Appropriate use criteria for osteoporotic compression fractures
BACKGROUND CONTEXT: There is a lack of consensus regarding optimal indications for treatment of patients with osteoporotic vertebral fractures. An opportunity exists to improve outcomes if these indications can be clarified.
PURPOSE: The purpose of the North American Spine Society (NASS) Appropriate Use Criteria (AUC) was to determine the appropriate (ie, reasonable) multidisciplinary treatment recommendations for patients with osteoporotic vertebral fractures across a spectrum of more common clinical scenarios.
STUDY DESIGN: A Modified Delphi process.
PATIENT SAMPLE: Modified consensus based guideline.
OUTCOME MEASURES: Final rating for treatment recommendations as either “Appropriate,” “Uncertain,” or “Rarely Appropriate” based on the median final rating among the raters.
METHODS: The methodology was based on the AUC development process established by the Research AND Development (RAND) Corporation. The topic of osteoporotic vertebral compression fracture was selected by NASS for its Clinical Practice Guideline development (CPG). In conjunction, the AUC committee determined key modifiers and adapted the standard definitions developed by the CPG with minimal modifications. A literature search and evidence analysis performed by the CPG were reviewed by the AUC work group. A separate multidisciplinary rating group was assembled. Clinical scenarios were generated based on a matrix of the modifiers, to rate the appropriateness of medical management, cement augmentation, or surgery. Based on the literature, provider experience, and group discussion, each scenario was scored on a 9-point scale on two separate occasions: once without discussion and again following discussion of the initial responses. The median rating for each scenario and level of agreement was then used to determine final indications as rarely appropriate with agreement (1 – 3), uncertain or disagreement (4-6), or appropriate with agreement (7-9). Consensus was not mandatory.
RESULTS: Medical management was appropriate across all scenarios. Cement augmentation was rarely appropriate in 60% of scenarios and uncertain or disagreement in 35% of scenarios. In the 5% of scenarios rated as appropriate with agreement for cement augmentation, high pain scores, acute duration, and simple fracture pattern were always present. Surgery was appropriate in 35% of scenarios and strongly influenced by instability and stenosis with neurological findings. Surgery was rarely appropriate in 18%, and uncertain or disagreement in 47% of scenarios.
CONCLUSIONS: Multidisciplinary appropriate treatment criteria for osteoporotic vertebral fractures were generated based on the RAND methodology. This document provides comprehensive evidence-based recommendations for evaluation and treatment of osteoporotic vertebral fractures. The document in its entirety will be found on the NASS website (https://www.spine.org/Research-Clinical-Care/Quality-Improvement/Appropriate-Use-Criteria).
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Work Title Appropriate use criteria for osteoporotic compression fractures Access Creators - Charles Cho
- Jeffrey Hills
- Paul Anderson
- Thiru Annaswamy
- R. Carter Cassidy
- Chad Craig
- Russell DeMicco
- John Easa
- Scott Kreiner
- Daniel Mazanec
- John O'Toole
- George Rappard
- Robert Ravinsky
- Andrew Schoenfeld
- John Shin
- Greg Whitcomb
- Charles Reitman
Keyword - Osteoporotic vertebral fracture
- Appropriate use criteria
License In Copyright (Rights Reserved) Work Type Article Publisher - Spine Journal
Publication Date August 2025 Publisher Identifier (DOI) - https://doi.org/10.1016/j.spinee.2025.02.007
Deposited June 08, 2026 Versions
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Version 1
published-
Created
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Added
AUC_Osteoporotic_compression_fractures_2025.pdf -
Added Creator Charles Cho
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Added Creator Jeffrey Hills
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Added Creator Paul Anderson
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Added Creator Thiru Annaswamy
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Added Creator R. Carter Cassidy
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Added Creator Chad Craig
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Added Creator Russell DeMicco
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Added Creator John Easa
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Added Creator Scott Kreiner
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Added Creator Daniel Mazanec
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Added Creator John O'Toole
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Added Creator George Rappard
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Added Creator Robert Ravinsky
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Added Creator Andrew Schoenfeld
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Added Creator John Shin
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Added Creator Greg Whitcomb
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Added Creator Charles Reitman
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Published
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Updated
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Updated Keyword, Description Show ChangesKeywordDescription
- Osteoporotic vertebral fracture, Appropriate use criteria
BACKGROUND CONTEXT: There is a lack of consensus regarding optimal indications for treatment of patients with osteoporotic vertebral fractures. An opportunity exists to improve outcomes if these indications can be clarified. PURPOSE: The purpose of the North American Spine Society (NASS) Appropriate Use Criteria (AUC) was to determine the appropriate (ie, reasonable) multidisciplinary treatment recommendations for patients with osteoporotic vertebral fractures across a spectrum of more common clinical scenarios. STUDY DESIGN: A Modified Delphi process. PATIENT SAMPLE: Modified consensus based guideline. OUTCOME MEASURES: Final rating for treatment recommendations as either “Appropriate,” “Uncertain,” or “Rarely Appropriate” based on the median final rating among the raters. METHODS: The methodology was based on the AUC development process established by the Research AND Development (RAND) Corporation. The topic of osteoporotic vertebral compression fracture was selected by NASS for its Clinical Practice Guideline development (CPG). In conjunction, the AUC committee determined key modifiers and adapted the standard definitions developed by the CPG with minimal modifications. A literature search and evidence analysis performed by the CPG were reviewed by the AUC work group. A separate multidisciplinary rating group was assembled. Clinical scenarios were generated based on a matrix of the modifiers, to rate the appropriateness of medical management, cement augmentation, or surgery. Based on the literature, provider experience, and group discussion, each scenario was scored on a 9-point scale on two separate occasions: once without discussion and again following discussion of the initial responses. The median rating for each scenario and level of agreement was then used to determine final indications as rarely appropriate with agreement (1 – 3), uncertain or disagreement (4-6), or appropriate with agreement (7-9). Consensus was not mandatory. RESULTS: Medical management was appropriate across all scenarios. Cement augmentation was rarely appropriate in 60% of scenarios and uncertain or disagreement in 35% of scenarios. In the 5% of scenarios rated as appropriate with agreement for cement augmentation, high pain scores, acute duration, and simple fracture pattern were always present. Surgery was appropriate in 35% of scenarios and strongly influenced by instability and stenosis with neurological findings. Surgery was rarely appropriate in 18%, and uncertain or disagreement in 47% of scenarios. CONCLUSIONS: Multidisciplinary appropriate treatment criteria for osteoporotic vertebral fractures were generated based on the RAND methodology. This document provides comprehensive evidence-based recommendations for evaluation and treatment of osteoporotic vertebral fractures. The document in its entirety will be found on the NASS website (https://www.spine.org/Research-Clinical-Care/Quality-Improvement/Appropriate-Use-Criteria).- BACKGROUND CONTEXT: There is a lack of consensus regarding optimal indications for treatment of patients with osteoporotic vertebral fractures. An opportunity exists to improve outcomes if these indications can be clarified.
- PURPOSE: The purpose of the North American Spine Society (NASS) Appropriate Use Criteria (AUC) was to determine the appropriate (ie, reasonable) multidisciplinary treatment recommendations for patients with osteoporotic vertebral fractures across a spectrum of more common clinical scenarios.
- STUDY DESIGN: A Modified Delphi process.
- PATIENT SAMPLE: Modified consensus based guideline.
- OUTCOME MEASURES: Final rating for treatment recommendations as either “Appropriate,” “Uncertain,” or “Rarely Appropriate” based on the median final rating among the raters.
- METHODS: The methodology was based on the AUC development process established by the Research AND Development (RAND) Corporation. The topic of osteoporotic vertebral compression fracture was selected by NASS for its Clinical Practice Guideline development (CPG). In conjunction, the AUC committee determined key modifiers and adapted the standard definitions developed by the CPG with minimal modifications. A literature search and evidence analysis performed by the CPG were reviewed by the AUC work group. A separate multidisciplinary rating group was assembled. Clinical scenarios were generated based on a matrix of the modifiers, to rate the appropriateness of medical management, cement augmentation, or surgery. Based on the literature, provider experience, and group discussion, each scenario was scored on a 9-point scale on two separate occasions: once without discussion and again following discussion of the initial responses. The median rating for each scenario and level of agreement was then used to determine final indications as rarely appropriate with agreement (1 – 3), uncertain or disagreement (4-6), or appropriate with agreement (7-9). Consensus was not mandatory.
- RESULTS: Medical management was appropriate across all scenarios. Cement augmentation was rarely appropriate in 60% of scenarios and uncertain or disagreement in 35% of scenarios. In the 5% of scenarios rated as appropriate with agreement for cement augmentation, high pain scores, acute duration, and simple fracture pattern were always present. Surgery was appropriate in 35% of scenarios and strongly influenced by instability and stenosis with neurological findings. Surgery was rarely appropriate in 18%, and uncertain or disagreement in 47% of scenarios.
- CONCLUSIONS: Multidisciplinary appropriate treatment criteria for osteoporotic vertebral fractures were generated based on the RAND methodology. This document provides comprehensive evidence-based recommendations for evaluation and treatment of osteoporotic vertebral fractures. The document in its entirety will be found on the NASS website (https://www.spine.org/Research-Clinical-Care/Quality-Improvement/Appropriate-Use-Criteria).
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Updated Creator Charles Cho
-
Updated Creator Jeffrey Hills
-
Updated Creator Paul Anderson
-
Updated Creator R. Carter Cassidy
-
Updated Creator Chad Craig
-
Updated Creator Russell DeMicco
-
Updated Creator John Easa
-
Updated Creator Scott Kreiner
-
Updated Creator Daniel Mazanec
-
Updated Creator John O'Toole
-
Updated Creator George Rappard
-
Updated Creator Robert Ravinsky
-
Updated Creator Andrew Schoenfeld
-
Updated Creator John Shin
-
Updated Creator Greg Whitcomb
-
Updated Creator Charles Reitman
-
Updated Publication Date Show ChangesPublication Date
2025-08-01- 2025-08