Definitive Study (69, 000 Patients) Last Word on Cement for VCF Care?
Johns Hopkins researchers, using data from 69, 000 Medicare patients, have found that people with spine compression fractures who undergo operations to strengthen back bones with cement survive longer and have shorter overall hospital stays than those who rely on bed rest, pain control and physical therapy. Richard Skolasky, Jr., Sc.D. is Associate Professor of Orthopaedic Surgery at the Spine Outcomes Research Center of Johns Hopkins University. He tells OTW:
“There has been conflicting information in the literature on the effectiveness of vertebral augmentation over nonsurgical care. Cohort studies have shown that vertebral augmentation improved outcomes over non-operative care in terms of pain and functional limitation. More recently, two randomized controlled trials (RCTs) looking at vertebral augmentation versus a sham intervention found that in the short term there is no benefit to vertebral augmentation in terms of pain relief and mobility. There are two camps now. The first camp endorses the results of the RCTs, stating that because the treatment decision depends on the patient and provider, sicker and older patients may not be offered surgery. This treatment bias would lead to worse results among those treated non-operatively. The opposing camp says, ‘the RCT studies have only followed patients to six months. Because augmentation restores strength and the anatomic integrity to the vertebrae, you will see longer lasting benefits requiring longer follow-up.’
To clarify things, we examined three categories of fracture care: non-operative, vertebroplasty and kyphoplasty. We looked at differences in survival at six months, one year, two years and three years after surgery. In addition, we examined complications, length of hospital stay, charges assessed by the discharging hospital and/or the health care provider delivering services, 30-day readmission rates and the need for repeat procedures.
Our data set was large enough to allow for adjustment for age and presence of comorbid conditions. We chose 2006 as the index year and identified patients diagnosed with vertebral compression fractures [VCF]. We excluded those who had previous spinal surgeries. We found that patients treated with vertebroplasty had a higher two-year survival rate (67%) compared to non-operative care (61%); for kyphoplasty two-year survival was 75%. Those undergoing kyphoplasty had higher charges and shorter hospital stays and were less likely to develop pneumonia compared to those who had non-operative treatment. The upshot is yes, surgical care is initially more expensive, but may actually be cost effective in the long run.
Our study relied on administrative data, thus, we know there are certain limitations to the interpretation of our results. The Medicare population may not be representative of the larger U.S. population, especially in terms of racial and ethnic composition. The literature shows that racial and ethnic minorities may use healthcare differently than white patients. There remains the concern that sicker patients may be getting placed in non-operative groups. While we attempted to adjust for that statistically you never know if you have adequately adjusted for everything. What is needed are prospective studies with adequate demographic and clinical matching of patients.”
RA Patients Twice as Likely to Develop Heart Disease
Those with rheumatoid arthritis (RA) have enough to contend with…including the prospect of developing cardiovascular disease. In fact, says a new study from Mayo Clinic, if there is a high disease burden on the joints in the first year of RA, there is already a very strong predictor of future cardiovascular disease. Eric Matteson is chair of Rheumatology at Mayo Clinic in Rochester, Minnesota. He tells OTW,
“My colleagues and I set out to learn why people with RA are at an increased risk for heart disease. We know that inflammation can affect the blood vessels of the heart muscle, something that is likely a major contributor to an increased risk these patients have for heart disease. It’s interesting to note that RA adds even more risk to the already known risks of smoking and cholesterol.
We looked at the disease severity of RA and found that those with the worst RA are twice as likely to develop heart disease. We wanted to know what was happening at the molecular level, and we found that people with RA and heart disease have higher levels of certain biomarkers that are associated with cytomegalovirus stimulation. This may lead to an alteration in the immune system and that may be related to why people get heart disease and how it develops.
This work is an indication that we need to pay more attention to the possibility of heart disease in people with RA. Orthopedic surgeons should be aware of the relationship with heart disease and when evaluating these patients for surgery should take this into account. It may involve a preoperative close look at whether the person has heart disease, i.e., stress testing, an echocardiogram, and assessment of carotid blood vessels. At Mayo we have created a cardiology-rheumatology clinic where patients can be evaluated by a cardiologist—even when they may not have traditional risk factors for heart disease.”
Roberto Civitelli, M.D. Elected President of ASBMR
Roberto Civitelli, M.D., has been elected president of the American Society for Bone and Mineral Research (ASBMR). Dr. Civitelli is the Sydney M. & Stella H. Schoenberg Professor of Medicine at Washington University in St. Louis. In addition to his research, Civitelli serves as chief of the Division of Bone and Mineral Diseases and director of the Metabolic Skeletal Disorders Training Program at the School of Medicine. He also treats patients at Barnes-Jewish Hospital. Dr. Civitelli’s research focuses on cell communication and signaling in bone and their roles in metabolic bone diseases, especially osteoporosis.
Civitelli earned his undergraduate and graduate degrees in medicine from the Siena University School of Medicine in Siena, Italy. He came to Washington University in 1985 as a fellow in endocrinology and metabolism. In 1989, he joined the faculty as an assistant professor of medicine, becoming an associate professor in 1995 and a professor in 2000, with joint appointments in orthopedic surgery and cell biology and physiology.
Dr. Civitelli is editor emeritus of Calcified Tissue International and also has served on the editorial boards of The Journal of Clinical Endocrinology and Metabolism, the Journal of Bone and Mineral Research and The Journal of Laboratory and Clinical Medicine.
Dr. Civitelli has received the Fuller Albright Young Investigator Award from the American Society for Bone and Mineral Research, and Washington University has recognized him with the Outstanding Faculty Mentor Award.
Spine Fellowship Match Reaches Milestone
Edward Dohring, M.D. is an orthopedic surgeon with the Spine Institute of Arizona, and is the spine surgery fellowship director at that facility. Dr. Dohring, who is chairman of the North American Spine Society (NASS) Resident and Fellowship Education Committee, says that spine fellowship programs are in better shape than ever. He tells OTW:
“We have recently learned that we have hit a new high as far as applications to the spine fellowship match—both on the part of residents and spine programs. This is likely due to the fact that the application process has been reorganized. At one point, before a formal matching process was instituted, residents were told, ‘We will offer you a spot now but you must give us an answer within 24 hours.’ Programs were anxious because there are many more fellowship program spots in spine than there are American graduate candidates. However, this process was not fair to residents.
NASS, the Cervical Spine Research Society, and the Scoliosis Research Society decided to put teeth behind the match. They determined that if a program offers a position before the match date, then for two years program representatives would not be allowed to present papers and not allowed to participate as faculty at their meetings. Nor could individuals from these programs serve in officer positions for those organizations. Programs came to realize that ‘cheating’ on the match backfires in the form of peer disapproval. And residents realized that they don’t have to accept a position in haste, because the chances were high that they would get into one of their favorite programs (93% get one of their top three choices). Now everyone is on the same page, and we are turning our focus to the quality of fellowship education. We now see that many programs are not matching unless they offer a higher quality program. Residents are asking, ‘OK, do they just want someone to do rounds and take call, or is this a program that is mostly focused on training me thoroughly.’
These advances are especially important because spine fellows have a slightly higher failure rate on the American Board of Orthopaedic Surgery part two exam. This has put the onus on fellowship programs to ensure that graduating fellows have a strong conceptual as well as technical foundation in spine. Indeed, the American Council for Graduate Medical Education (ACGME) is creating, with help from NASS members, educational “milestones” for spine fellowships and their fellows: for example, one milestone might be that fellows should be able to understand the indications for, and competently perform, a laminectomy within three months of the start of their fellowship. These milestones will be incorporated into the ACGME certification process, and if programs and their fellows ignore the milestones then they will receive a warning of sorts, or eventually risk losing their accreditation.”
