VCF CLINICAL CARE PATHWAY

A multispecialty expert panel recommendation for data-driven treatment of vertebral compression fracture (VCF) patients. 

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Alert Indications, Safety, and Warnings

A CLINICAL CARE PATHWAY FOR VERTEBRAL COMPRESSION FRACTURES

The vertebral compression fracture (VCF) clinical care pathway was developed by a multispecialty expert panel using the RAND™/UCLA Appropriateness Method (RAM). Below you’ll find a summary of patient-specific guidelines based on the panel’s recommendations.1

RAM PANEL RECOMMENDATIONS

vcf-clinical-care-pathway.png

CONSIDER KEY SIGNS AND SYMPTOMS OF VCF

The panel assessed key signs and symptoms found in the literature. Ten were considered to be most specific for 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 process(es)
  • Pain exacerbates by change of position, with reluctance to move
  • Midline back pain 

The probability of a VCF was categorized based on the number of signs and symptoms present:  

Number of Signs
and Symptoms 

Probability of VCF 

1-3

Low probability

4-6

Intermediate probability

7 or more

High probability

RECOMMEND DIAGNOSTIC EVALUATION OF PATIENTS WITH SUSPECTED VCF 

After weighing the appropriateness of all advanced imaging modalities (MRI, CT, nuclear bone scan) for patients suspected of having VCF, the panel considered advanced imaging: 

  • Unnecessary for patients with moderate symptoms and a low probability of VCF 
  • Indicated for all patients with severe symptoms and/or intermediate to high probability of VCF 
  • With MRI being most appropriate 
  • With nuclear bone scan and CT good alternatives when MRI cannot be performed

VALIDATE APPRORIATENESS CRITERIA OF VERTEBRAL AUGMENTATION VS. NON-SURGICAL MANAGEMENT 

The panel agreed on seven key clinical findings used to prescribe vertebral augmentation or non-surgical management.

Clinical Finding

Categories Considered

1. Duration of pain
  • < 1 day 
  • 1–3 days 
  • 3–6 days 
  • > 6 weeks 

2. Advanced imaging findings (MRI, CT, nuclear bone scan)
  • Negative 
  • Positive (concordant with or supportive of acuity of fracture)

3. Degree of vertebral height reduction
  • Mild (< 25%) 
  • Moderate (25–40%) 
  • Severe (> 40%)

4. Kyphotic deformity
  • No 
  • Yes 

5. Progression of vertebral height loss
(additional height reduction on radiologic images at follow-up) 
  • No 
  • Yes 

6. Evolution of symptoms
  • Improved since onset but VAS still ≥ 5 
  • Stable on medication but VAS still ≥ 5 
  • Worsened despite optimal medication 

7. Impact of VCF on daily functioning
  • Moderate (cf. Roland Morris Disability Questionnaire 12–17) 
  • Severe (cf. Roland Morris Disability Questionnaire > 17) 

 

PANEL RECOMMENDATIONS

ram-panel-vcf-flow-chart.png

Panel recommendations on the appropriateness of treatment for VCF. Blue outlined boxes indicate a present condition. 

REVIEW CONTRAINDICATIONS FOR VERTEBRAL AUGMENTATION 

The panel considered 11 conditions to assess appropriateness for VA. Full agreement was reached on recommendations for absolute and relative contraindications for vertebral augmentation. 

Absolute contraindication:

  • Active infection at surgical site
  • Untreated blood-borne infection

Strong contraindication:

  • Osteomyelitis

Usually contraindication:

  • Pregnancy

Relative contraindication:

  • Allergy to fill material
  • Coagulopathy
  • Spinal instability
  • Myelopathy from the fracture
  • Neurologic deficit
  • Neural impingement

Generally not a contraindication: 

  • Fracture repulsion
  • Canal compromise

ENDORSE FOLLOW UP TREATMENT

Panel consensus was reached on the following statements related to follow-up of patients:

  • After either VA or NSM, a follow-up visit should be planned at 2 to 4 weeks.
  • In patients with a satisfactory result of VA at first follow-up (2 to 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) is mandatory.
  • If the pain is not resolved after VA, a 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.)

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1

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.