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BackTable / VI / Article
Balloon Kyphoplasty Pearls: Indications, Access & Filling Technique
Delaney Aguilar • Dec 16, 2021 • 290 hits
Balloon kyphoplasty and vertebroplasty are minimally invasive procedures that are used to treat vertebral compression fractures. In this article, we address when to select balloon kyphoplasty over vertebroplasty, different balloon access techniques, and how to deploy the ideal amount of kyphoplasty cement filling.
The BackTable Brief
• Vertebroplasty may be indicated over balloon kyphoplasty in the event that vertebral compression fracture reduction may not be feasible due to chronic changes to the bony matrix.
• Accessing the vertebral body can be done via unipedicular or bipedicular approach. The use of curved needle catheters may not always be required, particularly when the vertebral body is soft.
• Cement filling is a delicate process which requires adequate reduction of the vertebral compression fracture without over-compressing the adjacent bone.
Table of Contents
(1) Indications for Balloon Kyphoplasty and Vertebroplasty
(2) Balloon Kyphoplasty Access
(3) Balloon Kyphoplasty Cementing
Indications for Balloon Kyphoplasty and Vertebroplasty
Vertebroplasty and balloon kyphoplasty are two distinct approaches to vertebral augmentation, and both are designed to reduce vertebral compression fractures by plumping up the void left by the fracture with a cement cast. Ballooning before cementing can offer greater height reduction in acute settings, but older fractures may be too settled to offer much of a reduction. Below, Dr. Andreshak describes his preference of vertebroplasty over balloon kyphoplasty in instances such as these.
[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?
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Balloon Kyphoplasty Access
How many times should you poke the patient? Using a bipedicular approach for balloon kyphoplasty can offer extremely accurate placement of cement in the fracture void. Dr. Andreshak likes to plan for a bipedicular approach but is also happy if the unipedicular access does the job. He describes bending his balloon catheter instead of using curved needles to get into the vertebral body, which allows him good access into the void.
[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.
Balloon Kyphoplasty Cementing
Although fluoroscopy offers great real-time visualization of cement filling during balloon kyphoplasty, great care needs to be taken to achieve the ideal filling endpoint. Classically, only 3 cc’s of cement were deployed into each fracture. Then, treatment steered towards maximizing fill and regaining height with bigger balloons and more cement. Dr. Andreshak describes the delicate balance of cement filling during balloon kyphoplasty to achieve fracture reduction while avoiding over-stiffening and stressing adjacent end plates.
[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
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). (2021, November 15). Ep. 165 – 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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