Updated: Apr 9, 2019
Proper perioperative management of patients with spinal compression fractures can lead to reduced hospital stays and increased health care savings. Evidence clearly demonstrates that increased bedrest is associated with increased morbidity and mortality in patients undergoing vertebral augmentation procedures. Developing a plan for both inpatient and outpatient settings can improve postsurgical outcomes.
The BackTable Brief
If conservative treatment fails, vertebral augmentation is an option for acute pain control within four to six weeks after diagnosis of a vertebral compression fracture.
In the outpatient setting Dr. Kumar Madassary and Dr. Venu Vadlamundi encourage patients to ambulate within 2-3 hours post-procedure.
Increased bedrest is associated with muscle wasting, deterioration and increased DVT risk.
Physical therapy is an essential service following vertebral augmentation procedures.
Disclaimer: The opinions expressed by the participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
When to Consider Vertebral Augmentation: When Conservative Management Fails
...And I think one of the other changes in our practice, after the VAPOUR trial came out, was trying to get to these patients much quicker than I think the previous idea of, we’ll give them maybe four to six weeks or something of conservative management. Well I think that trial helped prove to us what we probably know anecdotally is, the quicker you can address the fracture and the pain, the better these patients are going to do. So I think that was an important point from that trial, which we now try to incorporate.
As soon as we can know about a patient, not that we immediately put needles in every patient, you know, we do need to get at least some sense of how are they doing with some conservative management, but I think we're going to be much more aggressive about trying to help their fracture pain quicker rather than giving them weeks and weeks of the uncontrolled pain.
Postoperative Care in the Outpatient Setting
Yeah, and I was curious to know also about your post op care. Are you sending people home later that day? I guess it depends on the setting and the degree of severity of the fracture and so forth, [with] comorbidities and what not. When you can, are you trying to get people home right away or are you keeping them overnight?
For us, if it's an outpatient procedure and they're not an inpatient, pretty much my standard, or our standard post procedures are about three hours bedrest, immediate ambulation, and then home as fast as humanly possible. The majority of these patients, you know, with these fractures they have enough issues going on and the longer they're in our hospital, the bigger chance they're going to stay in the hospital.
So if it's an outpatient setting, we literally want them ambulating as soon as possible as long as they're safe to do so. We stress that in our consultation time too. When we get the consult either as an inpatient or an outpatient we say, we want you up and out as soon as possible. If you look at the data, every day that a patient is on bed rest, how much morbidity that adds to them, it's kind of astounding. So you gotta get them up and moving as soon as possible. So for an outpatient they're hopefully gone within four hours from our hospital, and then we see them in clinic with new x-rays just as a baseline within a few weeks. That's good for everybody.
Yeah, I would say our practice is pretty similar to Kumar's. We usually do regardless of the patient setting, two hours of bedrest post operatively and then after that two hour mark, try to get them moving as quickly as possible. And again as Kumar pointed out, the data is very clear, the longer they're on bedrest, they have muscle wasting, deterioration, increased DVT risk, etc ... So all of that morbidity increases the longer they're in a bed, so the quicker you get them moving, the better. And that's again, one of the things just like Kumar's group does.
Using Physical Therapy to Augment Patient Recovery Times
Are you having them do physical therapy while they're inpatient, or wait until they're outpatient?
On the inpatient side, I think the physical therapy parts are great. Alternative to that, as soon as they're back and they're able to, they should be with some kind of physical therapy while inpatient to get them going. And I tell patients, you know outpatient physical therapy is a great recommendation as well and I refer them to our Fracture Liaison Service, whether inpatient or outpatient, so that's kind of how our practice is.
Podcast Participants: Dr. Venu Vadlamudi is a practicing interventional radiologist in Alexandria, Virginia. Dr. Kumar Madassery is a practicing interventional radiologist with Rush University in Chicago. Dr. Aaron Fritts is a practicing interventional radiologist and founding partner of BackTable. Cite this podcast: BackTable, LLC (Producer). (2018, January 28). Ep 21 – Vertebral Augmentation [Audio podcast]. Retrieved from https://www.backtable.com/podcasts Medical Disclaimer: The Materials available on the BackTable Blog are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. Disclosures: None.