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Orthopaedic Proceedings
Vol. 103-B, Issue SUPP_11 | Pages 25 - 25
1 Sep 2021
Shah N Shafafy R Selvadurai S Benton A Herzog J Molloy S
Full Access

Introduction

Patients with metastatic spinal cord compression (MSCC) or unstable spinal lesions warrant early surgical consultation. In multiple myeloma, chemotherapy and radiotherapy have the potential to decompress the spinal canal effectively in the presence of epidural lesions. Mechanical stability conferred by bracing may potentiate intraosseous and extraosseous bone formation, thus increasing spinal stability. This study aims to review the role of non-operative management in myeloma patients with a high degree of spinal instability, in a specialist tertiary centre.

Methods

Retrospective analysis of a prospectively collected database of 83 patients with unstable myelomatous lesions of the spine, defined by a Spinal Instability Neoplastic Score (SINS) of 13–18. Data collected include patient demographics, systemic treatment, neurological status, radiological presence of cord compression, most unstable vertebral level and presence of intraosseous and extraosseous bone formation. Post-treatment scores were calculated based on follow-up imaging which was carried out at 2 weeks for cord compression and 12 weeks for spinal instability. A paired t-test was used to identify any significant difference between pre- and post-treatment SINS and linear regression was used to assess the association between variables and the change in SINS.


The Bone & Joint Journal
Vol. 102-B, Issue 10 | Pages 1368 - 1374
3 Oct 2020
McDonnell JM Ahern DP Lui DF Yu H Lehovsky J Noordeen H Molloy S Butler JS Gibson A

Aims

Whether a combined anteroposterior fusion or a posterior-only fusion is more effective in the management of patients with Scheuermann’s kyphosis remains controversial. The aim of this study was to compare the radiological and clinical outcomes of these surgical approaches, and to evaluate the postoperative complications with the hypothesis that proximal junctional kyphosis would be more common in one-stage posterior-only fusion.

Methods

A retrospective review of patients treated surgically for Scheuermann’s kyphosis between 2006 and 2014 was performed. A total of 62 patients were identified, with 31 in each group. Parameters were compared to evaluate postoperative outcomes using chi-squared tests, independent-samples t-tests, and z-tests of proportions analyses where applicable.


The Bone & Joint Journal
Vol. 102-B, Issue 3 | Pages 371 - 375
1 Mar 2020
Cawley D Dhokia R Sales J Darwish N Molloy S

With the identification of literature shortfalls on the techniques employed in intraoperative navigated (ION) spinal surgery, we outline a number of measures which have been synthesised into a coherent operative technique. These include positioning, dissection, management of the reference frame, the grip, the angle of attack, the drill, the template, the pedicle screw, the wire, and navigated intrathecal analgesia. Optimizing techniques to improve accuracy allow an overall reduction of the repetition of the surgical steps with its associated productivity benefits including time, cost, radiation, and safety.

Cite this article: Bone Joint J 2020;102-B(3):371–375.


The Bone & Joint Journal
Vol. 102-B, Issue 1 | Pages 5 - 10
1 Jan 2020
Cawley DT Rajamani V Cawley M Selvadurai S Gibson A Molloy S

Aims

Intraoperative 3D navigation (ION) allows high accuracy to be achieved in spinal surgery, but poor workflow has prevented its widespread uptake. The technical demands on ION when used in patients with adolescent idiopathic scoliosis (AIS) are higher than for other more established indications. Lean principles have been applied to industry and to health care with good effects. While ensuring optimal accuracy of instrumentation and safety, the implementation of ION and its associated productivity was evaluated in this study for AIS surgery in order to enhance the workflow of this technique. The aim was to optimize the use of ION by the application of lean principles in AIS surgery.

Methods

A total of 20 consecutive patients with AIS were treated with ION corrective spinal surgery. Both qualitative and quantitative analysis was performed with real-time modifications. Operating time, scan time, dose length product (measure of CT radiation exposure), use of fluoroscopy, the influence of the reference frame, blood loss, and neuromonitoring were assessed.


The Bone & Joint Journal
Vol. 98-B, Issue 9 | Pages 1234 - 1239
1 Sep 2016
Yu HM Malhotra K Butler JS Patel A Sewell MD Li YZ Molloy S

Aims

Patients with multiple myeloma (MM) develop deposits in the spine which may lead to vertebral compression fractures (VCFs). Our aim was to establish which spinopelvic parameters are associated with the greatest disability in patients with spinal myeloma and VCFs.

Patients and Methods

We performed a retrospective cross-sectional review of 148 consecutive patients (87 male, 61 female) with spinal myeloma and analysed correlations between spinopelvic parameters and patient-reported outcome scores. The mean age of the patients was 65.5 years (37 to 91) and the mean number of vertebrae involved was 3.7 (1 to 15).


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_15 | Pages 26 - 26
1 Oct 2014
Molloy S Butler J Yu H Sewell M Benton A Selvadurai S Agu O
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To assess implant performance, to evaluate fusion and to assess clinical and radiologic outcome of circumferential fusion using porous tantalum cages for ALIF in a 360-degree fusion.

A retrospective cohort study was performed over a 4-year period that included the implantation of 280 tantalum cages in 98 patients by the technique of anterior lumbar interbody fusion (ALIF) and posterolateral spondylodesis. Radiographic follow-up was performed to document any implant related problems. Preoperative and postoperative clinical outcome measures were assessed.

No neurological, vascular or visceral injuries were reported. There were no rod breakages and no symptomatic non-unions. One revision procedure was performed for fracture. Mean VAS back pain score in our patient cohort improved from 7.5 preoperatively to 1.9 at latest follow-up, mean VAS leg pain score improved from 6.2 to 1.1 and mean ODI score improved from 51.1 to 18.3.

Porous tantalum cages have high strength and flexibility, in addition to having similar biomaterial properties to cancellous bone. Their use in 360-degree spondylodesis to treat degenerative lumbar spine deformity has been demonstrated to be very safe and effective, with excellent clinical and functional outcomes.


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_15 | Pages 27 - 27
1 Oct 2014
Molloy S Butler J Yu H Selvadurai S Panchmatia J
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To evaluate the incidence of complications and the radiographic and clinical outcomes from 2-stage reconstruction including 3-column osteotomy for revision adult spinal deformity.

A prospective cohort study performed over 2 years at a major tertiary referral centre for adult spinal deformity surgery. All consecutive patients requiring 2-stage corrective surgery for revision adult spinal deformity were included. Radiographic parameters and clinical outcome measures were collected preoperatively and at 6 weeks, 6 months, 1 year and 2 years postoperatively. Radiographic parameters analysed included pelvic incidence, pelvic tilt, sacral slope, lumbar lordosis, thoracic kyphosis and sagittal vertical axis. Clinical outcome measures collected included EQ-5D, ODI, SRS 22 and VAS Pain Scores.

Performing anterior column reconstruction followed by 3-column osteotomy and extension of instrumentation for revision spinal deformity resulted an excellent correction of sagittal alignment, minimal surgical complications and significant improvements in HRQOL. Restoration of lumbar lordosis, pelvic tilt and sagittal vertical axis were observed in addition to postoperative improvements in EQ-5D, ODI, SRS 22 and VAS Pain Scores at follow-up.

Performing anterior column reconstruction prior to a 3-column osteotomy minimises complications associated with 3-column osteotomy and extension of posterior instrumentation. We propose a treatment algorithm for safe and effective treatment in revision adult deformity surgery.


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_15 | Pages 33 - 33
1 Oct 2014
Molloy S Butler J Patel A Bentom A Jassim S Sewell M Aftab S
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To assess the clinical and radiologic outcome of MM patients with thoracic spine involvement and concomitant pathologic sternal fractures with a resultant severe sagittal plane deformity.

A prospective cohort study (n=391) was performed over a 7-year period at a national tertiary referral centre for the management of multiple myeloma with spinal involvement. Clinical, serological and pathologic variables, radiologic findings, treatment strategies and outcome measures were prospectively collected. Pre-treatment and post-treatment clinical outcome measures utilised included EQ-5D, VAS, ODI and RMD scoring systems.

13 MM patients presented with a severe symptomatic progressive sagittal plane deformity with a history of pathologic thoracic compression fractures and concomitant pathologic sternal fracture. All patients with concomitant sternal fractures displayed the radiographic features and spinopelvic parameters of positive sagittal malalignment and attempted clinical compensation. All patients had poor health related quality of life measures when assessed.

Pathologic sternal fracture in a MM patient with thoracic compression fractures is a risk factor for the development of a severe thoracic kyphotic deformity and sagittal malalignment. This has been demonstrated to be associated with a very poor health related quality of life.


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_15 | Pages 34 - 34
1 Oct 2014
Molloy S Bruce G Butler J Benton A
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To examine the impact of a structured rehabilitation programme as part of an integrated multidisciplinary treatment algorithm for adult spinal deformity patients.

A prospective cohort study was performed over a 2-year period at a major tertiary referral centre for adult spinal deformity surgery. All consecutive patients requiring 2-stage corrective surgery for sagittal malalignment were included (n=32). Details of physiotherapy initial evaluation, inpatient rehabilitation progress, details of bracing treatment and time to discharge were collected. Clinical outcome scores were measured preoperatively and at 6 weeks, 6 months and 1 year postoperatively.

After second stage corrective surgery, the mean time to standing without assistance was 2.1 days, mean time to independent ambulation was 4.2 days, mean time to competent ascending and descending stairs was 5.6 days and mean time to moulded orthosis application 7.1 days. Successful progression through the structured rehabilitation programme was associated with high clinical outcome scores and improved health related quality of life (HRQOL).

The introduction of this programme contributed to the development of an enhanced recovery pathway for patients having adult spinal deformity surgery, reducing inpatient length of stay and optimising clinical outcomes.


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_15 | Pages 23 - 23
1 Oct 2014
Molloy S Butler J Yu H Benton A Selvadurai S
Full Access

To evaluate the differences between spinopelvic parameters before and after sagittal malalignment correction and to assess the relationship between these radiologic parameters and clinical outcome scores.

A prospective cohort study was performed over a 2-year period at a major tertiary referral centre for adult spinal deformity surgery. All consecutive patients requiring 2-stage corrective surgery were included (n=32). Radiographic parameters and clinical outcome measures were collected preoperatively and at 6 weeks, 6 months, 1 year and 2 years postoperatively. Radiographic parameters analysed included pelvic incidence, pelvic tilt, sacral slope, lumbar lordosis, thoracic kyphosis and sagittal vertical axis. Clinical outcome measures collected included EQ-5D, ODI, SRS 22 and VAS Pain Scores.

Correction of sagittal malalignment was associated with significant improvements in HRQOL. Restoration of lumbar lordosis, pelvic tilt and sagittal vertical axis correlated with postoperative improvements in EQ-5D, ODI, SRS 22 and VAS Pain Scores at follow-up.

This study demonstrates that the magnitude of sagittal plane correction correlates with the degree of clinical improvements in HRQOL. This further underlines the need for spinal surgeons to target complete sagittal plane deformity correction if they wish to achieve the highest rates of HRQOL benefit in patients with marked sagittal malalignment.


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_15 | Pages 30 - 30
1 Oct 2014
Molloy S Aftab S Patel A Butler J Balaji V Wilson L Lee R
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To assess screw malposition rates and complications associated with pedicle screw insertion using 3D navigation technology.

A retrospective study was undertaken for all cases where O-arm® and StealthStation® systems were used over a 2-year period. The primary outcome measure was return to theatre rates for pedicle screw malposition.

A total of 938 screws were inserted (934 thoracolumbar and 4 cervical), and 103 patients underwent spinal fixation using O-arm® and StealthStation® navigation. 64 were revision cases and 39 primary cases. Average number of levels was 4.6. There were a total of 10 complications: 3 infections, 1 DVT, 1 PE, 1 fast atrial fibrillation (AF), 1 screw malposition, 1 non-union, 1 undisplaced vertebral body fracture and 1 nerve root compression following osteotomy. The percentage return to theatre for screw malposition using 3D navigation was 1% of patients and 0.1% of pedicle screws. No patients developed permanent neurological compromise.

These systems provide accuracy that is comparable to traditional 2D fluoroscopic techniques. We advocate their use in the safe insertion of pedicle screws in complex revision deformity cases where original anatomical landmarks are absent or obscured. We also believe that radiation exposure is considerably less with navigation especially in these complex and revision cases.


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_15 | Pages 25 - 25
1 Oct 2014
O'Brien A Molloy S
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Retrospective review of blood loss during posterior instrumented fusion in Adult Deformity Surgery before and after the introduction of the ultrasonic bone cutter into routine surgical technique

We retrospectively reviewed a large series of adult patients undergoing four or more levels of posterior instrumented fusion (+/− osteotomies/decompressions) over an eight year period. The senior surgeon (SM) switched to using the ultrasonic bone cutter instead of conventional cutting techniques at a specific point in time. We reviewed the clinical records of cases performed both before and after this time point and were able to identify blood loss from the clinical records. We reviewed actual blood loss by evaluating several aspects, including suction volumes, swab weights, re-infusion volumes, pre- and post- operative haemoglobin values and the type and amount of haemostatic agents used.

We demonstrated that a significant reduction in blood loss intra-operatively occurred with reduced use of haemostatic agents following introduction of the ultrasonic bone cutter as the method of bone removal.

Significant reductions in blood loss were achieved with implications in terms of patient mortality and morbidity, improved surgical field and reduced amount and cost of haemostatic agents.


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_15 | Pages 29 - 29
1 Oct 2014
Molloy S Butler J Selvadurai S Whitman P
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To describe a staged surgical technique to correct significant progressive sagittal malalignment, without the need for 3-column osteotomy, in patients with prior long thoracolumbar instrumentation for scoliosis and to evaluate the radiographic and clinical outcome from this surgical strategy.

A small cohort study (n=6) of patients with significant sagittal malalignment following extensive thoracolumbar instrumented fusions for scoliotic deformity. Radiographic parameters analysed included pelvic incidence, pelvic tilt, sacral slope, lumbar lordosis, thoracic kyphosis and sagittal vertical axis. Clinical outcome measures collected included EQ-5D, ODI, SRS 22 and VAS Pain Scores.

3 patients had 2-stage anterior release and instrumented fusion followed by a posterior instrumented fusion 3 patients with a large sagittal plane deformity had a 3-stage surgical technique. All patients achieved an excellent correction of sagittal alignment, with no surgical complications and excellent health related quality of life (HRQOL) outcome measures at follow-up. There was no symptomatic non-unions or implant failures including rod breakages.

We present a safe and effective surgical strategy to treat the complex problem of progressive sagittal malalignment in the previously instrumented adult deformity patient, avoiding the need for 3-column osteotomies in the lumbar spine.


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_15 | Pages 28 - 28
1 Oct 2014
Molloy S Sewell MD Patel AS Fahmy A Platinum J Selvadurai S Hargunani R Kyriakou C
Full Access

This study assesses whether balloon kyphoplasty (BKP) can safely restore height and correct deformity for cancer-related vertebral compression fractures (VCFs) involving the posterior vertebral body wall (PVBW), which is normally considered a relative contraindication.

Retrospective cohort study of 158 patients (99M:59F; mean age 63 years) with 228 cancer-related VCFs, who underwent BKP. 112 had VCFs with PVBW defects, and 46 had VCFs with no PVBW defect. Data was assessed preoperatively and at 3 months.

In the PVBW defect group, mean pain score decreased from 7.5 to 3.6 (p<0.001). There was a significant decrease in kyphotic angle (p<0.01), anterior vertebral body height (AVBH) (p<0.01) and mid-vertebral body height (MVBH) (p<0.05). In the PVBW intact group, mean pain score decreased from 7.3 to 3.3 (p<0.001). There was a significant improvement in AVBH and MVBH (p<0.001). When comparing groups, kyphotic angle, AVBH and MVBH were significantly worse in the PVBW defect group (P<0.05). More cement leaks occurred in the PVBW defect group.

BKP can alleviate pain but does not restore height or correct kyphosis in patients with cancer-related VCFs and PVBW defects. There is no appreciable increase in surgical risk.


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_6 | Pages 14 - 14
1 Apr 2014
Anwar H Rajakulendran K Shetty N Molloy S Liantis P
Full Access

Aim:

To simplify sagittal plane spinal assessment by describing a single novel angle in the lumbar spine equivalent to the difference between pelvic incidence (PI) and lumbar lordosis (LL) and evaluate its reliability.

Methods:

New sagittal modifiers in the classification of adult degenerative spinal deformity have been shown to be valid and reliable with the greatest variability being for pelvic incidence minus lumbar lordosis (PI-LL). This measurement can be simplified to a new angle (alpha) without the need to determine either PI or LL. This angle is between a line intersecting the bicoxofemoral centre and perpendicular to the L1 endplate (alpha line) and a line from the bicoxofemoral centre to the centre of the sacral endplate. Two readers graded 40 non-premarked cases twice each, approximately 1 week apart. Inter- and intra-rater variability and agreement were determined for PI-LL and alpha angle separately. Fleiss' kappa was used for reliability measures.


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_6 | Pages 13 - 13
1 Apr 2014
Anwar H Yarashi T Rajakulendrun K Molloy S
Full Access

Aim:

To establish whether there is a direct relationship between pelvic morphology and lumbar segmental angulation in the sagittal plane.

Methods:

40 lateral whole spine radiographs with normal sagittal profiles were reviewed. Pelvic incidence (PI), Lumbar Lordosis (LL), Thoracic Kyphosis (TK) and segmental angulation at each level from L1 to the sacrum were measured (from endplate to endplate) distinguishing the vertebral body and intervertebral disc contribution. Pearson correlation coefficients were used to analyse any relationship between pelvic parameters and segmental angulation.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_III | Pages 290 - 290
1 Jul 2011
Langdon J Molloy S Bernard J
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Objective: In 1989 Mirels published a scoring system for identifying impending pathological fractures in long bones. However, the spine is the most common site of skeletal metastases. A MR-based scoring system is proposed to quantify the risk of sustaining a pathological fracture through a metastatic lesion in a vertebral body.

Methods: A retrospective analysis of 101 vertebral body metastatic lesions was carried out. The metastases were identified through the onco-radiology database. Only lesions with a MR scan and subsequent imaging within 24-months of the index scan were included. Variables potentially predictive of impending fracture were analysed for significance. The significant variables were then statistically weighted. The original MR scans were scored, and the subsequent imaging was used to identify which lesions fractured. The scores were compared between the fracture and non-fracture group. Analysis was carried out for each predictive variable to establish whether they were individually as good as the scoring system alone in predicting fracture. Intra and inter-observer variability was assessed using kappa statistics.

Results: Twenty-one of the 101 lesions fractured within 24 months. A mean score of 0.65 was identified in the non-fracture group, whilst the fracture group had a mean score of 6.52 (p< 0.0001). The percentage risk of a lesion sustaining a pathological fracture was calculated for any given score. As the score increased above 4, so did the percentage risk of fracture (sensitivity 85.7%, specificity 97.5%). Very good intra and inter-observer agreement was present, showing the scoring system to be reliably reproducible.

Conclusions: The authors propose that all painful vertebral body metastatic lesions be evaluated by MR scanning. Lesions with a score of 3 or less can be left untreated. Lesions with scores of 4 or higher are at risk of fracture and should be considered for prophylactic cement augmentation.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_I | Pages 27 - 27
1 Jan 2011
Hudd A Bernard J Molloy S
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The aim of the study was to assess the safety of a novel anatomical landmark in the placement of thoracic pedicle screws. It is our clinical observation that the sagittal plane of the screw trajectory is perpendicular to the plane of the superior articular facet, when the entry point is in the lateral half of the articular surface of the corresponding superior facet.

Using SECTRA software on a PACS digital imaging system, morphometric analysis was performed on thoracic vertebrae imaged using computed tomography (CT). For inclusion, the scan had to have no reported bony abnormality. It was determined whether a trajectory as described at 90 degrees to the articular facet, with an entry point just caudal to the lateral half of the facet to a depth of 25mm would breach either the medial wall of the pedicle or lateral vertebral body wall anterior to the costovertebral facet.

Sixty-two CT scans (744 segments, 1488 pedicle-facet complexes) were reviewed. 1154 complexes were suitable for full analysis. Exclusions were due to the lumbarisation of the T12 facet joints (62) or inability to clearly define the facet surface due to the plane of the CT slice (272). Of 1154 entry points assessed, 1154 (100%) were safe to be entered at 90 degrees to a depth of at least 25mm.

We have demonstrated the safety and reliability of a novel anatomical landmark in normal thoracic pedicles. We believe this will improve sagittal plane alignment and reduce further the risk of medial pedicle breach.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_I | Pages 27 - 27
1 Jan 2011
Langdon J Way A Bernard J Molloy S
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Acute osteoporotic vertebral compression fractures (VCFs) are frequently misdiagnosed as there is often no history of preceding trauma. VCFs not only cause back pain, but can also result in a loss of function, spinal deformity and increased mortality. Cement augmentation has been shown to effectively treat these fractures. It is impossible to diagnose an acute fracture on plain x-ray and therefore identify those likely to benefit from this treatment. The definitive investigation to determine the presence of an acute fracture is a MR scan, but this is a limited resource. The aim of this paper is to evaluate 2 new clinical signs which we believe aid in the diagnosis of an acute VCF: firstly closed fist percussion at the level of an acute VCF resulting in a severe, sharp fracture pain, and secondly the inability of a patient to lie supine. This was a prospective study of 78 patients with suspected acute VCFs.

48/78 had an acute fracture on MR. 42/45 patients who were positive for closed fist percussion, had an acute fracture on their MR scan. There were 6 patients who were negative for closed fist percussion who had an acute fracture (sensitivity 87.5%, specificity 90%).

39/41 patients who were positive for the supine sign had an acute fracture on their MR scan. There were 9 patients who were comfortably able to lay supine who had an acute fracture (sensitivity 81.25%, specificity 93.33%).

Either a positive closed fist percussion sign or a positive supine sign is a reliable indicator of the presence of an acute VCF. By incorporating these signs into our routine clinical assessment we are better able to predict which patients have an acute fracture, and therefore decide which patients need a MR scan.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_IV | Pages 602 - 602
1 Oct 2010
Langdon J Bernard J Molloy S
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Objective: In 1989 Mirels published a scoring system for identifying impending pathological fractures in long bones, and it is now standard practice that long bones with metastases at risk of fracture are treated with prophylactic internal fixation. The spine is the most common site of skeletal metastases, with spinal metastases present in up to 36% of patients with terminal cancer. A pathological fracture through a vertebral body can result in paralysis, incontinence and severe pain. However, there is no equivalent of the Mirels’ scoring system to aid the spinal surgeon in determining the probability of an impending spinal fracture.

A weighted scoring system is proposed to quantify the risk of sustaining a pathological fracture through a metastatic lesion in a vertebral body. This system analyzes and combines four magnetic resonance (MR) risk factors into a single score.

Methods: A retrospective analysis of 100 vertebral body metastatic lesions was carried out. The original MR scans were scored, and the subsequent imaging was used to identify which vertebral body lesions fractured. Patients with no subsequent imaging within 12 months were excluded.

Results: Twenty of the 100 lesions fractured within 12 months. A mean score of 0.64 was identified in the non-fracture group, where as the fracture group had a mean score of 6.80. The percentage risk of a lesion sustaining a pathological fracture was calculated for any given score. As the score increased above 3, so did the percentage risk of fracture (sensitivity 90%, specificity 91%).

Conclusions: The authors propose that all painful vertebral body metastatic lesions be evaluated by MR scanning. Lesions with a score of 2 or less can be left untreated, while lesions with scores of 3 or higher should be considered for prophylactic balloon kyphoplasty.