L1 fx 50% loss, 8 M out, not healing, Kypho?

[specepic]

L1 fx 50% loss, 8 M out, not healing, persistent edema, Kypho?. no h/o malignancy. known osteoporosis

for Kypho, is there a hard deadline after fx. ?

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[RoloTomassi]

Sounds like a great candidate

 

[lobelsteve]

L1 fx 50% loss, 8 M out, not healing, persistent edema, Kypho?. no h/o malignancy. known osteoporosis

for Kypho, is there a hard deadline after fx. ?

Edema means acute component. Fix it. What is plan for OP?

 

[paindoc007]

As long as it’s causing pain..

 

[Laryngospasm]

Not healing with pain Kypho reasonable

 

[specepic]

Thank you for the input everyone

 

[Multimodal]

what about the 12 week time limitation? here in the PNW, if a patient still had edema on MRI even though pain started 12+ weeks ago, then the kypho will be denied. is there a way around this now? I agree, otherwise if symptomatic with edema on STIR, then kypho away.

 

[PMROralBoards]

If a patient has two compression fractures but only one seems to be most painful, do you generally recommend doing the more painful one and re-evaluating the patient in clinic a week later to see how they are doing, or would you just take care of both at the same time? Private practice but still trying to do the best thing for the patient.

 

[lobelsteve]

If a patient has two compression fractures but only one seems to be most painful, do you generally recommend doing the more painful one and re-evaluating the patient in clinic a week later to see how they are doing, or would you just take care of both at the same time? Private practice but still trying to do the best thing for the patient.

If both acute and light up on STIR. You would be wrong and bad to not fix both.

 

[PMROralBoards]

If both acute and light up on STIR. You would be wrong and bad to not fix both.

I appreciate it. So many things like this that you don’t always have someone there to tell you about. I just assumed you treat what is painful, but what I found now is that even if one seems to be painful and the other isn’t, usually it’s just being overshadowed and the patient acknowledges the second one as being painful later. Crappy feeling but at least I’m learning this lesson early on for future patients. Thanks for the advice

 

[paindoc007]

If a patient has two compression fractures but only one seems to be most painful, do you generally recommend doing the more painful one and re-evaluating the patient in clinic a week later to see how they are doing, or would you just take care of both at the same time? Private practice but still trying to do the best thing for the patient.

It depends where the fractures are.

If there are two acute fractures, far apart, say L2 and T6, and only one is painful, only kypho the painful one. There is no indication for kypho for the non painful one here. Incidental.

On the flip, if you have a T12 and L1, of course fix both. Clinical, you won’t be able to tell the difference anyway. Knock ‘em both out together.

 

[lobelsteve]

It depends where the fractures are.

If there are two acute fractures, far apart, say L2 and T6, and only one is painful, only kypho the painful one. There is no indication for kypho for the non painful one here. Incidental.

On the flip, if you have a T12 and L1, of course fix both. Clinical, you won’t be able to tell the difference anyway. Knock ‘em both out together.

You cannot tell where the pain is coming from.

Additionally, leaving an acute Fx unfixed may lead to its collapse and kyphosis, limiting TV (impairing lung function). Ong et al have determined number needed to treat to save a life = 15. Same as cardiac stents.

ALso: If you fix one and bring patient back after global to fix next- you are perceived as a greedy SOB and not caring for the patient as much as caring for the profits.

 

[paindoc007]

I’m a fan of kypho as much as anyone except you maybe and Doug Beal. You’re preaching to the quire of the value of kyphoplasty. The rest of the forum doesn’t believe in its value one iota (do a forum search). Most here will say do blocks and let time heal.

We disagree on the non painful fractures though. Separated by enough space with an exam like closed fist percussion or whatever, you can identify the painful one. I only treat painful ones here.

 

[PMROralBoards]

You cannot tell where the pain is coming from. View attachment 381518

Additionally, leaving an acute Fx unfixed may lead to its collapse and kyphosis, limiting TV (impairing lung function). Ong et al have determined number needed to treat to save a life = 15. Same as cardiac stents.

ALso: If you fix one and bring patient back after global to fix next- you are perceived as a greedy SOB and not caring for the patient as much as caring for the profits.

Much appreciated. For what it’s worth, I at least do bilateral RFAs rather than having the patient come back on a separate day. I will definitely change how I do kyphos going into the future. Thank you for that diagram, I’ve never seen it before. My patient had a type A pattern for the first fracture, and now a type b1 for the second.

 

[lobelsteve]

Much appreciated. For what it’s worth, I at least do bilateral RFAs rather than having the patient come back on a separate day. I will definitely change how I do kyphos going into the future. Thank you for that diagram, I’ve never seen it before. My patient had a type A pattern for the first fracture, and now a type b1 for the second.

Here is the corresponding chart that shows you what percent of patients have that pain pattern due to VCF.

 

[MitchLevi]

Question for the board - How long does a vertebral compression light up on STIR?

 

[lobelsteve]

Question for the board - How long does a vertebral compression light up on STIR?

4 months. Unless refracture or further collapse.

 

[au bon pain]

You cannot tell where the pain is coming from. View attachment 381518

Additionally, leaving an acute Fx unfixed may lead to its collapse and kyphosis, limiting TV (impairing lung function). Ong et al have determined number needed to treat to save a life = 15. Same as cardiac stents.

ALso: If you fix one and bring patient back after global to fix next- you are perceived as a greedy SOB and not caring for the patient as much as caring for the profits.

Not sure I follow.
Are you saying that you'd be OK to kypho a patient who has self-reported Type C if they also had TTP at the fracture site?
Or that you'd kypho a patient with self-reported Type C and also doesn't have TTP at the location of the actual fracture?

This study has less than 60 patients (and n<30 comprising C).
Average patient age is ~71.
The above are pain diagrams draw by the patient and collected by a nurse--no actual physician physical exams are described in the paper.

 

[lobelsteve]

Not sure I follow.
Are you saying that you'd be OK to kypho a patient who has self-reported Type C if they also had TTP at the fracture site?
Or that you'd kypho a patient with self-reported Type C and also doesn't have TTP at the location of the actual fracture?

This study has less than 60 patients (and n<30 comprising C).
Average patient age is ~71.
The above are pain diagrams draw by the patient and collected by a nurse--no actual physician physical exams are described in the paper.

Id say you are wrong if you see acute fxs on mri and don’t fix both of them.

 

[Ducttape]

procedural scheduling question - does insurance allow you to bill for thoracic and for lumbar kyphoplasty on the same date?

there are different CPT codes for each procedure, correct?

i could see some advantages - from a non-financial standpoint - for, say, doing a T9 kypho on a different date than an L5....



similar to how someone would not perform a C56 RFA concurrently with an L45 RFA

 

[lobelsteve]

procedural scheduling question - does insurance allow you to bill for thoracic and for lumbar kyphoplasty on the same date?

there are different CPT codes for each procedure, correct?

i could see some advantages - from a non-financial standpoint - for, say, doing a T9 kypho on a different date than an L5....



similar to how someone would not perform a C56 RFA concurrently with an L45 RFA

Yes they do.
22513+22514.
If 2 levels in same region, the second code is 22515.

 

[soccrwz]

procedural scheduling question - does insurance allow you to bill for thoracic and for lumbar kyphoplasty on the same date?

there are different CPT codes for each procedure, correct?

i could see some advantages - from a non-financial standpoint - for, say, doing a T9 kypho on a different date than an L5....



similar to how someone would not perform a C56 RFA concurrently with an L45 RFA

I was confused by this as well, I think there may be a primary code for both lumbar and thoracic, do we bill the primary code and the add on code is for any additional Thoracic or lumbar. Also which one is primary thoracic or lumbar one?

 

[Ducttape]

so... would you do a T8 kypho and a L5 kypho, for sake of argument, on the same day or separate sessions?

from a medical standpoint, thats a fair amount of radiation and 2 separate potential painful injections to do in 1 day, with fairly large prep.

and from a financial standpoint, it seems from the 2 separate codes, you would do better doing them in 2 separate sessions instead of same session.

 

[lobelsteve]

so... would you do a T8 kypho and a L5 kypho, for sake of argument, on the same day or separate sessions?

from a medical standpoint, thats a fair amount of radiation and 2 separate potential painful injections to do in 1 day, with fairly large prep.

and from a financial standpoint, it seems from the 2 separate codes, you would do better doing them in 2 separate sessions instead of same session.

Another reason to do them at same visit.

 

[paindoc007]

Yes they do.
22513+22514.
If 2 levels in same region, the second code is 22515.

Hmm. I was told differently, that you pick a segment as your primary level, and anything additional is always the 22515 code. I’ve done t12 and l1 before for example, and it’s 13 and 15 to bill.

I’ll look into it more and get back on that

 

[au bon pain]

Id say you are wrong if you see acute fxs on mri and don’t fix both of them.

Context and symptoms don’t matter?

 

[soccrwz]

so... would you do a T8 kypho and a L5 kypho, for sake of argument, on the same day or separate sessions?

from a medical standpoint, thats a fair amount of radiation and 2 separate potential painful injections to do in 1 day, with fairly large prep.

and from a financial standpoint, it seems from the 2 separate codes, you would do better doing them in 2 separate sessions instead of same session.

Did a T10 and L4 yesterday. Seems dumb to bring them back twice. One ballon, two separate cements

 

[lobelsteve]

Context and symptoms don’t matter?

You cannot reliably tell where the symptoms are coming from. Between T6-L5 Fx.
Fist percussion? Not a real thing.
Context is acute Fx on MRI STIR sequence and back pain with little to no trauma.

 

[MD87]

You cannot reliably tell where the symptoms are coming from. Between T6-L5 Fx.
Fist percussion? Not a real thing.
Context is acute Fx on MRI STIR sequence and back pain with little to no trauma.

I have a patient with 10-20% height loss. Fell 6 weeks ago. Pain was a 9, now a 6. MRI shows edema. If it were your spine, are you getting a kypho or giving it more time? Historically, I have told patients to continue to monitor their symptoms and if they do not continue to improve to reach out to schedule a procedure.

 

[RoloTomassi]

I have a patient with 10-20% height loss. Fell 6 weeks ago. Pain was a 9, now a 6. MRI shows edema. If it were your spine, are you getting a kypho or giving it more time? Historically, I have told patients to continue to monitor their symptoms and if they do not continue to improve to reach out to schedule a procedure.

What's the pt age and fx level?

 

[MD87]

What's the pt age and fx level?

L2. 69 year old woman. Fell down stairs. Don’t have DEXA.

 

[RoloTomassi]

L2. 69 year old woman. Fell down stairs. Don’t have DEXA.

I would probably not kypho unless 6/10 is too much for her to deal with for a few more weeks.

A patient like this--traumatic incident, not just bending over or ground level fall, at a VB level that's not kyphotic, not much collapse, not ancient age--will not collapse further from waiting.

So the only kypho benefit is potentially faster pain relief, that has to be weighed against the potential risks, which are not insignificant.

 

[lobelsteve]

I have a patient with 10-20% height loss. Fell 6 weeks ago. Pain was a 9, now a 6. MRI shows edema. If it were your spine, are you getting a kypho or giving it more time? Historically, I have told patients to continue to monitor their symptoms and if they do not continue to improve to reach out to schedule a procedure.

Fix now. Start OP meds as soon as possible. Get more of the fall story. Fx over 50 is OP. Unless fall of roof or ladder or high speed mva.

 

[Tboned]

I’m in the Steve Lobel camp. If two fractures, fix them in one setting. Unless you can be certain one is not painful, which is near impossible if in close proximity.

I also see type C pain patterns frequently. If you told me that my acute TL junction/upper lumbar fracture was lumbosacral facet pain and you wanted to do some MBBs…I’d be pissed.

Performing vertebral augmentation has been the most rewarding thing that I do, hands down. Nothing else comes close IMO.

 

[manowar rules]

If someone has progressed to vertebra plana, fracture < 3 months old and pain still present, how frequently do y’all notice MBBs are helpful? I honestly don’t seem to notice much aside from perhaps the usual transient relief of the local.

 

[IHawkDO]

Hmm. I was told differently, that you pick a segment as your primary level, and anything additional is always the 22515 code. I’ve done t12 and l1 before for example, and it’s 13 and 15 to bill.

I’ll look into it more and get back on that

Any update on this? I’m a newer attending and have a two level Kypho coming up (T12 and L1). I was planning to bill it as a 22513 and 22515, but if anyone has another recommendation, I’m all ears.