Re-do Kyphoplasty??

[NJPAIN]

Patient with persistent thoracic pain. Sent with painful subacute T7 fracture to IR for augmentation several months ago. PCP told her to go to local neurosurgeon/"interventional pain doc" instead who did case in his office. Patient reports significant procedural pain and SOB (heavy smoker, post COVD-19, no supplemental oxygen available) during procedure. Attached films show result. Pain is unchanged. Does this warrant consideration of a re-do now months later or has that ship sailed?

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[DesertDoc16]

I don’t even do much kypho… but I would think that ship has sailed. Sucks for the patient…. Terrible looking cement placement.

I think there might be some utility in thoracic RF at this level, I’ve had it help with persistent axial pain at fracture levels.

What does the rest of the hive think?

 

[Taus]

Patient with persistent thoracic pain. Sent with painful subacute T7 fracture to IR for augmentation several months ago. PCP told her to go to local neurosurgeon/"interventional pain doc" instead who did case in his office. Patient reports significant procedural pain and SOB (heavy smoker, post COVD-19, no supplemental oxygen available) during procedure. Attached films show result. Pain is unchanged. Does this warrant consideration of a re-do now months later or has that ship sailed?View attachment 341901View attachment 341900

I’d get new mri. If still inc t2/stir I’d consider a redo in highly experienced hands…. But also completely reasonable to do adjacent facet mbb/rfa

 

[Agast]

Facet joint procedures can be pretty effective for compression fx pain. Sometimes I do that first.

 

[BobBarker]

I would redo it. I have redone many over the years due to refracture or poor prior fill with pain still concordant with VCF.

 

[RoloTomassi]

I had a WC patient with compression fx who had been through the WC hoops (long delays in care, very conservative tx, multiple docs). By the time he got to me, 14 mo later, he had failed extensive therapy, RFA. Updated MRI negative STIR. Pain was consistent with fx the whole time. Talked to several colleagues about kypho. Found some studies supporting it on old fx. Long discussion of risks and minimal evidence it'll help, but he wanted to do it. Pain almost fully relieved after kypho. Very sclerosed, balloons barely filled, more of vertebroplasty.

 

[DrSpine]

Get new MRI and CT. Consider re-do of Kypho/Vertebroplasty if not adequate filling, or Thoracic MBB/RFA. Vertebro is fair because can help fill the body while the thermal heat of the cement essentially ablates the basi-vertebral nerves (at least what I postulate).

 

[painfree23]

How many levels would u thoracic mbnb?

 

[Ferrismonk]

How many levels would u thoracic mbnb?

As many as the insurance will allow, but usually at least the one above and below.

 

[Multimodal]

As many as the insurance will allow, but usually at least the one above and below.

this is what I would do too. never done a redo kypho so to me seems intimidating.

 

[NJPAIN]

this is what I would do too. never done a redo kypho so to me seems intimidating.

Doesn't intimidate me because I'm not doing it. There is a neurosurgeon about 30 min away who is a MASTER. I'm inquiring here because I don't want to send to him if it is a complete waste of time. I wanted patient to go there in the first place but she is one of those country bumpkins who doesn't leave the county.

 

[Orin]

Doesn't intimidate me because I'm not doing it. There is a neurosurgeon about 30 min away who is a MASTER. I'm inquiring here because I don't want to send to him if it is a complete waste of time. I wanted patient to go there in the first place but she is one of those country bumpkins who doesn't leave the county.

It looks amenable to a refill in skilled hands as there are windows above and contralateral to the fill. Order an MRI + STIR sequence. Send it regardless. Temporize with blocks.

 

[JelloIsJigglin]

i've been getting a handful of VCF referrals but all of them have retropulsion. I thought this was a contraindication given concern of cement leakage, but then I hear many folk still doing them. I"m curious what is everyone's general thoughts here?

 

[lobelsteve]

No issue if less than third canal compromise. Search forums.

 

[Gnarvin]

I have heard so many differing things when it comes to contraindication for kypho. I have heard retropulsion being a contraindication, retropulsion causing more than one third canal compromise being a contraindication , retropulsion causing severe stenosis being a complication. I have also been told that retropulsion is not a contraindication at all unless there is neurological compromise (cauda equina syndrome, myelopathy). I am not sure what to go by to be honest.

 

[soccrwz]

I have heard so many differing things when it comes to contraindication for kypho. I have heard retropulsion being a contraindication, retropulsion causing more than one third canal compromise being a contraindication , retropulsion causing severe stenosis being a complication. I have also been told that retropulsion is not a contraindication at all unless there is neurological compromise (cauda equina syndrome, myelopathy). I am not sure what to go by to be honest.

It’s more of a watch your filling technique so it doesn’t go back into the canal thing, and try not to be over eager with filling. Usually the PLL provides some support. Discuss r/b/a, art more than an exact science. Retropulsion generally okay, unless significant stenosis/cord signal changes, also be careful if pedicle fracture

 

[BobBarker]

I was taught retropulsion was a contraindication in fellowship but it isn’t. With good technique, you can reduce the retropulsion. It’s fine to proceed. Just be mindful of your fill as mentioned above. I have done around 1000 levels.