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WAY overly complex - March 10, 2006 3:16:00 PM   
SJBird55

 

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I think Chris is going to be able to assist me because I'm not completely computer savy.

I just had a gentleman begin therapy on 3/7/06. I treated him about 4-5 years ago and he is in need of PT services again. He yacked at me in the store the other day and he's now considered an active patient on my schedule. (I believe that sometimes it could be a good idea to duck down some weird food aisle to avoid previous patients... he's not a bad patient, just really, really complex.)

He had some major spinal surgery so I asked for his operative report to more fully understand and appreciate one factor I'll be dealing with - his spine. Also, he's 53 years old.

1) he does have spina bifida
2) pre-operatively his diagnosis: thoracic myelopathy secondary to T11-T12 stenosis and progressive kyphotic deformity secondary to anterior fusion of cervicothoracic junction (previous surgery to C-spine performed by a different neurosurgeon)
3) surgical procedures on 12/6/2005: Lamina of T11 and T12 were drilled out and the ligamentum flavum was removed in that area.
4)basically from C4 to T3 the patient had pedicle screws bilaterally drilled in with bilateral rods from C5 to I'm not sure what level in the thoracic spine... and with fluroscopy the spondylolisthesis he had at C7/T1 was reduced (the rods tightened down once the positioning was achieved) and then he had chunks of bone taken out of his iliac crest as an autograft to corticate C4 down to T3 bilaterally.

Could be a straight forward case... but I doubt it. Chis will add to the story when he gets a chance with the PDF file I'll send him.
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Re: WAY overly complex - March 10, 2006 11:06:00 PM   
Synergy

 

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SJ,

I'm struggling on my end trying to figure out a way to post the link. As of right now, I have been unsuccessful! :(

I can help you upload it to your webspace if you like and then you should be able to post the file.

_____________________________

Chris Adams, PT, MPT

(in reply to SJBird55)
Post #: 2
Re: WAY overly complex - March 11, 2006 6:46:00 AM   
SJBird55

 

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Hmmm... okay, I'll email you.

I'll continue the story a bit.

He doesn't smoke and says he's smoke-free. Ah, but it wasn't until I read a little that he's smoke-free as of 91 days ago (he stopped the day he had surgery). Now, the surgeons in my little area will refuse to perform any kind of spinal fusion on smokers - they have a little rule that the person has to stop smoking prior to surgery for 3 months or so.

Well, prior to surgery, this guy was falling all the time because his his lower extremities were buckling on him. (That myelopathy issue, I guess, was quite symptomatic.)

So... because of his smoking history, he will have a greater chance of a failure rate with the autograft. Also, the surgeon is being more conservative and wanting him wearing the neck brace (a Miami J?) for longer than 3 months. He is allowed out of the brace in PT, but I'm not to do any manual anything with this guy. AND... ibuprofen isn't allowed (which he is used to taking for pain control for the spina bifida) because bone healing is reduced if a person is taking ibuprofen. So, he says that he's in a substantial amount of lumbar pain 7/10 to 9/10 all the time.

More later.

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Re: WAY overly complex - March 11, 2006 10:14:00 AM   
Dr.Wagner


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Yeah the Ibuprofen and bone healing has only been confirmed in rats...

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Post #: 4
Re: WAY overly complex - March 11, 2006 10:37:00 AM   
SJBird55

 

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LOL them there rats are having an impact on medical decision-making. 4-5 years ago when my horse busted my clavicle - the ortho got wiggy on me popping a few ibuprofen to eliminate my discomfort while at work. For this gentleman though... he's already at a risk for fusion failure secondary to smoking, so I can see where the neuro guy wants things to be as optimal as can be.

There's a lot more with this guy...

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Re: WAY overly complex - March 12, 2006 9:00:00 AM   
SJBird55

 

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NSAIDs may have an effect on human bone formation. This study looked at the 10 year follow up after a total hip arthroplasty. The only question in my mind is that historically revisions normally occur at 10-15 years anyways... so is it NSAID related?

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16470423&query_hl=22&itool=pubmed_docsum

But then... using medium to high doses of NSAID reduce heterotopic bone formation after total hip arthroplasty...

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15266441&query_hl=29&itool=pubmed_docsum

And why does the type of arthroplasty potentially have different results?

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15723007&query_hl=29&itool=pubmed_DocSum

And then, in weighing the risk factors, how the use of NSAIDS could be reduced:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16369754&query_hl=37&itool=pubmed_docsum

And this article substantiates the neurosurgeon's rationale for not prescribing NSAIDs to this particular patient:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9563116&query_hl=48&itool=pubmed_docsum

and so did this article:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15872130&query_hl=50&itool=pubmed_docsum

So, Wags, your off the cuff remark about only being confirmed in rats was inaccurate...

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Re: WAY overly complex - March 12, 2006 10:40:00 AM   
Dr.Wagner


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Well the remark was not "off the cuff".
I just did a literature journal club review one year ago on this poorly researched idea. While many of the remarks SEEM "off the cuff", I am a pretty calculated guy.

Well, this is WHY WE REVIEW ARTICLES...because the ones you posted to substantiate your claims are SO FULL OF ERROR, they only support ONE CLAIM "The immediate post operative of TORADOL IV or IM MAY cause delayed healing in SPINAL FUSIONS" That is it, nothing else.

"The effect of postoperative nonsteroidal anti-inflammatory drug administration on spinal fusion" This is a RETROSPECTIVE CHART REVIEW...no controls. This speaks ONLY of IV or IM Ketorlac (TORADOL) in the hospital. This is NOT USED at home. Furthermore, the surgeries were done 13 years ago...they are just NOW making these conclusions? They widdle it down to the first or second day post op? Come on.

"Heterotrophic ossicfication after Primary shoulder arthroplasty"...well all this said was "Nonsteroidal anti-inflammatory drugs (NSAIDs) did not appear to have any effect on HO as in hip replacement, as HO developed in 15.15% of patients having NSAIDs postoperatively and in 15.05% of patients without NSAIDS" and???? who cares?

next

"DO NSAIDS cause Endoprosthetic loosening..."
Good Idea.
Where are the controls??? Where where where where where are the controls?? They make a BOLD statement that Ibuprofen in the first week post op lead to revisions and they have stated NO CONTROLS?? They are kidding right? Seriously. This is a HORRIBLE STUDY.


This is why we do literature review.

_____________________________

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Moderator of Medical Complexity Forum

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Post #: 7
Re: WAY overly complex - March 12, 2006 11:41:00 AM   
SJBird55

 

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Oh, go shoot down the studies I present and ignore that you said that the only studies on bone healing were done on rats. You did use that "only" word, which is always a red flag for me. LOL That was an inaccurate statment. I heard a bit of sarcasm in the written remark and yes, THAT remark did feel as an "off the cuff" remark.

There are not a lot of studies out there on the combination of ibuprofen and spinal fusions. Before you decide to slam what I presented, see if you can find anything better. And I didn't plan on sitting here for hours on end, but spent 45 minutes to an hour just to see what was out there because your off the cuff remark got me curious.

Just the idea that there were studies on heterotopic bone formation was interesting to me... IF ibuprofen CAN reduce heterotopic bone formation after an arthroplasty, then there may be some validity to ibuprofen reducing osteoblast activity... Which after finding the shoulder arthroplasty study, did make me waiver in my thoughts as to the power of ibuprofen reducing osteoblast activity.

Wags, on that first study, on whether NSAIDs cause endoprosthetic loosening... ummm, there were 3 randomized groups - group 1 had ibuprofen for 1 week postoperatively, group 2 for 2 weeks postoperatively and group 3 had no ibuprofen. They were looking at the number of revisions... of the 142 patients, only 13 had revisions. 12 of those that had revisions were in the ibuprofen group. The main reason for revision was aseptic loosening... I'm not really sure if ibuprofen IS the variable because then later they assessed 94 other patients that were still alive radiographically - 9 loose prostheses were found in those living and the loose ones were not just found in those treated with ibuprofen but equally distributed. Personally, I kind of think that the reason for revisions is just the plain and simple fact that the loosening occurs because of the materials used and the inability for those materials to withstand the stresses/forces put on them over time.

If you had a shoulder arthroplasty and had a heterotopic ossification, I think you would care. It wouldn't be a very favorable outcome. IF it were found that ibuprofen use in the initial couple of weeks were helpful in reducing HO, well, I think you'd probably pop a few.

So, back to my guy... I saved what seemed to be the most relevant article for last... He is in a very high risk category for non-union/ non-fusion - smoker and multiple level fusions. And, from reading the articles, I do have the question in my head as to whether over the counter ibuprofen taken by the patient independently happens to have an impact. Technically, I don't believe over the counter use was addressed in the studies, nor did I find a study that addressed use of ibuprofen at home.

(in reply to SJBird55)
Post #: 8
Re: WAY overly complex - March 12, 2006 9:43:00 PM   
Dr.Wagner


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SJ...
the first article HAD NO CONTROLS. Zero, look at the article, the methods show virtually ZERO detail? How can you even validate the information? I mean a study in Sweden on THA on 144 patients only and you are claiming this is PROOF? They once again do retrospective chart review...look at this statement "10 years after surgery, all 144 of the patient medical records were reviewed"...I mean this is shoddy at best.

And regarding the "rat studies comment"...those are the only in vivo studies of significance and are the studies in rats and are the studies cited by the AAOS. Those are the in vivo studies.

I simply take issue with blind support of poor research. I am certainly not upset with you...but you quote these articles with blind faith...WITHOUT critically appraising them.

Still the standard of care is summed up in this article

http://www.emedicine.com/emerg/topic200.htm

when it states "Opioid analgesics and nonsteroidal anti-inflammatory agents are the DOCs for pain associated with fractures."

Hey, avoiding Toradol post operatively for spinal fusion sounds like a good idea...but long term pain control simply MUST find a happy medium between NSAID and opiates...WE CANNOT DEMONIZE an ENTIRE class of drugs based on "iffy" clinical research and in vivo rat studies.

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Post #: 9
Re: WAY overly complex - March 12, 2006 10:19:00 PM   
SJBird55

 

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Why don't you give me your definition of "control"? (No THA can't be a control because a revision wouldn't be required.) I view the one group randomized to no ibuprofen as the control group. And, yes... it was a retrospective study. It began that way 10 years prior to see if ibuprofen had an effect on the procedure (it was a planned retrospective study). The abstract didn't look that shoddy to me. The only thing that I believe is a weakness is the simple fact that they re-evaluated the status of patients 10 years after, which is within the normal time period that revisions normally occur anyways and to correlate ibuprofen use to requiring a revision does seem somewhat of a stretch to me.

It wasn't blind faith...

The other issue is assessing NSAIDs would be the time period in which they are prescribed. There are dosage issues and time frame issues in my mind.

Now you want to jump to bone fractures... I think I did read something that basically mentioned to consider all variables when prescribing ibuprofen with fractures, especially in the initial inflammatory stage because there is a possibility that ibuprofen has an effect with prostaglandins? I can't remember, but there isn't enough clinical evidence either way regarding the effect on osteoblast activity.

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Post #: 10
Re: WAY overly complex - March 13, 2006 12:13:00 AM   
Synergy

 

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SJ,

Sorry this took so long, but I think the following link will work. We shall see! :)

[URL=http://myweb.cebridge.net/cdadams/medical_systems_review.pdf]Medical Systems Review[/URL]

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Chris Adams, PT, MPT

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Post #: 11
Re: WAY overly complex - March 13, 2006 6:38:00 AM   
SJBird55

 

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I can't view it.. but hey, at least you have a web page that works. LOL I keep being told mine doesn't exist.

Your link says that the page can't be found... click on the next link in that message and I'm not authorized to view.

Anyways... if Chris figures it out OR if I can figure out how to do it, the next part of the story... the patient's systems review.

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Post #: 12
Re: WAY overly complex - March 13, 2006 9:04:00 AM   
Synergy

 

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Oops! I changed the format of the link last night and forgot to correct it in my above post. Here's the new and improved link. ;)

[URL=http://myweb.cebridge.net/cdadams/medical%20systems%20review.pdf]Medical Systems Review[/URL]

There...nice and LARGE!

_____________________________

Chris Adams, PT, MPT

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Post #: 13
Re: WAY overly complex - March 13, 2006 10:35:00 AM   
SJBird55

 

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Hey, you are good! (I'm sure you're told that ALL the time...) Thanks!

So, from a physical therapist perspective, whenever I see a patient provide me a medical systems review like this one... I know I'm in for a challenge. So much for taking 45 minutes for an eval AND a treatment... :)

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Post #: 14
Re: WAY overly complex - March 13, 2006 1:56:00 PM   
Zeke W.

 

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SJBird55,

When will your learn DocWagner does not like to be wrong and he is always right, even when he's wrong.

Zeke

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Post #: 15
Re: WAY overly complex - March 14, 2006 6:44:00 AM   
SJBird55

 

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I can't believe no one has any comments? His Medical Systems Review was a mess!

From that I asked a lot of questions, but the "new" symptoms that I don't believe any physician is aware of are:

1) fatigue (I have no idea why....)

2) increased thirst (he really commented on that and I have no idea why - maybe med related?)

3) increased nightly urination (within the last 2-3 weeks) NOTE: he did have prostate cancer in 2004 and had his prostate supposedly surgically removed and he did not mention if he had any further treatment and he does have spina bifida

4) constipation that is worse than normal... last 2-3 weeks, changes in stool shape to being ribbon like (although he does have hemorroids) and that history of cancer does concern me a little

5) definite depression - but he's supposedly being treated for it (on my subjective form, he indicated the "yeses" that indicate depression AND he wanted help with it... he's already supposedly being treated for it)

6) oh, and 2 to 3 or 5, 6, or 7 beers/night Not really sure why he's doing that. He says pain control but it could be to just take him away from life for a while.

7) He's been off work since mid to late last year. His profession is an 8th grade history teaacher

8) He's on narcotics...

9) He doesn't want to go back to work.

OH... and he wants to have his upper extremities work normally AND he wants to walk normally. LOL

Does anyone have any thoughts?

(in reply to SJBird55)
Post #: 16
Re: WAY overly complex - March 14, 2006 3:10:00 PM   
ehanso

 

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Anecdotal comment. The orthopaedic and spine surgeons in our area are very careful to instruct patients not to take Ibuprofen post operatively. I think they limit the time frame but I am not sure what it is. The 2 I am have the most contact with, don't actually say it but hint that it is defensive incase there are issues down the rode.

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Re: WAY overly complex - March 14, 2006 5:46:00 PM   
SJBird55

 

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LOL yeah... like a non-union and then a patient saying, "you didn't tell me."

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Re: WAY overly complex - March 14, 2006 8:06:00 PM   
Dr.Wagner


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ZEKE W...shhh. You no talk now.

SJ, sorry I jumped the topic to fracture...there are so many similarities to fracture healing and post op orthopedic procedures one freely uses the comparisons frequently. They go hand in hand...no?
By control, I want strict subgroup analysis. I it needs to be broken down into age or controlled for specific co-morbid conditions. The methods section is SOOO exceedingly poor, this research can't even be reproduced. But, the results are compelling...there just needs to be BETTER research to take this stuff as Gospel.


SJ, sometimes when I re-read my posts they sound very fiery. They aren't meant to be that way. I "try" to reproduce my conversation teaching style onto a posting and sometimes it doesn't work well. If you were here in front of me...it would come out better.
Sorry.

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Moderator of Medical Complexity Forum

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Post #: 19
Re: WAY overly complex - March 14, 2006 9:11:00 PM   
SJBird55

 

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Wags... I wasn't upset in the least. I still disagree with you. I, of course, do not have access to the article, but by reading the abstract it does seem pretty straight forward to me .... originally 144 patients decided to participate in a randomized controlled trial originally for whether ibuprofen had a preventative effect on heterotrophic ossification - 48 had ibuprofen for 1 week post-op... 48 had ibuprofen for 2 weeks post-op... and then 48 didn't have ibuprofen. Then, 10 years later after the original study... the investigators wanted to see how many revisions occurred and what group tended to have the most revisions. With surgical procedures it does seem that a lot of studies are done retrospectively - and there isn't anything wrong with a retrospective design - it all depends on the question being asked. Age? I didn't see age listed in the abstract, but I'd be willing to bet that it wasn't some huge age range... and what co-morbid conditions would you be concerned about? I'm sure they met the requirements for a THA... what might be better to pick apart would be the prosthetic devices used or maybe the procedure or cement or no cement (seeing that that aspect wasn't mentioned in the abstract), but you are being kind of vague in how you think it should have been broken down. If the population in which data were collected overall did represent the population that normally has a THA, well, that's a good thing. Clinically, everything can't always be controlled.

Yes, you did jump to fracture... but, I don't know... personally, I'd think that a fracture is different than a surgical procedure with hardware. Again, that's just my opinion. Should they go hand in hand or is that just an assumption?

You don't have to apologize. I wasn't upset.

I also don't believe that ibuprofen should be trashed... from reading the articles, I do think though that some thought and some consideration of risk would be a good thing though.

(in reply to SJBird55)
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