Deep learning application of vertebral compression fracture detection using mask R-CNN.

Vertebral compression fractures (VCFs) of the thoracolumbar spine are commonly caused by osteoporosis or result from traumatic events. Early diagnosis of vertebral compression fractures can prevent further damage to patients. When assessing these fractures, plain radiographs are used as the primary diagnostic modality. In this study, we developed a deep learning based fracture detection model that could be used as a tool for primary care in the orthopedic department. We constructed a VCF dataset using 487 lateral radiographs, which included 598 fractures in the L1-T11 vertebra. For detecting VCFs, Mask R-CNN model was trained and optimized, and was compared to three other popular models on instance segmentation, Cascade Mask R-CNN, YOLOACT, and YOLOv5. With Mask R-CNN we achieved highest mean average precision score of 0.58, and were able to locate each fracture pixel-wise. In addition, the model showed high overall sensitivity, specificity, and accuracy, indicating that it detected fractures accurately and without misdiagnosis. Our model can be a potential tool for detecting VCFs from a simple radiograph and assisting doctors in making appropriate decisions in initial diagnosis.

The positive impact of smoking cessation on fracture risk in a nationwide cohort study.

Many studies sought to demonstrate the association between smoking and fracture risk. However, the correlation between smoking and fractures remains controversial. This study aimed to examine the impact of smoking and smoking cessation on the occurrence of fractures using prospective nationwide cohort data. We enrolled those who underwent a National Health Insurance Service (NHIS) health checkup in 2009-2010 who had a previous health checkup 4-year prior (2005-2006). The study population of 4,028,559 subjects was classified into three groups (non-smoker, smoking cessation, current smoker). The study population was also analyzed according to fracture type (all fractures, vertebral fracture, hip fracture). Lastly, the smoking cessation group and current smoker group were divided into four subgroups based on a lifetime smoking amount cut-off of 20 pack-years (PY). Multivariate-adjusted hazard ratios (HRs) of fracture were examined through a Cox proportional hazards model. After multivariable adjustment, non-smokers showed the lowest risk of fracture (HR = 0.818, CI 0.807-0.828, p < 0.0001) and smoking cessation significantly lowered the risk of fracture (HR 0.938, 95% CI 0.917-0.959, p < 0.0001) compared to current smokers. Regardless of 20PY, all smoking cessation subgroups showed significantly less risk of fractures than current smokers with ≥ 20PYs. Smoking increases the risk of fracture, and smoking cessation lowers the risk of fracture.

Weight changes after smoking cessation affect the risk of vertebral fractures: a nationwide population-based cohort study.

BACKGROUND CONTEXT: Smoking cessation reduces the risk of vertebral and hip fractures but usually increases body weight. Since underweight is known as a risk factor for vertebral fractures, smoking cessation is considered to have a protective effect on vertebral fractures. However, the actual effect of weight change after smoking cessation on the risk of vertebral fractures remains uncertain. PURPPOSE: This study aimed to assess the risk of vertebral fractures among individuals who reported smoking cessation with a specific focus on changes in body weight. STUDY DESIGN: Retrospective cohort study based on nationwide health insurance database. PATIENT SAMPLE: Participants were from nationwide biennial health checkups between 2007 and 2009 conducted by the Korean National Health Insurance Service. Participants were followed up from 2010 to 2018 to find incidence of newly developed vertebral fractures. OUTCOME MEASURES: The incidence rate was defined as the incidence rate (IR) per 1,000 person-years (PY). Cox proportional regression analysis was used to analyze the risk of vertebral fracture to determine the hazard ratio (HR) associated with the incidence of vertebral fractures based on smoking status and weight changes. METHODS: Based on their self-reported questionnaires, the participants were classified into three groups: current smokers, quitters, and nonsmokers. The quitter was defined as an individual who were smokers in 2007 and ceased smoking in 2009. Individuals with smoking cessation were categorized according to the weight change between baseline and 2 years prior: weight maintenance (-5∼5 % of weight change), weight loss (<-5 % of weight change), and weight gain (>5 % of weight change). We used Cox proportional hazards analysis to determine the hazard ratio (HR) associated with the incidence of vertebral fractures based on smoking status and temporal weight change over 2 years. RESULTS: This study evaluated 913,805 eligible participants, of whom 672,858 were classified as nonsmokers, 34,143 as quitters, and 206,804 as current smokers. Among quitters, 2,372 (6.9%) individuals had weight loss, and 7,816 (22.9%) had weight gain over 2 years. About 23,952 (70.2%) individuals maintained their weight over 2 years. The overall risk of vertebral fractures was significantly higher in quitters (adjusted HR [aHR]=1.110, 95% confidence interval [CI] 1.013-1-216) than in nonsmokers, but it was lower than in current smokers (aHR=1.197, 95%CI 1.143-1.253), regardless of weight change after smoking cessation. However, individuals who experienced weight loss after smoking cessation exhibited a notably higher risk of vertebral fractures than current smokers (aHR=1.321, 95%CI 1.004-1.461). In the female population, weight gain after smoking cessation was associated with a higher risk of vertebral fractures (aHR = 1.470, 95%CI 1.002-2.587) than in current female smokers. CONCLUSIONS: Maintaining weight after smoking cessation may mitigate the risk of vertebral fractures. Weight loss after smoking cessation adversely affects the protective effects of smoking cessation on vertebral fractures in the general population.

Lumbar radiculopathy and fracture risk: A Korean nationwide population-based cohort study.

INTRODUCTION: Lumbar radiculopathy is a common disease with a high economic burden, and fractures in adults are a significant public health problem. However, studies of the relationship between lumbar radiculopathy and fractures are scarce. We investigated the fracture risk in patients with lumbar radiculopathy. METHODS: This nationwide retrospective cohort study identified 815,101 patients with lumbar radiculopathy and randomly matched individuals without lumbar radiculopathy (1:1) who were included in the Korean National Health Insurance System in 2012. Cox proportional hazards regression analyses were performed to calculate the hazard ratio (HR) for fracture risk in patients with lumbar radiculopathy. RESULTS: The study included 301,347 patients with lumbar radiculopathy and matched 289,618 individuals without lumbar radiculopathy. Compared to individuals without lumbar radiculopathy, patients with lumbar radiculopathy had a 27 % increased fracture risk (adjusted HR = 1.27, 95 % confidence interval = 1.24-1.31). The Kaplan-Meier plot showed a significantly higher fracture incidence in patients with lumbar radiculopathy than in individuals without lumbar radiculopathy at all times. CONCLUSION: Lumbar radiculopathy is significantly associated with fracture risk.

Incidence and Risk Factors for Wound Revision after Surgical Treatment of Spinal Metastasis: A National Population-Based Study in South Korea.

Wound complications are commonly seen after surgeries for metastatic spine tumors. While numerous studies have pinpointed various risk factors, there is ongoing debate. Therefore, this study aimed to verify various factors that are still under debate utilizing the comprehensive Korean National Health Insurance Service database. We identified and retrospectively reviewed a cohort of 3001 patients who underwent one of five surgical treatments (corpectomy, decompression and instrumentation, instrumentation only, decompression only, and vertebroplasty) for newly diagnosed spinal metastasis between 2009 and 2017. A Cox regression analysis was performed to determine the risk factors. A total of 197 cases (6.6%) of wound revision were found. Only the surgical method and Charlson comorbidity index were significantly different between the group that underwent wound revision and the group that did not. Regarding surgical methods, the adjusted hazard ratios for decompression only, corpectomy, instrumentation and decompression, and instrumentation only were 1.3, 2.2, 2.2, and 2.4, with these ratios being compared to the vertebroplasty group (p for trend = 0.02). In this regard, based on a sizable South Korean cohort, both surgical methods and medical comorbidity were found to be associated with the wound revision rate among spinal surgery patients for spinal metastasis.

Factors affecting successful immediate indirect decompression in oblique lateral interbody fusion in lumbar spinal stenosis patients.

Background: Oblique lumbar interbody fusion (OLIF) offers indirect decompression of stenotic lesions of the spinal canal and foramen through immediate disc height restoration. Only a few studies have reported the effect of cage position and associated intraoperatively modifiable factors for successful immediate indirect decompression following OLIF surgery. This study aimed to investigate the intraoperatively modifiable factors for successful radiological outcomes of OLIF. Methods: This study included 46 patients with 80 surgical levels who underwent OLIF without direct posterior decompression. Preoperative and postoperative radiological parameters were evaluated and intraoperatively modifiable radiologic parameters for successful immediate radiologic decompression on magnetic resonance image (MRI) were determined. Radiologic parameters were preoperative and postoperative radiological parameters including anterior disc height (ADH), posterior disc height (PDH) lumbar lordotic angle (LLA), segmental lordotic angle (SLA), foraminal height (FH), cage position, cross-sectional area (CSA) of the thecal sac, cross-sectional foraminal area (CSF), facet distance (FD). Results: All radiologic outcomes significantly improved. Comparing preoperative and postoperative values, mean CSA increased from 99.63±40.21 mm2 to 125.02±45.90 mm2 (p<.0001), and mean left CSF increased from 44.54±12.90 mm2 to 69.91±10.80 mm2 (p<.0001). FD also increased from 1.40±0.44 to 1.92±0.71 mm (p<.0001). FH increased from 16.31±3.3 to 18.84±3.47 mm (p<.0001). ADH and PDH also significantly increased (p<.0001). Immediate postoperative CSF and FH improvement rate (%) were significantly correlated with posterior disc height restoration rate (%) (p=.0443, and p=.0234, respectively). In addition, the patients with a cage positioned in the middle of the vertebral body experienced a greater FH improvement rate (%) compared to the patients with a cage positioned anteriorly. Finally, Visual analogue scale (VAS) for leg pain was improved immediately. Conclusions: OLIF provided satisfactory immediate indirect decompression in central and foraminal spinal stenosis. Moreover, intraoperative surgical technique for successful radiologic CSF and FH improvement included restoration of the PDH and placement of the cage in the middle.

The novel use and feasibility of hemostatic oxidized regenerated cellulose agent (SurgiGuard®): multicenter retrospective study.

Background: SurgiGuard® is an absorbent hemostatic agent based on oxidized regenerated cellulose. The efficacy, effects and safety of SurgiGuard® are equivalent to existing hemostatic agents in animal experiments. This study was designed to confirm that the use of SurgiGuard® alone is effective, safe and feasible compared to combination with other hemostatic methods. Methods: We retrospectively reviewed clinical data from 12 surgery departments in seven tertiary centers in South Korea nationwide. All surgeries were performed between January and December 2018. Results: A total of 807 patients were enrolled; 447 patients (55.4%) had comorbidities. The rate of major surgery (operative time ≥4 hours) was 44% (n=355 patients). Regarding the type of SurgiGuard® used in surgery, more than 70% of minor surgeries used non-woven types. In major surgery, more than five SurgiGuards® were used in 7.3% (26 patients), and the proportion of co-usage (with four other hemostatic products) was 19.7% (70 patients). The effectiveness score was higher when SurgiGuard® was used alone in both major (5.3±0.5 vs. 5.1±0.6, P=0.048) and minor surgery (5.4±0.6 vs. 5.2±0.4, P<0.001). Seven patients had immediate re-bleeding, and all of them used SurgiGuard® and other products together. Nine patients reported adverse effects, such as abscess, bleeding, or leg swelling, but we found no direct correlation with SurgiGuard®. Conclusions: SurgiGuard® exhibited greater effectiveness when used alone. No direct adverse effects associated with SurgiGuard® use were reported, and SurgiGuard® had stable feasibility. Prospective comparative studies are needed in the future.

Spinal epidural abscess as predicting factor for the necessity of early surgical intervention in patients with pyogenic spondylitis.

BACKGROUND: Pyogenic spondylitis is a condition with low incidence that can lead to neurological sequelae and even life-threatening conditions. While conservative methods, including antibiotics and bracing, are considered the first-line treatment option for pyogenic spondylitis, it is important to identify patients who require early surgical intervention to prevent progressive neurologic deficits or deterioration of the systemic condition. Surgical treatment should be considered in patients with progressive neurologic deficits or deteriorating systemic condition. However, currently, there is a lack of treatment guidelines, particularly with respect to whether surgical treatment is necessary for pyogenic spondylitis. This study aims to analyze the radiological epidural abscess on MRI and clinical factors to predict the need for early surgical intervention in patients with pyogenic spondylitis and provide comprehensive insight into the necessity of early surgical intervention in these patients. METHODS: This study retrospectively reviewed 47 patients with pyogenic spondylitis including spondylodiscitis, vertebral osteomyelitis, epidural abscess, and/or psoas abscess. All patients received plain radiographs, and a gadolinium-enhanced magnetic resonance imaging (MRI) scan. All patients have either tissue biopsies and/or blood cultures for the diagnosis of a pathogen. Demographic data, laboratory tests, and clinical predisposing factors including comorbidities and concurrent other infections were analyzed. RESULTS: We analyzed 47 patients, 25 of whom were female, with a mean age of 70,7 years. MRI revealed that 26 of 47 patients had epidural abscesses. The surgical group had a significantly higher incidence of epidural abscess than the non-surgical group (p = 0.001). In addition, both CRP and initial body temperature (BT) were substantially higher in the surgical group compared to the non-surgical group. There was no significant difference between the surgical group and the non-surgical group in terms of age, gender, comorbidities, and concurrent infectious disorders, as well as the number of affected segments and affected spine levels. However, the surgical group had lengthier hospital stays and received more antibiotics. CONCLUSION: The presence of an epidural abscess on MRI should be regarded crucial in the decision-making process for early surgical treatment in patients with pyogenic spondylitis in order to improve clinical outcomes.

Anterior Cervical Discectomy and Fusion Performed Using a CaO-SiO2-P2O5-B2O3 Bioactive Glass Ceramic or Polyetheretherketone Cage Filled with Hydroxyapatite/ß-Tricalcium Phosphate: A Prospective Randomized Controlled Trial.

A CaO-SiO2-P2O5-B2O3 bioactive glass-ceramic (BGS-7) spacer provides high mechanical stability, produces a chemical bond to the adjacent endplate, and facilitates fusion after spine surgery. This prospective, randomized, single-blind, non-inferiority trial aimed to evaluate the radiographic outcomes and clinical efficacy of anterior cervical discectomy and fusion (ACDF) using a BGS-7 spacer for treating cervical degenerative disorders. Thirty-six patients underwent ACDF using a BGS-7 spacer (Group N), and 40 patients underwent ACDF using polyetheretherketone (PEEK) cages filled with a mixture of hydroxyapatite (HA) and ß-tricalcium phosphate (ß-TCP) for the treatment of cervical degenerative disorders. The spinal fusion rate was assessed 12 months postoperatively using three-dimensional computed tomography (CT) and dynamic radiographs. Clinical outcomes included patient-reported outcome measures, visual analog scale scores for neck and arm pain, and scores from the neck disability index (NDI), European Quality of Life-5 Dimensions (EQ-5D), and 12-item Short Form Survey (SF-12v2). All participants were randomly assigned to undergo ACDF using either a BGS-7 spacer or PEEK cage filled with HA and ß-TCP. The primary outcome was the fusion rate on CT scan image at 12 months after ACDF surgery based on a per-protocol strategy. Clinical outcomes and adverse events were also assessed. The 12-month fusion rates for the BGS-7 and PEEK groups based on CT scans were 81.8% and 74.4%, respectively, while those based on dynamic radiographs were 78.1% and 73.7%, respectively, with no significant difference between the groups. There were no significant differences in the clinical outcomes between the two groups. Neck pain, arm pain, NDI, EQ-5D, and SF-12v2 scores significantly improved postoperatively, with no significant differences between the groups. No adverse events were observed in either group. In ACDF surgery, the BGS-7 spacer showed similar fusion rates and clinical outcomes as PEEK cages filled with HA and ß-TCP.

Anterolateral versus posterior minimally invasive lumbar interbody fusion surgery for spondylolisthesis: comparison of outcomes from a global, multicenter study at 12-months follow-up.

BACKGROUND CONTEXT: Several minimally invasive lumbar interbody fusion techniques may be used as a treatment for spondylolisthesis to alleviate back and leg pain, improve function and provide stability to the spine. Surgeons may choose an anterolateral or posterior approach for the surgery however, there remains a lack of real-world evidence from comparative, prospective studies on effectiveness and safety with relatively large, geographically diverse samples and involving multiple surgical approaches. PURPOSE: To test the hypothesis that anterolateral and posterior minimally invasive approaches are equally effective in treating patients with spondylolisthesis affecting one or two segments at 3-months follow-up and to report and compare patient reported outcomes and safety profiles between patients at 12-months post-surgery. DESIGN: Prospective, multicenter, international, observational cohort study. PATIENT SAMPLE: Patients with degenerative or isthmic spondylolisthesis who underwent 1- or 2-level minimally invasive lumbar interbody fusion. OUTCOME MEASURES: Patient reported outcomes assessing disability (ODI), back pain (VAS), leg pain (VAS) and quality of life (EuroQol 5D-3L) at 4-weeks, 3-months and 12-months follow-up; adverse events up to 12-months; and fusion status at 12-months post-surgery using X-ray and/or CT-scan. The primary study outcome is improvement in ODI score at 3-months. METHODS: Eligible patients from 26 sites across Europe, Latin America and Asia were consecutively enrolled. Surgeons with experience in minimally invasive lumbar interbody fusion procedures used, according to clinical judgement, either an anterolateral (ie, ALIF, DLIF, OLIF) or posterior (MIDLF, PLIF, TLIF) approach. Mean improvement in disability (ODI) was compared between groups using ANCOVA with baseline ODI score used as a covariate. Paired t-tests were used to examine change from baseline in PRO for both surgical approaches at each timepoint after surgery. A secondary ANCOVA using a propensity score as a covariate was used to test the robustness of conclusions drawn from the between group comparison. RESULTS: Participants receiving an anterolateral approach (n=114) compared to those receiving a posterior approach (n=112) were younger (56.9 vs 62.0 years, p <.001), more likely to be employed (49.1% vs 25.0%, p<.001), have isthmic spondylolisthesis (38.6% vs 16.1%, p<.001) and less likely to only have central or lateral recess stenosis (44.9% vs 68.4%, p=.004). There were no statistically significant differences between the groups for gender, BMI, tobacco use, duration of conservative care, grade of spondylolisthesis, or the presence of stenosis. At 3-months follow-up there was no difference in the amount of improvement in ODI between the anterolateral and posterior groups (23.2 ± 21.3 vs 25.8 ± 19.5, p=.521). There were no clinically meaningful differences between the groups on mean improvement for back- and leg-pain, disability, or quality of life until the 12-months follow-up. Fusion rates of those assessed (n=158; 70% of the sample), were equivalent between groups (anterolateral, 72/88 [81.8%] fused vs posterior, 61/70 [87.1%] fused; p=.390). CONCLUSIONS: Patients with degenerative lumbar disease and spondylolisthesis who underwent minimally invasive lumbar interbody fusion presented statistically significant and clinically meaningful improvements from baseline up to 12-months follow-up. There were no clinically relevant differences between patients operated on using an anterolateral or posterior approach.

Underweight and risk of fractures in adults over 40 years using the nationwide claims database.

We aimed to investigate how underweight affects the incidence of fractures, as well as the influence of cumulative, longitudinal periods of low body mass index (BMI) and changes in body weight on fracture development. Data on adults aged 40-year and over who had three health screenings between January 1, 2007, and December 31, 2009 were used to determine the incidence of new fractures. The hazard ratios (HRs) for new fractures depending on BMI, total cumulative number of underweight, and weight change over time were calculated using Cox proportional hazard analysis. In this study, 15,955 (2.8%) of the 561,779 adults were diagnosed with fractures more than once over three health examinations. The fully adjusted HR for fractures in underweight individuals was 1.173 (95% Confidence interval [CI] 1.093-1.259). Underweight individuals diagnosed only once, twice, or three times had an adjusted HR of 1.227 (95%CI 1.130-1.332), 1.174 (95%CI 1.045-1.319), and 1.255 (95%CI 1.143-1.379), respectively. Although the adjusted HR was higher in adults who consistently had underweight (HR; 1.250 [95%CI 1.146-1.363]), those with underweight had an increased risk of fractures regardless of weight change (HR; 1.171 [95%CI 1.045-1.312], and 1.203[95%CI 1.075-1.346]). Underweight is a risk factor for fractures in adults over the age of 40 years, even if they returned to normal weight.

Risk of fracture according to temporal changes of low body weight changes in adults over 40 years: a nationwide population-based cohort study.

BACKGROUND: Low body weight is associated with an increased risk of fractures. However, the effect of temporal changes in the low body weight status on the risk of fracture remains unknown. This study aimed to evaluate the relationships between temporal changes in low body weight status and the risk of fractures in adults over the age of 40 years. METHODS: This study included data on adults over 40 years old who underwent two biannual consecutive general health examinations between January 1, 2007 and December 31, 2009 extracted from the National Health Insurance Database, a large nationwide population database. Fracture cases in this cohort were monitored from the time of the last health examination to the end of the designated follow-up period (from January 1, 2010 to December 31, 2018) or the participant's death. Fractures were defined as any fracture resulting in hospitalization or outpatient treatment claim after the date of general health screening. The study population was then separated into four groups based on the temporal changes in low body weight status as follows: low body weight to low body weight (L-to-L), low body weight to non-low body weight (L-to-N), non-low body weight to low body weight (N-to-L), and non-low body weight to non-low body weight (N-to-N). The hazard ratios (HRs) for new fractures, depending on weight changes over time, were calculated using Cox proportional hazard analysis. RESULTS: Adults in the L-to-L, N-to-L, and L-to-N groups had a substantially increased risk of fractures after multivariate adjustment (HR, 1.165; 95% confidence interval [CI], 1.113-1.218; HR, 1.193; 95% CI, 1.131-1.259; and HR, 1.114; 95% CI, 1.050-1.183, respectively). Although the adjusted HR was greater in participants who changed into having a low body weight, followed by those with consistently low body weight, those with low body weight remained to have an elevated risk of fracture independent of weight fluctuation. Elderly men (aged over 65 years), high blood pressure, and chronic kidney disease were significantly associated with an increase in fractures (p < 0.05). CONCLUSION: Individuals aged over 40 years with low body weight, even after regaining normal weight, had an increased risk of fracture. Moreover, having a low body weight after having a normal body weight increased the risk of fractures the most, followed by those with consistently low body weight.

Underweight as a risk factor for vertebral fractures in the South Korean population.

BACKGROUND CONTEXT: Being underweight is a known risk factor for osteoporosis and sarcopenia that is strongly associated with vertebral fractures, particularly in the elderly. Being underweight can accelerate bone loss, contribute to impaired coordination, and increase fall risk in the elderly and the general population. PURPOSE: This study aimed to identify the degree of underweight as a risk factor for vertebral fractures in the South Korean population. STUDY DESIGN: Retrospective cohort study based on national health insurance database. PATIENT SAMPLE: Participants were included from nationwide regular health check-ups conducted by the Korean National Health Insurance Service in 2009. Participants were followed up from 2010 to 2018 to identify the incidence of newly developed fractures. OUTCOME MEASURES: The incidence rate (IR) was defined as the incident per 1,000 person-years (PY). Vertebral fracture development risk was analyzed using Cox proportional regression analysis. Subgroup analysis was performed based on several factors, including age, sex, smoking status, alcohol consumption, physical activity, and household income. METHODS: Based on body mass index, the study population was categorized into normal weight (18.50-22.99 kg/m2), mild underweight (17.50-18.49 kg/m2), moderate underweight (16.50-17.49 kg/m2), and severe underweight (<16.50 kg/m2) groups. Cox proportional hazards analyses were performed to calculate the hazard ratios for vertebral fractures based on the degree of underweight with respect to normal weight to identify the associated risk. RESULTS: This study evaluated 962,533 eligible participants, of whom 907,484 were classified as normal weight, 36,283 as mild underweight, 13,071 as moderate underweight, and 5,695 as severe underweight. The adjusted hazard ratio of vertebral fractures increased as the degree of underweight increased. Severe underweight was associated with a higher likelihood of vertebral fracture. The adjusted hazard ratio was 1.11 (95% confidence interval [CI], 1.04-1.17) in the mild underweight group, 1.15 (1.06-1.25) in the moderate underweight group, and 1.26 (1.14-1.40) in the severe underweight group when compared with the normal weight group. CONCLUSIONS: Underweight is a risk factor for vertebral fractures in the general population. Furthermore, severe underweight was associated with a higher risk of vertebral fractures, even after adjustment for other factors. Clinicians could provide real-world evidence that being underweight carries the risk of vertebral fractures.

The Impact of Persistent Low Weight Status on the Occurrence of Vertebral Fractures: A Nationwide Population-Based Cohort Study.

BACKGROUND: Although, being underweight is commonly associated with osteoporosis and sarcopenia, its association with vertebral fractures (VFs), is less well researched. We investigated the influence of cumulative, chronic periods of low weight and changes in body weight on VF development. METHODS: We used a nationwide, population-based database with data on people (> 40 years) who attended three health screenings between January 1, 2007, and December 31, 2009 to assess the incidence of new VFs. Cox proportional hazard analyses were used to establish the hazard ratios (HRs) for new VFs based on the degree of body mass index (BMI), the cumulative numbers of underweight participants, and temporal change in weight. RESULTS: Of the 561,779 individuals in this analysis, 5,354 (1.0%) people were diagnosed three times, 3,672 (0.7%) were diagnosed twice, and 6,929 (1.2%) were diagnosed once. The fully adjusted HR for VFs in underweight individuals was 1.213. Underweight individuals diagnosed only once, twice, or three times had an adjusted HR of 0.904, 1.443, and 1.256, respectively. Although the adjusted HR was higher in adults who were consistently underweight, there was no difference in those who experienced a temporal change in body weight. BMI, age, sex, and household income were significantly associated with VF incidence. CONCLUSION: Low weight is a risk factor for VFs in the general population. Given the significant correlation between cumulative periods of low weight and the risk of VFs, it is necessary to treat underweight patients before a VF to prevent its development and other osteoporotic fractures.

Cumulative Burden of Being Underweight Increases the Risk of Hip Fracture: A Nationwide Population-Based Cohort Study.

(1) Background: Being underweight is a known risk factor for hip fractures. However, it is unclear whether the cumulative underweight burden affects the incidence of hip fractures. Therefore, we explored the effect of the cumulative underweight burden on the development of hip fractures; (2) Methods: In a cohort of adults aged 40 years and older, 561,779 participants who were not underweight and had no hip fractures from 2007 to 2009 were identified. The risk of hip fracture from the time of the last examination to December 2018 according to the cumulative burden of being underweight (based on 0 to 3 examinations) was prospectively analyzed; (3) Results: During follow-up (mean 8.3 ± 0.8 years), the prevalence of newly diagnosed hip fractures was 0.2%, 0.4%, 0.5%, and 0.9% among those with 0, 1, 2, and 3 cumulative underweight, respectively. The adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) of groups meeting the diagnostic criteria for underweight 1, 2, and 3 compared to 0 were 2.3 (1.6−3.3), 2.9 (1.8−4.5), and 4.5 (3.4−6.1), respectively (p for trend < 0.01); (4) Conclusions: The risk of hip fracture increased as the burden of underweight accumulated.

The Efficiency and Reliability of Minimally Invasive Anterior Corpectomy and Percutaneous Posterior Stabilization for the Treatment of Unstable Thoracolumbar Burst Fractures.

OBJECTIVE: The purpose of this study was to evaluate the radiological and clinical outcomes of minimally invasive anterior corpectomy and percutaneous posterior stabilization for treating unstable thoracolumbar burst fractures. METHODS: Patients with unstable thoracolumbar burst fractures who underwent minimally invasive anterior corpectomy and percutaneous posterior stabilization between 2012 and 2019 at a tertiary hospital were enrolled. Radiological outcomes such as endplate subsidence and fusion status were identified on preoperative and postoperative plain radiographs and computed tomography images. Preoperative and postoperative neurological statuses were evaluated using the American Spinal Injury Association impairment scale. Furthermore, operation-related parameters were analyzed. RESULTS: In total, 21 patients (mean follow-up period, 21.7 months) were included in this study. Of them, 17 (80.95%) patients exhibited complete fusion according to the Bridwell's criteria at the final follow-up, and only 1 patient exhibited nonunion at the surgical level. Endplate subsidence was observed in 6 (28.57%) patients; however, there were no definite symptoms that would have necessitated a revision surgery. Of 15 patients with preoperative neurological impairment, 7 exhibited neurological improvement during follow-up. None of the patients experienced postoperative neurological deterioration. Regarding operation-related parameters, the mean operative time and intraoperative blood loss were 266.19 ± 51.54 min and 520.71 ± 190.86 ml, respectively. The mean length of hospital stays and days to postoperative ambulation were 12.14 and 4.20 days, respectively. CONCLUSIONS: Minimally invasive anterolateral corpectomy with percutaneous pedicle screw fixation is a reliable surgical treatment option for unstable thoracolumbar burst fractures.

Comparison of minimally invasive and open TLIF outcomes with more than seven years of follow-up.

Background: Few studies directly comparing minimally invasive (MI) transforaminal lumbar interbody fusion (TLIF) and open TLIF offering long-term follow-up data have been performed to date. Therefore, we sought to compare mid- to long-term outcomes between these two surgical approaches. Methods: This was a retrospective data analysis of two surgical groups. We analyzed the details of 97 patients with degenerative lumbar disease who were treated with MI TLIF (n = 55) or open TLIF (n = 42) between 2011-2014 and had at least seven years of follow-up data available. Peri- and postoperative outcomes were compared. To evaluate rates of adjacent segment disease (ASD) and revisions, frequencies of radiologic, symptomatic, and operative ASD were analyzed accordingly. Results: In terms of clinical outcome, the Oswestry Disability Index and visual analog scale scores were significantly reduced, with no difference between the groups. However, data for several peri- and postoperative outcomes, including perioperative blood loss, ambulation day, hospital stay, and operation time, varied in a manner favoring the MI TLIF group (P < 0.05). Rates of radiologic ASD and symptomatic ASD were significantly higher in the open TLIF group beginning at five years of follow-up (P < 0.05), while the rate of operative ASD and the revision rate were similar between the groups. Other long-term outcomes, including fusion rate and complications, remained similar between the two groups at 7 years. Conclusion: Patients undergoing MI TLIF showed favorable immediate postoperative outcomes and less radiographic ASD. However, the rates of fusion and operative ASD remained similar between the two groups after 7 years of follow-up.

Incidence of hip fracture in underweight individuals: a nationwide population-based cohort study in Korea.

BACKGROUND: Hip fracture is a major public health problem worldwide and being underweight is a risk factor for fractures. Few studies have investigated the association between being underweight and hip fracture in the general population. The present study investigated the incidence of hip fracture in a large population cohort based on detailed information about the degree of underweight. METHODS: A nationwide retrospective cohort study of adults ≥40 years of age included 962,533 subjects who were not overweight or obese in 2009. The incidence and risk of hip fracture occurring between 2010 and 2018 was assessed based on the degree of underweight. Based on body mass index (BMI), the study population was categorized into normal (18.50-22.99 kg/m2 ), mild (17.00-18.49 kg/m2 ), moderate (16.00-16.99 kg/m2 ), and severe underweight (<16.00 kg/m2 ) groups. Cox proportional hazards analyses were performed to calculate the hazard ratio (HR) for the hip fracture based on the degree of underweight in reference to the normal weight. RESULTS: Compared with subjects who were normal weight, those who were classified as mild underweight (1.03/1000 person-years (PY) increase in incidence rate (IR); adjusted HR (aHR) 1.61; 95% confidence interval (CI) 1.48-1.76), moderate underweight (2.04/1000 PY increase in IR; aHR 1.85; 95% CI 1.65-2.08), or severe underweight (4.58/1000 PY increase in IR; aHR 2.33; 95% CI 2.03-2.66) were at significantly increased risk of hip fracture. CONCLUSIONS: The severity of underweight was significantly associated with risk of hip fracture. The subdivision of underweight helps to estimate fracture risk more accurately.

Severity of underweight and risk of fracture: a Korean nationwide population-based cohort study.

Underweight is an important modifiable risk factor for fractures. However, there have been few large cohort studies regarding the relationship between underweight and fracture in the general population. We investigated the risk of fracture development according to underweight severity in a large population cohort. This nationwide cohort study included 2,896,320 people aged ≥ 40 years who underwent national health checkups in 2009 and were followed up to identify the incidence of fracture until December 31, 2018. After applying the exclusion criteria that included overweight and obese individuals, the study population was divided according to body mass index (BMI) into normal weight (18.5 ≤ BMI < 23.0), mild underweight (17.5 ≤ BMI < 18.5), moderate underweight (16.5 ≤ BMI < 17.5), and severe underweight (BMI < 16.5) groups. Cox proportional hazards regression analyses were performed to calculate the hazard ratios for risk of fracture according to underweight severity. Severely underweight participants had a 28% increased fracture risk (adjusted hazard ratio [HR] 1.28, 95% confidence interval [CI] 1.20-1.37) compared with those of normal weight. In addition, fracture risk was increased by 14% in individuals with moderate underweight (adjusted HR 1.14, 95% CI 1.08-1.19) and 9% in those with mild underweight (adjusted HR 1.09, 95% CI 1.06-1.13). The severity of underweight was significantly associated with risk of fracture.

The Influence of Rheumatoid Arthritis on Higher Reoperation Rates over Time Following Lumbar Spinal Fusion-A Nationwide Cohort Study.

This study aimed to compare the rates of reoperation over time following first lumbar fusion in rheumatoid arthritis (RA) patients and non-RA patients. This study was conducted using Korean Health Insurance Review and Assessment (HIRA) data. We identified the RA group as 2239 patients who underwent their first lumbar fusion with RA and the control group as 11,195 patients without RA. This reflects a ratio of 1:5, and the participants were matched by sex, age, and index surgery date. The index dates were between 2012 and 2013. When comparing the rate of patients undergoing reoperation, the adjusted HR was 1.31 (95% CI: 1.10−1.6) in the RA group (p = 0.002). In terms of the three time intervals, the values in the time frames of <3 months and 3 months−1 year were not statistically significant. However, at 1 year post-surgery, there was a higher risk of reoperation in the RA group, as demonstrated by the Kaplan−Meier cumulative event analysis. This higher risk of reoperation continued to increase throughout 5 years of follow-up, after which it was stable until the last follow-up at 7 years. This population-based cohort study showed that the RA patients had a 1.31 times higher risk of reoperation following lumbar fusion than did the controls. This difference was more pronounced at 1 year post-surgery.