Evidence on the effectiveness and cost-effectiveness of vertebroplasty: A review of policy makers' responses

Evaluation of surgical outcome of Jack vertebral dilator kyphoplasty for osteoporotic vertebral compression fracture-clinical experience of 218 cases

Background

Osteoporotic vertebral compression fracture is a serious complication of osteoporosis. Various vertebral kyphoplasty surgeries, which have their own unique features, are commonly used for osteoporotic vertebral compression fracture. Based on the anatomic property of the thoracolumbar vertebral pedicle that its horizontal diameter is twice that of the vertical diameter, we designed Jack vertebral dilator for better restoration of the vertebral height by manipulating the mechanical force.

Methods

A total of 218 patients (236 vertebrae) with osteoporotic vertebral compression fracture were treated with Jack vertebral dilator. Surgery was successfully completed in all cases, and all the 218 patients were followed up for an average of 14.2 months (range 3 to 30 months).

Results

Bone cement leakage occurred in 12 cases, but no symptoms were reported. No other complications were noticed. The VAS scores were 8.2 ± 1.3, 1.7 ± 0.9, and 1.8 ± 0.8 and the ODI was 78.2 ± 13.3 %, 18.5 ± 7.3 %, and 20.9 ± 6.8 % before surgery and 1 week after surgery and at the final follow-up, respectively. The anterior vertebral body height was 19.3 ± 3.2, 25.1 ± 2.6, and 24.9 ± 2.6 mm and the central vertebral body height was 18.7 ± 3.0, 24.8 ± 3.0, and 24.5 ± 2.9 mm before surgery and 1 week after surgery and at the final follow-up, respectively. Cobb angle was 16.2° ± 6.6°, 8.1° ± 5.6°, and 8.5° ± 5.6° before surgery and 1 week after surgery and at the final follow-up, respectively.

Conclusions

Jack vertebral dilator kyphoplasty for osteoporotic vertebral compression fracture is safe, feasible, and effective and has the prospect of further broad application in the future.

Electronic supplementary material

The online version of this article (doi:10.1186/s13018-016-0371-4) contains supplementary material, which is available to authorized users.

Surgical procedure and initial radiographic results of a new augmentation technique for vertebral compression fractures

PURPOSE

Recently, a new minimally invasive technique called 'vertebral body stenting' (VBS) was introduced for the treatment of osteoporotic vertebral fractures. The technique was developed to prevent the loss of reduction after deflation of the balloon and to reduce the complication rate associated with cement leakage.

METHODS

The amount of kyphosis correction, improvement of vertebral body height and quantitative cement leakage rate by applying CT-based quantitative volumetry after VBS were measured in 27 patients (55 vertebra) and compared with a control group (29 patients, 61 vertebrae), which was treated with conventional vertebroplasty.

RESULTS

After VBS, a significant improvement was seen in vertebral height, compared to conventional vertebroplasty. The mean improvement in segmental kyphosis and vertebral kyphosis were 5.8° (p < 0.05) and 3.5° (p < 0.05), respectively. In the VBS group, the mean injected volume of cement per vertebral body was 7.33 cm(3) (3.34-10.19 cm(3)). The average amount of cement outside the vertebrae was 0.28 cm(3) (0.01-1.64 cm(3)), which was 1.36% of the applied total cement volume. In the vertebroplasty group, the applied mean volume of the cement per level was 2.7 cm(3) (1-5.8 cm(3)) and the average amount of cement outside the vertebrae was 0.15 cm(3) (0.01-1.8 cm(3)), which was 11.5% (0.2-60%) of the applied total volume of cement.

CONCLUSION

The frequency of cement leakage after VBS was 25.5% compared to 42.1% in the vertebroplasty group. VBS led to a significant decrease in the leakage rate compared with conventional vertebroplasty.

A prospective comparative study of kyphoplasty using the Jack vertebral dilator and balloon kyphoplasty for the treatment of osteoporotic vertebral compression fractures

This study prospectively compared the efficacy of kyphoplasty using a Jack vertebral dilator and balloon kyphoplasty to treat osteoporotic compression fractures between T10 and L5. Between 2004 and 2009, two groups of 55 patients each underwent vertebral dilator kyphoplasty and balloon kyphoplasty, respectively. Pain, function, the Cobb angle, and the anterior and middle height of the vertebral body were assessed before and after operation. Leakage of bone cement was recorded. The post-operative change in the Cobb angle was significantly greater in the dilator kyphoplasty group than in the balloon kyphoplasty group (-9.51 degrees (sd 2.56) vs -7.78 degrees (sd 1.19), p < 0.001)). Leakage of cement was less in the dilator kyphoplasty group. No other significant differences were found in the two groups after operation, and both procedures gave equally satisfactory results in terms of all other variables assessed. No serious complications occurred in either group. These findings suggest that vertebral dilator kyphoplasty can facilitate better correction of kyphotic deformity and may ultimately be a safer procedure in reducing leakage of bone cement.

Percutaneous vertebral compression fracture management with polyethylene mesh-contained morcelized allograft bone

STUDY DESIGN

A comprehensive systematic review of the literature.

OBJECTIVES

To assess the modern literature on the use of polyethylene mesh-contained morcelized allograft (PMCMA) bone for spinal fusion and vertebral compression fracture management.

SUMMARY OF BACKGROUND DATA

There are presently no systematic reviews of PMCMA.

METHODS

A systematic literature review was performed within three databases (OVID, PubMed, and Google Scholar) using the following keyword search terms: vertebroplasty, kyphoplasty, vertebral compression fracture, percutaneous, polyethylene mesh, and osteoporosis.

RESULTS

The initial search identified 764 items, from which two pertinent technique-based articles were identified. There were no published scientific peer-reviewed or case series reporting the clinical results of this technique. The use of PMCMA in the management of vertebral compression fractures (VCFs) is similar to vertebroplasty and kyphoplasty. This novel, percutaneous system uses the properties of granular mechanics to establish a conforming, semirigid graft that is purportedly capable of withstanding physiologic loads.

DISCUSSION

PMCMA is a novel percutaneous technology for the management of VCF and possibly for use as a conforming interbody graft. The available published literature lacks outcome data of the use of PMCMA. Careful, independent research is needed to assess the viability of this technology and its long-term results.

Acute vertebral fracture

Vertebral fractures resulting from osteoporosis are a significant cause of morbidity and mortality in the aging population and are commonly seen in the hospital setting. Appropriately assessing and treating these conditions continues to be a challenge. This article is an evidence-based clinical update on the evaluation and management options of acute vertebral fractures, ranging from conservative treatment to surgical intervention. Hospitalists can play an influential role in the management of osteoporosis.

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.)

Vertebroplasty and kyphoplasty for the treatment of vertebral compression fractures: an evidenced-based review of the literature

BACKGROUND

Vertebroplasty (VP) and kyphoplasty (KP) are routinely used to treat vertebral body compression fractures (VCFs) resulting from osteoporosis or vertebral body tumors in order to provide rapid pain relief. However, it remains debated whether VP or KP results in superior outcomes versus medical management alone in patients experiencing VCFs.

PURPOSE

To determine the level of evidence supporting VP or KP for the treatment of VCFs.

STUDY DESIGN

Systematic review of the literature.

PATIENT SAMPLE

Patients with osteoporotic or tumor-associated VCFs.

OUTCOME MEASURES

Self-reported and functional measures.

METHODS

We reviewed all articles published between 1980 and 2008 reporting outcomes after VP or KP for osteoporotic or tumor-associated VCFs and rated the level of evidence and grades of recommendation (per North American Spine Society [NASS] guidelines) supporting the use of VP or KP for the treatment of VCFs.

RESULTS

Seventy-four VP studies for osteoporotic VCF (1 level I, 3 level II, 70 level IV), 35 KP studies for osteoporotic VCF (2 level II, 33 level IV), and 18 VP/KP for tumor VCFs (all level IV) were reviewed. There is good evidence (level I) that VP results in superior pain control within the first 2 weeks of intervention compared with optimal medical management for osteoporotic VCFs. There is fair evidence (level II-III) that VP results in less analgesia use, less disability, and greater improvement in general health when compared with optimal medical management within the first 3 months after intervention. There is fair evidence (level II-III) that by 2 years after intervention, VP provides a similar degree of pain control and physical function as optimal medical management. There is fair evidence (level II-III) that KP results in greater improvement in daily activity, physical function, and pain relief when compared with optimal medical management for osteoporotic VCFs by 6 months after intervention. There is poor-quality evidence that VP or KP results in greater pain relief for tumor-associated VCFs.

CONCLUSIONS

Although evidence suggests that physical disability, general health, and pain relief are better with VP and KP than those with medical management within the first 3 months after intervention, high-quality randomized trials with 2-year follow-up are needed to confirm this. Furthermore, the reported incidence of symptomatic procedure-related morbidity for both VP and KP is very low.

Costs and state-specific rates of thoracic and lumbar vertebroplasty, 2001-2005

STUDY DESIGN

Sequential cross-sectional analysis.

OBJECTIVE

To document vertebroplasty rates and costs.

SUMMARY OF BACKGROUND DATA

Little is known about interstate variation in rates or about nation-wide costs associated with the growing use of percutaneous vertebroplasty.

METHODS

Using specific CPT-4 billing codes, we reviewed aggregate Medicare Part B fee-for-service claims data (cross-stratified by physician specialty and treatment setting) on thoracolumbar vertebroplasties performed from 2001-2005. Vertebroplasty rates for individual states were expressed per 100,000 Part B fee-for-service enrollees. Nation-wide facility and physician charges (combining expected contributions from all sources) allowed by Medicare for vertebroplasties and associated imaging guidance procedures were applied to observed vertebroplasty volumes. These charges (reflecting direct medical costs from an all-payer perspective) were expressed in 2005 dollars using the Producer Price Index.

RESULTS

Vertebroplasty rates for individual states rose but varied considerably, ranging from 0.0 to 515.6/100,000 Medicare Part B fee-for-service enrollees in 2001 (median state rate = 35.4), and from 9.8 to 849.5 in 2005 (median state rate = 75.0). On average, 1.3 vertebral levels were treated per procedure, varying by treatment site and physician specialty. Fluoroscopic rather than computed tomography guidance was used in 98.7% of cases. Total nation-wide inflation-adjusted charges rose from $76.0 million for 14,142 cases performed in 2001 to $152.3 million for 29,090 cases in 2005. While vertebroplasty was predominantly an outpatient procedure, inpatient cases generated most of the charges. Increasing volumes and costs were associated with cases performed in ambulatory surgery centers and physicians' offices.

CONCLUSION

Nation-wide vertebroplasty volumes and inflation-adjusted charges doubled from 2001 to 2005 in this Medicare population. Procedure rates varied considerablyby state. Almost all cases involved fluoroscopic guidance; procedures treating multiple vertebral levels were not uncommon. Procedures performed in free-standing facilities are of growing importance. Given the issues surrounding appropriate vertebroplasty use, future practice patterns and outcomes should be closely tracked.

Technology assessment: approach and reimbursement

STUDY DESIGN

Review of technology assessment process for novel spine patient care.

OBJECTIVE

To discuss the issues surrounding the introduction of novel technologies for spine patient care.

SUMMARY OF BACKGROUND DATA

The parties involved in the technology development and assessment process include clinicians, researchers, academic institutions, governmental organizations, and private health care payors.

METHODS

Description of the responsibilities and processes of various parties involved in technology assessment.

RESULTS

The process for introduction of novel spine technologies is complex and will become more efficient as each party involved increases its understanding of the roles played by all the others.

CONCLUSIONS

The technology assessment process involves clinicians, researchers, governmental agencies, and private payors. All must work in concert for the efficient introduction of safe, efficacious, reasonable, and cost-effective novel treatments for spine patients.

Computerized detection of vertebral compression fractures on lateral chest radiographs: preliminary results with a tool for early detection of osteoporosis

Vertebral fracture (or vertebral deformity) is a very common outcome of osteoporosis, which is one of the major public health concerns in the world. Early detection of vertebral fractures is important because timely pharmacologic intervention can reduce the risk of subsequent additional fractures. Chest radiographs are used routinely for detection of lung and heart diseases, and vertebral fractures can be visible on lateral chest radiographs. However, investigators noted that about 50% of vertebral fractures visible on lateral chest radiographs were underdiagnosed or under-reported, even when the fractures were severe. Therefore, our goal was to develop a computerized method for detection of vertebral fractures on lateral chest radiographs in order to assist radiologists' image interpretation and thus allow the early diagnosis of osteoporosis. The cases used in this study were 20 patients with severe vertebral fractures and 118 patients without fractures, as confirmed by the consensus of two radiologists. Radiologists identified the locations of fractured vertebrae, and they provided morphometric data on the vertebral shape for evaluation of the accuracy of detecting vertebral end plates by computer. In our computerized method, a curved search area, which included a number of vertebral end plates, was first extracted automatically, and was straightened so that vertebral end plates became oriented horizontally. Edge candidates were enhanced by use of a horizontal line-enhancement filter in the straightened image, and a multiple thresholding technique, followed by feature analysis, was used for identification of the vertebral end plates. The height of each vertebra was determined from locations of identified vertebral end plates, and fractured vertebrae were detected by comparison of the measured vertebral height with the expected height. The sensitivity of our computerized method for detection of fracture cases was 95% (19/20), with 1.03 (139/135) false-positive fractures per image. The accuracy of identifying vertebral end plates, marked by radiologists in a morphometric study, was 76.6% (400/522) and 70.9% (420/592) for cases used for training and those for testing, respectively. We prepared 32 additional fracture cases for a validation test, and we examined the detection accuracy of our computerized method. The sensitivity for these cases was 75% (24/32) at 1.03 (33/32) false-positive fractures per image. Our preliminary results show that the automated computerized scheme for detecting vertebral fractures on lateral chest radiographs has the potential to assist radiologists in detecting vertebral fractures.