Vertebroplasty for vertebral fractureBMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d3470 (Published 12 July 2011) Cite this as: BMJ 2011;343:d3470
All rapid responses
While we agree with Dr Wilson that vertebroplasty cannot be
recommended as first line therapy,1 current evidence also does not support
any role. The combined data from the only two placebo controlled trials
performed to date found that vertebroplasty conferred no benefit over a
sham procedure, and this lack of benefit was consistent across a variety
of subgroups of patients including those who had symptoms for longer than
6 weeks.2 Most if not all published randomized controlled trials of
vertebroplasty for osteoporotic vertebral fractures have included
participants who have had inadequate pain relief with standard medical
therapy, i.e. have already demonstrated failure to respond to first line
therapy. In weighing up the relative merits of performing the procedure,
the editorial also failed to point out the potential harms of
We are also concerned that Dr Wilson's advice to administer local
anaesthetic and perhaps glucocorticoid injections in the region of the
pain as first line therapy seems premature at the very least in light of
the well-known risk of fracture with systemic glucocorticoids, and the
lack of any evidence from randomized controlled trials of the benefit of
these approaches. While his own prospective case series reported positive
results with facet joint injection of local anaesthetic and glucocorticoid
for people with vertebral fractures, these results need to be confirmed in
high quality randomized controlled trials, particularly as this treatment
has not been proven effective for low back pain.3 Open and uncontrolled
studies are highly likely to overestimate treatment benefit for a variety
of reasons not least of which is the favourable natural history of the
condition, and failure to take performance, detection and expectation bias
If any doubts remain about the role of vertebroplasty in the
management of osteoporotic vertebral fracture, it would be essential that
any additional randomized trial, even with "more tightly controlled
patient selection", blind the treatment allocation, the participants and
the investigators - which will necessitate the use of a sham or placebo
Monash Department of Clinical Epidemiology, Cabrini Institute and
Department of Epidemiology and Preventive Medicine, School of Public
Health and Preventive Medicine, Monash University, Melbourne, VIC
Centre for Research in Evidence-Based Practice, Faculty of Health
Sciences, Bond University, Gold Coast, QLD,
1. Wilson DJ. Vertebroplasty for vertebral fracture. BMJ
2. Staples MP, Kallmes DF, Comstock BA, Jarvik JG, Osborne RH, Heagerty
PJ, et al.
Effectiveness of vertebroplasty using individual patient data from two
randomised placebo controlled trials: meta-analysis. BMJ 2011;343:d3952.
3. Carette S, Marcoux S, Truchon R, Grondin C, Gagnon J, Allard Y, et al.
A controlled trial of corticosteroid injections into facet joints for
chronic low back pain. N Engl J Med. 1991; 325 (14):1002-1007.
Competing interests: R Buchbinder was an author of one of the placebo-controlled trials of vertebroplasty for osteoporotic vertebral fracture and an author on the individual patient data meta-analysis that appeared in the same issue of BMJ.
Need for clinicians to treat underlying osteoporosis in vertebral
Denys A Wahl(1), Cyrus Cooper(2), Steven Boonen(3)
1. Science manager at the International Osteoporosis Foundation,
2. Professor of rheumatology and director of the MRC Lifecourse
Epidemiology Unit at the University of Southampton and chair of
Musculoskeletal Science at the University of Oxford, UK
3. Professor of clinical gerontology and geriatric medicine, Division of
Gerontology and Geriatrics and Center for Musculoskeletal Research, Leuven
University Department of Experimental Medicine, Belgium
The benefits and remaining uncertainties of vertebroplasty are well
described in David Wilson's Editorial . Although prospective controlled
evidence is consistent with short-term clinical benefits in subgroups of
patients with vertebroplasty compared to non-surgical management , the
meta-analysis from Staples and colleagues [3-5] re-emphasizes the need for
further randomised controlled clinical trials using localised anaesthetics
as a control.
Regardless of the exact role of vertebral augmentation in treating
acute pain of spinal fractures, we would like to highlight some steps to
consider when responding to David Wilson's question: "what should a
physician do in the light of current evidence?"
A vertebral compression fracture signals a patient at particularly
high risk of subsequent fractures [6, 7] who should be managed
appropriately. Vertebral fractures have debilitating consequences  and
even increase the risk of death [9, 10]. Coordinated, multi-disciplinary
and systematic systems of care are being implemented worldwide, which
capture fracture patients and accompany them through diagnosis, treatment
and follow-up. These systems are cost-effective and can contribute
significantly to preventing recurrent fractures . In this multi-
disciplinary approach, a key objective is the treatment of the underlying
cause of vertebral fracture, which in most cases is osteoporosis.
Treatments do not prevent all fractures, but large-scale clinical trials
have demonstrated that osteoporosis therapies can reduce vertebral
fracture rates by 30-70% [12, 13]. However, patients are still being
missed and left undiagnosed, and untreated. In elderly hospitalised
patients who had a lateral chest radiograph, less than 50% of vertebral
fractures identified later on by X-rays were reported in the radiological
reports and even fewer in the medical records . Less than one fifth of
patients identified with vertebral fractures received appropriate
treatment for osteoporosis within the year following fracture [15, 16].
We thus urge all physicians to narrow this care gap.
1. Wilson DJ. Vertebroplasty for vertebral fracture BMJ 2011; (EDITOR
2. Boonen S, Wahl DA, Nauroy L, Brandi ML, Bouxsein ML, Goldhahn J, et al.
Balloon kyphoplasty and vertebroplasty in the management of vertebral
compression fractures. Osteoporos Int 2011; DOI 10.1007/s00198-011-1639-5
3. Staples MP, Kallmes DF, Comstock BA, Jarvik JG, Osborne RH, Heagerty P,
Buchbinder R. Effectiveness of vertebroplasty using individual patient
data from two randomised placebo controlled trials: meta-analysis. BMJ
2011; (EDITOR TO COMPLETE)
4. Buchbinder R, Osborne RH, Ebeling PR, Wark JD, Mitchell P, Wriedt C, et
al. A randomized trial of vertebroplasty for painful osteoporotic
vertebral fractures. N Engl J Med 2009; 361:557-68.
5. Kallmes DF, Comstock BA, Heagerty PJ, Turner JA, Wilson DJ, Diamond TH,
et al. A randomized trial of vertebroplasty for osteoporotic spinal
fractures. N Engl J Med 2009; 361:569-79.
6. Melton LJ 3rd, Atkinson EJ, Cooper C, O'Fallon WM, Riggs BL. Vertebral
fractures predict subsequent fractures. Osteoporos Int 1999; 10:214-221.
7. Lindsay R, Silverman SL, Cooper C, Hanley DA, Barton I, Broy SB, et al.
Risk of new vertebral fracture in the year following a fracture. JAMA
8. Oleksik A, Lips P, Dawson A, Minshall ME, Shen W, Cooper C, Kanis J.
Health-related quality of life (HRQOL) in postmenopausal women with low
BMD with or without prevalent vertebral fractures. J Bone Miner Res 2000;
9. Cauley JA, Thompson DE, Ensrud KC, Scott JC, Black D. Risk of mortality
following clinical fractures. Osteoporos Int 2000; 11:556-561.
10. Ismail AA, O'Neill TW, Cooper C, Finn JD, Bhalla AK, Cannata JB, et
al. Mortality associated with vertebral deformity in men and women:
results from the European Prospective Osteoporosis Study (EPOS).
Osteoporos Int 1998; 8:291-297.
11. Marsh D, ?kesson K, Beaton DE, Bogoch ER, Boonen S, Brandi ML, et al.
Coordinator-based systems for secondary prevention in fragility fracture
patients. Osteoporos Int 2011; 22:2051-2065
12. Compston J. Clinical and therapeutic aspects of osteoporosis. Eur J
Radiol 2009; 71: 388-91.
13. Boonen S, Kay R, Cooper C, Haentjens P, Vanderschueren D, Callewaert
F, et al. Osteoporosis management: a perspective based on bisphosphonate
data from randomised clinical trials and observational databases. Int J
Clin Pract 2009; 63:1792-804.
14. Majumdar SR, Kim N, Colman I, Chahal AM, Raymond G, Jen H, et al.
Incidental vertebral fractures discovered with chest radiography in the
emergency department: prevalence, recognition, and osteoporosis management
in a cohort of elderly patients. Arch Intern Med 2005; 165:905-909.
15. Giangregorio L, Papaioannou A, Cranney A, Zytaruk N, Adachi JD.
Fragility fractures and the osteoporosis care gap: an international
phenomenon. Semin Arthritis Rheum 2006; 35:293-305.
16. Elliot-Gibson V, Bogoch ER, Jamal SA, Beaton DE. Practice patterns in
the diagnosis and treatment of osteoporosis after a fragility fracture: a
systematic review. Osteoporos Int 2004; 15:767-78.
Competing interests: No competing interests