Difficult situation, progressive osteoporotic compression fracutres

[thecentral09]

Hey guys and girls, any input would be helpful.
Heres the situation. A midlevel in my hospital system has a relative w/ recent dx of Wegeners granulomatosis. Had complete kidney failure treated with high dose steroids. post admission is on a multiple monthlong prednisone wean and currently taking 30mg predisone daily, and is not yet year halfway through wean. Has had 1 compression fracture d/t steroid induced osteoporosis per month for the last 4 months (started at T12, now with T11,T10, and likely T9 compression fracture yesterday). Fracture yesterday was during laying on table in MRI scanner to eval thoracic compression fractures. They are wondering about kypho. I am concerned for a number of reasons, but I am unsure of how to proceed. Suggestions please! Thanks for all input

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[lobelsteve]

Tymlos first, prolia with it or after.

Then if painful, fix the one with stir signal hyperintensity.

 

[SommeRiver]

I have a pt who now has 6 kyphos. She broke one, had cement and then broke two, so on and so forth. I am considering SCS for her. Would any of yall consider that for the OP's pt? Seems like ppl keep fracturing when cement is placed in soft bones.

 

[Ducttape]

since when did you start recommending Tymlos? just out of curiosity, what kind of EBM do you have (besides drug company stuff)?



and SCS for nociceptive pain from compression fractures? ive not heard it used successfully. where is your EBM on that indication? (fwiw, a pubmed search for "compression fracture neuromodulation" and "compression fracture stimulation" revealed nada)

 

[SSdoc33]

i have a lot of these patients. usually have some other chronic illness.

if you kypho 1 or 2 levels, you are asking for trouble, as you know the adjacent levels will go next. brace them, treat their osteoporosis, and move on.

 

[Orin]

As far as I can see in the literature, it's hard to say if they fracture because of the cement, the underlying pathology, or the mechanical changes.
In this scenario, stay conservative until things stabilize. Get the bone healthier. Get them through the acute issues.

I worry about SCS with on going fractures, but I have seen it done and had it work for me with chronic post VCF pain.

 

[Aether2000]

The literature is indeed unclear about adjacent segment fractures. There is a study showing an equal fracture rate with cement vs conservative treatment but the kyphoplasty induced adjacent fractures occurred much sooner (Single-level vertebral kyphoplasty is not associated with an increased risk of symptomatic secondary adjacent osteoporotic vertebral compression fr... - PubMed - NCBI). Another study found a barely statistically different increase in cement augmented adjacent segment fractures of p=0.044 that in some circles is no longer considered statistically significant (Risk Factors for Newly Developed Osteoporotic Vertebral Compression Fractures Following Treatment for Osteoporotic Vertebral Compression Fractures. - PubMed - NCBI)

 

[SommeRiver]

since when did you start recommending Tymlos? just out of curiosity, what kind of EBM do you have (besides drug company stuff)?



and SCS for nociceptive pain from compression fractures? ive not heard it used successfully. where is your EBM on that indication? (fwiw, a pubmed search for "compression fracture neuromodulation" and "compression fracture stimulation" revealed nada)

I'm sorry I don't have a massive trove of data to support SCS in pts with axial pain s/p repeated kyphos, but I fail to see how that is a bad idea other than the possibility of the pt fracturing again and that causing problems.

 

[Orin]

He needs the double blind RCT...

Use of Spinal Cord Stimulation in Elderly Patients with Multi-Factorial Chronic Lumbar and Non-Radicular Lower Extremity Pain. - PubMed - NCBI
They have a few VCFP cases thrown into this series.

But in all seriousness, the concept of SCS for post-VCF pain makes sense if you're trying to treat the radicular component or a neuropathic state in a chronic fracture. I just worry about the mechanics of the spine and possible compression with more fractures in this setting. If they're well cemented at your entry level and through to the target site, then that's less of a concern.

I would not expect SCS to help for the acute/subacute VCF pain.

It's almost enough to make me want to do a TF-DRG stim, but not really.

 

[lonelobo]

I'm sorry I don't have a massive trove of data to support SCS in pts with axial pain s/p repeated kyphos, but I fail to see how that is a bad idea other than the possibility of the pt fracturing again and that causing problems.

This just sounds like a bad idea.
Interventions don't fix everyone

 

[SommeRiver]

He needs the double blind RCT...

Use of Spinal Cord Stimulation in Elderly Patients with Multi-Factorial Chronic Lumbar and Non-Radicular Lower Extremity Pain. - PubMed - NCBI
They have a few VCFP cases thrown into this series.

But in all seriousness, the concept of SCS for post-VCF pain makes sense if you're trying to treat the radicular component or a neuropathic state in a chronic fracture. I just worry about the mechanics of the spine and possible compression with more fractures in this setting. If they're well cemented at your entry level and through to the target site, then that's less of a concern.

I would not expect SCS to help for the acute/subacute VCF pain.

It's almost enough to make me want to do a TF-DRG stim, but not really.

Yeah, definitely the acute/subacute setting no, and I would only consider it with a negative STIR.

 

[SommeRiver]

This just sounds like a bad idea.
Interventions don't fix everyone

I'm sure you would agree that interventions DO improve the QOL in SOME pts right?

 

[Orin]

 

[Ducttape]

I'm sorry I don't have a massive trove of data to support SCS in pts with axial pain s/p repeated kyphos, but I fail to see how that is a bad idea other than the possibility of the pt fracturing again and that causing problems.

It’s a bad idea if it doesn’t work and you are exposing a treatment that really exists solely on your financial renumeration.

There seems little sound basis for neuromodulation for a nociceptive pain process.

Your study is a fluff retrospective study whose primary purpose seems to be to justify SCS.

Only 1 out of the 17 patients had VCF as the sole diagnosis. And the purpose seemed to focus on coverage of limb pain.

The use of high cost procedures with little sound basis for it and no clinical evidence to support it demeans the field of pain medicine and taints public perception that those in pain are only in it for the money.

 

[SommeRiver]

It’s a bad idea if it doesn’t work and you are exposing a treatment that really exists solely on your financial renumeration.

There seems little sound basis for neuromodulation for a nociceptive pain process.

Your study is a fluff retrospective study whose primary purpose seems to be to justify SCS.

Only 1 out of the 17 patients had VCF as the sole diagnosis. And the purpose seemed to focus on coverage of limb pain.

The use of high cost procedures with little sound basis for it and no clinical evidence to support it demeans the field of pain medicine and taints public perception that those in pain are only in it for the money.

1. I didn't post that study. Like I said, I have no study to show you.
2. You can choose to attribute financial gain incentives to me if you would like, but that's simply not the case. I see no reason to make that leap if I have a pt with severe back pain for 4 yrs that is refractory to everything that's been tried, and she has 6 kyphos (not by me bc I don't do them) and is managed with opiates. I inherited this pt and her life sux...Nice old lady...

 

[Ducttape]

yes, there are thousands of people like that. are you seriously using the fact that she has pain as justification for an invasive procedure that is invasive, expensive, and not known to have a track record for helping this condition? personally, I can get over the first 2 barriers. its the 3rd that I am taking issue with.

if she has so much pain, why don't you recommend bilateral knee and hip replacements for her? or maybe thoracic spinal cord lesioning, render her pain free, but paraplegic?

just saying.

 

[lobelsteve]

1. I didn't post that study. Like I said, I have no study to show you.
2. You can choose to attribute financial gain incentives to me if you would like, but that's simply not the case. I see no reason to make that leap if I have a pt with severe back pain for 4 yrs that is refractory to everything that's been tried, and she has 6 kyphos (not by me bc I don't do them) and is managed with opiates. I inherited this pt and her life sux...Nice old lady...

So why does she have pain if she is s/p kypho? What is her pain generator?

 

[SommeRiver]

yes, there are thousands of people like that. are you seriously using the fact that she has pain as justification for an invasive procedure that is invasive, expensive, and not known to have a track record for helping this condition? personally, I can get over the first 2 barriers. its the 3rd that I am taking issue with.

if she has so much pain, why don't you recommend bilateral knee and hip replacements for her? or maybe thoracic spinal cord lesioning, render her pain free, but paraplegic?

just saying.

You're comparing an SCS trial to hip/knee replacements and a cord lesion?

Be a little more dramatic would you. I really don't see what is so nuts about this. Like I said, it is something I am considering but by no means have I said I am pushing for it or being super aggressive about it. I brought it up here to get any opinions yall might have on the matter considering a lot of posters here have a lot more experience than me.

You asked me if I am using pain as a justification for something invasive, expensive, and without a track record of it helping that specific Dx...Well yeah, I am doing exactly that...

Show me why this is such a bad idea. Where is the harm, and what is so crazy about this? Surely you aren't so insane to suggest this is anything remotely akin to a joint replacement.

Edit - I get this isn't supported by two or three RCT, but my question is why you think this is so ridiculous and you've hid behind the data argument, AND you made the classic financial gain argument.

Specifically why is this such a bad idea?

 

[SommeRiver]

So why does she have pain if she is s/p kypho? What is her pain generator?

Couldn't tell you. Kyphos all look good. It is back pain exclusively, and at this point she has received a well-rounded care plan without benefit.

Maybe I could send her to Pain Psych and they'll fix all of her problems.

 

[lobelsteve]

Couldn't tell you. Kyphos all look good. It is back pain exclusively, and at this point she has received a well-rounded care plan without benefit.

Maybe I could send her to Pain Psych and they'll fix all of her problems.

MBB/RF sounds more like our speed.

 

[SommeRiver]

MBB/RF sounds more like our speed.

Failed it. That's the first thing I did.

Edit - By the way, let's all be honest here and realize that every person in this forum has a handful of pts that simply do NOT represent the norm for whatever condition they have, and we have all considered things that are not perfectly spelled out in whatever journal we think exists to justify our profession. As soon as someone mentions anything that isn't perfectly supported by 5 RCT they get assaulted with accusations of greed.

Edit - MBB/RF would be the first thing any normal Pain MD would do...Obviously, in a good faith discussion one should assume I already did that before mentioning SCS as a salvage treatment.

 

[lobelsteve]

SCS as salvage sounds terrible.

 

[emd123]

i have a lot of these patients. usually have some other chronic illness.

if you kypho 1 or 2 levels, you are asking for trouble, as you know the adjacent levels will go next. brace them, treat their osteoporosis, and move on.

This would apply to any patient with an osteoporotic compression fracture. There's never any guarantee that adjacent levels won't fracture.

 

[emd123]

Hey guys and girls, any input would be helpful.
Heres the situation. A midlevel in my hospital system has a relative w/ recent dx of Wegeners granulomatosis. Had complete kidney failure treated with high dose steroids. post admission is on a multiple monthlong prednisone wean and currently taking 30mg predisone daily, and is not yet year halfway through wean. Has had 1 compression fracture d/t steroid induced osteoporosis per month for the last 4 months (started at T12, now with T11,T10, and likely T9 compression fracture yesterday). Fracture yesterday was during laying on table in MRI scanner to eval thoracic compression fractures. They are wondering about kypho. I am concerned for a number of reasons, but I am unsure of how to proceed. Suggestions please! Thanks for all input

What are the reasons you're concerned about?
And what are the contraindications?

 

[emd123]

I have a pt who now has 6 kyphos. She broke one, had cement and then broke two, so on and so forth. I am considering SCS for her. Would any of yall consider that for the OP's pt? Seems like ppl keep fracturing when cement is placed in soft bones.

Stim for fracture pain?
Hmm...Definitely off label.

 

[emd123]

Specifically why is this such a bad idea?

Why is it a good idea?

 

[emd123]

Edit - By the way, let's all be honest here and realize that every person in this forum has a handful of pts that simply do NOT represent the norm for whatever condition they have, and we have all considered things that are not perfectly spelled out in whatever journal we think exists to justify our profession. As soon as someone mentions anything that isn't perfectly supported by 5 RCT they get assaulted with accusations of greed.

Don't take it personally. It's just that you're asking us a question we cannot answer. "Does spinal cord stim help patients with refractory axial pain from multiple vertebral compression fractures?"

That's you question. And we cannot answer it, because we'd be guessing. We'd be experimenting on our patients to do this. It sound like an idea for someone to potentially study, but just randomly experimenting on a single patient with it, is, well....experimenting. When I have a question like this, I usually decide not to do it and leave these more fringe ideas to the academic guys that have grants to study stuff not yet supported by literature and not yet paid for by insurance. That's another issue. How are you going to get insurance to pay for this? You'd either have to get special approval for off an off label indication, or commit fraud by making up an approved indication (which obviously you shouldn't do).

 

[SommeRiver]

Of course it is off label and I'm sure I'd lose a peer to peer over it bc I have no idea what to call this other than low back pain, bc that's essentially what it is. Obviously not failed back. Someone comes in with chronic myofascial pain of the lumbar spine and they're not getting Nevro. What makes me even consider trying to get this approved is that we have 6 kypho levels, all of which is normal in appearance and looks well done. I've tried multiple other interventions and nothing helps. She's on Norco, but still miserable. Like I said, this is salvage and I have no idea how I could even get it covered and I'm bringing it up to see if any of yall have any experience with it. I want to know if there is a specific contraindication to it.

 

[Orin]

Again, I think the question of SCS for chronic VCF pain is open and not unreasonable to trial a patient for as it is something we would agree of as a neuropathic pain state, assuming they've failed MBB/RFA.

Save the pump for salvage though, we wouldn't want to sully SCS' good name with anything too difficult

 

[lobelsteve]

Pain is transmitted by the nerves.
All pain is neuropathic.
#scsforall

 

[thecentral09]

What are the reasons you're concerned about?
And what are the contraindications?

Reasons concerned- pt with now 4 compressions fractures in the past 4 months, last one last week while still taking the medication that is making her osteoporosis worse. I can’t think it’s a good idea to place cement in the middle of her spine at this point.
No true contraindication, but I don’t think kypho is her best treatment at the present time

 

[callmeanesthesia]

Has anyone tried just injecting a bunch of local in the area (like the sham arms of some of the kypho trials)? Basically a high volume MBB or deep TPI? If so did you have any luck? (Yes, I realize it’s anecdotal and there may be placebo effect, but depending on how you look at it there’s RCT data to support local anesthetic infiltration for VCF).

I did a T7 kypho on Monday, guy said he felt better for 2 days then the pain came back worse. Went to the ER, got a CTA, then came to see me. I looked at the images and there’s a new fracture at T6 (radiologist didn’t comment on it, btw). I don’t want to keep chasing these up his spine with cement but the guy is miserable.

 

[Ducttape]

Failed it. That's the first thing I did.

Edit - By the way, let's all be honest here and realize that every person in this forum has a handful of pts that simply do NOT represent the norm for whatever condition they have, and we have all considered things that are not perfectly spelled out in whatever journal we think exists to justify our profession. As soon as someone mentions anything that isn't perfectly supported by 5 RCT they get assaulted with accusations of greed.

Edit - MBB/RF would be the first thing any normal Pain MD would do...Obviously, in a good faith discussion one should assume I already did that before mentioning SCS as a salvage treatment.

Because you are preaching snake oil in attempt to justify doing such procedures. You are giving false hope and praying that a placebo effect will help your patient. You are not practicing medicine; you are experimenting. With no sound basis other than “well, I tried everything else”.


This “logic” is why “we” did SGB for fibro(literature review), SCS and/or ITP for everybody and everything, including PTSD, disc bulges, central stroke syndrome, myofascial pain (these are based on actual cases that I have seen).

If you want to try something, go ahead and get informed consent and insurance approval. But before you do so, do your patient a favor and review all the literature on the subject. Find some literature to back your trial, even if they are only case reports. Make sure your patient is aware that what you are doing is a dangerous crap shoot.



You have nothing in pubmed on SCS for VCF that I can find... not even a case report...

 

[lobelsteve]

Has anyone tried just injecting a bunch of local in the area (like the sham arms of some of the kypho trials)? Basically a high volume MBB or deep TPI? If so did you have any luck? (Yes, I realize it’s anecdotal and there may be placebo effect, but depending on how you look at it there’s RCT data to support local anesthetic infiltration for VCF).

I did a T7 kypho on Monday, guy said he felt better for 2 days then the pain came back worse. Went to the ER, got a CTA, then came to see me. I looked at the images and there’s a new fracture at T6 (radiologist didn’t comment on it, btw). I don’t want to keep chasing these up his spine with cement but the guy is miserable.

When did you start the Tymlos or Prolia to help prevent the next Fx?

 

[SommeRiver]

Because you are preaching snake oil in attempt to justify doing such procedures. You are giving false hope and praying that a placebo effect will help your patient. You are not practicing medicine; you are experimenting. With no sound basis other than “well, I tried everything else”.


This “logic” is why “we” did SGB for fibro(literature review), SCS and/or ITP for everybody and everything, including PTSD, disc bulges, central stroke syndrome, myofascial pain

I realize this is an internet forum and the way ppl interact is based merely off of the manner in which they read, so I won't allow myself to grow completely tired of you just yet.

1. I am not preaching anything. I asked a question and you responded, in typical fashion, with BS about me trying to make money. If there is an ANATOMICAL or PHYSIOLOGICAL contraindication for SCS in a pt with multiple kyphoplasties and no relief in pain, I'd love to hear it.
2. All of those examples you listed are crazy, and significantly different than what I'm talking about, and anyone with a brain can see that. Like I've said repeatedly now, I realize I don't have data to support this but if you've got a reason it wouldn't work lemme have it.

 

[lobelsteve]

I realize this is an internet forum and the way ppl interact is based merely off of the manner in which they read, so I won't allow myself to grow completely tired of you just yet.

1. I am not preaching anything. I asked a question and you responded, in typical fashion, with BS about me trying to make money. If there is an ANATOMICAL or PHYSIOLOGICAL contraindication for SCS in a pt with multiple kyphoplasties and no relief in pain, I'd love to hear it.
2. All of those examples you listed are crazy, and significantly different than what I'm talking about, and anyone with a brain can see that. Like I've said repeatedly now, I realize I don't have data to support this but if you've got a reason it wouldn't work lemme have it.

This is not a neuropathic pain state. Next you will join ranks of treating OA and FMS with SCS. Because other treatments failed is not a medical indication for SCS for unknown back pain.

 

[callmeanesthesia]

When did you start the Tymlos or Prolia to help prevent the next Fx?

Working on that too. I’ve been deferring that to PCP - no prior experience managing it or following up bone density because we didn’t do that in fellowship (I’m 4 months out), but I told the patient that treating the bone density is the most important thing for him. Would appreciate any recommendations you have, or directions to a good article on choosing between agents and follow up needed. I haven’t heard of Tymlos before.

 

[Ducttape]

Leave it to Steve to succinctly and bluntly state what I tried to get you to intellectualize.

SCS is not for nociceptive spinal pain. If it works, placebo effect is the cause.

 

[lobelsteve]

Working on that too. I’ve been deferring that to PCP - no prior experience managing it or following up bone density because we didn’t do that in fellowship (I’m 4 months out), but I told the patient that treating the bone density is the most important thing for him. Would appreciate any recommendations you have, or directions to a good article on choosing between agents and follow up needed. I haven’t heard of Tymlos before.

Here is what I give all patients with osteoporosis and/or Fx (that defines osteoporosis). I do not find any utility in BMD after Fx as optimal treatment at this time includes 18mo Tymlos followed by lifelong Prolia or until something better comes along. If they Fx on these meds, Endocrine consult needed.

https://img.grepmed.com/uploads/282...ifferential-comparison-secondary-original.png

https://www.researchgate.net/profil...515/Classification-of-hyperparathyroidism.png

Fracture risk in primary hyperparathyroidism. - PubMed - NCBI

 

[emd123]

Reasons concerned- pt with now 4 compressions fractures in the past 4 months, last one last week while still taking the medication that is making her osteoporosis worse. I can’t think it’s a good idea to place cement in the middle of her spine at this point.
No true contraindication, but I don’t think kypho is her best treatment at the present time

I probably would kypho, if for no reason other than pain control. Plus, if they're still on the offending meds, these 4 levels make collapse pancake flat and then she's really screwed. At least stabilizing 4 of them might give her some pain control and prevent her from a kyphosis so bad she looks like a question mark, even if one or two more crack. If you had a patient that broke their forearm, you'd cast it. If they broke their other forearm, you'd cast it. If they showed up on the ED the next day having had broken both their ankles, would you suddenly not splint/cast/ORIF their ankles, because after four broken bones, they're maxed out, so you just leave them alone?

Maybe I haven't read the thread closely enough, but other than having 4 VCFs (which is not a contraindication to kypho, as far as I know) opposed to 2 or 3, I'm not sure what the reason not to do kypho, is. That being said, if you think kypho is not the best thing for her at this time, then I'm not going to try to convince you to do something that's not in the interest of your patient. There's probably some reason you haven't mentioned, or that I skipped over in the thread because I'm watching football.