Doctors at odds over spine treatments

CHCF Center for Health ReportingMay 25, 2013 

Should doctors be injecting acrylic cement to fix broken vertebrae? It depends on whom you ask.

Since two studies were published in the New England Journal of Medicine in 2009 raising questions about the effectiveness of two minimally invasive spine treatments — vertebroplasty and kyphoplasty — a rift has emerged between national doctors' organizations about their value.

Don't do vertebroplasties at all, advises the American Academy of Orthopedic Surgeons, and the case for kyphoplasty "is very weak, at best."

Go ahead and do both, recommends the Society of Interventional Radiology, the procedures can produce "remarkable" results.

The medical community is awash in conflicting attitudes about the quality of the 2009 studies. Doctors on both sides offer strongly worded opinions about the effectiveness of the procedures for patients with spinal compression fractures due to osteoporosis.

Dr. Sean Tutton, a professor of radiology and surgery at the Medical College of Wisconsin in Milwaukee, and an expert on the treatments for the Society of Interventional Radiology, says the studies were designed "beautifully" but did not enroll enough participants.

Tutton, who has performed more than 2,000 of the procedures in the past decade, said he has seen "absolutely phenomenal results, where you take patients that are horribly debilitated, you treat them, and they're dramatically better."

'Safe and effective'

"In medicine, I always use that rule: What would you do for your mother, what would you do for your grandmother? In my heart of hearts, I believe these procedures are safe and effective," he said.

He notes that the United Kingdom's National Institute for Health and Care Guidance recently completed an exhaustive review of the literature and recommended using the two procedures to treat compression fractures.

That position is at odds with that of the American Academy of Orthopaedic Surgeons, which in 2010 completed a similar review before recommending against vertebroplasty.

Dr. Stephen Esses, an orthopedic spine surgeon in Houston and chairman of the committee that issued the recommendation, said, "I don't think there's one true, valid argument to suggest that the information from these studies isn't clear or reliable."

"All of us have access to the same information," said Esses. "Either we can choose to use that information wisely, or we can choose to ignore the information that's available."

Evidence lacking?

While the committee did not make a similar recommendation about kyphoplasty, Esses said the evidence of its effectiveness is "very weak."

Dr. David Kallmes, a professor of radiology at the Mayo Clinic in Rochester, Minn., who authored one of the 2009 studies that sparked the controversy, said that each year there are some 700,000 vertebral fractures in the United States — and that about 200,000 of them are treated with vertebroplasty or kyphoplasty.

When he began his research, Kallmes said he had done the procedures for years and fully expected to find they were effective at reducing pain and disabil- ity. He was shocked by the results.

For now, Kallmes said, he continues to perform the procedures on certain patients who have not responded well to a course of bed rest and pain medication. He believes the procedures merit further research.

"The study I did raised a lot of questions," he said.

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