Kypho tips under local

[manowar rules]

I currently do my kyphos in an ASC, with anesthesia who seem usually help keeps the patients comfortable with a propofol infusion and maybe prn ketamine and versed. I am in the process of getting an in-office suite however and would like to bring my kyphos there.

Does anyone have any tips to maximize patient comfort when doing kyphos under straight local? Thanks!

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[emd123]

I currently do my kyphos in an ASC, with anesthesia who seem usually help keeps the patients comfortable with a propofol infusion and maybe prn ketamine and versed. I am in the process of getting an in-office suite however and would like to bring my kyphos there.

Does anyone have any tips to maximize patient comfort when doing kyphos under straight local? Thanks!

I give an Rx for xanax 1mg, #1 tabs, take 1-2 tab 60 min prior to arrival.
I also have the take 1 hydrocodone or percocet with it.
Driver is a must, obviously.
Must be someone who can lay on their stomach for a long time and breath okay without airway help (bad COPD-ers on O2 aren't good candidates).
I also book more time than I would in the OR, make it last case of day, take my time and use lots of local, including in the bone if needed.
Works out well for the easier cases and patients who aren't super anxious.

 

[lobelsteve]

10cc syringe x3
1% lido with epi in 1 syringe for skin
1% plain lido in others.

I use a 27g1.25" needle to make a large wheal on skin overlying left pedicle shadow with ipsilateral rotation and placing pedicle mid vert body medial to lateral and superior to inferior. 1cc for the wheal, 3cc total for the 27G. Change to 25G 3.5" needle and drop 5-10cc plain lido through wheal to pedicle shadow. Get subperiosteal and add more lido on center of pedicle.
11 blade stab incision, then pain free, blood free. Only times anyone hurts after that is about a third get pain when pulling out stylet of 10G kypho needle and getting suction style pain.
Have done several dozen (many more than that) in office without issues.

 

[Extralong]

I give an Rx for xanax 1mg, #1 tabs, take 1-2 tab 60 min prior to arrival.
I also have the take 1 hydrocodone or percocet with it.
Driver is a must, obviously.
Must be someone who can lay on their stomach for a long time and breath okay without airway help (bad COPD-ers on O2 aren't good candidates).
I also book more time than I would in the OR, make it last case of day, take my time and use lots of local, including in the bone if needed.
Works out well for the easier cases and patients who aren't super anxious.

Not a fan of sedation, but if benzodiazepines are given, I use Valium instead of Xanax. Valium enters fast to take effect, and exits slow, perfect for output kypho length. Xanax enters really slow and exits super fast. I do 50% of my Kyphos outpatient without any sedation; riskier populations, I bring to asc.

 

[emd123]

Not a fan of sedation, but if benzodiazepines are given, I use Valium instead of Xanax. Valium enters fast to take effect, and exits slow, perfect for output kypho length. Xanax enters really slow and exits super fast. I do 50% of my Kyphos outpatient without any sedation; riskier populations, I bring to asc.

The onset of action for both po xanax and valium are about an hour.
Xanax will work. Valium will work, too. So will any other benzo.
But if you're worried about duration of action of benzos, and xanax not lasting long enough, be aware that the half-life of xanax is 6+ hours. That's plenty long for any in office procedure, and then some.
For valium, it's 20+ hours (up to 100 hrs for metabolites).
If you want to use valium, that's fine, but xanax is plenty long acting for my kyphos.
COMPARISON OF BENZODIAZEPINES

 

[bronchospasm]

I give versed 2 mg Iv and Fentanyl 2 ml/ 100 mcg Iv once patient is on the table and monitor patient for 30 minutes. It takes me about that much time to setup everything. Including opening the tray, iv antibiotic sterile prep and drape, setting up tray, ballon, cement mixer , currette etc, 2% lidocaine on skin, subq, as well as the track till Pedicles is contacted. Inject about 3 ml on the Pedicle.

Always bipedicular. Used to do unipedicular initially, but I now feel that I have more options with cement fill with the second needle in place.

Once the needle is advanced in the vertebral body after breaching the posterior wall, I inject 2 cc of 2 % lidocaine and put the styler back for another minute or so. This helps with pain of ballon inflation, negative pressure with styler removal etc.

Typically takes 30 minutes+ 30 minutes of actual procedure. Only do kypho and SCS trials on Fridays. No office visits on those days.

I picked up this technique for a Private practise attending.

Has worked really well for over 150+ Kypho’s.

 

[Ducttape]

Er, 2 mg fentanyl?
From my anesthesia days, the most I’ve ever pushed at once was 500 mcg?

 

[lobelsteve]

I'm unipedicular 99.9% of time. Have not needed bipedicular approach in over 8 years.

I plot my course on the MRI using measurement tools to make sure I can go across midline with needle tip.
Have not had any issues, but have gone parapedicular rather than bipedicular to make it work.

 

[bronchospasm]

Er, 2 mg fentanyl?
From my anesthesia days, the most I’ve ever pushed at once was 500 mcg?

Typo corrected

 

[bronchospasm]

I'm unipedicular 99.9% of time. Have not needed bipedicular approach in over 8 years.

I plot my course on the MRI using measurement tools to make sure I can go across midline with needle tip.
Have not had any issues, but have gone parapedicular rather than bipedicular to make it work.

That is a great idea.

 

[NJPAIN]

I'm unipedicular 99.9% of time. Have not needed bipedicular approach in over 8 years.

I plot my course on the MRI using measurement tools to make sure I can go across midline with needle tip.
Have not had any issues, but have gone parapedicular rather than bipedicular to make it work.

Two questions for you Steve:

1. Do you use a classic unipedicular approach or a para-pedicular approach going lateral a distance equal to the vertebral body width? I have seen that described by Doug Beall, an IR doc in Oklahoma, who describes it as a way to avoid bipedicular kypho.
2. You talk about a lot of MRI measurements to plan your approach for a variety of procedures. Are these standard "tools" on your standard reader or do you use an enhanced DICOM reader or some other tool kit?

 

[lobelsteve]

Two questions for you Steve:

1. Do you use a classic unipedicular approach or a para-pedicular approach going lateral a distance equal to the vertebral body width? I have seen that described by Doug Beall, an IR doc in Oklahoma, who describes it as a way to avoid bipedicular kypho.
2. You talk about a lot of MRI measurements to plan your approach for a variety of procedures. Are these standard "tools" on your standard reader or do you use an enhanced DICOM reader or some other tool kit?

90% are transpedicular and 10% are parapedicular. Of the parapediculars, I usually start to enter the pedicle 1/3 way in on the pedicle. I have lectured with Beall in the past. I pick a spot less than 8cm from the midline.

My current software is Novarad. But they all have measurement tools built in.

 

[Extralong]

The onset of action for both po xanax and valium are about an hour.
Xanax will work. Valium will work, too. So will any other benzo.
But if you're worried about duration of action of benzos, and xanax not lasting long enough, be aware that the half-life of xanax is 6+ hours. That's plenty long for any in office procedure, and then some.
For valium, it's 20+ hours (up to 100 hrs for metabolites).
If you want to use valium, that's fine, but xanax is plenty long acting for my kyphos.
COMPARISON OF BENZODIAZEPINES

I guess I just have a bias, Xanax is highly addictive due to its properties, don’t like giving anyone a taste of it.

 

[Extralong]

Question: Is there good data for which is more effective, kyphoplasty vs. vertebroplasty? Or is just a preference?
Looking for non-anecdotal data, not data that is funded by companies, and not a review saying that we more data.

It would really help me make better patient care. There’s a lot of smart people on this forum. Thanks!