VCF referred pain revisited

[SIIMS]

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I've posted on the topic before but it keeps coming back up

82 year old tough as nails german lady that is a patient of mine previously for c-spine

saw her today now 2 months s/p acute hospitalization for severe low back pain, axial, L-S junction right >left, constant worse with ambulation (don't know why she went so long without follow up)

MR T-L and Pelvis done in hospital reviewed, acute VCF T12 (30-40 loss in height, inferior endplate, edematous on STIR) No other old or new fx's

The rest of her spine looks like her C-spine..... very degenerative, mild Central stenosis all levels, NF stenosis severe most levels, SI arthritic, hips arthritic, facets......

Put in brace after discharge and can't wear it cause it "pinches", Percocet etc. still with severe limiting pain, avoiding ambulation ADL's etc. (PT put in notes that pain is still limiting factor)

Exam today, no focal neuro problems, ABSOLUTELY NO pain on palp/percussion around T12 including love taps from my hammer, all her pain is Lumbosacral junction bilat, didn't bother with other provoc. maneuvers as she is painful with just standing.

No serious episodes of back pain before admission despite that degen. spinal disease brewing for about as long as I've existed (no history of neuroclaud., radic, etc. previously )

Can't think what else would cause that kind of pain that required hospitalization and is still persisting to this degree

Anybody else putting cement in that fracture because I don't know how to proceed at this point ??

 

[lobelsteve]

I've posted on the topic before but it keeps coming back up

82 year old tough as nails german lady that is a patient of mine previously for c-spine

saw her today now 2 months s/p acute hospitalization for severe low back pain, axial, L-S junction right >left, constant worse with ambulation (don't know why she went so long without follow up)

MR T-L and Pelvis done in hospital reviewed, acute VCF T12 (30-40 loss in height, inferior endplate, edematous on STIR) No other old or new fx's

The rest of her spine looks like her C-spine..... very degenerative, mild Central stenosis all levels, NF stenosis severe most levels, SI arthritic, hips arthritic, facets......

Put in brace after discharge and can't wear it cause it "pinches", Percocet etc. still with severe limiting pain, avoiding ambulation ADL's etc. (PT put in notes that pain is still limiting factor)

Exam today, no focal neuro problems, ABSOLUTELY NO pain on palp/percussion around T12 including love taps from my hammer, all her pain is Lumbosacral junction bilat, didn't bother with other provoc. maneuvers as she is painful with just standing.

No serious episodes of back pain before admission despite that degen. spinal disease brewing for about as long as I've existed (no history of neuroclaud., radic, etc. previously )

Can't think what else would cause that kind of pain that required hospitalization and is still persisting to this degree

Anybody else putting cement in that fracture because I don't know how to proceed at this point ??

How about put cement in the fracture cause she hurts despite conservative care.

Look at your last thread:

http://forums.studentdoctor.net/showthread.php?p=11906299#post11906299

 

[SIIMS]

How about put cement in the fracture cause she hurts despite conservative care.

Look at your last thread:

http://forums.studentdoctor.net/showthread.php?p=11906299#post11906299

I read the last thread, I read the article..... thanks, no one else seemed to have an opinion either way on the last thread, just that they have appreciated this same scenario before, I was looking for a little anecdotal support in addition to the 6 out of 64 patients in the korean study that fit a type c pain referral pattern from a T12 VCF

Any other opinions, certainly I'm just trying to do right by this patient......would you try fixing the fracture, in the patient presented, before you pursued more focal therapies where she feels her pain??





Would you mind elaborating

 

[Ducttape]

Steve, you seem very pro-kyphosis for these VCF patients. On the other hand, I am hearing from my spine surgeons, one of whom did a grand rounds recently, that these procedures are no better than placebo...

I know some of the lit out there. Honestly, what is your success rate?

Currently, I'm TLSO'ing them, mild opioids, and RFA median branches ATM...

 

[lobelsteve]

Steve, you seem very pro-kyphosis for these VCF patients. On the other hand, I am hearing from my spine surgeons, one of whom did a grand rounds recently, that these procedures are no better than placebo...

I know some of the lit out there. Honestly, what is your success rate?

Currently, I'm TLSO'ing them, mild opioids, and RFA median branches ATM...

Spine surgeons: is there a different pubmed for them? Do we not treat the same patients?

My results are fantastic. I fix fractures that are acute VCF, mostly due to osteoporosis, between T7-L5. Patients fail opiate, Miacalcin, bracing, and 2-3 weeks minimum time from fracture. Once past 4 months I dissuade patients from kypho/vert and try MBB.

I saw one patient yesterday whose Fx was in August and pain is 3/10. Her fracture went from 10% to 90% compressed between August and October. She is pissed because her spine surgeon did not fix it and now she is shorter and afraid to garden as she does not want another Fx. MBB and Forteo. Saw another patient back 2 weeks post-Fx yesterday and 3/10 pain off dilaudid and wearing a brace, using Miacalcin. Now getting Prolia.

To say VCF aug doesn't work is just plain stupid. See what the NAS guys said after Kalmes crap study came out:

http://dl.dropbox.com/u/35727246/NASSComment_on_Vertebroplasty.pdf

 

[facets]

no pain over the fracture, pain over the si joint?
any fracture is associated with facet and SI syndrome, see anatomy
before putting cement in try mbbb l4 l5 si s2 maybe s3 for fun (u wont get paid anyway) if her pain is gone rf. the literature showing increasing risk of fracture at adjacent levels that have cement concerns me. If no relief with mbb, then no harm, u can still v plasty but u will feel like an ass if u v plasty a non tender area and she still hurts

 

[lobelsteve]

no pain over the fracture, pain over the si joint?
any fracture is associated with facet and SI syndrome, see anatomy
before putting cement in try mbbb l4 l5 si s2 maybe s3 for fun (u wont get paid anyway) if her pain is gone rf. the literature showing increasing risk of fracture at adjacent levels that have cement concerns me. If no relief with mbb, then no harm, u can still v plasty but u will feel like an ass if u v plasty a non tender area and she still hurts

Adjacent fracture data:

If you want increased fracture risk, put in more cement and restore height more.

http://journals.lww.com/spinejournal/Abstract/2012/02010/Subsequent_Vertebral_Fracture_After.5.aspx

If you want no increased risk then:

http://onlinelibrary.wiley.com/doi/...nticated=false&deniedAccessCustomisedMessage=

 

[facets]

Vielen Dank, Herr Lobel

 

[PMR 4 MSK]

It would not hurt to try some diagnostic SIJ or facet/MB blocks before cementing.

 

[Tenesma]

i see this quite often T12/L1 fractures - get treated with Kypho and they still have LBP --- they end up getting SI joint or lower lumbar facet injection, with great relief... I almsot wonder if the fracture and kyphotic change/angulation, causes some type of muscular/tendinous strain in that area???

 

[SIIMS]

Thanks for the replies

I'm going to start with the standard for the lumbosacral area in an 80 year old with spondylosis at every possible lumbar level.

Her fracture is edematous on STIR in the inferior endplate without significant angulation or deformity and I still wonder despite all her degen. changes how she landed in the hospital acutely without any other lumbar pain prior to that event that has persisted for two months despite bracing and analgesics, just doesn't smell right unless its fracture pain

If the above fails I am going to vertebro and I will let you all know how it goes


With that in mind I have seen two patients with almost the same findings in the last one month, both with VCF at T12 treated with brace and analgesics, both now have osteonecrosis of the vertebral body with nothing holding the posterior VB from jamming back into the cord, one with deficits on exam and the other without

One is still being worked up, the other is going for a corpectomy, just food for thought

 

[lobelsteve]

83 yo male. Brought from snf by daughter and wife. 4 week old L3 fx with no retropulsion. Chronic 16mm L5 on S1 listhesis. Mild pain prior to fx. Fall 4 weeks ago with 3 day admit for pain control then turf to snf for pt/OT. Saw wife 1 week ago as new patient. C/o husbands pain more than hers. He got no brace, no procedure, no miacalcin. Just 7.5 hydro and snf stay. Told family to bring me images and I'd see what I could do to help.
Images favorable. No consult. Just kypho'd today due to failure of last 4 weeks. Unipedicular and 8cc infused. Threw on free esi for L5-S1 and right butt pain due to exac of pars area. Pain free in recovery. Made daughter, wife, patient cry. Wished they hadn't wasted the last 3 weeks.

 

[facets]

Yes I have noticed this also. there was an article in one of the journals about this about a year ago, with photos and a great explaination. Basically any force bad enough to break a vertebra will destabilize the facets.

i see this quite often T12/L1 fractures - get treated with Kypho and they still have LBP --- they end up getting SI joint or lower lumbar facet injection, with great relief... I almsot wonder if the fracture and kyphotic change/angulation, causes some type of muscular/tendinous strain in that area???

 

[PinchandBurn]

83 yo male. Brought from snf by daughter and wife. 4 week old L3 fx with no retropulsion. Chronic 16mm L5 on S1 listhesis. Mild pain prior to fx. Fall 4 weeks ago with 3 day admit for pain control then turf to snf for pt/OT. Saw wife 1 week ago as new patient. C/o husbands pain more than hers. He got no brace, no procedure, no miacalcin. Just 7.5 hydro and snf stay. Told family to bring me images and I'd see what I could do to help.
Images favorable. No consult. Just kypho'd today due to failure of last 4 weeks. Unipedicular and 8cc infused. Threw on free esi for L5-S1 and right butt pain due to exac of pars area. Pain free in recovery. Made daughter, wife, patient cry. Wished they hadn't wasted the last 3 weeks.

It's great that it worked out.

Question, assuming this fracture is d/t osteoporosis so acutely, is it a good idea to give steroids (ESI), in light of this? Or do you think doing a unilateral L4 and L5 MBB and then RFA (w/o steroids) for the buttock pain?