Innovations

Kyphoplasty: When you can't bear the back pain

The last time they saw Aunt Helen, she was driving herself to bridge club. Her shoulders were slightly rounded, her head was bowed, and she had to peer up through the steering wheel for visibility as she drove, but she always managed to get there on her own.

This time, as she was wheeled into the room for a visit, she was slumped forward in her chair like a rag doll. Unable to navigate her own wheelchair, she clearly could no longer drive a car, walk to the park, or hold her own at bridge. Had it really been just a year?

Aunt Helen had experienced a series of vertebral compression fractures, quite common among those suffering the effects of osteoporosis, a disease resulting from a loss of bone density. In Helen’s case, this caused a weakening of the skeletal structure whose carriage had once reflected her pride, her dignity, her zest for life.

Spinal compression fractures, commonly caused by osteoporosis, metastatic cancer, or myeloma, as well as an extended use of prednisone, often don’t include any symptoms. And any pain can resolve itself without treatment. However, some cases are accompanied by misalignment of the spine, incapacity, and chronic pain that can become intolerable.

“For a long time, the only realistic treatment for these people had been bed rest and waiting to heal,” says Monterey diagnostic and interventional radiologist Dr. J. Randall Forbes, “which is really the last thing we want to prescribe for an older person. The paradox is that once you take the weight off the bones, they quickly become even more brittle. We actually want the elderly to engage in weight-bearing exercise as much as possible to keep bones strong.”

Vertebroplasty is a minimally invasive surgical treatment designed to mend vertebral compression fractures and alleviate pain. Invented in France and introduced to the United States in the late 1990s, it involves putting a needle into the fractured part of the spine and injecting an acrylic bone cement — a substance also used to cement artificial hips — to restore weightbearing structure. An excellent procedure for easing pain, it may no longer be the best we can do.

An evolution of vertebroplasty, kyphoplasty is intended to help restore the normal alignment of the spine, improving respiratory problems, helping prevent additional fractures, and relieving pain.

The cases performed thus far at Community Hospital, says Forbes, have been without complication; and most patients treated with kyphoplasty have experienced marked pain relief.

Unlike vertebroplasty, kyphoplasty involves inserting and inflating a balloon within the spine, where Forbes and Monterey private practice orthopedic surgeon Dr. Mark Howard create an actual cavity, which is then filled with the acrylic cement. Forbes likens a fractured vertebra to shattered glass inside a bag. And this procedure is like filling the bag with cement to solidify the pieces.

“When inserting cement under relatively high pressure, as we do with vertebroplasty,” says Forbes, “the cement has to be rather thin or liquidy, which increases the risk of cement flowing outside the space to somewhere you don’t want it. Conversely, with kyphoplasty, we can use thicker cement to fill the space we’ve created for it. We insert it through a thin metal tube, very slowly and under less pressure, minimizing the likelihood that it will travel elsewhere.”

Forbes cautions that neither kyphoplasty nor vertebroplasty are for everyone. And they are not intended to reduce back pain caused by arthritis or disk problems, or to treat fractures that have already healed.

“Also, if you have a compression fracture from osteoporosis,” he says, “you are anywhere from 15 to 50 times more likely than those who don’t to have another fracture. A few of our patients have returned with new fractures elsewhere in their spines. However, there are a lot of causes of back pain, and it’s most important to make sure we are doing the right procedures for the right patients. 

PVP: New procedure treats enlarged prostate

If you are a normal, healthy man in your mid-40s or older, it is quite possible you have an enlarged prostate gland, also known as benign prostate hypertrophy. If you don’t, the likelihood of developing it increases as you age. And there’s a good chance that there’s nothing inherently wrong with you when it happens.

The prostate is a male reproductive gland that makes fluids that help in the nourishment and transport of sperm. It serves no useful purpose once a man’s reproductive years have passed.

The prostate is normally the size of a small walnut. But as a man ages, it increases in size and can become as large as a grapefruit, says Monterey private-practice urologist Dr. Donald Goldman, chairperson of the Surgery Department at Community Hospital.

“The reason the prostate starts to enlarge is not well understood,” says Goldman. “But it begins to do so in all men around the early-to-mid-40s and continues throughout life. As a result, most men start noticing changes in their pattern of urination in their mid-50s, and the problem gets progressively worse.”

That’s the bad news. The good news is that advanced technology can provide relief from pain or discomfort, while increasing the efficiency (medically speaking) with which a man is able to urinate.

The procedure, called photovaporization of the prostate or PVP, is performed at the hospital under spinal or general anesthesia.

An outpatient procedure, it takes about half an hour to complete. It does require that the patient wear a catheter for 24 to 48 hours postoperatively, but he can do so in the comfort of his home.

Although the patient should anticipate a return to normal activities within several days after catheter removal, it may take a couple of weeks for him to experience the full benefit of the procedure — namely, a marked increase in efficiency of urination.

The potential candidates for photovaporization are men having difficulty with urinating; perhaps they go too often, experience a slow urinary stream, or have to wait to get started. Chances are they have an enlarged prostate and would benefit from the procedure, which would be helpful, says Goldman, for men currently using medication to treat their symptoms but not achieving adequate results. The next step for a man experiencing such problems would be to contact his physician for further evaluation.

Here’s how it works: The key to photovaporization is the KTP laser, a special fiber connected to a machine that generates the laser light. The fiber is passed through a telescope under the surgeon’s direct vision. At the end of the fiber is a mirror, which reflects the light into the prostate gland.

“When this light interacts with the prostate tissue,” says Goldman, “it is absorbed by hemoglobin, which causes vaporization of the tissue; we literally see the tissue melt away as we point the laser light at it. The result, at the completion of the procedure, is a large cavity through the center of the prostate, which relieves the bladder obstruction that the enlarged prostate had been causing.”

The advantages of photovaporization over the more traditional approach, which uses an electric current to cut through the prostate, are decreased blood loss, shorter hospital stay, fewer complications, less discomfort, and quicker recovery.

“This is a wonderful procedure,” says Goldman, who notes that nearly 90 percent of patients require no more than one photovaporization treatment. “The effectiveness of thisparticular laser has been dramatically increased by virtue of the newer machine’s ability to deliver higher energies. To my knowledge, we are the only ones near this area offering it.”

The other problem that can develop in the prostate as men age is prostate cancer, which is a process that can occur independently of prostate enlargement. Moreover, treatment of an enlarged prostate does not change a man’s risk of developing prostate cancer. He must still participate in a program of regular surveillance for prostate cancer even if his ability to urinate is improved through photovaporization.

“About 150,000 to 200,000 new cases of prostate cancer are diagnosed every year in this country, causing about 30,000 deaths per year,” Goldman says. “We don’t know how to prevent prostate cancer, so a routine examination and PSA (prostatic specific antigen) blood test should be done annually, beginning at age 45. If the man has a family history of prostate cancer, screening should begin at 40.”