Predicting Secondary Vertebral Compression Fracture After Vertebral Augmentation via CT-Based Machine Learning Radiomics-Clinical Model.

RATIONALE AND OBJECTIVES: Secondary vertebral compression fractures (SVCF) are very common in patients after vertebral augmentation (VA). The aim of this study was to establish a radiomic-based model to predict SVCF and specify appropriate treatment strategies. MATERIALS AND METHODS: Patients diagnosed with osteoporotic vertebral compression fracture (OVCF) and undergoing VA surgery at our center between 2017 and 2021 were subject to a retrospective analysis. Radiological features of the T6-L5 vertebrae were derived from CT images. Clustering analysis, t-test, and LASSO (least absolute shrinkage and selection operator) regression were used to identify the optimization characteristics. A radiological signature model was constructed through the best combination of 13 machine learning algorithms. Radiomics signature was integrated with clinical characteristics into a nomogram for clinical applications. The model reliability was assessed by receiver operating characteristic (ROC) curve, calibration curve, clinical decision analysis (DCA), log-rank test, and confusion matrix. RESULTS: A total of 470 eligible patients (81 with SVCF and 389 without) were identified in the clinical cohort. Eight radiomics features were identified and incorporated into machine learning, and "XGBoost" model showed the best performance. Final logistic nomogram included radiomics signature (P < 0.001), bone cement volume (P = 0.034), and T-scores of L1-L4 (P = 0.001), and showed satisfactory prediction capability in training set (0.986, 95%CI 0.969-1.000) and verification set (0.884, 95%CI 0.823-0.946). CONCLUSION: Our radiomics-clinical model based on machine learning showed potential to prospectively predict SVCF after VA and provide precise treatment strategies.

Esophageal perforation with near fatal mediastinitis secondary to Th3 fracture.

A 74-year-old male patient was referred with signs of sepsis 5 days after having been diagnosed with a rib fracture following a fall out of bed. Novel hypodensities were visible on thoracic X­rays and laboratory tests revealed elevated inflammatory parameters. Subsequently performed thoracic computed tomography (CT) scan showed burst fracture of the 3rd thoracic vertebra, posttraumatic esophageal rupture at the same level and mediastinitis. Furthermore, marked degenerative changes of the spinal column (diffuse idiopathic skeletal hyperostosis) were present. The patient underwent emergency thoracotomy and esophagectomy. Gastric pull-up with esophagogastrostomy was postponed for 3 days. After 14 days on the intensive care unit (ICU) and 12 days of i.v. antibiotics, the patient was transferred to the general ward and 7 weeks after trauma the patient was infection-free without difficulties in swallowing. Up to the latest follow-up 41 months following injury, several endoscopic dilations with a bougie due to constrictions at the anastomosis have been performed. Similar to previous cases in the literature, esophageal injury was diagnosed delayed, with the patient already having developed severe complications. This extremely seldom injury should be suspected in young patients following high-energy trauma, but also in older patients after low-energy trauma but known degenerative changes of the vertebral column.

Comparative analysis of different treatment strategies for septic spondylitis: a retrospective study of one hundred and twelve patients.

PURPOSE: To compare the clinical efficacy and prognosis differences between conservative treatment and surgical treatment in patients with non-serious neurologically intact pyogenic spondylitis (Nsi-Nsni-PS), and to provide theoretical reference for the clinical treatment of Nsi-Nsni-PS patients. METHODS: A retrospective analysis was conducted on 112 cases of Nsi-Nsni-PS patients treated in our hospital from June 2016 to June 2021. According to different treatment methods, they were divided into conservative treatment group (53 cases) and surgical treatment group (59 cases). The general data, laboratory tests, imaging examinations, length of hospital stay, duration of antibiotic use, VAS for pain before and after treatment, ODI, local kyphotic angle correction of diseased vertebrae, and recurrence rate were collected and analyzed in both groups. SPSS 26.0 statistical software was used for analysis. Measurement data were expressed as mean ± standard deviation, and independent sample t-test or rank sum test was used for comparison between groups, while variance analysis was used for intra-group comparison. Count data were expressed as number (%) and compared between groups using chi-square test or Fisher's exact test. Mann-Whitney U test was used to evaluate the changes in local kyphotic angle between the two groups. A p value < 0.05 was considered statistically significant. RESULTS: There were no significant differences in general data and imaging characteristics between the two groups (P > 0.05); there were no statistically significant differences in the positive culture rate of pathogens, length of hospital stay, duration of antibiotic use, treatment complications, WBC, CRP, ESR levels at admission and discharge, VAS and ODI at admission and last follow-up between the two groups (P > 0.05). The WBC and CRP levels of patients in the conservative group at discharge were lower than those in the surgical group (P < 0.05), and there was no significant difference in the decrease in inflammatory indicators (WBC, CRP, ESR) between the two groups (P > 0.05). By the last follow-up, the neurological function of patients in both groups had significantly improved compared to admission (P < 0.05), with 12 out of 15 ASIA grade D patients in the conservative group recovering to grade E, and 21 out of 25 grade D patients in the surgical group recovering to grade E, with no worsening of neurological function in either group. The differences in VAS and ODI scores at the last follow-up compared to before treatment were statistically significant in both groups (P < 0.05), and all patients regained normal activity. Compared with before treatment, the correction degree of local kyphotic angle in the surgical group at the last follow-up was 0.93 ± 4.94°, slightly higher than that in the conservative group (-0.83 ± 3.37°), and the difference was statistically significant(P < 0.05). CONCLUSIONS: During our follow-up, we found that both conservative and surgical treatments achieved satisfactory clinical outcomes in patients with Nsi-Nsni-PS. Compared to conservative treatment, surgical intervention did not demonstrate significant advantages in reducing hospitalization time and antibiotic usage duration, increasing pathogen culture positivity rate, lowering treatment complications, or controlling recurrence. However, surgical intervention showed superiority in correcting the local kyphotic angle of spinal lesions, albeit with relatively increased surgical trauma, risks, and treatment costs. At the last follow-up, the surgical group did not exhibit better long-term efficacy. Therefore, when formulating clinical treatment strategies for patients with Nsi-Nsni-PS, it may be preferable to prioritize conservative treatment, supplemented by the use of sensitive or empiric antibiotics for infection management, to improve patient prognosis.

Vertebral bone quality score was associated with paraspinal muscles fat infiltration, but not modic classification in patients with chronic low back pain: a prospective cross-sectional study.

BACKGROUND: The lumbar vertebra and paraspinal muscles play an important role in maintaining the stability of the lumbar spine. Therefore, the aim of this study was to investigate the relationship between paraspinal muscles fat infiltration and vertebral body related changes [vertebral bone quality (VBQ) score and Modic changes (MCs)] in patients with chronic low back pain (CLBP). METHODS: Patients with CLBP were prospectively collected in four hospitals and all patients underwent 3.0T magnetic resonance scanning. Basic clinical information was collected, including age, sex, course of disease (COD), and body mass index (BMI). MCs were divided into 3 types based on their signal intensity on T1 and T2-weighted imaging. VBQ was obtained by midsagittal T1-weighted imaging (T1WI) and calculated using the formula: SIL1-4/SICSF. The Proton density fat fraction (PDFF) values and cross-sectional area (CSA) of paraspinal muscles were measured on the fat fraction map from the iterative decomposition of water and fat with the echo asymmetry and least-squares estimation quantitation (IDEAL-IQ) sequences and in/out phase images at the central level of the L4/5 and L5/S1 discs. RESULTS: This study included 476 patients with CLBP, including 189 males and 287 females. 69% had no Modic changes and 31% had Modic changes. There was no difference in CSA and PDFF for multifidus(MF) and erector spinae (ES) at both levels between Modic type I and type II, all P values>0.05. Spearman correlation analysis showed that VBQ was weakly negatively correlated with paraspinal muscles CSA (all r values < 0.3 and all p values < 0.05), moderately positive correlation with PDFF of MF at L4/5 level (r values = 0.304, p values<0.001) and weakly positively correlated with PDFF of other muscles (all r values<0.3 and all p values<0.001). Multivariate linear regression analysis showed that age (ß = 0.141, p < 0.001), gender (ß = 4.285, p < 0.001) and VBQ (ß = 1.310, p = 0.001) were related to the total PDFF of muscles. For MCs, binary logistic regression showed that the odds ratio values of age, BMI and COD were 1.092, 1.082 and 1.004, respectively (all p values ＜ 0.05). CONCLUSIONS: PDFF of paraspinal muscles was not associated with Modic classification. In addition to age and gender, PDFF of paraspinal muscles is also affected by VBQ. Age and BMI are considered risk factors for the MCs in CLBP patients.

Comparison of the efficacy and safety of vertebroplasty with different pedicle approaches for osteoporotic vertebral.

OBJECTIVE: To compare the efficacy and safety of vertebroplasty through different pedicle approaches in the treatment of osteoporotic vertebral compression fracture osteoporotic vertebral compression fractures (OVCF) by network meta-analysis. METHODS: Pubmed, Embase, Cochrane Library, Web of Science. Database for literature retrieval, retrieval time from the establishment of the database to April 2023, the randomized controlled trials of unilateral vertebroplasty (UVP), bilateral vertebroplasty (BVP), unilateral kyphoplasty (UKP), bilateral kyphoplasty (BKP), curved vertebroplasty (CVP) and curved kyphoplasty (CKP) were screened, evaluated and the data were extracted and included in the analysis. STATA 15.0 and ReMan 5.3 were used for data analysis. This study was registered in the National Institute for Health Research (NIHR) with the registration number CRD42023405181. RESULTS: This study included 16 articles with a total of 1712 patients. The order of visual analogue scale (VAS) improvement from good to bad is CVP > BVP > UVP > CKP > BKP > UKP. The order of kyphotic angles improvement from good to bad is CKP > UKP > UKP > UVP > BVP > CVP. The order of bone cement injection from less to more is UVP > CVP > UKP > CKP > BVP > BKP. The order of bone cement leakage rate from less to more is CKP > CVP > UKP > BKP > UVP > BVP. The order of X-ray exposure time from less to more is CKP > CVP > UVP > BVP > UKP > BKP. The order of operation time from less to more is CVP > UVP > UKP > CKP > BVP > BKP. CONCLUSION: For patients with kyphotic angles, kyphoplasty has unique advantages in improving kyphotic angles. But generally speaking, curved approach can optimize the distribution of bone cement through unilateral approach to achieve the orthopedic effect of bilateral approach, which is a minimally invasive technique with better curative effect and higher safety in the treatment of OVCF.

MRI study on the influence of lumbosacral vertebral body and disc factors on lumbar lordosis in children.

PURPOSE: To evaluate the influence of vertebral and disc wedging on the contribution of lumbar lordosis and the change of disc thickness before and after walking based on MRI. METHODS: Cross-sectional study. A total of 96 normally developing children, aged 5.7 ± 3.0 years old, 55 boys and 41 girls. They were divided into 3 groups: Pre-walking group, Walking group, and Post-walking group. PARAMETERS: lumbar lordosis Angle (LLA), the sum of the lumbar disc wedge Angle (∑D), the sum of the lumbar vertebral body wedge Angle (∑B), disc height (DH). RESULTS: (1) LLA, ∑D, ∑B, and DHL1-S1 were 33.2 ± 8.7°, 14.1 ± 8.6°, 11.9 ± 8.6°, and 6.9 ± 1.2 mm, 7.6 ± 1.4 mm, 8.2 ± 1.6 mm, 8.9 ± 1.7 mm, 8.5 ± 1.8 mm. (2) The difference in LLA values between the Pre-walking and the Post-walking group was statistically significant. DH were significantly different among the three groups. (3) In the Post-walking group, LLA value of girls was significantly higher than that of boys, and DHL3 - 4 and DHL4 - 5 values of girls were significantly lower than that of boys. (4) Age had a low positive correlation with LLA and ∑D and a moderate to strong positive correlation with DH; LLA showed a moderate positive correlation with ∑D, and a low positive correlation with ∑B and DH. CONCLUSION: Age and walking activity are the influencing factors of lumbar lordosis and disc thickening. Walking activity can significantly increase lumbar lordosis, and age is the main factor promoting lumbar disc thickening. DHL4-5 was the thickest lumbar intervertebral disc with the fastest intergroup thickening. Disc wedging contributes more to lumbar lordosis than vertebral wedging.

Does ponticulus posticus affect vertebral artery diameter.

PURPOSE: Ponticulus Posticus, atlantooccipital ligament ossification-induced anomaly, surrounds the vertebral artery and the first cervical nerve root. It is believed to wrap around the first cervical nerve root and the vertebral artery, causing compression. We hypothesized that it would also reduce the diameter of the vertebral artery. METHODS: Between January 1, 2022, and December 31, 2022, cervical spine CT scans taken for any reason were retrospectively reviewed. The images of 1365 patients suitable for evaluation were evaluated by two expert radiologists in 3 dimensions. Among patients with PP, those who underwent cervical angiography were identified for vertebral artery diameter measurement. RESULTS: The average age of the 1365 individuals included in the study (732 males, 633 females) was 55.78 (± 18.85) with an age range of 1-96. Among this group, PP was detected in 288 individuals, resulting in a total prevalence of 21.1%. Right and left vertebral artery diameters were significantly lower in patients with complete PP compared to the absent group (p < 0,001, p < 0,001, respectively). Additionally, it was observed that width and height diameters and artery diameters were positively correlated in patients with Complete PP. CONCLUSIONS: Ponticulus posticus can cause vertebrobasilar insufficiency by reducing the diameter of the vertebral artery. Therefore, imaging and detailed evaluation of this region are important in symptomatic patients.

Soft Tissue Dissection in the Transcondylar Approach: A Modified Layered Technique to Maximize Lateral Access.

Objective While the transcondylar approach is technically challenging, it provides generous ventral and caudal exposure to the craniovertebral junction. This approach requires navigation around multiple eloquent neurovascular structures including the lower cranial nerves, vertebral artery and its branches, and the brainstem. Superficial exposure, including incision location and muscle dissection, can dramatically affect the surgical angle and maneuverability at depth. Methods We demonstrate the transcondylar approach in a step-by-step fashion in a formalin-embalmed, latex-injected cadaver head. Dissection within each layer of the suboccipital muscles was performed. A small cohort with an illustrative case is also included herein. Results The sternocleidomastoid (SCM) muscle was retracted anteriorly; the splenium capitis, semispinalis capitis, and longissimus capitis muscles were disconnected from the superior nuchal line and reflected inferomedially. The suboccipital muscle group was fully exposed. The superior and inferior oblique muscles were disconnected from the transverse process of C1. The superior oblique and the rectus capitis posterior major muscles were then dissected off the inferior nuchal line, and the suboccipital muscle group was retracted inferomedially en bloc . The greater auricular nerve was retracted laterally with the SCM, and the greater occipital nerve was retracted inferomedially with the suboccipital muscle group. Conclusion This technique avoids the obstructive muscle bulk that results from a myocutaneous approach while maximizing deep exposure. Understanding the detailed muscular anatomical relationship with the insertion location and suboccipital nerves is key to complete and safe extracranial dissection. Diligent dissection helps minimize postoperative pain and muscle spasm while optimizing the closure technique.

Selective postmortem arterial angiography of head and neck using digital x-ray or computed tomography: A practical and rapid method to identify vascular injuries.

Identification of vascular injuries is crucial for complete postmortem evaluation and understanding of trauma deaths by the Medical Examiner. Some vascular injuries are difficult to evaluate due to challenging anatomic locations, especially in the head and neck. Documenting injuries of the facial and vertebral arteries is challenging and necessitates time-consuming dissections that can create artifacts and disfigurement. In busy medical examiner offices with a significant number of traumatic injuries, finding a creative solution to employ reliable postmortem angiography is desirable. At the Office of the Chief Medical Examiner for the State of Maryland (OCME), we created and effectively implemented a selective angiography procedure using traditional indwelling Foley catheters and water-soluble barium swallow contrast to evaluate arterial injuries using either digital radiography or computed tomography imaging modalities. This technique and imaging interpretation can be performed by a medical examiner or forensic pathology fellow after basic technical training and basic radiology training. This study outlines the technique, methods, and utilization of the procedure and describes the findings of six deaths due to vascular lesions from different injury mechanisms and disease processes and describes the ease of implementation on a broader scale in busy Medical Examiner's offices.

Fully Automatic Deep Learning Model for Spine Refracture in Patients with OVCF: A Multi-Center Study.

BACKGROUND: The reaserch of artificial intelligence (AI) model for predicting spinal refracture is limited to bone mineral density, X-ray and some conventional laboratory indicators, which has its own limitations. Besides, it lacks specific indicators related to osteoporosis and imaging factors that can better reflect bone quality, such as computed tomography (CT). OBJECTIVE: To construct a novel predicting model based on bone turn-over markers and CT to identify patients who were more inclined to suffer spine refracture. METHODS: CT images and clinical information of 383 patients (training set = 240 cases of osteoporotic vertebral compression fractures (OVCF), validation set = 63, test set = 80) were retrospectively collected from January 2015 to October 2022 at three medical centers. The U-net model was adopted to automatically segment ROI. Three-dimensional (3D) cropping of all spine regions was used to achieve the final ROI regions including 3D_Full and 3D_RoiOnly. We used the Densenet 121-3D model to model the cropped region and simultaneously build a T-NIPT prediction model. Diagnostics of deep learning models were assessed by constructing ROC curves. We generated calibration curves to assess the calibration performance. Additionally, decision curve analysis (DCA) was used to assess the clinical utility of the predictive models. RESULTS: The performance of the test model is comparable to its performance on the training set (dice coefficients of 0.798, an mIOU of 0.755, an SA of 0.767, and an OS of 0.017). Univariable and multivariable analysis indicate that T_P1NT was an independent risk factor for refracture. The performance of predicting refractures in different ROI regions showed that 3D_Full model exhibits the highest calibration performance, with a Hosmer-Lemeshow goodness-of-fit (HL) test statistic exceeding 0.05. The analysis of the training and test sets showed that the 3D_Full model, which integrates clinical and deep learning results, demonstrated superior performance with significant improvement (p-value < 0.05) compared to using clinical features independently or using only 3D_RoiOnly. CONCLUSION: T_P1NT was an independent risk factor of refracture. Our 3D-FULL model showed better performance in predicting high-risk population of spine refracture than other models and junior doctors do. This model can be applicable to real-world translation due to its automatic segmentation and detection.

A Real-world Study of Denosumab For Reducing Refracture Risk after Percutaneous Vertebral Augmentation.

OBJECTIVE: To investigate the use of anti-osteoporotic agents and refracture incidence in patients with osteoporotic vertebral compression fracture (OVCF) following percutaneous vertebral augmentation (PVA) and to evaluate the real-world treatment of patients using denosumab following PVA. This study aims to provide spine surgeons with empirical insights derived from real-world scenarios to enhance the management of bone health in OVCF patients. METHODS: This retrospective cohort study was based on data from the MarketScan and Optum databases from the USA. Female patients aged 55-90 years who underwent PVA for OVCF between January 2013 and March 2020 were included and followed up from the day after surgery. Patients who received at least one dose of denosumab were included in the denosumab cohort and were further divided into the on-treatment and off-treatment groups according to whether they received a second dose of denosumab, with follow-up beginning on the index day (225 days after the first denosumab dose). In this study, the off-treatment group was considered as the control group. Refracture incidence after PVA, the proportion of patients using anti-osteoporotic agents in the total study population, and refracture incidence after the index day in the denosumab cohort were analyzed. RESULTS: A total of 13,451 and 21,420 patients from the MarketScan and Optum databases, respectively, were included. In the denosumab cohort, the cumulative incidence of clinical osteoporotic fractures within 3 years after the index day was significantly lower in the on-treatment group than in the off-treatment group (MarketScan database: 23.0% vs 39.0%, p = 0.002; Optum database: 28.2% vs 40.0%, p = 0.023). The cumulative incidence of clinical vertebral fractures was also lower in the on-treatment group than in the off-treatment group, with a significant difference in the MarketScan database (14.4% vs 25.5%, p = 0.002) and a numerical difference was found in the Optum database (20.2% vs 27.5%, p = 0.084).The proportion of patients using anti-osteoporotic agents was low at 6 months postoperatively, with only approximately 7% using denosumab and 13%-15% taking oral bisphosphonates. CONCLUSION: Postmenopausal women have a high refracture rate and a low proportion of anti-osteoporotic drug use after PVA. Continued denosumab treatment after PVA is associated with a lower risk of osteoporotic and clinical vertebral fractures. Therefore, denosumab may be a treatment option for patients with osteoporosis after PVA.

Prediction of Screw Loosening After Dynamic Pedicle Screw Fixation With Lumbar Polyetheretherketone Rods Using Magnetic Resonance Imaging-Based Vertebral Bone Quality Score.

OBJECTIVE: To investigate the correlation between magnetic resonance imaging-based vertebral bone quality (VBQ) score and screw loosening after dynamic pedicle screw fixation with polyetheretherketone (PEEK) rods, and evaluate its predictive value. METHODS: A retrospective analysis was conducted on the patients who underwent dynamic pedicle screw fixation with PEEK rods from March 2017 to June 2022. Data on age, sex, body mass index, hypertension, diabetes, hyperlipidemia history, long-term smoking, alcohol consumption, VBQ score, L1-4 average Hounsfield unit (HU) value, surgical fixation length, and the lowest instrumented vertebra were collected. Logistic regression analysis was employed to assess the relationship between VBQ score and pedicle screw loosening (PSL). RESULTS: A total of 24 patients experienced PSL after surgery (20.5%). PSL group and non-PSL group showed statistical differences in age, number of fixed segments, fixation to the sacrum, L1-4 average HU value, and VBQ score (p < 0.05). The VBQ score in the PSL group was higher than that in the non-PSL group (3.56 ± 0.45 vs. 2.77 ± 0.31, p < 0.001). In logistic regression analysis, VBQ score (odds ratio, 3.425; 95% confidence interval, 1.552-8.279) were identified as independent risk factors for screw loosening. The area under the receiver operating characteristic curve for VBQ score predicting PSL was 0.819 (p < 0.05), with the optimal threshold of 3.15 (sensitivity, 83.1%; specificity, 80.5%). CONCLUSION: The VBQ score can independently predict postoperative screw loosening in patients undergoing lumbar dynamic pedicle screw fixation with PEEK rods, and its predictive value is comparable to HU value.

Key risk factors and adverse outcomes in metachronous vertebral osteomyelitis following periprosthetic joint infection: A 5-year retrospective study.

Purpose: Periprosthetic joint infection (PJI) is a leading cause of joint arthroplasty failure, potentially leading to critical complications like vertebral osteomyelitis (VO). The factors contributing to VO after PJI and the outcomes for these patients are not well understood. Our study aims to (1) identify risk factors for VO following PJI and (2) assess the clinical outcomes in these cases. Methods: We included PJI patients treated surgically at our centre from January 2006 to December 2020, excluding those with simultaneous VO post-PJI. Our focus was on patients with VO occurring after PJI, monitored for at least 5 years. Analysis included patient comorbidities, PJI treatment approaches, pathogen identification and clinical outcomes. Results: Of 1701 PJI cases, 21 (1.23%) developed VO. Key risk factors for VO post-PJI were identified: systemic inflammatory response syndrome, substance misuse, polymicrobial infection and undergoing at least three stages of resection arthroplasty (odds ratios: 1.86, 54.28, 52.33 and 31.88, respectively). Adverse outcomes were noted in VO patients, with recurrent VO in 6/21 and repeated PJIs in 18/21 cases. Conclusions: Patients with PJI, especially those with certain risk factors, have an increased likelihood of developing VO and encountering negative outcomes. The potential role of bacteremia in the development of VO after PJI needs further exploration. Level of Evidence: Level III.

Infective endocarditis and spondylodiscitis-impact of sequence of surgical therapy on survival and recurrence rate.

OBJECTIVES: To date, there are no standardized treatment algorithms or recommendations for patients with infective endocarditis (IE) and concomitant spondylodiscitis (SD). Therefore, our aim was to analyse whether the sequence of surgical treatment of IE and SD has an impact on postoperative outcome and to identify risk factors for survival and postoperative recurrence. METHODS: Patients with IE underwent surgery in 4 German university hospitals between 1994 and 2022. Univariable and multivariable analyses were performed to identify possible predictors of 30-day/1-year mortality and recurrence of IE and/or SD. RESULTS: From the total IE cohort (n = 3991), 150 patients (4.4%) had concomitant SD. Primary surgery for IE was performed in 76.6%, and primary surgery for SD in 23.3%. The median age was 70.0 (64.0-75.6) years and patients were mostly male (79.5%). The most common pathogens detected were enterococci and Staphylococcus aureus followed by streptococci, and coagulase-negative Staphylococci. If SD was operated on first, 30-day mortality was significantly higher than if IE was operated on 1st (25.7% vs 11.4%; P = 0.037) and we observed a tendency for a higher 1-year mortality. If IE was treated 1st, we observed a higher recurrence rate within 1 year (12.2% vs 0%; P = 0.023). Multivariable analysis showed that primary surgery for SD was an independent predictor of 30-day mortality. CONCLUSIONS: Primary surgical treatment for SD was an independent risk factor for 30-day mortality. When IE was treated surgically 1st, the recurrence rate of IE and/or SD was higher.

Novel MRI-Based Pedicle Bone Quality Score Independently Predicts Pedicle Screw Loosening after Degenerative Lumbar Fusion Surgery.

Pedicle screw loosening after posterior lumbar fusion is associated with poor bone quality, which often determines screw pull-out strength, insertion torque, and vertebral body loading characteristics. Magnetic resonance imaging (MRI)-based vertebral bone quality (VBQ) score were associated with poor bone quality. Current evidence suggests that pedicle bone quality (PBQ) has a greater impact on screw stability. However, the correlation between MRI-based PBQ score and screw loosening has not been reported. PURPOSE: To introduce and evaluate an MRI-based PBQ score to determine its effectiveness in predicting pedicle screw loosening following lumbar fusion surgery. METHODS: The retrospective study analyzed 244 patients who underwent posterior lumbar interbody fusion (PLIF) with pedicle screws between December 2017 and December 2021, with CT and MRI imaging before surgery. Data collected included patient demographics and preoperative radiological data. Radiographic screw loosening was measured at 12 months postoperatively. Clinical assessments included pain visual analog scale (VAS) and Oswestry Disability Index (ODI) scores. The PBQ score was measured using MRI scans. We use univariate analysis for preliminary screening of the risk factors of screw loosening. Subsequent analysis involved multivariate logistic regression to identify independent predictive factors for screw loosening. We constructed the receiver operating characteristic (ROC) curve to ascertain the discriminative capacity of the PBQ score. The area under the curve (AUC) quantified its predictive accuracy. Additionally, we evaluated the association between PBQ score and screw loosening using Spearman's correlation analysis. RESULTS: Overall, 244 patients who underwent PLIF with pedicle screw fixation participated in this study, including 35 in the loosening group and 209 in the non-loosening group. PBQ score in the loosening group was significantly higher than that in the non-loosening group. On multivariate logistic regression, the higher PBQ score (OR = 8.481, 95% CI: 3.158-22.774; p < 0.001) and the lower mean Hounsfield unit (HU) value of L1-4 (OR = 0.967, 95% CI 0.951-0.984; p < 0.001) were the variables that significantly predicted screw loosening. The AUC for the PBQ score and HU value were 0.751 (95% CI: 0.673-0.828) and 0.702 (95% CI: 0.612-0.791). The PBQ score optimal cutoff to differentiate patients with loosening and with non-loosening was calculated as 3.045 with a sensitivity of 85.7% and specificity of 76.9%, while the optimal cutoff of the HU value was 151.5 with a sensitivity of 64.6% and specificity of 89.5%. CONCLUSIONS: The association between the PBQ score and the propensity for lumbar pedicle screw loosening was found to be substantial. As a predictive measure, the PBQ score outperformed the HU value in forecasting the likelihood of screw loosening post-posterior lumbar fusion.

Radiomics Based on Multimodal magnetic resonance imaging for the Differential Diagnosis of Benign and Malignant Vertebral Compression Fractures.

OBJECTIVES: Recent studies have indicated that radiomics may have excellent performance and clinical application prospects in the differential diagnosis of benign and malignant vertebral compression fractures (VCFs). However, multimodal magnetic resonance imaging (MRI)-based radiomics model is rarely used in the differential diagnosis of benign and malignant VCFs, and is limited to lumbar. Herein, this study intends to develop and validate MRI radiomics models for differential diagnoses of benign and malignant VCFs in patients. METHODS: This cross-sectional study involved 151 adult patients diagnosed with VCF in The First Affiliated Hospital of Soochow University in 2016-2021. The study was conducted in three steps: (i) the original MRI images were segmented, and the region of interest (ROI) was marked out; (ii) among the extracted features, those features with Pearson's correlation coefficient lower than 0.9 and the top 15 with the highest variance and Lasso regression coefficient less than and more than 0 were selected; (iii) MRI images and combined data were studied by logistic regression, decision tree, random forest and extreme gradient boosting (XGBoost) models in training set and the test set (ratio of 8:2), respectively; and the models were further verified and evaluated for the differential diagnosis performance. The evaluated indexes included area under receiver (AUC) of operating characteristic curve, accuracy, sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and 95% confidence intervals (CIs). The AUCs were used to assess the predictive performance of different machine learning modes for benign and malignant VCFs. RESULTS: A total of 1144 radiomics features, and 14 clinical features were extracted. Finally, 12 radiomics features were included in the radiomics model, and 12 radiomics features with 14 clinical features were included in the combined model. In the radiomics model, the differential diagnosis performance in the logistic regression model with the AUC of 0.905 ± 0.026, accuracy of 0.817 ± 0.057, sensitivity of 0.831 ± 0.065, and negative predictive value of 0.813 ± 0.042, was superior to the other three. In the combined model, XGBoost model had the superior differential diagnosis performance with specificity (0.979 ± 0.026) and positive predictive value (0.971 ± 0.035). CONCLUSION: The multimodal MRI-based radiomics model performed well in the differential diagnosis of benign and malignant VCFs, which may provide a tool for clinicians to differentially diagnose VCFs.

The Role of the GH Receptor Polymorphisms as a Prognostic Factor of Vertebral Fractures in Acromegalic Patients Resistant to First-generation SSAs and Treated with Pegvisomant or Pasireotide LAR.

BACKGROUND: Acromegaly is associated with skeletal fragility and increased prevalence of vertebral fractures (VF). Two isoforms of GH receptor (GHR) have been described, which differ in the presence or absence of a transcript of exon 3 of the GHR gene. Both isoforms produce a functional receptor, but the exon 3-deleted isoforms (d3-GHR) have greater sensitivity to endogenous and recombinant GH than the full-length isoform (fl-GHR). OBJECTIVE: We conducted a longitudinal, retrospective, observational, single-center study to investigate the role of GHR polymorphism as a prognostic factor of incidental VF (I-VF) in firstgeneration somatostatin analogs (fg-SSAs)-resistant acromegalic patients and treated with Pegvisomant or Pasireotide LAR. METHODS: Seventy-two patients with active acromegaly were included: 28 patients carried the d3-GHR isoform, and 44 patients carried the fl-GHR isoform. Forty-six patients were treated with Pegvisomant in combination with fg-SSAs, and 26 were treated with Pasireotide LAR. At the last follow-up, 58 patients achieved biochemical control of acromegaly. Eighteen patients carried prevalent VF (P-VFs), while 14 patients experienced the occurrence of I-VFs. RESULTS: From the group treated with Pegvisomant in combination with fg-SSAs, 32 patients carried the fl-GHR isoform, and 14 carried the d3-GHR isoform. From the group treated with Pasireotide LAR, 12 patients had the fl-GHR isoform, and 14 patients carried the d3-GHR isoform. I-VF occurred more frequently in patients with the fl-GHR isoform compared to d3-GHR (p =0.04); otherwise, I-VF occurred more frequently in patients with the d3-GHR isoform than fl-GHR (p =0.01). CONCLUSION: The GHR polymorphisms could improve the therapeutic approach in acromegaly, tailored to the individual patient, in the context of personalized medicine.

Development and validation of a predictive model for vertebral fracture risk in osteoporosis patients.

OBJECTIVE: This study aimed to develop and validate a predictive model for osteoporotic vertebral fractures (OVFs) risk by integrating demographic, bone mineral density (BMD), CT imaging, and deep learning radiomics features from CT images. METHODS: A total of 169 osteoporosis-diagnosed patients from three hospitals were randomly split into OVFs (n = 77) and Non-OVFs (n = 92) groups for training (n = 135) and test (n = 34). Demographic data, BMD, and CT imaging details were collected. Deep transfer learning (DTL) using ResNet-50 and radiomics features were fused, with the best model chosen via logistic regression. Cox proportional hazards models identified clinical factors. Three models were constructed: clinical, radiomics-DTL, and fusion (clinical-radiomics-DTL). Performance was assessed using AUC, C-index, Kaplan-Meier, and calibration curves. The best model was depicted as a nomogram, and clinical utility was evaluated using decision curve analysis (DCA). RESULTS: BMD, CT values of paravertebral muscles (PVM), and paravertebral muscles' cross-sectional area (CSA) significantly differed between OVFs and Non-OVFs groups (P < 0.05). No significant differences were found between training and test cohort. Multivariate Cox models identified BMD, CT values of PVM, and CSAPS reduction as independent OVFs risk factors (P < 0.05). The fusion model exhibited the highest predictive performance (C-index: 0.839 in training, 0.795 in test). DCA confirmed the nomogram's utility in OVFs risk prediction. CONCLUSION: This study presents a robust predictive model for OVFs risk, integrating BMD, CT data, and radiomics-DTL features, offering high sensitivity and specificity. The model's visualizations can inform OVFs prevention and treatment strategies.

Incidence of four major osteoporotic fragility fractures among older individuals in Sado, Japan, in 2020.

INTRODUCTION: This study compared the 2020 incidence of fragility fractures in Sado City with those from 2004 to 2015. MATERIALS AND METHODS: Data from patients aged ≥ 60 years living in Sado City with fragility fractures in the hip, vertebral, distal radius, and proximal humerus between January 1 and December 31, 2020, were collected. We examined the number and incidence of four types of osteoporotic fractures in the older population aged ≥ 60 years living in Sado City in 2020. We compared the results with those of the 2004, 2010, and 2015 surveys, examining the temporal change and trend in the incidence of the four fracture types in this population. We investigated the use rate of anti-osteoporotic medications and the relationship between their administration and the occurrence of fragility fractures. RESULTS: The age-specific incidence of hip fractures slightly decreased from 2015. However, the incidence of the other three fractures slightly increased, although the difference was not statistically significant. The incidence of hip fractures markedly increased in the 80 s. In 2020, the percentage of patients taking anti-osteoporotic agents before the occurrence of fractures decreased to 12.4% from 14.5% in 2015; it increased from 4% in 2004 to 7.6% in 2010. CONCLUSION: The 2020 incidence of the four fractures did not decrease, and the percentage of patients receiving anti-osteoporotic agents did not increase. A higher frequency of osteoporosis treatment is necessary to reduce the incidence of fragility fractures. We recommend using anti-osteoporotic agents to prevent hip fractures among individuals in their mid-70 s and above.

Chest tube management following two row vertebral body tethering for adolescent idiopathic scoliosis.

BACKGROUND: The current gold standard of scoliosis correction procedures is still posterior spinal fusion, an extensively studied procedure. anterior vertebral body tethering is a newer surgical technique for the correction of scoliotic curves. Consequently, best practices have yet to be determined. METHODS: A single-institution, retrospective, review of all patients diagnosed with adolescent idiopathic scoliosis who underwent two row anterior vertebral body tethering between June 2020 and April 2022 was performed. RESULTS: Over the study period, 95 patients met inclusion: 79 females (83.2%) and 16 males (16.8%), age 14.4 ± 2.5 years, with a body mass index of 20.0 ± 2.9, and an average of 8.4 ± 2.1 levels treated. 28 (29.5%) procedures were for double curves and 67 (70.5%) for single curves. After tethering, a chest tube was positioned in each corrected side. A total of 123 chest tubes were analyzed, including 67 single curves and 28 double curves. Average chest tube duration was 2.5 ± 1.1 days and average length of stay was 5.0 ± 2.0 days. Average chest tube output eight hours prior to removal was 61.1 ± 45.6 mL. There was no significant difference in average length of stay for patients who underwent correction of a single curve versus a double curve nor was there a difference in average length of stay or chest tube duration for revisions compared to primary procedures. For the entire cohort, 30-day emergency department visit rate was 7.4% (n = 7) and readmission rate was 4.2% (n = 4). CONCLUSIONS: This early review of a 2-year two row vertebral body tethering postoperative experience provides a report of a safe and effective approach to chest tube management at a single academic center.