Does Kyphoplasty Cause Adjacent Level Fractures?

One of the most frequently asked questions I hear about vertebral fractures is this. Does placement of bone cement via vertebroplasty or kyphoplasty make the adjacent level more likely to fracture? This is a medical 'old wives tale' that is generally propagated by people who aren't familiar with these procedures.

Those who think bone cement causes adjacent level fractures usually suggest that it makes the fixed vertebral body harder that the adjacent level vertebrae. What people fail to consider is that the intervertebral disc acts as a cushion, dampening forces as the spine is loaded.

Theorhetically, if a disc is severely degenerated (end-stage intervertebral osteochondrosis), we might be transmitting forces directly across to the next vertebral endplate. However, I rarely see that severe of disc disease in osteoporotic patients.

I have seen several well-funded studies that have tried to prove the old 'adjacent level fracture' myth. All have tried and failed. A couple in particular have compared traditional vertebral augmentation using PMMA with that done using 'softer' material such as morselized (ground up) bone graft or osteoconductive material. None has shown an increased rate of adjacent level fractures with PMMA.

Still, when a patient comes in with a fracture and they get PMMA, then next time they have a fracture, they often fracture at an adjacent level. The reason is simple--biomechanics.

Biomechanical Causes Of Adjacent Level Fractures
The first reason that patients tend to fracture at an adjacent level is because most vertebral fractures due to osteoporosis occur between the T11 and L2 levels, most at T12 and L1. Hence, when a patient has a T12 or L1 fracture (the most common areas), the next fracture they have tends to be at an adjacent level because that's where they usually happen anyway.

Second, for someone who has a significant compression fracture, particularly an anterior wedge fracture, there is generally anterior shift of the center of gravity due to increased kyphosis. This results in redistribution of weight anteriorly (relative to before) along the anterior column.

Similar to the femur, when load-bearing stresses change in location, bony remodeling occurs to better allow the bone to bear that load. In patients with metabolic bone disease, such as osteoporosis, the speed of remodeling is impaired. As a result, the weight is shifted anteriorly, where the supporting vertical trabeculae are weaker. Thus, a fracture is more likely to occur here. This partly explains why most osteoporotic VCFs are anterior wedge in morphology.

Third, when there is an increase in kyphosis, the gravity creates a vector force due to the weight of the entire upper body being shifted anterior relative to the spine below the fracture. This increase in angular momentum and force meet at the fractured vertebral body (which serves as a fulcrum). This is the reason fractures tend to continue to collapse with time. The immediately adjacent vertebral bodies are also closer to the fulcrum and recieve a higher force/stress than vertebral bodies further away.

Summary
The result of all of this is that when a patient gets one VCF, they tend to get additional VCFs. These new VCFs tend to be next to the affected vertebral body for a variety of reasons--and this happens whether the initial fracture has been fixed or not.

The picture above is a great, practicle example. This patient developed a T12 fracture that was not treated. She now has presented with an adjacent level endplate compression at L1--note that it is at the superior endplate and closest to the fulcrum of T12.

So the next time someone suggests that vertebral augmentation causes adjacent level fractures, you now know why that is a myth. You also have a great example of the real underlying cause.

Pathologic Fracture

There are a variety of reasons that a person can have a pathologic fracture. A simple bone cyst, metastasis, or other lesion that replaces normal bone can make the bone more susceptible to injury. Relatively mild stress from normal activities or minor trauma, such as getting a finger caught in a door (as in this patient) may cause a fracture.

More aggressive processes can appear similar, so this is a great example of why the radiologist needs to know what's going on with the patient.

Can CT Scans In Smokers Save Lives?

New research from the National Cancer Institute suggests that screening helical CT scans in heavy smokers can save lives. In fact, the study compared patients who were heavy smokers and were screened for lung cancer by either chest x-ray or helical CT scans (also known as "CAT Scans").

What researchers founds was a surprising outcome--those that were screened using CT were 20% less likely to die of lung cancer during the study period. The study evaluated over 50,000 patients who were smokers between the ages of 55 and 75.

There are several reasons why CT may be better. First, CT is better at detecting lung cancers. Yet, many of the abnormalities detected on CT turn out to be normal. Often this results in unnecessary additional testing such as biopsies that could potentially be dangerous. It is important that if an abnormality is detected on CT, that the patient and physician not be overly aggressive in further evaluation.

Most lesions found on a CT that are small (4mm or less) are benign, so a biopsy may add more danger than benefit.

What About Radiation Exposure?
There has been a lot of discussion in the media about the radiation exposure that patients receive when undergoing CT scans. Although this is certainly a concern of ours, it is important to note that there are some theorhetical benefits to low dose radiation, such as seen in CT. For example, some authors have noted that low doses of radiation seem to activate the normally present, complex DNA repair mechanisms in our bodies' cells. In theory, low dose radiation may 'rev up' these repair mechanisms and help reverse some of the DNA damage that can lead to cancer.

How Do I Learn More?
If you are a heavy smoker and are interested in having a screening CT, you may call our office for more information. (918) 260-9932

To read more about the study, you can view the National Cancer Institute's press release, here.

About the MILD Procedure

Back Pain Relief Without Surgery or Narcotics

By using a structured approach, >97% of our patients last year were helped without the need for invasive surgery.

Although most people with pain get better, some don’t. For those with continued pain, Dr. Webb can offer real hope for targeted pain relief. Not only is Dr. Webb an expert pain , in pain management, he is also board certified in Radiology. This makes him uniquely qualified to both diagnose the cause of pain using imaging and treat that pain with the latest, clinically proven, minimally invasive techniques.

Dr. Webb is the only physician in Tulsa currently trained to perform the “MILD” procedure. This is a new, minimally invasive alternative to lumbar fusion surgery for patients with lumbar spinal stenosis. Common symptoms that would benefit from this procedure are back and leg pain (including sciatica) that gets worse with standing or walking.

Whether your pain is from a bulging disc or a vertebral fracture, Dr. Webb is your best choice for expert imaging and pain management in Tulsa. Call for an appointment at(918) 260-9322.

You Paid How Much?





It seems that when I talk to a patient with a fracture, I have to spend 5-10 minutes debunking myths and misinformation that they have received from their doctors. It seems that even in 2010, a lot of patients are being treated like it was 1980. "There's nothing we can do for you" or "It will heal on its own" are common things I hear, as well as lack of knowledge about procedures to fix these painful fractures.

Training at the University of Oklahoma, I frequently heard "Don't ask your barber if you need a haircut"--a colloquial way of saying 'Don't ask your surgeon if you need surgery'. When I do see patients who have been treated for their fractures, it's usually with metal hardware (usually costing well over $10,000) or an expensive 'kyphoplasty' kit.

There are many places where common sense could save a lot of money in healthcare. For example, you would never pay $3,000 for a procedure that could cost you $300--or would you?

When you're suffering from a painful vertebral compression fracture (VCF), cost is often the last thing on your mind. However, by choosing the wrong doctor, you could end up with a procedure that costs thousands more.

I specifically use devices to fix these painful VCFs which cost substantially less than other devices while delivering comparable results, particularly in pain reduction. One commonly used device typically used by other doctors costs about $5,500 to fix just fracture. If you were to have two fractures fixed, this generally costs $10,000 or more.

By contrast, the systems that I use typically cost about $1,200--and can treat 2, 3, sometimes even 4 fractures for that cost if needed.

I can remember a case when I first came to Tulsa. At a local hospital, a radiologist used equipment cost about $17,000. This was performed by a so-called expert in the field listed as a "Top Radiologist". However, the same procedure could have easily been performed for less than $1,500. That's would have resulted in savings of over 90% and knocked the patient's cost for the equipment from $3,400.00 to $300.00

These costs are passed on to the patients. I realize that a lot of doctor's don't consider the cost of a procedure. For example, a typical Medicare patient has a 20% copay. If you chose me over another provider, you could save up to $900 on the cost of a typical procedure.

If you happen to go to a doctor who doesn't consider your costs, you could pay up to $3,000 more for your procedure with typical copays. That's just money out the window, which is hard to justify in boom times, much less this economy.

Add to that, the fact that I fix hundreds of fractures each year where most docs only fix a few, and the choice is clear. When it comes to VCF, we offer Cadillac quality at Ford prices.

New Pampers Causing Severe Diaper Rash

Today is a post about pain that I don't usually see. Apparently Proctor and Gamble has changed something about their diapers and it appears to be causing severe diaper rashes in babies. And I'm not talking about just a bad diaper rash. These newborns are experiencing a chemical burn that causes bleeding and oozing.

Unfortunately, I know this from experience. Our newborn was using the new Pampers (given to her at St. Francis) and experienced the exact same symptoms. We tried numerous things, including maternal diet modification, changing to formula, creams. Nothing helped until we switched to cloth diapers at our pediatrician's suggestion.

Now the rash has totally cleared up. We have since went back to using manufactured diapers (Huggies) without any problem.

If you've had a similar experience, please post. Also, here are some related links. So far, Proctor and Gamble has been denying this, saying that it is very rare.

http://www.nbcconnecticut.com/news/Parents-Claim-Skin-Rashes-Linked-To-DryMax-Diapers-93176669.html

http://cnmnewsnetwork.com/112291/diaper-recall-2010-looming-government-inspecting-procter-gamble-dry-max-diapers/

http://www.aboutlawsuits.com/pampers-diaper-rash-reports-investigation-10089/

http://consumerist.com/2010/04/new-dry-max-pampers-causing-rash-burns-sores-boils.html

Consumer Product Saftery Commission report - over 4,700 complaints

You can also joint this Facebook group which has over 11,000 affected members.

New alternative to back surgery.

The Vertos MILD procedure is a minimally invasive alternative to surgery. The procedure is done completely through a needle sheath and under x-ray guidance.

The company has released data from its ongoing FDA trial. So far, 67 percent of study participants had a successful outcome based on pain relief and improved function. In addition, to date, patients have shown clinically significant improved function from baseline per the study guidelines set by the U.S. Food and Drug Administration panel on orthopedic and rehabilitation devices.

Study leaders have also noted that the data confirmed mild’s safety profile, with no dural tears, blood transfusions or other procedure or device-related complications having occurred.

Dr. Webb is the only physician in the Tulsa area trained to provide this minimally invasive alternative to invasive spine surgery.

Latest News - Prolia

We are now offering Prolia injections at our Tulsa office in continuing our tradition of bringing the latest, FDA approved treatment options to our patients with osteoporosis.

Prolia (denosumab) is the first drug approved by the FDA in an entirely new class of osteoporosis-fighting medications known as RANKL, or RANK ligand inhibitors. These medications work decrease bone loss in a way that is different from other osteoporosis medications (such as Fosamax, Boniva, etc.)

Our patients who have chosen Prolia so far have done so mostly because it is better tolerated than some oral medications such as Fosamax. In addition, convenience can play a role as Prolia is typically given every 6 months, rather than every day.

Compared to other injectable therapies done by intravenous (IV) infusion, Prolia can be injected in office under the skin, much like a flu shot. This typically takes about 15 minutes, including observation afterwards.

If you are interested in Prolia, or for more information, call our office at (918) 260-9322.

The newly approved drug, denosumab (Prolia), is an injectable medication derived from a synthetic antibody. It is approved by the FDA for treating postmenopausal women with osteoporosis and other patients who have failed or couldn't tolerate other medications.

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.

The IV Arthrogram

If your doctor has ordered an arthrogram, there is an alternative for many patients--they can undergo what is called an 'indirect arthrogram'.

A conventional arthrogram involves a minor procedure where the skin over the joint is sterilized and draped. Then, local anesthetic is administered and a needle is placed into the joint. Next, the joint is distended with contrast and the patient then goes for an MRI (or sometimes, CT).

An indirect arthrogram is a much simpler procedure as the contrast is administered through an IV line instead. After a brief delay, the patient then undergoes the MRI without having a needle placed in the joint. For most clinical questions, the images from an indirect arthrogram are equivalent to those obtained after a conventional arthrogram.

This approach has a number of advantages, including decreased risk of infection and bleeding. Also, many patients are nervous for a procedure such as an arthrogram.

The conventional arthrogram is one of the many procedures that a musculoskeletal (MSK) radiologist specializes in. Since relatively few facilities have an MSK radiologist, the physican who performs the arthrograms often has limited experience. An indirect arthrogram may also be helpful in this case and make for a more pleasant experience for the patient.

Here is an article about the effectiveness of indirect arthrography in the shoulder that was published in Radiology.

Strengthening Your Bones

Ask someone what a bone looks like and many people will think about a skeleton such as from biology class or a dinosaur skeleton in a museum. Perhaps that's because both are great visuals.

Thinking of those bones, however, can give the impression that bones are static and unchanging, like rock or marble. However, our bones are an amazing, living organ with tissue that continually remodels and rebuilds during our lifetimes. In fact, children replace their entire skeleton every 2 years. Even adults, after reaching skeletal maturity, continue to replace their skeleton every 7 years.

One reason that our bones are so active in remodeling is the stress our bodies go under, from exercise to trauma. Also, much like muscles, our bones get larger and stronger when used actively. Therefore, it's important to exercise our bones, particularly weight-bearing and muscle-building exercises.

There are numerous exercises of each type that can be beneficial. To learn more, call our office or visit the National Osteoporosis Foundation website for more information: Exercise for Healthy Bones | National Osteoporosis Foundation

New Osteoporosis Medication Approved By FDA

The US Food and Drug Administration(FDA) recently approved the first drug in a new class of osteoporosis-fighting medications known as RANKL, or RANK ligand inhibitors. These medications work decrease bone loss in a way that is different from other osteoporosis medications (such as Fosamax, Boniva, etc.)

The newly approved drug, denosumab (Prolia), is an injectable medication derived from a synthetic antibody. It is approved by the FDA for treating postmenopausal women with osteoporosis and other patients who have failed or couldn't tolerate other medications.

To learn more, call 260-9322.

How We're Different

Many doctors approach patients with back pain by using narcotics or recommending surgery. By the time a patient sees a pain specialist, they are often going to get 3 steroid injections and then sent for a variety of tests leading up to spinal fusion.

At our clinic, we try to help patients avoid surgery. Here are some key ways that we are different:

* Advanced imaging studies, such as MRI, are critical to selecting the correct treatment plan for patients with pain. Dr. Webb is the only pain physician in Tulsa who is board-certified to read imaging studies.
* You get seen in days, not weeks.
* Pain relieving procedure done within days, not weeks.
* Leader in minimally invasive alternatives to surgery for patients with pain.
* Comprehensive pain intervention from epidural steroid injections to minimally invasive decompression.
* Focus on osteoporosis, spine fracture fixation with advanced level of training and specializing in complex cases.

New Treatment for Spinal Stenosis

Dr. Webb is now offering an advanced new procedure called minimally invasive lumbar decompression, or MILD. The MILD procedure is a great technological advance over invasive surgical fusion.

For patients with back pain due to lumbar spinal stenosis, the MILD procedure may be the key to avoiding invasive back surgery. Traditional invasive lumbar fusion typically takes several hours, requires a few days hospital stay and weeks to months of rehabilitation.

In contrast, the MILD procedure typically takes less than 2 hours and the patients are usually discharged after 2-3 hours. Most patients have a 75% reduction in their pain.

How do you know if your back pain is due to spinal stenosis? Only a physician can diagnosis this condition, however, patients most commonly present with lower back pain that radiates into one or both legs. The pain is usually worse with walking and relieved by either sitting down or leaning forward (such as on a shopping cart).

Call us for more information today at (918) 260-9322.

How To Save Over $3,000 On Kyphoplasty/Vertebroplasty

You Paid How Much?









There are many places where common sense could save a lot of money in healthcare. For example, you would never pay $3,000 for a procedure that could cost you $300--or would you?

When you're suffering from a painful vertebral compression fracture (VCF), cost is often the last thing on your mind. However, by choosing the wrong doctor, you could end up with a procedure that costs thousands more.

Dr. Webb uses devices to fix these painful VCFs which cost substantially less than other devices while delivering comparable results, particularly in pain reduction. One commonly used device typically costs about $5,500 to fix just one level. If you were to have two VCFs fixed, this generally costs $10,000 or more.

By contrast, the systems Dr. Webb uses typically cost about $1,200--and can treat 2, 3, sometimes even 4 fractures for that cost if needed.

We are aware of a case at one local hospital where the equipment cost about $17,000. This was performed by a so-called expert in the field listed as a "Top Radiologist". However, the same procedure could have easily been performed for less than $1,500. That's would have resulted in savings of over 90% and knocked the patient's cost for the equipment from $3,400.00 to $300.00

These costs are passed on to the patients. For example, a typical Medicare patient has a 20% copay. If you chose Dr. Webb over another provider, you could save up to $900 on the cost of a typical procedure.

If you happen to go to a doctor who doesn't consider your costs, you could pay up to $3,000 more for your procedure with typical copays. That's just money out the window, which is hard to justify in boom times, much less this economy.

Add to that, the fact that Dr. Webb fixes hundreds of fractures each year where most only fix a few, and the choice is clear. When it comes to VCF, Dr. Webb offers Cadillac quality at Ford prices.

New Osteoporosis Center in Tulsa

Since 1996, the late Dr. David Browning set the gold standard for ostoeporosis care in Tulsa through Diagnostica Osteoporosis Center.

Advance Imaging (AI), a full service radiology clinic located at 6757 S. Yale in Tulsa, Oklahoma, has recently acquired the bone density scanner from Diagnostica and the practice associated with Dr. Browning. This practice includes one of the leading bone density scanners in Tulsa.

With this acquisition, we are now able to provide comprehensive management of the patient with osteoporosis at one location. Dr. Webb's patients can now have their bone density tests done at the same location. This also means that Dr. Browning's patient can continue to have their examinations performed and read on the same machine and with the same experienced personnel, with their previous studies available for direct comparison.

For more information or to schedule a bone density test, call (918)260-9322 and ask for Lisa.