VERTOS-II: Percutaneous Vertebroplasty Versus Conventional Therapy

Percutaneous vertebroplasty is a new procedure for treating painful osteoporotic compression fractures of the spine. Five-thousand out of 12.000 patients (16.000 vertebral fractures/year in the Netherlands) present with sudden, severe back pain in the region of the fracture. The pain appears to be due in part to instability (non-union or slow-union) at the fracture site and often disappears within a few days to weeks.

Until recently, bed rest, analgesia and physical support were the only treatment options. However, half of the patients (± 2.500/year) continue to have pain that does not respond sufficiently to conservative therapy. In these patients, percutaneous vertebroplasty can be used for acute pain relief. However, previous studies have been short in duration and have not had a comparison group of patients with usual care.

Design:

This will be a multicenter (3 centers), prospective, randomised, intervention study. Eligible patients will be randomised for percutaneous vertebroplasty or analgesics.

Study population:

Age: 50 and older, vertebral fracture: 15-85% height loss, level: thoracic vertebral body 5 (Th 5) or lower, osteopenia (T-score less than -1 SD), back pain for no more than 6 weeks and edema in the vertebrae on MR imaging Statistical analyses All analyses will be performed on an 'intention to treat' principle. The planned number of subjects will be 200 in total, 100 in each intervention arm. This number is based on conventional assumptions of alfa=0.05 and ß=0.20, withdrawal from intervention of 20%, supposing that significant pain relief will be evident in 70% of the "vertebroplasty group" and 20% in the "analgesics group".

Economic evaluation:

Cost-effectiveness will be assessed. The costs of the procedure and the medical treatment, and of visits to medical specialists, GP's and physical therapists will be compared.

Time schedule:

The total study will take 36 months

Condition	Intervention
Osteoporotic Vertebral Fractures.	Procedure: Vertebroplasty

Further study details as provided by UMC Utrecht:

Primary Outcome Measures: 

• To compare the quality of life of the patients in the two groups.

Secondary Outcome Measures: 

• To compare the cost-effectivity in the two groups

Total Enrollment:  200

Design:

This will be a multicenter (5 centers), prospective, randomised, intervention study. Eligible patients will be randomised for percutaneous vertebroplasty or analgesics.

Study population:

Two hundred patients will be included; the St. Lucas Hospital Gent will include 80 patients, the St. Elisabeth Hospital and the University Medical Center Utrecht 60 patients each.

Inclusion criteria:

• age: 50 and older
• vertebral fracture: 15-85% height loss
• level: thoracic vertebral body 5 (Th 5) or lower
• osteopenia (T-score less than -1 SD)
• back pain for at least no longer than 6 weeks
• edema in the vertebrae on MR imaging

Exclusion criteria:

• complete loss of vertebral body height
• fracture through or destruction of the posterior vertebral wall
• pressure of bone fragments on the spinal cord
• osteomyelitis or spondylodiscitis
• vertebral column neoplasms
• uncorrectable coagulation disorder
• medical conditions that would make the patient ineligible for emergency decompressive surgery should it be necessary to treat a complication of the procedure.

Patient selection:

Patients will be referred from the GP to the radiology department for acute back pain. The GP will order an X-ray of the thoracic and lumbar spine to establish an osteoporotic vertebral fracture(s). Subsequently, the hospital radiologist will pick out the cases with vertebral fracture(s). Subsequently, the general physician/ geriatrician will confirm the diagnosis of 'osteoporotic' vertebral fracture, and exclude other causes of vertebral fracture (e.g. tumour, major trauma). Finally, the patient and their GP will be asked to participate in our study.

Eligible patients will be randomised for percutaneous vertebroplasty and painmedication or only analgesics.

Procedure:

The treatment consists of a transpedicular injection of polymethylmethacrylate bone cement into the collapsed vertebral body (maximal 2 vertebrae in 1 treatment session) using fluoroscopic and/or computed tomographic (CT) guidance. The procedure is performed under the use of local anesthetics and the patient can be discharged the same day or after 1 night of hospital stay.

Conventional treatment (analgesics):

The general physician involved will decide which analgesics are best to optimalize pain relief for an individual patient. Paracetamol, non-steroidal anti-inflammatory drugs (NSAIDS) and/or opiates will be used for this purpose.

Outcome parameters:

The primary outcome for the clinical study as well as the economic evaluation will be adequate relief of pain. Pain intensity will be measured by means of a visual analogue scale (VAS). Relief of up to 3,0 to 4,4 scale points (scale 0-10) is associated with a clinically relevant pain reduction (Beurskens et al 1995). The main goal of the economic evaluation is to assess the balance between costs and effects of percutaneous vertebroplasty and painmedication as compared to usual care (analgesics, physiotherapy, visits to general practitioner) after 4 weeks and after 1 year.

The clinical research objectives are to compare the effects (after 4 weeks and 12 months) of vertebroplasty with conventional therapy on a) back pain, b) activities of daily living (ADL), c) mood, d) general health and e) quality of life in patients with painful osteoporotic vertebral fractures. Other objectives are to study the 1 year incidence of recurrent fractures, especially adjacent to treated levels of

Measurements:

a), b), c), d) and e) are measured by using the visual analogue scale (VAS) for pain intensity, the Roland Disability Questionaire (RDQ) for functional status, while the SF36, the HRQoL, the EQ6D and the Qualeffo-41 focus on quality of life, mood and general health. Data will be collected about units of resource utilisation with an explicit clause asking whether it can be related to the vertebral fracture.

(New) osteoporotic vertebral fractures are assessed at baseline by conventional radiography and magnetic resonance (MR) imaging. The incidence of recurrent fractures will be determined by conventional X-rays at 12 months.

Economic evaluation:

The goal of the economic evaluation is to assess the balance between costs and effects of vertebroplasty as compared to usual care.

We will initially perform a cost-effectiveness analysis with a one month time horizon. Given immediate pain relief in a majority after vertebroplasty, already a cost-effectiveness ratio can be calculated.

Estimates of other relevant outcomes such as costs and quality of life will also be entered in the model to allow a full economic evaluation. We will estimate incremental costs per additional year freed of pain of immediate vertebroblasty as compared to vertebroplasty after one month and (synthetic scenario of) care as usual. As the latter does involve extrapolation using estimates not actually observed in the trial we can not use bootstrap simulation to assess uncertainty. Accordingly, multivariate probabilistic sensitivity analysis (Monte carlo simulations) will be used to evaluate uncertainty in the cost-effectiveness ratios. As we will take into account a time horizon up till one year costs nor effects will be discounted. Finally, a cost-utility analysis is foreseen based on utility scores obtained over the first month of observation after randomisation.

The direct medical costs will be estimated from a societal perspective. This implies that resource use such as GP visits, analgesics, physiotherapy and consultation of orthopaedic surgeons or generalphysicians will be recorded in the CRF and in patient diaries. In parallel, actual costs of the resources, i.e., unit costs, will be estimated. The majority will be based on the estimates gathered in the Dutch guidelines for economic evaluation published by CVZ. Subsequentely, multiplication of units costs with resource use will yield cost estimates on an individual patient level. With regard to costs due to losses in productivity we pose that the majority of patients does not have a paid job. Time spent by spouses, family and friends taking over certain houshold activities or other unpaid activities will be accounted for using shadow prices.

The primary outcome for the economic evaluation will be adequate relief of pain. Pain will be measured by means of a visual analogue scale (VAS). Relief of up to 3,0 to 4,4 scale points is considered adequate. Time until this outcome is attained will explicitely be accounted for in the economic evaluation.

In addition to pain health related quality of life will be measured. By means of the SF36 administered at t= 0 and subsequently at 2 week intervals during the first month after randomisation, the impact of the fractures on the various domains of HRQoL will be assessed. After one month the interval of measurement will be increased to a period of one month until three months.

After three month the intervals will again be increased to three months until 12 month after randomisation. The EQ5D will be administered simultaneously and the scores obtained will be used to estimate quality adjusted survival time over the previous period. Subsequent summation over the period of follow up will yield overall QALYs up to a year for each arm of the trial.

In the cost effectiveness analysis we will take care of the differences in the Belgium and Dutch healthcare system.

Statistical analyses All analyses will be performed on an "intention to treat" principle. In addition, analyses will be performed.

The short-term effects (after 4 weeks) on the different outcomes will be compared between the two groups with the Student's t-test for continuous normally distributed variables, with the Mann-Whitney test for variables that are not normally distributed and with the chi² test for categorical variables. In addition, subgroups (e.g. long/shot duration of complaints) will be examined in which vertebroplasty has a more (or less) pronounced effect by introducing interaction terms in linear regression models with change in pain and quality of life as outcome variables.

The one-year cumulative incidence of new fractures adjacent to the treated/old fracture levels will be compared between patients who were treated with vertebroplasty and those who were not with Cox-proportional hazards analyses, adjusting for confounders.

Power calculations:

The planned number of subjects will be 200 in total, 100 in each intervention arm. This number is based on conventional assumptions of alfa=0.05 and ß=0.20, withdrawal from intervention of 20%, based on a pilot study and on the literature significant pain relief will be found in greater than 60% of the patients, supposing that significant pain relief will be evident in 70% of the vertebroplasty group and 20% in the analgesics.

Time schedule:

The total study will take 36 months. It is expected that inclusion of the patients will take 16 months.

Twelve months later, the last assessments will be finished. The final 8 months will be devoted to data-analysis and writing of publications.

Expertise, voorgaande activiteiten en producten / Expertise, prior activities and products

Experience with percutaneous vertebroplasty procedure:

Gent: greater than 500 procedures Tilburg: greater than 130 procedures Utrecht: greater than 50 procedures. In general it takes one year to get the logistic organisation in place, get the knowledge and experience.

After 30 patients have been done, learning curve is over.

Ages Eligible for Study:  50 Years and above,  Genders Eligible for Study:  Both

Criteria

Inclusion criteria:

• age: 50 and older
• vertebral fracture: 15-85% height loss
• level: thoracic vertebral body 5 (Th 5) or lower
• osteopenia (T-score < -1 SD)
• back pain for at least no longer than 6 weeks
• edema in the vertebrae on MR imaging

Exclusion criteria:

• complete loss of vertebral body height
• fracture through or destruction of the posterior vertebral wall
• pressure of bone fragments on the spinal cord
• osteomyelitis or spondylodiscitis
• vertebral column neoplasms
• uncorrectable coagulation disorder
• medical conditions that would make the patient ineligible for emergency decompressive surgery should it be necessary to treat a complication of the procedure

Please refer to this study by ClinicalTrials.gov identifier  NCT00232466

Caroline AH Klazen, MD      0031641326739    cahklazen@hotmail.com

Belgium
      AZ St. Lucas Ziekenhuis, Gent,  9000,  Belgium; Recruiting
Netherlands
      St. Elisabeth Ziekenhuis, Tilburg,  5022 GC,  Netherlands; Recruiting
      Catharina-Ziekenhuis, Eindhoven,  5623 EJ,  Netherlands; Recruiting
      UMCU, Utrecht,  3508 GA,  Netherlands; Recruiting
Netherlands, Utrecht
      Diakonessenhuis, Utrecht/Zeist/Doorn,  Utrecht,  3508 TG,  Netherlands; Recruiting

Study chairs or principal investigators

Willem Mali, MD.PhD,  Principal Investigator,  UMC Utrecht 

Study ID Numbers:  945-06-351
Last Updated:  March 17, 2006
Record first received:  September 30, 2005
ClinicalTrials.gov Identifier:  NCT00232466
Health Authority: Netherlands: The Central Committee on Research Involving Human Subjects (CCMO)
ClinicalTrials.gov processed this record on June 12, 2007