PRACTICE PERSPECTIVES Critique of the Analysis of UpToDate.com on the Treatment of Painful Vertebral Compression Fractures: Time to Update UpToDate

SUMMARY: The treatment of painful vertebral compression fractures has changed substantially since the introduction of vertebroplasty in the mid-1980s and balloon kyphoplasty in the late 1990s. Both procedures were widely accepted with the vertebral fractures treated reaching 150,000 per annum in 2009 prior to the publication of 2 randomized controlled trials comparing vertebroplasty with a sham treatment published in the New England Journal of Medicine in August 2009. Since then, there has been a flood of information on vertebral augmentation and balloon kyphoplasty. It is worth evaluating this information especially because it relates to current recommendations that are often followed blindly by medical and administrative groups unfamiliar with either the procedure or the high level of evidence surrounding vertebral augmentation. To streamline the evaluation of some current recommendations, we limited the analysis to the recommendations found on UpToDate.com. This Web site is an evidence-based, peer-reviewed source of information available for patients, doctors, health insurance companies, and population-based medical decision-making. ABBREVIATIONS: BKP balloon kyphoplasty; NSM nonsurgical management; VA vertebral augmentation; VCF vertebral compression fracture; VP vertebroplasty The treatment of painful vertebral compression fractures (VCFs) has changed substantially since the introduction of vertebroplasty in the mid-1980s. The advent of balloon kyphoplasty in the late 1990s represented a new variation of the procedure by using balloons to reduce the vertebral fracture and create a void within the vertebral body. Both procedures were widely accepted with vertebral fractures treated reaching 150,000 per annum in 2009 before the publication of 2 randomized controlled trials comparing vertebroplasty with a sham treatment published in the New England Journal of Medicine in August 2009. The publication of the trials generated a substantial controversy because the results seemed to fly in the face of clinical experience; consequently, numerous societies and physician groups issued statements commenting on the conclusions of the studies. The Society of Interventional Radiology and the North American Spine Society issued statements commenting on the trials with the Society of Interventional Radiology stating that “based on the ... weakness in the studies and the degree of discordance between the outcomes of these studies, prior studies and experience, we believe it is premature—and possibly incorrect—to conclude that vertebroplasty is no better than a control sham procedure” and the North American Spine Society stating that “[b]eyond the lay press releases which claim ‘Vertebroplasty found to be useless for osteoporotic fracture and disk pain,’ it is time for cooler heads to prevail. The medical literature thirsts for evidence. The data from these two studies must be considered carefully and thoughtfully.... More practical conclusions should be made based on a thorough and systematic review of all the literature to better define the subgroup of patients for which vertebroplasty might be