Kyphoplasty in clinic

[tmvguy03]

For those who do kyphoplasty, are you doing this in clinic or OR/ASC? I'm considering adding this to my practice (outpatient clinic). We don't use IV sedation for procedures (valium 5-10mg for SCS trials), but I know kyphoplasty is a different- would it be reasonable to rely on oral sedation and sufficient local though? Thanks

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[lobelsteve]

All the time.

 

[chudat]

In terms of sterility and air flow, still doable?

 

[Espn123]

Office. Good local goes a long way

 

[Orin]

All the time.

How do you handle the hammering?

 

[deleted875186]

This is fascinating. Never seen them in the office setting, especially with just local and mild sedation.

 

[swamprat]

I do them no sedation just local. Essentially every step of the way lido with Epi starting with a spinal needle down to the target pedicle and Flooding the area. If osteoporotic u usually can get away without hammering just gentle back and forth twisting with some pressure. Any pain I inject local. Once I’m in the body I use some local then blow up balloon. It’s worked out pretty well

 

[Espn123]

How do you handle the hammering?

I used to use a mallet every time, but now rarely do

 

[manowar rules]

I do these all the time too. I use xanax for peri-procedural sedation. Usually I can talk to them through the procedure, sometimes they'll snore away which I don't mind. I've never had an issue with it. If they can tolerate lying on the table without exquisite pain, they can get through the kypho.

 

[RoloTomassi]

Yes, combination of PO benzo and opioid. Heavy local on and under the periosteum, and waiting a few minutes before tapping in makes a big difference. Small rapid taps rather than big whacks.

 

[drusso]

Office with mild IV sedation.

 

[pmrmd]

Office with IV sedation usually, sometimes just local.

 

[gdub25]

We use local, Valium, and titrate in some nitrous if they need it. We do a bunch and like others have said patients do fine.

 

[callmeanesthesia]

Local, with a low dose of Xanax and Norco (most are already on an opiate for the fracture anyway). Most do fine.

 

[TIVAndy]

agree with others - valium, oral opioid maybe, and LOCAL. i've learned recently to inject some local in the vertebral body - helps with pain during ballooning. (although becareful with absorption. likely very rapid due to vascularity)

 

[painfree23]

Does the cement stink up the procedure room?

 

[lobelsteve]

How do you handle the hammering?

With a mallet. When needed. Most of these bones are pretty OP and easy to drive through with just the needle. Drill comes in my kits as well, but mostly for extra reach in adipose rich patients.

Mallet is in sterile pack like everything else, drop it on the mayo. As far as swinging it, tell the patient they will say ouch, but it will not hurt, it just seems like it should because I am hitting them with a hammer. Honestly, the stylet removal hurts more people than the mallet.

 

[jsaul]

all the spine surgeons around me do this under general.
I do it at the facility with IV sedation

 

[mid|ine]

I have done a few in the office, but can't get them regularly enough to get the logistics to work out, so I just send them to the Neurosurgeon in our group.

 

[CATS22]

For those of you doing in office kyphoplasty are you using one or two c-arms? I don't do them any longer but in fellowship I believe we did both. My partner is looking to bring these on and is saying he would like a second c-arm. Our procedure room is decent size but would be a pain to store a second c-arm. Same goes for the clinic. Not a ton of room. This seems like more of an efficiency issue than a safety one?
Thanks

 

[drusso]

For those of you doing in office kyphoplasty are you using one or two c-arms? I don't do them any longer but in fellowship I believe we did both. My partner is looking to bring these on and is saying he would like a second c-arm. Our procedure room is decent size but would be a pain to store a second c-arm. Same goes for the clinic. Not a ton of room. This seems like more of an efficiency issue than a safety one?
Thanks

If you know trigonometry what do you need the second c-arm for?

 

[RoloTomassi]

For those of you doing in office kyphoplasty are you using one or two c-arms? I don't do them any longer but in fellowship I believe we did both. My partner is looking to bring these on and is saying he would like a second c-arm. Our procedure room is decent size but would be a pain to store a second c-arm. Same goes for the clinic. Not a ton of room. This seems like more of an efficiency issue than a safety one?
Thanks

Would not invest just to do kypho unless you're doing crazy volume. It does make it faster not having to go back and forth, and safer as you can see lateral extravertebral spread and some vascular uptake that lateral view can miss but really you just need to worry the most about canal spread on lateral view.

 

[lobelsteve]

Double the radiation. Sounds great. Did in office with local yesterday on my lunch break. Too many fractures this year.

 

[myrandom2003]

Are these patients getting an IV in place, just in case? Any preprocedural antibiotics?

 

[RoloTomassi]

Are these patients getting an IV in place, just in case? Any preprocedural antibiotics?

I do both

 

[Propofool123]

I remember seeing these done by interventional radiology during anesthesia residency under GA. In fellowship we do IV sedation + generous local. I think good local and hand holding during the balloon makes all the difference.

 

[ateria radicularis magna]

For those of you doing in office kyphoplasty are you using one or two c-arms? I don't do them any longer but in fellowship I believe we did both. My partner is looking to bring these on and is saying he would like a second c-arm. Our procedure room is decent size but would be a pain to store a second c-arm. Same goes for the clinic. Not a ton of room. This seems like more of an efficiency issue than a safety one?
Thanks

I would not get another c arm unless you are just rolling in cash and don’t care about the cost

 

[CATS22]

Would not invest just to do kypho unless you're doing crazy volume. It does make it faster not having to go back and forth, and safer as you can see lateral extravertebral spread and some vascular uptake that lateral view can miss but really you just need to worry the most about canal spread on lateral view.

Just curious. What would be "high volume". One a week? Several a week? Also, can someone give a ballpark of what the supplies cost for a one level or two level procedure? I've seen numbers for 1.5k? The people that are doing sedation do you bring on a CRNA? Or are you pushing the IV versed yourself or with an RN... an then lots of local. If you use a CRNA are they billing themselves or are you paying them?

 

[RoloTomassi]

Just curious. What would be "high volume". One a week? Several a week? Also, can someone give a ballpark of what the supplies cost for a one level or two level procedure? I've seen numbers for 1.5k? The people that are doing sedation do you bring on a CRNA? Or are you pushing the IV versed yourself or with an RN... an then lots of local. If you use a CRNA are they billing themselves or are you paying them?

In the context of your c-arm question, high volume is the volume it would take where however many minutes you would save on flipping between views adds up enough that you could squeeze in more procedures and pay for that second c-arm in relatively short order, assuming you're busy enough.

In the general sense, volume is highly variable, dependent hospital employed vs PP, as well as your payer mix. I don't do many because I have a Medicare cap and in my area IR gets the bulk.

 

[thecentral09]

Just curious. What would be "high volume". One a week? Several a week? Also, can someone give a ballpark of what the supplies cost for a one level or two level procedure? I've seen numbers for 1.5k? The people that are doing sedation do you bring on a CRNA? Or are you pushing the IV versed yourself or with an RN... an then lots of local. If you use a CRNA are they billing themselves or are you paying them?

Agree with anyone who can add additional input to this question. Also considering adding IV sedation in an office setting, is there additional permit that you need to provide IV sedation?, Do we need a CRna if we are an anesthesiologist?

 

[fathead88]

No you don't need a CRNA. We do in office IV moderate sedation (we are a group of anesthesia/pain docs) for Kypho. IV ketamine is great for those.

 

[manowar rules]

No you don't need a CRNA. We do in office IV moderate sedation (we are a group of anesthesia/pain docs) for Kypho. IV ketamine is great for those.

So are your main agents ketamine and versed? Who gives your meds, an RN?

I’ve been getting by with oral meds, but I’d like to have IV as an option

 

[fathead88]

I give the first push of meds prior to gowning. Typically this is 2-3 mg versed and 10-20 mg ketamine. Then LOTS of lidocaine. About 80% of the time no further IV meds are needed. This patient population typically is easy to sedate.

 

[drrosenrosen]

I give the first push of meds prior to gowning. Typically this is 2-3 mg versed and 10-20 mg ketamine. Then LOTS of lidocaine. About 80% of the time no further IV meds are needed. This patient population typically is easy to sedate.

We also use IV versed and ketamine for procedural sedation in office. For kyphos or stim trials, one of us usually helps with sedation for the operating doc (we're all anesthesiologists). We set those cases up early morning before the office usually opens, so it doesn't throw off our schedule for regular clinic and procedures

 

[painfree23]

We also use IV versed and ketamine for procedural sedation in office. For kyphos or stim trials, one of us usually helps with sedation for the operating doc (we're all anesthesiologists). We set those cases up early morning before the office usually opens, so it doesn't throw off our schedule for regular clinic and procedures

Who starts the IV?

 

[drrosenrosen]

Who starts the IV?

We start our own IVs. We have one MA who is good enough that we trust him to do them sometimes.

 

[lobelsteve]

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[Orin]

What's a good source for a mallet for in-clinic kypho?

 

[BobBarker]

eBay

 

[Ferrismonk]

What's a good source for a mallet for in-clinic kypho?

Your rep will likely give you one if you ask nicely.

 

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[Doctodd]

Just curious. What would be "high volume". One a week? Several a week? Also, can someone give a ballpark of what the supplies cost for a one level or two level procedure? I've seen numbers for 1.5k? The people that are doing sedation do you bring on a CRNA? Or are you pushing the IV versed yourself or with an RN... an then lots of local. If you use a CRNA are they billing themselves or are you paying them?

High volume anything would be a reason to have 2. Around 25-30+ basic procedures per day is high volume….15 in AM and 15 in PM which is 3-4 per hour or 1 every 15”. If you have the support staff and the room it can be done.

 

[sdnuser001]

For those who do kyphoplasty, are you doing this in clinic or OR/ASC? I'm considering adding this to my practice (outpatient clinic). We don't use IV sedation for procedures (valium 5-10mg for SCS trials), but I know kyphoplasty is a different- would it be reasonable to rely on oral sedation and sufficient local though? Thanks

Can kypho be done in office if no IV is being placed? I know some are doing with just local and oral sedation but have typically always seen IV antibiotics given beforehand

 

[nopain1234]

All the time.

This guy is a savage with kypho. Don’t listen to him

 

[lobelsteve]

Can kypho be done in office if no IV is being placed? I know some are doing with just local and oral sedation but have typically always seen IV antibiotics given beforehand

All the time.
Savage.
I use up to 10cc local per level.

 

[BobBarker]

I inject about 10ml local but also give toradol, Promethazine, and Rocephin IM/SQ With oral diazepam and nitrous.

 

[lobelsteve]

I inject about 10ml local but also give toradol, Promethazine, and Rocephin IM/SQ With oral diazepam and nitrous.

Crap load of things to complicate a procedure. Toradol adds nothing. IM Rocephin hurts more than a kypho. Promethazine- pointless.
I give Ativan 1mg #2. One when leaving house, one on arrival. 2g Ancef IV 40 min prior to procedure.

 

[SC Tian]

Here kyphos are traditionally performed by ortho with two carms under general, even they were switched to mac now, they cannot believe those can be done in office. Thanks for the information.

 

[BobBarker]

Promethazine helps with the nausea from
the nitrous and gets them sleepier. Toradol acutely has significant pain relieving properties (see Mahomes, Patrick). Rocephin mixed with lido is not very painful.

 

[RoloTomassi]

Promethazine helps with the nausea from
the nitrous and gets them sleepier. Toradol acutely has significant pain relieving properties (see Mahomes, Patrick). Rocephin mixed with lido is not very painful.

Nitrous is awesome. Been using for 2 mo. How often is nausea, have not seen.