Downloaded 258 times
![Pain associated with
Compression vertebral fractures
• Primary osteoporosis
• steroid-induced osteoporosis
• Neoplastic-induced fracture
• Sub-acute traumatic collapse
• Vertebral angiomas
• Symptomatic microfracture [MRI]
• Lytic lesion [CT] without loss of vertebral height](https://image.slidesharecdn.com/techniques-191123161646/85/Vertebroplasty-and-Kyphoplasty-Techniques-6-320.jpg)
Uploaded byProf. Dr. Mohamed Mohi Eldin
Vertebroplasty and Kyphoplasty Techniques
This document discusses vertebroplasty and kyphoplasty techniques. It describes: 1. Vertebroplasty involves injecting bone cement like PMMA into a vertebral body to treat osteoporotic fractures, while kyphoplasty also involves cavity creation before injection. 2. The document outlines the procedure for vertebroplasty, including patient selection, anesthesia, needle placement using fluoroscopy guidance, cement mixing and injection, and monitoring for complications like leakage. 3. Key aspects of the procedure discussed are pedicle definition, approaches like transpedicular, cement properties, and ensuring the needle and cement stay within the vertebral body to avoid issues. Safety and complications are emphasized throughout.
More Related Content
Similar to Vertebroplasty and Kyphoplasty Techniques
More from Prof. Dr. Mohamed Mohi Eldin
Vertebroplasty and Kyphoplasty Techniques
- 1. Vertebroplasty and Kyphoplasty Techniques MohamedMohi Eldin, Professor of Neurosurgery, Faculty of Medicine, Cairo University One-Day Spine Clinic 4th workshop & hands-on, 27-28 December 2017
- 2. PEDICLE DEFINITION, L1VERTEBRA Wire wrapped around the waist of the pedicle
- 3. PEDICLE DEFINITION, L1VERTEBRA The A-P image of the pedicle corresponds to the waist of the pedicle, not the base
- 4. PEDICLE DEFINITION, T10VERTEBRA T10T10
- 5. Vertebral Augmentation Vertebroplasty (1984): Injectionof material (usually PMMA cement) into vertebral body Kyphoplasty (1998): Injection after manipulation involving cavity creation
- 6. Pain associated with Compressionvertebral fractures • Primary osteoporosis • steroid-induced osteoporosis • Neoplastic-induced fracture • Sub-acute traumatic collapse • Vertebral angiomas • Symptomatic microfracture [MRI] • Lytic lesion [CT] without loss of vertebral height
- 7. The Osteoporotic VertebralFracture
- 8. Predictors of fracture 19.2%a second fracture within one year 24% a further fracture within a year
- 9. We use MRIfor Preoperative evaluation of vertebroplasty in all patients unless contraindicated Precontrast sagittal T1, fat suppressed T2-weighted and postcontrast sagittal fat suppressed T1-weighted images
- 10. Vertebroplasty – howto do it MRI of Acute Compression Fracture T8 Plain film T8 T2W T8 T1W post-Gd showing a significantly enhanced T8 indicating a recent fracture. T9 is a chronic fracture and does not need vertebroplasty.
- 11. Pre-Operative Bone Scan •In patients who cannot have an MRI • In identifying which fractures are more acute in nature and most likely to contribute to the patient’s symptoms. T8
- 12. Patient selection The keyto success of vertebroplasty • Pain should be – focal, – intense, – deep, – local tenderness – corresponding with imaging findings, – No radiation to the legs.
- 13. Medicolegal • The procedureis discussed – with the patient and/or family, – benefits, risks, and possible complications are explained. • Obtain informed consent.
- 14. Before discussing thetechnique.. Possible complications..? • Bleeding • Infection • Fracture of the pedicle • Damage to the nerve roots or spinal cord • Worsening of symptoms • Spinal cord or nerve root compression (radiculopathy) from cement leakage • Pulmonary embolism
- 15. For treatment ofpotential complications We should have • Immediate access to: – CT Scan and / or MRI. – ICU. – Operating Room.
- 16. Instruments and tablesetting We use 13-gauge bone biopsy needles
- 18. Cement, barium andtobramycin cranioplastic mixture (30g), sterile barium sulfate powder (12g), and tobramycin (1.2g).
- 19. Vertebroplasty Imaging • Highquality fluoroscopy – Biplane – Single plane – C-arm • Computed tomography – CT and fluoroscopy
- 20.
- 21. Combined CT andmobile fluoroscopy SETUP
- 22. High quality fluoroscopy Fixed“C” Arm • Easier operation • Better imaging quality • High cost • Availability..!? Mobile “C” Arm • More difficult operation • Less image quqlity • Lower cost • More available
- 23. Procedure: Anesthesia • Intravenoussedation – Sedation: midazolam – Analgesia: fentanyl • Local – 1% Lidocaine – 0.5% Bupivicaine on bone • General anesthesia – Rarely required Local GeneralNeurolepto Selection will depend on surgeon’s experience and characteristics of patient.
- 24. Main advantages ofLocal Anesthesia Allows surgeon to communicate with patient Benefits Early diagnosis of lesions (radicular / pleural) which might not be diagnosed otherwise. • Determine cement injection speed. • Anticipate corrective measures. • Abort the procedure.
- 25. During Local Anesthesia 1.Ancef 1g IV is given pre-operatively 2. Oxygen mask – provide sensation of comfort to patient
- 26. Patient Monitoring • Nursing •Intravenous line • Continuous Intraoperative monitoring – ECG. – O2 Saturation (early diagnosis of pleural lesion). – Pressurometry (occasional vagal reaction).
- 27. Vertebral Approaches (will varyaccording to surgeon’s specialty and experience) • Cervical Spine: Anterior • Dorsal Spine: Transpedicular • Lumbar Spine: Transpedicular Lateral
- 28. Anterior Cervical Approach Manualdisplacement of the carotid–jugular complex Guide needle insertion Needle position can be confirmed with CT.
- 29.
- 31. C3 VP formetastasis The needle was inserted with finger compression of the visceral tissue (left). Bone cement was injected into the C3 vertebral body, and simultaneously an esophagogram was performed to check the esophageal injury (middle). Postoperative lateral view (right).
- 32. Thoraco-lumbar Vetebroplasty • Chooseapproach – Transpedicular – Parapedicular – Lateral-transpedicular – Lateral-antepedicular • Needle insertion: – unilateral or – bilateral
- 33. Parapedicular Approach (lateral topedicle and above the transverse process) This avoids the exiting nerve root (courses under the pedicle) The needle entry site along the lateral aspect of the vertebra Does not allow local pressure after needle removal, the chance for bleeding higher than with the transpedicular approach
- 34. Lateral Extrapedicular Approach utilizesEffective Pedicle (the rib-pedicle complex) The instrument must also be angulated more toward the midline to avoid lateral penetration of the vertebral body
- 35.
- 36.
- 37. Unilateral Transpedicular Vertebroplasty Injectionof bone cement (methyl-methacrylate)
- 38. The three stepsof vertebroplasty: 1. placement of Needle 2. insertion of a working cannula 3. injection of cement filler
- 39. Patient Positioning Prone positionon radiolucent table Radiolucent chest rolls
- 40. Patient Positioning Make surepatient is lying with comfort “squared up” on the table
- 41. Patient Positioning Prior toprepping the skin Check that fluoro is adequate Localize symptomatic vertebral body level Beware of deformity and obesity
- 42. Preoperative Planning andSet UP Prepping targeted area Strict sterile technique
- 43. Preoperative Planning andSet UP Fluoroscopy Guidance The TRUE image
- 44. • Have planeAP and lateral x-ray films hanging – Help with determining the angle of pedicle being targeted • Place targeted vertebrae in the middle of image • Vertebral endplates parallel • Line up spinous process midpoint between pedicles – Adjust for rotation in scoliosis Pedicle Targeting Spinous process in midline End plate seen in single plane Center targeted vertebrae
- 45. ANATOMIC VARIATIONS Critically important,particularly in rotated vertebrae and deformed spines, as in scoliosis or spondylolisthesis.
- 46. Cannulation of smallpedicles technically difficult In the mid-upper thoracic spine The change in pedicle angulations at the T1 to T4 levels. Pre-operative The pedicle must have a width of at least 3 to 4 mm.
- 47. Sclerotic hard pedicles difficultJamshidi placement Can be frustrating Rarely the technique needs to be abandoned and an open direct cannulation of the pedicle with a high- speed drill is required
- 48. Entry point &trajectory of needle insertion in transpedicular approach
- 49.
- 50. Technique - Preliminary Pedicleidentified on AP fluoro Starting point on skin is lateral to the pedicle by 2 cm
- 51. Needle Insertion Locate bonylandmarks Determine exact location of incision with spinal needle and fluoroscopy first Advance needle to desired location using imaging guidance
- 52. Pre-operative localization Mark EntryPoints AP and lat VIEWS to target and mark the correct pedicle entry points
- 53. Planning and SetUP Fluoroscopy Guidance
- 55. Paramidline incision overlying transverseprocess-facet junction
- 56. The skin incisionis 1 cm lateral of entry point for L1 to L4, and 2 cm lateral for L5
- 57. In case ofObesity MOVE LATERAL!
- 58. Technique After making a1.5cm skin incision, the needle is advanced to the facet/TP intersection AP Fluoroscopy is KEY to safe pedicle navigation. The critical aspect relates to staying lateral to the medial wall. AP Fluoro is the only view that gives that information. A good AP will also give some sagital plane information
- 59. Pedicle identified on AP& Lat fluoroscopy
- 60. Fluoroscopy of theLumbar Pedicle • The lumbar pedicle is oval shaped • It should be projected at the upper third of the lumbar vertebra • The AP tube is angled to find the oval appearance of the pedicle for the entry.
- 61. Entry point isat the junction of the mid- transverse process and the lateral edge of the SAF
- 62. Entry Point Transpedicular:at 10 & 2 o’clock at the pedicular rim Extrapedicular: at 9 & 3 o’clock, 2 mm lateral to the pedicular ring
- 63. Starting point ofright transpedicular access between 1 and 3 o’clock
- 64. Starting point ofleft transpedicular access between 9 and 11 o’clock
- 65. Ending points fortranspedicular access Convergence towards the midline, which however should not be crossed
- 66. Jamshidi needle dockedat the facet/TP Junction The ''3 o'clock position‘’
- 67.
- 68. OSTEOPOROSIS The risk ofdamaging a pedicle can be decreased by careful initial placement of the hole and pedicle screw, avoiding multiple redirections or passes.
- 69. Pedicle Preparation Tap needlethrough pedicle
- 70. Needle Placement As theneedle is advanced into the pedicle, the position of the needle tip is checked frequently in both planes.
- 71. On the APview On the lateral view The needle tip should not touch the medial curve of the pedicle which forms the wall of spinal canal. The needle should be parallel to the superior and inferior edge of the pedicle.
- 72. Fluoroscopy of the lumbarPedicle When the needle reaches the junction of the vertebral body in the lateral view, it should be still a space between the tip of the needle and the medial pedicle in the AP view.
- 73. Jamshidi needle advancedand confirmed with fluoroscopy
- 74. Technique The needle isthen advanced through the pedicle to the dorsal aspect of the vertebral body The intersection of the pedicle and vertebral body is the critical junction. If the needle is not medial to the medial wall when the needle is at this depth, then a safe trajectory has been found. Key point Medial pedicle wall at posterior vertebral body or deeper
- 75. Safety for injection Pictorialof trajectory ‘‘stopping points’’ to ensure safe placement of the Jamshidi needle
- 76.
- 77.
- 78.
- 79.
- 80.
- 82. In most cases weuse a bilateral approach with one needle through left and another through the right pedicle
- 83. Compare the 2views
- 84. Venogram Injection of contrastthrough needle. Visualize vertebral body and epidural and paraspinal veins. May predict pattern of cement injection. Will identify a direct venous communication. May interfere with visualization of opacified cement.
- 85. Epidural leakage • High,up to 50–70% in osteolytic metastasis or myeloma • Mostly asymptomatic; however, few patients may undergo surgery because of radiculopathy. • can occur through – fracture line, – cortical destruction, – needle track, or – epidural and paravertebral venous plexus
- 86. Pulmonary embolism • Bonecement via the venous channel can enter the systemic circulation. • Filtered in the pulmonary circulation system (3–4%) • Most patients may be asymptomatic. • If symptomatic, patients complain of – Tachypnea – Respiratory difficulty. • So, tachycardia is monitored. • Most patients can be treated with anticoagulant therapy and respond favorably.
- 88. Ready to injectcement Once the needle passes the pedicle into the vertebral body, the needle tip can be advanced to the junction between anterior and middle third of the vertebral body. Then the second needle is placed into the contralateral half of the vertebra body in a similar fashion.
- 89. Procedure: Cement Mixture •Polymer powder • Liquid monomer • Opacifying agent – Barium sulfate powder – Tungsten – Tantalum • Optional additive: antibiotic powder (Tobramycin)
- 90. Cement Mixture • Vacuummixer • Limited working time. – 10-15 minutes depending on temperature and cement mixture. • – Injection devices – Luer-Lok syringes – “Jack-screw” hydraulic injector.
- 91. Mixing First powder polymethylmethacrylateis mixed with barium sulfate and tobramycin in a sterile plastic bowl. Then liquid polymethylmeth-acrylate is added and admixtured by a tongue blade to a dough-like consistency. The cement is then poured into a 10 ml syringe, and divided into multiple one-milliliter Luer-Lock syringes.
- 92. Integrated Mixing andDelivery System
- 93. Goal: no runny cementor dry patches • Let the cement rest until it begins to thicken. • This is typically 1½ minutes, however temperature and humidity will affect this period. • Cement consistency is a better indicator of completion of rest period. • When cement is no longer runny and uniformly coats the inside of the powder chamber it is ready to be inserted into reservoir.
- 94. Cement Injection • Meticulousfluoroscopic monitoring during the injection process. • Liquefied cement is injected into the vertebral body. • Termination of injection. – Cement in posterior 1/3 vertebral body on lateral projection. – Cement extruding into epidural, foraminal or paraspinal veins. – Significant disk space penetration. – Posterior 1/3.
- 95. Cement Injection We use1 ml syringes attached directly to the bone biopsy needle to inject the cement. Meticulous fluoroscopic control is important for early detection of leakage.
- 96. VOLUME OF BONECEMENT • From 3 to 10cc; • Larger volume may not be the most optimal, • Improvement achieved by use of a lower cement volume with symmetrical placement. • Also, with unipedicular approach, the stiffness comparable to the intact body can be achieved in cases of symmetrical distribution of bone cement.
- 97. Safety for cementinjection The tip at the junction of the anterior and middle third of the vertebra away from the large venous confluence in the posterior of the vertebra
- 98. The second needle Thewhite line shows its trajectory predict the ultimate needle tract make adjustments
- 99. Cement injection isthe last step in all levels
- 100. Termination of injection?? Cement in posterior 1/4 of vertebral body on lateral projection Cement extending outside vertebra
- 101. Completed vertebroplasty Injection iscontinued until the vertebral body is filled. If there is significant leakage, we stop the injection.
- 102. Cement hardening The patientshould remain on the table until the cement is completely hard (approximately 15 minutes). This can be confirmed by keeping excess cement in your hand (body temperature).
- 103. Video (Actual Procedure underLocal Anesthesia)
- 104. Cement delivery trouble •No flow? – Clear cannula with blunt stylet – Check for cement flow through tube prior to reconnect • Thick cement – Caused by poor mixing, hot room, humidity, storage too hot or humid (prolonged) – Cement sat mixed but not used too long (encourage user to better time cement use) • Cement still won’t transfer – Too much dry powder left from mixing step; more thorough mixing needed
- 105. What does thismean? • Cement is sensitive to heat and humidity – Storage conditions should be “cool, dry place” – OR that are warm (>25°C) will cause cement to thicken and cut working time – Working in humid conditions will also shorten working time • If your OR is warm (and or humid) you need to work faster; and store cement in a cool dry place.
- 106. Post Operative Care Dressingat needle site. Strict bed rest for 2-3 hours. Monitor vital signs. Monitor neurologic examination.
- 107. Discharge The patient isdischarged 3 hours after the procedure and follow-up is done the next day, one week, one month, and six months after the procedure. Most of the follow-up is done over the telephone.
- 108. Patient Follow-up • PatientInstructed to call for – New back pain – Chest pain – Lower extremity weakness – Fever >100 degrees • Follow-up at 24 hours and 1 week.
- 109. Post-operative CT We usepost-operative CT to document the location of the cement. This is especially valuable in cases where there has been cement leakage.
- 110. Complications - <10% • Neuralgia • Infection • Cord compression • Pulmonary Embolism • Vascular injury - haematoma • Rib fractures • CSF leakage • Hypotension • Increased pain
- 111.
- 112.
- 113. In conclusion • PVis a Minimally Invasive Procedure. • Surgical Technique may be acquired in a short time. • PV may be performed on outpatients. • Excellent tolerance to Local Anesthesia. • May be combined with instrumental arthrodesis of the spine. • Short and Long Term results are encouraging.
- 116. KYPHOPLASTY • Percutaneous introduction ofballoon into the vertebral body through a cannula – Cannula – bipedicular approach – Balloon inflation – reduce Fx – balloon deflation – PMMA
- 117.
- 118. The five stepsof kyphoplasty: 1. placement of Needle 2. insertion of a working cannula 3. Reaming working channels beyond the cannula tips 4. Balloon insertion, inflation, deflation, and removal 5. injection of void filler
- 121.
- 122.
- 124.
- 126. It is importantto fill the anterior 2/3–3/4 of the vertebral body
- 127. Cement should reachor cross the midline to reinforce both halves of the vertebra (white arrows)
- 128. A Unipedicular PV showsdistribution of cement into both halves of the vertebra
- 129. Inflatable ballon inthe midline of the fractured body Tip of the guide pin over the center of the vertebral body
- 130.
- 131.
- 132.
- 133.
- 134.
- 135.
- 136.
- 137.
- 138.
- 139.
- 140.
- 141.
- 142. Wong W, MathisJM. Vertebroplasty and kyphoplasty: techniques for avoiding complications and pitfalls. Neurosurg Focus 18 (3):E2, 2005. Extrapedicular
- 143.
- 144.
- 145. Kyphoplasty – “TheGood” • A modification of the vertebroplasty procedure to: – restore vertebral body height – Low risk of clinically evident cement extravasation.
- 146. Kyphoplasty – “TheBad” There is still a risk of extravasation Close analysis of literature indicates height restorations as an insignificant result.!!!
- 147. Kyphoplasty – “TheUgly” The big question, “Is this cost justified (when compared to vertebroplasty) for the added safety?” Most studies are retrospective analyses. This is an area ripe for further analysis.
- 148.
- 149. Technical Aspects of Percutaneous VPand KP procedures The Neurosurgeon’s perspective
- 150. Percutaneous VP andKP Simple procedures However, must be treated with respect, as its application, without appropriate preparation and physician knowledge, can quickly produce increased pain, permanent neurologic injury, and even death
- 151.
- 152. Cement Extrusion Kyphoplasty withsmall amount of anterior (white arrow) and lateral (black arrow) cement extrusion rarely associated with clinical sequelae
- 153. However, leakage maybe significant !!
- 154. To prevent raresignificant neurologic deficit associated with PVP, intact posterior vertebral body cortex is one of the most important prerequisite that must be thoroughly confirmed preoperatively
- 155. Cement too liquidwhen injected tracked backward along the needle path leaving cement in the soft tissues
- 156. In myeloma andosteolytic metastases Complete destruction of the posterior cortical wall
- 157. Special techniques incases of myeloma and osteolytic metastases • The risk of cement leakage is greater, – the egg-shell technique should be preferred to the conventional balloon kyphoplasty technique • Pedicles may be affected by osteolysis, making transpedicular access no longer safe – a contralateral single approach via a still intact pedicle or – an extrapedicular approach can be chosen. • The possibility of dislocation of the cement block has to be taken into account if the anterior cortical substance is missing
- 158. Tumour migration withcement injection
- 159. Dislocation of thecement Vertebroplasty of T12 with osteolysis and unknown primary tumor with ventral dislocation of the cement beginning after 3 weeks 9 months 2 years3 weeksIntraop.
- 160. Cement dislodgement 6months after the percutaneous vertebroplasty
- 161.
- 162. C7 & T1Visualization fluoroscopically impossible shoulders very small epidural leak of cement (CT guided PV)
- 163. Leakage into inferiordisc (No clinical consequence)
- 164. Cement leak intothe disc space (arrow). The cement was allowed to harden and the cannula exchanged over a wire so that subsequent cement injection could take place
- 165. The severe collapse extremecompression of T12 with residual marrow space
- 166. Height restoration withtraction
- 167. A bilateral transpedicularapproach Pedicle of collapsed vertebra seen Trajectory through the lower aspect of the pedicle parallel to the residual endplates to access the anterior part of the vertebral body
- 168. The amount ofcement into an extremely collapsed vertebra much smaller than is usually used for less collapsed vertebrae
- 169. Digital subtraction venogram Thecontrast leak is not predictive of where the cement go. Also, the contrast obscures detection of early cement leak
- 170. Difficult Reductions: Balloon doesnot inflate adequately Using the Bone Curette • in older fractures • a specially designed curette retracted and advanced to score the bone in the region. • The curette is removed, and balloon inflation is again attempted.
- 171. Standard balloons, eccentricexpansion with risk of blowout of the vertebral walls or endplates a directional balloon tamp may be desired
- 172. Vertebral Body Breakthrough: EggshellTechnique of Containing Bone Cement
- 173. Partial loss ofreduction after balloons deflated … Lordoplasty (indirect reduction maneuver)
- 175. Burst fracture ofL1 With good reduction one month after instrumentation removal (18 months posttrauma)
- 176. Sacroplasty Sacral insufficiency fractures Bestperformed under CT guidance.
- 177.
- 178. Developments….. • Calcium phosphatein young patients with traumatic fractures • Prophylaxis by adding chemotherapy agents or radioactive isotopes to the cement in tumour