Comparison of refracture risk between sandwich vertebrae and ordinary adjacent vertebrae_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

LIU Jin ^1,2 , TANG Jing ³ , CHEN Guo ¹ , GU Zuchao ¹ , ZHANG Yu ¹ , YU Shenghui ¹ ,  LIU Hao ²

1. Department of Orthopedics, Chengdu First People’s Hospital, Chengdu Sichuan, 610041, P.R.China;
2. Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China;
3. Department of Radiology, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China;

Corresponding author：

LIU Hao, Email: liuhao6304@163.com

Keywords：

Osteoporotic vertebral compression fracture; sandwich vertebrae; refracture; Cox’s proportional hazards regression model; vertebral augmentation

DOI：

10.7507/1002-1892.202104060

Video：

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Objective To compare the refracture risk between sandwich vertebrae and ordinary adjacent vertebrae, and to explore the risk factors related to refracture.Methods Retrospective analysis was performed on the data of patients who received percutaneous vertebral augmentation (PVA) and formed sandwich vertebrae between April 2015 and October 2019. Of them, 115 patients were enrolled in the study. There were 27 males and 88 females with an average age of 73.9 years (range, 53-89 years). Univariate analysis was performed to analyzed the patients’ general data, vertebral augmentation related indexes, and sandwich vertebrae related indexes. Survival analysis was performed for all untreated vertebrae at T₄-L₅ of the included patients at the vertebra-specific level, and risk curves of refracture probability of untreated vertebrae between sandwich vertebrae and ordinary adjacent vertebrae were compared. Cox’s proportional hazards regression model was used to analyze risk factors for refracture.Results The 115 patients were followed up 12.6-65.9 months (mean, 36.2 months). Thirty-seven refractures involving 51 vertebral bodies occurred in 31 patients. The refracture rate of 27.0% (31/115) in patients with sandwich vertebrae was significantly higher than that of 15.2% (187/1228) in all patients who received PVA during the same period (χ²=10.638, P=0.001). Univariate analysis results showed that there was a significant difference in the number of augmented vertebrae between patients with and without refractures (Z=0.870, P=0.004). However, there was no significant difference in gender, age, body mass index, whether had clear causes of fracture, whether had dual energy X-ray absorptiometry testing, whether the sandwich vertebra generated through the same PVA, puncture method, method of PVA, number of PVA procedures, number of vertebrae with old fracture, whether complicated with spinal deformity, bone cement distribution, and kyphosis angle of sandwich vertebral area (P>0.05). Among the 1 293 untreated vertebrae, there were 136 sandwich vertebrae and 286 ordinary adjacent vertebrae. The refracture rate of sandwich vertebrae was 11.3% which was higher than that of ordinary adjacent vertebrae (6.3%)(χ²=4.668, P=0.031). The 1- and 5-year fracture-free probabilities were 0.90 and 0.87 for the sandwich vertebrae, and 0.95 and 0.93 for the ordinary adjacent vertebrae, respectively. There was a significant difference between the two risk curves of refracture (χ²=4.823, P=0.028). Cox’s proportional hazards regression model analysis results showed that the sandwich vertebrae, thoracolumbar location, the number of the augmented vertebrae, and the unilateral puncture were significant risk factors for refracture (P<0.05).Conclusion The sandwich vertebrae has a higher risk of refracture when compared with the ordinary adjacent vertebrae, and its 1- and 5-year fracture-free probabilities are lower than those of the ordinary adjacent vertebrae. However, the 5-year fracture-free probability of sandwich vertebrae is still 0.87, so prophylactic enhancement is not recommended for all sandwich vertebrae. In addition, the sandwich vertebrae, thoracolumbar location, the number of the augmented vertebrae, and the unilateral puncture were important risk factors for refracture.

Citation： LIU Jin, TANG Jing, CHEN Guo, GU Zuchao, ZHANG Yu, YU Shenghui, LIU Hao. Comparison of refracture risk between sandwich vertebrae and ordinary adjacent vertebrae. Chinese Journal of Reparative and Reconstructive Surgery, 2021, 35(9): 1161-1166. doi: 10.7507/1002-1892.202104060 Copy

1.	Fuggle NR, Curtis EM, Ward KA, et al. Fracture prediction, imaging and screening in osteoporosis. Nat Rev Endocrinol, 2019, 15(9): 535-547.
2.	中华医学会骨质疏松和骨矿盐疾病分会. 中国骨质疏松症流行病学调查及 “健康骨骼” 专项行动结果发布. 中华骨质疏松和骨矿盐疾病杂志, 2019, 12(4): 317-318.
3.	van der Jagt-Willems HC, Vis M, Tulner CR, et al. Mortality and incident vertebral fractures after 3 years of follow-up among geriatric patients. Osteoporos Int, 2013, 24(5): 1713-1719.
4.	Ong KL, Beall DP, Frohbergh M, et al. Were VCF patients at higher risk of mortality following the 2009 publication of the vertebroplasty “sham” trials? Osteoporos Int, 2018, 29(2): 375-383.
5.	Clark W, Bird P, Gonski P, et al. Safety and efficacy of vertebroplasty for acute painful osteoporotic fractures (VAPOUR): a multicentre, randomised, double-blind, placebo-controlled trial. Lancet, 2016, 388(10052): 1408-1416.
6.	Clarençon F, Fahed R, Gabrieli J, et al. Safety and clinical effectiveness of percutaneous vertebroplasty in the elderly (≥80 years). Eur Radiol, 2016, 26(7): 2352-2358.
7.	Hinde K, Maingard J, Hirsch JA, et al. Mortality outcomes of vertebral augmentation (vertebroplasty and/or balloon kyphoplasty) for osteoporotic vertebral compression fractures: a systematic review and meta-analysis. Radiology, 2020, 295(1): 96-103.
8.	Pitton MB, Herber S, Bletz C, et al. CT-guided vertebroplasty in osteoprotic vertebral fractures: incidence of secondary fractures and impact of intradiscal cement leakages during follow-up. Eur Radiol, 2008, 18(1): 43-50.
9.	Kurutz M, Varga P, Jakab G. Prophylactic vertebroplasty versus kyphoplasty in osteoporosis: A comprehensive biomechanical matched-pair study by in vitro compressive testing. Med Eng Phys, 2019, 65: 46-56.
10.	Jia P, Tang H, Chen H, et al. Prophylactic vertebroplasty procedure applied with a resorbable bone cement can decrease the fracture risk of sandwich vertebrae: long-term evaluation of clinical outcomes. Regen Biomater, 2017, 4(1): 47-53.
11.	Wang L, Yang H, Shi Y, et al. Sandwich vertebral fracture in the study of adjacent-level fracture after vertebral cement augmentation. Orthopedics, 2012, 35(8): e1225-e1230.
12.	Chiu PY, Kao FC, Hsieh MK, et al. A retrospective analysis in 1347 patients undergoing cement augmentation for osteoporotic vertebral compression fracture: is the sandwich vertebra at a higher risk of further fracture? Neurosurgery, 2021, 88(2): 342-348.
13.	蒋继乐, 肖斌, 茅剑平, 等. 骨水泥强化治疗 “三明治型” 骨质疏松性椎体压缩骨折对邻近椎体再次骨折的影响. 骨科临床与研究杂志, 2017, 2(4): 236-240.
14.	管华清, 郭炯炯, 姜为民, 等. 椎体强化术治疗脊柱骨质疏松性三明治骨折术后夹心椎再骨折的影响因素分析. 中华创伤杂志, 2018, 34(9): 793-798.
15.	杨家骥, 王星亮, 刘云鹏. 脊柱骨质疏松性三明治骨折椎体强化术后夹心椎再骨折的危险因素探讨. 创伤外科杂志, 2020, 22(6): 433-437.
16.	Liu J, Tang J, Liu H, et al. A novel and convenient method to evaluate bone cement distribution following percutaneous vertebral augmentation. Sci Rep, 2020, 10(1): 16320. doi: 10.1038/s41598-020-73513-2.
17.	Han S, Jang IT. Analysis of adjacent fractures after two-level percutaneous vertebroplasty: is the intervening vertebral body prone to re-fracture? Asian Spine J, 2018, 12(3): 524-532.
18.	蔡凯文, 卢斌, 罗科锋, 等. 骨质疏松椎体压缩性骨折椎体强化术后邻椎骨折危险因素的研究进展. 中华骨科杂志, 2019, 39(17): 1087-1095.
19.	Anderson PA, Conley RB. Secondary fracture prevention: review of recent American Society for Bone and Mineral Research multidisciplinary stakeholder consensus recommendations. Spine J, 2020, 20(7): 1044-1047.
20.	吴斌, 白峰华, 林明侠, 等. 骨水泥注射椎体后凸成形对老年妇女邻近椎体塌陷影响的风险评估. 中国组织工程研究, 2020, 24(12): 1829-1834.
21.	Polikeit A, Nolte LP, Ferguson SJ. The effect of cement augmentation on the load transfer in an osteoporotic functional spinal unit: finite-element analysis. Spine (Phila Pa 1976), 2003, 28(10): 991-996.
22.	Ren HL, Jiang JM, Chen JT, et al. Risk factors of new symptomatic vertebral compression fractures in osteoporotic patients undergone percutaneous vertebroplasty. Eur Spine J, 2015, 24(4): 750-758.
23.	陈贤艺, 陈扬, 陈显辉, 等. 单侧与双侧穿刺 PKP 术后相邻节段生物力学的三维有限元分析. 中国骨与关节损伤杂志, 2020, 35(1): 56-58.
24.	Lee BG, Choi JH, Kim DY, et al. Risk factors for newly developed osteoporotic vertebral compression fractures following treatment for osteoporotic vertebral compression fractures. Spine J, 2019, 19(2): 301-305.
25.	曹源, 郭金超, 马超, 等. 骨水泥椎体强化与保守治疗骨质疏松椎体压缩性骨折再骨折风险的 Meta 分析. 中国脊柱脊髓杂志, 2018, 28(9): 792-800.
26.	Nieuwenhuijse MJ, Putter H, van Erkel AR, et al. New vertebral fractures after percutaneous vertebroplasty for painful osteoporotic vertebral compression fractures: a clustered analysis and the relevance of intradiskal cement leakage. Radiology, 2013, 266(3): 862-870.
27.	Marshall D, Johnell O, Wedel H. Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ, 1996, 312(7041): 1254-1259.
28.	Yu WB, Jiang XB, Liang D, et al. Risk factors and score for recollapse of the augmented vertebrae after percutaneous vertebroplasty in osteoporotic vertebral compression fractures. Osteoporos Int, 2019, 30(2): 423-430.
29.	宁磊, 万双林, 杨明, 等. 经皮椎体后凸成形术后非骨折椎体骨折的原因分析. 中华骨科杂志, 2015, 35(10): 990-996.
30.	Lin WC, Cheng TT, Lee YC, et al. New vertebral osteoporotic compression fractures after percutaneous vertebroplasty: retrospective analysis of risk factors. J Vasc Interv Radiol, 2008, 19(2 Pt 1): 225-231.
31.	Baek SW, Kim C, Chang H. The relationship between the spinopelvic balance and the incidence of adjacent vertebral fractures following percutaneous vertebroplasty. Osteoporos Int, 2015, 26(5): 1507-1513.
32.	Wang H, Sribastav SS, Ye F, et al. Comparison of percutaneous vertebroplasty and balloon kyphoplasty for the treatment of single level vertebral compression fractures: a meta-analysis of the literature. Pain Physician, 2015, 18(3): 209-222.
33.	Lin H, Bao LH, Zhu XF, et al. Analysis of recurrent fracture of a new vertebral body after percutaneous vertebroplasty in patients with osteoporosis. Orthop Surg, 2010, 2(2): 119-123.

1. Fuggle NR, Curtis EM, Ward KA, et al. Fracture prediction, imaging and screening in osteoporosis. Nat Rev Endocrinol, 2019, 15(9): 535-547.
2. 中华医学会骨质疏松和骨矿盐疾病分会. 中国骨质疏松症流行病学调查及 “健康骨骼” 专项行动结果发布. 中华骨质疏松和骨矿盐疾病杂志, 2019, 12(4): 317-318.
3. van der Jagt-Willems HC, Vis M, Tulner CR, et al. Mortality and incident vertebral fractures after 3 years of follow-up among geriatric patients. Osteoporos Int, 2013, 24(5): 1713-1719.
4. Ong KL, Beall DP, Frohbergh M, et al. Were VCF patients at higher risk of mortality following the 2009 publication of the vertebroplasty “sham” trials? Osteoporos Int, 2018, 29(2): 375-383.
5. Clark W, Bird P, Gonski P, et al. Safety and efficacy of vertebroplasty for acute painful osteoporotic fractures (VAPOUR): a multicentre, randomised, double-blind, placebo-controlled trial. Lancet, 2016, 388(10052): 1408-1416.
6. Clarençon F, Fahed R, Gabrieli J, et al. Safety and clinical effectiveness of percutaneous vertebroplasty in the elderly (≥80 years). Eur Radiol, 2016, 26(7): 2352-2358.
7. Hinde K, Maingard J, Hirsch JA, et al. Mortality outcomes of vertebral augmentation (vertebroplasty and/or balloon kyphoplasty) for osteoporotic vertebral compression fractures: a systematic review and meta-analysis. Radiology, 2020, 295(1): 96-103.
8. Pitton MB, Herber S, Bletz C, et al. CT-guided vertebroplasty in osteoprotic vertebral fractures: incidence of secondary fractures and impact of intradiscal cement leakages during follow-up. Eur Radiol, 2008, 18(1): 43-50.
9. Kurutz M, Varga P, Jakab G. Prophylactic vertebroplasty versus kyphoplasty in osteoporosis: A comprehensive biomechanical matched-pair study by in vitro compressive testing. Med Eng Phys, 2019, 65: 46-56.
10. Jia P, Tang H, Chen H, et al. Prophylactic vertebroplasty procedure applied with a resorbable bone cement can decrease the fracture risk of sandwich vertebrae: long-term evaluation of clinical outcomes. Regen Biomater, 2017, 4(1): 47-53.
11. Wang L, Yang H, Shi Y, et al. Sandwich vertebral fracture in the study of adjacent-level fracture after vertebral cement augmentation. Orthopedics, 2012, 35(8): e1225-e1230.
12. Chiu PY, Kao FC, Hsieh MK, et al. A retrospective analysis in 1347 patients undergoing cement augmentation for osteoporotic vertebral compression fracture: is the sandwich vertebra at a higher risk of further fracture? Neurosurgery, 2021, 88(2): 342-348.
13. 蒋继乐, 肖斌, 茅剑平, 等. 骨水泥强化治疗 “三明治型” 骨质疏松性椎体压缩骨折对邻近椎体再次骨折的影响. 骨科临床与研究杂志, 2017, 2(4): 236-240.
14. 管华清, 郭炯炯, 姜为民, 等. 椎体强化术治疗脊柱骨质疏松性三明治骨折术后夹心椎再骨折的影响因素分析. 中华创伤杂志, 2018, 34(9): 793-798.
15. 杨家骥, 王星亮, 刘云鹏. 脊柱骨质疏松性三明治骨折椎体强化术后夹心椎再骨折的危险因素探讨. 创伤外科杂志, 2020, 22(6): 433-437.
16. Liu J, Tang J, Liu H, et al. A novel and convenient method to evaluate bone cement distribution following percutaneous vertebral augmentation. Sci Rep, 2020, 10(1): 16320. doi: 10.1038/s41598-020-73513-2.
17. Han S, Jang IT. Analysis of adjacent fractures after two-level percutaneous vertebroplasty: is the intervening vertebral body prone to re-fracture? Asian Spine J, 2018, 12(3): 524-532.
18. 蔡凯文, 卢斌, 罗科锋, 等. 骨质疏松椎体压缩性骨折椎体强化术后邻椎骨折危险因素的研究进展. 中华骨科杂志, 2019, 39(17): 1087-1095.
19. Anderson PA, Conley RB. Secondary fracture prevention: review of recent American Society for Bone and Mineral Research multidisciplinary stakeholder consensus recommendations. Spine J, 2020, 20(7): 1044-1047.
20. 吴斌, 白峰华, 林明侠, 等. 骨水泥注射椎体后凸成形对老年妇女邻近椎体塌陷影响的风险评估. 中国组织工程研究, 2020, 24(12): 1829-1834.
21. Polikeit A, Nolte LP, Ferguson SJ. The effect of cement augmentation on the load transfer in an osteoporotic functional spinal unit: finite-element analysis. Spine (Phila Pa 1976), 2003, 28(10): 991-996.
22. Ren HL, Jiang JM, Chen JT, et al. Risk factors of new symptomatic vertebral compression fractures in osteoporotic patients undergone percutaneous vertebroplasty. Eur Spine J, 2015, 24(4): 750-758.
23. 陈贤艺, 陈扬, 陈显辉, 等. 单侧与双侧穿刺 PKP 术后相邻节段生物力学的三维有限元分析. 中国骨与关节损伤杂志, 2020, 35(1): 56-58.
24. Lee BG, Choi JH, Kim DY, et al. Risk factors for newly developed osteoporotic vertebral compression fractures following treatment for osteoporotic vertebral compression fractures. Spine J, 2019, 19(2): 301-305.
25. 曹源, 郭金超, 马超, 等. 骨水泥椎体强化与保守治疗骨质疏松椎体压缩性骨折再骨折风险的 Meta 分析. 中国脊柱脊髓杂志, 2018, 28(9): 792-800.
26. Nieuwenhuijse MJ, Putter H, van Erkel AR, et al. New vertebral fractures after percutaneous vertebroplasty for painful osteoporotic vertebral compression fractures: a clustered analysis and the relevance of intradiskal cement leakage. Radiology, 2013, 266(3): 862-870.
27. Marshall D, Johnell O, Wedel H. Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ, 1996, 312(7041): 1254-1259.
28. Yu WB, Jiang XB, Liang D, et al. Risk factors and score for recollapse of the augmented vertebrae after percutaneous vertebroplasty in osteoporotic vertebral compression fractures. Osteoporos Int, 2019, 30(2): 423-430.
29. 宁磊, 万双林, 杨明, 等. 经皮椎体后凸成形术后非骨折椎体骨折的原因分析. 中华骨科杂志, 2015, 35(10): 990-996.
30. Lin WC, Cheng TT, Lee YC, et al. New vertebral osteoporotic compression fractures after percutaneous vertebroplasty: retrospective analysis of risk factors. J Vasc Interv Radiol, 2008, 19(2 Pt 1): 225-231.
31. Baek SW, Kim C, Chang H. The relationship between the spinopelvic balance and the incidence of adjacent vertebral fractures following percutaneous vertebroplasty. Osteoporos Int, 2015, 26(5): 1507-1513.
32. Wang H, Sribastav SS, Ye F, et al. Comparison of percutaneous vertebroplasty and balloon kyphoplasty for the treatment of single level vertebral compression fractures: a meta-analysis of the literature. Pain Physician, 2015, 18(3): 209-222.
33. Lin H, Bao LH, Zhu XF, et al. Analysis of recurrent fracture of a new vertebral body after percutaneous vertebroplasty in patients with osteoporosis. Orthop Surg, 2010, 2(2): 119-123.

Chinese Journal of Reparative and Reconstructive Surgery

Comparison of refracture risk between sandwich vertebrae and ordinary adjacent vertebrae

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