Kyphoplasty in young patients

[masterPain]

What are your thoughts on kyphos in young patients? I have a 28 year old who’s quite symptomatic and failing conservative measures for 8 weeks. I worry about adjacent level issues this young

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[CleanUp]

Hmmmm how did she get the VCF?

 

[lobelsteve]

Facepalm x2

 

[SpineandWine]

Traumatic VCF - rare to get approval sometimes

 

[masterPain]

Hmmmm how did she get the VCF?

He was hit by a vehicle while riding motorcycle

 

[masterPain]

Facepalm x2

Ouchie

Mind expanding your highness?

 

[lobelsteve]

Without osteoporosis what makes you think there would be increased risk of adjacent level fracture?

With osteoporosis what makes you think there would be increased risk of adjacent level fractures?

Data for VA is not robust for traumatic fxs and most insurances will not cover because of the weak literature.

Brace and miacalcin. If ongoing pain beyond 8 weeks I suspect secondary gain. Fxs heal in young people.

 

[masterPain]

PMMA alters the biomechanics of that part of the spine leading to potential issues decades down the road in younger patients.

Some studies suggest that there is an increased risk of ALD in kyphoplasty patients due to the altered biomechanics and increased stress on adjacent vertebrae. This can be worse for younger patients.

 

[DrSpine]

I would not. 28 year old should be fine with bracing.

 

[lobelsteve]

PMMA alters the biomechanics of that part of the spine leading to potential issues decades down the road in younger patients.

Some studies suggest that there is an increased risk of ALD in kyphoplasty patients due to the altered biomechanics and increased stress on adjacent vertebrae. This can be worse for younger patients.

Latest review of literature shows no increased risk of fracture after treating with VA, as long as underlying OP treated.

 

[Ducttape]

PMMA alters the biomechanics of that part of the spine leading to potential issues decades down the road in younger patients.

Some studies suggest that there is an increased risk of ALD in kyphoplasty patients due to the altered biomechanics and increased stress on adjacent vertebrae. This can be worse for younger patients.

you ask about kypho in a young person, then you make statements about how kypho has potential increased risk in younger group.


you have answered your own question as to not offering kypho to a young person who does not have OP.

and everyone agrees with you.




the best treatment you can give him is to advise him not to ride the donorcycle any more.

 

[lobelsteve]

you ask about kypho in a young person, then you make statements about how kypho has potential increased risk in younger group.


you have answered your own question as to not offering kypho to a young person who does not have OP.

and everyone agrees with you.




the best treatment you can give him is to advise him not to ride the donorcycle any more.

It is not the riding, it is the crashing that gets you.

 

[Ducttape]

yes, and it is the signed organ donor card that ER docs rifle through belongings to find. that and loose change.

 

[lobelsteve]

yes, and it is the signed organ donor card that ER docs rifle through belongings to find. that and loose change.

Code: Airway, breathing, circulation.
Code: Watch, wallet, keys.

 

[masterPain]

I would not. 28 year old should be fine with bracing.

I hadn’t planned on it but kid is miserable

 

[masterPain]

you ask about kypho in a young person, then you make statements about how kypho has potential increased risk in younger group.


you have answered your own question as to not offering kypho to a young person who does not have OP.

and everyone agrees with you.




the best treatment you can give him is to advise him not to ride the donorcycle any more.

Clearly it was not in my original plan I’ve performed TESI and now considering TMBB but have low likelihood of fixing the problem. Just doing anything I can and I do think kypho would make him better but have serious reservations for the obvious reasons

 

[SpineandWine]

I’ve had this situation of refractory pain.
Usually to get approval, they are hospitalized and inpatient kyphoplasty performed - again not ideal option but can be done if severe loss of functionality/job/etc.

Obviously not a textbook answer

 

[masterPain]

I’ve had this situation of refractory pain.
Usually to get approval, they are hospitalized and inpatient kyphoplasty performed - again not ideal option but can be done if severe loss of functionality/job/etc.

Obviously not a textbook answer

I can 100% get it approved. Giving him more time but you’re exactly right. He’s completely disabled.

 

[lobelsteve]

I can 100% get it approved. Giving him more time but you’re exactly right. He’s completely disabled.

PMH?
Imaging?
Completely disabled? My dad burst L1 in boating accident and was back at work 3 days later while in a brace for a few months.

 

[BoardingDoc]

yes, and it is the signed organ donor card that ER docs rifle through belongings to find. that and loose change.

I resent that. I'm not digging through your pockets unless I think there's $20 or more in there.

 

[masterPain]

PMH?
Imaging?
Completely disabled? My dad burst L1 in boating accident and was back at work 3 days later while in a brace for a few months.

I’m sorry this offends you so much. No burst. Completely healthy 28 year old. SEP Fx with minimal height loss lights up on STIR. Wrap around pain the whole bit.

 

[Laryngospasm]

It’s probably already partially healed and hard as a rock in a 28 yo male. Maybe basivertebral ablation would help? I’d ask if he has a lawyer for the accident.

 

[Ducttape]

not everything is cured with an injection.

id get good odds that his pain gets worse after the injection, so much so that you will feel forced to prescribe a minimum of 24 months of percocet or his no fault runs out, whichever comes first.

 

[paindoc007]

Why is everyone so triggered by this question? It’s a very reasonable medical discussion.

People here much prefer to discuss how we celebrate pride month on this forum. Makes sense

 

[masterPain]

Why is everyone so triggered by this question? It’s a very reasonable medical discussion.

People here much prefer to discuss how we celebrate pride month on this forum. Makes sense

Exactly wtf

 

[Ducttape]

not triggered.

but you all have stated what the right thing is to not do, yet some of you are still trying to convince yourself otherwise.

 

[lobelsteve]

I'm triggered by the apparent lack of education in our younger doctors. Or those who lack critical thinking skills and rely on KOLs to teach or sway them to do things that are not supported. Our SIS kyphoplasty review is complete and hopefully published this year.

 

[paindoc503]

I have nothing clinical to add to this discussion. That being said, It would be nice to have more fruitful discussions on this forum. As a younger doc myself, I learn a lot from these conversations and from the wisdom of the more experienced docs here. I really don’t think there is a need to insult people’s lack of education or critical thinking skills.. instead it can be used as a moment of education. Maybe these younger docs will learn something and pass it down one day.

Just my two cents, I’ll go away if y’all don’t agree.

 

[SpineandWine]

Pain medicine education is trash. Need oral boards
Ortho spine. Random cases are picked from first year of attending. They have to defend it

 

[masterPain]

I'm triggered by the apparent lack of education in our younger doctors. Or those who lack critical thinking skills and rely on KOLs to teach or sway them to do things that are not supported. Our SIS kyphoplasty review is complete and hopefully published this year.

Sorry for asking a fing question on a difficult case. If the patient was 60 I’d have done the kypho two months ago.

I’ll try BVN

The arrogance is astounding

 

[masterPain]

I have nothing clinical to add to this discussion. That being said, It would be nice to have more fruitful discussions on this forum. As a younger doc myself, I learn a lot from these conversations and from the wisdom of the more experienced docs here. I really don’t think there is a need to insult people’s lack of education or critical thinking skills.. instead it can be used as a moment of education. Maybe these younger docs will learn something and pass it down one day.

Just my two cents, I’ll go away if y’all don’t agree.

People being pricks makes them feel good about themselves.

Funniest part is in this game there’s no right or wrong answer a lot of times.

They call medicine and art for a reason.

 

[SpineandWine]

People being pricks makes them feel good about themselves.

Funniest part is in this game there’s no right or wrong answer a lot of times.

They call medicine and art for a reason.

100% art
Very little evidence

 

[lobelsteve]

These questions were asked on this form 15 years ago 10 years ago, five years ago and last year try and use the search function. All of these questions have been answered at nausea. It’s not arrogance. It’s your laziness.

 

[Tboned]

Sorry for asking a fing question on a difficult case. If the patient was 60 I’d have done the kypho two months ago.

I’ll try BVN

The arrogance is astounding

Intracept? Not indicated. And not reasonable IMO. Brace and time.
Good luck getting Intracept approved for a traumatic subacute fracture, although maybe no fault insurance is this ridiculous?

 

[masterPain]

These questions were asked on this form 15 years ago 10 years ago, five years ago and last year try and use the search function. All of these questions have been answered at nausea. It’s not arrogance. It’s your laziness.

Dude you’re acting like I asked if I should put in a T5/T6 vertiflex or minuteman

I’m currently giving conservative treatment with NSAID/bracing/PT

I respect your knowledge but chill

 

[clubdeac]

You’re gonna be hammering really hard to get through that guys bone. I tried it once and was whacking as hard as could, and that’s when I could bench 300lb. That’s right ssdoc. It’s not worth it

 

[lobelsteve]

You’re gonna be hammering really hard to get through that guys bone. I tried it once and was whacking as hard as could, and that’s when I could bench 300lb. That’s right ssdoc. It’s not worth it

You never benched 300, that's why pain and not Ortho.
And the drill gets through bone no matter what. And easily.

 

[BobBarker]

Perhaps, a good case to be done at an ASC, bipedicular, with Styker Cortoss if you are going to do it. 2.5lb mallet.

 

[Status Sciaticus]

Doesnt the ASPN guidelines mention kypho is indicated for traumatic VCF? I used that a few times to get non-osteoporotic fractures approved. Most medical directors are using the AAOS guidelines.

 

[Taus]

Perhaps, a good case to be done at an ASC, bipedicular, with Styker Cortoss if you are going to do it. 2.5lb mallet.

My only experience is on bvna on younger guys …. I use the 2.5lb routinely, occasionally 5lb mallet (thanks tha/tka docs at asc). F’ing steel for bones sometimes. I’ve heard of a drill being used but prefer not to have a “firsts” on live patients.

 

[clubdeac]

You never benched 300, that's why pain and not Ortho.
And the drill gets through bone no matter what. And easily.

I did (actually 315) and that’s what helped herniate 2 discs in my neck. No exaggeration. Now I bench no more than 185lb. Lost 20lbs of muscle as well

 

[RoloTomassi]

Either kypho or BVNA would likely help. Both would be hard to get approved through the insurance route. What level is the fx?

 

[lobelsteve]

My only experience is on bvna on younger guys …. I use the 2.5lb routinely, occasionally 5lb mallet (thanks tha/tka docs at asc). F’ing steel for bones sometimes. I’ve heard of a drill being used but prefer not to have a “firsts” on live patients.

I use the drill routinely in kypho cases. Not so much for stronger bones, but more often the additional depth needed for the osteoporotic despite biscuit poisoning.

 

[Ducttape]

Dude you’re acting like I asked if I should put in a T5/T6 vertiflex or minuteman

I’m currently giving conservative treatment with NSAID/bracing/PT

I respect your knowledge but chill

i think you still miss the point.

there is no evidence to offer kypho on this patient, just like you mention minuteman. your words imply you know this to be true but it really feels like you are desperately pushing to get someone to agree with you.

do a pubmed search. you will find a few case reports from 10 years ago, but no studies, no higher level clinical evidence.



i understand that there are KOLs who are spouting all this aggressive interventional treatment and pushing the envelope with needles. but there just is insufficient evidence of clinical efficacy and plenty of evidence for potential harm with injections.


just like an ortho wouldnt go in and pin and plate a fibula fracture, or wouldnt surgically stabilize an uncomplicated rib fracture, or pin a distal phalanx toe fracture. could they? sure. will they?

the patient just needs time.

 

[masterPain]

i think you still miss the point.

there is no evidence to offer kypho on this patient, just like you mention minuteman. your words imply you know this to be true but it really feels like you are desperately pushing to get someone to agree with you.

do a pubmed search. you will find a few case reports from 10 years ago, but no studies, no higher level clinical evidence.



i understand that there are KOLs who are spouting all this aggressive interventional treatment and pushing the envelope with needles. but there just is insufficient evidence of clinical efficacy and plenty of evidence for potential harm with injections.


just like an ortho wouldnt go in and pin and plate a fibula fracture, or wouldnt surgically stabilize an uncomplicated rib fracture, or pin a distal phalanx toe fracture. could they? sure. will they?

the patient just needs time.

I think you missed the context of the thread. I clearly am asking the question under the notion this isn’t probably the best option for the patient given age and type of pathology.

But options are limited and he can’t get back to work, thus, asking a panel of experts their opinion. I have gotten several DMs where physicians on this board have proceeded with kyphoplasty and patient did quite well. (Young patient with traumatic fracture) They think the aggression towards me for asking the question in a difficult case is ridiculous. Good day.

 

[Ducttape]

ah well. i guess you still miss the point.

not indicated is not indicated regardless of how you sugar coat it.

 

[SpineandWine]

ah well. i guess you still miss the point.

not indicated is not indicated regardless of how you sugar coat it.

What would you do if same patient had severe pain requiring hospitalization.
Unable to wean off PCA to PO meds despite multiple adjuncts - tried for last 3-4 weeks, started ketamine drip
How would you manage?

 

[masterPain]

Hence, why I asked your opinions

 

[SpineandWine]

I wonder if there is role of spine jack in traumatic compression fractures- not necessarily balloon kyphoplasty

 

[lobelsteve]

What would you do if same patient had severe pain requiring hospitalization.
Unable to wean off PCA to PO meds despite multiple adjuncts - tried for last 3-4 weeks, started ketamine drip
How would you manage?

Turf to IR and Psych. Assuming only this Fx reportedly causing this pain. Fracture 3 to 4 weeks with control via pca needed means you are missing something or patient defective.