Elsevier

The Spine Journal

Volume 11, Issue 8, August 2011, Pages 737-744
The Spine Journal

Clinical Study
Kyphoplasty and vertebroplasty: trends in use in ambulatory and inpatient settings

https://doi.org/10.1016/j.spinee.2011.07.002Get rights and content

Abstract

Background context

Vertebral compression fractures (VCFs) are a substantial health concern. Kyphoplasty (KP) and vertebroplasty (VP) are vertebral augmentation procedures (VAPs) used to treat VCFs.

Purpose

To compare VP and KP patient demographics and evaluate inpatient and outpatient utilization trends.

Study design

Retrospective analysis of patient demographics, and inpatient and outpatient utilization trends, from California, New York, and Florida inpatient and ambulatory discharge databases.

Methods

Hospitalizations for VP and KP were identified from California, New York, and Florida inpatient and ambulatory discharge databases from 2005 to 2008. International Classification of Diseases, Ninth Revision diagnosis codes for pathologic, dorsal, and lumbar fracture of vertebrae were cross-referenced with ICD-9 procedure codes and Current Procedural Terminology codes to select the population. Patients younger than 40 years or those who underwent both procedures were excluded.

Results

The final population contained 61,851 VAPs (35,805 KPs and 26,046 VPs). Kyphoplasty showed increased inpatient and outpatient utilization. Vertebroplasty utilization remained at a low level of 6/100,000 capita. Kyphoplasty patients had more comorbidities than VP patients. In Florida in 2008, radiologists performed most VPs (52.3%) and orthopedists performed the most KPs (35.45%). Postoperative complication rates were significantly different; 0.79% of KPs had cardiac complications versus 0.57% of VPs (p=.0073). Respiratory complications occurred in 0.83% of KPs and 0.49% of VPs (p<.0001).

Conclusions

Vertebral augmentation procedures have seen a continued increase in use from 2004 to 2008. Use of KP significantly outpaces the use of VP. Reasons for the increasing utilization of KP likely include financial incentives, the specialty performing KP, perceived safety, and effectiveness of vertebral height restoration. Conflicting evidence regarding which procedure is safer warrants further evaluation.

Introduction

Evidence & Methods

Kyphoplasty (KP) and vertebroplasty (VP) have been used commonly to treat osteoporotic compression fractures over the last decade. The authors assessed databases from three states to compare utiltization rates of these two procedures.

From 2005 to 2008, VP use remained stable (6/100,000) while KP use expanded greater than six times. The authors offer potential reasons for the increased use of KP, which include financial incentives, predominant use by orthopedic surgeons, perception of safety and efficacy, and potentially greater correction of deformity.

Database analyses provide excellent information regarding trends in utilization. However, explaining why such trends occur is difficult and most often speculative. The editors hope that the authors will perform a follow-up study to examine the trends since 2009 given recent controlled trials and changes in reimbursement. More importantly, it is hoped that further independent controlled trials will be performed to better delineate which particular patients might benefit from these procedures so that clearer value can be assigned to interventions that are currently controversial for general application.

—The Editors

Vertebral compression fractures (VCFs) are a growing health concern in the United States. Vertebral compression fractures affect approximately 25% of postmenopausal women, and the prevalence increases to 40% for women aged 80 years and older [1], [2], [3]. Vertebral compression fractures are less common in older men but still pose a significant health risk [4], [5], [6]. This condition is caused by osteoporosis, metastatic cancer, or trauma. The vast majority, approximately 750,000, are secondary to osteoporosis, which afflicts over 28 million people in the United States [6], [7], [8]. Patients with a VCF have a high risk of morbidity, including chronic back pain, decreased activity, decreased lung function, and adjacent-level fractures [9], [10], [11]. Vertebral compression fractures are also associated with increased mortality [12].

Traditional nonoperative treatments of VCFs include bed rest, analgesics, and bracing. Prolonged bed rest may cause a further decrease of bone mass in the elderly leading to additional fractures and a decrease in quality of life [13]. Musculoskeletal, cardiovascular, and immune complications from bed rest and analgesics can lead to a downward spiral of functional decline, as well as increased morbidity and mortality. Vertebral augmentation procedures (VAPs) can accelerate the return of patient function and quality of life and are often used for fractures not amenable to nonoperative treatments.

Vertebroplasty (VP) and kyphoplasty (KP) are two VAPs commonly used to treat VCFs after failure of conservative management and therapy. Vertebroplasty was first reported in France in 1984 for the treatment of hemangiomas and later adapted for treatment of VCFs [14]. The procedure involves percutaneous injection of polymethyl methacrylate (PMMA) into the fractured vertebral body, thereby strengthening the bone, alleviating painful symptoms, and preventing further vertebral compression. Kyphoplasty is a modified version of VP introduced in 1998, involving inflation of a balloon to create a cavity in the bone [15]. The balloon provides height restoration, creating a hollow space for the PMMA to enter, and thereby reduces the pressure of the cement injection. Kyphoplasty is associated with a lower risk of cement extravasation and improved vertebral height restoration [16]. Because of this, it is advantageous in cases of tumor infiltration and a compromised posterior vertebral margin. Both procedures are effective treatments of VCFs and show a significant postoperative decrease in pain, increase in function, and improved sagittal alignment [17], [18], [19].

Vertebral augmentation procedures have been rapidly increasing in the inpatient population [20]. The present study evaluates trends of VP and KP use in inpatient and outpatient populations from 2005 to 2008 and compares patient characteristics for both procedures using a large sample of clinical practices in the United States.

Section snippets

Methods

California, New York, and Florida inpatient and ambulatory discharge databases from 2005 to 2008 were used to identify hospitalizations for VP and KP. The agencies that provided databases were the New York Statewide Planning and Research Cooperative System, Florida Agency of Healthcare Administration, and the California Office of Statewide Health Planning and Development. The data sets lacked patient identifiers, such as social security numbers, hospital-assigned patient identification (ID), or

Results

The final data set contained a total of 61,851 VAPs (35,805 KPs and 26,046 VPs) performed on patients older than 40 years between 2005 and 2008 in the three states studied (New York, California, and Florida). Kyphoplasty showed a trend in increasing use for both inpatient and outpatient populations (Fig. 1). Inpatient KP use increased by 43% over the 4-year period, whereas outpatient KP use grew by almost sixfold from 730 to 4,344 procedures per year. The use of VP remained at a relatively

Discussion

Vertebroplasty and KP are two procedures indicated for vertebral fractures refractory to nonoperative treatments. Although the increasing use of vertebral augmentation procedures has been previously documented up to 2004 [20], our data show a continued increase through 2008. Most of this surge in VAPs can be attributed to the increasing popularity of KP in both ambulatory and inpatient settings. The use of VP has remained relatively stable on a per 100,000 capita basis during the 4 years

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      Given the expanding population of the elderly, increasing prevalence of osteoporotic disease and consequent health care and homecare burden [15,17,18], cost-effective treatment strategies are needed. Vertebral augmentation (VA) procedures such as vertebroplasty (VP) and balloon kyphoplasty (BK) are procedures increasingly being used to stabilize vertebral fractures, relieve pain, allow for more rapid mobilization and return to baseline function [19,20]. Both VP and KP consists of percutaneous bone cement injections into the fractured vertebral body.

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      During the same period, VP utilization experienced minimal growth between 2005 and 2008 and has been slowly declining since 2009. A previous article on the topic using data from New York, California, and Florida found increasing trends in utilization of VAPs through 2008 [30]. Since that study two RCTs evaluating the effectiveness of VP have been published, both suggesting poor results in the treatment of painful VCFs.

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      The analysis is restricted to Florida and may not necessarily reflect national trends in the use of VAPs. Previous research has demonstrated that there is substantial variation in VAPs across regions.3,19 Trends in use of vertebral augmentation procedures may have been affected by factors other than the release of trial results and guidelines, including the recession that began in 2007 or a natural slowdown in procedure growth, which would skew our regression-based percentage change estimates, although not our “simple” estimates.

    • ACR appropriateness criteria management of vertebral compression fractures

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      Supporters of the findings of the 2 trials mention that these are the highest-level trials investigating VP to date [54]. However, despite this controversy, use of vertebral augmentation procedures increased from 2001 through 2008 [55]. The trend for increased use is likely attributable to individual physician experience on the efficacy of vertebral augmentation as well as numerous and ever-increasing alternative research studies showing its benefit.

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    FDA device/drug status: Not applicable.

    Author disclosures: VG: Nothing to disclose. SMK: Nothing to disclose. NNE: Nothing to disclose. AJM: Nothing to disclose. SAG: Nothing to disclose. ACH: Consulting: Stryker Spine (C), Zimmer Spine (C); Scientific Advisory Board: Musculoskeletal Transplant Foundation (Nonfinancial); Other: Journal of Spinal Disorders (Nonfinancial). SAQ: Speaking/Teaching Arrangements: Stryker Spine (B); Other: Pioneer Surgical (A).

    The disclosure key can be found on the Table of Contents and at www.TheSpineJournalOnline.com.

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