Procedures for treating vertebral fractures

Two minimally invasive procedures — vertebroplasty and kyphoplasty — involve the injection of a medical cement to stabilize compressed vertebrae. Introduced in the United States in the 1990s, they've become increasingly available for the treatment of fracture pain that doesn't respond to more conservative therapy. According to Dr. John Pan, a radiologist at Boston's Brigham and Women's Hospital, bracing and analgesics are usually tried first "to see if the fracture heals on its own. If it doesn't and the person continues to have pain — usually after four to six weeks — that's when the procedure is considered."

There are very few controlled studies comparing the long-term effectiveness and safety of vertebroplasty and kyphoplasty — with each other or with conservative treatment. It's not clear whether either procedure improves spine stability or prevents fractures in the long run. But the main reason for these procedures is pain, and as many as 85% to 90% of people who undergo them experience immediate relief. A review of 21 studies involving 1,309 patients, published in 2007 in the journal Pain Physician, found that both techniques reduced pain by more than 50%.

No one knows exactly how these procedures do that. One theory is that the pain is largely an inflammatory response to the uneven distribution of mechanical forces caused by bone fragmentation. The cement is thought to help by restabilizing the vertebra, which reduces inflammation and thus pain. It's also possible that the cement destroys pain-conducting nerve endings in the vertebra.

Before either procedure, MRI is usually performed to determine if the patient is likely to benefit. A good candidate is one whose MRI shows the presence of bone edema, or fluid, which is associated with recent fracture. If bone edema is absent, that implies the fracture has healed and is not what's causing the pain. An MRI can also help ascertain whether a disk, the spinal cord, or other soft tissue is involved.

Both kyphoplasty and vertebroplasty are performed percutaneously (that is, through the skin), often as day surgery and under conscious sedation. If the fractures are numerous or severe, or the patient is older and in poor health — or cannot tolerate lying on his or her stomach — general anesthesia may be used. Sometimes an overnight hospital stay is necessary. Here's what's involved:

Vertebroplasty. Guided by computed tomography (CT) or fluoroscopy (real-time x-rays), a specially trained radiologist, neurologist, or orthopedic surgeon inserts a hollow needle through a small incision in the skin into the compressed portion of the vertebra. When the needle is in place, she or he injects a surgical cement (methyl methacrylate), which has the consistency of toothpaste. It's mixed with an agent that allows the physician to see its flow into the vertebra. The cement hardens within about 15 minutes. The patient is monitored for two to three hours in the recovery room before going home.

Kyphoplasty. In this procedure, which is also image-guided and performed through tiny incisions in the back, inflatable balloons are inserted through tubes in both sides of the fractured vertebra (see illustration). The balloons are inflated, creating a cavity and restoring vertebral height. They are then deflated and withdrawn and the cavity is filled with cement. The procedure takes 30 to 60 minutes for each fracture and sometimes involves an overnight hospital stay.

What is kyphoplasty? Kyphoplasty is a two-step process. First, a tubelike device with a balloon at the end is inserted into each side of the collapsed vertebra (A). The balloons are then inflated, creating a cavity and restoring vertebral height. The balloon is withdrawn and cement is injected, filling the cavity (B).

How Can Osteoporosis Affect My Spine?

Given the prevalence of osteoporosis, it is not surprising that fractures resulting from the disease are quite common. In addition to other fractures such as the wrist, forearm, or hip, osteoporosis causes approximately 700,000 to 750,000 vertebral compression fractures (VCFs) annually. For people suffering from osteoporosis, VCFs can result from many different regular, everyday activities. Unlike other types of fracture associated with osteoporosis (for example, fractures of the hip), VCFs are less associated with falls. Bending forward, lifting objects, climbing stairs, and even seemingly minor movements like coughing or sneezing can lead to a vertebral compression fracture.

These fractures can happen to vertebrae in any part of the spine, and can vary in type. A wedge fracture occurs when the front or back of a vertebra collapses, while a biconcave fracture is the result of the central portion of both vertebral body endplates collapsing. A crush fracture means the entire vertebra has collapsed. VCFs can cause back pain, spinal deformity, impaired physical function, decreased pulmonary function, decreased lung capacity, loss of appetite, and sleep issues. As with many types of chronic pain and spine injuries, they can also decrease quality of life in many other ways, leading to anxiety, depression, and feelings of frustration and defeat.

Treatment Options for Vertebral Compression Fractures

What are the Symptoms of Vertebral Compression Fractures?
Pain varies from person to person, depending on the location and severity of the fracture, as well as the individual’s overall health. For some people, the pain is minimal and subsides as the bone heals (usually over a period of two to three months). For others, the pain may continue even after the fracture has healed.

Unlike with a broken wrist or hip, you may not know that you have suffered a VCF. Symptoms that may indicate a VCF include sudden, severe back pain; worsening pain when walking or standing, difficulty and increased pain when bending and twisting; a curved or stooped posture; and experiencing some relief from pain when lying down. For an accurate diagnosis, an x-ray or another form of imaging is needed.

Having one VCF is a major risk factor for incurring another one. Multiple vertebral compression fractures can lead to spinal deformity and can make normal activities painful and difficult.

What are the Treatment Options for Vertebral Compression Fractures?
Conservative treatments for VCFs include bed rest, oral pain medications, steroid or pain relieving injections, back braces, physical therapy, and anti-inflammatory drugs. For many, this is not enough to alleviate the pain from a VCF. In the past, any additional treatment required open back spinal surgery. Today however, those who do not respond to non-operative treatments and are faced with severe pain and/or disability can also consider two types of minimally invasive spine surgery to treat vertebral compression fractures. These are vertebroplasty and kyphoplasty.

Percutaneous vertebroplasty was developed in France in the 1980s, and has been performed in the United States for nearly twenty years. This minimally invasive procedure is designed to relieve the pain caused by vertebral compression fractures, and to strengthen weakened vertebral bodies in the hopes of preventing future fractures. In this procedure, a small amount of medical grade acrylic cement called polymethylmethacrylate (PMMA) is injected into the collapsed vertebra to stabilize and strengthen the fracture and vertebral body. Using a flexible needle, the surgeon is able to directly access the entire vertebra through one small incision and precisely deliver the bone cement. When the cement is injected it is a viscous paste, but it hardens rapidly. Most percutaneous vertebroplasty patients are ambulatory within a few hours after the procedure. Patients often experience significant improvement from their fracture symptoms within six to twelve weeks, and can return to their normal activities once the fracture has fully healed.

Percutaneous Vertebral Augmentation, or kyhphoplasty, is a newer treatment option which is also a percutaneous and minimally invasive procedure. In kyphoplasty, a device is used to create a space within the vertebral body which is then filled with bone cement to strengthen the vertebra. Kyphoplasty is performed under local or general anesthesia. Using image guidance x-rays, a small incision is made, and a device is inserted into the center of the vertebral body to the site of the fractured bone. The space created by the device is then filled with PMMA, the same orthopedic cement used in vertebroplasty, to seal up the fracture. As in vertebroplasty, the cement hardens quickly, providing strength and stability to the vertebra.

Procedures such as vertebroplasty and kyphoplasty can provide substantial benefits, including pain relief, stabilization of bone fractures, and a reduction of the debilitating effects of progressive osteoporosis. Compared to traditional surgical procedures, these minimally invasive procedures generally require a much smaller incision, can be performed on an outpatient basis, and allow patients to enjoy a quicker return to normal activity. Though no surgery can have a guaranteed outcome, these new treatments provide more options for people who have suffered a vertebral compression fracture. 

Snoring - Treatments

The treatment will depend on whether the board certified sleep physician finds that you have sleep apnea. If you do not have sleep apnea, the sleep physician and his or her team may offer the following treatments:

Behavioral Changes

Weight loss
Weight loss can help reduce or eliminate your snoring for some people. If you are overweight or obese losing weight should be a priority. Weight gain can make snoring worse, and may even lead to sleep apnea.

Positional therapy
For some people, snoring mostly occurs while they sleep on their back. If you are one of these types of snorers, you may be able to improve your snoring by changing your sleep position. There are a variety of products that you can wear when you go to sleep that prevent you from sleeping on your back. You can also attach a tennis ball to the back of your shirt or pajamas. This does not work for everyone.

Avoiding alcohol, muscle relaxants and certain medications
These can relax your throat or tongue muscles causing you to snore. By avoiding use of these substances, you may be able to reduce or eliminate your snoring. Speak to your primary care physician about alternative medications if your medication is causing you to snore.

Treatment

Oral appliances
An oral appliance is a small plastic device that fits in your mouth over your teeth while you sleep that stops you from snoring. It may resemble a sports mouth guard or an orthodontic retainer. The device prevents the airway from collapsing by holding the tongue in position or by sliding your jaw forward so that you can breathe when you are asleep. A dentist trained in dental sleep medicine can fit you with an oral appliance. Read more...

Surgery
There are a variety of elective surgeries you can have to reduce your snoring. The most common surgeries reduce or eliminate the bulky tissue in your throat. Other more complicated procedures can adjust your bone structure. Read more...

If your snoring is a symptom of obstructive sleep apnea, these treatments may not be effective. A board certified sleep medicine physician may recommend other treatments, including CPAP, the front-line treatment for obstructive sleep apnea. Find a sleep medicine physician at an AASM-Accredited Sleep Center near you. 

Snoring - Self-Tests and Diagnosis

Does your partner complain that you snore regularly?

Have you recently gained weight or stopped exercising?

Do you have family members that snore?

If you answered yes to any of these questions you either snore or are at risk for snoring. You may want to see a sleep medicine physician if you snore regularly or loudly. If you also make choking or gasping sounds as you snore, you will need to be tested for obstructive sleep apnea.

In addition to a complete medical history, the physician will need to know how long you have been snoring. You will also need to tell the physician whether you recently gained weight or stopped exercising. Be sure to tell your physician of any past or present drug and medication use. If you can, ask your partner, roommate or family member if they have ever heard you snore.

A sleep medicine physician will recommend a home sleep test, or in some cases an in-lab sleep study. A board-certified sleep physician is specially trained to diagnose sleep apnea.

Snoring - Causes and Symptoms

Causes

Obesity, Pregnancy and Genetic Factors

Extra tissue in the throat can vibrate as you breathe in air in your sleep, causing you to snore. People who are overweight, obese or pregnant often have extra bulky throat tissue. Genetic factors that can cause snoring include extra throat tissue as well as enlarged tonsils, large adenoids, long soft palate or long uvula. 

Allergies, Congestion and Certain Nasal Structures

Anything that prevents you from breathing through your nose can cause you to snore. This can include congestion from a cold or flu, allergies or deformities of the nose such as a deviated septum.

Alcohol, smoking, aging and certain drugs and medications, including muscle relaxants

You may snore when your throat or tongue muscles are relaxed. Substances that can relax these muscles may cause you to snore. This includes alcohol, muscle relaxants and other medications. Normal aging and the prolonged effects of smoking can also relax your throat and tongue muscles. 

Symptoms

The primary symptom of snoring is unmistakable - the often loud, harsh or hoarse noises that you make while you are asleep. Other symptoms may include waking up with a sore throat or dry mouth. 

If you have any of the following symptoms you may have sleep apnea:

• Excessive daytime sleepiness
• Choking or gasping while you sleep
• Pauses in breathing
• Morning headaches
• Difficulty concentrating
• Moodiness, irritability or depression
• Frequent need to urinate during the night

WHAT IS A TRACHEOSTOMY? WHEN IS IT PERFORMED FOR THE TREATMENT OF SLEEP APNEA?

As noted earlier, OSA can have significant impact on patients’ health and – in some cases – life-expectancy. In severe cases of OSA, extreme interventions may be required. In a tracheotomy, a surgical opening is made through the skin of the lower neck and directly into the trachea. A hole is cut into the trachea thereby bypassing the sites of obstruction higher up. While a tracheotomy is typically considered “curative” of OSA, it is an extreme measure with potentially severe complications, and is performed only in special circumstances.

DOES THE TONGUE CONTRIBUTE TO SNORING AND SLEEP APNEA? IF SO, HOW CAN THIS BE TREATED?

In some patients, an enlarged tongue base which relaxes during sleep may fall back in the oral airway (“hypopharynx”) and contribute to obstruction, turbulence and – ultimately – snoring and OSA. Surgeries to treat this area include a Midline glossectomy and – more recently – Radiofrequency ablation (RFA) of the tongue base. Midline glossectomy is less commonly performed given the significant post-operative complications of bleeding, difficulty swallowing, and airway edema necessitating possible tracheostomy98. RFA of the tongue base appears to be reasonably affective for snoring in appropriate patients. It does; however, often require multiple treatments over a period of weeks to months before noticeable improvement is appreciated. Data does not seem to support the same efficacy of RFA for treatment of OSA with success rates reported under 40%99.

WHAT IS THE UVULA? DOES IT CONTRIBUTE TO SNORING/SLEEP APNEA? IF SO, HOW IS IT TREATED?

The uvula, the “punching bag” in the back of your throat, is comprised of a series of intertwined muscles with a mucosal lining. On occasion, an enlarged uvula may contribute to snoring and /or OSA. In these instances the uvula may be surgically resected or removed. Usually, the uvula alone is not a significant enough source of snoring/obstruction that removal of just the uvula will solve the patients’ problem. It is for this reason that uvulectomy is usually performed as an adjunct to other procedures (i.e., Pillar Procedure, tonsillectomy, etc). Patients have noted significant pain after this procedure89.

WHAT ARE THE ADENOIDS, AND CAN THEY CONTRIBUTE TO SNORING/SLEEP APNEA?

The adenoids are typically normal lymphoid tissue that rest in the nasopharynx (where the nasal cavity turns into the “throat” in the back). In children it is not uncommon for the adenoids to be large enough (“hypertrophied”) to obstruct nasal airflow and lead to snoring and, in some cases, OSA. While the adenoids typically shrink and regress with age, there are several adults in whom the adenoids are persistent and large. In these cases, the adenoids may lead to nasal airway blockage, turbulent airflow, snoring, and/or OSA.

CAN RADIOFREQUENCY ABLATION BE USED ON THE PALATE FOR SNORING AND SLEEP APNEA?

While the bulk of data seems to support the safety and efficacy of the Pillar Implants for snoring and sleep apnea, the past few decades have also seen the rise of radiofrequency treatments for OSA and snoring. Many surgeons around the world have suggested the use of radiofrequency ablation (RFA) on the palate as a minimally-invasive treatment option. A recent review of 30 articles published between 1998 and 2008 found that while RFA treatments for snoring appeared relatively safe, there was insufficient evidence to support the claim that this treatment method is effective over the long-term86.

WHAT IS THE PILLAR PROCEDURE FOR SNORING AND SLEEP APNEA? DOES IT REALLY WORK?

In the Pillar Procedure, small implants are inserted into the soft palate to help stiffen the soft palate and diminish the collapse that contributes to snoring and sleep apnea. The Pillar Procedure is performed under local anesthesia and takes around 20 minutes to perform in the clinic setting with most patients. Several studies have shown a significant decrease in patient snoring intensity with associated decreases in daytime sleepiness and significant improvements in lifestyle after patients underwent the Pillar Procedure. Other studies have demonstrated patient and bed partner satisfaction with the reduction in snoring after the Pillar Procedure at 80% or higher77 78. Studies of patients with OSA demonstrate approximately 80% of patients with a reduction in their AHI (sleep index), and results were sustained at one year after palatal implants/Pillar Procedure79 80 81 82 83 84. Another study has documented significant improvement in snoring and sleep apnea with insertion of palatal implants in patients who had failed surgical intervention with prior uvulapalatopharyngoplasty85. The data in support of the Pillar Implant as an effective, minimally invasive treatment for patients with snoring and/or OSA continues to grow.

CAN WEIGHT LOSS IMPROVE MY SNORING AND/OR SLEEP APNEA?

There exist a large number of studies which support the notion that signs and symptoms of OSA and snoring can be improved with weight loss57 58 59. In some patients with significant obesity, surgical intervention (ie-bariatric surgery) may be utilized to help patients with OSA lose weight60. Studies seem to support the efficacy of these interventions, although long-term follow-up data is incomplete61 62. It is apparent that a patient’s overweight status can play a significant role in his/her snoring and OSA. In addition to the other health benefits of good nutrition and fitness, working towards a healthy weight may have significant benefits for patients with OSA and snoring. It is, therefore, imperative that patients with OSA and snoring examine the status of their nutrition and fitness with an eye towards healthy, balanced interventions.

DOES DRINKING ALCOHOL CONTRIBUTE TO MY SNORING AND/OR SLEEP APNEA?

Drinking alcohol may cause the soft tissues of the airway to relax and increase the likelihood of soft tissue collapse associated with snoring and sleep apnea. In fact, it the increased rate of sleep apnea in patients who drink has been well documented63 64. Changing drinking habits and patterns, including decreased nocturnal alcohol consumption may have a positive impact on patients’ sleep and snoring signs and symptoms.

WHAT ARE ORAL APPLIANCES? HOW DO THEY HELP WITH SNORING AND SLEEP APNEA?

In some cases of snoring and OSA an oral appliance may be used for treatment. An oral appliance is an artificial (often plastic or acrylic) device similar in appearance to a mouth-guard [FIGURE 2]. The device is intended to be worn at night during sleep. By moving the lower jaw (mandible) forward, the appliance decreases the likelihood of the oral soft tissues collapsing and obstructing the airway. It is this obstruction that may contribute to snoring and OSA. A second type of oral appliance – a Tongue Retaining Device – applies suction to the tongue at night in order to keep it from falling back in the throat [FIGURE 3].

A 2006 review of 41 studies found mixed results with oral appliances. Only 52% of patients were able to control their OSA with an oral appliance, and oral appliances were found to be less effective than CPAP49. As with CPAP, it appears that many patients find it difficult to tolerate oral appliances. Patient compliance rates seem to vary in studies, and have been reported to be as low as 25%.50

The use of oral appliances may have associated complications. Commonly reported minor (often temporary) side effects have been noted to occur in up to 86% of patients. More severe and persistent complications have been noted to occur in up to 75% of patients. Complications/ adverse events include TMJ (temporomandibular joint) pain, myofascial pain, dental/tooth pain, tongue pain, dry mouth, gum irritation, severe gagging, excessive salivation, occlusal/bite changes, and TM joint sounds.51

Treatments for Snoring and Sleep Apnea

Effective treatment of snoring and OSA depends on proper diagnosis and location of the anatomic source of the problem. Treatments can be medical or surgical and vary in efficacy. Medical treatments include lifestyle changes (weight loss and dietary changes), sleep positioning pillows, nasal sprays, dental/oral appliances, nasal strips, and positive pressure mask devices. Inhalant allergies may also contribute to snoring and OSA, and should be treated when present. Medical interventions are preferable to surgery; however, some of the interventions (ie-use of the continuous positive airway pressure device) are uncomfortable and have poor patient compliance.

Surgical treatments include nasal surgery, adenoid and tonsil surgery, palate surgery, and jaw surgery (mandibular advancement). Some of these surgeries may be performed with the laser (laser-assisted uvulopalatoplasty, or LAUP) Unfortunately most of the surgeries involving the oral cavity (tonsils, palate, jaw) and pharynx (uvulopalatopharyngoplasty, or UPPP) have significant pain and morbidity as well as lengthy patient recovery times with only modest success rates.

Fortunately, the past few years have seen the rise of a variety of effective, minimally-invasive treatments for snoring and sleep apnea. These treatments, along with others, will be discussed in detail in this and the following chapters.

DOES SLEEP APNEA AFFECT MY HEART?

OSA appears to be related to the development of heart and vascular disease, as noted by a 2008 publication of the American Heart Association and the American College of Cardiology.27 Almost 40% of patients with OSA have elevated blood pressure. Moreover, it appears that patients with OSA may have a 2 to 3 times increased risk of heart attack and stroke.28, 29, 30 Americans who have OSA are more likely to die suddenly of cardiac causes between 10 p.m. and 6 a.m. than during the other 16 hours of the day combined, according to findings of a Mayo Clinic study.

WHAT ABOUT SNORING AND DIABETES?

In women aged 25-79 years old, one recent study found snoring with or without sleep apnea to be related to the presence of diabetes mellitus7. This is of particular concern, as diabetes is strongly related to cardiovascular disease and early death. An earlier study supports these results, having found a two-fold higher risk of developing diabetes in women who snore compared to women who do not snore8. Fortunately, there is some evidence that in diabetic patients with sleep apnea, diabetic parameters improve when patients’ sleep apnea is brought under control.

HOW COMMON IS SNORING?

Snoring is widespread, and is believed to affect as many as 50% of adults including both men and women; over 45 million Americans. In one 2006 survey of over 2,000 British couples, 56% of respondents admitted that they snored (70% of men admitted to snoring; 40% of women admitted to snoring). 30% of the respondents stated that their bed partner snores1. 48% of the respondents stated that snoring affected their personal relationships, with 46% of respondents admitting that they sleep in separate bedrooms as a result of snoring. Respondents noted that they felt snoring had caused them to be irritable (47%), had led to arguments (36%), and had impacted their sexual relationships (17%). Some respondents stated that snoring had led to their divorce. Others noted that snoring had led to poor sleep (72%), and had impacted their ability to work effectively (38%).

ANATOMIC CAUSES OF SNORING

Snoring is commonly associated with abnormalities of the soft palate or uvula. An overly long or floppy soft palate may vibrate irregularly with airflow. This abnormal vibration makes a sound – snoring. Other sources may also contribute to snoring and, for this reason, careful and complete evaluation is imperative in order to direct effective treatment. Nasal sources (deviated septum, inferior turbinate hypertrophy, polyps, chronic and allergic nasal congestion), nasopharyngeal sources (enlarged adenoids and nasopharyngeal growths) oral sources (enlarged tongue base, small jaw, enlarged uvula or tonsils), and throat and neck sources (floppy neck soft tissues) may all contribute to snoring and to sleep apnea. In some cases, snoring may be increased by alcohol consumption late at night (which causes your throat to relax and become more floppy).

What happens if you break a fixed deposit?

Breaking a fixed deposit means withdrawing the money before the maturity expires. This may be necessary if you urgently require the funds or if there are better investment opportunities elsewhere. You will have to pay a cost; for instance you may receive an interest rate 1 per cent lower than the stated interest rate on the FD.


For example if you invested in a 3 year FD with 9 per cent and you break it after two years you may receive only 8 per cent interest for those two year instead of 9 per cent.


An alternative to breaking a fixed deposit is taking a loan against the FD. Such loans are quite easy to obtain with amounts ranging up to 90 per cent of the principal and accumulated interest.

Yoga as an effective treatment for back pain

New researchs from the U.S. suggests that the millennia-old therapy of yoga could benefit millions of people who suffer from back pain problems. In an article published in the Annals of Internal Medicine on December 20, researchers concluded that yoga act as a more effective treatment for back pain than conventional therapy.
A study conducted at the Group Health Cooperative in Washington State required 101 adults to follow a choice of remedial treatments – a 12-week course in yoga, 12 weeks of standard therapeutic exercise or the same period following instructions in a self-help book. The results showed yoga both expedited relief from pain and had longer lasting benefits. Lead researcher Dr. Karen Sherman said this was because “mind and body effects” were in collusion.

The article states that: “Most treatments for chronic low back pain have modest efficacy at best. Exercise is one of the few proven treatments…however, its effects are often small, and no form has been shown to be clearly better than another. Yoga, which often couples physical exercise with breathing, is a popular alternative form of ‘mind–body’ therapy…[It] may benefit patients with back pain simply because it involves exercise or because of its effects on mental focus. We found no published studies in western biomedical literature that evaluated yoga for chronic low back pain; therefore, we designed a clinical trial to evaluate its effectiveness.” Millions of people worldwide swear by yoga to improve their mental and physical health.