Procedure Guides
Neurovascular

Vertebral Augmentation

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Procedure Guide

  • Symptomatic compression fracture (AO classification A)

    • Pain level >=5 (newer guidelines say 7), limits ADLs, edema on STIR, progressive height loss (even w/out severe pain)

    • Good for A1-4 if neurologically intact. A1 = wedge compression, A2 = split (both endplates), A3 = incomplete burst, comminuted with one end plate, A4 = complete burst, both end plates

    • Procedure of choice for pathologic fractures associated with multiple myeloma per international working group vs radiation if there is cord compression and leptomeningeal disease

  • Symptomatic vertebral hemangioma

  • Symptomatic neoplastic vertebral body lesions (combined RFA and kyphoplasty/vertebroplasty).

  • Septicemia / Active target vertebral osteomyelitis

  • Retropulsed bone fragment resulting in myelopathy or neurologic symptoms -> neurosurgical referral

  • Fracture of posterior vertebral body wall that could result in cement extrusion

  • Allergy to bone cement or opacification agents

  • INR >1.3, Plts <70K, or other uncorrected coagulopathy

  • Tumor/mass extends into spinal canal

  • Generally, 90% of patients have complete pain relief for acute fractures, 75-80% if osteoporotic fracture is >1 year old, 60-80% pain relief for metastases, 80-90% for primary hemangiomas.

    • Once a vertebral compression fracture has occurred, there is 5xs increased risk of subsequent vertebral fracture, 12xs the risk if 2 or more vertebral fractures, 75xs the risk if low bone mass with 2 or more fractures.

  • Fewer major complications (3-11 v. 20%) and 30d mortality (<1 v. 5.9%) than surgery

  • Less risk of pneumonia, DVT, MI, and UTI than medical management. Systematic review showing superior pain reduction, less function fractures, and better QoL compared to medical management.

  • Generally, there is more data supporting vertebroplasty; however, most people prefer kyphoplasty unless there is little compression of the vertebral body. Systematic review showed less cement extravasation with kyphoplasty. There are also likely mechanical benefits and further pain reduction with height restoration.

    • VERTOS 4 trial vs sham fail to show difference but did pain surveys over phone with examination.

    • FREE study – prospective RCT, 300 VCF patients, Kyphon BKP increased QoL via mobility and ADLs

    • CAFÉ study – 134 cancer patients, Kyphon BKP markedly decreased back pain and use of pain medications while improving QoL

    • KAST study - Kiva device similar to better than kyphoplasty.

  • Multiple small studies suggest mechanical augmentation with devices like SpineJack provides better height restoration and less cement leakage since less cement is needed and less adjacent level fractures. Supported by larger SAKOS multicenter study. However, other studies suggest similar height restoration with kyphoplasty. Bipedicular kyphoplasty is likely superior to both vertebroplasty and unipedicular kyphoplasty for height restoration with no difference in cement extravasation.

Vertebroplasty

  • Set true AP and lateral projections on the fluoro machine. Biplane fluoroscopy can also be used.

    • Often the AP view needs to be angled caudally to have the pedicles en face.

    • Lateral view should line up the endplates as well as possible. Prep and drape area -> inject local anesthetic down to periosteum -> 

  • Anesthetize skin and subcutaneous tissues down to the periosteum (may need a spinal needle to reach).

  • Use lidocaine needle to plan approach in AP view. Should target the more superolateral aspect of the pedicle angling a little medial and inferior.

  • Remove the lidocaine needle and make a small incision.

  • Advance metal cannula using the bevel or diamond needle tip and hammer.

    • Regularly check AP and lateral while advancing in small increments. Do NOT cross the medial cortex of the pedicle in AP until beyond the posterior cortex on lateral. This avoids entering the spinal canal.

    • Bevel is easier to slide along medial cortex but diamond tip is easier for beginners.

    • Advance until the cannula is in the anterior third of the vertebral body.

  • Repeat for other side if using bipedicle approach.

    • Bipedicular approach is likely ideal in most cases to fill the maximum amount of the vertebral body. Unipedicular approach is most helpful for unilateral fractures or tumors.

  • Mix and prepare cement in 1 mL syringes or in proprietary delivery system.

    • Can keep a sample on the backtable to see when it is hardened.

  • Inject cement through introducer monitoring filling and for extravasation.

    • Ideal to fill until cement enters posterior third of vertebral body.

    • If any extravasation occurs, pause 30s, adjust cannula, and re-inject.

  • Remove cannula and achieve hemostasis.

  • (Optional) Some apply antibiotic ointment at the treatment sites.

  • Keep patient on the table until the cement hardens.

Kyphoplasty (standard technique)

  • Similar initial steps to above but metal cannulas are advanced to posterior third of vertebral body followed by drilling to anterior third to ream a channel for the balloons OR cannula can be advanced to anterior third and balloons unsheathed without using the drills

    • If using the unsheathing technique, consider shortening the stylet as you approach the anterior third to avoid violating the anterior cortex. Unscrewing the stylet 90* reduces how much the stylet extends out the cannula 50%, 180* turn reduces 75%.

  • Hand drill is used through the metal cannulas to ream a channel for the inflatable balloon.

  • Advance balloon ensuring it is fully outside the cannula in lateral view.

  • Inflate the balloon ensuring it stays within the vertebral body (stop at pressure limit, volume limit, or if any cortical margin is reached)

  • Deflate and remove balloon.

  • Inject cement and fill space similar to above. May need to adjust cannula positioning.

  • Remove cannula and achieve hemostasis.

  • (Optional) Some apply antibiotic ointment at the treatment sites.

  • Keep patient on the table until the cement hardens.

Kyphoplasty (advanced techniques, images contributed by Medtronic)

  • Extrapedicular Access for small, inaccessible pedicles to avoid pedicular fracture or unfavorable angulation. This is also helpful for L5 to get more medial within the vertebral body (see image below with more ideal access in green).

    • Consider mapping out on pre-procedural imaging with angles and skin access points relative to spinous process. Often access is much more lateral.

    • Target the lateral cortex of the pedicle on AP advancing slowly medially and inferiorly. Should hit the cortex of the posterolateral vertebral body. Do NOT pass beyond the medial cortex of the pedicle on AP view until beyond the posterior cortex of the vertebral body on lateral view to avoid entering the canal.

    • Remainder of the procedure is the same.

  • Cement Resistance for violation of cortex with concern for extravasation or to maintain height restoration.

    • Keep one balloon inflated in area of concern while filling contralateral side. May require filling balloon with dilute contract to see cement.

    • Likely not necessary to maintain height restoration given the patient is prone.

  • Eggshell Technique for violation of cortex with concern for extravasation.

    • Inject warmed, thick cement at defect, inflate the balloon, and allow to harden creating an eggshell appearance.

    • Inject non-warmed cement into the eggshell

  • Modified Inferior Endplate Approach (rare)

    • Course inferior to pedicule to better access the inferior endplate. Comes with increased risk of nerve root injury so consider neuromonitoring.

Mechanical with SpineJack (Stryker)

  • Similar initial steps but requires device specific introducer.

  • Choose largest SpineJack size that fits pedicle.

  • Position where lift is desired.

  • Inject cement around the device. Less is more, just enough to surround device.

  • Cement extravasation - small amounts of extravasation is common and almost to be expected if sufficiently filling the vertebral body. The key is recognizing it and knowing which areas are benign vs more dangerous.

  • Cement embolization - small emboli are also likely more common than reported. Large clinically significant/symptomatic emboli are rare if good technique is used.

  • New fracture in adjacent vertebra 7-25%

  • Very rare - infection, hematoma, nerve trauma, allergic reaction

  • Observe 1-3 hrs. Some tenderness and bruising are common.

  • Consider obtaining a CXR for thoracic vertebra to rule out pneumothorax.

  • Some obtain post-procedure CT to document cement position while others do not. This is probably only necessary if concerned about a complication.

  • Consider PT/OT referral to help patients regain strength and address potential habits putting them at risk for additional fractures.

  • Follow up 1-day, 1-week, 1-month, and 6-months post-op.

    • Assess spine ROM (imaging not necessary), pain, functional status, breathing.

    • If persistent pain, consider a non-drowsy muscle relaxant. If still persistent pain, consider pain specialist consult.