Space between bone cement and bony endplate can trigger higher incidence of augmented vertebral collapse: An in-silico study.

BACKGROUND: The pathogenesis of postoperative complications in patients with osteoporotic vertebral compressive fractures (OVCFs) undergoing percutaneous vertebroplasty (PVP) is multifaceted, with local biomechanical deterioration playing a pivotal role. Specifically, the disparity in stiffness between the bone cement and osteoporotic cancellous bone can precipitate interfacial stress concentrations, potentially leading to cement-augmented vertebral body collapse and clinical symptom recurrence. This study focuses on the biomechanical implications of the space between the bone cement and bony endplate (BEP), hypothesizing that this interface may be a critical locus for stress concentration and subsequent vertebral failure. METHODS: Leveraging a validated numerical model from our previous study, we examined the biomechanical impact of the cement-BEP interface in the L2 vertebral body post-PVP, simulated OVCF and PVP and constructed three distinct models: one with direct bone cement contact with both cranial and caudal BEPs, one with contact only with the caudal BEPs and one without contact with either BEP. Moreover, we assessed stress distribution across cranial and caudal BEPs under various loading conditions to describe the biomechanical outcomes associated with each model. RESULTS: A consistent trend was observed across all models: the interfaces between the bone cement and cancellous bone exhibited higher stress values under the majority of loading conditions compared to models with direct cement-BEP contact. The most significant difference was observed in the flexion loading condition compared to the mode with direct contact between BEP and cement. The maximum stress in models without direct contact increased by at least 30%. CONCLUSIONS: Our study reveals the biomechanical significance of interfacial stiffness differences at the cement-BEP junction, which can exacerbate local stress concentrations and predispose to augmented vertebral collapse. We recommend the strategic distribution of bone cement to encompass a broader contact area with the BEP for preventing biomechanical failure and subsequent vertebral collapse.

Modified posterior osteotomy for osteoporotic vertebral collapse with neurological dysfunction in thoracolumbar spine: a preliminary study.

OBJECTIVE: The risk of osteoporotic vertebral collapse (OVC) associated with delayed neurological dysfunction (DND) is substantial, and performing surgery for this condition in elderly patients presents challenges. The focus of the current research is on simplifying surgical procedures while maintaining their effectiveness. This study was designed to contribute clinical data supporting the use of modified posterior osteotomy for treating thoracolumbar OVC with DND. The study compares perioperative clinical parameters, imaging data characteristics, and changes in efficacy outcome indicators to provide evidence for the advancement of this technique. METHODS: A total of 12 patients diagnosed with osteoporotic vertebral collapse and neurological dysfunction were included in the study. All patients underwent modified posterior osteotomy. Data regarding perioperative and radiological parameters as well as complications such as surgery duration, blood loss, ASIA grade, VAS, ODI, regional kyphosis angle (RKA), anterior vertebral height ratio (AVHr), and spinal canal clearance ratio (SCCr), were collected retrospectively. These parameters were then analysed to evaluate the clinical efficacy and safety of the modified posterior osteotomy technique. RESULTS: A total of 12 patients were included in the study, with a mean age of 65.5 ± 9.7 years. The average follow-up period was 29.4 ± 5.0 months. The mean operative blood loss was 483.3 ± 142.0 ml, and the average operative time was 3.7 ± 0.7 h. The visual analogue scale (VAS) score decreased from a preoperative value of 5.8 ± 0.7 to a final follow-up value of 1.3 ± 0.8 (P < 0.05), indicating a significant improvement in pain. The ODI decreased from 65.2 ± 6.0 before surgery to 20.5 ± 7.0, indicating a decrease in disability, and the postoperative neurological function showed a significant improvement. Correction of the RKA was observed, with the angle changing from 35.8 ± 10.8° before surgery to 20.0 ± 3.5° after surgery and to 22.5 ± 3.1° at the final follow-up. Similarly, correction of the AVHr was observed, with the height changing from 39.3 ± 18.0 to 63.0 ± 14.3 after surgery and to 53.9 ± 8.9 at the final follow-up. Correction of the SCCr was also observed, with the ratio changing from 54.9 ± 5.4 to 68.1 ± 5.3 after surgery and to 68.68 ± 6.76 at the final follow-up. CONCLUSIONS: Posterior modified osteotomy is an effective treatment for thoracolumbar osteoporotic fractures with OVC combined with DND. It can significantly preserve vertebral height, increase vertebral canal volume, correct kyphotic angle, and improve postoperative neurological function. The simplified osteotomy also offers advantages in terms of operating time, blood loss, postoperative VAS score, and improvement in lumbar function.

Biomechanical effect of endplate defects on the intermediate vertebral bone in consecutive two-level anterior cervical discectomy and fusion: a finite element analysis.

BACKGROUND: Intermediate vertebral collapse is a newly discovered complication of consecutive two-level anterior cervical discectomy and fusion (ACDF). There have been no analytical studies related to the effects of endplate defects on the biomechanics of the intermediate vertebral bone after ACDF. This study aimed to compare the effects of endplate defects on the intermediate vertebral bone biomechanics in the zero-profile (ZP) and cage-and-plate (CP) methods of consecutive 2-level ACDF and to determine whether collapse of the intermediate vertebra is more likely to occur using ZP. METHODS: A three-dimensional finite element (FE) model of the intact cervical spine (C2-T1) was constructed and validated. The intact FE model was then modified to build ACDF models and imitate the situation of endplate injury, establishing two groups of models (ZP, IM-ZP and CP, IM-ZP). We simulated cervical motion, such as flexion, extension, lateral bending and axial rotation, and compared the range of motion (ROM), upper and lower endplate stress, fusion fixation device stress, C5 vertebral body stress, intervertebral disc internal pressure (intradiscal pressure, or IDP) and the ROM of adjacent segments in the models. RESULTS: There was no significant difference between the IM-CP model and the CP model in the ROM of the surgical segment, upper and lower endplate stress, fusion fixation device stress, C5 vertebral body stress, IDP, or ROM of the adjacent segments. Compared with the CP model, the endplate stress of the ZP model is significantly higher in the flexion, extension, lateral bending and axial rotation conditions. Compared with the ZP model, endplate stress, screw stress, C5 vertebral stress and IDP in IM-ZP were significantly increased under flexion, extension, lateral bending and axial rotation conditions. CONCLUSIONS: Compared to consecutive 2-level ACDF using CP, collapse of the intermediate vertebra is more likely to occur using ZP due to its mechanical characteristics. Intraoperative endplate defects of the anterior lower margin of the middle vertebra are a risk factor leading to collapse of the middle vertebra after consecutive 2-level ACDF using ZP.

A triple minimally invasive surgery combination for subacute osteoporotic lower lumbar vertebral collapse with neurological compromise: a potential alternative to the vertebral corpectomy/expandable cage strategy.

OBJECTIVE: Acute/subacute osteoporotic vertebral collapses (OVCs) in the lower lumbar spine with neurological compromise, although far less well documented than those in the thoracolumbar junction, may often pose greater treatment challenges. The authors clarified the utility of 3 familiar combined techniques of minimally invasive surgery for this condition as an alternative to the corpectomy/expandable cage strategy. METHODS: This report included the authors' first 5 patients with more than 2 years (range 27-48 months) of follow-up. The patients were between 68 and 91 years of age, and had subacute painful L4 OVC with neurological compromise and preexisting lumbar spinal stenosis. The authors' single-stage minimally invasive surgery combination consisted of the following: step 1, balloon kyphoplasty for the L4 OVC to restore its strength, followed by L4-percutaneous pedicle screw (PPS) placement with patients in the prone position; step 2, tubular lateral lumbar interbody fusion (LLIF) at the adjacent disc space involved with endplate injury, with patients in the lateral position; and step 3, supplemental PPS-rod fixation with patients in the prone position. RESULTS: Estimated blood loss ranged from 20 to 72 mL. Neither balloon kyphoplasty-related nor LLIF-related potentially serious complications occurred. With CT measurements at the 9 LLIF levels, the postoperative increases averaged 3.5 mm in disc height and 3.7 mm in bilateral foraminal heights, which decreased by only 0.2 mm and 0 mm at the latest evaluation despite their low bone mineral densities, with a T-score of -3.8 to -2.6 SD. Canal compromise by fracture retropulsion decreased from 33% to 23% on average. As indicated by MRI measurements, the dural sac progressively enlarged and the ligamentum flavum increasingly shrank over time postoperatively, consistent with functional improvements assessed by the physician-based, patient-centered measures. CONCLUSIONS: The advantages of this method over the corpectomy/expandable cage strategy include the following: 1) better anterior column stability with a segmentally placed cage, which reduces stress concentration at the cage footplate-endplate interface as an important benefit for patients with low bone mineral density; 2) indirect decompression through ligamentotaxis caused by whole-segment spine lengthening with LLIF, pushing back both the retropulsed fragments and the disc bulge anteriorly and unbuckling the ligamentum flavum to diminish its volume posteriorly; and 3) eliminating the need for segmental vessel management and easily bleeding direct decompressions. The authors' recent procedural modification eliminated step 3 by performing loose PPS-rod connections in step 1 and their tight locking after LLIF in step 2, reducing to only once the number of times the patient was repositioned.

Comparison of Outcomes between Minimally Invasive Lateral Approach Vertebral Reconstruction Using a Rectangular Footplate Cage and Conventional Procedure Using a Cylindrical Footplate Cage for Osteoporotic Vertebral Fracture.

The aim of the current study was to compare outcomes between lateral access vertebral reconstruction (LAVR) using a rectangular footplate cage and the conventional procedure using a cylindrical footplate cage in patients with osteoporotic vertebral fracture (OVF). We included 46 patients who underwent anterior-posterior combined surgery for OVF: 24 patients underwent LAVR (Group L) and 22 underwent the conventional procedure (Group C). Preoperative, postoperative, and 1- and 2-year follow-up X-ray images were used to measure local lordotic angle, correction loss, and cage subsidence (>2 mm in vertebral endplate depression). In anterior surgery, the operation time was significantly shorter (183 vs. 248 min, p < 0.001) and the blood loss was significantly less (148 vs. 406 mL, p = 0.01) in Group L than in Group C. In Group C, two patients had anterior instrumentation failure. Correction loss was significantly smaller in Group L than in Group C (1.9° vs. 4.9° at 1 year, p = 0.02; 2.5° vs. 6.5° at 2 years, p = 0.04, respectively). Cage subsidence was significantly less in Group L than in Group C (29% vs. 80%, p < 0.001). LAVR using a rectangular footplate cage is an effective treatment for OVF to minimize surgical invasiveness and postoperative correction loss.

Biportal endoscopic posterior lumbar decompression and vertebroplasty for extremely elderly patients affected by lower lumbar delayed vertebral collapse with lumbosacral radiculopathy.

BACKGROUND: Lower lumbar osteoporotic vertebral compression fracture in extremely elderly patients can often lead to lumbosacral radiculopathy (LSR) due to delayed vertebral collapse (DVC). Surgical intervention requires posterior instrumented lumbar fusion as well as vertebral augmentation or anterior column reconstruction depending on the cleft formation and intravertebral instability. However, it is necessary to decide on surgery in consideration of the patient's frail status, surgical invasiveness, and rehabilitation. In the lower lumbar DVC without intravertebral instability, biportal endoscopic posterior lumbar decompression and vertebroplasty (BEPLD + VP) can be simultaneously attempted. This study aimed to assess the clinical outcomes of BEPLD + VP for the treatment of DVC-related LSR. METHODS: This retrospective case series enrolled 18 consecutive extremely elderly (aged ≥ 75-year-old) patients (6 men and 12 women) who had lower lumbar (at or below L3) DVC-related LSR. Patients who require anterior column reconstruction, such as cleft formation accompanied by intravertebral instability and patients who have not been followed for more than 6 months, were excluded from this study. All patients underwent BEPLD + VP under epidural anesthesia. Clinical results were evaluated by the visual analog scale (VAS) score and the modified Japanese Orthopedic Association (mJOA) scores. RESULTS: Most of the patients had DVC affecting level L4, with the deformation being a flat type or concave type rather than a wedge type. The VAS score (back and leg) significantly decreased from 7.78 ± 1.17 and 6.89 ± 1.13 preoperatively to 2.94 ± 0.64 and 2.67 ± 1.08 within 2 postoperative days (p < 0.001). The mJOA score significantly improved from 4.72 ± 1.27 preoperatively to 8.17 ± 1.15 in the final follow-up (p < 0.001). The mean recovery rate (RR) in the last follow-up was 56.07% ± 9.98. Incidental durotomy was reported in two patients and epidural hematomas in another two patients; however, all patients improved with conservative treatment, and no re-operation was required. CONCLUSIONS: BELPD + VP was a type of salvage therapy that reduces surgical morbidity, requires major spine surgery under general anesthesia and provides good clinical outcomes in extremely elderly patients with DVC-related LSR.

Short- versus long-segment posterior spinal fusion with vertebroplasty for osteoporotic vertebral collapse with neurological impairment in thoracolumbar spine: a multicenter study.

BACKGROUND: Vertebroplasty with posterior spinal fusion (VP + PSF) is one of the most widely accepted surgical techniques for treating osteoporotic vertebral collapse (OVC). Nevertheless, the effect of the extent of fusion on surgical outcomes remains to be established. This study aimed to evaluate the surgical outcomes of short- versus long-segment VP + PSF for OVC with neurological impairment in thoracolumbar spine. METHODS: We retrospectively collected data from 133 patients (median age, 77 years; 42 men and 91 women) from 27 university hospitals and their affiliated hospitals. We divided patients into two groups: a short-segment fusion group (S group) with 2- or 3-segment fusion (87 patients) and a long-segment fusion group (L group) with 4- through 6-segment fusion (46 patients). Surgical invasion, clinical outcomes, local kyphosis angle (LKA), and complications were evaluated. RESULTS: No significant differences between the two groups were observed in terms of neurological recovery, pain scale scores, and complications. Surgical time was shorter and blood loss was less in the S group, whereas LKA at the final follow-up and correction loss were superior in the L group. CONCLUSION: Although less invasiveness and validity of pain and neurological relief are secured by short-segment VP + PSF, surgeons should be cautious regarding correction loss.

Spinal Ewing's Sarcoma Presenting as an Epidural Collection: A Rare Presentation of a Rare Entity.

Rare entities are difficult to predict. They are considered last rightly, to expedite treatment and alleviate symptoms quickly. Rare presentations of rare diseases form a particularly difficult section of diagnoses that are not only impossible to predict but difficult to recognize, diagnose, and treat. Often the dilemma is to, investigate thoroughly saving time but financially burdening the patient and hospital, or, to investigate in gradual increments taking more time and effort, especially in rare cases where prolonged hospitalization and suffering occurs before the diagnosis is reached. This approach, however, wastes critically important time, which, especially in neurological compression, may often lead to irreversible deficits. This dilemma is admirably demonstrated in this case report of spinal Ewing's sarcoma. A young female presented to us with recurrent high cervical epidural collections presenting as compressive myelopathy. She underwent repeated decompressions, and the collection was misdiagnosed as tuberculosis, which was treated without empirical evidence, leading to significant irreversible disability. Finally, when she came to us, the histopathological assessment was done to reveal the diagnosis. Ewing's sarcomas, and indeed the whole gamut of small-round-cell malignancies, are great imitators. They are known to exist in the skull base mimicking schwannomas, chordomas, germinomas, pituitary adenomas, and even epidermoids and occasionally extend to the vertebral bodies and the cranio-vertebral Junction (CVJ) leading to instability and neurological compression. Here, they mimic vertebral tumors, discitis, infective abscesses, and even myeloma. Predictably, such an entity is diagnosed last, and diagnosed late, leading to bad consequences for the patient. Such was the fate of our patient. The report emphasizes the diagnostic dilemma and presents the need to use protocols for diagnosis and treatment, even in rare cases, to effect the best possible outcomes for patients. The use of a thorough diagnostic and management algorhythm prevents deeper and sinister disease processes from being missed.

Application of percutaneous vertebroplasty and percutaneous kyphoplasty in treating Kümmell's patients with different stages and postural correction status.

Objectives: To compare the effects of percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP) in treating Kümmell's disease (KD) patients.Methods: This prospective cohort study involved 19 KD patients (20 involved vertebrae). The surgical selection was dependent on clinical stages and postural correction status. The status of vertebral reduction, amount of cement injection, and amount of cement leakage during the surgery were recorded. The anterior vertebral height and kyphotic angle were measured by X-ray scan. The degree of low back pain and the quality of life were assessed by the visual analog scale and Oswestry disability index, respectively.Results: On the third-day post-operation and the last follow-up, anterior vertebral height was increased, kyphosis angle was reduced, low back pain was relieved, and life quality was improved in both groups compared with pre-operation. There was no significant difference between the two groups in cement amount, cement leakage rate, vertebral height correction, and kyphotic correction angle. The nerve function of stage III patients with spinal cord injury was improved from a Frankel grade D to E.Expert Opinion: PVP and PKP could be used in treating KD patients, and the surgical selection could be dependent on the clinical stages and status of postural correction.Conclusion: PVP and PKP could be used in treating KD patients, and the surgical selection could be dependent on the clinical stages and status of postural correction.

Analysis of clinical efficacy of modified cross-puncture vertebroplasty in the treatment of osteoporotic vertebral compression fracture / 上海交通大学学报（医学版）

Objective: To compare the clinical efficacy of cross puncture technique with traditional puncture technique in the treatment of osteoporotic vertebral compression fracture (OVCF). Methods: Patients with OVCF treated with percutaneous vertebroplasty (PVP) were selected. According to the puncture method, the patients were divided into cross puncture group and traditional puncture group, with 70 cases in each group. The clinical data, imaging parameters, pain score, dysfunction score, overall satisfaction and related complications of the two groups were compared before and after operation, and the clinical efficacy of the two groups was evaluated. Results: Compared with the traditional puncture group, the wedge angle in the cross puncture group decreased at 6 and 12 months after operation (both P=0.000), while the leading edge height increased (P=0.012, P=0.000). During the follow-up, there was no significant difference in pain score and dysfunction score between the two groups. Compared with the traditional puncture group, the proportion of the excellent and great grades (Odom standard) of patients in the cross puncture group was higher (P=0.000, P=0.003), and the incidence of vertebral collapse, kyphosis deformity and spinal stenosis were lower (P=0.000, P=0.002, P=0.031). Conclusion: At 6 and 12 months after operation of cross puncture PVP, the follow-up changes of wedge angle and leading edge height of vertebral body were smaller than those of traditional puncture technique, that is, more stable. The incidence of vertebral collapse was lower, and the overall satisfaction of the curative effect was higher.

Diffusion-weighted Magnetic Resonance Imaging in Non-traumatic Vertebral Collapse: A Relook Into Its Utility in Making the Diagnosis in a Population Where Infections of Spine Are a Common Cause.

AIM: Magnetic resonance imaging (MRI) is the imaging investigation of choice in vertebral collapse. In this study, we considered various MRI features and appearance based on morphological features, signal intensity, contrast enhancement characteristics, and diffusion-weighted imaging (DWI) of various types of non-traumatic vertebral collapse for differentiating benign from malignant causes and its role in differentiating cases of infectious causes of vertebral collapse from malignant causes. MATERIALS AND METHODS: Between November 2014 to November 2016 a total of 100 consecutive patients from the MRI centre of JN Medical College and Hospital, Aligarh, were evaluated for the study. Inclusion criteria included patients presenting with backache, limb weakness, and fever who had undergone radiography of the spine that showed features of collapse. All patients underwent MRI on a 1.5 T MR Scanner. Coronal, sagittal and axial spine images were obtained using T1 weighted, T2 weighted, short tau inversion recovery, T1 postcontrast, and DWI sequences. RESULTS: In our study, we found different causes of non-traumatic vertebral collapse that were broadly categorized as benign or malignant. The benign causes were further sub-categorized into osteoporotic or infectious based on morphological features, signal intensity characteristics, and DWI. However, on DWI, the patients with infective collapse showed mean apparent diffusion coefficient values of 884 × 10-6 mm2/s ranging between 700 and 1,100 × 10-6 mm2/s between those of malignant and benign osteoporotic collapse, with significant overlap. The statistical difference between the malignant and infective cases, as well as between osteoporotic and infective cases, was not found to be statistically significant (P > .05). CONCLUSION: MRI plays a key role in establishing the cause of vertebral collapse, classifying it as either benign or malignant. DWI, although described in various studies as highly sensitive in differentiating benign osteoporotic and malignant collapse, was found to be good in differentiating only osteoporotic from malignant collapse, with the infectious cases proving to be a grey zone with significant overlap of quantitative diffusion findings.

Osteoporotic vertebral fractures: predictive factors for conservative treatment failure. A systematic review.

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.

Impact of spino-pelvic and global spinal alignment on the risk of osteoporotic vertebral collapse.

INTRODUCTION: Numerous studies have reported the risk factors of osteoporotic vertebral collapse. However, whether spino-pelvic and global spinal alignments are associated with the occurrence of osteoporotic vertebral collapse remains unclear. This study aimed to investigate the association between spino-pelvic and global spinal alignments and the occurrence of osteoporotic vertebral collapse. METHODS: A total of 46 consecutive patients who underwent a nonoperative treatment for a single-level fresh osteoporotic thoracolumbar vertebral compression fracture (T10 to L3) were retrospectively reviewed. The parameters evaluated were the pelvic incidence, anterior deviation of the C7 plumb line, distance between the C7 plumb line and the center of the fractured vertebra, and kyphotic wedge angle of the fractured vertebra in a standing whole-spine radiograph at the beginning of the nonoperative treatment. As an outcome measure, the presence or absence of osteoporotic vertebral collapse was radiographically evaluated at the final follow-up. Multiple logistic regression analysis was used to determine significant risk factors of osteoporotic vertebral collapse. RESULTS: The mean values for each parameter were as follows: pelvic incidence, 58.0 degrees; anterior deviation of the C7 plumb line, 3.0 cm; distance between the C7 plumb line and the center of the fractured vertebra, 5.7 cm; and kyphotic wedge angle of the fractured vertebra, 14.6 degrees. Multiple logistic regression analysis revealed that the distance between the C7 plumb line and center of the fractured vertebra was a significant risk factor of osteoporotic vertebral collapse (p = 0.012; odds ratio, 1.025). The anterior deviation of the C7 plumb line (p = 0.214), pelvic incidence (p = 0.728), and kyphotic wedge angle of the fractured vertebra (p = 0.07) did not affect the occurrence of osteoporotic vertebral collapse. CONCLUSIONS: A large distance between the C7 plumb line and center of the fractured vertebra was a significant risk factor of osteoporotic vertebral collapse. The distance approximately represents that of between gravity center of trunk cranial to the fractured vertebra and the fractured vertebra. Accordingly, the large distance may cause larger flexion moment to the fractured site, leading to stress concentration that results in insufficient bone healing.

Difference of clinical course between cases with bone union and those with delayed union following osteoporotic vertebral fractures.

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.

Spontaneous and complete regeneration of a vertebra plana after surgical curettage of an eosinophilic granuloma.

PURPOSE: The eosinophilic granuloma is a unifocal or multifocal Langerhans cell histiocytosis characterized by an expanding proliferation of Langerhans cells in bones. Skeletal LCH is a rare condition, and vertebral regeneration in cases of vertebral body collapse is even rarer. We report the case of a girl with spontaneous complete healing. METHODS AD RESULTS: A 3-year-old girl was referred for nighttime back pain, with no fever and no neurologic signs. Within a few days, she developed sudden painful restriction of all spine movements. X-ray and computed tomography (CT) of the spine showed reduced T7 vertebral body height (vertebra plana).The patient underwent T7 curettage and the histopathological exam was suggestive of LCH. Two additional skull lesions were found and therefore she underwent chemotherapy. After 7 years of follow-up, total vertebral reconstruction was observed. CONCLUSIONS: Despite the rarity of the condition and despite the rarity of vertebral body lesion resolution, total vertebral body reconstruction was observed over a 7-year period. Long-term follow-up is necessary for a better understanding of the final outcome of patients with EG.

Therapeutic Effect of Posterior Decompression, Internal Fixation and Interlaminar Fusion for Severe Osteoporotic Vertebral Fractures and Collapse Complicated with Spinal Canal Encroachment / 广州中医药大学学报

Objective To evaluate the clinical effect of posterior decompression, internal fixation and interlaminar fusion for the treatment of severe osteoporotic vertebral fracture and collapse complicated with spinal canal encroachment. Methods A retrospective study was carried out in 27 cases of severe osteoporotic vertebral fractures complicated with spinal canal encroachment. The patients were treated with posterior decompression, internal fixation and interlaminar fusion during the period from January 1, 2009 to December 31, 2014. All patients were given vertebral pedicle screw fixation after pedicle augmentation with bone cement. The pain scores of visual analogue scale(VAS), Oswestry Disability Index(ODI), Cobb angle , thoracolumbar Cobb angle and the recovery of neurological function(estimated by Frankel grading system) of the patients were compared beforeoperation, one week after operation and at the end of follow-up. The incidences of internal fixation failure, adjacent vertebral fracture and bone cement leakage also were recorded. Results The patients were followed up for an average of 27 months. The spinal canal occupation rate caused by fracture fragment of posterior vertebral wall was 27.41%~63.85%, with an average of(43.24 ± 10.61)%. Postoperative VAS pain scores, ODI, Cobb angle and thoracolumbar Cobb angle were statistically different from those before operation (P 0.05). In respect of Frankel grading of neurological function at the end of the follow-up, 6 cases were in grade D and 19 cases were in grade E, but the differences were insignificant compared with those before operation (P > 0.05). None of the patients had surgical site infection, screw looseness or breakage, or rod breakage during the follow-up period. There were 8 patients with asymptomatic bone cement leakage after operation. Vertebral compression fractures recurred in 5 patients, of which 2 had adjacent vertebral fractures and 3 had non -adjacent segment. Conclusion The therapy of posterior decompression, internal fixation and interlaminar fusion is effective for the treatment of severe osteoporotic vertebral fracture and collapse complicated with spinal canal encroachment by obviously relieving pain, improving the physiological function of the spine and stabilizing the spine.

Chemical shift magnetic resonance imaging in differentiation of benign from malignant vertebral collapse in a rural tertiary care hospital in North India.

INTRODUCTION: Magnetic resonance imaging (MRI) is the modality of the first choice for evaluation of vertebral compression/collapse. Many MRI qualitative features help to differentiate benign from malignant collapse. We conducted this study to look for a quantitative difference in chemical shift values in benign and malignant collapse using dual-echo gradient echo in-phase/out-phase imaging. MATERIALS AND METHODS: MRI examinations of a total of 38 patients were retrospectively included in the study who had vertebral compression/collapse with marrow edema in which final diagnosis was available at the time of imaging/follow-up. Signal intensity value in the region of abnormal marrow signal and adjacent normal vertebra was measured on in phase/out phase images. Signal intensity ratio (SIR) was measured by dividing signal intensity value on opposite phase images to that on in phase images. SIR was compared in normal vertebrae and benign and malignant vertebral collapse. RESULTS: There were 21 males and 17 females with mean age of 52.4 years (range 28-76 years). Out of total 38 patients, 18 were of benign vertebral collapse and 20 of malignant vertebral collapse. SIR in normal vertebrae was 0.30 ± 0.14, 0.67 ± 0.18 in benign vertebral collapse, and 1.20 ± 0.27 in malignant vertebral collapse with significant difference in SIR of normal vertebrae versus benign collapse (P < 0.01) and in benign collapse versus malignant collapse (P < 0.01). Assuming a cutoff of <0.95 for benign collapse and ≥0.95 for malignant collapse, chemical shift imaging had a sensitivity of 90% and specificity of 94.4%. CONCLUSION: Chemical shift imaging is a rapid and useful sequence in differentiating benign from malignant vertebral collapse with good specificity and sensitivity.

Intravertebral cleft in pathological vertebral collapse resulting from cancer metastasis: report of three cases.

Intravertebral cleft (IVC) is a common finding in osteoporotic compression fracture. However, since the vertebral collapse attributable to cancer metastasis is rarely associated with IVC, the phenomenon is generally considered as a sign of a benign lesion. In this study, we retrospectively reviewed the radiographs, computed tomography scans, and magnetic resonance images of 111 patients with spinal metastasis. Three cases (2.7 %) had IVC in the collapsed thoracic vertebral bodies (T7, T8, and T11) attributable to cancer metastasis. IVC alone is not necessarily an indicator of a benign vertebral collapse.

Evaluation of low back pain with low field open magnetic resonance imaging scanner in rural hospital of Southern India.

BACKGROUND: Low back pain (LBP) is the most common symptom which is associated with limitation of normal activities and work-related disability. Imaging techniques are often essential in making the correct diagnosis for prompt management. Plain Radiography though remain a first imaging modality, magnetic resonance imaging (MRI) due to its inherent softtissue contrast resolution and lack of ionizing radiation remains invaluable modality in the evaluation of LBP. AIM: To find the common causes of LBP in different age groups and the role of MRI in detecting the spectrum of various pathological findings. MATERIALS AND METHODS: This is a prospective study done in the Department of Radiodiagnosis during a period of 2 years from July 2013 to July 2015. The study population includes all the cases referred to our department with complaints of LBP. Patients with ferromagnetic metallic implants and uncooperative cases were excluded. HITACHI 0.4 Tesla open MRI machine was used for imaging. RESULTS AND CONCLUSION: This study involved a total of 235 cases. There were 121 males and 114 females. The age of the patient ranged from 21 to 68 years with an average of 41.3 years. Back pain was commonly observed in the third to fifth decade. The common causes for back pain are disc herniations (disc bulge - 35.3%, disc protrusion - 39.6%, disc extrusion - 7.2%) accounting to 82.1%, followed by normal study (10.2%), vertebral collapse (traumatic - 2.1%, osteoporotic - 1.7%), infections (2.1%), and neoplasm (1.7%). MRI provides valuable information regarding the underlying causes of LBP, especially in disc and marrow pathology.

Surgical techniques for osteoporotic vertebral collapse with delayed neurological deficits: A systematic review.

INTRTODUCTION: Osteoporotic vertebral collapse (OVC) with delayed neurological deficits (DND) is one severe subtype of OVC, for which surgical intervention is more complicated and difficult. Although many individual case reports and series have described the surgery for stabilization and neurological decompression of OVC with DND, no systematic review has been published. METHODS: We searched eligible studies in PubMed, SCOPUS, EMBASE and ISIWeb of Knowledge for eligible studies and conducted comprehensive analysis. RESULTS: A total of 29 publications involving 596 patients of OVC with DND were included in this review. There are 36.6%, 60.6% and 2.8% of patients receiving anterior neural decompression and reconstruction, posterior surgery which can be further divided into 6 distinct groups, and posteroanterior surgery, respectively. Among them, patients in the posteroanterior surgery had the longest time (351.0 min) for operation and the largest volume of mean blood loss (2892.0 ml). For clinical outcomes, patients in the posterior spinal shortening osteotomy with direct neural decompression group had the most significantly LKA correction effect, with mean LKA correction 21.3°, while the posterior decompression and posterior column reconstruction group exhibited the lowest LKA correction loss rate (14.7%). CONCLUSION: Although the optimal treatment has not been determined for patients of OVC with DND in this study, our analysis could provide guidance for choosing an appropriate approach. Besides, effective treatment for OVC with DND requires multidisciplinary collaboration, such as geriatricians, interventional radiologists, respiratory disease experts, and spine surgeons. On light of the above analysis, we believe that individualized surgical approach should be introduced based on the clinical characteristics of each patient.