Mercadante, S., Klepstad, P., Kurita, G.P., Sjøgren, P., Pigni, A., & Caraceni, A. (2016). Minimally invasive procedures for the management of vertebral bone pain due to cancer: The EAPC recommendations. Acta Oncologica, 55, 129–133.

STUDY PURPOSE: To review the evidence that supports the performance of percutaneous procedures in adult patients with cancer with vertebral pain for updating the European Association for Palliative Care recommendations for cancer pain management.

TYPE OF STUDY: Systematic review

DATABASES USED: Medline, Embase and Cochrane Central Register of Controlled Trials electronic databases

INCLUSION CRITERIA: Studies in which the interventional studies were compared with analgesic drugs, or sham procedure, adult patients with cancer pain, pain as an outcome, and written in English.

EXCLUSION CRITERIA: Retrospective data, data from mixed cancer and non-cancer populations, proceeding abstracts, double publications.

TOTAL REFERENCES RETRIEVED: 754

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Quality scoring system ranged from +4 or A to +1 or D or +4 or A = high quality, +3 or B = moderate, +2 or C = low, +1 or D = very low. Study quality, consistency, directness, and imprecise or sparse data were considered while grading the studies.

FINAL NUMBER STUDIES INCLUDED: Nine studies were fully examined and the final review included five studies

TOTAL PATIENTS INCLUDED IN REVIEW: 485

SAMPLE RANGE ACROSS STUDIES: Three studies with 100-134 patients, two studies with 50-65 patients 

KEY SAMPLE CHARACTERISTICS: Adult patients with cancer with tumor metastases, most of the studies included patients with myeloma with mets to vertebra; techniques used in patients: kiphoplasty, vertebroplasty. Studies with radiofrequency ablation, cryoablation procedures did not meet the inclusion criteria.

PHASE OF CARE: End-of-life care     

APPLICATIONS: Palliative care

Kyphoplasty: Two studies reviewed. One study showed efficacy in treating osteolytic vertebral compression fracture, but it had a low sample size (< 100) and pain outcomes were not clearly presented. The other study (RCT with 134 patients) was very low quality. Vertebroplasty: One study showed 86% good efficacy. Other two studies showed reduced pain intensity and improved disability. One study showed reduced analgesic requirement. These studies were observational in nature; therefore, the results should be considered with caution.

Although the authors recommended kiphoplasty in patients with vertebral tumors and metastases, the quality of study designs are very low and some studies showed the procedure resulting in adverse effects or complications. More RCTs are needed to improve the strength of these findings.

• Limited search
• No quality evaluation
• Mostly low quality/high risk of bias studies
• High heterogeneity
• Four out of five studies did not provide analgesic consumption, which might be a confounder. The evidence table is not detailed.

As findings are not strong enough and given the considerable number of complications, the decision for recommending these procedures should be made by the physician on a individual basis.