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A multispecialty expert panel’s recommendation
for data-driven treatment of vertebral compression fracture patients

The VCF clinical care pathway was developed using the RAND™/UCLA appropriateness method (RAM) to evaluate vertebral augmentation (VA) and non-surgical management (NSM) as treatment options. This summary of patient-specific guidelines is based on the panel’s recommendations.1

Consider key signs and symptoms of VCF 

Ten signs and symptoms were considered to be most specific for VCF.

History of present illness:

  • Severe limitation in mobility/activities of daily living (ADL) due to pain
  • Pain diminishes or is resolved with rest
  • Recent history of minimal/low-velocity trauma
  • Pain is related to activity or movement

Past medical history, including relative risk factors:

  • Osteoporosis or osteopenia
  • Previous VCF
  • Chronic use of corticosteroids

Physical exam:

  • Tenderness to palpation/percussion over posterior spinous process(es)
  • Pain exacerbates by change of position, with reluctance to move
  • Midline back pain


Of the 576 clinical scenarios: 16% were deemed appropriate for nonsurgical management (NSM), 46% were deemed appropriate for vertebral augmentation (VA), and 38% were uncertain.

The probability of a VCF was categorized based on the number of signs and symptoms present: 1–3 low, 4–6 intermediate, and 7+ high.

Recommended diagnostic evaluation of patients with suspected VCF

After weighing the appropriateness of all advanced imaging modalities (MRI, CT, nuclear bone scan) for patients suspected of having VCF, the panel considered advanced imaging:

  • Unnecessary for patients with moderate symptoms and a low probability of VCF
  • Indicated for all patients with severe symptoms and/or intermediate to high probability of VCF
  • With MRI being most appropriate
  • With nuclear bone scan and CT good alternatives when MRI cannot be performed
A woman tries to be active but experiences back pain.

Validate appropriateness criteria of vertebral augmentation versus non-surgical management

The panel agreed on seven key clinical findings used to prescribe vertebral augmentation or non-surgical management.

Clinical finding Categories considered

1. Duration of pain
  • <1 week
  • 1–3 weeks
  • 3–6 weeks
  • >6 weeks

2. Advanced imaging findings (MRI, CT, nuclear bone scan)
  • Negative
  • Positive (concordant with or supportive of acuity of fracture)

3. Degree of vertebral height reduction
  • Mild (<25%)
  • Moderate (25-40%)
  • Severe (>40%)

4. Kyphotic deformity
  • No
  • Yes

5. Progression of vertebral height loss (additional height reduction on radiologic images at follow-up)
  • No
  • Yes

6. Evolution of symptoms
  • Improved since onset but visual analog scale (VAS) still ≥5
  • Stable on medication but VAS still ≥5
  • Worsened despite optimal medication

7. Impact of VCF on daily functioning
  • Moderate (cf. Roland Morris Disability Questionnaire 12–17)
  • Severe (cf. Roland Morris Disability Questionnaire >17)

Panel recommendations


 

Review contraindications for vertebral augmentation

The panel considered 11 conditions to assess the appropriateness of vertebral augmentation. Full agreement was reached on recommendations for absolute and relative contraindications. 

Absolute contraindication:

  • Active infection at surgical site

  • Untreated blood-borne infection

Strong contraindication:

  • Osteomyelitis

Usually a contraindication:

  • Pregnancy

Relative contraindication:

  • Allergy to fill material
  • Coagulopathy
  • Spinal instability
  • Myelopathy from the fracture
  • Neurologic deficit
  • Neural impingement

Generally not a contraindication:

  • Fracture repulsion
  • Canal compromise

Endorse follow-up treatment 

Panel consensus was reached on the following statements related to patient follow up:

  • After either VA or NSM, a follow-up visit should be planned at two to four weeks.

  • In patients with a satisfactory result of VA at first follow-up (two to four weeks after the procedure) there is generally no need for further post-operative monitoring. Follow-up for management of the underlying pathology does not need to be managed by the proceduralist. 

  • All patients presenting with VCF should be referred for bone mineral density evaluation and for osteoporosis education and subsequent treatment as indicated.

  • All patients with VCF should be instructed to take part in an osteoporosis prevention/treatment program.

  • If symptoms are not resolved at follow-up, repeat imaging (preferably MRI) is mandatory.

  • If the pain is not resolved after VA, a repeat augmentation (at the same level) may be considered, but does require a careful diagnostic evaluation to identify any other sources of pain (additional fractures, facet arthropathy, etc.). 

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