Updated: Mar 11, 2019
Currently there are numerous needle options available for cement delivery to vertebral compression fractures. Vertebral augmentation veterans Dr. Kumar Madassary and Dr. Venu Vadlamudi discuss the utility of curved balloons and needles for unipedicular approaches during vertebral augmentation procedures.
The BackTable Brief
Curved balloons and needles can be easily maneuvered for improved cement distribution.
For compression fractures in the thoracic spine the curved balloons and needles from Stryker, Merit and Medtronic have greater maneuverability and result in less emphasis on a lateral to medial approach.
Cement distribution across the fracture line can lead to compression fracture stabilization and subsequent clinical improvement of pain.
Ideal needle positioning and sound technical skills are acquired over time; Dr. Vadlamudi cites it takes 30-40 cases to refine the anatomic placement of the needle.
Disclaimer: The opinions expressed by the participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
Using Curved Balloons and Needles During a Unipedicular Approach
Equipment wise, I'm actually a big fan of the new curved balloons and needles on the market and I've gone unilateral on several of my recent cases, both T and L-spine. I'd like to know your experiences with the curved balloons and needles and if you guys use it much.
I have used and like the new curved needles from Stryker, for example. I've used those on a few cases and I've had very nice cement distribution. DFINE, which is now part of Merit, they have their flexible curved osteotome, which is a nice device. Especially the newest iteration of it. [It’s] more rigid and robust, I think, and really can create some nice channels for cement distribution.
And so I think those adjuncts can allow for a unipedicular approach in most cases. I think in our practice, a lot of the cases that we do tend to be unipedicular.
Yeah, I agree, I agree with Venu that the curved needle from Stryker [has] given a lot of ease and approach, especially of the thoracic spine, because it gives you a lot more leeway for not having to be such a lateral to medial approach. I do like that aspect of it.
And also with the Merit, I find the curved curette gives you a lot of maneuverability in creating your channels that you're doing. We also have the Medtronic one but I think the curved needle particularly has helped. [It] gives you a lot more forgiveness in there because the biggest thing you try to teach the fellows is imagine the pedicle as a clock face and how you're going to really strive to get to that across the midline, the curved needle itself on that really helps you.
So what whatever you're doing I think the advantage of that is the importance is getting to the right spot and that comes with, as we've all learned, is just practice, experience and a lot of fear in the beginning.
Going Back to Basics with Sound Technical Skills
And then I think even beyond some of those newer adjuncts that could help, I think if we go back to good technical skills and abilities as far as getting the needle from a unilateral approach to the sort of ideally midline and anterior one-third, middle one-third junction, that takes practice. I can tell you it probably takes 30 or 40 cases to get that art in place.
One of my senior partners, honestly, I'm amazed at how accurately she can get the needle placed from a unipedicular approach, multi-levels or what not, and I sort of strive for that. I look at that, I was like, wow, that's excellent technical placement of the needle and I think that's why she rarely uses any of the adjuncts and from a unipedicular approach gets excellent cement distribution. So I think that's another piece of things that we can all continue to strive for.
Identifying the Fracture Line for Ideal Cement Distribution
Yeah, even cranio-caudally, you know, if you have a superior end plate fracture, [or] an inferior end plate fracture, you can direct that needle up or down nicely, which is what I like about it. Just to get it, like you guys said, just to get it in the right spot and once you find that fracture line, the cement just kind of goes in the pathway of least resistance.
Yeah, I agree completely. And often with those paralleling fractures, which they very often are, I often will try to get the needle right into that cleft. Like you said, the cement's going to go in and nicely and distribute right across that cleft, that fracture line. Usually if I get that, that may be enough of a stopping point. I don't necessarily need to have cement go all the way from the top to the bottom if I can get it right across that fracture plane. That may be enough to get that stabilization and pain relief and often that's what translates clinically.
Podcast Participants: Dr. Venu Vadlamudi is a practicing interventional radiologist in Alexandria, Virginia. Dr. Kumar Madassery is a practicing interventional radiologist with Rush University in Chicago. Dr. Aaron Fritts is a practicing interventional radiologist and founding partner of BackTable. Cite this podcast: BackTable, LLC (Producer). (2018, January 28). Ep 21 – Vertebral Augmentation [Audio podcast]. Retrieved from https://www.backtable.com/podcasts Medical Disclaimer: The Materials available on the BackTable Blog are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. Disclosures: None.