Vertebroplasty and kyphoplasty: New evidence adds heat to the debate

aDepartment of Anesthesia and Alan Edwards McGill Pain Center bDepartment of Surgery, Division of Orthopedics, McGill University Health Center, Montreal Quebec, Canada.
Current opinion in anaesthesiology (Impact Factor: 1.98). 08/2012; 25(5):577-83. DOI: 10.1097/ACO.0b013e328357a2c7
Source: PubMed


Cement bone augmentation has become very popular worldwide in treating painful noncomplicated spine fractures. Controversy about the effectiveness was raised by two randomized trials in 2009. Recent new evidence contradicts those findings giving credit to vertebroplasty/kyphoplasty.
Well designed prospective clinical trials in cancer and noncancer vertebral fractures as well as an excellent meta-analysis showed that painful vertebral compression fractures have better and faster pain relief, better functional outcomes, and with low complication rate when treated with percutaneous cement than conservatively.
The saga is unfinished. The treatment of vertebral compression fractures with cement augmentation is still in its infancy. The potential for development with new materials and the injection of biologic and active bone cements or anticancer products, in metastatic disease, will revolutionize the treatment of this condition.

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    • "The debate about vertebral augmentation continues. One ongoing study that may shed light on the matter is the VERTOS IV trial, a non-industry supported, prospective randomized controlled trial of 180 patients that compares vertebroplasty to sham procedure, similar to the New England Journal of Medicine studies, but uses the strict inclusion criteria of the VERTOS II trial.69,70 "
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    ABSTRACT: 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.
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    ABSTRACT: Vertebral compression fractures are a common pathology affecting primarily the elderly, postmenopausal women, and those with metastatic vertebral disease. Vertebral augmentation procedures are popular treatment options for stability and pain relief. Preliminary studies have suggested that such procedures are adequately efficacious. However, the first randomized controlled trials (RCTs) published in the New England Journal of Medicine in 2009 showed that these procedures were not significantly different than placebo with regards to pain relief and quality of life. These studies were met with considerable criticism. The matter was further complicated when The Lancet published an RCT of its own that demonstrated the superiority of vertebroplasty over conservative management. The conflicting evidence has sparked ongoing debate in the medical community. All sides have provided arguments supported by evidence of varying strength and validity. To provide a concise and comprehensive presentation of the controversy surrounding vertebral augmentation procedures and the evidence cited by proponents on both sides of the debate. We began by researching the major randomized controlled trials both for and against vertebroplasty. These articles were already known to us, and were used as a starting point. We then performed a literature search in PubMed for articles dated from 2000 through 2012. The bibliographies of major articles and reviews were also cross-referenced for additional sources. A number of articles that included comprehensive and systematic reviews, meta-analyses, and commentaries about noted studies were found. These provided a broad, detailed overview of the subject. Many of the common themes of these articles included limitations in the design, methods, and patient selection with regard to the RCTs and other available studies. This review does not analyze the quality of evidence available nor does it provide an opinion in this regard. The conclusions of the present article are, therefore, general and descriptive in nature. The arguments presented by proponents of both sides of the debate appear to have validity. All of the major studies cited as evidence for or against vertebral augmentation procedures have limitations in their quality. Consequently, the debate cannot be concluded, convincingly, until more elaborate studies are conducted involving larger numbers of patients with clear procedure methods agreed upon by the major authorities in the field.
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