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Dr. Nick Spina talks about his medical philosophy…
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As we age, our bones become weaker, meaning…
Date Recorded
April 25, 2017 Health Topics (The Scope Radio)
Bone Health Transcription
Dr. Miller: Thin bones and the risk of fracture and what to do about that. We're going to talk about that next on Scope Radio.
Announcer: Health tips, medical news, research, and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.
Dr. Miller: I'm Dr. Tom Miller and I'm here with Dr. Nick Spina, and he's an orthopedic surgeon here at the University of Utah, in the Department of Orthopedics. He's an expert in spine care. Nick, how do you get a fracture when you have thin bones or osteoporosis? What happens? Where do they occur typically in the back? Tell me about that. It's a lot at risk.
Dr. Spina: Yeah. Osteoporotic compression fractures or what we call fragility fractures are probably the most common fracture we see in spine surgery. It tends to be on the more elderly side of the population.
Dr. Miller: At the time when we lose our bone mass.
Dr. Spina: Exactly, at the time when we lose our bone mass. So I'd like to describe them to people to imagine a soda can or a pop can. And each patient's vertebral body is like a pop can. So it has a hard rim on the top and a hard rim on the bottom, and the center part of the can is relatively empty. As we age and we get osteoporosis, the center of the can becomes even more empty. And so, as we stress the top, the can eventually cracks and crushes where our end plates become closer together or the ends of the can become closer together.
Dr. Miller: And so, what happens to precipitate that fracture? My understanding is they could just happen spontaneously if your bone density is so low.
Dr. Spina: Right. Depending on the degree of your osteoporosis or the degree of the strength of your bone, it can happen with just minimal activities such as waking up from sleep, standing, walking. They are commonly precipitated from falls, so patients often come in after a fall from standing or a fall during gardening, or routine activity around the house where they develop an acute onset of back pain.
Dr. Miller: Or one of the favorites from my patients would be shoveling snow.
Dr. Spina: Exactly. It seems no one should shovel snow anymore. That's pretty much a general rule.
Dr. Miller: So what happens? Do they have pain typically after that?
Dr. Spina: So the most common presenting symptom is acute back pain. Some of the worst pain you've had in the center of your back. It tends to be localized to the midline or right in the middle. Our muscles also become very inflamed, so it can radiate out towards our rib cage. It tends to be in the mid portion of the back. For women, right around their bra strap, and for men, kind of in-between the shoulder blades.
Dr. Miller: Now, you would find more osteoporotic fractures in women, I would think, right?
Dr. Spina: It does.
Dr. Miller: Osteoporosis is more common in women.
Dr. Spina: It's more common in women. So we do tend to see more osteoporotic fractures in elderly women versus men.
Dr. Miller: So, aside from analgesics, pain killers, that type of thing, what can you do to alleviate the pain or help with the pain?
Dr. Spina: So we sort of take a two-tier approach. One is a reduction in activities and modification of daily living, to avoid those activities such as heavy lifting, bending over at the waist, stressing the spine by bending forward or twisting. And the second would be we occasionally use a brace to provide an external support, kind of external crutch you can think of to keep the spine upright or support it while a bone tends to heal in that compressed manner.
Dr. Miller: What's this brace look like? Is it corset?
Dr. Spina: Yes. It tends to be a corset. It kind of looks like a turtle shell, hard in the front and hard in the back, and it wraps around your torso.
Dr. Miller: And usually, how long would a person have to wear that for that to work?
Dr. Spina: We tend to use them for about two months. And then, we tend to wean out of it because as we put people in braces, their muscles, obviously, become weaker. And having good muscular strength is one of the ways we compensate for having fractures. And so we don't cut them cold turkey. We often ask people to slowly come out of them and wear them when they're upright or up for long periods of time, and then remove them when they're sleeping or sitting.
Dr. Miller: Now, tell me a little bit about what's call kyphoplasty. I understand there's a little bit of controversy about the use of this technique and has been for a number of years.
Dr. Spina: So kyphoplasty and vertebroplasty were very common about 10 to 15 years ago. They sort of exploded in the world of spine surgery. And the procedure itself is directed at restoring the height of that pop can. So what we do is . . .
Dr. Miller: So this maintains height in the patient. So the concept, I guess, was if you increase the height of the crushed pop can, then the person wouldn't lose height.
Dr. Spina: Exactly. And so we insert a probe from the back of the spine into the front, the vertebral body. And there are two different means. One, we use a balloon to try to restore the height of the body. And the second is we just inject a material to try to restore the height. And the bottom line is that we take the empty space in the vertebral body, that space that's crushed down, and we try to stabilize it and if not, restore it by putting cement in the front of the vertebral body.
Dr. Miller: So what is the controversy surrounding this technique?
Dr. Spina: So there have been a couple large studies that have been done, that have looked at patients who have not had vertebroplasty or kyphoplasty and who have, and they haven't shown much of a difference as far as long term outcomes. So, in my practice, we tend to reserve them for those patients with intractable pain after about six weeks of non-operative care.
Dr. Miller: So they have some role in alleviating pain if it's not treated with the standard sort of non-interventional means that you just spoke about a few minutes ago?
Dr. Spina: Exactly. In those patients out of refractory which are very, very few in my practice, tend to see a little bit of benefit from doing a kyphoplasty. But again, we tend to reserve that to those people that fail all the non-operative means which we start with in the beginning.
Dr. Miller: The other point would be that if a patient has osteoporosis, they should also be treated for that with one of the newer medications. I should say newer. The medications have been around now for 10 years, and there's new medicines coming out all the time.
Dr. Spina: Exactly. One of the biggest risk factors for vertebral body compression fracture or fragility fracture is having a previous fracture. So it's our routine practice when we identify these patients to make sure that they have a pipeline of care through either us as treating providers or their primary care physicians to check their bone quality through a DEXA scan and address the degree of osteoporosis that they have.
Dr. Miller: Screening becomes very important in this age group, especially women over 65 years of age.
Dr. Spina: Exactly. Screening is probably the best form of prevention for these fractures that we have.
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The human spine is meant to bend naturally, but…
Date Recorded
February 21, 2017 Health Topics (The Scope Radio)
Bone Health Transcription
Dr. Miller: Kyphosis, or a bend in the spine. What is it? What can we do about it? We're going to talk about that next on Scope Radio.
Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists, with Dr. Tom Miller, is on The Scope.
Dr. Miller: I'm Dr. Thomas Miller and I'm here with Dr. Nicholas Spina. He's an orthopedic surgeon here at the University of Utah in the department of orthopedics. Nick, tell us a little bit about kyphosis and what causes that. I understand there are a couple of causes.
Dr. Spina: Kyphosis basically refers to the curvature of your upper back, or your thoracic spine. The body's natural position is to keep its head centered over its hips. In our lumbar spine, we have a curve backward, and then our thoracic spine reflexively curves forward.
Dr. Miller: Sometimes that curve is too accentuated? Too great?
Dr. Spina: Too accentuated or too great.
Dr. Miller: And that's what we call kyphosis.
Dr. Spina: And that is what we call kyphosis. There is normal kyphosis and there’s also increased kyphosis or abnormal kyphosis.
Dr. Miller: And who gets that?
Dr. Spina: So everyone has a natural portion of kyphosis built into their thoracic spine and so some degree of kyphosis is normal.
Dr. Miller: And also protective, right? Because that little bit of curvature actually mechanically increases the strength of the spine, I think.
Dr. Spina: It does. It's naturally biomechanically favorable to have some degree of thoracic kyphosis through the mid-portion of your upper spine. Some patients, though, develop increased kyphosis. And there are a couple causes of that. One is what we think of sort of an inherited or congenital kyphosis. We call it Scheuermann's kyphosis, and that refers to a natural shape of the vertebral bodies where they're angulated or wedged in the front. So they're shorter in the front than they are in the back. And when you have a section of the spine with two or three of these segments in a row, that is considered abnormal kyphosis or what we call Scheuermanna's Kyphosis.
Dr. Miller: And you tend to be born with that or develop it over time?
Dr. Spina: You tend to develop it over time. It's commonly seen in young, teenage males. As males hit their growth spurt, they tend to notice an increased kyphosis, or increased hunchback, per se, through their upper spine.
Dr. Miller: So what is the other group that might have that? Older folks? Older patients?
Dr. Spina: So the second group of patients that typically develops kyphosis tends to be the older population. This is the population who develop osteoporotic compression fractures. It's also the population that sees significant disc degeneration. And so what we like to say is that life is a kyphosing event, and as we age, we all . . .
Dr. Miller: That doesn't sound good.
Dr. Spina: No, no. It doesn't sound good, but it's normal. And as we age, we all develop a degree of kyphosis. So the natural tendency is for us to lean more and more forward as we hit our upper decades.
Dr. Miller:And as we do that, when does it become a problem so that moving around becomes difficult or even one develops pain?
Dr. Spina: So people tolerate different degrees of kyphosis and it all depends on the patient specific. Some patients can tolerate a high degree of kyphosis and it's mainly due to the large muscles that sit next to your spine and try to keep us upright. And so the more kyphosis we have, the more forward our head is, relative to our pelvis, and the more energy we have to expend to stand upright and keep a horizontal gaze and be able to look at where we're going or who we're talking to. So as we get increasing kyphosis, our back muscles have to do more and more to keep ourselves upright and that's when it tends to become a problem and we see increasing pain associated with increasing kyphosis.
Dr. Miller: So can physical therapy assist in preventing forward kyphosis?
Dr. Spina: So physical therapy is a useful tool in treating acquired kyphosis.
Dr. Miller: So that would be in the first group that you talked about.
Dr. Spina: That would be in the first group. Either the young group or also the older patients that tend to go on to develop kyphosis. The back muscle's job is to keep us upright and looking forward. And the stronger those muscles are, the more we can compensate for increasing degrees of kyphosis. So our body's natural job is to compensate for our alignment, but the energy it takes to compensate is directly related to the degree of kyphosis that you have.
Dr. Miller: So, as an orthopedic surgeon, when do you decide to intervene in cases that are severe? Or do you?
Dr. Spina: So treating kyphosis is a very difficult subject and it's a very difficult task. We tend to intervene when everything else fails, as in a lot of other areas of orthopedics. We tend to start with physical therapy. We tend to start with trying to help people compensate for their natural alignment. When they cannot compensate any longer or their pain becomes debilitating, we consider intervening.
And the problem with interventions for kyphosis is they tend to be on the larger scale. We don't have a simple surgical tool or a simple intervention that can correct kyphosis. It often involves a multi-level thoracic fusion with some type of procedure where we cut the bone and realign it. And so it's a pretty large endeavor that we try to reserve as a last resort in treating patients with acquired kyphosis.
Dr. Miller: So what would you say to patients that are looking to prevent kyphosis from becoming worse?
Dr. Spina: So . . .
Dr. Miller: How do they do that?
Dr. Spina: Yeah.
Dr. Miller: Because I think a number of people that might be listening may not know when to seek assistance or seek advice.
Dr. Spina: So it's sort of a three-fold way to try to prevent kyphosis. In my mind, it all starts with activity and, as we age, to try to stay as active as possible. The second aspect would be trying to keep your core musculature and your paraspinal muscles as strong as possible. And so that would be through a course of increased physioactivity, core strengthening programs, a program that can be shown through physical therapy. And then, finally, it's to keep an eye on your bone quality. Osteoporosis is a significant risk factor and contributor to increasing acquired kyphosis, due to vertebral compression fractures.
Dr. Miller: So in that last category, having bone density studies done according to when you should have them done, if you're 65 and older or if you have risk factors, then that would help determine if you have a risk of vertebral fracture, thoracic fracture. And you could begin to intervene to prevent those fractures with certain medications.
In the second group that you mentioned, this is the physical therapy that you prescribe. Now, you have a set of physical therapists that work at the orthopedic center and I'm sure that other physical therapists in the valley, you prescribe certain therapies for your patients with the physical therapists.
Dr. Spina: We do. We work closely with the physical therapist based on the presenting symptoms. And often times with kyphosis, we focus on an extension strengthening program, so, an effort to strengthen the paraspinal muscles that run along the spine through a postural-based exercise program. We also, as patients, we also focus on flexion, because flexion is also involved in the core muscles of the abdomen, which all help stabilize the thoracic and lumbar spine.
Dr. Miller: In the first group, you mentioned the thing that I love is "use it or lose it." So what type of physical therapy would you . . . not physical therapy. What kind of exercises? Would you just recommend walking? Is that good enough?
Dr. Spina: So walking is great. Any exercise is better than no exercise. But, ideally, as we age, the lower impact exercises are great and exercises that incorporate a lot of muscle groups are great. So I try to encourage people to get into a pool when they can. If they are unable to swim, just walking laps in a pool also helps. The reason is it takes gravity out of the picture and so the stress on the joints is much lower, but you're still getting that resistance that strengthens the muscles. And it also works on your balance.
Dr. Miller: So the bottom line is if you're worried about kyphosis or the development of kyphosis, stay physically active. That might be your number one preventative treatment. The second thing is if you are developing kyphosis, you can see an orthopedic specialist or a sports medicine specialist who understands spine and then go to a physical therapist for focused treatment. And then the last piece would be to make sure that you don't have osteoporosis through appropriate screening.
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