Epidural or SpineJack/Kypho

[PMROralBoards]

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New stat consult for next week. LOL with OP. Severe point tenderness pain apparently in thoracic region. Lateral aspects of the vertebral body are greater heights, but central is pretty squished. About 2mm retropulsion but doesn’t contact the cord on any mri slices.

Would you offer an epidural for palliation, spinejack for fix with lower likelihood of further retropulsion/lower volume of cement, or still try balloon kypho? I am leaning toward spinejack or just vertebroplasty over epidural, last preference would be the balloon. I appreciate any input

 

[Taus]

New stat consult for next week. LOL with OP. Severe point tenderness pain apparently in thoracic region. Lateral aspects of the vertebral body are greater heights, but central is pretty squished. About 2mm retropulsion but doesn’t contact the cord on any mri slices.

Would you offer an epidural for palliation, spinejack for fix with lower likelihood of further retropulsion/lower volume of cement, or still try balloon kypho? I am leaning toward spinejack or just vertebroplasty over epidural, last preference would be the balloon. I appreciate any input

Don’t know what an epidural would be expected to do here.

I’d do kypho. Can try to get a little lift with the balloon, particularly if under a month or so from injury, and inject cement- anticipating some disc extrav. Don’t know how you’d get the larger spine jack equipt in there (caveat… I’ve never done spine jack).

 

[PMROralBoards]

Don’t know what an epidural would be expected to do here.

I’d do kypho. Can try to get a little lift with the balloon, particularly if under a month or so from injury, and inject cement- anticipating some disc extrav. Don’t know how you’d get the larger spine jack equipt in there (caveat… I’ve never done spine jack).

My understanding of the pain mechanism is localized irritation of nerves (sinuvertebral, basivertebral, sympathetic fibers, nerve roots, etc) that could be reduced by the epidural steroid.

It’s just one slice of the sagittal- there was enough room lateral to this. Like you mention though I am worried about disc extravasation for higher risk adjacent level fracture in addition to further retropulsion.

 

[oneforfighting]

Biped kypho. Go slow. It’ll be okay. I don’t do spinejack but not sure you’d fit the jacks in there.

 

[SpineandWine]

This will be a tough spine jack case.
For spine jack, you have to go through Pedicles so depends on how they’re oriented with regards to vertebral body. Will be tough to not get jacks/reamer in disc space.

I’d do traditional kypho or curved needle with unipedicular access

 

[pmrmd]

Looks too flat for the jacks.

 

[Orin]

You're looking at the midline cut. Take a peak at the sagittal cuts along the pedicles to see if you can access with a jack or balloons. The midline is generally flattest but you don't have to be that medial on access with balloons or jacks to regain height.

I would probably think bipedicular balloons first but jacks would be safer if truly a mobile posterior cortex.

ESI after the vertebral augmentation if needed, unless this is 2-3 months old in which case do it concurrent as you won't get much height restoration.

 

[lobelsteve]

Cannot tell anything from that pic. Looks plana. If space for cement, kypho/vertebro. If no space: MBB above and at level of Fx.
No retropulsion in that pic. But need several more cuts and an Xray to decide.

 

[lobelsteve]

New stat consult for next week. LOL with OP. Severe point tenderness pain apparently in thoracic region. Lateral aspects of the vertebral body are greater heights, but central is pretty squished. About 2mm retropulsion but doesn’t contact the cord on any mri slices.

Would you offer an epidural for palliation, spinejack for fix with lower likelihood of further retropulsion/lower volume of cement, or still try balloon kypho? I am leaning toward spinejack or just vertebroplasty over epidural, last preference would be the balloon. I appreciate any input

Also, when you say retropulsion and the measurement above is on the bulging disc at T7-8, are we to take your post seriously?

 

[PMROralBoards]

Also, when you say retropulsion and the measurement above is on the bulging disc at T7-8, are we to take your post seriously?

Thanks for the feedback. My impression of the center sagittal cut is that this is at least mild retropulsion from the inferior aspect of the vertebral body as a result of the angulation. I guess my incorrect assumption was that you could summate that with the disc herniation because further dorsal movement of the vertebral body would also push the herniation backwards— ultimately causing more compression on the csf space.

I come on here for discussion and productive education. I appreciate your discussion on this.

 

[BobBarker]

It’s a tough case. I would go with gentle kyphoplasty using probably just the curette and curved needle. Giving up on height restoration.

 

[pmrmd]

Yep, don't spinejack that. Kypho best you can and personally I would do extra-pedicular at the CV joint instead of the expensive curved Stryker kit that isn't going to get you that much improvement anyway. Expect some cement into the adjacent disc and its okay if/when it does.

 

[Ducttape]

cant comment on spinejack or kypho. would not do epidural.

if she is very frail and you want to limit procedures due to that frailty, id suggest an MBB first.

otherwise, id refer for kypho..

 

[mygalperin]

No epidural, it will only help for 2-3 days, but will add to osteoporosis. Very high chance of leake with vertebroplasty, kypho is a lot safer

 

[DrSpine]

Till this day I fail to understand the idea of an epidural for VCF. Might provide relief for a few days, but fails to do anything and likely worsens osteoporosis/further possibility of fracturing. If anything, I agree with MBB over an epidural if all hope is lost for treatment, and seeing what that does.

My recommendation is: Kypho unipedicular with Stryker's curved system. SpineJack would be great but I'd def look at the size of the pedicles, and might have difficulty. This is a tough case regardless since its vertebra plana.

 

[Taus]

Till this day I fail to understand the idea of an epidural for VCF. Might provide relief for a few days, but fails to do anything and likely worsens osteoporosis/further possibility of fracturing. If anything, I agree with MBB over an epidural if all hope is lost for treatment, and seeing what that does.

My recommendation is: Kypho unipedicular with Stryker's curved system. SpineJack would be great but I'd def look at the size of the pedicles, and might have difficulty. This is a tough case regardless since its vertebra plana.

It is doable with straight needle unipedicular (vs >1k more for curved…unless your hospital based and it’s not on your dime). Just need to map out trajectory on axial mri via parapedicular and angle like this carefully through to target.

 

[Taus]

It is doable with straight needle unipedicular (vs >1k more for curved…unless your hospital based and it’s not on your dime). Just need to map out trajectory on axial mri via parapedicular and angle like this carefully through to target.

Couple examples. See L4 on the 3 level case.

 

[RoloTomassi]

Couple examples. See L4 on the 3 level case.

Wow what's the story on that L1-5? Did you do L1 and 5 later?

 

[Taus]

Wow what's the story on that L1-5? Did you do L1 and 5 later?

90yo. Multiple falls from cervical spondylitic myelopathy s/p decompression. Older fractures w/o much edema at 1/5 vs 2-4. Did 2-4, patient doing very well.

 

[PMROralBoards]

Patient has 100% relief. I had counseled the patient on the risk of extravasation into the discs. I used the unipedicular curved needle from Stryker. No balloon.