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!

Simple exercises for relief from knee pain

A lot of people suffer from knee pain, some hereditary, some due to injuries and some due to other reasons. Whatever be the reasons, the pain is very bothersome. 

Try the following exercises regularly to get relief from knee pain.

1. Leg lifts - sit straight on a chair with your feet firmly on the ground. Lift the leg for which the knee pains, until it is parallel to the ground. Hold for a couple of seconds and bring back to the initial position. Do 10 reps every day.

2. Knee bending - sit on a chair and keep a stool of same height as the chair in front of you. Place your knee on the stool, knee slightly bent. Slowly, straighten your leg and hold in the straight position for a couple of seconds before you release. Do 10 reps.

3. Leg straightening - stand straight and place the foot on a low platform. Bend down, place both your palms on the knee and slowly push it down until your leg is straight. Push only as far as it doesn't hurt too much. Hold for a few seconds and release.

4. Stretching - sit upright. Bring your leg towards your chest by bending the knee and keeping your hand above the ankle. Push your heel towards your buttocks. Release after a couple of seconds.

5. Chair pulling - stand straight near a door keeping your feet apart (shoulder-width), in front of a chair. Hold the knob of the door and slowly, sit back on the chair. Feel the pull in the muscles and go back to previous position after 2-3 seconds. Repeat.

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5 Only Exercises For Easy Relief From Knee Pain

There are various forms of Paralysis. Paralysis of the lower limbs is one of the most severe forms of Paralysis. It is also known as Paraplegia. People suffering from such Paralysis lose all sense below the waist. They cannot move their legs or hips, cannot void without help, and cannot have intercourse. They barely feel anything below their waist. However, the degree of inability may vary from one person to another.

In people suffering from such Paralysis, there is usually substantial impairment in movement. Though such inability is not necessarily permanent, rarely do people recover from such inability. Lower Limb Paralysis may put people at risk of deep Vein Thrombosis.

Causes of Lower Limbs Paralysis:

Paralysis of the lower limbs usually results from injury to the spinal cord or the brain. However, spinal cord injury is the most common cause of such Paralysis. Such injuries inhibit the ability of the brain to receive and send signals from lower limbs. Causes of such inability may include:

Infections in the spinal cord

Lesions of the spinal cord

Tumors in the brain

Infections in the brain  

Nerve damage at the hip or waist.

Oxygen deprivation in the brain or spinal cord due to choking, violence, or surgical accidents.

Stroke

Congenital spinal cord deformities such as Spina Bifida etc.

However, the most common cause of Lower Limb Paralysis is congenital spinal deformity, such as Spina Bifida. The degree of Paralysis depends on the location of the spinal lesion and the extent of spinal cord or nerve damage. Some people with spinal lesions may even walk independently if the lesion is lower down the spine. However, people with upper spinal lesions are usually not able to do that. They may require ortho shoes as well as walking aids in order to ambulate. If these don t work, they may need wheelchairs for mobility. Usually these people learn to ambulate with the aid of ankle foot orthoses.

Treatment of Lower Limbs Paralysis:

There is no treatment for Paralysis. However, in some cases, people suffering from Lower Limb Paralysis are able to regain some of their ability with the help of physical therapy. What physiotherapy does is that it retains the spinal cord and the brain to strengthen nerve connections and muscles so that patients can work around their limitations. If paralysis is due to some underlying cause, removal of the cause can treat the patient.

If an infant is found to be suffering from Spina Bifida, doctors can operate on his spinal cord and bring down the severity of the problem. Such children are less likely than others to use walking devices.

Bowel and Bladder Management:

This is a serious aspect of Lower Limb Paralysis. Patients need to undergo routine bladder and bowel evaluation and device management plans to reduce the risk of organ damage.

Conclusion:

There is hardly any treatment for Lower Limb Paralysis. However, physical therapy may solve some of the problems. If it does not, management of bowel and bladder and watching out for deep Vein Thrombosis should be done on a regular basis.

One can also use alternative methods like Acupuncture, Chiropractic, Massage, and other holistic treatments. However, it is always recommended to consult an orthopedic doctor before opting for any methods.

Paralysis Of Lower Limbs!

Spinal fractures occur as a result of an injury or dislocation of the bony vertebra. This causes the bone fragments to pinch and damage the spinal cord. Fractures can occur anywhere along the spine but the most common site of fracture is the lower back.

What causes spinal fractures?

Spinal fractures are often a result of the following-

  A sudden traumatic injury
  A high-velocity accident
  Falling from a height
  Sports injuries
  Spinal instability
  A whiplash

Types of spinal fractures:

Spinal fractures are classified into three categories, such as the following-

  Compression fracture - If you exert excessive pressure on the vertebra, it will break. This type of fracture occurs when the bones in the spine become fragile or weak to the extent that they easily crumble. People living with osteoporosis, certain types of cancer or tumours are prone to a compression fracture.

  Dislocation - When the discs and/or ligaments linking the vertebrae is torn or stretched, the bones may dislocate or come out of alignment.

  Fracture-dislocation - Torn ligament and broken bone lead to this condition. A fracture-dislocation is a debilitating condition and often requires surgical intervention.

Symptoms of spine fractures:

Following an accident or an injury, you can tell if you have ended up fracturing your spinal column by identifying these symptoms-

  Excruciating pain
  Tingling sensation
  Numbness
  Muscle spasm
  Swelling of the muscle
  Sudden onset of back pain
  Restricted spinal mobility
  The pain worsens if you walk or stand for long
  Deformity or disability of the spine

How are spinal fractures treated?

Spinal fracture treatment begins with administering pain-management drugs and medications to ease the symptoms, and stabilization methods to prevent injury. Depending on the nature of the fracture, your doctor may follow these lines of treatment-

  Fusion and instrumentation - These are surgical procedures to cure unstable fractures. Fusion refers to the joining of the vertebrae using a bone graft along with hardware such as hooks, rods, plates, or pedicle screws. The bone graft joins the vertebrae below and above to form a solid piece of bone.

  Kyphoplasty and vertebroplasty - These are minimally invasive procedures, wherein the surgeon injects bone cement into the fractured body through a needle. During kyphoplasty, the surgeon first inserts and inflates a balloon to expand the compressed vertebrae and then fills it with bone cement.

Spinal fractures are an extremely uncomfortable and painful condition to live with. It can hinder your day-to-day activities and affect your quality of life. It is imperative that you seek immediate treatment if you end up with fractures or dislocation of the spine.

Spine Fracture - How Can You Get It Fixed?

The deltoid muscle is situated around the shoulder joint that makes up the shoulder. It is classified into three parts - front, side and rear deltoids. It is one of the most frequently used muscles in the body, its major functions are abduction and forward elevation of the arm.

Causes
A deltoid strain is a condition where you experience pain and tenderness in the shoulder area due to various causes like overuse of the deltoid muscle. It is very common in weightlifting and various sports such as cricket. It may even lead to partial loss of function in the deltoid muscle. Deltoid strain may be caused due to overworking of the muscle without adequate rest. It may also be caused due to lengthening of the deltoid muscle under stress or direct trauma to the muscle.

There are three types of deltoid strains

Grade 1 deltoid strain: It is characterized by tight muscles with some possible swelling. There may be mild pain when you use your shoulders for any activity.
Grade 2 deltoid strain: This strain is a result of a major injury to the deltoid muscle; there may be visible swelling and pain while carrying out activities that require movement of the shoulder. Lifting your arm to the front or the sides becomes difficult and painful.
Grade 3 deltoid strain: This form of deltoid strain is the most severe of the three; it may cause the shoulders to become immobile. You usually will experience excessive pain and severe swelling. You might not be able to move your arm and carry out any activity that requires the shoulders.
Diagnosis
The diagnosis of a deltoid strain starts with a physical exam where the doctor will understand the symptoms of the deltoid strain. Various imaging tests such as x-rays may be required for the diagnosis. The basic treatment for shoulder strain comprises of the RICE protocol (rest, ice, compression and elevation) which is used to treat grade 1 and grade 2 strains. Grade 3 strains may require surgery in addition to the above treatment methods. In case of excess pain, the doctor may prescribe non-steroidal anti-inflammatory drugs to ease the pain.

All About Deltoid Strain!

Back pain is one of the most common debilitating disorder in the world today. The pain affects 90% of people at some point of their lives. Human back comprises of various structures (see figure) which are nerves, bones, muscles, ligaments, and tendons, any or all of which can be a source of pain. Once back pain occurs, it may become chronic (more than 4 weeks) and you shall need to consult a pain physician for relief and accurate diagnosis.
Since prevention is always better than cure,  you can save yourself from having back pain if you follow these basic tips.
Regular Exercise in Correct Form: Regular exercise is important to maintain proper muscular strength of the back. Human back is supported by several big muscle groups (see figure). They serve two functions - one is to facilitate the posture and movements of the back itself and the other is to help movements of the rest of the body appendages (arms, head, pelvis and legs).The health of these muscle group is important to take stress off the spinal bones and maintain proper function. Most of these muscles are red muscle fibers as they need to maintain their activity for prolonged periods of time. Just to give you an idea - your biceps (arm muscles) have to work only when you bend your arm. But your back muscles have to function all the time - whether you sit, walk, stand or even sleep. But the point is what kind of exercises are good for your back? The best exercises for back include body weight low impact aerobics like brisk walking, swimming, stationary bicycling, extension exercises and yoga. What is important to remember while doing these exercises if that you need to be gentle in your movements and achieve correct "form" - this is possible if you can ask someone (preferably a trainer) to observe and point out whether the back stays straight during the exercise. It has been seen that arching and excessive bending is associated with injury to the back while exercising.
Stay Hydrated and Eat Natural Nutritious diet:The inter vertebral discs contain 70 - 80% water. The muscles and tissues have 60% water content. Therefore, it is important to stay hydrated. In addition, you must eat a nutritious diet consisting of green leafy vegetables, good protein source and just enough carbohydrates. Deficiencies of essential nutrients like Vitamin D can result in diseases like osteoporosis. Another important aspect is to maintain body weight within healthy limits. This is very important as increased belly fat is linked to increased back pain due to mechanical factors.
Lift objects correctly and maintain proper posture:While lifting objects, keep them as close to body as possible. Do not slouch or bend excessively while lifting. Just keep your back straight at all times. You may bend your knees a little if required (see figure). Think before you lift and get help if needed.
While working, you must not sit for more than 45 minutes at a stretch. Walk for two minutes, go to a colleague's desk and say hi or even just drink some water or visit the washroom. Humans evolved as hunter - gatherers and our bodies are more adapted to walking / standing than to sitting for prolonged periods. Those of you who travel more and have to sit for long periods of time also need to follow above tips - avoid prolonged sitting in same posture.While exercising, improper position can do more harm than good. Therefore, proper form and posture is a must.
Bonus tip: Avoid cigarette smoking and those who smoke cigarettes to decrease your chances of having degenerative disc diseases leading to chronic back pain early in life.
Word of caution to prevent permanent damage: In case of back pain, which is not responding to home remedies or over the counter painkillers, please contact a Pain Physician to pinpoint the diagnosis and appropriate management.

3 Essential Tips to Prevent Back Pain

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