Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care
Diagnosis and Treatment of Adults with Neoplastic Vertebral Fractures
Recommendations:
Medical Treatments
Medical Treatment Question 1: How do nonpharmacologic treatments (eg, bracing, physical therapy, acupuncture, massage, cannabis, exercise, etc.) compare in terms of reducing severity and duration of pain and disability in neoplastic vertebral fractures?
A systematic review of the literature yielded no studies to adequately address this question.
FLASK Future Directions for Research
The work group recommends high-quality studies comparing nonpharmacologic treatments in terms of reducing severity and duration of pain and disability in adults with neoplastic vertebral fractures.
Medical Treatment Question 2: Do restrictions on patient activity alter outcomes in patients with neoplastic vertebral fractures?
A systematic review of the literature yielded no studies to adequately address this question.
FLASK Future Directions for Research
The work group recommends high-quality studies evaluating the role of activity restrictions on clinical outcomes in adults with neoplastic vertebral fractures.
Medical Treatment Question 3: How do pharmacologic treatments (nonchemotherapeutic) and nonpharmacologic treatments compare with interventional treatments in terms of reducing severity and duration of pain and disability in neoplastic vertebral fractures?
There is insufficient evidence to make a recommendation for or against interventional treatment as compared to noninterventional pharmacologic treatments and nonpharmacologic treatments in terms of reducing severity and duration of pain and disability in adults with neoplastic vertebral fractures.
Grade of Recommendation: I
In a prospective randomized control trial study, Berenson et al1 evaluated the effectiveness and safety of balloon kyphoplasty compared to nonsurgical fracture management for the treatment of adults with neoplastic vertebral fractures. The authors concluded that for painful vertebral fractures “in patients with cancer, kyphoplasty is an effective and safe treatment that rapidly reduces pain and improves function.” The work group downgraded this potential Level I paper due to nonconsecutive and nonmasked patients, nonmasked reviewers, lack of subgroup analysis, high crossover after one month, and an unclear description of the non-surgical management group. This paper provides Level II evidence that kyphoplasty is an effective and safe treatment in patients with neoplastic vertebral fractures for rapid reduction in pain and improvement of function in comparison to nonsurgical treatment.
References:
- Berenson J, Pflugmacher R, Jarzem P, et al. Balloon kyphoplasty versus non-surgical fracture management for treatment of painful vertebral body compression fractures in patients with cancer: a multicentre, randomised controlled trial. Lancet Oncol. 2011;12(3):225-235. doi:10.1016/S1470-2045(11)70008-0
FLASK Future Directions for Research
The work group recommends further high-quality prospective comparative studies comparing interventional treatments and noninterventional treatments (eg, pharmacological, nonpharmalogical) in patients with neoplastic vertebral fractures.
Medical Treatment Question 4: Does timing or sequencing of interventions (eg, analgesics, bisphosphonates, chemotherapy, XRT, stereotactic XRT, bracing, surgery or vertebral augmentation) improve patient outcomes?
There is insufficient evidence to make a recommendation for or against sequencing of radiation therapy and vertebral augmentation in adults with neoplastic vertebral fractures.
Grade of Recommendation: I
In a retrospective comparative study, Hirsch et al1 investigated the effectiveness of vertebral augmentation (VA) in relieving fracture-related pain, identify procedural and clinical variables that can influence any outcomes in the population, and assess the impact of treatment sequence on pain outcomes in patients with cancer who have received treatments of vertebral augmentation and external beam radiation therapy. The authors concluded that “a multimodality approach for the management of malignant compression fractures (MCFs) includes VA procedures. The majority of patients with MCFs [AS1] have excellent palliation with this approach. In patients who receive both external beam radiation therapy (EBRT) and VA, the sequence in which they are given does not affect pain improvement outcomes.” The work group downgraded this potential Level III paper due to nonconsecutive, nonrandomized, and nonmasked patients, nonmasked reviewers, small sample size, diagnostic method not being stated, and the outcome measures used not being validated. This paper provides Level IV evidence that the sequence of vertebral augmentation and external beam radiation therapy does not affect patient outcome in the approach for the management of adults with neoplastic vertebral fracture.
References:
- Hirsch AE, Jha RM, Yoo AJ, et al. The use of vertebral augmentation and external beam radiation therapy in the multimodal management of malignant vertebral compression fractures. Pain Physician. 2011;14(5):447-458.
There is insufficient evidence to make a recommendation for or against timing of non-interventional therapy or vertebral augmentation in adults with neoplastic vertebral fractures.
Grade of Recommendation: I
In a retrospective case series study, Malhotra et al1 aimed to understand the manner in which spinal deformity affects clinical outcomes, and the impact of time on the effectiveness of spinal treatment modalities. The authors concluded that “vertebral augmentation and thoracolumbar bracing improve patient reported outcome scores in patients with spinal myeloma. However, delay in treatment negatively impacts clinical outcome, particularly if managed non-operatively. It is important to screen and treat patients with multiple myeloma and back pain early to prevent deformity and improve quality of life.” This paper provides Level IV evidence that patients with multiple myeloma and vertebral fractures respond better to kyphoplasty or thoracic-lumbar-sacral orthosis (TLSO) if treated within 195 days of presentation. Delay in non-interventional treatment of neoplastic vertebral fractures negatively impacts clinical outcomes particularly if managed with thoracolumbar bracing.
References:
1. Malhotra K, Butler JS, Yu HM, et al. Spinal disease in myeloma: cohort analysis at a specialist spinal surgery centre indicates benefit of early surgical augmentation or bracing. BMC Cancer. 2016;16:444. Published 2016 Jul 11. doi:10.1186/s12885-016-2495-7
FLASK Future Directions for Research
The work group recommends high-quality prospective studies evaluating the role of timing or sequencing of treatments on outcomes in patients with neoplastic vertebral fractures.
Medical Treatment Question 5: Do general and individualized physical therapy programs differ in pain and functional outcomes for patients with neoplastic vertebral fractures?
A systematic review of the literature yielded no studies to adequately address this question.
FLASK Future Directions for Research
The work group recommends high-quality studies assessing whether general and individualized physical therapy programs differ in pain and functional outcomes for patients with neoplastic vertebral fractures.