THIS WEEK'S ARTICLES
Ensuring Patients Have Access to Treatments for Fractures and Osteoporosis - Sponsored Content
A Key Component of Successful Balloon Kyphoplasty Procedures
Surgeons should preemptively treat — or at least evaluate — the patient's underlying condition to ensure the treatment's effectiveness.
For older patients whose experiences with conservative pain management approaches such as immobilization, braces, physical therapy and pain medication have proven ineffective, a balloon kyphoplasty presents an opportunity to put their osteoporotic compression fractures in the rear-view mirror and to live active lives. During a balloon kyphoplasty, a small balloon gently lifts bone fragments into their correct positions. For this minimally invasive treatment to succeed, however, providers must take a big-picture view of the patient's underlying condition.
Al Rhyne, MD, a spine surgeon at OrthoCarolina who has performed about 2,000 balloon kyphoplasties over two decades, says surgeons shouldn't perform the procedure until they have a clearer picture of the individual patient. "The first step is to make sure they're being treated, or at least evaluated for, osteoporosis," he says. "That's as important as fixing the fracture because osteoporosis is a systemic disease. If the patient has a single compression fracture, there's a high correlation of developing subsequent fractures from both the underlying osteoporosis as well as the change in the spine alignment from the initial fracture."
Treating the underlying condition could lead the surgeon to take a step back and consult with other providers with more experience as to what's best for the patient. "I sometimes defer to the patient's primary physician or engage an endocrinologist or rheumatologist with expertise in osteoporosis management," says Dr. Rhyne.
He says a holistic, multipronged approach is essential to treating prospective balloon kyphoplasty patients for a variety of reasons, including the fact that in a very small subset of patients, osteoporotic compression fractures can be the result of something pathologic such as lymphoma, myeloma or an undiagnosed metastatic disease.
"The disease puts pressure on the vertebral bodies above and below the location of the first break," adds Dr. Rhyne. "Not treating the underlying osteoporosis increases the probability of developing more fractures."
Patients, Providers Underestimate Spine Surgery Radiation
Study on perceived amounts of exposure suggests more education is needed.
While outpatient spine surgery may be more convenient and efficient than inpatient care, it still exposes patients and providers to radiation. Unfortunately, members of these groups aren't as aware of this exposure as one might expect.
That's one of the key findings from a recent cross-sectional survey that examined patients' and surgeons' estimates of the amount of radiation they are exposed to during spine surgery.
According to the survey, past research suggests that patients and providers have little knowledge about the radiation exposure that takes place during outpatient spine procedures. To understand subjects' awareness and knowledge of radiation exposure in outpatient and intraoperative settings, the authors devised a questionnaire that asked patients and surgeons to estimate chest radiograph (CXR) equivalent radiation from cervical and lumbar radiographs, computed tomography, magnetic resonance imaging, intraoperative fluoroscopy and intraoperative CT. Their responses were compared to literature-reported radiation doses.
Echoing prior research, the survey concluded that both patients and surgeons underestimated the amount of radiation they were exposed to, particularly with lumbar O-arm imaging. For intraoperative specific cervical and lumbar imaging, patients underestimated radiation exposure by 11-fold and surgeons did by three-fold.
An alarming number of patients were never even informed they were exposed to radiation. Of the 100 patients who completed the survey, just 31 were told about the risk of radiation exposure.
The findings suggest that more education about radiation is warranted for all types of imaging. The study called out O-arm imaging specifically in its conclusion: "The significant underestimation of intraoperative cross-sectional imaging (O-arm) is notable and needs attention in the era of increased use of such technology for imaging, navigation and robotic spine surgery."
Ensuring Patients Have Access to Treatments for Fractures and Osteoporosis
Education, relationships are first steps on successful VCF care pathway
For Dr. Anthony Alastra, education has been key to developing a consistent care pathway for patients with painful vertebral compression fractures.
Alastra, a neurointerventionalist with a private practice in Palm Springs, Calif., has built relationships with staff where he works at Desert Regional Medical Center, with referring physicians and other specialists to ensure patients have access to appropriate treatments such as vertebral augmentation via balloon kyphoplasty.
"It starts with word of mouth," Alastra says. "Going out there and kind of doing some legwork and putting together some seminars, just to develop that relationship, letting them know that patients with these types of fractures don't need to sit and suffer."
Alastra also has reached out to senior centers to build awareness about VCFs among the Palm Springs area's large population of retirees.
"Just to kind of educate patients and potential referrals from the older community that's going to be affected by osteoporosis and fractures," he says.
Education and Coordination
Alastra described a recent case to illustrate how his efforts to educate colleagues and patients can pay off with successful treatment.
A 76-year-old woman visited his clinic after being referred by her primary care physician. She recently fell and suffered a compression fracture to her L2 vertebra. She had fractured the same vertebra previously and had been treated with kyphoplasty; however, that procedure did not provide complete pain relief.
"She had the compression on top of her same area," Alastra says, "so we went back and treated that area again, and she did really well, almost complete resolution of all her symptoms."
The patient had received a DXA scan in her initial workup that found she had osteoporosis. She also went through conservative management, but her pain did not improve.
"She went through the normal 6-week period of conservative treatment, but at the same time was given referral over to our office so we could kind of get things moving along, finish any workup that was required, if necessary," he says. "The question was, is she a candidate for a new kyphoplasty, or did she need anything else done, and then when we saw that she had continued osteoporotic collapse around the previous kyphoplasty, then we decided we can just continue with the kyphoplasty."
Although the complication rate for Balloon Kyphoplasty is low, as with most surgical procedures serious adverse events, some of which can be fatal, can occur including heart attack, cardiac arrest (heart stops beating), stroke and embolism (blood, fat or cement that migrates to the lungs or heart). Other risks include infection; leakage of bone cement into the muscle and tissue surrounding the spinal cord and nerve injury that can, in rare instances, cause paralysis; leakage of bone cement into the blood vessels resulting in damage to the blood vessels, lungs and/or heart.
Alastra credited good coordination with the primary care physician for the patient's successful outcome.
"A lot of times patients get lost to follow-up or referring doctors that see them as outpatient don't remember, or they have their own pattern of referral," Alastra says, "so we try to make sure we intervene as soon as possible and get that kyphoplasty cemented in their regimen of care."
Note: The preceding testimonial contains the opinions of and personal surgical techniques practiced by Dr. Anthony Alastra. The opinions and techniques presented herein are for information purposes only and the decision of which technique to use in a particular surgical application should be made by the surgeon based on the individual facts and circumstances of the patient and previous surgical experience.
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The Case for Adding Spinal Cord Stimulators
This two-step procedure can benefit frustrated patients while setting your facility apart from the pack.
Chronic pain patients who don't benefit from conventional therapy, aren't good candidates for spine surgery or who had failed surgeries in the past can benefit from spinal cord stimulator (SCS) implants, as can the facilities that insert them.
Just ask Harriet Willoughby, RN, BSN, CEO of Gadsden (Ala.) Surgery Center, which recently added SCS to its offerings and has benefitted from the move. The facility's addition of SCS was prompted by the country's largest payer. "When CMS announced it was reimbursing the stimulator implant, we decided it was a good opportunity for us to move into spine procedures," says Ms. Willoughby.
During the minimally invasive procedure, two electrodes are placed via an epidural needle at the back of the spinal cord, where they stimulate the dorsal columns to inhibit pain in the back of the legs. The electrodes are left in for five to seven days to see how much improvement the patient feels and if the patient likes the device. If the patient is satisfied, the devices are then implanted.
Some newer SCS systems alleviate pain without eliciting additional sensations, says Steven P. Cohen, MD, chief of pain medicine at Johns Hopkins Medicine in Baltimore. "Patients feel a vibratory sensation or a tingling instead of pain, and because the fibers in the nerves that transmit those sensations are much larger and travel faster, they crowd out the pain," he explains.
SCS instrumentation is a significant investment for facilities not already outfitted for spine procedures. They'll need a Jackson table with a Wilson frame, a cooling vest, a basic laminectomy tray and at least two electrocautery machines, says Pat Daniel, RN, manager at Gadsden Surgery Center. At the center, the approximately hour-long procedure — not including 20 to 30 minutes of placing the patient in the prone position — requires a physician and physician assistant in addition to two circulating nurses, two OR techs and an X-ray tech.
Physician Buy-in Is Key to Spine Surgery Success
From equipment to design, surgeon feedback is essential.
If leaders want their facilities to flourish in the spine surgery space, they must keep their surgeons happy and heavily involved in the decision-making process, says Clint Devin, MD, an orthopedic spine surgeon at Steamboat Orthopaedic & Spine Institute (SOSI) in Steamboat Springs, Colo. SOSI, a partnership with UCHealth Yampa Valley Medical Center (YVMC) that opened in July 2020, went to great lengths to include Dr. Devin in every step of its creation.
The primary goal of any spine surgery is motion preservation, says Dr. Devin. To preserve motion and perform these complex procedures effectively, proper technology is a must, he says, and the best way leaders can ensure their facilities are properly outfitted is to get detailed info from the surgeons who will perform the cases there. "Some of the spinal surgery techniques are very demanding, so the more technology surgeons have to help them operate, the more precise they can be," says Dr. Devin.
Leaders at facilities in the process of building new ORs or renovating existing rooms might want to access surgeons' perspectives beyond equipment purchasing and technology. For instance, while Dr. Devin was still working as an associate professor of orthopedic surgery and neurosurgery at Vanderbilt University in Nashville — where he performed more than 4,500 spine surgeries — he took part in several months of planning, meetings and hands-on interaction about the creation of SOSI.
"I had pretty significant input into how the ORs would be designed, as did my colleagues," he says. "The key with spine is making sure the ORs are big enough to house the necessary equipment."