European Spine Journal

, Volume 27, Supplement 2, pp 190–197 | Cite as

Vertebral body osteonecrosis: proposal of a treatment-oriented classification system

  • Matteo Formica
  • Andrea Zanirato
  • Luca Cavagnaro
  • Marco Basso
  • Stefano Divano
  • Claudio Lamartina
  • Pedro Berjano
  • Lamberto Felli
  • Carlo Formica
Ideas and Technical Innovations



To present a classification system for vertebral body osteonecrosis (VBON) based on imaging findings and sagittal alignment and consequently to propose treatment guidelines.


Chart review and classification of imaging and clinical findings. An analysis of literature about VBON has been evaluated to conceive the classification. The current data allows to correlate radiological findings with different stages of the pathophysiological process and consequently to propose a patient-tailored treatment plan.


The classification identifies 4 stages: stage 0 (theoretical phase), stage 1 (early phase), stage 2 (instability phase) and stage 3 (fixed deformity phase). Local (angular kyphosis expressed as anterior–posterior wall height ratio) and global (sagittal vertical axis and pelvic tilt) sagittal alignment are considered as complementary modifiers to tailor the most suitable treatment. Stage 1 is generally managed conservatively. Stage 2 and 3 often require different surgical approaches according to local and global sagittal alignment.


The classification allows a systematic staging of this disease and can help establish a proper and patient-oriented treatment plan. Further researches are advocated to fully validate the proposed classification system.

Graphical abstract

These slides can be retrieved under Electronic Supplementary Material.


Vertebral osteonecrosis Vertebral non-union Classification Sagittal alignment Adult deformity 



There is no funding source for this article.

Compliance with ethical standards

Conflict of interest

Pedro Berjano received honorarium for surgeons’ education activities from Nuvasive, Medacta, DepuySynthes and his department received unrestricted research grants from Nuvasive, Medacta, DepuySynthes and K2 M. Claudio Lamartina received honorarium for surgeons’ education activities from Nuvasive, Medacta, DepuySynthes and K2 M and his department received unrestricted research grants from Nuvasive, Medacta, DepuySynthes and K2 M. No other disclosures by the rest of authors.

Supplementary material

586_2018_5600_MOESM1_ESM.pptx (191 kb)
Supplementary material 1 (PPTX 191 kb)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Matteo Formica
    • 1
  • Andrea Zanirato
    • 1
  • Luca Cavagnaro
    • 1
  • Marco Basso
    • 1
  • Stefano Divano
    • 1
  • Claudio Lamartina
    • 2
  • Pedro Berjano
    • 2
  • Lamberto Felli
    • 1
  • Carlo Formica
    • 2
  1. 1.Clinica Ortopedica – Ospedale Policlinico San MartinoGenoaItaly
  2. 2.Gspine4 - IRCCS Istituto Ortopedico GaleazziMilanItaly

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