Diagnositic Algorithm And Treatment Analysis Of Painful Osteoporotic Vertebral Compression Fractures

Background:With population aging and longer average life span,osteoporosis becomes a more paramount public health issue than ever.Most devastating sequela of osteoporosis is fracture.Osteoporotic vertebral compression fractures?OVCFs?is one of most common frailty,threatening the health of postmenopausal women and the elderly populations.Currently,under-recognition of initial OVCFs is a worldwide problem at the time of occurrence,with a high proportion of misdignosis and underdignosis.Innumerable studies focused on the etiology,imaging diagnostic investigations,fracture risk assessment,prognosis,prevention,and management of OVCFs.However,there were few literatures on symptoms and clinical signs.It is well known that well-recognized clinical features of a disease,particularly red flag symptoms and physical examinations are conducive to evidence-informed downstream clinical decision making,facilitating timely referral for proper management.It is a problem with far-reaching medical and social impacts that identification of the characteristic clinical signs and symptoms of a disease which would help clinicians detect serious underlying pathology,such as malignancy,infection and fractures.Patients with OVCFs live in a poor quality of life due to back pain,with a high mortality and refracture risk.Approriated medical intervention can improve the prognosis.Currently,there are three major methods for treatmentof OVCFs,including conservative treatment,vertebral augmentation?VA?,and open surgery.Percutaneous vertebroplasty?PVP?and percutaneous kyphoplasty?PKP?are two methods of VA.However,the treatment options for OVCFs are still controversial,particularly for conservative treatment,mainly due to lack of standardized treatment framework,and high-level evidence-based evidence.As PVP is generalized due to minimally invasive and rapid and obvious analgesic effect,the significance of conservative treatment has been neglected.Objective:A prospective observational study was performed to evaluate the accuracy of back pain-inducing test?lying supine-rolling over-sitting up,BPIT?screening for painful OVCFs.And the consistency between back pain site,level of spinous process closed-fist percussion sign,and the location of vertebral fracture for patients with OVCFs was anlyzed.A retrospective study was designed to analyze the correlation between conservative treatment,vertebral augmentation,open surgery and clinical features in patients with painful OVCFs.Methods and results:Part 1Diagnostic algorithm for painful OVCFs:a prospective observational study.From November 1st 2016 to July 30th 2018,629 potential participants who complain back pain,were recruited in the spine clinic of Daping hospital.Inclusion criterion:?postmenopausal women or over age 50,men over age 60;?history of prolonged use of glucorticosteroids more than 3 months at any age for both genders.Exclusion criterion:?back pain with radiating pain to limbs or night/rest pain;?definite recent high-energy trauma;?established radiological diagnosis of infection,tumor or fractures in other medical facility before the interview with us;?back pain with quadriplegic,spinal cord injury or nerve root dysfunction;?incapable to accomplish the test due to cognitive or mental impairment,dysfunction in communication?deaf and/or dumb?;?6?failure to complete MRI scan due to any condition,such as claustrophobia,artificial peacemaker implantation.Eligible subjects were invited into examination room to inform the procedure of BPIT,which was conducted after informed consent.A physical examination?PE?named BPIT was designed based on our rationale of“dynamic back pain”in patients with vertebral fractures.It included three consecutive movements?lying in a supine position,rolling over,and sitting up?and was performed during routine spine care.A numerical rating scale?NRS?or verbal descriptor was used to assess back pain experienced during every movement described above in a face-to-face interview during the PE.BPIT was defined as positive?primary diagnosis of OVCFs?if individuals complained of back pain during any of the three consecutive movements and negative if no pain was experienced?primary diagnosis of non-OVCFs?,the BPIT result was also defined as positive?primary diagnosis of OVCFs?if patients could not accomplish any of the three movements due to back pain.Spinous process closed-fist percussion sign?SPCFP?and spinal axial closed-fist percussion sign?SACFPS?were performed,the positive results and the level of back pain was recorded.Subsequently,the whole spine magnetic resonance imaging?MRI?scans were performed to evaluate the presence or absence of OVCFs.Our results show:Five hundred and ten patients who completed the BPIT and MRI evaluation were included in all the following analyses.The sensitivity,specificity,and accuracy of BPIT for diagnosing primary OVCFs were 99.1%?95%CI 97.5%-99.8%?,67.9%?95%CI 60.4%-74.5%?,89.0%,respectively.The positive and negative predictive values were 86.6%?95%CI 82.9%-89.6%?and 97.4%?95%CI92.6%-99.3%?,respectively.Cutoff scores for the NRS when patients were lying supine,rolling over,and sitting up were 3,0,and 2,respectively.The corresponding AUROC of each individual movement was 0.898?95%CI 0.868-0.922?,0.884?95%CI 0.854-0.911?,and 0.910?95%CI 0.882-0.933?.Therefore,“sitting up”carries the best diagnostic value of NRS.Logistic multiple regression analysis showed that BPIT?OR:140.630,p<0.001?,NRS?5?OR:1.350,p<0.05?,history of vertebral fracture?OR:6.108,p<0.05?were predictorsof OVCFsin the female population.There were no valuable predictors of OVCFs yielded in the male population.In this study,SPCFP is positive for 44.9%patients of 345patients with OVCFs,there was significantly poor consistency between the level of SPCFP and the location of vertebral fracture?Kappa=0.118,p<0.001?,back pain site and the level of SPCFP?Kappa=0.153,p<0.001?;there was significantly low consistency between back pain site and the location of vertebral fracture,Kappa value was 0.223,p<0.001.SACFPS is positive for 23.8%patients with OVCFs,and the location of SACFPS is consistency with the level of veterbral fractures.Part 2 Treatment analysis of painful OVCFs:a retrospective study.Two thousand seven hundred and fifty-five patients with OVCFs who were managed from January 1^st 2010 to December 31^st 2017 in Daping Hospital were enrolled,with 774 in conservative treatment group?CT-G?,2070 in vertebral augmentation group?VA-G?including 103 patients failure for conservative treatment,and 14 in open surgery group?OS-G?.Inclusion criteria:patients with primary or secondary osteoporosis;recent vertebral fractures or unhealed fractures diagnosed by magnetic resonance imaging?MRI?.Exclusioncriteria:lactating women;patients with pathological vertebral fractures caused by infection or tumor.Data of gender,age,duration of back pain,history of injury,spinal deformity,previous vertebral fracture,history of vertebral augmentation,visual analogue scale?VAS?,outcome,bone mineral density?BMD?of L1-L4,MRI characteristics,anti-osteoporosis drugs were analyzed.The results indicated:Of 2755 patients with OVCFs,592 were males and 2163 were females,range 37 to 99 years,average age for males and females were?74.8±9.0?and?71.3±8.5?,respectively.671 patients?86.7%?in the CT-G were satisfied with back pain improving within 3 months,dropping from?5.81±0.56?to?1.02±0.83?in VAS.103 cases?13.30%?were transferred to the VA-G due to persistent pain within 4weeks,decreasing from?6.74±0.24?to?5.35±0.73?for VAS.There were significantly heterogeneous between valid subgroup and invalid subgroup in CT-G for age?70?,history of injury,history of vertebral augmentation,spinal deformity,pain duration,number of vertebral fractures,pain severity,signals of MRI and BMD of L1-L4?P?0.001?.The pain was effectively relieved after VA for 2037 patients?98.40%?in VA-G,with VAS?2.464 cases?16.84%?were diagnosed with recurrent OVCFs,including unsystemic anti-osteoporosis treatment in 282 patients.Due to osteoporotic vertebral collapse,spinal deformity,spine instability,nerve compression,14 cases of OVCFs were treated with posterior decompression,malformation correction,nailing reinforced using bone cement and pedicle screw fixation.At the last follow-up all were obtained bone fusion.Conclusions:?1?BPIT,as a segment of routine PE for spine examination,is a convenient,sensitive,and cost-effective screening test to identify painful vertebral compression fracture in population with high risk of osteoporosis.?2?BPIT?OR:140.630,p<0.001?,NRS?5?OR:1.350,p<0.05?,history of vertebral fracture?OR:6.108,p<0.05?were predictors of OVCFs in the female population.There were no significant predictors for female population due to a small sample size.?3?Patients with OVCFs have low positive rate of SPCFP and SACFPS.There were significantly poor inconsistency between back pain site and the location of vertebral fracture,the level of SPCFP and the location of vertebral fracture.The location of SACFPS is the level of veterbral fractures.The whole spine MRI examination should be peformed in patients of strongly-suspected OVCFs.?4?Related factors of outcomes for CT-G were age?70?,history of injury,history of vertebral augmentation,spinal deformity,pain duration,number of vertebral fractures,pain severity,signals of MRI and BMD.In VA-G,the risk of re-fracture was associated with compliance of anti-osteoporosis management.Indications of open surgery were OVCFs with vertebral bursts,neurological element compression,or spinal instability.