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Social responsibility in medical reporting
  1. Joshua A Hirsch1,
  2. Ariel E Hirsch2,
  3. Gregg H Zoarski3,
  4. Allan L Brook4,
  5. Jeffrey A Stone5,
  6. Donald V Heck6,
  7. Albert J Yoo1
  1. 1Department of Interventional Neuroradiology/Endovascular Neurosurgery, Massachusetts General Hospital, USA
  2. 2Boston Medical Center, Massachusetts General Hospital, USA
  3. 3Department of Diagnostic Imaging, University of Maryland Medical Center, USA
  4. 4Montefiore Medical Center, Bronx, NY USA
  5. 5Mayo Clinic Florida, USA
  6. 6Forsyth Radiological Associates, USA
  1. Correspondence to Joshua A Hirsch, Department of Interventional Neuroradiology/Endovascular Neurosurgery, Massachusetts General Hospital, 55 Fruit Street, Gray 241, Boston, MA 02114, USA; hirsch{at}snisonline.org

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On August 6, 2009, the New England Journal of Medicine (NEJM), arguably the world's most influential medical journal, published the results of two randomized controlled trials (RCTs) of vertebroplasty that demonstrated equivalence to a controlled intervention.1 2 Set against the backdrop of a heated national health care debate, these articles created a media frenzy and placed the NeuroInterventional community (amongst others) under immediate and intense scrutiny.

The articles sparked a sensationalistic and sometimes hostile debate in which vertebral augmentation specialists were called upon to comment, render opinions and seemingly “defend” their practice.3 4 Sadly for our patients, many of these responses were emotional, reactionary and antagonistic to evidence-based medicine (EBM)—an opportunity for a healthy and reasoned debate was lost.

The large body of evidence that supports the practice of vertebral augmentation cannot be easily dismissed. Practitioners of vertebral augmentation have seen countless patients with vertebral fractures who are hospitalized for intractable back pain and go home pain-free after injection of polymethylmethacrylate (PMMA) cement. Supporting this anecdotal experience are numerous large cohort analyses, both retrospective and prospective,5 6 as well as RCT evidence.7 Put simply, prior to the release of the NEJM articles, the vast majority of the existing thoughts, commentary and literature had supported vertebral augmentation in its various forms, attesting to the safety and apparent effectiveness of these treatments.8

Negative publicity also spilled over to discredit the growing practice of vertebral augmentation for malignant compression fractures. Sound bites or misinformed articles in the lay press following the release of the RCTs failed to mention that these studies excluded patients suffering from malignant compression fractures. Like their counterparts with benign osteoporotic compression fractures, cancer patients who were successfully treated with augmentation were likely confused by the reporting. Unfortunately, it is likely that many cancer patients had their referrals to augmentation specialists delayed or even canceled in the period surrounding release of these articles. Based on the growing body of evidence that supports the use of vertebral augmentation for malignant compression fractures,9 10 we believe strongly that augmentation should be included in the armamentarium of local palliative treatment options.

To its credit, the NEJM published a contemporaneous invited commentary by Dr James Weinstein,11 who is a well known and highly regarded orthopedic surgeon with acknowledged expertise in public policy.12 13 His editorial was a fair and cogent analysis of the trials which contained excellent discussion points on decision-making in health care. Dr Weinstein's commentary, however, did not address the positive 15-year US experience with augmentation, nor did it mention the limitations of the two RCTs. It therefore failed to place the new articles into their appropriate context.

It should be acknowledged that SNIS has supported the role of EBM in the development of clinical guidelines,14 and that members of our community had previously called for an RCT to study augmentation.15 Unfortunately, the manner in which the results of these studies were released moved the early discussion about these papers outside of the traditional scientific forum. In our view, the NEJM should have solicited commentary (under embargoed conditions) that reflected the opinions of well-regarded practitioners and content experts in order to provided a fair and balanced perspective on what reasonably could have been anticipated to be a hotly debated topic. In this way, the NEJM could have facilitated the balanced dispersal of information to various media outlets. Instead and not surprisingly, the results of these important studies became sensationalized.

In summary, Kallmes et al and Buchbinder et al should be commended for performing these two randomized controlled studies on vertebroplasty. However, the readers of the NEJM, as well as the public, would have been better served by an associated commentary citing the extensive and highly relevant existing literature on vertebral augmentation. The sensational media release was unfortunate, and provides an important learning opportunity for the medical community at large: Not only is it vital that medical practice be held to the rigors of scientific inquiry, but it is equally essential that there be social responsibility in the dissemination of medically relevant information.

References

Footnotes

  • Competing interests JS is a consultant and minor shareholder for CareFusion. The company makes products for vertebral augmentation. AB is a consultant for CareFusion. GZ is a consultant for Sotiera, Synthes, and a DeDuy course instructor.

  • Provenance and peer review Commissioned; not externally peer reviewed.