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BackTable / MSK / Article
Steerable Medical Devices for Minimally Invasive Spine Procedures
Kaitlin Sheppard • Updated Aug 29, 2025 • 44 hits
Navigating spinal anatomy often requires more than a straight path. Steerable devices have introduced a new level of precision and adaptability in minimally invasive spine procedures, enabling real-time trajectory adjustments– an advantage in cases with kyphosis, scoliosis, or lesions located in difficult-to-reach areas.
From improving cement delivery in vertebral augmentation to enhancing access in tumor and basivertebral nerve ablations, steerable systems offer a versatile solution to an array of procedural challenges. By allowing clinicians to customize their approach mid-procedure, these technologies are expanding what’s possible in spine intervention– without compromising safety.
This article features excerpts from the BackTable MSK Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable MSK Brief
• When paired with fluoroscopy, steerable tools offer real-time directional control, improving targeting and cement delivery during kyphoplasty and vertebroplasty.
• In thoracic spine tumor ablations, fluoroscopy may offer greater flexibility than CT guidance for navigating difficult angles, particularly in the presence of kyphosis or scoliosis.
• Steerable probes can markedly improve access to posterior vertebral lesions, reducing reliance on radiation oncology for difficult-to-access areas and improving therapeutic outcomes for lytic metastases.
• Although designed for tumor ablation, these steerable tools have been adapted for broader applications, including vertebrogenic pain procedures and osteoporotic compression fractures.
Table of Contents
(1) Advancing Kyphoplasty with Steerable Devices
(2) Fluoroscopy, CT & MRI in Bone Tumor Ablation: Optimizing Image-Guided Technique
(3) Beyond Tumors: Broader Applications of Steerable Spine Technology
Advancing Kyphoplasty with Steerable Devices
The kyphoplasty toolkit has come a long way from straight needles and rigid, fixed paths. Today’s steerable systems give operators real-time directional control inside the vertebral body, allowing them to fine-tune their trajectory to accommodate compressed anatomy, avoid critical structures, and deliver cement precisely where it’s needed. As Dr. David Prologo explains, this evolution isn’t just about technology– it’s about expanding the scope and safety of practice. Steerable tools offer added versatility for tumor ablation, reduce complications like venous plexus hematomas, and preserve the safety of transpedicular access even in anatomically complex cases.
[Dr. David Prologo]:
What you asked about were the evolution of the devices, and we've seen the evolution of the devices go from straight needles that were made to be hammered into the vertebral body and either installation of cement or a creation of a cavity with a balloon and subsequent installation of cement to devices that can now be guided into the vertebral body are already reshaped. They're shaped to cross the midline or whichever way you aim them if you're coming in low to go high. Those can also accommodate a balloon and subsequent cement installation. Then we've seen the evolution of a radiofrequency ablation probe that goes through the coaxial anchor that we put there in the cases where we want to ablate a tumor and also ameliorate that contact between the neoplasm and the bone.
Then finally, Merit, in particular, has developed a device that is sort of the next step beyond a preformed directional device used for kyphoplasty, vertebroplasty and/or these ablations, and that's a steerable device. That's a device that can be put in through your coaxial anchor. You can pick a direction and then sort of turn the knob and really steer the device to the location that you desire. That gives us much more specificity for vertebral bodies that might be compressed and create a difficult angle or vertebral bodies that might contain a tumor that's in a particular spot and we want to target. I like them a lot.
[Dr. Jacob Fleming]:
Yes. I think there's a couple examples we could give and you could address yours. One is, I talk about safety and there was a local case where someone tried to get access to the vertebral body and end up going extra-pedicular, presumably by accident, caused a big venous plexus hematoma that required the patient to live in the hospital for a few days. Some people talk about trans-pedicular as the safest and most appropriate unless you have a reason you can't do it.
[Dr. David Prologo]:
I might gently push back on that a little and refine that to say that trans-pedicular is probably the safest route because you avoid these vessels that are on the outside and you avoid the neural structures that are on the inside or medial and lateral, respectively. If you can take the angle that you want through the pedicle, then you're always surrounded by bone and it's a safer approach with less damage to those surrounding structures.
Where that falls apart is if you've only got a straight needle and the angle that you need to stay on the pedicle might not result in the needle being where you want it at the end of the advancement, right? I have to take a particular angle in order to remain trans-pedicular. I might end up more lateral than I'd like to be.
That is where these steerable devices really come into play. You can ensure that you're on that pedicle, and even though your target, which is straight ahead at the beginning, isn't or is suboptimal, once you get into the vertebral body, you start to steer this thing in whatever direction you want. It can be cephalad, it can be caudal, it can be medial, it can be lateral. Therefore, stay on the pedicle and avoid any damage to these surrounding structures. That's where the complications arise.
[Dr. Jacob Fleming]:
I think as you are noting for anyone that hasn't utilized these devices is you can articulate them as much or as little as you want so it gives the control to the operator.
[Dr. David Prologo]:
Right. That's exactly right. It's important not only if you're targeting a specific portion of the vertebral body, but sometimes the very nature of the angle that you have to take in order to stay trans-pedicular isn't going to end up in the vertebral body at all or is going to end up too far posterior, for example. Even the pre-curved devices that are made by Stryker, for example, will help you end up in a different place. The ability to steer the inside of the needle as you're moving forward in real-time as you're watching has been quite an advance.
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Fluoroscopy, CT & MRI in Bone Tumor Ablation: Optimizing Image-Guided Technique
In spinal tumor ablation, image guidance is key– but not all modalities offer the same flexibility. While both CT and fluoroscopy provide real-time visualization, fluoroscopy may offer a technical advantage in the thoracic spine, where variable pedicle angles and kyphosis can make in-plane access challenging. Steerable devices further enhance control by enabling directional adjustments mid-procedure, helping clinicians safely reach posterior lesions and navigate complex anatomy. As Dr. Prologo emphasizes, MRI also plays a crucial role in preoperative planning, particularly in identifying anatomical variants that could lead to mistargeting if levels are miscounted.
[Dr. Jacob Fleming]:
One of the interesting discussions has been, when we get into all types of different modalities for ablation, sometimes people will say, "Well, Majid can do these really unique microwave cases in the spine and Prologo can do these crazy cryo-neurolysis cases," but how do we take the Jack Jennings approach and just make this completely simple and safe to make improved access and widespread use? Do you have any thoughts in terms of different modalities and how we make bone tumor ablation accessible to everyone?
[Dr. David Prologo]:
Bone tumor ablation, as it applies to these new devices and in the context of steerability, the only steerable bone tumor ablation set that I'm aware of is the STAR ablation device now marketed and controlled by Merit. Then, of course, we've got the Osteocool device by Medtronics, and now recently, OptaBlade from Stryker. The question is, how can we make this a procedure that we can all do safely given the differing products and the differing angles of each one of our patients and the different skill sets, presumably cross-sectional versus fluoroscopy?
My answer to that is, I think the great majority of these cases from T5 down can and should be done in fluoro. The reason that I say that, I didn't think that for quite a while, but the reason that I say that is because the angles that are created in the thoracic spine by kyphosis, scoliosis, et cetera, can be accommodated for with an II that you can move in all four directions. When you take that same patient to CT, unless you're going to tilt the gantry and you start to work in the axial plane, that pedicle is almost never in the axial plane.
This is a classic case of us trying to put a square into a round hole. We want to see a nice axial cut where we have two needles that are trans-particular and land in the middle of the vertebral body. That's really not the angle. I think, for that reason, they should be done in fluoro. That said, the transition to fluoro in a high thoracic vertebral body, there's a high learning curve there, a steep learning curve would be the more appropriate way to say it, because you've got to understand what level you are on and you've got to be able to sort of phase out all these other structures that are in the way and you have to realize that the risk is higher if you miss because there's a lot of critical structures around there.
As we're talking about this, Dana, I hope you don't mind, I'd like to drop in a pearl for any of the young listeners. When you have a lesion in the thoracic spine, it is very important, it is imperative that you have an entire spine image from MRI. What do I mean by that? If you get a thoracic spine MRI on a patient who came through the ER, and so when you show up in the morning, you've got a patient with a fracture and a thoracic spine MRI, and you can see this level and you're ready to take the patient to fluoroscopy.
What you don't have in that situation is the lumbar spine. When you go to localize that vertebral body that some diagnostic radiologist has labeled, you have to count from somewhere. You either have to count from the bottom, which is much easier, or you have to count from the top. If you don't have the corresponding vertebral bodies on some other image, then your counting can be off, right?
Someone called that T5. You put the patient on the table, you start counting from below. If that patient has 6 vertebral bodies or 13 ribs, if you're looking at the AP, then your counting is going to be off and you're going to land at the wrong level. It's always important to know, however you intend to count during the procedure, that you have that MR image projected in the room and you can correlate where you're going to start and where you're going to end up so you don't end up cementing the wrong level.
Beyond Tumors: Broader Applications of Steerable Spine Technology
Steerable ablation technology has improved access to the posterior central vertebral body– a difficult-to-reach region in spinal tumor cases, especially when lesions are near the posterior cortex. As Dr. Prologo explains, steerable tools like the STAR device provide real-time directional control, allowing operators to redirect their path towards posterior lesions that might otherwise be missed using straight-line or pre-curved devices. This level of control is particularly important in lytic metastases, where safe and effective targeting can be technically demanding.
The same steerable mechanism used in STAR also supports accurate basivertebral nerve ablation, which requires precise posterior central targeting to interrupt nociceptive signals from degenerated discs. While STAR is designed for tumor ablation, clinicians have adapted its steerable tools– such as the osteotome– for broader applications, including access in non-tumor cases, such as vertebrogenic pain procedures or osteoporotic fractures. As these treatments expand, steerable systems offer an efficient and reliable way to reach complex targets across a range of spinal interventions.
[Dr. Jacob Fleming]:
I was recently meeting with our friend Junjian who Josh Hirsch refers to as probably one of the greatest future leaders we have. He's done some great research and clinical outcomes on different devices for basivertebral nerve ablation. I think it gets back to what you were addressing with lytic metastasis and the posterior central aspect of the vertebral body, is how do you target the most difficult part of the vertebral body?
[Dr. David Prologo]:
Great question. The only way to get there, as far as I can tell now, is to use the STAR ablation device’s steerable component. I want to be clear that it is steerable, and I recently learned that there's a difference between steerability and pre-curved. Pre-curved does allow you to put something into the vertebral body that will take a different angle, but steerability is something that allows you to get to something in real-time, right? If you've got a focus of a tumor in the posterior portion of the vertebral body, which by the way, is a difficult place for the radiation oncologist to treat. It's tough all the way around.
The way that you can get there is by putting your coaxial needle to the posterior border and then you can use this inner steerable osteotome and advance it, maybe you advance it in one centimeter and then when you turn the handle, which is outside of the body, the tip of the needle, the tip of the osteotome will actually turn. If you turn it again, it'll turn again. It'll turn 90 degrees. You can use that ability to turn 90 degrees once entering the posterior border of the vertebral body to advance to the center and ablate. That's how you can target. With any other device, you really can't do that. You just have to go straight in and you're going to get an ablation zone in the middle and oftentimes leave the middle posterior portion of it untouched. Then the radiation oncologists have to try to get to that. Of course, that's also the lesion that's going to end up in disruption of the posterior border and potential neurological sequelae.
It's been a brilliant evolution to watch the STAR ablation device, which I started with so many years ago, become better and better and better as they learn to steer this thing inside of a coaxial anchor straight to the target that you need. You can use that same. By the way, I am a consultant for Merit, not in the spine division, but I've recently reviewed some of their embolics. I don't have any personal gain from the use of any one of these different products. I just want to use what's going to help the patient. Hopefully, all those stories I told about taking care of the patient will lend me some credibility. I just want the device that's going to allow me to take care of the patient.
If that focus is in the posterior third in the middle, I've got a way to get to it. If it's not, and I have the same device, then I can go to the anterior two thirds on one side or I can cross the midline with that, if I want to stay unipedicular, or if it's a particular relaxed day and I just want a large ablation zone, we could put a second one in and do a bipedicular approach and create a large ablation zone with the same Merit devices. They also have pre-curved devices for osteoporotic compression fractures. You can use the osteotome in an osteoporotic compression fracture. It doesn't have to be a tumor.
All of these things allow you to have quite a bit of variability in one set. I remember when I was at the Merit headquarters talking about embolics and I remember saying that if we had everything in one set, in one place, that would be a lot easier than trying to get something from here and something from there. I think in the spine division, where I'm really not involved at all, other than as a user in this discussion, they've done that.
[Dr. Jacob Fleming]:
Just to clarify because not everyone has quite your spine experience, but you're addressing, right there, bone tumor ablation and what about to differentiate that from steerability for the basivertebral nerve, why is posterior central so important.
[Dr. David Prologo]:
Right. That's our target for basivertebral nerve ablation, which is a recently, as you know, exploding field for a population of millions of patients with discogenic pain and no other option. I'm sorry if I misunderstood the original question, but that's where the basivertebral nerve target is. That's where we want to be to essentially perform radiofrequency ablation, just like we do in the knee, just like we've been doing for 30 years for medial branch nerves that supply arthritic facets. In this case, we want to knock out the signal from a painful desiccated disc. Being able to get to that same location, in this case, non-osteoporotic, nontumor containing vertebral body but instead to make sure we target our nerve to stop the signal and improve symptoms in patients with desiccated discs. I didn't even think of that, actually. When I said that they add everything in one box there for you, I didn't even consider that. They really do. You can do all of these procedures with that same box.
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Cite This Podcast
BackTable, LLC (Producer). (2024, April 9). Ep. 47 – Kyphoplasty Evolution: Steering Toward Targeted Therapy [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com 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. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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