As we age, bone strength decreases and can cause fractures in the spine called vertebral compression fractures. A vertebral compression fracture occurs when too much pressure is placed on a weakened vertebrae, and the front of it cracks and loses height. They can result from a fall or doing everyday things such as reaching, coughing, or sneezing. In many cases, people get better with conservative treatment such as rest, medication, or a brace. If you are suffering from severe back pain from a recent fracture that is not responding to non-surgical treatment, your doctor may recommend kyphoplasty. This minimally-invasive procedure repairs a vertebral compression fracture. It helps restore the spine’s natural shape and some patients experience rapid pain relief after the procedure.

Before the procedure, you are anesthetized. The physician guides a needle through the skin of your back and into your fractured vertebrae. A special x-ray device called a fluoroscope helps the physician position the needle. A balloon device is placed into the vertebrae through the needle. The physician inflates this balloon to expand the fractured bone. When the balloon is deflated, it leaves a cavity in the middle of the vertebral body. Once the balloon is removed, the physician injects bone cement through the needle. This cement fills the cavity and hardens inside the vertebral body, stabilizing the fracture.

What is a facet joint injection?

The facet joints, found on both sides of the back of the spine, can become irritated and painful. A facet joint injection may help diagnose the source of a patient’s pain, or may be used to relieve pain and inflammation.

What is radiofrequency ablation?

Radiofrequency ablation (RFA) is a procedure used to provide longer term back pain relief than that provided by simple injections or nerve blocks. This procedure is also called radiofrequency neurotomy or radiofrequency rhizotomy. It can treat pain that doesn’t respond to medications or to physical therapy. By selectively destroying nerves that carry pain impulses, the painful structure can be effectively denervated and the pain reduced or eliminated for anywhere from a few months to up to 12 months.

Radiofrequency waves are electromagnetic waves which travel at the speed of light, or 186,000 miles per second (300,000 km/s). Radiofrequency Energy is a type of heat energy that is created by a special generator at very high or super high frequencies. With the use of this specialized generator, heat energy is created and delivered with precision to target nerves that carry pain impulses. The resulting “lesion” involves a spherical area of tissue destruction at the tip of the RF needle that can include pain-carrying nerves.

Once a structure has been determined to be a pain generator, its nerve supply is targeted for interruption. A small insulated needle or RF cannula is positioned next to these nerves with fluoroscopic guidance (live video X-Ray). Your doctor knows where to place the RF cannula because he is an expert in anatomy. The shaft of this cannula except for the last 5 to 10 mm is covered with a protective insulation so that the electric current only passes into the surrounding tissues from the very tip of the cannula. When the cannula appears to be in good position, the doctor may perform a test and release a small amount of electric current through the needle tip at two different frequencies. This test helps to confirm that the cannula tip is in close proximity to the target nerve and that it is not near any other nerve. After a successful test confirms good cannula tip position, a local anesthetic is injected to numb the area. The RF generator is then used to heat the cannula tip for up to 90 seconds, and thus the target nerve is destroyed.

There are a multitude of chronic pain conditions that respond well to this treatment. Chronic spinal pain, including spinal arthritis (spondylosis), post-traumatic pain (whiplash), pain after spine surgery, and other spinal pain conditions are those most commonly treated with RFL. Other conditions that are known to respond well to RFL include some neuropathic pain conditions like Complex Regional Pain Syndrome, (CRPS or RSD), peripheral nerve entrapment syndromes, and other assorted chronic pain conditions. A patient’s candidacy for RFL is usually determined by the performance of a Diagnostic Nerve Block. This procedure will help to confirm whether a patient’s pain improves just for the duration of the local anesthetic (or not). Patients who have little to no pain relief after a diagnostic nerve block are not candidates for a neurodestructive procedure like RF Lesioning.

Is this procedure painful? 

This procedure can be moderately painful, it ranges from mild to severe, but typically severe pain is for a minute or less. Patients are often given mild intravenous sedation during the procedure, but sedation is not absolutely required. Deep sedation is not a safe alternative and is therefore not offered for RFA procedures. It is quite common for neck or back pain to increase for a few days or longer after before it starts to improve.

What should I do to prepare for my procedure?

If you are scheduled to receive sedation during the procedure, you must have someone available to drive you home. If you are receiving IV sedation, follow the instructions from your doctor or nurse on limiting food and beverages before the procedure. If you usually take medication for high blood pressure or any kind of heart condition, it is very important that you take this medication at the usual time with a sip of water before your procedure. If you are taking any type of medication that can thin the blood and cause excessive bleeding, you should discuss with your doctors whether to discontinue this medication prior to the procedure. These anticoagulant meds are usually prescribed to protect a patient against stroke, heart attack, or other vascular occlusion event. Therefore the decision to discontinue one of these medications is not made by the pain management physician but rather by the primary care or specialty physician (cardiologist) who prescribes and manages that medication. Examples of medications that could promote surgical bleeding include Coumadin, Plavix, Aggrenox, Pletal, Ticlid, and Lovenox.

What should I do after my procedure?

Following discharge home, you should plan on simple rest and relaxation. If you have pain at the needle puncture sites, icing this area should be helpful. If you receive intravenous sedation, you should not drive a car until the next day. Patients are generally advised to go home and not return to work after this type of procedure. Some patients do return to work the next day.

Could there be side effects or complications?

Your physician will discuss these issues with you, and you will be asked to carefully read and sign a consent form before any procedure is performed.

Can this procedure be repeated if my pain returns?

It is possible for the treated nerve(s) to regenerate, which could lead to recurrent pain. However, this procedure is repeatable for nerve regeneration if it worked the first time around.

What are epidural steroid injections?

Conditions such as herniated discs and spinal stenosis can compress nerves, causing severe pain and inflammation. An epidural steroid injection may reduce inflammation and provide back pain relief, while avoiding the need for surgery to fix the problem.

The procedure is performed with the patient lying down. A region of skin and tissue of the neck is numbed with a local anesthetic delivered through a small needle. Using x-ray guidance (also called fluoroscopy), the physician guides a larger needle to the painful area of the neck. The needle is inserted into the epidural space, which is the region through which spinal nerves travel. A contrast dye is injected into the space to make sure the needle is properly positioned near the irritated nerve or nerves. Then the anti-inflammatory steroid is injected and absorbed by the inflamed nerves to decrease swelling and relieve pressure. Some patients may need only one injection, but it may take two or three injections to provide significant pain relief. 

As one of the most commonly used non-invasive and conservative treatments for a variety of cervical spine issues, the injections are known to provide comfort for more than half of those who use them, and they can be safely repeated if pain returns or if therapy needs to progress a bit farther for the best outcome.

What is a quadriceps tendon tear?

Tendons are strong cords of fibrous tissue that attach muscles to bones. The quadriceps tendon works with the muscles in the front of your thigh to straighten your leg.

Quadriceps tendon tears can be either partial or complete. Small tears of the tendon can make it difficult to walk and participate in other daily activities. A large tear of the quadriceps tendon is a disabling injury. It usually requires surgery and physical therapy to regain full knee function.

Causes and risk factors

Quadriceps tendon tears are not common. They most often occur among middle-aged people who play running or jumping sports. A quadriceps tear often occurs when there is a heavy load on the leg with the foot planted and the knee partially bent. Think of an awkward landing from a jump while playing basketball. The force of the landing is too much for the tendon and it tears. Tears can also be caused by falls, direct force to the front of the knee, and lacerations (cuts).

Symptoms

When a quadriceps tendon tears, there is often a tearing or popping sensation. Pain and swelling typically follow, and you may not be able to straighten your knee. Additional symptoms include:

• An indentation at the top of your kneecap where the tendon tore
• Bruising
• Tenderness
• Cramping
• Your kneecap may sag or droop because the tendon is torn
• Difficulty walking due to the knee buckling or giving way

Diagnosis and treatment

Your doctor will consider several things when planning your treatment, including:

• The type and size of your tear
• Your activity level
• Your age

Most small, partial tears respond well to nonsurgical treatment including immobilization and physical therapy.

Most people with complete tears will require surgery to repair the torn tendon. Surgical repair reattaches the torn tendon to the top of the kneecap. People who require surgery do better if the repair is performed soon after the injury. Early repair may prevent the tendon from scarring and tightening into a shortened position.

What's a patellar tendon tear?

Tendons are strong cords of fibrous tissue that attach muscles to bones. The patellar tendon works with the muscles in the front of your thigh to straighten your leg.

Small tears of the tendon can make it difficult to walk and participate in other daily activities. A large tear of the patellar tendon is a disabling injury. It usually requires surgery and physical therapy to regain full knee function.

Causes and risk factors

A very strong force is required to tear the patellar tendon.

Falls – Direct impact to the front of the knee from a fall or other blow is a common cause of tears.

Cuts – often associated with this type of injury.

Jumping – The patellar tendon usually tears when the knee is bent and the foot planted, like when landing from a jump or jumping up.

A weakened patellar tendon is more likely to tear. Several things can lead to tendon weakness such as patellar tendinitis, chronic disease, and steroid use.

Patellar tendon tear symptoms

When a patellar tendon tears there is often a tearing or popping sensation. Pain and swelling typically follow, and you may not be able to straighten your knee. Additional symptoms include:

• An indentation at the bottom of your kneecap where the patellar tendon tore
• Bruising
• Tenderness
• Cramping
• Your kneecap may move up into the thigh because it is no longer anchored to your shinbone
• Difficulty walking due to the knee buckling or giving way

Patellar tendon tear diagnosis and treatment

Your doctor will consider several things when planning your treatment, including:

• The type and size of your tear
• Your activity level
• Your age

Very small, partial tears respond well to nonsurgical treatment including immobilization and physical therapy. Most people require surgery to regain knee function. Surgical repair reattaches the torn tendon to the kneecap. People who require surgery do better if the repair is performed soon after the injury. Early repair may prevent the tendon from scarring and tightening into a shortened position.

What is a medial collateral ligament (MCL) injury?

Your knee ligaments connect your thighbone to your lower leg bones. The medial collateral ligament (MCL) and lateral collateral ligament (LCL) are found on the sides of your knee. Three bones meet to form your knee joint: your thighbone (femur), shinbone (tibia), and kneecap (patella). Your kneecap sits in front of the joint to provide some protection. Because the knee joint relies just on these ligaments and surrounding muscles for stability, it is easily injured. Any direct contact to the knee or hard muscle contraction — such as changing direction rapidly while running — can injure a knee ligament.

Causes and risk factors

Knee ligament sprains or tears are a common sports injury.  Athletes who participate in direct contact sports like football or soccer are more likely to injure their collateral ligaments. The MCL is injured more often than the LCL. Due to the more complex anatomy of the outside of the knee, if you injure your LCL, you usually injure other structures in the joint, as well.

Symptoms

• Pain at the sides of your knee. If there is an MCL injury, the pain is on the inside of the knee; an LCL injury may cause pain on the outside of the knee.
• Swelling over the site of the injury.
• Instability — the feeling that your knee is giving way.

Diagnosis and treatment

Injuries to the MCL rarely require surgery. If you have injured just your LCL, treatment is similar to an MCL sprain. But if your LCL injury involves other structures in your knee, your treatment will address those, as well.

Ice. Icing your injury is important in the healing process. The proper way to ice an injury is to use crushed ice directly to the injured area for 15 to 20 minutes at a time, with at least 1 hour between icing sessions. Chemical cold products (“blue” ice) should not be placed directly on the skin and are not as effective.

Bracing. Your knee must be protected from the same sideways force that caused the injury. You may need to change your daily activities to avoid risky movements. Your doctor may recommend a brace to protect the injured ligament from stress. To further protect your knee, you may be given crutches to keep you from putting weight on your leg.

Physical therapy. Your doctor may suggest strengthening exercises. Specific exercises will restore function to your knee and strengthen the leg muscles that support it.

If the collateral ligament is torn in such a way that it cannot heal or is associated with other ligament injuries, your doctor may suggest surgery to repair it.

Grand Rounds - Feb. 18, 2022
"Multiple Myeloma"

Speaker: Kanwarpal S. Kahlon, MD. Division of Hematology-Oncology, UCLA.

Objectives

1. Demonstrate an awareness of the epidemiology, clinical presentation, laboratory, and diagnostic evaluation.
2. Differentiate multiple myeloma from other paraprotein disorders and plasma cell dyscrasias: monoclonal gammopathy of undetermined significance (MGUS), smoldering multiple myeloma (SMM), Waldenstrom Macroglobulinemia (WM), plasmacytoma, primary amyloidosis, and POEMS Syndrome.
3. Acquire an awareness of risk stratification, staging, prognosis and therapeutic options for Multiple Myeloma.
4. Recognize and manage medical complications.
5. Describe age, gender, racial, ethnic and socioeconomic factors in the incidence, manifestation, and management of Multiple Myeloma.

Accreditation: St. Charles Health System is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. St. Charles Health System designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)^TM.

The period to claim credit for this activity expires one year after its original publication. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Claim Credit

Target Audience: Physicians, Nurses, Pharmacists, Allied Health Professionals

Accessibility/Program Questions: St. Charles Health System encourages persons with disabilities to participate in its programs and activities. If you anticipate needing any type of accommodation or have questions about the physical access provided, please contact Continuing Medical Education at [email protected].

Oher CME or Clerkship questions: also contact Continuing Medical Education at [email protected].

As part of its ongoing effort to ensure all people feel welcome at its facilities, St. Charles Health System has named Dr. Shilo Tippett as its first manager of caregiver inclusion and experience.

Tippett will oversee the organization’s work to establish and grow a culture of inclusion, diversity, equity and acceptance (IDEA) for St. Charles patients and employees – work that is central to the health system’s vision of creating America’s healthiest community, together, said Jody Saffert, director of People and Organizational Development for St. Charles.

“We already had a grassroots effort of caring, compassionate and committed caregivers who wanted St. Charles to be a more inviting and inclusive place to work and receive care,” he said. “Securing resources and action behind this commitment is what advocates of this work want and need to see. It can’t just be words on paper – action is needed.”

Tippett is a Central Oregon native, a resident of Madras and a member of the Confederated Tribes of Warm Springs. Before taking her new job, she spent seven years practicing as a clinical psychologist at St. Charles’ Madras Family Care Clinic, where she had daily interactions with the people in her community. But when she saw that the health system was hiring an IDEA manager, she knew it was her opportunity to make a broader impact on St. Charles and the region it serves.

“There’s a lot of research showing that bringing in more people with different backgrounds and experiences brings more creative ideas and satisfaction to a workplace,” Tippett said. “And the more diversity we have among our caregivers, the stronger we’ll be and the better care we’ll provide for our patients.”

Bringing more diverse workers to a predominantly white area will be a challenge, but Tippett believes St. Charles’ status as Central Oregon’s largest employer means the organization has an opportunity to make an outsized impact on the community by leading the way.

“If we start to set the tone for what diversity and inclusion looks like in our communities, we are definitely going to make a difference,” she said. “It's not going to happen overnight, of course. It’s going to take a sustained effort. But when I think about how much St. Charles can accomplish on this front and how we can affect Central Oregon, I’m excited about it.”

Tippett will work closely with the health system’s IDEA Council, a group of caregivers that formed five years ago to focus on IDEA-related initiatives at St. Charles. The caregivers are passionate about the work, but they all fit it in around their other personal and professional duties, said Carlos Salcedo, co-chair of the council. That means people come and go as they are able, which has affected the group’s ability to keep projects moving forward.

With Tippett on board and dedicated to the cause, Salcedo expects the IDEA Council to gain and maintain momentum on projects such as improving the health system’s interpretation and translation services. At the same time, he cautioned against expecting one person to shoulder all of the work.

“We’ve identified her as a person to lead this effort, but that doesn’t mean it’s completely on her to do it. That’s not representative of an organization that’s equitable,” he said. “It’s on all of us to show up and do the work.”

Tippett is intent on gaining traction, however. One of her primary goals in her new role is to increase what she calls the health system’s “belonging score,” which measures how much caregivers feel like they are welcome at St. Charles, that they are heard by leadership and that their ideas are valued. Toward that end, she and her team are developing programs to educate managers and physicians on inclusivity, incorporating IDEA concepts into the health system’s orientation for new caregivers and annual education requirements for all caregivers, and investing in IDEA training for key roles within the organization.

“We’re doing more than just talking about this stuff,” Tippett said. “We’re taking action.”

Saffert said he’s excited not only that St. Charles has someone on board to lead IDEA work, but also about what Tippett brings to the position.

“Her clinical psychology background, her experience as a behavioral health provider, her lived experience within Central Oregon and her passion for inclusion and equity make her the ideal person for this role,” he said. “Also, her desire to learn and to be an inspirational activist makes her the perfect candidate to help with this ongoing, worthy journey of creating a welcoming and inviting place for all.”

That’s a journey supported by St. Charles’ top leadership, the Executive Care Team, including President and CEO Joe Sluka.

“More than a century ago, the women who founded St. Charles promised Central Oregon that this organization would care for all people, or it would care for none,” Sluka said. “I am proud of the work we are doing to be a health system that is inclusive, diverse, equitable and accepting, and I believe it’s our next step toward upholding that commitment to care for all.”

Thanks to Valentine’s Day, the month of February is closely associated with hearts – more precisely, the well-known heart shape, usually in hues of pink or red.

But did you know February is also officially American Heart Month, according to the Centers for Disease Control? This time we’re talking about the actual heart – the muscular organ inside our chest that pumps blood throughout the body, carrying oxygen to our cells.

That’s important work, which is why the CDC sets aside February as a time for all people to focus on their cardiovascular health.

At St. Charles, we have a talented staff of cardiologists and caregivers at our Heart and Lung Center who provide cutting-edge and life-saving care every day to people with heart ailments. We are thankful for the incredible work they do.

I’d also like to use this opportunity to highlight the St. Charles Foundation’s Children’s Heart Fund, which offers a wide range of support services to families of children with congenital heart disease. Those services may include simple but vital help such as gas cards, food and lodging through the Ronald McDonald house, or it may mean complex assistance, such as providing the family with a case manager to help with care coordination and community services, or coordination of neurodevelopmental follow-up for at-risk children.

That’s a mouthful, so let me state it clearly: The Children’s Heart Fund helps families of kids with congenital heart disease when they need it most. By alleviating other stressors, it frees up parents to focus completely on their top priority: the health of their child.

The Children’s Heart Fund does tremendous work year-round, but February is when it makes its major fundraising push, and I believe it deserves your support. I would encourage you to watch the video below, then visit our Children’s Heart Fund fund web page to learn more about how you can help.

I wish you a very happy (and healthy) heart month.

Sincerely,
Joe