Review of Vertebral Augmentation: An Updated Meta-analysis of the Effectiveness

Retrospective Analysis of Cement Extravasation Rates in Vertebroplasty, Kyphoplasty, and Bone Tumor Radiofrequency Ablation

Background: Percutaneous vertebral augmentation techniques, including vertebroplasty, kyphoplasty, and bone tumor radiofrequency ablation (BT-RFA), are commonly used to treat painful vertebral compression fractures (VCFs). While generally safe and effective, they carry risks, including cement extravasation, which can lead to pulmonary embolism or spinal cord compression. This study aims to compare the rate of cement extravasation across different vertebral augmentation techniques and identify potential risk factors. Methods: A retrospective cohort study was conducted at a comprehensive cancer center on 1002 procedure encounters in 888 patients who underwent vertebral augmentation for painful VCFs. Data were collected on patient demographics, fracture pathology, procedure type, imaging guidance, and pain scores. Intraoperative and postoperative imaging were manually reviewed to assess cement extravasation. Statistical analyses were performed using pairwise comparisons with Tukey's Honest Significant Difference adjustment to compare cement extravasation rates across the procedure groups and generalized linear mixed models to assess the association between the cement extravasation with other variables. Results: Cement extravasation occurred in 573 (57.2%) encounters. Kyphoplasty had the lowest rate of cement extravasation (46.2%) with significantly lower odds compared to vertebroplasty (OR: 0.42, 95% CI: 0.30-0.58; p < 0.0001) and BT-RFA (OR: 0.57, 95% CI: 0.42-0.77; p = 0.0009). Pathologic fractures and multilevel augmentations were linked to a 64% (p = 0.001) and 63% (p = 0.0003) increased odds of cement extravasation, respectively. Male sex and older age were protective factors. Conclusions: Cement extravasation is a common but largely asymptomatic complication of percutaneous vertebral augmentation. It is crucial to consider patient-specific risk factors when selecting an augmentation technique to optimize outcomes. Kyphoplasty may be the optimal choice for patients at increased risk of cement extravasation.

Osteoporotic vertebral fractures and subsequent fractures: risk factors from a retrospective observational study of patients with osteoporosis

Purpose

Osteoporosis is a progressive, systemic, skeletal disorder characterized by increased bone fragility and susceptibility to fracture. Prior fractures are a strong predictor of subsequent fractures, but it is essential to identify further clinical and demographic characteristics of patients with osteoporosis that are associated with subsequent fracture risk.

Methods

In this retrospective observational cohort study, male and female patients over the age of 55 years with osteoporosis who experienced vertebral fractures between 2019 and 2021 were included. All patients' basic clinical data, serum biochemical and bone turnover markers, bone mineral density, and other indicators were recorded uniformly. The incidence of subsequent fractures during the two-year follow-up period was analyzed. Independent risk factors for subsequent fractures were identified by binary logistic regression analysis.

Results

A total of 1,096 patients were included. Of these, 311 (28.4%) patients suffered a subsequent fracture during the two-year follow-up period. The incidences of subsequent fracture sites were 18.4% vertebral, 14.2% forearm/wrist/hand, and 9.9% hip/femur. Compared with the non-subsequent fracture group (non-SFG), binary logistic regression analysis showed that body mass index (BMI) (OR [95% CI] 0.825 [0.720-0.945]; P = 0.006), femoral neck bone mineral density (BMD) T-score (OR [95% CI] 0.067 [0.012-0.385]; P = 0.002), and C-terminal telopeptide of type 1 collagen (CTX) levels (OR [95% CI] 6.089 [1.735-21.375]; P = 0.005) were independent risk factors associated with subsequent fractures.

Conclusion

Patients with osteoporosis and previous vertebral fractures are at a higher risk of further fractures at a two-year follow-up period. BMI, femoral neck BMD T-score, and CTX levels were independent risk factors for refracture. Integrating BMI, femoral neck BMD, and CTX levels into an individualized care plan for patients with osteoporotic vertebral fractures may help prevent subsequent fractures in high-risk populations.

Real-world rates and risk factors for subsequent treatment with vertebroplasty or balloon kyphoplasty after initial vertebral augmentation: a retrospective cohort study

The purpose of this study was to determine the real-world incidence and predictors of additional vertebroplasty or balloon kyphoplasty after initial vertebral augmentation, as a proxy for subsequent symptomatic vertebral fracture. Of patients, 15.5% underwent subsequent vertebral augmentation. The patient's comorbidities are strongly associated with risk of subsequent treatment.

PURPOSE

To determine the real-world incidence and predictors of additional vertebroplasty or balloon kyphoplasty after initial vertebral augmentation, as a proxy for subsequent symptomatic and disabling vertebral fracture.

METHODS

We conducted a retrospective cohort study using commercial insurance claims data (Optum's de-identified Clinformatics® Data Mart Database). Adult patients who underwent subsequent treatment for vertebral fracture within 24 months of initial balloon kyphoplasty (BKP) or vertebroplasty (VP) were classified into "subsequent treatment" or "no subsequent treatment" cohorts. Survival analysis was applied to investigate the effect of risk factors on subsequent treatment.

RESULTS

Between 1 January 2008 and 30 June 2020, a total of 32,513 adult patients underwent a BKP/VP procedure following a diagnosis of vertebral compression fracture in the preceding 12 months. Five thousand thirty-five patients (15.5%) underwent a subsequent BKP/VP treatment within 2 years; 90% had a single fracture level treated. An increased hazard of subsequent treatment was associated with a number of fractures treated at initial BKP/VP (≥ 4 levels, adjusted hazard ratio (AHR) 1.68 (95% CI 1.24-2.26); steroid use, AHR 1.9 (95% CI 1.31-1.48); Elixhauser Comorbidity Index ≥ 4, AHR 1.44 (95% CI 1.17-1.77); and multiple myeloma, AHR 1.31 (95% CI 1.13-1.53)). Age < 70 years was associated with reduced hazard of subsequent treatment (AHR 0.81, 95% CI 0.74-0.89).

CONCLUSIONS

One in seven patients underwent subsequent treatment for vertebral fracture after initial vertebral augmentation. Baseline patient characteristics were associated with increased risk of subsequent fracture within 2 years, suggesting that a patient's natural history is strongly associated with risk of subsequent treatment rather than the initial surgical procedure itself.

Early-Onset Adjacent Vertebral Fractures after Balloon Kyphoplasty and SpineJack Kyphoplasty for the Management of Single-Level Thoracolumbar Vertebral Compression Fractures

BACKGROUND

 The aim of this study was to evaluate the risk factors contributing to early-onset adjacent level fractures (ALFs) occurring within 1 month following either balloon kyphoplasty (BKP) or SpineJack kyphoplasty (SJ) for the treatment of thoracolumbar vertebral compression fractures (TLVCFs).

METHODS

 This retrospective analysis enrolled patients with single-level TLVCFs (T11-L2) who underwent either BKP or SJ between July 2013 and June 2019. We recorded the ALF occurrences within 1 month. Age, osteoporosis, severity and shape of TLVCFs, and surgical type were compared between patients with and without early-onset ALFs.

RESULTS

 Altogether, 106 TLVCF patients were enrolled, comprising 64 BKP and 42 SJ cases. We observed 19 early-onset ALFs, with 9 and 10 cases in the BKP and SJ, respectively. Patients with early-onset ALFs have significantly more severe TLCVFs (severe vs. mild, 25 vs. 0%, p = 0.055), and wedge-shaped TLVCFs (26.47 vs. 2.63%, p = 0.002), older age (81.05 vs. 73.34 years, p < 0.001), and kyphoplasty performed within 1 month are risk factors for early-onset ALFs (26.92 vs. 9.26%, p = 0.018). Univariable analysis showed that kyphoplasty timing within 1 month (odds ratio [OR]: 0.193; p = 0.008), wedge-shaped TLVCFs (OR: 5.358; p = 0.036), and advanced age (OR: 1.119; p = 0.001) are significant risk factors for early-onset ALFs.

CONCLUSIONS

 The occurrence rate of early-onset ALFs between BKP or SJ techniques in treating TLVCFs does not differ. Preoperative wedge-shaped TLVCFs, advanced age, and early treatment within 1 month are the risk factors for early-onset ALFs following kyphoplasty for TLVCFs.

Vertebral Augmentation for Osteoporotic Vertebral Compression Fractures: What is the Current Evidence Pro and Con?

Osteoporotic vertebral compression fractures can be quite challenging to treat, especially since they often occur in older adults and can be associated with significant morbidity and mortality. The standard treatment for these fractures has been medical management, as many of these patients are not candidates for open surgery. Vertebral augmentation procedures have emerged as another treatment option. Though initially accepted by clinicians, the benefit of these procedures has been questioned by several clinical trials. Safety concerns related to adjacent level fractures and cement extravasation have also been raised. We review these controversies in the context of the current literature.

Treatment Strategies in the Osteoporotic Spine

This article reviews the appropriate assessment and management of osteoporotic compression fractures and discusses the implications of osteoporosis on initial patient evaluation, medical optimization for surgery, selection of instrumentation, and surgical technique. Adverse outcomes associated with osteoporosis are discussed. Failure to appropriately evaluate, optimize, and treat spine patients with osteoporotic bone can lead to disastrous complications. Weakened bone can lead to implant failure through cage subsidence and screw pullout, as well as, peri-implant fractures, failure of deformity correction, and proximal kyphosis. These risks must be taken into account when considering operative interventions in these patients.

Thoracic Pyogenic Spondylitis Misdiagnosed As Osteoporotic Compression Fracture Status Post Vertebral Augmentation With Resultant Paraplegia: A Case Report

This paper describes a case of serious complications following vertebral augmentation resulting from a misdiagnosis of pyogenic spondylitis as osteoporotic compression fracture (OCF). A 56-year-old female with systemic lupus erythematosus underwent vertebral augmentation following a diagnosis of T10 OCF based on plain film analysis. Note that preoperative computed tomography (CT) and magnetic resonance imaging (MRI) were not performed. One day after vertebral augmentation, the patient experienced a recurrence of low back pain with fever and paraplegia. MRI findings revealed paravertebral and epidural soft tissue over T9 and T10 with cord compression. Subsequent laminectomy of T9 and T10 revealed devitalized lamina, epidural abscess, and granulation tissue. Pathological analysis indicated a combination of acute and chronic inflammation. A pus culture identified Staphylococcus aureus, indicative of pre-existing pyogenic spondylitis. Further revision surgery was performed at another hospital. The patient remained in a paraplegic state one year after surgery. Infectious spondylitis often manifests with nonspecific symptoms similar to those of compression fracture, and plain radiographs are insufficient to differentiate between the two, often leading to misdiagnosis and mistreatment. Nonetheless, many practitioners base preoperative planning solely on plain film imaging. We advocate the routine usage of CT and/or MRI for patients diagnosed with compression fractures, particularly for immunocompromised individuals.

Three cases of kyphoplasty performed in the lateral position due to significant comorbidities

Background

More than 700,000 people suffer from vertebral compression fractures attributed to osteoporosis, metastatic disease, or trauma each year in the United States, and undergo kyphoplasty. They are typical. These often undergo kyphoplasty to treat resultant pain or new neurological deficits. Here, we present three patients who, due to significant comorbidities, underwent kyphoplasty performed in the lateral decubitus rather than the prone position.

Case Description

Three females, two with metastatic cancer and one with osteoporosis, presented with lumbar compression fractures and new accompanying pain and/or neurological deficits. Due to significant accompanying comorbidities, kyphoplasty was safely and effectively performed in all three patients utilizing the lateral decubitus rather than the prone position.

Conclusion

Although vertebral kyphoplasties are typically performed in the prone position, here, we present three patients who, due to significant comorbidities, safely and effectively underwent kyphoplasties performed in the lateral decubitus position.

Multidisciplinary and Coordinated Management of Osteoporotic Vertebral Compression Fractures: Current State of the Art

Osteoporotic vertebral compression fractures (OVCFs) present a significant health concern, affecting a substantial portion of the older adult population worldwide. This narrative review explores the prevalence, diagnostic challenges and management strategies for OVCFs. Despite the increasing incidence and impact on morbidity and mortality, existing clinical guidelines lack consistency and clear diagnostic and therapeutic recommendations. The review addresses key questions faced by physicians dealing with older adult patients experiencing acute back pain, offering insights into triage, radiological assessments and classification systems. We propose a comprehensive algorithm for clearing OVCF, considering clinical presentation, radiological findings and morphological aspects. Emphasis is placed on the importance of medically treating osteoporosis alongside OVCF management. The review encompasses relevant literature from 1993 to 2023, provides a detailed discussion on triage issues and incorporates a clinically oriented classification system developed by the German Society for Orthopaedics and Trauma. The Material and Methods section outlines the extensive literature search carried out in PUBMED, encompassing clinical and experimental studies, systematic reviews and meta-analyses. The articles retained focused mainly on answering critical questions regarding radiological assessments, imaging modalities and the presence of a specific classification system for OVCFs. The review emphasises that the evaluation and management of OVCFs necessitates a multidisciplinary approach involving spine specialists and bone disease experts. It also addresses the role of conservative versus surgical treatments, with a focus on percutaneous vertebral augmentation. The conclusion summarises the algorithm derived for use in emergency departments and general practice, aiming to streamline OVCF management, reduce unnecessary examinations and ensure optimal patient care. The algorithm recommends primary diagnosis using computed tomography, with magnetic resonance imaging reserved for specific cases. The review advocates a holistic approach, integrating medical and surgical interventions to address the complex challenges posed by OVCFs in ageing populations.

EFFECTIVENESS AND SAFETY OF SPINEJACK SYSTEM IN THE MANAGEMENT OF VERTEBRAL FRAGILITY FRACTURES: A SYSTEMATIC REVIEW

Introduction: The SpineJackⓇ (SJ) system received FDA clearance in 2018, therefore this device is currently available to perform kyphoplasty in osteoporotic vertebral fractures. This study aims to assess the outcome of the SJ system in the management of vertebral fragility fractures (VFFs).

Evidence Acquisition and Synthesis: OVID-MEDLINEⓇ, EMBASE, Cochrane Library, SCOPUS, Springer Link, Web of Science, Google Scholar and PubMed were searched from January 2015 to November 2021 to identify relevant studies. The methodological qualities of the studies were evaluated, and relevant data were extracted.

Seven clinical trials, recruiting 644 patients with 690 VFFs were included. Although PVP, balloon kyphoplast (BKP) and SJ showed comparable effectiveness in back pain relief in patients with VFFs, SJ showed a faster and higher pain relief and a better quality of life, compared with the other two augmentation techniques. Moreover, patients treated with SJ, compared with PVP and BKP, showed a better vertebral body height (VBH) restoration and kyphotic correction; these findings were confirmed also at long-term follow-up. Asymptomatic cement leakage and adjacent level fractures (ALFs) were observed in patients treated with SJ, but with a lower incidence compared with PVP and BKP.

Conclusions: This systematic review shows that SJ has an excellent risk/benefit profile and is more effective than the other augmentation techniques in VBH restoration and kyphotic correction. These findings correlate with a better postoperative quality of life.

A Toolbox of Bone Consolidation for the Interventional Radiologist

Bone consolidation is increasingly used in the treatment of both benign and malignant bone conditions. Percutaneous vertebroplasty, for example, has been shown to be useful in vertebral compression fractures in the VAPOUR trial which showed its superiority to placebo for pain reduction in the treatment of acute vertebral compressive fractures. Further tools have since been developed, such as kyphoplasty, spinal implants, and even developments in bone cements itself in attempt to improve outcome, such as chemotherapy-loaded cement or cement replacements such as radio-opaque silicon polymer. More importantly, bone fixation and its combination with cement have been increasingly performed to improve outcome. Interventional radiologists must first know the tools available, before they can best plan for their patients. This review article will focus on the tool box available for the modern interventional radiologist.

Clinical Outcomes and Safety Comparison of Vertebroplasty, Balloon Kyphoplasty, and Vertebral Implant for Treatment of Vertebral Compression Fractures

BACKGROUND AND PURPOSE

Vertebral compression fracture represents a major health burden for the aging populations globally. However, limited studies exist on the relative efficacy and safety of surgical interventions for vertebral compression fracture. Here, we aim to compare clinical and patient-reported outcomes following vertebral augmentation using balloon kyphoplasty, vertebroplasty, and SpineJack vertebral implant.

MATERIALS AND METHODS

An institutional review board-approved, retrospective, multi-institutional review of patients undergoing vertebral augmentation with kyphoplasty, vertebroplasty, and/or a SpineJack vertebral implant was performed between 2018 and 2021. Primary outcomes included pre- and postprocedural pain ratings and vertebral body height restoration. The secondary outcome was a change in the local kyphotic angle. The Kruskal-Wallis test was used to compare outcomes across 3 treatment options. Complications were reviewed during and 30-90 days after the procedure.

RESULTS

Vertebral augmentation of 344 vertebral compression fracture levels was performed during the study period. Sixty-seven patients had 79 kyphoplasty procedures (55% women; mean age, 64.2 [SD, 12.3] years). Seventy-four patients underwent a mean of 84 vertebroplasty procedures (51% women; mean age, 63.5 [SD, 12.8] years), and 61 patients had a mean of 67 SpineJack vertebral implant procedures (57.4% women; mean age, 68.3 [SD, 10.6] years). Following kyphoplasty, vertebroplasty, and SpineJack vertebral implant, pain scores improved significantly (P < .001). Resting pain improvement was similar across the 3 procedures, whereas improvement of "worst pain" was significantly better following a SpineJack vertebral implant compared with kyphoplasty and vertebroplasty (P < .001). Patients with a SpineJack vertebral implant had greater improvement in vertebral body height restoration and local kyphotic angle compared with those undergoing kyphoplasty and vertebroplasty. Adjacent level fractures (6.7% incidence) occurred similarly in the 3 procedure types. There were no other peri- or postoperative complications.

CONCLUSIONS

The SpineJack vertebral implant showed equivalent pain improvement compared with vertebroplasty and kyphoplasty, but it had superior vertebral body height restoration and local kyphotic angle improvement. This study supports the SpineJack vertebral implant as a safe and effective alternative (adjunct) for vertebral augmentation, especially in patients with moderate-to-severe vertebral compression fractures for greater improvement in vertebral body height restoration.

Advances in materials used for minimally invasive treatment of vertebral compression fractures

Vertebral compression fractures are becoming increasingly common with aging of the population; minimally invasive materials play an essential role in treating these fractures. However, the unacceptable processing-performance relationships of materials and their poor osteoinductive performance have limited their clinical application. In this review, we describe the advances in materials used for minimally invasive treatment of vertebral compression fractures and enumerate the types of bone cement commonly used in current practice. We also discuss the limitations of the materials themselves, and summarize the approaches for improving the characteristics of bone cement. Finally, we review the types and clinical efficacy of new vertebral implants. This review may provide valuable insights into newer strategies and methods for future research; it may also improve understanding on the application of minimally invasive materials for the treatment of vertebral compression fractures.

Vertebral augmentation: an overview

Vertebral compression fractures (VCFs) are a common pathologic process seen in 30-50% of individuals over the age of 50 years. Historically, VCFs were first treated with nonsurgical management while vertebral augmentation was reserved for severe cases resulting in deformity or significant disability. Current treatment algorithms based on established appropriateness criteria have changed recommendations towards supporting early vertebral augmentation for the VCFs causing the most clinically difficulty and taking into account the degree of vertebral body height loss, kyphotic deformity, and the degree of clinical progression. Percutaneous vertebroplasty (PVP) involves injecting primarily polymethacrylate (PMMA) bone cement directly into the cancellous bone of the vertebral body. There is recent literature showing the effectiveness of PVP including data comparing vertebroplasty to sham treatment. Vertebroplasty evolved into balloon kyphoplasty (BKP) where a balloon is first inserted into the vertebral body to create a cavity and reduce the fracture followed by an injection of bone cement. Both PVP and BKP have been shown to be significantly more effective at treatment of VCFs compared to nonsurgical management. The benefits shown in the literature have been demonstrated randomized control trials, cohort matched trials, post-market trials, registries, and many other data sources with approximately 250 manuscripts produced per year dedicated to the topic of vertebral augmentation.

Effect of bone cement distribution on adjacent disc degeneration after vertebral augmentation for osteoporotic vertebral compression fractures in aging patients

Background

The influence of vertebral augmentation on adjacent intervertebral discs remains controversial. The purpose of this study is to evaluate the effect of bone cement distribution on adjacent disc degeneration after vertebral augmentation for osteoporotic vertebral compression fractures (OVCFs).

Methods

Patients with single level OVCF and upper endplate injury who underwent vertebral augmentation were enrolled. The patients were divided into four groups: Group A: bone cement contacted both the cranial and the distal endplates; Group B: bone cement only contacted the cranial endplate; Group C: bone cement only contacted the distal endplate; and Group D: bone cement contacted neither the cranial nor the distal endplates. The cranial discs of the fractured vertebrae were defined as adjacent discs and the upper discs proximally to the adjacent discs were defined as control discs. Degenerative disc change (DDC) was defined as a deteriorated postoperative Pfirrmann score compared with the preoperative score on MR images. The number of DDC cases and the disc heights were analyzed among the groups.

Results

A total of 184 patients with an average follow-up time of 28.6 months were included. The number of DDC cases in the adjacent discs was significantly higher than in the control discs in groups A (p < 0.001), B (p = 0.002), and D (p = 0.028), whereas the difference in group C was not statistically significant (p = 0.237). The incidence of adjacent disc degeneration was significantly higher in group A than that in group C (p = 0.06). The adjacent disc heights decreased significantly in groups A, B, and D (p < 0.001, p < 0.001, and p = 0.012, respectively), but did not decrease significantly in group C (p = 0.079). However, no statistical differences were detected among the four groups with respect to the preoperative adjacent disc height, follow-up adjacent disc height, preoperative control disc height, or follow-up control disc height.

Conclusion

Bone cement distribution influences adjacent disc degeneration after vertebral augmentation in OVCFs. Cement distribution proximal to the injured endplate can accelerate adjacent disc degeneration, and cement in contact with both the cranial and distal endplates can induce a higher incidence of adjacent disc degeneration.

Cost-effectiveness and willing-to-pay thresholds for vertebral augmentation of osteoporotic vertebral fractures, what are they based on: a systematic review

OBJECTIVE

Although there is substantial clinical evidence on the safety and effectiveness of vertebral augmentation for osteoporotic vertebral fractures, cost-effectiveness is less well known. The objective of this study is to provide a systematic review of cost-effectiveness studies and policy-based willingness-to-pay (WTP) thresholds for different vertebral augmentation (VA) procedures, vertebroplasty (VP) and balloon kyphoplasty (BK), for osteoporotic vertebral fractures (OVFs).

DESIGN

A systematic review targeting cost-effectiveness studies of VA procedures for OVFs.

DATA SOURCES

Six bibliographic databases were searched from inception up to May 2021.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

Studies were eligible if meeting all predefined criteria: (1) VP or BK intervention, (2) OVFs and (3) cost-effectiveness study. Articles not written in English, abstracts, editorials, reviews and those reporting only cost data were excluded.

DATA EXTRACTION AND SYNTHESIS

Information was extracted on study characteristics, cost-effective estimates, summary decisions and payer WTP thresholds. Incremental cost-effective ratio (ICER) was the main outcome measure. Studies were summarised by a structured narrative synthesis organised by comparisons with conservative management (CM). Two independent reviewers assessed the quality (risk of bias) of the systematic review and cost-effectiveness studies by peer-reviewed checklists.

RESULTS

We identified 520 references through database searching and 501 were excluded as ineligible by titles and abstract. Ten reports were identified as eligible from 19 full-text reviews. ICER for VP versus CM evaluated as cost per quality-adjusted life-year (QALY) ranged from €22 685 (*US$33 395) in Netherlands to £-2240 (*US$-3273), a cost-saving in the UK. ICERs for BK versus CM ranged from £2706 (*US$3954) in UK to kr600 000 (*US$90 910) in Sweden. ICERs were within payer WTP thresholds for a QALY based on historical benchmarks.

CONCLUSIONS

Both VP and BK were judged cost-effective alternatives to CM for OVFs in economic studies and were within WTP thresholds in multiple healthcare settings.

Early cement augmentation may be a good treatment option for pain relief for osteoporotic compression fractures: a systematic review and meta-analysis

PURPOSE

The incidence of osteoporotic compression fractures (VCFs) have been rising over the past decades. Presently, vertebral cement augmentation procedures such as balloon kyphoplasty and vertebroplasty are common treatments allowing pain relief and functional recovery. However, there is controversy on whether different timeframes for cement augmentation affects clinical outcomes. Hence, this study aimed to compare pain relief and complication rates between early versus late cement augmentation.

METHODS

A comprehensive systematic review of PubMed, EMBASE, Scopus and Cochrane Library was conducted, identifying studies that compared early versus late cement augmentation for VCFs. As the definitions of "early" and "late" phases across studies are heterogenous, we established the cut-off between early and late phase as intervals to accommodate as many studies as possible for analysis. We conducted two separate analyses with different cut-off intervals and included studies that reported interventions within these respective time intervals. In analysis 1, we included studies which grouped patients into "early" and "late" group based on a cut-off time frame of 2-4 weeks. On the other hand, in analysis 2, we included studies which grouped patients into "early" and "late" groups based on a cut-off time frame of 6-8 weeks. Meta-analysis was conducted via random-effect models, comparing outcomes of interest between early and late groups.

RESULTS

Eleven studies were included. The total cohort size was 712 and 775 patients in analysis 1 and 2 respectively. Mean follow-up was 12.9 ± 3.7 months and 11 ± 0.6 months respectively. VAS change at final follow-up was significantly greater in the early group for both analyses. (MD = - 0.66, p = 0.01; and MD = - 1.18, p < 0.005 respectively). There was no significant difference in post-operative absolute VAS score, number of cement leakage, number of adjacent compression fractures and local kyphotic angle, for both analyses. Patients in both groups experienced reductions in VAS score that exceeded the minimum clinically important difference.

CONCLUSION

Both early and late timeframes for cement augmentation offered significant improvement in pain relief, with similar post-operative absolute pain score, kyphotic angle, cement leakage and adjacent vertebral fractures. Early surgery may offer substantial pain relief in patients presenting with pain as early as < 2-4 weeks of VCFs.

Anterior thoracolumbar column reconstruction with the vertebral body stent-safety and efficacy

PURPOSE

The aim of this study was to assess safety and efficacy of vertebral body stenting (VBS) by analyzing (1) radiographic outcome, (2) clinical outcome, and (3) perioperative complications in patients with vertebral compression fractures treated with VBS at minimum 6-month follow-up.

METHODS

In this retrospective cohort study, 78 patients (61 ± 14 [21-90] years; 67% female) who have received a vertebral body stent due to a traumatic, osteoporotic or metastatic thoracolumbar compression fracture at our hospital between 2012 and 2020 were included. Median follow-up was 0.9 years with a minimum follow-up of 6 months. Radiographic and clinical outcome was analyzed directly, 6 weeks, 12 weeks, 6 months postoperatively, and at last follow-up.

RESULTS

Anterior vertebral body height of all patients improved significantly by mean 6.2 ± 4.8 mm directly postoperatively (p < 0.0001) and remained at 4.3 ± 5.1 mm at last follow-up compared to preoperatively (p < 0.0001). The fracture kyphosis angle of all patients improved significantly by mean 5.8 ± 6.9 degrees directly postoperatively (p < 0.0001) and remained at mean 4.9 ± 6.9 degrees at last follow-up compared to preoperatively (p < 0.0001). The segmental kyphosis angle of all patients improved significantly by mean 7.1 ± 7.6 degrees directly postoperatively (p < 0.0001) and remained at mean 2.8 ± 7.8 degrees at last follow-up compared to preoperatively (p = 0.03). Back pain was ameliorated from a preoperative median Numeric Rating Scale value of 6.5 to 3.0 directly postoperatively and further bettered to 1.0 six months postoperatively (p = 0.0001). Revision surgery was required in one patient after 0.4 years.

CONCLUSION

Vertebral body stenting is a safe and effective treatment option for osteoporotic, traumatic and metastatic compression fractures.

[Osteoporotic vertebral fractures-From diagnosis to treatment]

The aim of the present work is an overview of current concepts in the treatment of osteoporotic vertebral fractures, risk factors, clinical presentation and conservative and operative management. Osteoporotic vertebral fractures are a widespread problem, affecting between 700,000 and 1.5 million adults annually in the USA alone. Osteoporotic vertebral fractures can cause severe physical impairment, including back pain, dysfunction, and progressive thoracic kyphosis. Mortality after osteoporotic vertebral fractures is still increased compared to age-matched controls. In the reality of care, advocates of purely conservative therapy as well as advocates of surgical treatment can be found all over the world. In summary, understanding the risk factors, appropriate clinical evaluation and treatment strategies are crucial. When surgery is indicated, balloon kyphoplasty shows significantly better pain reduction and lower mortality compared to nonsurgical treatment.

Vertebral Augmentation: Is It Time to Get Past the Pain? A Consensus Statement from the Sardinia Spine and Stroke Congress

Vertebral augmentation has been used to treat painful vertebral compression fractures and metastatic lesions in millions of patients around the world. An international group of subject matter experts have considered the evidence, including but not limited to mortality. These considerations led them to ask whether it is appropriate to allow the subjective measure of pain to so dominate the clinical decision of whether to proceed with augmentation. The discussions that ensued are related below.

Cost-effectiveness studies of vertebral augmentation for osteoporotic vertebral fractures: a systematic review

BACKGROUND CONTEXT

Osteoporotic vertebral fractures (OVF) dramatically increase with age and are serious life altering adverse events for seniors resulting in increased rates of institutionalization, morbidity and mortality. Given the expanding population of the elderly and increasing prevalence of OVFs, cost-effective treatment strategies need to be considered. Percutaneous vertebral augmentation (VA) procedures such as vertebroplasty (VP) or balloon kyphoplasty (BK) are increasingly employed to treat painful vertebral fractures not responding to conservative management (CM) of bedrest and analgesia. Both VA procedures have been shown to be effective treatments for OVFs in multiple systematic reviews of randomized controlled trials. In this systematic review, analytical strategies, designs and results were compared for health economic studies evaluating cost-effectiveness of VA procedures, VP or BK for OVFs. Furthermore, assessments of quality (risk of bias) were conducted for the systematic review and the individual studies with peer-reviewed checklists recommended for cost-effectiveness studies.

PURPOSE

To provide an up-to-date systematic review of peer-reviewed studies evaluating cost-effectiveness of VA procedures, VP or KP for OVFs to support treatment and health care funding decisions.

STUDY DESIGN

This study is a systematic literature review and structured narrative synthesis.

STUDY SAMPLE

Peer reviewed health economic studies reporting cost-effectiveness for VA procedures, VP or BK for OVFs OUTCOME MEASURES: The following information extracted from the studies included: report country and year, study design, comparators, population, perspective, health valuations, costing sources and cost-effectiveness measures. For economic studies involving modeling, information was also extracted for model type, time horizon, key model drivers, and handling of uncertainty. Incremental cost-effectiveness ratio (ICER), the ratio of differences between comparator treatment groups in costs and health benefits, was considered the main cost-effectiveness measure.

METHODS

A systematic review was conducted of MEDLINE, EMBASE, CINAHL, ECONLIT, Cochrane Library and DARE databases up to the review date May 2021. Studies were reviewed for those reporting cost-effectiveness analyses on VA procedures including VP or BK for OVFs. Studies including only costs, abstracts, editorials, methodologies and reviews were not included. The selection of articles was reported in line with PRISMA guidance. A descriptive framework was developed to classify types of cost-effectiveness studies based on methodological differences and a structured narrative synthesis was used to summarize studies. Quality assessments were made with British Medical Journal checklist for individual cost-effectiveness studies and the CiCERO checklist for systematic reviews of cost-effectiveness studies.

RESULTS

In this systematic review, 520 references were identified through database searching and 501 were excluded as ineligible by titles and abstract based on prior eligibility criteria. From full-text reviews of 19 reports, ten were identified as eligible for the systematic review evaluating cost-effectiveness of VA procedures for OVFs. All references were published between 2008 and 2020. The ten cost-effectiveness studies, three for VP, three for BK and four for both VP and BK, all involved CM for OVFs as a treatment comparator. The studies involved different methods of economic analysis, modeling assumptions, cost and health valuations conducted in different health care setting over different time periods. A framework for the review outlines key features of cost-effectiveness study designs consisting of unmatched, matched, or randomized controls involving cost-effectiveness or cost-utility) analyses. Both VP and BK were cost-effective alternatives to CM for OVFs with earlier health gains and significantly shorter hospital stays. Cost-effectiveness estimates, ICERs, remained relatively stable and within willingness-to-pay thresholds under a range of sensitivity analyses. Comparisons between VP and BK were variable depending on modeling assumptions, but generally the procedures had similar health benefit gains with VP having lower acute procedural costs.

CONCLUSIONS

Both VP and BK, have been shown to be cost-effective alternatives to CM for osteoporotic vertebral fractures in diverse cost-effectiveness studies conducted in multiple health care settings. Trial-based cost-utility contributed the strongest evidence supporting cost-effectiveness determination for VP and BK for OVFs.

Management of Osteoporosis and Spinal Fractures: Contemporary Guidelines and Evolving Paradigms

Physicians involved in treating spine fractures secondary to osteopenia and osteoporosis should know the pathogenesis and current guidelines on managing the underlying diminished bone mineral density, as worldwide fracture prevention campaigns are trailing behind in meeting their goals. This is a narrative review exploring the various imaging and laboratory tests used to diagnose osteoporotic fractures and a comprehensive compilation of contemporary medical and surgical management. We have incorporated salient recommendations from the Endocrine Society, the American Association of Clinical Endocrinology (AACE), and the American Society for Bone and Mineral Research (ASBMR). The use of modern scoring systems such as Fracture Risk Assessment Tool (FRAX®) for evaluating fracture risk in osteoporosis with a 10-year probability of hip fracture and major fractures in the spine, forearm, hip, or shoulder is highlighted. This osteoporosis risk assessment tool can be easily incorporated into the preoperative bone health optimization strategies, especially before elective spine surgery in osteoporotic patients. The role of primary surgical intervention for vertebral compression fracture and secondary fracture prevention with pharmacological therapy is described, with randomized clinical trial-based wisdom on its timing and dosage, drug holiday, adverse effects, and relevant evidence-based literature. We also aim to present an evidence-based clinical management algorithm for treating osteoporotic vertebral body compression fractures, tumor-induced osteoporosis, or hardware stabilization in elderly trauma patients in the setting of their impaired bone health. The recent guidelines and recommendations on surgical intervention by various medical societies are covered, along with outcome studies that reveal the efficacy of cement augmentation of vertebral compression fractures via vertebroplasty and balloon kyphoplasty versus conservative medical management in the elderly population.

Trends in opioid use following balloon kyphoplasty or vertebroplasty for the treatment of vertebral compression fractures

This retrospective analysis of insurance claims evaluated real-world trends in prescription fills among patients treated with balloon kyphoplasty (N = 6,656) or vertebroplasty (N = 2,189) following diagnosis of vertebral compression fracture. Among those with evidence of opioid use, nearly half of patients discontinued or reduced prescription fills relative to pre-operative levels.

INTRODUCTION

Vertebral compression fractures (VCF) are associated with debilitating pain, spinal misalignment, increased mortality, and increased healthcare-resource utilization in elderly patients. This study evaluated the effect of balloon kyphoplasty (BKP) or vertebroplasty (VP) on post-procedure opioid prescription fills and payer costs in patients with VCF.

METHODS

This was a retrospective analysis of a large, nationally representative insurance-claims database. Clinical characteristics, opioid prescription patterns, and payer costs for subjects who underwent either BKP or VP to treat VCF were evaluated beginning 6 months prior to surgery through 7-month follow-up that included a 30-day, postoperative medication washout. Patient demographics, changes in opioid utilization, and payer costs were analyzed.

RESULTS

A total of 8,845 patients met eligibility criteria (75.3% BKP and 24.7% VP) with a mean of age 77 and 74% female. Among the 75% of patients who used opioids, 48.7% of patients discontinued opioid medication and 8.4% reduced prescription fills versus preoperative baseline. Patients who reduced or discontinued prescriptions exhibited a decrease in all-cause payer costs relative to pre-intervention levels, which was a significantly greater change relative to patients with no change, increase, or new start of opioids.

CONCLUSIONS

Interventional treatment for VCF was associated with decreased or discontinued opioid prescription fills and reduced payer costs in follow-up in a significant proportion of the study population. Reduction of opioid-based harms may represent a previously unrecognized benefit of vertebral augmentation for VCF, especially in this elderly and medically fragile population.

Interventional Management of Painful Vertebral Body Metastases

Management of osseous metastatic disease has advanced over the years with the advent of ablation and interventional technologies. Painful metastatic vertebral body lesions have been particularly studied in the recent years, as open surgery is usually reserved for emergent cord compression. Minimally invasive options in managing these lesions include percutaneous vertebral augmentation, percutaneous ablation, and embolization. This article will include an overview of these procedures including the most recent literature.

Multidisciplinary Care of a Vertebral Fracture in a Patient with Hematopoietic Stem Cell Transplant: Safety Appropriateness in Interventional Pain Management and Rehabilitation Considerations

Bone loss leading to fragility fracture is a highly prevalent late effect in hematopoietic stem-cell transplant patients, who are affected 8–9 times more than the general population, particularly for vertebral compression fractures. Spinal interventions such as lumbar epidural steroid injections and vertebral augmentation may be helpful for providing pain relief and improved function, quality of life and return to ambulation. However, interventional procedures should be approached with caution in these patients. Our study found that there is a paucity of scientific studies addressing the risks of spinal injections in these patients and there is no absolute recommendation specific to spinal injections in patients receiving immunosuppressive agents or who have a history of solid organ or hematopoietic stem cell transplant. It is imperative to consider proper timing of the intervention to minimize risks while optimizing the benefits of the intervention combined with a well-defined post-transplant rehabilitation plan. Moreover, the decision to proceed with spinal interventions should be done case by case and with caution. Therefore, this article reports the case of a multidisciplinary treatment for a vertebral compression fracture in a patient with a hematopoietic stem-cell transplant, in particular discussing safety appropriateness in interventional pain management and rehabilitation considerations for this condition in this patient population.

Vertebral Augmentation of Cancer-Related Spinal Compression Fractures: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

To compare the magnitude and duration of pain relief with vertebral augmentation to any other therapy for the treatment of cancer-related vertebral compression fractures through meta-analysis of randomized controlled trials.

SUMMARY OF BACKGROUND DATA

Derived from search on PubMed, EMBASE, CINAHL, Scopus, Central, Scopus, and Web of Science databases in May 2020. Studies selected were limited to randomized controlled trials comparing vertebral augmentation, either Balloon Kyphoplasty or Percutaneous Vertebroplasty (PVP) with or without additional therapy to any other intervention or placebo/sham.

METHODS

The methodological quality of each included study was assessed according to the Cochrane Collaboration's domain-based framework. Random effects model, Q test, and I2 statistics were implemented.

RESULTS

Of 180 records identified, 7 were considered relevant, and included 476 participants. The risk of bias was considered "Low" in all studies. In five of the studies, vertebral augmentation alone (either PVP or Balloon Kyphoplasty) comprised one group, while comparative treatments included nonsurgical management, Kiva implantation, PVP and radiofrequency therapy, PVP and chemotherapy, PVP and intrasomatic injection of steroid, and PVP with 125I seeds. Two studies compared PVP with an additional therapy against the standard of care. With regard to changes in pain severity, the effect sizes varied from 0.0 (95% -1.7 to 1.7) to -5.1 (95% -5.3 to -4.9). Most studies demonstrated a positive and statistically significant effect associated with PVP. Four of the seven studies demonstrated a clinically significant effect as well. Other than cement leakage, with an event rate of 0.24 (95% CI 0.11-0.44) or 24% (95% CI 11%-44%), there were no major adverse events consistently observed across multiple studies.

CONCLUSIONS

The included randomized controlled trials demonstrated an overall positive and statistically significant effect of vertebral augmentation surgeries, such as vertebroplasty and kyphoplasty, for the treatment of cancer-related vertebral compression fractures, especially when compared with nonsurgical management, radiofrequency ablation, or chemotherapy alone.Level of Evidence: 1.

Multidisciplinary management of osteoporotic vertebral fractures. An overview

Vertebral fractures represent the most frequent complication associated with osteoporosis. Patients harboring a vertebral fracture complain physical impairment including low back pain and spine balance alteration, i.e., kyphosis, leading to subsequent systemic complication, with an increase in morbidity and mortality risk. Different strategies are available in the management of osteoporotic vertebral fractures: medical therapy acts as a prevention strategy while surgical vertebral augmentation procedures, when correctly indicated, aim to reduce pain and to restore the physiological vertebral height. Considering the growing prevalence and incidence of this condition and its socio-economic burden, prevention, diagnosis and treatment of osteoporotic vertebral fractures are of utmost importance. Our aim is to review the current strategies for the management of osteoporotic vertebral fractures providing an integrated multidisciplinary endocrinological, radiological and neurosurgical point of view.

Interventional Procedures for Vertebral Diseases: Spinal Tumor Ablation, Vertebral Augmentation, and Basivertebral Nerve Ablation-A Scoping Review

Low back pain is consistently documented as the most expensive and leading cause of disability. The majority of cases have non-specific etiologies. However, a subset of vertebral diseases has well-documented pain generators, including vertebral body tumors, vertebral body fractures, and vertebral endplate injury. Over the past two decades, specific interventional procedures targeting these anatomical pain generators have been widely studied, including spinal tumor ablation, vertebral augmentation, and basivertebral nerve ablation. This scoping review summarizes safety and clinical efficacy and discusses the impact on healthcare utilization of these interventions. Vertebral-related diseases remain a top concern with regard to prevalence and amount of health care spending worldwide. Our study shows that for a subset of disorders related to the vertebrae, spinal tumor ablation, vertebral augmentation, and basivertebral nerve ablation are safe and clinically effective interventions to decrease pain, improve function and quality of life, and potentially reduce mortality, improve survival, and overall offer cost-saving opportunities.

Risk factors for secondary fractures to percutaneous vertebroplasty for osteoporotic vertebral compression fractures: a systematic review

BACKGROUND

Osteoporotic vertebral compression fracture (OVCF) is one of the most common fragile fractures, and percutaneous vertebroplasty provides considerable long-term benefits. At the same time, there are many reports of postoperative complications, among which fracture after percutaneous vertebroplasty is one of the complications after vertebroplasty (PVP). Although there are many reports on the risk factors of secondary fracture after PVP at home and abroad, there is no systematic analysis on the related factors of secondary fracture after PVP.

METHODS

The databases, such as CNKI, Wan Fang Database and PubMed, were searched for documents on secondary fractures after percutaneous vertebroplasty published at home and abroad from January 2011 to March 2021. After strictly evaluating the quality of the included studies and extracting data, a meta-analysis was conducted by using Revman 5.3 software.

RESULTS

A total of 9 articles were included, involving a total of 1882 patients, 340 of them diagnosed as secondary fractures after percutaneous vertebroplasty.

CONCLUSION

The additional history of fracture, age, bone mineral density (BMD), bone cement leakage, intravertebral fracture clefts and Cobb Angle might be risk factors related to secondary fractures after percutaneous vertebroplasty for osteoporotic vertebral compression fractures. The height of vertebral anterior and body mass index (BMI) were not correlated.

Systematic Review and Meta-Analysis of 3 Treatment Arms for Vertebral Compression Fractures: A Comparison of Improvement in Pain, Adjacent-Level Fractures, and Quality of Life Between Vertebroplasty, Kyphoplasty, and Nonoperative Management

BACKGROUND

Osteoporotic vertebral fractures (OVFs) have become increasingly common, and previous nonrandomized and randomized controlled trials (RCTs) have compared the effects of cement augmentation versus nonoperative management on the clinical outcome. This meta-analysis focuses on RCTs and the calculated differences between cement augmentation techniques and nonsurgical management in outcome (e.g., pain reduction, adjacent-level fractures, and quality of life [QOL]).

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, and the following scientific search engines were used: MEDLINE, Embase, Cochrane, Web of Science, and Scopus. The inclusion criteria included RCTs that addressed different treatment strategies for OVF. The primary outcome was pain, which was determined by a visual analog scale (VAS) score; the secondary outcomes were the risk of adjacent-level fractures and QOL (as determined by the EuroQol-5 Dimension [EQ-5D] questionnaire, the Oswestry Disability Index [ODI], the Quality of Life Questionnaire of the European Foundation for Osteoporosis [QUALEFFO], and the Roland-Morris Disability Questionnaire [RDQ]). Patients were assigned to 3 groups according to their treatment: vertebroplasty (VP), kyphoplasty (KP), and nonoperative management (NOM). The short-term (weeks), midterm (months), and long-term (>1 year) effects were compared. A random effects model was used to summarize the treatment effect, including I2 for assessing heterogeneity and the revised Cochrane risk-of-bias 2 (RoB 2) tool for assessment of ROB. Funnel plots were used to assess risk of publication bias. The log of the odds ratio (OR) between treatments is reported.

RESULTS

After screening of 1,861 references, 53 underwent full-text analysis and 16 trials (30.2%) were included. Eleven trials (68.8%) compared VP and NOM, 1 (6.3%) compared KP and NOM, and 4 (25.0%) compared KP and VP. Improvement of pain was better by 1.31 points (95% confidence interval [CI], 0.41 to 2.21; p < 0.001) after VP when compared with NOM in short-term follow-up. Pain effects were similar after VP and KP (midterm difference of 0.0 points; 95% CI, -0.25 to 0.25). The risk of adjacent-level fractures was not increased after any treatment (log OR, -0.16; 95% CI, -0.83 to 0.5; NOM vs. VP or KP). QOL did not differ significantly between the VP or KP and NOM groups except in the short term when measured by the RDQ.

CONCLUSIONS

This meta-analysis provides evidence in favor of the surgical treatment of OVFs. Surgery was associated with greater improvement of pain and was unrelated to the development of adjacent-level fractures or QOL. Although improvements in sagittal balance after surgery were poorly documented, surgical treatment may be warranted if pain is a relevant problem.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Early mobilization reduces the medical care cost and the risk of disuse syndrome in patients with acute osteoporotic vertebral fractures

STUDY DESIGN

A retrospective observational study.

PURPOSE

To compare two conservative treatments for acute osteoporotic vertebral fractures (OVFs).

OVERVIEW OF LITERATURE

Several studies have reported conservative treatments for OVFs in terms of using a brace, rehabilitation, and bed rest. However, there is no consensus about the conservative treatment for OVFs.

METHODS

We evaluated 68 patients with acute OVF treated in our hospital from 2007 to 2011. Thirty-four patients treated in prolonged bed rest (PBR) regimen underwent rehabilitation wearing a Jewett's brace after three weeks of bed rest. In contrast, the other 34 patients underwent rehabilitation wearing a Jewett's brace as soon as possible, which we called a stir-up (SU) regimen. We compared two treatment groups for medical costs, hospital length of stay (LOS), pain according to the numeric rating scale (NRS), the activities of daily living (ADL), and imaging studies.

RESULTS

The average hospital LOS was significantly shorter in patients treated by the SU regimen, which resulted in the medical costs reduction. There was no significant difference in the NRS through 6 months between the two groups. Although many patients in both groups experienced at least one level reduction in ADL at 6 months after the injury, patients in the SU group tended to maintain their pre-injury ADL, which almost agrees with past reports. In terms of imaging studies, patients in the PBR group showed milder vertebral compression rate over time. Pseudoarthrosis occurred in 2 patients in the SU group, who presented with mild pain, which had little influence on their daily lives.

CONCLUSION

We compared two conservative treatments for OVFs. Early rehabilitation was useful treatment for OVFs to minimize the risk for disuse syndrome, maintain pre-injury ADL status, and reduce the medical costs.

Expandable Intravertebral Implants: A Narrative Review on the Concept, Biomechanics, and Outcomes in Traumatology

Expandable intravertebral implants are self-expanding devices applied percutaneously by the posterior transpedicular approach. These devices introduce the concept of anatomical restoration of vertebral body endplates and direct anatomical reduction performed from the interior of the vertebral body with a compression fracture. This paper aims to provide a narrative review on the concept, indications, biomechanical characteristics, as well as functional and radiographic outcomes of the main expandable intravertebral implants currently available, in terms of their application to thoracolumbar spine traumatology. To this end, we performed a search in July 2021 on the MEDLINE/PubMed platform with the words "expandable intravertebral implant", "armed kyphoplasty", "Vertebral Body Stenting" or "stentoplasty" and "SpineJack". The search yielded 144 papers, and of those, we included 15 in this review. We concluded that percutaneous transpedicular posterior access, the ability to reduce vertebral body fractures, particularly of the vertebral endplates and to maintain the vertebral body height, makes the application of expandable intravertebral implants an attractive option in the treatment of thoracolumbar vertebral compression fractures. However, more prospective, randomized, and large-scale blinded studies are still warranted, especially comparative studies between treatments and about the preferential use of an expansive implant over others, in order to gain definitive insights into the effectiveness and indications of each of these devices.

Efficacy of a Novel Vertebral Body Augmentation System in the Treatment of Patients with Symptomatic Vertebral Body Fractures

Purpose

To evaluate the safety and efficacy of a novel augmentation implant in the treatment of patients with symptomatic vertebral body fractures.

Materials and Methods

Thirty consecutive patients (seven males and 23 females), mean age of 70 years (range 56 to 89) with osteoporotic fractures and/or low-energy trauma fractures (osteoporosis confirmed by CT), were enrolled in an IRB-approved prospective study. The type of fracture was classified according to the Magerl classification. The patients were treated with the Tektona^® dedicated vertebral body augmentation system. Visual analogue scale (VAS) and Oswestry Disability Index (ODI) scores were obtained after 1, 6 and 12 months. Quality of life was assessed with the SF36 score.

Results

A total of 37 vertebral bodies, mostly from T6 to L5, were treated in the 30 enrolled patients. In 67.6% of the cases (n = 25), lumbar fractures were treated. Most of the fractures (43%; n = 16) were A1.1 according to the Magerl classification. A significant pain reduction evaluated by VAS scores (p < 0.0001) was observed on average 7.6 (before the procedure) to 2.8 (immediately post-treatment), 2.1 and 2.7 (after 6 and 12 months later, respectively). The mean ODI score was 55.5% before treatment, and this was statistically significant reduced to 22.3% and 26.9%, respectively, at 6 and 12 months after treatment (p < 0.0001). The SF36 scores, both physical and mental components, showed statistically significant variations (p < 0.0001) whose direction was subpopulation dependent.

Conclusion

Patients with confirmed osteoporosis, suffering from symptomatic vertebral body fractures (osteoporotic and/or low-energy traumatic), were treated safely and effectively using this novel implant.

Vertebral fragility fractures: clinical and radiological results of augmentation and fixation-a systematic review of randomized controlled clinical trials

AIM

To assess the outcome of augmentation techniques, i.e., percutaneous vertebroplasty (PVP), balloon kyphoplasty (BKP), vertebral body stenting (VBS) and fixation techniques in the management of vertebral fragility fractures (VFFs).

METHODS

OVID-MEDLINE®, EMBASE, Cochrane Library, SCOPUS, Springer Link, Web of Science, Google Scholar and PubMed were searched from January 2009 to February 2019 to identify relevant studies. The methodological qualities of the studies were evaluated and relevant data were extracted.

RESULTS

Thirteen randomized controlled trials, recruiting 1963 patients, were included. PVP, compared with conservative management (CM), showed a greater pain relief and an improved vertebral body height (VBH) restoration. Moreover, PVP revealed superior to a sham procedure for pain relief in acute VFFs. BKP, compared with CM, rapidly reduces pain and improves quality of life without increasing the risk of additional VFFs. BKP, compared with PVP, has fewer cement leakage rates and is more effective in VBH restoration. BKP should also be preferred to VBS, since it is associated with less material-related complications. Pedicle screw fixation associated with PVP, compared with PVP alone, revealed effective in preventing secondary VFFs.

CONCLUSIONS

BKP showed better clinical and radiological outcomes compared with CM and PVP. BKP revealed as effective as VBS in VBH restoration with less material-related complications.

Comparison of Costs and Postoperative Outcomes between Vertebroplasty and Kyphoplasty for Osteoporotic Vertebral Compression Fractures: Analysis from a State-Level Outpatient Database

BACKGROUND

Vertebral cement augmentation techniques are routinely used to treat osteoporotic vertebral compression fractures (VCFs). In the current study, we used a state-level outpatient database to compare costs and postoperative outcomes between vertebroplasty and kyphoplasty.

METHODS

We queried the 2016 Florida State-Ambulatory Surgery Database of the Healthcare Cost and Utilization Project for patients undergoing thoracolumbar vertebroplasty or kyphoplasty for osteoporotic VCFs. Demographic and clinical characteristics, as well as postoperative outcomes were compared between the 2 groups.

RESULTS

A total of 105 patients (11.6%) who underwent vertebroplasty and 801 patients (88.4%) who underwent kyphoplasty were identified. Patients undergoing kyphoplasty were more likely to stay overnight or longer, with the P value trending toward significance (kyphoplasty with >1 day stay: 7.4% vs. vertebroplasty with >1 day stay: 1.9%; P = 0.086). Patients undergoing vertebroplasty had a significantly higher rate of discharge to home routine compared with patients undergoing kyphoplasty (97.1% [n = 102] vs. 94.1% [n = 754]; P < 0.001). Undergoing kyphoplasty was also associated with higher index admission costs ($40,706 vs. $18,965; P < 0.001) and higher readmission costs ($27,038 vs. $11,341; P = 0.046). The rates of 30-day and 90-day readmission were similar between the 2 groups (all P > 0.05). The rates of 30-day, 90-day, and overall readmission because of a new-onset fracture were also similar (all P > 0.05). However, vertebroplasty had a higher rate of readmissions associated with a procedure within a year (21.9% [n = 23] vs. 14.5% [n = 116]; P = 0.047).

CONCLUSIONS

Our analyses from a state-level database of patients undergoing vertebroplasty and kyphoplasty for osteoporotic VCFs show similar postoperative outcomes for the 2 procedures but a higher cost for kyphoplasty.

Socioeconomic disparities in the utilization of spine augmentation for patients with osteoporotic fractures: an analysis of National Inpatient Sample from 2011 to 2015

BACKGROUND CONTENT

Vertebral augmentation procedures are used for treatment of osteoporotic compression fractures. Prior studies have reported disparities in the treatment of patients with osteoporotic vertebral fractures, particularly with regards to the use of vertebroplasty and kyphoplasty.

PURPOSE

The purpose of this study is to report updates in racial and health insurance inequalities of spine augmentation procedures in patients with osteoporotic fractures.

METHODS

With the use of the National Inpatient Sample, we identified hospitalized patients with osteoporotic fractures between the period of 2011 and 2015. Patients with spine augmentation, defined by the utilization of vertebroplasty and kyphoplasty, were also identified. Our primary outcome was defined as the utilization of spine augmentation procedures across ethnic (white, hispanic, black, and asian/pacific islander) and insurance (self-pay, private insurance, Medicare, and Medicaid) groups. Variables were identified from the NIS database using International Classification of Diseases, Ninth and Tenth diagnosis codes. Univariate and multivariate regression analysis was used for statistical analysis with p value <.05 considered significant. A subgroup analysis was performed across the utilization of kyphoplasty, vertebroplasty, and Medicare coverage.

RESULTS

We identified a total of 110,028 patients with a primary diagnosis of vertebral fracture between 2011 and 2015 (mean age: 74.4±13.6 years, 68% women). About 16,237 patients (14.8%) underwent any type of spine augmentation with over 75% of the patients receiving kyphoplasty. Multivariate analysis showed that black patients (odds ratio [OR]=0.64, 95% confidence interval [CI]: 0.58-0.70, p<.001), Hispanic patients (OR=0.79, 95% CI: 0.73-0.86, p<.001), and Asian/Pacific Islander (OR=0.79, 95% CI: 0.70-0.89, p<.001) had significantly lower odds for receiving any spine augmentation compared with white patients. Patients with Medicaid (OR=0.59, 95% CI: 0.53-0.66, p<.001), private insurance (OR=0.90, 95% CI: 0.85-0.96, p=.001), and those who self-pay (OR=0.57, 95% CI: 0.47-0.69, p<.001) had significantly lower odds of spine augmentation compared with those with Medicare. Comparative use of kyphoplasty was not significantly different between white and black patients (OR=0.85, 95% CI: 0.70-1.04, p=.12). However, Hispanic patients (OR=0.84, 95% CI: 0.71-0.99, p=.04) and Asian/Pacific Islander patients (OR=0.73, 95% CI: 0.58-0.92, p=.007) had significantly lower use of kyphoplasty compared with white patients. The comparative use of kyphoplasty among patients receiving spine augmentation was not significantly different across each insurances status when compared with patients with Medicare.

CONCLUSIONS

Our study suggests that racial and socioeconomic disparities continue to exist with the utilization of spine augmentation procedures in hospitalized patients with osteoporotic fractures.

Current Concepts in the Management of Vertebral Compression Fractures

PURPOSE OF REVIEW

This comprehensive review of current concepts in the management of vertebral compression fractures is a manuscript of vertebral augmentation literature of risk factors, clinical presentation, and management. The objective of this review is to compare outcomes between multiple augmentation techniques and ongoing discussions of effectiveness of vertebral augmentation procedures.

RECENT FINDINGS

Vertebral compression fractures (VCFs) are a prevalent disease affecting approximately 1.5 million US adults annually. VCFs can cause severe physical limitations, including back pain, functional disability, and progressive kyphosis of the thoracic spine that ultimately results in decreased appetite, poor nutrition, impaired pulmonary function, and spinal cord compression with motor and sensory deficits. The deconditioning that affects patients with vertebral compression fractures leads to mortality at a far higher rate than age-matched controls. The management of vertebral compression fractures has been extensively discussed with opponents arguing in favor or restricting conservative management and against augmentation, while proponents argue in favor of augmentation. The literature is well established in reference to the effects on mortality when patients undergo treatment with vertebral augmentation; in over a million patients with vertebral compression fractures treated with vertebral augmentation as compared with patients treated with non-surgical management, the patients receiving augmentation performed well with a decrease in morbidity and mortality. Summary of the literature review shows that understanding the risk factors, appropriate clinical evaluation, and management strategies are crucial. Analysis of the evidence shows, based on level I and II studies, balloon kyphoplasty had significantly better and vertebroplasty tended to have better pain reduction compared with non-surgical management. In addition, balloon kyphoplasty tended to have better height restoration than vertebroplasty.

[Vertebroplasty and kyphoplasty : A critical statement]

BACKGROUND

Despite optimal drug-conservative therapy, a relevant percentage of patients with vertebral compression fractures (WKF) do not experience any relevant improvement in their pain symptoms. Vertebroplasty (VP) and kyphoplasty (KP) are described in the literature as percutaneous interventional procedures for the treatment of WKF.

OBJECTIVE

Assessment of the effectiveness of the VP and KP in the treatment of WKF and discussion of the procedures in the context of the current literature.

MATERIAL AND METHODS

Presentation of the fundamentals of VP and KP and their further developments. Description of indications and contraindications. Discussion of the current literature and recommendations of the individual professional associations.

RESULTS

In patients with vertebral compression fractures, VP or KP of the affected vertebral body leads to a pain reduction in more than 90% of cases. Clinically relevant complications occur in less than 1% of interventions.

CONCLUSION

VP and KP are a safe and effective method for treating painful WKF. Optimal patient selection improves the clinical outcome.

A Comparison of Kyphoplasty, Vertebroplasty, or Non-Surgical Treatment of Traumatic/Atraumatic Osteoporotic Vertebral Compression Fractures: A Short Review

Background:

Although the majority of patients with traumatic/atraumatic osteoporotic vertebral compression fractures (OVCFs) may be managed with non-surgical treatment (NST), a subset (e.g. 40%) with significant pain, loss of vertebral height, and other factors may warrant percutaneous vertebroplasty (V), or percutaneous kyphoplasty (K).

Methods:

We compared the impact of these three treatment modalities, V, K, or NST, for managing OVCFs.

Results:

In several studies, both V and K resulted in comparable improvement in pain relief, postoperative kyphotic angles, increased anterior vertebral heights, and frequency of leakage of bone cement. One study evaluating 16 RCT’s (Randomized Controlled Studies), however, observed K significantly; “decreased the kyphotic wedge angle, increased the postoperative vertebral body height, and decreased the risk of cement leakage vs. V”. Further, in some series, both V and K resulted in higher quality of life scores and better pain relief vs. NST, while other studies showed V was superior to K. Further, although the risk of adjacent level fractures (ALF) following V, K, and NST were comparable in most studies, one clearly demonstrated NST had the lowest incidence of ALF. Despite all these findings, most studies concluded outcomes were comparable for all 3 groups.

Conclusions:

Although most OVCFs are still managed with non-surgical treatment (NST), a subset (e.g. about 40%) may warrant V or K. Although both V and K have been shown to result in significantly better pain relief, higher quality of life scores, increased postoperative vertebral body height compared with NST, outcomes for all 3 groups remained the same.

ISASS Policy 2018-Vertebral Augmentation: Coverage Indications, Limitations, and/or Medical Necessity

The ISASS Policy Statement on vertebral augmentation has the objectives to provide a background and an update with the latest clinical evidence for the international spine community. A SpineLine Panel Review (2010) appropriately recommended an exploration of "the seeming disconnect between the conclusions of … two [Level I] PRCT's and previous experience and data" regarding vertebral augmentation. ISASS responded by supporting a comprehensive meta-analysis to help frame a cogent historical analysis of vertebral augmentation. This ISASS Policy 2018 is based on a thorough literature search for relevant studies, including systematic reviews and meta-analyses, that are subjected to thorough quality appraisal for the purpose of informing public opinion and decision making. Given the abundance of high-quality information, ISASS can confidently advocate that there is strong support for vertebral augmentation in the treatment of symptomatic vertebral compression fractures.