Sunday, December 21, 2008
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Thursday, December 18, 2008
Monday, December 15, 2008
Sunday, December 7, 2008
Although we want to think that osteoporosis medications increase our bone density, it's very common for the bone density tests to stay the same on bisphosphonates such as Fosamax.
On an anabolic agent, like teriparatide (Forteo), bone density should almost always increase unless there is an underlying medical condition causing the bone loss (secondary osteoporosis).
For people on medicine for osteoporosis, the most common cause of continued bone loss is vitamin D deficiency. In children, vitamin D deficiency is called rickets, but it is called osteomalacia in adults. Unfortunately, if you have vitamin D deficiency, taking the 1000 IU vitamin D is not enough to overcome the deficiency in a timely manner.
For example, patients in our clinic with ricketts will get a 50,000 IU dose for 30 days and recheck the blood level. However, it's important to check the level before and during treatment. The National Osteoporosis Foundation recently increased their recommended daily intake of Vitamin D to 800-1000 IU for patients 50 and over. That includes all sources, so if you have vitamin D intake from foods such as milk and cheese, these count towards the total.
It's important to note that that is the recommended total amount needed to prevent deficiency in healthy adults. If you already have deficiency, you will need a higher dose.
Make sure that your physician checks your vitamin D level before you are started on any kind of osteoporosis medication. If you don't have adequate vitamin D, your body can make enough new bone to overcome osteoporosis. Although many labs use 30ng/mL as the lower limit of normal for a vitamin D level, it really should be 40 or more.
About 90 percent of the patients we see (most who have fractures) have osteomalacia (rickets in adults). Also, if you have continued decrease on your Dexa despite religiously taking your medications, you should have a comprehensive metabolic workup for secondary causes--that is, something else is usually going on and several blood and urine tests are usually needed to find out why.
Always consult your physician. I recommend finding a qualified physician in your area who has an interest in osteoporosis. Preferably they will be involved with the NOF or at least aware of its recommendations. You need the best team on your side to beat this disease.
Monday, October 27, 2008
As an example, in the last 6 months, I have treated three young men, between the ages of 35 and 42 years old. Although that's not the type of person we usually associated with osteoporosis, all three of these men had fragility fractures.
Why would they get this at their age? The answer might surprise you. All three men had vitamin D deficiency. That's right--osteomalacia, the same disorder that is known as rickets in children. A recent study reported at the American Society of Bone Mineral Research showed that 90% Canadian children had rickets.
What's more, most every patient with a fragility fracture that I treat also has vitamin D deficiency. These findings suggest that this disease is being seen in epidemic proportions.
Monday, October 20, 2008
While we want to think that these medications increase our bone density, it's very common for the bone density tests to stay the same on bisphosphonates like Actonel and Fosamax. However, when they stay the same or decrease on medical therapy, a search for underlying causes should be done. For people on medicine for osteoporosis, the most common cause of continued bone loss is vitamin D deficiency.
The National Osteoporosis Foundation recently increased their recommended daily intake of Vitamin D to 800-1,000 IU for all patients 50 and over. A study in 1997 documented that doses up to 2,000 IU are safe for adults.
Unfortunately, if you have vitamin D deficiency (also known as ricketts), taking the recommended 800-1,000 IU vitamin D is not enough to overcome it in a timely manner. Commonly, patients with ricketts be treated with a 50,000 IU pill daily for 30 days and recheck the blood level. It's important that your physician checks your vitamin D level before and during treatment. Although most labs use 30 ng/ml as the minimum normal level, it really should be 40 ng/ml or more.
About 90 percent of the patients we see (most who have fractures) have ricketts. Also, if you have continued decrease on your Dexa despite religiously taking your meds, you should have a comprehensive metabolic workup for secondary causes--that is, something else is usually going on and several blood and urine tests are usually needed to find out why.
Always consult your physician. I recommend finding a qualified physician who has an interest in osteoporosis. Preferably they will be involved with the NOF or at least aware of its recommendations. You need the best team on your side to beat this disease.
Tuesday, October 7, 2008
To understand why this is important, we need to talk about how amazing the bones that make up the skeletal system are. When we think of bones, we often associate them with long dead animals, like dinosaur bones in a museum. So, we tend to think that they don't change once we become adults.
In truth, however, our bones are actually living organs, just as vital to our survival as the heart or liver. Our bodies are constantly taking up old bone and laying down new bone in it's place.
Every cell in the human body requires calcium to function. From the beating heart to our muscles and nerves, if there isn't enough calcium, they cease to function. If the calcium levels in our blood get to low, the body takes calcium out of the bones to keep those levels high enough. When there is plenty of calcium in the blood, that is one of the factors that allows the body to lay down new bone using calcium.
Unfortunately, the average American diet has too little calcium. Vitamin D is also required for the body to absorb calcium from the gut (ie, from pills). If the body has too little vitamin D (also known as vitamin D deficiency or osteomalacia) the body can't absorb adequate calcium and--as a result--cannot lay down new bone.
Even if you took an entire bottle of calcium pills every day--which could kill you--if you don't have enough vitamin D in your body, you won't be able to use the calcium.
So how much vitamin D is needed? We'll talk about that on my next post, because there is a lot of controversy about that.
Tuesday, September 16, 2008
One of the questions that came up tonight was how do we know what causes back pain. While there are many different causes of back pain, most can be lumped into to groups--pain involving either the soft tissues or bone.
Pain from soft tissues can be due to muscle problems (spasm, strain, etc), intervertebral disc problems (disc tears, herniations, etc) and nerves (compression, nerve irritation, etc). Bone problems are usually due to arthritis (spondylosis, facet arthritis, etc) or fracture (vertebral compression fractures, etc).
Sometimes back pain is causes by both soft tissue and bone problems. It's important to remember that back pain can be caused by referred pain. When pain occurs because of disease in one area, but feels like it is in another, this is called referred pain. For example, back pain can be caused by arthritis in the hip or pain from the internal organs of the pelvis and abdomen.
Since there are so many different causes of chronic back pain, it's important to see a qualified physician who is skilled in the diagnosis and treatment of back pain. Only by reviewing your history and physical examination can a physician accurately determine the cause of your pain. Even then it usually takes imaging studies (such as x-rays and MRI) to confirm before effective treatment can begin.
Monday, September 15, 2008
Sunday, September 7, 2008
Please join us for this informative event. Call (918) 260-9322 to register for this FREE seminar.
Time: Tuesday, September 16th at 6:00 p.m.
Location: Citiplex Towers at 81st & Lewis
Complimentary refreshments will be provided.
Wednesday, June 11, 2008
I am often asked by patients "My doctor told me I had a fracture, but that it will probably get better." Sometimes the doctor will tell them that "there is nothing we can do for it." While it's true that some fractures will get better with conservative therapy, many do not. In my opinion, it is important to take into account the amount of pain and suffering the patient has before decided if and when to fix the fracture.
As far as there being "nothing we can do about it", that's hogwash--as my patients know. In fact, if you have pain from a vertebral compression fracture, we can take that pain away in nearly 100% of the cases. There are two reasons doctors would say there is nothing can be done:
1. They don't know about the procedure.
2. They don't have experience with the procedure.
First of all, there is a huge amount of new information bombarding everyone, including doctors, everyday. Although vertebroplasty and kyphoplasty have been around for several years, most doctors haven't had direct experience with the procedure.
There are other doctors who know about vertebroplasty and kyphoplasty for compression fractures, but who have limited experience with it. They trained in an era when there literally was nothing that could be done for vertebral compression fractures (VCF). They have practiced for years when there was no effective therapy. Many are experienced spine surgeons who see how poorly these patients do at surgery, but haven’t had experience with vertebroplasty and kyphoplasty. Why is this? Until recently, the only treatment for vertebral compression fracture (VCF) was bed rest and oral pain medications, and those don't work for all patients. But as we will see in the next post, even these conservative therapies can be dangerous for the patient.
Thus, there are effective treatments for VCF, but most doctors haven't yet seen how effective the treatment is first hand. If you or a loved one are suffering from the pain of a VCF, give us a call. We would love help or refer you to a doctor in your area who can.
Sunday, April 20, 2008
In general, these can be divided into vertebroplasty and vertebral body augmentation (VBA). Simple vertebroplasty is highly effective, however involves only placing a needle into the fractured vertebral body and injecting bone cement (PMMA).
Vertebral augmentation (VBA) goes a step further by creating a cavity in the body prior to stabilizing the fracture. This is usually done to try to 'lift' the fracture back into place, but can have other effects. One reason I prefer to use VBA is because it creates a cavity and disrupts the plexus of blood vessels in the vertebral body. As a result, this decreases the likelihood of cement leakage so that patients have better outcomes.
Although the most common form of VBA is known as kyphoplasty, there are several other procedures that accomplish the same thing (see below).
Common procedures to fix VCFs
· Vertebroplasty: Simply involves putting a needle into the fractured vertebral body and injecting bone cement (PMMA).
· AVA Flex: Uses an advanced flexible needle to create a cavity and deliver targeted bone cement.
· Balloon VBA (‘Kyphoplasty”): Uses a balloon to create a cavity and then deliver targeted bone cement.
· Allograft Bone VBA (“Spinoplasty”): Uses allograft bone in an implant to stabilize the fracture like a sandbag.
· Sacroplasty: Vertebroplasty technology is applied to fix painful fractures of the sacrum.
· Osteoplasty: Relieves pain from chronic and atypical fractures using the same technology as vertebroplasty.
There are many different factors that affect which procedure is best for your situation. Discussing this with your doctor is essential to make the best decision.
Saturday, April 5, 2008
Bone pain generally results in aching as well as pain and muscle spasm. For instance, in the case of arthritis, sensory fibers of the joint may respond to sympathetic activity due to inflammation. Most people know someone with arthritis. Sometimes the pain of arthritis is due to joint inflammation, but even this inflammatory response can cause bone pain.
Most body tissues, including bones, produce a number of chemicals and hormones that cause pain. Some examples are substance P, histamine and one class chemicals called prostaglandins. These are all associated with pain. Prostaglandins also play an important role in pain caused by bone metastases.
One of the most common reasons for bone pain is fracture due to trauma or osteoporosis. When normal bones are subjected to abnormal mechanical forces, a fracture can occur. Unfortunately in patients with osteoporosis, even normal mechanical stress can cause a fracture. This can result in disruption of the cortical bone and stimulation of the nociceptive (pain) nerve endings.
Although most people think of bone as a hard, unchanging tissue (like skeletons), our bones are living, active, changing organisms just like other organs. One reason fracture and other causes of bone pain hurt so much it of the exquisite nerve supply. Most of the nerves that cause pain appear to serve the periosteum.
The periosteum is the living, outer lining of bone that serves as a type of covering as well as a a type of anchor site for tendons and ligaments to attach to bone. When you pull a muscle or strain a ligament, much of the pain is associated with the stress on the periosteum and stimulation of the pain fibers there. This also is a factor in many forms of arthritis and the periosteum lines the bone up to the level of the joint.
As such, inflammation, fracture and even other pathological processes to which bone is subjected can result pressure changes which, in turn, results in bone pain. For example, during a bone marrow biopsy, a needle is placed into the marrow cavity and a sample obtained. This causes negative pressure (vacuum) that stimulates the pain fibers. In fact, this procedure is one of the most painful 'routine' medical procedures that we do. It's no surprise, therefore, that people with metastatic cancer or other bone pathology have so much pain.
Tuesday, April 1, 2008
One cause that can occur even in young patients is failure to deposit enough normal bone mass during development--that is, prior to reaching skeletal maturity. This can occur with many disease states, typically endocrine (hormonal) disorders.
After skeletal maturity (usually about age 25), many factors can decrease bone mass, including diseases that cause excessive resorption of bone, impaired bone remodeling. In all patients, decreased bone mass may be worsened by smoking, drinking excessive soda or coffee, poor diet, lack of excerise and steroid use.
Thursday, March 6, 2008
For ill or good, osteoporosis is often thought of as a disease of women. In fact, one of the major hospitals in Tulsa advertises osteoporosis as an area of focus at their women's health center. It's true that osteoporosis is more commonly seen in women, but why is that?
It comes down to math. Women get osteoporosis earlier and they live longer than men, in general. Let me explain.
Due to several factors, women present with osteoporosis at an earlier age--about ten years before men. For example, in my practice, women tend to present with osteoporosis and its related complications of VCF about age 65 and older. Men don't tend to present until they are in their seventies.
One reason for this discrepancy is overall bone density. Men tend to start out with high bone density than women. In the most simple terms, this is because men tend to be larger than women. While our bones are still growing, the body is actively laying down calcium and other bone minerals. This occurs until about age 25, after which the human body starts to lose bone density.
After that point, it's all downhill. The body slowly loses calcium rather than stores it. Although many factors can increase the rate at which we lose calcium, it is a part of aging. Some things that speed calcium loss are poor diet, lack of exercise, smoking, sodas and steroids.
So, although both men and women begin to lose calcium at this point, this reaches a critical level earlier in women. You can think of it like a savings account, where you have calcium instead of money--keep making the same small withdrawals and you run out over time. Since men generally have higher bone mass to start with, it takes them longer to run out.
Add to that, the fact that the life expectancy of women is typically several years longer than that of men, it's no surprise that we see more women with the disease.
Sunday, March 2, 2008
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Wednesday, February 27, 2008
The answer is they are never too old if the patient is symptomatic from the fracture. Of course, many fractures heal on their own. Also, many old fractures do not cause clinical symptoms because they have healed on their own. For patients that have an older fracture that still causes pain, however, VCF fixation is highly effective.
One of my favorite examples is a patient I treated during my fellowship at the University of Oklahoma Health Sciences Center. This was an otherwise healthy lady in her thirties. She had suffered a single level VCF at from a car wreck about fifteen (15) years before. This was at T12 (one of the most common locations for these fractures).
To be sure, I was skeptical. At this point, I had experienced a lot of success from treating VCFs with vertebroplasty and kyphoplasty. Up until now, though, we had always used MRI as the gold standard for which fractures to treat. This patient's vertebral body had an abnormal shape, but no other signs of a unhealed fracture on MRI. So, her MRI was considered negative.
Her neurosurgeon, however, felt that the pain was due to the fracture. After examining her, we agreed. She had pain that was the classic 10 out of 10 and was worse with axial loading, such as standing and transferring from chairs.
We treated that patient with kyphoplasty and she was pain free afterwards--her postoperative pain level was zero. Since then, I've treated numerous patients with so-called old or healed fractures. I have found that the success rate for VCF fixation is similar to that seen in other patients--nearly 100% success.
So if you or someone you know has an old fracture and your doctor has told you there is nothing that can be done--rest assured that it can be treated. For more information, contact us at firstname.lastname@example.org.
Wednesday, February 20, 2008
Friday, February 8, 2008
CEU credit for case managers is pending, so check back here for updates. We will let you know as soon as we receive official approval.
Sunday, February 3, 2008
Saturday, February 2, 2008
By day, I am a musculoskeletal interventional radiologist. I perform minimally invasive pain management procedures. Perhaps my favorite thing I do as a physician is fix vertebral compression fractures. This is done in a procedure that takes 20 minutes and has an astronomical success rate.
I hope that you can find some useful information here. If I can be of assistance, please let me know.
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