A Clinical Care Pathway Developed by a Multispecialty Panel Using the RAND™/UCLA Appropriateness Method
An expert panel recommended that clinicians take these steps for osteoporotic patients with suspected vertebral compression fracture (VCF)1:
Watchful waiting: While it is not depicted in the graphic, a number of patients who are not treated, but who continue to have untreated symptoms, may end up being “looped” back into the algorithm at some point.
1. CONSIDER key signs and symptoms for the suspicion of VCF.
History of present illness
Past medical history including relative risk factors
2. RECOMMEND advanced diagnostic imaging for patients with suspected VCF (with MRI being the preferred diagnostic tool).
3. VALIDATE appropriateness criteria of VA vs. NSM and when to refer to specialist.
Seven signs/symptoms that were agreed to by the panelists as key to determining if VA or NSM should be prescribed:
|Signs and Symptoms||Variations Considered|
|Duration of pain||< 1 day; 1-3 days; 3-6 days; > 6 weeks|
|Advanced imaging findings||Negative; Positive (= concordant with or supportive of acuity of fracture)|
|Degree of vertebral height reduction||Mild (< 25%); Moderate (25-40%); Severe (> 40%)|
|Kyphotic deformity||No; Yes|
|Progression of vertebral height loss (increased height reduction on radiologic images at follow-up)||No; Yes|
|Evolution of symptoms||Has improved since onset (but VAS still ≥ 5); Stable on medication (but VAS still ≥ 5); Has worsened despite optimal medication|
|Impact of VCF on daily functioning||Moderate (cf. Roland Morris Disability Questionnaire 12-17); Severe (cf. Roland Morris Disability Questionnaire > 17)|
Panel was presented with >500 potential patient scenarios on which they voted the appropriateness of treating with VA vs. NSM. See the details.
4. REVIEW contraindications for VA.
5. ENDORSE follow up after treatment with continuous osteoporosis evaluation, treatment, and education.
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BKP is a minimally invasive procedure for the treatment of pathological fractures of the vertebral body due to osteoporosis, cancer, or benign lesion. The complication rate with BKP has been demonstrated to be low. There are risks associated with the procedure (e.g., cement extravasation), including serious complications, and though rare, some of which may be fatal.
Risks of acrylic bone cements include cement leakage, which may cause tissue damage, nerve or circulatory problems, and other serious adverse events, such as: cardiac arrest, cerebrovascular accident, myocardial infarction, pulmonary embolism, or cardiac embolism.
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Learn more about balloon kyphoplasty.
Reprinted from The Spine Journal 2018, Hirsch JA, Beall DP, Chambers MR et al. Management of vertebral fragility fractures: a clinical care pathway developed by a multispecialty panel using the RAND/UCLA Appropriateness Method. Nov;18(11):2152-2161, Copyright 2018, with permission from Elsevier.