Vertebroplasty and Kyphoplasty

VERTEBROPLASTY AND KYPHOPLASTY
Dr. Sandeep Mishra

Brief history
Indications
Contraindications
Preprocedure evaluation - history/ examination/ Imaging
Procedure
Risks and complications
Benefits
Future directions
Literature review

VERTEBRAL AUGMENTATION
Minimally invasive percutaneous procedure
Fast-setting polymer is injected into pathological vertebrae
▪ Vertebroplasty: Injection of material (usually PMMA cement) into vertebral body
▪ Kyphoplasty: Insertion and inflation of a balloon before injection of material

HISTORY
First percutaneous vertebroplasty, 1984 at the University Hospital of Amiens, France
Deramond and Galibert injected PMMA into a C2 vertebra partially destroyed by
an aggressive hemangioma.
The idea of kyphoplasty was conceived by an orthopedic surgeon, Dr. Mark Reiley,
in the early 1990s.
Kyphx inflatable balloon tamp (Kyphon Corporation, Sunnyvale, CA) performed
with combined effort by Dr. Reiley and a neuroradiologist in 1999.
Mathis, John. Percutaneous Vertebroplasty and Kyphoplasty. Percutaneous Vertebroplasty: Procedure Technique.Springer.2006.112-134

INDICATIONS
Pain WITH vertebral compression fractures
Osteoporosis
Neoplasm (Mulitple myeloma, hematogenous spread)
Vertebral hemangiomas
Pain WITHOUT vertebral compression fractures
Lytic metastatic neoplasm
Chronically non-healing traumatic fractures
*Clifford J. Eskey,Chapter 173 - Vertebroplasty and Kyphoplasty: Indications and Techniques.
Schmidek and Sweet Operative Neurosurgical Techniques (Sixth Edition) W.B. Saunders; 2012. Pages 1973-1983

CONTRAINDICATIONS
Absolute
Recent systemic or spinal infection
Uncorrected bleeding diathesis
Fracture- related compromise of the spinal canal sufficient to result in myelopathy
or radiculopathy
Asymptomatic compression fracture or healed fractures

MECHANISM OF PAIN RELIEF
The action mechanism for pain relief from PVP are
Thermal ablation of sinuvertebral and sympathetic nerves from the heat of the
PMMA
Chemical neurolysis from the toxin of the PMMA
Mechanical stabilization from the volume of PMMA

PRE-PROCEDURE EVALUATION
HISTORY
Acute VCF-sudden onset deep pain, midline
Worsens with weight bearing and improves with recumbency
Localized to the area of the fracture and lacks radicular qualities
Assessment of the effect of the pain on activities of daily living and sense of well-
being
EXAMINATION
Inspection of the back, palpation for focal areas of tenderness, and correlation of
the site of pain with anatomic landmarks
Palpation on the spinous process should elicit pain (point tenderness)

IMAGING
PLAIN RADIOGRAPHS:
Confirm the presence of fracture,
Determine the location of fractures,
Assess the degree of height loss and kyphosis, and
Identify anatomic variants
With prior radiographs for comparison, new VCF can be identified
*Clifford J. Eskey,Chapter 173 - Vertebroplasty and Kyphoplasty: Indications and Techniques. Schmidek and Sweet
Operative Neurosurgical Techniques (Sixth Edition) W.B. Saunders; 2012. Pages 1973-1983

MRI:
Test of choice
Advantages:
(1) distinguish new or unhealed fractures from healed
fractures,
(2) identify other causes of pain, and
(3) evaluate the risk of symptomatic cement leakage during
the procedure
T2-weighted sequence with fat suppression: most useful
sequence
Recent or unhealed fractures show a hyperintense signal
within the bone marrow
T7 verterbrae shows
hyperintense signal

BONE SCAN
Test of choice if MRI is contraindicated
Allow the differentiation of healed and recent fractures
Recent fractures take up the injected technetium 99m–medronate tracer in much
higher concentrations
Identifying fractures which are more acute in nature (normal on MRI)
Recent fractures take up the injected technetium 99m–medronate tracer in much
higher concentrations

COMPUTED TOMOGRAPHY
Not necessary for osteoporotic fractures
Useful for preprocedural evaluation of burst fractures and metastasis and
postprocedural evaluation of unexpected symptoms
Assess cortical integrity of posterior vertebral body and pedicles

VERTEBROPLASTY: TECHNIQUE
SEDATION
Begins with informed consent about possible complications and what to expect from the
procedure
Vertebroplasty can generally be performed with local anaesthesia and sedation.
Kyphoplasty generally is performed under general anaesthesia
Sedation can be achieved with intravenous midazolam and fentanly
Continuous patient monitoring done with electrocardiogram, pulse oximetry and blood
pressure measurement.

TECHNIQUE: POSITIONING
The ideal position for thoracic or lumbar procedure is prone.
The patient’s arms are placed above the shoulders, joints are slightly flexed, and
adequate padding is placed beneath potential pressure points
A special table and cushions may be used to support the head and body
Adherence to strict sterile protocol
is the standard of practice

TECHNIQUE: ANTIBIOTIC PROPHYLAXIS
Intravenous antibiotics are routinely given, usually 30 minutes before starting the
procedure
The most common antibiotic used in this application is cephazolin (1g)
Continued for 24 hours after the completion of the procedure.
Antibiotics are added to the cement only in the situation of immunocompromise

TECHNIQUE: IMAGE GUIDANCE
High quality fluoroscopy
1. Biplane
2. Single plane
3. C-arm
Biplane fluoroscopy allows multiplanar, real-time visualization for cannula
introduction and cement injection.
It is expensive and not as commonly available in interventional suites or operating
rooms
It takes longer to acquire two-plane guidance and monitoring information with a
single-plane than with a biplane system

Computed tomography
CT and fluoroscopy
CT is preferred over fluoroscopy include the treatment of cervical or high thoracic
vertebra (where the approach is anterior and fluoroscopy is inadequate to see
critical structures such as carotid or vertebral arteries), destroyed vertebra with risk
of cement leakage, and sacral insufficiency fractures.

TECHNIQUE: NEEDLE PLACEMENT
There are two principal approaches for needle placement:
transpedicular and
parapedicular
The transpedicular approach: most common approach;
complete intraosseous path protects the nerve roots and blood vessels from direct
injury and the soft tissues from cement leakage along the tract;
provides a safe entry point that allows easy compression of overlying soft tissues,
postprocedure, to minimize bleeding

A: Needle system developed by Stryker
B: Needle tip: diamond vs bevel
C: Stryker cannula with the trocar removed
D: Stryker biopsy device (black arrow) inserted through the cannula
Smaller gauge needles used routinely (13–15 gauge).The diamond tip configuration offers the
maximal ease of needle introduction into bone

Image: UT Southwestern Medical Center Radiology

A parapedicular approach: when the transpedicular route is not desirable or possible (e.g.,
small pedicle)
The needle is directed along the lateral cortex of the pedicle, and the needle pierces the
cortex at the junction of the pedicle and vertebral body
Angles the needle tip more toward the center of the vertebral body- allow easier filling of the
vertebra with a single injection
Increases the risk of paraspinous hematoma and pneumothorax
For either approach, there are two image guidance strategies.
The “end-on” approach
The AP approach

PARAPEDICULAR APPROACH
(LATERAL TO PEDICLE AND ABOVE THE TRANSVERSE PROCESS)
This avoids the exiting nerve root (courses under the pedicle)
Does not allow local pressure after needle removal,
the chance for bleeding higher than with the transpedicular approach

END-ON TECHNIQUE
The operator rotates the fluoroscopy unit into an ipsilateral oblique view that places the
fluoroscopy beam, the pedicle and needle tract perfectly parallel to each other.
The image intensifier is first rotated to a true AP position, aligning the spinous process
midway between the pedicles.
The craniocaudal angulation is changed to bring the pedicles to the midportion of the
vertebral body.
The image intensifier is then rotated to bring the ipsilateral pedicle so that its medial cortex
is at the middle third of the vertebral body.This rotation can only be continued as long as the
medial cortex of the pedicle remains clearly visible.
The needle is placed so that it is “end on” to the image intensifier and appears as a small
circle or ellipse
.The needle is then advanced through the pedicle, maintaining the end-on appearance of the
needle.
The needle tip should be at the junction of the anterior and middle thirds of the vertebral
body.

Needle placement with end- on approach.
A, Initial AP view.
B, Cranio- caudal angulation to place the pedicle at the vertical middle of the vertebral body.
C, Ipsilateral oblique view to place the pedicle over the medial aspect of the vertebral body.
D, Ipsilateral oblique view with the needle (black circle) in proper alignment.
E and F, Lateral and AP views with final needle location.

AP TECHNIQUE
The craniocaudal angulation is adjusted to bring the vertebral body end plates
perpendicular to the image.
The skin entry site is placed about 1 cm superior and lateral to the center of the
pedicle.
The needle is advanced anteriorly, medially, and caudally.
By the time it reaches the bone surface, the tip should project over the upper outer
cortex of the pedicle.
The needle is advanced so that its tip projects over the center of the pedicle on
both AP and lateral views.The tip should project over the medial pedicle cortex as
the needle traverses the posterior third of the vertebral body.
The final position is again adjusted on the lateral view.

Needle placement with the AP approach.
A, AP view with the site of skin entry (black dot).
B, Needle appearance as it enters the posterior pedicle surface.
C, Needle appearance when it has been advanced to the midpoint of pedicle on the lateral view.
If the needle tip is more medial at this point, there is risk for traversing the medial pedicle cortex.

Large needle are advanced either using a drilling motion or tapping with a small
hammer.
The needle position should be checked frequently in the oblique (or AP) view for
two reasons
1. to ensure that the needle does not violate the medial cortex of the pedicle
2. needle trajectory cannot be markedly altered once the needle has passed beyond
a small distance into the pedicle

The final tip of the needle should be at the junction of anterior 1/3 and posterior
2/3 rd of the vertebral body.
Vertebroplasty can be performed using a unipedicular or bipedicular approach.
Bipedicular approach: independent of the precise lateral position of the needle tip
within its half of the vertebral body
Unipedicular approach: a near-midline position of the needle tip provides more
reliable filling of the vertebral body

PARAMIDLINE INCISION OVERLYING
TRANSVERSE PROCESS-FACET JUNCTION

ENTRY POINT & TRAJECTORY OF NEEDLE INSERTION IN
TRANSPEDICULAR APPROACH

ON THE AP VIEW ON THE LATERAL VIEW
The needle should be parallel to
the superior and inferior edge of
the pedicle.
The needle tip should not touch
the medial curve of the
pedicle which forms the wall
of spinal canal.

TECHNIQUE: VENOGRAPHY
Injection of contrast through the needle.
Visualize vertebral body and epidural and paraspinal veins.
Will identify a direct venous communication.
Can avoid backward leakage of cement via the
venous channel and prevent pulmonary embolism.
Not necessary for the safe placement of cement

TECHNIQUE: CEMENT INJECTION
Cement is prepared only after all needles are placed
The needle tip can be advanced to the junction between anterior and middle third
of the vertebral body.
Cement mixture:
Polymer powder
Liquid monomer
Opacifying agent
Barium sulfate powder
Optional additive: antibiotic powder

CEMENT MIXING
First powder PMMA is mixed with barium sulfate and tobramycin in a sterile plastic
bowl.
Then liquid PMMA is added and mixed by a tongue blade to a dough-like
consistency.
The cement is then poured into a 10 ml syringe, and divided into multiple 1ml
Luer-Lock syringes.
Limited working time: 10-15 minutes depending on temperature and cement
mixture.
Goal: no runny cement or dry patches (toothpaste consistency)

CEMENT INJECTION
Meticulous fluoroscopic monitoring during the injection process.
Liquefied cement is injected into the vertebral body using a 1ml syringe attached directly to
the biopsy needle.
Termination of injection.
Cement in posterior 1/3 vertebral body on lateral projection.
Cement leakage beyond the marrow space
Cement filling the vertical expanse of the vertebra and
extending across the midline
VOLUME OF BONE CEMENT: 3-10cc; larger volume may not be
optimal

CEMENT HARDENING
The patient should remain on the table until the cement is completely hard
(approximately 15 minutes).
This can be confirmed by keeping excess cement in one’s hand (body
temperature).

VP: POSTPROCEDURE CARE
Post operative:
Manual compression and dressing at puncture site.
Strict bed rest for 1-2 hours.
Monitor vital signs and neurologic assessment (focussed on the extremities)
Discharge: 3 days of limited activity and monitoring of the puncture sites
Patient Follow-up: Patient instructed to call for
Worsening of pain or new symptoms
Chest pain
Lower extremity weakness
Fever

KYPHOPLASTY
Developed to restore the VB height and to address the kyphotic deformity
Height restoration and reduction of cement leakage are the main points that theoretically
distinguish KP from PV
The average kyphotic angle correction is reportedly 9°
Percutaneous introduction of balloon into the vertebral body through a cannula

KYPHOPLASTY: TECHNIQUE
Most of the steps and guidelines similar to vertebroplasty
Patient preparation, sedation, positioning, and image guidance are the same
The key differences are the cannula introducer system, the balloon tamp and
pressurization system and the details of cement delivery
The cannula is only advanced to the posterior aspect of the vertebral body
The stylet or introducer is then exchanged for a hand-operated drill bit
This drill is carefully advanced to the anterior aspect of the vertebral body, 3 to 4
mm posterior to the anterior cortical margin

The drill or introducer is removed, and the space thus created is smoothed with a
blunt stylet
A deflated balloon tamp is advanced into this small cavity so that the posterior
balloon marker is sufficiently anterior to the cannula tip.
A second system is then placed from the other side in a similar manner
Each balloon tamp, attached to a locking syringe with a digital manometer, is slowly
inflated with iodinated contrast.
The inflation is performed synchronously and is monitored with the pressure
transducer and intermittent fluoroscopy

Inflation continues slowly until
(1) the kyphotic deformity is corrected,
(2) the balloon tamp reaches one of the cortical margins, or
(3) the system reaches maximum pressure or maximum balloon volume
The balloon is then deflated
Cement is prepared and placed into tubular bone fillers and allowed to reach desired
consistency
The loaded bone filler is placed through the cannula into the cavity, and the cement is
injected under fluoroscopic guidance
The cement fills the cavity, matching or slightly exceeding the volume of the inflated balloon
tamp.

COMPLICATIONS
Cement leakage:
Spinal Cord compression: from cement leakage
Pulmonary Embolism: cement passage into perivertebral veins
Rare:
Hematoma
Pedicle Fracture
Noninfectious discitis/spinal infection
Transient Hypotension
Transient fever

TIMING
Best results achieved when operated within 6 weeks of onset
>50% patients get better with nonoperative therapy in 6 weeks
Most fractures treated are >3 months old

BENEFITS
PAIN RELIEF AND ACTIVITY
Primary goal
Pain relief is often immediate and complete
FRACTURE STABILIZATION
Secondary goal
Prevents additional deformity
HEIGHT RESTORATION AND KYPHOSIS CORRECTION
Height improvement is achieved to some degree in 80%1; and complete or near-complete height
restoration is achieved in 10% to 20% 2
1. Garfin SR,Buckley RA,Ledlie J.Balloon kyphoplasty for symptomatic vertebral body compression fractures results in
rapid,significant,and sustained improvements in back pain,function,and quality of life for elderly patients.Spine.2006;31:2213-2220
2. Ledlie JT, Renfro M. Balloon kyphoplasty: one-year outcomes in vertebral body height restoration, chronic pain, and
activity levels. J Neurosurg.2003;98:36-42

FUTURE DIRECTIONS
Percutaneously placed curettes of several forms can now be used to disrupt
trabeculae and form a cavity for cement placement
One device provides a polyethylene terephthalate semiporous balloon that is
expanded by the infused cement
Another replaces the balloon tamp with permanently implanted, stacked, plastic
wafers
New PMMA formulations available with different setting and mechanical
properties*. One approach includes extracorporeal radiofrequency heating of the
PMMA and controlled high-pressure cement injection
*Jasper LE, Deramond H, Mathis JM, et al. Material properties of various cements for use with vertebroplasty. J Mat Sci Mat
Med. 2002;13:1-5

PMMA has been mixed with radioactive materials in a form of brachytherapy for spine
metastases#
Bioactive cement materials may one day replace PMMA. Strontium-containing
hydroxyapatite (Sr-HA) bioactive bone cement delivered locally has the same effect, with
a low setting temperature, adequate stiffness, and low viscosity makes this a good
bioactive cement for vertebroplasty and kyphoplasty*.
# Ashamalla H, Cardoso E, Macedon M, et al. Phase I trial of vertebral intracavitary cement and samarium (VICS): novel technique
for treatment of painful vertebral metastasis.Int J Radiat Oncol Biol Phys. 2009;75:836-842
*Cheung KMC, Lu WW.Vertebroplasty by Use of a Strontium-Containing Bioactive Bone Cement. Spine. 2005;30(17 Suppl):S84-91

LITERATURE REVIEW
Conservative management vs PVP / PKP in osteoporotic VCFs
Evidence of PVP/PKP in cancer related VCFs
Vertebroplasty (PVP) vs Kyphoplasty (PKP)

TAKE HOME MESSAGE
PVP/PKP offer significant pain relief in cancer associated vertebral collapse
Kyphoplasty - offers better vertebral height restoration, kyphosis correction,
reduced cement leakage with increased operative time and cost but without any
significant difference in pain scores.

Vertebroplasty and Kyphoplasty

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