Wednesday, August 5, 2009

The Vertebroplasty Debate Heats Up, No Pun Intended!

The WSJ ran an article tonight which highlighted two recent studies, one that was subsidized by the NIH, to qualify whether there was any benefit to Vertebroplasty. Before I get into the meat of the article, this topic was hotly debated about 3 years ago in the NY Times. At that time, the clinical efficacy of Kyphoplasty was questioned. As the government looks for ways to cut the cost of medicine in the U.S., studies like these should begin to appear frequently to justify their intention.

The one study that was funded by the NIH, found that there is no detectable benefit to a vertebroplasty with PMMA when compare to "placebo" surgeries. Jeffrey Jarvik, of the University of Washington, is quoted as saying; "vertebroplasty should not be done any longer!" In addition to being a researcher involved with this study, could Dr. Jarvik be influenced by his position as a senior author on a study that was funded by the NIH? What was the intent of the study?

Dr. Allan Brook, the Director of Interventional Neuroradiology at the Montefiore Medical Center in the Bronx, NY, contends that patients in the study may have been the ones to benefit the most from the surgery, because, most patients that were offered the opportunity to participate declined because they did not want to be in the control group that received the placebo.

As in any study the results indicated that both groups "test" and "control" saw a substantial reduction in pain. The question must be asked: how does one measure pain? Is there such a thing as equal pain? Do some people have 40% pain versus 65% pain? One has to wonder why is the government spending money to negate a procedure that does provide real benefit to the elderly. Allowing senior citizens to ambulate and get out of bed minimizes the potential of other medical complications which drive up the cost of hospitalization. Yes bloggers, I would rather allow my surgeon to make the appropriate decision rather they lay in bed and potentially risk shooting a pulmonary emboli. In addition with the advent of newer and improved products by Orthovita (Cortoss) and Spine Wave (StaXx Fx) who cares about Vertebroplasty with PMMA? With the introduction of newer technologies that have a better modulus of elasticity than cement, the long term prognosis should be better for these patients. The SpineBlogger wants to know what you fellow Orthovita and SpineWavers think?


  1. Like so many procedures, patent selection is the key. In acute fractures, there is no doubt in my mind that PMMA vertebroplasty improves pain. The problem is that many vertebral compression fractures are of indeterminate age, and injecting these won't help.

    A bigger question is whether the more expensive procedures like balloon kyphoplasty or Staxx result in improved pain and function over straight vertebroplasty. This is still very debatable - especially since the studies in this area are vulnerable to commercial influence.

  2. SpineDoc1: As usual, thanks for your valuable insight. Patient selection is the greatest challenge that every surgeon contends with. Many times, Medicine ulike accounting, is more art than science. Since Congress enacted legislation under the Stimulus Bill to allocate $1.1 billion to compare drugs, medical devices, surgery and other ways of treating specific conditions, we will see more of these studies challenge our technology, and those of other disciplines in the medical industry. Your last point is well taken, how much that is desseminated from the podium is fact, or how much of it is pure marketing? Keep on Blogging!

  3. Another thought concerning this "is patient selection compromised by the cuts in re-imbursment". Since none of us has seen any reduction in the cost of our health care from the cuts made to physicians re-imbursments should we now look at the relevance between patient selection vs. payment to the surgeon?

    We are currently going after the surgeons for their involvement in "business" rather than just being doctors but we then turn on them when they make their money from volume of surgery.

    I think that when doctors were making better money for the actual treatment of patients they made better patient selection and were less involved in the business side. Most surgeons and doctors I know (at least the good ones) truly have a passion for what they do. However if you cut not only their revenue but also narrow their ability to earn by only operating why are we surprised that the number of procedures goes up? And one of the easiest ways to increase your surgical load is to expand your indications for selection.