Updated: Mar 11, 2019
With every surgical procedure it’s important to discuss the risks and benefits of intervention. It is equally important to set expectations regarding recovery times. Initial consultation with patients should aim to individualize a treatment plan with the goal of setting realistic outcomes.
The BackTable Brief
The initial patient consultation should include discussion and confirmation of patient expectations for recovery following vertebral augmentation.
Pain cessation is optimal, yet pain improvement should be the goal for all patients.
Altered biomechanics of the musculoskeletal system can lead to continued pain despite surgical correction of the compression fracture.
Review and address patient specific risk factors to optimize their recovery time and prevent future fractures.
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.
Setting Expectations During Patient Consultations
Ever have any issues with people [having] unrealistic expectations? They come out and they still have pain and you didn't take care of all their pain. How do you deal with that kind of patient?
I think that's the critical point of what I think Venu and I just kind of mentioned earlier, that the consultation is really a critical part of what we do in IR that we should be doing everywhere and hopefully everybody's doing it. Spending time setting the expectations initially, especially with the patient's family as well as the patient. You want to tell them that this is not a guarantee, like you're going to cartwheel out of here. If you have significant pain attributed to this fracture, this will help reduce that pain. Some people walk out feeling great, some people have residual pain. It's not 100% but it involves pain control still after that for some patients.
And I think as long as you have an honest and realistic conversation with the patient and their family, then they're all very realistic and accept the results as long as everything goes fine.
Yeah, I definitely agree that the consultation and the discussion about the procedure, what's the intent and what [are] the goals, has to be based in reality. I tell patients, look, if I can take every patient from 10 out of 10 to zero out of 10, I mean, that's a grand slam. But we know that that's not going to be the case for every patient, but I tell them well, if I can take you from 8, or 9, or 10 out of 10 pain to 3 or a 4, that's still very good, because a 3 or a 4 is something we can deal with better. You still may require pain medication but hopefully less of them.
...And also one other something I'd like to add on the consultation and expectation part is that I think it's really important we need to all tell the patients and their families that your body mechanics have changed now [and] you have weak bones globally. We're going to try to help you with this one but just understand that because of the physics and how things have changed now, you're prone to more fractures, next to or separate from what you're treating now. So part of the expectation [when] looking ahead you have to tell them, you're going to feel good and you might try to overexert yourself after that, and you're already at risk, so just understand that this may not be a one and done process with your spine.
And that's something I've told ... after I started doing this and I realized it's helpful because they do come back and some patients you’ve treated over the course of a year with three, four levels at separate times because their mechanics have changed, their bones have changed. Even though you send them to get their bones optimized, they have weak, bad bones. So I think that's another good expectation to let the patient and their family know, that you may be seeing them again for other levels.
The Changing Biomechanics of the Musculoskeletal System After Vertebral Augmentation
...When we see them in follow up, which is usually around the two week mark after the procedure, we talk about, well, there's this other musculoskeletal aspect after compression fracture that I think they have to be aware of, because the biomechanics of the spine have changed because of the compression.
Regardless how much height restoration you get, you'll never restore it to completely normal height. And so there's that kyphosis and change in how the muscles are interacting and the ligaments are interacting, and so that's actually I think one of the common things that we not only have to talk about up front, but that we kind of see on the back end. Now [that] they're adjusting to this new normal and we assure them that this is part of that recovery process. And again, in that consultation I show them the spine model and I think they're usually pretty good about understanding why that's going to change.
So it's not just the pain alone from the fracture, but it's the change in how the remaining bones and muscles are working together, which may have some of this ongoing pain. But I think if you set the expectations realistically at the consultation, they're much more on board with the progress that they'll make.
Addressing Patient Specific Risk Factors
With each patient, I will actually specifically review their particular risk factors. So we'll talk about age, or sex, or race, smoking if they are and of course lots of good reasons to get them to quit smoking, this being of course another one. And then right, specifically talk about their particular fracture. In some of the cases they may have had prior fractures that were not clinically significant, but then we start to talk about, well, now you've had one, or two, or three levels fractured, this is the statistical increase that we see on average of how and why you probably will have future fractures.
And right, a lot of these patients may end up being, to a certain extent, kind of chronic patients of your practice because inevitably they may come back with other levels fractured. But I think again, setting that expectation that this is certainly is a possibility, and simply the fact of having had a fracture is now a new independent risk factor, even if they've never had a fracture before. So that, again, adds to their particular patient specific risk profile.
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.