Kyphoplasty with 2 C arms

[bronchospasm]

Guys,

Has anyone done a kyphoplasty with 2 C-arms. Fixed for AP and Lateral. ?

If so do you have any pics / diagrams / visuals ?

I have 3 kyphos tomorrow and was hoping for some guidance on Carm and monitor placement.

Any and all help is appreciated.

Thank you

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[lobelsteve]

So you want to try something new?
1 arm works fine. more space to work.

 

[fathead88]

I much prefer to use 1 C-arm. On occasion when anesthesia pushes the cases to the main OR, the rad techs will want to set up 2 C-arms as opposed to my surgery center team that know my preferences. On average a 1 level case takes 15-18 minutes. It inevitably takes the rad tech and the scrub tech 10 minutes of screwing around to position and drape 2 C-arms., which defeats the purpose. Any caudal/cephalad tilt will also be a monumental task for most rad techs with 2 C-arms because the AP C-arm does not come in perpendicular to the OR bed.

 

[Baron Samedi]

Two C-arms is for nerds.

 

[nvrsumr]

Nice to have 3 kyphos in a day

 

[oneforfighting]

Found this on the web as I don't have any pics of my own set up but this is pretty close. The "lateral" c-arm is at toward the head of the bed and tilted forward to give you space to work. The "AP" c-arm is set up at an angle so as to not run into the other c-arm. I have both sets of monitors placed side by side so I know where to turn to look. The hardest part of kyphos is making sure the pictures look good/pedicles aligned, etc. Unless you have multiple levels far apart or scoliosis, there really isn't much extra movement of the c-arms once you're set up.

I do all of my kyphos with 2 c-arms. Takes the guesswork out of having my rad tech flip back and forth. All they have to do is click a couple of buttons.

 

[BobBarker]

3 kyphos at the hospital. Fun to do, but better off doing basic procedures financially.

 

[GoBeers]

honestly, with 1 c-arm, it's so easy doing kypho via en-face view

 

[bronchospasm]

3 kyphos at the hospital. Fun to do, but better off doing basic procedures financially.In office

 

[BobBarker]

Man, there is no way I would mess with 2 c arms in office.

 

[Orin]

View attachment 379045

Found this on the web as I don't have any pics of my own set up but this is pretty close. The "lateral" c-arm is at toward the head of the bed and tilted forward to give you space to work. The "AP" c-arm is set up at an angle so as to not run into the other c-arm. I have both sets of monitors placed side by side so I know where to turn to look. The hardest part of kyphos is making sure the pictures look good/pedicles aligned, etc. Unless you have multiple levels far apart or scoliosis, there really isn't much extra movement of the c-arms once you're set up.

I do all of my kyphos with 2 c-arms. Takes the guesswork out of having my rad tech flip back and forth. All they have to do is click a couple of buttons.

Yeah, I put both arms on one side, monitors at the foot of the bed. It really is a lot easier after the initial setup struggles as the rad tech involvement is minimal.

 

[thecentral09]

built my own rooms in private practice. Always 2 c arms. We did 5 cases last week before 11am. Same as Orin except monitors at head. Bring lateral in first, then prep pt and drape lateral under sterile field

 

[nvrsumr]

I’m starting to figure out the 2 million plus crew from the comp survey…

 

[Asclepius186]

I do this in a cath lab with c arm hanging from ceiling coming in from the head and second c arm brought in lateral. If you can become efficient at getting the setup it’s super nice and makes the procedure quicker. Also, it makes me feel much better during cement injection when I can see both views simultaneously to ensure no extravasation.

 

[lobelsteve]

Single C takes 10 min from skin to bandaid.

 

[CleanUp]

Single C takes 10 min from skin to bandaid.

You can do a kypho in 10 mins?! Wow.

 

[BobBarker]

If I have an asleep patient and OR staff it is about 7 minutes start to finish for a single level. It is 20-30 minutes room in to room out in an office. Lots of time getting the LOL comfy, awake, on and off the table.

 

[TIVAndy]

i tried it once but it was more painful to set it up - turn over was horrible. since then i stick to one c arm

 

[Ferrismonk]

Two C-arms makes sense if you're a surgeon and aren't used to using oblique or if your rad techs are new and don't understand oblique.

 

[bronchospasm]

Guys, the dual c arm setup was a pain to setup and the working space was limited due to a fixed lateral. But once the C arms were in place the procedure time was about 10-12 minutes.

The next week I did another Kyphoplasty the old fashioned way. Setup was easy but took just a bit longer due to AP/lat positioning.

Overall, prefer the old fashioned way. Not too excited about the 2 C arm setup. It was more work than expected but biggest issue was limited working area.

Thank you all for your inputs.

 

[SC Tian]

Single C takes 10 min from skin to bandaid.

Can you explain the tricks you can do this so fast, my cement prep is 8 minutes, times I need to redirect the trochar, thanks

 

[lobelsteve]

Review trajectory on MRI prior to procedure. I like to oblique to angle that I chose on MRI to get across midline and into right anterior VB from the left pedicle shadow. Drive needle in oblique view. Know depth to posterior VB at pedicle junction. Use the lines on the needle to tell you how much further to make sure you are approaching but not crossing the medial border of pedicle. Once at VB, change to steering stylet and drive it home.

 

[SC Tian]

Review trajectory on MRI prior to procedure. I like to oblique to angle that I chose on MRI to get across midline and into right anterior VB from the left pedicle shadow. Drive needle in oblique view. Know depth to posterior VB at pedicle junction. Use the lines on the needle to tell you how much further to make sure you are approaching but not crossing the medial border of pedicle. Once at VB, change to steering stylet and drive it home.

thanks for the information, my observation, unipedicular approach, the cement delivery is in lower vb on the opposite side, higher vb on the injection side, the cement is not able to cover the upper endplate well, do you modify the needle based on this? thanks.

 

[po_boy]

Review trajectory on MRI prior to procedure. I like to oblique to angle that I chose on MRI to get across midline and into right anterior VB from the left pedicle shadow. Drive needle in oblique view. Know depth to posterior VB at pedicle junction. Use the lines on the needle to tell you how much further to make sure you are approaching but not crossing the medial border of pedicle. Once at VB, change to steering stylet and drive it home.

Do you ever do bilateral?

 

[lobelsteve]

Do you ever do bilateral?

Not unless technically not possible to go unipedicular.

 

[Orin]

Do you ever do bilateral?

Not unless technically not possible to go unipedicular.

Conversely, I always do bilateral for MFE and the theoretical advantages in height restoration and tumor ablation unless contraindication to pedicle access

 

[pmrmd]

thanks for the information, my observation, unipedicular approach, the cement delivery is in lower vb on the opposite side, higher vb on the injection side, the cement is not able to cover the upper endplate well, do you modify the needle based on this? thanks.

Easy to change entry angle to avoid this. Unipedicular will get directly under endplate every time.

Kypho is a 10 minute procedure with Steve’s technique.

 

[po_boy]

Conversely, I always do bilateral for MFE and the theoretical advantages in height restoration and tumor ablation unless contraindication to pedicle access

MFE?

 

[SC Tian]

Easy to change entry angle to avoid this. Unipedicular will get directly under endplate every time.

Kypho is a 10 minute procedure with Steve’s technique.

nice, could you elaborate more on how you adjust to cover the upper endplate well? for example, you access from the left-sided pedicle, the needle goes from the upper part of the vertebrate on the left side to the lower part of the vertebrate on the right side, and cement delivery to the left lower part of the body can be very difficult, I think the bipedicular approach has more capacity of reduction and evenly cement distribution.

 

[lobelsteve]

nice, could you elaborate more on how you adjust to cover the upper endplate well? for example, you access from the left-sided pedicle, the needle goes from the upper part of the vertebrate on the left side to the lower part of the vertebrate on the right side, and cement delivery to the left lower part of the body can be very difficult, I think the bipedicular approach has more capacity of reduction and evenly cement distribution.

Not what the literature says...better outcomes with unipedicular approach.

Pedicles are 3d structures. You can start low on a pedicle and come out high. You can use the curved stylet and get anywhere in the bone.
You can put in the needle too far and leak cement out the opposite front of the bone (oops, last weeks problems (eggshelled and all good)).

 

[oneforfighting]

Not what the literature says...better outcomes with unipedicular approach.

Pedicles are 3d structures. You can start low on a pedicle and come out high. You can use the curved stylet and get anywhere in the bone.
You can put in the needle too far and leak cement out the opposite front of the bone (oops, last weeks problems (eggshelled and all good)).

Where in the literature does it say there are better outcomes with unipedicular? I do unipedicular but it’s due to the time savings, less fluoro and technically easier. But biped has been shown to produce superior height restorations. Both produce excellent clinical results.

 

[lobelsteve]

Comparison of unipedicular and bipedicular kyphoplasty for treating acute osteoporotic vertebral compression fractures in the lower lumbar spine: a retrospective study - BMC Musculoskeletal Disorders

Background Unipedicular and bipedicular approaches for percutaneous kyphoplasty are reportedly both effective in treating osteoporotic vertebral compression fractures (OVCFs). However, most studies have reported thoracolumbar fractures, with few reports describing the treatment of the lower...

bmcmusculoskeletdisord.biomedcentral.com

Several others. I went through literature for SIS review and uncovered the literature. Will look for it.

 

[SC Tian]

In this paper, need reach midline and front of vertebra, could you show us how you deliver cement to the circled area? Appreciated.

 

[lobelsteve]

In this paper, need reach midline and front of vertebra, could you show us how you deliver cement to the circled area? Appreciated.

Need axial and sag cuts to show exact trajectory. But look how much lower in that pedicle that needle could be.

 

[NJPAIN]

Need axial and sag cuts to show exact trajectory. But look how much lower in that pedicle that needle could be.

Steve, I’d love to see how you plan this out step by step. I’m about to start doing vertebral augmentation now, late in my career.

I have to say that this type of procedure is where individuals who have had technically demanding jobs or hobbies really excel. One of the KOAs who teaches for virtually every device manufacturer, and has what I consider to be exceptional technical skills, worked repairing machinery in a spark plug factory before going into medicine.

 

[SC Tian]

Need axial and sag cuts to show exact trajectory. But look how much lower in that pedicle that needle could be.

I do unipedicular approach as well, my needle trajectory just like that, do you mind to show how you needle placement like, AP, Lateral and Cement delivery

 

[lobelsteve]

I do unipedicular approach as well, my needle trajectory just like that, do you mind to show how you needle placement like, AP, Lateral and Cement delivery

If Anes does not cancel my L2-4 kypho today I can show you Left L2 and L4 as well as right L3 uniped apporach. Awaiting cards and pulm clearance at last minute- leads to me turfing to IR.

 

[Ducttape]

Steve, I’d love to see how you plan this out step by step. I’m about to start doing vertebral augmentation now, late in my career.

kudos to you and good luck!

it is nerve racking to add to your regimen as you get older, and i commend you for doing so.

 

[Orin]

MFE?

maximal fellow education

 

[SC Tian]

If Anes does not cancel my L2-4 kypho today I can show you Left L2 and L4 as well as right L3 uniped apporach. Awaiting cards and pulm clearance at last minute- leads to me turfing to IR.

Could you show us the style you do the kypho? thanks

 

[Espn123]

I use the same unipedicular approach described. The key is filling all four “quadrants” and thinking 3 dimensionally to manipulate the curve. As I have become more experienced I manipulate the curve AND the initial access cannula to achieve bilateral and front to back fills.

There was a post earlier w a picture asking how to fill the ipsilateral lower quadrant w a unipedicular approach…..for me that is the last area I fill after retracting the access cannula close to the posterior border then using a curve directed south.

 

[SC Tian]

I use the same unipedicular approach described. The key is filling all four “quadrants” and thinking 3 dimensionally to manipulate the curve. As I have become more experienced I manipulate the curve AND the initial access cannula to achieve bilateral and front to back fills.

There was a post earlier w a picture asking how to fill the ipsilateral lower quadrant w a unipedicular approach…..for me that is the last area I fill after retracting the access cannula close to the posterior border then using a curve directed south.

thanks for the information, which company has this curved stylet, only straight stylet is provided from Medtronic, our kits are basic ones, low quality cements, pulling cannula close to posterior border to deliver the cement is not risky to leak cement posteriorly?

 

[BobBarker]

You can only typically afford to use a curved kit in the hospital setting. Medtronic/stryker/everyone has curved products available.

 

[nvrsumr]

I think my guy charges $100 extra for the curved trochar. I haven’t used but probably will start

 

[Espn123]

thanks for the information, which company has this curved stylet, only straight stylet is provided from Medtronic, our kits are basic ones, low quality cements, pulling cannula close to posterior border to deliver the cement is not risky to leak cement posteriorly?

With experience you develop a feel for the flow of cement. This is done towards the end of the case as cement is not as free flowing as it is early in the case.

I use a kit from IZI medical but I think many have a curved needle.

 

[Espn123]

You can only typically afford to use a curved kit in the hospital setting. Medtronic/stryker/everyone has curved products available.

Definitely not the case

 

[SC Tian]

With experience you develop a feel for the flow of cement. This is done towards the end of the case as cement is not as free flowing as it is early in the case.

I use a kit from IZI medical but I think many have a curved needle.

Thanks, could you show us some of Kypho pictures, appreciate it.