Sunday, April 20, 2008

Should I have Vertebroplasty or Kyphoplasty

I am frequently asked by patients and their families which procedure is best to fix vertebral compression fractures (VCFs). There are numerous procedures available, and the choices can be confusing. The good news is that almost all of these choices are 'medical miracles' that have success rates near 100% for pain relief. In experienced hands, any of these proven procedures can be a 'magic bullet' for VCF pain.

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.

Other Procedures
· 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

Why Do My Bones Hurt?

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

Some Causes of Osteoporosis

Osteoporosis is due to reduction in overall bone mass, resulting in weakened strength of bones. This leads to higher risk of fractures. Basically, the weaker the bone, the less able it is to hold up to high stresses. The reduction in bone mass can be caused due to many factors.

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.

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