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Introduction | Metastatic Disease and New Ontario Guidelines
Introduction | Metastatic Disease and New Ontario Guidelines
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Ontario Health Advisory Committee (OHTAC) Recommendations  | Metastatic Disease and New Ontario Guidelines
Ontario Health Advisory Committee (OHTAC) Recommendations | Metastatic Disease and New Ontario Guidelines
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Case 1: Vertebral Fractures in Primary Amyloidosis | Metastatic Disease and New Ontario Guidelines
Case 1: Vertebral Fractures in Primary Amyloidosis | Metastatic Disease and New Ontario Guidelines
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Imaging Assessment | Metastatic Disease and New Ontario Guidelines
Imaging Assessment | Metastatic Disease and New Ontario Guidelines
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Acute and Chronic Myeloma | Metastatic Disease and New Ontario Guidelines
Acute and Chronic Myeloma | Metastatic Disease and New Ontario Guidelines
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Referral and Management Options | Metastatic Disease and New Ontario Guidelines
Referral and Management Options | Metastatic Disease and New Ontario Guidelines
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Communication Tools: SINS & ESCC | Metastatic Disease and New Ontario Guidelines
Communication Tools: SINS & ESCC | Metastatic Disease and New Ontario Guidelines
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Management Algorithms | Metastatic Disease and New Ontario Guidelines
Management Algorithms | Metastatic Disease and New Ontario Guidelines
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Case 2: Mechanical Pain Post-Radiation, No Cortex | Metastatic Disease and New Ontario Guidelines
Case 2: Mechanical Pain Post-Radiation, No Cortex | Metastatic Disease and New Ontario Guidelines
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The Multiple Myeloma Dilemma: Multi-Level Procedures | Metastatic Disease and New Ontario Guidelines
The Multiple Myeloma Dilemma: Multi-Level Procedures | Metastatic Disease and New Ontario Guidelines
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Case 3: Vertebral Fractures in Multiple Myeloma 1 | Metastatic Disease and New Ontario Guidelines
Case 3: Vertebral Fractures in Multiple Myeloma 1 | Metastatic Disease and New Ontario Guidelines
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Objectives | Metastatic Disease and New Ontario Guidelines
Objectives | Metastatic Disease and New Ontario Guidelines
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Questions and Answers | Metastatic Disease and New Ontario Guidelines
Questions and Answers | Metastatic Disease and New Ontario Guidelines
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Transcript

- Well, I'm going to take us in a slightly different direction. I'm going to come at this from a slightly more clinical perspective. And I'm going to come at it from a cancer point of view. So we're leaving osteoporosis on one side and we're coming at this from cancer.

There's a reason for this. The main reason is that we're able to leverage cancer in terms of generating funding. It's always been funded by OHIP, we talked about Ontario, it's always been funded by OHIP. But to make it a special case

to get specific funding for these procedures has been difficult. And in the reviews previously, whether you do kyphoplasty or vertebroplasty, it comes down to it's part of global funding. So we leveraged cancer as a means

of accessing balloon kyphoplasty. And the interesting thing about that is that you can't differentiate in terms of results whether you use a balloon or whether you do a vertebroplasty. You can't separate them.

So it's worked out for everybody at the end, both ways we're going. This is the sort of patient that gets presented. They get referred because of pain.

All right, so this is, it's a little busy. But it's really just saying a lot of

what has already been said so far, and that is that metastatic spinal tumors are very, very common. Cancer is being treated. Whether the cure rates are going up or whether patients are just being managed

more actively and more functionally for longer periods, we see a lot of bone metastasis. And the spine is very commonly affected. And the tumors that we see most often are kidney, breast, lung and prostate, although pretty much everything, if it lives long enough,

will present with mets to the spine. And the other area which we've not mentioned specifically here is multiple myeloma. So you're myopathic. What we're really looking at is preservation of neurologic function, pain relief,

and stabilization of a mechanical structure. And I think that's what we have to look at. So we're looking at that fact. And then I've just listed them there, but there are lots of reasons why you can have pain, from local things to chemical things.

There we go. And of course the perfect thing is that we have an opiod crisis. So patients are either being referred to you because they've got pain and the family physicians won't put them on opioids,

or they're giving you referrals in cancer of patients to try and reduce the opioids before they start trying to stabilize them on them. So OHTAC came out, we put this through OHTAC and there was a big epidemiology review, meta analysis, and the results came out.

And this really followed on from the nice report that happened in the UK, where they looked at it in the same way. And then the latter part is a year later. After the release of that, we've come to some guidelines. OHTAC recommended, and this is about

as strong a recommendation as they've ever put out, that vertebral augmentation be publicly funded and made accessible for appropriately selected cancer patients with vertebral compression fractures. That's a pretty big statement. And they said that Cancer Care Ontario

should be the overseer and they should work out and determine the criteria needed to provide the funding for these things. And that's where we are right now. The funding is actually there and it's flowing and will be literally in people's pockets

at the beginning of the next fiscal year, which is in April. These reports are available. You can go online, you can get them. You can look at them. They've been circulated through a variety of channels.

This really, it says that those patients which have acute painful vertebral fractures that should be treated within six weeks of fracture, unless other circumstance is deemed appropriate. Some of these are wordings that have been placed in there so they're not too controversial.

But again it's reflecting a lot of the conservative approach to the fractures. Really, when has conservative management failed? If a patient can't take opioids and you have no means of giving them something to reduce the pain, it's a failed management.

So it could be day one, it could be day two, or it could be three or four weeks after they've done some other things. Symptomatic fractures with load bearing pain or axial tenderness. So you're really talking about load bearing pain.

The patient that wakes up at night, in the middle of the night, when they're horizontal and they've got pain, that's not a compression fracture. That's cancer. High risk impending fractures.

So the patient that may fracture because the thing, we'll deal with that. And we brought in the spinal instability neoplastic score. We're talking about a culture of communication when we come to this. These are cancer care criteria.

So they should be treated within six weeks of fracture. And this is for balloon kyphoplasty. Fractures with gas filled cleft or un-united fracture, there's an implication that there's a sort of mobility there. And fractures with soft tissue tumor and absent cortex.

And we're talking, again, because we're trying to control cement. It's really control that you're talking about. And right now the balloon is one of the better ways of doing that. The absolute contraindications are,

these (mumbles) out for presence of cord compression, spinal instability, that's really posterior element instability, presence of septicemia or sepsis, ongoing bacteremia, and sclerotic bone metastases. There's no point in trying to use a balloon

or radiofrequency for a sclerotic metastasis. Spine instability neoplastic score. This is, the money is tied to cancer care. To get the money, you have to fulfill the criteria that Cancer Care Ontario have imposed there. So they're talking about multidisciplinary consultation

on every case, whether it's reporting to that body or whether it's part of the discussion. It's actually quite exciting because this is a new program that they haven't done before. So we're talking about, we're going to come back to the spinal instability neoplastic score.

So anything greater than seven is going to be discussed. Prophylactic referrals for cases with bone metastasis. In other words, you've got a metastasis with a lot of lytic disease there. Fractures between C7 and T4,

they're really out of the realm of, not many augmentations take place in that level. And then we've got multi-modality treatments, stereotactic radiation, radiation, RFA. Those that have decompression. And then obviously vertebral collapse

and tissue in the spinal canal. These are all complicated cases and require.

Now this is a typical picture in a cancer patient. First of all, this is his vertebra that we can see here while he was on the table. But the patients present like this.

This is a primary amyloid. Patient was in renal failure, on peritoneal dialysis, had Type II diabetes. So you've got steroids, you've got secondary osteoporosis, you've got decreased ambulation and you've got weight gain, all the comorbidities that go with this.

Presents, this scale at the bottom is in months. So they presented with pain that's about seven or eight out of 10. Had an augmentation, it dropped down to one at a month. Then 14 months later, represents with another fracture, pain up in the same level,

same drop in pain at the end of the month. In fact, it's within a few days. And then that time, the time between the first and the second and between the second and the third presentation, tends to get shorter

as we're moving through the disease process with the patients. And this is very, it's a very common picture.

I just like seeing that vertebra squeezing like that. So the patients then have some form of assessment. And plain films are not sufficient.

You won't do the procedure on plain films. So they're going to have MR or they're going to have CT. If it's an acute fracture, you often can't wait the three months or the four months for the MRI scan, because that's the delay that's put into the system

unless you stress that it has to be done more urgently because it's a fracture. And you can get a CT scan very quickly. But remembering what happens, that Kirin just spoke about with the loss of muscle mass, the deconditioning that takes place in an elderly patient,

same thing happens with a cancer patient. They decondition very fast if they're put to bed and they're just given analgesia. So you want to manage them relatively rapidly to avoid that deconditioning. Because it just means that they get up

and get going a lot faster. And here just some examples. This is just a type of case that you're going to get. Here is a case, there's some loss of cortex, we've got tumor bulging back into the canal. But you wouldn't know it from looking at this,

that the front of the body is missing. So there's a huge spectrum of different disease. Myeloma with soft tissue in the canal, and there's the hollowed-out vertebral body that you see. And then other cases there.

Myeloma is a special case, a special scenario

where you have multiple vertebrae involved. You can use MR. T1-weighted image, T2-weighted image. You can see the sort of somewhat soft, fluffy appearance of acute myeloma. It's a diffuse disease process throughout the spine.

And we've got sitting at one fracture here and then you can see the T1 corresponding effect there. This is the CT scan. The patient presented with the CT scan. And you can see the concavity of the end plates at these two levels.

These are acute fractures. Don't be fooled that they are chronic fractures and that this is sclerotic change post-therapy. This was all in the acute phase. And this is just compacted bone, where the fracture's actually collapsed and compacted.

And if you look in the axial plane, you'll often see the cracks in the end plate. That's why CT in the acute phase is really good as well. Same patient, four and a half years later. Represents with myeloma recurrence, because myeloma is not about treating the disease

with stem cell transplant, it's about managing recurrence now. So this patient, you know, 20 years ago, this patient might not even have survived to this length of time. But now we're seeing them and it's pretty standard to them

to be coming back five years, six years after an augmentation procedure. But you can see the previous augmentations, and there are the acute fractures, again, there's the ster sequence and you can see the end plate changes,

the high signal in the end plates related to the acute fractures. This is different to the chronic myeloma patient, who presents, they've been chugging along just fine, everything's been going fine, and then they have acute pain in their back.

And then there you have the acute fracture. The T1-weighted image is very useful. If you don't have a ster sequence, you can see how in T2, other than the morphologic change in the vertebra, you may not necessarily see the fracture to the same extent.

Single level, whether it's a augmentation, whether it's a kyphoplasty, whether it's a vertebroplasty, it really doesn't matter. But a single level, nice result, maintains the vertebral body height, and patient went out the door pain free again.

There are a lot of people involved in oncology. So it's multi-modality. This is where generating and building the practice comes in because all of these people are involved in the patient management. And they're also where all of the referrals are coming from,

because the patient's coming in or being referred in to these various people. So they could be coming into palliative care or in (mumbles) my case, we're actually getting direct referrals from the community. Neurosurgery, if you have a spine service,

or it could be orthopedics, radiation oncology and medical oncology. So all of these patients are coming in and being filtered out by that. The unmet need in this province, we're probably, we're looking at,

there are about 2,000 patients in the province that should, by just the criteria that we have now, be receiving an augmentation procedure for a fracture, because they're in pain and they're being managed some other way, every year. And we're not even getting to 500

in the province at the moment. So there's a big need. I'm responsible for doing half of the patients in the province last year, that we're getting them. So they're distributed across the province,

but the funding is province-wide. So we've been working hard to try and get there. These are your management options. While this seems to be at the bottom of the list, if the patient goes to radiation therapy, radiation therapy sucks the patients out of society

and they radiate them. They vanish until radiation therapy says they're still in pain, and they've got recurrence of pain after the initial radiation therapy. And then they sort of spit them out.

You have surgery, and depending on your environment, orthopedic surgeons like doing big operations. They do corpectomies, they do all sorts of things. They put the patients to bed, they get screws and rods and what have you. And so this part, certainly in a big treatment center

and a center where you have a cancer care option, is dropping away and we're moving to minimal access surgery or where the idea is to just de-bulk the tumor, and you're trying to reduce the volume of the tumor, away from the spinal cord, away from the canal. So it's cord-sparing,

or whatever other term you want to use, surgery to allow for the stereotactic radiation and allow for radiation therapy to be delivered without radiating the cord. So it's being done by minimal access. And that's the sort of standard of care that's happening.

And then you have kyphoplasty, vertebroplasty, focal tumor ablation and augmentation coming in at that. But by no means must this be thought of as an end stage. It's part of an adjunct to everything that's going on through the process.

But the patients need to be assessed clinically. Their imaging needs to be assessed. There's consultation. It's either in a clinic or it's by virtual consultation. The Cancer Care Conference, the MCC, Multidisciplinary Cancer Care Conference,

this is inbuilt and it's embedded in the cancer care program for the future. It's taken a long time to get it established, but the patients are, this is huge in terms of cancer care and in terms of funding. Everything is linked to that process.

And even the concept of a virtual consultation or the corridor consultation does not meet the criteria for an MCC. We're taking in to every length and every height in the thing to see if we can get round it and make it an easier process, but the answer is no.

They're totally committed to this thing happening here. Palliative, we have a palliative radiation oncology program. So your patients come in acutely, they're for acute referrals, they were coming in in pain or with the tumors. And then obviously this is the next step

that we're trying to build at the moment, a spinal metastasis clinic.

So you need to know your center, you need to know what your center's management and their treatment options are, whether you're at Sunnybrook or whether you're at UHN

is going to determine how your patients are managed. And so we have some communication tools. Some of you I've shown these slides before. So what's the SINS, spinal instability neoplastic score? Anybody looks at this can generate a score out of it. This is a spinal instability neoplastic score.

It works on the basis that location, whether there's pain, whether there's a bone lesion, radiographic spinal alignment, vertebral body collapse, and evolvement of the spinal elements. The lower the score, the more stable the spine. If you're over seven,

it's a surgical consultation that's required. The higher the number, the more instability there is. And it's very easy to communicate. You can do it for multiple vertebrae in the same patient. You know, T7 fracture, SIN score seven, or so on. So this is important.

And if you follow these patients and you look back at their imaging history to when they first presented, you can actually track that with time, and it may be months, it may be years, with time they progress higher and higher and higher

in their number. So it's a good, it's very reliable. The second thing, epidural tumor. We have to credit Mark Bilsky at TMD Anderson for doing this. The idea is, by communicating how much contact there is

with the spinal cord and the neural elements from epidural disease. It's insufficient to just say there's epidural disease. Try and put a number on it. 'Cause that number the radiation oncologists understand. So they will treat any one of these,

1a, b, and c. They won't treat two and they won't treat three without something being done. The whole point is, by doing sort of de-bulking, minimally invasive de-bulking surgery, you can move it from a two down to a 1a,

and then they can radiate it with stereotactic radiation. Or you have to do it. So this one here, it's not fit for stereotactic radiation, it may need de-bulking or it may need chemotherapy to shrink it.

Then you have to know what your management algorithm is.

At UHN, the commitment is to stereotactic radiation and chemotherapy. Up at Sunnybrook, they're doing radiofrequency ablation and then augmentation or whatever. So you can use the NOM scale, which is neurologic, oncologic, mechanical and systemic,

which is another very, and most of the programs that are being used are using some version of it or how they interpret the different parts of that. If you go to stereotactic radiation, even radioresistant tumors can be burned out of there and killed.

The problem is that, once you're getting up to very high doses, you're talking about 40 to 50% of the patients will have a vertebral compression fracture as a result of the radiation. So augmentation at or around the time of doing it

or slightly delayed from the radiation therapy is a very viable and a very important thing to do. We've tried cases where we did some staged procedures where we did a one-level fusion, essentially, with the radiation, and then about six months after that, then they start getting mechanical pain again

and then you can augment the vertebra after that. But it really is a part of this algorithm.

So if you know what your center does, then you're fitting into that program. And that's where you want to be. You want to be working within that framework.

Now, this is they type of case that you can't do a vertebroplasty on. And I put it in here really because you have to have some options. Whether you use a balloon, whether you do an RFA to try and create some space or do something,

there are some cases that you can't do a straightforward vertebroplasty on. There are some cases you can't do the balloon on. And the idea here is, she's had a fusion, there was a metastasis in the L5 body, and it had been radiated,

and she started having incredible mechanical pain after all of this. And there is a fracture there. So the idea is to try, and this is not an empty space. There's tissue there. But there's no cortex.

There's no cortex and you can't be certain if you're just injecting some ANT in there with a needle that it's going to stay there. So in fact, did a balloon kyphoplasty here, just came in around the side of the instrumentation, nicely into the midline,

and then did a controlled cement injection in there and she was pain free and leaving from day surgery that same afternoon. And you know when they can stand up and walk from this type of procedure, that it's not from the local anesthetic that you put in,

'cause that's just on the periosteum. That's on the periosteum back here. You know that it's not the load bearing part that has been involved there.

Then you have what I call the multiple myeloma dilemma. You get these patients to come in through the door.

And they got multiple fractures and they got terrible pain. In the acute phase of the disease, they have pain and they have muscle spasm. And it's one of the features about acute myeloma, is the incredible muscle spasms that they get.

And they will tell you, "It's not the pain when I'm standing. "It's just that when the pain hits, I'm just in spasm," and they have to wait for these spasms to go. They sort of reach a point which one of my big supporters calls

the wet noodle phase, where you're lying on the floor and you don't know whether to stand up or crawl like a snake to go to the bathroom or what you want to do, because you can't do anything. You stand up and you get spasm.

You lie down, you get little less spasm, you still got pain. And you feel so weak because of the disease you don't know what to do. Or you get them and they come, and they've been through that, they've been treated,

and this is what the spine looks like. But they've still got pain. They can't do things because they've got pain. How many vertebrae are there? We're looking at one, two, three, four, five, six, seven, eight, maybe nine,

10, 11, 12, 13, 14, we've got 14 fractures here. All right? Sometimes you have a ster sequence, and that helps. It'll show that you've got some. But they're complaining of pain in their lower, upper, mid-thoracic.

They're talking about pain at their thoracolumbar junction, they're talking about pain in their lower lumbar spine. So what do you do? You treat them all. And this is where it comes down to philosophy in a sense. But they do incredibly well.

Sometimes you will know when you inject one of the levels, maybe this level or this one, they will, even under the sedation, they will move, they will demonstrate signs of pain. And you say, "Okay, that was clearly a more acute fracture." The difference is, when you treat them all,

it's really very straightforward. But myeloma makes great, big holes in the bone. Great, big ve-na-sinusoids. And so you have to be very careful. This is where high viscosity cement will make a big difference.

Because you want it to stay in the vertebral body and to treat it. Otherwise you have to be very careful and cautious because the cement is always going to be more liquid for you. But I do it because I'm unable to localize the pain

in many of them. In myeloma, vertebral augmentation treats myeloma pain that comes from the bone as well as fracture pain. This is part of the thing. It's a team approach,

and anesthesia are very happy to do it. We work together. If anesthesia is unhappy, I'm unhappy, all right? If anesthesia say we've got to stop for any reason because they're showing desaturation or because they're showing something

that they're not happy with, we stop. Doesn't matter how many needles you've got there, doesn't matter what you've planned to do, you stop. We work together, and generally speaking, we've only had sort of one patient where we've actually stopped in the middle

to see what was, and stopped because of it. It works very well. It avoids multiple procedures. While this may be different in some parts of the country, a lot of our patients in Ontario have come from 14, 15 hours away.

They keep coming backwards and forwards, even if they're on a travel ground, they can't do that. So it makes a big difference to treat them at once. When you're doing as many levels, do you use a balloon at multiple levels?

No, probably not, we don't. That's expensive. Can you get height restoration back from them? Some of them you might be able to, some of them not. If you've got a vertebra that's acutely fractured and you do want to try and get some height back,

if your option is regular cement or a balloon, then try the balloon kyphoplasty to get some height restoration that way, 'cause really what we're trying to do is reduce the kyphosis at the end of the day. And very often they're sort of hybrid procedures

at the end of the day, and it works very well.

I'm showing you this one for a very, very specific reason, because this has not been, to the best of my knowledge, reported yet. And that is, here's a patient with really bad active disease.

We've got acute fractures at all of these levels coming up here. Acute end plate changes. I saw the patient, they're all acute, there's lots of pain, and I treated. I didn't treat the one vertebra.

Didn't need to, never needed to be. And it's always surprising when you get one like that. So treated them all, this is all with vertebroplasty. Single pedicle vertebroplasty. And this is the appearance two years later. There's the kyphosis above it.

Her spine, his spine? It's a her, actually. Was straight through the level that was augmented, on multiple levels, better than any brace I've seen that's done that, and because they went back

to medical oncology and internal medicine, when they had this fracture here, they said, "Go to bed, it'll get better. "You're on treatment." Then they had this second fracture. And so these fractures occurred

under conservative management by the internal medicine. Yes, they were being consulted with oncology. And then she came back. She was referred back because she was having terrible, terrible mechanical pain and load bearing pain in this upper part of her spine.

But we'd missed the opportunity to perhaps do two or three more levels in the acute phase of that illness and keep her thoracic spine straight. But this is very impressive, and I've got more than one case that has shown

that they've stayed straight with augmentation.

But this is another myeloma patient, done multiple of. These were not done at the same time, but look at the size of these, this is what myeloma does. It hollows out the inside of the bone.

And she would go away and she'd come back with another, I mean, many of these were acute fractures when they were done. But that's what they looked like. And this was vertebroplasty. I think this vertebra here took about nine or 10 cc's

and then she came back 'cause she was having sacral pain. And I think there's 18 cc's on one side and 12 cc's on the other side in the ay-la there. And then she disappears. Not because she's, you know, gone to another place, but she's disappeared because she's no longer in pain

and she's being managed just fine. She may be due to come back, (mumbles). But this is the appearance of her spine. Look at the osteopenia in the sacrum. And this is why she was getting a lot of the pain. But there's room for all of them.

We've sort of discussed the pain, opioid crisis, some of the communication tools. I think the important thing to remember is that they're patients, not images, and that you need to know your center. I think those are the two really big messages,

because you're going to have a practice and you want it to fit into that. You're not in conflict. But you can do an awful lot for the patients. They walk in and they walk, they crawl in and they walk out.

One of the things I've found is that they are so delighted to be pain free that they actually leave any device that they use just to be a little more stable, sort of out in the corridor or in the car, rather than bringing it into the office afterwards,

because they want to show you that they're not in pain and they're stable again. And with the myeloma patients, to a person, when you've treated multiple levels, they say that they get proprioception back. They don't use that, that's a medical term.

But that's actually what they get back. And they couldn't believe how unstable and how unbalanced they were prior to having the augmentation. And that's what we give them in cancer. So if it's one level or two levels,

not only do they have pain, they become unstable. They become very fearful of falling and they become limited in what they're doing by virtue of that. And augmentation restores that. So however you get the cement in doesn't matter.

What you want is, you want to do it safely and you want to try and do it. So multiple level cases. And looking at my thing, in cancer it's about four levels per patient by the time they get to you, that you treat.

In osteoporosis by the time we get to them, and they're coming because of pain, pain management issues, there are usually three fractures. And when they come for an external source or external center and they've had pain from the time of the procedure, the correct level was not augmented

at the time of doing it. So the natural history is, you augment, they get pain free. They go three or four days and they get severe pain again. That's a recurrent fracture. That's a new fracture til proved otherwise. And that's 'cause they're so happy to be pain free

that they rush around. Or they have pain immediately after the augmentation. They need an MRI and they need a ster sequence because you need to see if it's a fracture, another fracture, and where that fracture is. The common thing is that they've been treated

at a level that's had a fracture, it's a more chronic fracture, the acute fracture is beside that and the acute fracture wasn't treated. On that lesson, thank you. Any questions?

(audience applauds)

- If a patient presents with multiple osteoporotic fractures, do you make an effort to try and identify which one is the source of pain and treat it? Or do you treat them all, kind of?

- I think yes, it's still worth trying. I mean, yes is the answer. I mean, you want to try and establish which one is causing the pain. And I think that's reasonable in terms of clinical management.

Or you can do it by MR and you can do it with ster sequences. So you're using radiological imaging lines or you're doing it clinically. At the end of the day, you may end up having to do them. And if you get a really good result from it,

if it's so osteoporotic that they have multiple fractures, it's a moot question. I mean, Kirin spends longer trying to identify exactly which level is fractured, whereas I might be a little more, I'm not cavalier about it, but I believe

you can do multiple levels and it's an effective way of doing it. - So if there's multiple fractures and the ster sequence shows bone marrow edema, at one level we only treat that one level? - You have to look at it carefully

because often there is, you only need to see a very, very, very thin line adjacent to an end plate on a ster sequence for that to be a fracture. - I think that's true, because I've had people come back more than once,

you know, to treat 'em again, and then what it essentially does is make people suffer for six weeks, when I could have gotten rid of all that at one time had I done more. But there's a internal voice you have to listen to

in these things, you know? I can justify doing x. How do I justify doing x, y and z? Usually it's one or two symptomatic levels, in my experience, but I understand what Roger is doing and there are a lot of people who do what Roger does,

like Jim (drowned out by ambient noise). He injects small amounts of cement at multiple levels. We're talking two and three cc's of cement on multiple levels, not eight. - But again, the patient selection is one of the most challenging to me,

and we go back to talks, (drowned out by ambient noise) and still I'm confused. So let's say they've got an abnormal MR and they come to you saying, "I've got back pain," but I've been taught through exam and (drowned out by ambient noise).

And I find not infrequently it doesn't really hurt where the MR abnormality is or the fracture is. Think it hurst a little bit distant to it, or they just complain (mumbles) general pain. Should I just be, if they've had an abnormal MR factor and pain somewhere, should it be treating them?

- I, just think. Again, all of these things, all the things are relative. My approach is, I want to know if they've got pain, and I do see if you have pain here or here, or is it high up? Where do you feel the pain?

And I haven't told them where the fracture is at that point. (both talk simultaneously) (drowned out by ambient noise) Well, some of them do. But they have no idea where that fracture is on their body. They don't tell you, "I've got an L2 fracture" or whatever

because they've already got their imaging. But it's really important, if they say that the pain is up in the, is mid-thoracic and the fracture is at L2, you know, it doesn't fit. If they're not complaining of pain, and it's load bearing pain,

at the level that you see the fracture on the imaging, that's important because it's not related to that. If their pain is getting better day by day, week by week, that's a really good sign not to do something. And it's sort of again, it's that feel you get.

If there's a fracture and it's got (mumbles), and that MR is within, let's say, four weeks or sooner, so it's a recent MR and they're complaining of pain, it should be pain in and around that area. But if they're not complaining of pain in that area, you can try and temporize sometimes,

and they're already coming down. - Pain is really difficult to describe. And it's very difficult to say where a pain is, what a pain is like, put that into a. Had to get it from your (drowned out by ambient noise) and prevent that in a way somebody else can complete that,

it's a difficult thing. It's often that pain will be transmitted along the (mumbles), it'll be a level lower than where the fracture is. And some folks will have radicular pain in the thoracic spine, along the intercostal nerves,

and that's difficult to get rid of sometimes because it's abnormal soft tissue or neural foraminal narrowing from loss of height around the intercostal nerve. So it's, I certainly use the imaging a lot to try and figure out where the pain is.

And obviously is something is normal, I'm not going to treat it. - If there's a strong history of ver-ni-cu-lopathy, I actually come out right at the start and I'd say, "The procedures we're going to be talking about "are not to treat the pain you're describing.

"I can treat the vertebra that's got a fracture "and I know that that vertebra is not "going to hurt afterwards. "I'm treating that pain. "But I can't guarantee that the pain you're talking about "that's coming around here or is going down your leg

"is going to go." In practice, about 80% of them it does because it's referred pain, or there's some stability that comes back to the spine afterwards, or just because they're not in pain from the vertebra,

they start working on the muscles, start using core muscles to support themselves and the radiculopathy is settled. So, yes it does, but it's not a direct effect from it. And I want to say one thing about extravasation in the disc space.

In the literature support it says that if you get extravasation into the disc space that's an increased risk of having an adjacent level fracture. In practice, that is when it goes and extravasates through the fracture

and you get a spicule of PMA going into the disc space. To begin with, when I started, I used to say, "Oh, it's going to the disc space, I'm going to stop now." I don't anymore. In fact, I inject as much as I can into that disc space and let it flow,

as Kirin demonstrated, going to the adjacent vertebra. But I'm relying on the integrity of the end plates around that fracture. And the cement, if you inject it and keep injecting, goes in and it flattens out across the disc space. 'Cause the disc is already disrupted

in the elderly patient. And it flattens out and it ceases to have an impact on the adjacent vertebra. And you get a good result, you get a good pain result, without the risk of a fracture because you've actually done something with that cement.

So that's something which, just from doing the procedure, I realize you can actually avoid that, you can prevent that fracture by injecting the disc space. - Another thing to do would be to do a vertebroplasty or something with intercostal nerve pain,

and then bilateral neural foraminal steroid injections at the same time. It takes two minutes to do it. You know, 80-gauge spinal needle into the neural foramen bilaterally. Think posterior and inferior in the neural foramen,

that's the vessels around here (mumbles) here, and just inject 40 milligrams of (mumbles) and one cc to .5 (mumbles). If you've already got (mumbles) on the (mumbles), so you've done that, and then you numb their neural foramen as well

and give them some pain relief, and then you give them some optimism because optimism is essential to recovery, and optimists do better than pessimists. It's very difficult to get pessimistic patients well. But if you make people pain free and optimistic,

they do well. - In fact, the pessimistic patients are liver transplants and lung transplants who have osteoporotic fractures as a result of their therapy and they're in pain, they've been on huge doses of hydromorphone

or methadone, whatever they're onto eventually, and that's their lifestyle. And you can treat the fractures, but you don't make them happy, because they continue to complain of pain and problems. Those are the only patients,

and that would be the 5% that you've had in your thing. My 5% of those patients. But you know you've treated them and you know that the fractures, that they're better, from that point of view, and you can see that followup imaging.

But they are the same people (laughs) at the end of it. Sorry, not stereotyping, but it's a group. Yep. - [Man] I'm sure I'll get a different answer from the two of you, but I'm trying to wrap my head around

which cases will benefit from using a balloon to create a cavity, and which patients don't require it and just have a plain vertebroplasty. - One of the sort of consensus papers that (mumbles) and Jeff Cohen (mumbles) as part of that present thing is,

if there's absent cortex, that's probably, that is the patient that the vertebroplasty can be done, but it's a very, very, very much more riskier procedure. And your chances of getting the same result. So where you want to control the symptoms and protect the cement and protect the cord,

then that's why I'd use a balloon. I think that's also where radiofrequency ablation comes in or cryoablation or some other focal tumor ablation technique comes in which is going to actually create or render, while they're not actually removing tumor

or compacting tumor, these other techniques, they're creating a virtual space that augmentation can take place at that point. And I think that that's really the main criteria. If you have a fracture that, for instance that one that you see

where the vertebra is doing this. Those are very hard to treat with vertebroplasty 'cause there's so much movement happening just with respiration that you do treatment by putting two balloons in, one on each pedicle, you leave one balloon out

while you, in fact, put the cement on the other side, and then you actually allow that, you wait for that to polymerize and then you drop the balloon on the other side and then you've (mumbles). So there are different things that you can do.

I like to do, if I'm doing that tumor that has tumor in the canal or coming back towards the canal and they're getting pain and it's palliative, now we're talking palliative patients here, I do a very anterior balloon kyphoplasty. So I'll put the in the anterior 2/3 of the body.

And that, I don't want to see cement in the posterior third of the vertebral body.

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