New Clinical Practice Guidelines for Spinal Compression FracturesSurgeons from around the United States who are members of the American Academy of Orthopaedic Surgeons gathered together in 2010. Their goal was to review and analyze data from studies on the treatment of one particular spine problem. That condition is spinal fractures (in particular compression fractures) caused by osteoporosis.
Osteoporosis is a thinning of the bone associated with aging and other factors. The bone becomes brittle and fragile. Cracks in the bone further weaken the structure. The weight of the body on the spine is enough to cause the body of the vertebra (spinal bone) to compress down. That load combined with the weak bone structure leads to compression fractures.
In this article, the 13 members of the Academy panel who reviewed the results of treatment for symptomatic osteoporotic spinal compression fractures present their recommendation. There are 11 recommendations in all.
Symptomatic fracture is a key distinction here as many older adults have spinal compression fractures that are painless. In fact, they usually don't even know they have a fractured vertebra. The diagnosis is made when an X-ray is taken for something else and the damaged bone is seen for the first time.
Strength of evidence determines how strong the recommendation is. For example, high level evidence (level I) from high quality studies yields a strong, conclusive recommendation. Low-quality studies often provide inconclusive results and weak or inconclusive guidelines. Some studies produce mild-to-moderate strength of evidence to support a specific treatment recommendation.
And that's exactly happened with these guidelines. After looking over all the data and evidence so far, this panel found only one strong recommendation. There were four weak-to-moderate guidelines. More than half of the recommendations ended up being "inconclusive" -- just not enough evidence to say one way or the other.
Let's take a look at some of the specifics. The strong recommendation was against using a procedure known as vertebroplasty to treat the problem. Vertebroplasty is designed to restore the strength of the fractured bone, thereby reducing pain.
The surgeon squeezes special liquid cement into the broken bone. The cement hardens and strengthens and stiffens the vertebra. But this procedure doesn't restore the original height of the broken vertebra. Nor does it prevent the kyphosis (hunchback) deformity that sometimes results from compression fractures.
There were two high level (level I) studies comparing vertebroplasty to a sham (pretend) procedure. Three level II studies (no sham group) showed similar results: vertebroplasty did not give any better results in terms of pain relief when compared with a pretend treatment.
Instead of a vertebroplasty, the evidence supports the use of calcitonin. Calcitonin is a non-sex, non-steroid hormone. Calcitonin binds to osteoclasts (the bone cells that reabsorb bone). It decreases osteoclast numbers and activity levels. The end result is that it prevents bone from melting away. It doesn't build up missing bone but it at least keeps the bone that's there from being broken down and reabsorbed.
Calcitonin is available in a nasal spray and should be used for osteoporotic spinal fractures within five days of the injury. Calcitonin has been shown to relieve pain when tested in four different positions (e.g., in bed, sitting, standing, and walking).
If you know about vertebroplasty, you may be wondering about a similar procedure called kyphoplasty. For a kyphoplasty, the surgeon inserts a deflated balloon into the fractured and collapsed vertebral body.
Hydraulic pressure is used to inflate the balloon. The balloon is inflated until the vertebral body height is restored to normal or until the balloon is fully inflated. The balloon is then collapsed and removed. The empty space left by the inflated balloon is quickly filled in with cement that is injected into the area.
Does this procedure work better than a vertebroplasty? Is it among the practice guidelines? There was only weak evidence to support the use of kyphoplasty for symptomatic osteoporotic spinal compression fractures.
That's not necessarily because the procedure doesn't work -- the weakness of the evidence comes from the fact that the studies available were so different. The study design and measurement of outcomes looked at different things (e.g., acute versus chronic fractures, short versus long-term results, pain versus function), so they couldn't really be compared directly.
The other clinical practice guidelines for treatment of this condition had to do with other (nonoperative) approaches. Methods evaluated included the use of bracing, bed rest, complementary and alternative care, pain relievers, nerve root blocks, medications to slow/stop bone resorption, electrical stimulation, and exercise.
Most of these had weak evidence or inconclusive findings. The recommendation for most of these was the same: "We are unable to recommend for or against treatment" with X, Y, Z (insert name of modality here)."
With so little evidence to support so many different approaches to the problem, there's room for many future studies. Good, quality research is clearly needed in this area. Surgeons evaluating and treating patients with pain from vertebral compression fractures need to know what works and when to use it.
There's plenty of evidence that pain doesn't necessarily come from these fractures. Many people with confirmed compression fractures (as seen on X-rays) don't have any pain at all. It's not clear that the bone fracture is the true cause of pain for anyone with this condition who does have pain.
While we wait for proper, reliable evidence, patients are looking for some answers. Surgeons want to provide them with fast and effective pain relief that will improve their function and help them maintain their independence. Trial and error may continue as the main means of finding the best treatment for each person until better evidence is available.
Patients who have serious neurologic symptoms (numbness, weakness, paralysis, even death) from pressure on the spinal cord or spinal nerve roots need more than hope for future research. They need immediate emergency care. Unfortunately, the panel was unable to recommend for or against any specific treatment for these folks either.
Stephen I. Esses, MD, et al. The Treatment of Symptomatic Osteoporotic Spinal Compression Fractures. In Journal of the American Academy of Orthopaedic Surgeons. March 2011. Vol. 19. No. 3. Pp. 176-182.
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