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Vertebral Augmentation

Vertebral augmentation includes both vertebroplasty and kyphoplasty procedures. Both procedures are used for the treatment of benign and malignant painful spinal compression fractures. Although the mechanisms for each fracture can vary, both procedures involve the percutaneous injection of cement into the diseased vertebral body. The primary goal of treatment is pain relief. Secondary goals often include stabilization of the fracture and restoration of potential height loss. Vertebral augmentation surgery is one tool of many in the treatment arms for vertebral compression fractures. Vertebral augmentation surgery techniques and devices can vary between operators. However, a constant for this procedure is the importance of the preprocedural evaluation and workup, which are paramount for appropriate patient selection.

Vertebral Augmentation Procedure Information

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Ep 211 Extraspinal Augmentation and the Future of Vertebral Augmentation with Dr. Douglas Beall
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Pre-Procedure Prep

Modalities

Vertebral augmentation: injection of cement into vertebral body
Vertebroplasty: augmentation with acrylic cement into vertebral body
Kyphoplasty: balloon catheter following by injection of acrylic cement
Vertebral compression fracture (VCF)

Indications

• Painful vertebral compression fracture
• Painful osteolytic metastasis
• Painful hemangioma
• Kummel's disease
Some argue the above are indications only in the setting of failed conservative treatment
Patients requiring hospital admission and/or IV narcotics may warrant earlier treatment

Time frame of treatment:
• Varies with different clinical scenarios and location of VCF
• Consider 4-6 weeks of conservative treatment before intervention

Conservative treatment:
• Bed rest
• Pain control with medications
• Medical treatment of underlying osteoporosis
• Physical therapy
• Bracing - no good data to suggests this works except in specific circumstances
Must consider risk of immobility with conservative management:
• Bone loss
• Strength loss
• Contractures
• Pressure sores
• Increased risk of DVT

Vertebral Augmentation Contraindications

• Spinal infection
• Uncorrectable bleeding diathesis
• Myelopathy related to spinal canal stenosis from retropulsed compression fracture
• Radiculopathy related to neuroforaminal stenosis from compression fracture
• Asymptomatic VCF

Relative vertebral augmentation contraindications:
• Disruption of posterior cortex
• Epidural extension of tumor
• Central canal narrowing without myelopathy

Pre-Procedural Evaluation

• History: description of pain; attempt to tease apart different pain and pain sources. Ask patient what pain is most bothersome/lifestyle limiting
• Physical exam: identify and characterize neurological deficits
• VCF: typically midline pain, sudden onset and exacerbated by motion
• Preprocedure MRI is gold standard. CT with bone scan often helpful if patient with contraindication to M

Vertebral Augmentation Podcasts

Listen to leading physicians discuss vertebral augmentation on the BackTable VI Podcast. Get tips, tricks, and expert guidance from your peers and level up your practice.

Episode #211

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In this episode, host Dr. Jacob Fleming interviews Dr. Douglas Beall, interventional radiologist, about extravertebral augmentation, new technology in interventional spine, and intrathecal drug pumps.

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Episode #210

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In this episode, host Dr. Jacob Fleming interviews Dr. Douglas Beall, interventional radiologist, about the latest advances in vertebral augmentation, how to reduce complications, and tips for producing successful and sustainable outcomes.

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Episode #209

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In this episode, host Dr. Jacob Fleming interviews Dr. Douglas Beall about current osteoporosis diagnosis criteria, his treatment algorithm, and recent data showing efficacy of osteoanabolic agents and vertebroplasty.

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Episode #208

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In this episode, host Dr. Jacob Fleming interviews Dr. Douglas Beall about the importance of interventional radiologists stepping up to address the entire picture of osteoporosis and taking the initiative to treat the underlying cause of the disease.

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Episode #165

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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.

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Episode #161

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Neurosurgeon Dr. Nam Tran from Moffitt Cancer Center talks with us about RF ablation for painful spinal metastases, including patient selection and the importance of a multidisciplinary approach.

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Episode #94

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Dr. Douglas Beall from Oklahoma Spine Hospital discusses his drive for innovation in minimally invasive spine interventions, as well as the inspiration behind his new comprehensive book on Vertebral Augmentation.

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Episode #68

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Dr. Jason Levy and Dr. Sandeep Bagla discuss palliative treatment of bone metastases with radiofrequency ablation, as well as recent results from the OPuS One trial.

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Episode #34

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Our second podcast recorded live from Western Angiographic (WAIS) conference in Maui 2018! Dr. Sabeen Dhand interviews Dr. Peder Horner on how he built a spinal tumor ablation practice in Denver, CO, including tips/tricks on equipment and patient selection.

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Episode #21

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Vertebral augmentation with special guests Venu Vadlamudi, MD, RPVI of Alexandria CVIR and Sreekumar Madassery MD of Rush VIR. This week our IR's talk practice building, techniques, and equipment, as well a candid discussion of vertebroplasty versus kyphoplasty.

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Vertebral Augmentation Procedure Steps

Antibiotic

• 1-2 g cefazolin (Ancef) IV
• Vancomycin for PCN allergy

Patient Positioning

• Prone best
• Can sometimes be done in prone obliquity or decubitus
• Locate the level to be treated and correlate with preprocedure imaging
• Flatten the superior and inferior endplates with craniocaudal tilt of image intensifier

Approach

Posterior for thoracic and lumbar; anterior for cervical
Transpedicular vs parapedicular

Transpedicular:
• Less risk of injury to structures between skin and pedicle
• Refluxed cement contained within pedicles
• More common
Parapedicular:
• Needle placed lateral to the pedicle
• Can obtain more medial needle placement

Needle Placement

Target needle placement for cement deposition within anterior third of vertebral body. Try and administer cement along fracture line
Biplane extremely helpful
Use 22 g spinal needle to administer lidocaine to periosteum. Helps with trajectory planning

Ipsilateral oblique: view pedicle en fosse "down the barrel"
• Center needle trajectory on pedicle
• Avoid transgressing inferior or medial cortex of pedicle
• Confirm AP direction with biplane
Anterior-posterior projection
• Position spinous process in center of vertebral body
• Skin entry site superior and lateral to pedicle: ~1 cm superior and 2 cm lateral to pedicle
• Confirm AP direction with biplane
• Can maintain AP projection for contralateral side when performing bipedicular needle placement
Once beyond posterior cortex of vertebral body, needle can cross medial cortex of pedicle
Diamond tip and bevel tip needles for maneuverability once seated within bone

Cement Administration

• Mix cement
• Monitor cement administration under fluoroscopy
• Try to fill cement within fracture plane
• Some attempt to fill endplate to endplate and front to back: biomechanics and pain relief
• Evaluate for extravasation outside of vertebral body
• Confirm adequate coverage
• Cement volume: 4.5 mL is predictor of pain relief

Replace trocar and remove needles
Sterile dressings to skin entry site

Vertebral Augmentation Articles

Read our exclusive BackTable VI Articles for quick insights on vertebral augmentation, provided by physicians for physicians.

Balloon kyphoplasty on fluoroscopy

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.

CT scan of patient being prepped for vertebral compression fracture treatment

This article aims to help you guide your patient through their pain while discussing the hows, whens, and whats of vertebral compression fracture treatment.

Curved needle used for vertebral augmentation

Currently there are numerous needle options available for cement delivery to vertebral compression fractures. Vertebral augmentation verterans Dr. Kumar Madassary and Dr. Venu Vadlamudi discuss the utility of curved balloons and needles for unipedicular approaches during vertebral augmentation procedures.

Physician talking with patient about vertebral augmentation recovery and pain relief

With every surgical procedure it’s important to discuss the risks and benefits of intervention. It is equally important to set expectations regarding recovery times. Initial consultation with patients should aim to individualize a treatment plan with the goal of setting realistic outcomes.

Kyphoplasty vs. vertebroplasty in the treatment of spinal compression

Vertebral augmentation can be accomplished through various techniques - Dr. Venu Vadlamundi and Dr. Kumar Madassery shed light on the utility of kyphoplasty vs. vertebroplasty when treating compression fractures of the spine.

Vertebral augmentation x-ray fluoroscopy

Proper perioperative management of patients with spinal compression fractures can lead to reduced hospital stays and increased health care savings. Evidence clearly demonstrates that increased bedrest is associated with increased morbidity and mortality in patients undergoing vertebral augmentation procedures.

Post-Procedure

Post-Procedural Care

• Bed rest 2-4 hours
• Bed flat
• Follow up physical exam with neurologic evaluation and pain level
• Avoid strenuous activity x 24 hours

Follow-Up

• Clinic visit in 2-4 weeks
• If symptoms resolved, no additional follow-up or imaging necessary
• Need treatment and education related to bone mineral density

Complications

• Clinic visit in 2-4 weeks
• If symptoms resolved, no additional follow-up or imaging necessary
• Need treatment and education related to bone mineral density

Important Trials

• EVOlVE Trial 2017
• VAPOUR Trial 2016
• FREE study 2009
• Buchbinder R, Osborne RH, Ebeling PR, et al. A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med. 2009

References

[1] Bousson V, Hamze B, Odri G, Funck-Brentano T, Orcel P, Laredo JD. Percutaneous Vertebral Augmentation Techniques in Osteoporotic and Traumatic Fractures. Semin Intervent Radiol. 2018;35(4):309‐323. doi:10.1055/s-0038-1673639
[2] Kallmes DF, Comstock BA, Heagerty PJ, et al. A randomized trial of vertebroplasty for osteoporotic spinal fractures [published correction appears in N Engl J Med. 2012 Mar 8;366(10):970]. N Engl J Med. 2009;361(6):569‐579. doi:10.1056/NEJMoa0900563
[3] Papanastassiou ID, Phillips FM, Van Meirhaeghe J, et al. Comparing effects of kyphoplasty, vertebroplasty, and non-surgical management in a systematic review of randomized and non-randomized controlled studies. Eur Spine J. 2012;21(9):1826‐1843. doi:10.1007/s00586-012-2314-z
[4] Katsanos, K., Sabharwal, T., & Adam, A. (2010). Percutaneous cementoplasty. Seminars in Interventional Radiology, 27(2), 137–147. http://doi.org/10.1055/s-0030-1253512
[5] Eckel TS, Olan W. Vertebroplasty and vertebral augmentation techniques. Tech Vasc Interv Radiol. 2009;12(1):44‐50. doi:10.1053/j.tvir.2009.06.005
[6] Buchbinder R, Osborne RH, Ebeling PR, et al. A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med. 2009;361(6):557‐568. doi:10.1056/NEJMoa0900429

Disclaimer: The Materials available on https://www.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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Podcasts

Extraspinal Augmentation and the Future of Vertebral Augmentation with Dr. Douglas Beall on the BackTable VI Podcast)
Modern Vertebral Augmentation with Dr. Douglas Beall on the BackTable VI Podcast)
Primer on Medical Treatment of Osteoporosis and Non-Surgical Management with Dr. Douglas Beall on the BackTable VI Podcast)
Why We Need to Be Treating Osteoporosis for Our Compression Fracture Patients with Dr. Douglas Beall on the BackTable VI Podcast)
Unipedicular vs. Bipedicular Approach for Kyphoplasty with Dr. Thomas Andreshak on the BackTable VI Podcast)
New Tools to Treat Severe Distal Femoropopliteal Disease with Dr. John Rundback on the BackTable VI Podcast)

Articles

Balloon kyphoplasty on fluoroscopy

Balloon Kyphoplasty Pearls: Indications, Access & Filling Technique

CT scan of patient being prepped for vertebral compression fracture treatment

Guiding Your Patient Through Vertebral Compression Fracture Treatment

Curved needle used for vertebral augmentation

Using Curved Balloons and Needles for Improved Cement Distribution

Contributors

Dr. Thomas Andreshak on the BackTable VI Podcast

Dr. Thomas Andreshak

Dr. Douglas Beall on the BackTable VI Podcast

Dr. Douglas Beall

Dr. Jason Levy on the BackTable VI Podcast

Dr. Jason Levy

Dr. Venu Vadlamudi on the BackTable VI Podcast

Dr. Venu Vadlamudi

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