In adults with osteoporotic vertebral compression fractures with burst morphology, both vertebral augmentation and instrumented fusion may be considered as treatment options as they appear to provide similar clinical outcomes.

Grade of Recommendation: C

In a retrospective comparative study, An et al1 compared the clinical and radiological outcomes in patients undergoing PKP as a treatment for osteoporotic burst fractures refractory to conservative treatment of a 4-week duration. The authors concluded that “PKP is safe and useful for treating osteoporotic burst fractures.” The work group downgraded this potential Level III paper due to nonrandomized, nonmasked, and nonconsecutive patients, small sample size, selection bias, and the method of the assignment of patients to treatment groups not being described. This paper provides Level IV evidence that in female patients with OVCF with burst morphology, kyphoplasty, and instrumented fusion are equally effective in improving kyphosis, VAS, and mobility and both management approaches provide more improvement than medical treatment. In a retrospective comparative study, Kim et al2 compared the radiologic and clinical outcomes of patients with OVCF and intravertebral pseudarthrosis who underwent short segment percutaneous pedicle screw fixation (PPF) with PMMA augmentation to patients who were treated by percutaneous vertebroplasty. The authors concluded that “short-segment PPF with PMMA augmentation may be an effective minimally invasive treatment for cases of osteoporotic vertebral compression fractures with Kummell’s osteonecrosis.” The work group downgraded this potential Level III paper due to nonconsecutive patients, small sample size, and the method of treatment allocation not being described. This paper provides Level IV evidence that in patients with OVCF and nonhealing intravertebral cleft, PPF with PMMA versus PVP provides similar clinical outcomes but PPF with PMMA provides better radiological outcomes at 2-year post-treatment compared to PVP. References 1. An KC, Kang S, Choi JS, Seo JH. The clinical and radiological availability of percutaneous balloon kyphoplasty as a treatment for osteoporotic burst fractures. Asian Spine J. 2008;2(1):9-14. doi:10.4184/asj.2008.2.1.9 2. Kim HS, Heo DH. Percutaneous Pedicle Screw Fixation with Polymethylmethacrylate Augmentation for the Treatment of Thoracolumbar Intravertebral Pseudoarthrosis Associated with Kummell’s Osteonecrosis. BioMed Research International. 2016;2016:3878063.

There is conflicting evidence to make a recommendation for or against instrumented fusion in adults with acute osteoporotic vertebral compression fractures compared to interventional procedures with respect to radiological outcomes.

Grade of Recommendation: I

In a retrospective comparative study, An et al1 investigated the clinical and radiological outcomes in patients undergoing PKP as a treatment for osteoporotic burst fractures refractory compared to conservative treatment of a 4-week duration. The authors concluded that “PKP is safe and useful for treating osteoporotic burst fractures.” The work group downgraded this potential Level III paper due to nonrandomized, nonmasked, and nonconsecutive patients, small sample size, selection bias, and the method of the assignment of patients to treatment groups not being described. This paper provides Level IV evidence that in female patients with OVCF with burst morphology, kyphoplasty, and instrumented fusion are equally effective in improving kyphosis, VAS, and mobility and both management approaches provide more improvement than medical treatment. In a retrospective comparative study, Kim et al2 compared the radiologic and clinical outcomes of patients with OVCF and intravertebral pseudarthrosis who underwent short segment percutaneous PPF with PMMA augmentation to patients who were treated by percutaneous vertebroplasty. The authors concluded that “short-segment PPF with PMMA augmentation may be an effective minimally invasive treatment for cases of osteoporotic vertebral compression fractures with Kummell’s osteonecrosis.” The work group downgraded this potential Level III paper due to nonconsecutive patients, small sample size, and the method of treatment allocation not being described. This paper provides Level IV evidence that in patients with OVCF and nonhealing intravertebral cleft, PPF with PMMA versus PVP provides similar clinical outcomes but PPF with PMMA provides better radiological outcomes at 2 years post-treatment compared to PVP. References 1. An KC, Kang S, Choi JS, Seo JH. The clinical and radiological availability of percutaneous balloon kyphoplasty as a treatment for osteoporotic burst fractures. Asian Spine J. 2008;2(1):9-14. doi:10.4184/asj.2008.2.1.9 2. Kim HS, Heo DH. Percutaneous Pedicle Screw Fixation with Polymethylmethacrylate Augmentation for the Treatment of Thoracolumbar Intravertebral Pseudoarthrosis Associated with Kummell’s Osteonecrosis. BioMed Research International. 2016;2016:3878063. Doi: 10.1155/2016/3878063

There is insufficient evidence to make a recommendation for or against minimally invasive surgical approaches compared to open surgical approaches in adults undergoing surgery for acute osteoporotic vertebral compression fractures.

Grade of Recommendation: I

In a retrospective comparative study, Liu et al1 evaluated the efficacy of minimally invasive PPF compared to open pedicle screw fixation for osteoporotic vertebral fractures. The authors concluded that “both minimally invasive percutaneous pedicle screw and open pedicle screw fixation can achieve satisfactory internal fixation, while the former has less trauma, shorter operative time, fast recovery, few postoperative complications and lighter [sic] postoperative pain.” The work group downgraded this potential Level III paper due to nonconsecutive enrollment of patients, uncertainty of acute fracture, and inability to determine clinical significance. This paper provides Level IV evidence that in patients with OVCF undergoing surgical fixation, the use of minimally invasive percutaneous pedicle screws (compared to open pedicle screw placement) provides a greater magnitude of VAS improvement and ODI scores at 6 months and reduces operative time, intraoperative blood loss, hospital length of stay, and incision size. References 1. Liu G, Liu B, Yang Y, Tian L, Liu Y, Wang J. Minimally invasive percutaneous pedicle screw fixation versus open pedicle screw fixation for senile osteoporotic vertebral fracture. Int J Clin Exp Med. 2020;13(3):1816-1822.

Spine care providers may consider preoperative hypoalbuminemia* as associated with an increased risk of post-operative mortality in adults undergoing surgical treatment for osteoporotic vertebral compression fractures. Grade of Recommendation: C *Work Group Narrative: The work group emphasizes that hypoalbuminemia, as it relates to the recommendation above, can be interpreted as a sign of physiologic stress, potentially resulting from disease or trauma‐related inflammation, rather than solely a reflection of nutrition status. The work group cautions providers to assess the underlying cause of hypoalbuminemia while applying this recommendation.

In a retrospective comparative study, Gupta et al1 aimed to determine the association between lower albumin levels and higher incidence of mortality, complications, 30-day readmission (postsurgical treatment for an OVCF). The authors concluded that “Preoperative albumin has the potential to serve as a prognostic indicator of adverse outcomes for patients undergoing surgery for OVCF.” This paper provides Level III evidence that preoperative hypoalbuminemia is associated with increased rates of postoperative complications in the surgical treatment of OVCF. In a retrospective case control study, Obha et al2 evaluated the preoperative factors that affected the postoperative mortality of patients who had undergone spinal surgery for an insufficient bone union following an osteoporotic vertebral fracture. The authors concluded that “preoperative hypoalbuminemia was associated with postoperative mortality following surgery for OVF.” The work group downgraded this potential Level III paper due to unclear diagnostic methods and the fact that timing of outcome measure was not clearly described. This paper provides Level IV evidence that in patients undergoing surgery for OVCF, preoperative hypoalbuminemia is associated with increased mortality at 2-years postoperatively. References 1. Gupta A, Upadhyaya S, Cha T, Schwab J, Bono C, Hershman S. Serum albumin levels predict which patients are at increased risk for complications following surgical management of acute osteoporotic vertebral compression fractures. Spine J. 2019;19(11):1796-1802. doi:10.1016/j.spinee.2019.06.023 2. Ohba T, Yokomichi H, Koyama K, Tanaka N, Oda K, Haro H. Factors affecting postoperative mortality of patients with insufficient union following osteoporotic vertebral fractures and impact of preoperative serum albumin on mortality. BMC Musculoskelet Disord. 2020;21(1):528. doi:10.1186/s12891-020-03564-z

There is insufficient evidence to make a recommendation regarding other patient or fracture characteristics affecting outcomes after surgical intervention for osteoporotic vertebral compression fractures.

Grade of Recommendation: I

In a retrospective comparative study, Isogai et al1 investigated the postoperative complications, and postoperative functional and radiographic outcomes, in patients who had fusion surgery for lower lumbar OVF with neurological deficits. The authors concluded that “surgical intervention for OVF is effective in patients with myelopathy or radiculopathy regardless of the surgical level.” The work group downgraded this potential Level III paper due to the diagnostic methods not being described. This paper provides Level IV evidence that in patients undergoing surgical treatment of OVCF, those with lower lumbar fractures compared to thoracolumbar junction fractures have higher rates of postoperative mechanical failure (instrumentation failure, cage subsidence or fracture at upper instrumented vertebrae (UIV)/lowest instrumented vertebrae (LIV). In a retrospective comparative study, Maruo et al2 evaluated the prevalence and effect of TPTD on consecutive VFs after long-instrumented fusion surgery for OVFs. The authors concluded that “pre- and postoperative TPTD treatment significantly reduced the incidence of subsequent VFs after instrumented fusion surgery for OVFs.” The work group downgraded this potential Level III paper due to small sample size and diagnostic methods not being described. This paper provides Level IV evidence that for patients undergoing surgery for OVCF, the use of teriparatide in the perioperative setting reduces the incidence of subsequent OVCFs compared to bisphosphonate treatment. In a retrospective case control study, Murata et al3 aimed to determine the prognostic factors for postoperative function in ADL despite differences seen between bedridden/chair bound patients and walkers. The authors concluded that “preoperative neurological deficit, perioperative complication, and absence of postoperative rPTH administration were considered as predictors for postoperative poor ADL in patients with OVF. Neurological deficits and complications are often inevitable factors; therefore, rPTH is an important option for postoperative treatment for OVF.” The work group downgraded this potential Level III paper due to unclear methodological concerns regarding rPTH administration. This paper provides Level IV evidence that for patients undergoing surgery for OVCF, the presence of a preoperative neurological deficit (Level III) or perioperative complication (Level III) or the absence of postoperative rPTH administration (Level IV) is associated with chair bound or bedridden functional status postoperatively.

In a retrospective observational study, Tamai et al4 studied independent risk factors and incidence of PJFr in patients following surgical treatment for osteoporotic vertebral collapse. The authors concluded that “PJFr was found in 16% [of] cases within 4 years after surgery; independent risk factors were severe osteoporosis and extended fusion to the sacrum. The lumbar BMD with cut-off value 0.61 g/cm2 may potentially predict PJFr. Our findings can help surgeons select perioperative adjuvant therapy, as well as a surgical strategy to prevent PJFr following surgery.” The work group downgraded this potential Level III paper due to the diagnostic methods not being described. This paper provides Level IV evidence that for patients undergoing instrumented fusion for osteoporotic fracture with a neurologic deficit, the following characteristic is associated with PJFr: severe baseline osteoporosis (based on a qualitative radiographic assessment). In addition, lumbar BMD rather than hip BMD is predictive of PJFr. References 1. Isogai N, Hosogane N, Funao H, et al. The Surgical Outcomes of Spinal Fusion for Osteoporotic Vertebral Fractures in the Lower Lumbar Spine with a Neurological Deficit. Spine Surg Relat Res. 2020;4(3):199-207. Published 2020 Jan 29. doi:10.22603/ssrr.2019-0079 2. Maruo K, Tachibana T, Arizumi F, Kusuyama K, Kishima K, Yoshiya S. Effect of Teriparatide on Subsequent Vertebral Fractures after Instrumented Fusion Surgery for Osteoporotic Vertebral Fractures with Neurological Deficits. Asian Spine J. 2019;13(2):283-289. doi:10.31616/asj.2018.0098 3. Murata K, Matsuoka Y, Nishimura H, et al. The factors related to the poor ADL in the patients with osteoporotic vertebral fracture after instrumentation surgery. Eur Spine J. 2020;29(7):1597-1605. doi:10.1007/s00586-019-06092-0. 4. Tamai K, Terai H, Suzuki A, et al. Risk Factors for Proximal Junctional Fracture Following Fusion Surgery for Osteoporotic Vertebral Collapse with Delayed Neurological Deficits: A Retrospective Cohort Study of 403 Patients. Spine Surg Relat Res. 2018;3(2):171-177. Published 2018 Oct 19. doi:10.22603/ssrr.2018-0068