Vertebroplasty vs kyphoplasty

I would like to comment on your supplement “Vertebral compression fractures in primary care: Recommendations from a consensus panel” (J Fam Pract 2005;54(9):781–788). This is a very useful article to hopefully raise awareness of the new treatments for this painful condition.

While I agree with much of what you say, I am concerned about a few things. First of all, historically the first vertebroplasty was performed over 20 years ago by a French radiologist named Herve Deramond. He was a practicing radiologist. This is important, because as these procedures become more prevalent, there will be more competition for them. Your patients and physicians should know that radiologists have been actively involved in the treatment of these for almost 2 decades.

This is important as well, because the sites you reference for finding a suitable specialist are 2 websites, one of which charges nearly $900 to register, and both of which are somewhat biased toward surgical physicians. While this alone isn’t necessarily a problem, there’s no mention at all of professional societies like the Society of Interventional Radiology (SIR), which has listed qualified interventional radiologists who provide vertebral augmentation procedures for many years. I do not think you have done yourselves a service by omitting this organization, or the websites of other similar professional societies.

In addition, your article is sponsored by Kyphon, an orthopedic company that markets very aggressively. While their procedure is very enticing, and while I have performed it, there are some issues you have neglected.

First, kyphoplasty, which by the way is a trade name, is more expensive than vertebroplasty. In some cases, the kit can add thousands of dollars to the cost. Second, at least originally kyphoplasty was done as an inpatient procedure, and with general anesthesia. Some of our local orthopedic surgeons still do them this way. We’ ve done them as outpatient procedures with IV conscious sedation. The use of general anesthesia and hospital admission obviously adds considerably to the cost. Next, even in good hands, and by their sales reps’ own admission, kyphoplasty takes longer than vertebroplasty, so there is more radiation exposure to the patient and the physicians and support personnel in the room. Likewise, there is more time under anesthesia.

Finally, and this hasn’t been proven, but I can assure you there is considerable skepticism amongst the interventionalists who perform these procedures, much of the purported vertebral body height restoration may be imaginary. Certainly there are impressive pictures floating around, but no one to my knowledge has done a head-to-head comparison to see whether or not kyphoplasty really does what it says—namely, restore body height with less extravasation and fewer adjacent level fractures. Until that question is answered, and until real questions about cost, radiation exposure, and anesthesia time are objectively evaluated, physicians should exercise some degree of restraint when referring for kyphoplasty. If pain relief is the primary desire, at this time vertebroplasty does the job as well, faster, and cheaper. In addition it may be better to evaluate these results using volumetric CT or MRI to see whether the central portion of the body is elevated, rather than looking at the endplates only as seen on conventional radiographs.

Joseph M. Ullman, MD
Vanguard Imaging, PA,
St. Mary’s Regional Medical Center, Lewiston, Maine

The authors respond:

We thank Dr Ullman for his interest in our consensus statement.

Vertebroplasty was first performed in France in 1984 by Galibert, a neurosurgeon in France, for the treatment lumbar and cervical angiomas, not osteoporotic fractures.¹ Use of vertebroplasty for painful osteoporotic compression fractures was developed later and is now the primary use of the procedure in North America.

As stated in our article, balloon kyphoplasty was developed in the late 1990s. The focus of our consensus statement, however, was to promote awareness among family physicians regarding the important consequences of vertebral body compression fractures as well as the availability of these 2 procedures for the treatment of persistent or prominent pain resulting from these fractures.

While it can be difficult to find local providers, the number of physicians performing vertebroplasty and kyphoplasty is growing steadily. To our knowledge, the 2 web sites cited in the article (spine-health.com and spineuniverse.com) do not require registration in order to locate physicians skilled in vertebral augmentation procedures. One site requires a fee for physicians to post their information, a practice we do not think is biasing. The Society for Interventional Radiology’s website (sirweb.org) also has an excellent search page that allows search by specialty (https://directory.sirweb.org/eseries/scriptcontent/index_members_search.cfm).

Dr Ullman highlights several distinctions between vertebroplasty and kyphoplasty. While our consensus statement focused on the important consequences of compression fractures and the availability of treatments, several points should be noted.