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!

Knee pain is a common phenomenon that plagues most of the people irrespective of their age. It can be the outcome of a torn cartilage or a ruptured ligament. Medical complications, such as infections, gout or arthritis (painful inflammation and stiffness of the joints) can also give way to knee pain. Minor knee pain can be eased by self-care remedies such as physical therapy or by putting on knee braces. However, few complications might demand surgical repair. Pain can be managed by the pain management specialists.

Tips to manage knee pain

1. Medications such as naproxen, ibuprofen and acetaminophen can be administered to help remedy knee pain.
2. You can seek relief by massaging your knees with ointments constituting of a number of agents such as capsaicin or lidocaine.
3. Keep away from your usual chores to prevent repetitive strains on the knees, thus, allowing the injury to heal as well as to stay safe from further damage.
4. Applying an ice pack in a towel can ease the inflammation and pain. But do not extend its usage for more than 20 minutes because that might harm the skin and nerves.
5. Compression bandages can inhibit fluid accumulation in the damaged tissues aiding knee alignment stability. Ensure that it is tight enough to render support to your knees without actually obstructing blood circulation.
6. To pacify the swelling, try resting your sore leg on a pillow (the idea here is to keep the affected leg elevated to reduce further pain).
7. Shed off your extra pounds as being overweight increases chances of other disorders such as osteoarthritis.
8. Go for regular work outs to enhance and maintain the flexibility of your muscles as excessively weak or abnormally tight muscles can contribute to injuries. Be smart while choosing your method of exercise based on the condition you are suffering from.

Knee Pain - 8 Effective Ways to Manage it

Total Hip Replacement is also known as Total Hip Arthroplasty, in which the damaged cartilage and bones in the hip area are removed and replaced with prosthetic components. On the other hand, Total Knee Replacement, also known as Total Knee Arthroplasty or resurfacing, involves replacing the bone surface of the knee area. 

Causes of Hip and Knee Pain 

Arthritis is the most common cause of chronic hip and knee pain or disability. Other causes include: 

  Avascular necrosis or Osteonecrosis is a condition where there is an inadequate supply of blood to the femoral head due to a hip injury. The inadequate supply of blood may cause the bone surface to collapse and this can result in arthritis. 

  Rheumatoid Arthritis is the most common inflammatory Arthritis. In this condition, the synovial membrane surrounding the joint begins to thicken and become inflamed. This results in cartilage loss, stiffness, and pain. 

  Osteoarthritis is the type of arthritis, usually related to old age but can occur among young people too. The cartilage cushioning the hip and knee bones becomes soft and gradually wears off. The bones eventually start rubbing against each other which causes stiffness and pain in the knee and hip area. 

  Post-Traumatic Arthritis can follow a severe hip and knee fracture or injury. 

  Some children with hip disease or problem, even after treatment, can develop into arthritis later. This may be caused by uneven or unusual growth of hip which affects the joint surfaces. 

Knee Replacement Procedure 

  Bone Preparation: The surface of impaired cartilage at the end of the tibia and femur are separated besides a small extent of the underlying bone. 

  Locating the Metal Implants: The removed bone and cartilage are substituted by metal implants creating the joint surface. These metal pieces may either be press-fit or cemented into the bone. 

  Resurfacing the Patella: The undersurface of the kneecap or Patella is cropped and reformed with a plastic button. This process is variable depending upon the condition. 

  Inserting a Spacer: To form a smooth gliding surface, a plastic spacer of medical-grade is positioned between the metal components. 

Hip Replacement Procedure 

  Metal stem replaces the damaged femoral head and positioned into the femur s hollow center. 

  On the upper portion of the stem, a ceramic or metal ball is planted. This ball acts as a substitute for the damaged/detached femoral head. 

  The damaged Acetabulum or cartilage surface of the socket is discarded and supplanted by a metal socket. Cement or screws are used to sustain the socket in place. 

  A spacer, either metallic, plastic or ceramic is placed between the socket and the new ball for a smooth gliding surface. 

Take Away 

Knee and Hip Replacement are taken as the last option for the patient. The surgery and its outcome vary depending upon various factors. One should consult the doctor before undergoing for the Hip and Knee Replacement Surgery.

Primary Knee & Hip Replacement - Know More About Them!

The term Sciatica is used to describe leg pain, tingling, numbness or weakness that travels down the low back via the sciatic nerve to the back of leg. Sciatic nerve arises from each side of lower spine and passes deep in the buttock along the back of thigh and legs. The pain of Sciatica may be irregular/ infrequent or persistent causing severe agony to the patients. The pain of Sciatica may be confined to low back or hips or may extend up to toes. The pain of Sciatica can be excruciating and "not relieved by painkillers".

What causes Sciatica?

Pain in Sciatica is due to irritation or pinching of Sciatic nerve within the spine. This occurs most commonly due to prolapsed intervertebral disc (slip disc) causing nerve compression resulting in pain.

Is surgery the only treatment for Sciatica?

Most patients can be managed with medication/exercises. So surgery is not the only way out. Patients who have severe pain can also benefit from "Epidural Steroid Injection". This treatment has proven to be effective in avoiding spine surgery in such patients.

What is Epidural Steroid Injection?

Epidural Steroid Injection is a procedure done by a Specialist (Interventional Pain) in an Operation Theatre using X-Ray (Image Intensifier) to locate exact level of injection. A drug mixture consisting of Steroid with Local Anaesthetic is injected at the epidural space of affected nerve root. The steroid washes away inflammatory mediators from the epidural space which decreases the pain. Steroid also decreases the inflammatory response of body to the prolapsed disc. As a result the pain arising from nerve inflammation is decreased. This is a day care procedure i.e. the patients are discharged the same day.

How is the possibility of surgery ruled out?

Epidural Steroid Injection is a proven, safe and an effective treatment that works on the concept of Interventional pain management - to provide relief from persistent and chronic pain of Sciatica. Generally, a single injection is sufficient to relieve patients of the pain. The procedure can be repeated for a maximum 3 times in a year, depending on the patient's response. With effective pain relief, surgery is negated.

Non-Surgical Treatment For Sciatica

The backbone is made up of multiple small bones which are connected together by a softer bone. The spine is what allows important body movements including bending and walking. The issue is, with age, the backbone also loses its elasticity and becomes rigid. Though this is a natural process with ageing, lack of exercise and sedentary lifestyle makes it worse.

Lumbar spondylosis is the medical term for this chronic, degenerative condition of the lumbar and the sacral spines (the lower portion of the backbone). This leads to chronic stiffening of the spine, affecting movement. This joint is very crucial in all bending movements and spinal movements.

Causes of Lumbar Spondylosis:

Ageing: As the condition progresses, the nerves that run through the spines can get exposed and there could be pain and irritation
Genetic abnormalities that produce a weak bone
Spinal trauma like accident or falls
Sedentary lifestyle: Sitting in front of the computer for prolonged hours also causes lumbar spondylosis
Overuse: People who are weightlifters tend to put excessive pressure on the spine, causing lumbar spondylosis
Symptoms:

Stiffness and pain in the low back
Pain with continued sitting
Numbness and tingling if nerves are getting affected
Loss of balance, leading to frequent falls
Losing control over bowel and bladder movement
Pain radiating to the lower legs
Ayurvedic remedies: This includes a combination of external applications, yoga, and food preparations including kashayas and tailas.

This condition is caused by increased Vata and Kapha. Maharasnadi kashayam, Astavarga kashayam, and Dashamoola kashayam reduce these elements.
Pain and inflammation is relieved by the use of various Guggulu including Mahayogaraja Guggulu, Simhanada Guggulu, Trayodashang Guggulu, and Dhanvantara Vati  
The affected joints can be hydrated with the use of gandha taila and dhanwantharam.
Kukkutandatvak bhasma is known to strengthen the bone.
Ashwagandha is known to lubricate the vertebral disks and joints
External treatments like Abhyanga are useful in improving joint movement. They improve circulation and help in removal of toxins so that pure blood can flow and reduce inflammation.
Vasti: This helps in improving nutrition to the joints and bones, thereby helping them repair themselves and heal.
Yogas for lumbar spondylosis: The five most effective asanas are:

Ardhakati chakrasana
Pada hastasana
Matsyasana
Ardha chakrasana
Vakrasana (sitting in a chair)
Additional measures:

Sit in a comfortable position with adequate back support
Take short breaks to avoid continued sitting
Sleep comfortably, by resting the back adequately
Strengthen the back muscles by regular exercises.
Eat healthy, avoid junk, and drink plenty of water.

Lumbar Spondylosis & Ayurveda - What To Expect

Ayurveda is a very old system of medicine, which originated in India. Using herbs found in nature to cure various illnesses, knee pain can also be permanently cured with this method indigenous to India. It reduces knee pain caused by various illnesses including arthritis, inflammation of the cartilage and wearing of the patella among others. Here are some common Ayurvedic remedies, which help reduce knee pain:

1. Alfalfa: Alfalfa is medically known as Medicago Sativa. Alfalfa is excellent for making sure that your joint pain reduces, when taken in liquid form four times a day.

2. Ashwagandha: Ashwagandha is medically known as Withania Somnifera. In the West, Ashwagandha is popularly known as Winter Cherry. Also, it has a lot of therapeutic properties, which include reducing joint pains. 

3. Banyan: The Banyan tree's medical name is Ficus Benghalensis. It has a sap very similar to the form of rubber known as latex is derived from the Banyan tree. The Banyan tree's sap is externally applied over the joints and the pain usually disappears after a few regular applications. 

4. Bishop's weed: The medical name for Bishop's weed is Trachyspermum Ammi. The oil extracted from this herb is usually applied to the knees to reduce the intensity of such knee pains.

5. Celery: The medical name for celery is Apium Graveolens. Celery is not only an effective treatment for rheumatoid arthritis and associated pains in the knees, but it is also helpful in treating gout. It is usually agreed upon that this particular treatment is usually long lasting because of its alkaline nature.

6. Dandelion: Dandelion's biological name is Taraxacum Officinale. It is rich in magnesium and is crucial for the correct mineralization of the bones. This mineralization allows the bones to become stronger and also prevents knee pain.

7.  Garlic: The medical name for garlic is allium sativum. Five to six cloves eaten everyday has proved to reduce knee pains.

8. Ginger: Ginger is biologically called Zingiber Officinale. These can be easily included in your diet and go a long way in curbing knee pain.

Ayurveda and Knee Pain

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