Often patients are confused because x-ray techs (who go to college for 2 or 4 years) are called radiographers. This is confusing for patients because they always see a radiography or x-ray tech when they are having a procedure done, but they usually don’t see the radiologist. When I speak with patients, I try to identify myself as a radiology physician or radiology doctor, so that they know they are speaking with a physician.

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What is Radiology?
Radiology is one of the broadest fields of medicine and encompasses diagnostic and interventional radiology. Diagnostic imaging are tests used to detect and monitor disease states in the body. This includes x-rays, computed tomography (CT or CAT scan), MRI, ultrasound, nuclear medicine, mammography and PET, among others.

Interventional radiology focuses on therapeutic use of imaging, mainly using x-ray, CT or ultrasound guidance to perform minimally invasive procedures. The goal of interventional radiology is to treat or cure diseases with less invasive procedures, in order to avoid major surgery. This includes angiography, biopsies, stents, drains, vertebral augmentation, interventional pain procedures among others.

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Billing
Why did I receive two bills for a procedure?
When you have an imaging procedure, you will usually receive two bills—one from the hospital and one from the radiologist. The hospital bill is for the technical part of the exam—cost of buying, maintaining, servicing the equipment, etc. The radiologist bill is for the professional part—the professional interpretation and medical report.

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Vertebral Compression Fractures
About Vertebral Compression Fractures (VCF)

Over 750,000 people suffer a vertebral compression fracture (VCF) each year. For most (about 2/3), they may not be aware of the fracture or it may not hurt enough to see a doctor. For those that do, most people are placed on bed rest and pain medication, known as conservative, or traditional therapy. Until recently, this was the only option available for VCF. Some patients got better, but many continued to have pain despite conservative measures.

Now there is a highly effective procedure available to cure the pain of VCF. Commonly known as vertebroplasty or kyphoplasty, vertebral body augmentation fixes fractures by gluing them back together with a minimally invasive procedure (see below).

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About Vertebral Body Augmentation (VBA)

Vertebral body augmentation, or VBA, is a procedure that helps heal the pain from vertebral compression fractures (VCF).

The procedure is done through a small incision under light sedation. This is called conscious sedation and uses short-acting medications (typically Fentanyl and Versed) to achieve quick, effective but brief sedation—similar to that used for colonoscopy or a root canal. The procedure typically takes 20 minutes or less, a needle is placed into the fractured vertebral body. Bone cement is injected into the fractured vertebrae in a liquid state like toothpaste. Once in place, the bone cement sets up harder that your bone within minutes.

In experienced hands, like those of Dr. Webb, VBA is a safe, effective procedure with very low risk of serious side effects. If you have a bleeding disorder, are on blood thinning medications or have an active infection, you should let your doctor know before you proceed.

After the procedure, you will be monitored for complications. If you are younger than 65 and healthy, with no serious medical conditions, the procedure can be done as an outpatient. For patients over 65, or those with serious medical conditions, like diabetes, stroke, heart disease, you may be admitted to the hospital. If admitted, hospital stays are typically short.

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Common Questions About Vertebral Body Augmentation (VBA)

Our doctor says that there is nothing that can be done about vertebral compression fractures except for rest and pain medications. Is this correct?
Absolutely not. Vertebroplasty and kyphoplasty are two highly effective treatments for vertebral compression fractures.

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What is vertebral augmentation?
Vertebral augmentation is a procedure that stabilizes fractured vertebrae by injecting bone cement to fix the fractures internally. Examples are vertebroplasty , osseoplasty and kyphoplasty (click on the link for more information).

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Why do you think that some doctors don't seem to know about treating VCFs with vertebroplasty or kyphoplasty?

Many doctors just don’t know about procedures for vertebral compression fractures. For example, these procedures have only been practically available in Oklahoma for about 10 years or so. Add to that the fact that there literally was nothing that could be done before this (other than their recommendations) and you can see why we spend a lot of time educating patients and their physicians.

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Is vertebroplasty or kyphoplasty only used as a last resort for those who obtain no relief from pain medications?
Sadly, the procedures are often not used. VCF fixation procedures (vertebroplasty and kyphoplasty) are just as effective in an acute fracture patient as a chronic one. Since there were no effective therapies available before this, all patients were treated with ‘conservative therapy’—i.e., bed rest and pain medications.

I consider it a travesty that patients with VCF are made to suffer through conservative therapy while hip fracture patients are operated on the same day. In my opinion, VCFs should be treated acutely, minimizing the complications associated with them and relieving the pain. Unfortunately, most insurers and Medicare still adhere to the trial of conservative therapy.

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What are some reasons that vertebroplasty or kyphoplasty couldn’t be done?
Severe bleeding tendency, currently on blood thinners or active infections are the main reasons we can’t do the procedure on someone.

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My doctor says that my fracture is old and can’t be treated. Is this true?
Vertebral augmentation is highly effective at relieving fracture pain from vertebral fractures, regardless of age. Dr. Webb has successfully treated fractures as old as 35 years with complete pain relief for the patient.

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Why does a radiology report call my fracture old?
Often reports on x-rays presume that the fractures are old. Sometimes this is because the radiologist didn’t get enough information. MRI reports usually call a fracture old when it no longer ‘lights up’ on fluid sensitive images. Unfortunately, doctors presume that this means the fracture isn’t painful. However, this is not usually the case. Further, I have had patients whose acute fractures stopped lighting up on MRI after 4-6 weeks. Their fracture was still painful and the pain was relieved by vertebral augmentation.

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Our doctor said that the fracture was pushed back into the spinal canal, so vertebroplasty or kyphoplasty cannot be done. Is this correct?
Absolutely not. Although this scenario (spinal stenosis from a retropulsed fragment) is a relative reason not to do the procedure, Dr. Webb has fixed many patients with this condition. Although there is some increased risk, we recommend that these cases are treated by specialists who see a high volume of cases (i.e., doctors who routinely fix 20 or more fractures per month). In the proper hands, vertebral augmentation is safe even in these patients.

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How safe is this procedure, especially in older patients with multiple medical problems?
Dr. Webb has personally performed in patients from the ages of 9 to 103 years of age. We routinely do these procedures in patients with multiple medical problems, even severe heart and lung disease and stroke.

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Does the procedure use both the balloon and cement?
We use a cavity creation device that works the same as the balloon, but at a fraction of the cost. Usually our device costs about $1,000 rather than $5,000 for the ‘balloon’. The pain relief is the same, but the costs are lower.

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How long does the procedure take?
In most cases the actual procedure takes about 15-20 minutes or less. Things that prolong the procedure are getting the patient on and off of the table, adequately sedated, etc. So on average, it’s usually 30-45 minutes from when the family goes out to the waiting room and I come talk to them after we’re done.

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Is it common to perform vertebral augmentation more than once on the same person?
As far as repeat procedures, yes, these can be done and are relatively common. Repeat procedures are most commonly seen in patients with osteoporosis. Almost always these are at different vertebrae. Having the procedure done before does not prevent a patient from having it done again. In fact, although rare, patients may fracture the same vertebral body again.

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Why Choose Dr. Webb?
Aside from Dr. Webb’s training and credentials, you can rest assured that you are being treated by the most experienced physician in the region. Dr. Webb routinely fixes more fractures each month than most doctors treat in a year. He routinely treats 20-40 fractures every month. Most doctors treat one or two fractures a month.

The difference in experience doesn’t stop there. Most doctors simply fix the fracture and send the patient home without addressing the underlying cause. These patients continue to have additional fractures, without appropriate medical therapy. Dr. Webb is an active member of the National Osteoporosis Foundation and (at the time of this writing) is the only doctor in Oklahoma who is a member of the NOF Professional Partners Network.

In addition to experience, Dr. Webb is involved in research and bringing the latest cutting-edge technology to his patients. Dr. Webb repeatedly does the first new procedures in Tulsa for new types of VBA (spineoplasty, AVAFlex and structural kyphoplasty to name a few). He is on faculty with several companies and teaches other physicians from around the country how to do these procedures.

A friendly, caring attitude and genuine concern for patients sets Dr. Webb apart from many of his peers. It’s this concern that convinced Dr. Webb to become the first doctor in Tulsa to offer comprehensive osteoporosis treatment for his patients.

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How important is experience in choosing a provider for vertebral augmentation?
Like anything else, experience does matter. Dr. Webb focuses on VCF fixation and osteoporosis. He does the workup and treats patients for this daily, including managing their medications related to underlying causes.

How many fractures have you treated? Is this your first fracture?
Most doctors that do this procedure may do one or two per month. Dr. Webb typically fixes 20-40 fractures per month. In this regards, we are the leading provider in the Tulsa area and offer a great advantage. Furthermore, it’s important to make sure that your doctor has performed these before. Some doctors may get trained at a weekend course and have very little experience.

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After The Procedure

Will you know immediately if the surgery is a success? How long does it usually take to know?
We can usually tell right after the procedure, but not always. Sometimes the patient is too sleepy afterwards, but after a couple of hours they should have a good idea. Most patients will be able to sit up in a chair and walk around that evening, even though these activities may have been painful before.

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When do patients go home?
Most patients go home the next day.

Will the patient need a walker or anything like that after the procedure?
A walker can help patients with stability and decrease the chance of falls. We will typically prescribe physical therapy for many patients after the procedure to focus on fall prevention, balance control and strengthening their core muscles.

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What are things I can do to prevent falls at home?
Keep your floor clear of clutter. When our patients fall at home and get a fractures, the most common household culprits extension cords, throw rugs and step ladders.

Can I melt the cement with heat?
No. Once the cement is set up, it is an irreversible process.

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Can I injure the cement?
No. The cement is harder than bone and will not fracture, bend or break. In rare cases, patients can fracture the bone again around the cement,. In our experience, less than 5% of patients will ever have this happen at any treated level.

What can I expect after the procedure?
After the procedure, you will be observed for a few hours until the sedation wears off. After that time, your nurse may help you up to the restroom. Most patients can sit up in a chair or walk around that evening. If you are under 75 and otherwise healthy, the procedure may be done as an outpatient. If you are older than 75 or have serious medical conditions, such as diabetes, high blood pressure or heart disease, a short hospital stay is usually indicated.

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How common is post-procedure pain?
Most patients report that their pain is gone immediately after the procedure. Patients who still have pain after the procedure usually fall into one of the following three categories:
1. Untreated fractures: Medicare and most insurance companies limit treatment to one or two levels. Most patients with more than two fractures will notice significant improvement. Sometimes, if we fix the most painful fractures, that will unmask pain at the other fractures. If this occurs, the other levels can be treated after about 2 weeks.
2. Incisional pain: Mild incisional tenderness is normal for a few days and resolves by 3-4 days in the majority of patients. This is usually not a problem except in patients who are on chronic pain medication (such as methadone, lortab, and darvocet).

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What if my incisional pain lasts longer than 3-4 days or is severe?
These are very uncommon situations. However, if incisional pain is persistent, it is rare to last more than 2 weeks at the most. If the pain is new and severe, then additional evaluation may be needed to exclude a complication or a new fracture.

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Can I continue to see my chiropractor?
Absolutely. In fact, you will probably find that chiropractic manipulation and other treatments are more effective once a fracture is fixed.

If you have an established relationship with a chiropractor, they can typically accomplish the same goals as physical therapy. If you don’t see a chiropractor but would like to try one rather than physical therapy let us know. We work closely with a number of chiropractors around the state.

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Prescriptions

Osteoporosis Medication Prescriptions

A variety of medications may be prescribed for you if you have osteoporosis. The most common is a high-dose form of vitamin D for those with low levels (also known as osteomalacia).

For patients with fractures due to osteoporosis, many will receive teriparatide (Forteo). This is an injectible medication that helps your body increase bone density by increasing bone turnover. This should not be used if you have a history of multiple myeloma or other forms of bone cancer, including metastasis.

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Osteoporosis Evaluation and Management

Why is a radiologist treating osteoporosis?
Osteoporosis is a disease that ‘slips through the cracks’ in modern medicine. There is no single medical specialty that specializes in osteoporosis. For a partial list, primary care physicians, orthopedic surgeons, breast surgeons, gynecologists, endocrinologists, rheumatologists, nephrologists and radiologists all see patients with osteoporosis.

Most radiologists and pain management physicians only treat the fractures without treating the underlying osteoporosis. A basic principle in medicine is to always treat the underlying disease rather than the symptom or complication. We believe that treating the fracture without treating the underlying cause is a disservice to the patient.

For years, Dr. Webb treated fracture patients and relied on their primary doctor to treat the osteoporosis. However, after seeing many treatment failures and many patients not being treated, Dr. Webb began providing complete osteoporosis assessment and management. At the time of this writing, he is currently the only member of the National Osteoporosis Foundation PPN in Oklahoma.

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Why does my doctor need a Dexa scan?
A bone density test, most commonly a DEXA scan, is needed to measure your bone density. This tells us how severe your osteoporosis is. Osteoporosis is the leading cause of vertebral compression fracture, even in young patients.

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Why does my doctor need to check my Vitamin D level?

This lab test is done by drawing blood. Over 90% of the patients we see with osteoporotic vertebral compression fractures have vitamin D deficiency. This disorder is called osteomalacia; in children it is known as rickets. This is the most common underlying disorder we see in our patient population and is a known cause for failed osteoporosis therapy. Therefore, it is important to treat the underlying cause, otherwise any medications we give you for osteoporosis may not work.

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How much Vitamin D should I take?
The National Osteoporosis Foundation recently increased its recommendations for vitamin D intake. Currently, the NOF recommends up to 1,000 IU each day for adults to prevent deficiency. It’s important to note that that should get at least that much to maintain a healthy (normal) level. If you are deficient, you will require higher doses of vitamin D.

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What medical therapy do you use for osteoporosis?
We prescribe teriparatide (Forteo) for most of the patients we see with VCF. The reason is that this is the most effective drug for osteoporosis available in the United States.
For osteoporotic patients without fractures, we will generally use a bisphosphonate, such as aledronate (Fosamax) or (Boniva).

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Why is it important to take my osteoporosis medication? I feel better after the procedure.
Osteoporosis is a sneaky disease. There are no signs or symptoms. Much like high blood pressure is silent until a stroke or heart attack, osteoporosis is usually asymptomatic until a fracture occurs.
Then it usually becomes a downward spiral. Once you get one vertebral compression fracture from osteoporosis, you’re about 5x as likely to get a second fracture. After the second fracture, that risk increases to about 10X the risk—and it goes downhill from there.
Although many patients will continue to have fractures despite medical therapy, this is the only way to decrease the risk of future fractures.

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Why did you take me off of Micalcin (or Fosamax, etc)?
These medications are less effective than teriparatide, which also decreases generalized back pain in patients with osteoporosis. Micalcin is commonly prescribed because it is an easy to use nose spray and patients may have better compliance. However, in our experience, it is less effective at increasing bone density than teriparatide.

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What are the advantages of teriparatide (Forteo) therapy?
1. Most effective medication available for osteoporosis. It promotes the body’s natural process of bone turnover. For example, with teriparatide, we typically see a 12% increase in bone density over two years, as opposed to 3-6% for the same period with other therapies.
2. Only take it for 2 years.

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What are the disadvantages of teriparatide (Forteo) therapy?
1. Injection. Since it is an injection (under the skin), some patients do not want to take it. This is easy to learn, and there are monthly classes in Tulsa as well as a support group.
2. Cost. This is an expensive medication, but is covered by insurance in most instances. If it isn’t covered by your insurance, the manufacturer has an assistance program that will often pay for the drug for people with lower income.
3. This drug caused certain types of bone cancer in animal models, so it has a black box warning. As such, we do not prescribe in patients with multiple myeloma, osteosarcoma, bone metastasis or other forms of bone cancer. This is likely erroneous (like the saccharine study)—so far in follow up, no link has been seen in human patients.

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What are the disadvantages of bisphosphonate (Fosamax, Boniva, etc) therapy?
Bisphosphonates work by killing osteoclasts, or the body’s natural cells that promote turnover and remodeling of bone. So, new bone is laid down over old bone. This increases bone density, but many feel it is at the expense of increased bone fragility.
In fracture patients, this is a problem because fractures heal best with your body turns over bone naturally.

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Pain Medication Prescriptions

Although we may prescribe certain medications, Dr. Webb does not write prescriptions for narcotics for chronic pain. If you are looking for chronic medical pain management, we can refer you to a physician who does this.

If you feel that you are addicted to narcotics and wish to ‘kick the habit’ or need similar help, we can refer you to other physicians that do this. Most patients who really want to stop find 12 step groups such as Narcotics Anonymous helpful.

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About Insurance and Payment

Is this covered by insurance/Medicare?
Vertebral augmentation is covered by all but the most backwards insurance companies. Even Blue Cross Blue Shield now covers. It has been covered by Medicare and Medicaid for years. However, most insurance will require conservative treatment before approving the procedure, even when common sense says otherwise.

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Do you accept Medicaid or patients without insurance?
We do not limit or restrict the number of Medicaid or cash pay patients that we see.
This is usually a limiting factor with the hospital. In general, if someone doesn't have insurance and have low income, they can often qualify for Medicaid—which we accept. We will work with patients to help this process. Otherwise, this is usually negotiated with our business office by calling (281) 358-7758.

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What if I can’t afford to pay?
For patients who are truly indigent there is a process that must be followed. We do require that all indigent patients to apply for Medicaid before being seen.

All cash pay patients must pay for the professional (doctor’s) portion of their payment before the procedure is done. Hospital (technical) portion is negotiated separately and we do not handle this part.

Please note that these procedures are in place to prevent fraud by those who falsely claim to be indigent, but aren’t. Good examples of these people include those with cell phones, sports season tickets, designer clothes, new vehicles or those who routinely purchase tobacco and alcohol.

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General Back Pain
This section is under development.

I have a bulging disk and I don't want surgery.
There are a variety of procedures that may be done to avoid spinal fusion surgery. Some of these may be called minimally invasive surgery, but are not true surgery. These usually include injecting medication or administering radiofrequency ablation through needles to target the specific pain generators in the body.
The most conservative therapy is doing nothing. There are many options between this and surgery that can usually help and allow the patient to avoid surgery.

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