Treatment Strategies in the Osteoporotic Spine.

This article reviews the appropriate assessment and management of osteoporotic compression fractures and discusses the implications of osteoporosis on initial patient evaluation, medical optimization for surgery, selection of instrumentation, and surgical technique. Adverse outcomes associated with osteoporosis are discussed. Failure to appropriately evaluate, optimize, and treat spine patients with osteoporotic bone can lead to disastrous complications. Weakened bone can lead to implant failure through cage subsidence and screw pullout, as well as, peri-implant fractures, failure of deformity correction, and proximal kyphosis. These risks must be taken into account when considering operative interventions in these patients.

Stem Cell and Regenerative Therapies for the Treatment of Osteoporotic Vertebral Compression Fractures.

Osteoporotic vertebral compression fractures (OVCFs) significantly increase morbidity and mortality, presenting a formidable challenge in healthcare. Traditional interventions such as vertebroplasty and kyphoplasty, despite their widespread use, are limited in addressing the secondary effects of vertebral fractures in adjacent areas and do not facilitate bone regeneration. This review paper explores the emerging domain of regenerative therapies, spotlighting stem cell therapy's transformative potential in OVCF treatment. It thoroughly describes the therapeutic possibilities and mechanisms of action of mesenchymal stem cells against OVCFs, relying on recent clinical trials and preclinical studies for efficacy assessment. Our findings reveal that stem cell therapy, particularly in combination with scaffolding materials, holds substantial promise for bone regeneration, spinal stability improvement, and pain mitigation. This integration of stem cell-based methods with conventional treatments may herald a new era in OVCF management, potentially improving patient outcomes. This review advocates for accelerated research and collaborative efforts to translate laboratory breakthroughs into clinical practice, emphasizing the revolutionary impact of regenerative therapies on OVCF management. In summary, this paper positions stem cell therapy at the forefront of innovation for OVCF treatment, stressing the importance of ongoing research and cross-disciplinary collaboration to unlock its full clinical potential.

Capacitive biophysical stimulation improves the healing of vertebral fragility fractures: a prospective multicentre randomized controlled trial.

BACKGROUND: Capacitively coupling electric fields (CCEF) is a method of non-invasive biophysical stimulation that enhances fracture repair and spinal fusion. This multicentre randomized controlled trial aimed to further examine the roles of CCEF in (1) the resolution of vertebral bone marrow oedema (VBME) using a follow-up MRI study and (2) pain relief, analgesic drug consumption and quality of life improvement in stimulated patients who were referred with acute vertebral fragility fractures (VFFs) compared to non-stimulated patients. METHODS: Between September 2016 and December 2019, patients who were referred to the spine centres that participated in this multicentre randomized clinical study with acute VFFs of type OF1 or OF2 were included in the present study. All the VFFs were conservatively managed according to Good Clinical Practice. Moreover, the patients were randomized into two groups: the CCEF group received, as an adjunct to the clinical study protocol, biophysical stimulation with a CCEF device (Osteospine, IGEA) for 8 h per day for 60 days, whereas the control group was treated according to the clinical study protocol. At baseline (T0), the 30-day follow-up (T1), the 60-day follow-up (T2), and the 6-month follow-up (T3), each patient underwent clinical evaluation using the Visual Analogue Scale (VAS) for Pain and the Oswestry Disability Index (ODI). Analgesic therapy with paracetamol 1000 mg tablets for 7 days-or longer, depending on the pain intensity-was performed; patients were required to report their paracetamol consumption on a specific sheet between study day 8 to 180 days of follow-up. MRI studies of the thoracolumbar spine were performed at 0 (T0), 30 (T1) and 60 days of follow-up (T2) using a 1.5-T MRI system in all of the centres that took part in the study. For each VBME area examined via MRI, the vertebral body geometry (i.e. anterior wall height/posterior wall height and vertebral kyphosis) were assessed. RESULTS: A total of 66 patients (male: 9, 13.63%; mean age: 73.15 years old) with 69 VFFs were included in the present study and randomized as follows: 33 patients were included in the control group and the remaining 33 patients were randomized into the CCEF group. In the CCEF group, good compliance with CCEF therapy was observed (adherence = 94%), and no adverse effects were recorded. In the stimulated patients, faster VBME resolution and significantly less vertebral body collapse during follow-up were observed compared to the control patients. Moreover, in the active group, faster pain reduction and improvement in the ODI mean score were observed. Stimulated patients also reported a significantly lower paracetamol consumption rate from the third follow-up after treatment until the 6-month follow-up. In terms of sex-related differences, in the CCEF group, VBME showed a faster resolution in male patients compared with females. CONCLUSION: Biophysical stimulation with CCEF, as an adjunct to traditional conservative treatment, is a useful tool to hasten the VBME resolution process and prevent vertebral body deformation. These MRI findings also correlate with faster back pain resolution and quality of life improvement. From the third follow-up after treatment until the 6-month follow-up, stimulated patients reported a significantly lower paracetamol consumption than control patients, even though back pain and quality of life showed no significant differences between the two groups. LEVEL OF EVIDENCE: II. Trial Registration Register: ClinicalTrials.gov, number: NCT05803681.

Patient Preferences for Operative Versus Nonoperative Treatment of LC1 Pelvis Fracture: A Discrete Choice Experiment.

OBJECTIVES: To quantify how patients with lateral compression type 1 (LC1) pelvis fracture value attributes of operative versus nonoperative treatment. DESIGN: Discrete choice experiment. SETTING: Three US Level 1 trauma centers. PATIENT SELECTION CRITERIA: Adult survivors of an LC1 pelvis treated between June 2016 and March 2023 were identified from institutional registries. The choice experiment was administered as a survey from March through August 2023. OUTCOME MEASURES AND COMPARISONS: Participants chose between 12 hypothetical comparisons of treatment attributes including operative or nonoperative care, risk of death, severity of pain, risk of secondary surgery, shorter hospital stay, discharge destination, and independence in ambulation within 1 month of injury. The marginal utility of each treatment attribute, for example, the strength of participants' aggregate preference for an attribute as indicated by their survey choices, was estimated by multinomial logit modeling with and without stratification by treatment received. RESULTS: Four hundred forty-nine eligible patients were identified. The survey was distributed to 182 patients and collected from 72 patients (39%) at a median 2.3 years after injury. Respondents were 66% female with a median age of 59 years (IQR, 34-69 years). Before injury, 94% ambulated independently and 75% were working; 41% received operative treatment. Independence with ambulation provided the highest relative marginal utility (21%, P < 0.001), followed by discharge to home versus skilled nursing (20%, P < 0.001), moderate versus severe postdischarge pain (17%, P < 0.001), shorter hospital stay (16%, P < 0.001), secondary surgery (15%, P < 0.001), and mortality (10%, P = 0.02). Overall, no relative utility for operative versus nonoperative treatment was observed (2%, P = 0.54). However, respondents strongly preferred the treatment they received: operative patients valued operative treatment (utility, 0.37 vs. -0.37, P < 0.001); nonoperative patients valued nonoperative treatment (utility, 0.19 vs. -0.19, P < 0.001). CONCLUSIONS: LC1 pelvis fracture patients valued independence with ambulation, shorter hospital stay, and avoiding secondary surgery and mortality in the month after their injury. Patients preferred the treatment they received rather than operative versus nonoperative care.

Vertebral compression fractures managed with brace: risk factors for progression.

PURPOSE: The aim of this study is to identify risk factors for vertebral compression fracture (VCF) progression in patients treated conservatively with a brace. Then, a case-control study was designed. METHODS: All patients over 50 years old with diagnosis of thoracic or lumbar VCF (T5 to L5) in absence of underlying oncological process, treated conservatively with brace, and consecutively attended at our department from January 2017 to June 2021 were retrospectively selected for analysis. Patients missed for follow-up or dead during the first 3 months of follow-up were excluded. RESULTS: Five hundred and eighty-two consecutive patients were recorded. Incomplete follow-up excluded 74 patients and other 19 died in the first three months after diagnosis, so 489 cases were finally analyzed. Median follow-up was 21 (IQR 13;30) weeks. Increased collapse of the vertebral body was found in 29.9% of VCFs with a median time to progression of 9 (IQR 7;13) weeks. Male gender (OR 1.6), type A3 fracture of the AOSpine classification (OR 2.7), thoracolumbar junction location (OR 1.7), and incorrect use of the brace (OR 3.5) were identified as independent risk factors for progression after multivariable analysis. CONCLUSION: Male gender, type A3 fracture of the AOSpine classification, thoracolumbar junction location, and incorrect use of the brace were identified as independent risk factors for VCF progression, which resulted in worse pain control, when treated with brace. Thus, other treatments such as percutaneous vertebral augmentation could be considered to avoid progression in selected cases, since collapse rate has been demonstrated lower with these procedures.

ACR Appropriateness Criteria® Management of Vertebral Compression Fractures: 2022 Update.

Vertebral compression fractures (VCFs) can have a variety of etiologies, including trauma, osteoporosis, or neoplastic infiltration. Osteoporosis related fractures are the most common cause of VCFs and have a high prevalence among all postmenopausal women with increasing incidence in similarly aged men. Trauma is the most common etiology in those >50 years of age. However, many cancers, such as breast, prostate, thyroid, and lung, have a propensity to metastasize to bone, which can lead to malignant VCFs. Indeed, the spine is third most common site of metastases after lung and liver. In addition, primary tumors of bone and lymphoproliferative diseases such as lymphoma and multiple myeloma can be the cause of malignant VCFs. Although patient clinical history could help raising suspicion for a particular disorder, the characterization of VCFs is usually referred to diagnostic imaging. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Effects of hospitalist co-management on rate of initiation of osteoporosis treatment in patients with vertebral compression fractures: Retrospective cohort study.

BACKGROUND: Vertebral compression fractures are common in elderly people and most are due to osteoporosis. Osteoporosis treatment is effective for secondary prophylaxis, so initiation is recommended. Despite the clear benefits, the rate of initiation of osteoporosis treatment is very low. It is reported to be due to several factors including insufficient systems-based approaches for hospitals and post-acute care. Hospitalists, who are physicians dedicated to the treatment of patients in hospital and whose activity is generalist rather than specialized, are reported to be associated with higher-quality inpatient care because of, among other things, closer adherence to guidelines. Co-management by hospitalists for patients with vertebral compression fractures has potential benefits towards improving the outcomes. We compared the rate of initiation of osteoporosis treatment for patients with vertebral compression fractures between conventional orthopedic surgeon-led care (conventional group) and hospitalist co-management care (co-management group). METHODS: This is a single-center retrospective cohort study to evaluate the rate of initiation of osteoporosis treatment and reasons for non-initiation of osteoporosis treatment. Other clinical indicators were also evaluated, including length of hospital stay, preventable complications during hospitalization, and rate of 30-day readmission. RESULTS: We identified 55 patients in the conventional group and 93 patients in the co-management group. The rate of initiation of osteoporosis treatment was higher in the co-management group (45.2% vs. 3.6%, OR 21.5; 95%CI 5.12-192.0; P < 0.01). Most of the patients with non-initiation in the co-management group had reasons for it described in the medical records, but in the conventional group the reasons were unknown. There was no significant difference in length of hospital stay, preventable complications during hospitalization, or 30-day readmission between the groups. CONCLUSIONS: Hospitalist co-management of patients with vertebral compression fractures showed significantly higher rate of initiation of osteoporosis treatment than conventional orthopedic surgeon-led care.

Compliance with wearing a thoracolumbar orthosis in nonoperative treatment of osteoporotic vertebral fractures: a prospective sensor-controlled study.

BACKGROUND CONTEXT: Hyperextension orthoses (HOs) for nonoperative treatment of osteoporotic vertebral fractures (OVFs) are widely prescribed. However, the compliance, how much an HO is worn after it has been prescribed, is widely unknown. PURPOSE: This study was performed to assess the wearing time of HOs for OVFs in a prospective blinded, sensor-controlled manner. STUDY DESIGN / SETTING: A prospective, single blinded observational study was performed. PATIENT SAMPLE: This study prospectively included 18 patients who were treated nonoperatively with an HO for OVFs. OUTCOME MEASURES: The true wearing time was measured using a hidden temperature-based sensor. The patients were invited to return for regular follow-up every 2 weeks for 6 weeks, at which time clinical evaluation (including a visual analog scale for pain and the Oswestry disability questionnaire) and radiographs of the spine were performed. METHODS: Full compliance was defined as a wearing time of 15 hours per day. Correlation between compliance and demographic differences, patient reported outcomes and radiographic changes of the vertebral structures were calculated. RESULTS: The mean HO wearing time was 5.5±3.3 hours (37%±22% compliance). Female patients used the HO significantly longer per day than did male patients (6.5±3.2 vs 2.9±2.0 hours, p=.039). Age and body mass index had no influence on wearing behavior. CONCLUSIONS: Overall, compliance with wearing HOs is poor and shows great variability with significant gender-dependency but not associated with BMI, age, or pain-level. Further studies are required to confirm our results that the wearing time does not have an influence on kyphotic progression of the osteoporotic fractured segment, nor on clinical outcome at short term. LEVEL OF EVIDENCE: I.

[Osteoporotic vertebral fractures-From diagnosis to treatment]. / Osteoporotische Wirbelkörperfrakturen ­ Von der Diagnose zur Therapie.

The aim of the present work is an overview of current concepts in the treatment of osteoporotic vertebral fractures, risk factors, clinical presentation and conservative and operative management. Osteoporotic vertebral fractures are a widespread problem, affecting between 700,000 and 1.5 million adults annually in the USA alone. Osteoporotic vertebral fractures can cause severe physical impairment, including back pain, dysfunction, and progressive thoracic kyphosis. Mortality after osteoporotic vertebral fractures is still increased compared to age-matched controls. In the reality of care, advocates of purely conservative therapy as well as advocates of surgical treatment can be found all over the world. In summary, understanding the risk factors, appropriate clinical evaluation and treatment strategies are crucial. When surgery is indicated, balloon kyphoplasty shows significantly better pain reduction and lower mortality compared to nonsurgical treatment.

Effects of transitional care based on the social support theory for older patients with osteoporotic vertebral compression fractures: A quasi-experimental trial.

OBJECTIVES: This study aimed to investigate the effects of transitional care (TC) programs on the health outcomes of discharged older patients with osteoporotic vertebral compression fractures (OVCFs). METHODS: A total of 160 older patients were recruited from two campuses of a public teaching hospital in China. Patients were grouped according to the campus to which they were admitted. The TC programs commenced one day before discharge and lasted 6 months after discharge. Repeated-measures analysis of variance was used to analyse the effects of the TC programs. RESULTS: The TC programs improved the discharge of older patients with OVCF in their activities of daily living (ADLs), pain levels and social support, and decreased fracture recurrence rates. CONCLUSIONS: This study provides evidence of concurrent clinical improvements and health outcomes in discharged older patients with OVCFs from the effects of TC programs based on social support theory.

Predictive Factors for Sustained Pain after (sub)acute Osteoporotic Vertebral Fractures. Combined Results from the VERTOS II and VERTOS IV Trial.

PURPOSE: Osteoporotic vertebral compression fractures are treated conservatively or in selected cases with percutaneous vertebroplasty (PV). The purpose of this retrospective analysis is to determine predictive factors for a high visual analogue scale (VAS) pain score after conservative, sham or PV and is based on previously published randomized trials. METHODS: The VERTOS II compared conservative versus PV, and VERTOS IV compared sham versus PV treatment. The conservative group received pain medication. The sham and PV group received subcutaneous lidocaine/bupivacaine. In addition, the PV group received cementation, which was simulated in the sham group. Nineteen different predictors of high (≥ 5) versus low (< 5) VAS pain score at 12 months were investigated. RESULTS: 20.7% of patients in the PV group demonstrated a VAS ≥ 5 at the 12-month, compared to 40.1% in the conservative or sham group, with a significant difference (χ2(1) = 15.26, p < 0.0001, OR = 2.57, 95% CI = 1.59 to 4.15). In the subgroup analysis, we detected five predictors for the risk of high pain scores (VAS ≥ 5 after 12 months follow-up), namely: female, baseline VAS > 8, long-term baseline pain, mild/severe Genant and new fractures. CONCLUSIONS: Statistically significant more patients had a high pain score at 12 months in the sham and conservative group when compared with the PV group. Five predictors were identified for sustained high local back pain, regardless of the received treatment. Patients with moderate fracture deformity were less likely to have high pain scores at 12 months if they received PV than if they had sham or conservative therapy.

Effectiveness and cost-effectiveness of dynamic bracing versus standard care alone in patients suffering from osteoporotic vertebral compression fractures: protocol for a multicentre, two-armed, parallel-group randomised controlled trial with 12 months of follow-up.

INTRODUCTION: Patients with osteoporosis may suffer from a fracture after minimal trauma. Osteoporotic vertebral compression fractures (OVCFs) are among the most common fractures, often leading to substantial pain. There is a need for evidence-based conservative treatment to aid in the management of OVCFs. The objective of this randomised controlled trial (RCT) is to evaluate the effectiveness and cost-effectiveness of dynamic bracing in addition to standard care for improving quality of life (QoL) in patients suffering from an OVCF. METHODS AND ANALYSIS: Ninety-eight postmenopausal women from two academic and four community hospitals with a recent symptomatic thoracolumbar OVCF will be randomised into either the standard care or dynamic bracing group. In the dynamic bracing group, the Spinova Osteo orthosis will be used in addition to standard care. Standard care comprises pain control with analgesics, physical therapy and osteoporosis medication. The primary outcome parameter is QoL 1 year after inclusion, as measured by the Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO-41). Secondary outcome parameters are pain, pain medication used, functional disability, sagittal spinal alignment, recurrence rate of OVCFs and physical activity in daily life. A trial-based economic evaluation consisting of both cost-effectiveness analysis and cost-utility analysis will be performed based on empirical data obtained in the RCT. A process evaluation will assess the feasibility of dynamic bracing. All outcomes will be assessed at baseline, 6 weeks, 3 months, 6 months, 9 months and 12 months. ETHICS AND DISSEMINATION: Ethical approval has been granted by the Medical Ethics Committee, University Hospital Maastricht and Maastricht University (METC azM/UM) (NL74552.068.20/METC 20-055). Patients will be included only after verification of eligibility and obtaining written informed consent. Results will be disseminated via the Dutch National Osteoporosis Patient Society and via publications and conferences. TRIAL REGISTRATION NUMBER: NL8746.

Management of Osteoporosis and Spinal Fractures: Contemporary Guidelines and Evolving Paradigms.

Physicians involved in treating spine fractures secondary to osteopenia and osteoporosis should know the pathogenesis and current guidelines on managing the underlying diminished bone mineral density, as worldwide fracture prevention campaigns are trailing behind in meeting their goals. This is a narrative review exploring the various imaging and laboratory tests used to diagnose osteoporotic fractures and a comprehensive compilation of contemporary medical and surgical management. We have incorporated salient recommendations from the Endocrine Society, the American Association of Clinical Endocrinology (AACE), and the American Society for Bone and Mineral Research (ASBMR). The use of modern scoring systems such as Fracture Risk Assessment Tool (FRAX®) for evaluating fracture risk in osteoporosis with a 10-year probability of hip fracture and major fractures in the spine, forearm, hip, or shoulder is highlighted. This osteoporosis risk assessment tool can be easily incorporated into the preoperative bone health optimization strategies, especially before elective spine surgery in osteoporotic patients. The role of primary surgical intervention for vertebral compression fracture and secondary fracture prevention with pharmacological therapy is described, with randomized clinical trial-based wisdom on its timing and dosage, drug holiday, adverse effects, and relevant evidence-based literature. We also aim to present an evidence-based clinical management algorithm for treating osteoporotic vertebral body compression fractures, tumor-induced osteoporosis, or hardware stabilization in elderly trauma patients in the setting of their impaired bone health. The recent guidelines and recommendations on surgical intervention by various medical societies are covered, along with outcome studies that reveal the efficacy of cement augmentation of vertebral compression fractures via vertebroplasty and balloon kyphoplasty versus conservative medical management in the elderly population.

Diagnosis and Management of Vertebral Compression Fracture.

Vertebral compression fractures are the most common complication of osteoporosis, with 700,000 cases reported every year in the United States. Vertebral compression fractures typically present with abrupt-onset low back pain with or without a history of trauma, although more than two-thirds are detected incidentally. Diagnosis is confirmed using plain radiographs, while computed tomography and magnetic resonance imaging may be required to evaluate for a malignant cause or if there are neurological deficits on examination. Magnetic resonance imaging is also the modality of choice to determine if the fracture is acute vs chronic in nature. Patients can be managed with a combination of nonsurgical modalities including medications, bracing, and physical therapy, although when indicated, kyphoplasty or vertebroplasty may be considered to provide symptom relief.

[Topical issues of rehabilitation of patients with osteoporotic vertebral fractures]. / Aktual'nye voprosy reabilitatsii patsientov s perelomami pozvonkov na fone osteoporoza.

The literature review analyzed 20 Russian and 69 foreign publications on the rehabilitation of elderly patients with osteoporotic vertebral fractures. The article deals in detail with the prevalence, medical and social significance of pathological osteoporotic fractures, including vertebral deformities. The data confirming the importance of osteoporosis for physical and rehabilitation medicine specialists are presented. Changes in the quality of life, functional and gate disorders associated with osteoporotic vertebral fractures are described. Based on the available literature data, the principles of rehabilitation of patients with osteoporotic vertebral compression fractures are formulated, including the effectiveness of various methods of physical therapy, mechanotherapy and apparatus physiotherapy. From the standpoint of evidence-based medicine, the role of orthotics in the complex rehabilitation of such patients is described. Based on the analysis of literature data, it was concluded that the problem of osteoporosis is relevant for physicians working in the field of rehabilitation medicine; osteoporotic vertebral fractures are characterized by a high prevalence over the age of 50 years and are associated with a decrease in the quality of life, motor and functional limitations, and an increased risk of death, and well-planned medical rehabilitation programs including physical exercises, physiotherapy and orthotics can significantly improve patient functionality.

Trends in hospitalizations for vertebral compression fracture in ankylosing spondylitis: data from the National Inpatient Sample 2000-2014.

Ankylosing spondylitis (AS) patients are at increased risk of vertebral compression fractures (VCF). Our objective was to examine the yearly trend of VCF hospitalizations in AS patients as compared to rheumatoid arthritis (RA) and the general population. National Inpatient Sample (NIS) database (2000-2014) was used to identify adult (≥ 18 years) hospitalizations, based on validated ICD-9 diagnosis codes. The rate of VCF hospitalizations, as a primary diagnosis, was assessed in three mutually exclusive groups: AS, RA, and the general population. The prevalence of VCF hospitalization was highest in AS (2.70%), compared to 0.77% in RA and 0.35% in the general population. Over the 15-year period, VCF hospitalization in AS was noted to have an increasing trend (Annual Percent Change (APC) = 4.73, p < 0.05) in contrast to the stable trend in the general population (APC = 0.34, p = NS) and a declining trend in RA (APC -3.61, p < 0.05). VCF related to AS was also associated with a longer hospital stay as compared to the general population (8.1 days vs. 5.1 days, p < 0.05) and higher inpatient mortality (3.4% vs. 1.0%, p < 0.05). A higher rate of VCF hospitalization along with an increasing trend was noted in AS as compared to RA and compared to the general population. Better screening approaches and treatment strategies for AS patients with VCF risk are urgently needed to reduce hospitalizations and related complications. Key Points • An increasing trend of VCF hospitalization was noted in AS, in contrast to a declining trend in RA and a stable trend in the general population. • VCF in AS was associated with longer hospital stay and higher inpatient mortality than in RA and the general population.

Clinical Efficacy and Safety of Zoledronic Acid Combined with PVP/PKP in the Treatment of Osteoporotic Vertebral Compression Fracture: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

OBJECTIVE: We conducted this meta-analysis to provide better evidence of the efficacy and safety of zoledronic acid (ZA) combined with percutaneous vertebroplasty/kyphoplasty (PVP/PKP) on osteoporotic vertebral compression fracture (OVCF) and proposed a protocol for its application in clinical practice. METHODS: All randomized controlled trials (RCTs) of ZA combined with PVP or PKP compared to individual PVP/PKP for the management of patients with OVCFs were included in this study. Electronic database searches were conducted from database inception to November 2020, including the Cochrane Library, PubMed, Web of Science, and Embase. The pooled data were analyzed using RevMan 5.3 software. RESULTS: Seven RCTs with 929 subjects were finally included. All included studies reported visual analog scores (VAS), and no statistically significant differences were identified at follow-ups of 3 d and 1 w (P > 0.05). In contrast, significant differences were observed at the 1 mo, 3 mo, 6 mo, and 12 mo follow-ups (P < 0.05). Two trials reported the Cobb angle and vertebral body height (VBH), including 182 subjects without significant differences at the 12 mo follow-up (P > 0.05). In addition, significant differences in the bone mineral density (BMD), ß-isomerized C-terminal telopeptide of type I collagen (ß-CTX), N-terminal propeptide of type I collagen (PINP), and N-terminal molecular fragment (N-MID) levels were observed between the two groups (P < 0.05). All trials reported side effects. Significant differences in recurrent fractures, fever, flu-like symptoms, and arthralgia or myalgia were identified (P < 0.05); however, no significant difference in postoperative leakage was detected (P > 0.05). CONCLUSION: Compared to PVP/PKP alone, an additional ZA injection had advantages of long-term analgesic effects with improved bone metabolism indexes. Moreover, combination therapy significantly prevented complications and drug reactions were well tolerated. Overall, this systematic review revealed that ZA combined with PVP/PKP was an effective, safe, and comprehensive therapy for patients with OVCFs.

Osteoporosis Is Undertreated After Low-energy Vertebral Compression Fractures.

INTRODUCTION: Despite guidelines recommending postfracture bone health workup, multiple studies have shown that evaluation and treatment of osteoporosis has not been consistently implemented after fragility fractures. The primary aim of this study was to evaluate rates of osteoporosis evaluation and treatment in adult patients after low-energy thoracolumbar vertebral compression fractures (VCFs). METHODS: We retrospectively reviewed all patients ≥60 years old presenting to a single academic trauma center with acute thoracolumbar VCFs after a ground-level fall from 2016 to 2020 . Rates of osteoporosis screening with dual-energy x-ray absorptiometry and initiation of pharmaceutical treatment were recorded at four time points: before the date of injury, during index hospitalization, at first primary care provider follow-up, and at final primary care provider follow-up. Rates of subsequent falls and secondary fragility fractures were recorded. One-year mortality and overall mortality were also calculated. RESULTS: Fifty-two patients with a mean age of 83 years presenting with thoracic and/or lumbar fractures after a ground-level fall were included. At a mean final follow-up of 502 days, only 10 patients (19.2%) received pharmacologic therapy for osteoporosis and only 6 (11.5%) underwent postinjury dual-energy x-ray absorptiometry evaluation. Twenty-five patients (48%) had at least one subsequent fall at a mean of 164 days from the initial date of injury. Eleven patients with subsequent falls sustained an additional fragility fracture because of the fall, including six operative injuries. One-year mortality among the 52 patients was 26.9%, and the overall mortality rate was 44.2% at the final follow-up. DISCUSSION: Osteoporosis remains a major public health issue that markedly affects quality of life and healthcare costs. Our study demonstrates the additional need for improved osteoporosis workup and intervention among patients who have sustained VCFs. We hope that our study helps raise awareness for improved osteoporosis evaluation and treatment among spine surgeons and all medical professionals treating patients with fragility fractures. LEVEL OF EVIDENCE: Retrospective Case Series, Level IV Evidence.