Kypho gone wrong

[Timeoutofmind]

This 84yo lady presented to me

Left sided thoracic spine pain

No neuropathic pain descriptors are present (no signs of radicular pain or spinal cord impingement)

History of T11 compression fracture
S/p T11 kyphoplasty 1/18 by a different doc
On imaging, extraosseous cement, primarily on the left side of the vertebral body adjacent to the aorta.

ESIs, BL T11-L1 RF without improvement prior to my involvement

Saw a surgeon who didnt recommend surgery.

BL T9-11 RF (the facets above and below fracture) by myself without much relief

Has failed many many meds, both adjuncts and opioids.

She is fairly comorbid.

A fib
CAD
Cardiomyopathy
CHF
CKD
COPD
Diabetes
Pacemaker in place
Hyperlipidemia
Gout
Glaucoma
Hypertension
Obstructive sleep apnea
Pacemaker

I really feel bad for her as she is totally miserable and not doing anything anymore and prior to this has had six kids etc without ever complaining about anything.

Would anyone stim her? Its axial pain and some risks of procedure to her esp of stopping her anticoag for something I am not confident will help.

Just tell her she has to live with it?

---

Members don't see this ad.

 

[lobelsteve]

I wouldnt say she had a kyphoplasty. But something was done around the spine. Poor thing. Stim with pacer wires that close- no bueno. Butrans 10? Make her comfy. Cannot be fixed.

 

[Ferrismonk]

I'm assuming spinal pain is concordant with the cement? Did she have similar pain before the kypho or is it different now?

Agree there is not much you can offer. Stim has low chance of success and high risk, I wouldn't offer. Try a TLSO?

 

[Gnarvin]

I don’t like to do IT pump for non-cancer pain, but elderly patients with vertebral compression fractures that have failed everything else (TLSO, NSAIDS, possible ILESI, thoracic MBB) are cases I would consider it for.

 

[lobelsteve]

Better you than me (or any one else). If she burps, it is the pump, if she sleeps, it is the pump, if she dies, it is the pump, if she doesn't die, it is the pump. If it is not the pump, it is the pump.

 

[swamprat]

I’d fuse her SI joint - she has Medicare right ?

 

[Gnarvin]

Better you than me (or any one else). If she burps, it is the pump, if she sleeps, it is the pump, if she dies, it is the pump, if she doesn't die, it is the pump. If it is not the pump, it is the pump.

I agree I am not a fan of pumps. I trained at one of the biggest pump programs in the country and held the pager 24/7 on my call weeks and dealt with all the pages. I am not saying I personally would or wouldn’t do it for this patient, but it is reasonable to consider.

 

[BobBarker]

Doug Beall would redo the kypho. Pain before kypho led to imaging and finding the comp fx, the comp fx was inadequately repaired, so still suffering from comp fx pain. Isn’t there a study that the organs don’t have innervation for pain signal transmission?

 

[Orin]

Doug Beall would redo the kypho. Pain before kypho led to imaging and finding the comp fx, the comp fx was inadequately repaired, so still suffering from comp fx pain. Isn’t there a study that the organs don’t have innervation for pain signal transmission?

I would get a SPECT-CT or MRI if the AICD allowed.

If the fracture is active, go with the repeat BKP. I would consider T10/T11 nerve root blocks bilaterally and thermal ablation vs DREZ with neurosurgery if they helped.

If not that aggressive consider intrathecal ziconotide. If systemic opioids provide no help, intrathecal opioids aren't guaranteed to help.

This is a good case for an academic pain provider if you have one comfortable with challenging cases.

 

[Agast]

Poor lady. How does a mistake like that even happen? Did the trocar slip off the pedicle and get advanced in lateral view without checking AP until cement?? It doesn’t look like it tracks out of vertebral body.

 

[epidural man]

Is money a concern? If not, consider SPRINT SPR leads paraspinal (I would go pretty deep with ultrasound) for 60 days. This can be done without much concern with her anticoagulation.

I agree with BUTRANS.

 

[drusso]

I’d fuse her SI joint - she has Medicare right ?

First, Vertiflex...

 

[DOctorJay]

I would get a SPECT-CT or MRI if the AICD allowed.

If the fracture is active, go with the repeat BKP. I would consider T10/T11 nerve root blocks bilaterally and thermal ablation vs DREZ with neurosurgery if they helped.

If not that aggressive consider intrathecal ziconotide. If systemic opioids provide no help, intrathecal opioids aren't guaranteed to help.

This is a good case for an academic pain provider if you have one comfortable with challenging cases.

What’s an academic pain provider?

 

[Orin]

What’s an academic pain provider?

Someone who is in academia where ideally the system allows them to work on complicated high risk cases in a collaborative manner with other specialties. It doesn't seem to work as well for pain as it does for other specialties, but in some regions it makes sense.

 

[swamprat]

Someone who is in academia where ideally the system allows them to work on complicated high risk cases in a collaborative manner with other specialties. It doesn't seem to work as well for pain as it does for other specialties, but in some regions it makes sense.

Yeah I feel like Im doing way more "cutting edge" stuff in private practice than the academic guys at my fellowship whom are just doing bread and butter pain. Great training dont get me wrong but for example one of the guys still implanting tonic only systems. I also did 1 kypho my entire training as no one did them.

 

[Orin]

Yeah I feel like Im doing way more "cutting edge" stuff in private practice than the academic guys at my fellowship whom are just doing bread and butter pain. Great training dont get me wrong but for example one of the guys still implanting tonic only systems. I also did 1 kypho my entire training as no one did them.

This is a major problem with pain medicine. It isn't that way in every academic practice though, but in general the larger systems have a hard time with new techniques.

 

[gdub25]

I wouldnt say she had a kyphoplasty. But something was done around the spine. Poor thing. Stim with pacer wires that close- no bueno. Butrans 10? Make her comfy. Cannot be fixed.

Not sure what you mean regarding stim and the pacer wires. I do a lot of SCS and work hard to be as much of an expert regarding this therapy as I can be. I’ve never seen any literature regarding any type of interference and was part of a study looking at this exact issue in fellowship however the research department kind of fell apart and the whole thing died. In our practice we implant with cardiac devices in place all the time. What is it that I don’t know here?

 

[lobelsteve]

Not sure what you mean regarding stim and the pacer wires. I do a lot of SCS and work hard to be as much of an expert regarding this therapy as I can be. I’ve never seen any literature regarding any type of interference and was part of a study looking at this exact issue in fellowship however the research department kind of fell apart and the whole thing died. In our practice we implant with cardiac devices in place all the time. What is it that I don’t know here?

1. Educate the patient on the theoretical hazards and risks of SCS in the setting of a preexisting PPM or ICD, particularly with a unipolar lead.
Ensure that the patient is followed by a cardiologist/electrophysiologist and obtain prior approval from that provider.
Identify the PPM/ICD device manufacturer and indication for cardiac device implantation.
Coordinate trial/SCS implantation with the cardiac device manufacturer to have on-site support for interrogation of the cardiac device during and after the procedure, to assure functionality of the PPM or ICD after the SCS implantation.
Changes in the SCS settings should be made in the stimulation and frequency parameters tested for safety at time of implantation. If changes outside of these settings are made, it is recommended to have the cardiac device evaluated for compatibility.



However: I assume you would do pns field stim as there is no named nerve in this area and there is no indication for epidural placement as this is an area not topographically amenable to scs.

What is chance of success with pns here?
I see it as a money grab and preying on the frail. I do not see this as a realistic treatment.

 

[NDcienporciento100]

View attachment 320608
View attachment 320609

This 84yo lady presented to me

Left sided thoracic spine pain

No neuropathic pain descriptors are present (no signs of radicular pain or spinal cord impingement)

History of T11 compression fracture
S/p T11 kyphoplasty 1/18 by a different doc
On imaging, extraosseous cement, primarily on the left side of the vertebral body adjacent to the aorta.

ESIs, BL T11-L1 RF without improvement prior to my involvement

Saw a surgeon who didnt recommend surgery.

BL T9-11 RF (the facets above and below fracture) by myself without much relief

Has failed many many meds, both adjuncts and opioids.

She is fairly comorbid.

A fib
CAD
Cardiomyopathy
CHF
CKD
COPD
Diabetes
Pacemaker in place
Hyperlipidemia
Gout
Glaucoma
Hypertension
Obstructive sleep apnea
Pacemaker

I really feel bad for her as she is totally miserable and not doing anything anymore and prior to this has had six kids etc without ever complaining about anything.

Would anyone stim her? Its axial pain and some risks of procedure to her esp of stopping her anticoag for something I am not confident will help.

Just tell her she has to live with it?

I’m an Interventional Radiology resident. Doing Kyphoplasty’s is Integrated into my training and its only one of many image guided Interventions we do. So it is very obvious why we are allowed to do them. My question for pain management physicians is what training do you get to do Kyphoplasty’s and what is the credentialing process like that qualifies you to do them?

 

[lobelsteve]

I’m an Interventional Radiology resident. Doing Kyphoplasty’s is Integrated into my training and its only one of many image guided Interventions we do. So it is very obvious why we are allowed to do them. My question for pain management physicians is what training do you get to do Kyphoplasty’s and what is the credentialing process like that qualifies you to do them?

Also done as part of our training. So as long as you do enough in training as per the ACGME criteria as outlined in the PIF you are good to go. But unlike most IR, we are trained to care for the patient, not take 15 min to treat a bone. I am in charge of making sure the underlying osteoporosis is treated. Ortho calls it “Owning the bone”.

 

[NDcienporciento100]

Also done as part of our training. So as long as you do enough in training as per the ACGME criteria as outlined in the PIF you are good to go. But unlike most IR, we are trained to care for the patient, not take 15 min to treat a bone. I am in charge of making sure the underlying osteoporosis is treated. Ortho calls it “Owning the bone”.

Ahh I won’t sweat what you just said because I have seen first hand how false it is. Once saw a patient a Paine doc did an alcohol nerve block and caused necrosis of the skin to bone. Patient required multiple surgery’s patient told Me the doc washed his hands completely stopped seeing her. Had a pt in the middle of the night in excruciating pain after a Kyphoplasty from a pain doc. I called the pain doc and told him the situation and he literally had nothing to offer other then say he does not manage patients in the hospital. You have to be very selective with who gets Kyphoplasty’s and from what I have seen pain docs are the least selective. Secretary’s have to be paid and lights in fancy private offices have to stay on and Kyphoplasty’s help pay for that. Your profession is the absolute least qualified to perform a Kyphoplasty. Many IRs have clinics and follow patients longitudinal and we are experts in image guided procedures. Don’t throw shade next time someone is curious. No physician manages every aspect of the disease process and you absolutely don’t.

 

[Laryngospasm]

With all due respect you seem to be the one “throwing shade”

 

[paindoc007]

. Your profession is the absolute least qualified to perform a Kyphoplasty.

Wtf dude. You come here on this forum to try to puff out your chest and call us out as unqualified. I’m plenty qualified for kypho, as is the rest of the forum. We don’t need to defend our qualifications to you. Learn some humility. It’ll be a long life and career for you if you’re already as arrogant as you sound .

 

[MD87]

I’m an Interventional Radiology resident. Doing Kyphoplasty’s is Integrated into my training and its only one of many image guided Interventions we do. So it is very obvious why we are allowed to do them. My question for pain management physicians is what training do you get to do Kyphoplasty’s and what is the credentialing process like that qualifies you to do them?

It depends on the training program. I would not consider it to be a "bread and butter" pain procedure (epidural steroid injections, radiofrequency ablation). Lots of pain fellowship programs get no exposure to them at all. However, at my program, we did do a fair number of kyphoplasty procedures. To quote you, I would consider it to be "integrated into my training program." We have extensive training in fluoroscopic-guided procedures (pretty much makes up the vast majority of what we do). Like any field, there are plenty of great docs and plenty of docs who are complete garbage. Sounds like the ones you have had exposure to are the latter.

 

[BobBarker]

You are showing lots of hubris. Your wings will get burned eventually. I did around 50 kyphoplasties with 3 different supervising physicians in my pain fellowship. I have done around 500 in private practice.

 

[bedrock]

You are showing lots of hubris. Your wings will get burned eventually. I did around 50 kyphoplasties with 3 different supervising physicians in my pain fellowship. I have done around 500 in private practice.

Agree completely. I have seen dozens of examples of spine procedures where it appears that IR couldn’t hit the side of a barn. My most recent example from just 3 weeks ago was a patient with no relief after a lumbar epidural. Fortunately I was able to pull up the hospital images and it was clearly not epidural spread.

Fortunately for the patient, she then had a correctly performed epidural by a fellowship trained pain physician and she’s doing much better now!

And IR in general does a **** job of managing patients, and the private practice IR almost never do a clinic, even if you may have seen it in academics.

 

[BobBarker]

@NDcienporciento100 If I show mine will you show me yours??

 

[SommeRiver]

I’m an Interventional Radiology resident. Doing Kyphoplasty’s is Integrated into my training and its only one of many image guided Interventions we do. So it is very obvious why we are allowed to do them. My question for pain management physicians is what training do you get to do Kyphoplasty’s and what is the credentialing process like that qualifies you to do them?

When you graduate from residency and you're out in the real world for a few yrs come back and we'll talk.

Your opinion is emotionally charged bc you're brand new at this...

 

[Orin]

A pump can cover the pain pattern if you're inclined.

I am torn with the PNS question here as the platform advocated above is more of a percutaneous field stim. The cardiac device here looks an AICD and I'm just not sure how it'll sense the stimulation. I agree that SCS or DRG may be more feasible and safe. I would still do a pump though if you gave me a single chance to fix things.

I agree that the IR docs get more training on how to do kyphoplasties but I've seen more and less aggressive providers on both sides. I would venture to say IR docs have a lot more overhead to deal with though than pain docs.

 

[PainandGain]

Ahh I won’t sweat what you just said because I have seen first hand how false it is. Once saw a patient a Paine doc did an alcohol nerve block and caused necrosis of the skin to bone. Patient required multiple surgery’s patient told Me the doc washed his hands completely stopped seeing her. Had a pt in the middle of the night in excruciating pain after a Kyphoplasty from a pain doc. I called the pain doc and told him the situation and he literally had nothing to offer other then say he does not manage patients in the hospital. You have to be very selective with who gets Kyphoplasty’s and from what I have seen pain docs are the least selective. Secretary’s have to be paid and lights in fancy private offices have to stay on and Kyphoplasty’s help pay for that. Your profession is the absolute least qualified to perform a Kyphoplasty. Many IRs have clinics and follow patients longitudinal and we are experts in image guided procedures. Don’t throw shade next time someone is curious. No physician manages every aspect of the disease process and you absolutely don’t.

Ah, the arrogant resident. By far the most respected of the various medical personae. I can almost feel the hubris flowing through you.

Seriously though, if your goal in life was to walk around with that kind of self importance, you should have tried harder and matched Neurosurgery. Because nobody thinks IR is special besides of course.. IR.

As much as your two stories will forever change my outlook on my career and just life in general, when you take off the training wheels and join the real world you’ll see that things are more complex than I’m the best because I did this residency.

Our local IR doc loves his unipedicular technique (because it saves 5 minutes) where he only fills half the vertebral body about half the time. They usually show up in my office wondering why it didn’t work.. I also know a neurosurgeon who I’m fairly certain tries to fill up the adjacent disc first, then get whatever is left in the bone. But, in your expert opinion both are much more qualified than I could ever hope to be. Are they?

There’s a reason why humility is an admired characteristic in a medical professional and arrogance and pride are not. Take some time a see if you can figure out why.

 

[Agast]

Don't feed the troll.........

 

[DOctorJay]

Someone who is in academia where ideally the system allows them to work on complicated high risk cases in a collaborative manner with other specialties. It doesn't seem to work as well for pain as it does for other specialties, but in some regions it makes sense.

I was being facetious, we shouldn't refer to physicians as "providers"

 

[SommeRiver]

I was being facetious, we shouldn't refer to physicians as "providers"

The term "physician" will ultimately become triggering for midlevels and "provider" becomes the catch-all term in the future.

Like the "R word" going from a legitimate medical term and now completely canceling if used.

 

[Ducttape]

Don't feed the troll.........

I cant... cant resist...…..

Ahh I won’t sweat what you just said because I have seen first hand how false it is. Once saw a patient a Paine doc did an alcohol nerve block and caused necrosis of the skin to bone. Patient required multiple surgery’s patient told Me the doc washed his hands completely stopped seeing her. Had a pt in the middle of the night in excruciating pain after a Kyphoplasty from a pain doc. I called the pain doc and told him the situation and he literally had nothing to offer other then say he does not manage patients in the hospital. You have to be very selective with who gets Kyphoplasty’s and from what I have seen pain docs are the least selective. Secretary’s have to be paid and lights in fancy private offices have to stay on and Kyphoplasty’s help pay for that. Your profession is the absolute least qualified to perform a Kyphoplasty. Many IRs have clinics and follow patients longitudinal and we are experts in image guided procedures. Don’t throw shade next time someone is curious. No physician manages every aspect of the disease process and you absolutely don’t.

if that were the case, then please cease and desist on performing SI injections.

the average length of fluoro time that I have seen from IR is 2 1/2 minutes for a unilat Sacroiliac injection. I saw such a case last week.

of course, it didn't help, because it wasn't the source of pain or even the general location. in all sympathy to the IR doc, it would have been hard for him to figure this out since he never saw the patient - the ordering PCP did.

that's why referrals to an IR doctor is not a referral for "pain evaluation" but a referral for a specific procedure.




wait, IR docs might not worry that "lights in fancy private offices have to stay on", but don't they need power for their machines?

 

[Baron Samedi]

Thank you Mr. Resident for coming on here and trashing a bunch of Board-Certified Subspecialists and teaching us how awful we are. Also, I will take my coffee with a bit of skim milk, please. Used to drink it black but trying to avoid teeth staining.

This patient is a perfect example of someone who would likely benefit from chronic opioid therapy for nonmalignant pain. Another procedure could kill her, would definitely not go stim or pump. Agree that Butrans would be a great option.

 

[Ferrismonk]

I cant... cant resist...…..


if that were the case, then please cease and desist on performing SI injections.

the average length of fluoro time that I have seen from IR is 2 1/2 minutes for a unilat Sacroiliac injection. I saw such a case last week.

of course, it didn't help, because it wasn't the source of pain or even the general location. in all sympathy to the IR doc, it would have been hard for him to figure this out since he never saw the patient - the ordering PCP did.

that's why referrals to an IR doctor is not a referral for "pain evaluation" but a referral for a specific procedure.




wait, IR docs might not worry that "lights in fancy private offices have to stay on", but don't they need power for their machines?

Fluoro? I usually see IR do CT-guided SI injections and bill for the CT read too.

 

[manowar rules]

320769[/ATTACH]
View attachment 320770

Ok the fusion kypho I’m curious about. Where are you putting the access cannulas when there are pedicle screws?

 

[BobBarker]

Ok the fusion kypho I’m curious about. Where are you putting the access cannulas when there are pedicle screws?

this one I did a modified subpedicular. Low and lateral to the pedicle typically but I started a little higher than the spot typically taught for subpedicular. Check out the Beall Seattle Science Foundation lectures. They are free.

 

[paindoc007]

this one I did a modified subpedicular. Low and lateral to the pedicle typically but I started a little higher than the spot typically taught for subpedicular. Check out the Beall Seattle Science Foundation lectures. They are free.

So you basically do 45 degree ipsilatsral oblique and aim at the anterior/inferior VB? All that vascularity near that makes me nervous. Ever had any issues w bleeding?

 

[BobBarker]

Rotate over oblique like you said and touch down lateral and inferior to the pedicle typically. And just drive the trochar where you want it after that.

Doug talks about the vascularity in the lecture. Nothing to be concerned about as far as bleeding. He bled more than typical for sure though. I only use that approach for cases like this or plana fx

 

[mid|ine]

I did over 100 vertebral augmentations in training.
I will put my procedure skills against IR any day. In a previous job, procedures were rotated between a few docs, including IR. Most of the IR docs ESIs were NOT in the epidural space and took more than 5 min of fluoro time!!
IR docs do a lot of different procedures. However, I assure you, of the procedures I do, I am better than >95% of IR docs at those procedures.

 

[ateria radicularis magna]

I like IR doctors! I also like neurosurgery and ortho spine and interventional pain. I cannot generalize about them because I know really good doctors and also bad doctors in all of them. I’m sure there are some great IR diagnosticians and some pain doctors who do kyphoplasty poorly. Big deal. We have all heard the stories of the bad players, and we will continue to hear them. The trick is to not become a bad player.
Regarding keeping the lights on and fancy private offices, hospital based vertebral augmentation is WAY more expensive when you factor everything in, which is why in-office is reimbursed well (it was an attempt by the insurance companies to save money by keeping the procedures away from the hospital). At least this is the narrative I heard. Please correct me if I’m wrong!

 

[craigkes]

Fluoro? I usually see IR do CT-guided SI injections and bill for the CT read too.

Same here. Or have a PA do it under their "supervision". I see these more times than I can count in rural Montana. I can't imagine doing a SI joint (or repeating them) with CT. Sure there will always be exceptions but 99% of the time it makes no sense to put them through that much. The amount of radiation compared to the 3 seconds under flouro just doesn't compute. I say this because I asked the radiologist at the outside facility why his numbers/the PA's numbers were so much higher as compared to mine (fortunate that they screen shot total time and radiation dose given and could compare it to mine). I was told the calculation was "different". Same for an ESI. Right.

 

[craigkes]

I like our IR doctors. I don't send anyone to them but usually they get sent the cases that have had 8 random injections by IR and then dumped on my doorstep to take care of. Usually by one of the neurosurgeons in town. The IR doctors here are nice to talk to.....but they do nothing with the patient other than poke them. They do what they are asked. Simple as that. They are private.....until January as they were bought out by the hospital. They don't lay hands on the patient until they drape for the procedure. I think I remember something about a physical exam somewhere.....saves the patients procedures most of the time (but not always). I see it not infrequently where they do a random IL ESI for a radiculopathy simply because they were asked to do so. I don't get the feeling that most of them care otherwise.

 

[DocMorpheus]

My favorite IR procedure that I’ve actually seen in real life is a CT-guided trigger point injection...what a joke.

 

[Chn96]

Ahh I won’t sweat what you just said because I have seen first hand how false it is. Once saw a patient a Paine doc did an alcohol nerve block and caused necrosis of the skin to bone. Patient required multiple surgery’s patient told Me the doc washed his hands completely stopped seeing her. Had a pt in the middle of the night in excruciating pain after a Kyphoplasty from a pain doc. I called the pain doc and told him the situation and he literally had nothing to offer other then say he does not manage patients in the hospital. You have to be very selective with who gets Kyphoplasty’s and from what I have seen pain docs are the least selective. Secretary’s have to be paid and lights in fancy private offices have to stay on and Kyphoplasty’s help pay for that. Your profession is the absolute least qualified to perform a Kyphoplasty. Many IRs have clinics and follow patients longitudinal and we are experts in image guided procedures. Don’t throw shade next time someone is curious. No physician manages every aspect of the disease process and you absolutely don’t.

Oh yeah
Saw 2 patients last month , both had kyphoplasty by Hospital IR , . Went back to IR post op with persistent, asked her to see pain management as IR don’t treat pain. One of the patient has moderate to severe spinal stenosis with relief in symptoms after ESI.