Compression Fracture Pain Question

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Louisville04

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I have been seeing a patient who has several compression fractures for over 1 year. He already had a CASH brace and was taking Lortab for pain. Since he was taking 4-6 tablets of Lortab a day, I started him on 10mg Oxycontin BID. This was eventually increased to 20 mg BID. He still takes 1-2 Lortab a day for breakthrough pain. He has seen a spine surgeon and a neurosurgeon and was not a candidate for kypho or vertebroplasty. The patient has had physical therapy, a TENS unit, still smokes, ambulates with a cane, lives independently and drives.
I am trying to wean him off. He tried taking half a tablet (10mg) BID but did not tolerate it well. My understanding is compression fractures heal in 8-12 weeks. Should he still have pain from it? Is it okay to continue the Oxycontin or should I try to substitute with a non narcotic?

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wean him off narcotics and for heaven's sake don't have pts halve their oxycontin tabs!!!!
 
cracked oxycontin tabs --> hillbilly heroine

Did either of the spine docs he has seen offer vertebro or kyphoplasty ? Why was he not a candidate ?
 
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f_w said:
cracked oxycontin tabs --> hillbilly heroine

Did either of the spine docs he has seen offer vertebro or kyphoplasty ? Why was he not a candidate ?

I referred them for vertebro and kypho.....I think they said the fractures were too old for the procedure. I guess in hindsight I should have written a RX for 2 10mg tablets BID. Anyway he is a very complaint patient regarding therapy, seeing other specialists. I was hoping the TENS would help decrease his pain so I could decrease the oxycontin.
 
I referred them for vertebro and kypho.....I think they said the fractures were too old for the procedure.

Well, then you have to ask yourself whether the compressions are the true cause for his ongoing back pain. Did any of them still show edema on MRI ?
 
of course he is compliant... he duped you into writing more narcotics... i bet that as soon as you wean him he will be less compliant... maybe i am too cynical
 
I agree at this point one should look for other pathologies. A bone scan or MRI should show any remaining active processes within the trabecular bone. Sometimes fractures cause a secondary facet syndrome in the lumbar spine or a ligamentous insertional strain on the costotransverse ligament in the thoracic spine. Also, remember there is a facet between the rib and the transverse process that can be deranged by angulation due to fracture. A grey ramus communicans block may help determine if the pain is coming from the lateral fractured cortex, although it is unlikely at this point. However, there was a vertebroplasty study on patients with old fractures demonstrating significant improvement of pain even after one year post fracture, although this is contrary to the conventional wisdom
 
on patients with old fractures demonstrating significant improvement of pain even after one year post fracture, although this is contrary to the conventional wisdom

Age doesn't matter unless you are a cheese.

It is my understanding (and experience) that if the MRI doesn't show edema, the prospect of helping these patients with a v-plasty is slim. If there continues to be edema, the rate of relief is considerable. The bone-scan is not such a great test in this setting. It may remain hot after a compression fx for a prolonged period of time without it being indicative of an ongoing unstable fx. Bone scan should only be resorted to if the patient is too frail to undergo the MRI or if there are absolute contraindications like pre 2000 aneurysm clips.
 
The frailty issue is certainly of concern, and patients with significant kyphosis may simply not be able to tolerate the MRI due to positioning necessary. A CT spiral scan takes about 8 seconds and a bone scan is more comfortable than a MRI for most patients but I agree MRI is a much better gauge of current condition of the fracture. We usually obtain STIR images in any patient with multiple fractures as this teases out active remodeling vs old fractures much better than T1 or T2 images.
 
Make sure that your radiologist knows what you are interested in. Realistically, all you need is some sort of T1 and a STIR. These patients don't need the complete study with angled axials, it can be significantly abbreviated for the purpose of pre-vertebroplasty eval.
 
bone scans are useful because an old compression fracture won't light up... and an MRI doesn't always tell the whole story. Sometimes a plain old thin-slice CT scan is all you need...
 
bone scans are useful because an old compression fracture won't light up.

Old as in over a year old, yes.

The bone scan doesn't show a fracture, it shows the laying down of new bone. So even after a lesion has healed back to mechanical stability, the ongoing remodeling will show uptake for up to a year.
So, if it is positive and the findings correlate with plain radiographs and clinical exam, it can be helpful. But if you see a couple of levels lighting up, the information gained might not be all that helpful.

Ideally, I would like to see both, an MRI and a CT. But you have to be reasonable in how much of your patients money and time you burn.
 
As a follow up to my patient with T6-T7 compression fractures who is on Oxycontin 20mg BID with Vicodin for breakthrough whom I am having a hard time weaning off:

I referred the patient to the pain clinic at the hospital which uses a multidisciplinary approach.

The pain doctor switched him to Oxycontin 10mg PO TID reasoning that his pain is moderate to severe during midday and TID may control his pain better over 24 hours.

His Vicodin was switched to Norco 10/325 BID. This is to see if he gets better pain relief with a higher dose of hydrocodone and lesser dose of acetaminophen.

The pain doctor plans to slowly introduce low doses of an anticonvulsant as well as a muscle relaxant.
 
Louisville04 said:
As a follow up to my patient with T6-T7 compression fractures who is on Oxycontin 20mg BID with Vicodin for breakthrough whom I am having a hard time weaning off:

I referred the patient to the pain clinic at the hospital which uses a multidisciplinary approach.

The pain doctor switched him to Oxycontin 10mg PO TID reasoning that his pain is moderate to severe during midday and TID may control his pain better over 24 hours.

His Vicodin was switched to Norco 10/325 BID. This is to see if he gets better pain relief with a higher dose of hydrocodone and lesser dose of acetaminophen.

The pain doctor plans to slowly introduce low doses of an anticonvulsant as well as a muscle relaxant.


The beauty and pitfalls of pain medicine. What is the role of the AED drug in Fx related pain? Oxycontin tid id more than rasonable, but the NT dose should be decreased in frequency to account for the increased dose frequency of the Oxycontin. Is clinical psych involved? How much catastrophizing does the patient do? That small study that Algosdoc mentioned- I believe it goes out to 4 years post fracture and included an N=5 but with 4/5 receiving good to excellent relief.

The patient needs to be stratified towards intervention as vertebroplasty, MBB's, or even ESI and if not than co-treated with clinical psychology to help minimize his chronic pain.

BTW, I do not advocate ESI for compression Fx- but I have a pateinet who has a T12 Fx from 10/05 and refused kyphoplasty when I sent her to the NS- due to referral base I did not offer vertebro. She returned to me 1 month ago with the same pain and requested an epidural to see what it would do. In follow-up she is doing much better and thinks another injection will help more. I feel this is where ethics may play a role- she understands that I think another will not help, that the literature does not support it, and the risks of ESI- and wishes to proceed. That is informed consent. N of 1 = N of Zero.
 
I agree with previous suggestions to get bone scan or MRI scan. There was a study about three years ago that said even if it chronic if it lights up on bone scan, good chance vertebroplasty (or kyphoplasty, I cannot remember which one was used) could help with pain. I am not aware of this type data with MRI scan, but we already know that edema is brighter with T2 or STIR images.
 
lobelsteve said:
The beauty and pitfalls of pain medicine. What is the role of the AED drug in Fx related pain? Oxycontin tid id more than rasonable, but the NT dose should be decreased in frequency to account for the increased dose frequency of the Oxycontin. Is clinical psych involved? How much catastrophizing does the patient do? That small study that Algosdoc mentioned- I believe it goes out to 4 years post fracture and included an N=5 but with 4/5 receiving good to excellent relief.

The patient needs to be stratified towards intervention as vertebroplasty, MBB's, or even ESI and if not than co-treated with clinical psychology to help minimize his chronic pain.

BTW, I do not advocate ESI for compression Fx- but I have a pateinet who has a T12 Fx from 10/05 and refused kyphoplasty when I sent her to the NS- due to referral base I did not offer vertebro. She returned to me 1 month ago with the same pain and requested an epidural to see what it would do. In follow-up she is doing much better and thinks another injection will help more. I feel this is where ethics may play a role- she understands that I think another will not help, that the literature does not support it, and the risks of ESI- and wishes to proceed. That is informed consent. N of 1 = N of Zero.

What if you were to block the GRC instead, and if you got relief, (I can see the steam coming out of Algos' ears already) pulse it.
 
Is there a radicular component to this patient's thoracic pain? I have had a few patients with subsequent narroing of the neuroforamina because the loss height. They were helped by thoracic ESI. Like Algo said, also look for facet generated pain as well.
 
C Fiber said:
Is there a radicular component to this patient's thoracic pain? I have had a few patients with subsequent narroing of the neuroforamina because the loss height. They were helped by thoracic ESI. Like Algo said, also look for facet generated pain as well.

The patient did not mention any radicular component. He was originally admitted due to a fall with back pain. Since the x rays showed compression fractures, I think that is why other diagnoses were not considered. The pain doctor did mention possible ESI, but did not feel that strongly about it. Right now the patient is independent with all ADL's, drives, lives alone and is complaint with everything I recommended (except the smoking cessation)

He has a CASH brace. Is something he should wear indefinitely or approximately 3 months (about how long it takes compression fxs to heal)? If worn indefinitely, would it not weaken his abdominal muscles?
 
If the patient has an ANTERIOR compression fracture, while it is POSSIBLE he has a comormidity in the POSTERIOR column, it certainly sounds like a one size fits all approach to be looking to do ESI's unless one is actually indicated, rather than simply using it as te next thing to do in your algorithm.

Oxycontin is a DELIVERY system built around oxycodone. So if you are giving anyone HALF an oxycontin, you are in effect giving them immediate release oxycodone, not any form of a sustained release medication.

The doc who put your patient on oxycontin TID, a muscle relaxant, and an anti-convulsant sounds like he is putting him on his standard pain cocktail, not necessarily listening to his and then individualizing his theraputic choices.
 
Retrospective study. Still, MRI signal changes had the highest predictive value:

Spine. 2005 Jan 1;30(1):87-92. Predictors of outcomes of percutaneous vertebroplasty for osteoporotic vertebral fractures. Alvarez L, Perez-Higueras A, Granizo JJ, de Miguel I, Quinones D, Rossi RE

If you believe this article, it doesn't make a difference whether there is edema on MRI (given the small number of patients in the study I see some potential for type2 error here):

AJR Am J Roentgenol. 2005 Jun;184(6):1951-5. Correlation between preprocedural MRI findings and clinical outcomes in the treatment of chronic symptomatic vertebral compression fractures with percutaneous vertebroplasty. Brown DB, Glaiberman CB, Gilula LA, Shimony JS.
 
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