Vertebroplasty and the placebo response

Comparative Efficacy of Surgical Interventions for Osteoporotic Vertebral Compression Fractures: A Systematic Review and Network Meta-analysis

OBJECTIVE

We aimed to comprehensively compare surgical methods for osteoporotic vertebral compression fracture (OVCF) using systematic review and network meta-analysis to understand their effectiveness and outcomes, as current research provides limited overviews.

METHODS

We followed PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines, preregistering our protocol with PROSPERO. We analyzed Englishpublished randomized controlled trials (RCTs) on adults with OVCFs that evaluated pain intensity or functionality using tools like visual analogue scale (VAS) or Oswestry Disability Index (ODI). Exclusions included non-RCTs, malignancy-related fractures, and certain interventions. Using the RoB 2 tool, we assessed bias and visualized results with Robvis. Our primary outcome was pain intensity, with secondary outcomes including disability, new fractures, and cement leakage. Results were synthesized using Stata/MP.

RESULTS

Thirty-four RCTs from 10 countries, totaling 4,384 patients, were analyzed. Shortterm VAS indicated kyphoplasty with facet joint injection (KIJ) as the top treatment at 87.7%, while unipedicular kyphoplasty (UKP) led to long-term at 74.9%. Short-term ODI favored vertebroplasty with facet joint injection (VIJ) at 98.4%, with kyphoplasty (KP) leading longterm at 66.0%. All surgical techniques were superior to conservative treatment. Vertebral augmentation devices reported the fewest new fractures and curved vertebroplasty had the least cement leakage. SUCRA (surface under the cumulative ranking) analyses suggested UKP and VIJ as top choices for postoperative pain relief, with VIJ excelling in postoperative disability improvement.

CONCLUSION

Our analysis evaluates 12 OVCF interventions, underscoring KIJ for short-term pain relief and VIJ and UKP for long-term efficacy. Notably, VIJ stands out in disability outcomes, emphasizing the need for comprehensive OVCF management.

Vertebroplasty for osteoporotic vertebral fracture

Appropriate care of patients with a recent painful osteoporotic vertebral fracture (VF) requires immobilisation, analgesics and spinal orthoses. Some VFs are however responsible for disabling pain and prolonged bed rest. In this context, vertebroplasty techniques have been proposed with a large benefit in case series and open-label randomised studies, but lack efficacy in three among four double-blind randomised studies. The objectives of the treatment of a recent painful VF are to relieve pain and to preserve mechanical conditions. With this in mind, we report an experts’ opinion paper on the indications for vertebroplasty and research agenda for clinical studies.

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.

Interventional Techniques to Management of Cancer-Related Pain: Clinical and Critical Aspects

Interventional techniques to manage cancer-related pain may be efficient treatment modalities in patients unresponsive or unable to tolerate systemic opioids. However, indication and selection of the right technique demand knowledge, which is still incipient among clinicians. The present article summarizes the current evidence regarding the five most essential groups of interventional techniques to treat cancer-related pain: Neuraxial analgesia, minimally invasive procedures for vertebral pain, sympathetic blocks for abdominal cancer pain, peripheral nerve blocks, and percutaneous cordotomy. Furthermore, indication, mechanism, drug agents, contraindications, and complications of the main techniques of each group are discussed.

Phase IIb Study of Intranasal Glutathione in Parkinson's Disease

BACKGROUND

Reduced glutathione (GSH) is an endogenously synthesized tripeptide depleted early in the course of Parkinson's disease (PD) and GSH augmentation has been proposed as a therapeutic strategy in PD.

OBJECTIVE

This Phase IIb study was designed to evaluate whether a Phase III study of intranasal GSH, (in)GSH, for symptomatic relief is warranted and to determine the most appropriate trial design for a disease-modification study.

METHODS

This was a double-blind, placebo-controlled trial of 45 individuals with Hoehn & Yahr Stage 1-3 PD. Participants were randomized to receive intranasal placebo (saline), 100 mg GSH, or 200 mg GSH thrice daily for three months, and were observed over a one-month washout period.

RESULTS

All cohorts improved over the intervention period, including placebo. The high-dose group demonstrated improvement in total Unified PD Rating Scale (UPDRS) (-4.6 (4.7), P = 0.0025) and UPDRS motor subscore (-2.2 (3.8), P = 0.0485) over baseline, although neither treatment group was superior to placebo. One participant in the high-dose GSH cohort developed cardiomyopathy.

CONCLUSIONS

Although predicted improvements in PD total and motor scores were observed, these data do not suggest (in)GSH is superior to placebo after a three month intervention. The symptomatic effects are sufficient to warrant a delayed-start or wash-out design study for disease-modification trials. Whether long-term use of (in)GSH leads to clinical improvements that are sustained and significantly different than placebo will require appropriately-powered longer-duration studies in larger cohorts. The improvement in the placebo arm was more robust than has been observed in previous PD studies and warrants further investigation.

Utilization of vertebroplasty and kyphoplasty procedures throughout the United States over a recent decade: an analysis of the Nationwide Inpatient Sample

BACKGROUND

Given the increasing societal focus on health care utilization and value-based care, it is essential to understand the demographic and economic data surrounding percutaneous vertebral augmentation procedures performed in the United States. Double-blinded prospective randomized controlled trials have shown no benefit to the use of vertebroplasty over a sham procedure in the treatment of vertebral fractures. Contrastingly, kyphoplasty may be beneficial when appropriately indicated.

METHODS

The National Inpatient Sample (NIS) database was queried for patients who underwent either kyphoplasty (ICD-9-CM 81.66) or vertebroplasty (ICD-9-CM 81.65) procedures between 2006 and 2014 across 44 states. Demographic and economic data were obtained which included the annual number of surgeries, age, sex, insurance type, location, and frequency of routine discharge. The NIS database represents a 20% sample of discharges from U.S. hospitals, which is weighted to provide national estimates.

RESULTS

In 2014, an estimated total number of 19,420 kyphoplasty and 6,130 vertebroplasty procedures were performed across the United States. The number of vertebroplasty procedures decreased 53% from 13,128 in 2008. Similarly, the number of kyphoplasty procedures decreased 17% from 23,320 in 2007. Based on payer, Medicare patients comprised 83% of those billed for kyphoplasty and vertebroplasty, and 75% of procedures were utilized in areas designated as "not low income". In 2014, patients in the South Atlantic region comprised 24% of vertebroplasty and 28% of kyphoplasty cases, far more than any other region. Additionally, kyphoplasty and vertebroplasty were more often performed in teaching facilities rather than community hospitals (60% and 67%, respectively).

CONCLUSIONS

Since the publication of two double-blind, prospective randomized controlled trials showed no benefit of vertebroplasty over a sham procedure, there has been a significant decrease in both kyphoplasty and vertebroplasty procedures.

Trends in Inpatient Vertebroplasty and Kyphoplasty Volume in the United States, 2005-2011: Assessing the Impact of Randomized Controlled Trials

STUDY DESIGN

Retrospective analysis of the Nationwide Inpatient Sample, 2005-2011.

OBJECTIVE

To identify trends in procedural volume and rates in the time period surrounding publication of randomized controlled trials (RCTs) that examined the utility of vertebroplasty and kyphoplasty.

SUMMARY OF BACKGROUND DATA

Vertebroplasty and kyphoplasty are frequently performed for vertebral compression fractures. Several RCTs have been published with conflicting outcomes regarding pain and quality of life compared with nonsurgical management and sham procedures. Four RCTs with discordant results were published in 2009.

MATERIALS AND METHODS

The Nationwide Inpatient Sample provided longitudinal, retrospective data on United States' inpatients between 2005 and 2011. Inclusion was determined by a principal or secondary International Classification of Diseases, Ninth Revision, Clinical Modification code of 81.65 (percutaneous vertebroplasty) or 81.66 (percutaneous vertebral augmentation; "kyphoplasty"). No diagnoses were excluded. Years were stratified as "pre" (2005-2008) and "post" (2010-2011) in relation to the 4 RCTs published in 2009. Patient, hospital, and admission characteristics were compared using Pearson χ test.

RESULTS

The estimated annual inpatient procedures performed decreased from 54,833 to 39,832 in the pre and post periods, respectively. The procedural rate for fractures decreased from 20.1% to 14.7% (P<0.0001). Patient and hospital demographics did not change considerably between the time periods. In the post period, weekend admissions increased (34.2% vs. 12.4%, P<0.0001), elective admissions decreased (21.4% vs. 40.0%, P<0.0001), routine discharge decreased (33.0% vs. 52.1%, P<0.0001), and encounters with ≥3 Elixhauser comorbidities increased (54.5% vs. 39.1%, P<0.0001).

CONCLUSIONS

The absolute rate of inpatient vertebroplasty and kyphoplasty procedures for fractures decreased 5% in the period (2010-2011) following the publication of 4 RCTs in 2009. The proportion of elective admissions and routine discharges decreased, possibly indicating a population with greater disease severity. Although our analysis cannot demonstrate a cause-and-effect relationship, the decreased inpatient volume and procedural rates surrounding the publication of sentinel negative RCTs is clearly observed.

Bias in cervical total disc replacement trials

PURPOSE OF REVIEW

Cervical disc replacement (CDR) has emerged as a motion-preserving alternative to anterior cervical discectomy and fusion in selected cases. Despite favorable literature, CDR is not universally accepted because of concerns regarding bias in the existing literature. The purpose of this review is to identify the possible biases in the disc replacement literature.

RECENT FINDINGS

Recent studies that compare CDR and ACDF have demonstrated equivalent or superior outcomes, lower rates of secondary surgery, and equivalent safety at medium- and long-term follow-up. In our review, we identified four types of bias that may affect the CDR literature: publication bias, external validity, confounding bias, and financial conflicts of interest. Bias, whether intentional or unintentional, can impact the interpretation and outcome of CDR studies. Recognition of this issue is critical when utilizing the existing literature to determine the efficacy of CDR and designing future studies.

Minimally invasive procedures for the management of vertebral bone pain due to cancer: The EAPC recommendations

BACKGROUND

Image-guided percutaneous ablation methods have proved effective for treatment of benign bone tumors and for palliation of metastases involving the bone. However, the role of these techniques is controversial and has to be better defined in the setting of palliative care.

METHODS

A systematic review of the existing data regarding minimally invasive techniques for the pain management of vertebral bone metastases was performed by experts of the European Palliative Care Research Network.

RESULTS

Only five papers were taken into consideration after performing rigorous screening according to inclusion and exclusion criteria (low number of patients, retrospective series, proceedings).

DISCUSSION

According to the present data a recommendation should be made to perform kiphoplasty in patients with vertebral tumors or metastases. However, the strength of this recommendation was based on one randomized controlled study. Several weaknesses and low quality of study design were observed with other techniques.

CONCLUSION

Further randomized controlled trials are required to improve the strength of evidence available to suggest these procedures on large scale. Until then, the balance of evidence favors the use of these procedures in a small select cohort of patients with severe and disabling back pain refractory to medical therapy.

Compression Fractures in the Setting of Diffuse Idiopathic Skeletal Hyperostosis

Compression fractures are the most common vertebral fractures. They involve the anterior column of the spine, and are considered stable fractures due to the presence of intact posterior ligaments that aid in resisting further collapse and deformity. They are thus often managed conservatively. We describe a series of 3 cases that were initially diagnosed as compression fractures and managed conservatively. With the abundance of compression fractures and increase in preference for conservative management of compression fractures, it is of utmost importance to recognize the possibility of other spinal co-pathologies, especially that of hyperostosis of the spine, both by clinical judgment as well as radiological analysis before embarking on conservative management, should there be under-treatment and development of complications that could have otherwise been avoided, as in the cases presented in this series.

Comparison of Vertebroplasty, Kyphoplasty, and Nonsurgical Management of Vertebral Compression Fractures and Impact on US Healthcare Resource Utilization

Study Design

Retrospective propensity score-matched cohort analysis of the Thomson Reuters MarketScan database.

Purpose

To compare the outcomes of vertebral compression fracture (VCF) treatment options, with an emphasis on reoperation, complications, costand overall healthcare resource use between 2005 and 2009 in the United States.

Overview of Literature

Options for the treatment of VCFs include conservative management, kyphoplasty, and vertebroplasty. The cost-effectiveness of surgical intervention for VCF has been criticized, and some suggest their outcomes to be similar to placebo.

Methods

Patients 18 years of age and older who developed a VCF were identified and separated into three treatment cohorts: vertebroplasty, kyphoplasty, and non-surgical. Propensity score matching was performed to match patients between cohorts. Main outcomes assessed included reoperation, complications, healthcare resource use and associated cost. Outcomes were compared at three separate time intervals (patients at index hospitalization; patients with at least 2-year follow-up data; and those with at least 4-year follow-up data).

Results

Twenty thousand seven hundred forty patients were identified with VCFs, yielding 7,290 after propensity score matching. The mean age of the patients was 78±12 years; and 5,507 (75.5%) were female. All reoperation rates ranged from 6%-17%, while complication rates ranged from 7%-10%, which did not differ significantly among the three cohorts at all follow-up periods. Overall costs were noted to be significantly greater in both the kyphoplasty and vertebroplasty groups at 1-year follow-up, not at 2-year and 4-year follow-up.

Conclusions

Our data suggests that the treatment of a VCF patient will likely be associated with similar long-term operative and complication rates regardless of treatment modality.

Two-year results of a randomized placebo-controlled trial of vertebroplasty for acute osteoporotic vertebral fractures

We previously reported the results of a randomized controlled trial that found no benefit of vertebroplasty over a sham procedure for acute osteoporotic vertebral fractures up to 6 months. We report here the 12-month and 24-month clinical outcomes of this trial. Eligible participants (n = 78) were randomly assigned to receive either vertebroplasty (n = 38) or a sham procedure (n = 40). Randomization was stratified by treatment center, sex, and symptom duration (<6 weeks or ≥6 weeks). Participants, investigators (except the treating radiologists), and outcome assessors were blinded to group assignments. Enrolment occurred between April 2004 and October 2008 with follow-up completed October 2010. The primary outcome was overall pain measured on a scale of 0 (no pain) to 10 (maximal imaginable pain). Secondary outcomes included pain at rest and at night, disability, quality of life, perceived recovery, and adverse events, including incident clinically apparent vertebral fractures. At 12 and 24 months, complete data were available for 67 (86%) and 57 (73%) participants, respectively. At 12 months participants in the active group improved by 2.4 ± 2.7 (mean ± SD) units in overall pain compared with 1.9 ± 2.8 units in the sham group, adjusted between-group mean difference (MD) 0.3 (95% confidence interval [CI], –0.9 to 1.5), whereas at 24 months participants in the active group had improved by 3.0 ± 3.1 units compared with 1.9 ± 3.0 units in the sham group, MD 1.1 (95% CI, –0.3 to 2.4). No significant between-group differences were observed for any of the secondary efficacy outcomes at 12 or 24 months. There were no between-group differences in incident clinical vertebral fractures up to 24 months (active: n = 14, sham: n = 13), although the study had inadequate power for this outcome. These results provide further evidence that the use of this treatment in routine care is unsupported.

Does bone cement in percutaneous vertebroplasty act as a stress riser?

STUDY DESIGN

An in vitro cadaveric study.

OBJECTIVE

To determine whether percutaneous vertebroplasty (PVP) with a clinically relevant amount of bone cement is capable of causing stress peaks in adjacent-level vertebrae.

SUMMARY OF BACKGROUND DATA

It is often suggested that PVP of a primary spinal fracture causes stress peaks in adjacent vertebrae, thereby leading to additional fractures. The in vitro studies that demonstrated this relationship, however, use bigger volumes of bone cement used clinically.

METHODS

Ten fresh-frozen vertebrae were loaded until failure, while registering force and displacement as well as the pressure under the lower endplate. After failure, the vertebrae were augmented with clinically relevant amounts of bone cement and then again loaded until failure. The force, displacement, and pressure under the lower endplate were again registered.

RESULTS

Stress peaks were not related to the location of the injected bone cement. Both failure load and stiffness were significantly lower after augmentation.

CONCLUSION

On the basis of our findings, we conclude that vertebral augmentation with clinically relevant amounts of bone cement does not lead to stress peaks under the endplate. It is therefore unlikely that PVP, in itself, causes detrimental stresses in the adjacent vertebrae, leading to new vertebral fractures.

LEVEL OF EVIDENCE

N/A.

Vertebral compression fractures: a review of current management and multimodal therapy

Vertebral compression fractures are a prevalent disease affecting osteoporotic patients. When symptomatic, they cause significant pain and loss of function and have a high public health impact. In this paper we outline the diagnosis and management of these patients, with evidence-based review of treatment outcomes for the various therapeutic options. Diagnosis involves a clinical history focusing on the nature of the patient’s pain as well as various imaging studies. Management is multimodal in nature and starts with conservative therapy consisting of analgesic medication, medication for osteoporosis, physical therapy, and bracing. Patients who are refractory to conservative management may be candidates for vertebral augmentation through either vertebroplasty or kyphoplasty.

Is severe pain immediately after spinal augmentation a predictor of long-term outcomes?

BACKGROUND AND PURPOSE

Severe, immediate postprocedural pain and the need for analgesics after vertebroplasty can be a discouraging experience for patients and caregivers. The goal of this study was to investigate whether the presence of severe pain immediately after vertebroplasty predicts short- and long-term pain relief.

MATERIALS AND METHODS

A chart review was performed to categorize patients regarding pain severity and analgesic usage immediately after vertebroplasty (< 4 h). "Severe" pain was defined as at least 8 of 10 with the 10-point VAS. Outcomes were pain severity and pain medication score and usage at 1 month and 1 year after vertebroplasty. Outcomes and clinical characteristics were compared between groups by using the Wilcoxon signed-rank test and the Fisher exact test.

RESULTS

Of the 429 vertebroplasty procedures identified, 69 (16%) were associated with severe pain, and 133 (31%) were associated with analgesic administration immediately after the procedure. The group experiencing severe pain had higher preprocedure median VAS rest pain scores (5 [IQR, 2-7]) and activity pain scores (10 [IQR, 8-10]) compared with patients who did not experience severe pain (3 [IQR, 1-6]; P = .0208, and 8 [IQR, 7-10]; P = .0263, respectively). At 1 month postprocedure, VAS rest and activity pain scores were similar between the severe pain group and the nonsevere pain group (P = .16 and P = .25, respectively) and between the group receiving pain medication and the group not receiving pain medication (P = .25 and P = .67, respectively). This similarity continued for 1 year after the procedure. Analgesic usage was similar among all groups at 1 year postprocedure.

CONCLUSIONS

Patients with severe pain immediately after vertebroplasty have similar long-term outcomes compared with patients without severe pain.

Vertebroplasty and kyphoplasty: new evidence adds heat to the debate

PURPOSE OF REVIEW

Cement bone augmentation has become very popular worldwide in treating painful noncomplicated spine fractures. Controversy about the effectiveness was raised by two randomized trials in 2009. Recent new evidence contradicts those findings giving credit to vertebroplasty/kyphoplasty.

RECENT FINDINGS

Well designed prospective clinical trials in cancer and noncancer vertebral fractures as well as an excellent meta-analysis showed that painful vertebral compression fractures have better and faster pain relief, better functional outcomes, and with low complication rate when treated with percutaneous cement than conservatively.

SUMMARY

The saga is unfinished. The treatment of vertebral compression fractures with cement augmentation is still in its infancy. The potential for development with new materials and the injection of biologic and active bone cements or anticancer products, in metastatic disease, will revolutionize the treatment of this condition.

Validity of intervertebral bone cement infusion for painful vertebral compression fractures based on the presence of vertebral mobility

BACKGROUND AND PURPOSE

It is uncertain whether analgesic effects of vertebroplasty in patients with painful VCF are actually attributable to intervertebral cement infusion. This study aims to assess the validity of cement infusion performed for pain relief based on the presence or absence of pseudoarthrosis.

MATERIALS AND METHODS

We compared therapeutic effects between PVP and vertebral perforation without bone cement infusion in patients with painful VCF. The subjects were 64 patients undergoing PVP (PVP group) and 67 undergoing vertebral perforation (perforation group). In all patients, preoperative dynamic radiography was performed to assess the presence of vertebral mobility. Patients were classified into 2 groups, those with and those without vertebral mobility, and changes in VAS and ADL scores before and after surgery were compared between the PVP and perforation groups.

RESULTS

Regarding patients with vertebral mobility, VAS improved during the 3 months immediately after surgery in the PVP group compared with the perforation group (P < .05). Although no significant difference in postoperative ADL scores was observed between the 2 treatment groups, the scores 3 months after surgery were better in the PVP group than in the perforation group. Meanwhile, in the subgroup of patients without vertebral mobility, both treatments produced marked pain relief, but the difference was not significant (P > .05). Moreover, there was no difference in ADL scores between the 2 treatment groups.

CONCLUSIONS

Intervertebral cement infusion exerts analgesic effects in patients with VCF with pseudoarthrosis. However, in those without vertebral mobility, the analgesic effects of vertebroplasty are the same regardless of bone cement infusion.

Should we reconsider the routine use of placebo controls in clinical research?

BACKGROUND

Modern clinical-research practice favors placebo controls over usual-care controls whenever a credible placebo exists. An unrecognized consequence of this preference is that clinicians are more limited in their ability to provide the benefits of the non-specific healing effects of placebos in clinical practice.

METHODS

We examined the issues in choosing between placebo and usual-care controls. We considered why placebo controls place constraints on clinicians and the trade-offs involved in the choice of control groups.

RESULTS

We find that, for certain studies, investigators should consider usual-care controls, even if an adequate placebo is available. Employing usual-care controls would be of greatest value for pragmatic trials evaluating treatments to improve clinical care and for which threats to internal validity can be adequately managed without a placebo-control condition.

CONCLUSIONS

Intentionally choosing usual-care controls, even when a satisfactory placebo exists, would allow clinicians to capture the value of non-specific therapeutic benefits that are common to all interventions. The result could be more effective, patient-centered care that makes the best use of both specific and non-specific benefits of medical interventions.

The placebo phenomenon and medical ethics: rethinking the relationship between informed consent and risk-benefit assessment

It has been presumed within bioethics that the benefits and risks of treatments can be assessed independently of information disclosure to patients as part of the informed consent process. Research on placebo and nocebo effects indicates that this is not true for symptomatic treatments. The benefits and risks that patients experience from symptomatic treatments can be shaped powerfully by information about these treatments provided by clinicians. In this paper we discuss the implications of placebo and nocebo research for risk-benefit assessment and informed consent.