Episode 21

Vertebral Augmentation

Dr. Venu Vadlamudi and Dr. Kumar Madassery

Dr. Venu Vadlamudi of Association of Alexandria VIR, and Dr. Kumar Madassery of Rush University VIR discuss techniques and equipment for vertebral augmentation, including vertebroplasty vs. kyphoplasty.

Cite this podcast: BackTable, LLC (Producer). (2018, January 28). Ep 21 – Vertebral Augmentation [Audio podcast]. Retrieved from https://www.backtable.com/podcasts

Full Transcript Below

In this Episode

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.

Disclaimer: The Materials available on the BackTable Podcast 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. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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Full Transcript

Vertebral Augmentation

[Aaron Fritts]

Hello everyone, welcome to the Back Table podcast, your resource to connect with your IR colleagues and learn tips, techniques, and the ins and outs of the devices in your cabinets. This is Aaron Fritts. I'll be filling in as your host this week and I'd like to remind you that you can find our whole catalog of podcasts on the BackTable app found in the Apple Store.

I'm here with Dr. Venu Vadlamudi and Dr. Kumar Madassery to talk about treatment of compression fractures in the spine. Great to have you back fellas. For any new listeners, I'd like you to just briefly introduce yourselves, where you're located and kind of how vertebroplasty and/or kyphoplasty became a part of your IR practice.

[Venu Vadlamudi]

Okay, sure, yeah. As Aaron mentioned, it's certainly great to be back on the podcast. I think this is an excellent resource and really kudos to Aaron and Mike for kind of spearheading and pushing this forward as another resource. Especially for I think younger IR's, it's a really nice resource.



[Venu Vadlamudi]

As Aaron mentioned, my name is Venu Vadlamudi. I'm a body IR and neuro IR trained and I'm in private practice in Alexandria, Virginia. And just sort of briefly about vertebral compression fractures and that aspect of our practice, my senior partners, well before I joined the practice, had been treating vertebral compression fractures and have gone through probably most of the different iterations of the tools that are out there, kyphoplasty, vertebroplasty, vertebral augmentation, you know with osteotomes and that sort of thing. At this point we predominately do either straight vertebroplasty or in some cases vertebral augmentation with vertebroplasty and then somewhat separate, but certainly related is spine tumor ablation and vertebroplasty following that. So, just sort of a brief overview of the kind of practice that we have.


And like I said, we've been incorporating that in our practice for well over probably about 15 years now. And so I think that really offers a great service, especially in terms of palliative pain control for patients. And so we find good referrals based on our kind of long track record.



[Kumar Madassery]

Exactly what I would say there, that's pretty good there Venu. This is Kumar Madassery, one of the Interventional Radiologists at Rush University Medical Center in warm Chicago. Our practice is a ... well, first off actually, Aaron and Mike, you do a fantastic job with this podcast. It's something great that we never had earlier on that I think is of immense benefit as Venu said to everybody out there, especially the young guys. So, kudos to you guys.



[Aaron Fritts]

Thanks Kumar, appreciate it.



[Kumar Madassery]

In our practice we use kyphoplasty, vertebroplasty, actually augmentation, kind of in a mixed bag as it depends on operator preference and also just because we have fellowship and trainings and we like to have all the options so everybody learns what they see are the differences, what we think are best, and we can kind of develop our own kind of understanding of what we think benefits patients.

Also, we do the spine tumor ablation as well, along with kyphoplasty or vertebroplasty, depending on the patient. Our mixed referral system gives us about I'd say 50% outpatient and 50% inpatient. It just depends on the time of the year I guess. But I think we can get into what we think about it as we go, but that's kind of how our set up is.



[Aaron Fritts]

Yeah, I mean, that kind of leads into the next question I had, which is how patients present to your practice. In my former practice, it was mostly through the ER and so I'm really curious to know how you build those outpatient referrals. So [do] you guys have any pearls or pitfalls on kind of building that outpatient referral pattern?



[Kumar Madassery]

Yeah, so thanks. At our place we've developed over the years a good pattern of being able to have outpatients sent to our clinic directly. Basically every day we have a clinic, an outpatient clinic, that's run by MA's and one of us and as well as mid level, so everybody has been made aware over the last couple of years, especially our orthopedic surgery spine surgeons as well as neurosurgeons and family medicine and internal medicine teams, we've talked to all of them, as well as the ER itself. But they're able to just basically put an outpatient order in immediately when they see the patient. We see that order and we get to call the patient and maybe same day, just have them walk over.



[Kumar Madassery]

That's made life easier a lot easier for our referring physicians, and more importantly the patient themselves, so they can get typed into the system immediately. So once we started promoting that, telling them how easy it is, made easy through our EPIC system, it's almost instantaneous for us. That really helped us out over the last couple years.

And then the second one is, at our place we have a service line called the Fracture Liaison Service and it's actually headed by an endocrinologist physician who's older aged, but he's an expert on fractures and fracture medical management. So he's a person that automatically gets consults by the system any time a patient comes in with a pelvic or vertebral fracture. So, a while back I met with him, we kind of realized that there's a lot to work together on, so he and his team get called on any fracture, then he is an expert on the medical management, which we probably aren't the biggest experts on but we can work together. Similarly when I see a patient in the clinic, I send them as a follow up to his clinic as well, so he makes sure they're optimized from a bone health standpoint.

Having these multiple kind of avenues have really helped us out, build that up slowly over time.



[Aaron Fritts]

Yeah, that sounds a great partnership to have. How is it on your side, Venu?



[Venu Vadlamudi]

Yeah, we kind of get a mix, I would say our outpatient versus inpatient mix is maybe about 30 to 70 or 40 to 60, so skewed certainly towards the inpatient side. But one of the things we've been actively working on over the last, probably at least year and half to two years, is working more directly with not just the primary care physicians, especially those who deal with geriatric populations, but also with the emergency room. Giving them education and talks, just saying if these patients present to the emergency room department, in a lot of the cases they may be on, let's say blood thinners, you know, a lot of these older patients may be on coumadin or other blood thinners. So we're not going to be immediately able to treat them anyway. You know, we might have to wait for the blood thinner to wear off and what not.


So we work with them to say, okay, let's try to get some acute pain control, get them seen in consultation, and get them an appointment made to come back as an outpatient to get the procedure done unless something dramatically improves with the pain. And as I mentioned, I think doing outreach with primary care offices is part of the way we get some of those outpatient referrals. Again, they will come to our clinic and see us for a formal consultation.


We not only go over their fracture and the pathology behind it, but really, what are their particular risk factors. And one of the things that we do in our practice is, essentially all of our patients get a referral to physical therapy programs that are around here, kind of really specifically targeting osteoporotic patients so we know that that is one of the ways that we can try to help them, in addition to the medical management.


And usually from the medical management side of things, we do some of the management but like Kumar, and it's great to hear in his set up that they have a dedicated endocrinologist focusing on this group of patients, 'cause it's a lot of patients and they do often times need some very specific help. So we'll usually work again, either with the primary care doctor or sometimes refer them to endocrinology, if they do need more specific medical management.



[Aaron Fritts]

Yeah, so along the lines of reaching out to outpatient primary care docs, one challenge that I've seen is that the outpatient docs and primary care especially aren't as familiar with the broad scope of the IR practice, you know, what we're capable of. And they might think of kyphoplasty or vertebroplasty as a case for a spine surgeon or a pain management doc. Do you have any suggestions on how to overcome that hurdle? Do you have any sort of ... do you send out marketers or are you actually going in yourself into these offices to talk to the docs?



[Venu Vadlamudi]

Kind of a bit of both. So in our practice we do have a couple of folks who specifically do marketing for our practice as a whole, and that includes the IR side of things. So we'll have them make office visits. Honestly, we try to utilize some of the vendors themselves, because they often in those companies will have specific people focused on education. You know, that's their sole job and we want to try to employ them really get awareness and education out there.


But you're right, I think the broad scope of things that IR does often maybe beyond what the primary care physician may be thinking about. I think that's where us going particularly to these offices and just talking with them, sitting down. In fact, just like five minutes before this podcast, I was emailing with one of my partners because we're going to go meet with the hospitalist at one of the hospitals. And again, here's sort of a brief but somewhat comprehensive list of services that IR performs. And among that is of course spine services relating to compression fractures and then other things, pain injections, which can certainly relate with these same subgroups of patients.


So, I think that it’s important for them to realize that IR does see these patients and can manage them. It doesn't always mean that it's a vertebroplasty as far as the right procedure or something that might help them. Maybe something else is a better option. And I think just again, kind of reinforcing that this is a true clinical service, that we're going to see and help these patients and manage them clinically and it's not simply going to get dumped back on them. We'll try to make sure to take care and follow through where we need to.


Another one of our referral sources, I think similar to Kumar's, is actually spine surgery. One of the orthopedic spine guys in our area, he has a busy enough practice that frankly he can't take on this volume, and so that's been a really good relationship to have. He recognizes we offer a good service, we help these patients, and so he will often either redirect these patients to us or if they happen upon his clinic, he'll say, "Okay, I'm going to send you over to these guys. They'll take it from there." So that's another kind of way to show that we can offer a good service, and again, kind of that good clear communication about all the different types of things that can do in IR is important.



[Aaron Fritts]

Yeah, and another question, on the inpatient side, are your diagnostic colleagues assisting with identifying these patients? So when they come in with the MRI or the CT...yeah go head Kumar.



[Kumar Madassery]

That's exactly what I was going to point out. I agree with everything Venu was saying about the outpatient side, but on the imaging side, our colleagues can be a great resource to say. Especially for us, our radiologists catch most of these MRI fractures or find them or diagnose them, and you say, okay, who are these people and you look it up and you talk to the patient and say, hey we know this is a fracture, how's this patient doing. It's part of our global need to increase awareness of what we do.


But then you reach out yourself and you talk to them, and say, “hey, how's this patient doing? I'd be glad to see this patient.” And you've got to make them comfortable, [and let them] understand that you're not just out there treating every patient, but you'd like to see the patient and evaluate [them]. And patients may not be good for it, but at least you get your name in their face and that you're available right away and you could do it. I think you take ownership, but like Vanu said, the imaging colleagues are a great resource because they're the first ones seeing them.


So you start developing a system. We do that for PAD as well sometimes. You have them kind of give you a heads up or you look at it, and then you reach out and I think that's a great way to start building your relationships.



[Venu Vadlamudi]

Yeah, I agree with Kumar. I mean, we have to in the same sort of vein of educating primary care doctors, ER doctors, as far as what we can do in IR, a lot of times we actually have to have continual education even for our diagnostic colleagues because IR does so many different things. I could tell you even within our own practice, sometimes they may not even be totally aware of all the things that we can do, or that we're sometimes if it's something we're willing to try, and I think that's an important education piece internally. And again, trying to get them to not just do their part of things, which is recognizing it from an imaging standpoint, but hopefully giving us a notification and I would say, in our practice a lot of the times, they do give us sort of that heads up, that hey, there's a compression fracture.


And then from there, similar to kind of Kumar's approach, we'll proactively reach out and talk with whoever the referring doctor was, whether it’s outpatient or inpatient, and find out more about the patient and see perhaps if there's something we can help with, if the patient's pain is not under good control.



[Aaron Fritts]

Great, yeah, so I wanted to get into a little bit about technique, because I know Venu, you actually perform more vertebroplasty than kyphoplasty and I was just curious to know, how that came about. I'm just trained doing kyphoplasty. I have never actually done vertebroplasty and so I'm curious to know how you started leaving out the balloon?



[Venu Vadlamudi]

Sure. During my training I did train on both but a little bit I would have to say is from looking at the literature, looking what's out there. I think in some of the meta analysis that are out there, there might be a slight advantage of kyphoplasty over vertebroplasty, but I think all in all I would say, at least my opinion is that, the data is mostly a wash. Obviously some sort of vertebral augmentation, if we kind of lump them in that more broad category, seems to work in the right patient. With the pain and the fracture, putting it all together, we know we can help these patients.


And so almost in a sense of simplicity, [in] our practice we meet quite often, we sit down and say well, as a section, “what do we want to do,” “how do we want to make services available,” etc ... and so we've looked through and looked at data that's available and said, well, maybe we should simplify things and go with the straight vertebroplasty.


And that's part of what I talk about in consultations with patients. I talk about the fact that there's these different flavors of ultimately getting cement into the bone and how much cement you get in there. Height restoration I think is something that sounds great in theory, but there has not been any hard data that shows that it actually makes a difference in specific outcomes. And so there's lots of different devices and tools and techniques, and including things that are not even available in the U.S., but I don't know that there's enough hard data to say that any of them are truly superior to vertebroplasty alone. So, that's kind of the scientific rationale that we use behind that.


This past fall when I was at WFITN in Budapest, Mary Jensen who is a neurointerventionalist from UVA and their group was the first to describe, back in 1987, vertebroplasty for compression fracture. You know she did a really nice comprehensive review of literature and the devices and things that are out there, and I remember that was one of her particular conclusions, was that looking at all the data, all the different devices, there's not really a clear cut benefit of any additional manipulation over plain cement alone.


So that again, for me personally, helped solidify that approach. But I'm certainly curious to hear Kumar's approach to things, because I think in his setting, I think it's actually important that trainees certainly have that ability and exposure to learn about all the different tools.



[Kumar Madassery]

Yeah, you know I think you made some really excellent points about what the individual operator chooses when they go off to their own place, and that's kind of how you should be operating. 'Cause you're using it based on evidence and I think that's how we should be training. At our place we have three different systems. Primarily we end up using two, whether its kyphoplasty or vertebroplasty, but we do have three because one is a kypho with a RFA, the other one's a vertebro with RFA and then the other one's curved. So we have all of them. Most of us who do it, we pick and choose based on the patient and then not because we think the evidence is better, but mostly so our fellows get trained at all of them since they have to go out and be the ones like yourselves who are making the choices on which one system makes sense for their practice.


So in that sense we do teach all three and my own personal choice is, if I believe the height restoration makes a difference and when I see a big height loss, I'll consider using the balloon more than the straight vertebroplasty. Our augmentation with the curved curette and all that. I do agree with all the data review that Venu talked about, that's kind of the most important thing you have to teach the trainees and everybody. There are the talks about the sham and this and that, but if you're going to do it and you feel it helps the patient, what are you going to choose and why and how are you going to justify that to your practice.


So I guess for us, having them learn how to use all of them makes a .... or at least the main ones makes a difference in the training aspect of it. But I do agree with mainly whether or not you think the height restoration was different, there's also some data or study showing that having the balloon has a lessened chance of cement extravasation. I mean, not many of us see that anymore, but it's a possibility. So if you believe in that, that's one thing to consider.


So if I'm in the upper thoracic level and it's a big fracture, then the balloon makes more sense to me or if height loss is great, the balloon makes more sense to me. It's just operator dependent again [and] I think the outcome for us, subjectively, they're the same.



[Venu Vadlamudi]

And I think along those lines there comes into play, out of the science, the art of it. And I think that's where, well, which tool do you pick when? I mean, I think it's hard to say, “well, I only ever go unipedicular and just put cement or something like that.” No, I mean each case is going to be different. There's that kind of tactical satisfaction with the result. Did I feel like I got good cement distribution, is it side to side, top to bottom ideally, or is it like, okay, I have a focal blob of cement right around where the needle went in and I don't have good cement distribution to the other side.


Again, if I purely look at the data, it sort of says it kind of doesn't matter if you have a bunch of cement, or a little cement. You know, the volume of cement from the science says it doesn't matter. But in reality, I think there's that art where you want a satisfactory result and hopefully that's going to most importantly translate into a good clinical result.



[Aaron Fritts]

Yeah and equipment wise, I'm actually a big fan of the new curved balloons and needles on the market and I've gone unilateral on several of my recent cases, both T and L-spine. I'd like to know y'all's experiences with the curved balloons and needles and if you guys use it much.



[Venu Vadlamudi]

I have used and like the new curved needles from Stryker, for example. I've used those on a few cases and I've had very nice cement distribution. DFINE, which is now part of Merit, they have their flexible curved osteotome, which is a nice device. Especially the newest iteration of it. [It’s] more rigid and robust, I think, and really can create some nice channels for cement distribution.


And so I think those adjuncts can allow for a unipedicular approach in most cases. I think in our practice, a lot of the cases that we do tend to be unipedicular. And then I think even beyond some of those newer adjuncts that could help, I think if we go back to good technical skills and abilities as far as getting the needle from a unilateral approach to the sort of ideally midline and anterior one-third, middle one-third junction, that takes practice. I can tell you it probably takes 30 or 40 cases to get that art in place.


One of my senior partners, honestly, I'm amazed at how accurately she can get the needle placed from a unipedicular approach, multi-levels or what not, and I sort of strive for that. I look at that, I was like, wow, that's excellent technical placement of the needle and I think that's why she rarely uses any of the adjuncts and from a unipedicular approach gets excellent cement distribution.



[Venu Vadlamudi]

So I think that's another piece of things that we can all continue to strive for.



[Kumar Madassery]

Yeah, I agree, I agree with Venu that the curved needle from Stryker [has] given a lot of ease and approach, especially of the thoracic spine, because it gives you a lot more leeway for not having to be such a lateral to medial approach. I do like that aspect of it.

And also with the Merit, I find the curved curette gives you a lot of maneuverability in creating your channels that you're doing. We also have the Medtronic one but I think the curved needle particularly has helped. [It] gives you a lot more forgiveness in there because the biggest thing you try to teach the fellows is imagine the pedicle as a clock face and how you're going to really strive to get to that across the midline, the curved needle itself on that really helps you.



[Kumar Madassery]

So what whatever you're doing I think the advantage of that is the importance is getting to the right spot and that comes with, as we've all learned, is just practice, experience and a lot of fear in the beginning.



[Aaron Fritts]

Yeah, even cranio-caudally, you know, if you have a superior end plate fracture, [or] an inferior end plate fracture, you can direct that needle up or down nicely, which is what I like about it. Just to get it, like you guys said, just to get it in the right spot and once you find that fracture line, the cement just kind of goes in the pathway of least resistance.



[Venu Vadlamudi]

Yeah, I agree completely. And often with those paralleling fractures, which they very often are, I often will try to get the needle right into that cleft. Like you said, the cement's going to go in and nicely and distribute right across that cleft, that fracture line. Usually if I get that, that may be enough of a stopping point. I don't necessarily need to have cement go all the way from the top to the bottom if I can get it right across that fracture plane. That may be enough to get that stabilization and pain relief and often that's what translates clinically.



[Aaron Fritts]

Right, especially with the pain relief.



[Kumar Madassery]

Great point, that's a great point, yeah.



[Aaron Fritts]

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? Are you having them do physical therapy while they're inpatient, or wait until they're outpatient? Just walk me through your post op care.

You go ahead and start Kumar.



[Kumar Madassery]

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.



[Kumar Madassery]

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.


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.



[Venu Vadlamudi]

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.


We explain to them during the consultation whether on the outpatient or inpatient side. Same thing, I definitely agree, working with physical therapists and maybe this even relates back to one of the earlier points of outreach. That's actually another group I failed to mention that we actually try to give lectures to and talk to, because they're almost always going to get involved in these cases on the inpatient side for sure. And so, sometimes they may actually be the ones that sort of prompt the discussion or at least a question, maybe you guys should call IR about this case to see if they have something to offer. And so that's been another resource for us.


But nonetheless, physical therapy is clearly an important aspect of things. 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.



[Aaron Fritts]

Right. 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?



[Kumar Madassery]

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.



[Venu Vadlamudi]

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.

I emphasize the physical therapy aspect of things of how that's going to help. And then finally, I think one of the things, and we see this 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.



[Kumar Madassery]

Yeah, I totally agree. 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.



[Venu Vadlamudi]

Yeah, I think that's an absolutely great point. 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.



[Aaron Fritts]

Yeah, hey fellas, this has been really, really great information and I think it would be very helpful for anybody trying to build a vertebro or kyphoplasty practice. Anything else that you guys want to add?



[Kumar Madassery]

I think it's important if you're going to start building this to know the data, like Venu was talking about before, know the studies. You know there's a lot of skepticism from the medicine side of our colleagues from reading the JAMA articles of 2009 and such, but it's important to know those and the other trials and the randomized trials and know the limitations of all of them. There's a review article I think in [Journal of] Neuroradiology this past winter 2017, where they reviewed all those kind of studies and gives you an insight as to the limitations and the biases. So at least having that, you have to know what they know and know how to counter it with why you think it's beneficial.


So I think if you're going to try to build this up, know those studies, at least the summaries of them, so you can be educated in your discussions.



[Aaron Fritts]

I think that's great advice.



[Venu Vadlamudi]

Yeah, I mean, I agree with what Kumar said about certainly knowing the data, knowing what's out there. If they have certain impressions, being able to educate people about well, here's where we stand as of 2018. But I think another thing, and this is maybe a little bit more targeted towards trainees, medical students, residents, fellows, in some places maybe they're not going to have as direct exposure, like in Kumar's program, to being able to do these types of procedures and see these kind of patients that might feel, well maybe this falls under ortho spine, or neurosurgery spine, or a very separated neurointerventional division or something like that. So I think trying to get that exposure is important if you don't have access to it. Hopefully most programs do have access for the trainees to see these kind of procedures and I think getting that broad exposure during your training is important.


I'm glad to hear programs Kumar's are exposing the fellows to all the different modalities that are really out there, so that ultimately when they go off to the practice that they're going to be in, they'll have had good technical training and hopefully complimenting with that of course, good background knowledge and scientific understanding of this important procedure. 'Cause this is really one of the most gratifying procedures we can do in interventional radiology and especially those grand slam kind of cases I was mentioning earlier. You know, the ones that walk out of their outpatient procedures feeling like a million bucks. I mean, that's really one of the best feelings you can have so I think it's a very important skill set in the armamentarium for an IR.



[Aaron Fritts]

Anything else I guess you want to add before we finish up?



[Kumar Madassery]

No, just want to say thanks. It's always great talking to Vanu virtually.



[Venu Vadlamudi]

Same here, great talking with you guys. Again, I think just to emphasize this is such a great resource and [I’m] really happy to participate. Thank you again for the invitation.


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