2007, before sagittal CT reconstructions were obtained routinely. Transverse (axial) and retrospective sagittal multidetector CT reconstructions were reviewed for the presence of moderate or severe vertebral body compression fractures of the lower thoracic and lumbar spine by using the Genant visual semiquantitative method. Twenty-six patients were excluded for evidence of pathologic fracture or for technical factors limiting compression fracture detection. Electronic medical records were reviewed for patients with moderate or severe compression fractures to determine whether the fracture was reported at prospective CT interpretation, was known previously, or was diagnosed subsequently. Correlation was made with central DXA T scores. Statistical analysis was performed with the Student t test and Fisher exact test. At least one moderate or severe vertebral body compression fracture was identified retrospectively at CT in 97 patients (mean age, 70.8 years). Fractures involved one level in 67 and multiple levels in 30 patients, for a total of 141 fractures. In 81 (84%) patients, prospective CT diagnosis was not made. Patients in whom fractures were reported prospectively were significantly older and were more likely to have a severe compression fracture (P < .05). In 52 (64%) patients with an unreported fracture, the vertebral compression fracture was not known clinically. In 18 patients, subsequent diagnosis of a compression fracture was determined by means of another imaging study (median interval, 7 months). At DXA, 39 (48%) of 81 patients with unreported vertebral body compression fractures had a nonosteoporotic T score (greater than -2.5). Most clinically important vertebral body compression fractures in nontrauma patients at risk for low bone mineral density may go unreported at abdominal multidetector CT if sagittal reconstructions are not routinely evaluated.

Vertebroplasty and kyphoplasty have become common surgical techniques for the treatment of vertebral compression fractures. Vertebroplasty involves the percutaneous injection of bone cement into the cancellous bone of a vertebral body with the goals of pain alleviation and preventing further loss of vertebral body height. Kyphoplasty utilizes an inflatable balloon to create a cavity for the cement with the additional potential goals of restoring height and reducing kyphosis. Vertebroplasty and kyphoplasty are effective treatment options for the reduction of pain associated with vertebral body compression fractures. Biomechanical studies demonstrate that kyphoplasty is initially superior for increasing vertebral body height and reducing kyphosis, but these gains are lost with repetitive loading. Complications secondary to extravasation of cement include compression of neural elements and venous embolism. These complications are rare but more common with vertebroplasty. Vertebroplasty and kyphoplasty are both safe and effective procedures for the treatment of vertebral body compression fractures.

Objective To determine the risk factors for new vertebral fractures following percutaneous vertebroplasty (PVP) for osteoporotic vertebral compression fractures (OVCF). Methods This retrospective study included 703 patients (133 males and 570 females; 59-88 years, mean 76 years) treated with PVP for OVCF from January 2006 to June 2015. Involved vertebrae included 5 T6,3 T7,19 T8,16 T9,14 T10,46 T11,218 T12,241 L1,137 L2,108 L3,55 L4 and 37 L5. A total of 80 patients were detected with further vertebral fractures (new fracture group) and 623 patients with no new vertebral fractures (control group). Possible risk factors for new vertebral fractures were noted, including age, gender, body mass index (BMI), bone mineral density, involved vertebral segment, amount of cement injection, intradiscal cement leak, and anterior-posterior ratio of the fractured vertebrae. And the fracture group were subdivided into adjacent vertebral fracture group (n=48) and non-adjacent vertebral fracture group (n=32). Results Eighty (11%) of the 703 patients had subsequent vertebral fractures after PVP. Bone mineral density differed significantly between new fracture and control groups [(-3.31±0.74)SD vs. (-2.98±0.86)SD ] (P 0.05). There were no significant differences in all the factors between adjacent vertebral fracture and non-adjacent vertebral fracture groups (P>0.05). Conclusions Severe osteoporosis is the main risk factor of new vertebral fractures after OVCF managed with PVP. Therefore, treatment of osteoporosis is the key point to prevent postoperative new vertebral fractures. Key words: Spinal fractures; Vertebroplasty; Bone density

This review article develops a biomechanical rationale for the clinical consequences and treatment of osteoporotic vertebral body compression fracture. In patients with osteoporotic vertebral fractures and spinal deformity, altered spinal biomechanics and global spinal imbalance are important factors in the increased morbidity and mortality reported in this population. Severe spinal deformity impairs physical functioning, health, and quality of life. The spinal deformity itself, independent of pain, is a significant cause of disability. Spinal deformity is also an independent risk factor for hip fracture. Treatments directed at osteoporotic vertebral compression fractures should ideally address spinal deformity as well as pain. Balloon kyphoplasty, the minimally invasive technique of reduction and internal fixation of osteopenic vertebral body compression fractures that addresses pain and spinal deformity, is discussed.

This is a case study of a 66-yr-old woman with osteoporosis and thoracic kyphosis who had been receiving alendronate for 8 yrs. Her chief complaint was her stooped posture that was “getting worse.” She had had frequent chiropractic “adjustments” for occasional back pain but was pain-free at the time of her evaluation at our institution. Neurologic examination was within normal limits. Lumbar spine radiographs were negative for vertebral compression fractures. No thoracic spine radiographs had been obtained before her referral to the Rehabilitation of Osteoporosis Program–Exercise (ROPE), despite the location of her thoracic deformity. Before the patient’s entry into the ROPE program, thoracic spine radiographs were obtained, and these showed a compression fracture of a midthoracic vertebral body and moderately severe thoracic hyperkyphosis (Fig. 1). A proper back exercise program for strengthening the back extensors, postural exercises, and a weighted kypho-orthosis were provided to the patient, along with instructions to avoid straining her spine. Pharmacotherapy including antiresorptive agents and proper intake of calcium and vitamin D were reviewed with the patient.Figure 1:: Left, radiographic image showing a 66-yr-old woman with anterior compression of a midthoracic vertebral body, with moderately increased kyphosis at this level, and a few small Schmorl’s nodes at the midthoracic spine; right, osteopenic lumbar spine.This case illustrates the need for a thorough evaluation with radiographs before initiation of an exercise program. Despite ongoing pharmacotherapy for osteoporosis and the lack of significant back pain, this patient had a compression fracture that, if left undiagnosed, could have progressed into a more serious condition during the course of her physical therapy or her chiropractic manipulations. Vertebral compression fractures are common and can be insidious in the osteoporotic population. Although fractures generally are associated with pain, it is important to consider the possibility of vertebral involvement in this population, despite the absence of discomfort, particularly when there is obvious progression of kyphotic deformity. Patients with previous vertebral fractures are at risk for further vertebral fractures. They also have an increased risk of falls and mortality. Exercise is an integral part of the management of patients with osteoporosis and has been associated with improved physical ability, bone mineral density, and decreased pain. Elizabeth Huntoon, MD Mehrsheed Sinaki, MD, MS From the Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota.

Objective To investigate the risk factors of degenerative scoliosis patients with osteoporotic vertebral compression fracture. Methods The data of 150 cases of degenerative scoliosis were retrospectively reviewed from October 2007 to October 2015. According to the occurrence of vertebral compressive fractures, the 150 patients were divided into the experiment group(fracture) and control group(non-fracture). Visual analogue scale(VAS) was used to assess the back pain, and the bone mineral density were measured in patients by using dual-energy X-ray absorptiometry, Cobb angle was measured to evaluate the severity of scoliosis. The occurrence of osteopontin in scoliosis were observed and analyzed. Logistic analysis was used to investigate the risk factors of vertebral compression fractures. Results ①In experiment group, there were T11 vertebral compression fractures in 4 cases, T12 vertebral compression fractures in 13 cases, L1 vertebral compression fractures in 16 cases, and both T12 and L1 vertebral fracture in 5 cases. ②The gender composition of the two groups had no significant difference(χ2=0.253, P=0.615). Compared with the control group, the average age of the experiment group was lower(t=4.392, P<0.01), VAS score was higher(t=14.350, P<0.01), more severe osteoporosis(t=13.296, P<0.01), a higher incidence of osteopontin(χ2=11.824, P=0.001). The Cobb angle of the two groups had no significant difference(t=1.749, P=0.082). After analysis of Logistic regression, trauma history(OR=1.57, 95% CI: 1.09-2.11), bone bridge formation(OR=3.46, 95% CI: 2.10-5.38) and bone osteoporosis(OR=2.48, 95% CI: 1.58-4.36) will increase the chances of patients with fractures. Conclusions Osteoporotic vertebral compression fracture usually occur in thoraco-lumbar region in patients with degenerative scoliosis, and its risk factor are trauma, history, osteoporosis and bone bridge formation. Key words: Osteoporotic fractures; Vertebral compression frature; Degenerative scoliosis; Risk factors

Objective To determine the effects of unilateral and bilateral vertebral transpedicular vertebroplasty and kyphoplasty for the treatment of severe osteoporotic vertebral compression fracture. Methods The clinical data of 63 patients with severe osteoporotic vertebral compression fracture, who underwent vertebroplasty or kyphoplasty in our hospital between January 2013 and August 2016, were retrospectively analyzed. The operative time, intraoperative fluoroscopy time, average vertebral bone cement injection volume, bone cement leakage, preoperative and postoperative visual analogue scale (VAS) scores, pain remission rate, and SF-36 health survey questionnaire were recorded. The changes of the vertebral anterior wall, center, and posterior wall vertical height and vertebral kyphosis angle were compared at the baseline, at 3d after the operation, and at the last follow-up. The patients were followed up for 1 year after the operaiton and the time of new vertebral fracture was recorded. Results For the treatment of severe osteoporotic vertebral compression fracture, unilateral transpedicular vertebroplasty was least costly on the operative time and fluoroscopy time. Its bone cement volume per section was less than that of the kyphoplasty, which was the same as the bilateral transpedicular vertebroplasty. The unilateral and bilateral transpedicular vertebroplasty showed more bone cement leakage and the new vertebral fracture time was shorter. The VAS score, physical health comprehensive score and mental health comprehensive score after the operation in the 3 groups were better than those before the operation. Both of the unilateral and bilateral transpedicular vertebroplasty could effectively relieve pain symptoms. The anterior wall, center and posterior wall vertical height significantly increased after the operation compared with those before the operation. The vertebral kyphosis angle in the 3 groups was significantly improved (all P<0.05). Kyphoplasty significantly favored the recovery of anterior wall, center and posterior wall vertical height and improvement of vertebral kyphosis angle. Conclusion For the treatment of severe osteoporotic vertebral compression fracture, vertebroplasty and kyphoplasty may effectively relieve pain symptoms, restore the vertebral body structure and vertebral height. The effect of unilateral and bilateral vertebroplasty is generally the same, with simple operation, short operative time and less cost, whereas the cement leakage rate and the recovery of vertebral height are less than those of kyphoplasty. Key words: Vertebroplasty; Osteoporosis; Compressive fractures

Radiologists interpreting body CT scans may be the first to identify osteoporosis and associated vertebral fractures. This study correlates L1 trabecular attenuation measurements with prevalent vertebral body fractures in older adults undergoing routine CT. Mean L1 trabecular attenuation was measured at thoracoabdominal CT in 1966 consecutive adults (983 men and 983 women) 65 years and older (mean age, 74.1 ± 6.6 [SD] years). Sagittal reconstructions and lateral scouts were analyzed for moderate or severe thoracolumbar vertebral compression fractures according to the Genant semiquantitative assessment method. The diagnostic performance of L1 attenuation for the evaluation of prevalent vertebral fractures was assessed, including ROC curve analysis. A total of 162 (8.2%) individuals (mean age, 78.3 years; 66 men, 96 women) had at least one moderate or severe vertebral fracture. The mean L1 attenuation was 70.2 HU among patients with a prevalent fracture, whereas it was 132.3 HU among patients without fracture (p < 0.001). The prevalence of moderate or severe vertebral compression fractures was 32.5% when L1 attenuation was ≤ 90 HU. Prevalence increased to 49.2% with L1 attenuation of ≤ 50 HU. ROC curve analysis determined an optimal threshold of 90 HU (sensitivity = 86.9%, specificity = 83.9%), with a corresponding AUC of 0.895. The odds ratio of having a moderate or severe vertebral compression fracture was 31.9 for L1 attenuation ≤ 90 HU (95% CI, 20.2-50.5; p < 0.001). Patients with moderate or severe vertebral compression fractures have significantly lower L1 attenuation values than patients who do not. L1 attenuation ≤ 90 HU may represent an optimal threshold for determining risk for osteoporotic vertebral fractures.

Objective To investigate the effect of bisphosphonate medication (zoledronic acid,aclasta) on spinal fusion for osteoporotic patients through radiographic,clinical,and biological assessments.Methods A total of 79 patients with osteoporosis who were candidates for single-level posterior lumbar interbody fusion was randomly assigned to the experimental group (zoledronic acid injection,5mg,on the third day after surgery) or the control group (the same amount of saline injection,on the third day after surgery).Functional radiography and CT scans were used to evaluate fusion status.Bridging bone formation was graded into 3 categories:Grade A (bridging bone through bilateral vertebral),Grade B (bridging bone through a unilateral vertebral),or Grade C (incomplete bony bridging).The incidence of vertebral compression fractures occurring after surgery was assessed by means of MR imaging.A solid fusion was defined as less than 5° of angular motion in flexion-extension radiographs and the presence of Grade A or B bridging bone.Bone metabolic markers (β-C-terminal telopeptide of type Ⅰ collagen,β-CTX; and N-terminal propeptide of type Ⅰ collagen,PINP) were measured to investigate the biological effects of zoledronic acid on spinal fusion.Bone mineral density of femoral neck was measured by the dual X-ray absorptiometry.Clinical outcome was evaluated by means of the Oswestry Disability Index (ODI).Results Grade A or B bridging bone was more frequently observed in the experimental group at 3,6,and 9 months postoperatively (all P ＜ 0.05,respectively,Mann-Whitney U-test).At 12-months postoperative follow-up,bridging bone and solid fusion were not significantly different.No vertebral fractures were observed in the experimental group,whereas 6 patients in the control group showed vertebral compression fractures(P ＜ 0.05,Mann-Whitney U-test).Biochemical analysis of bone turnover demonstrated that zoledronic acid inhibited bone resorption from the early phase of the fusion process and also suppressed bone formation.Poor clinical results in the control group were demonstrated by ODI.Conclusions Osteoporosis patients undergoing spinal fusion who take bisphosphonates throughout the postoperative period was recommended. Key words: Imidazoles/therapeutic use; Phosphonic acids/therapeutic use; Osteoporosis/surgery; Lumbar vertebrae ; Fracture fixation, internal ; Spinal fusion ; Randomized controlled trial

Although many vertebral fractures are clinically silent, they are associated with increased risk for subsequent osteoporotic fractures. A substantial number of these fractures are demonstrable using instant vertebral assessment with Hologic densitometers. Whether similar recognition is possible using dual-energy lateral vertebral assessment (LVA) with GE Lunar densitometers remains uncertain. Thus, we evaluated the ability of clinicians using LVA to detect prevalent vertebral fractures. Dual-energy LVA and conventional thoracic and lumbar spine radiographs were concurrently obtained in 80 postmenopausal women. Using an established visual semiquantitative system, vertebral fractures were identified individually by two non-radiologist clinicians on LVA images, and the results were compared with spinal radiograph evaluation by an expert radiologist. Using LVA, 95% of vertebral bodies from T7 through L4 were evaluable, but a majority (66%) of vertebrae from T4 to T6 were not adequately visualized. In the LVA-evaluable vertebrae, prevalent fractures were identified in 40 vertebral bodies by radiography. In this regard, the clinicians using LVA detected 17 of 18 radiographically evident vertebral fractures of grade 2 or 3, a false negative rate of 6%. They identified 50% (11/22) of grade 1 fractures. Additionally, the vast majority of evaluable non-fractured vertebrae, (764/794, 96.2%) were correctly classified as normal by LVA. Thus, clinicians utilizing LVA correctly identified the vast majority of grade 2 or 3 vertebral compression fractures and normal vertebral bodies, although detection of grade 1 fractures was less effective. In conclusion, the low-radiation, dual-energy LVA technique provides a rapid and convenient way for clinicians to identify patients with, and without, grade 2 or 3 vertebral fractures, thereby enhancing care of osteoporotic patients.

Height restoration of osteoporotic vertebral compression fractures using different intravertebral reduction devices: a cadaveric study

The study is an observational cohort study. To determine the incidence and the long-term outcome of thoracic or lumbar vertebral fractures in children. The incidence of vertebral fractures in children is described as rare and the outcome as favorable. However, no studies evaluate the clinical and radiographic long-term outcome and if a fractured vertebra could be rebuilt during growth. The incidence of vertebral fractures in children was evaluated through the radiographic archives. Twelve boys and 12 girls, aged 7-16 when sustaining the fracture, 21 one-column compression fractures and 3 burst fractures Denis type B, all without neurologic deficits, attended the follow-up. Primary treatment consisted of immediate mobilization without brace. Clinical and radiographic examinations were performed 27-47 years after the injury. The annual incidence of thoracic and lumbar vertebral body fractures in individuals below age 16 was 0.07%. Twenty-one individuals had, at follow-up, no subjective complaints, 3 had occasional back pain (Oswestry Scores 8, 22, and 26), 23 were classified as Frankel E, and 1 as Frankel D. The radiographic ratio anterior height/posterior height of the fractured vertebral body increased from 0.75 after injury to 0.87 at follow-up (P < 0.001). The posttraumatic kyphosis in the fractured region decreased in 8 individuals (33%), all aged 13 or less at fracture. No increased disc degeneration was observed. Thoracolumbar vertebral fractures without neurologic deficits, sustained during growth, have a favorable long-term outcome. A modeling capacity, reducing the fracture deformity, exists at least in the youngest patients.

Segmental spinal deformity results from vertebral compression fracture (VCF) and progressive collapse of the fractured vertebral body (VB). The VB stenting (VBS) systemⓇ comprises a balloon-assisted, expandable, intrasomatic, metal stent that helps maintain the restored VB during balloon removal and cement injection, which minimizes cement leakage. We performed a prospective, multicenter, clinical trial of the VBS system in Japanese patients with acute VCF owing to primary osteoporosis. Herein, 88 patients, 25 men and 63 women aged 77.4±8.3 years, with low back pain, numerical rating scale (NRS) score of ≥4, and mean VB compression percentage (VBCP) of <60% were enrolled. The primary endpoints were the VBCP restoration rate and reduction in low back pain 1 month and 7 days after VBS surgery, respectively. Secondary endpoints included changes in VBCP, NRS pain score, Beck index, kyphosis angle, and quality of life according to the short form 36 (v2) score. Safety was assessed as adverse events, device malfunctions, and new vertebral fractures. Overall, 70 patients completed the study. VBS surgery increased the restoration rates of anterior and midline VBCP by 31.7%±26.5% (lower 95% confidence intervals (CI): 26.8) and 31.8%±24.6% (lower 95% CI: 27.2), respectively, and the reduction in NRS pain score was -4.5±2.4 (upper 95% CI: -4.0). As these changes were greater than the predetermined primary endpoint values (20% for VBCP and -2 for NRS score), they were judged clinically significant; these changes were maintained throughout the 12-month follow-up (p<0.001). Likewise, significant improvement was observed in the Beck index, kyphosis angle, and quality of life score, which were maintained throughout the follow-up. There were three serious adverse events. New fractures occurred in 12 patients-all in the adjacent VB. VBS surgery effectively restored the collapsed VB, relieved low back pain, and was tolerable in patients with acute osteoporotic VB fracture.

Background: The causes of subsequent vertebral fractures after kyphoplasty are debated. It is reported that most new vertebral fractures after kyphoplasty develop in adjacent vertebrae. Objectives: We explored whether kyphoplasty increases the incidence of adjacent vertebral fractures and identified risk factors for new vertebral compression fractures (VCFs) after kyphoplasty. Study Design: Retrospective study. Setting: Inpatient population of a single center. Methods: We studied 356 patients treated with kyphoplasty from January 2008 to March 2012. Among those patients, there were 35 new VCFs after kyphoplasty. Subsequently, these patients were divided into 2 groups: an “adjacent fracture” group and a “nonadjacent fracture” group. In addition, all patients treated with kyphoplasty were further assigned to either a “new fracture” group or a “no fracture” group. Results: The occurrence of new VCFs in the “nonadjacent fracture” group was significantly higher than that in the “adjacent fracture” group. The average bone mineral density (BMD) of the spine was -3.95 in the “new fracture” group and -2.86 in the “no fracture” group. The risk of new vertebral fracture increased as the bone mineral density decreased (P &lt; 0.05). The morbidity of women was significantly higher in the “new fracture” group (94.29%) than in the “no fracture” group (77.88%) (P = 0.025). Limitations: Retrospective study at a single center. Conclusion: New VCFs after kyphoplasty occurred most often in nonadjacent vertebrae. VCFs after kyphoplasty were common in patients with low bone mineral density and in women, suggesting that osteoporosis is an underlying mechanism. Institutional Review: This study was approved by the institutional review board. Key words: Percutaneous kyphoplasty, vertebral compression fractures, bone mineral density, polymethylmethacrylate, adjacent vertebral fracture

Vertebral fractures are important indicators of osteoporosis. Fractures with partial collapse of vertebral bodies are referred to as vertebral compression fractures (VCFs) that are usually non-traumatic in nature. Some common causes of VCFs are trauma, bone failure related to osteoporosis (benign) and metastatic cancer (malignant). This paper aims at developing a system for computer-aided diagnosis to help in the detection, labeling and segmentation of lumbar vertebral body (VB) and to further classify each VB into normal, malignant and benign VCFs. After the initial preprocessing, morphological, shape and angular features are used in the detection, labeling and segmentation steps. Various shape and statistical texture features are extracted from the segmented VB and are fed to the classifier for the final decision. The segmentation and classification results obtained were compared with the ground truth manual segmentation of the lumbar VB and the decision labels of the fractures provided by the experts. The dice similarity coefficient (DSC) for segmentation reached up to 94.27%, and the classification results show that shape and texture features together are able to correctly classify with an accuracy rate of 95.34%. The final outcomes are expected to be useful in the analysis of vertebral compression fractures.