{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,31]],"date-time":"2026-07-31T05:41:12Z","timestamp":1785476472915,"version":"3.56.0"},"reference-count":55,"publisher":"MDPI AG","issue":"23","license":[{"start":{"date-parts":[[2025,12,1]],"date-time":"2025-12-01T00:00:00Z","timestamp":1764547200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background\/Objectives: Long-term bisphosphonate (BP) therapy is an effective treatment for osteoporosis but has been associated with rare complications such as atypical femoral fractures (AFFs). Emerging reports suggest that similar insufficiency fractures may also occur in other skeletal sites, including the lumbar pedicles. This study reports two rare cases of isolated bilateral lumbar pedicle stress fractures in patients on prolonged BP therapy. Along with a structured literature review, the objective was to evaluate whether diagnostic criteria derived from those used for AFFs may apply to these atypical vertebral fractures. Methods: Two patients with osteoporosis and on long-term BP therapy diagnosed with isolated lumbar pedicle stress fractures were retrospectively analyzed. A structured literature review identified similar reported cases. All cases were evaluated using the 2010 American Society for Bone and Mineral Research AFF criteria to assess applicability to isolated pedicle stress fractures. Results: Both patients demonstrated bilateral lumbar pedicle fractures without vertebral body involvement. One was treated conservatively; the other underwent robotic-assisted percutaneous pedicle screw fixation with documented fracture healing at six months. The literature review identified eight similar cases of isolated pedicle fractures in patients on prolonged BP therapy. Clinical course and imaging findings demonstrated stress-type features analogous to AFFs. The proposed AFF-based diagnostic criteria for pedicular insufficiency fractures were found to be applicable to all ten patients. Conclusions: Isolated bilateral pedicle stress fractures may represent a spinal analog of AFFs. Based on shared clinical and imaging features, we propose preliminary diagnostic criteria for atypical pedicular insufficiency fractures. Increased awareness and standardized criteria may aid in early diagnosis and reporting, encouraging further studies on this rare spinal entity.<\/jats:p>","DOI":"10.3390\/jcm14238537","type":"journal-article","created":{"date-parts":[[2025,12,8]],"date-time":"2025-12-08T16:20:29Z","timestamp":1765210829000},"page":"8537","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Isolated Atypical Pedicle Stress Fractures in Patients on Prolonged Bisphosphonate Therapy: Report of Two Cases and a Literature-Based Proposal for Diagnostic Criteria"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8049-9750","authenticated-orcid":false,"given":"Maria","family":"Auron","sequence":"first","affiliation":[{"name":"Spine Surgery Unit, Department of Orthopedics, Hadassah Hebrew University Medical Center, Kalman Yaakov Man St., Jerusalem 9112001, Israel"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tamar","family":"Fisher-Negev","sequence":"additional","affiliation":[{"name":"Spine Surgery Unit, Department of Orthopedics, Hadassah Hebrew University Medical Center, Kalman Yaakov Man St., Jerusalem 9112001, Israel"},{"name":"School of Pharmacy, Faculty of Medicine, Hebrew University of Jerusalem, Kalman Yaakov Man St., Jerusalem 9112001, Israel"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gal","family":"Barkay","sequence":"additional","affiliation":[{"name":"Spine Surgery Unit, Department of Orthopedics, Hadassah Hebrew University Medical Center, Kalman Yaakov Man St., Jerusalem 9112001, Israel"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Josh E.","family":"Schroeder","sequence":"additional","affiliation":[{"name":"Spine Surgery Unit, Department of Orthopedics, Hadassah Hebrew University Medical Center, Kalman Yaakov Man St., Jerusalem 9112001, Israel"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,12,1]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1344","DOI":"10.1001\/jama.282.14.1344","article-title":"Effects of risedronate treatment on vertebral and nonvertebral fractures in women with postmenopausal osteoporosis: A randomized controlled trial. Vertebral Efficacy with Risedronate Therapy (VERT) Study Group","volume":"282","author":"Harris","year":"1999","journal-title":"JAMA"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"2267","DOI":"10.1002\/jbmr.253","article-title":"Atypical subtrochanteric and diaphyseal femoral fractures: Report of a task force of the American Society for Bone and Mineral Research","volume":"25","author":"Shane","year":"2010","journal-title":"J. Bone Miner. Res."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1595","DOI":"10.1210\/jc.2019-00221","article-title":"Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society* Clinical Practice Guideline","volume":"104","author":"Eastell","year":"2019","journal-title":"J. Clin. Endocrinol. Metab."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"494","DOI":"10.1302\/2058-5241.3.170070","article-title":"The enigma of atypical femoral fractures: A summary of current knowledge","volume":"3","author":"Larsen","year":"2018","journal-title":"EFORT Open Rev."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1002\/jbmr.1998","article-title":"Atypical subtrochanteric and diaphyseal femoral fractures: Second report of a task force of the American society for bone and mineral research","volume":"29","author":"Shane","year":"2014","journal-title":"J. Bone Miner. Res."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1","DOI":"10.9734\/BJMMR\/2017\/31269","article-title":"Bisphosphonate-associated Atypical Fractures that are not \u2018Atypical Femoral Fractures\u2019","volume":"19","author":"Hinshaw","year":"2017","journal-title":"Br. J. Med. Med. Res."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"e446","DOI":"10.1097\/MD.0000000000000446","article-title":"Successful Conservative Treatment: Multiple Atypical Fractures in Osteoporotic Patients After Bisphosphate Medication: A Unique Case Report","volume":"94","author":"Kim","year":"2015","journal-title":"Medicine"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"316","DOI":"10.1007\/s00586-007-0396-9","article-title":"Acute L5 pedicle fracture and contralateral spondylolysis in a 12-year-old boy: A case report","volume":"16","author":"Vialle","year":"2007","journal-title":"Eur. Spine J."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"580","DOI":"10.1097\/00007632-200103010-00026","article-title":"Pedicle Fracture After Instrumented Posterolateral Lumbar Fusion","volume":"26","author":"Macdessi","year":"2001","journal-title":"Spine"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"185","DOI":"10.1097\/00007632-199102000-00016","article-title":"Stress fracture of the lumbar pedicle. Case reports of \u2018pediculolysis\u2019 and review of the literature","volume":"16","author":"Gunzburg","year":"1991","journal-title":"Spine"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"63","DOI":"10.1097\/00007632-198601000-00018","article-title":"Unilateral Spondylolysis and Contralateral Pedicle Fracture","volume":"11","author":"Garber","year":"1986","journal-title":"Spine"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"206","DOI":"10.1007\/s00586-008-0816-5","article-title":"Bilateral pedicle stress fracture in a patient with osteoporotic compression fracture","volume":"18","author":"Doita","year":"2009","journal-title":"Eur. Spine J."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"19","DOI":"10.1097\/01.BRS.0000105988.43472.2B","article-title":"Bilateral Pedicle Stress Fractures in a Female Athlete Case Report and Review of the Literature","volume":"29","author":"Parvataneni","year":"2004","journal-title":"Spine"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"555","DOI":"10.22603\/ssrr.2023-0005","article-title":"Bilateral Lumbar Pedicle Fracture in a Patient Receiving Long-term Bisphosphonate Therapy: A Case Report","volume":"7","author":"Karasawa","year":"2023","journal-title":"Spine Surg. Relat. Res."},{"key":"ref_15","first-page":"97","article-title":"Atraumatic Bilateral Lumbar Pedicle Fractures in a Patient with Back Pain and History of Long-term Bisphosphonate Therapy: A case report","volume":"4","author":"Meleger","year":"2020","journal-title":"Pain Med. Case Rep."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"E1769","DOI":"10.1097\/BRS.0b013e3182174d0a","article-title":"Atypical bilateral pedicle fracture in long-term bisphosphonate therapy","volume":"36","author":"Wolff","year":"2011","journal-title":"Spine"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"102786","DOI":"10.1016\/j.bas.2024.102786","article-title":"Atypical lumbar pedicle fractures. A case report and comparative review of the literature: Bisphosphonate-related? Possible matching with diagnostic criteria of atypical fractures of the femur","volume":"4","author":"Theodorakis","year":"2024","journal-title":"Brain Spine"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"218","DOI":"10.1016\/j.jclinepi.2017.04.026","article-title":"CARE guidelines for case reports: Explanation and elaboration document","volume":"89","author":"Riley","year":"2017","journal-title":"J. Clin. Epidemiol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1758","DOI":"10.1007\/s00586-018-5776-9","article-title":"The use of CT Hounsfield unit values to identify the undiagnosed spinal osteoporosis in patients with lumbar degenerative diseases","volume":"28","author":"Zou","year":"2019","journal-title":"Eur. Spine J."},{"key":"ref_20","first-page":"340","article-title":"Multi-level, bilateral pedicle fractures: Case report","volume":"25","author":"Karabay","year":"2015","journal-title":"Turk. Neurosurg."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"717","DOI":"10.1017\/cjn.2018.329","article-title":"Spontaneous Atraumatic Bilateral Pedicle Insufficiency Fractures","volume":"45","author":"Surur","year":"2018","journal-title":"Can. J. Neurol. Sci."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"103","DOI":"10.1007\/s11657-024-01462-8","article-title":"Bilateral lumbar pedicle fracture in a patient receiving long-term bisphosphonate therapy: A case report with pathological evaluation","volume":"19","author":"Fujita","year":"2024","journal-title":"Arch. Osteoporos."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"169","DOI":"10.1016\/j.bone.2010.05.019","article-title":"Atypical fractures of the femur and bisphosphonate therapy: A systematic review of case\/case series studies","volume":"47","author":"Giusti","year":"2010","journal-title":"Bone"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1531","DOI":"10.1007\/s00198-017-3909-3","article-title":"Fuleihan Worldwide prevalence and incidence of osteoporotic vertebral fractures","volume":"28","author":"Ballane","year":"2017","journal-title":"Osteoporos. Int."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"234","DOI":"10.1302\/0301-620X.60B2.659472","article-title":"The fatigue strength of the lumbar neural arch in spondylolysis","volume":"60-B","author":"Cyron","year":"1978","journal-title":"J. Bone Jt. Surg. Br."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"295","DOI":"10.1007\/BF01627881","article-title":"Pedicles of lumbar vertebrae","volume":"15","author":"Maillot","year":"1993","journal-title":"Surg. Radiol. Anat."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"321","DOI":"10.1016\/8756-3282(90)90087-F","article-title":"Long-term fatigue behavior of compact bone at low strain magnitude and rate","volume":"11","author":"Schaffler","year":"1990","journal-title":"Bone"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1147","DOI":"10.1007\/s00590-019-02402-w","article-title":"Adjacent Bi-level bilateral pedicle stress fractures after instrumented posterolateral lumbar fusion\u2014A case report and review of the literature","volume":"29","author":"Jorge","year":"2019","journal-title":"Eur. J. Orthop. Surg. Traumatol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"662","DOI":"10.1111\/1756-185X.12469","article-title":"Unusual osteoporotic stress fracture: Adjacent bilateral pedicle fractures","volume":"20","author":"Kim","year":"2017","journal-title":"Int. J. Rheum. Dis."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"682","DOI":"10.1007\/s00776-012-0324-7","article-title":"Bilateral pedicle stress fracture with adjacent old osteoporotic compression fractures that induced spondylolisthesis","volume":"19","author":"Kang","year":"2014","journal-title":"J. Orthop. Sci."},{"key":"ref_31","first-page":"426940","article-title":"Unilateral Pedicle Stress Fracture in a Long-Term Hemodialysis Patient with Isthmic Spondylolisthesis","volume":"2015","author":"Maruo","year":"2015","journal-title":"Case Rep. Orthop."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1454","DOI":"10.2106\/00004623-198668090-00025","article-title":"Fracture of the pedicle of the fourth lumbar vertebra associated with contralateral spondylolysis. Report of a case","volume":"68","author":"Aland","year":"1986","journal-title":"J. Bone Jt. Surg. Am."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"930","DOI":"10.1097\/00007632-199306000-00021","article-title":"Stress Fracture of the Pedicle. A late complication of posterolateral lumbar fusion","volume":"18","author":"Robertson","year":"1993","journal-title":"Spine"},{"key":"ref_34","first-page":"e7273","article-title":"Bilateral Acute Osteoporotic Lumbar Pedicle Fracture Presenting with Associated Neurological Deficit: A Case Report and Review of Literature","volume":"12","author":"Ebot","year":"2020","journal-title":"Cureus"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"2541","DOI":"10.1097\/00007632-200010010-00019","article-title":"Goff Contralateral Spondylolysis and Fracture of the Lumbar Pedicle in an Elite Female Gymnast","volume":"25","author":"Guillodo","year":"2000","journal-title":"Spine"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"397","DOI":"10.1007\/s00402-008-0685-8","article-title":"Fresh stress fractures of lumbar pedicles in an adolescent male ballet dancer: Case report and literature review","volume":"129","author":"Amari","year":"2009","journal-title":"Arch. Orthop. Trauma. Surg."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"140","DOI":"10.2106\/00004623-198769010-00022","article-title":"Bilateral stress fracture of the lumbar pedicles in a ballet dancer","volume":"69","author":"Ireland","year":"1987","journal-title":"A case report. J. Bone Jt. Surg. Am."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"598","DOI":"10.1016\/j.radcr.2020.12.037","article-title":"Unexpected bilateral pedicle stress fractures of the lumbar spine","volume":"16","author":"Tahir","year":"2021","journal-title":"Radiol. Case Rep."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"653","DOI":"10.1007\/s00586-006-0184-y","article-title":"Bilateral pedicle stress fracture in the lumbar spine of a sedentary office worker","volume":"15","author":"Sadiq","year":"2006","journal-title":"Eur. Spine J."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"338","DOI":"10.1097\/00004728-199103000-00033","article-title":"Bilateral Pedicle Stress Fractures","volume":"15","author":"Traughber","year":"1991","journal-title":"J. Comput. Assist. Tomogr."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"398","DOI":"10.3171\/2015.7.SPINE141207","article-title":"Posterior osteosynthesis of a spontaneous bilateral pedicle fracture of the lumbar spine","volume":"24","author":"Han","year":"2016","journal-title":"J. Neurosurg. Spine"},{"key":"ref_42","first-page":"77","article-title":"Distribution of atypical fractures and cortical stress lesions in the femur: Implications on pathophysiology","volume":"52","author":"Koh","year":"2011","journal-title":"Singap. Med. J."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"1827","DOI":"10.1002\/jor.21464","article-title":"Bisphosphonate treatment delays stress fracture remodeling in the rat ulna","volume":"29","author":"Kidd","year":"2011","journal-title":"J. Orthop. Res."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"348","DOI":"10.1097\/SPC.0b013e3283552d7d","article-title":"Atypical femoral fractures: Epidemiology, etiology, and patient management","volume":"6","author":"Donnelly","year":"2012","journal-title":"Curr. Opin. Support. Palliat. Care"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"725","DOI":"10.1016\/j.beem.2018.05.003","article-title":"Bone turnover: Biology and assessment tools","volume":"32","author":"Szulc","year":"2018","journal-title":"Best Pract. Res. Clin. Endocrinol. Metab."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"224","DOI":"10.1016\/j.injury.2007.08.036","article-title":"An emerging pattern of subtrochanteric stress fractures: A long-term complication of alendronate therapy?","volume":"39","author":"Kwek","year":"2008","journal-title":"Injury"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"895","DOI":"10.1097\/00007632-200004010-00022","article-title":"Iatrogenic spondylolysis leading to contralateral pedicular stress fracture and unstable spondylolisthesis: A case report","volume":"25","author":"Maurer","year":"2000","journal-title":"Spine"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"475","DOI":"10.3171\/2014.5.SPINE13860","article-title":"Adaptive remodeling at the pedicle due to pars fracture: A finite element analysis study","volume":"21","author":"Mageswaran","year":"2014","journal-title":"J. Neurosurg. Spine"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"1","DOI":"10.3171\/foc.2002.13.2.10","article-title":"Stress fracture of the pedicle after extensive decompression and contralateral posterior fusion for lumbar stenosis","volume":"13","author":"Sheehan","year":"2002","journal-title":"Neurosurg. Focus"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"E158","DOI":"10.1097\/01.BRS.0000058951.16468.24","article-title":"Bilateral Pedicle Stress Fracture after Instrumented Posterolateral Lumbar Fusion","volume":"28","author":"Ha","year":"2003","journal-title":"Spine"},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"221","DOI":"10.1007\/s42399-022-01289-9","article-title":"Lumbar Pedicular Stress Fracture Post-laminectomy: A Case Report","volume":"4","author":"Ampe","year":"2022","journal-title":"SN Compr. Clin. Med."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"256","DOI":"10.3171\/2012.6.SPINE12227","article-title":"Morphometric analysis using multiplanar reconstructed CT of the lumbar pedicle in patients with degenerative lumbar scoliosis characterized by a Cobb angle of 30\u00b0 or greater","volume":"17","author":"Makino","year":"2012","journal-title":"J. Neurosurg. Spine"},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"1333","DOI":"10.1259\/bjr\/99102700","article-title":"Skeletal complications of bisphosphonate use: What the radiologist should know","volume":"85","author":"Haworth","year":"2012","journal-title":"Br. J. Radiol."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"197","DOI":"10.1007\/s00586-017-5029-3","article-title":"A rare case of non-traumatic, multi-level, bilateral pedicle fractures of the lumbar spine in a 60-year-old patient","volume":"26","author":"Schmid","year":"2017","journal-title":"Eur. Spine J."},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"1627","DOI":"10.1210\/jc.2010-2520","article-title":"Teriparatide, vitamin D, and calcium healed bilateral subtrochanteric stress fractures in a postmenopausal woman with a 13-year history of continuous alendronate therapy","volume":"96","author":"Gomberg","year":"2011","journal-title":"J. Clin. Endocrinol. Metab."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/23\/8537\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,8]],"date-time":"2025-12-08T16:33:32Z","timestamp":1765211612000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/23\/8537"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,12,1]]},"references-count":55,"journal-issue":{"issue":"23","published-online":{"date-parts":[[2025,12]]}},"alternative-id":["jcm14238537"],"URL":"https:\/\/doi.org\/10.3390\/jcm14238537","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,12,1]]}}}