Predicting the Nonunion of the Acute Osteoporotic Vertebral Compression Fracture Following Low-Energy Injuries by Quantifying Vertebral Marrow Fat Fraction on T₂-Weighted Dixon Sequences

Abstract

Objective: Increased marrow fat fraction (MFF) of vertebrae was detected in patients with osteoporosis. However, MFF of the fractured vertebrae decreased significantly following the fracture. The aim of this study was to assess the predictive value of fractured vertebrae MFF quantified on T₂-weighted Dixon sequences for the prediction of nonunion risk of acute OVCF.

Materials and Methods: Medical records of 39 patients with OVCF, including a total of 60 fractured vertebrae, were reviewed retrospectively. Fractured vertebrae in the acute phase were grouped into the nonunion group (20 vertebrae) and the union group (40 vertebrae), based on the OVCF prognosis confirmed by computer tomography (CT). MFF of the fractured vertebrae was quantitatively assessed with the software Matlab on T₂-weighted Dixon sequences. Interclass correlation coefficients (ICC) were analyzed to assess the repeatability of MFF measurement. Binary logistic regression analysis was performed to determine the relative contribution of the MFF for predicting the prognosis of OVCF. Receiver operating characteristic (ROC) curve analysis was performed to determine the diagnostic performance of MFF.

Results: The ICC indicated that the repeatability of MFF measurement was excellent (all p < 0.001). The MFF (42.25% ± 26.61%) decreased significantly compared to the value before OVCF (79.84% ± 9.65%) (p < 0.001). The MFF of the fractured vertebrae was lower in the nonunion group (16.40% ± 15.65%) than in the union group (55.18% ± 20.93%) (p < 0.001). Binary logistic regression analysis indicated that MFF of fractured vertebrae could independently predict the prognosis of acute OVCF (p < 0.001). ROC analysis indicated the area under the curve was 0.928 (95% CI, 0.831–0.979, p < 0.0001).

Conclusions: The MFF quantified on T₂-weighted Dixon sequences was a useful marker for assessing the nonunion risk of acute OVCF. The fractured vertebra with low MFF should be carefully monitored for nonunion.

Keywords

fracture / magnetic resonance imaging / marrow fat fraction / nonunion / osteoporosis

References

[1] P. D. Miller, “Management of Severe Osteoporosis,” Expert Opinion on Pharmacotherapy 17 (2016): 473-488.

[2] G. Ballane, J. A. Cauley, M. M. Luckey, and G. el-Hajj Fuleihan, “Worldwide Prevalence and Incidence of Osteoporotic Vertebral Fractures,” Osteoporosis International 28 (2017): 1531-1542.

[3] M. Ruiz-Adame and M. Correa, “A Systematic Review of the Indirect and Social Costs Studies in Fragility Fractures,” Osteoporosis International 31 (2020): 1205-1216.

[4] P. R. Ebeling, K. Akesson, D. C. Bauer, et al., “The Efficacy and Safety of Vertebral Augmentation: A Second ASBMR Task Force Report,” Journal of Bone and Mineral Research 34 (2019): 3-21.

[5] C. E. Firanescu, J. de Vries, P. Lodder, et al., “Vertebroplasty Versus Sham Procedure for Painful Acute Osteoporotic Vertebral Compression Fractures (VERTOS IV): Randomised Sham Controlled Clinical Trial,” BMJ 361 (2018): k1551.

[6] R. Buchbinder and L. Busija, “Why We Should Stop Performing Vertebroplasties for Osteoporotic Spinal Fractures,” Internal Medicine Journal 49 (2019): 1367-1371.

[7] R. Buchbinder, R. V. Johnston, K. J. Rischin, et al., “Percutaneous Vertebroplasty for Osteoporotic Vertebral Compression Fracture,” Cochrane Database of Systematic Reviews 4 (2018): CD006349.

[8] S. Luthman, J. Widen, and F. Borgstrom, “Appropriateness Criteria for Treatment of Osteoporotic Vertebral Compression Fractures,” Osteoporosis International 29 (2018): 793-804.

[9] T. Tsujio, H. Nakamura, H. Terai, et al., “Characteristic Radiographic or Magnetic Resonance Images of Fresh Osteoporotic Vertebral Fractures Predicting Potential Risk for Nonunion: A Prospective Multicenter Study,” Spine (Phila Pa 1976) 36 (2011): 1229-1235.

[10] D. Bliuc, N. D. Nguyen, V. E. Milch, T. V. Nguyen, J. A. Eisman, and J. R. Center, “Mortality Risk Associated With Low-Trauma Osteoporotic Fracture and Subsequent Fracture in Men and Women,” JAMA 301 (2009): 513-521.

[11] Y. Zhao, R. Xue, N. Shi, et al., “Aggravation of Spinal Cord Compromise Following New Osteoporotic Vertebral Compression Fracture Prevented by Teriparatide in Patients With Surgical Contraindications,” Osteoporosis International 27 (2016): 3309-3317.

[12] P. Gou, Z. Wang, Z. Zhao, Y. Wang, Y. Jiang, and Y. Xue, “Restoration of the Intravertebral Stability in Kummell's Disease Following the Treatment of Severe Postmenopausal Osteoporosis by 1-34PTH-a Retrospective Study,” Osteoporosis International 32 (2021): 1451-1459.

[13] P. G. Gou, Z. H. Zhao, J. M. Zhou, et al., “Vertebral Collapse Prevented Following Teriparatide Treatment in Postmenopausal Kummell's Disease Patients With Severe Osteoporosis,” Orthopaedic Surgery 13 (2021): 506-516.

[14] P. Gou, Z. Zhao, C. Yu, et al., “Efficacy of Recombinant Human Parathyroid Hormone Versus Vertebral Augmentation Procedure on Patients With Acute Osteoporotic Vertebral Compression Fracture,” Orthopaedic Surgery 14 (2022): 2510-2518.

[15] V. Singhal and M. A. Bredella, “Marrow Adipose Tissue Imaging in Humans,” Bone 118 (2019): 69-76.

[16] W. Shen, R. Scherzer, M. Gantz, et al., “Relationship Between MRI-Measured Bone Marrow Adipose Tissue and Hip and Spine Bone Mineral Density in African-American and Caucasian Participants: The CARDIA Study,” Journal of Clinical Endocrinology and Metabolism 97 (2012): 1337-1346.

[17] A. K. Wong, A. Chandrakumar, R. Whyte, et al., “Bone Marrow and Muscle Fat Infiltration Are Correlated Among Postmenopausal Women With Osteoporosis: The AMBERS Cohort Study,” Journal of Bone and Mineral Research 35 (2020): 516-527.

[18] T. Kanchiku, Y. Imajo, H. Suzuki, Y. Yoshida, and T. Taguchi, “Usefulness of an Early MRI-Based Classification System for Predicting Vertebral Collapse and Pseudoarthrosis After Osteoporotic Vertebral Fractures,” Journal of Spinal Disorders & Techniques 27 (2014): E61-E65.

[19] H. Inose, T. Kato, S. Ichimura, et al., “Risk Factors of Nonunion After Acute Osteoporotic Vertebral Fractures: A Prospective Multicenter Cohort Study,” Spine (Phila Pa 1976) 45 (2020): 895-902.

[20] S. Ahn, K. Ryu, J. Park, et al., “Early Bone Marrow Edema Pattern of the Osteoporotic Vertebral Compression Fracture: Can be Predictor of Vertebral Deformity Types and Prognosis?,” Journal of Korean Neurosurgical Association 59 (2016): 137-142.

[21] R. Donners, M. M. Obmann, D. Boll, A. Gutzeit, and D. Harder, “Dixon or DWI - Comparing the Utility of Fat Fraction and Apparent Diffusion Coefficient to Distinguish Between Malignant and Acute Osteoporotic Vertebral Fractures,” European Journal of Radiology 132 (2020): 109342.

[22] J. S. Yun, H. D. Lee, K. S. Kwack, and S. Park, “Use of Proton Density Fat Fraction MRI to Predict the Radiographic Progression of Osteoporotic Vertebral Compression Fracture,” European Radiology 31 (2020): 3582-3589.

[23] G. W. Li, Z. Xu, Q. W. Chen, et al., “Quantitative Evaluation of Vertebral Marrow Adipose Tissue in Postmenopausal Female Using MRI Chemical Shift-Based Water-Fat Separation,” Clinical Radiology 69 (2014): 254-262.

[24] F. Ergen, G. Gulal, A. Yildiz, et al., “Fat Fraction Estimation of the Vertebrae in Females Using the T₂*-IDEAL Technique in Detection of Reduced Bone Mineralization Level: Comparison With Bone Mineral Densitometry,” Journal of Computer Assisted Tomography 38 (2014): 320-324.

[25] D. Kim, H. Yoo, S. Hong, et al., “Differentiation of Acute Osteoporotic and Malignant Vertebral Fractures by Quantification of Fat Fraction With a Dixon MRI Sequence,” AJR. American Journal of Roentgenology 209 (2017): 1331-1339.

[26] T. A. Bley, O. Wieben, C. J. Francois, et al., “Fat and Water Magnetic Resonance Imaging,” Journal of Magnetic Resonance Imaging 31 (2010): 4-18.

[27] C. A. Kohl, F. S. Chivers, R. Lorans, C. C. Roberts, and M. J. Kransdorf, “Accuracy of Chemical Shift MR Imaging in Diagnosing Indeterminate Bone Marrow Lesions in the Pelvis: Review of a Single Institution's Experience,” Skeletal Radiology 43 (2014): 1079-1084.

[28] R. Donners, A. Hirschmann, A. Gutzeit, and D. Harder, “T₂-Weighted Dixon MRI of the Spine: A Feasibility Study of Quantitative Vertebral Bone Marrow Analysis,” Diagnostic and Interventional Imaging 102 (2021): 431-438.

[29] D. B. Hoffmann, C. Popescu, M. Komrakova, et al., “Chronic Hyponatremia in Patients With Proximal Femoral Fractures After Low Energy Trauma: A Retrospective Study in a Level-1 Trauma Center,” Bone Reports 12 (2020): 100234.

[30] T. Kato, H. Inose, S. Ichimura, et al., “Comparison of Rigid and Soft-Brace Treatments for Acute Osteoporotic Vertebral Compression Fracture: A Prospective, Randomized, Multicenter Study,” Journal of Clinical Medicine 8 (2019): 8.

[31] T. H. Diamond, W. A. Clark, and S. V. Kumar, “Histomorphometric Analysis of Fracture Healing Cascade in Acute Osteoporotic Vertebral Body Fractures,” Bone 40 (2007): 775-780.

[32] D. Zou, W. Li, C. Deng, G. du, and N. Xu, “The Use of CT Hounsfield Unit Values to Identify the Undiagnosed Spinal Osteoporosis in Patients With Lumbar Degenerative Diseases,” European Spine Journal 28 (2019): 1758-1766.

[33] J. T. Mauch, C. M. Carr, H. Cloft, and F. E. Diehn, “Review of the Imaging Features of Benign Osteoporotic and Malignant Vertebral Compression Fractures,” AJNR. American Journal of Neuroradiology 39 (2018): 1584-1592.

[34] S. Takahashi, M. Hoshino, K. Takayama, et al., “Predicting Delayed Union in Osteoporotic Vertebral Fractures With Consecutive Magnetic Resonance Imaging in the Acute Phase: A Multicenter Cohort Study,” Osteoporosis International 27 (2016): 3567-3575.

[35] K. Odeh, A. Rosinski, J. Leasure, and D. Kondrashov, “Pedicle Screws Challenged: Lumbar Cortical Density and Thickness Are Greater in the Posterior Elements Than in the Pedicles,” Global Spine J 11 (2019): 34-43.

[36] J. E. Compston, M. R. McClung, and W. D. Leslie, “Osteoporosis,” Lancet 393 (2019): 364-376.

[37] T. D. Rachner, S. Khosla, and L. C. Hofbauer, “Osteoporosis: Now and the Future,” Lancet 377 (2011): 1276-1287.

[38] D. Hasic, R. Lorbeer, R. C. Bertheau, et al., “Vertebral Bone Marrow Fat Is Independently Associated to VAT but Not to SAT: KORA FF4-Whole-Body MR Imaging in a Population-Based Cohort,” Nutrients 12 (2020): 1527.

[39] G. Tang, Z. Lv, R. Tang, et al., “Evaluation of MR Spectroscopy and Diffusion-Weighted MRI in Detecting Bone Marrow Changes in Postmenopausal Women With Osteoporosis,” Clinical Radiology 65 (2010): 377-381.

[40] H. Kugel, C. Jung, O. Schulte, and W. Heindel, “Age- and Sex-Specific Differences in the 1H-Spectrum of Vertebral Bone Marrow,” Journal of Magnetic Resonance Imaging 13 (2001): 263-268.

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