mbb/rf levels with chronic compression fractures

[bedrock]

I'm sure you all see from time to time, patient with partial relief and chronic pain after a compression fracture. I refer to fractures that were treated either conservatively or with kypho. I intermittently see patients who have 2/3rd relief after someone else did a kyphoplasty.

I find that some of these patients respond to mbb/rf, and my question concerns the optimal levels to be treated.

For example, patient with old L1 compression fracture, s/p kypho. Would you just treat the medial branches lying across L1 (T12mbb)? Or would you proceed to T12,L1 MBB, or T12,T11, or T11,T12,L1?

Let's assume for this exercise, that these upper lumbar facet joints don't look that bad, and new MRI stir images negative for further fracture.

Thoughts?

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[epidural man]

I have written on here about this before.

There is some thought - although never proven - that the whole reason compression fractures hurt is from the stress on the facets. And in fact, the whole reason that kypho/vertebralplasty works is because you stick a large trochar through the medial branch and it may have nothing to do with the cement.

No one will do the study though - people like money.

I wanted to do the study. We only see active duty in our clinic, so the folks at our hospital that do kypho are the IR guys. I asked them about it and they had no interest. They really like doing kyphoplasty so a study that would threaten that business is a scary proposition.

I have no idea if it is true. It is a cool idea. I know people can easily say - "epidural man...you are nuts to think that the medial branch neurotomy will help with vertebral fractures. Who even licensed you!" Too this I will respond...perhaps...but DO the study. What is the harm in answering the question. Guessing does no one any good.

What if a lot of the vertebral body is innervated by the medial branch?

By the way, I think there is a case report or two of people doing RF to the medial branch and getting really good response for vertebral fractures.

Bedrock - this doesn't answer your question. I have no idea the optimal level.

 

[DOctorJay]

I almost did this study in fellowship but never got around to it. I've done FJI and MBBs on a couple people above and below the fracture and relieved their pain. Biomechanically it makes sense and I think Bogduk may have written on the topic as well.

 

[Pacman27]

Consider palpating under imaging

I have had success with doing the ones below typically, but my N is small

 

[lobelsteve]

I have written on here about this before.

There is some thought - although never proven - that the whole reason compression fractures hurt is from the stress on the facets. And in fact, the whole reason that kypho/vertebralplasty works is because you stick a large trochar through the medial branch and it may have nothing to do with the cement.

No one will do the study though - people like money.

I wanted to do the study. We only see active duty in our clinic, so the folks at our hospital that do kypho are the IR guys. I asked them about it and they had no interest. They really like doing kyphoplasty so a study that would threaten that business is a scary proposition.

I have no idea if it is true. It is a cool idea. I know people can easily say - "epidural man...you are nuts to think that the medial branch neurotomy will help with vertebral fractures. Who even licensed you!" Too this I will respond...perhaps...but DO the study. What is the harm in answering the question. Guessing does no one any good.

What if a lot of the vertebral body is innervated by the medial branch?

By the way, I think there is a case report or two of people doing RF to the medial branch and getting really good response for vertebral fractures.

Bedrock - this doesn't answer your question. I have no idea the optimal level.

Ive done enough parapedicular kypho to say hot Fx is not innervated by MBB. Maybe basovertebral and sinuvertebral nerves.

 

[DOctorJay]

Bogduk article
http://www.ncbi.nlm.nih.gov/pubmed/21044256

Thoracic facets
http://www.ncbi.nlm.nih.gov/pubmed/21029349

for those of you doing kypho/v-plasty, would you consider consenting the patients for MBB right before the procedure, see how they respond, and then do your planned procedure?

when I discussed this with my fellowship director, Tim Maus, and Felix Diehn, we were talking about asking patients with VCF to undergo the MBB or FJI prior to v-plasty to see if their pain was primarily posterior element related.

do people really do ESI for VCF?

 

[PainandGain]

I like this topic and Bogduk's thoughts on it. I think it makes sense to do the kyphoplasty and restore as much of the natural biomechanics as possible, possibly reducing the likelihood of facet arthropathy. A RF vs Kypho study would be interesting.

 

[epidural man]

Another study would be to do MBB prior to kypho to see if procedural (kypho) pain is better with MBB vs NS or however the study was designed.

 

[bedrock]

appreciate all the thoughts, none of which address my primary question--

my question concerns the optimal levels to be treated.

For example, patient with old L1 compression fracture, s/p kypho. Would you just treat the medial branches lying across L1 (T12mbb)? Or would you proceed to T12,L1 MBB, or T12,T11, or T11,T12,L1?

I agree with addressing the biomechanical issue, so if I see a patient with a new compression fracture, after some basic conservative care, I'm going to do the kyphoplasty as the primary treatment.

HOWEVER, if the patient still has significant residual pain afterward, does anybody here do MBB/RF, and if so which levels?

 

[DOctorJay]

Bedrock,

See my post above where I stated above and below fx. Also refer to Bogduk's article I posted which states the same.

 

[bedrock]

Bedrock,

See my post above where I stated above and below fx. Also refer to Bogduk's article I posted which states the same.

Sorry Jay,

You did try to help and I thank you.

So to be clear, for my example of a patient with old L1 compression fracture, s/p kypho. You are suggesting treating the T11,T12,L1, medial branches, which would denervate the T12-L1 and L1-L2 joints?

I suppose it makes sense, if you theorized that a fractured segment causes stress on the facet joints. Change in biomechanics of the L1 level would affect the two joints L1 interacts with, so T12-L1 and L1-L2.

 

[DOctorJay]

Exactly

 

[NOSfan]

Bogduk article
http://www.ncbi.nlm.nih.gov/pubmed/21044256

Thoracic facets
http://www.ncbi.nlm.nih.gov/pubmed/21029349

for those of you doing kypho/v-plasty, would you consider consenting the patients for MBB right before the procedure, see how they respond, and then do your planned procedure?

I typically do MBB as part of my vertebroplasty technique via placing a 25-gauge 3.5" needle down to pedicle and anesthetize all the way back up to skin. It helps the patient tolerate the procedure well.

While trauma to the facet capsule due to biomechanical stress can be an additional source of pain, there are instances where this does not seem to be a factor; such as in the setting of endplate fractures with fissures. The overall vertebral height appears intact. You will see some filling through the fissure and the patient tends to respond very well from a symptomatic standpoint.

But, yes, the facet joints are also a player for the most part.

 

[emd123]

I typically do MBB as part of my vertebroplasty technique via placing a 25-gauge 3.5" needle down to pedicle and anesthetize all the way back up to skin. It helps the patient tolerate the procedure well.

While trauma to the facet capsule due to biomechanical stress can be an additional source of pain, there are instances where this does not seem to be a factor; such as in the setting of endplate fractures with fissures. The overall vertebral height appears intact. You will see some filling through the fissure and the patient tends to respond very well from a symptomatic standpoint.

But, yes, the facet joints are also a player for the most part.

Agree. These patients are typically elderly and often have multiple potential pain generators to begin with and when one domino falls (VCF) it brings other factors into play. In the ones with significant height loss and kyphosis, you can imagine how the diameter of the neural foramen could even be reduced from the forward flexion of the spine. Couldn't that generate pain, in a patients with an already narrow foramen without much room around the nerve root?

 

[NOSfan]

Agree. In the ones with significant height loss and kyphosis, you can imagine how the diameter of the neural foramen could even be reduced from the forward flexion of the spine. Couldn't that generate pain, in a patients with an already narrow foramen without much room around the nerve root?

Indeed, have seen a number of fx with subsequent radiculopathy secondary to 'new' stenosis. Even a seen few with SIJ dysfunction due to altered biomechanics.

 

[mid|ine]

I think it would be reasonable and if you can get it covered I would do the level of the fracture as well as one above and one below.