OBJECTIVE: To evaluate the diagnostic accuracy of machine learning (ML) in detecting vertebral fractures, considering varying fracture classifications, patient populations, and imaging approaches.
METHODS: A systematic review and meta-analysis were conducted by searching PubMed, Embase, Cochrane Library, and Web of Science up to December 31, 2023, for studies using ML for vertebral fracture diagnosis. Bias risk was assessed using QUADAS-2. A bivariate mixed-effects model was used for the meta-analysis. Meta-analyses were performed according to five task types (vertebral fractures, osteoporotic vertebral fractures, differentiation of benign and malignant vertebral fractures, differentiation of acute and chronic vertebral fractures, and prediction of vertebral fractures). Subgroup analyses were conducted by different ML models (including ML and DL) and modeling methods (including CT, X-ray, MRI, and clinical features).
RESULTS: Eighty-one studies were included. ML demonstrated a diagnostic sensitivity of 0.91 and specificity of 0.95 for vertebral fractures. Subgroup analysis showed that DL (SROC 0.98) and CT (SROC 0.98) performed best overall. For osteoporotic fractures, ML showed a sensitivity of 0.93 and specificity of 0.96, with DL (SROC 0.99) and X-ray (SROC 0.99) performing better. For differentiating benign from malignant fractures, ML achieved a sensitivity of 0.92 and specificity of 0.93, with DL (SROC 0.96) and MRI (SROC 0.97) performing best. For differentiating acute from chronic vertebral fractures, ML showed a sensitivity of 0.92 and specificity of 0.93, with ML (SROC 0.96) and CT (SROC 0.97) performing best. For predicting vertebral fractures, ML had a sensitivity of 0.76 and specificity of 0.87, with ML (SROC 0.80) and clinical features (SROC 0.86) performing better.
CONCLUSIONS: ML, especially DL models applied to CT, MRI, and X-ray, shows high diagnostic accuracy for vertebral fractures. ML also effectively predicts osteoporotic vertebral fractures, aiding in tailored prevention strategies. Further research and validation are required to confirm ML\'s clinical efficacy.

OBJECTIVE: Both vitamin C and D deficiencies are extremely common in clinical practice, especially in elderly population. Unfortunately, the role of vitamin C deficiency in osteoporosis related consequences is often neglected. The aim of the present study is to analyse if combined vitamin C and D deficiency would have an association with bone mineral density (BMD) and osteoporotic vertebral fracture (OVF).
METHODS: Ninety-nine post-menopausal female patients admitted in the department of spine surgery of third affiliated hospital of Sun Yat-sen University were enrolled in the study. The participants were divided into four groups; vitamin D deficiency alone (comparator group), vitamin C deficiency alone and combined vitamin C and D deficiency as experimental group. The levels of vitamin C, vitamin D, calcium, phosphorous, BMD and condition of OVF were analysed.
RESULTS: There were statistically significant differences between the groups in terms of vitamin C and D levels. In terms of lumbar BMD, significant differences were observed between vitamin D deficiency alone and combined vitamin C and D deficiency. Only the combined vitamin C and D deficiency had a significant negative association with lumbar BMD and T-score. Similarly, combined vitamin C and D deficiency had a significant positive association with lumbar osteoporosis. None of the groups had any significant association with OVF. Combined vitamin C and D deficiency was found to be significantly associated with lower lumbar BMD and osteoporosis.
CONCLUSIONS: Combined vitamin C and D deficiency results in lower bone mineral density and higher risk of osteoporosis. We believe that existence of deficiencies of both vitamins could have a synergistic effect. Therefore, we recommend that vitamin C and D should be routinely measured in clinical practice.

Percutaneous vertebroplasty (PVP) is a common method used to treat Kümmell disease. In patients without neurologic symptoms, we sought to evaluate whether using the new spiral injectors instead of the traditional push-rod injectors in PVP can result in improved clinical efficacy for the treatment of Kümmell disease.
A clinical retrospective study was conducted between August 2018 and December 2020. The study included patients diagnosed with single-level thoracolumbar Kümmell disease who underwent PVP surgery. The patients were divided into 2 groups: an observation group consisting of 53 patients treated with spiral injectors and a control group consisting of 68 patients treated with push-rod injectors.
A 2-year follow-up period was adopted. The bone cement injection volume and occurrence of bone cement leakage were significantly greater in the observation group compared with the control group (P < 0.05). The observation group had significantly shorter operation time and intraoperative fluoroscopy times compared with the control group (P < 0.05). The scores for the visual analog scale and Oswestry Disability Index in both groups were significantly lower at 3 days or 3 months and 2 years after surgery compared with before surgery, with the scores at 2 years after surgery being significantly lower than those at 3 days or 3 months for both groups (P < 0.05). The relative anterior ledge height and Cobb angle showed significant improvement at 3 days and 2 years after surgery compared with before surgery in both groups (P < 0.05), but patients in the observation group experienced substantial improvement at 3 days and 2 years after surgery compared with those in the control group (P < 0.05). In both groups, the relative anterior ledge height was noticeably lower 2 years after surgery compared with 3 days after surgery (P < 0.05). Concurrently, there was a significant increase in the local Cobb angle over time in both groups (P < 0.05).
The implementation of both spiral injectors and traditional push-rod injectors in PVP surgery yields effective pain relief, improved function, partially restored vertebral height, and corrected kyphosis in treating Kümmell disease. Compared with the push-rod injector, the spiral injector is highly efficient in restoring vertebral height, correcting kyphosis, and minimizing fluoroscopy use and operation time, but it carries a greater risk of bone cement leakage.

OBJECTIVE: To compare the performance of areal Hounsfield units (aHUs), volumetric Hounsfield units (vHUs), and volumetric bone mineral density (vBMD) by quantitative CT (QCT) in discriminating vertebral fractures (VFs) risk.
METHODS: We retrospectively included CT scans of the lumbar spine 101 VFs cases (60 women, mean age: 64 ± 4 years; 41 men, mean age: 73 ± 10 years) and sex- and age-matched 101 control subjects (60 women, mean age: 64 ± 4 years; 41 men, mean age: 72 ± 7 years). In order to assess the discriminatory capability of aHU, vHU, and vBMD measurements at the L1 and L2 levels in identifying VFs, we conducted binary logistic regression and receiver operating characteristic (ROC) curve analyses in men and women. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated.
RESULTS: In both men and women with and without VFs, aHU, vHU, and vBMD were highly correlated with each other (r2 from 0.832 to 0.957, all P < .001). There was a statistically significant difference in aHU, vHU, and vBMD between subjects with and without VFs (P < .001). When age, gender, and BMI were taken into account as covariances and adjusted simultaneously, odds ratios (ORs) for aHU, vHU, and vBMD values, which represent the risk of VFs, were significant (P < .001). Compared with aHU and vHU, vBMD was more strongly associated with VF risk (vBMD: OR, 6.29; 95% CI, 3.83-10.35 vs vHU: OR, 3.64; 95% CI, 2.43-5.46 vs aHU: OR, 2.56; 95% CI, 1.79-3.67). In both men and women, further, vBMD had higher values for AUC, sensitivity, specificity, PPV, and NPV compared to vHU, with vHU in turn surpassing aHU. The area under the receiver operating characteristic curve (AUC) for discriminating VFs using the average aHU, vHU, and vBMD of 2 vertebrae was 0.72, 0.77, and 0.87 in men and 0.76, 0.79, and 0.86 in women. In both men and women, there exist statistically significant differences in the AUC when employing the 3 measurements-namely, aHU, vHU, and vBMD-to discriminate fractures (P < .05).
CONCLUSIONS: The QCT-measured vBMD is more associated with acute VFs than vHU and aHU values of the lumbar spine. Although the use of vHU and aHU values for the diagnosis of osteoporosis and discriminating fracture risk is limited to scanner- and imaging protocol-specific, they have great potential for opportunistic osteoporosis screening, particularly vHU.
CONCLUSIONS: The novelty of this study presents a comparison of the VF discriminative capabilities among aHU, vHU, and vBMD. The vHU values introduced in this study demonstrate a greater capacity to discriminate fractures compared to aHU, presenting an improved clinical choice. Although its discriminatory capability is slightly lower than that of vBMD, it is more convenient to measure and does not require specialized software.

Morphometric vertebral fractures (VFs) and osteopathy are prevalent and clinically significant complications of Cushing disease (CD). However whether they represent an early occurrence in the natural progression of the disease is an ongoing debate. This study aimed to assess the prevalence and determinants of VFs in patients newly diagnosed with CD.
This cross-sectional case-control study recruited 75 newly diagnosed CD patients and compared them with a control group of individuals without pituitary disorders or secondary forms of osteoporosis. Demographic, clinical and biochemical data were collected. The VFs were assessed using preoperative lateral chest radiography.
We found a significantly higher prevalence of VFs in the CD group than in the control group (58.7% vs. 14.5%; P < 0.001). Among the CD patients with VFs, 27 (61.4%) showed moderate/severe VFs. The CD patients with VFs had significantly higher preoperative 8 am serum cortisol (8ASC) levels than those without VFs (P < 0.001). The preoperative 4 pm adrenocorticotropic hormone (ACTH) levels (P = 0.031), preoperative 0 am ACTH levels (P = 0.021) and systolic blood pressure were slightly higher in CD patients with VFs than in those without VFs (P = 0.028). A binary multiple logistic analysis showed that 8ASC was an independent predictor of VF risk (P = 0.003). The optimal cut-off value of the preoperative serum 8ASC level for predicting VFs was 22.18 ng/mL.
This is the first study reporting a high prevalence of radiologic VFs in recently diagnosed CD patients. VFs may represent an early manifestation of CD and may be related to cortisol levels. Therefore, VF assessment should be included in the workup during CD diagnosis.

BACKGROUND: Pertussis is a highly contagious respiratory disease caused by the bacterium Bordetella pertussis, characterized by paroxysms of severe coughing, and predominantly affects children. We report the first case of multiple fractures in the ribs, lumbar spine, and sacrum associated with severe coughing caused by Bordetella pertussis infection in an adult.
METHODS: A 49-year-old female presented with acute-onset chest wall pain for 3 weeks. Imaging results revealed multiple fractures in the ribs and vertebrae, as well as bilateral pleural effusion, pericardial effusion, right pneumothorax, and enlargement of the left parapharyngeal and subclavian lymph nodes. The patient\'s bone density scan, autoimmune antibodies, bone marrow biopsy, and sacral bone biopsy all came back normal. Imaging test results found no evidence of solid tumors or active TB infection. The patient later recalled having violent coughing prior to the onset of chest pain and several family members having similar symptoms. Her blood sample was sent to the CDC, revealing Bordetella pertussis toxin (PT) IgG titer of 110.68 IU/mL. The patient was diagnosed with pertussis and multiple stress fractures from violent coughing. Symptomatic treatments were administered, and the patient\'s symptoms improved. The patient was followed up 8 weeks later, she reported no more coughing or chest pain.
CONCLUSIONS: Pertussis is not just a pediatric disease, but diagnosis in adults is challenging as patients may present with a myriad of confusing symptoms, such as multiple stress fractures due to violent coughing. Medical and epidemiological histories are key to reaching the correct diagnosis, which is essential for appropriate treatments to avoid further complications. Adult immunization should be suggested both for the protection of the adult population and to prevent transmission to children.

UNASSIGNED: There are many pharmaceutical interventions available to prevent osteoporotic vertebral fractures in postmenopausal women, but the efficacy and safety of these drugs are unknown. This study aimed to investigate the efficacy and safety of drugs in the prevention of osteoporotic vertebral fractures.
UNASSIGNED: PubMed, Embase, and the Cochrane Library were comprehensively searched for randomized controlled trials (RCTs) published up to February 15, 2020, including postmenopausal women with osteoporosis. Network meta-analysis was conducted based on the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The relative risk (RR) and 95% confidence interval (CI) were used to report the results. This study was registered with PROSPERO, number CRD42020201167. Main Outcomes were incidences of new vertebral fracture and serious adverse events.
UNASSIGNED: Fifty-five RCTs (n = 104 580) evaluating vertebral fractures of sixteen kinds of pharmacologic therapies were included in the network meta-analysis. Abaloparatide (RR, 0.21; [95% CI, 0.09 to 0.51]), alendronate (RR, 0.55; [95% CI, 0.38 to 0.81]), calcitonin (RR, 0.44; [95% CI, 0.25 to 0.78]), denosumab (RR, 0.33; [95% CI, 0.14 to 0.61]), parathyroid hormone (PTH) (RR, 0.32; [95% CI, 0.10 to 0.97]), risedronate (RR, 0.65; [95% CI, 0.42 to 1.00]), romosozumab (RR, 0.31; [95% CI, 0.16 to 0.61]), strontium ranelate (RR, 0.62; [95% CI, 0.42 to 0.93]), teriparatide (RR, 0.27; [95% CI, 0.17 to 0.43]), and zoledronate (RR, 0.41; [95% CI, 0.93]) were associated with lower vertebral fracture risk compared to placebo. PTH was associated with more adverse event rates. For any two drug treatments, the RR of serious adverse events was not statistically significant. Hormone replacement therapy (HRT) and calcitonin may be slower to work because they have only been shown to reduce the risk of vertebral fractures in long-term (>18 months) follow-up.
UNASSIGNED: A variety of drugs are safe and effective in preventing osteoporotic vertebral fractures. HRT and calcitonin only reduced the risk of vertebral fractures during a follow-up of 21-72 months.

The efficacy of the prevention of vertebral fractures in men with osteoporosis by treatment with denosumab is debated. This study aimed to update the comparative effectiveness of denosumab and bisphosphonates for preventing vertebral fractures in men with osteoporosis.
We searched PubMed, EMBASE, and Cochrane Central Register of Controlled Trials for randomized controlled trials that enrolled men with osteoporosis. Fixed-effects network meta-analysis was performed to evaluate the risk of vertebral fractures, and the relative risk (RR) and 95% confident interval (CI) values were calculated.
Sixteen studies were included, and the identified bisphosphonates were risedronate, alendronate, zoledronic acid, and ibandronate. Compared with placebo or control, a significant reduction in vertebral fractures was observed for denosumab (RR 0.30, 95%CI 0.13 0.68), risedronate (RR 0.39, 95%CI 0.19 0.77), and zoledronic acid (RR 0.45, 95%CI 0.21 0.98). According to the surface under the cumulative ranking curve (SUCRA), denosumab was the most effective one among the included agents for the risk reduction of vertebral fracture. However, compared with each bisphosphonate, the RR values of denosumab were not significant [RR 0.78 (95%CI 0.25 2.43) vs. risedronate, RR 0.55 (95%CI 0.18 1.75) vs. alendronate, RR 0.66 (95%CI 0.19 2.32) vs. zoledronic acid and RR 1.12 (95%CI 0.08 14.83) vs. ibandronate].
Denosumab effectively reduced the risk of vertebral fractures in men with osteoporosis, and this effect was comparable to that of bisphosphonates.

BACKGROUND: To review, analyze and characterize the pregnancy and lactation-related osteoporosis (PLO) with vertebral fractures based on the extraction data in the previous studies.
METHODS: A comprehensive literature search of electronic databases including the PubMed, Embase and Web of Science was conducted from January 1st,1990 to December 1st, 2020. The enrolled data were pooled to analyze the baseline characteristics, clinical features, risk factors and treatment options.
RESULTS: A total of 65 articles with 338 cases were enrolled for data extraction. The enrolled cases aged from 19 to 47 years, with a mean value of 35.7 years old. The average body mass index (BMI) was 22.2 kg/m2 ranged from 16.0 to 39.0 kg/m2. Of the 173 cases, 149 cases with vertebral fractures occurred in the first pregnancy, 19 cases in the second pregnancy, four cases in the third pregnancy and one case in the fourth pregnancy. Up to 91.5% of the back pain occurred within the last 3 months of pregnancy and the first 3 months after delivery. The most involved vertebral levels were L2, L1 and T12 accounting for 32.6% of all the fractures. The average fracture numbers were 4.4 levels per patient. The lumbar Z-scores were mostly recorded with a mean value of - 3.2 ranged from - 7.8 to 0.
CONCLUSIONS: PLO with vertebral fractures is a rare clinical entity, which is more likely to occur in older and thinner pregnant women. Back pain is the clinical complaint and mostly occurs in the late pregnancy and early lactation periods. Most vertebral fractures appear in the first pregnancy but it can occur in any time of pregnancy. Thoracolumbar region is the mostly involved region. As compared with postmenopausal osteoporotic fractures, PLO usually has multiple levels fractures. Bisphosphonates are the most widely used treatment so far, however, many factors need to be taken into account to decide which drug to choose in PLO and further studies are necessary for clear recommendation in the future.

Areal and volumetric BMD (aBMD and vBMD) measured by DXA and quantitative CT (QCT), respectively, are usually employed to predict vertebral fracture risks. In this study, we induced compression and wedge vertebral fractures to test if the types of fracture could influence the selection of bone mineral measures to predict biomechanical properties of vertebral bodies. DXA and QCT were employed to scan twenty-four male cadaveric vertebral bodies of humans for bone mineral content (BMC) and aBMD measures, and vBMD measures, respectively. We computed vBMD measures from three kinds of volumes of interest: intact structures (vertebral body, cortical compartment, and trabecular core), axially middle sections (1.250-1.875 cm height) of the intact structures, and clinically used elliptical regions of trabecular bone. We loaded vertebral bodies to failure for properties of strength (Pu), failure displacement (δu), and stiffness (K). Thirteen vertebral bodies sustained compression fractures and the remaining sustained wedge fractures. Linear and power regression models were used to test bone mineral predictions for Pu, δu, and K. We also did equality tests of correlation coefficients. Our results showed aBMD, BMC, and vBMD of the middle section of trabecular bone had the strongest correlations with Pu (R2 = 0.6420, p < 0.001), δu (R2 = 0.4619, p < 0.001), and K (R2 = 0.5992, p < 0.001) in power regression models, respectively when compression and wedge fractures were mixed. Considering compression fractures only, vBMD of the intact vertebral body displayed the strongest correlations with both Pu (R2 = 0.6529, p < 0.001) and K (R2 = 0.6354, p < 0.001) while BMC showed the strongest correlation with δu (R2 = 0.4376, p < 0.001) in linear regression models. When only wedge fractures were analyzed, vBMD of the elliptical regions of trabecular bone exhibited the strongest correlations with both Pu (R2 = 0.5845, p < 0.001) and K (R2 = 0.6420, p < 0.001) in power regression models, however, no bone mineral measure could significantly correlate with δu. These results may suggest the type of fracture could influence the determination of bone mineral measures to predict biomechanical properties of vertebral bodies.