Appropriate use criteria
ACR Appropriateness Criteria® Management of Vertebral Compression Fractures

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Abstract

Vertebral compression fractures (VCFs) have various causes, including osteoporosis, neoplasms, and acute trauma. As painful VCFs may contribute to general physical deconditioning, management of painful VCFs has the potential for improving quality of life and preventing superimposed medical complications. Various imaging modalities can be used to evaluate a VCF to help determine the etiology and guide intervention. The first-line treatment of painful VCFs has been nonoperative or conservative management as most VCFs show gradual improvement in pain over 2 to 12 weeks, with variable return of function. There is evidence that vertebral augmentation (VA) is associated with better pain relief and improved functional outcomes compared to conservative therapy for osteoporotic VCFs. A multidisciplinary approach is necessary for the management of painful pathologic VCFs, with management strategies including medications to affect bone turnover, radiation therapy, and interventions such as VA and percutaneous thermal ablation to alleviate symptoms.

The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Section snippets

Introduction/Background

Vertebral compression fractures (VCFs) can be caused by osteoporosis, neoplasms, metabolic disorders including renal osteodystrophies, congenital disorders such as osteogenesis imperfecta, infections, and acute trauma. Painful VCFs may cause a marked decline in physical activity and quality of life, leading to general physical deconditioning. This in turn may prompt further complications related to poor inspiratory effort (atelectasis and pneumonia) [1] and venous stasis (deep venous thrombosis

Variant 1: New Symptomatic Compression Fracture Identified on Radiographs or CT. No Known Malignancy

The body regions covered in this clinical scenario are cervical, thoracic, and lumbar spine. These body regions might be evaluated separately or in combination as guided by physical examination findings, patient history, and other available information including prior imaging.

For some authors, focal tenderness upon palpation in correlation with radiographs of the vertebral column is a satisfactory indication for intervention. However, spine radiographs are often nonspecific with respect to the

Summary of Recommendations

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    Variant 1: For patients, without known malignancy, with new symptomatic compression fracture identified on radiographs or CT, medical management and MRI spine area of interest without IV contrast or CT spine area of interest without IV contrast is usually appropriate.

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    Variant 2: For patients with osteoporotic compression fractures, with or without edema on MRI or no “red flags,” with or without spinal deformity, worsening symptoms, or pulmonary dysfunction, medical management is usually

Summary of Evidence

Of the 155 references cited in the ACR Appropriateness Criteria® Management of Vertebral Compression Fractures document, 30 are categorized as therapeutic references including 12 well-designed studies and 3 good-quality studies. Additionally, 117 references are categorized as diagnostic references including 12 well-designed studies, 40 good-quality studies, and 22 quality studies that may have design limitations. There are 58 references that may not be useful as primary evidence. There are 8

Supporting Documents

For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.

References (155)

  • T. Diekhoff et al.

    Dual-energy CT virtual non-calcium technique for detection of bone marrow edema in patients with vertebral fractures: a prospective feasibility study on a single- source volume CT scanner

    Eur J Radiol

    (2017)
  • H.H. Lin et al.

    Determination of the painful level in osteoporotic vertebral fractures—retrospective comparison between plain film, bone scan, and magnetic resonance imaging

    J Chin Med Assoc

    (2015)
  • M. Sola et al.

    Value of bone SPECT-CT to predict chronic pain relief after percutaneous vertebroplasty in vertebral fractures

    Spine J

    (2011)
  • S.L. Silverman

    The clinical consequences of vertebral compression fracture

    Bone

    (1992)
  • H.M. Do

    Percutaneous vertebroplasty: rationale, clinical outcomes, and future directions

    Neuroimaging Clin N Am

    (2003)
  • C.A. Klazen et al.

    Vertebroplasty versus conservative treatment in acute osteoporotic vertebral compression fractures (Vertos II): an open-label randomised trial

    Lancet

    (2010)
  • D. Wardlaw et al.

    Efficacy and safety of balloon kyphoplasty compared with non-surgical care for vertebral compression fracture (FREE): a randomised controlled trial

    Lancet

    (2009)
  • K. Fizazi et al.

    Denosumab versus zoledronic acid for treatment of bone metastases in men with castration-resistant prostate cancer: a randomised, double-blind study

    Lancet

    (2011)
  • R. Teasell et al.

    Complications of immobilization and bed rest. Part 2: Other complications

    Can Fam Physician

    (1993)
  • American College of Radiology. ACR Appropriateness Criteria®: Osteoporosis and Bone Mineral Density. Available at:...
  • E.S. Siris et al.

    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

    (2006)
  • S.J. Bigos et al.

    Acute low back problems in adults. Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642

    (December 1994)
  • F. Schajowicz

    Aneurysmal bone cyst

  • D.F. Kallmes et al.

    Percutaneous vertebroplasty

    Radiology

    (2003)
  • D.R. Fourney et al.

    Spinal instability neoplastic score: an analysis of reliability and validity from the spine oncology study group

    J Clin Oncol

    (2011)
  • S. Faruqi et al.

    Vertebral compression fracture after spine stereotactic body radiation therapy: a review of the pathophysiology and risk factors

    Neurosurgery

    (2018)
  • M.H. Bilsky et al.

    Reliability analysis of the epidural spinal cord compression scale

    J Neurosurg Spine

    (2010)
  • P. Korovessis et al.

    Is Kiva implant advantageous to balloon kyphoplasty in treating osteolytic metastasis to the spine? Comparison of 2 percutaneous minimal invasive spine techniques: a prospective randomized controlled short-term study

    Spine (Phila Pa 1976)

    (2014)
  • A.O. Ortiz

    Use and evaluation of a semi-permeable mesh implant in vertebral augmentation for the treatment of painful osteoporotic vertebral compression fractures

    J Neurointerv Surg

    (2016)
  • S.M. Tutton et al.

    KAST Study: the Kiva System as a vertebral augmentation treatment-a safety and effectiveness trial: a randomized, noninferiority trial comparing the Kiva system with balloon kyphoplasty in treatment of osteoporotic vertebral compression fractures

    Spine (Phila Pa 1976)

    (2015)
  • M.R. Farrokhi et al.

    Randomized controlled trial of percutaneous vertebroplasty versus optimal medical management for the relief of pain and disability in acute osteoporotic vertebral compression fractures

    J Neurosurg Spine

    (2011)
  • C. Chen et al.

    Unilateral versus bilateral vertebroplasty for severe osteoporotic vertebral compression fractures

    J Spinal Disord Tech

    (2014)
  • M. Dohm et al.

    A randomized trial comparing balloon kyphoplasty and vertebroplasty for vertebral compression fractures due to osteoporosis

    AJNR Am J Neuroradiol

    (2014)
  • J. Du et al.

    Kyphoplasty versus vertebroplasty in the treatment of painful osteoporotic vertebral compression fractures: two-year follow-up in a prospective controlled study

    Acta Orthop Belg

    (2014)
  • A.J. Evans et al.

    Randomized controlled trial of vertebroplasty versus kyphoplasty in the treatment of vertebral compression fractures

    J Neurointerv Surg

    (2016)
  • J.T. Liu et al.

    Long-term follow-up study of osteoporotic vertebral compression fracture treated using balloon kyphoplasty and vertebroplasty

    J Neurosurg Spine

    (2015)
  • D.H. Zhao et al.

    Postoperative functional evaluation of percutaneous vertebroplasty compared with percutaneous kyphoplasty for vertebral compression fractures

    Am J Ther

    (2016)
  • D.B. Brown et al.

    Treatment of chronic symptomatic vertebral compression fractures with percutaneous vertebroplasty

    AJR Am J Roentgenol

    (2004)
  • M.J. Nieuwenhuijse et al.

    Percutaneous vertebroplasty for subacute and chronic painful osteoporotic vertebral compression fractures can safely be undertaken in the first year after the onset of symptoms

    J Bone Joint Surg Br

    (2012)
  • A. Venmans et al.

    Natural history of pain in patients with conservatively treated osteoporotic vertebral compression fractures: results from VERTOS II

    AJNR Am J Neuroradiol

    (2012)
  • American College of Radiology. ACR–ASNR–ASSR–SIR–SNIS Practice Parameter for the Performance of Vertebral Augmentation....
  • P.L. Yang et al.

    Image-guided minimally invasive percutaneous treatment of spinal metastasis

    Exp Ther Med

    (2017)
  • P.M. Parizel et al.

    Trauma of the spine and spinal cord: imaging strategies

    Eur Spine J

    (2010)
  • R.J. Nairn et al.

    Current perspectives on percutaneous vertebroplasty: current evidence/controversies, patient selection and assessment, and technique and complications

    Radiol Res Pract

    (2011)
  • L. Karaca et al.

    The feasibility of dual-energy CT in differentiation of vertebral compression fractures

    Br J Radiol

    (2016)
  • M. Kaup et al.

    Dual-energy CT-based display of bone marrow edema in osteoporotic vertebral compression fractures: impact on diagnostic accuracy of radiologists with varying levels of experience in correlation to MR imaging

    Radiology

    (2016)
  • B.K. Benz et al.

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

    Spine (Phila Pa 1976)

    (2009)
  • X. Ma et al.

    Value of preoperative magnetic resonance imaging measurements in thoracic percutaneous vertebroplasty using unilateral

    Chin Med J (Engl)

    (2010)
  • U.J. Spiegl et al.

    Value of MRI imaging prior to a kyphoplasty for osteoporotic insufficiency fractures

    Eur Spine J

    (2009)
  • S.Y. Park et al.

    Usefulness of MRI in determining the appropriate level of cement augmentation for acute osteoporotic vertebral compression fractures

    J Spinal Disord Tech

    (2013)

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    The American College of Radiology 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.

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    Dr. Cassidy reports a one-time consulting engagement for Johnson&Johnson for a cervical instrumentation system. Johnson&Johnson also has products that can be used to treat VCF. Dr. Jennings reports personal fees from Merit Medical, personal fees from Medtronic and grants from BTG, during the conduct of the study; and personal fees from Bard, outside the submitted work. Dr. Lo reports other from Elekta AB, other from Elekta AB, and other from Springer Nature, outside the submitted work. Dr. Reitman reports a position on the Board of Directors for the North American Spine Society, other from Clinical Orthopaedics and related research, outside the submitted work; past educational seminars with Elekta AB, Accuray Inc., and Varian medical systems; research grant with Elekta AB; and travel, accomodations/expenses from Elekta and Varian. Dr. Sahgal also belongs to the Elekta MR Linac Research Consortium. The other authors have no conflicts of interest related to the material discussed in this article.

    Disclaimer: The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists, and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.

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