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!

The presence of a lump or a tumor in the breast is not always indicative of breast cancer. In some instances, the breast tumor can be benign or noncancerous as well. Thus, to understand breast cancer better, one should know the difference between a benign and malignant breast tumor. In this article, we will discuss the factors that differentiate a benign breast tumor from a malignant one.

Breast Fibroadenomas

Breast Fibroadenomas are benign breast tumors that often affect women in their early 20s and 30s (can also affect women of other age groups). Research suggests that in spite of being benign and noncancerous, breast fibroadenomas make a woman more susceptible to breast cancer in the future.
It may be difficult to decipher the underlying factor that triggers fibroadenomas. However, increased use of birth control pills (that results in an elevated estrogen level) can be a contributing factor.
Thus, in spite of no discomfort, it is safe to get fibroadenomas removed by lumpectomy or by radiation therapy. There are also instances when fibroadenomas dissolved on their own.
Sometimes, the lobules of the breast can undergo enlargement resulting in the formation of lumps (can be a tumor or a cyst) that are non-cancerous in nature. Such tumors are known as Adenosis.
The benign tumor growth can also develop in the milk ducts of the nipples, a condition known as  Intraductal papillomas (characterized by discharge from the nipples).
To stay safe and lower the risk of breast cancer, doctors often recommend the removal of the tumor.
Differences between Benign and Malignant Breast Tumors

One of the major factors resulting in a tumor is the abnormal growth of cells that could be triggered by an injury, an infection or prolonged inflammation.
A factor that plays a pivotal role in differentiating malignant from benign breast lumps or tumors is its ability to metastasize or invade other organs, cells and tissues of the body.
A malignant tumor starts off as a primary tumor that remains confined within its point of origin. Gradually, the cancerous growth metastasize, invading other neighboring as well as distant cells and body organs (Secondary cancer or tumor).
Benign tumors, on the other hand, contains chemical adhesions that prevent their metastasis and invasion to the other vital organs in the body.
As compared to malignant tumors, benign breast tumors, once removed, do not recur.
On the cellular level, microscopic examination reveals that malignant breast tumors often contain unusual, mutated, and modified genes and chromosomes.
More than often, malignant breast tumors give rise to Paraneoplastic Syndrome. The Paraneoplastic Syndrome is characterized by an elevated production of substances (can be antibodies or hormones) by the cancerous growths or tumors. The hormones or the antibodies circulate in the bloodstream and can alter the functioning of a host of vital body tissues and organs with deleterious health consequences.
Such things seldom take place in the case of benign breast tumors.

Benign & Malignant Breast Tumors - Things You Must Be Aware Of!

In case you have a diseased uterus, which makes you infertile, you can undergo a procedure known as uterus transplant or uterine transplant to get pregnant. In the process of sexual reproduction, a diseased uterus does not allow embryonic implantation. This factor is referred to as uterine factor infertility or UFI. As a result, you will not be able to get pregnant.

Who requires a uterus transplant?
This procedure involves women who have UFI and women who had their uterus removed by hysterectomy. Women who have a damaged uterus on account of an injury or infection, which does not function anymore, can also undergo a uterus transplant procedure. Women from the age of 21 to 45 are eligible for this procedure. Many women are born without having a uterus. This condition is called Mayer-Rokitansky-K ster-Hauser syndrome.

Procedure
Uterus transplantation begins with undertaking a uterus retrieval surgery on the uterus donor. The uterus, which is recovered has to be stored and transported to the location of the patient undergoing the transplant. An ischemic tolerance may last over 24 hours. Three major surgeries have to be carried out with the recipient. Firstly, a transplantation surgery is required in which the donor s uterus gets transplanted. In case pregnancy develops, a caesarean section surgery has to be performed. The patient is given immune suppressive therapy. After childbirth, a hysterectomy is done in order to terminate the immune suppressive therapy.

Will the women be able to get pregnant after having sex?
Women receiving a uterus transplant will not be capable of becoming pregnant without undergoing fertility treatments. The transplanted uterus is not connected with the fallopian tubes, which is the location of the normal fertilisation process. The women will require to carry out IVF or in vitro fertilisation to become pregnant after a uterus transplant. IVF is a process in which the eggs are removed from the ovaries and get fertilised in a laboratory. Then, they are implanted in the uterus. After undergoing the uterus transplant procedure, a woman has to wait for a period of one year. The uterus requires time for healing and after recovery, the embryo may be implanted for pregnancy. After giving birth successfully, a woman will be able to keep the transplanted uterus.

She has the option to get pregnant again. However, after giving birth twice, a hysterectomy must be carried out for the removal of the uterus. This is done so that the woman can stop using the immune suppressant drugs, which are associated with major risks. Uterus transplant is a relatively new technology. In October 2014, the first healthy baby was born to a woman who had undergone a uterus transplant. This surgery is kind of experimental in nature and is usually the last option for getting pregnant. 

Diseased Uterus - Can it be Replaced?

If you are concerned about breast cancer, you should know about the steps you can take to prevent the condition. Breast cancer is a type of cancer developing from the breast tissue. Symptoms such as a lump in the breast, fluid flowing from the nipple, changes in the shape of the breast and occurrence of red scaly patches on the breast denote breast cancer.

You need to make certain lifestyle changes in order to prevent breast cancer. The ways you should adopt include the following:

Limit your alcohol intake: The more you consume alcohol, the more you put yourself at the risk of getting breast cancer. It is recommended for you not to drink more than one drink per day. Small amounts of alcohol increase the risk of breast cancer as well.

Abstain from smoking: There is a direct link between tobacco smoking and breast cancer, and the risk is even more in premenopausal women. You should quit smoking to reduce the risk of breast cancer along with many other conditions, which can develop because of the ill-effects of smoking.

Control your weight: Obese women are more prone to breast cancer when compared with women with a healthy weight. This is especially true when obesity occurs at a later stage in life, after menopause.

Keep physically active: Regular physical activity is essential for you to maintain a healthy weight, which is important for preventing breast cancer. 150 minutes of moderate aerobic exercises or 75 minutes of vigorous exercises are recommended along with strength training.

Breastfeed: Breastfeeding plays an important role in preventing breast cancer. The more you breastfeed your baby, the more protected you are from breast cancer.

Limit the dosage and duration of hormone therapy: If you undertake combination hormone therapy for more than three to five years, you are at a higher risk of developing breast cancer. In case you are taking hormone therapy for menopausal symptoms, you should talk to your doctor about alternative options such as non-hormonal therapy and medications. If you still require hormonal therapy, you must use the lowest dose that will be effective.

Avoid exposure to radiation and pollution: Certain medical imaging procedures like computerized tomography involves radiation of high doses. There is a link between breast cancer and radiation exposure. Thus, you should abstain from getting exposed to radiation and avoid taking such tests if it is not very urgent.

Maintaining a healthy diet also helps in reducing your risk of developing breast cancer. You should include food items which are plant based in your regular diet, such as fruits, vegetables, nuts, whole grains and legumes. Also, consume healthy fats such as olive oil instead of red meat and butter.

How Can You Prevent Breast Cancer?

Many women develop uterine fibroids by the time they hit the age of 50 years and above. These are non-cancerous growths that may occur in the uterus. Most women go through severe bleeding and pain as well as discomfort as a result of these fibroids. Age, family history of the same condition, obesity or being overweight, eating habits and even ethnicity play a large role in deciding the risk of each individual patient. These fibroids can grow in the submucosal, intramural and subserosal areas.

Following are the common side effects of uterine fibroids:

    Frequent urination: Due to the pressure of the fibroids on the uterus, the patient may experience a constant feeling of fullness in the lower pelvic area of the body, which may lead to frequent filling of the bladder. This gives rise to frequent trips to the washroom for urination. 
    Heavy Bleeding: Severe bleeding is one of the most common causes of the presence of these kinds of fibroids. The patient may experience a lot of bleeding during menstrual periods, as well as pain and cramps the rest of the time. The periods will also be very painful when there are fibroids in the uterus or the uterine lining.
    Painful Intercourse: It is a well-known fact that any kind of infection or growth as well as sores and other such ailments can lead to vaginal dryness as well as pain during sexual intercourse. This is true for uterine fibroids as well, which can lead to severe pain during sexual activity. These fibroids can also give rise to pain in the lumbar or lower back region.
    Abdomen Swelling: The abdomen may go through significant swelling in such a condition and the patient may even look like she is pregnant. The growth can push the shape of the abdomen outwards and create a full feeling.
    Pregnancy Complications: The presence of uterine fibroids can give rise to several complications during pregnancy and even after child birth. One of the most common problems in this case is bleeding, followed by more severe outcomes like miscarriage. The women suffering from uterine fibroids are at greater risk of undergoing a caesarean section for the delivery of the baby. The baby may also be born breech and a premature delivery may take place. 
    Infertility: This is also a rare side effect of the uterine fibroids and is generally seen only in very severe cases. 
    Cancer: Only one in every 1000 cases might transform into malignant tumours. These uterine fibroids are generally known to be non-malignant. 

Any symptoms must be reported to a gynaecologist at the earliest to avoid any serious complications.

Common Side Effects of Uterine Fibroids

Any kind of bleeding from the uterus, which is not normal, can be termed as abnormal uterine bleeding. This refers to bleeding between periods or before periods, bleeding after having sex, spotting, abnormally heavy bleeding or bleeding after attaining menopause. If you are suffering from any of these issues, you need to check with the doctor. 

Diagnosis
It is very important to diagnose abnormal uterine bleeding. There are several examinations and tests that have to be carried out, depending on age. For irregular spotting, a pregnancy test can be undertaken in case you think you could be pregnant. If your uterine bleeding is very heavy, a test has to be performed to check blood count. This is done to observe whether you have anemia. An ultrasound test of the pelvic region will also be advised by your doctor to know the cause of the bleeding. Several hormonal tests and thyroid function tests are required as well.

Other diagnostic tests include:

Sonohysterography: When fluid is placed within the uterus and ultrasound images of the uterus are taken. An image of the pelvic organs is obtained.
Hysteroscopy: It can be carried out when a device is inserted via the vagina and enables the doctor to examine the uterus internally.
Magnetic resonance imaging: This is also used to get images of the organs.
Endometrial biopsy:  It involves insertion of a catheter to take out a tissue which is microscopically observed. 
Treatment
There are different types of treatment for abnormal uterine bleeding depending upon factors such as the cause of bleeding and the age of the patient.

Medications: Several medicines are used to treat abnormal uterine bleeding. Sometimes hormonal medicines are used. Birth control pills are also used to improve the regularity of periods. Hormonal infections, vaginal creams and an IUD device releasing hormone can be used. Non steroidal anti-inflammatory drugs are also used to control bleeding. Several antibiotics may also be prescribed.
Surgery: In some cases of abnormal uterine bleeding, a woman has to undergo a surgery for the removal of growth such as polyps and fibroids, which results in bleeding. While some fibroids can be removed via hysteroscopy, others require different techniques for treatment.
Endometrial ablation: It can be undertaken to control bleeding. This mode of treatment aims at reducing the bleeding permanently. In case all treatment methods fail, hysterectomy has to be carried out. This is a serious surgery and after it is performed, a woman does not have periods anymore and will not be able to conceive a child.
Abnormal uterine bleeding is a serious health condition, which may lead to severe complications. Immediate diagnosis and appropriate treatment methods should be undertaken in case of any abnormal uterine bleeding.

Abnormal Uterine Bleeding - 3 Ways to Treat it!

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