AAOS declares Vertebroplasty ineffective!

[Ligament]

http://www.beckersasc.com/orthopedi...ineffective-in-treating-spinal-fractures.html

thoughts?

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[geauxg8rs]

thanks to the orthos for this lovely conclusion. So what will the Orthopods conclude is appropriate, vertebrectomy?

 

[jsaul]

thanks to the orthos for this lovely conclusion. So what will the Orthopods conclude is appropriate, vertebrectomy?

fusion; because it's so great and pays well too

 

[lobelsteve]

Lancet article from Italy out last month pokes at Kalmes studies.

Vertebroplasty works just fine.

Who is ready to do fusion bs sham fusion study? Or is that just rehashed charite data. Meat heads

 

[onewithpain]

Maybe MBB and RFA, based on the article by Bogduk in the latest journal of the AAPM. I like to do the MBB before I do the vertebroplasty, and often get a good reponse.

 

[PMR 4 MSK]

Fusion is not reasonable in most of the cases - there's no bone to work with - it's like trying to mold butter.

 

[Tenesma]

i have had quite a few patients in my office in tears, dyspneic because of their pain, not responding to opioids... - i am convinced that a v-plasty is what they really need.... however, by the time i get them scheduled for a v-plasty their pain is usually already better....

i am starting to believe that waiting 3-6 weeks is just as effective if not more than v-plasty.... on the other hand, the patient ain't too happy about those 3-6 weeks

 

[SleepIsGood]

i have had quite a few patients in my office in tears, dyspneic because of their pain, not responding to opioids... - i am convinced that a v-plasty is what they really need.... however, by the time i get them scheduled for a v-plasty their pain is usually already better....

i am starting to believe that waiting 3-6 weeks is just as effective if not more than v-plasty.... on the other hand, the patient ain't too happy about those 3-6 weeks

But you could make that claim for some special cases of back pain too. Just wait 6 months....Problem is most people cant wait that long and want to get back on their feet.

Just look at any one of us on here. I'd venture to say that given the profession we are in, we are all 'high functioning' and highly motivated people. If we had to sit out for 6 weeks-6months, I dont think our professional lives would allow for that.

 

[Ligament]

Based on the AAOS guidelines recommending against Vertebroplasty, one of the ASCs I work at is NOT allowing me to perform vertebroplasty at their ASC! I'm really pissed...who the hell decided AAOS has the final word on this procedure?

 

[Jcm800]

so what about KYPHOplasty...

what is the AAbOneheadS view of Kyphos...does it not work either, and they should not do it.

Interesting, these articles are all about vertebroplasty. And most surgeons do Kyphos...

will they stop that too?

 

[Tenesma]

most of the 87 year olds who have compression fractures are hardly "high-functioning"... they spend most of their day sitting in a chair/recliner, playing bingo or watching TV...

and yes, most patients do fine with time --- one of the problems with "injectionists" or "fellows" or "young, highly-functioning patients" is that everything needs to be treated with a procedure right away... that is the beauty of PT... not because PT does much, but rather, because most people get better with time, but at least they feel like something is being done...

 

[Jcm800]

I would say on averageMost of my patients at end up getting a vertebroplasty wait at least 3-4 weeks prior to having it done. Many that I think will actually need it, get better and many think will get better actually end up getting the procedure. I usually do either an ESI or more likely facet injections prior to the vertebral augmentation.

I will say this,my volume has significantly dropped for this...

 

[lobelsteve]

most of the 87 year olds who have compression fractures are hardly "high-functioning"... they spend most of their day sitting in a chair/recliner, playing bingo or watching TV...

and yes, most patients do fine with time --- one of the problems with "injectionists" or "fellows" or "young, highly-functioning patients" is that everything needs to be treated with a procedure right away... that is the beauty of PT... not because PT does much, but rather, because most people get better with time, but at least they feel like something is being done...

Let me fracture your T12 and see how well you do playing bingo. We are not the ones to determine the daily activities. We are here to allow them to do theirs with less pain. Tsk tsk.

 

[SSdoc33]

Let me fracture your T12 and see how well you do playing bingo. We are not the ones to determine the daily activities. We are here to allow them to do theirs with less pain. Tsk tsk.

playing the devil's advocate here, but do you really have that strong of a case? so, the little old lady needs to be in pain for a few weeks. i dont like it any more than you do, but if they get to the same place, what is truly the harm? these patients are largely medicare, and the payment for the procedure is pretty high. this is exactly the type of procedure that patients should be allowed to pay out of pocket for, rather than use taxpayer dollars. if you take yourself out of the sphere of pain medicine and look at it logically, its not that cut and dried.

i suppose the same thing can be said for any injection we do, but nevertheless.....

 

[lobelsteve]

playing the devil's advocate here, but do you really have that strong of a case? so, the little old lady needs to be in pain for a few weeks. i dont like it any more than you do, but if they get to the same place, what is truly the harm? these patients are largely medicare, and the payment for the procedure is pretty high. this is exactly the type of procedure that patients should be allowed to pay out of pocket for, rather than use taxpayer dollars. if you take yourself out of the sphere of pain medicine and look at it logically, its not that cut and dried.

i suppose the same thing can be said for any injection we do, but nevertheless.....

That;s why I do it this way:

1. Bracing
2. Dilaudid 2mg tid prn for 3 weeks then re-eval, Miacalcin NS bid
3. If no better 6-8 weeks post-fracture, offer Vertebroplasty
4. MBB for those who cannot come off anticoagulation.

I see primarily Medicare patients, and I have implanted a90 y/o patient so she could continue golfing.

 

[Tenesma]

lobel - your last post completely went against the point you made initially....

treating compression fractures the old fashioned way with bracing, analgesics and time is just as effective a v-plasty in my experience (not as satisfying though)... and considering MOST patients get better with time, i think conservative care is appropriate

based on your initial argument, maybe all disc herniations should be treated with immediate surgical discectomy??? i don't think so...

 

[lobelsteve]

lobel - your last post completely went against the point you made initially....

treating compression fractures the old fashioned way with bracing, analgesics and time is just as effective a v-plasty in my experience (not as satisfying though)... and considering MOST patients get better with time, i think conservative care is appropriate

based on your initial argument, maybe all disc herniations should be treated with immediate surgical discectomy??? i don't think so...

10% of my conservative care fractures get better and the rest get cemented.
I don't let them wait it out for 3 months. If not improving a lot by 6 weeks, they are cemented at 8 weeks. If cannot tolerate pain meds or pain severe enough to warrant an ER visit after I see them, we go to the cement mixer.
Conservative care is warranted whenever a progressive or severe neurologic compromise is not present. Failure of conservative care is always a judgment call.

 

[Tenesma]

my rule is: if you can sit in a chair, or walk to the bathroom, with minimal assistance, on pain meds, then NO v-plasty

if you can't sit upright, if you can't transfer out of bed, despite optimal drug management and a few days, it's a go for v-plasty...

so far, in my experience, less than 20% end up getting v-plasty

 

[lobelsteve]

my rule is: if you can sit in a chair, or walk to the bathroom, with minimal assistance, on pain meds, then NO v-plasty

if you can't sit upright, if you can't transfer out of bed, despite optimal drug management and a few days, it's a go for v-plasty...

so far, in my experience, less than 20% end up getting v-plasty

I will go for plasty if their golf score suffers due to fx pain.

If they need assist for ADL's- I'll plasty. If pain 7+/10, I'll plasty- if taking meds, not off meds.

 

[clubdeac]

playing the devil's advocate here, but do you really have that strong of a case? so, the little old lady needs to be in pain for a few weeks. i dont like it any more than you do, but if they get to the same place, what is truly the harm? these patients are largely medicare, and the payment for the procedure is pretty high. this is exactly the type of procedure that patients should be allowed to pay out of pocket for, rather than use taxpayer dollars. if you take yourself out of the sphere of pain medicine and look at it logically, its not that cut and dried.

i suppose the same thing can be said for any injection we do, but nevertheless.....

What's the harm in waiting it out? Well let me see, prolonged bedrest leads to...

- Deep venous thrombosis/PE
- Worsening of osteoporosis
- Increased mortality
Cardiovascular effects
* Progressive loss of fluid, primarily from the extracellular space
* Intravascular volume preferentially distributed in the upper body
* Orthostatic hypotension which may take weeks to correct
* Fall in stroke volume and cardiac output
* Increase in resting and submaximal heart rate
Musculoskeletal effects
* Loss of contractile force
* Shortening of muscle fibers and total muscle length
* Increase in calcium loss from the bone
- Increased risks of falls and subsequent fractures
Urinary tract effects
* Stagnation in calyces
* Incomplete bladder emptying
Pulmonary effects
* Cilia less effective
* Mucous pools
* Chest movement restricted in a supine position
Gastrointestinal effects
* Loss of appetite
* Decreased peristalsis
- Constipation
- Bowel obstruction
Skin effects
* Pressure ulcers
Psychological effects
* Anxiety
* Depression
* Disorientation
* Fostered dependency/learned helplessness


At least that's what Jensen and other proponents of Vplasty would say

 

[Aether2000]

If vertebroplasty is not effective, then neither is kyphoplasty. Hopefully the new studies that are coming out will poke holes in the AAOS position but for now perhaps their stance may mean more pain docs doing plasties

 

[Jcm800]

If vertebroplasty is not effective, then neither is kyphoplasty. Hopefully the new studies that are coming out will poke holes in the AAOS position but for now perhaps their stance may mean more pain docs doing plasties

this is is my point, if vertebro is ineffective then so is kypho, but have you noticed none of the AAOS or other opponents ever say kyphoplasty?

 

[KmB247]

this is is my point, if vertebro is ineffective then so is kypho, but have you noticed none of the AAOS or other opponents ever say kyphoplasty?

The entire document is available at http://www.aaos.org/research/guidelines/SCFguideline.asp

Kyphoplasty and other treatments are discussed

 

[FLK 1]

I've seen mild fractures go on to become vertebra plana and cord/cauda equina compression a few too many times to not be a believer in early augmentation.

 

[Jcm800]

i just read this study and the comparison and their "logic" for their support of kyphoplasty and not vertebroplasty...

its silly. if it comes to it... ill just use one of those silly "cavity creation" devices and do a "kyphoplasty"...

clearly there is no difference between the procedures except that vertebroplasty actually works better in my mind...