Vertebral fractures and spinopelvic parameters in patients with osteoporosis

Abstract

Aim: Bone mineral density (BMD) generally assesses fracture risk in the elderly but is not included in assessment of vertebral fracture status. In this study we aimed to investigate spinal alignment and pelvic orientation in patients with osteoporosis and identify indicators of vertebral fractures (VFs).

Methods: Seventy patients above 50 years of age with osteoporosis were included in this retrospective cohort study. Patients were allocated to two groups comprising 29 patients with and 41 patients without VFs. Demographic and clinical characteristics and back pain scores evaluated by Visual Analogue Scale were obtained by scanning patient files. Sagittal vertebral axis (SVA), spinal and pelvic parameters were evaluated with lateral radiography. All parameters and their effect of VFs were compared in both groups. 

Results: Femoral neck BMD, sacral slope, lumbar lordosis, and pain scores were significantly different in patients with and without VFs (P=0.016, P=0.032, P=0.010, P<0.001, respectively). However, no significant difference was observed in terms of lumbar spine BMD, pelvic tilt, pelvic incidence, and thoracic kyphosis (P=0.394, P=0.313, P=0.258, P=0.341, respectively). Sacral slope and lumbar lordosis were positively correlated in patients with and without VFs (r=0.54, P=0.003 and r=0.50, P=0.001, respectively). SVA>50 mm and pain scores were predictors of VFs according to results of logistic regression. 

Conclusion: The spinal deformity in patients with osteoporosis may be explained by the spinal parameters. In our study, we concluded that pain and sagittal imbalance in osteoporosis patients are important parameters for vertebral fractures.

Keywords

• Osteoporosis,Sagittal balance,Spinopelvic parameters,Vertebral fracture

Osteoporozlu hastalarda vertebral kırıklar ve spinopelvik parametreler

Abstract

Amaç: Kemik mineral yoğunluğu (KMY) genellikle yaşlı bireylerin kırık riski değerlendirmesini gösterir ancak vertebral kırık durumunun değerlendirilmesini içermez. Biz bu çalışmada osteoporozlu hastalarda spinal sagital denge bozukluğu ve pelvik uyum bozukluklarını araştırmayı ve vertebral kırıkların (VK) tahmini göstergelerini tanımlamayı amaçladık.

Yöntemler: Bu retrospektif kohort çalışmada 50 yaş üzeri 70 osteoporoz hastası dahil edildi. Hastalar vertebral kırıkları olan; 29 VK(+) ve olmayan; 41 VK(-) olmak üzere iki gruba ayrıldı. Demografik ve klinik özellikler ile Görsel Analog Skala ile ölçülen sırt ağrısı skorları dosya taraması yolu ile elde edildi. Lateral radyolojik inceleme ile sagital vertebral aks (SVA), spinal ve pelvik parametreler değerlendirildi. Tüm parametreler her iki grupta da karşılaştırıldı ve bu parametrelerin VK üzerindeki etkisi analiz edildi.

Bulgular: Vertebral kırığı olan ve olmayan hastalarda femur boynu KMY, sakral eğim, lomber lordoz ve ağrı skorlarının anlamlı derecede farklı olduğu bulundu (sırasıyla P=0.016, P=0.032, P=0.010, P<0.001). Bununla birlikte, lomber omurga KMY, pelvik

tilt, pelvik insidans ve torakal kifoz açısından anlamlı bir fark gözlenmedi (sırasıyla P=0.394, P=0.313, P=0.258, P=0.341). Sakral eğim ile lomber lordoz arasında pozitif anlamlı bir korelasyon bulunmuştur (sırasıyla r=0.54, P=0.03 ve r=0.50, P=0.001). Lojistik regresyon sonuçlarına göre SVA >50 mm ve ağrı skorları VK’ın belirleyicileriydi.

Sonuç: Osteoporozlu hastalarda omurga deformitesi omurga parametreleriyle açıklanabilir. Çalışmamızda osteoporoz hastalarında ağrı ve sagital dengesizliğin, vertebral kırıkların göstergeleri olduğu sonucuna varıldı.

Keywords

• Osteoporoz,Sagital denge,Spinopelvik parametreler,Vertebral kırık

References

1. 1. Reginster JY, Burlet N. Osteoporosis: a still increasing prevalence. Bone. 2006;38:4-9.
2. 2. Yuan HA, Brown CW, Phillips FM. Osteoporotic spinal deformity: a biomechanical rationale for the clinical consequences and treatment of vertebral body compression fractures. J Spinal Disord Tech. 2004;17:236–42.
3. 3. Lindsay R, Silverman SL, Cooper C, Hanley DA, Barton I, Broy SB, et al. Risk of new vertebral fracture in the year following a fracture. JAMA. 2001;285:320–3.
4. 4. Kerkeni S, Kolta S, Fechtenbaum J, Roux C. Spinal deformity index (SDI) is a good predictor of incident vertebral fractures. Osteoporos Int. 2009;20:1547–52.
5. 5. Siris ES, Genant HK, Laster AJ, Chen P, Misurski DA, Krege JH. Enhanced prediction of fracture risk combining vertebral fracture status and BMD. Osteoporos Int. 2007;18:761–70.
6. 6. Briggs AM, Greig AM, Wark JD. The vertebral fracture cascade in osteoporosis: a review of aetiopathogenesis. Osteoporos Int. 2007;18:575–84.
7. 7. Roux C, Fechtenbaum J, Kolta S, Said-Nahal R, Briot K, Benhamou CL. Prospective assessment of thoracic kyphosis in postmenopausal women with osteoporosis. J Bone Miner Res. 2010;25:362–8.
8. 8. Kobayashi T, Takeda N, Atsuta Y, Matsuno T. Flattening of sagittal spinal curvature as a predictor of vertebral fracture. Osteoporos Int. 2008;19:65–9.

9. 9. Roussouly P, Pinheiro-Franco JL. Sagittal parameters of the spine: biomechanical approach. Eur Spine J. 2011;20(Suppl 5):578–85.
10. 10. Roussouly P, Nnadi C. Sagittal plane deformity: an overview of interpretation and management. Eur Spine J. 2010;19:1824–36.
11. 11. Barrey C, Roussouly P, Le Huec JC, D'Acunzi G, Perrin G. Compensatory mechanisms contributing to keep the sagittal balance of the spine. Eur Spine J. 2013;22(Suppl 6):S834–S841.
12. 12. Schwab F, Lafage V, Boyce R, Skalli W, Farcy JP. Gravity line analysis in adult volunteers: age-related correlation with spinal parameters, pelvic parameters, and foot position. Spine (Phila Pa 1976). 2006 Dec 1;31(25):E959-67.
13. 13. Schwab F, Lafage V, Patel A, Farcy JP. Sagittal plane considerations and the pelvis in the adult patient. Spine (Phila Pa 1976). 2009;34(17):1828-33.
14. 14. Geiger EV, Müller O, Niemeyer T, Kluba T. Adjustment of pelvispinal parameters preserves the constant gravity line position. Int Orthop. 2007;31:253–8.
15. 15. Hirose D, Ishida K, Nagano Y, Takahashi T, Yamamoto H. Posture of the trunk in the sagittal plane is associated with gait in community- dwelling elderly population. Clin Biomech. 2004;19:57–63.
16. 16. Gelb DE, Lenke LG, Bridwell KH, Blanke K, McEnery KW. An analysis of sagittal spinal alignment in 100 asymptomatic middle and older aged volunteers. Spine. 1995;20:1351–8.
17. 17. Jackson RP, Kanemura T, Kawakami N, Hales C. Lumbopelvic lordosis and pelvic balance on repeated standing lateral radiographs of adult volunteers and untreated patients with constant low back pain. Spine. 2000;25:575–86.
18. 18. Angevine PD, O'Leary PT, Bridwell KH. Fixed sagittal imbalance. In: Herkowitz H, Garfin S, Eismont F, Bell G, Balderston R, editors. Rothman-Simeone The Spine. 6th ed. Philadelphia, PA: Elsevier; 2011. p. 1285–1296.
19. 19. Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care Res (Hoboken). 2011;63(11):240-52.
20. 20. Cosman F, de Beur SJ, LeBoff MS, Lewiecki EM, Tanner B, Randall S, et al. Clinician's Guide to Prevention and Treatment of Osteoporosis. Osteoporos Int. 2014;25(10):2359-81.
21. 21. WHO expert consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. The Lancet. 2004;363(9403):157-63.
22. 22. NIH consensus development panel. Osteoporosis prevention, diagnosis, and therapy. JAMA. 2001;285(6):785-95.
23. 23. Cassar-Pullicino VN, Eisenstein SM. Imaging in scoliosis: what, why and how? Clin Radiol. 2002;57(7):543–62.
24. 24. Todd C, Kovac P, Swärd A, Agnvall C, Swärd L, Jon Karlsson, et al. Comparison of radiological spino-pelvic sagittal parameters in skiers and non-athletes. J Orthop Surg Res. 2015;(10):162.
25. 25. Schwab F, Ungar B, Blondel B, Buchowski J, Coe J, Deinlein D, et al. Scoliosis Research Society-Schwab adult spinal deformity classification: a validation study. Spine. 2012;37(12):1077–82.
26. 26. Genant HK, Wu CY, van Kuijk C, Nevitt MC. Vertebral fracture assessment using a semiquantitative technique. J Bone Miner Res. 1993;8:1137-48.
27. 27. Zoran Bursac, C Heath Gauss, David Keith Williams, David W Hosmer. Purposeful selection of variables in logistic regression. Source Code Biol Med. 2008;3:17.
28. 28. Marcus R. Clinical review 76: The nature of osteoporosis. J Clin Endocrinol Metab. 1996;81(1):1-5.
29. 29. Huang MH, Barrett-Connor E, Greendale GA, Kado DM. Hyperkyphotic posture and risk of future osteoporotic fractures. J Bone Miner Res. 2006;21(3):419-2.
30. 30. Cortet B, Houvenagel E, Puisieux F, Roches E, Garnier P, Delcambre B. Spinal curvatures and quality of life in women with vertebral fractures secondary to osteoporosis. Spine. 1999;24:1921-5.
31. 31. Cortet B, Roches E, Logier R, Houvenagel E, Gaydier-Souquières G, Puisieux F, et al. Evaluation of spinal curvatures after a recent osteoporotic vertebral fracture. Joint Bone Spine. 2002;69:201–8.
32. 32. Jackson RP, McManus AC. Radiographic analysis of sagittal plane alignment and balance in standing volunteers and patients with low back pain matched for age, sex, and size. A prospective controlled clinical study. Spine (Phila Pa 1976). 1994;19(14):1611-8.
33. 33. Schwab FJ, Blondel B, Bess S, Hostin R, Shaffrey CI, Smith JS, et al. Radiographical spinopelvic parameters and disability in the setting of adult spinal deformity: a prospective multicenter analysis. Spine (Phila Pa 1976). 2013;38(13):E803-12.
34. 34. Terran J, Schwab F, Shaffrey CI, Smith JS, Devos P, Ames CP, et al. The SRS-Schwab adult spinal deformity classification: assessment and clinical correlations based on a prospective operative and nonoperative cohort. Neurosurgery. 2013;73(4):559-68.
35. 35. Lafage R, Schwab F, Challier V, Henry JK, Gum J, Smith J, et al. Defining Spino-Pelvic Alignment Thresholds: Should Operative Goals in Adult Spinal Deformity Surgery Account for Age? Spine. 2016;41:62-8.
36. 36. Pirro M, Fabbriciani G, Leli C, Callarelli L, Manfredelli MR, Fioroni C, et al. High weight or body mass index increase the risk of vertebral fractures in postmenopausal osteoporotic women. J Bone Miner Metab. 2010;28(1):88-93.
37. 37. Lee JS, Lee HS, Shin JK, Goh TS, Son SM. Prediction of sagittal balance in patients with osteoporosis using spinopelvic parameters. Eur Spine J. 2013;22:1053–8.
38. 38. Jackson RP, Peterson MD, McManus AC, Hales C. Compensatory spinopelvic balance over the hip axis and better reliability in measuring lordosis to the pelvic radius on standing lateral radiographs of adult volunteers and patients. Spine. 1998;23:1750–67.
39. 39. Silverman SL, Minshall ME, Harper KD, Xie S. The relationship of health-related quality of life to prevalent and incident vertebral fractures in postmenopausal women with osteoporosis. Arthritis Rheum. 2001 Nov;44(11):2611-9.
40. 40. Glassman SD, Berven S, Bridwell K, Horton W, Dimar JR. Correlation of radiographic parameters and clinical symptoms in adult scoliosis. Spine. 2005;30:682–8.
41. 41. Glassman SD, Bridwell K, Dimar JR, Horton W, Berven S, Schwab F. The impact of positive sagittal balance in adult spinal deformity. Spine. 2005;30:2024–9.
42. 42. Takeda N, Kobayashi T, Atsuta Y, Matsuno T, Shirado O, Minami A. Changes in the sagittal spinal alignment of the elderly without vertebral fractures: a minimum 10-year longitudinal study. J Orthop Sci. 2009;14:748–53.