As life expectancy is increasing so is the incidence of vertebral body (VB) fractures now being the commonest fracture of the body. PVP is an established interventional technique in which bone cement is injected under local anaesthesia via a needle into a fractured VB with imaging guidance providing instant pain relief, increased bone strength, stability, decreasing analgesic medicines, increased mobility with improved quality of life and early return to work in days.

In this era of minimally access surgery replacing open surgeries, PVP is a novel procedure & should be in the first line of management in place of conservatism or major spine surgery for painful uncomplicated compression fracture spine.

Morbidity & consequences of spinal fracture:

Traumatic VB is a painful condition requiring bed rest restricting daily activities markedly
Left untreated it can cause DVT, increase osteoporosis, loss of VB height, respiratory & GI disturbances, emotional & social problems secondary to unremitting pain, loss of independence with high cost of rehabilitation.
High risk of primary or consequential damage to neural, bony or disc element
Increased wedging, deformity & increase incidence of adjacent VB
Chronic pain of altered spine mechanics
Uncomfortable braces & sleep disturbance because of pain & discomfort with its sequels.
Cost of surgery and hospital treatment
Cost of implants
Phobia of surgery
Prolonged recovery period & Extensive rehabilitation
Changed spinal mechanics & transition syndrome
Major surgery & anesthesia with its own complications
Results / Outcome

PVP is a novel procedure with high benefit to risk ratio, which is highly underutilized in relation to the high prevalence of the vertebral.
Different studies show an immediate pain relief in (85   90)% of patients with low complication rate ranging from (1-5)% depending upon the type of lesion.
PVP does augment height of VB but ideal would be kyphoplasty
Patient is either off medicine or on reduced doses.
Patient feels so well that he almost forgets if he had VB

Percutaneous Vertebroplasty (PVP) is an emerging interventional technique in which surgical polymethyl methacrylate bone cement is injected under local anaesthesia via a large bore needle into a vertebral body (VB) under imaging guidance providing increased bone strength, stability, pain relief, decreased analgesics, increased mobility with improved QOL and early return to work. Started in 1984 by Galibert PVP is done in host of indications.

Senile osteoporotic compression remains the commonest Indication. Other indications are Metastatic VB, Multiple myeloma VB, VB haemangioma, Vertebral osteonecrosis & for strengthening VB before major spinal surgery. The benefit has been extended to the traumatic stable uncomplicated VB compression (VCF) which is commoner in younger age group with active life profile and prime of their career where strict bed rest and acute or chronic pain are unacceptable and they are more demanding for proactive treatment approach so as to be back to work ASAP.

Discovering the fact that VB is the commonest of body, its incidence >the hip, it becomes imperative to take it more seriously. With increasing life-span there is more of aged osteoporotic population, more so due to sedentary indoor lifestyle and post menopausal osteoporosis. Diabetics, smokers & alcoholics are at higher risk of developing osteoporosis. I have seen such alcoholic patient developing six spine fractures in just three months time from a single fracture being on complete bed rest.

Quick fix of fracture spine makes patient walk back same day instead of bed rest of months together avoiding morbidity & mortality of prolonged bed rest, making bedridden patient walk, in a way bringing patient back to normal life.

In this era of MAS replacing open surgeries, PVP is a novel procedure & should be in the first line of management in place of conservatism or major spine surgery for painful uncomplicated compression.

Morbidity & consequenses of spinal 

Traumatic VB is a painful condition requiring bed rest restricting daily activities markedly.
Left untreated it can cause DVT, increase osteoporosis, loss of VB height, respiratory &
GI disturbances, emotional & social problems secondary to unremitting pain, loss of independence with high cost of rehabilitation.
High risk of primary or consequential damage to neural, bony or disc elements.
Increased wedging, deformity & increase incidence of adjacent VB
Chronic pain of altered spine mechanics.
Uncomfortable braces & sleep disturbance because of pain & discomfort with its sequels.
Morbidity and complication of spinal surgery 

Cost of surgery and hospital treatment
Cost of implants
Phobia of surgery
Prolonged recovery period & Extensive rehabilitation
Changed spinal mechanics & transition syndrome
Major surgery & anesthesia with its own complications
Preparation & Procedure:
X-ray spine in a/p & lat view. CT is more informative of bone & morphology. MRI is good for soft tissue injuries. Ask for pedicle size in all dimensions and construct a 3D image aiming needle placement and cement filling in scan room itself as rehearsal of PVP. This reduces operative time & gives better results. Conventionally PVP is done by hammering the vertebroplasty needle through the bone. Here we use light weight drill to bore through the vertebra. It is important to set the needle at exact entry site & side with right trajectory aiming the defects.

In lateral view needle should go through middle of the pedicle going up to anterior 1/3 of VB. In P/A view the needle can be in midline or paramedian depending upon & if uni/bipedicular approach is planned. Approach varies as per location of vertebra, anterolateral in cervical, costotransverse/parapedicular in thoracic & transpedicular in lumbar vertebra.

Do bone biopsy if there is any doubt about lession. Do dye test (vertebral venography). Make cement more radiopaque by adding barium /or tungsten. Inject cement with 1or2 ml luerlock syringes strictly under fluoroscope in lateral view & cross checking in P/A view. Stop injecting either there is adequate filling or at the first sight of ectopic cement leak. Keep sample cement to see for hardening. Remove needle with rotational movement before cement hardens.

Pain relief is by virtue of different mechanisms postulated :

Cementing of fragments.
Thermal neurolysis of VB nerve ending due to heat of polymerization.
Washing away of nociceptor chemicals.
Neurolytic action of liquid monomer.
By allowing early ambulation decreasing pains of immobility & bed rest.
Complications 

PVP is generally safe with low risk.
Ectopic cement leak is frequent but generally inconsequential.
Outcome 

PVP is a novel procedure with high benefit to risk ratio, which is highly underutilized in relation to the high prevalence of the vertebral
Different studies show an immediate pain relief in (85   90)% of patients with low complication rate ranging from (1-5)% depending upon the type of lesion.
PVP does augment height of VB but ideal would be kyphoplasty.
Patient is either off medicine or on reduced doses.
Patient feels so well that he almost forgets if he had VB

Vertebroplasty (PVP) / Kyphoplasty - Approach To Management Of Vertebral Body Fractures!

A broken bone is medically termed as a fracture.Fractures are linked with age as bones tend to become weak as one ages, so, the chances of a fracture occurring also increases. Fractures are usually classified into four types-
1. Closed fracture - In this type of fracture, the breaking of the bone does not result in an open wound
2. Open fracture- The opposite of closed fracture, the bone breaks through the skin. This may result in infections
3. Non-displaced fracture - in this type of fracture, the bone cracks but is not shifted out of its regular position.
4. Displaced fracture - A displaced fracture occurs when the affected bone is shifted out of its natural position.

Causes
Fractures can be caused by a number of factors, they are
1. Road accidents
2. When someone falls from a height
3. When the bone is directly exposed to a strong blow
4. When the bone is exposed to a repetitive force from activities such as sprinting
5. Osteoporosis, which is a condition where the bones become weak
6. The bones in the body tends to weaken with age, so at this time they become highly susceptible to fractures

Symptoms
1. Swelling in the area accompanied by pain
2. Limited movement of the affected joint
3. Muscle spasms
4. The affected area may also become numb

Diagnosis
The first step to diagnose a fracture is the knowing about the medical history of the patient and conducting a physical exam. The diagnosis is further confirmed by using imaging tests such as -
1. Magnetic resonance imaging (MRI) - In this procedure, images of internal body parts are taken with the help of a magnetic field and pulses of radio energy. MRIs can pick up signs of fractures very quickly, that is within the first week of injury. It is also easier to distinguish fractures from other related injuries in case of MRI.
2. X-rays -X-rays are a procedure that involves sending x-ray particles through an area to detect a fracture. Signs of a fracture may take several weeks to show up in x-rays.
3. Bone scan - In bone scans, some radioactive material is put inside the body through intravenous methods. These material tend to accumulate in the fractured area which then shows up in the images as a bright spot. If you wish to discuss about any specific problem, you can consult an Orthopedist.

How Is A Fracture Diagnosed?

At some point in life most people experience acute pain in their lower back which is extremely painful. Pain in the spine causes a lot of discomfort and disruption in the life of an individual and hence, it is always better to get it checked on time. There are patients who even wonder when they should consult a neurosurgeon or a spine surgeon for their back pain. It is advisable that a physical examination is done by a primary care physician for low back pain before consulting a spine surgeon.

Why consult a Physical care Physician First?
The main reason to consult a primary care physician at first is that he would prescribe medications for severe lower back pain. The medications could include non-narcotic pain medications such as Ultram or non-steroidal anti-inflammatory drugs such as Motrin. The physician can even refer you to a chiropractor or for physical therapy to get relief from the back pain. Mechanical means are made use of by a chiropractor mainly to alleviate the back pain of the patient.

If the patient feels better with the physical therapy or the medications prescribed by the family doctor and is able to resume normal activities, then there is no need to see a spine surgeon. It is often recommended to take good care of the back and to exercise. A combination of ergonomics, regular stretching and improved everyday posture is beneficial as it reduces the chance of causing pain in the lower back. Exercise plays a very important role and it provides the possibility of reducing the pain.

Conservative Care for Treating Lower back Pain
It is best for patients to consult a conservative care specialist if after consulting a chiropractor they do not find any reduction in their pain and they do not want to undergo spine surgery. The conservative care specialists are well-trained in rehabilitation of musculoskeletal disorders and specialize in spine care. The role of the conservative care specialist is similar to a cardiologist who specializes in treating neurological disorders.

The specialist for spine care works along with the surgeon in a spine center to treat the lower back pain. The specialist is trained in diagnostic techniques and is capable of making use of a combination of diagnostic tests as well as injection techniques such as epidural steroid injections to diagnose the source of the lower back pain in a patient. They can even advise patients whether it is appropriate to consult a spine surgeon for surgery. Surgery is done to correct the anatomical conditions and it is performed only when non-surgical treatments are not successful in alleviating the pain of the patient.

When Is The Right Time To See A Spine Surgeon?

Spinal fusion is a surgery in which two or more vertebrae in the vertebral column or back are fused or joined to treat a slew of spinal problems and diseases, which cause debilitating back pain. This surgery helps to remove bone and tissue that are narrowing the spinal canal, squeezing the spinal cord and nerves, reducing pain and improving function.

There are many different causes of back pain like injury, poor posture, age, osteoarthritis, herniation of disc between two vertebrae, degenerative disc disease, narrowing of spine called stenosis, and spondylosis or lessening of space between the vertebrae- most of these can be treated using spinal fusion.

All of these causes put tremendous pressure on the vertebrae and pinch spinal nerves that pass through the back and radiate out into the arms, legs and torso. Apart from the pain, patients experience nerve and muscle weakness and irreversible damage affecting normal life.

Spinal fusion started off as just a treatment for fractures but now it has become the surgery of choice for a number of spine problems. Though it can be done anywhere in the spine, it is very effective when done in the lower part of the spine called lumbar spinal fusion or arthrodesis.

Spinal fusion is done by forming a direct bony connection between the vertebrae surrounding the painful discs, the cushioning between the vertebrae. Pain is stopped by stopping the motion of the painful discs.

There are different methods of spinal fusion each with its own advantages and limitations.

Techniques include fusion approached from the front, the back, or both of the vertebral column. Sometimes surgeons decide to use intervertebral cages or metal screws to provide internal structural support while the bone fuses. These cages may be placed between the vertebrae and packed with bone graft material taken from the patient or constructed out of synthetic materials.

What to expect?
Spinal fusion is not a risk-free procedure. It is a major surgery lasting several hours and carrying a number of risks like-

Failure of the vertebral fusion and breaking of metal implants
The vertebrae above and below the fusion can wear away aggravating problems
Blood clots may be formed that can travel to lungs causing embolism
Injury to spinal nerves causing permanent weakness in legs and problem with bladder and bowel function
Infections and blood loss
Heart attack or stroke during surgery
The patient has to be kept in hospital for a couple of days for post-operative care after which he will have to undergo rehabilitation for months. Hence, one should really think before going for spinal fusion. And when it is recommended, seek a second opinion before making a decision. 

Spinal Fusion Surgery - What To Expect?

A spinal cord injury is a damage to the spinal cord. It s an extremely serious type of physical trauma that s likely to have a lasting and significant impact on most aspects of daily life.

The spinal cord is responsible for sending messages from the brain to all parts of the body. It also sends messages from the body to the brain. We are able to perceive pain and move our limbs because of messages sent through the spinal cord.

If the spinal cord sustains an injury, some or all of these impulses may not be able to  get through . The result is a complete or total loss of sensation and mobility below the injury. A spinal cord injury closer to the neck will typically cause paralysis throughout a larger part of the body than one in the lower back area.

Causes-

A spinal cord injury is often the result of an unpredictable accident or violent event. The following can all result in damage to the spinal cord:

a violent attack such as a stabbing or a gunshot
diving into water that s too shallow and hitting the bottom
trauma during a car accident (specifically, trauma to the face, head and neck region, back, or chest area)
falling from a significant height
head or spinal injuries during sporting events
electrical accidents
severe twisting of the middle portion of the torso
Symptoms-

Some symptoms of a spinal cord injury include:

problems walking
loss of control of the bladder or bowels
inability to move the arms or legs
feelings of spreading numbness or tingling in the extremities
unconsciousness
headache
pain, pressure, stiffness in the back or neck area
signs of shock
unnatural positioning of the head
If you suspect that someone has a back or neck injury:

Don t move the injured person   permanent paralysis and other serious complications may result
Call 911 or your local emergency medical assistance number
Keep the person still
Place heavy towels on both sides of the neck or hold the head and neck to prevent them from moving until emergency care arrives
Provide basic first aid, such as stopping any bleeding and making the person comfortable, without moving the head or neck
Prevention-

Because spinal cord injuries are often due to unpredictable events, the best you can do is reduce your risk.

 Some risk-reducing measures include:

always wearing a seatbelt while in a car
wearing proper protective gear while playing sports
never diving into water unless you ve examined it first to make sure it s deep enough and free of rocks

Spinal Cord Injury - Signs, Causes & Prevention

Breaking a bone no matter how small is painful. This pain is caused both by the actual break in the bone and the damage to surrounding muscles, ligaments, nerves and other soft tissue. There are three stages of pain caused by a fracture:

Acute Pain: Pain that occurs immediately after a bone is fractured
Sub-Acute Pain: Pain experienced while the one and soft tissues heal
Chronic Pain: Pain experienced after the fracture has healed
Any kind of fracture can cause these types of pain. However, it is not essential for everyone who has had a fracture to experience all the three kinds of pain. Many people experience pain only when the fracture occurs but in few cases, a person may break a bone and not realize it. Each type of pain needs to be dealt with in a different way.

Acute Pain: Acute pain reduces as the fracture heals. For this, the fractured bone must be reset in place and held together with a splint, brace or cast so as to immobilize it. In some cases, surgery may also be needed. Over the counter pain medication is often prescribed to help deal with this type of pain. The patient is also advised to rest the broken bone and avoid certain types of movement that could worsen the break. A broken bone takes a minimum of 6 to 8 weeks to heal. However, in cases of other conditions such as osteoporosis, this time period could be much longer.
Sub-Acute Pain: As the injury heals, the sub-acute pain experienced reduces. Immobilizing a broken bone to help it heal causes the muscles and soft tissues around it to stiffen and weaken thus triggering this type of pain. Physical therapy can be very helpful in dealing with this type of pain. Along with strengthening the muscles and reducing stiffness, physical therapy also helps reduce inflammation and scar tissue. Physical therapy can be provided in many ways including exercises, electrical stimulation, ultrasounds, massage etc. It is important to remember that at this stage of treatment, the more the affected limb is used, the faster it will heal. However, it is advisable to avoid putting too much pressure on the bone.
Chronic Pain: Some people may experience pain for several months and even years after a fracture has healed. This is usually caused by nerve damage or the development of scar tissue. Underlying conditions such as arthritis could also trigger this type of pain. Management of chronic pain varies from individual to individual. Treatment usually takes the form of medication, exercises and physical therapy. It is important not to avoid this type of pain and consult a doctor to ensure that it is not being caused by any other condition.

Fracture Pain - How To Deal With It?

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