ACR Appropriateness Criteria Management of Vertebral Compression Fractures

doi:10.1016/j.jacr.2014.04.011

Journal of the American College of Radiology

Volume 11, Issue 8, August 2014, Pages 757-763

https://doi.org/10.1016/j.jacr.2014.04.011 Get rights and content

This is an updated review of management of vertebral compression fracture for both benign osteoporotic and malignant causes. Vertebral compression fracture radiologic imaging evaluation is discussed. A literature review is provided of current indications for vertebral augmentation with percutaneous vertebroplasty and kyphoplasty as well as medical management. Limitations and potential benefits of these procedures are discussed. Variant tables describing various clinical situations are also provided to assist in determining appropriate use of these treatments for patient care.

The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to formulate recommendations for imaging or treatment.

Section snippets

Summary

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Conservative management is the traditional first-line management for osteoporotic compression fractures.
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Use of vertebral augmentation is controversial, owing to two previous independent level-1 trials that demonstrated no clinical validity for VP over the sham control groups. Conclusions from these studies have divided the medical community with respect to the efficacy of vertebral augmentation.
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Despite this controversy, increased use of vertebral augmentation for managing painful osteoporotic

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Monovalent cations, Cs⁺, and alkylammonium ([NR₄]⁺) salts have traditionally been used to precipitate the anions of boranes, carborane and metallocarborane clusters. In contrast, in the body and in living organisms in general, divalent cations have a special relevance. In this work, we isolate for the first time the cobaltabis(dicarbollide) salts of the biocompatible divalent cations of biological importance that can have application both in biology and in materials science. The preparation of Ca²⁺, Mg²⁺ and Fe²⁺ salts of anionic iodinated nido-[C₂B₉H₁₂]⁻ and cobaltabis(dicarbollide) as well as its di-, tetra- and octa-iodinated derivatives are reported. Ca²⁺ and Mg²⁺ are hard Lewis acids and thus forms aqua ions if water is present in the synthetic process. All solid Ca²⁺ and Mg²⁺ salts studied in this work contained water molecules coordinated that have been detected by IR and TGA/DSC. Fe²⁺ is a medium hard Lewis acid and Fe³⁺ is a hard one. In acetone they do not coordinate to cobaltabis(dicarbollide) anion, but are solvated by acetone. The studied Ca²⁺ salts of iodinated cobaltabis(dicarbollide) are basically inorganic small molecules that provide at once the biocompatible divalent Ca²⁺ cation and and iodinated anions thus simultaneously providing an X-ray contrast agent and/or bone defect repairing agent in regenerative medicine.
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This is due to an average per-procedure payment of $3,212 in 2018 which was more than double that for orthopedic surgery and almost four times that for radiology and neurosurgery. This was due in large part to the shift to more office-based procedures performed by anesthesia and pain management which were reimbursed at the nonfacility rate, as discussed above [18]. Limitations include the retrospective and observational nature of this study.
In 2010, the American Academy of Orthopedic Surgeons published guidelines strongly recommending against the use of vertebroplasty following the publication of randomized control trials that failed to show significant improvement in pain. Vertebroplasty has remained controversial since those findings.
To study and provide an update on utilization of vertebroplasty and kyphoplasty procedures among Medicare beneficiaries by physician specialty and practice setting following publication of recommendations against vertebroplasty in 2010.
This study uses Medicare Part B Physician/Supplier Procedure Summary Master File (PSPSMF) for the years 2010 to 2018 to determine trends in volume and reimbursement by physician specialty and practice setting.
All vertebral augmentation procedures with a physician reimbursement claims approved by Medicare Part B from 2010 to 2018.
This study analyzes trends in volume and physician payment of vertebroplasty and kyphoplasty procedures by physician specialty for the time period 2010 to 2018.
Claims from the Medicare Part B PSPSMF for the years 2010 to 2018 were extracted using the Current Procedural Terminology codes for vertebroplasty and kyphoplasty. Total volumes, payment amounts (professional component), and trends were analyzed by physician specialty.
Between 2010 and 2018, the total volume of vertebroplasties decreased by 61.2% (29,995 to 11,654), whereas the volume of kyphoplasties increased modestly by 14.4% (59,691 to 68,294). Radiologists performed an increasing share of both procedures over this time period, from 68.5% to 75.1% for vertebroplasties and 28.9% to 37.1% for kyphoplasties.
Total payment for vertebroplasties decreased by 74.3% from $14.8 million in 2010 to $3.8 million in 2018; whereas it increased by 235.3% for kyphoplasty procedures from $26.7 million to $89.7 million. This is driven in large part by a 6,833% increase in office based kyphoplasties which bill at the higher nonfacility rate that incorporates overhead, staff, and equipment.
Previous studies have demonstrated mixed evidence for benefits of vertebroplasty procedures and decreasing volumes over time. Data show continued downtrend in vertebroplasty and increased utilization of kyphoplasty among Medicare beneficiaries. In addition, the growing number of kyphoplasties correlated with a sharp rise in volume and increased reimbursement for office-based procedures. Radiologists have been performing an increasing share of both procedures.
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In this retrospective study, 260 vertebral bodies from 30 patients (11 males, 19 females, mean age of 81) were assessed by MRI and dual-energy material density analysis. Diagnostic accuracy was assessed using the receiver operating characteristic (ROC) curve. Fifty-two of the 260 vertebral bodies were considered to have BME based on the dual-energy material density analysis images; 50 were deemed to have BME by MRI.
ROC analysis of the dual-energy material density analysis values revealed an area under the ROC curve of 0.95 for radiologist 1, 0.97 for radiologist 2, and 0.96 for radiologist 3. A mean cutoff value of 1032.6 mg/cm³ provided an overall sensitivity of 93.0% (95% confidence intervals [CI]: 86.0%–99.9%), specificity of 98.0% (95% CI: 95.5%–99.0%), accuracy of 97.0% (95% CI: 95.2%–99.0%), positive predictive value of 95.0% (95% CI: 81.0%–97.5%), and negative predictive value of 98.0% (95% CI: 93.0%–99.9%).
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: Reprint requests to: [email protected].

: The ACR seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document. No conflict of interest was reported.

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Original articleACR Appropriateness Criteria Management of Vertebral Compression Fractures

Section snippets

Summary

J Vasc Interv Radiol

Spine J

Spine J

Acad Radiol

Surg Neurol

Pain

Bone

J Vasc Interv Radiol

J Vasc Interv Radiol

Spine J

Lancet

Lancet

Spine J

Neurologia i Neurochirurgia Polska

Lancet Oncology

Percutaneous vertebroplasty

Radiology

Epidemiology, etiology, and diagnosis of osteoporosis

Am J Obstet Gynecol

The effect of age and bone mineral density on the absolute, excess, and relative risk of fracture in postmenopausal women aged 50-99: results from the National Osteoporosis Risk Assessment (NORA)

Osteoporos Int

Percutaneous vertebroplasty compared to conservative treatment in patients with painful acute or subacute osteoporotic vertebral fractures: three-months follow-up in a clinical randomized study

Spine (Phila Pa 1976)

Twelve-months follow-up in forty-nine patients with acute/semiacute osteoporotic vertebral fractures treated conservatively or with percutaneous vertebroplasty: a clinical randomized study

Spine (Phila Pa 1976)

Trends of inpatient spine augmentation: 2001-2008

AJNR Am J Neuroradiol

Percutaneous vertebroplasty for pain management in malignant fractures of the spine with epidural involvement

Radiology

Misoprostol reduces serious gastrointestinal complications in patients with rheumatoid arthritis receiving nonsteroidal anti-inflammatory drugs. A randomized, double-blind, placebo-controlled trial

Ann Intern Med

NSAID-induced gastroduodenal damage: Is prevention needed? A review and metaanalysis

J Clin Gastroenterol

A randomized trial of vertebroplasty for osteoporotic spinal fractures

N Engl J Med

Clinical profile of acute vertebral compression fractures in osteoporosis

Br J Rheumatol

Percutaneous vertebroplasty in the treatment of osteoporotic vertebral compression fractures: an open prospective study

J Rheumatol

Percutaneous vertebroplasty: state of the art

Radiographics

Percutaneous vertebroplasty in the treatment of osteoporotic compression fractures

Neuroimaging Clin N Am

Percutaneous polymethylmethacrylate vertebroplasty in the treatment of osteoporotic vertebral body compression fractures: technical aspects

AJNR Am J Neuroradiol

Value of immediate preprocedure magnetic resonance imaging in patients scheduled to undergo vertebroplasty or kyphoplasty

Spine (Phila Pa 1976)

Point of view. Efficacy of vertebroplasty and kyphoplasty

Spine (Phila Pa 1976)

Trauma of the spine and spinal cord: imaging strategies

Eur Spine J

Impact of magnetic resonance imaging on decision making for thoracolumbar traumatic fracture diagnosis and treatment

Eur Spine J

Original article
ACR Appropriateness Criteria Management of Vertebral Compression Fractures