Sunday, December 21, 2008

NEW: Osteoporosis and Pain Support Forum

We're excited to announce that our Osteoporosis and Pain Support Forum is now up and running! Here you can post questions more easily.

This is currently a work in progress and is not available to our general internet viewers. However, for viewers of our blog, you are invited to beta test by registering and posting questions to the forums using this link:

Hope to see you there!

Thursday, December 18, 2008

If It’s A Back Fracture, Why Can’t We Cast It?

A vertebral compression fracture (VCF) is, indeed, a fracture. However, it is a very different fracture that that seen in other parts of the body. For example, with most long bones, such as the humerus or femur, a fracture usually occurs as a break into two or more pieces.

Although I am simplifying things when I tell my patients that this is like snapping a stick in two, that is a simple concept that most people can grasp. By contrast, though, a vertebral compression fracture is usually more of a crushing injury than a simple break. It is more akin to crushing a can with your foot. A better analogy is probably crushing a brick with a sledge hammer. The injury usually results in many small broken pieces that are harder to put together.

Also, vertebral compression fractures (VCF) are notoriously difficult to fix and usually have a hard time healing, compared to other fractures. The multiple pieces in these types of crush fractures are typically two small to put surgical in screws. Many talented surgeons have tried throughout the years to come up with an effective way to treat these fractures at surgery, but have failed.

Second, a key to healing a fracture is relieving the broken pieces from stress. If a fracture of the radius in two pieces starts to heal, and you pick up something heavy with your arm, it will often refracture. Then the process of healing has to start over again. An example would be using glue to put our broken stick back together. If we pick the stick up before the glue has set, then the other piece falls off.

Thus, most fractures are initially placed in a cast—to immobilize the fracture fragments and allow them to heal. If you have a vertebral compression fracture (VCF) and we were trying to put it in a cast, we would use a device known as a TLSO, or thoracolumbosacral orthosis. Commonly known as a back brace, a TLSO provides support for the spine and decreases weight-bearing forces. This stabilizes the spine and also decreases pain by physically redirecting axial loading forces from the spine to the pelvis.

Monday, December 15, 2008

Cervical Kyphoplasty

There are very few doctors who perform vertebroplasty or kyphoplasty in the upper thoracic or cervical spine. Luckily for our patients, we do.

This is a rotary kyphoplasty we performed today at the C7 vertebral body. This patient had suffered from the pain for over 7 years. It's another key example of a fracture that a radiologist called "old" or chronic, yet responds to treatment.
Due to potentially life-threatening complications, cervical fracture fixation is not to be taken lightly and should only be performed by experienced doctors. Although there are about 20 doctors in our area who have trained to fix fractures, only one or two of us perform them in the cervical spine. Who would you rather have fixing a fracture in your loved one?

Sunday, December 7, 2008

Vitamin D and Osteoporosis Medications

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.

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