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BackTable / MSK / Podcast / Transcript #24
Podcast Transcript: Unipedicular vs. Bipedicular Approach for Kyphoplasty
with Dr. Thomas Andreshak
Interventional radiologist Michael Barraza talks with orthopedic spine surgeon Thomas Andreshak about his approach to vertebral augmentation for compression fractures, including unipedicular vs. bipedicular approach, technique pearls, and post-procedure care. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Triaging a Vertebral Fracture
(2) Vertebroplasty vs Kyphoplasty
(3) Getting Access
(4) Benefits of Unipedicular vs Bipedicular Access
(5) End Point for Cement Fill
(6) Anesthesia Considerations
(7) Patient Considerations
(8) Patient Expectations and Outcomes
(9) Using the Kyphon Assist
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[Dr. Michael Barraza]:
This is Michael Barraza returning as your host. I'm thrilled to be joined by Dr. Tom Andreshak, an orthopedic spine surgeon with Consulting Orthopedic Associates in Toledo, Ohio. Today, we're going to be talking about vertebral augmentation, particularly performing vertebral augmentation for me, the unipedicular or bipedicular access. Dr. Andreshak, thank you for joining us today.
[Dr. Tom Andreshak]:
Thanks for having me.
[Dr. Michael Barraza]:
Uh, you're in Toledo, right?
[Dr. Tom Andreshak]:
Yes I am. Metro Toledo area.
[Dr. Michael Barraza]:
How's the weather there today?
[Dr. Tom Andreshak]:
It's actually bright and sunny, but chilly,
[Dr. Michael Barraza]:
Not working?
[Dr. Tom Andreshak]:
Not today.
[Dr. Michael Barraza]:
Good. so you're actually the second spine surgeon in a row that I've had on the podcast, which is kind of unusual. Last episode I hosted was with a spine surgeon talking about radiofrequency ablation for spine metastasis. And that was a neurosurgeon, which we all know is not as good. So glad to have the better type of spine surgeon on today. So thank you for sharing your time and superior expertise.
[Dr. Tom Andreshak]:
Oh, not a problem. You know, we all have to learn to play in the sandbox together. We all do the same thing. So we all have a little bit of different things to add.
[Dr. Michael Barraza]:
That's right. And, you know, that's kind of one of our things at backtable. We're about collaboration rather than competition and we really value having physicians of different specialties than us. You know, we're mostly interventional radiologists here. I think we really gain a lot from getting perspective from different specialties and we really appreciate having yours on here.
So Tom, if you don't mind, tell me what your practice is like, what you do, what your group is like and what type of hospital or outpatient setting. Where do you work?
[Dr. Tom Andreshak]:
So I am in the Toledo Metro area. I work at a major level one trauma center called St. Vincent Mercy, and I'm a solo practitioner. I don't have a group. I work with residents at the hospital. I do cover two smaller community hospitals and 90 some percent is spine surgery. The rest is basic general orthopedics. And been doing kyphoplasties for 21 years.
[Dr. Michael Barraza]:
Wow. All right. So, I mean, is that a large part of your practice? You're doing a lot of them.
[Dr. Tom Andreshak]:
I do probably 200 to 250 a year, depending on the times.
[Dr. Michael Barraza]:
That is a lot.
[Dr. Tom Andreshak]:
Yep.
[Dr. Michael Barraza]:
Are there other physicians who do these at your institution?
[Dr. Tom Andreshak]:
Yeah, it's a combination as you had stated of neurosurgeons, orthopedic surgeons, pain management, interventional radiologists. The training in the beginning, as you kind of remember, they trained mostly for kyphoplasty orthopedic surgeons and neurosurgeons thinking this was a reduction of fractures. So therefore it was specifically a surgeon based practice. But, interventional radiologists were the smart ones into the vertebroplasties learn the technique and then of course the orthopedist kind of expanded on it just to try to up at one and try to get more of a reduction.
[Dr. Michael Barraza]:
Yeah, that's actually how I started doing them: by working with spine surgeons who would have us do them for prevention of proximal junctional kyphosis after fusion. And that's actually how I learned, was working with them and then kind of expanding my practice from there.
To your institution, how do these patients with vertebral compression factors, how did they get triaged? How do they end up getting you involved?
[Dr. Tom Andreshak]:
So my practice has changed remarkably as we all have during the COVID time. But the majority of my referrals come from inpatient referrals. Patients who've had pain symptoms go to the emergency room, get triaged, either admitted or sent to the office. Some are sent primarily by the family practice doc based on their continued pain over time. And that's probably the majority of the practice that I see. Over the last two years, as we all have, those patients are sent outpatient and come to the office. And this period of time, it's probably presenting more six to eight weeks after their injury. Whereas previously I really saw those people within the first week or two.
[Dr. Michael Barraza]:
Yeah, that's interesting. I'm in a job, I work in Louisiana and I've been here for about a year. And before I moved here, I moved back in the middle of the first wave of the pandemic. And before that I was actually seeing a lot of these inpatients and we would treat some of them while they were still there. We had basically a system we worked out with the ER. They would get them admitted for the night and we would treat them the next day. And now, the majority of ours are outpatient as well. But that's really interesting. We are, we're also seeing, a higher proportion of these later on than we had a year or two before. That's interesting. I hadn't really thought about that.
[Dr. Tom Andreshak]:
I've noticed that I don't get the reductions I used to get. I don't get the lift of the height and patients tend to have a few more recurrent fractures.
(1) Triaging a Vertebral Fracture
[Dr. Michael Barraza]:
So, that brings up an important point about the timing of the fracture in terms of treatment. When you're working these patients up, I mean, ideally we want to get them in the acute phase, but I mean, how long do you consider too long after an injury to forego treatment?
[Dr. Tom Andreshak]:
That's an interesting question because really there is no too long of a treatment so long as you have a DEMA, MRI scan or stir image. If you have activity in a bone scan or you see fractured clefts on CT, I've treated patients a year, almost a year and a half out that still have micro motion and fracture.
[Dr. Michael Barraza]:
Yeah, we kind of do the same. We basically, and unless we know for sure, it's very acute, you know what I mean? If somebody comes in with trauma or an acute injury, we'll be fine with a CT. But for pretty much everybody else we're requiring an MRI. Is that the same for you?
[Dr. Tom Andreshak]:
If possible. Yeah, absolutely. It seems like the cardiologists in my area have given everyone pacemakers, defibrillators, or now bladder stimulators. So we're kind of messed up on getting an MRI, but truly MRI is the gold standard, yes.
[Dr. Michael Barraza]:
How are you managing that when you can't get an MRI in terms of triage? I mean, you go by exam? Bone scan?
[Dr. Tom Andreshak]:
Combination of both. Yeah. I think as an orthopedic surgeon, my first line of evaluation is a standing upright x-ray. Everyone says “really? Why standing?” Well, I've seen a lot of fractures. Probably at least 1 out of 10 had CT head imaging at the ER, didn’t have a standing x-ray. I see them normally within a week from the ER, many times within 2-3 days. You get a standing upright x-ray and they suddenly have a collapse. I've seen a complete...
[Dr. Michael Barraza]:
No kidding.
[Dr. Tom Andreshak]:
Yeah, absolutely. It's incredible, the difference.
[Dr. Michael Barraza]:
I've never even thought to order them as a standing film for these patients. That's really useful information.
[Dr. Tom Andreshak]:
Yeah. I mean, commonly also as examples, spondylolisthesis is missed. You get an MRI, you get a plain x-ray and you stand the patient up. They have a grade one slip. So same as with fractures.
(2) Vertebroplasty vs Kyphoplasty
[Dr. Michael Barraza]:
So Tom, in terms of treating these patients, are you doing exclusively kyphoplasty or do you also perform vertebroplasty or other forms of vertebral augmentation for compression fractures?
[Dr. Tom Andreshak]:
Probably 90-95% are vertebral augmentation. I do a vertebroplasty if I do a big degenerative spine scoliosis to offset the proximal junctional kyphosis and my proximal screws. If I see an older real chronic type fracture, mild edema, I know I'm not going to get a reduction. So to me a vertebroplasty is great for that. Or if they have one of those segmental fractures between a fixed level, that little bit of a demon in the anterior edge, which I think is a common missed thing not read by some of the colleagues, I will put a vertebroplasty in there to stabilize it.
[Dr. Michael Barraza]:
Okay. And you do that at the same time as a kyphoplasty for other levels? Or occasionally just bring that patient in and treat a vertebroplasty at that level?
[Dr. Tom Andreshak]:
The same time.
[Dr. Michael Barraza]:
Okay. Yeah. I'm with you. It's interesting, in my last job I was at least 90% kyphoplasty. I would occasionally, as you said, for like an older looking fracture and then for me, sometimes for vertebral plane where I'm nervous about inflating a balloon there, I'll sometimes just go with cement, but I joined a new practice here and it was a group that did exclusively vertebroplasty. There was a guy who didn't really believe in using the balloons. And so that was a battle I had in my first year here. I still am a believer. You know, one of the things we brought you on to talk about today was, doing these from unipedicular bipedicular access.
I mean, for me, that wasn't really an option until like five years ago. But, interesting to note that, I was talking about the guys in my group, they actually do all of their vertebroplasties from unipedicular access. But without curved needles they rotate the eyes such that they can get the needle directly in the middle. And that's how they do all of them. For you, roughly what proportion of compression fractures are you treating for unipedicular access compared to bipedicular?
(3) Getting Access
[Dr. Tom Andreshak]:
It's probably 20%. A lot of it is random luck. I'm planning bipedicular and my needle catheter balloon is in the midpoint and it's like, Hey, this is great. Reduce the fracture, got my void. I'm good with it. So it's probably 20%. Those that have multilevel fractures, such as in the myeloma patient, the primary steroid induced osteoporosis from secondary, those definitely multi levels, just for cost savings, I'll go unipedicular.
[Dr. Michael Barraza]:
Okay. Do you ever use any of the curved needles to get across?
[Dr. Tom Andreshak]:
I don't. I bend my balloon catheter. Actually, if you make a little curve in the catheter you get to your midpoint. Yeah. It actually works pretty good.
[Dr. Michael Barraza]:
Do you have to put a cannula or anything out passer to get the balloon or, I mean, I guess for soft vertebral bodies, you may not have to.
[Dr. Tom Andreshak]:
Right. Usually for those that have clefts, they have the, let's term Kummel’s Disease, the osteonecrosis, those are great. That curves right along the front and really inflates it excellent.
(4) Benefits of Unipedicular vs Bipedicular Access
[Dr. Michael Barraza]:
So you said cost savings. Are there any other benefits of doing it from unipedicular access rather than bipedicular?
[Dr. Tom Andreshak]:
I mean that has been debated in all the studies. And I actually kind of looked up a lot of the stuff to see, theoretically according to all the meta analysis, not really. You decrease the cement fill, you decrease the usage of the cement, you can get a volume less, normally with unipedicular. But it's the cost and the time and then less radiation possibly.
[Dr. Michael Barraza]:
Yeah. And, I guess, theoretically, just going from one side, I guess slightly less invasive. I mean, it's still the same procedure, pretty much. I used to use the curved balloons for unipedicular accessing and get across and the curved cannulas and I did have good results from that. I found that there was a learning curve with that in terms of getting out there and covering as much of the vertebral bodies I could. But the argument that was made to me for why you should stick with bipedicular access was just that you get superior cement fill.
I don't know. What's your take on that?
[Dr. Tom Andreshak]:
Well, as an orthopedic surgeon in training of fractures, that's how I base it. I mean fracture principles based on the AOL principles is you've got to have fracture fixation and atomically. Then you have to make sure that you do it as a soft tissue sparing approach, which vertebroplasty and vertebral augmentation . You want to mobilize the patient safely, but you also want that stability. The question is absolute stability or relative stability. And that goes back to again, differences between colleagues and orthopedic and neurosurgeons. We believe in the bone. Be the bone, we own the bone.
So fracture healing is different. You know, you have your, whether it's the spine, long bone fracture, you still heal through the same four phases, which is hematoma in the first week. Then you have your fibrocartilage. So your cartilage model kind of forming the fracture, stabilizing it. Then by the third week, you start to have callus formation into cartilage. And then finally long-term remodeling.
The issue is the flat bones tend to heal more by intramembranous ossification versus what's called endochondral.
So like you, I've actually been doing a little bit more vertebroplasty. My practice changed. I tend to not be filling as much because I'm wondering if we're making them too stiff and too rigid.
(5) End Point for Cement Fill
[Dr. Michael Barraza]:
You're doing them then, what's your end point when you're treating these in terms of cement fill? Do you use a volume or do you use kind of imaging findings? That's something, I mean endpoint it's been a challenge for me since I started doing these. I will go to great lengths to not reflux cement. I'm so nervous about getting into the epidural space or something like that. And to this day I haven't done that, but you know, I see some people out there, you see cases shared on Twitter where people are really aggressive and you see these vertebral bodies that are entirely black. I haven't been able to pull the trigger on going to that length.
[Dr. Tom Andreshak]:
That has been the trend but I think it's falling away. In the beginning, the fill was important. We used to fill 3 cc balloon, we only filled 3 cc’s. Early studies in the early 2000s showed that if we don't get the bone interdigitating between the compacted bone, you lose your end plate.
So you collapse a little bit, lose your reduction or your height. The trend then was to go to a fuller fill, bigger balloons, and maximize the fill. In terms of orthopedics, we always say it's about the reduction. So force equals pressure times area. The more force with the balloon, including the second generation balloons, over a larger surface area with more force got your reduction. But that also compacted the bone so much that we ended up having a very stiff vertebragrams, I call it, where yes, it's this big black cement filled vertebrae. And we know that that puts some stress on the adjacent end plates. So I was always feeling a little bit more trying to make sure I filled the clefts and the crevices without overfilling, but it's tough to do because it's all patient variables. So I've actually gone to little bit less trying to get not as expanded balloon, get my reduction, but don't overfill.
[Dr. Michael Barraza]:
I do like to see it enter that cleft if it's a kind of horizontal fracture plane, if I can get it. But Tom, how do you gauge your production?
[Dr. Tom Andreshak]:
You know, by x-ray and I do all my reductions on a Jackson table. As a surgeon, I do them in the operating room. It's just easier for me
[Dr. Michael Barraza]:
Yeah, with general anesthesia?
(6) Anesthesia Considerations
[Dr. Tom Andreshak]:
Most of the time, yeah, I'd probably do 90% general, 10% conscious sedation. Because again, it's about the reduction. Patients get fidgety, they're not moving around if I can do it. And I think I can do a better job, especially if I'm doing unipedicular, not irritating the soft tissues as much. So that's how I do it. Really get them lordotic trying to create that reduction moment and then expand my balloon and see what happens.
[Dr. Michael Barraza]:
That's interesting. So how do you get them lordotic?
[Dr. Tom Andreshak]:
The Jackson table is a, what's called a four poster. They have a chest pad that sits right in the chest and they sit on the iliac crest and the pelvis. And then the whole entire thoracolumbar and lumbar spine is free. So they're very lordotic extension based. And it's amazing. The reduction you get just from that.
[Dr. Michael Barraza]:
Okay. That's new to me, Tom. Okay.
[Dr. Tom Andreshak]:
It's harder to do when the patient's under conscious sedation because you're trying to force the patient up, extend the patient and they're hurting. So to me, that's one of the reasons even with my conscious sedation, our goal is, as example, you give them some sedation, you give them a little Diprivan little fentanyl. And if we're doing a conscious sedation, they're always up and sitting in a bed, right. And then as you lower the stretcher back extending, if they don't have pain then we can get them flat and lay them on the table. So they have to be able to completely extend flat from that sitting posture in order to do a conscious sedation
[Dr. Michael Barraza]:
Also think about how I would want to have this done. You know when I'm doing this, I use a mallet and that is a really jarring thing for a patient who's not entirely out, is feeling that mallet. I mean, it's not necessarily the pain. But I mean feeling and hearing that mallet for patient, who's not like completely out, they do remember something to me, it seems like they remember that. And, I have really, I started doing these with conscious sedation and I have really gradually gone farther toward general anesthesia and the vast majority when I can.
[Dr. Tom Andreshak]:
I agree. Patients hate that sound of the mallet. They hate that banging on the back, that pressure feeling. And I tell the patient I'm poking around your nerves and spinal cord. I don't want you moving. And I wouldn't want it that way. And most of them agree. Oh, absolutely. I want to be knocked out completely.
[Dr. Michael Barraza]:
I mean, Tom, if you're doing my kyphoplasty in the future, I'm going to demand general anesthesia. And so, but that's kinda what I told most of these patients. If I'm getting one, I'm gonna want anesthesia and it's not always an option, but when I can, that's what I'm doing.
(7) Patient Considerations
[Dr. Tom Andreshak]:
Yeah, completely agree. And same here. I tell them I would have it done. Be back working the next day.
[Dr. Michael Barraza]:
Yeah. And that's one of the great things about this procedure. Generally you can have them doing the majority of their activities within a couple of days or so, we'll get a good, clinical result. Tom, does your approach to doing these from a technical standpoint change? You know, that the higher you go up in the vertebral column?
[Dr. Tom Andreshak]:
You, it does. But it's based on anatomy. I told the patient and when I teach the residents, they always have the typical training bull: extrapedicular approach, peripedicular approach up above T9 or 10. And you get up to T2-3-4, they're huge pedicles, long, wide, half the body. So it's really a transpedicular approach.
It's just a very small body and you've got to be careful. So every patient is dependent on the fracture pattern. I really look at it, gauge my angle. Can I do it as unipedicular? Or is this truly one that needs a reduction because it's at that thoracolumbar junction where you really want to get that sagittal alignment.
[Dr. Michael Barraza]:
Do you ever because you're in the operating room and we do something kind of a hybrid approach where you make a larger incision and actually visualize the vertebral body?
[Dr. Tom Andreshak]:
No, no, no. Unless I'm doing an open decompression. There are those patients that have the fracture, they're on top of a stenotic segment, say a spondylolisthesis at L4-5, they need a reduction. So those, I will do kind of an open hybrid.
[Dr. Michael Barraza]:
Tom, can you walk me through, basically your follow up for these patients? How do you assess your outcome and, when you see him again and when you have circumstances where there's more to do?
(8) Patient Expectations and Outcomes
[Dr. Tom Andreshak]:
Yup. Standard lecture to the patient in pre-op is that we fix the fracture. You should be 50 to 70% better right away. Your sharp, transitional, and mechanical pain is that pain getting up, getting down, moving should be gone. I see them back at two weeks. I tell them to be careful bending and lifting, not to lift more than 10 pounds and keep weights close.
And when I see them back, first thing I ask them is how’s your pain. Not a scale, but getting up and down. I make him stand up and show me their pain, point to it. Where's it at? And I ask them what their pain level is. If they're 75 - 80% better, I'm not too worried about adjacent level fracture. If they're like well, yeah, it still hurts. It still hurts here. It's 60 - 40% better, they have an adjacent level fracture. So I then get standing upright x-ray right there in the office. And almost always you see that adjacent level fracture.
[Dr. Michael Barraza]:
No kidding. And so where do you go from there?
[Dr. Tom Andreshak]:
Well, then I talked to him about, is this something we should fixt? Is it because we made it too stiff? Did they have a fracture? Say they only had a CT scan that didn't show the fracture. Or are they willing to go through “medical augmentation:” calcium, vitamin D, brace, give them a couple of weeks, see them back in two weeks, get another upright x-ray. If they show a fracture, then we talk about surgery, but I give them the option of going back and doing the adjacent segmentation.
[Dr. Michael Barraza]:
And so when you say surgery, are you talking about a fusion? Are you talking about doing another vertebral augmentation?
[Dr. Tom Andreshak]:
Another augmentation. Or possibly vertebroplasty, especially if that inferior end plate is starting to break, I'd want to make it stiff because I have seen same horribly osteoporotic patient who, as a side, I always try to get a DEXA scan before their procedure so I know what I'm dealing with. But if they have terrible primary osteoporosis, I'll then recommend like a vertebroplasty instead, because I think it's less stiff.
[Dr. Michael Barraza]:
Okay, Tom, what else am I missing that's important to talk about regarding this procedure?
(9) Using the Kyphon Assist
[Dr. Tom Andreshak]:
Well, one of the things that I have been working with lately has been the Kyphon Assist helping reduction. I think as much information as we have, as much literature is out there, we really don't know how much cement do we really need? And in what patient, you know, we know if you get kind of a blocky chop squared off dense bone, you tend to have an adjacent increasing fracture.
If you kind of get that spongy kind of describe flow in vertebroplasty pattern, they tend not to be as stiff and sore. And then I think it's a matter of what do we do? So for me, the reduction has been better with the Kyphon Assist. And the good point is I can get that flow into the other parts of the vertebrae as a vertebroplasty by rotating my Kyphon Assist or scoop cannula, so I call it to get the other areas so I can control the flow into the vertebra.
[Dr. Michael Barraza]:
Tom for the listeners. What is the Kyphon Assist?
[Dr. Tom Andreshak]:
So Kyphon Assist is basically a scooped cutout cannula, the same as your size two or size three cannula and it acts as a ramp so the balloon gets directed to a certain area. It helps increase height reduction. And it controls your flow of the cement.
[Dr. Michael Barraza]:
Do you still do a single inflation when you're using the Kyphon Assist? Or will you ever direct it to the top or the middle of bottom inflight more than once?
[Dr. Tom Andreshak]:
Both. If I am too lateral with my needle catheter, I can use the Kyphon Assist or scoop to push it more medial. If I'm too low, I can push it high. And sometimes I will bail out and go to the Kyphon Assist because it makes my fill better. So each of those are great options and great tools that I think people need to know about in doing vertebral augmentation.
[Dr. Michael Barraza]:
I'll ask my rep this week. Well, Tom, thank you. We really appreciate having you on here and for sharing your expertise and perspective. This has been extremely valuable for me to really hear how you look at this as, as a spine surgeon, as a bone specialist, which frankly is a bit different from how I do. And, I think we can really all get a lot from this, but so again, thank you for sharing your time.
[Dr. Tom Andreshak]:
My pleasure. Thank you for having us.
Podcast Contributors
Dr. Thomas Andreshak
Dr. Thomas Andreshak is an orthopaedic spine surgeon at Consulting Orthopaedic Associates, Inc. in Toledo, Ohio.
Dr. Michael Barraza
Dr. Michael Barraza is a practicing interventional radiologist (and all around great guy) with Radiology Associates in Baton Rouge, LA.
Cite This Podcast
BackTable, LLC (Producer). (2023, July 26). Ep. 24 – Unipedicular vs. Bipedicular Approach for Kyphoplasty [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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