The case of vertebroplasty trials: promoting a culture of evidence-based procedural medicine

Invasive Treatments for Low Back Disorders

OBJECTIVE

This abbreviated version of the American College of Occupational and Environmental Medicine's Low Back Disorders guideline reviews the evidence and recommendations developed for invasive treatments used to manage low back disorders.

METHODS

Comprehensive systematic literature reviews were accomplished with article abstraction, critiquing, grading, evidence table compilation, and guideline finalization by a multidisciplinary expert panel and extensive peer-review to develop evidence-based guidance. Consensus recommendations were formulated when evidence was lacking and often relied on analogy to other disorders for which evidence exists. A total of 47 high-quality and 321 moderate-quality trials were identified for invasive management of low back disorders.

RESULTS

Guidance has been developed for the invasive management of acute, subacute, and chronic low back disorders and rehabilitation. This includes 49 specific recommendations.

CONCLUSION

Quality evidence should guide invasive treatment for all phases of managing low back disorders.

Percutaneous Vertebroplasty: A History of Procedure, Technology, Culture, Specialty, and Economics

Percutaneous vertebroplasty (VP) progressed from a virtually unknown procedure to one performed on hundreds of thousands of patients annually. The development of VP provides a historically exciting case study into a rapidly adopted procedure. VP was the synthesis of information gained from spinal biopsy developments, the inception of biomaterials used in medicine, and the unique health care climate in France during the 1980s. It was designed as a revolutionary technique to treat vertebral body fractures with minimal side effects and was rapidly adopted and marketed in the United States. The impact of percutaneous vertebroplasty on spine surgery was profound.

How does surgery compare with advanced intra-articular therapies in knee osteoarthritis: current thoughts

The objectives of osteoarthritis (OA) management are to reduce pain and inflammation, slow cartilage degradation, improve function and reduce disability. Current strategies for managing knee OA include nonpharmacological interventions, oral pharmacological treatments, localized intra-articular injections, and surgery. It has become evident that the inflammatory response is a key contributor to the development and progression of knee OA. Signaling pathways involving growth factors and cytokines are being investigated for the development of new therapies that target the underlying biological processes causing the disease. This concept of 'molecular orthopedics' enables more patient-centered diagnostic and treatment strategies. In contrast to other conservative therapies, which ultimately only address OA symptoms, intra-articular injections, in particular autologous conditioned serum (ACS), provide benefits that have the potential to outweigh those of established pharmacological treatments and surgery. Surgery has historically been considered the final solution for treatment of knee OA, both by treating physicians and by patients; however, there are increasing concerns regarding the lack of randomized clinical trials providing evidence to support this opinion. Intra-articular injection of ACS has demonstrated efficacy as a treatment for knee OA in a number of studies, with a very low rate of adverse events and side effects, compared with surgery. Treatment with ACS utilizes the release of anti-inflammatory cytokines and regenerative growth factors to support the natural healing processes in the knee, and has the potential to provide a valuable alternative to surgical intervention.

Kyphoplasty in osteoporotic vertebral compression fractures--guidelines and technical considerations

Osteoporotic vertebral compression fractures are a menace to the elderly generation causing diminished quality of life due to pain and deformity. At first, conservative treatment still is the method of choice. In case of resulting deformity, sintering and persistent pain vertebral cement augmentation techniques today are widely used. Open correction of resulting deformity by different types of osteotomies addresses sagittal balance, but has comparably high morbidity.

Besides conventional vertebral cement augmentation techniques balloon kyphoplasty has become a popular tool to address painful thoracic and lumbar compression fractures. It showed improved pain reduction and lower complication rates compared to standard vertebroplasty. Interestingly the results of two placebo-controlled vertebroplasty studies question the value of cement augmentation, if compared to a sham operation. Even though there exists now favourable data for kyphoplasty from one randomised controlled trial, the absence of a sham group leaves the placebo effect unaddressed. Technically kyphoplasty can be performed with a transpedicular or extrapedicular access. Polymethyl methacrylate (PMMA)-cement should be favoured, since calcium phosphate cement showed inferior biomechanical properties and less effect on pain reduction especially in less stable burst fractures. Common complications of kyphoplasty are cement leakage and adjacent segment fractures. Rare complications are toxic PMMA-monomer reactions, cement embolisation, and infection.