Response to "randomized vertebroplasty trials: bad news or sham news?"

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

STUDY DESIGN

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

OBJECTIVE

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

SUMMARY OF BACKGROUND DATA

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Surgical versus non-surgical treatment for vertebral compression fracture with osteopenia: a systematic review and meta-analysis

BACKGROUND

Surgical and non-surgical interventions are the two categories for treatment of vertebral compression fractures (VCFs). However, there is clinical uncertainty over optimal management. This study aimed to examine the safety and effectiveness of surgical management for treatment of VCFs with osteopenia compared with non-surgical treatment.

METHODS

We conducted a systematic search through electronic databases from inception to June 2014, with no limits on study data or language. Randomized controlled trials (RCTs) evaluating surgical versus non-surgical interventions for treatment of patients with VCFs due to osteopenia were considered. Primary outcomes were pain and adverse effects. A random-effects model was used to calculate the pooled mean difference (MD) or risk ratios with 95% confidence interval (CI).

RESULTS

Sixteen reports (11 studies) met the inclusion criteria, and provided data for the meta-analysis with a total of 1,401 participants. Compared with conservative treatment, surgical treatment was more effective in reducing pain (short-term: MD -2.05, 95% CI -3.55 to -0.56, P=0.007; mid-term: MD -1.70, 95% CI -2.78 to -0.62, P=0.002; long-term: MD -1.24, 95% CI -2.20 to -0.29, P=0.01) and disability on the Roland-Morris Disability score (short-term: MD -4.97, 95% CI -8.71 to -1.23, P=0.009), as well as improving quality of life on the Short-Form 36 Physical Component Summary score (short-term: MD 5.53, 95% CI 1.45 to 9.61, P=0.008) and the Quality of Life Questionnaire of the European Foundation for Osteoporosis score (short-term: MD -5.01, 95% CI -8.11 to -1.91, P=0.002). Indirect comparisons between vertebroplasty and kyphoplasty found no evidence that the treatment effect differed across the two interventions for any outcomes assessed. Compared with the sham procedure, surgical treatment showed no evidence of improvement in pain relief and physical function. Based on these two comparisons, no significant difference between groups was noted in the pooled results for adverse events.

CONCLUSION

Compared to conservative treatment, surgical treatment was more effective in decreasing pain in the short,mid and long terms. However, no significant mid- and long-term differences in physical function and quality of life was observed. Little good evidence is available for surgical treatment compared with that for sham procedure. PV and BK are currently used to treat VCFs with osteopenia, with little difference in treatment effects. Evidence of better quality and from a larger sample size is required before a recommendation can be made.

SYSTEMATIC REVIEW REGISTRATION

http://www.crd.york.ac.uk/PROSPERO PROSPERO registration number: CRD42013005142.

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

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

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

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

Impact of sham-controlled vertebroplasty trials on referral patterns at two academic medical centers

Debate persists regarding the merit of vertebroplasty following publication of blinded vertebroplasty trials in 2009, one of which was the Investigational Vertebroplasty Efficacy and Safety Trial (INVEST). This study was performed to determine whether referring physicians at two academic medical centers were aware of the trial results and to assess if this awareness prompted a change in their treatment of osteoporotic fractures. E-mail surveys were distributed to physicians within the Mayo Clinic and Baylor Health Care System (BHCS). Of 1390 surveys sent, 194 (14%) were returned. Results showed that 92 of 158 respondents (58%) reported familiarity with INVEST; 66 of 92 (72%) agreed that INVEST changed their understanding of vertebroplasty efficacy; and 64 of 92 (70%) agreed that INVEST diminished their enthusiasm to refer patients for vertebroplasty. However, 105 of 159 respondents (66%) felt vertebroplasty was an effective procedure in appropriate patients. Mayo physicians were more likely than BHCS physicians to be aware of INVEST (73% vs 67%, P < .0001), respond that INVEST changed their understanding of the appropriate treatment for osteoporotic compression fractures (79% vs 57%, P = 0.026), view vertebroplasty less favorably (45% vs 21%, P = 0.005), and treat osteoporotic compression fractures with medical therapy/pain management alone (73% vs 48%, P = 0.003). INVEST changed referring physicians' understanding of the role of vertebroplasty and diminished their willingness to refer osteoporotic compression fracture patients; the impact varied by location.

Guidance on the management of pain in older people

This guidance document reviews the epidemiology and management of pain in older people via a literature review of published research. The aim of this document is to inform health professionals in any care setting who work with older adults on best practice for the management of pain and to identify where there are gaps in the evidence that require further research. The assessment of pain in older people has not been covered within this guidance and can be found in a separate document (http://www.britishpainsociety.org/pub_professional.htm#assessmentpop). Substantial differences in the population, methods and definitions used in published research makes it difficult to compare across studies and impossible to determine the definitive prevalence of pain in older people. There are inconsistencies within the literature as to whether or not pain increases or decreases in this age group, and whether this is influenced by gender. There is, however, some evidence that the prevalence of pain is higher within residential care settings. The three most common sites of pain in older people are the back; leg/knee or hip and 'other' joints. In common with the working-age population, the attitudes and beliefs of older people influence all aspects of their pain experience. Stoicism is particularly evident within this cohort of people. Evidence from the literature search suggests that paracetamol should be considered as first-line treatment for the management of both acute and persistent pain, particularly that which is of musculoskeletal origin, due to its demonstrated efficacy and good safety profile. There are few absolute contraindications and relative cautions to prescribing paracetamol. It is, however, important that the maximum daily dose (4 g/24 h) is not exceeded. Non-selective non-steroidal anti-inflammatory drugs (NSAIDs) should be used with caution in older people after other safer treatments have not provided sufficient pain relief. The lowest dose should be provided, for the shortest duration. For older adults, an NSAID or cyclooxygenase-2 (COX-2) selective inhibitor should be co-prescribed with a proton pump inhibitor (PPI), and the one with the lowest acquisition cost should be chosen. All older people taking NSAIDs should be routinely monitored for gastrointestinal, renal and cardiovascular side effects, and drug–drug and drug–disease interactions. Opioid therapy may be considered for patients with moderate or severe pain, particularly if the pain is causing functional impairment or is reducing their quality of life. However, this must be individualised and carefully monitored. Opioid side effects including nausea and vomiting should be anticipated and suitable prophylaxis considered. Appropriate laxative therapy, such as the combination of a stool softener and a stimulant laxative, should be prescribed throughout treatment for all older people who are prescribed opioid therapy. Tricyclic antidepressants and anti-epileptic drugs have demonstrated efficacy in several types of neuropathic pain. But, tolerability and adverse effects limit their use in an older population. Intra-articular corticosteroid injections in osteoarthritis of the knee are effective in relieving pain in the short term, with little risk of complications and/or joint damage. Intra-articular hyaluronic acid is effective and free of systemic adverse effects. It should be considered in patients who are intolerant to systemic therapy. Intra-articular hyaluronic acid appears to have a slower onset of action than intra-articular steroids, but the effects seem to last longer. The current evidence for the use of epidural steroid injections in the management of sciatica is conflicting and, until further larger studies become available, no firm recommendations can be made. There is, however, a limited body of evidence to support the use of epidural injections in spinal stenosis. The literature review suggests that assistive devices are widely used and that the ownership of devices increases with age. Such devices enable older people with chronic pain to live in the community. However, they do not necessarily reduce pain and can increase pain if used incorrectly. Increasing activity by way of exercise should be considered. This should involve strengthening, flexibility, endurance and balance, along with a programme of education. Patient preference should be given serious consideration. A number of complementary therapies have been found to have some efficacy among the older population, including acupuncture, transcutaneous electrical nerve stimulation (TENS) and massage. Such approaches can affect pain and anxiety and are worth further investigation. Some psychological approaches have been found to be useful for the older population, including guided imagery, biofeedback training and relaxation. There is also some evidence supporting the use of cognitive behavioural therapy (CBT) among nursing home populations, but of course these approaches require training and time. There are many areas that require further research, including pharmacological management where approaches are often tested in younger populations and then translated across. Prevalence studies need consistency in terms of age, diagnosis and terminology, and further work needs to be done on evaluating non-pharmacological approaches.

Augmentation of implant fixation in osteoporotic bone

Osteoporosis presents a dilemma for the orthopedic surgeon. Screw fixation within the bone is crucial for mechanical stabilization, maintenance of reduction, and ultimately, fracture healing. For the patient, soft bones and physiological fragility usually benefit from immediate weight bearing and mobility to avoid further disuse osteoporosis, deconditioning, and immobility. For implant companies, traditional screws, plates, and nails function for simple fractures and compliant patients. Locked plating has improved screw purchase in osteoporotic bone and has expanded fracture fixation capabilities but is not the panacea for all fractures. For orthopedic surgeons, traditional surgical augmentation for osteoporosis consisting of dual plating, augmentation with polymethyl methacrylate, joint replacement, and now locked plating are beneficial. In order to advance orthopedic care in the expanding population of elderly osteoporotic patients, modern solutions utilizing the dual properties of secure fixation and relatively flexible implants are required. Endosteal substitution, extraosteal substitution, and combined nail/plate combinations are methods of utilizing traditional implants in a nontraditional way. Nonsurgical augmentation of fracture fixation is also paramount.

Percutaneous vertebroplasty for subacute and chronic painful osteoporotic vertebral compression fractures can safely be undertaken in the first year after the onset of symptoms

The optimal timing of percutaneous vertebroplasty as treatment for painful osteoporotic vertebral compression fractures (OVCFs) is still unclear. With the position of vertebroplasty having been challenged by recent placebo-controlled studies, appropriate timing gains importance. We investigated the relationship between the onset of symptoms - the time from fracture - and the efficacy of vertebroplasty in 115 patients with 216 painful subacute or chronic OVCFs (mean time from fracture 6.0 months (sd 2.9)). These patients were followed prospectively in the first post-operative year to assess the level of back pain and by means of health-related quality of life (HRQoL). We also investigated whether greater time from fracture resulted in a higher risk of complications or worse pre-operative condition, increased vertebral deformity or the development of nonunion of the fracture as demonstrated by the presence of an intravertebral cleft. It was found that there was an immediate and sustainable improvement in the level of back pain and HRQoL after vertebroplasty, which was independent of the time from fracture. Greater time from fracture was associated with neither worse pre-operative conditions nor increased vertebral deformity, nor with the presence of an intravertebral cleft. We conclude that vertebroplasty can be safely undertaken at an appropriate moment between two and 12 months following the onset of symptoms of an OVCF.

Continuing conservative care versus crossover to radiofrequency kyphoplasty: a comparative effectiveness study on the treatment of vertebral body fractures

BACKGROUND

There is controversy about how to treat vertebral fractures. Conservative care is the default approach. Radiofrequency kyphoplasty uses ultrahigh viscosity cement to restore spinal posture and stabilize the fracture. The aims of this study were to compare radiofrequency kyphoplasty to conservative care and assess the usual algorithm of starting all patients on conservative care for 6 weeks before offering surgery.

METHODS

Elderly patients with painful osteoporotic vertebral compression fractures were all treated with 6 weeks of conservative care (analgesics, bracing, and physiotherapy). They were then offered the choice of continuing conservative care or crossing over to radiofrequency kyphoplasty, at 6 and 12 weeks. Clinical success was defined as: (1) VAS pain improvement ≥2, (2) final VAS pain ≤5, (3) no functional worsening on ODI.

RESULTS

After the initial 6 weeks of conservative care, only 1 of 65 patients met the criteria for clinical success, and median VAS improvement was 0. After 12 weeks of conservative care, only 5 of 38 patients met the criteria for clinical success, and median VAS improvement was 1. At the 6-week follow-up after radiofrequency kyphoplasty, 31 of 33 surgery patients met the criteria for clinical success, and median VAS improvement was 5.

CONCLUSION

For the vast majority of patients with a VAS ≥5, conservative care did not provide meaningful clinical improvement. In contrast, nearly all patients who underwent radiofrequency kyphoplasty had rapid substantial improvement. Surgery was clearly much more effective than conservative care and should be offered to patients much sooner.

Cement leakage in percutaneous vertebroplasty for osteoporotic vertebral compression fractures: identification of risk factors

BACKGROUND CONTEXT

Percutaneous vertebroplasty (PVP) is a common treatment modality for painful osteoporotic vertebral compression fractures (OVCFs). The complication rate of PVP is low, but cement leakage occurs in up to 90% of the treated levels. Recent evidence suggests that sequelae of cement leakage may be more common and clinically relevant than previously thought. Preoperative appreciation of risk factors would therefore be helpful but has not been thoroughly investigated.

PURPOSE

Identification of preoperative risk factors for the occurrence of cement leakage in PVP for painful OVCFs.

STUDY DESIGN

Retrospective assessment of risk factors using multivariate analysis.

PATIENT SAMPLE

Eighty-nine patients treated with PVP for 177 painful OVCFs.

OUTCOME MEASURE

Occurrence of cement leakage.

METHODS

The influence of all known risk factors and other parameters potentially affecting the occurrence of cement leakage was retrospectively assessed using multivariate analysis. Patient age, sex, and spinal deformity index; fracture age, level, type, and semiquantitative severity grade (1-4), the presence of an intravertebral cleft and/or cortical disruption on preoperative magnetic resonance imaging (MRI), and the viscosity of bone cement were included. Cement leakage was assessed on direct postoperative computed tomography scanning of the treated levels. In addition to cement leakage in general, three fundamentally different leakage types (cortical, epidural, and anterior venous), with different possible clinical sequelae, were discerned, and their respective risk factors were assessed.

RESULTS

In 130 of 173 (75.1%) treated OVCFs, cement leakage was detected. Leakage incidence was found to increase approximately linear with advancing severity grade. High fracture semiquantitative severity grade (adjusted per grade relative risk [RR], 1.14; 95% confidence interval [CI], 1.05-1.24; p=.002) and low bone cement viscosity (medium vs. low viscosity: adjusted RR, 0.73; 95% CI, 0.61-0.87; p<.001) were strong risk factors for cement leakage in general. For cortical leakage (in 95% intradiscal leakage), the presence of cortical disruption on MRI (adjusted RR, 1.62; 95% CI, 1.16-2.26; p=.004) and an intravertebral cleft on MRI (adjusted RR, 1.43; 95% CI, 1.07-1.77; p=.017) were identified as additional strong risk factors.

CONCLUSIONS

High fracture severity grade and low viscosity of polymethylmethacrylate bone cement are general, strong, and independent risk factors for cement leakage. Using MRI assessment, cortical disruption and the presence of an intravertrebral cleft were identified as additional strong risk factors regarding cortical (intradiscal) cement leakage, thereby potentiating anticipation.

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

OBJECTIVE

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

DESIGN

Meta-analysis of combined individual patient level data.

SETTING

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

PARTICIPANTS

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

INTERVENTION

Percutaneous vertebroplasty versus a placebo procedure.

MAIN OUTCOME MEASURE

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

RESULTS

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

CONCLUSIONS

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

The case of vertebroplasty trials: promoting a culture of evidence-based procedural medicine

Two independent, randomized controlled trials of vertebroplasty for the relief of pain associated with vertebral fractures demonstrated that this procedure was no better than a sham intervention. Publication of the trial results prompted strong, critical commentaries by practitioners and professional societies. In this article we offer a psychological explanation of this dismissive response to rigorous scientific evidence, which appeals to the “placebo reactions” of physicians when dramatic improvement is noted in patients’ symptoms following administration of invasive procedures. We argue that the story of the response to the vertebroplasty trials underscores the need to develop a culture of evidence-based procedural medicine.

Invited editorial presents an accurate summary of the results of two randomised placebo-controlled trials of vertebroplasty

Our recent editorial in the Journal presents an accurate summary of our two randomised trials of vertebroplasty, which found no benefit of vertebroplasty over placebo. Participants in both trials are representative of patients seen in clinical practice and who would qualify for government-subsidised funding of vertebroplasty in Australia. Clinical experience and previous published literature are likely to have overestimated the treatment benefit of vertebroplasty for many reasons. This is why randomised placebo-controlled trials are required to determine the efficacy of treatment interventions, particularly when the condition being treated is self-limiting and the primary end point is improvement of symptoms. Based on the best evidence currently available, the routine use of vertebroplasty outside of the research setting for painful osteoporotic vertebral fractures appears unjustified.