Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, The Netherlands.
Spine (Phila Pa 1976). 2012 May 15;37(11):974-81. doi: 10.1097/BRS.0b013e318238bf22.
Prospective follow-up study.
Evaluation of the diagnostic assessment and clinical significance of the intravertebral cleft in painful, long-standing osteoporotic vertebral compression fractures (OVCFs) treated with percutaneous vertebroplasty (PVP).
Patients with painful OVCFs with intravertebral clefts provide a unique and possibly superior indication for PVP. However, comparative studies are scarce, and the results are conflicting. The extent of the difference attributable to interobserver variation in the identification of an intravertebral cleft is currently unknown.
A total of 102 patients received PVP for 197 painful long-standing OVCFs and were prospectively observed, using a pain-intensity numerical-rating scale for back pain, the 36-Item Short Form Health Survey quality-of-life questionnaire, and routine spinal radiographs. Three experienced examiners retrospectively examined all preoperative radiographs and magnetic resonance imaging (MRI) T1-weighted and short-tau-inversion-recovery (STIR) sequences and the direct postoperative computed tomographic scans for the presence of an intravertebral cleft. Disagreements were re-examined and discussed for consensus.
Interobserver agreement for the detection of an intravertebral cleft was moderate on preoperative radiography (κ, 0.55-0.59) and substantial on preoperative MRI (κ, 0.71-0.79) and postoperative computed tomography (κ, 0.67-0.85). On the basis of consensus, 42 (21.3%) clefts were detected. The associated sensitivity of preoperative radiography was low (31.7%-48.8%), but the specificity was high (94.7%-99.3%). The diagnostic performance of preoperative MRI T1-weighted and STIR sequences was excellent, with both high sensitivity (85.7%-88.1%) and high specificity (89.7%-98.1%). Pain decrease and increase in quality of life obtained from PVP were ultimately comparable with patients without intravertebral clefts but was obtained more gradually during the first postoperative year. An intravertebral cleft was a strong risk factor for the occurrence of cortical cement leakage (odds ratio, 4.29; 95% confidence interval, 1.51-12.2; P = 0.006).
There is variation between observers in the identification of an intravertebral cleft, and the identification of an intravertebral cleft is not always straightforward. For preoperative assessment, we recommend MRI with T1-weighted and STIR sequences. Regarding patient-reported outcome, patients with long-standing OVCFs with intravertebral clefts benefit from PVP, but, compared with patients with OVCFs without intravertebral clefts, the benefit obtained was not superior and may be delayed.
前瞻性随访研究。
评估经皮椎体成形术（PVP）治疗疼痛性、长期骨质疏松性椎体压缩性骨折（OVCFs）时椎体内裂隙的诊断评估和临床意义。
有椎体内裂隙的疼痛性、长期 OVCFs 患者为 PVP 提供了一个独特的、可能更优的指征。然而，比较性研究很少，结果相互矛盾。目前尚不清楚观察者之间在识别椎体内裂隙方面的差异程度归因于何种差异。
共 102 例患者因 197 例疼痛性长期 OVCFs 接受 PVP 治疗，并前瞻性观察，使用背痛疼痛强度数字评分量表、36 项简短健康调查问卷（SF-36）生活质量问卷和常规脊柱 X 线片。3 名经验丰富的检查者回顾性分析所有术前 X 线片和磁共振成像（MRI）T1 加权和短 tau 反转恢复（STIR）序列以及直接术后 CT 扫描，以确定是否存在椎体内裂隙。意见分歧时，重新检查并讨论以达成共识。
术前 X 线片上观察者对椎体内裂隙的检测具有中等一致性（κ 值，0.55-0.59），术前 MRI（κ 值，0.71-0.79）和术后 CT（κ 值，0.67-0.85）上具有明显一致性。根据共识，检测到 42 个（21.3%）裂隙。术前 X 线片的相关敏感性较低（31.7%-48.8%），但特异性较高（94.7%-99.3%）。术前 MRI T1 加权和 STIR 序列的诊断性能优异，均具有较高的敏感性（85.7%-88.1%）和特异性（89.7%-98.1%）。PVP 获得的疼痛减轻和生活质量提高最终与无椎体内裂隙的患者相当，但在术后第一年更缓慢。椎体内裂隙是皮质骨水泥渗漏发生的强危险因素（比值比，4.29；95%置信区间，1.51-12.2；P=0.006）。
观察者在识别椎体内裂隙方面存在差异，而且识别椎体内裂隙并不总是那么容易。对于术前评估，我们建议采用 MRI 联合 T1 加权和 STIR 序列。关于患者报告的结果，有椎体内裂隙的长期 OVCFs 患者从 PVP 中获益，但与无椎体内裂隙的 OVCFs 患者相比，获益不更优，可能更延迟。
