Kyphoplasty

Medicine and Health

As I’ve mentioned before, I am currently working as a medical assistant in pain management. It’s now been almost a month that I started my new job and I love it! I get to work alongside the best pain management doctors in my area and have learned so much in a short amount of time. Last week, I had the privilege of shadowing several Epidural Steroid procedures as well as a Kyphoplasty procedure. It was the coolest thing I’ve seen since tori removal back in my oral surgery days. If you don’t know what a Kyphoplasty is, keep reading because this post is all about it!

What’s a Kyphoplasty?

A Kyphoplasty is a procedure performed to correct vertebral compression fractures (VCF) through the use of polymethylmethacrylate (PMMA) aka bone cement. The leading cause of VCFs is osteoporosis (Cooper and O’Fallon, 1992), but falling or high risk activities like lifting heavy weights could also lead to a fracture. Due to the nature of the fracture, VCFs can be very painful; the vertebral body collapses causing the patient to lose height in their spine. During the procedure, a hollow needle is inserted into the body of the vertebra through the pedicle. An inflatable balloon is then placed inside, inflated to restore the vertebral height and to create a working channel for the cement to flow into. The entire procedure is guided through a fluoroscope and contrast medium.

Why a Kyphoplasty?

Other treatment options for patients with painful VCFs include non-surgical management (NSM) and a Vertebroplasty procedure. A Vertebroplasty is very similar to a Kyphoplasty. The primary difference is that a balloon is not used to create a working space for the cement to flow into and the cement used tends to have a lower viscosity. Both of these factors increase the most pertinent risk associated with the procedure: bone cement extravasating into the epidural space. Without a working space, the physician doesn’t have as much control of where the cement is flowing into. Also, bone cement viscosity is identified as a decisive guideline influencing leakage in a Vertebroplasty, so using a cement with a higher viscosity reduces the risk of extravasation (Giannitsios, 2005). In fact, the incidence of leakage during a Vertebroplasty ranges between 2-67% compared to 0-13.5% for a Kyphoplasty (Denaro, 2009). Other risks to consider include heart attack, cardiac arrest and stroke. In addition to surgical procedures, there are also NSM options for patients with VCFs. These include bed rest, pain relief medication and back bracing. Compared to patients who undergo a Kyphoplasty procedure, patients following a NSM treatment plan for VCFs experience less pain relief and improvement (Meirhaeghe, 2013). For these reasons, if a non-surgical treatment is insufficient, a Kyphoplasty is often the preferred treatment option for VCFs.

What are the main indications for the procedure?

  • Patients with Osteoporosis
  • Patients experiencing intense pain adjacent to the level of the fracture
  • Patients diagnosed with a fracture by an MRI, CT or X-Ray
  • Patients who failed non-surgical management for at least 4 weeks
  • Patients with lesion causing benign and metastatic tumors

Which patients are not candidates for the procedure?

  • Patients who did not fail non-surgical management for at least 4 weeks
  • Patients with asymptomatic vertebral compression fractures
  • Patients with allergies to materials used in the procedure such as PMMA or barium contrast
  • Patients with bleeding disorders that are unmanageable

How is the procedure performed?

  1. The patient is placed on the table, face down with a gown open to the back. The patient’s skin where the needle will be inserted is prepped with an antiseptic solution. Most patients are sedated for comfort and since the procedure is minimally invasive, local anesthetic is primarily used.
  2. The provider starts by inserting a bone access needle into the area affected to determine the trajectory of the working cannula. Once it’s confirmed through the fluoroscope that the access needle is at the correct location (on pedicle of vertebra), a bone drill is used to create a pathway through the pedicle into the vertebral body.
  3. Once the pathway is created, a curved-tip osteotome is inserted into the vertebral body and manually curved/directed towards the fracture.
  4. The balloon is inserted through the hollow needle and inflated to compact the soft porous bone inside of the vertebral body. Doing this not only restores the natural height of the vertebra but also creates a working channel for the cement to flow into. This decreases the chances of the cement flowing to places it shouldn’t flow into and gives the doctor more control of the cement’s trajectory. A contrast is used to visualize the inflation of the balloon and its location through the fluoroscope.
  5. Finally, the balloon can be removed and cement is injected into the working channel under pressure using a special cement filler cannula. The pressure and quantity of cement being injected is strictly controlled to prevent leakage. The needle is removed slowly and carefully, ensuring the cement is not following the needle forming a “tail.” This is done by waiting for the cement to slightly harden and monitoring its progress through the fluoroscope.
  6. The needle is removed and the incision is closed with either steri-strips or skin glue. Once the remaining cement on the table hardens, the patient is ready to be moved to the recovery room.

Pictures from the procedure I shadowed:

Works Cited

Giannitsios, D., Ferguson, S., Heini, P., Baroud, G., Steffen, T. (2005). “High Cement Viscosity Reduces Leakage Risk in Vertebroplasty”. European Cells & Mat 10, Poster No. 314. http://www.ors.org/Transactions/5thCombinedMeeting/0314.pdf

McCall, T., Cole, C., Dailey, A. (2008). “Vertebroplasty and Kyphoplasty: A Comparative Review of Efficacy and Adverse Events.” Current Reviews in Musculoskeletal Medicine, Vol. 1: 17-23, doi: 10.1007/s12178-007-9013-0. https://link.springer.com/article/10.1007/s12178-007-9013-0

Meirhaeghe, J., Leonard, B., Steven, B., Jonas, R., John, T. (2013). A Randomized Trial of Balloon Kyphoplasty and Nonsurgical Management for Treating Acute Vertebral Compression Fractures. Spine, Vol. 38 Issue 12: 971-983, doi: 10.1097/BRS.0b013e31828e8e22. https://pubmed.ncbi.nlm.nih.gov/23446769/

Denaro, V., Longo, U., Nicola, M., Denaro, L. (2009). Vertebroplasty and Kyphoplasty. Clinical Cases in Mineral And Bone Metabolism: The Official Journal of the Italian Society of Osteoporosis, Mineral Metabolism, and Skeletal Diseases, Vol. 6 Issue 2: 125-130. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2781232/

Disparities in Health

Medicine and Health

The United States is known for having one of the most expensive and worst health care systems in the world.17.2% of our GDP is directed to health expenditures, compared to only 9.7% in the U.K, 10.9% in Japan, and 11.3% in Germany. Not only do we spend outrageously more than any other country, we don’t have a better system to show for it. Our death rate per 100,000 children aged 1-19 is 259 compared to 170 in the U.K, 147 in Japan and 166 in Germany. Even though we are one of the richest countries in the world, our people have one of the shortest life expectancies of any industrialized nation. Why in the world do we still have millions of Americans that don’t have access to basic preventative services and why do we pay so much?

The John D. and Catherine T. MacArthur Foundation Research Network on Socioeconomic Status and Health related societies to ladders. In this relationship, the rungs of the ladder are equivalent to the resources available for individuals in that “step” to live a healthy, secure, and prosperous life. This means that the individuals at the top of the ladder are the ones who possess college degrees, respected careers, and are financially prosperous. The individuals at the bottom of the ladder are not as privileged. They aren’t as educated, have lower income or unstable employment, and aren’t financially comfortable. Socioeconomic status contributes to disparities in health in that an individual’s place on the ladder directly affects how healthy they are or will be in their lifetime. For example, the risk of dying prematurely is 3 times greater for low socioeconomic individuals who fall on the lower rungs of the social ladder. When considering people in the middle, they are still 2 times as likely to die prematurely than the individuals at the top of the ladder. In addition to life expectancy, individuals at the bottom of the ladder are more likely to suffer from hypertension, obesity, diabetes, heart disease, HIV/AIDS, mental illness, and experience newborn health complications such as low birth weight, premature birth and birth defects.

The power that social status has over health and the quality of life we live is colossal and pervasive.

Individual Behavior vs. Genetics

There is a reason providers review family history with patients: genetics plays a role in the health of an individual, but behavior also largely contributes to health status. This doesn’t necessarily mean that the responsibility of health falls on the individual at 100%. The lower they are on the social ladder, the harder it is for them to practice healthy behaviors. An individual’s environment has the ability to expand or constrain the options and habits that improve health and prevent chronic diseases. For example, lower socioeconomic communities have fewer (or sometimes lack) fresh produce supermarkets, recreational facilities, libraries, and safety but have more liquor stores, fast food restaurants, and drug trafficking. to accompany this environment, stress levels are high in individuals who live in such communities. Stress directly impacts physical health, but also leads to individuals partaking in destructive behaviors such as smoking, abusing alcohol and consuming high levels of sugar and fat.

Social Determinants of Health by the Henry J Kaiser Family Foundation

Clearly, the relationship between behavior and the ladder isn’t as easy as scaling will-power. The issue with our medical model today is that many physicians look at patients and their diseases through only the biomedical model of health. Social and psychological factors are rarely accounted for. Appointment slots are 15-minutes for most practices and providers who feel compelled to do more simply don’t have the time. We can’t look at an obese patient and think “they have no moral fortitude and are lazy!” Alternately, we need to consider the patient’s position on the ladder to better understand their behaviors and properly formulate a treatment plan. Individuals on the bottom rungs of the ladder face environmental and social conditions that induce unhealthy behaviors. They are exposed heavier cigarette and alcohol marketing, they live with chronic high levels of stress, don’t have the same access to healthy food options due to location and price and have fewer educational and job opportunities. Motivational interviewing is new technique recommended for providers to help their patients practice healthier behaviors, but that discussion will have to be for another day.

Minorities and Health

The inequalities in health status shared among minorities in the United States is shocking. Not only are minorities more likely to be at the bottom of the social ladder, they have a much higher risk of developing various diseases compared to non-minorities in the same position on the ladder. Racial health disparities are due (mostly) to an unjust distribution of socioeconomic resources and not genetics. Minorities are more likely to live at or below 200% of the Federal Poverty Line, be less educated, and live in low socioeconomic communities. These are a few of many social factors that determine the health of an individual. Instead of being considered separate entities, they are a reflection of one another. Low education leads to low paying jobs. Low paying jobs leads to living in low-income communities. Low-income communities lack social resources (recreational facilities, libraries, fresh produce supermarkets) and have high crime rates. This environment influences health damaging behaviors like smoking, drinking alcohol, and abusing recreational drugs. Although Medicaid is available to low-income individuals, people who have a job and make more than the limit, don’t qualify for Medicaid but also can’t afford private insurance. This lands them in the insurance gap position, with little to no access to preventative services. This means they seek health care services when they are very ill or in life threatening situations.

In 2016, 40% of people living in the United States were people of color. By 2050, that number is projected to increase to over half of the population. Given that people of color make a disproportionate share of the low-income and the uninsured relative to their size in the population, addressing health care disparities is extremely important. Disparities not only affect the groups directly suffering, but also hinders improvement in the quality of care and health for the broader population and leads to unnecessary costs.

Why Address Inequality in Health and How to Do It

Not only are we improving individual health, we are decreasing health care expenditures because healthy people require less medical services. Pinpointing the underlying determinants of disease and successfully addressing it is the first step in reducing health care expenditures. The John D. and Catherine T. MacArthur Foundation Research Network on Socioeconomic Status and Health identified two policies that are required to reduce premature death and eliminate the increase in disparities as you move down the social ladder:

  1. Policies that affect the length of the ladder and the distance between it’s rungs.
  2. Policies that buffer the damaging conditions of living below the top rungs.

Changing the Ladder

To alter the length of the social ladder in the United States, we need to advocate for policies that improve access to quality education and impact income distribution. There is no reason for a qualified student to not attend college in the United States of America because of financial barriers. Also, public education should be of high and equivalent quality throughout all K-12 levels. In terms of income and wealth distribution, we need policies that increase saving incentives in family households and offer opportunities for job training and community colleges to lower socioeconomic individuals.

Limiting Consequences

To ameliorate the risks linked to an individual’s socioeconomic status, we need policies that improve the environment and limit bad behaviors. Such policies should reduce violence and crime, increase affordable housing, improve access to drug and alcohol abuse programs as well as smoking cessation programs, increase taxes on cigarettes, fast food and alcohol, make school lunches more nutritional, and support green markets and fresh produce grocery stores. These are some examples of many policies that would improve the quality of life that individuals on the bottom of the ladder live.

What You Can Do to Help

You don’t have to start a non-profit or get into politics. Although those are great things to do, you can help in many other ways. Here are five things you can do right now, regardless of your financial situation, to help bring health care access to people in your community.

  1. Become a mentor to a minority student at your local high school. Help them find their passion and motivate them to pursue a higher education. Educate them on requirements to get into college and how to finance the costs.
  2. Create a book drive to provide a mini public library to a neighborhood in your area that doesn’t have one. Books can be donated to the local school or could be handed out to students at an event.
  3. Volunteer your skills. If you are a nutritionist or maybe a personal trainer, consider offering free services on the weekend to people in your community who need it most. Educate them on how to make better food choices and teach them exercises they can do at home.
  4. Donate to smoking cessation or alcohol abuse programs in your community.
  5. Help a neighbor plant a garden. Motivate your peers to eat healthier and make better health choices.

Remember: a little goes a long way. Just because you don’t see the results of your efforts immediately, doesn’t mean you aren’t making a difference! Keep pushing towards a better future for our generation and the next.

Works Cited

Orgera, K., Artiga, S. (2018). Disparities in Health and Health Care: Five Key Questions and Answers. 2020 Kaiser Family Foundation.

Adler, N., Stewart, J. (2010). Reaching for a Healthier Life: Facts on Socioeconomic Status and Health in the U.S. The John D. and Catherine T. MacArthur Foundation Research Network on Socioeconomic Status and Health.

Fiscella, K., Williams, D. (2004). Health Disparities Based on Socioeconomic Inequities: Implications for Urban Health Care. Academic Medicine, Vol 79, No. 12.

Pampel, F., Krueger, P., Denny, J. (2010). Socioeconomic Disparities in Health Behaviors. National Institute of Health Annual Review Social, 36: 349-370, doi: 10.1146.

Cohen, S., Janicki-Deverts, D., Chen, E., Matthews, K. (2010). Childhood Socioeconomic Status and Adult Health. Annals of the New York Academy of Sciences: The Biology of Disadvantage, doi: 10.1111.

My International Medical Volunteer Trip

Pre-Med

This week’s blog will be a little different than the usual. Instead of me taking the lead, I let you guys ask questions about my volunteer trip abroad. In December of 2019, I went on a 1 week medical mission trip to Costa Rica. I graduated that same month and that was my graduation gift to myself. It was one of the best experiences I’ve ever had and it made me realize how much I love volunteering and why I want to be in medicine. I could sit here and write 10 pages on my experience and why I think everyone should do an international volunteer trip at least once in their life. Instead, I’ll answer questions you guys have about my trip.

Here are answers to the top asked questions about my trip:

1. What organization did you use?

I volunteered with International Volunteer HQ. I researched different organizations for a couple of weeks, and decided that IVHQ was the one for me because it was affordable and I felt safe traveling with them. I joined their facebook group and asked questions to current and past volunteers about their experiences and how they liked it. Every person I asked said their trip was very safe, the organization was reliable and their experience was life changing. IVHQ also had the most destinations available in comparison to other organizations. Their projects aren’t all medical, this means that if you want to volunteer in a different area or let your talents shine, you can.

Aside from Medical and Health, some of their other projects include:

• Childcare
• Teaching
• Wildlife and Animal Care
• Construction and Renovation
• Environment and Conservation Arts and Music
• Sports
• NGO Support
• Refugee Support
• Women’s Empowerment
• Community Development
• Elderly Care
• Special Needs Care

They have volunteer opportunities in:

• Africa (Ghana, Kenya, Madagascar, Morocco, South Africa, Tanzania, Uganda, Victoria Falls, Zambia)
• Middle East (Jordan)
• Asia (Bali, Cambodia, China, India, Laos, Nepal, Philippines, Sri Lanka, Thailand, Vietnam)
• North America (Mexico, United States)
• Central America (Costa Rica, Guatemala)
• Caribbean (Belize, Jamaica, Puerto Rico)
• South America (Argentina, Brazil, Colombia, Ecuador, Peru)
• Europe (Belgium, Croatia, Greece, Italy, Portugal, Romania, Spain)
• Pacific (Australia, Fiji, New Zealand)

2. How much did it cost?

Every project and destination will have a different cost. The cost depends on where you go, what project you are doing, how long you will be staying and whether you will want to do other “touristy” activities before you leave. The Costa Rica medical trip I went on was only $445 for 1 week. The rest of the cost covered flights, a background check, transportation and other small fees like lunch and snacks. The program was very independent. We were volunteering through their local organization called Maximo Nivel and aside from being dropped off at our host family’s house, we had to get around on our own.This meant taking the bus to and from work and doing anything else while we were there. In total, I spent about $1,300 for everything. The most costly were the flights because I booked them last minute and couldn’t find any deals ($600 for round trip, ouch!). I didn’t have to pay for breakfast or dinner because my host mom cooked for me and of course, I stayed at her home for free. I only had to pay for lunch and transportation. Tourism was an option, but the cost of my trip would’ve increased and I would’ve had to extend the trip to accommodate the extra activities. Considering I was there to primarily volunteer, I didn’t worry too much about the extras. I wanted to volunteer and live like a Tica for a week. I rode the bus, ate Gallo Pinto, and practiced my Spanish. Depending on how much money you have to spare, you can add different excursions and activities to your trip to mix tourism and volunteering. It’s entirely up to you!

3. Were you allowed to do “hands-on patient” work?

Yes and no. I was required to submit proof that I was a pre-pa, pre-medical or pre-dental student. I also had to submit proof that I had some sort of experience in the medical field. Not every volunteer needs to do that though. Depending on how many science classes you’ve taken and your major, you don’t have to provide proof of Certification or health care experience. Since I was just starting my pre-requisites, I submitted proof that I was a Certified Expanded Functions Dental Assistant (CEFDA) and had 2 years of experience. I worked in a nursing home and was able to shadow the nurses, doctors, nurse practitioners and physical therapists. I was also able to feed the patients, transport them, help change their clothes and participate in fun activities. Aside from patient care, I helped with laundry and cleaning. My house-buddy was in nursing school at the time and she volunteered with me at the same nursing home. She was allowed to do a little more than I was, so it really depends on your experience and how much you know. Everyone was very supportive and trusting. They let you get as much hands-on as you want, you just had to take the initiative.

4. Were translators provided?

No! Translators were not provided and we had to get by on our own. This was intimidating at first but I am so thankful for it. I practiced my Spanish the entire week and came back home speaking Spanish 10x better than before I left. A lot of my friends there had google translate open and used it to communicate. I spoke the most Spanish out of our group, so most of the time, I was translating for them. Costa Ricans are very welcoming and had no problem trying to communicate with us. Don’t be shy if you don’t speak Spanish or the language spoken in the country you volunteer at. Embrace the experience and communicate through compassion. A smile is understood universally, so is a hug, a handshake, a pat on the back. Use hand gestures and body language to communicate. If you want to practice and learn the language, they did offer Spanish classes for students who were interested. The classes were divided into different levels and ranged from $125 to $390 a week depending on whether the class was private and the size of the group. So if you are intimated by the language barrier, that is always an option. A little costly, but, an option.

5. Did you volunteer the entire time or were there other activities?

I mostly volunteered, but there were options to do a lot of other activities. Some volunteers were planning on staying for weeks or months, so they traveled during the weekend to different tourist spots. I was only there for 1 week, so I wanted to spend 95% of my time volunteering. Various activities and excursions were offered through the organization and they were affordable. Some volunteers decided to explore on their own and utilized Uber or public transportation to site-see on their own. Unless you are with a group, I wouldn’t recommend that because it’s not as safe as having a guide. I volunteered the entire week and on my last day went to La Paz Waterfalls with friends I made on the trip. It was a lot of fun and since there was a big enough group, we were able to split the fare making the excursion fairly inexpensive. If you have more than a week to spare, you can chose different volunteering and tourism options. Some volunteers will work for 1 week and travel for the other or will travel on weekends and work the full 2 weeks. It all depends on how much money you want to spend and how much time you to have to spare.

6. Did you pay for everything alone?

Almost. I had $200 in donations from family and friends to help fund my trip. The rest was paid 100% by me. If you are concerned about how you will afford the trip, try fundraising. You can use Go Fund Me or sell baked goods to raise the money. I didn’t sell any goods to fund my trip because I didn’t have the time. I was working and finishing up my Bachelor’s, so I decided to bite the bullet and gift myself the opportunity. From my personal research, IVHQ seemed to be one of the most affordable organizations to travel with. There are also church and school organizations that participate in international volunteer trips. If you don’t have the money to spare for IVHQ, you can always seek opportunities at your University and church.

7. Did you feel safe throughout the trip?

Yes. Costa Rica is a very safe country. Did you know they don’t have a military? Since I was traveling alone, safety played a big role in me picking Costa Rica as my destination. Of course, I took extra precautions because there are bad people everywhere. I did not travel with any expensive jewelry, kept my phone put away, and didn’t go anywhere alone. Like I said, we traveled around the city by ourselves and utilized public transportation because it was cheaper than Uber. Not once did I feel unsafe. I always had a friend with me and maintained full awareness of my surroundings. Unfortunately, I can only speak for Costa Rica. Check out the IVHQ Facebook page and ask around. There are volunteers in that group from all over the world and they can give you more insight on the safety of their destination.

8. Did you learn anything important that you’d like to share?

Oh, absolutely! First, I learned that I am 100% meant to be in medicine. Costa Rica was beautiful and traveling was fun, but my favorite part was being in the nursing home and working with patients. I loved spending time with the residents, getting to know them, and being hands on. When the week was over, I didn’t want to come home. I wanted to stay and work more. It really showed me how much I love what I do and how much compassion good quality health care requires. It takes more than being clinically sound to be a good physician or any provider of care. It takes patience, compassion, understanding, and love for your neighbor. This is one of the reasons I think everyone should volunteer abroad in a health care setting. You will know right then and there if you are seeking medicine because you love it or not.