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Back Pain

01 March 2019

Expert panel says two back pain procedures may be useless

Each year, thousands suffer compression fractures in their spine, resulting in acute and chronic back pain, impaired mobility and disability.

Injecting cement into broken vertebrae to stabilise an osteoporosis-related spinal fracture does little to reduce pain and disability, a new report says.

Two surgeries are used for these types of fractures: vertebroplasty, in which medical grade cement is injected into broken vertebrae to fuse the fragments together; and balloon kyphoplasty, where a balloon is inserted into a compressed area of spine to lift it and allow cement to be inserted before the balloon removal.

Comparison trials

But vertebroplasty provided no clearly significant benefit in pain control over placebo procedures in five randomised placebo-controlled trials, according to the report by an American Society for Bone and Mineral Research global task force of bone health experts.

It also said there is a lack of placebo-controlled trials for balloon kyphoplasty, and a small number of comparison trials found that kyphoplasty provided no more benefits than vertebroplasty.

The report was published in the Journal of Bone and Mineral Research.

Each year, about 750 000 Americans suffer compression fractures in their spine caused by osteoporosis. These fractures result in acute and chronic back pain, impaired mobility and disability.

The two types of surgery are aggressively marketed as "noninvasive" ways to get immediate relief from pain and as a way to avoid potential opioid addiction caused by narcotic painkillers.

The report's message "for doctors and their patients suffering from painful spinal fractures is that procedures to stabilise spinal fractures should not be a first choice for treatment," said report lead author Dr Peter Ebeling. He's head of the Department of Medicine at Monash University in Australia.

No significant benefit

"While patients who had these surgeries may have had a short-term reduction in pain, we found that there was no significant benefit over the long term in improving pain, back-related disability and quality of life when compared with those who did not have the procedures," Ebeling said in a journal news release.

But one back pain specialist noted there may still be a place for the procedures.

If a patient can't move because of pain from a spinal fracture, bone cement might not be so bad, Dr Joshua Hirsch, from Massachusetts General Hospital, told the New York Times.

"You have a choice," Hirsch told the newspaper. "Opiates and lying in bed with diminished activity, or a procedure that can mobilise patients and improve them."

About 300 000 US patients underwent the procedures between 2006 and 2014, according to Medicare data. Of those, 73% had the more expensive balloon cement injection procedure.

Need for prevention

As the US population ages, the number of people having the procedures is expected to rise, but this "report makes it clear that these procedures are not a magic bullet," said Dr Bart Clarke, president of the American Society for Bone and Mineral Health.

"Until now, doctors have been left to sift through the data on their own to determine whether these procedures can benefit their patients. This report coalesces all that information concisely and provides recommendations to guide them," said Clarke, co-author of an accompanying editorial in the journal.

The task force report also emphasised the need for prevention. Patients who have had a first fracture of the hip or spine likely have osteoporosis and are likely to experience a second fracture. About 25% of older patients who have a hip fracture will have a second fracture within one year, as will around 20% of older patients who have a vertebral fracture.

But research shows that treatment rates for hip fracture patients are low and decreasing.

"Overall, prevention is critical and we need to get these high-risk patients on anti-osteoporosis drugs that have proven to reduce future fractures by as much as 70%," Clarke said.

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