Professional Statements and Societal Positions Guidelines
Practice Guidelines and Position Statements
Guidelines or position statements will be considered for inclusion in ‘Supplemental Information’ if they were issued by, or jointly by, a US professional society, an international society with US representation, or National Institute for Health and Care Excellence (NICE). Priority will be given to guidelines that are informed by a systematic review, include strength of evidence ratings, and include a description of management of conflict of interest.
American College of Radiology et al
The American College of Radiology (2014) and seven (7) other surgical and radiologic specialty associations published a joint position statement on percutaneous vertebral augmentation.30, This document stated that percutaneous vertebral augmentation, using vertebroplasty or kyphoplasty and performed in a manner consistent with public standards, is a safe, efficacious, and durable procedure in appropriate individuals with symptomatic osteoporotic and neoplastic fractures. The statement also indicated that these procedures be offered only when nonoperative medical therapy has not provided adequate pain relief, or pain is significantly altering the individual's quality of life.
A joint practice parameter for the performance of vertebral augmentation was updated in 2017.31,
Society of Interventional Radiology
In a quality improvement guideline on percutaneous vertebroplasty from the Society of Interventional Radiology (2014) vertebral augmentation was recommended for compression fractures refractory to medical therapy.30, Failure of medical therapy includes the following situations:
- Individuals who are "rendered non-ambulatory as a result of pain from a weakened or fractured vertebral body, pain persisting at a level that prevents ambulation despite 24 hours of analgesic therapy";
- Individuals with "sufficient pain from a weakened or fractured vertebral body that physical therapy is intolerable, pain persisting at that level despite 24 hours of analgesic therapy"; or
- Individuals with "a weakened or fractured vertebral body, unacceptable side effects such as excessive sedation, confusion, or constipation as a result of the analgesic therapy necessary to reduce pain to a tolerable level."
American Academy of Orthopaedic Surgeons
The American Academy of Orthopaedic Surgeons (2010) approved clinical guidelines on the treatment of osteoporotic spinal compression fractures, which had a weak recommendation for offering kyphoplasty to individuals who "present with an osteoporotic spinal compression fracture on imaging with correlating clinical signs and symptoms...and who are neurologically intact."32, The American Academy of Orthopaedic Surgeons indicated that future evidence could overturn existing evidence and that the quality of the current literature is poor. These recommendations were based on the literature reviewed through September 2009.
National Institute for Health and Care Excellence
The National Institute for Health and Care Excellence (2013) issued a guidance that recommended percutaneous vertebroplasty and percutaneous balloon kyphoplasty as treatment options for treating osteoporotic vertebral compression fractures in persons having severe, ongoing pain after a recent unhealed vertebral fracture, despite optimal pain management, and whose pain has been confirmed through physical exam and imaging at the level of the fracture.33, This guidance did not address balloon kyphoplasty with stenting, because the manufacturer of the stenting system (Synthes) stated there is limited evidence for vertebral body stenting given that the system had only recently become available.
The Institute (2008) issued guidance on the diagnosis and management of adults with metastatic spinal cord compression. It was last reviewed in 2014, and placed on the static list (no major ongoing studies identified, with the next review in 5 years).34, The guidance stated that vertebroplasty or kyphoplasty should be considered for individuals who have vertebral metastases, and no evidence of spinal cord compression or spinal instability if they have mechanical pain resistant to conventional pain management and vertebral body collapse. Surgery should only be performed when all appropriate specialists, agree. Despite a relatively small sample base, the Institute concluded the evidence suggests, in a select subset of individuals, that early surgery may be more effective at maintaining mobility than radiotherapy.