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.



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