You Pay For It--And Your Doctor May Be Making Money On It

Here we show the difference between two types of MRI. One is the industry standard, high field 1.5 Tesla MRI that has superb image quality. This is the larger image on the top. The second, middle image is from a low field 0.3 Tesla MRI that has inferior image quality. There are several technical problems with this images. This is a low field magnet that does not have optimized imaging protocols.

The bottom image, for comparison, is also a low field magnet image, but it has optimized protocols with closely followed quality assurance protocols.

None of these images has been altered except to remove confidential patient information. These are truly 'what you see is what you get' images from these different scanners.

Unfortunately, even though the image quality and, therefore, the ability to make an accurate diagnosis is impaired on a low field MR, they cost the same. Insurance companies, Medicare, Medicaid, etc, all pay the same. As a result, your copay or the amount that YOU have to pay is the same. You don't just get a discount because the image quality is suboptimal.

While this all seems unfair--and it is--what you may not know is that that low field MRI that your doctor is sending you to may be sending your doctor a check every month. For example, the image above is from a facility in Tulsa that is owned by physicians. They send their patients there not because of the image quality but, one can easily argue, because they are shareholders in the company that owns the MRI. However, I have had a physician investor at this magnet tell me that their image quality is better.

This was doctor who has no training in imaging, physics or image quality. You tell me what you think--which is clearer, more easy to see, the image on the top or the image on the bottom. Then tell me--do you think that the physician is more concerned with getting a check from his imaging center or the quality of the MRI that his patient receives? This type of unethical behavior gives the good doctors a bad name--and angers me.

There are legitimate reasons for doctors to send to certain imaging centers. Generally, hospitals do poorer quality imaging studies because they have a captive audience (at least in Tulsa). Also, I will usually send to a specific center because either I know that they perform quality imaging studies there or I am the one supervising and/or reading the imaging study.

That brings up another point. If you have an MRI, whether in a hospital or in an outpatient center, you may very well have a non-fellowship trained radiologist reading the MRI. I know this because I constantly have patients bringing in MRI reports from other facilities where the reading radiologist trained before MRI came into existence (in the 1980s) or who is just a general radiologist with no subspecialty training.

While these radiologists are board-certified, that doesn't mean that they are the best person to read your MRI. For example, who would you rather read your mother's mammogram, a fellowship-trained breast imaging specialist or me, a fellowship-trained orthopedic radiologist? When it comes to my family and my patients, I prefer for them to get the best possible treatment, and the most value for their healthcare dollar.

And no, I am not an investor at any of the imaging centers I read at.

Life or Death - Fixing Your Fracture

I continue to be amazed by the attitude taken by many spine surgeons regarding fixation of vertebral fractures. I can only assume that they are either uneducated or callous.

On a daily basis I hear local surgeons opine (either directly or indirectly through my patients) that vertebroplasty and kyphoplasty 'don't work', that fractures get better by themselves and that having a fracture 'won't kill you'. Although I would prefer that other doctors listen and modify their behavior, I continue to try to do the best thing for the patient. The truth is that people die of vertebral fractures--and they die for many reasons.

I can remember as an intern in internal medicine at the VA Medical Center in Oklahoma City being taught by our house officer that if a veteran came in with a vertebral fracture, that their likelihood of death was roughly equivalent to a patient being admitted for congestive heart failure or pneumonia. Yet, the next year in radiology residency, I was instructed by multiple board-certified radiologists to 'ignore those fractures' because 'they all have them.' I can't think of a more poignant contrast in knowledge and ignorance when it comes to training physicians to treat patients with osteoporotic vertebral compression fractures.

Today I would like to draw attention to yet another article showing the benefits of treating these fractures, rather than ignoring them--a recent article published in the Journal of Bone and Mineral Research (JBMR). The authors looked at death rates in 858,978 Medicare patients who were diagnosed with vertebral compression fractures. Those who underwent treatment with vertebroplasty or kyphoplasty were 37% less likely to die in the next 4 years.

There are many reasons why people die after a vertebral fracture. They often are immobilized, laid up in bed and unable to get around. They become weak and deconditioned. They develop blood clots in the legs that can travel to the heart and lungs (pulmonary embolus). They get bedsores. They get depressed and lose the will to live because of constant pain. Perhaps worst of all, fracture pain prevents them from living a normal life and stops them from doing the things that they love--the very things that make life worth living.

So, if you or a loved one suffers a vertebral fracture, this study suggests that if it is NOT treated, then you or they are 37% more likely to die in the next 4 years than if it was treated.

Yet again, more proof positive that interventional specialists who treat these fractures are on the right track. Everyday by fixing these vertebral fractures, they are not only taking away the pain, they are saving lives. Meanwhile, the doctors who continue to deny the efficacy of these procedures do so at the peril of their own patients.

Reference
Edidin A, et al. Mortality Risk for Operated and Non-Operated Vertbral Fracture Patients in the Medicare Population. JBMR, 2011: Feb 9. DOI: 10.1002/jbmr.353

On Car Crashes and Chronic Pain

A new study in the March 21st issue of the journal, Arthritis Care & Research found that people in car wrecks have an 84% increased risk of developing new onset chronic pain.

The study was done at the University of Aberdeen in Scotland, UK. The researchers reviewed over 2,000 patients who suffered from chronic pain. Out of these, 241 patients had new onset of chronic widespread pain after certain events such as trauma, hospitalization, surgery, etc.

What the study found was that those who said they had been in a car wreck had an 84 % increased chance of developing chronic pain--that is they didn't have chronic pain before the car wreck.

Unfortunately, the authors seem a little confounded. Many doctors will attribute this finding to a pre-existing physical or mental predisposition. Often, these poor patients will be dismissed as trying to game the system and trying to get a large insurance settlement from personal injury tort lawsuits.

However, I see these patients all the time. Most commonly, they have undiagnosed fractures. They have a fracture that is mistaken as a normal variant, just because it doesn't 'light up' on MRI. They have all of the other obvious clinical features, such as midline and/or radiating pain, pain worse with standing or lifting, and tenderness to palpation of the spinous process at the involved vertebrae.

What's more is these patients are often on narcotics. The doctors they have seen before have said that there is nothing that can be done. I hear that from patients so many times that it makes me angry. I just don't understand why other doctors insist on ignoring these clinically obvious fractures and choose to sentence their patients to a lifetime of narcotics which don't help. Often, this choice to do nothing leads to unnecessary loss of productivity and income, but also robs the patients of enjoying life.

Years ago, there was nothing that could be done for fractures. I understand why people have been suffering for years from a car wreck 20 years ago. However, now there are effective, non-operative, solutions for fractures that are effective in up to 95% of patients with back pain.

So, if your doctor has told you or a loved one that there is nothing that can be done, especially if you've been in a car wreck, please--get a second opinion. As an expert, board-certified radiologist, I am available to review films and do this for patients outside of Oklahoma.

Why I Love My Job

Some days it's just incredible how life sets gifts on your door.

Today I had a patient in his forties who has been suffering from back pain since a motorcycle wreck 17 years ago. We all know people who were hurt in a wreck or other accident when we were in high school. This still young man had been living with back pain for two decades. He had had three back surgeries, one of which didn't take.

He came to my clinic, able to walk, but in severe, activity-limiting daily pain. He has fractures that were overlooked by other doctors. There are two main reasons why.

First, they were very mild fractures on x-ray and MRI. Most of the spine surgeons I work with would blow them off. Yes, they are subtle and they are mild, but they do not look like normal vertebrae. Personally, I used to blow them off too, because that is the standard of care and that is how I was trained. However, that is not the right thing for the patient--we'll come back to that.

The other problem that these types of patients encounter is that their fracture is remote. I heard from self-proclaimed expert spine surgeons all the time that fractures don't respond to vertebroplasty after 6 months. Really? These opinions are usually most vehemently held by the surgeons that don't even perform vertebroplasty. So they have zero clinical experience with a procedure that cures pain from vertebral compression fractures in 95% of patients.

I guess if I had trained in 1970s or 80s, that I might be in the same boat. However, doctors are supposed to be patient advocates. We have to do the best thing for our patients. And because I perform hundreds of vertebral fractures each year, I see those who were blown off by other docs. True, some of them aren't painful. But most of the ones are. Sometimes it is the subtle finding that is the only imaging indication of a big problem.

So, the young man in question. When I see him in clinic, I spend 20 minutes going over the subtleties of his situation and why other doctors haven't been able to help him. I also tell him that he has a greater than 80% chance of being pain free after vertebroplasty.

Today we fixed the fracture. Afterwards, he got up, went through all the range of motion exercises that usually cause him pain. He said his pain was gone.

It makes me very sad to think that this young man had to suffer for all of those years. Granted, vertebroplasty has only been around in Tulsa for about 10 years. But even 10 years is too long to suffer when it isn't necessary.

I really feel for those patients out there who suffer from back pain day to day and haven't found the solution, because sometimes it is that easy. But it really gives me indescribable joy when I can help another human like this end decades of suffering. Giving hope to the hopeless is what I love doing--and I am lucky to be able to do it everyday.

"I Don't Want Spine Surgery"

This is one of the most common 'chief complaints' I hear from patients with back pain. Often they have seen several doctors and lumbar fusion has been recommended.

Often, lumbar fusion surgery is contemplated in patients who have spinal stenosis with 'neurogenic claudication'. This occurs when you have pain that is worse with standing and/or walking and relieved by sitting. Fortunately, in cases like this, then the Vertos MILD (minimally invasive lumbar decompression)procedure is usually helpful.

With MILD ~70% patients have complete or significant pain relief. Although not perfect, it is about a 2/3 response rate, better than most things in modern medicine. Better yet, if it doesn't work, there are no implants and it doesn't preclude you from having something else done if you're in that unlucky 1/3. Here are the main advantages of this procedure over a fusion:

outpatient procedure - go home after 1-2 hours.
procedure time only 1, maybe 2 hours
light sedation (rather than anesthesia)
return to usual activities next day (as opposed to months)
no surgical incision - done through a needle hole about the size of a pencil
no implants
does not affect spine stability
I've yet to have a patient who was WORSE after the MILD procedure
you can always have a fusion after a MILD if it is really needed
no blood transfusions or dural tears reported to date in the US (vs. ~10% in open surgery)

In addition, the MILD procedure can provide relief in patients who are 'poor surgical candidates' for spine surgery, such as the elderly, those with heart disease or other medical conditions.

The other option to think about if your pain is mainly in your lower back and not into your legs is a facet block--works well typically for lower back pain that doesn't radiate.

Help and Hope When Other Doctors Have Failed

I am often asked what I can do for patients in chronic pain that have seen multiple physicians. Often these patients are on chronic narcotics for pain and their doctors have given up on finding a solution for their pain. As an aside, for chronic pain, opiate narcotics such as lortab really just exacerbate the problem.

We frequently see patients who come to us who have seen other doctors, had injections and are still in pain. Most of these patients we can help by trying a different approach that the other doctors have overlooked. Most commonly this is done by addressing facet pain, spinal stenosis or fractures.

I am continually AMAZED at the number of patients who come in with no hope that have an UNTREATED FRACTURE. If it's a vertebral fracture, we can almost always take away or significantly reduce the pain. Even with other causes of pain, we have great results.

Main Pain Causes
My systematic approach considers the most common causes of pain. For example, the most common causes of back pain that I see are:
1. Muscle strain or other soft tissue injury (usually self-limited).
2. Disc disease (annular tears, bulges, herniations, intervertebral osteochondrosis, etc.)
3. Facet osteoarthritis
4. Vertebral fractures, painful hemangiomas and similar conditions.
5. Sacroiliac joint arthritis.

Typically, when a patient sees a pain doctor, they are past the phase where #1 is usually a factor. Most commonly, patients will progress on to epidural injections. If there is no help, and the patient has disk disease, often the patients are sent to surgery or placed on chronic pain medications.

Why Repeat Epidurals
Lastly, even though a patient may have had an epidural injection before, I will usually repeat this because about 1/2 of these patients will get significant sustained relief when I do the injection. I can't always explain why, but frequently when the I do an epidural and the patient gets excellent relief for months, it suggests that the previous injection may have been in the wrong place.

For example, we always use x-ray guidance. A recent study showed that even the most experienced pain doctors injected in the wrong place 25% of the time if they didn't use x-ray guidance.

Also, often people had a steroid shot in the hip muscles, but not an epidural injection. These are two completely different procedures. It's hard for me to know which a patient had unless I have the operative report. An intramuscular steroid injection is no more effective that taking oral steroids and has all the same side effects as systemic steroid administration.

Radicular pain from fractures

A phenomenon associated with vertebral compression fractures (VCFs) that is documented in the medical literature is the fact that 10% of these fractures have radicular symptoms that mimic a slipped disc and that goes away with fixing the fracture.

Think about it. We all know patients with thoracic fractures that presented like rib or anterior chest pain or angina (radicular pain). Often a thoracic fracture is mistaken for pneumonia or a heart attack.

However, when a patient has radicular symptoms due to a lower back (lumbar) fracture and it goes into the legs, most spine surgeons think slipped disc and patients frequently get what I consider unnecessary fusions. Many of these surgeons will argue with this, but one of the most common causes of failed back surgery syndrome (aka post-laminectomy syndrome) is an untreated fracture. I see this on a monthly and, unfortunately often weekly, basis. One of the saddest things that I see in clinic when a patient has had a $50,000-$100,000 fusion and is worse off than before surgery--then we fix them with a procedure that costs about $2,000.

This bias against and ignorance of the fractures as a common and grossly under-diagnosed cause of back pain is best exemplified by a patient story here. This patient was diagnosed with a thoracic compression fracture, but all of her 'doctors' agreed that it couldn't possibly be causing her pain. They did test after unnecessary test and eventually performed a splenectomy because they refused to believe that her diagnosed fracture could cause her pain. As soon as we fixed her fracture, her pain was gone.

I would love to discuss more. Feel free to contact me at jrw@tulsamsk.com or call our office at (918) 260-9322.

Chronic Vertebral Fractures--do they respond to therapy?

The Question--Chronic Fractures

I had a question today from a chiropractor regarding so-called chronic vertebral compression fractures (VCFs). In particular, this regarded a patient with a 3 year old fracture.

The Answer Is Easy

Let me be clear--in my experience, as long a vertebral fracture is clinically symptomatic, it has a near 100% success rate with vertebroplasty or kyphoplasty. By symptomatic, I mean that the patient has a fracture, has back pain and has tenderness to palpation or percussion at the spinous process.

Belt Line Pain Syndrome

Often, folks will present with remote fractures at the thoracolumbar junction, commonly T11-L1 sustained in a car crash perhaps 20 years or so ago. However, their main complaint of back pain is lower, often described as "belt line pain". My theory is that this is due to chronic paraspinal muscle spasm due to the fracture. Why? Because this, too, goes away immediately after fixing the fracture. In fact I've had 2 patients this month with that exact phenomenon.

I have personally fixed fractures up to 35 years old with complete pain relief afterward.

Medical Literature

Some notes from the medical literature regarding chronic fractures. These are often overlooked our flat out ignored by most doctors--
1. 94% success rate for vertebroplasty on fractures <1 year old
2. 80% success rate for vertebroplasty on fractures >1 year old.


I would love to discuss more. Feel free to contact me at jrw@tulsamsk.com or call our office at (918) 260-9322.

Insurance won't cover Sacroplasty? We have a solution.

I recently had a patient ask if I performed many sacroplasties. The answer is absolutely. I counted 22 patients that we performed sacroplasty on in 2010. I have two patients scheduled for sacroplasty in the next two weeks.

Sacroplasty was part of my fellowship training and I often get referred sacral fractures from other doctors around the state as well as in Tulsa. For example, we often have patients come from out of state or patients may be referred by other pain specialists in town because they don't perform this procedure. We even get patients transferred from local hospitals. Of the two specialty hospitals I operate at in Tulsa, I am the only one I'm aware of who performs sacroplasty at either location.

Sacroplasty is typically done as an outpatient and takes me about 15 minutes to perform in most cases. Patients can go home after a brief monitoring period and resume their normal activities generally on the next day.

We often see patients for osteoporotic fractures who are confined to nursing homes because of decreased mobility. It's very gratifying to be able to help these patients, because if that's the only reason they are in a nursing home, they can usually go back to their homes afterward. In fact, I have been able to get more patients out of a nursing home and back home with sacroplasty than with any other procedure that I do. I think the reason is that sacral fractures affect the entire pelvic ring and more often progress to unstable lesions than vertebral fractures.

Unfortunately, although sacroplasty is a proven, effective treatment for sacral insufficiency fractures, many insurances won't cover it. In that case, we have a cash pay arrangement in clinic with a 30% discount for upfront payment. If you or someone you love has a painful sacral insufficiency fracture, call (918) 260-9322 for more details.