5 level kypho - possible?

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55 yo with prior compression fracture, osteoporosis on Ca Vit D prolia, 1 month of acute LBP

MRI showing strong stir on T11 L1 L2 L3 L4. 20-30% compression fracture on each level, no retropulsion.

pt begging for kypho - i am ambivalent about this given extensive levels

anyone with more than 3 level experience?
 
Yeah, can stage it if but it's safe and feasible. The cement toxicity is minimal these days but the larger issue is probably the marrow embolization and how much they can tolerate.

If both scare you, I would treat the T11, L1, and L2 and do MBBs at the other levels with dense bupi. LSO brace with restrictions.

Come back 11 days later outside the global period for the rest.
 
I’d consider IT pump long term. More fx possibly coming
 
why IT pump?

i mean what the heck?

there appear to be some on this forum who have absolutely no experience of the long term management consequences of IT pumps...





addendum: at least, think oral or transdermal analgesics /opioids before jumping all the way to ITP......
 
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Check some labs too to rule out multiple myeloma. Should show up on MRI but could have an atypical appearance.
Put the on the table and have them show you where the worst pain is, and start with the 2-3 levels there. Agree with Orin on doing MBB on the rest of them.
 
Would want to know the timing of Prolia. With COVID we have had many missed doses leading to Fx within a month. Great for business, bad for patients.
 
I would do the top 3. Those are the ones that have higher chance of progression.
 
Is the pain actually from all 5 levels? I would do facets first. People ask for all sorts of things when they’re in pain.
 
Agast said:
Is the pain actually from all 5 levels? I would do facets first. People ask for all sorts of things when they’re in pain.
Click to expand...

Acute compression fractures, with edema on inversion recovery and tenderness with closed fist percussion. And it’s the fault of the facet joints for the patients pain? Sigh.
 
paindoc007 said:
Acute compression fractures, with edema on inversion recovery and tenderness with closed fist percussion. And it’s the fault of the facet joints for the patients pain? Sigh.
Click to expand...
Where was this mentioned?
 
lobelsteve said:
Would want to know the timing of Prolia. With COVID we have had many missed doses leading to Fx within a month. Great for business, bad for patients.
Click to expand...

The rebound fractures going off Prolia are so worrisome.
 
Nodolor said:
Where was this mentioned?
Click to expand...

The implication from the question is this. Do you think she has a different pain pattern and the OP asking just forgot to mention her pain is occipital tenderness but still wants kypho?
 
paindoc007 said:
The implication from the question is this. Do you think she has a different pain pattern and the OP asking just forgot to mention her pain is occipital tenderness but still wants kypho?
Click to expand...
Well I can tell you I have been sent a ton of compression factures typically lower Thoracic and upper Lumbar that have acute to subacute findings on MRI and when I examine the pt and ask where there pain is....it is no where near the fracture. Many times their SIJ or lower facets.

I treat the patient not the imaging
 
Nodolor said:
Well I can tell you I have been sent a ton of compression factures typically lower Thoracic and upper Lumbar that have acute to subacute findings on MRI and when I examine the pt and ask where there pain is....it is no where near the fracture. Many times their SIJ or lower facets.

I treat the patient not the imaging
Click to expand...
I see that referral pattern all the time.

I don't do many kyphos (wait out about 80% of them (maybe 90% and they get better) but it almost always seems to have a referral pattern lower. I try to use onset of pain/acuity and rely less on "pain over fracture"

Clinical Relevance of Pain Patterns in Osteoporotic Vertebral Compression Fractures - PMC

Few studies have been conducted to explain the pain patterns resulting from osteoporotic vertebral compression fractures (OVCF). We analyzed pain patterns to elucidate the pain mechanism and to provide initial guide for the management of OVCFs. ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
 
Nodolor said:
Well I can tell you I have been sent a ton of compression factures typically lower Thoracic and upper Lumbar that have acute to subacute findings on MRI and when I examine the pt and ask where there pain is....it is no where near the fracture. Many times their SIJ or lower facets.

I treat the patient not the imaging
Click to expand...
This x100

This is what separates us from the Interventional Radiologist. The fact that we examine our patients before we start poking at them.
 
Nodolor said:
Well I can tell you I have been sent a ton of compression factures typically lower Thoracic and upper Lumbar that have acute to subacute findings on MRI and when I examine the pt and ask where there pain is....it is no where near the fracture. Many times their SIJ or lower facets.

I treat the patient not the imaging
Click to expand...

I guess that’s fair. I’d assume in our forum a pain physician posting his question that clinical exam matches the image, and he’s asking if 5 levels is doable in that situation. What I took from agast’s comments was don’t bother w the augmentation go and try facets at that level.
 
Screen Shot 2021-10-07 at 7.30.12 PM.png
 

Attachments

paindoc007 said:
I guess that’s fair. I’d assume in our forum a pain physician posting his question that clinical exam matches the image, and he’s asking if 5 levels is doable in that situation. What I took from agast’s comments was don’t bother w the augmentation go and try facets at that level.
Click to expand...
You would do a 5-level augmentation for a month of acute pain?
 
Agast said:
You would do a 5-level augmentation for a month of acute pain?
Click to expand...

If you read the posts above, I recommended to do 3 levels, not 5.

If you’re asking me would I kypho a patient a month after a vcf, then the answer is absolutely, 100% I would. Concordance of sx and imaging, mri shows edema on inversion recovery, pain severe at least 7-8/10, no myelopathic sx obviously, then it’s a no brainer. You wouldn’t? Why not? Leave them to suffer w/debility, bed sores, addiction to opioids, etc is better? I don’t understand that at all
 
Agree that pain referral pattern is often more caudal than level of fx. If there was an accident there may also be facet/SI pain but I would start with the smoking gun.

pubmed.ncbi.nlm.nih.gov

Percutaneous kyphoplasty for the treatment of distal lumbosacral pain caused by osteoporotic thoracolumbar vertebral fracture - PubMed

Background Kyphoplasty has been demonstrated to be minimally invasive and effective in treating osteoporotic vertebral fracture patients with back pain over the level of the fractured vertebrae. Rare studies have reported on thoracolumbar vertebral fracture patients presenting with distal...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
 
paindoc007 said:
If you read the posts above, I recommended to do 3 levels, not 5.

If you’re asking me would I kypho a patient a month after a vcf, then the answer is absolutely, 100% I would. Concordance of sx and imaging, mri shows edema on inversion recovery, pain severe at least 7-8/10, no myelopathic sx obviously, then it’s a no brainer. You wouldn’t? Why not? Leave them to suffer w/debility, bed sores, addiction to opioids, etc is better? I don’t understand that at all
Click to expand...
I’ve discovered most patients do fine with a back brace and prn meds after 2 months. None of them are addicts. And none of my patients have bedsores. I make my patients wait closer to six weeks and by then they’re turning a corner. Nothing aggressive needed.
 
Orin said:

https://www.amazon.com/There-fracture-need-Orthopedic-T-Shirt/dp/B07NG55X58​

From the pain perspective, MBBs are as effective as augmentation for short term pain control.
From the mortality perspective, you should cement it.

pubmed.ncbi.nlm.nih.gov

Vertebral Augmentation Is More than Just Pain Palliation, It Is about Improved Mortality - PubMed

Vertebral Augmentation Is More than Just Pain Palliation, It Is about Improved Mortality
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
Click to expand...

I believe that the new facet guidelines state specifically that in order to do an MBB there must be “no non-facet” cause that could explain the pain, including but not limited to fractures, tumors, etc. So we may be out of luck on that one soon enough.
 
Agast said:
I’ve discovered most patients do fine with a back brace and prn meds after 2 months. None of them are addicts. And none of my patients have bedsores. I make my patients wait closer to six weeks and by then they’re turning a corner. Nothing aggressive needed.
Click to expand...

We will agree to disagree. NNT to save one life at one year is 17. Beal has a lot of great stuff on this. Doing nothing when pain is severe with an acute vcf is not acceptable in my opinion. To each his own.

Edit - nnt is 15. Link below for those interested

pubmed.ncbi.nlm.nih.gov

Number Needed to Treat with Vertebral Augmentation to Save a Life - PubMed

Both augmentation modalities conferred a prominent mortality benefit over nonsurgical management in this analysis of the US Medicare registry, with a low number needed to treat. The calculations based on this data base resulted in a low number needed to treat to save 1 life at 1 year and at 5 years.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
 
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i refer all patients i see with VCF for kypho, but there has been ample data including some posted on this forum that suggests that kyphoplasty is not the panacea that you make it out to be.
 
I have a patient on chronic steroids who has multi-level (4-5) compression fractures. L4 is the worst and I believe that is the level causing the most pain. Is there a level of osteopenia that would prevent you guys from treating this single level?
 
Darkside_ said:
I have a patient on chronic steroids who has multi-level (4-5) compression fractures. L4 is the worst and I believe that is the level causing the most pain. Is there a level of osteopenia that would prevent you guys from treating this single level?
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No? Not sure I follow. If the patient has compression fractures with h/o osteopenia then the osteopenia is a major reason that they have the fractures in the first place with steroids being the likely driver in this case. Osteopenia or osteoporosis isn't a contraindication to kypho. If you treat a single level, however, they may still complain of pain at the other levels. If the other levels are adjacent, they will be at risk for worsened compression deformities.
 
Pick the 3 worst ones and cement them?

Refer to endocrine for osteoporosis eval/treatment.

If still painful - come back and do the other 1-2 levels after several weeks?

Alternatively - pump?
 
Ducttape said:
why IT pump?

i mean what the heck?

there appear to be some on this forum who have absolutely no experience of the long term management consequences of IT pumps...





addendum: at least, think oral or transdermal analgesics /opioids before jumping all the way to ITP......
Click to expand...

IT pumps were the dream of the 1990s. Such a great solution. If only we could find a good problem for it. Works well for spasticity #Gamechanger #QualityofLife.
 
gaspasser786 said:
Pick the 3 worst ones and cement them?

Refer to endocrine for osteoporosis eval/treatment.

If still painful - come back and do the other 1-2 levels after several weeks?

Alternatively - pump?
Click to expand...
I'm shocked you would even suggest a pump, ever.

Especially without even knowing what meds they are on and if they have side effects. wtf.
 
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