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:

Flowchart for care of patients presenting with back pain.

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

  • Severe limitation in mobility/activities of daily living (ADL) due to pain
  • Pain diminishes or is resolved with rest
  • Recent history of minimal/low-velocity trauma
  • Pain is related to activity or movement

Past medical history including relative risk factors

  • Osteoporosis or osteopenia
  • Previous VCF
  • Chronic use of corticosteroids

Physical exam

  • Tenderness to palpation/percussion over posterior spinous processes
  • Pain exacerbates by change of position, with reluctance to move
  • Midline back pain

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)


Flowchart for care of patients depending upon results of advanced imaging.

Panel was presented with >500 potential patient scenarios on which they voted the appropriateness of treating with VA vs. NSM. See the details.

Flowchart for assessing appropriateness of care for patients.

4. REVIEW contraindications for VA.

  • Absolute: active infection at surgical site; untreated blood-borne infection
  • Strong contraindication: osteomyelitis
  • Usually contraindication: pregnancy
  • Relative: allergy to fill material; coagulopathy; spinal instability; myelopathy from the fracture; neurologic deficit; neural impingement
  • Generally, not a contraindication: fracture repulsion/canal compromise

5. ENDORSE follow up after treatment with continuous osteoporosis evaluation, treatment, and education.

  • After VA or NSM, a follow-up visit should be planned at 2–4 weeks.
  • In patients with a satisfactory result of VA at first follow-up (2–4 weeks after the procedure), there is generally no need for further post-operative monitoring. Follow-up for management of the underlying pathology does not need to be managed by the proceduralist.
  • All patients presenting with VCF should be referred for evaluation of bone mineral density and osteoporosis education for subsequent treatment as indicated.
  • All patients with VCF should be instructed to take part in an osteoporosis prevention/treatment program.
  • If symptoms are not resolved at follow-up, repeat imaging (preferably MRI) was mandatory.
  • If the pain is not resolved after VA, repeat augmentation (at the same level) may be considered, but does require a careful diagnostic evaluation to identify any other sources of pain (additional fractures, facet arthropathy, etc.).
Flowchart for contraindications and follow-up care.

About Balloon Kyphoplasty (BKP)

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.

For complete information regarding indications for use, contraindications, warnings, precautions, adverse events, and methods of use, please reference the devices’ Instructions for Use included with the product.

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.