DIAGNOSTICS SPINE Volume 37, Number 11, pp 974–981 ©2012, Lippincott Williams & Wilkins 974 www.spinejournal.com May 2012 The Intravertebral Cleft in Painful Long-Standing Osteoporotic Vertebral Compression Fractures Treated With Percutaneous Vertebroplasty Diagnostic Assessment and Clinical Significance Marc J. Nieuwenhuijse, MD ,* Carla S. P. van Rijswijk, MD, PhD,† Arian R. van Erkel, MD, PhD ,† and Sander P. D. Dijkstra, MD, PhD* Study Design. Prospective follow-up study. Objective. 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). Summary of Background Data. 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. Methods. 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. Results. 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 P atients who present themselves with painful osteopo- rotic vertebral compression fractures (OVCFs) with intravertebral clefts represent a specific subgroup for treatment with percutaneous vertebroplasty (PVP). The pres- ence of an intravertebral cleft within an OVCF is regarded as the manifestation of delayed traumatic collapse, avascu- lar necrosis, and (resulting) pseudoarthrosis, 1 –3 and an OVCF with an intravertebral cleft shows increased mobility, 4 ,5 pres- ents itself with intense pain, 3 ,6 and considerable benefit of PVP is obtained from the clinician’s perspective. 7 ,8 It has been pro- posed that patients with painful OVCFs with intravertebral clefts may provide a unique and possibly superior indication for treatment with PVP. 8 –10 However, studies comparing PVP in OVCFs with and with- out intravertebral clefts are scarce, and the results are con- flicting. Benefit obtained from PVP in OVCFs with intraver- tebral clefts may be superior, 3 comparable, 7 ,11 ,12 or inferior 13 From the *Department of Orthopaedic Surgery, and †Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands. Acknowledgment date: May 25, 2011. First revision date: August 5, 2011. Acceptance date: September 20, 2011. The device(s)/drug(s) is/are FDA approved or approved by corresponding national agency for this indication. No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. Address correspondence and reprint requests to Marc J. Nieuwenhuijse, MD, Department of Orthopedic Surgery, Leiden University Medical Center, Albinusdreef 2, P.O. Box 9600, 2300 RC Leiden, the Netherlands; E-mail: m.j.nieuwenhuijse@lumc.nl 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). Conclusion. 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. Key words: percutaneous vertebroplasty, osteoporotic vertebral compression fractures, intravertebral cleft, diagnostic assessment, clinical significance, long-standing. Spine 2012;37:974–981 DOI: 10.1097/BRS.0b013e318238bf22 Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.