Percutaneous vertebroplasty for osteoporotic vertebral compression fracture

  • Review
  • Intervention

Authors

  • Rachelle Buchbinder,

    Corresponding author
    1. Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Monash Department of Clinical Epidemiology, Cabrini Institute, Malvern, Victoria, Australia
    • Rachelle Buchbinder, Monash Department of Clinical Epidemiology, Cabrini Institute, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, 4 Drysdale Street, Malvern, Victoria, 3144, Australia. rachelle.buchbinder@monash.edu.

  • Renea V Johnston,

    1. Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Monash Department of Clinical Epidemiology, Cabrini Hospital, Malvern, Victoria, Australia
  • Kobi J Rischin,

    1. Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Monash Department of Clinical Epidemiology, Cabrini Hospital, Malvern, Victoria, Australia
  • Joanne Homik,

    1. University of Alberta, Department of Medicine, Edmonton, AB, Canada
  • C Allyson Jones,

    1. University of Alberta, Department of Physical Therapy, Faculty of Rehabilitation Medicine, Edmonton, AB, Canada
  • Kamran Golmohammadi,

    1. University of British Columbia, School of Population and Public Health, Vancouver, British Columbia, Canada
  • David F Kallmes

    1. Mayo Clinic, Department of Diagnostic Radiology, Rochester, MN, USA

Abstract

Background

Percutaneous vertebroplasty remains widely used to treat osteoporotic vertebral fractures although our 2015 Cochrane review did not support its role in routine practice.

Objectives

To update the available evidence of the benefits and harms of vertebroplasty for treatment of osteoporotic vertebral fractures.

Search methods

We updated the search of CENTRAL, MEDLINE and Embase and trial registries to 15 November 2017.

Selection criteria

We included randomised and quasi-randomised controlled trials (RCTs) of adults with painful osteoporotic vertebral fractures, comparing vertebroplasty with placebo (sham), usual care, or another intervention. As it is least prone to bias, vertebroplasty compared with placebo was the primary comparison. Major outcomes were mean overall pain, disability, disease-specific and overall health-related quality of life, patient-reported treatment success, new symptomatic vertebral fractures and number of other serious adverse events.

Data collection and analysis

We used standard methodologic procedures expected by Cochrane.

Main results

Twenty-one trials were included: five compared vertebroplasty with placebo (541 randomised participants), eight with usual care (1136 randomised participants), seven with kyphoplasty (968 randomised participants) and one compared vertebroplasty with facet joint glucocorticoid injection (217 randomised participants). Trial size varied from 46 to 404 participants, most participants were female, mean age ranged between 62.6 and 81 years, and mean symptom duration varied from a week to more than six months.

Three placebo-controlled trials were at low risk of bias and two were possibly susceptible to performance and detection bias. Other trials were at risk of bias for several criteria, most notably due to lack of participant and personnel blinding.

Compared with placebo, high- to moderate-quality evidence from five trials (one with incomplete data reported) indicates that vertebroplasty provides no clinically important benefits with respect to pain, disability, disease-specific or overall quality of life or treatment success at one month. Evidence for quality of life and treatment success was downgraded due to possible imprecision. Evidence was not downgraded for potential publication bias as only one placebo-controlled trial remains unreported. Mean pain (on a scale zero to 10, higher scores indicate more pain) was five points with placebo and 0.6 points better (0.2 better to 1 better) with vertebroplasty, an absolute pain reduction of 6% (2% better to 10% better, minimal clinical important difference is 15%) and relative reduction of 9% (3% better to14% better) (five trials, 535 participants). Mean disability measured by the Roland-Morris Disability Questionnaire (scale range zero to 23, higher scores indicate worse disability) was 14.2 points in the placebo group and 1.7 points better (0.3 better to 3.1 better) in the vertebroplasty group, absolute improvement 7% (1% to 14% better), relative improvement 10% better (3% to 18% better) (three trials, 296 participants).

Disease-specific quality of life measured by the Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO) (scale zero to 100, higher scores indicating worse quality of life) was 62 points in the placebo group and 2.75 points (3.53 worse to 9.02 better) in the vertebroplasty group, absolute change: 3% better (4% worse to 9% better), relative change: 5% better (6% worse to 15% better (two trials, 175 participants). Overall quality of life (European Quality of Life (EQ5D), zero = death to 1 = perfect health, higher scores indicate greater quality of life) was 0.38 points in the placebo group and 0.05 points better (0.01 better to 0.09 better) in the vertebroplasty group, absolute improvement: 5% (1% to 9% better), relative improvement: 18% (4% to 32% better) (three trials, 285 participants). In one trial (78 participants), 9/40 (or 225 per 1000) people perceived that treatment was successful in the placebo group compared with 12/38 (or 315 per 1000; 95% CI 150 to 664) in the vertebroplasty group, RR 1.40 (95% CI 0.67 to 2.95), absolute difference: 9% more reported success (11% fewer to 29% more); relative change: 40% more reported success (33% fewer to 195% more).

Moderate-quality evidence (low number of events) from seven trials (four placebo, three usual care, 1020 participants), up to 24 months follow-up, indicates we are uncertain whether vertebroplasty increases the risk of new symptomatic vertebral fractures (70/509 (or 130 per 1000; range 60 to 247) observed in the vertebroplasty group compared with 59/511 (120 per 1000) in the control group; RR 1.08 (95% CI 0.62 to 1.87)).

Similarly, moderate-quality evidence (low number of events) from five trials (three placebo, two usual care, 821 participants), indicates uncertainty around the risk of other serious adverse events (18/408 or 76 per 1000, range 6 to 156) in the vertebroplasty group compared with 26/413 (or 106 per 1000) in the control group; RR 0.64 (95% CI 0.36 to 1.12). Notably, serious adverse events reported with vertebroplasty included osteomyelitis, cord compression, thecal sac injury and respiratory failure.

Our subgroup analyses indicate that the effects did not differ according to duration of pain ≤ 6 weeks versus > 6 weeks. Including data from the eight trials that compared vertebroplasty with usual care in a sensitivity analyses altered the primary results, with all combined analyses displaying considerable heterogeneity.

Authors' conclusions

Based upon high- to moderate-quality evidence, our updated review does not support a role for vertebroplasty for treating acute or subacute osteoporotic vertebral fractures in routine practice. We found no demonstrable clinically important benefits compared with placebo (sham procedure) and subgroup analyses indicated that the results did not differ according to duration of pain ≤ 6 weeks versus > 6 weeks.

Sensitivity analyses confirmed that open trials comparing vertebroplasty with usual care are likely to have overestimated any benefit of vertebroplasty. Correcting for these biases would likely drive any benefits observed with vertebroplasty towards the null, in keeping with findings from the placebo-controlled trials.

Numerous serious adverse events have been observed following vertebroplasty. However due to the small number of events, we cannot be certain about whether or not vertebroplasty results in a clinically important increased risk of new symptomatic vertebral fractures and/or other serious adverse events. Patients should be informed about both the high- to moderate-quality evidence that shows no important benefit of vertebroplasty and its potential for harm.

Plain language summary

Vertebroplasty for treating spinal fractures due to osteoporosis

Background

Osteoporosis is characterised by thin, fragile bones and may result in minimal trauma fractures of the spine bones (vertebrae). They can cause severe pain and disability.

Vertebroplasty involves injecting medical-grade cement into a fractured vertebra, under light sedation or general anaesthesia. The cement hardens in the bone space to form an internal cast.

Study characteristics

This Cochrane review is current to November 2017. Studies compared vertebroplasty versus placebo (no cement injected) (five studies, 541 participants); usual care (eight studies, 1136 participants); kyphoplasty (similar, but before cement is injected a balloon is expanded in the fractured vertebra; seven studies, 968 participants) and facet joint steroid injection (one study, 217 participants). Trials were performed in hospitals in 15 countries, the majority of participants were female, mean age ranged between 63.3 and 80 years, and symptom duration ranged from a week to six months or more. Eight trials received at least some funding from medical device manufacturers and only two reported that they had no role in the trial.

Key results

Compared with a placebo (fake) procedure, vertebroplasty resulted in little benefit at one month:

Pain (lower scores mean less pain)

Improved by 6% (2% better to 10% better), or 0.6 points (0.2 better to 1.0 better) on a zero-0 to 10-point scale.

• People who had vertebroplasty rated their pain as 4.4 points.

• People who had placebo rated their pain as 5 points.

Disability (lower scores mean less disability)

Improved by 7% (1% better to 14% better), or 1.7 points (0.3 better to 3.1 better) on a zero to 23-point scale.

• People who had vertebroplasty rated their disability as 12.5 points.

• People who had placebo rated their disability as 14.2 points.

Vertebral fracture or osteoporosis-specific quality of life (lower scores mean better quality of life)

Better by 3% (4% worse to 9% better), or 2.75 points better (3.53 worse to 9.02 better) on a zero to 100-point scale.

.• People who had vertebroplasty rated their quality of life related to their fracture as 59.25 points.

• People who had placebo rated their quality of life related to their fracture as 62 points.

Overall quality of life (higher scores mean better quality of life)

Improved by 5% (1% better to 9% better), or 0.05 units (0.01 better to 0.09 better) on a zero = death to one = perfect health scale.

• People who had vertebroplasty rated their general quality of life as 0.43 points.

• People who had placebo rated their general quality of life as 0.38 points.

Treatment success (defined as pain moderately or a great deal better)

9% more people rated their treatment a success (11% fewer to 29% more), or nine more people out of 100.

• 32 out of 100 people reported treatment success with vertebroplasty.

• 23 out of 100 people reported treatment success with placebo.

Compared with a placebo or usual care:

New symptomatic vertebral fractures (at 12 to 24 months)

1% more new fractures with vertebroplasty (7% fewer to 9% more), or one more person out of 100.

• 13 out of 100 people had a new fracture with vertebroplasty.

• 12 out of 100 people had a new fracture with placebo or usual care.

Other serious adverse events:

1% fewer people (5% fewer to 3% more), had other serious adverse events with vertebroplasty; relative change 36% fewer (64% fewer to 12% more).

• eight out of 100 people reported other serious adverse events with vertebroplasty.

• 11 out of 100 people reported other serious adverse events with placebo.

Quality of the evidence

High-quality evidence shows that vertebroplasty does not provide more clinically important benefits than placebo. We are less certain of the risk of new vertebral fractures or other serious effects; quality was moderate due to the small number of events.

Serious adverse events that may occur include spinal cord or nerve root compression due to cement leaking out from the bone, cement leaking into the blood stream, rib fractures, infection in the bone, fat leaking into the bloodstream, damage to the covering of the spinal cord that could result in leakage of cerebrospinal fluid, anaesthetic complications and death.

Ringkasan bahasa mudah

‘Vertebroplasty’ untuk merawat fraktur spina akibat osteoporosis

Latar belakang

Osteoporosis adalah berciri tulang yang nipis, rapuh dan boleh menyebabkan fraktur trauma minimal tulang belakang (vertebra). Ia boleh menyebabkan sakit yang teruk dan hilang upaya.

‘Vertebroplasty’ melibatkan suntikan simen gred perubatan ke dalam vertebra yang fraktur, di bawah sedasi ringan atau anestesia umum. Simen tersebut mengeras di dalam ruang tulang untuk membentuk sebuah acuan dalaman.

Ciri-ciri kajian

Ulasan Cochrane ini adalah terkini sehingga November 2017. Kajian-kajian tersebut membandingkan ‘vertebroplasty’ dengan plasebo (tiada simen disuntik) (lima kajian, 541 peserta); penjagaan biasa (lapan kajian, 1136 peserta); ‘kyphoplasty’ (sama caranya, tetapi sebiji belon dikembangkan dalam vertebra sebelum simen disuntik; tujuh kajian, 968 peserta) dan suntikan steroid ke facet sendi (satu kajian, 217 peserta). Kajian-kajian dijalankan di hospital-hospital di 15 buah negara, majoriti peserta adalah wanita, purata umur di antara 63.3 dan 80 tahun dan tempoh gejala adalah dari seminggu hingga 6 bulan atau lebih. Lapan kajian menerima dana daripada para pengilang peranti perubatan dan hanya dua melaporkan mereka tidak terlibat dalam kajian tersebut.

Keputusan utama

Berbanding dengan prosedur plasebo (palsu), ‘vertebroplasty’ hanya menghasilkan sedikit manfaat pada tempoh satu bulan:

Kesakitan (skor lebih rendah bermakna kurang sakit)

Telah menambahbaik sebanyak 6% (dari 2% lebih baik ke 10% lebih baik), atau 0.6 mata (dari 0.2 lebih baik ke 1.0 lebih baik) pada skala kosong-0 hingga 10-mata.

.• Orang yang menerima ‘vertebroplasty’ menilai sakit mereka sebanyak 4.4 mata.

• Orang yang menerima plasebo menilai sakit mereka sebanyak 5 mata.

Hilang upaya (skor lebih rendah bermakna kurang kehilangan upaya)

Menambahbaik sebanyak 7% (dari 1% lebih baik ke 14% lebih baik), atau 1.7 mata (dari 0.3 lebih baik ke 3.1 lebih baik) pada skala 23-mata.

• Orang yang menerima ‘vertebroplasty’ menilai tahap hilang upaya mereka sebagai 12.5 mata.

• Orang yang menerima plasebo menilai tahap hilang upaya mereka sebagai 14.2 mata.

Keretakan tulang vertebra atau kualiti hidup dengan osteoporosis (markah lebih rendah bermakna kualiti hidup yang lebih baik)

Menambahbaik sebanyak 3% (dari 4% lebih teruk ke 9% lebih baik), atau menambahbaik sebanyak 2.75 mata (3.53 lebih buruk ke 9.02 lebih baik) pada skala 100-mata.

. • Orang yang menerima ‘vertebroplasty’ menilai kualiti hidup mereka yang dikaitkan dengan fraktur sebagai 59.25 mata.

• Orang yang menerima plasebo menilai kualiti hidup mereka yang dikaitkan dengan fraktur sebagai 62 mata.

Kualiti hidup keseluruhan (skor lebih tinggi bermakna kualiti hidup lebih baik)

Telah menambahbaik 5% (1% lebih baik hingga 9% lebih baik), atau 0.05 unit (0.01 lebih baik hingga 0.09 lebih baik)pada skala kosong = kematian hingga seorang pesakit = sempurna sihat.

• Orang yang menerima ‘vertebroplasty’ menilai kualiti hidup keseluruhan mereka sebagai 0.43 mata.

• Orang yang menerima plasebo menilai kualiti hidup keseluruhan mereka sebagai 0.38 mata.

Kejayaan rawatan (ditakrifkan sebagai kesakitan sederhana atau penambahbaikan yang banyak)

Lebih sebanyak 9% pesakit menilai rawatan mereka berjaya (11% kurang ke 29% lebih banyak), atau lebih sebanyak sembilan daripada 100 orang pesakit.

• 32 daripada 100 orang pesakit melaporkan kejayaan rawatan dengan ‘vertebroplasty’.

• 23 daripada 100 orang pesakit melaporkan kejayaan rawatan dengan plasebo.

Berbanding dengan plasebo atau rawatan biasa:

Fraktur tulang dengan gejala yang baharu (pada 12 hingga 24 bulan)

Lebih 1% fraktur tulang baru dengan ‘vertebroplasty’ (dari 7% kurang ke 9% lebih banyak), atau sebanyak lebih dari seorang daripada 100 orang.

• 13 daripada 100 orang mendapat fraktur baharu dengan ‘vertebroplasty’.

• 12 daripada 100 orang mendapat fraktur tulang yang baharu dengan plasebo atau penjagaan biasa.

Peristiwa buruk serius yang lain:

Kurang 1% orang (dari 5% kurang ke 3% lebih banyak), mengalami peristiwa buruk serius yang lain dengan ‘vertebroplasty’; peubahan relatif 36% (dari 64% kurang ke 12% lebih banyak) .

• lapan daripada 100 orang melaporkan peristiwa buruk serius lain dengan ‘vertebroplasty’.

• 11 daripada 100 orang melaporkan peristiwa buruk serius lain dengan plasebo.

Kualiti bukti

Bukti berkualiti tinggi menunjukkan ‘vertebroplasty’ tidak memberi lebih banyak manfaat klinikal yang penting berbanding plasebo. Kami kurang pasti risiko fraktur tulang vertebra baharu atau kesan sampingan serius lain; kualiti adalah sederhana kerana bilangan kecil peristiwa.

Peristiwa buruk serius yang mungkin berlaku termasuklah pemampatan saraf tunjang atau akar akibat kebocoran simen dari tulang, kebocoran simen ke dalam aliran darah, fraktur tulang rusuk, jangkitan tulang, kebocoran lemak ke dalam aliran darah, kerosakan lapisan luar saraf tunjang yang boleh mengakibatkan kebocoran cecair cerebrospinal, komplikasi anaesthetic dan kematian.

Catatan terjemahan

Diterjemahkan oleh Zcho Huey Lee (Penang Medical College). Disunting oleh Noorliza Mastura Ismail (Kolej Perubatan Melaka-Manipal). untuk sebarang pertanyaan berkaitan terjemahan ini, sila hubungi zchohuey_c2017@ms.pmc.edu.my