A letter to Michael Wolff of Vanity Fair

Mr. Wolff

I'm a busy physician and respect your writing. I hope that you'll appreciate the time I took to write this to you. I hope you can see a commonsense perspective that the vested interests in DC (both Dems and GOP) are missing.

I read your "I’ve Changed My Mind on the Obama-Fox Showdown" piece on newser.com. As an independent, I didn't vote for Obama, but I admire his concern for health care. And I think he has some good ideas. Of course the Republicans are all up in arms, but they had 6 years with a majority and never got a substantial bill to the table.

Yet, as a physician, I'm perplexed at why you would characterize the public revulsion to nationalized health care as 'perplexing'. Here's my opinion. It's because 'reform' is going the wrong way. It's not reform at all, but a government takeover. A better alternative would be increased government regulation and oversight.

You can cite polls to show public support for something, but this will vary based on how the question is asked. However, a stable trend this year has been seen in Gallup polls on this issue: 80% of Americans are happy (satisfied or very satisfied) with their current health care. A majority are concerned about the costs.

That begs the question of why we would want to muck up something that a super-majority are happy with? What we should be doing is fixing the costs--something that no bill that has made it out of committee in either house of Congress addresses. If you want to know what public opinion is, look at that poll. Most people are happy with their health care. The number one complaint I hear from patients is the cost of insurance. Number two is lack of access to care from my Medicare and Medicaid patients.

That's the essence of my argument. If you care to, please read on...

Everyone today thinks they are an expert in health care. I am an expert and certainly more of one than the people writing the bills. The public is rightly alarmed at what has been proposed as legislation this year. For example, HR 3200 was a slippery slope to a government takeover of health care. Why? If you look at that bill, it was crafted to force all employers with $400,000 or more in payroll to offer the public option or face a fine of 8% of payroll. Lots of businesses would be exempt, but it would move a large number of low wage earners into the public option.

Example: You're an employer like Walmart, McDonalds, etc. with mostly minimum or near minimum wage workers. So round their yearly pay to $20,000. Are you going to pay another $9,000-12,000 per year for commercial insurance, pay $1,600 for the public option or pay the fine. That's a no-brainer. Again, won't affect all workers, but it will entrench the public option (which will be a new entitlement).

In my opinion, what we need is increased regulation of the health insurance industry, rather than a government takeover of our multiple health care delivery systems. The federal government already has a proven track record in health care--a record of failure, namely 1) Medicare, 2) Medicaid, 3) VA and 4) IHS. Medicare and social security will both be bankrupt in the next decade. We don't have the funds to pay for our current entitlements and Congress wants to charge more to our national credit card? The worst part about the current Senate bill is it will add roughly 1 trillion to the budget, but it will still leave half of the currently uninsured still uninsured.

With the economic meltdown, people are realizing that politicians don't have all of the answers they say they do. They look at the bailout that was rushed through without anyone in Congress reading it. They see it hasn't worked where they live and now they see all the pork that was included in it.

There are many common sense solutions, most of which aren't even being discussed:

1. Tort reform--because the biggest driver of increase in expensive tests (other than shift in average age of population) is due to defensive medicine. However, this will probably never get passed since the vast majority of those in Congress are trial attorneys.
2. Make insurance providers compete across state lines--it's baffling that this hasn't been done.
3. Eliminate waiting periods--one of the largest chunks of people commonly lumped in as 'uninsured'.
4. Eliminate exclusion for preexisting conditions--duh.
5. Repeal nonprofit status for hospitals--these hospitals only provide <5% charity care, yet don't pay taxes due to nonprofit status.
6. Eliminate or reform Medicare D.

Thanks for your time.

Jim Webb, MD

More Smoke and Mirrors on Healthcare Reform

There is a current bill in the U.S. Senate, SB 1776, that is being touted as an "18 line bill" that would solve Medicare problems by repealing the Sustainable Growth Rate (SGR). This is being touted by the AMA and state medical associations as a good thing. Unfortunately, it's another game of smoke and mirrors in Washington with the AMA playing along.

What's the SGR?

The bill repeals the Sustainable Growth Rate (SGR) freezes physician payments from Medicare for the next ten years. The SGR is a flawed law that was passed by Congress many years ago to fool the taxpayers into thinking that Medicare funding isn't as bad as it really is--that is, so these fat cats can get reelected. By mandating cuts in physician reimbursement every year, on paper it looks like they are saving money.

On the other hand, these elected criminals vote every year to cancel out the reduction, leaving the payments the same. However, by the law, this decreases each year. This snowballs, such that this year it was scheduled to decrease 21%. Basically, this allows our congressional representatives to vote to prevent the cut so they look good. Yet, they still have this big accounting flaw right there. If you and I did that on our taxes, we'd be in prison.

Isn't the American Medical Association (AMA) the Voice of Doctors?

Most people don't realize it, but the AMA represents less than 20% of physicians nationwide and most of the membership is medical students and residents--that is, a significant amount of them aren't what we would call 'real doctors' yet. We don't know the number for sure, because the AMA won't release the information to the public, but it's estimated that they make up at least 1/3 of the membership.

These doctors in training join the AMA because they're told that the AMA represents physicians in America (and because they get discounted membership rates). That certainly isn't the case today, yet the mainstream media acts as if like the AMA in a unified voice for doctors.

When the media reports that the AMA is backing something, they spin it to imply that almost all physicians are backing it. Nothing could be further from the truth. When I was in medical school, the AMA faced a backlash when it tried to make money by selling it's logo for product placement on silly and unrelated things like kitchen appliances.

Earlier in the year, the AMA pledged its support for President
Obama's healthcare reform in return for a permanent SGR fix. For an organization that is supposed to have the best interests of physicians at heart, this was an utterly idiotic political move. This resulted in alienating many physicians that still were in the AMA. Several thousand more doctors left the AMA this spring after this fiasco.

The Real Reason Behind S1776

From what I have heard from my senators offices is that this bill was offered by
the democratic leadership to buy off the AMA--so that they would stop
pushing for medical malpractice reform.

Medical malpractice reform is probably the number one thing we could do to control healthcare costs. Our current healthcare crisis is largely due to increasing medical costs because of:
1. There are more older people on Medicare now than younger employed people paying into the system.
2. US doctors are forced to order many unnecessary, expensive and potentially harmful tests because of the out of control medical malpractice industry in our country. This is referred to as defensive medicine. As a radiologist I see defensive medicine being practiced on an hourly basis.


In conclusion, SB 1776, with it's patriotic looking bill number will be touted as a quick fix for Medicare physician reimbursement by the media over the next week. However, like most bills originating in Washington DC, it's a bunch of smoke and mirrors hiding yet another empty gesture.

Dr. Webb will be playing keyboards with the Persuaders tonight, Thursday October 8th, at the historic Cain's Ballroom in Tulsa. The concert starts at 7pm. Tickets are only $8 or $10 at the door. The concert features 6 local bands and is part of the Rock the 918 funderaiser for the Tulsa Area United Way. Hope to see you there.

For tickets, visit:
http://www.tauw.org
http://www.cainsballroom.com

What SHOULD Healthcare Reform Look Like?

This is such an important topic, I wanted to share with you, something a little off our usual topic. In my last post, I showed how the slippery slope in HR3200 will lead to a socialized healthcare system by mandating employers cover all workers
So don't let anyone tell you that this isn't socialized medicine. Any public option = socialized medicine by default.

However, we can't just attack the current plan without offering alternatives. So, here are my healthcare reform suggestions.
1. Let doctors write off their uncompensated care. Currently doctors are one of the only professions that can't deduct bad debt as ordinary business expenses. Limit the deduction so that primary care doctors have an advantage over specialists. That instantly solves care for the truly indigent.
2. Mandate that all insurance companies offer at least two tiers of coverage.
a. First tier is catastrophic health coverage, like it used to be. However, available to everyone, no preexisting condition exclusion.
b. Additional premium tiers for people who wan't Cadillac policies or don't want to pay copays (see number 4).
3. Let individuals write off the cost of their self-paid health insurance premiums.
4. Make non-indigent patients responsible to pay part of their expenses (ie, copays/deductibles). Currently we have people who don't pay a dime because their insurance has no copay. Yet, these same people have cell phones, cable TV, internet, new cars, etc. If you don't have to pay to take your car to the mechanic, you'll take it in more often. Same is true for healthcare.
5. Illegal aliens. They're not going away and account for a huge burden on our healthcare system. I suggest at least make them pay taxes and play by the same rules as we do. Maybe be grant them citizenship in return.
6. Make insurance portable between jobs to eliminate waiting periods for preexisting conditions when you change jobs.
7. Pass medical tort reform. States that have this have lower costs and have plenty of physicians. States that don't have physician shortages. For example, I have never been sued, but my malpractice insurance this year cost about $20,000. This would probably not pass Congress because most of them are attorneys, but it is the number one thing that could be done to decrease overall healthcare costs.
Why? Doctors order tons of unnecessary and expensive tests to keep from getting sued. It's sad but absolutely true. Let's say a doctor has a patient who has a 1/10,000 chance of having a serious but rare problem. If they don't order the test(s) there are plenty of attorneys advertising on television to take their case to court.
Oh, and illegal aliens can sue also, even though they may go to an ER and never pay a dime. I'm not bashing aliens, I'm just pointing out a major flaw in our current system.

Again both parties have their share of the blame. There are dozens of bills in congress that are more balanced (like Coburn's Patients First Act), but the democrats won't let them out of committee. The flip side is the republicans had a majority for 6 years and never brought anything up.

Health Care Reform

This is such an important topic, I wanted to share with you, something a little off our usual topic.

I'm not sure what you know or think you know about the current so-called healthcare reform legislation known as HR 3200. If you think that socialized medicine is the way to go, then that's your opinion. However, if you think that this bill is not socialized medicine, I respectfully beg to differ--and that's the entire point of this post.

HR 3200 will bring about socialized government run medicine in the United States. You will get the same shameful care that our returning heroes get at the VA. Know someone with Medicare or Medicaid? That will look like a walk in the park. Except now everyone will get it, except for members of Congress and the very rich.

The democrats and even Obama (depending on the day) are flip-flopping on whether this is a public option. Let me be perfectly clear: Any public option in this plan will lead to socialized medicine. Why?

A slippery slope in HR3200 as it stands makes it mandatory that all employers must offer the public option or pay 8% payroll tax (for companies with total payroll 400k +).

Giving insurance to all minimum wage workers would be great. However, look at it this way. Under HR3200, all minimum wage workers will be put into the government plan. Why?

If I pay someone $10 (we'll round up from minimum wage) and they work full time, they get paid $20,800 per year. My choices as an employer are to add them to our company insurance (mine is $10k this year) or pay $1,664 per year for them to be in the public option. What do you think the major low-paying employers like public schools, McDonalds, Wal Mart et al will do?

If you're a public school teacher and you make $30k per year, do you think your school district is going to give you the plan that costs $10,000 or $2,400 (a difference of 4x)?

What would you do as an employer? Pay $10,000 or $1,664 for each minimum wage employee?

So don't let anyone tell you that this isn't socialized medicine. Any public option = socialized medicine by default.

Again both parties have their share of the blame. There are dozens of bills in congress that are more balanced (like Coburn's Patients First Act), but the democrats won't let them out of committee. The flip side is the republicans had a majority for 6 years and never brought anything up.

Response to NEJM Articles

Last week, there were two studies published in the New England Journal of Medicine that posited that vertebroplasty is no more effective than a 'sham' procedure. One study was from the Mayo Clinic (Kallmes et al) and the other was from Australia. I'll focus on the former

I recommend the following analysis debunking the paper. My comments follow. http://www.prweb.com/releases/2009/08/prweb2727074.htm

Unfortunately, both studies have major flaws and it's pretty sad that they made it into such a prestigious journal. Unfortunately, that de rigeur for major medical journals--many of them end up publishing studies that have big flaws. It's also common for Medicare and private insurers to use studies like this to make determinations for coverage. Translation: the authors did their job poorly, yet patients may end up suffering as a result.

First, the suggestion that vertebroplasty doesn't work is simple nonsense. However, let me define this in terms that the authors didn't. Vertebroplasty is highly effective at fixing acute pain from vertebral compression fractures (VCF). It doesn't treat any other kind of back pain. Second, patients who get VCFs tend to get additional fractures.

Major problems:
1. Not enough patients. Not only did the studies fail to their target number of patients, too many patients declined to enroll in the study. Translation: the patients who were more likely to benefit from vertebroplasty went on to have vertebroplasty anyway because they didn't want the risk of having to continue living with the pain.
2. Poor patient selection/Wrong patients. The patients that were actually in the study had relatively low pain ratings. The typical patient I see rates their pain from 8-10 on a scale from 1-10.
3. Flawed sham procedure. What the authors describe as a sham procedure actually amounts to a facet block. This is relatively effective procedure for one of the most common causes of midline axial back pain. Take this and the relatively low pain ratings, it is likely that many of the patients had facet mediated pain and the sham procedure was actually a treatment for that.
4. Crossover. Patients were allowed to crossover after one month. Of the control/sham patients, almost half of them chose to have a vertebroplasty. Yet 88% of the vertebroplasty group patients chose not to crossover. This is consistent with previous studies showing efficacy of vertebroplasty around 85-95%.
5. Statistical significance. The authors state that there was no significant difference in pain levels after one month, but that the vertebroplasty group tended to have better pain relief at 3 months compared to the control/sham group. That is congruent with a positive result from a facet injection wearing off.

Summary
1. Patients who were more likely to benefit from vertebroplasty went on to have vertebroplasty anyway and weren't included in the study.
2. This was not a properly controlled-study; the sham procedure was essentially a facet block.
3. Almost half of the patients in the 'control' group eventually elected to have vertebroplasty.
4. 88% patients who had vertebroplasty were happy with the results.

Lastly, for those who have had patients who have undergone vertebroplasty or kyphoplasty, you know how effective the procedure is. I find it almost farcical that this paper was published in NEJM. However, this shouldn't surprise any of us as we are heading down a road toward increasing government interference in the doctor-patient relationship.

Next Tulsa Osteoporosis Support Group Meeting Announced

The Tulsa Osteoporosis Support Group has announced their next meeting for July 28th, 2009 at the Panera Bread at 71st and Lewis. The meeting will begin at 6:00 p.m.

Ms. Lisa Bates, the Clinical Director of Diagnostica Osteoporosis Center will be the featured speaker. Ms. Bates is actively involved with osteoporotic patients. She will be discussing the in's and out's of bone density (Dexa) scans. Come and learn why this crucial testing is so important for patients with and at risk for osteoporosis.

Free light refreshments will be provided.

Hope to see you there!

Vertebral Compression Fractures in the Aging Work Force

Join us for a presentation at the first inaugural CMSA of Northeastern Oklahoma Conference at the Southern Hills Marriott in Tulsa, Oklahoma on Thursday May 14th, 2009. Conference registration begins at 7:00 am.

Dr. Webb will be presenting a discussion titled "Vertebral Compression Fractures in the Aging Work Force" which looks at some of the issues involved in treating older workers with back pain.

National Osteoporosis Foundation Tulsa Support Group

The National Osteoporosis Foundation Tulsa Support Group is open to anyone affected by, or interested in learning more about, osteoporosis. Our first meeting will be an educational and support group meeting at 6:00 pm on Tuesday, May 26th at Panera Bread located at 6981 South Lewis Ave., Tulsa.

Anyone interested is welcome to attend. This support group is affiliated with the National Osteoporosis Foundation, but is fully independent and not allied with any particular physician or healthcare organization.

During our first meeting, we will discuss the support group and plans for the future. Our guest speaker for this meeting is Dr. James Webb, who will present on who gets osteoporosis and the factors that put individuals at risk. There will be time for discussion and a question and answer session along with informational handouts. Upcoming topics of interest include diagnosis and treatments for osteoporosis.

The meeting is free and open to the public. For more information, contact Lisa @ 260-9322. Please join us!

What: Tulsa Osteoporosis Support Group

Who: Anyone affected by or interested in osteoporosis

When: Tuesday, May 26th at 6:00 pm

Where: Panera Bread located at 6981 South Lewis Ave., Tulsa

May is Osteoporosis Awareness and Prevention Month

Here are five tips from the National Osteoporosis Foundation for improve bone health and prevent osteoporosis:

1. Get the daily recommended amounts of calcium and vitamin D
2. Engage in regular weight-bearing and muscle-strengthening exercise
3. Avoid smoking and excessive alcohol
4. Talk to your healthcare provider about bone health
5. Have a bone density test and take medication when appropriate

Bringing The Latest Research To Tulsa: Upcoming FDA Trials

We are pleased to announce that Dr. Webb has been selected to be a Prinicpal Investigator in two separate upcoming FDA clinical trials for different medical devices to treat vertebal compression fracture devices.

This means that our patients now have even more choices for the latest and most advanced technologies available for vertebral compression fracture management. These devices are only available for use by physicians participating in these trials.

For more information on the clinical trials, or to find out if you or loved one are eligible for enrollment in the trials, contact our research coordinator at Lisa@TulsaMSK.com

Reader Question: What Are Other Causes of Osteoporotic Fractures?

Question: I keep seeing that one cause of osteoporotic fractures is certain bone disorders. I have looked around and couldnt find any specific names of disorders.

Answer: Almost all vertebral compression fractures are due to either osteoporosis, trauma or tumors (metastasis or primary bone tumors like multiple myeloma). There, a combination of the above. However, almost anything else that weakens the bone can cause a VCF.

Certain medical conditions make osteoporosis worse. The result is that patients with these disorders, also known as secondary osteoporosis, started getting fractures earlier. The two most common causes of secondary osteoporosis that I see are 1) chronic steroid use and 2) vitamin D deficiency (osteomalacia).

Chronic medical steroid use is relatively common in usually seen in patients with painful arthritis, such as rheumatoid arthritis. It is also commonly used on chronic basis in patients with lung disorders such as pulmonary fibrosis and chronic obstructive pulmonary disease (COPD).

In addition to these causes, most patients that I see with VCF also have osteomalacia (vitamin D deficiency). Abnormalities in thyroid, parathyroid or androgen (testosterone/estrogen) hormones are also very common secondary causes.

The most common medication that causes osteoporosis is steroids, probably followed by seizure medications (dilantin, etc). There several nutritional factors that can alter calcium metabolism and cause or worsen osteoporosis. These include frequent or excessive soda intake (alters the bodies normal acid-base balance), impaired calcium absorbtion (crohn's disease, sprue) or decreased calcium or vitamin D intake (lactose intolerate, etc).

So Why Does Does a Radiologist Treat Osteoporosis?

Radiologists in general don't typically see patients directly. They spend most of their time interpreting imaging studies. The sterotypical radiologist spends their days in a dark room looking at x-rays.

Although that is true to some extent, interventional radiologists typically take a more active role in seeing patients and directing patient care. For example, as an interventional musculoskeletal radiologist, I see patients on a daily basis with vertebral compression fractures.

Like many radiologists, when I started fixing these fractures with vertebroplasty and kyphoplasty I sent them back to thier doctor, presuming that the primary care physician to take care of medical management of osteoporosis. After several years of experience, however, I began noticing that we would see patients back again and again. Their doctor never did get them started him on appropriate therapy.

My intention is not to bash primary care physicians (PCPs)--far from it. Actually, there are many reasons for this phenomenon. First, PCPs have less time than ever to do their job. Two big factors are pressures from HMOs and insurers to see more patients in less time and the sheer number of medications that the average geriatric patient is on.

Second, osteoporosis management is complicated and requires a high degree of sophistication and diligence in order to achieve satisfactory management. Try doing that in a five minute visit with a patient on 20 medications.
Yet, a recent industry study looked at a list of things a doctor needs to address with patients during a routine visit. Osteoporosis didn't even make it into the top 10.

We kept seeing our patients coming back with more fractures and never placed on medication. So, we took ownership of managing this disease in our patients. I have personally devoted lot of time and energy, including continuing medical education compromise management for my patients.

Of course, there are many capable PCPs who prefer to continue managing osteoporosis in their patients. However, there are many more who would appreciate our approach and actually prefer to let us handle this work for them.

Who Treats Osteoporosis?

Who do you see if you have a heart attack? A cardiologist. What if you have a brain tumor? A neurosurgeon. If you have osteoporosis? There is really no one right answer.

Osteoporosis is an unusual disease, in that no single medical specialist is considered the "go to" physician for treatment. If you find an osteoporosis specialist in your area, their medical specialty may vary: family practice, rheumatologists, endocrinologists, internists, nephrologists, orthopedic surgeons and radiologists. The reason for this is that osteoporosis is a complex chronic disease it has many underlying causes factors and manifestations.

Someone with uncomplicated located osteoporosis--that is, no fragility fractures--is often managed medically. Most commonly this is done by the patient's primary care physician such as a family physician, internists her OB/GYN.

If they have a hip fracture, then they will likely see an orthopedic surgeon. Or, they may see an interventional radiologist for a vertebral compression fracture. But often these physicians may not treat the underlying medical cause.

Other times, the patient have osteoporosis secondary to medications they are on or medical conditions they suffer from. For example,rheumatologists often see patients on chronic steroids for rheumatoid arthritis or other painful joint conditions. Likewise, nephrologists often see patients with chronic renal failure which is a cause of osteoporosis. In these situations, this particular physician see a large number patients with osteoporosis and therefore treat the disease.

There other physicians who take an interest in managing osteoporosis due to the large volume patients that they see with this condition. For example, in my community many OB/GYN and women's specialists as well as myself see patients with osteoporosis.

Radiologist don't commonly treated patients with osteoporosis. In my next post I will discuss why we began this treatment.

Pain After Vertebral Augmentation

Vertebroplasty is effective at relieving pain for vertebral compression fractures. However there are some situations and which patients will continue to have pain afterwards. Which is commonly in 3 sets of patients.

The most common cause of residual back pain after vertebroplasty or kyphoplasty is incisional pain. This is usually mild and self-limited. With any procedure, even minimally invasive procedures, patients should expect some pain after the procedure due to the incision. However with vertebroplasty and kyphoplasty most patients don't even notice or report incisional pain. Patients who are the most at risk for having postoperative incisional pain include those on chronic narcotic medications such as Lortab, Percocet, Fentanyl or methadone. Even with these patients, however it is unusual for incisional pain the last more than one week.

A second cause of residual pain after the procedure is untreated fractures. Unfortunately, Medicare and most insurance companies will only let us fixed 1 or 2 fractures at a time, even in patients that have multiple fractures. Although this goes against common sense, unfortunately it is status quo. If we are unable to treat all of your fractures the first time, you can return for treatment at a later time--typically a few weeks.

A third common cause of pain after these procedures is pain that is unrelated to fractures. This would include pain due to chronic arthritis, disc bulges and other nonfracture spinal disorders. This also includes pain due to causes outside of the spine.

For example, hip pain commonly presents as back pain. Likewise, disease in the chest, such as pneumonia, can present as back pain. Although this can be problematic, these types of pain are typically not as severe as fracture pain.

It's important to speak with her physician if you experience any residual pain after the procedure. That way you and your physician can work together to find a solution to your problem and properly manage your pain.

Pain after

I have a vertebral compression fracture (VCF)--what can be done?

Until recently, conservative therapy (bedrest and pain medications) was the only option for treatment of vertebral compression fracture (VCF) until recent development of a procedure known as vertebroplasty.

Since then, vertebroplasty and other procedures that fix these fractures have been developed, including kyphoplasty. Virtually all of these procedures have a high success rate for pain relief. They can also be safely performed by experienced doctors even in patients that are not candidates for surgery.

This is especially helpful since many patients with a VCF are older and more prone to having chronic diseases such as hardening of the arteries and lung disease. These diseases can increase a person's risk of serious complication during major surgery. Vertebroplasty and kyphoplasty, however, are minimally invasive procedures that can be done with intravenous (IV) sedation rather than general anesthesia.

What's Bone Cement-Part I

We get a lot of different questions from our patients about bone cement that is used to fix painful VCFs. While an exhaustive explanation is beyond the scope of this blog, I am going to answer some of the most common questions we get.

What is bone cement?
Also known as bone glue, the material we commonly call 'bone cement' is a polymer called polymethylmethacrylate, or PMMA for short. This is made from mixing a powder and a liquid together in the operating room. This forms a paste that quickly hardens up in about 15-25 minutes. It starts out thin like cream, then gets thicker, like toothpaste by the time it's used in the body. Then it gets as thick as modelling clay toward the end of the procedure. By the time the procedure is over, the PMMA is hardened to a consistency just harder than bone.

Can I melt the cement if I use a heating pad?
No, once the bone cement sets up it's that way forever.

Can I break the cement by certain activities?
No, I've never heard of anyone breaking their cement. Rarely, a patient may have another fracture at a treated level, but it's usually in severe osteoporosis and not usually related to a known cause.

Does the cement dissolve over time?
No, there is no evidence that the cement dissolves or dissipates over time.
Can the cement leak into the body?Once it sets up (by the end of the procedure) the answer is no. During the liquid state, it can leak lots of places. This is usually only an issue if a large amount leaks into the veins or by the spinal cord or nerves. Careful observation during injection is required to avoid this.


I've heard bone cement heats up; can it burn you?
When the PMMA hardens, it gives off heat. This is a common chemical phenomenon known as an exothermic reaction. If there is cement in contact with nerves, for example, it can cause irritation, however, this is very rare. Actually, the heating process has been theorized as one cause of pain relief.


That's it for now. As we get more questions we'll post them here, as well as on our FAQ at www.tulsamsk.com

Who Should Fix My Fracture? (Part 2 of 2)

Recap

In the last post, we talked about differences in training that different doctors receive. Many doctors go to a weekend course to learn the procedure--and they may have never actually treated a live patient before they operate on you or a loved one. So, it's important to check their credentials out.

In this post, we'll talk about how ongoing experience affects performance with doctors. We'll also include a list of questions that you may find useful to ask your physician.

Ongoing Experience

There are variable amounts of experience for fracture care. Some doctors read articles in medical journals about these procedures. Others write those articles. Some doctors try out new procedures to fix the fractures. Others are involved in the research and development stage before these procedures are available for most doctors to 'try out'.

For example, in the Tulsa metropolitan area, there are at least 15 doctors who are trained to perform these procedures. That may sound like a lot, but several only trained and rare perform the procedure. The majority may do 1 or 2 cases per month. Out of those doctors, there are probably only three or four of us who treat 10 or more cases a month consistently.

Summary

Although we would be delighted to help everyone with their fractures, we realize not everyone can travel to Oklahoma to have their VCF fixed.

As you can see, there are a lot of factors to consider when choosing a physician for VCF treatment. So, to help, here is a list of questions to ask your doctor to help you decide.

1. What kind of training did you receive to treat these fractures?

2. How many fractures have you treated?

3. How many fractures do you treat per month?

4. When was the last fracture you treated?

5. What is your success rate at treating fractures?

6. Have you ever had any serious complications with a patient?

7. Do you test for and treat underlying conditions (such as osteoporosis)?

Who Should Fix My Fracture? (Part 1 of 2)

There are many doctors who perform vertebroplasty or kyphoplasty. They have different levels of experience in dealing with vertebral compression fractures (VCF). There are two areas where the degree of experience is important: training and ongoing experience.

Training

Most of the doctors who perform vertebroplasty or kyphoplasty learned how to do these procedures at a weekend course. That is, they went to a course, usually sponsored by a device company, where they attended some classes, then did the procedure on cadavers.

Others have had more extensive training, such as a fellowship. For me, I did a fellowship where treated over 100 live patients with these procedures.

In my next post, we'll talk about other factors in selecting a doctor for fixing fractures, including ongoing experience. I'll also include a list of questions to ask your doctor to help see if they are the right doctor for you.

Digg Question: Spinal Fracture

We received this question from a Digg user:

My mother got a compression fraction of a lumbar vertebrae last July. She has constant pain but was told there is no treatment. She is 92. She also has 2 old vertebral compression fractures. Would she be a candidate for spinoplasty?

If her doctor thinks her pain is due to the fractures, then yes, she is a candidate for fixation. We routinely perform vertebroplasty, kyphoplasty and even spinoplasty in patients over 100. This can be done even if the patient has severe medical disease, such as heart disease, stroke or diabetes. This is a significant advantage of these procedures because they do not require general anesthesia like major surgery does.

The interesting part of the question is spinoplasty. In experienced hands, spinoplasty is effective, however, it is not currently performed by many doctors. Personally, I performed the first spinoplasty in Tulsa. However, I have lately done more cement procedures because they cost the patient less and are essentially 100% effective at taking away pain.
read more digg story

Gift Basket Winner!

Thank you to everyone who stopped by our booth at the Tulsa Women's Living Expo. It was great to meet so many of you. Congratulations to Jean McDonald who was the lucky winner of the gift basket giveaway!

We are in the process of forming an Osteoporosis Support Group in cooperation with the National Osteoporosis Foundation so check back as we will be posting details here in the next few weeks.

Dr. Webb Speaking at the Tulsa Women's Expo

If you're planning on attending the Tulsa Women's Expo (see previous post) on Saturday, make sure you're there at 11am. Dr. Webb will be speaking about Osteoporosis on the Lifestyle Stage.

The Lifestyle Stage is located immediately to the right from the main entrance to the QuickTrip Center. Admission is $5 at the door with hundreds of vendors. Hope to see you there!

Tulsa Women's Expo

Come on out to the Women's Expo at the Tulsa Fairgrounds. We are located at booth 219, near the main stage in the QuickTrip Center. This is the building that has the golden driller in front of it.

While you're there, chat with our staff and be sure to sign up for our free gift basket drawing. There is plenty of free information about osteoporosis at our booth, as well as numerous freebies!

What's the time limit on fixing fractures?

I am amazed at the number of times this question comes up. I hear it from patients, I hear it from family doctors. I even hear it from experienced spine surgeons.

The answer is simple enough. There is no time limit on fixing vertebral compression fractures. Even if the fracture is 20 years old or older, as long as a patient has back pain and your physician thinks that pain is from the fracture, it will almost always respond to therapy.

In the medical literature, older fractures have documented success. In one study that looked at patients with chronic fractures, 70% of them got essentially complete pain relief from vertebroplasty. In my experience, the success rate is even higher.

The more significant question to ask is this. If a patient has back pain and has a fracture, why wouldn't the doctor treat it using proven therapy such as vertebroplasty? It certainly costs a lot less than having surgery. Unfixed vertebral compression fractures are a known cause of so-called failed back surgery syndrome (post-laminectomy syndrome). Unfortunately, this is a fact lost on a lot of spine surgeons, as I continue to see patients get fusions for these fractures when vertebroplasty is more effective.

What is Radiology?

Radiology is one of the broadest fields of medicine and encompasses diagnostic and interventional radiology. Diagnostic imaging are tests used to detect and monitor disease states in the body. This includes x-rays, computed tomography (CT or CAT scan), MRI, ultrasound, nuclear medicine, mammography and PET, among others.

Interventional radiology focuses on therapeutic use of imaging, mainly using x-ray, CT or ultrasound guidance to perform minimally invasive procedures. The goal of interventional radiology is to treat or cure diseases with less invasive procedures, in order to avoid major surgery. This includes angiography, biopsies, stents, drains, vertebral augmentation, interventional pain procedures among others.

To learn more or to ask a question, visit our discussion board at www.tulsamsk.com/forum.

Help! My Bone Density Is Decreasing On Forteo...

I recently received a question from an out-of-state patient whose bone mineral density did not improve after the first year of Forteo. It's uncommon for bone density to not improve on Forteo, however, in this post, I'll list some common reasons we see in our patient population. This is meant to clear up confusion rather to provide medical advice--always speak with your physician.

Common Causes
Here are a couple of common causes of this problem, from my experience.

1. Unknown cause (idiopathic): First of all, sometimes we can't identify a reason. Despite appropriate evaluation and follow-up, bone density doesn't increase on teriparatide (Forteo).

2. Secondary osteoporosis: When we do identify a cause, however, one of the most common reasons we see patients who don't improve with teriparatide (Forteo) therapy is an underlying medical disorder, usually severe vitamin D deficiency. There are upwards of twenty other medical causes--anything from hormonal imbalance to idiopathic hypercalcuria.

3. Other Medications: Another commonly identified cause is a drug interaction or side effect. Some diuretics can directly cause calcium loss through the kidneys. This is very common with loop diuretics, such as furosemide (Lasix), and bisphosphonates, such as Fosamax and Actonel, basically kill off osteoclasts--the cells that take up old bone (by contrast, osteoblasts are the cells that lay down new bone). In this case, it can take a while for the osteoclasts to be replaced after the bisphosphonate is stopped. From a biological standpoint, different people seem to react to the above issues differently.

4. Nutrition/Absorbtion Causes: Sometimes the cause is basic nutrition--patients may not have adequate calcium or vitamin D in their diets to lay down new bone. Some medications can decrease absorbtion of these nutrients. In addition, certain inflammatory gastrointestinal conditions, such as Celiac disease or nontropical sprue can cause malabsorption, leading to deficiency of vitamin D (among other things). This can also be a problem after gastric bypass, although this is not commonly seen (most bypass patients are younger than osteoporosis patients).

What Can You Do To Help
It's important to at least check a vitamin D level before STARTING Forteo, but this guideline isn't always followed. Unfortunately, I have seen two patients in the last year who continued to lose or didn't improve after even two years. Both patients had vitamin D deficiency--apparently their doctor (not me) didn't check the level before they started.

In summary, though it's common to not change or continue to lose measured bone density after other therapy, it's uncommon to not improve in after the first year of Forteo. If this should occur, it should definitely prompt an investigation by your physician.

What Is A Radiologist?

There is a common misconception among patients about what a Radiologist does. Because of unfortunately similar names, many patients think that a radiographer (0r x-ray tech) is a Radiologist.

A radiographer (x-ray tech) typically undergoes between 2 and 4 years of training after high school. By contrast, Radiologists, or Radiology Physicians, are doctors who have undergone at least 13 years of specialized medical training.

For example, after high school, I completed 4 years of college, another 4 years of medical school. Then I completed ACGME-accredited training including one year internship in Internal Medicine, four years of Diagnostic Radiology residency and a one year fellowship in Musculoskeletal Radiology. If you're counting, that's 6 years of training even after completion of medical school.

It's interesting to note that the one year of internal medicine is a full third of the post-graduate training an Internist receives. Very few specialties--such as neurosurgery and cardiovascular surgery (typically one more year)--have longer training times. For Radiologists, such as myself, who perform minimally invasive spine procedures, we actually have the same number of years of post-graduate training that most orthopedic spine surgeons have.

Many doctors receive some limited training to interpret imaging studies in their training. Often, this training consists of a month or two of formal training, whereas Radiologists receive--at a minimum--48 months of formal imaging training. So while your OB/GYN may be able to read an ultrasound or your orthopedic surgeon may read your x-rays, a Radiologist is the doctor that is the most qualified physician to interpret any and all medical images (such as x-rays, MRI and CT) to diagnosis and treat medical disorders.

Interventional Radiologists (such as myself) also treat patients with minimally invasive procedures. Even Radiologists who don't directly treat patients (Diagnostic Radiologists) still play a critical role in your medical care. Radiologists are often able to detect problems early using imaging and are able to provide an accurate diagnosis to your physician.

It's certain that as the number of minimally invasive procedures and technologies grow, that Radiologists, such as myself, will continue to play an increasingly significant role in other aspects of your medical care.

Is it dangerous to treat fractures conservatively?

Until recently, conservative therapy (bedrest and pain medications) was the only option for treatment of vertebral compression fractures (VCF). With recent developments of procedures known as vertebroplasty and kyphoplasty, this has changed.

These procedures have a high success rate for pain relief, approaching 100%. Yet, unfortunately, a lot of doctors and insurance companies haven't changed. They're ignorant of how amazing these procedures really are.


Although some fractures will heal on their own, most that aren't better in 2-4 weeks will continue to have at least some pain associated with them for months. By treating patients conservatively in the beginning, we give them a chance to heal the fracture on their own.



Many patients, however, have other factors--such as endocrine imbalances or vitamin D deficiency--that can impair thier ability to heal the fracture.



Also, immobilization, or being stuck in bed can cause rapid deterioration of health and can lead to various complications. The most common complication I see is muscle wasting, or deterioration of the muscles. This leads to weakness, decreased exercise tolerance and even makes patients more prone to developing back strain (injury to the muscles).



The most feared, and often fatal, complication of immobilization is pulmonary embolism or PE. A PE results from formation of a blood clot in the leg that breaks off and travels to the lung. Other common complications include bedsores, malnutrition, and depression.



The other mainstay of conservative therapy is pain medications. Many patients don't like to use the medications because they may feel drugged or they are afraid of getting addicted to the drugs. Although there is some risk, most patients who take them as prescribed will not get addicted. The most common complication for pain medications in the elderly is constipation, which can be serious.



The good news is that for patients with a VCF, vertebroplasty and kyphoplasty can also be safely performed by experienced doctors even in patients that are not candidates for surgery. This is especially helpful since many patients with a vertebral compression fracture (VCF) are older and more prone to having chronic diseases such as hardening of the arteries and lung disease. These diseases can predispose a patient to serious complications during surgery.



Contact us for more information at info@tulsamsk.com or post a question on our message board at www.tulsamsk.com/forum.