History And Physical Examination

History and physical examination are key components in the evaluation of patients being considered for percutaneous vertebroplasty. A focused history and examination concentrating on the patient's back pain, mobility level, and medication use (including analgesics, steroids, and osteoporosis antagonists) is recommended. Presenting symptoms, pertinent medical, surgical and allergy histories, a list of current medications, and evidence of failed medical therapy are documented. Use of visual analog scales for determining pain levels, dermatome drawings for pain localization, and standardized questionnaires are helpful for collecting data pre- and post-procedure.

Contraindications to the procedure should be excluded. Vertebroplasty contraindications include evidence of substantial spinal canal compromise as indicated by clinical symptoms and signs that suggest spinal cord or nerve root impingement (17,24). This would include, but not be limited to, radicular pain, sensory level, or bowel or bladder dysfunction. Further imaging workup should be pursued if neurological dysfunction is suspected. In certain instances, the history of radicular pain is not considered a contraindication to vertebroplasty. These cases are fairly unusual, and often indicate an unstable fracture with the presence of a cavity (Kummell's osteonecrosis) (31).

Physical examination should at least include documentation of motor and sensory dysfunction as well as reflexes where appropriate. Another component of the physical examination is that of manual palpation of the spine. Early practitioners of vertebroplasty considered that patients who would be expected to respond to vertebroplasty would demonstrate localized pain on palpation of the spinous process of the involved vertebra. However, the authors have found no statistically significant difference in treatment outcomes between a group of patients with localized tenderness and a group with nonspecific or non-localizing pain (31a). Indeed, patients may present with pain that is several levels away from the fracture site, or may even present with pain that is entirely subjective in nature and is not elicited with manual palpation. Although back palpation remains a part of the physical exam, patients without focal pain should not be excluded from treatment.

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Dealing With Back Pain

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