Of the randomized control trials discussed in this document, only 2 studies showed a statistically significant difference in the rate of adjacent vertebral fractures in follow-up between the VA and control groups, one favoring VA and the other nonsurgical management. In addition, VP and BK may be protective against further height loss of a fractured vertebra. In the VERTOS IV trial, the risk of further height loss was almost 10 times higher after the sham procedure compared with VA treatment [133,134]. Patients with ongoing compression at a previously treated level can undergo a second augmentation, especially if the initial fluid-filled cleft did not completely fill or the cleft enlarges afterward. In several large studies, intravertebral clefts were identified in between 90% and 100% of cases of recurrent fractures in a previously treated level [135,136]. The goal is more uniform filling of the vertebra to decrease the micromotion at the fractured vertebral endplates, which helps in pain palliation. After initial augmentation, the development of a new adjacent level fracture can also be addressed by repeating the procedure for the new fracture level. Percutaneous Ablation Spine Percutaneous thermal ablation procedures are reserved for symptomatic spinal metastatic disease [112]. Surgical Consultation Surgery is typically reserved for patients who have developed new neurologic compromise, new spinal instability, or leakage of cement into the spinal epidural space with canal compression and the development of new radicular symptoms. Observational studies suggest that surgical decompression and stabilization improve neurological status from nonambulatory to ambulatory as well as pain relief [137]. Surgical consultation can be performed concurrently with other procedures. Vertebral Compression Fractures Radiation Oncology Consultation There is no role for RT in a patient without a cancer diagnosis and a nonpathologic VCF.
Management of Vertebral Compression Fractures PCAs. Of the randomized control trials discussed in this document, only 2 studies showed a statistically significant difference in the rate of adjacent vertebral fractures in follow-up between the VA and control groups, one favoring VA and the other nonsurgical management. In addition, VP and BK may be protective against further height loss of a fractured vertebra. In the VERTOS IV trial, the risk of further height loss was almost 10 times higher after the sham procedure compared with VA treatment [133,134]. Patients with ongoing compression at a previously treated level can undergo a second augmentation, especially if the initial fluid-filled cleft did not completely fill or the cleft enlarges afterward. In several large studies, intravertebral clefts were identified in between 90% and 100% of cases of recurrent fractures in a previously treated level [135,136]. The goal is more uniform filling of the vertebra to decrease the micromotion at the fractured vertebral endplates, which helps in pain palliation. After initial augmentation, the development of a new adjacent level fracture can also be addressed by repeating the procedure for the new fracture level. Percutaneous Ablation Spine Percutaneous thermal ablation procedures are reserved for symptomatic spinal metastatic disease [112]. Surgical Consultation Surgery is typically reserved for patients who have developed new neurologic compromise, new spinal instability, or leakage of cement into the spinal epidural space with canal compression and the development of new radicular symptoms. Observational studies suggest that surgical decompression and stabilization improve neurological status from nonambulatory to ambulatory as well as pain relief [137]. Surgical consultation can be performed concurrently with other procedures. Vertebral Compression Fractures Radiation Oncology Consultation There is no role for RT in a patient without a cancer diagnosis and a nonpathologic VCF.