Kyphoplasty / Vertebroplasty in the office

[mid|ine]

I am thinking of doing these procedures in the office.

Does anyone else here do them in the office?

Is anyone having trouble getting reimbursed for kyphoplasty balloons in the office?

Does anyone have an office protocol they would be willing to share?

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[lobelsteve]

I am thinking of doing these procedures in the office.

Does anyone else here do them in the office?

Is anyone having trouble getting reimbursed for kyphoplasty balloons in the office?

Does anyone have an office protocol they would be willing to share?

Doing them since January.

No problems (all MC)

MRI with STIR, failed meds, brace, miacalcin with 5+/10 pain

IV ABX, prep/drape (half-sheet and sleeves)
Do procedure.
Monitor 30 mn post-op.

 

[nvrsumr]

My local Medicare administrator Trailblazer wont approve Kypho for in office. ANyone else see this?

 

[PinchandBurn]

For those of you like steve, putting people on intranasal calcitonin. how long can you put them on it for. Is it indefinite? Any labs you have to order? I've used it on pts, so far they do great, they've been doing it for a month.

 

[lonelobo]

My local Medicare administrator Trailblazer wont approve Kypho for in office. ANyone else see this?

Might check that again, Have Trailblazer in NM and is now approved for office

 

[ghost dog]

Doing them since January.

No problems (all MC)

MRI with STIR, failed meds, brace, miacalcin with 5+/10 pain

IV ABX, prep/drape (half-sheet and sleeves)
Do procedure.
Monitor 30 mn post-op.

Clinical case: I saw a 22 yr old pt yesterday who presented with a 2 wk Hx of lumbar spine pain after an assault ( 2 people kicked him in the back). He attended the ER, and a Chest X-ray revealed a thoracic compression fracture of indeterminate age. Surprisingly, he was not referred to the fracture clinic ( I'm guessing they thought it was an old fracture , and not relevant to his current presentation).

On exam in my office, he was moderately tender over the L3 spinous process. He complained of severe lumbar spine pain, much worse than his usual baseline pain ( this pt has a hx of previously existing chronic LBP). He was neurological intact.

PMHx : on seroquel 25 - 50 mg PRN for insomnia d / t chronic LBP. No underlying medical conditions.

His family MD had performed a prior chest X-ray and lumbar spine X-ray 6 months ago: both were normal (i.e. no compression fracture visualized).

Keeping in mind the below study , is this a case of referred pain ?



http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2610635/

 

[lobelsteve]

Clinical case: I saw a 22 yr old pt yesterday who presented with a 2 wk Hx of lumbar spine pain after an assault ( 2 people kicked him in the back). He attended the ER, and a Chest X-ray revealed a thoracic compression fracture of indeterminate age. Surprisingly, he was not referred to the fracture clinic ( I'm guessing they thought it was an old fracture , and not relevant to his current presentation).

On exam in my office, he was moderately tender over the L3 spinous process. He complained of severe lumbar spine pain, much worse than his usual baseline pain ( this pt has a hx of previously existing chronic LBP). He was neurological intact.

PMHx : on seroquel 25 - 50 mg PRN for insomnia d / t chronic LBP. No underlying medical conditions.

His family MD had performed a prior chest X-ray and lumbar spine X-ray 6 months ago: both were normal (i.e. no compression fracture visualized).

Keeping in mind the below study , is this a case of referred pain ?



http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2610635/

Stopped caring when you wrote 22 y/o with chronic pain on seroquel. Brace and bye bye.

seriously, get MRI with stir and check for osteogenesis imperfecta variant. Hard to break your back twice by 22.

 

[PinchandBurn]

Stopped caring when you wrote 22 y/o with chronic pain on seroquel. Brace and bye bye.

seriously, get MRI with stir and check for osteogenesis imperfecta variant. Hard to break your back twice by 22.

whts your age "cut off" for Vert Aug . Say brace, calcitonin,pain meds dont work. Would anyone consider it in this kid if he STIR imaging positive for edema.

BTW...one of the radiologists that does a lot of these suggested do MRI with STIR w/CONTRAST. is that what most of you do too?

 

[embolize]

maybe looking for an underlying lesion in a pt who shouldnt otherwise have a compression fx? def need the STIR though.

 

[Pain Applicant1]

Doing them since January.

No problems (all MC)

MRI with STIR, failed meds, brace, miacalcin with 5+/10 pain

IV ABX, prep/drape (half-sheet and sleeves)
Do procedure.
Monitor 30 mn post-op.

What are you using for sedation?

 

[lobelsteve]

What are you using for sedation?

Local for half of them. The other half get local, fent/versed.
I'm PMR so no propofol for me.

 

[Pain Applicant1]

Local for half of them. The other half get local, fent/versed.
I'm PMR so no propofol for me.

Wow, local for Kyphoplasty, nice.

 

[emd123]

Clinical case: I saw a 22 yr old pt yesterday who presented with a 2 wk Hx of lumbar spine pain after an assault ( 2 people kicked him in the back). He attended the ER, and a Chest X-ray revealed a thoracic compression fracture of indeterminate age. Surprisingly, he was not referred to the fracture clinic ( I'm guessing they thought it was an old fracture , and not relevant to his current presentation).

On exam in my office, he was moderately tender over the L3 spinous process. He complained of severe lumbar spine pain, much worse than his usual baseline pain ( this pt has a hx of previously existing chronic LBP). He was neurological intact.

PMHx : on seroquel 25 - 50 mg PRN for insomnia d / t chronic LBP. No underlying medical conditions.

His family MD had performed a prior chest X-ray and lumbar spine X-ray 6 months ago: both were normal (i.e. no compression fracture visualized).

Keeping in mind the below study , is this a case of referred pain ?



http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2610635/

How big of a compression? This is crucial. My guess is the classic "5-10% age indeterminant", vertebral compression NON-fracture.

It's quite odd to get a vertebral body "compression" fracture from direct blows or kicks to the back. Usually, direct blows are more likely to cause myofascial bruising, or with severe blows, possibly renal injury. If any bony injury occurs, it would likely be the fracture of a spinous/transverse process which are the only bones superficial enough to be affected by a kick . With an otherwise normal normal spine, some sort axial load or hyperflexion type mechanism would be more likely to cause a compression, like a significant MVA or fall from height >8-10 ft. Sometimes (in fact often) a 5 or 10% "compression" can actually be a congenital variant that may be mentioned by one radiologist on one film in the setting of trauma, and not even commented on on another film, yet actually unchanged on direct comparison (did you look at the films and compare them?). I've seen this hundreds of times. In the setting of trauma it's more likely to be called "acute" due to the clinical history reported to the radiologist, but may actually be a red herring, and completely normal.

I smell no acute fracture. The ER knew this. Did they do a CT to rule out a burst which can be missed on plain films? Doesn't sound like it. Thats why they sent him to you, not spine or neurosurg. They blew it off. No acute fracture (unless you tell me you compared the films side by side and one was stone-cold normal and the other was >10% compressed)

This patient, my friend, has something we call.....

CHRONIC pain.

 

[101N]

How big of a compression? This is crucial. My guess is the classic "5-10% age indeterminant", vertebral compression NON-fracture.

It's quite odd to get a vertebral body "compression" fracture from direct blows or kicks to the back. Usually, direct blows are more likely to cause myofascial bruising, or with severe blows, possibly renal injury. If any bony injury occurs, it would likely be the fracture of a spinous/transverse process which are the only bones superficial enough to be affected by a kick . With an otherwise normal normal spine, some sort axial load or hyperflexion type mechanism would be more likely to cause a compression, like a significant MVA or fall from height >8-10 ft. Sometimes (in fact often) a 5 or 10% "compression" can actually be a congenital variant that may be mentioned by one radiologist on one film in the setting of trauma, and not even commented on on another film, yet actually unchanged on direct comparison (did you look at the films and compare them?). I've seen this hundreds of times. In the setting of trauma it's more likely to be called "acute" due to the clinical history reported to the radiologist, but may actually be a red herring, and completely normal.

I smell no acute fracture. The ER knew this. Did they do a CT to rule out a burst which can be missed on plain films? Doesn't sound like it. Thats why they sent him to you, not spine or neurosurg. They blew it off. No acute fracture (unless you tell me you compared the films side by side and one was stone-cold normal and the other was >10% compressed)

This patient, my friend, has something we call.....

CHRONIC pain.

All this doesn't matter. We don't augment non-osteoporotic fractures.

 

[lobelsteve]

All this doesn't matter. We don't augment non-osteoporotic fractures.

Sometimes I do. Depends on age, pain, situation.

And also mets. But they aren't really fractures.

 

[drf]

Sometimes I do. Depends on age, pain, situation.

And also mets. But they aren't really fractures.

I read a couple of recent articles regarding bony met pain. One was by Rinoo Shah I believe and he vert or kyphoed a sternal met with cavitation with excellent result. Another used multiple RF needles to denervate an entire met. Multiple bipolar and tripolar passes with I think 17g needles with up to 30 mm active tips. Here is the reference for the second study. I read the first in the paper journal then threw it out so dont have that one. Finally some of our ortho onc and IR docs are doing high frequency US to denervate these. Anyone else do anything fancy for bony met pain?

Author Manuscript
Cancer. Author manuscript; available in PMC 2011 February 15.

Published in final edited form as:
Cancer. 2010 February 15; 116(4): 989–997. doi:10.1002/cncr.24837.
Percutaneous Radiofrequency Ablation of Painful Osseous Metastases: A Multi-center American College of Radiology Imaging Network Trial
Damian E. Dupuy, M.D.1, Dawei Liu, Ph.D.9, Donna Hartfeil, RN5, Lucy Hanna, Ph.D.4, Jeffrey D. Blume, Ph.D.4,8, Kamran Ahrar, M.D.6, Robert Lopez, M.D.7, Howard Safran, M.D. 2, and Thomas DiPetrillo, M.D.3
1 Department of Diagnostic Imaging, The Warren Alpert Medical School at Brown University
2 Department of Hematology/Oncology, The Warren Alpert Medical School at Brown University 3 Department of Radiation Medicine, The Warren Alpert Medical School at Brown University
4 Center for Statistical Sciences, Brown University
5 American College of Radiology Imaging Network (ACRIN)
6 MD Anderson Cancer Center
7 University of Alabama at Birmingham Medical Center
8 Department of Biostatistics, Vanderbilt University School of Medicine 9 Department of Statistics, Unversity of Iowa
Abstract
Background—To determine if radiofrequency ablation (RFA) can safely reduce pain from
osseous metastatic disease.
Methods—A single arm prospective trial in patients with a single painful bone metastasis with unremitting pain of at least a score above 50 on a pain scale of 0–100. Percutaneous CT guided RFA of the bone metastasis to temperatures above 60 degrees Celsius was performed.
Endpoints were the toxicity and pain effects of RFA before and at 2 weeks, one and three months after RFA.
Results—55 patients completed RFA. Grade 3 toxicities occurred in 3 of 55 patients (5%). RFA reduced pain at 1- and 3-month for all pain assessment measures. The average increase in pain relief from pre-RFA to 1-month follow-up is 26.27 (95% CI, 17.65 to 34.89, P<0.0001) and the increase from pre-RFA to 3-month follow-up is 16.38 (95% CI, 3.37 to 29.39, P=0.02). The average decrease in pain intensity from pre-RFA to 1-month follow-up was 26.9 (P<0.0001) and 14.2 for 3-month follow-up (P=0.02). The odds of being in lower pain severity at 1-month follow- up is 14.03 (95% CI, 2.33 to 25.73, P<0.0001) times higher than that at pre-RFA, and the odds at 3-month follow-up is 8.00 (95% CI, 0.85 to 15.15, P<0.001) times higher than that at pre-RFA. The average increase in mood from pre-RFA to 1-month follow-up was 19.9 (P<0.0001) and 14.9 for 3-month follow-up (P=0.005).

 

[ghost dog]

How big of a compression? This is crucial. My guess is the classic "5-10% age indeterminant", vertebral compression NON-fracture.

It's quite odd to get a vertebral body "compression" fracture from direct blows or kicks to the back. Usually, direct blows are more likely to cause myofascial bruising, or with severe blows, possibly renal injury. If any bony injury occurs, it would likely be the fracture of a spinous/transverse process which are the only bones superficial enough to be affected by a kick . With an otherwise normal normal spine, some sort axial load or hyperflexion type mechanism would be more likely to cause a compression, like a significant MVA or fall from height >8-10 ft. Sometimes (in fact often) a 5 or 10% "compression" can actually be a congenital variant that may be mentioned by one radiologist on one film in the setting of trauma, and not even commented on on another film, yet actually unchanged on direct comparison (did you look at the films and compare them?). I've seen this hundreds of times. In the setting of trauma it's more likely to be called "acute" due to the clinical history reported to the radiologist, but may actually be a red herring, and completely normal.

I smell no acute fracture. The ER knew this. Did they do a CT to rule out a burst which can be missed on plain films? Doesn't sound like it. Thats why they sent him to you, not spine or neurosurg. They blew it off. No acute fracture (unless you tell me you compared the films side by side and one was stone-cold normal and the other was >10% compressed)

This patient, my friend, has something we call.....

CHRONIC pain.

Actually the pt was called back the next day, as the ER had apparently missed the above abnormality of indeterminate age.

I would be quite impressed if the ER MD's thought process was involved as that above. It's my impression the vast majority of fractures are punted to the fracture
clinic. Missing abnormalities does not impress me in regards to the ERs thoroughness.

I am in the process of ordering an MRI.

 

[emd123]

All this doesn't matter. We don't augment non-osteoporotic fractures.

It is relevant to know, whether the thing you're treating actually is a fracture or is congenital. A congenital variant needs no treatment all all, because it isn't a pain generator. If its even a fracture at all, then you can argue over how you're going to treat it. The OP hasn't said what % the compression was. My point is that I wouldn't be surprised if his follow up MRI shows that it's not a fracture at all. That matters.

 

[emd123]

Missing abnormalities does not impress me in regards to the ERs thoroughness. .

I suppose it depends if it's a clinically relevant abnormality (fracture=pain generator) or a clinically irrelevant "abnormality" (congenital variant= non-pain generator).

A lot of times radiology will pick up BS next-day false positives that generate lots of (very expensive) follow up studies (MRI, CT, Ultrasound) that turn out to be entirely normal or clinically irrelevant and the patient is left with a lot of wasted time, a lot more radiation induced breaks in their DNA base pairs, and a lighter wallet.

You're right on this ER doctor not being too bright though, because obviously if he was he'd be applying to Pain fellowships right now

Just sayin'

How much is the vertebral body compressed in %?

 

[Ducttape]

Slightly off topic, but I clearly remember a case of a patient that presented to a local ED with traumatic back pain 20+ years ago. X rays revealed an abnormality. He was admitted, on iv Demerol for days, then got a ct scan, initially read as fx but retread as a shmorls node. Left AMA. Apparently on further digging, he would drive from one city to another getting admitted for this shmorl's node....

 

[emd123]

Slightly off topic, but I clearly remember a case of a patient that presented to a local ED with traumatic back pain 20+ years ago. X rays revealed an abnormality. He was admitted, on iv Demerol for days, then got a ct scan, initially read as fx but retread as a shmorls node. Left AMA. Apparently on further digging, he would drive from one city to another getting admitted for this shmorl's node....

Thank you. Dig a little deeper. That's what I'm saying.

 

[jsaul]

Sometimes I do. Depends on age, pain, situation.

And also mets. But they aren't really fractures.

I just did kypo pn 38 year old with MS who falls frequently. She had L1 fx since decemeber. Was on norco since then. Did the kypho 2 weeks ago and has been med free. However it was not an easy procedure as the bone was hard as diamond

 

[lobelsteve]

I just did kypo pn 38 year old with MS who falls frequently. She had L1 fx since decemeber. Was on norco since then. Did the kypho 2 weeks ago and has been med free. However it was not an easy procedure as the bone was hard as diamond

I've had 2 in the last 2 years. One was sclerosed due to XRT, the other was a traumatic Fx in a 75 y/o. I use Stryker and my rep hands me a drill bit stylet. I like it better than a mallet.

 

[Jcm800]

I've had 2 in the last 2 years. One was sclerosed due to XRT, the other was a traumatic Fx in a 75 y/o. I use Stryker and my rep hands me a drill bit stylet. I like it better than a mallet.

i recently did a fracture post XRT, and only 3-4 sessions and the bone had hardened.

I did one a few years ago on a post radiation patient, the bone was hard it was like a hammering into metal, it made a "ping sound" crazy. I usually drill when i can, but i could drill into this...

 

[PinchandBurn]

I've had 2 in the last 2 years. One was sclerosed due to XRT, the other was a traumatic Fx in a 75 y/o. I use Stryker and my rep hands me a drill bit stylet. I like it better than a mallet.

Hey Steve-


I'm trying to be an 'equal opportunist". So I did use Kyphon for one of my cases. Was going to use Stryker for the next one.

The Stryker rep is trying to push his new cement, called "Cortoss". It's obviously more expensive. He claims it's better for people that are first time fracturers, as it is more 'flexible' and so reduces to the chances of fractures at subsequent levels.

Is he trying to make an extra buck? Or is it legit? Others have opinions on it?

 

[lobelsteve]

Hey Steve-


I'm trying to be an 'equal opportunist". So I did use Kyphon for one of my cases. Was going to use Stryker for the next one.

The Stryker rep is trying to push his new cement, called "Cortoss". It's obviously more expensive. He claims it's better for people that are first time fracturers, as it is more 'flexible' and so reduces to the chances of fractures at subsequent levels.

Is he trying to make an extra buck? Or is it legit? Others have opinions on it?

Extra buck. It is better cement for working time and time to cure. But it is a lot more costly. I use it and it is easier for me to work with.

 

[Taus]

For those of you like steve, putting people on intranasal calcitonin. how long can you put them on it for. Is it indefinite? Any labs you have to order? I've used it on pts, so far they do great, they've been doing it for a month.

Resurrecting an old thread.....

Thoughts on how long you keep on intranasal calcitonin with an acute or subacute VCF? Especially if no Vert/kyphoplasty planned. Thanks.

 

[lobelsteve]

Resurrecting an old thread.....

Thoughts on how long you keep on intranasal calcitonin with an acute or subacute VCF? Especially if no Vert/kyphoplasty planned. Thanks.

2 months. 6 months or longer may be associated with increased risk of developing a cancer.

 

[Taus]

2 months. 6 months or longer may be associated with increased risk of developing a cancer.

Thanks. Empirically, in the cases where it's helped, about how long has it taken to notice an effect?

 

[lobelsteve]

Thanks. Empirically, in the cases where it's helped, about how long has it taken to notice an effect?

Days.