c/o Elaine P. Henze, BJ, ELS, Medical Editor and Director, Editorial Services, Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, #A665, Baltimore, MD 21224-2780. E-mail address for R.L. Skolasky:
J Bone Joint Surg Am. 2013 Oct 2;95(19):1729-36. doi: 10.2106/JBJS.K.01649.
The treatment of vertebral compression fractures with vertebral augmentation procedures is associated with acute pain relief and improved mobility, but direct comparisons of treatments are limited. Our goal was to compare the survival rates, complications, lengths of hospital stay, hospital charges, discharge locations, readmissions, and repeat procedures for Medicare patients with new vertebral compression fractures that had been acutely treated with vertebroplasty, kyphoplasty, or nonoperative modalities.
The 2006 Medicare Provider Analysis and Review File database was used to identify 72,693 patients with a vertebral compression fracture. Patients with a previous vertebral compression fracture, those who had had a vertebral augmentation procedure in the previous year, those with a diagnosis of malignant neoplasm, and those who had died were excluded, leaving 68,752 patients. The patients were stratified into nonoperative treatment (55.6%), vertebroplasty (11.2%), and kyphoplasty (33.2%) cohorts. Survival rates were compared with use of Kaplan-Meier analysis and Cox regression. Results were adjusted for potential confounding variables. Secondary parameters of interest were analyzed with the chi-square test (categorical variables) and one-way analysis of variance (continuous variables), with the level of significance set at p < 0.05.
The estimated three-year survival rates were 42.3%, 49.7%, and 59.9% for the nonoperative treatment, vertebroplasty, and kyphoplasty groups, respectively. The adjusted risk of death was 20.0% lower for the kyphoplasty group than for the vertebroplasty group (hazard ratio = 0.80, 95% confidence interval, 0.77 to 0.84). Patients in the kyphoplasty group had the shortest hospital stay and the highest hospital charges and were the least likely to have had pneumonia and decubitus ulcers during the index hospitalization and at six months postoperatively. However, kyphoplasty was more likely to result in a subsequent augmentation procedure than was vertebroplasty (9.41% compared with 7.89%; p < 0.001).
Vertebral augmentation procedures appear to be associated with longer patient survival than nonoperative treatment does. Kyphoplasty tends to have a more striking association with survival than vertebroplasty does, but it is costly and may have a higher rate of subsequent vertebral compression fracture. These provocative findings may reflect selection bias and should be addressed in a prospective, direct comparison of methods to treat vertebral compression fractures.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
椎体增强手术治疗椎体压缩性骨折可迅速缓解疼痛并改善活动能力，但对治疗方法的直接比较有限。我们的目标是比较 Medicare 患者新发生的椎体压缩性骨折的急性治疗中使用经皮椎体成形术、球囊扩张椎体后凸成形术和非手术治疗的生存率、并发症、住院时间、住院费用、出院地点、再入院率和重复手术率。
使用 2006 年 Medicare 提供者分析和审查文件数据库确定 72693 名椎体压缩性骨折患者。排除有先前椎体压缩性骨折、前一年接受过椎体增强手术、诊断为恶性肿瘤和已死亡的患者，共 68752 名患者。患者分为非手术治疗（55.6%）、经皮椎体成形术（11.2%）和球囊扩张椎体后凸成形术（33.2%）组。使用 Kaplan-Meier 分析和 Cox 回归比较生存率。结果调整了潜在混杂变量。使用卡方检验（分类变量）和单因素方差分析（连续变量）分析感兴趣的次要参数，显著性水平为 p < 0.05。
非手术治疗、经皮椎体成形术和球囊扩张椎体后凸成形术组的估计三年生存率分别为 42.3%、49.7%和 59.9%。与经皮椎体成形术组相比，球囊扩张椎体后凸成形术组的死亡风险降低 20.0%（风险比=0.80，95%置信区间，0.77-0.84）。球囊扩张椎体后凸成形术组的住院时间最短，住院费用最高，在指数住院期间和术后 6 个月时，肺炎和褥疮的发生率最低。然而，球囊扩张椎体后凸成形术比经皮椎体成形术更有可能导致后续的增强手术（9.41%比 7.89%；p < 0.001）。
与非手术治疗相比，椎体增强手术似乎与患者的生存时间延长有关。与经皮椎体成形术相比，球囊扩张椎体后凸成形术与生存率的相关性更强，但费用更高，且后续椎体压缩性骨折的发生率可能更高。这些有争议的发现可能反映了选择偏倚，应在治疗椎体压缩性骨折的方法的前瞻性直接比较中加以解决。
治疗性 III 级。有关证据水平的完整描述，请参阅作者指南。
