Treatment and Outcome of Osteoporotic Thoracolumbar Vertebral Fractures With Anterior or Posterior Tension Band Failure (OF 5): Short-Term Results From the Prospective EOFTT Multicenter Study.

STUDY DESIGN Subgroup analysis of a multicenter prospective cohort study. OBJECTIVE To analyse surgical strategies applied to osteoporotic thoracolumbar osteoporotic fracture (OF) 5 injuries with anterior or posterior tension band failure and to assess related complications and clinical outcome. METHODS A multicenter prospective cohort study (EOFTT) was conducted at 17 spine centers including 518 consecutive patients who were treated for an osteoporotic vertebral fracture (OVF). For the present study, only patients with OF 5 fractures were analysed. Outcome parameters were complications, Visual Analogue Scale (VAS), Oswestry Disability Questionnaire (ODI), Timed Up & Go test (TUG), EQ-5D 5L, and Barthel Index. RESULTS In total, 19 patients (78 ± 7 years, 13 female) were analysed. Operative treatment consisted of long-segment posterior instrumentation in 9 cases and short-segment posterior instrumentation in 10 cases. Pedicle screws were augmented in 68 %, augmentation of the fractured vertebra was performed in 42%, and additional anterior reconstruction was done in 21 %. Two patients (11 %) received short-segment posterior instrumentation without either anterior reconstruction or cement-augmentation of the fractured vertebra. No surgical or major complications occurred, but general postoperative complications were observed in 45%. At a follow-up of mean 20 ± 10 weeks (range, 12 to 48 weeks), patients showed significant improvements in all functional outcome parameters. CONCLUSIONS In this analysis of patients with type OF 5 fractures, surgical stabilization was the treatment of choice and lead to significant short-term improvement in terms of functional outcome and quality of life despite a high general complication rate

Georg Schmorl prize of the German spine society (DWG) 2022: current treatment for inpatients with osteoporotic thoracolumbar fractures-results of the EOFTT study

AIM Osteoporotic thoracolumbar fractures are of increasing importance. To identify the optimal treatment strategy this multicentre prospective cohort study was performed. PURPOSE Patients suffering from osteoporotic thoracolumbar fractures were included. Excluded were tumour diseases, infections and limb fractures. Age, sex, trauma mechanism, OF classification, OF-score, treatment strategy, pain condition and mobilization were analysed. METHODS A total of 518 patients' aged 75 ± 10 (41-97) years were included in 17 centre. A total of 174 patients were treated conservatively, and 344 were treated surgically, of whom 310 (90%) received minimally invasive treatment. An increase in the OF classification was associated with an increase in both the likelihood of surgery and the surgical invasiveness. RESULTS Five (3%) complications occurred during conservative treatment, and 46 (13%) occurred in the surgically treated patients. 4 surgical site infections and 2 mechanical failures requested revision surgery. At discharge pain improved significantly from a visual analogue scale score of 7.7 (surgical) and 6.0 (conservative) to a score of 4 in both groups (p < 0.001). Over the course of treatment, mobility improved significantly (p = 0.001), with a significantly stronger (p = 0.007) improvement in the surgically treated patients. CONCLUSION Fracture severity according to the OF classification is significantly correlated with higher surgery rates and higher invasiveness of surgery. The most commonly used surgical strategy was minimally invasive short-segmental hybrid stabilization followed by kyphoplasty/vertebroplasty. Despite the worse clinical conditions of the surgically treated patients both conservative and surgical treatment led to an improved pain situation and mobility during the inpatient stay to nearly the same level for both treatments

Treatment and Outcome of Osteoporotic Thoracolumbar Vertebral Body Fractures With Deformation of Both Endplates With or Without Posterior Wall Involvement (OF 4): Short-Term Results from the Prospective EOFTT Multicenter Study.

STUDY DESIGN: Multicenter prospective cohort study. OBJECTIVE: To analyse therapeutical strategies applied to osteoporotic thoracolumbar OF 4 injuries, to assess related complications and clinical outcome. METHODS: A multicenter prospective cohort study (EOFTT) including 518 consecutive patients who were treated for an Osteoporotic vertebral compression fracture (OVCF). For the present study, only patients with OF 4 fractures were analysed. Outcome parameters were complications, Visual Analogue Scale, Oswestry Disability Questionnaire, Timed Up & Go test, EQ-5D 5L, and Barthel Index after a minimum follow-up of 6 weeks. RESULTS: A total of 152 (29%) patients presented with OF 4 fractures with a mean age of 76 years (range 41-97). The most common treatment was short-segment posterior stabilization (51%; hybrid stabilization in 36%). Mean follow up was 208 days (±131 days), mean ODI was 30 ± 21. Dorsoventral stabilized patients were younger compared to the other groups (P .602, Barthel: P > .252, EQ-5D 5L index value: P > .610, VAS-EQ-5D 5L: P = 1.000). The inpatient complication rate was 8% after conservative and 16% after surgical treatment. During follow-up period 14% of conservatively treated patients and 3% of surgical treated patients experienced neurological deficits. CONCLUSIONS: Conservative therapy of OF 4 injuries seems to be viable option in patients with only moderate symptoms. Hybrid stabilization was the dominant treatment strategy leading to promising clinical short-term results. Stand-alone cement augmentation seems to be a valid alternative in selected cases

Clinical Evaluation of the Osteoporotic Fracture Treatment Score (OF-Score): Results of the Evaluation of the Osteoporotic Fracture Classification, Treatment Score and Therapy Recommendations (EOFTT) Study.

STUDY DESIGN Multicenter prospective cohort study. OBJECTIVE The study aims to validate the recently developed OF score for treatment decisions in patients with osteoporotic vertebral compression fractures (OVCF). METHODS This is a prospective multicenter cohort study (EOFTT) in 17 spine centers. All consecutive patients with OVCF were included. The decision for conservative or surgical therapy was made by the treating physician independent of the OF score recommendation. Final decisions were compared to the recommendations given by the OF score. Outcome parameters were complications, Visual Analogue Scale, Oswestry Disability Questionnaire, Timed Up & Go test, EQ-5D 5 L, and Barthel Index. RESULTS In total, 518 patients (75.3% female, age 75 ± 10) years were included. 344 (66%) patients received surgical treatment. 71% of patients were treated following the score recommendations. For an OF score cut-off value of 6.5, the sensitivity and specificity to predict actual treatment were 60% and 68% (AUC .684, P < .001). During hospitalization overall 76 (14.7%) complications occurred. The mean follow-up rate and time were 92% and 5 ± 3.5 months, respectively. While all patients in the study cohort improved in clinical outcome parameters, the effect size was significantly less in the patients not treated in line with the OF score's recommendation. Eight (3%) patients needed revision surgery. CONCLUSIONS Patients treated according to the OF score's recommendations showed favorable short-term clinical results. Noncompliance with the score resulted in more pain and impaired functional outcome and quality of life. The OF score is a reliable and save tool to aid treatment decision in OVCF

The role of routine transpedicular biopsies during kyphoplasty or vertebroplasty for vertebral compression fractures in the detection of malignant diseases: a systematic review

Introduction Procedures like kyphoplasty or vertebroplasty have become an established treatment option for vertebral compression fractures (VCF). The transpedicular approach used during these procedures allows to take biopsies from the affected vertebral body. The aim of this study was to systematically summarize the existing knowledge on the value of routine transpedicular biopsies during kyphoplasty or vertebroplasty for vertebral compression fractures. Methods A systematic review of the literature using PubMed/Medline databases with the goal of finding all articles describing the value trans-pedicular biopsies for detecting primary bone tumors, metastases, bone diseases, or spondylitis in patients with vertebral compression fractures was performed. Search terms were (*biopsy/ OR biops*.ti,ab.) AND (vertebral compression fracture*.ti,ab.). Results Sixteen articles met the inclusion criteria, among these were six prospective and ten retrospective case series. Publication dates ranged from 2005 to 2020. A total of 3083 patients with 3667 transpedicular biopsies performed were included. Most biopsies confirmed osteoporosis as the dominant underlying pathology of VCFs. Transpedicular biopsies revealed an unexpected malignant diagnosis in 0.4-6% of the cases. Conclusion Routine transpedicular biopsies during kyphoplasty or vertebroplasty detect unexpected malignant lesions in 0.4-6% of the patients, even though the definition of unexpected varies among the analyzed studies. The evidence to support a routine biopsy is inconsistent. Nevertheless, routine biopsies can be considered, especially when sufficient preoperatvie imaging is not available or radiological findings are unclear

OF-Pelvis classification of osteoporotic sacral and pelvic ring fractures

Objectives Osteoporotic fractures of the pelvis (OFP) are an increasing issue in orthopedics. Current classification systems (CS) are mostly CT-based and complex and offer only moderate to substantial inter-rater reliability (interRR) and intra-rater reliability (intraRR). MRI is thus gaining importance as a complement. This study aimed to develop a simple and reliable CT- and MRI-based CS for OFP. Methods A structured iterative procedure was conducted to reach a consensus among German-speaking spinal and pelvic trauma experts over 5 years. As a result, the proposed OF-Pelvis CS was developed. To assess its reliability, 28 experienced trauma and orthopedic surgeons categorized 25 anonymized cases using X-ray, CT, and MRI scans twice via online surveys. A period of 4 weeks separated the completion of the first from the second survey, and the cases were presented in an altered order. While 13 of the raters were also involved in developing the CS (developing raters (DR)), 15 user raters (UR) were not deeply involved in the development process. To assess the interRR of the OF-Pelvis categories, Fleiss’ kappa (κF) was calculated for each survey. The intraRR for both surveys was calculated for each rater using Kendall’s tau (τK). The presence of a modifier was calculated with κF for interRR and Cohen’s kappa (κC) for intraRR. Results The OF-Pelvis consists of five subgroups and three modifiers. Instability increases from subgroups 1 (OF1) to 5 (OF5) and by a given modifier. The three modifiers can be assigned alone or in combination. In both surveys, the interRR for subgroups was substantial: κF = 0.764 (Survey 1) and κF = 0.790 (Survey 2). The interRR of the DR and UR was nearly on par (κF Survey 1/Survey 2: DR 0.776/0.813; UR 0.748/0.766). The agreement for each of the five subgroups was also strong (κF min.–max. Survey 1/Survey 2: 0.708–0.827/0.747–0.852). The existence of at least one modifier was rated with substantial agreement (κF Survey 1/Survey 2: 0.646/0.629). The intraRR for subgroups showed almost perfect agreement (τK = 0.894, DR: τK = 0.901, UR: τK = 0.889). The modifier had an intraRR of κC = 0.684 (DR: κC = 0.723, UR: κC = 0.651), which is also considered substantial. Conclusion The OF-Pelvis is a reliable tool to categorize OFP with substantial interRR and almost perfect intraRR. The similar reliabilities between experienced DRs and URs demonstrate that the training status of the user is not important. However, it may be a reliable basis for an indication of the treatment score

OF-Pelvis classification of osteoporotic sacral and pelvic ring fractures

Objectives Osteoporotic fractures of the pelvis (OFP) are an increasing issue in orthopedics. Current classification systems (CS) are mostly CT-based and complex and offer only moderate to substantial inter-rater reliability (interRR) and intra-rater reliability (intraRR). MRI is thus gaining importance as a complement. This study aimed to develop a simple and reliable CT- and MRI-based CS for OFP. Methods A structured iterative procedure was conducted to reach a consensus among German-speaking spinal and pelvic trauma experts over 5 years. As a result, the proposed OF-Pelvis CS was developed. To assess its reliability, 28 experienced trauma and orthopedic surgeons categorized 25 anonymized cases using X-ray, CT, and MRI scans twice via online surveys. A period of 4 weeks separated the completion of the first from the second survey, and the cases were presented in an altered order. While 13 of the raters were also involved in developing the CS (developing raters (DR)), 15 user raters (UR) were not deeply involved in the development process. To assess the interRR of the OF-Pelvis categories, Fleiss’ kappa (κF) was calculated for each survey. The intraRR for both surveys was calculated for each rater using Kendall’s tau (τK). The presence of a modifier was calculated with κF for interRR and Cohen’s kappa (κC) for intraRR. Results The OF-Pelvis consists of five subgroups and three modifiers. Instability increases from subgroups 1 (OF1) to 5 (OF5) and by a given modifier. The three modifiers can be assigned alone or in combination. In both surveys, the interRR for subgroups was substantial: κF = 0.764 (Survey 1) and κF = 0.790 (Survey 2). The interRR of the DR and UR was nearly on par (κF Survey 1/Survey 2: DR 0.776/0.813; UR 0.748/0.766). The agreement for each of the five subgroups was also strong (κF min.–max. Survey 1/Survey 2: 0.708–0.827/0.747–0.852). The existence of at least one modifier was rated with substantial agreement (κF Survey 1/Survey 2: 0.646/0.629). The intraRR for subgroups showed almost perfect agreement (τK = 0.894, DR: τK = 0.901, UR: τK = 0.889). The modifier had an intraRR of κC = 0.684 (DR: κC = 0.723, UR: κC = 0.651), which is also considered substantial. Conclusion The OF-Pelvis is a reliable tool to categorize OFP with substantial interRR and almost perfect intraRR. The similar reliabilities between experienced DRs and URs demonstrate that the training status of the user is not important. However, it may be a reliable basis for an indication of the treatment score

„Hounsfield units“ als Maß für die Knochendichte – Anwendungsmöglichkeiten in der Wirbelsäulenchirurgie

Despite today's good diagnostic and therapeutic options for osteoporosis, the number of unidentified cases is very high and therapy is therefore usually inadequate. Frequently, the diagnosis of osteoporosis is made only after the occurrence of a fracture. The reason for this, apart from the costs incurred as well as the additional radiation exposure of the diagnostics, is certainly the limited availability of dual energy X‑ray absorptiometry (DEXA) as well as quantitative computed tomography (q-CT). In search of an alternative technique, Hounsfield units (HU) of the clinical CT examination proved to be ground-breaking: the results of previous investigations demonstrated a reliable correlation between the T values of the DEXA measurement and the HU of the same vertebral body. Due to the widespread use of clinical CT scans of the thorax and the abdomen for a variety of indications, it is expected that the number of unidentified cases of osteoporosis can be significantly reduced-without additional costs and radiation exposure associated with osteoporosis screening. In addition to osteoporosis diagnostics, the calculated HU may also provide better preoperative planning as well as predicting the further course of the disease. Thus, the risk for vertebral body fractures, screw loosening and cage sintering after ventral fusion operations can be sufficiently predicted. In this way, preoperative modifications to the surgical procedure can be made to reduce the risk of implant failure. Trotz der heutigen guten diagnostischen und therapeutischen Möglichkeiten ist die Dunkelziffer der an Osteoporose erkrankten Patienten weiterhin sehr hoch und die Therapie folglich meist unzureichend. Häufig wird die Diagnose erst nach Auftreten einer Fraktur gestellt. Ursächlich hierfür ist sicherlich neben den anfallenden Kosten wie auch der zusätzlichen Strahlenexposition die nur eingeschränkte Verfügbarkeit der Dual-energy-Röntgenabsorptiometrie (DEXA) als auch der quantitativen Computertomographie (q-CT). Auf der Suche nach einer alternativen Technik erwiesen sich die „Hounsfield units“ (HU) der klinischen CT-Untersuchung als richtungsweisend. So zeigte sich eine signifikante Korrelation zwischen den T‑Werten der DEXA-Messung und den HU des gleichen Wirbelkörpers. Aufgrund der weiten Verbreitung klinischer CT-Untersuchungen des Thorax und des Abdomens kann durch diese Methode die Dunkelziffer der Erkrankung im Rahmen des Osteoporosescreenings sicherlich deutlich reduziert werden – ohne zusätzliche Kosten, Strahlenexposition oder Mehraufwand für den Patienten. Neben der Osteoporosediagnostik ermöglichen die berechneten HU auch eine bessere präoperative Planung als auch Vorhersage des weiteren Krankheitsverlaufs. So lässt sich das Risiko für Wirbelkörperfrakturen, Schraubenlockerungen und Cagesinterungen nach ventralen Fusionsoperationen suffizient vorhersagen. Auf diese Weise lassen sich bereits präoperativ Modifikationen des chirurgischen Vorgehens treffen, um den Schraubenhalt und die Cageverankerung zu verbessern und Anschlussfrakturen zu vermeiden

Value of routine transpedicular biopsies in kyphoplasty and vertebroplasty for vertebral compression fractures A survey among 250 spine surgeons

Background Transpedicular cement augmentation is an established therapeutic option in the treatment of pathologic compression fractures of the spine. In addition to osteoporosis, underlying metastatic diseases or, more rarely, a primary bone tumor are recurrent causes of vertebral compression fractures without adequate trauma. Objective To obtain a current opinion among spine surgeons in Germany, Switzerland, and Austria on the value of transpedicular biopsy during kyphoplasty and vertebroplasty of vertebral body fractures. Material and methods A web-based (UmfrageOnline (R)) questionnaire with 11 questions was created and sent to the email distribution lists of the German Spine Society (DWG), the Austrian Society for Spine Surgery (spine.at), and the Swiss Society for Spinal Surgery (SGS), as well as to the email distribution list of the Spine Section of the German Society for Orthopedics and Trauma Surgery (DGOU). Results Of a total of 2675 spine surgeons contacted 250 (9.3%) responded to the survey. Approximately one third (29.8%) of respondents regularly perform a transpedicular biopsy with each kyphoplasty or vertebroplasty. Reasons cited for biopsy were image morphology (79.7%) or history of suspected (66.0%) or present (71.4%) tumor disease. Reasons cited against routine biopsy were the associated costs and the limited informative value of the biopsies obtained. Discussion Nearly one third of the spine surgeons surveyed regularly perform a transpedicular biopsy with each kyphoplasty or vertebroplasty. Almost all respondents perform biopsies at least when there is an imaging morphologic suspicion of tumor disease or tumor disease is known or suspected based on risk factors. Future studies need to further clarify the cost-effectiveness of transpedicular biopsy

Traumatic Fractures of the Thoracic Spine: Narrative Literature Review

The majority of traumatic vertebral fractures occur at the thoracolumbar junction and the lumbar spine and less commonly at the mid-thoracic and upper thoracic spine. In accordance, a high number of articles are dealing with thoracolumbar fractures focusing on the thoracolumbar junction. Nonetheless, the biomechanics of the thoracic spine differ from the thoracolumbar junction and the lumbar vertebral spine. The aim of this review is to screen the literature dealing with acute traumatic thoracic vertebral fractures in patients with normal bone quality. Thereby, the diagnostic of thoracic vertebral body fractures should include a CT examination. Ideally, the CT should include the whole thoracic cage particularly in patients suffering high energy accidents or in those with clinical suspicion of concomitant thoracic injuries. Generally, concomitant thoracic injuries are frequently seen in patients with thoracic spine fractures. Particularly sternal fractures cause an increase in fracture instability. In case of doubt, long segment stabilization is recommended in patients with unstable mid- und upper thoracic fractures, particularly in those patients with a high grade of instability. Zusammenfassung Die meisten Publikationen, die sich mit nicht zervikalen Wirbelkorperfrakturen befassen, schlie ss en die gesamte thorakolumbale Wirbelsaule ein und erfassen dabei hauptsachlich Frakturen des thorakolumbalen ubergangs und der Lendenwirbelsaule, sodass Frakturen der mittleren und oberen Brustwirbelsaule unterprasentiert sind. Dagegen unterscheidet sich die Biomechanik der Brustwirbelsaule erheblich von der des thorakolumbalen ubergangs und der Lendenwirbelsaule. Dieses Review befasst sich mit der Literatur, die sich isoliert mit traumatischen Frakturen der Brustwirbelsaule beschaftigt. Dabei zeigt sich, dass die Diagnostik eine CT einschlie ss lich der umgebenden Strukturen beinhalten sollte, da Begleitverletzungen am Thorax sehr haufig sind. Insbesondere zusatzliche Sternumfrakturen erhohen den Grad der Instabilitat. Der Goldstandard der Versorgung sollte insbesondere bei Frakturen mit hohem Grad an Instabilitat die langstreckige dorsale Stabilisierung sein