(1) The development of the nationwide incidence of vertebral fractures from 2009 to 2019.
In total 955,091 fractures of the spine were registered between 2009 and 2019. In comparison to the year 2009, in which 70,235 fractures were listed, the incidence increased by 45.6% from 105.8/100,000 inhabitants to 150.7/100,000 inhabitants (Figure 1). Of the overall vertebral fractures more occurred in women (57%) and 69.0% % were calculated for patients aged 70 years or older (Table 1).
Table 1: Development of fracture incidence from 2009 to 2019. Male/female ratio and ratio aged <70 years and ≥70 years. Changes were calculated relative to the incidence in 2009.
Year
|
Total number
|
Incidence per 100,000 inhabitants
|
Change relative to 2009 [%]
|
Ratio male/female
|
Ratio aged <70years/ ≥70years
|
2009
|
70,235
|
105.8
|
0.00
|
0.62
|
0.71
|
2010
|
74,588
|
112.1
|
6.20
|
0.60
|
0.67
|
2011
|
78,065
|
119.4
|
11.15
|
0.61
|
0.61
|
2012
|
79,426
|
121.0
|
13.09
|
0.60
|
0.57
|
2013
|
83,992
|
127.4
|
19.59
|
0.60
|
0.56
|
2014
|
86,865
|
130.3
|
23.68
|
0.60
|
0.52
|
2015
|
89,221
|
133.0
|
27.03
|
0.61
|
0.51
|
2016
|
94,706
|
140.4
|
34.84
|
0.58
|
0.49
|
2017
|
96,648
|
143.1
|
37.61
|
0.58
|
0.48
|
2018
|
99,060
|
146.3
|
41.04
|
0.59
|
0.48
|
2019
|
102,285
|
150.7
|
45.63
|
0.57
|
0.45
|
Figure 1 provides an overview of the distributions of vertebral fractures by anatomical location comparing data from 2009 and 2019. Fractures of the lumbar spine remain the most common vertebral fractures with a share of 56.0% in 2009 and 46.8% in 2019, followed by fractures of the thoracic spine (30.2% in 2009 and 27.4% in 2019). Whereas sacro-coccygeal fractures made up for 5.8% of all vertebral fractures in 2009 their proportion raised to 14.9% in 2019.
The most frequently occurring fractures in 2019 were at the lumbar spine with 47,874 registered cases and an incidence of 70.5 cases per 100,000 inhabitants. The most frequently documented fractures were L1 fractures in 21.9% of all cases. Followed by Th11 and Th12 fractures (cumulative 16.4%) and sacrum fractures (14.3%). Further, in 8.9% of all cases a L1 fracture was documented as secondary diagnosis. Lumbar spine fractures mainly affected women (61.7%). Here, 38.8% of all lumbar spine fractures occurred in female patients in the age group 80-89 years, 26.4% were registered in the age group 70-79 years and 9.7% involved female patients aged 90 years or older (Figure 2D). Men in the age group 80-89 years suffered from lumbar spine fractures in 28.4% of all cases (Figure 2D). Second, fractures of the thoracic spine were common with 28,057 hospitalized cases in 2019 and an incidence of 41.3 per 100,000 inhabitants. Of all the cases 63.6% were female and 36.4% male. Highest incidences were registered in women aged 80-89 years (38.6%), 70-79 years (25.9%) and female patients aged 60-69 years (11.5%), whereas 23.6% of all fractures occurred in men aged 80-89 years and 20.0% in men aged 70-79 (Figure 2C). These were followed by fractures of the sacrum and coccyx, which together affected 14,748 patients with an incidence of 21.7 cases per 100,000 inhabitants in 2019. More women than men suffered from fractures at this site (81.9% vs. 18.1%), whereby female patients in the age group 80-89 years comprised the largest cohort (45.4%), followed by women aged 80-89 years (30.2%) and older than 90 years (15.3%). For male patients most of the cases occurred in the age group 80-89 years with 30.2% of all fractures (Figure 2E). From all sacro-coccygeal fractures, when not differed by sex 78.8% of fractures were documented in patients 70 years or older.
With 5,593 cases and an incidence of 8.2 per 100,000 inhabitants, fractures of the axis were the fourth most common fractures of the spine in 2019, mainly affecting female patients (57.8%). Together with fractures of the atlas they made up for 6.8% of all vertebral fractures in 2019 (Figure 1). Again, most Atlas & Axis fractures were seen in females (56.6%) and of all Atlas & Axis fractures 67.0% were seen in patients older than 70 years. Most cases of Atlas & Axis fractures in females were listed for the increment 80-89 years (45.4%), 70-79 years (21.0%) and in patients older than 90 years (21.0%) (Figure 2A). In male patients most cases were documented in patients aged 80-89 years (37.8%), 70-70 years (23.7%) and 60-69 years (13.6%). In 2019, fractures of the subaxial cervical fractures made up for 6.8% of all registered spine fractures of hospitalized patients. 4,201 fracture cases were documented, resulting in an incidence of 6.2 per 100,000 inhabitants. Only in subaxial cervical spine fractures more patients were male (66.0%) than in female patients (34.0%). The majority of subaxial spine fractures in male patients was seen at the increment 80-89 years (24.7%), 70-79 years (18.6%) and 50-59 years (15.7%). In females most fractures were documented in patients aged 80-89 years (32.3%), 70-79 years (20.3%) and 60-69 years (10.9%) (Figure 2B).
Comparing the fracture incidences by location of the year 2009 to the year 2019 (Table 2), the highest increase was found in fractures of the sacrum (+306.6%) and at the subaxial cervical spine (+121.2%), followed by atlas (+106.4%) and axis fractures (+82.5%). Also, numbers considerable heightened for thoracic spine fractures (+32.2%) and lumbar spine fractures (+21.7%). There was only a slight increase of the incidence coccygeal fractures (+4.4%). A detailed analysis of the incidences and total numbers of vertebral fractures from 2009 to 2019 broken down according to the anatomical location, sex and age is provided in
Table 2
Fracture incidence divided by anatomical localization in 2019
Anatomical localization
|
Total number
|
Incidence per 100,000 inhabitants
|
2019 relative to 2009 [%]
|
Ratio male/female
|
Ratio aged <70years/ ≥70years
|
Atlas (C1)
|
1385
|
2.0
|
+ 106.4
|
0.93
|
0.31
|
Axis (C2)
|
5593
|
8.2
|
+ 82.5
|
0.73
|
0.23
|
Subaxial cervical spine
|
4201
|
6.2
|
+ 121.2
|
1.94
|
0.87
|
Thoracic spine
|
28057
|
41.3
|
+ 32.2
|
0.57
|
0.54
|
Lumbar spine
|
47874
|
70.5
|
+ 21.7
|
0.62
|
0.47
|
Sacrum
|
14748
|
21.7
|
+ 306.6
|
0.22
|
0.26
|
Coccyx
|
427
|
0.6
|
+ 4.4
|
0.33
|
0.78
|
(2) Secondary diagnoses, OPS codes and mortality of vertebral fractures in 2019.
In 2019, a total of 1,016,897 secondary diagnoses were documented, which equates to 9.7 documentations per case at average. N= 6,282 different ICD-10 codes for secondary diagnoses were used. In 18,773 (17.9%) cases a form of osteoporosis (M80.- and M81.-) was documented as secondary diagnosis. Type II diabetes mellitus (E11.-) was documented as secondary diagnosis in 17,006 (16.2%) cases. Summed up secondary diagnoses of malignant neoplasms were documented in 2.5% of cases. In 61,306 (58.4%) cases a concomitant vertebral fracture was documented as secondary diagnosis, most frequently located at the lumbar spine (28.9%). The most common secondary diagnoses, concomitant vertebral fractures and SCIs are listed in Table 3. In sum, 1,148 (1.1%) cases with SCIs, mainly at the cervical spine (0.5% of all fractures and 47.1% of all cases.
Table 3: Most common secondary diagnoses in vertebral fracture: Total numbers and share of all cases in 2019
|
Secondary diagnosis
|
ICD-10 code
|
[n]
|
Percentage of all cases
|
Secondary disease
|
Hypertension
|
I10.-
|
55,387
|
52.8%
|
Osteoporosis
|
M80.-; M81.-
|
18,773
|
17.9%
|
Atrial fibrillation
|
I48.-
|
18,238
|
17.4%
|
Type II diabetes
|
E11.-
|
17,006
|
16.2%
|
Chronic kidney disease
|
N18.1-; N19
|
15,876
|
15.1%
|
Congestive heart failure
|
I50.-
|
13,243
|
12.6%
|
Hypokalemia
|
E87.6
|
12,892
|
12.3%
|
Coronary arterial disease
|
I25.0; I25.10-.19
|
10,610
|
10.1%
|
Concomitant vertebral fractures
|
Axis
|
S12.0
|
1,025
|
1.0%
|
Atlas
|
S12.1
|
2,372
|
2.3%
|
Subaxial cervical spine
|
S12.21-.25; S12.7
|
4,664
|
4.4%
|
Thoracic spine
|
S22.-
|
18,420
|
17.5%
|
Lumbar spine
|
S32.-
|
30,293
|
28.9%
|
Sacrum
|
S32.1
|
4,532
|
4.3%
|
SCI
|
Cervical spine
|
S14.10-.13; S14.70-.77
|
541
|
0.5%
|
Thoracic spine
|
S24.10-.12; S24.70-.77
|
412
|
0.4%
|
Lumbar spine
|
S34.10-.11; S34.70-.75
|
195
|
0.2%
|
The use of 1,833 different OPS codes resulted in the documentation of N=493,043 OPS codes in 2019, which equates 5.0 codes per case at average. The analysis of OPS-codes of all documented cases of vertebral fractures showed a total number of approaches to the spine of 27,314 (26.1% of cases; Table 4). A rate of instrumentation procedures (5-83b.-) of 21.3% was documented. A kyphoplasty (5-839.a0-3) was conducted in 15.2% of cases, whereas a vertebroplasty was documented in 1.6% of cases. In 4.7% of cases screws were augmented. An autograft was used more often (2.8% of cases) than an allograft (1.7%) of cases. In 60.5% of cases a native computed tomography (CT) of the spine (3-203; 47.7%) or the pelvis (3-206; 12.8%) was documented. Native Magnet-resonance imaging (MRI) of the
Table 4: Frequencies and percentages of documented procedures according the OPS of vertebral fracture cases in 2019
Procedures
|
OPS code
|
[n]
|
Percentage of all cases
|
Approach to the cervical spine
|
5-030.-
|
4,890
|
4.7%
|
Approach to the thoracic spine
|
5-031.-
|
8,671
|
8.3%
|
Approach to the lumbar spine
|
5-032.-
|
13,753
|
13.1%
|
|
|
|
|
Instrumentation
|
5-83b.-
|
22,330
|
21.3%
|
Kyphoplasty
|
5-839.a0-3
|
15,904
|
15.2%
|
Fusion surgery
|
5-836.-
|
6,479
|
6.2%
|
Screw augmentation
|
5-83w.0
|
4,882
|
4.7%
|
Implant removal
|
5-839.0
|
4,165
|
4.0%
|
Use of autograft
|
5-835.9
|
2,947
|
2.8%
|
Vertebral canal decompression
|
5-033.0;
5-839.60-63
|
2,260
|
2.7%
|
Vertebral body replacement
|
5-837.-
|
2,343
|
2.2%
|
Use of allograft
|
5-835.a-.x
|
1,801
|
1.7%
|
Vertebroplasty
|
5-839.9-5
|
1,714
|
1.6%
|
The overall in-hospital mortality rate associated with vertebral fractures was 2.0%. The highest mortality rate (6.7%) was seen in cases of patients with Atlas & Axis fractures. Similar, cases with Atlas & Axis fractures were most associated with a treatment on an ICU (27.9% of cases). Overall, in 10.1% of cases patients received ICU treatment. Detailed numbers on in-hospital deaths and treatment on an ICU are displayed in Table 5.
(3) The economic burden of vertebral fractures for inpatient cases based on a G-DRG analysis in 2019.
Considering all vertebral fractures, the mean hospital stay was 10.7 ± 9.6 days. In cases with sacrum fractures the longest mean hospital stay (13.9 ± 9.8 days per case) was documented. At average in 16.8% of all cases high clinical complexity levels (PCCL ≥ 3) were seen. In patients with Atlas & Axis fractures 24.4% of cases were classified PCCL ≥ 3, in patients with subaxial cervical fractures 24.7% and in patients with fractures of the sacrum 28.8%. Table 6 provides an overview of the mean hospital stay and the proportion of cases according to the PCCL for vertebral fractures.
The most frequently used G-DRG code in cases with vertebral fractures in 2019 was I68D (Diseases and injuries of the spine not treated surgically) in 33.3% of all cases. Second common was I41Z (Geriatric early rehabilitation and complex treatment for diseases and disorders of the musculoskeletal system and connective tissue) in 10.3% of the cases and third I09I (Specific operations on the spine without complicating factors) in 8.6% of the cases. A detailed list of the 50 most used DRG codes (in 98.9% of cases, only codes used in at least 0.05% of cases were considered), costs per case and their share of overall costs is provided in the supplementary material (Supplementary material 3).
The cost per case of the G-DRG codes that were analyzed ranged from €719 ± 262 (I68E: Diseases and injuries in the spine not treated surgically, one occupancy day) to €67,782 ± 16,714 (A09B: Ventilation> 499 hours or> 249 hours with intensive complex treatment). By multiplication of the number of cases with the respective average cost per case according to the used G-DRG code the approximately costs per G-DRG code were calculated: Summed up, in 2019 total costs of €589,205,715. were produced by the treatment of 103,773 inpatients with vertebral fractures (98.9% of all cases in 2019). This gives a mean cost of €5,612 per case. The DRG code accounting for the largest share of overall costs was I09F: Mean costs per case: € 10,160.00 ± 3,169.00; 13.4% of overall costs. Second was I41Z: Mean costs per case: € 5.878,00 ± 1.317,00; 10.8% of overall costs. Third ranked I68D: Mean costs per case: € 1.708,00 ± 636,00; 10.2% of overall costs. 40.7% of the total costs are attributable to G-DRG codes used in each <3.0% of all vertebral fracture cases (n=41 different G-DRG codes, supplementary material 3). Table 7 lists the cost per case and the share of total costs of the G-DRG codes in 2019 without cases accounting for <3.0% of cases. Summing up cases with applied codes for non-surgical treatment of vertebral disorders and injuries (I68A-E) results in 51,724 cases (49.3%). These codes accounted for €108,066,426 representing 18.3% of the overall costs. The entirety of cases in which codes for specific surgeries of the spine (I09A-I) were applied consisted of 27,381 (26,1%) cases but was accountable for 44.4% of the overall costs of the in-hospital treatment of vertebral fractures in 2019 (€261,532,171).
Table 5: Percentages of in-hospital deaths and cases with ICU treatment depending on the anatomical location of the fracture in 2019
|
Atlas & Axis
|
Subaxial
cervical spine
|
Thoracic spine
|
Lumbar spine
|
Sacrum
|
n
|
%
|
n
|
%
|
n
|
%
|
n
|
%
|
n
|
%
|
Number of in-hospital deaths
|
475
|
6.7
|
207
|
4.7
|
486
|
1.6
|
655
|
1.3
|
253
|
1.7
|
Cases with ICU treatment
|
1972
|
27.9
|
198
|
4.5
|
3157
|
10.7
|
4026
|
8.2
|
1243
|
8.3
|
Table 6: Mean hospital stay and distribution of the PCCL scoring depending on the anatomical location of vertebral fractures in 2019
|
All vertebral fractures
|
Atlas & Axis
|
Subaxial cervical spine
|
Thoracic spine
|
Lumbar spine
|
Sacrum
|
Mean hospital stay [d]
|
10.7
|
10.8
|
10.6
|
10.1
|
10.3
|
13.0
|
Standard deviation
|
9.6
|
11.2
|
13.4
|
9.3
|
9.0
|
9.8
|
PCCL
|
0
|
58.4%
|
50.3%
|
47.1%
|
61.4%
|
67.0%
|
31.6%
|
1
|
14.1%
|
13.7%
|
16.7%
|
13.0%
|
12.1%
|
22.4%
|
2
|
10.6%
|
11.5%
|
11.6%
|
9.9%
|
8.8%
|
17.2%
|
3
|
10.4%
|
13.7%
|
12.8%
|
9.3%
|
7.9%
|
18.2%
|
4
|
5.1%
|
7.8%
|
8.7%
|
4.9%
|
3.5%
|
8.5%
|
5
|
1.2%
|
2.5%
|
2.9%
|
1.3%
|
0.7%
|
1.9%
|
6
|
0.1%
|
0.4%
|
0.3%
|
0.1%
|
0.1%
|
0.2%
|
Table 7: Overview of the codes that each represent more than 3.0% of the cases.
Sorting according to frequency of use in 2019.