Cement augmentation of refractory osteoporotic vertebral compression fractures: survivorship analysis

Abstract

Study design: Retrospective cohort.

Objective: To compare survivorship after cement augmentation of refractory osteoporotic vertebral compression fractures (OVCFs) with traditional inpatient pain management and bracing.

Summary of background data: OVCFs can cause debilitating pain and functional decline necessitating prolonged bed rest and high-dose narcotics. Vertebroplasty and kyphoplasty are cement augmentation procedures used to control pain and restore function in patients with OVCF's that are refractory to conservative treatment. Early mobilization is associated with improved survival after other fractures in elderly patients.

Methods: A university hospital database was used to identify all participants treated with primary diagnosis of OVCF between 1993 and 2006. Chart review and imaging studies were used to confirm demographics, comorbidities, diagnosis, and treatment. Survival time was determined using hospital data, national death indices and patient follow-up. Exact Fisher tests, Mann-Whitney tests, and proportional hazards regression models with Kaplan-Meier plots compared patients treated with cement augmentation with controls treated with inpatient pain management and bracing. Patients with high-energy trauma, tumors or age more than 60 years were excluded.

Results: Within the past 12 years, 46 patients treated with cement augmentation and 129 matched controls met inclusion criteria. They did not differ with respect to age, sex, and comorbidities. A significant survival advantage was found after cement augmentation compared with controls (P < 0.001; log rank), regardless of comorbidities, age, or the number of fractures diagnosed at the start date (P = 0.565). Controlling simultaneously for covariates, the estimated hazard ratio associated with cementation was 0.10 (95% confidence interval [CI] = 0.02-0.43; P = 0.002) for year 1, 0.15 (95% CI = 0.02-1.12; P = 0.064) for year 2, and 0.95 (95% CI = 0.32-2.79; P = 0.919) for subsequent follow-up. The number of OVCFs at the start time of treatment did not affect survival benefit of cementation (P = 0.44).

Conclusion: Cement augmentation of refractory OVCF improves survival for up to 2 years when compared with conservative pain management with bed rest, narcotics, and extension bracing, regardless of age, sex, and number of fractures or comorbidities. Therefore, aggressive management should be considered for refractory OVCFs with intractable back pain.