Development and internal validation of a clinical prediction model for acute adjacent vertebral fracture after vertebral augmentation : the AVA score

Bone Joint J. 2022 Jan;104-B(1):97-102. doi: 10.1302/0301-620X.104B1.BJJ-2021-0151.R3.


Aims: To develop and internally validate a preoperative clinical prediction model for acute adjacent vertebral fracture (AVF) after vertebral augmentation to support preoperative decision-making, named the after vertebral augmentation (AVA) score.

Methods: In this prognostic study, a multicentre, retrospective single-level vertebral augmentation cohort of 377 patients from six Japanese hospitals was used to derive an AVF prediction model. Backward stepwise selection (p < 0.05) was used to select preoperative clinical and imaging predictors for acute AVF after vertebral augmentation for up to one month, from 14 predictors. We assigned a score to each selected variable based on the regression coefficient and developed the AVA scoring system. We evaluated sensitivity and specificity for each cut-off, area under the curve (AUC), and calibration as diagnostic performance. Internal validation was conducted using bootstrapping to correct the optimism.

Results: Of the 377 patients used for model derivation, 58 (15%) had an acute AVF postoperatively. The following preoperative measures on multivariable analysis were summarized in the five-point AVA score: intravertebral instability (≥ 5 mm), focal kyphosis (≥ 10°), duration of symptoms (≥ 30 days), intravertebral cleft, and previous history of vertebral fracture. Internal validation showed a mean optimism of 0.019 with a corrected AUC of 0.77. A cut-off of ≤ one point was chosen to classify a low risk of AVF, for which only four of 137 patients (3%) had AVF with 92.5% sensitivity and 45.6% specificity. A cut-off of ≥ four points was chosen to classify a high risk of AVF, for which 22 of 38 (58%) had AVF with 41.5% sensitivity and 94.5% specificity.

Conclusion: In this study, the AVA score was found to be a simple preoperative method for the identification of patients at low and high risk of postoperative acute AVF. This model could be applied to individual patients and could aid in the decision-making before vertebral augmentation. Cite this article: Bone Joint J 2022;104-B(1):97-102.

Keywords: Adjacent vertebral fracture; Clinical prediction model; Kyphoplasty; Multicentre cohort; Osteoporotic vertebral fracture; Vertebral augmentation; Vertebroplasty; adjacent vertebral fractures; intervertebral disc; kyphosis; logistic regression model; osteoporosis; prognostic study; vertebral augmentation; vertebral body; vertebral fractures; vertebroplasty.

Publication types

  • Multicenter Study
  • Validation Study

MeSH terms

  • Aged
  • Aged, 80 and over
  • Decision Support Techniques*
  • Female
  • Fractures, Compression / diagnostic imaging
  • Fractures, Compression / etiology*
  • Humans
  • Japan
  • Male
  • Postoperative Complications / diagnostic imaging
  • Postoperative Complications / etiology*
  • Prognosis
  • Retrospective Studies
  • Risk Factors
  • Sensitivity and Specificity
  • Spinal Fractures / diagnostic imaging
  • Spinal Fractures / etiology*
  • Vertebroplasty*