Vertebroplasty and KyphoplastyTechniques

1. Vertebroplasty and Kyphoplasty
Techniques
Mohamed Mohi Eldin,
Professor of Neurosurgery,
Faculty of Medicine,
Cairo University
One-Day Spine Clinic 4th workshop & hands-on,
27-28 December 2017

2. PEDICLE DEFINITION, L1 VERTEBRA
Wire wrapped around the
waist of the pedicle

3. PEDICLE DEFINITION, L1 VERTEBRA
The A-P image of the pedicle corresponds
to the waist of the pedicle, not the base

4. PEDICLE DEFINITION, T10 VERTEBRA
T10T10

5. Vertebral Augmentation
Vertebroplasty
(1984): Injection of material (usually PMMA cement)
into vertebral body
Kyphoplasty
(1998): Injection after manipulation involving cavity
creation

6. 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

7. The Osteoporotic Vertebral Fracture

8. Predictors of fracture
19.2% a second fracture
within one year
24% a further fracture
within a year

9. We use MRI for
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 – how to 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 key to success of vertebroplasty
• Pain should be
– focal,
– intense,
– deep,
– local tenderness
– corresponding with
imaging findings,
– No radiation to the
legs.

13. Medicolegal
• The procedure is discussed
– with the patient and/or family,
– benefits, risks, and possible complications are
explained.
• Obtain informed consent.

14. Before discussing the technique..
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 of potential complications
We should have
• Immediate access to:
– CT Scan and / or MRI.
– ICU.
– Operating Room.

16. Instruments and table setting
We use 13-gauge bone biopsy needles

18. Cement, barium and tobramycin
cranioplastic mixture (30g),
sterile barium sulfate powder (12g), and
tobramycin (1.2g).

19. Vertebroplasty Imaging
• High quality fluoroscopy
– Biplane
– Single plane
– C-arm
• Computed tomography
– CT and fluoroscopy

20. Typical biplane configuration

21. Combined CT and mobile 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
• Intravenous sedation
– 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 of Local 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 vary according to surgeon’s specialty and experience)
• Cervical Spine: Anterior
• Dorsal Spine: Transpedicular
• Lumbar Spine: Transpedicular
Lateral

28. Anterior Cervical Approach
Manual displacement of the carotid–jugular complex
Guide needle insertion
Needle position can be confirmed with CT.

29. Cervical Vetebroplasty

31. C3 VP for metastasis
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
• Choose approach
– Transpedicular
– Parapedicular
– Lateral-transpedicular
– Lateral-antepedicular
• Needle insertion:
– unilateral or
– bilateral

33. Parapedicular Approach
(lateral to pedicle 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
utilizes Effective Pedicle
(the rib-pedicle complex)
The instrument must also be angulated more
toward the midline to avoid lateral penetration of
the vertebral body

35. Transpedicular Approach

36. Bilateral Transpedicular Approach

37. Unilateral Transpedicular Vertebroplasty
Injection of bone cement (methyl-methacrylate)

38. The three steps of vertebroplasty:
1. placement of Needle
2. insertion of a working cannula
3. injection of cement filler

39. Patient Positioning
Prone position on radiolucent table
Radiolucent chest rolls

40. Patient Positioning
Make sure patient is lying with comfort
“squared up” on the table

41. Patient Positioning
Prior to prepping the skin
Check that fluoro is adequate
Localize symptomatic vertebral body level
Beware of deformity and obesity

42. Preoperative Planning and Set UP
Prepping targeted area
Strict sterile technique

43. Preoperative Planning and Set UP
Fluoroscopy Guidance
The TRUE image

44. • Have plane AP 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 small pedicles
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
difficult Jamshidi 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. Initial Orientation

50. Technique - Preliminary
Pedicle identified on AP fluoro
Starting point on skin is lateral to the pedicle by 2
cm

51. Needle Insertion
Locate bony landmarks
Determine exact location of incision with spinal needle
and fluoroscopy first
Advance needle to desired location
using imaging guidance

52. Pre-operative localization
Mark Entry Points
AP and lat VIEWS
to target and mark the correct
pedicle entry points

53. Planning and Set UP
Fluoroscopy Guidance

55. Paramidline incision overlying
transverse process-facet junction

56. The skin incision is 1 cm lateral of entry point
for L1 to L4, and 2 cm lateral for L5

57. In case of Obesity
MOVE LATERAL!

58. Technique
After making a 1.5cm 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 the Lumbar 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 is at 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 of right transpedicular
access between 1 and 3 o’clock

64. Starting point of left transpedicular
access between 9 and 11 o’clock

65. Ending points for transpedicular access
Convergence towards the midline,
which however should not be crossed

66. Jamshidi needle docked at the
facet/TP Junction
The
''3 o'clock position‘’

67. Pedicle Entrance

68. OSTEOPOROSIS
The risk of damaging a pedicle can be decreased
by careful initial placement of the hole and
pedicle screw,
avoiding multiple redirections or passes.

69. Pedicle Preparation
Tap needle through pedicle

70. Needle Placement
As the needle is advanced into the pedicle,
the position of the needle tip is checked
frequently in both planes.

71. On the AP view 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
lumbar Pedicle
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 advanced and
confirmed with fluoroscopy

74. Technique
The needle is then 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
Pictorial of trajectory ‘‘stopping points’’
to ensure safe placement of the Jamshidi needle

76. ENTRY POINT

77. MID-PEDICLE

78. NC JUNCTION

79. TOO MEDIAL

80. TOO LATERAL

82. In most cases
we use a bilateral
approach with
one needle
through left and
another through
the right pedicle

83. Compare the 2 views

84. Venogram
Injection of contrast through 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
• Bone cement 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 inject cement
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
• Vacuum mixer
• 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 polymethylmethacrylate is 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 and Delivery System

93. Goal: no runny
cement or 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
• Meticulous fluoroscopic 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 use 1 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 BONE CEMENT
• 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 cement injection
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
The white line shows its trajectory
predict the ultimate needle tract
make adjustments

99. Cement injection is the 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 is continued until the vertebral body
is filled. If there is significant leakage, we stop
the injection.

102. 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 your hand (body temperature).

103. Video
(Actual Procedure under Local 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 this mean?
• 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
Dressing at needle site.
Strict bed rest for 2-3 hours.
Monitor vital signs.
Monitor neurologic examination.

107. Discharge
The patient is discharged 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
• Patient Instructed 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 use post-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. Extravasation

112. Extravasation

113. In conclusion
• PV is 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 of balloon
into the vertebral body
through a cannula
– Cannula
– bipedicular approach
– Balloon inflation
– reduce Fx
– balloon deflation
– PMMA

117. On table reduction !!

118. The five steps of 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. Vertebra Plana

122. Pre Post 1y 3y

124. Kyphoplasty

126. It is important to fill the anterior 2/3–3/4
of the vertebral body

127. Cement should reach or cross the midline to
reinforce both halves of the vertebra (white
arrows)

128. A Unipedicular PV
shows distribution of cement into
both halves of the vertebra

129. Inflatable ballon in the midline of the fractured body
Tip of the guide pin over the center of the vertebral body

130. Transpedicular

131. Transpedicular

132. Transpedicular

133. Oblique View

134. Biopsy

135. Drill and Curette

136. Balloon Tamps

137. Cement Injection

138. Extrapedicular

139. Extrapedicular

140. Biopsy

141. Oblique View

142. Wong W, Mathis JM. Vertebroplasty and kyphoplasty: techniques for avoiding complications and pitfalls.
Neurosurg Focus 18 (3):E2, 2005.
Extrapedicular

143. Balloon Tamps

144. Cement

145. Kyphoplasty – “The Good”
• A modification of
the vertebroplasty
procedure to:
– restore vertebral
body height
– Low risk of clinically
evident cement
extravasation.

146. Kyphoplasty – “The Bad”
There is still a risk of extravasation
Close analysis of literature indicates
height restorations as an insignificant result.!!!

147. Kyphoplasty – “The Ugly”
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. Kyphoplasty Vs vertebroplasty

149. Technical Aspects of
Percutaneous
VP and KP procedures
The Neurosurgeon’s perspective

150. Percutaneous VP and KP
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. Pearls and Pitfalls

152. Cement Extrusion
Kyphoplasty with small amount of anterior
(white arrow) and lateral (black arrow) cement extrusion
rarely associated with clinical sequelae

153. However, leakage may be significant !!

154. To prevent rare significant 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 liquid when injected tracked
backward along the needle path leaving
cement in the soft tissues

156. In myeloma and osteolytic
metastases
Complete destruction of
the posterior cortical wall

157. Special techniques in cases 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 with cement
injection

159. Dislocation of the cement
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 6 months after the
percutaneous vertebroplasty

161. Pre Post 1y 3y

162. C7 & T1 Visualization
fluoroscopically impossible
shoulders
very small epidural leak of
cement (CT guided PV)

163. Leakage into inferior disc
(No clinical consequence)

164. Cement leak into the 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
extreme compression of T12 with residual
marrow space

166. Height restoration with traction

167. A bilateral transpedicular approach
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 of cement into an extremely
collapsed vertebra much smaller than is
usually used for less collapsed vertebrae

169. Digital subtraction venogram
The contrast leak is not predictive of where the cement go.
Also, the contrast obscures detection of early cement leak

170. Difficult Reductions:
Balloon does not 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, eccentric expansion with risk of
blowout of the vertebral walls or endplates
a directional balloon tamp may be desired

172. Vertebral Body Breakthrough:
Eggshell Technique
of Containing Bone Cement

173. Partial loss of reduction after
balloons deflated … Lordoplasty
(indirect reduction maneuver)

175. Burst fracture of L1
With good reduction one month after
instrumentation removal
(18 months posttrauma)

176. Sacroplasty
Sacral insufficiency fractures
Best performed under CT guidance.

177. PEDICULOPLASTY

178. Developments…..
• Calcium phosphate in
young patients with
traumatic fractures
• Prophylaxis by
adding chemotherapy
agents or radioactive
isotopes to the
cement in tumour