Search Results (143)

Background/Objectives: The optimal surgical approach for Percutaneous KyphoPlasty (PKP) in patients with recent single-level Osteoporotic Vertebral Compression Fractures (OVCFs) remains controversial. Most available previous meta-analyses included studies with variable heterogeneity, often mixing unilateral and bilateral MIS approaches, differing surgical techniques, and various fracture patterns, which limited the reliability of their conclusions. This meta-analysis aimed to compare the efficacy and safety of unilateral versus bilateral PKP exclusively in patients with recent single-level OVCFs only. Methods: A systematic review was conducted according to the PRISMA 2020 guidelines. PubMed, Scopus, Cochrane Library, and ScienceDirect were searched for comparative studies published between 2000 and 2025. Randomized Controlled Trials (RCTs), prospective, and retrospective comparative studies comparing unilateral and bilateral PKP for recent single-level OVCFs were included. Clinical and radiological outcomes as well as perioperative complications and safety outcomes were analyzed using random-effects meta-analysis. Predefined subgroup analyses according to study design and sensitivity analyses were performed. Results: Eleven studies involving 1374 patients (705 unilateral and 669 bilateral PKP) met the inclusion criteria. No significant differences were observed between the two surgical approaches regarding short- or long-term pain relief, cement leakage, number of adjacent vertebral fractures, or overall clinical outcomes. Bilateral PKP demonstrated statistically significant, but clinically negligible, advantages in anterior vertebral body height restoration and kyphosis correction. Unilateral PKP required an insignificantly lower cement volume. For operative time, the overall pooled estimate favored unilateral PKP by approximately 10 min but showed extreme heterogeneity (I² = 98.5%). Importantly, the two RCTs showed no statistically significant between-group difference (MD = +1.2 min, 95% CI −4.5 to +6.8), indicating that the apparent overall effect was largely driven by observational evidence. Similar discrepancies between randomized and retrospective studies were observed for several other outcomes, underscoring the importance of considering study design when interpreting the results. Conclusions: Current evidence does not demonstrate clinically meaningful superiority of either unilateral or bilateral PKP for the treatment of recent single-level OVCFs. Bilateral PKP may provide small advantages in selected radiographic outcomes, whereas unilateral PKP uses modestly less bone cement; however, the relevance of these differences remains clinically uncertain. Surgical approach selection may therefore be individualized according to vertebral morphology, pedicle anatomy, fracture characteristics, surgeon experience, and technical feasibility rather than expectations of superior clinical outcomes. Further adequately powered randomized trials with standardized outcome reporting and long-term follow-up are warranted. Full article

Background/Objectives: CT-based trabecular attenuation in Hounsfield units (HU) is used as a surrogate marker of bone quality, but most approaches rely on a single vertebral level, usually L1, where local abnormalities may limit reliability and availability. This study evaluated whether multilevel lumbar, reference-adjusted HU assessment beyond isolated L1 improves the identification of QCT-defined osteoporosis and the discrimination of prevalent fragility fracture status. Methods: Between 2021 and March 2024, 800 patients referred for evaluation of bone mineral density underwent QCT of the lumbar spine with a calibration phantom. Cancellous attenuation was measured in HU at L1–L3 using manually positioned ellipsoid regions of interest, with predefined adjacent levels (T12, L4) substituted when a target vertebra was unsuitable. Single-level HU, the mean multilevel HU value and the lowest valid HU value were compared with QCT-defined osteoporosis and prevalent fragility fracture status (vertebral or sacral) using ROC analyses and pairwise DeLong testing. Results: Mean multilevel HU correlated closely with mean vBMD (Spearman ρ = 0.988; p < 0.001); as both derive from the same acquisition, the same vertebral bodies and the same phantom, this reflects a strong association between two related measurements rather than validation against an independent standard. Osteoporosis was present in 483 patients (60.4%). Mean multilevel HU was associated with osteoporosis with an AUC of 0.996 (95% CI, 0.993–0.998) at an internally derived cut-off of ≤99.6 HU. In the 699 patients with a valid L1 measurement, in whom a paired comparison was possible, mean multilevel HU exceeded isolated L1-HU (0.992; p = 0.0028). For fracture status, the AUC was 0.975 (0.966–0.983) at ≤80.5 HU, without advantage over L1-HU (p = 0.816). A valid value was obtainable in all 800 patients versus 699 (87.4%) with L1 alone. All patients with a fracture had a vBMD below the osteoporosis threshold, so this endpoint is structurally dependent on the densitometric one. Conclusions: Multilevel lumbar HU assessment provides a practical marker of trabecular bone quality beyond isolated L1. Its principal advantage is measurement availability rather than a clinically meaningful gain in discrimination. The reported thresholds are internally derived, cohort- and protocol-specific, and require external validation. Full article

Diffusion-weighted imaging (DWI) has evolved from a niche research sequence into an increasingly valuable adjunct to conventional magnetic resonance imaging (MRI) in musculoskeletal (MSK) radiology. By providing qualitative and quantitative information on tissue microstructure through assessment of water diffusion and apparent diffusion coefficient (ADC) mapping, DWI offers functional insights beyond conventional morphological imaging. We aim to present the current evidence for DWI in MSK imaging organised around established applications and emerging applications, with particular emphasis on composition-related interpretive pitfalls relevant to differentiating tumours and other pathologies, and to review the technique’s evolving role in routine practice. This narrative review synthesises the current literature on the clinical utility of DWI in MSK imaging. It is structured in four parts: foundations and the tissue composition signal framework, including the basis of qualitative and quantitative assessment; established applications; emerging applications; and assessment of tissue composition-related interpretive as well as technical pitfalls, including those arising due to myxoid matrix, chondroid matrix, blood degradation products, organising thrombus, crystalline or mineralised material, keratinaceous debris, purulent content, cellular haematopoietic marrow, by using original cases from the authors’ institution, which have been confirmed either histologically or surgically. Applications are stratified by strength of evidence. Established applications of DWI include soft tissue abscess detection, differentiation of malignant from benign soft tissue tumours, differentiation of malignant from benign vertebral compression fractures, and myeloma staging and response assessment, as well as treatment response in soft tissue and bone sarcomas. Whole-body MRI with DWI for staging and response assessment in multiple myeloma is guideline-endorsed and supported by prospective multicentre data. Soft tissue abscess detection, soft tissue and bone tumour characterisation, and characterisation of vertebral compression fractures are supported by consistent evidence from multiple independent cohorts, although no universally transferable ADC threshold exists. The emerging applications, which are promising adjuncts supported by small, single-centre or heterogeneous studies with thresholds that have not been externally validated, include ADC ghost sign in osteomyelitis (high specificity but sensitivity of only 20%), peripheral nerve sheath tumour characterisation and surveillance in NF1 patients, peripheral neuropathy and plexopathy, predisposing conditions such as Li Fraumeni syndrome in paediatric cancers, inflammatory myopathy, and postsurgical assessment of residual disease, as well as opportunistic detection of venous thrombosis. Radiomics and machine learning approaches remain experimental. Recent technical advances, including reduced field-of-view imaging, multi-shot acquisition and improved fat suppression, have mitigated but not eliminated historical limitations of susceptibility artefacts and limited spatial resolution. DWI has become an important functional imaging technique that complements conventional MRI across a broad range of musculoskeletal disorders. Understanding the relationship between tissue composition and the diffusion signal is central to both interpreting DWI correctly and avoiding its characteristic pitfalls. DWI is best regarded not as a stand-alone technique but as one component of a multiparametric assessment, in which its functional information is integrated with conventional morphological imaging. Ongoing technical improvement and expanding clinical evidence are expected to further support its integration into routine MSK imaging and its development as a quantitative biomarker for diagnosis, prognostication, and treatment monitoring. Full article

Background and Objectives: Fragility fractures of the sacrum are increasingly recognized in elderly osteoporotic patients and can cause persistent pain, immobility, and progressive pelvic ring instability. We previously described a modified S1 corridor targeting the higher-density cranial–ventral S1 vertebral body for safe percutaneous implant placement. This study reports the clinical outcomes of osteoporotic and pathologic sacral fractures treated through this corridor and presents an exploratory comparison of two 3D-printed titanium sacroiliac fusion implants: the triangular iFuse™ Implant System and the threaded iFuse TORQ™ (SI-BONE, Inc., Santa Clara, CA, USA). Materials and Methods: This retrospective single-center study analyzed 58 patients with fragility or pathologic sacral fractures (FFP IIIb–V; OF 2–5) treated via the modified S1 corridor between January 2021 and March 2026. Of these, 27 patients received triangular iFuse™ implants, and 31 patients received threaded iFuse TORQ™ implants. The primary outcome was procedural safety (implant revision, neurological injury, cortical breach). Secondary outcomes included the Oswestry Disability Index (ODI), Visual Analog Scale (VAS) for pain, operative time, and need for additional fixation. Group comparisons used non-parametric tests; multivariable linear regression adjusted for age, fracture severity (OF classification), and additional fixation. Results: At a mean follow-up of 17.8 ± 9.1 months (iFuse) and 4.1 ± 2.1 months (TORQ), no implant revisions, clinically significant cortical breaches, or neurological injuries were observed in either group. Patient-reported outcome data were available for 48 of 58 patients (20 iFuse, 28 TORQ). Patients in the iFuse™ group were older (80.9 ± 8.5 vs. 76.0 ± 9.8 years; p = 0.050), and OF classification differed between groups, with a higher proportion of OF 4 fractures in the TORQ™ group (p = 0.003). After adjustment for age, OF classification, and additional fixation, TORQ™ implantation was associated with a 15.6-point lower postoperative ODI (p < 0.001), a 13.5-point greater ODI improvement (p < 0.001), a 0.94-point lower postoperative VAS (p = 0.006), and a 1.36-point greater VAS reduction (p < 0.001). Findings remained significant in a sensitivity analysis restricted to patients without additional fixation. Conclusions: Sacroiliac fusion via a modified density-oriented S1 corridor was safe for both large implant types, with no revisions in the analyzed cohort. In this retrospective, non-randomized cohort, threaded iFuse TORQ™ implants were associated with better patient-reported outcomes after adjustment for baseline imbalances. Because the groups were not randomized and follow-up duration differed substantially, these comparative findings are hypothesis-generating and require confirmation in prospective, controlled studies. Full article

Background and Objectives: Osteoporotic vertebral compression fractures affect approximately one in four postmenopausal women and carry substantial morbidity, yet established clinical tools such as dual-energy X-ray absorptiometry (DXA) provide only patient-level risk and do not identify which specific vertebra is most likely to fail. Computed tomography (CT) acquired for unrelated indications is the most widely available three-dimensional substrate for opportunistic screening, but published machine learning models for vertebral fracture risk almost universally operate at the patient level. The present study aimed to develop and rigorously validate a per-vertebra prediction pipeline applicable to both routine clinical lumbar-spine CT and opportunistic abdominal CT, both acquired for indications unrelated to osteoporosis screening. Materials and Methods: Two independent retrospective cohorts were assembled from a single academic centre: a routine clinical lumbar-spine CT cohort of 106 patients yielding 478 evaluable vertebrae, and a routine abdominal CT cohort of 126 patients yielding 589 evaluable vertebrae. Vertebral bodies were segmented automatically with TotalSegmentator v2 and the trabecular core isolated by morphological erosion. A panel of 505 quantitative imaging biomarkers compliant with Image Biomarker Standardisation Initiative recommendations was extracted, covering trabecular density, vertebral morphometry, classical texture, trabecular network architecture, sub-endplate vulnerability, low-density topology, radial heterogeneity and adjacent muscle quality. Within-patient feature engineering expanded the input pool to 1293 contextual descriptors. Three model families were evaluated under fully nested leave-one-patient-out cross-validation: ElasticNet logistic regression, a softmax-ranking approximation of conditional logistic regression, and a Two-Stage model combining a patient-level fragility score with a within-patient vertebral outlier score. Patient-level bootstrap resampling (2000 iterations) was used to obtain 95% confidence intervals. Results: On routine clinical lumbar-spine CT the Two-Stage model achieved a per-vertebra AUC of 0.750 (95% CI 0.704 to 0.795), an F1 of 0.549, a within-patient concordance index of 0.693, an expected calibration error of 0.044, and Hit@3 of 0.934. It was the only model evaluated that returned calibrated probabilities; the softmax-ranking and ElasticNet baselines gave expected calibration errors of 0.232 and 0.218 respectively. On opportunistic abdominal CT, the softmax-ranking model gave AUC 0.672 (95% CI 0.615 to 0.727). Selected biomarkers were dominated by regional trabecular density and trabecular network architecture; a stable core of lumbar features entered the model in 100% of cross-validation folds, indicating high reproducibility. The closest prior per-vertebra CT-based predictor in primary, non-surgical patients (Muehlematter and colleagues, 58-patient cohort) reported a per-vertebra AUC of 0.64, which is one of several reference points for the present results. Ten methodological variants and sensitivity analyses, including rank fusion, internal tissue normalisation and additional biomechanical features, did not provide statistically significant gains, indicating that the binding constraint at this sample size is data volume rather than methodology. Conclusions: A two-stage decomposition that separates systemic skeletal fragility from within-patient vertebral outlier status produces well-calibrated per-vertebra fracture-risk estimates from routine clinical lumbar spine CT and was the only model evaluated to do so, which is what permits a per-vertebra output to be reported as an absolute risk rather than as an ordering alone; a within-patient ranking model is preferable for opportunistic abdominal CT. The discrimination advantage of the decomposition over that baseline is numerical and consistent but not statistically established at this sample size, and the work is presented as a transparent and reproducible single-centre benchmark for the still under-developed per-vertebra prediction task. Its clearest near-term value is opportunistic, namely flagging elevated per-vertebra fracture risk on CTs already acquired for unrelated indications without additional radiation, cost or a dedicated densitometric study. External multi-centre validation is the necessary next step. Full article

Background/Objectives: Osteoporotic vertebral fractures (OVFs) can cause persistent pain and loss of independence. This study quantified impairment in basic and instrumental activities of daily living and identified independent cross-sectional correlates in postmenopausal women with OVFs. Methods: This cross-sectional analysis included 184 postmenopausal women from a 200-patient OVF cohort at a spine clinic in Vietnam. Functional status was assessed using the Barthel Index (BI) and Lawton Instrumental Activities of Daily Living (IADL) scale. Primary analyses used multivariable linear regression with HC3 robust inference; ordered-logistic and model-specification analyses assessed robustness. Results: Mean age was 69.95 ± 7.78 years and mean visual analog scale (VAS) pain score was 6.69 ± 1.58. Basic-activity dependence was present in 81.5% of participants (mean BI, 82.96 ± 16.45), and 66.8% had at least one IADL limitation (mean IADL, 5.84 ± 2.04). In the adjusted BI model, higher VAS pain intensity was the strongest observed correlate of poorer function (B = −7.996; β = −0.769; p < 0.001), and higher body mass index was associated with lower BI. In the adjusted IADL model, higher VAS pain intensity (B = −0.694; β = −0.538; p < 0.001) and older age were associated with lower scores. Ordinal sensitivity analyses confirmed the pain association, whereas the BMI finding was attenuated. Conclusions: Pain intensity was the strongest observed cross-sectional correlate of both functional domains. The findings support comprehensive functional assessment and hypothesis-driven longitudinal studies, but they do not establish that pain reduction will cause functional recovery. Full article

Vertebral fractures are among the most common skeletal injuries and present significant clinical and biomechanical challenges, particularly in older adults and individuals with low bone density. Accurate prediction of vertebral mechanical response and failure under varying loading conditions is essential for improving understanding of spinal injury mechanisms. This study develops a density-dependent viscoelastic analytical model to predict the stiffness and fracture force of human vertebral specimens subjected to different compression rates. The vertebral body is represented as a composite structure consisting of a cortical shell and a trabecular core. Cortical bone is modeled as a linear elastic material, whereas trabecular bone is described using a Kelvin–Voigt viscoelastic formulation. Density-dependent constitutive relationships are incorporated for the elastic modulus and viscous coefficient of trabecular bone. Unknown material parameters are identified through optimization using the Nelder–Mead algorithm, based on experimental compression data from cadaveric vertebral specimens tested under quasi-static and dynamic loading conditions. The calibrated model reproduced the overall trend of specimen-to-specimen mechanical variation observed experimentally. Predicted stiffness values were in reasonable agreement with measured data. Fracture force predictions showed moderate agreement for dynamically tested specimens (R² = 0.60), which improved to R² = 0.88 after exclusion of one statistically identified outlier. Compared with a purely linear elastic formulation, the proposed viscoelastic model demonstrated modest improvement in stiffness prediction and more substantial improvement in fracture force prediction. These findings indicate that incorporating density-dependent viscoelastic effects improves representation of vertebral mechanical behavior, particularly at higher loading rates. Owing to its simplicity and computational efficiency, the proposed model requires only limited imaging input and may be useful for future biomechanical investigations, rapid screening, and injury risk prediction. Full article

Osteoporotic vertebral fractures (OVFs) are the most common fragility fractures, representing a substantial burden on healthcare systems worldwide. Although up to 30% of OVFs may be clinically silent, a subset of patients experiences an unfavorable course, developing painful pseudoarthrosis/nonunion, progressive vertebral collapse, and even neurological compromise. While initial OVF management is typically nonoperative, a considerable proportion of patients ultimately require surgical intervention. However, clear and universally accepted surgical indications are lacking, rendering clinical decision-making complex and highly individualized. In this context, evaluating the spine’s ability to withstand physiological loads in the presence of potential instability is a critical step in the treatment algorithm. Nevertheless, spinal stability remains a dynamic and multifactorial concept that requires comprehensive assessment integrating both clinical and radiological parameters. This narrative review synthesizes the current state-of-the-art literature on the assessment of stability in OVFs, with particular clinical emphasis on clinical applicability. It revisits classical trauma-derived concepts and adapts them to the specific context of OVFs. We examine the respective roles of radiography, CT and MRI in evaluating fracture characteristics and spinal stability and summarize the main clinical and radiological markers. Furthermore, we distinguish between predictors of fracture progression and indirect indicators of established or evolving instability. Finally, we review current classification systems and outline general treatment considerations, focusing on how imaging findings may guide clinical decision-making in OVFs. Overall, this review provides a comprehensive framework of key imaging and clinical features that should be systematically assessed to estimate the risk of spinal instability. Full article

Background/Objectives: Although the Spinal Instability Neoplastic Score (SINS) is widely used to estimate spinal metastases fracture risk and guide decisions on stabilisation procedures, prior studies have demonstrated mixed results. Patients with the same score exhibit clinically heterogeneous outcomes, with some SINS criteria correlating less well with the estimated fracture risk than others. There are also barriers to implementation such as the time burden required for manual calculation and interobserver variability associated with qualitative morphological criteria. SINS also lacks sensitivity for detecting latent structural compromise in treatment-naive patients and those susceptible to the iatrogenic effects of stereotactic body radiation therapy. This review aims to evaluate emerging imaging, biomechanical, and microstructural markers with the potential to improve fracture risk stratification and prognostication for spinal oncology patients. Methods: We synthesise evidence across three innovative frontiers: (1) biomechanical modelling, including CT-derived finite element analysis and failure-load pattern models; (2) radiomics, utilizing radiomics features from radiological imaging to develop a predictive model; and (3) microstructural MRI biomarkers, exploring the translatability of the Vertebral Bone Quality score, fat fraction, and paraspinal muscle atrophy from osteoporosis to the metastatic spine. Results: Emerging biomechanical, radiomic and microstructural imaging markers show potential in addressing some limitations of traditional SINS criteria for fracture risk stratification across the spinal oncology treatment continuum, from initial diagnosis to post-radiation surveillance, thereby facilitating more precise risk assessment. However, current evidence remains largely retrospective and heterogeneous, and further validation is required before clinical adoption. Conclusions: We propose a framework that shifts the paradigm from conventional morphological scoring toward a multiparametric assessment of spinal stability. Full article

Background and Objectives: Percutaneous iliosacral screw fixation is a standard treatment for posterior pelvic ring instability and sacral insufficiency fractures. However, conventional transsacral S1 screw fixation is associated with notable complication rates, most commonly implant loosening; dysmorphic sacral anatomy increases the risk of iatrogenic L5 or S1 nerve root injury. This study presents a modified S1 trajectory to engage the high-density bone of the anterior and cranial S1 vertebral body (promontory) by transferring preoperative 3D planning to intraoperative 2D fluoroscopy. Materials and Methods: This retrospective study analyzed implant placements for posterior pelvic ring instability, including high-velocity trauma and fragility fractures of the pelvis (FFPs). Preoperative computed tomography (CT) multiplanar reconstruction defined a modified corridor from a posterior-caudal iliac entry point directed cranially and ventrally into the S1 promontory. The 3D trajectory was transferred intraoperatively using standard 2D fluoroscopy (lateral, anteroposterior, inlet, and outlet views) with the patient prone. In cases of reduced bone quality or intended sacroiliac fusion, 3D-printed titanium implants (triangular or cylindrical threaded, 10.0–13.5 mm outer diameter) were selected over 7.5 mm cannulated screws. Results: Overall, 137 implants were placed in 71 patients: 13 cannulated screws in high-velocity pelvic ring trauma, 72 triangular titanium sacroiliac fusion implants (iFuse Implant System^®, SI-Bone), and 52 threaded titanium fusion implants (iFuse TORQ^®, SI-Bone) in patients with FFP. The modified trajectory consistently engaged the anterior and cranial S1 vertebral body. Postoperative 3D CT confirmed accurate placement of all implants. No iatrogenic nerve injuries or revisions for implant malposition occurred. Mean follow-up was 12 ± 9 months. Conclusions: Preoperative 3D CT planning combined with standard 2D fluoroscopy guided a modified S1 trajectory toward the cranial S1 vertebral body. Accurate and safe implant placement was achieved in the prone position without navigation systems, providing a practical alternative when standard transverse trajectories are limited by narrow bony corridors or sacral or pelvic dysmorphy. Full article

Background: Thoracic paravertebral catheters are increasingly used in neonates to avoid neuraxial techniques during thoracoscopic tracheoesophageal fistula (TEF) repair. Catheter fracture and retention are exceedingly rare in this population, and optimal management remains undefined. Learning Objectives: Recognize this complication risk in neonatal paravertebral placement; identify appropriate imaging when retention is suspected; discuss conservative and surgical approaches; and understand the importance of early transparent communication with caregivers. Case: A 2-day-old term neonate weighing 2.90 kg underwent thoracoscopic repair of type C tracheoesophageal fistula with intraoperative placement of an ultrasound-guided right paravertebral catheter for continuous analgesia. The catheter was placed at the T5 vertebral level using a 20 G, 2-inch Tuohy needle with an in-plane lateral-to-medial approach. Saline hydrodissection was used to confirm entry into the paravertebral space. A 24 G radiopaque Perifix One catheter was initially inserted but proved difficult to advance. During attempted removal, some resistance was encountered, and both the needle and catheter were withdrawn together. Subsequent inspection suggested possible catheter shortening, raising concern for a retained fragment. A second catheter of size 20 G advanced via an 18 G needle was then successfully placed at the same level and was removed without complications on postoperative day 3. Comparison with an intact reference catheter revealed that the first-placed 24 G catheter was approximately 1.5 cm shorter, although the tip appeared intact. The pain physician promptly notified both the clinical teams and the family. One month later, during routine imaging for respiratory distress, a curvilinear opacity was noted at the T9 vertebral level. Dedicated thoracic spine films confirmed a 7 mm retained paravertebral catheter fragment. Multidisciplinary consensus (pain team, anesthesia, NICU, and surgery) determined that the fragment was small, non-metallic, and remote from critical structures. Conservative management with long-term follow-up was chosen. The family was informed early during initial suspicion and again upon confirmation. At 17-month follow-up, the child remained asymptomatic. Discussion: Retained catheter fragments are rare in pediatric regional anesthesia and may be radiographically occult early. In neonates, re-operation for a tiny, inert foreign body may cause more morbidity than observation. Prevention depends on appropriate equipment selection, catheter integrity checks pre- and post-placement, careful technique, and attention to resistance or difficulty during advancement or removal. Clear and timely communication with caregivers preserves trust when complications or iatrogenic uncertainty arise. Conclusions: In this neonate, a small retained paravertebral catheter fragment was identified incidentally and was safely managed with conservative observation. When such fragments are non-metallic, stable, and located away from critical structures, non-operative management with close follow-up may be an appropriate and safe approach. Full article

Background: The rising incidence of vertebral body fractures, vertebral infections and metastatic disease increases the need for diagnostic modalities with high specificity. Biopsy remains essential, yet comparative data on CT-guided versus intraoperative percutaneous fluoroscopy-guided biopsy are limited. Methods: This retrospective study compared two cohorts biopsied for spinal lesions between April 2015 and April 2024: CT-guided biopsy (n = 62), and intraoperative percutaneous biopsy (n = 154). Groups were analyzed for demographic and clinical characteristics, and diagnostic yield was defined by the conclusiveness of the primary biopsy; statistical comparisons were performed using Fisher’s exact test. Results: CT-guided biopsy yielded conclusive results in 46 of 62 cases (74.2%), whereas intraoperative, fluoroscopy-guided biopsy was conclusive in 41 of 154 cases (26.6%), representing a statistically significant difference (p < 0.001). In analogy, propensity score matching (1:1) resulted in similar significant (p < 0.001) results (CT-guided group vs. intraoperative, fluoroscopy-guided group: 86.7% vs. 35.6%) Conclusions: CT-guided biopsy demonstrated a substantially higher rate of conclusive results compared with intraoperative biopsy in this cohort. Further studies with larger and more balanced cohorts are needed to strengthen clinical recommendations. Full article

Background/Objectives: Vertebral body stenting (VBS) and balloon kyphoplasty (BKP) are widely used for the treatment of osteoporotic vertebral fractures (OVFs). However, it remains unclear whether the theoretical biomechanical advantages of VBS translate to superior clinical or radiographic outcomes. This study aimed to compare VBS and BKP with respect to clinical outcomes, radiographic parameters, and complications. Methods: In this multicenter retrospective comparative cohort study, 123 patients with OVF treated with VBS (n = 24) or BKP (n = 99) were analyzed. VBS was indicated for complex fracture patterns, including severe endplate injury, split-type fractures, and absence of interbody sclerosis; other fractures were treated with BKP. Pain outcomes, operative parameters, cement volume and leakage, and radiographic measures of vertebral kyphosis angle (VKA) and local kyphosis angle (LKA) were assessed. For group comparisons, we used independent-samples t tests or Mann–Whitney U tests for continuous variables and chi-squared or Fisher’s exact tests for categorical variables. Results: Baseline demographics and bone mineral density were comparable between groups. Surgical time was longer for VBS (39 ± 6 vs. 35 ± 9 min, p = 0.007). Both procedures produced significant pain reductions (p < 0.001), and postoperative VAS did not differ between VBS and BKP (18 ± 11 vs. 13 ± 12 mm, p = 0.06). Although VKA immediately after surgery was lower for VBS (4.8 ± 4.4° vs. 7.0 ± 4.9°, p = 0.03), the magnitude of correction, VKA, and LKA at final follow-up were comparable. Cement volume was similar (6.4 ± 1.4 vs. 6.7 ± 1.9 mL, p = 0.45), but cement leakage occurred more frequently with VBS (54% vs. 24%, p = 0.005). Rates of adjacent vertebral fracture (13% vs. 26%, p = 0.12) and revision surgery (4% vs. 8%, p = 0.44) were comparable between groups. Conclusions: Despite VBS being reserved for more complex fracture morphologies with split-type fractures and severe endplate defects, while BKP was generally used for uncomplicated OVF cases, VBS provided pain relief and radiographic correction comparable to BKP. Full article

Background/Objectives: Stereotactic body radiation therapy (SBRT) provides improved pain response and local control for spinal metastases. However, management of local failure after initial SBRT is challenging. We report institutional outcomes, dosimetry, and toxicity for reSBRT following SBRT. Methods: We retrospectively reviewed 61 lesions (55 patients) treated with reSBRT after prior SBRT. Both SBRT courses delivered a median dose of 27 Gy. Patients underwent clinical and radiological evaluation every three months. Toxicity was graded using CTCAE v5.0. Dosimetric parameters for the spinal cord (SC), cauda equina (CE), planning organ-at-risk volumes (PRV), and thecal sac were converted to equivalent dose in 2 Gy fractions (EQD₂) using the linear–quadratic model (α/β = 2). Results: Median follow-up was 10.3 months. Forty lesions (65%) were cervicothoracic and 21 (35%) were lumbosacral. One- and two-year overall survival (OS) were 45% and 29%, respectively, and one- and two-year local control (LC) were 89% and 88%, respectively. Gastrointestinal primary tumors were associated with inferior LC (HR 2.41, 95% CI 1.11–5.23, p = 0.026). Fifteen patients (27%) reported myelitis/neuropathic symptoms during follow-up; four (7%) developed new post-radiation myelitis or neuropathy (RMN) without radiologic progression. Five patients (9%) developed vertebral compression fractures (VCF). Cumulative EQD₂ was not significantly associated with RMN (p = 0.344); all affected patients had thecal sac EQD₂ > 95.5 Gy and relevant nerve roots EQD₂ > 108 Gy. Conclusions: ReSBRT provided a favorable LC with acceptable toxicity. High cumulative dose to the thecal sac and nerve roots may contribute to neurologic toxicity as peripheral nerve injury. Full article

Background and Objectives: Ventral stabilization of thoracolumbar spine fractures can be achieved using different interbody reconstruction techniques, including titanium cages, vertebral body replacements (VBR), and autologous pelvic bone grafts (APBG). Although all approaches aim to restore anterior column stability and alignment, comparative data on long-term patient-reported outcomes remain limited. The objective of this study was to compare long-term patient-reported wellbeing following ventral stabilization using these three techniques. Materials and Methods: A retrospective, non-randomized single-center cohort study with prospective follow-up was analyzed. Treatment allocation was indication-based. Ninety-one patients treated between 2008 and 2018 underwent ventral stabilization using cage implantation (n = 12), vertebral body replacement (n = 45), or autologous pelvic bone grafting (n = 34). Clinical outcome was assessed at least 12 months postoperatively using a modified Visual Analog Scale Spine Score (VAS-Spine). Statistical analysis included linear and ordinal regression adjusted for age and sex. Potential baseline differences between groups were considered in the interpretation of the results. Results: Sixty-three patients (mean age 52 ± 15 years; 41% female) completed follow-up. The mean VAS-Spine score was lowest after cage implantation (2.7 ± 3.6), followed by VBR (3.9 ± 2.8) and APBG (4.9 ± 1.8; p* = 0.021). The observed difference between cage and APBG approached the minimal clinically important difference reported for VAS-based measures. Patients treated with cage implantation reported less pain during rest and activity and fewer limitations in daily life. No significant differences were observed regarding age or sex. Conclusions: In this observational cohort, cage implantation was associated with more favorable patient-reported outcomes compared with VBR and APBG. Autologous pelvic bone grafting was associated with worse patient-reported outcomes, potentially related to donor-site morbidity. Given the non-randomized design and potential confounding, these findings should be interpreted as associative and hypothesis-generating. Full article