Choice of fracture fixes spurs radiology debate

Increasing numbers of patients with vertebral compression fractures are being rushed to vertebroplasty, perhaps unnecessarily, say some interventional and musculoskeletal radiologists. While some specialists rejoice to see patients quickly relieved of their back pain, others warn that unnecessary procedures could become a burden for the healthcare system and patients.

The issue sparked debate at the 2006 International Skeletal Society meeting in Vancouver.

Cases involving acute fractures that need to be treated immediately are rare. But in the U.S., whenever a patient has an acute fracture, some physicians want it treated right away.

That may not be the smartest move, considering that a large number of these patients will get better after one or two weeks with just an appropriate dose of painkillers or other treatment alternatives, said Dr. Louis A. Gilula, a professor of radiology at the Mallinckrodt Institute of Radiology in St. Louis.

"I feel strongly that you should wait to get a lateral view of that fracture at least one week later. That could be a proper indication that we need to start moving faster," he said.

Not everyone agrees with his assessment. Clinical data show both kyphoplasty and vertebroplasty to be almost equally safe and effective for pain relief. Other specialists consider a palliative procedure better than no procedure at all in many cases.

"These patients are miserable. If they are coming into the emergency room, they are going to have to be admitted, placed on bed rest, and put on antibiotics for a certain period of time. If your goal is to make them feel better, then you want to get them out of the hospital and get them mobilized and off pain medicines. That's the approach we take in our institution," said Dr. David Disler, an interventional radiologist in Richmond.

But Gilula and others view this approach with concern. They fear the push to do away with the red tape could eventually spur a backlash against patients. Looming Medicare policy changes may force some to pay out of their own pockets for procedures that are more expensive and lack definitive long-term benefits, such as kyphoplasty, he said. But Disler contends that interventionalists-who have more control of their patients-should be treating them immediately.

"If these patients get to the ER and are referred to us, they are our patients from that point on. They follow up with us, and if they have problems, they usually come back to us. We are the ones who manage the care for that problem," he said.