Is unilateral kyphoplasty as effective and safe as bilateral kyphoplasties for osteoporotic vertebral compression fractures? A meta-analysis

BACKGROUND

An osteoporotic vertebral compression fracture is a common condition in elderly people, especially women. The percutaneous kyphoplasty is an effective treatment for osteoporotic vertebral compression fractures. Controversy remains regarding whether a unilateral or a bilateral approach is superior, and to our knowledge, there have been no large studies comparing these two approaches, therefore a meta-analysis synthesizing the data on this question is warranted.

QUESTIONS/PURPOSES

We asked the following questions: (1) Is there evidence to suggest a benefit in clinical outcome as assessed by the VAS and Oswestry Disability Index of a unilateral kyphoplasty or bilateral kyphoplasties? (2) Are the complications associated with the two approaches different? (3) Do the procedures result in different kyphosis angle reduction or anterior vertebral height restoration? (4) Is the surgical time for the procedures different?

METHODS

We searched the Cochrane Library, PubMed MEDLINE, EMBASE, Web of Knowledge MEDLINE (January 1980 to June 2013), and reference lists of eligible prospective studies. The levels of the evidence and recommendations were assessed using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) system. Five studies encompassing 253 patients met the inclusion criteria.

RESULTS

The short- and long-term clinical outcomes as assessed by the VAS and Oswestry Disability Index showed no differences between unilateral and bilateral kyphoplasties (p = 0.41, p = 0.60 for VAS; p = 0.10, p = 0.36 for Oswestry Disability Index). There were no differences in complications such as cement leakage and adjacent vertebral fractures associated with the two approaches (p = 0.43 and p = 0.95). The kyphosis angle reduction and anterior vertebral height restoration showed no difference between the two approaches (p = 0.34 and p = 0.46). The unilateral approach was shorter in terms of surgical time (mean difference, -24.98; p < 0.0001). The overall GRADE system evidence quality was very low, with only high evidence for operation time, which lessens our confidence in recommendations.

CONCLUSIONS

Unilateral and bilateral percutaneous kyphoplasties appear to be safe and effective for treating osteoporotic vertebral compression fractures. No clinically important differences were found between them. Considering less operation time and less cost, we suggest that a unilateral percutaneous kyphoplasty is advantageous, but because of the poor quality of the evidence, high-quality randomized controlled trials are required to resolve this issue.

Natural history and risk factors for adjacent vertebral fractures in the fracture intervention trial

STUDY DESIGN

Retrospective analysis of prospectively collected follow-up data for 2.9 years.

OBJECTIVE

To determine the natural history of subsequent morphometric fracture rates at adjacent levels (one level above or below a previous known baseline fracture) in a large patient database.

SUMMARY OF BACKGROUND DATA

The long-term risk and risk factors for adjacent-level vertebral fractures in patients with osteoporosis are unknown.

METHODS

The fracture intervention trial is a large randomized, placebo-controlled trial of alendronate treatment for osteoporosis. Data from both bisphosphonate-treated and bisphosphonate-naive patients (N = 1950, vertebral fracture arm) was analyzed to detect incident morphometric fracture rates.

RESULTS

During a mean follow-up of 2.9 years, 3.4% of patients in the alendronate group and 7.4% in the placebo group experienced adjacent-level vertebral fractures. The annual rate of adjacent-level vertebral fractures was 1.2% in the alendronate group, and 2.5% in the placebo group (overall, 1.8% per year in both groups combined). As expected, the thoracolumbar region (defined as T11, T12, and L1) seemed to be the most prone to new adjacent-level fractures. Among females with baseline prevalent fractures at the thoracolumbar junction, who subsequently experienced at least one new fracture anywhere along the spine (N = 124), 40.3% had a new adjacent-level fracture in this region. Older age at randomization, lower bone mineral density, inactivity, and placebo therapy were significantly associated with the development of adjacent-level fractures in univariate analysis (P ≤ 0.05). Multivariate analysis indicated decreased odds of adjacent-level fractures with bisphosphonate therapy and higher bone mineral density, and increased odds with older age at randomization (P ≤ 0.05).

CONCLUSION

New vertebral fractures adjacent to prevalent fractures occurred relatively infrequently in this treatment trial of alendronate in females with osteoporosis, and were more common with older age at randomization, lower bone mineral density and placebo treatment.

Spine surgery research: on and beyond current strategies

BACKGROUND CONTEXT

Systematic reviews of the literature are powerful tools in evidence-based medicine. However, the design and report of systematic reviews in spinal surgery contain many aspects amenable to improvement.

PURPOSE

To discuss the issues especially relevant for systematic reviews in spinal surgery.

METHODS

From our experience of systematic reviews and meta-analyses of clinical trials in spinal surgery, we infer guidance for the design and execution of systematic literature reviews.

RESULTS

There are many difficulties associated with the design as well as conduct of clinical trials and consequently appraising evidence in spinal surgery. New treatments should be compared with the gold standard before other comparisons are investigated. Studies should present data as thoroughly as possible regarding all subgroups and follow-up moments, possibly in supplementary material. To provide the highest level of evidence, systematic reviews should be as rigorously designed as possible.

CONCLUSIONS

Gathering information on clinical effectiveness in spinal surgery can be improved both at the clinical study level and at the systematic review level. Alternatives to randomized controlled trials such as comparative studies can be valuable tools on the clinical effectiveness of treatments in spinal surgery. The experience reflected in this article can support the scientific efforts in this field.

Conservative management of patients with an osteoporotic vertebral fracture

Osteoporotic vertebral compression fractures (VCFs) are an increasing public health problem. Recently, randomised controlled trials on the use of kyphoplasty and vertebroplasty in the treatment of these fractures have been published, but no definitive conclusions have been reached on the role of these interventions. The major problem encountered when trying to perform a meta-analysis of the available studies for the use of cementoplasty in patients with a VCF is that conservative management has not been standardised. Forms of conservative treatment commonly used in these patients include bed rest, analgesic medication, physiotherapy and bracing.

In this review, we report the best evidence available on the conservative care of patients with osteoporotic VCFs and associated back pain, focusing on the role of the most commonly used spinal orthoses. Although orthoses are used for the management of these patients, to date, there has been only one randomised controlled trial published evaluating their value. Until the best conservative management for patients with VCFs is defined and standardised, no conclusions can be drawn on the superiority or otherwise of cementoplasty techniques over conservative management.

A randomised sham controlled trial of vertebroplasty for painful acute osteoporotic vertebral fractures (VERTOS IV)

Background

The standard care in patients with a painful osteoporotic vertebral compression fracture (VCF) is conservative therapy. Percutaneous vertebroplasty (PV), a minimally invasive technique, is a new treatment option. Recent randomized controlled trials (RCT) provide conflicting results: two sham-controlled studies showed no benefit of PV while an unmasked but controlled RCT (VERTOS II) found effective pain relief at acceptable costs. The objective of this study is to compare pain relief after PV with a sham intervention in selected patients with an acute osteoporotic VCF using the same strict inclusion criteria as in VERTOS II. Secondary outcome measures are back pain related disability and quality of life.

Methods

The VERTOS IV study is a prospective, multicenter RCT with pain relief as primary endpoint. Patients with a painful osteoporotic VCF with bone edema on MR imaging, local back pain for 6 weeks or less, osteopenia and aged 50 years or older, after obtaining informed consent, are included and randomized for PV or a sham intervention. In total 180 patients will be enrolled. Follow-up is at regular intervals during a 1-year period with a standard Visual Analogue Scale (VAS) score for pain and pain medication. Necessary additional therapies and complications are recorded.

Discussion

The VERTOS IV study is a methodologically sound RCT designed to assess pain relief after PV compared to a sham intervention in patients with an acute osteoporotic VCF selected on strict inclusion criteria.

Trial registration

This study is registered at ClinicalTrials.gov., NCT01200277.