Efficacy and safety of vertebroplasty for treatment of painful osteoporotic vertebral fractures: a randomised controlled trial [ACTRN012605000079640]

A composite of polymethylmethacrylate, hydroxyapatite, and β-tricalcium phosphate for bone regeneration in an osteoporotic rat model

The purpose of this study was to test several modifications of the polymethylmethacrylate (PMMA) bone cement by incorporating osteoconductive and biodegradable materials for enhancing bone regeneration capacity in an osteoporotic rat model. Three bio-composites (PHT-1 [80% PMMA, 16% HA, 4% β-TCP], PHT-2 [70% PMMA, 24% HA, 6% β-TCP], and PHT-3 [30% PMMA, 56% HA, 14% β-TCP]) were prepared using different concentrations of PMMA, hydroxyapatite (HA), and β-tricalcium phosphate (β-TCP). Their morphological structure was then examined using a scanning electron microscope (SEM) and mechanical properties were determined using a MTS 858 Bionics test machine (MTS, Minneapolis, MN, USA). For in vivo studies, 35 female Wister rats (250 g, 12 weeks of age) were prepared and divided into five groups including a sham group (control), an ovariectomy-induced osteoporosis group (OVX), an OVX with pure PMMA group (PMMA), an OVX with PHT-2 group (PHT-2), and an OVX with PHT-3 group (PHT-3). In vivo bone regeneration efficacy was assessed using micro-CT and histological analysis after injecting the prepared bone cement into the tibial defects of osteoporotic rats. SEM investigation showed that the PHT-3 sample had the highest porosity and roughness among all samples. In comparison to other samples, the PHT-3 exhibited favorable mechanical properties for use in vertebroplasty procedures. Micro-CT and histological analysis of OVX-induced osteoporotic rats revealed that PHT-3 was more effective in regenerating bone and restoring bone density than other samples. This study suggests that the PHT-3 bio-composite can be a promising candidate for treating osteoporosis-related vertebral fractures.

Safety and Efficacy of Bone Cement (Spinofill®) for Vertebroplasty in Patients with Osteoporotic Compression Fracture : A Preliminary Prospective Study

Objective

Although several commercialized bone cements are used during percutaneous vertebroplasty (PVP) for patients with osteoporotic vertebral compression fracture (OVCF), there are no reports using domestic products from South Korea. In this study, we investigated the safety and efficacy of Spinofill^® (Injecta Inc., Gunpo, Korea), a new polymethyl methacrylate product.

Methods

A prospective, single-center, and single-arm clinical trial of 30 participants who underwent PVP using Spinofill^® for painful thoracolumbar OVCF was performed with 6-months follow-up. Clinical and surgical outcomes included the Visual analog scale (VAS), Korean-Oswestry disability index (K-ODI), and Odom’s criteria, complication rate, and recurrence rate. Radiological outcomes were evaluated by measuring the findings of postoperative computed tomography and simple radiograph.

Results

The pain of VAS (from 8.95±1.05 to 4.65±2.06, p<0.001) and the life quality based on K-ODI (from 33.95±5.84 to 25.65±4.79, p<0.001) improved significantly, and successful patient satisfaction were achieved in 20 patients (66.7%) 1 day after surgery. These immediate improvements were maintained or more improved during the follow-up. There was no surgery- or product-related complications, but OVCF recurred in two patients (6.7%). Favorable cement interdigitation was reported in 24 patients (80.0%), and extra-vertebral cement leakage was reported in 13 patients (43.0%). The mean vertebral height ratio (from 60.49%±21.97% to 80.07%±13.16%, p<0.001) and segmental kyphotic angle (from 11.46°±8.50° to 7.79°±6.08°, p=0.002) improved one day after surgery. However, these short-term radiological findings somewhat regressed at the end.

Conclusion

The overall outcomes of PVP using Spinofill^® were as favorable as those of other conventionally used products.

Vertebroplasty, Kyphoplasty, and Implant-Based Mechanical Vertebral Augmentation

Vertebral compression fractures are a global public health issue with a quantifiable negative impact on patient morbidity and mortality. The contemporary approach to the treatment of osteoporotic fragility fractures has moved beyond first-line nonsurgical management. An improved understanding of biomechanical forces, consequential morbidity and mortality, and the drive to reduce opioid use has resulted in multidisciplinary treatment algorithms and significant advances in augmentation techniques. This review will inform musculoskeletal radiologists, interventionalists, and minimally invasive spine surgeons on the proper work-up of patients, imaging features differentiating benign and malignant pathologic fractures, high-risk fracture morphologies, and new mechanical augmentation device options, and it describes the appropriate selection of devices, complications, outcomes, and future trends.

Changes of the adjacent discs and vertebrae in patients with osteoporotic vertebral compression fractures treated with or without bone cement augmentation

BACKGROUND CONTEXT

Although vertebral augmentation with bone cement has been commonly used to treat symptomatic osteoporotic vertebral compression fractures, relatively little is known about the impact of augmentation on the adjacent spinal components.

PURPOSE

To determine the imaging effects of vertebral augmentation on the adjacent discs, the augmented vertebra, and the involved spinal segment.

STUDY DESIGN

Retrospective radiographic study.

PATIENT SAMPLE

Patients with acute osteoporotic vertebral compression fractures who underwent vertebral augmentation or nonoperative treatments.

OUTCOME MEASURES

On baseline and follow-up mid-sagittal T2W magnetic resonance images, quantitative measurements of disc degeneration, including disc height, bulging, and signal, vertebral height, wedge angle, and segmental kyphotic angle were acquired.

METHODS

Lumbar spine magnetic resonance images of patients with acute osteoporotic vertebral compression fractures at a local hospital in Eastern China between 2010 and 2017 were reviewed. Student's t-tests and χ² tests were used to examine the differences of baseline and changes over time between vertebrae underwent vertebral augmentation and those did not. Paired t-tests were used to examine the differences between baseline and follow-up to study the changes of adjacent disc degeneration, creep deformity of the vertebra and progression of segmental kyphosis.

RESULTS

There were 112 acute vertebral compression fractures (72 treated with kyphoplasty and 40 with nonoperative treatments) in 101 subjects. At final follow-up (mean 21.5 months), the cranial disc of the augmented vertebra decreased in height (p<.001), and both cranial and caudal discs decreased in signal intensity (p≤.02). The discs in the nonoperative group did not undergo such degenerative changes. For the fractured vertebra, vertebral height significantly decreased (p<.01 for both) and vertebral wedge angle significantly increased (p≤.01 for both), regardless of augmentation treatment or not. Segmental kyphotic angle significantly increased in vertebral fractures that underwent vertebral augmentation (p<.001), but not in those underwent nonoperative treatments.

CONCLUSIONS

Patients that underwent vertebral augmentation had more advanced disc degeneration at adjacent disc levels as compared to those without augmentation. The fractured vertebral body height decreased and the wedge angle increased, regardless of vertebral augmentation treatment or not. Vertebral augmentation may be associated with increased creep deformity of the adjacent vertebra and the progression of segmental kyphosis.

A Comparison of Percutaneous Vertebroplasty Versus Conservative Treatment in Terms of Treatment Effect for Osteoporotic Vertebral Compression Fractures: A Meta-Analysis

Background. Osteoporotic vertebral compression fractures (OVCFs) are common in older patients, which can cause back pain and even increase morbidity. However, the optimal therapy for patients with OVCFs remains unknown. Percutaneous vertebroplasty (PVP), a minimally invasive procedure, has been a therapy option that is known to be effective in the pain management. Aim. The meta-analysis aims to summarize current best evidence on the efficacy of PVP and conservative treatment (CT) for pain management and functional results among OVCFs patients. Methods. We searched the publications on comparison of the efficacy of PVP versus CT for OVCFs patients up to November 2018. After rigorous reviewing on the quality, the data were extracted from eligible trials. All trials analyzed the summary hazard ratios of the endpoints of interest. Results. Moderate-strong evidence indicated that PVP had benefits on pain relief at 1 week and 1 month, but not at 3 months. With regard to the quality of life, no significant differences were found in the Roland-Morris Disability Questionnaire (RMDQ). However, there is significant difference in terms of EuroQol and Quality of Life Questionnaire of the European Foundation for Osteoporosis but not the RMDQ. Moreover, there were no any benefit in terms of vertebral fracture between groups. Conclusions. The meta-analysis showed that patients treated with vertebroplasty were associated with better pain relief and improved quality of life, without increasing the incidence of vertebral fracture compared with the CT group.

Percutaneous vertebroplasty for osteoporotic vertebral compression fracture

BACKGROUND

Percutaneous vertebroplasty remains widely used to treat osteoporotic vertebral fractures although our 2015 Cochrane review did not support its role in routine practice.

OBJECTIVES

To update the available evidence of the benefits and harms of vertebroplasty for treatment of osteoporotic vertebral fractures.

SEARCH METHODS

We updated the search of CENTRAL, MEDLINE and Embase and trial registries to 15 November 2017.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials (RCTs) of adults with painful osteoporotic vertebral fractures, comparing vertebroplasty with placebo (sham), usual care, or another intervention. As it is least prone to bias, vertebroplasty compared with placebo was the primary comparison. Major outcomes were mean overall pain, disability, disease-specific and overall health-related quality of life, patient-reported treatment success, new symptomatic vertebral fractures and number of other serious adverse events.

DATA COLLECTION AND ANALYSIS

We used standard methodologic procedures expected by Cochrane.

MAIN RESULTS

Twenty-one trials were included: five compared vertebroplasty with placebo (541 randomised participants), eight with usual care (1136 randomised participants), seven with kyphoplasty (968 randomised participants) and one compared vertebroplasty with facet joint glucocorticoid injection (217 randomised participants). Trial size varied from 46 to 404 participants, most participants were female, mean age ranged between 62.6 and 81 years, and mean symptom duration varied from a week to more than six months.Four placebo-controlled trials were at low risk of bias and one was possibly susceptible to performance and detection bias. Other trials were at risk of bias for several criteria, most notably due to lack of participant and personnel blinding.Compared with placebo, high- to moderate-quality evidence from five trials indicates that vertebroplasty provides no clinically important benefits with respect to pain, disability, disease-specific or overall quality of life or treatment success at one month. Evidence for quality of life and treatment success was downgraded due to possible imprecision. Evidence was not downgraded for potential publication bias as only one placebo-controlled trial remains unreported. Mean pain (on a scale zero to 10, higher scores indicate more pain) was five points with placebo and 0.7 points better (0.3 better to 1.2 better) with vertebroplasty, an absolute pain reduction of 7% (3% better to 12% better, minimal clinical important difference is 15%) and relative reduction of 10% (4% better to 17% better) (five trials, 535 participants). Mean disability measured by the Roland-Morris Disability Questionnaire (scale range zero to 23, higher scores indicate worse disability) was 14.2 points in the placebo group and 1.5 points better (0.4 better to 2.6 better) in the vertebroplasty group, absolute improvement 7% (2% to 11% better), relative improvement 9% better (2% to 15% better) (four trials, 472 participants).Disease-specific quality of life measured by the Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO) (scale zero to 100, higher scores indicating worse quality of life) was 62 points in the placebo group and 2.3 points better (1.4 points worse to 6.7 points better), an absolute imrovement of 2% (1% worse to 6% better); relative improvement 4% better (2% worse to 10% better) (three trials, 351 participants). Overall quality of life (European Quality of Life (EQ5D), zero = death to 1 = perfect health, higher scores indicate greater quality of life) was 0.38 points in the placebo group and 0.05 points better (0.01 better to 0.09 better) in the vertebroplasty group, absolute improvement: 5% (1% to 9% better), relative improvement: 18% (4% to 32% better) (three trials, 285 participants). In one trial (78 participants), 9/40 (or 225 per 1000) people perceived that treatment was successful in the placebo group compared with 12/38 (or 315 per 1000; 95% CI 150 to 664) in the vertebroplasty group, RR 1.40 (95% CI 0.67 to 2.95), absolute difference: 9% more reported success (11% fewer to 29% more); relative change: 40% more reported success (33% fewer to 195% more).Low-quality evidence (downgraded due to imprecision and potential for bias from the usual-care controlled trials) indicates uncertainty around the risk estimates of harms with vertebroplasty. The incidence of new symptomatic vertebral fractures (from six trials) was 48/418 (95 per 1000; range 34 to 264)) in the vertebroplasty group compared with 31/422 (73 per 1000) in the control group; RR 1.29 (95% CI 0.46 to 3.62)). The incidence of other serious adverse events (five trials) was 16/408 (34 per 1000, range 18 to 62) in the vertebroplasty group compared with 23/413 (56 per 1000) in the control group; RR 0.61 (95% CI 0.33 to 1.10). Notably, serious adverse events reported with vertebroplasty included osteomyelitis, cord compression, thecal sac injury and respiratory failure.Our subgroup analyses indicate that the effects did not differ according to duration of pain (acute versus subacute). Including data from the eight trials that compared vertebroplasty with usual care in a sensitivity analyses altered the primary results, with all combined analyses displaying considerable heterogeneity.

AUTHORS' CONCLUSIONS

We found high- to moderate-quality evidence that vertebroplasty has no important benefit in terms of pain, disability, quality of life or treatment success in the treatment of acute or subacute osteoporotic vertebral fractures in routine practice when compared with a sham procedure. Results were consistent across the studies irrespective of the average duration of pain.Sensitivity analyses confirmed that open trials comparing vertebroplasty with usual care are likely to have overestimated any benefit of vertebroplasty. Correcting for these biases would likely drive any benefits observed with vertebroplasty towards the null, in keeping with findings from the placebo-controlled trials.Numerous serious adverse events have been observed following vertebroplasty. However due to the small number of events, we cannot be certain about whether or not vertebroplasty results in a clinically important increased risk of new symptomatic vertebral fractures and/or other serious adverse events. Patients should be informed about both the high- to moderate-quality evidence that shows no important benefit of vertebroplasty and its potential for harm.

Vertebral Augmentation can Induce Early Signs of Degeneration in the Adjacent Intervertebral Disc: Evidence from a Rabbit Model

STUDY DESIGN

An experimental study.

OBJECTIVE

The aim of this study was to determine the effect of polymethylmethacrylate (PMMA) augmentation on the adjacent disc.

SUMMARY OF BACKGROUND DATA

Vertebral augmentation with PMMA reportedly may predispose the adjacent vertebra to fracture. The influence of PMMA augmentation on the adjacent disc, however, remains unclear.

METHODS

Using a retroperitoneal approach, PMMA augmentation was performed for 23 rabbits. For each animal, at least one vertebra was augmented with 0.2 to 0.3 mL PMMA. The disc adjacent to the augmented vertebra and a proximal control disc were studied using magnetic resonance (MR) imaging, histological and molecular level evaluation at 1, 3, and 6 months postoperatively. Marrow contact channels in the endplate were quantified in histological slices and number of invalid channels (those without erythrocytes inside) was rated. Terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) was performed to determine disc cell apoptosis.

RESULTS

On MR images, the signal and height of the adjacent disc did not change 6 months after vertebral augmentation. Histological scores of the adjacent disc increased over time, particularly for the nucleus pulposus. The adjacent disc had greater nucleus degeneration score than the control disc at 3 months (5.7 vs. 4.5, P < 0.01) and 6 months (6.9 vs. 4.4, P < 0.001). There were more invalid marrow contact channels in the endplate of augmented vertebra than the control (43.3% vs. 11.1%, P < 0.01). mRNA of ADAMTS-5, MMP-13, HIF-1α, and caspase-3 were significantly upregulated in the adjacent disc at 3 and 6 months (P < 0.05 for all). In addition, there were more TUNEL-positive cells in the adjacent disc than in the control disc (43.4% vs. 24.0%, P < 0.05) at 6 months postoperatively.

CONCLUSION

Vertebral augmentation can induce early degenerative signs in the adjacent disc, which may be due to impaired nutrient supply to the disc.

LEVEL OF EVIDENCE

N/A.

Vertebroplasty and Kyphoplasty for Osteoporotic Vertebral Fractures: What Are the Latest Data?

Osteoporotic vertebral compression fractures frequently result in significant morbidity and health care resource use. For patients with severe and disabling pain, vertebral augmentation (vertebroplasty and kyphoplasty) is often considered. Although vertebroplasty was introduced >30 years ago, there are conflicting opinions regarding the role of these procedures in the treatment of osteoporotic vertebral compression fractures. This review article updates clinicians on the published prospective randomized controlled data, including the most recent positive trials that followed initial negative trials in 2009. Analysis of multiple national claim datasets has also provided further insight into the utility of these procedures. Finally, we considered the recent recommendations of national organizations and medical societies that advise on the use of vertebral augmentation procedures for osteoporotic vertebral compression fractures.

Percutaneous vertebroplasty for osteoporotic vertebral compression fracture

BACKGROUND

Percutaneous vertebroplasty remains widely used to treat osteoporotic vertebral fractures although our 2015 Cochrane review did not support its role in routine practice.

OBJECTIVES

To update the available evidence of the benefits and harms of vertebroplasty for treatment of osteoporotic vertebral fractures.

SEARCH METHODS

We updated the search of CENTRAL, MEDLINE and Embase and trial registries to 15 November 2017.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials (RCTs) of adults with painful osteoporotic vertebral fractures, comparing vertebroplasty with placebo (sham), usual care, or another intervention. As it is least prone to bias, vertebroplasty compared with placebo was the primary comparison. Major outcomes were mean overall pain, disability, disease-specific and overall health-related quality of life, patient-reported treatment success, new symptomatic vertebral fractures and number of other serious adverse events.

DATA COLLECTION AND ANALYSIS

We used standard methodologic procedures expected by Cochrane.

MAIN RESULTS

Twenty-one trials were included: five compared vertebroplasty with placebo (541 randomised participants), eight with usual care (1136 randomised participants), seven with kyphoplasty (968 randomised participants) and one compared vertebroplasty with facet joint glucocorticoid injection (217 randomised participants). Trial size varied from 46 to 404 participants, most participants were female, mean age ranged between 62.6 and 81 years, and mean symptom duration varied from a week to more than six months.Three placebo-controlled trials were at low risk of bias and two were possibly susceptible to performance and detection bias. Other trials were at risk of bias for several criteria, most notably due to lack of participant and personnel blinding.Compared with placebo, high- to moderate-quality evidence from five trials (one with incomplete data reported) indicates that vertebroplasty provides no clinically important benefits with respect to pain, disability, disease-specific or overall quality of life or treatment success at one month. Evidence for quality of life and treatment success was downgraded due to possible imprecision. Evidence was not downgraded for potential publication bias as only one placebo-controlled trial remains unreported. Mean pain (on a scale zero to 10, higher scores indicate more pain) was five points with placebo and 0.6 points better (0.2 better to 1 better) with vertebroplasty, an absolute pain reduction of 6% (2% better to 10% better, minimal clinical important difference is 15%) and relative reduction of 9% (3% better to14% better) (five trials, 535 participants). Mean disability measured by the Roland-Morris Disability Questionnaire (scale range zero to 23, higher scores indicate worse disability) was 14.2 points in the placebo group and 1.7 points better (0.3 better to 3.1 better) in the vertebroplasty group, absolute improvement 7% (1% to 14% better), relative improvement 10% better (3% to 18% better) (three trials, 296 participants).Disease-specific quality of life measured by the Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO) (scale zero to 100, higher scores indicating worse quality of life) was 62 points in the placebo group and 2.75 points (3.53 worse to 9.02 better) in the vertebroplasty group, absolute change: 3% better (4% worse to 9% better), relative change: 5% better (6% worse to 15% better (two trials, 175 participants). Overall quality of life (European Quality of Life (EQ5D), zero = death to 1 = perfect health, higher scores indicate greater quality of life) was 0.38 points in the placebo group and 0.05 points better (0.01 better to 0.09 better) in the vertebroplasty group, absolute improvement: 5% (1% to 9% better), relative improvement: 18% (4% to 32% better) (three trials, 285 participants). In one trial (78 participants), 9/40 (or 225 per 1000) people perceived that treatment was successful in the placebo group compared with 12/38 (or 315 per 1000; 95% CI 150 to 664) in the vertebroplasty group, RR 1.40 (95% CI 0.67 to 2.95), absolute difference: 9% more reported success (11% fewer to 29% more); relative change: 40% more reported success (33% fewer to 195% more).Moderate-quality evidence (low number of events) from seven trials (four placebo, three usual care, 1020 participants), up to 24 months follow-up, indicates we are uncertain whether vertebroplasty increases the risk of new symptomatic vertebral fractures (70/509 (or 130 per 1000; range 60 to 247) observed in the vertebroplasty group compared with 59/511 (120 per 1000) in the control group; RR 1.08 (95% CI 0.62 to 1.87)).Similarly, moderate-quality evidence (low number of events) from five trials (three placebo, two usual care, 821 participants), indicates uncertainty around the risk of other serious adverse events (18/408 or 76 per 1000, range 6 to 156) in the vertebroplasty group compared with 26/413 (or 106 per 1000) in the control group; RR 0.64 (95% CI 0.36 to 1.12). Notably, serious adverse events reported with vertebroplasty included osteomyelitis, cord compression, thecal sac injury and respiratory failure.Our subgroup analyses indicate that the effects did not differ according to duration of pain ≤ 6 weeks versus > 6 weeks. Including data from the eight trials that compared vertebroplasty with usual care in a sensitivity analyses altered the primary results, with all combined analyses displaying considerable heterogeneity.

AUTHORS' CONCLUSIONS

Based upon high- to moderate-quality evidence, our updated review does not support a role for vertebroplasty for treating acute or subacute osteoporotic vertebral fractures in routine practice. We found no demonstrable clinically important benefits compared with placebo (sham procedure) and subgroup analyses indicated that the results did not differ according to duration of pain ≤ 6 weeks versus > 6 weeks.Sensitivity analyses confirmed that open trials comparing vertebroplasty with usual care are likely to have overestimated any benefit of vertebroplasty. Correcting for these biases would likely drive any benefits observed with vertebroplasty towards the null, in keeping with findings from the placebo-controlled trials.Numerous serious adverse events have been observed following vertebroplasty. However due to the small number of events, we cannot be certain about whether or not vertebroplasty results in a clinically important increased risk of new symptomatic vertebral fractures and/or other serious adverse events. Patients should be informed about both the high- to moderate-quality evidence that shows no important benefit of vertebroplasty and its potential for harm.

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.

Percutaneous vertebroplasty for osteoporotic vertebral compression fracture

BACKGROUND

Percutaneous vertebroplasty is widely used to treat acute and subacute painful osteoporotic vertebral fractures although recent placebo-controlled trials have questioned its value.

OBJECTIVES

To synthesise the available evidence regarding the benefits and harms of vertebroplasty for treatment of osteoporotic vertebral fractures.

SEARCH METHODS

We searched CENTRAL, MEDLINE and EMBASE up to November 2014. We also reviewed reference lists of review articles, trials and trial registries to identify any other potentially relevant trials.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials (RCTs) including adults with painful osteoporotic vertebral fractures of any duration and comparing vertebroplasty with placebo (sham), usual care, or any other intervention. As it is least prone to bias, vertebroplasty compared with placebo was the primary comparison. Major outcomes were mean overall pain, disability, disease-specific and overall health-related quality of life, patient-reported treatment success, new symptomatic vertebral fractures and number of other serious adverse events.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials for inclusion, extracted data, performed 'Risk of bias' assessment and assessed the quality of the body of evidence for the main outcomes using GRADE.

MAIN RESULTS

Eleven RCTs and one quasi-RCT conducted in various countries were included. Two trials compared vertebroplasty with placebo (209 randomised participants), six compared vertebroplasty with usual care (566 randomised participants) and four compared vertebroplasty with kyphoplasty (545 randomised participants). Trial size varied from 34 to 404 participants, most participants were female, mean age ranged between 63.3 and 80 years, and mean symptom duration varied from a week to more than six months.Both placebo-controlled trials were judged to be at low overall risk of bias while other included trials were generally considered to be at high risk of bias across a range of criteria, most seriously due to lack of participant and study personnel blinding.Compared with placebo, there was moderate quality evidence based upon two trials that vertebroplasty provides no demonstrable benefits with respect to pain, disability, disease-specific or overall quality of life or treatment success. At one month, mean pain (on a scale 0 to 10, higher scores indicate more pain) was 5 points with placebo and 0.7 points better (1.5 better to 0.15 worse) with vertebroplasty, an absolute pain reduction of 7% (15% better to 1.5% worse) and relative reduction of 10% (21% better to 2% worse) (two trials, 201 participants). At one month, mean disability measured by the Roland Morris Disability Questionnaire (scale range 0 to 23, higher scores indicate worse disability) was 13.6 points in the placebo group and 1.1 points better (2.9 better to 0.8 worse) in the vertebroplasty group, absolute improvement in disability 4.8% (12.8% better to 3.3% worse), relative change 6.3% better (17.0% better to 4.4% worse) (two trials, 201 participants).At one month, disease-specific quality of life measured by the QUALEFFO (scale 0 to 100, higher scores indicating worse quality of life) was 2.4 points in the placebo group and 0.40 points worse (4.58 better to 5.38 worse) in the vertebroplasty group, absolute change: 0.4% worse (5% worse to 5% better), relative change 0.7% worse (9% worse to 8% better (based upon one trial, 73 participants). At one month overall quality of life measured by the EQ5D (0 = death to 1 = perfect health, higher scores indicate greater quality of life at one month was 0.27 points in the placebo group and 0.05 points better (0.01 worse to 0.11 better) in the vertebroplasty group, absolute improvement in quality of life 5% (1% worse to 11% better), relative change 18% better (4% worse to 39% better) (two trials, 201 participants). Based upon one trial (78 participants) at one month, 9/40 (or 225 per 1000) people perceived that treatment was successful in the placebo group compared with 12/38 (or 315 per 1000; range 150 to 664) in the vertebroplasty group, RR 1.40 (95% CI 0.67 to 2.95), absolute risk difference 9% more reported success (11% fewer to 29% more); relative change 40% more reported success (33% fewer to 195% more).Based upon moderate quality evidence from three trials (one placebo, two usual care, 281 participants) with up to 12 months follow-up, we are uncertain whether or not vertebroplasty increases the risk of new symptomatic vertebral fractures (28/143 observed in the vertebroplasty group compared with 19/138 in the control group; RR 1.47 (95% CI 0.39 to 5.50).Similary, based upon moderate quality evidence from two placebo-controlled trials (209 participants), we are uncertain about the exact risk of other adverse events (3/106 were observed in the vertebroplasty group compared with 3/103 in the placebo group; RR 1.01 (95% CI 0.21 to 4.85)). Notably, serious adverse events reported with vertebroplasty included osteomyelitis, cord compression, thecal sac injury and respiratory failure.Our subgroup analyses provided limited evidence that the effects did not differ according to duration of pain ≤ 6 weeks versus > 6 weeks. Including data from the six trials that compared vertebroplasty with usual care in a sensitivity analyses inconsistently altered the primary results, with all combined analyses displaying substantial to considerable heterogeneity.

AUTHORS' CONCLUSIONS

Based upon moderate quality evidence, our review does not support a role for vertebroplasty for treating osteoporotic vertebral fractures in routine practice. We found no demonstrable clinically important benefits compared with a sham procedure and subgroup analyses indicated that results did not differ according to duration of pain ≤ 6 weeks versus > 6 weeks. Sensitivity analyses confirmed that open trials comparing vertebroplasty with usual care are likely to have overestimated any benefit of vertebroplasty. Correcting for these biases would likely drive any benefits observed with vertebroplasty towards the null, in keeping with findings from the placebo-controlled trials.Numerous serious adverse events have been observed following vertebroplasty. However due to the small number of events, we cannot be certain about whether or not vertebroplasty results in a clinically important increased risk of new symptomatic vertebral fractures and/or other serious adverse events. Patients should be informed about both the lack of high quality evidence supporting benefit of vertebroplasty and its potential for harm.

New vertebral fractures after vertebroplasty: 2-year results from a randomised controlled trial

A randomised controlled trial of vertebroplasty (VP) versus placebo assessed the effect of VP on the risk of further vertebral fractures. While no statistically significant between-group differences for new or progressed fracture risk at 12 and 24 months were observed, we observed a consistent trend towards higher risk of any type of fracture in the group undergoing VP. Our analysis was underpowered, and further adequately powered studies are needed to be able to draw firm conclusions about further vertebral risk with vertebroplasty.

PURPOSE

This study seeks to assess the effect of VP on the risk of further radiologically apparent vertebral fracture within two years of the procedure.

METHODS

We conducted a randomised placebo-controlled trial of VP in people with acute osteoporotic vertebral fracture. Eligible participants were randomly assigned to VP (n = 38) or placebo (n = 40). Cement volume and leakage were recorded for the VP group. Plain thoracolumbar radiographs were taken at baseline, 12 and 24 months. Two independent radiologists assessed these for new and progressed fractures at the same, adjacent and non-adjacent levels.

RESULTS

At 12 and 24 months, radiographs were available for 45 (58 %) and 47 (60 %) participants, respectively. There were no between-group differences for new or progressed fractures: 32 and 40 in the VP group after 12 and 24 months compared with 21 and 33 in the placebo group (hazard ratio (HR) 1.80, 95 % confidence interval (CI) 0.82 to 3.94). Similar results were seen when considering only adjacent (HR (95 % CI) 2.30 (0.57 to 9.29)) and non-adjacent (HR (95 % CI) 1.45 (0.55 to 3.81) levels. In all comparisons, there was a consistent trend towards higher risk of any type of fracture in the group undergoing VP. Within the VP group, fracture risk was unrelated to total (HR (95 % CI) 0.91 (0.71 to 1.17)) or relative (HR (95 % CI) 1.31 (0.15 to 11.48)) cement volume or cement leakage (HR (95 % CI) 1.20 (0.63 to 2.31)).

CONCLUSION

For patients undergoing VP, our study did not demonstrate significant increases in subsequent fracture risk beyond that experienced by those with vertebral fractures who did not undergo the procedure. However, because of the non-significant numerical increases observed, studies with adequate power are needed to draw definite conclusions about fracture risk.

Is intervertebral cement leakage a risk factor for new adjacent vertebral collapse?

This retrospective study evaluated the relationship between intervertebral cement leakage and new adjacent vertebral fracture and describes the different characteristics of cement leakage. Increased risk of new adjacent vertebral fracture (NF) has been reported to be a complication of cement leakage in vertebroplasty. In our observation, an incidental intervertebral cement leakage may occur during vertebroplasty but is commonly asymptomatic. The study focused on osteoporotic collapse patients who had percutaneous vertebroplasty (PV) between 2005 and 2007. We divided patients into leakage and non-leakage groups and compared the incidence of NF. Leakage characteristics were divided into three types: Type I intervertebral-extradiscal leakage, Type II intradiscal leakage and Type III combined leakage. Visual analog scale for pain and the Karnofsky Performance Status at 24 h, three months, six months and one year were compared between groups and types of leakages. Among 148 PVs (102 patients) there were 30 leakages (20.27%) and 21(14.19%) NFs. The incidence of NF did not significantly differ between leakage and non-leakage groups (P<0.05). Type II was the most common type of leakage (15/30). Reduction of average pain and improvement of Karnofsky Performance Status score did not differ between groups (P< 0.05). Type II had decreased pain score < type I and III at 24 h (P < 0.01), three months and six months (P < 0.1) but not at one year (P<0.10). Type II also had decreased pain score < non-leakage group only at 24 h (P<0.05). Intervertebral cement leakage is not an increased risk for NF, influenced outcomes of pain relief or improvement of physical function. Intradiscal leakage (Type II) is the most common characteristic of cement leakage and probably related to delayed pain relief.

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.

Height restoration and maintenance after treating unstable osteoporotic vertebral compression fractures by cement augmentation is dependent on the cement volume used

BACKGROUND

Two different procedures, used for percutaneous augmentation of vertebral compression fractures were compared, with respect to height restoration and maintenance after cyclic loading. Additionally the impact of the cement volume used was investigated.

METHODS

Wedge compression fractures were created in 36 human cadavaric vertebrae (T10-L3). Twenty-seven vertebrae were treated with the SpineJack® with different cement volumes (maximum, intermediate, and no cement), and 9 vertebrae were treated with Balloon Kyphoplasty. Vertebral heights were measured pre- and postfracture as well as after treatment and loading. Cyclic loading was performed with 10,000cycles (1Hz, 100-600N).

FINDINGS

The average anterior height after restoration was 85.56% for Kyphoplasty; 96.20% for SpineJack® no cement; 93.44% for SpineJack® maximum and 96% for the SpineJack® intermediate group. The average central height after restoration was 93.89% for Kyphoplasty; 100.20% for SpineJack® no cement; 99.56% for SpineJack® maximum and 101.13% for the SpineJack® intermediate group. The average anterior height after cyclic loading was 85.33 % for Kyphoplasty; 87.30% in the SpineJack® no cement, 92% in the SpineJack® maximum and 87% in the SpineJack® intermediate group. The average central height after cyclic loading was 92% for Kyphoplasty; 93.80% in the SpineJack® no cement; 98.56% in the SpineJack® maximum and 94.25% in the SpineJack® intermediate group.

INTERPRETATION

Height restoration was significantly better for the SpineJack® group compared to Kyphoplasty. Height maintenance was dependent on the cement volume used. The group with the SpineJack® without cement nevertheless showed better results in height maintenance, yet the statistical significance could not be demonstrated.

Neurological deficit due to cement extravasation following a vertebral augmentation procedure

The authors endeavor to highlight the surgical management of severe neurological deficit resulting from cement leakage after percutaneous vertebroplasty and to systematically review the literature on the management of this complication. A patient presented after a vertebroplasty procedure for traumatic injury. A CT scan showed polymethylmethacrylate leakage into the right foramina at T-11 and L-1 and associated central stenosis at L-1. He underwent decompression and fusion for removal of cement and stabilization of the fracture segment. In the authors' systematic review, they searched Medline, Scopus, and Cochrane databases to determine the overall number of reported cases of neurological deficit after cement leakage, and they collected data on symptom onset, clinical presentation, surgical management, and outcome. After surgery, despite neurological recovery postoperatively, the patient developed pneumonia and died 16 days after surgery. The literature review showed 21 cases of cement extravasation with neurological deficit. Ultimately, 15 patients had resolution of the postoperative deficit, 5 had limited change in neurological status, and 2 had no improvement. Cement augmentation procedures are relatively safe, but certain precautions should be taken to avoid such complications including high-resolution biplanar fluoroscopy, considering the use of a local anesthetic, and controlling the location of cement spread in relationship to the posterior vertebral body. Immediate surgical intervention with removal of cement provides good results with complete recovery in most cases.

Meta-analysis of vertebral augmentation compared with conservative treatment for osteoporotic spinal fractures

Cement augmentation is a controversial treatment for painful vertebral compression fractures (VCF). Our research questions for the meta-analysis were: Is there a clinical and statistical difference in pain relief, functional improvement, and quality of life between conservative care and cement augmentation for VCF and, if so, are they maintained at longer time points? We conducted a search of MEDLINE from January 1980 to July 2011 using PubMed, Cochrane Database of Systematic Reviews and Controlled Trials, CINAHL, and EMBASE. Searches were performed from medical subject headings. Terms "vertebroplasty" and "compression fracture" were used. The outcome variables of pain, functional measures, health-related quality of life (HRQOL), and new fracture risk were analyzed. A random effects model was chosen. Continuous variables were calculated using the standardized mean difference comparing improvement from baseline of the experimental group with the control group. New vertebral fracture risk was calculated using log odds ratio. Six studies met the criteria. The pain visual analog scale (VAS) mean difference was 0.73 (confidence interval [CI] 0.35, 1.10) for early (<12 weeks) and 0.58 (CI 0.19, 0.97) for late time points (6 to 12 months), favoring vertebroplasty (p < 0.001). The functional outcomes at early and late time points were statistically significant with 1.08 (CI 0.33, 1.82) and 1.16 (CI 0.14, 2.18), respectively. The HRQOL showed superior results of vertebroplasty compared with conservative care at early and late time points of 0.39 (CI 0.16, 0.62) and 0.33 (CI 0.16, 0.51), respectively. Secondary fractures were not statistically different between the groups, 0.065 (CI -0.57, 0.70). This meta-analysis showed greater pain relief, functional recovery, and health-related quality of life with cement augmentation compared with controls. Cement augmentation results were significant in the early (<12 weeks) and the late time points (6 to 12 months). This meta-analysis provides strong evidence in favor of cement augmentation in the treatment of symptomatic VCF fractures.

The pathophysiology, diagnosis, and management of stress fractures in postmenopausal women

INTRODUCTION

Increasing numbers of elderly individuals are now participating in marathons. With increased participation in running, there has been an increase in the diagnosis of stress fractures in the elderly population. Postmenopausal women are particularly at risk due to osteoporosis.

DISCUSSION

There are numerous risk factors for stress fractures in the literature that need to be addressed to reduce the risk of injury and recurrence in postmenopausal women. Diagnostic tests include plain radiograph, ultrasound, therapeutic ultrasound, computed tomography scan, and isotope bone scans; however, magnetic resonance imaging remains the gold standard. Treatment is based on risk stratification, with high-risk fractures managed aggressively with either non-weightbearing or surgical intervention. Although exercise is prescribed as a well-recognized treatment modality of poor bone density, balance is essential to avoid precipitating stress fractures.

CONCLUSION

Optimal exercise programs should balance the beneficial effect of increasing bone mineral density through exercise with the detrimental effect of stress fractures. A useful algorithm is presented in this article to guide the clinician in the diagnosis and management of appropriate investigations and management of such injuries. This review article describes the pathophysiology and provides a review of the literature to determine the latest diagnostic and treatment strategies for this unique population.

Vertebroplasty and kyphoplasty--a systematic review of cement augmentation techniques for osteoporotic vertebral compression fractures compared to standard medical therapy

After more than two decades the treatment effect of cement augmentation of osteoporotic vertebral compression fractures (VCF) has now been questioned by two blinded randomised placebo-controlled trials. Thus many practitioners are uncertain on the recommendation for cement augmentation techniques in elderly patients with osteoporotic VCF. This systematic review analyses randomised controlled trials on vertebroplasty and kyphoplasty to provide an overview on the current evidence. From an electronic database research 8 studies could be identified meeting our inclusion criteria of osteoporotic VCF in elderly (age>60 years), treatment with vertebroplasty or kyphoplasty, controlled with placebo or standard medical therapy, quality of life, function, or pain as primary parameter, and randomisation. Only two studies were properly blinded using a sham-operation as control. The other studies were using a non-surgical treatment control group. Further possible bias may be caused by manufacturer involvement in financing of three published RCT. There is level Ib evidence that vertebroplasty is no better than placebo, which is conflicting with the available level IIb evidence that there is a positive short-term effect of cement augmentation compared to standard medical therapy with regard to QoL, function and pain. Kyphoplasty is not superior to vertebroplasty with regard to pain, but with regard to VCF reduction (evidence level IIb). Kyphoplasty is probably not cost-effective (evidence level IIb), and vertebroplasty has not more than short-term cost-effectiveness (evidence level IV). Vertebroplasty and kyphoplasty cannot be recommended as standard treatment for osteoporotic VCF. Ongoing sham-controlled trials may provide further evidence in this regard.

Effectiveness of vertebroplasty using individual patient data from two randomised placebo controlled trials: meta-analysis

OBJECTIVE

To determine whether vertebroplasty is more effective than placebo for patients with pain of recent onset (≤ 6 weeks) or severe pain (score ≥ 8 on 0-10 numerical rating scale).

DESIGN

Meta-analysis of combined individual patient level data.

SETTING

Two multicentred randomised controlled trials of vertebroplasty; one based in Australia, the other in the United States.

PARTICIPANTS

209 participants (Australian trial n = 78, US trial n = 131) with at least one radiographically confirmed vertebral compression fracture. 57 (27%) participants had pain of recent onset (vertebroplasty n = 25, placebo n = 32) and 99 (47%) had severe pain at baseline (vertebroplasty n = 50, placebo n = 49).

INTERVENTION

Percutaneous vertebroplasty versus a placebo procedure.

MAIN OUTCOME MEASURE

Scores for pain (0-10 scale) and function (modified, 23 item Roland-Morris disability questionnaire) at one month.

RESULTS

For participants with pain of recent onset, between group differences in mean change scores at one month for pain and disability were 0.1 (95% confidence interval -1.4 to 1.6) and 0.2 (-3.0 to 3.4), respectively. For participants with severe pain at baseline, between group differences for pain and disability scores at one month were 0.3 (-0.8 to 1.5) and 1.4 (-1.2 to 3.9), respectively. At one month those in the vertebroplasty group were more likely to be using opioids.

CONCLUSIONS

Individual patient data meta-analysis from two blinded trials of vertebroplasty, powered for subgroup analyses, failed to show an advantage of vertebroplasty over placebo for participants with recent onset fracture or severe pain. These results do not support the hypothesis that selected subgroups would benefit from vertebroplasty.

Randomized controlled trial of percutaneous vertebroplasty versus optimal medical management for the relief of pain and disability in acute osteoporotic vertebral compression fractures

OBJECT

Osteoporotic vertebral compression fractures (VCFs) are a major cause of increased morbidity in older patients. This randomized controlled trial compared the efficacy of percutaneous vertebroplasty (PV) versus optimal medical therapy (OMT) in controlling pain and improving the quality of life (QOL) in patients with VCFs. Efficacy was measured as the incidence of new vertebral fractures after PV, restoration of vertebral body height (VBH), and correction of deformity.

METHODS

Of 105 patients with acute osteoporotic VCFs, 82 were eligible for participation: 40 patients underwent PV and 42 received OMT. Primary outcomes were control of pain and improvement in QOL before treatment, and these were measured at 1 week and at 2, 6, 12, 24, and 36 months after the beginning of the treatment. Radiological evaluation to measure VBH and sagittal index was performed before and after treatment in both groups and after 36 months of follow-up.

RESULTS

The authors found a statistically significant improvement in pain in the PV group compared with the OMT group at 1 week (difference -3.1, 95% CI -3.72 to -2.28; p < 0.001). The QOL improved significantly in the PV group (difference -14, 95% CI -15 to -12.82; p < 0.028). One week after PV, the average VBH restoration was 8 mm and the correction of deformity was 8°. The incidence of new fractures in the OMT group (13.3%) was higher than in the PV group (2.2%; p < 0.01).

CONCLUSIONS

The PV group had statistically significant improvements in visual analog scale and QOL scores maintained over 24 months, improved VBH maintained over 36 months, and fewer adjacent-level fractures compared with the OMT group.

A clinical comparative study on low versus medium viscosity polymethylmetacrylate bone cement in percutaneous vertebroplasty: viscosity associated with cement leakage

STUDY DESIGN

Comparative, prospective follow-up study.

OBJECTIVE

Comparison of outcome between patients treated with Percutaneous VertebroPlasty (PVP) using low and medium viscosity PolyMethylMetAcrylate (PMMA) bone cement.

SUMMARY OF BACKGROUND DATA

Viscosity is the characterizing parameter of PMMA bone cement, currently the standard augmentation material in PVP, and influences interdigitation, cement distribution inside the vertebral body, injected volume and extravasation, thereby affecting the clinical outcome of PVP. Currently, low, medium, and high viscosity PMMA bone cements are used interchangeably. However, effect of viscosity on clinical outcome in patients with Osteoporotic Vertebral Compression Fractures (OVCFs) has not yet been explicit subject of investigation.

METHODS

Follow-up was conducted using a 0 to 10 Pain Intensity Numerical Rating Scale (PI-NRS) and the Short Form 36 (SF-36) Quality of Life questionnaire before PVP and at 7 days (PI-NRS only), 1, 3, and 12 months after PVP. Injected cement volume, degree of interdigitation, and cement leakage were analyzed on direct postoperative computed tomography scanning. At 6 and 52 weeks and at suspicion, patients were analyzed for new fractures.

RESULTS

A total of 30 consecutive patients received PVP using low viscosity PMMA bone cement (OsteoPal-V) for 62 OVCFs, followed by 34 patients who received PVP using medium viscosity PMMA bone cement (Disc-O-Tech) for 67 OVCFs. Results regarding PI-NRS and SF-36 were comparable between both groups. Postoperative comparison of injected cement volume, degree of interdigitation, proportion of bipedicular procedures, incidence of new vertebral fractures and complications revealed no differences between both groups. Viscosity was identified as a risk factor for the occurrence of cement leakage (yes/no, OR: 2.925, 95% confidence interval: [1.072-7.984], P = 0.036).

CONCLUSION

No major differences in clinical outcome after PVP in OVCFs using low and medium viscosity PMMA bone cement were found. Viscosity of PMMA bone cement was identified as an independent predictor of cement leakage.

Volume matters: a review of procedural details of two randomised controlled vertebroplasty trials of 2009

Two recent randomised controlled trials (RCT) published by the New England Journal of Medicine (NEJM) in 2009 comparing vertebroplasty to sham procedures have concluded that vertebroplasty is no more effective than injection of local anaesthetic at the pedicle entry point. This finding contradicts previously published clinical series on vertebroplasty which have shown clinical efficacy. The procedural details of the two RCTs are analysed specifically with regard to vertebral levels treated and injected polymethylmethacrylate (PMMA) volumes in an attempt to combine the data for assessment against the available basic science underpinning the effect of vertebral augmentation procedures. Neither investigation provides a breakdown of the vertebral levels treated in the original publication or in supplementary online material. Only one investigation provides information on fill volumes with an overall average fill volume of 2.8 ± 1.2 ml SD. The available basic science indicates a minimum fill volume of 13-16% of the vertebral body volume to be necessary for a relevant biomechanical effect on restoration of vertebral strength. The most commonly treated vertebrae of the thoracolumbar junction have an anatomical vertebral body volume of ~30 ml. An effective fill would require a minimum of ~4 ml PMMA. Anatomical volumes and required fill volumes increase towards the lower lumbar spine. According to the available basic science, only vertebrae of the upper to mid thoracic spine could reasonably have received a biomechanically effective fill with the declared average volume of 2.8 ± 1.2 ml SD. The available data of the NEJM publications strongly indicates that the treatment arm includes patients who were not treated in a reasonably effective manner. The technical information provided by the NEJM publications is insufficient to conclusively prove or disprove the clinical efficacy of vertebroplasty.

The effectiveness and safety of vertebroplasty for osteoporotic vertebral compression fractures. A double blind, prospective, randomized, controlled study

BACKGROUND

Vertebral compression fractures (VCFs) constitute a major health care problem in western countries. Several treatments modalities are available to relieve pain and allow increased activities. Percutaneous vertebroplasty (the injection of bone cement into the fractured vertebral body) is a relatively new procedure to manage patients with these fractures. The aim of this study is to evaluate the efficacy and safety of percutaneous vertebroplasty compared with standard conservative care.

METHODS/DESIGNS

In this double blind, prospective, randomized, controlled study the short- (3 months), medium- (6 months) and long-term (24 months) efficacy and safety of vertebroplasty to alleviate pain and improve function for painful osteoporotic vertebral fractures will be compared to standard conservative therapy. Conservative care will consist of 3 weeks of bed rest, wearing a rigid hyperextension corset, followed by 2-3 months in a Cheneau brace. In each of the two groups, patients will also receive treatment for osteoporosis according to their metabolic profile. Two hundred patients with painful osteoporotic vertebral compression fractures will be recruited over a 3 year period according to inclusion and exclusion criteria. We will randomly assign participants to receive either vertebroplasty or conservative care. Subjects will complete a battery of validated, standardized measures of pain, functional disability, and health related quality of life questionnaires at baseline and at post-randomization time points (1, 3, 6, 12 and 24 months). Each patient will be evaluated for pre-operative MRI, and pre- and post-operative radiographs; all scans will be evaluated independently by 2 orthopaedic surgeons. Laboratory tests to assess their metabolic bone profile will be also performed. Our primary outcome will be change from baseline to 1, 3, 6, 12 and 24 months in the VAS score between the 2 groups.

DISCUSSION

To date, vertebroplasty has been not been compared with standard conservative care for the management of patients with painful osteoporotic vertebral fractures in a randomised controlled trial. Therefore, the results of this study will allow to draw firm conclusions on this controversial topic.

Vertebroplasty and balloon kyphoplasty in osteoporosis: friends or foes?

Osteoporotic vertebral fractures are a common cause of pain and disability and increased mortality in western countries. We have analyzed three studies about Vertebroplasty and Balloon Kyphoplasty that have been recently published. We discuss potential complications, results of each technique, and whether the long-term outcome is similar in patients treated with Vertebroplasty and Balloon Kyphoplasty and non-surgical treatment, to decide the correct use of these minimally invasive techniques and for such patients.

A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures

BACKGROUND

Vertebroplasty has become a common treatment for painful osteoporotic vertebral fractures, but there is limited evidence to support its use.

METHODS

We performed a multicenter, randomized, double-blind, placebo-controlled trial in which participants with one or two painful osteoporotic vertebral fractures that were of less than 12 months' duration and unhealed, as confirmed by magnetic resonance imaging, were randomly assigned to undergo vertebroplasty or a sham procedure. Participants were stratified according to treatment center, sex, and duration of symptoms (< 6 weeks or > or = 6 weeks). Outcomes were assessed at 1 week and at 1, 3, and 6 months. The primary outcome was overall pain (on a scale of 0 to 10, with 10 being the maximum imaginable pain) at 3 months.

RESULTS

A total of 78 participants were enrolled, and 71 (35 of 38 in the vertebroplasty group and 36 of 40 in the placebo group) completed the 6-month follow-up (91%). Vertebroplasty did not result in a significant advantage in any measured outcome at any time point. There were significant reductions in overall pain in both study groups at each follow-up assessment. At 3 months, the mean (+/-SD) reductions in the score for pain in the vertebroplasty and control groups were 2.6+/-2.9 and 1.9+/-3.3, respectively (adjusted between-group difference, 0.6; 95% confidence interval, -0.7 to 1.8). Similar improvements were seen in both groups with respect to pain at night and at rest, physical functioning, quality of life, and perceived improvement. Seven incident vertebral fractures (three in the vertebroplasty group and four in the placebo group) occurred during the 6-month follow-up period.

CONCLUSIONS

We found no beneficial effect of vertebroplasty as compared with a sham procedure in patients with painful osteoporotic vertebral fractures, at 1 week or at 1, 3, or 6 months after treatment. (Australian New Zealand Clinical Trials Registry number, ACTRN012605000079640.)