Sacral insufficiency fractures

[Dr. Ice]

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Any of you all doing sacroplasty for these people?

 

[Orin]

Any of you all doing sacroplasty for these people?

Referring out to someone with CT guidance. I think about it for some of them, but then I remember how much I hate doing things like SI ablations due to the poor visualization down there. I got enough ways to torture myself without doing this.

 

[TIVAndy]

i usually try caudal ESI first before referring out for sacroplasty - been getting good results with sacral fractures

 

[lobelsteve]

Steroids? Fractured. Facepalm.

 

[SommeRiver]

Steroids? Fractured. Facepalm.

You say that...Similar situation or mine maybe 8 weeks ago - Elderly woman with a nasty L5 fracture with severe back pain and radic to the great toe.

L5-S1 TF turned it off nearly 100%.

I've not heard from her in 8 weeks.

 

[drusso]

Some good cases on Linked-In for SCS and sacral insufficiency fractures.

 

[pmrmd]

Sacroplasty. Target is centroid of S1.

 

[lobelsteve]

You say that...Similar situation or mine maybe 8 weeks ago - Elderly woman with a nasty L5 fracture with severe back pain and radic to the great toe.

L5-S1 TF turned it off nearly 100%.

I've not heard from her in 8 weeks.

She came to see me. Kypho. Prolia. You are welcome.

 

[SommeRiver]

She came to see me. Kypho. Prolia. You are welcome.

 

[DrSpine]

i usually try caudal ESI first before referring out for sacroplasty - been getting good results with sacral fractures

Personally, I will tell you why I am not a fan of that. I think the patient will get some relief initially, but throwing steroids on fractures will worsen the situation or cause further fracturing. If no sacroplasty or vertebroplasty, you could do conservative management or in conjunction with lateral branch/medical branch ablation if appropriate. I did read something in literature about Lumbar RFA if fracture was relatively stable and not that bad.

 

[clubdeac]

Everyone’s poo hooing an epidural before sacroplasty but do we really know how detrimental one epidurally place steroid is to bone strength/metabolism in the short term? I’ve done this on a number of patients that didn’t want to go through with vertebral augmentation and many do quite well and don’t end up needing the much more costly and higher risk alternative

 

[TIVAndy]

Steroids? Fractured. Facepalm.

Personally, I will tell you why I am not a fan of that. I think the patient will get some relief initially, but throwing steroids on fractures will worsen the situation or cause further fracturing. If no sacroplasty or vertebroplasty, you could do conservative management or in conjunction with lateral branch/medical branch ablation if appropriate. I did read something in literature about Lumbar RFA if fracture was relatively stable and not that bad.

i knew someone would comment on this. i used to send out for sacroplasty for sacral insufficiency fractures - they almost always came back to me again with pain. perhaps the guys in my town (IR) don't know how to do it properly.

for thoracic/lumbar compression fractures - i do kypho or i have done mbb with some success - there's some scarce data about mbb
however i didn't know there was evidence for sacral fractures and lateral branch block/RFA - and these are patients who are begging me to get anything done to bring down their pain even after sacroplasty. conservative and "proper" therapy has been done already.
i'd much rather see them up doing their ADL than worrying about additional risk of fracture due to steroid and provide them with nothing (or meds)

 

[SSdoc33]

there is a big different between an ESI for fracture-induced stenosis pain and and ESI to actually treat the fracture.

its seems like pretty poor form to treat fracture pain with steroids. call me crazy.

 

[clubdeac]

there is a big different between an ESI for fracture-induced stenosis pain and and ESI to actually treat the fracture.

its seems like pretty poor form to treat fracture pain with steroids. call me crazy.

You crazy

 

[bedrock]

Agree with deac. Repeated doses of steroids and other chronic factors cause fractures.

A single steroid injection for a patient who has an acute result of a chronic process can greatly help the acute pain and is not going to cause that much harm compared to all the other factors for a fracture for the several years preceding and several years following an acute fracture.

 

[DrSpine]

Agree with deac. Repeated doses of steroids and other chronic factors cause fractures.

A single steroid injection for a patient who has an acute result of a chronic process can greatly help the acute pain and is not going to cause that much harm compared to all the other factors for a fracture for the several years preceding and several years following an acute fracture.

That’s a different notion for sure and is acceptable.
That being said, this is a friendly learning environment and I respectfully gave my disagreement with his method. My number 1 pet peeve in medicine is immediate dismissal and hostility from colleagues - it’s not helpful at all. I remember being at an SIS conference, where one instructor said if your technic was slightly off in terms of needle, billing for an ablation procedure would be fraud. I just looked at the guy and said Cool man - I can’t stand that behavior.

 

[Ducttape]

do we have data to suggest that a steroid injection helps with sacral insufficiency fractures?

 

[lobelsteve]

The management of sacral stress fractures: current concepts - PMC

Sacral stress fractures are an unusual but curable cause of low-back pain that should be considered in differential diagnosis, particularly in elderly osteoporotic patients. Rarely, they may occur in young women during the last trimester of ...

www.ncbi.nlm.nih.gov

 

[ParaVert]

The management of sacral stress fractures: current concepts - PMC

Sacral stress fractures are an unusual but curable cause of low-back pain that should be considered in differential diagnosis, particularly in elderly osteoporotic patients. Rarely, they may occur in young women during the last trimester of ...

www.ncbi.nlm.nih.gov

10 year old article?

Most sacral insufficiency fractures only involve the ala and are easily cemented under fluoride using either a short axis or long axis approach parallel to the SI joint. I’ve done maybe 10 in 13 years of practice. Definitely under-diagnosed and underutilized technique.

 

[lobelsteve]

Sacroplasty is appropriate. But is it a covered service by CMS.
But that is not what was suggested as treatment.

 

[SommeRiver]

I see a lot of Medicare, and I get these on occasion. I do nothing but PT to comfort and meds.

 

[Agast]

Is there a required protocol to sacral insufficiency fractures before considering cement? Like 6 weeks of PT and some sort of bracing (not sure what you would brace but I don't want to make Medicare angry)

 

[SSdoc33]

Is there a required protocol to sacral insufficiency fractures before considering cement? Like 6 weeks of PT and some sort of bracing (not sure what you would brace but I don't want to make Medicare angry)

i dont know the answer but i suspect there is no "protocol". in 6 weeks, the fracture may be healed. also, broken bones don't like PT

 

[Agast]

i dont know the answer but i suspect there is no "protocol". in 6 weeks, the fracture may be healed. also, broken bones don't like PT

Ok, just comparing it to vertebral fracture treatment which I see more often. Strict protocols about trying and failing conservative measures first.

 

[SSdoc33]

Ok, just comparing it to vertebral fracture treatment which I see more often. Strict protocols about trying and failing conservative measures first.

no, i hear you.

do you send your vertebral compression fractures to PT?

 

[Agast]

no, i hear you.

do you send your vertebral compression fractures to PT?

Yes depending on how they look. There are specific PT exercise for patients with vertebral compression fractures to help protect the back.

 

[pmrmd]

Yes depending on how they look. There are specific PT exercise for patients with vertebral compression fractures to help protect the back.

Really? What are they? Fracture = brace and activity restriction until healed or I augment in my view.

 

[Agast]

Really? What are they? Fracture = brace and activity restriction until healed or I augment in my view.

Lumbar Compression Fracture

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www.physio-pedia.com

I've had patients do well with PT who hated wearing their brace.

 

[pmrmd]

When I had my L1 fracture the last thing I was going to do was exercise.

 

[Nodolor]

90% of pts I have seen don't tolerate Braces and it is obvious when I see them that they have not been wearing as most don't know how to don and doff it

 

[Orin]

Is there a required protocol to sacral insufficiency fractures before considering cement? Like 6 weeks of PT and some sort of bracing (not sure what you would brace but I don't want to make Medicare angry)

If I remember right last time I looked, sacroplasty is investigational/not covered most commonly