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Monday, July 21, 2014

The death of actress Sky McCole Bartusiak: Why patients die from Epilepsy

Actress SkyeMcCole Bartusiak, most famous for her portrayal as Mel Gibson's young daughter in the 2000 film "The Patriot," has died in her Houston home. She was only 21 years old.

Skye apparently died as a result of complications from epilepsy. The family believes she had a seizure and choked to death. She had suffered from epileptic seizures since she was a baby, although they disappeared for a few years until returning last week, her mother said. “They were working on her for 45 minutes and could not get a heartbeat. I’ve done CPR on that kid more than one time and it just didn’t work this time.”

What is death from Epilepsy?
Mortality due to epilepsy is a significant concern. Patients with epilepsy have a mortality rate significantly higher than that of the general population. Death from Epilepsy is called “Sudden Unexpected Death in Epilepsy” or SUDEP. SUDEP is defined as sudden, unexpected death in patients with epilepsy which is not related to trauma or drowning. No definite cause of death is identified by an autopsy.

How common is SUDEP?
SUDEP accounts for between 8-17% of deaths in patients with epilepsy. Of patients who are affected by severe epilepsy, it is estimated that 1 in 200 will die each year. 

What causes SUDEP?
The exact cause of SUDEP has not been established. However, there are a variety of theories which try to explain SUDEP:
1. The nerves which regulate our heartbeat, are often impaired in epilepsy. This can cause an abnormal and potentially fatal heart rhythm.
2. Epilepsy is known to cause apnea, or lack of breathing. This is due to a seizures effect on the brain’s breathing center. Longer periods of apnea can lead to cardiac arrest.
3. Patients suffering from certain types of epilepsy (generalized tonic-clonic seizures) often lose consciousness during and even after the seizure. This can lead to an obstruction of the airway and the inability to breathe. This appears to be especially likely when patients are on their stomach (prone).
4. Side effects from the medications used to treat epilepsy can contribute to SUDEP. Also, blood levels of these medications which are too low allow the brain to generate abnormally long or severe seizures. In addition, withdrawal from an anti-seizure medication could be a cause of SUDEP.
5. Seizures can also cause fluid to accumulate in patient’s lungs, which can make it difficult to breathe. This is called “neurogenic pulmonary edema”.

Who is at risk from SUDEP?
Here is a list of potential risks for a Sudden Unexpected Death in Epilepsy (SUDEP):
1. Risks related to patients:

- males more than females
- younger patients (25-35 years of age)
- African Americans are at higher risk
- patients using alcohol and recreational drugs
- seizures during sleep
- seizures while lying on stomach (prone)
- no supervision after seizures
 2. Risks related to the Seizure
-Seizure types called “Generalized tonic-clonic seizures”
-patients who started having seizures at younger ages
- patients who have had seizures for over 10 years
-patients with higher numbers of seizures
-patients who had recent seizures
- patients who have seizures at night

3. Risks related to the Treatment of Seizures
- Low Blood levels of Seizure medications
- Higher number of Seizure medications
-Recent changes in the Seizure medication
-Frequent changes in the Seizure medications
- High blood levels of Carbamazepine (Tegretol)


How can SUDEP be prevented?
Close monitoring of the patient during and in the minutes and hours after a seizure can be life-saving. Caregivers need to be trained how to monitor and resuscitate patients during and after seizures. This includes knowing how to position a patient and how to perform effective CPR. Caregivers must be aware of the increased risks presented by night-time seizures. Stimulating patients after their seizure can also help to stimulate breathing and prevent apnea.
The issue of SUDEP needs to be discussed with patients, families and caregivers. According to a recent survey, less than 5% of doctors discussed SUDEP with all of their patients.
Finding a single medication and optimizing its effectiveness against seizures, rather than relying on  combinations of medications, appears to lower the risk of SUDEP. Similarly, being compliant with the medication and taking it faithfully at the recommended intervals is a must.
Patients who have seizures which are not controllable by medication, should consider surgery. Studies have shown that patients who had successful Surgery (no further seizures), were no longer at risk for SUDEP.
 The Future

Much has yet to be studies and discovered about SUDEP. The National Institutes of Health (NIH) and National Institutes of Neurological Disorders and Stroke (NINDS) are working on a database of SUDEP deaths to help identify causes to better identify those at risk.

Future medical devices which can detect seizures and alert patients and caregivers can help in the earlier detection and treatment of complications related to seizures and help prevent SUDEP.















Sunday, July 20, 2014

Malaysian Airlines Flight MH17: An ongoing Crime and Tragedy

The initial unfathomable crime of the downing of an unarmed civilian airliner with 298 souls on board has only been surpassed by its aftermath. It is difficult, if not impossible to find an event in the history of aviation or modern warfare which bears any similarity to what has occurred and continues to occur in the aftermath of the tragedy of Flight MH17. The events of the last 3 days have proven that there is seemingly no end to crimes against humanity even in the year 2014 and on European soil. 
The Initial Rebel Reaction: 
Immediately following the “successful” downing of the aircraft, Rebel Commander Igor Strelkov bragged on Twitter: “We warned you not to fly in our sky”. “Our sky” seems to be a misunderstanding fostered by Russia that the Eastern Ukraine has become part of Russia rather than the sovereign Nation of Ukraine. The callous remark shows any lack of concern for anyone who might have been on the aircraft. 
Communication intercepts made public by the Ukraine government provide evidence of the immediate need for denial and cover-up without a single word of regret over the killing of 298 innocent passengers.
When asked “are there a lot of people?” an on-scene rebel responded with “F--k! The debris was falling straight into the yards”. The “debris” were human beings, falling to their deaths. Laughing and joking jubilant rebels exclaimed: "Look at those black spots, these are parts flying ...what a blast!" The "black spots" were aircraft parts and human beings.
Removing the Evidence:
Following the discovery of their tragic error, the rebels quickly moved the most incriminating evidence, the rocket launcher, out of the country. Photographs and Video showed that the “Buk” SA-11Rocket launcher was transported across the border into Russia on Friday morning, within hours after shooting down Flight MH17.
Ukraine’s government also states it has evidence that the Russian “BUK” SA-11 missile systems was brought in from Russia and operated by Russian citizens in the days before the tragedy. The Wall Street Journal also cited US Officials that they suspect Russia supplied the rebels with SA-11 system as well as training and potentially personnel to operate it.
The next item on the list of cover up necessities were aircraft's black boxes. The Black boxes of Flight MH17 have apparently been located and removed by rebels. Initial reports claimed they were on their way to Moscow. New reports quoted on Sunday claim that they are under rebel control and would be turned over to investigators from the International Civil Aviation Organization. It seems unlikely that they would be turned over intact.
Controlling the Crime Scene:
The Rebels were among the first to go through the crash site trying to assess what type of aircraft they had shot down. Since then they have controlled who and when anyone could have access. Journalists and officials have been escorted, threatened, and removed from the site without cause or reason. The reality that separatist rebels are in charge of the crime scene is akin to someone who just committed a murder and then stays in charge of the victim and their belongings.
Some people were seen looting valuables and souvenirs from the crash site in the immediate aftermath. Others have posed with parts of the wreckage. Reports have emerged that victim's Credit Cards have been used. Another crime in this ongoing saga.
Ukranian Emergency workers are allowed limited access but cannot collect and remove evidence. Instead the collected evidence is “secured” by the rebels. Rebels continue to block full access to the crime scene, blocking the work of experts. However, hundreds of untrained local volunteers are allowed to comb the site, picking through the wreckage with sticks. “The fighers are taking away all that has been found” said Ukranian Security Council spokesman Andriy Lysensko. Malaysian Transport Minister Liow Tiong Lai: “Failure to stop such interference would be a betrayal of the lives that were lost”. Prime Minister Tony Abbott described the site as “chaotic”. Mark Rutte, Holland’s Prime Minister: “I am shocked by the images of completely disrespectful behavior at this tragic place. In defiance of all the rules of proper investigation, people have evidently been picking through the personal and recognizable belongings of the victims. This is appalling.” "It basically looks like one of the biggest, or the biggest, crime scene in the world right now, guarded by a bunch of guys in uniform with heavy fire power, who are quite inhospitable," said Michael Bociurkiw of the Organization for Security and Cooperation in Europe.
The Victim's Remains:
From the onset, the Rebels have shown little if any regard for the victims of their crime. Bodies and body-parts have been moved randomly with little dignity, by untrained personnel, some of whom were reportedly drunk. Many of the victims were haphazardly placed in trash bags and dumped by the side of roads. Most recently, the Rebels have seized the bodies of about 200 victims from investigators of the Ukrainian National Security and Defense Council at gunpoint. They were loaded on a refrigerated train, reportedly to be moved to yet another Rebel stronghold. Prior to that, 38 bodies were already taken to the morgue in Donetsk, a rebel controlled city.
The Politics:
Flight MH17's crash site is not an “accident scene”, but rather an “international crime scene”. This makes it an entirely different matter, which should place it under the jurisdiction of the countries who had passengers on the flight.  However, there is an obvious disconnect by governments who cannot separate the issue of the crime from that of politics, agendas, and the need for political capitalization on the tragedy. Governments appear to hold the crime hostage to improve bargaining positions in hopes of affecting the outcome of the regional conflict. Rhetoric expressing "outrage", "disappointment", "last chance" and so on have so far rung hollow.
The voices of the victims and families only come into play when it suits the necessary rhetoric to push current and future agendas. Who is looking out for the victims and the families? No one.
The Victim's Families:
It is impossible to image the suffering incurred by the families of Flight MH17's victims. The initial horrible blow was the news that their loved ones died an unnecessary and horrible death. Following that, there has been blow after blow: The lack of remorse on the part of the perpetrators. The cover up of the missile system and missing black boxes. The fact that the Rebels are holding the victim's remains hostage. The manhandling of the victim's remains by often drunk perpetrators. The lack of Expert Investigators on the sight. The failure of politicians to secure the remains of their loved ones, and even begin a formal investigation.
It seems impossible that any of the victim's families could even begin the process of healing and moving on from this tragedy. Their loved one's remains are still in the hands of the perpetrators. It must seem like the crime is not over yet, but continues on and on.



Saturday, July 19, 2014

The Ebola Virus: A potential Worldwide Pandemic?

Movies and Novels have long used fictional Ebola outbreaks as popular pandemic plots. However, now fiction seems closer to becoming a reality.

Since the first reported case of the recent Ebola Outbreak believed to have started in Liberia in December, 2013, Ebola has killed over 600 people on the African continent. This is the most deadly and alarming outbreak of Ebola in history.
Ebola had first appeared in 1976 with two simultaneous outbreaks in Sudan and the Democratic Republic of Congo. The latter occurred near the Ebola River, hence the name. Within 7 weeks, 280 of the 318 people infected were dead. This accounted for a fatality rate of almost 90%. Since then, there have been 28 documented Ebola Outbreaks, mostly confined to rural Africa. However, the most recent outbreak has hallmarks to make it a potential pandemic which could affect other continents such as Europe, Asia, and the Americas.
Of the 5 know types of Ebola Viruses, the "Zaire" type is by the far the most aggressive and deadly kind. This is the same type which was identified in the initial deadly 1976 outbreak and also in the current crisis.
Ebola is thought to be carried by Fruit Bats which can transmit the Virus to other animals such as primates (monkeys, gorillas, chimpanzees) who then become ill. These animals are most likely to come into contact with humans and initiate the transmission of the Virus. In fact, in 1989, 1990 and 1996, monkeys imported from the Philippines to the United States, tested positive for the Ebola Virus. Fortunately, these were a less aggressive and transmittable type of Ebola and no humans were infected.

Leaderboard Broad

Once humans are infected, the Virus spreads quickly from human to human through miniscule droplets of secretions, blood or other bodily fluids. It is believed the Ebola Virus can survive for several days outside the human body. This makes it possible to become infected even without coming into direct contact with another infected human.
After Ebola is transmitted, it may take 2-21 days for a person to show signs of the disease. Due to this unusually long “incubation period", infected persons can travel long distances before they or anyone else would suspect the disease.
The earliest signs of the disease do not point directly at Ebola. Patients usually experience flu-like symptoms such as fevers, sore throats, muscle aches and intense fatigue. This makes it very likely that unsuspecting friends, relatives and health care providers come into contact with the Virus and become potential victims as well. It would take days before a suspicion of Ebola would lead to testing which could identify the Virus as the culprit.
Ebola’s first attacks the Immune System taking away the body’s defenses. The next victims are the organs and the body’s clotting mechanisms. This results in bleeding which can be seen externally, but creates far greater harm internally. Patients eventually succumb to blood loss and shock. Ebola is a fast and efficient killer, claiming the lives of up to 90% of all infected patients, typically within 10 days of falling ill.
Contrary to other Viral Diseases such as HIV, there is no treatment or cure for Ebola. Antiviral medications have not been shown effective. There is also no vaccination against Ebola to protect those at risk. Infected patients typically receive only supportive care such as Oxygen, hydration and treatment for infections, while time determines who lives and dies.
 While other outbreaks have been limited to remote locations in Africa, the most recent epidemic has spread to larger cities, like Conakry, home to 2 million people and the capitol of Guinea. Conakry is a hub for global travelers in Western Africa. An International Airport is nearby, making it far more likely for people who are unknowingly infected with Ebola to travel to distant destinations.
The WorldHealth Organization is calling for “drastic action” to contain the Ebola Virus which has spread from rural areas on larger cities. The Virus has now spread throughout Guinea, Liberia, and Sierra Leone, despite local and international efforts to contain it.

In recent days, 2 American citizens have been infected with the Ebola Virus. Dr. Kent Brantly, age 33, the medical director of the Ebola Case Management Center in Monrovia, the capital of Liberia, was announced last Saturday as having contracted the Ebola Virus. He had been treating Ebola victims in Africa since last October. Dr. Brantly, who was initially accompanied by his wife and children started feeling ill last week and isolated himself. His family has since returned to the United States. Today, it was announced that a second U.S. Health Care worker has contracted the Ebola Virus. Nancy Writebol, had been working as a Hygienist, decontaminating patients at the same Monrovia Hospital where Dr. Brantly contracted the Ebola Virus. Both a reported in serious condition.
The unique and potential catastrophic combination of the largest outbreak in history of Ebola, the most aggressive type of Ebola, and the presence of infected people in large African cities along international travel routes, make this current Ebola Epidemic a potential Global Pandemic. It is a matter of time before other continents are affected. Despite advanced health care systems in developed countries, the Ebola Virus has the potential to spread quickly among a highly mobile population. Due to the long incubation period, lack of specific treatments and high mortality rate, Ebola has the potential to kills thousands. Ebola is classified as a Category A Bioterrorism agent by the CDC for that reason. At this point, chances that Ebola remains an African problem are dim. Other continents and countries must prepare for a potential public health nightmare reminiscent of the movie “Outbreak”.




Wednesday, July 16, 2014

What is a the difference between a Regular Mammogram and a "3-D Mammogram"?

Every year, 200,000 women in the U.S. are diagnosed with Breast Cancer, and 40,000 lose their lives to the disease. 40 Million mammograms are performed to screen women for Breast Cancer. Over 1 Million of them will have biopsy procedures. These numbers tell the story of a devastating disease and the importance of having accurate and widely available screening tools to detect Breast Cancer early.

The traditional screening tool, a mammogram, has been used to screen women for Breast Cancer since the 1960's. It became widely used in the 1970s as more and more hospitals adopted the technology. In the 1980s and 90s, major improvements of the technology became available in the form of lower radiation doses, and the advent of digital images and computers which could detect abnormalities. Despite these advances, Mammograms remain controversial and are not the ideal Breast Cancer screening tool.

A regular, conventional screening mammogram involves taking two X-Ray Images of each Breast from a side-view and top-to-bottom view respectively. Each Image essentially looks through the entire Breast, detecting tissues with different densities along the way. The final Image is essentially a summary of all the information it gathers as the X-Ray beam travels through the Brest. A 3-D mammogram, also called "tomosynthesis", on the other hand rotates the X-Ray tube around the Breast, taking a series of pictures, similar to a CT Scan. The series of Images essentially creates layers or slices of Breast tissue which are computer processed into 3-D equivalent Images.

The Image below shows some of the differences between conventional and 3-D mammograms. The Image on the left, a 2-D mammogram essentially adds all the information gathered by the X-Ray beam together, while the 3-D mammogram just uses information obtained from one X-Ray beam at a time. This allows the Radiologist to see thin slices of Breast tissue across the Breast vertically and horizontally. Notice that the Image itself is not 3-Dimensional. Rather, the Radiologist can get a 3-Dimensional impression of the Breast after reviewing multiple Image slices. Notice how the circle in the Image below points to a specific abnormality which can be seen on a specific 3-D slice, whereas the 2-D Image shows too much overlapping tissue to isolate the abnormality.

Comparison of 2-D and 3-D Mammogram Images of the same Breast

The FDA approved 3-D mammography in 2011 as an "adjunct" to a conventional mammogram, meaning the two studies would have to be combined. A patient would get both a conventional and 3-D mammogram in one setting. This approval implied that the conventional screening mammogram would still be the standard test, while the 3-D mammogram would be an additional test if patients desired it. However, this also meant that patients would be exposed to two sources of radiation, one from each type of mammogram. This could potentially double the radiation dose to the patient. However the "double dose" of radiation was still considered within the safe radiation limits defined by the FDA.

In 2013, the FDA approved software which would allow patients to receive one single mammogram, which can be used to generate the 2-D and 3-D Images. This approval did not mean that 3-D mammograms were taking the place of the 2-D version, but rather if would allow the data needed for a 2-D mammogram to be extracted from the 3-D version. Again, this implies that 2-D mammograms are still the time-proven test. However, both the 2-D and 3-D version could now be generated through one radiation exposure to the patient. The software is not yet available to many Radiology Centers which have 3-D mammography units. This means many patients still have to undergo two separate studies.

The FDA approval of the technology has thus far not impacted on the insurance approval for the 3-D test. At this point the majority of insurers consider 3-D mammography experimental and do not cover the cost of the test. Patients who desire the 3-D mammogram have to pay out of pocket, which typically varies between $50-$100 per test.

3-D mammography equipment is more expensive than the standard equipment, roughly double that of a digital mammography unit. Currently approximately 10% of mammography centers offer 3-D units, which are available in 48 States. It is estimated that 6 Million U.S. women will undergo 3-D mammography this year.

What prompted the surge in interest and popularity of 3-D mammography were several studies which were published in recent years. In the next Blog we will take a close look at these studies to review the potential risks and benefits of 3-D mammography.

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Wednesday, July 9, 2014

Are Epidural Steroid Injections Safe?

Epidural Steroid Injections, also known as "ESIs" or "Cortisone Shots" are the most commonly performed back injections in the US. The first ESI was reported in 1901 by two French Physicians who injected a Local Anesthetic into the Epidural Space to help with pain from Sciatica. ESIs became popular in the 1970's after injectable steroids became available. Due to an aging population, reasonable insurance reimbursements, and an increasing number of physicians trained in the procedure, ESIs have nearly doubled between 2000 and 2008. Currently, over 9 Million of these Injections are performed every year.

What is an ESI Injection?

ESIs are performed to reduce the inflammation and pain related to a disease process of the Spine, most commonly Disc Herniations (slipped discs) and Spinal Stenosis (narrowing of the Nerve canal). The Epidural Space contains the Spinal Nerve Roots which are the target of the Injection. After cleaning the Skin over the Spine, a small amount of Local Anesthetic is injected to numb up the Skin. The Epidural Needle is then placed through the numbed area and slowly advanced into the Epidural Space. Ideally this is done with the help of an X-Ray machine called a "fluoroscope". Unlike ordinary X-Ray machines, the fluoroscope can take second-by-second pictures of the Spine. Once the needle is properly placed in the Epidural Space, a small amount of contrast dye is typically injected. This dye can be seen on the X-Ray and helps to verify the correct placement of the Epidural Needle. At this point, the medication to treat the pain and inflammation is injected. Often, this is a mixture of medications, which include the Steroid, a Local Anesthetic and Saline Solution. The Local Anesthetic can help the Sciatica Pain transiently, until the Steroid begins to take effect.

The Image below is a Color MRI Image which shows how an ESI is performed in the low back.
This Image is Interactive. Just move your Mouse Cursor over the Image and see the Image Tags come alive. Each tag displays text to explain a specific structure (if the Interactive Tags do not display properly due to slow Browser Speed, just refresh the page).

Sagittal Color MRI of a Lumbar Spine Epidural Steroid Injection
Interactive Color MRI showing an Epidural Steroid Injection

Here is another view of the Injection from a horizontal slice perspective. This Image is also Interactive.

Axial Color MRI Lumbar Spine Epidural Injection
Interactive Color MRI of an Epidural Steroid Injection

What are the possible benefits of an ESI Injection?

ESI Injections are ideally done to help with pain from Sciatica related to a Disc Herniation, or Nerve Pain from Spinal Stenosis. In this instance, an ESI injection can help control the pain for an average of 6 to 12 weeks in selected patients. Since the majority of Disc Herniations (approx. 70%) improve over time, ESIs can help control the pain until they resolve on their own. If the Sciatic Pain has been present for over 3 months, the effectiveness of the injection goes down. ESIs are generally most effective when combined with a Spine Rehabilitation program such as targeted Physical Therapy (PT).

What are the possible complications from ESIs?

Statistically, ESIs are reasonable safe when compared to many other invasive procedures, however some of the potential complications can have devastating consequences. Lets take a look at the most common and most serious complications. They are listed from least to most serious:

1. Vagal Reaction
A Vagal Reaction is the feeling of lightheadedness, dizziness and nausea patients experience mostly due to fear or discomfort from a medical procedure. This can occur in up to 8% of patients who have an ESI.

2. Pain from the ESI
Some patients will experience pain at the site where the Epidural Needle was placed through the Skin and Tissue. This pain is usually mild and disappears in a matter of days.

3. Insomnia
Some patients will have difficulty sleeping for the first few nights after the ESI. This is due to the Steroid Medication in the Injection which can make patients somewhat "hyper" and "edgy" for a short period of time.

4. Increase in Sciatic Pain
On rare occasions, patients will initially feel worsening symptoms compared to prior to the Injection. Since the Spinal Nerves are already inflamed and sensitive, they can react to making contact with the injected medication. This can initially lead to an increase in the inflammation until the Steroid can take effect.

5. Allergic Reaction
Patients can be allergic to the injected medications. The most likely one would be an iodine containing contrast dye which is often injected to verify the proper placement of the Epidural Needle.
It is less common to be allergic to the Steroid or Local Anesthetic.

6. Decrease in Immunity
Steroid Medications in general will decrease out body's immunity. This is more pronounced with Oral Steroid Medications, but can also occur with injectable ones. Patients who have a series of ESI injections and those who already have a poor immune system are at higher risks of developing an infection.

7. Adrenal Suppression
The body has many ways to regulate our Hormones. In order to do so, we have "sensors" which constantly measure how much of each Hormone is present in our blood stream. So, when these "sensors" notice that more steroid is circulating in the body, they will tell our own steroid-producing glands to lower the amount of steroid they are producing. This is called "Adrenal Suppression". This is thought to happen in 0.01% (1 in 10,000) of patients and typically resolved in 2-4 weeks after the Injection. Patients who receive very high doses of Steroids or have a large number of ESIs over a short period of time are at a higher risk. For this reason, it is generally not recommended for patients to have more than 3 ESIs per year.

8. Increase in Blood Sugar
This is primarily an issue for diabetic or borderline diabetic patients. Patients with poor Diabetic control and those who receive large doses of Steroids can experience very significant increases in Blood Sugar Readings. In one study, patients experienced an average rise in Blood Sugar from 160 to 285 mg/dL immediately after the Injection. This rise in Blood Sugar typically resolves over 2 days. As a result, Diabetic patients have to take frequent Blood Sugar Readings and potentially adjust their Diabetic Medications following an ESI. Patients should also have a Blood Sugar reading right before the ESI.

9. Postdural Puncture Headache (PDPH)
This type of Headache can happen when the Epidural Needle travels deeper than the Epidural Space and punctures the lining of the Spine Fluid Sac (dura). If some of the Spinal Fluid leaks from the dural sac, a Headache can occur. Statistically a PDPH happens in up to 7% of ESIs. This type of Headache can be very severe and incapacitating. 90% of PDPHs resolve over 10 days. Severe forms of this Headache can be successfully treated and stopped with a procedure called an Epidural Blood Patch.

10. Epidural Hematoma
An Epidural Hematoma is bleeding inside the Epidural Space. Apart from Spinal Nerves and Fat, the Epidural Space also contains Blood Vessels. A puncture of one of these Vessels can potentially lead to bleeding inside the Epidural Space, which can cause compression of the Spinal Nerves or Spinal Cord. While this is an extremely rare occurrence (1 in 200,000 ESIs), patients who are treated with Blood Thinners are at an elevated risk. Considering that many more patients are treated each year with Blood Thinners, the risk of Epidural Hematomas may increase over time.

11. Embolization
Embolization means that a particle travels through the body's Blood Vessels. Typically, embolization happens when blood clots travel within our body. However, some types of Steroids used for ESIs contain particles (methylprednisolone, triamcinolone) which can potentially travel to the Brain and elsewhere in the body and cause Strokes and even Deaths. The risk is higher (1 in 5000) when Steroids containing particles are used for specific Epidural Injections in the Neck (transforaminal ESI).

12. Arachnoiditis
Arachnoiditis is a chronic inflammatory condition of the bundle of Spinal Nerves within the Spinal Fluid Sac (dura). This has been reported when the Steroid is accidentally injected into the Spinal Fluid rather than the Epidural Space. The Spinal Nerves become inflamed which can cause them to "clump together". This can impair the Nerve function and lead to chronic Nerve Pain, numbness and weakness in the Legs.

13. Infection
While infections are rarely associated with ESIs, some types of infections can be devastating. Point in case are the batch of contaminated Steroids which were produced and sold by a compounding pharmacy in Massachusetts in 2012. Approximately 14,000 patients received injections from this batch of Steroids which was contaminated by a Fungus. Tragically, 48 patients died and 720 had to be chronically treated for Fungal Infections.

While this list of potential complications related to ESIs seems daunting, by and large the controversy about ESIs lies in their usefulness to treat pain, rather than the potential complication risks. However, patients must be aware of all the potential complications to allow them to make an informed decision about whether or not to pursue this elective procedure.

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Tuesday, July 8, 2014

A Spine Surgeon's Perspective: How can a Spine Company stand out in the crowd? Part II: Surgeon Websites

How can a Spine Company elevate itself above the competition? The ever increasing number of Spine start-ups combined with overseas competition, reduced reimbursements, and more government oversight is likely to make the Spine Implant field more and more competitive. Small and medium sized companies will find it more and more difficult to compete. The allure and potential for acquisitions and mergers will be largely dependent on documented sales and the existing customer base, the Spine Surgeons and Hospitals.

This is part II of our series which examines how a Spine Company can succeed in this difficult market, all from a Spine Surgeon's perspective.

Developing and fostering relationships with Spine Surgeons is, of course, one of the centerpieces for success. In our last Blog we introduced the idea of the broadening the Spine Rep's training and knowledge base as well as providing them with the tools to understand the Psychology of Spine Surgeons. Now lets take a look at how a Spine Company can help a Surgeon succeed with their business.

Understanding a Spine Surgeon's business realities and complexities can create the groundwork to develop ways to positively impact on their ability to remain or become successful. In general terms, Spine practices are increasingly forced to compete against each other as well as against non-surgical Spine Specialists such as Pain Physicians and Chiropractors.

One of the focal points and variables of a successful competition is the Spine Surgeon's website. Gone are the days, when you put out your shingle, create a Primary Care referral base and go on to have a successful career. The practice website is quickly becoming the most important aspect for a Spine Surgeon to create a brand, showcase their expertise and provide patient education. The website is not just meant to give existing patients a place to learn more about the practice, but is quickly becoming the cardinal tool to attract new patients. Even potential referrers gauge the website to gain an impression of the Surgeon and his/her practice. Unlike in days past, the practice website has to perform well not just locally, but regionally and even nationally depending on the size an scope of the practice.

Practice Websites need several key items to help the practice succeed:
1. A Brand which is recognizable, identifiable, and sets the tone for the entire operation
2. Content. The content is important to generate size and keywords to be competitive in the rankings.
3. Patient Education Materials to showcase knowledge and expertise as well as the specific treatments offered.
4. Links to gain "authority" and ranking.
5. Smart SEO

So, how can a Spine Company help the Surgeon's website succeed?

First off, most Spine Surgeons hate to deal with their website. They would rather pay someone else to deal with it. That "someone else" typically falls on the practice administrators who outsource this piece to website developers. The developer may or may not understand the business of Spine Surgery and will try to apply general business principles. However, that only goes so far. They often struggle to find relevant content and links in their frequently subpar attempts to provide SEO. They will try to twist the Spine Surgeon's arm to write content and patient information, which they may reluctantly do, but only intermittently and time-permitting. Forget about writing an ongoing Practice Blog...

This is where a Spine Company can step in. Here are some of the options:

1. Offer the Practice Website Links. Links provide "Google authority" for the site. This in turn provides rankings, i.e. SEO. The more valuable the link the better. A large Spine Company website can provide a valuable link. Beyond that, Spine Companies have the ability to provide further links from third parties. These can be based on business relationships, be purchased, etc. Help with Link building can elevate a practice website from obscurity to visibility.
2. Offer patient education materials. Practice website have an insatiable appetite and for patient education materials. Why? Because it helps to establish the Surgeon's credibility. In addition, Surgeons can save time in the office by directing patients to the their website to have further questions answered. Spine Companies can create comprehensive third party patient education websites. They can offer this educational material either as a link from the Surgeon's website or as direct content to be incorporated into the Surgeon's website. The material has to be of the highest quality and contain Images and Video as well as outgoing links to be the most SEO friendly. This, of course applies to disease education and procedural education. However, with regard to procedural education which outlines specific surgeries, a Spine Company has the unique opportunity to link to their own products.
3. Provide Social Media Content. While it is difficult and time consuming for Surgeons to be involved in the practice website creation and maintenance, they are often even less enthusiastic about giving up more of their valuable time to be involved in their own Social Media Campaign. However, the reality is that having a strong presence on Social Media Sites such as Twitter, Facebook and LinkedIn is becoming a Must. not an option. Here is another opportunity for a Spine Company to step in and provide ongoing content, images and video.

To go one step further, a Spine Company could invest in, or acquire a website development and digital marketing company, with the sole focus of creating, managing and promoting Spine Surgery websites as a powerful marketing tool to attract and retain Surgeon customers. This company would custom create patient education materials based on a surgical perspective, offer unique custom brands, provide immediate links, ongoing SEO, and integrate the site with the Spine Company to the extend possible. This company would also offer digital marketing and Social Media management to promote the Surgeon and Surgeries offered by the practice.

The website development company can be a stand-alone third party without a direct and obvious tie to the Spine Company. However, their products and services can be a marketing tool for the Spine Company.

In summary, the Surgeon's success is increasingly tied to a highly visible and successful website as well a significant Social Media presence and select digital marketing. A Spine Company can become indispensable to a practice by providing this type of expertise and involvement.

Monday, July 7, 2014

Neymar's Spine Condition: What is "Spondylolysis"?

Neymar da Silva Santos Júnior, Brazil's star soccer player likely sustained a serious spine injury in the game against Columbia. He received a hard blow in a collision with Columbia's Juan Camilo Zuniga. Zuniga's knee drove hard into Neymar's low back, causing him to collapse and be carried off the field. The injury was so severe that Neymar could not feel his legs in the minutes following the collision. This prompted the medical staff to rush him directly from the pitch to the helicopter pad to have Neymar flown to the hospital.
The public perception of the severity of his injury has been based on Brazil Team DoctorRodrigo Lasmar's statements that Neymar's injury is a "benign fracture" which "does not require surgery", but rather "conservative treatment and comfort to ease the pain".

The term "benign fracture" is not typically used to describe a spine fracture. The closest thing to a "benign fracture" of the spine is a fracture which involves either the small spike on the back of the spine (spinous process) or the wing on the side of the spine (transverse process). And here is where the confusion comes in. The Brazilian Television apparently obtained a copy of one of the CT Scan slices of Neymar's low back. This image has since been widely distributed and commented on.

Here is where it gets a bit confusing: The Brazilian Team doctor Rodrigo Lasmar stated that Neymar broke the "3rd Lumbar Vertebra". However, the published CT Scan slice seems to show a fracture of the 5th Lumbar Vertebra, i.e. two Vertebrae lower. Moreover, the fracture shown on this Image is not a "benign fracture" for a soccer star of Neymar's caliber. Rather, this fracture called a "Spondylolysis" is not usually associated with the kind of trauma Neymar sustained, but rather a sports injury due to repetitive activities such as Gymnastics. While this is only slice of the dozens of CT Scan slices which make up the whole CT Scan examination, it does raise a few questions:
1. Is this actually Neymar's or someone else's CT scan? Some versions of this Image have Neymar's name at the bottom, but that does not prove authenticity. However, thus far there has been no official denial of its authenticity, which make it very likely that this Image is truly Neymar's. 
2. The team doctor identified the L-3 Vertebra rather than L-5 after all. If he is correct, then there could be more than one fracture, a chronic one at L-5 and an acute one at L-3. This could be a troublesome combination of injuries.
3. This type of fracture is typically a chronic stress fracture rather than one due to the trauma from Zuniga's knee. This could imply that Neymar's Spine was weaker to begin with, due to a chronic stress fracture. While this weakness would not account for a fracture elsewhere in the Spine, it could mean that he has a vulnerability for future Spine problems.

To understand the implications of all this, lets take a look at this spine condition, called "Lumbar Spondylolysis".

What is Lumbar Spondylosis?

Lumbar Spondylosis is a fracture through the weakest part of the Vertebra, called the "Pars Interarticularis", which is a thin bone bridge on the back of the Vertebra. While this type of fracture can occur due to trauma it is far more commonly a chronic condition. In fact, it is present in 5-6% of the U.S. population. Most patients live just fine with this condition, however top athletes may or may not. A very high and repetitive level of athletics often causes pain at the site of the fracture and can eventually lead to a shift between the Vertebrae, called Spondylolisthesis. The latter condition can cause instability of the spine, nerve compression and chronic back pain. It is often treated surgically.

Why does this type of fracture not heal well? Unlike a broken arm or leg, the Spine cannot be casted. The closest thing to a cast is a rigid back brace. However even a brace allows for some motion. The small bone bridge which has fractured, is also under constant pressure whenever we are upright. Even keeping a patient on their back for several months would not guarantee that this type of fracture heals completely.

Here is a 3-D Color X-Ray which show a Spondylolysis Fracture from a side-view. This Image is Interactive. Just move your Mouse Cursor over the Image and see the Image Tags come alive. Each tag displays text to explain a specific structure (if the Interactive Tags do not display properly due to slow Browser Speeds, just refresh the page).

Interactive 3-D Color X-Ray showing a Spondylolysis Fracture

Here is the front view. This Image is also Interactive.

Interactive 3-D Color X-Ray showing a Spondylolysis Fracture

How is Lumbar Spondylolysis Treated?

Many patients who suffer from the chronic form of Spondylolysis are treated with conservative, non-surgical treatments such as back exercises and avoidance of the activities which cause pain. Gymnasts, weight lifters and football players are often asked to limit their involvement in these sports for a period of time to stop placing stress on the weakened area of the Spine. However, some patients will suffer from intermittent or ongoing back pain. These patients may need pain medications, targeted Physical Therapy and even Spine Injections. A small percentage of patients are incapacitated by the disease and need Surgery.

Someone, like Neymar who competes at the highest athletic level and is also subject to significant physical contact (fouls), may experience intermittent back pain and would likely require more care than the average person. If however his Spondylolysis is due to the injury from his collision with Zuniga, he will initially need a rigid back brace, a restricted activity level, pain medication, and time to recover. He would also need serial X-Rays and even potentially more CT Scans to evaluate the fracture. The largest concern is a slippage of the Vertebrae next to the fracture, called a "Spondylolisthesis". If this occurs, the condition would likely cause more pain and potentially numbness and weakness in the legs. This could jeopardize a professional soccer player's career.

What does Lumbar Spondylolysis mean for a Professional Soccer Player's career?

This is a very difficult question. Why? While this Spine Condition has been studied in soccer players, players like Neymar, Messi, Reynaldo are simply "abnormal" in a sense that they can accelerate, move, spin, and kick in ways others can't. So, are athletes at this level more or less likely to have chronic back pain than lesser athletes? The "more likely" argument could be based on the assumption that they have more wear and tear issues over time just due to more motion and force in the Spine. The "less likely" argument could include the assumption that the star players have "superior anatomy", meaning their spine muscles, ligaments and other parts are simply stronger, more durable than others.
So, all bets are off with regard to what will happen to Neymar's Spine in the future. At the age of 22, a Spine Injury can either be shrugged off as just another soccer injury, or become a nagging dagger in the side which can rob a star athlete of his confidence.

By all accounts, Neymar da Silva Santos Junior is not just a "once-a-generation" Brazilian Soccer phenomenon, but also an outstanding human being. We can only hope and pray that he can continue his amazing career and fulfill his dreams.

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