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?

Spinal trauma, also referred to as spinal cord injury, occurs when a section of your spinal cord or the nerves at the edge of your spinal canal is damaged. The spinal cord acts as a messenger between the brain and other parts of your body. If the spine sustains an injury, all or some of these impulses may not get through. This may result in complete loss of mobility and sensation below the site of injury. An injury closer to the neck can cause paralysis throughout a larger part of the body than in the lower back region.

How do such injuries occur?

Often, spinal trauma or injury results from a violent event or an unpredictable accident. The following may severely damage your spinal cord-

  A violent attack (a gunshot or a stabbing)
  A motor vehicle accident that may cause trauma to the neck, back or head
  Falling from a great height
  Spinal or head injuries during some sports activity
  Electrical accidents

What are the signs of a spinal cord injury?

The followings signs and symptoms can be observed after an injury to the spinal cord-

  Difficulty walking
  Restricted movement of the legs and arms
  Stiffness, pressure and intense pain in the neck/back
  Loss of sensation
  Muscle spasms
  Loss of bowel or bladder control
  A twisted neck or back
  Lack of coordination, weakness or paralysis in any of the body part

When should you see a doctor?

If you experience significant trauma to the neck or head, accompanied by the above symptoms, then visit a doctor immediately. Spinal trauma or injuries is a debilitating condition and can deteriorate further if you do not seek medical intervention. In fact, if such an injury is not detected on time, you may have to face more severe complications. For instance, paralysis or numbness may develop immediately or gradually as blood clots and swelling occur in the surrounding region of the spine.

The doctor can detect spinal injuries using any of the following methods-

  CT Scan
  MRI
  X-ray

What is the treatment for spinal trauma?

An orthopaedic will recommend the correct treatment for spinal trauma or spinal cord injuries, depending on the severity of the condition.

  Medications - Intravenous medications can help reduce the pain and symptoms of acute spinal cord injury
  Immobilization - Braces, corsets, or neck collar can help realign and stabilize the spine
  Surgery - Surgery may be performed to remove bone fragments, herniated disks, foreign objects, or fractured vertebrae that are compressing the spine. Surgery also prevents deformity and pain in the long run.

Recovery starts typically within a week after the treatment. If you undergo surgery, you will have to wait a little longer to get back to your day-to-day activities. It is advisable that you follow up with your doctor and carry on physiotherapy for the first six months at least.

Spinal Trauma - When Should You Consult A Doctor?

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

A broken bone or a fracture can be painful and it requires medical attention for the fracture to heal properly. Proper healing is necessary for the right alignment of the bone. A doctor chooses to either reduce or set the bone in terms of new alignment. The bone reduction can happen manually or surgically depending on the severity of the injury. A Surgical procedure known as the open reduction internal fixation is performed for serious fractures. It ensures that the all the broken pieces are fixed together and the injury can heal properly.
Post the fracture, the bone need to be immobilised for proper healing. This is generally achieved by imposing a cast. For fractures that are not severe in nature, a doctor might choose to impose a temporary cast so that simple motion can happen around the site of the injury. For serious fractures, a permanent cast is placed around the injury site. In the case of a shoulder injury, a patient is required to wear a sling so that the bones are immobilised.


Time Duration of a Therapy Session:
While the exact duration of physiotherapy can vary from individual to individual, it takes a minimum of 2-8 weeks for the fracture to completely heal. Certain fractures take more time to heal. The rate of healing also depends on the severity of the injury, pain threshold level of the patient, extent of work with the physiotherapist, the robustness of the physiotherapy program, extent of the injury of the soft tissue and certain other factors. Typically shoulder and neck injuries heal quicker than a fracture of the legs. The time duration of fracture healing also depends on the type of bone that has been affected.


Physiotherapy in a Hospital:
If the fracture happens in the ankle or leg, a physiotherapist might have to intervene in the hospital in order to teach patient about using assistive devices such as crutches and cane. Things that are taught during this time include using the device in order to climb stairs, right walking posture, getting into a car, taking the device off while sitting and such other techniques.


Physiotherapy at Home:
Physiotherapy can also happen from home if the doctor specifically instructs to do the same. This is typically done for people where the condition is too serious to go outside and get the physiotherapy done. Certain weight bearing restrictions are imposed around this time. The training remains the same as in the case with a hospital.


In the Clinic:
Once the patient becomes mobile enough, a doctor might suggest a patient go to a clinic to get the physiotherapy done. A physiotherapist evaluates certain things such as pain, range of motion, gait, flexibility etc. of the patient before suggesting a certain exercise plan. 




How Long Do You Need Physiotherapy Post-Fractures?

If you have been facing back problems in the form of pain and discomfort for a long time despite undergoing treatment and medications, then you must be wondering whether you should go for a spine surgery. With the advancement in technology in the field of medical surgery, spine surgery has gained popularity owing to its effectiveness and high success rate. However, there are plenty of misconceptions regarding spine surgery, which need to be busted so that people do not make decisions based on these false beliefs.

Here are five myths about spine surgery debunked-

  Myth: Surgery is a must if you have damaged discs.
Fact: Many people live with a herniated disc. It is a fairly common spinal condition. The common belief is that you need to undergo a surgery to fix the problem. However, it is not true. In fact, many people have found relief from back pain following non-surgical methods such as physiotherapy and low-key exercises. These are the initial course of the treatment and usually, the patient sees positive results after the completion of the course.

  Myth: Surgery can relieve you from back pain completely.
Fact: Spine surgery is meant to correct spinal problems by restoring the functioning of your spine and reducing back pain. However, a surgery cannot relieve you from the pain completely. In other words, it cannot fix the problem entirely. There are certain parameters, which you need to correct on your own. These include maintaining a healthy body weight, living a healthy and active life, eating a balanced diet etc. Nevertheless, if the spine problem/injury is diagnosed early, the chances of a successful spine surgery increase.

  Myth: Spine surgery has serious repercussions, and it is not worth a try.
Fact: Like all other types of surgery, spine surgery too has a few risks or side effects associated with it. The most common types include blood clots, infection, weakness, and bleeding. However, these are not as serious as it sounds like. Since most of the surgeries are minimally invasive today, the minor side effects do not last more than a week and recovery takes place sooner. The side effects can also be managed with pain management medications well so the patient need not worry.

  Myth: Visiting a spine surgeon means you will definitely need a surgery.
Fact: Your orthopaedic may advise you to see a spine surgeon if the symptoms of your spine injury/problem become severe. This does not necessarily mean you will have to undergo a surgery. Sometimes, the doctor may schedule an appointment with the surgeon to have a unique perspective of the condition. Surgery is prescribed only as the last resort.

  Myth: Undergoing a surgery once means you will need another one soon.
Fact: If you have gone under the knife once, it does not necessarily mean you will need another surgery soon. Multiple surgical procedures are required only if the patient has sustained complex trauma to the spine. Such cases are rare. Usually, the patient undergoes spine surgery once, following which he/she is provided with a post-operative guideline. The guideline suggests engaging in mild exercises and making vital lifestyle changes to ensure fast recovery.

If you have been suffering from persistent, recurring pain in the back or neck that has altered or affected your quality of life in a negative way, its time you should consult a doctor. Do not hesitate if you need to undergo e a spine surgery urgently. The facts stated above will help clear your mind and eliminate any false belief that you had been holding in.

Spine Surgery - Busting The Myths Around It!

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