Consensus statement finds vertebroplasty and kyphoplasty equivalent for treating compression fractures

Practitioners can choose either vertebroplasty or kyphoplasty to treat vertebral compression fractures until a prospective trial comparing the two techniques says otherwise, according a multisociety position statement in the Journal of Vascular and Interventional Radiology. The statement does not fully address the economic impact of each treatment choice.

The American Society of Interventional and Therapeutic Neuroradiology, the Society of Interventional Radiology, the American Association of Neurological Surgeons/Congress of Neurological Surgeons, and the American Society of Spine Radiology endorsed the statement. It asserts that vertebroplasty and kyphoplasty are safe and efficacious procedures for the treatment of painful vertebral compression fractures caused by osteoporosis or tumors. Both techniques provide long-lasting benefits that are superior to the conservative management of these patients, as long as they are performed in accordance with published standards (J Vasc Interv Radiol 2007;18[3]:325-330).

More than 450 articles on vertebroplasty have been published since French interventionalists described their pioneering experience with the procedure in 1987. Available data for kyphoplasty are not as extensive, but the societies concluded that the clinical response rate in patients treated with either technique seems equivalent.

"Overall, most people doing both procedures feel the results are essentially the same," said Dr. Louis Gilula, a professor of radiology, orthopedics, and plastic and reconstructive surgery at Washington University's Mallinckrodt Institute of Radiology in St. Louis.

The societies' position statement, however, does not deal at length with the significant differences in cost between the two procedures. This issue will become more pressing as U.S. healthcare costs continue to rise, Gilula said.

"The reason I do not do more kyphoplasty is the extreme cost and the slightly increased time necessary to put in two needles at each level," he said.

According to Gilula, kyphoplasty costs about $3400 more per level than vertebroplasty. A letter published in the American Journal of Neuroradiology in 2004 by Dr. Mark E. Myers, an interventional neuroradiologist in St. Paul, MN, admits that kyphoplasty is more expensive and takes longer to perform than vertebroplasty. Additional equipment, anesthesia, and hospitalization costs account for the difference. Myers argues that kyphoplasty is preferable to vertebroplasty for patients with significant vertebral collapse, kyphosis greater than 20%, or disruption of the posterior vertebral cortex (Am J Neuroradio 2004;25[7]:11297).

Most specialists believe that vertebroplasty and kyphoplasty are equivalent, said Dr. David F. Kallmes, an interventional neuroradiologist at the Mayo Clinic in Rochester, MN. Kallmes' institution, however, performs mostly vertebroplasty procedures because they are simpler, faster, and cheaper, he said.

Results from two ongoing studies comparing both techniques could change that outlook, Kallmes said. The Kyphoplasty and Vertebroplasty in the Augmentation and Restoration of Vertebral Body Compression Fractures (KAVIAR) trial and the Cost Effectiveness and Efficacy of Kyphoplasty and Vertebroplasty Trial (CEET), sponsored by Kyphon Inc. (Glendale, CA) and the Mayo Clinic, respectively, are recruiting patients. Their results could be available by 2011.

"Maybe we will know in a few years," said Kallmes, who is also the principal investigator for the CEET trial.

The societies underwriting the position statement agree that some features could indicate which procedure is preferable. These features include the degree of compression deformity, fracture age, and presence of neoplastic disease. However, the benefits of kyphoplasty relative to vertebroplasty in such subgroups remain undefined, they wrote.

A literature review establishes vertebroplasty's complications rate at 1.3%, 2.5%, and 10% for osteoporosis, hemangiomas, and neoplastic disease, respectively. Since the clinical outcomes related to pain relief, mobility restoration, and complication rates between the two procedures are similar, the societies consider kyphoplasty a valid alternative to vertebroplasty.

But kyphoplasty should prove a substantial clinical benefit over vertebroplasty to justify its cost, the societies wrote. On the other hand, they acknowledged that the performance of either procedure depends on the operator's experience or preference.

The societies recommend that practitioners incorporate thresholds in their quality improvement programs to help identify potential problems. Physicians can follow the procedural guidelines set by the American College of Radiology's practice guideline for the performance of percutaneous vertebroplasty and the SIR's quality improvement guidelines for percutaneous vertebroplasty.

Although imperfect, Gilula believes that the societies' position statement should not be construed as misleading.

"It is an honest statement," he said.

For more information from the Diagnostic Imaging archives:

MSK interventions open burgeoning new field

Choice of fracture fixes spurs radiology debate

MSK imaging, intervention head for explosive growth

Researchers wrangle over vertebral compression fracture therapies

Large trial boosts vertebroplasty's worth