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Impact of Nonoperative Treatment, Vertebroplasty, and Kyphoplasty on Survival and Morbidity After Vertebral Compression Fracture in the Medicare Population
Andrew T. Chen, MPH1; David B. Cohen, MD, MPH1; Richard L. Skolasky, ScD1
1 c/o Elaine P. Henze, BJ, ELS, Medical Editor and Director, Editorial Services, Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, #A665, Baltimore, MD 21224-2780. E-mail address for R.L. Skolasky: ehenze1@jhmi.edu
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Investigation performed at the Bloomberg School of Public Health and the Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland

A commentary by John Glaser, MD, is linked to the online version of this article at jbjs.org.



Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Oct 02;95(19):1729-1736. doi: 10.2106/JBJS.K.01649
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Abstract

Background: 

The treatment of vertebral compression fractures with vertebral augmentation procedures is associated with acute pain relief and improved mobility, but direct comparisons of treatments are limited. Our goal was to compare the survival rates, complications, lengths of hospital stay, hospital charges, discharge locations, readmissions, and repeat procedures for Medicare patients with new vertebral compression fractures that had been acutely treated with vertebroplasty, kyphoplasty, or nonoperative modalities.

Methods: 

The 2006 Medicare Provider Analysis and Review File database was used to identify 72,693 patients with a vertebral compression fracture. Patients with a previous vertebral compression fracture, those who had had a vertebral augmentation procedure in the previous year, those with a diagnosis of malignant neoplasm, and those who had died were excluded, leaving 68,752 patients. The patients were stratified into nonoperative treatment (55.6%), vertebroplasty (11.2%), and kyphoplasty (33.2%) cohorts. Survival rates were compared with use of Kaplan-Meier analysis and Cox regression. Results were adjusted for potential confounding variables. Secondary parameters of interest were analyzed with the chi-square test (categorical variables) and one-way analysis of variance (continuous variables), with the level of significance set at p < 0.05.

Results: 

The estimated three-year survival rates were 42.3%, 49.7%, and 59.9% for the nonoperative treatment, vertebroplasty, and kyphoplasty groups, respectively. The adjusted risk of death was 20.0% lower for the kyphoplasty group than for the vertebroplasty group (hazard ratio = 0.80, 95% confidence interval, 0.77 to 0.84). Patients in the kyphoplasty group had the shortest hospital stay and the highest hospital charges and were the least likely to have had pneumonia and decubitus ulcers during the index hospitalization and at six months postoperatively. However, kyphoplasty was more likely to result in a subsequent augmentation procedure than was vertebroplasty (9.41% compared with 7.89%; p < 0.001).

Conclusions: 

Vertebral augmentation procedures appear to be associated with longer patient survival than nonoperative treatment does. Kyphoplasty tends to have a more striking association with survival than vertebroplasty does, but it is costly and may have a higher rate of subsequent vertebral compression fracture. These provocative findings may reflect selection bias and should be addressed in a prospective, direct comparison of methods to treat vertebral compression fractures.

Level of Evidence: 

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Christof Birkenmaier, MD
    Posted on October 03, 2013
    Automatic generation of a bias in treatment decisions
    Department of Orthopedic Surgery, University of Munich, Grosshadern Medical Center, Munich, Germany

    It is reassuring to read, that we are finally moving beyond the misleading conclusions from the flawed Buchbinder and Kallmes RCTs. While we are awaiting a correction of the AAOS recommendation predominantly based on these 2 studies (compare comment on J Bone Joint Surg Am, 2011 Oct 19;93(20):1934-1936. doi: 10.2106/JBJS.9320ebo), subsequent studies have demonstrated the beneficial effects of vertebroplasty (VP) and kyphoplasty (KP), when properly indicated. The research performed by Chen and colleagues is yet another strong argument into this direction. When discussing the difference in outcome between VP and KP, though, the authors of the study as well as Dr. Glaser in his Commentary, do not point out one obvious possible explanation for this difference: While VP can and will often be performed under local anesthesia, KP in the large majority of cases will require a general anesthesia. This automatically generates a bias in treatment decisions towards VP for those patients who carry the highest risk for a general anesthesia, such as those with severe COPD, for example. Mr. Chen's paper lists the unavailability of data on whether general anesthesia was used as a limitation of their analysis. Table I shows that the VP group was significantly older than the KP group and that the comorbidities were also more severe in this group. These data support the presence of such a bias and the difference observed between the VP and KP groups could very well be because the VP group contained more of the very ill patients than the KP group did.

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