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