Kyphoplasty vs epidural

[GottaHaveIt]

Hey all,

I have this patient I recently saw. She has an acute compression fracture on imaging in the mid thoracic region noted on MRI. On exam however she has no pain on palpation of the spinouts process of the thoracic vertebrae. Sh has no tenderness anywhere at all. Her complaint is mid back pain that wraps around the ribs left > right. She is old and very sensitive to medications. She would like to avoid using any meds like gabapentin, tramadol, etc.

Typically if patients have no tenderness on exam, I defer kyphoplasty. In this case I am considering epidural. Wanted your expert opinions.

MRI shows no retropulsion. No canal or NF narrowing. However CT does reveal some narrowing of the NF per my review due to the worsening of the kyphophosis that has developed due to the fracture.

I'd love your thoughts on the case.

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[lobelsteve]

Pain pattern most consistent with kyphoplasty. Number needed to treat is 15 at a year to save a life. Not so much for epidurals.

 

[RoloTomassi]

I don't think tenderness is very sensitive/specific test. If it lights up on STIR it's probably painful. Especially since you say fx is thoracic and pain is thoracic, that's a go for me.

 

[Ducttape]

what would you be treating with an epidural? theres no spinal stenosis. that is not a clear cut story for thoracic radic.

steroids can worsen bone density.

no good clinical indication.



do the kypho.

 

[willabeast]

My opinion only. 1. if the ESI gets the patient walking, there will be no bone density worsening. 2. Before kyphoplasties became common (where I worked) I did ESI for acute compression Fx of spine. They always worked (in other words, they got the patient mobile and back home out of the hospital). Never had to do a second one. I have been retired now almost 9 years. When I did a Google search just now I got the following "When comparing ESI (epidural steroid injections) and kyphoplasty for treating vertebral compression fractures, kyphoplasty is generally considered more effective for structural correction and long-term pain relief by restoring the height of the fractured vertebra, while ESI provides temporary pain relief through inflammation reduction around the spinal nerves, but does not address the underlying bone fracture itself; making kyphoplasty the preferred option for significant vertebral compression fractures, especially in cases with noticeable deformity. "

 

[oneforfighting]

If this is a new or acutely worsened pain in the vicinity of the acute fracture then the fracture is the cause of the pain

 

[Ducttape]

kudos for you for looking up information.

here is data that i found - retrospective study suggesting those who got epidurals were more likely to develop VCF (retrospective, small group, obviously no blinding, and not causal association):

Increased Risk of Osteoporotic Vertebral Compression Fractures Following Epidural Steroid Injections in Patients with Lumbar Degenerative Disease: A Retrospective Cohort Study - PubMed

<span><b>Background/Objectives</b>: Lumbar degenerative disease is a common age-related condition, with epidural steroid injection (ESI) being a widely employed conservative treatment approach. However, the potential effect of ESI on osteoporosis and fracture risk remains unclear. This study...

pubmed.ncbi.nlm.nih.gov

and another retrospective study, for what its worth with same caveats, though the group was much larger because of methodology:

A retrospective analysis of vertebral body fractures following epidural steroid injections - PubMed

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

pubmed.ncbi.nlm.nih.gov

i found no studies that showed that epidural injections were beneficial for VCF.

i did find this study that showed that epidurals at the time of VCF shows some benefit in ODI but not in pain score.

ADDING EPIDURAL INJECTION TO VERTEBROPLASTY IMPROVES FUNCTION IN PATIENTS WITH VERTEBRAL COMPRESSION FRACTURE - The Journal of Turkish Spinal Surgery

ADDING EPIDURAL INJECTION TO VERTEBROPLASTY IMPROVES FUNCTION IN PATIENTS WITH VERTEBRAL COMPRESSION FRACTURE - The Journal of Turkish Spinal Surgery

jtss.org

 

[swamprat]

I generally will perform Kypho if they complain of pain in the region an STIR positive on MRI (and insurance approves - this is getting harder every year). I find essentially all the patient's pain I do this on resolves in a day or two after procedure. I think TTP over the spinous process is poorly sensitive and specific.

 

[Orin]

I have this patient I recently saw. She has an acute compression fracture on imaging in the mid thoracic region noted on MRI. On exam however she has no pain on palpation of the spinouts process of the thoracic vertebrae. Sh has no tenderness anywhere at all. Her complaint is mid back pain that wraps around the ribs left > right.

You're making it hard.

Clinical Relevance of Pain Patterns in Osteoporotic Vertebral Compression Fractures - PMC

Few studies have been conducted to explain the pain patterns resulting from osteoporotic vertebral compression fractures (OVCF). We analyzed pain patterns to elucidate the pain mechanism and to provide initial guide for the management of OVCFs. ...

pmc.ncbi.nlm.nih.gov

You may have been taught that patients should have tenderness on exam and a fracture should be a primarily Type A or Type B1 pain pattern. You may have been taught that radiating pain gets an epidural.

The paper above looked at 64 patients with VCFs that got vertebral augmentation.

Only about a third of them have the type of pain that you classically think of.

All of them respond to augmentation.

Don't make it difficult. The bone broke. She hurts. MRI shows the bone is still healing. Fix the bone. Deal with the left over pain later.

 

[PainMD23]

You're making it hard.

Clinical Relevance of Pain Patterns in Osteoporotic Vertebral Compression Fractures - PMC

Few studies have been conducted to explain the pain patterns resulting from osteoporotic vertebral compression fractures (OVCF). We analyzed pain patterns to elucidate the pain mechanism and to provide initial guide for the management of OVCFs. ...

pmc.ncbi.nlm.nih.gov

You may have been taught that patients should have tenderness on exam and a fracture should be a primarily Type A or Type B1 pain pattern. You may have been taught that radiating pain gets an epidural.
View attachment 395622
The paper above looked at 64 patients with VCFs that got vertebral augmentation.
View attachment 395623
Only about a third of them have the type of pain that you classically think of.
View attachment 395624
All of them respond to augmentation.

Don't make it difficult. The bone broke. She hurts. MRI shows the bone is still healing. Fix the bone. Deal with the left over pain later.

This has been my experience. Many times will see an SI-joint style pain pattern from the fractured level and get excellent relief s/p kypho.

 

[Taus]

This has been my experience. Many times will see an SI-joint style pain pattern from the fractured level and get excellent relief s/p kypho.

I have always found that type C pattern with pain at LS junction from TL junction fracture hard to reconcile. I figured if they fell hard enough to break a bone, they fell hard enough to aggravate something else lower down….. and I have historically chased that with minimal success…

 

[lobelsteve]

I have always found that type C pattern with pain at LS junction from TL junction fracture hard to reconcile. I figured if they fell hard enough to break a bone, they fell hard enough to aggravate something else lower down….. and I have historically chased that with minimal success…

Time to give into the science. More likely to hurt there than anywhere else.

 

[PMROralBoards]

Does anyone have an opinion on a two level kypho for a patient with thrombocytopenia (plt of 50) due to cirrhosis and hypersplenism? Radiology society recommends greater than or equal to 50 as a minimum. Pt is having significant pain from the compression fractures.

 

[lobelsteve]

No issues. 50 is 50. Stay away from medial border of pedicle.

 

[Orin]

Does anyone have an opinion on a two level kypho for a patient with thrombocytopenia (plt of 50) due to cirrhosis and hypersplenism? Radiology society recommends greater than or equal to 50 as a minimum. Pt is having significant pain from the compression fractures.

The platelet count is fine but the bigger issue may be the other coagulation parameters in that patient. I'd proceed in a hospital setting where you can check labs and transfuse products, but in a clinic/ASC that seems to be a higher risk procedure.

 

[callmeanesthesia]

The platelet count is fine but the bigger issue may be the other coagulation parameters in that patient. I'd proceed in a hospital setting where you can check labs and transfuse products, but in a clinic/ASC that seems to be a higher risk procedure.

Agreed. In cirrhosis they often have both quantitative and qualitative platelet defects. You could check a TEG if you’re feeling fancy, but personally I’d punt to the hospital.

 

[PMROralBoards]

The platelet count is fine but the bigger issue may be the other coagulation parameters in that patient. I'd proceed in a hospital setting where you can check labs and transfuse products, but in a clinic/ASC that seems to be a higher risk procedure.

Agreed. In addition to the platelets, INR isn’t reliable in liver failure. Ultimately decided to treat pharmacologically. Thank you both for your posts and concern!