Tips/Pearls to prevent extravasation with Vertebroplasty?

[cameroncarter]

I started accepting VCFs into my practice after a lot of work. Sadly, my ASC saw the reimbursements and is stopping carrying Kypho and is asking me to do Vertebroplasty instead. I’m scared of the increased extravastion risk though. Tips/pearls are appreciated.

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[gaspasser127]

Just go slow. Frequent fluoro shots. Don’t try to chase perfect.

 

[cameroncarter]

Just go slow. Frequent fluoro shots. Don’t try to chase perfect.

Thoughts on cement volume?

 

[Orin]

That's rough. Kyphoplasty seems safer for extravasation because of that space made by the balloon or osteotome, but you can create a cavity without a balloon. Drill a path, come back to the pedicle, then take another route at a slightly different trajectory. You're just trying to keep from injecting into a tight space right away where you're really flooding the vasculature.

Make sure you're anterior before you start injecting
Inject at lower pressures initially with multiple shots in the first 0.5 to 1 mL
Wait for the cement to be a touch more viscous/gummy in your hand before injecting into the body

The final volume is irrelevant to me as it's more a matter of where you inject and whether it's leaking.

The goal should not be to have zero leaks. Reality isn't going to allow for that. The goal needs to be identifying when you're leaking and to minimize symptomatic/dangerous leaks.

 

[DrMDAware]

Just go slow. Frequent fluoro shots. Don’t try to chase perfect.

is there any risk of going so slow the MMA hardens during the procedure and you can’t remove the sheath?

 

[SpineandWine]

if you’re advancing your needle anteriorly in lateral after vertebral body entry, keep in mind that even though you’re seeing a square in lateral fluoroscopy, it’s a circle/oval- the most anterior portion of that “square/rectangle” truly exists only if you’re perfectly midline.

 

[Ferrismonk]

In surprised by this. Kypho pays much better, IS better, and is safer. Have you considered just moving it to in-office?

 

[cameroncarter]

That's rough. Kyphoplasty seems safer for extravasation because of that space made by the balloon or osteotome, but you can create a cavity without a balloon. Drill a path, come back to the pedicle, then take another route at a slightly different trajectory. You're just trying to keep from injecting into a tight space right away where you're really flooding the vasculature.

Make sure you're anterior before you start injecting
Inject at lower pressures initially with multiple shots in the first 0.5 to 1 mL
Wait for the cement to be a touch more viscous/gummy in your hand before injecting into the body

The final volume is irrelevant to me as it's more a matter of where you inject and whether it's leaking.

The goal should not be to have zero leaks. Reality isn't going to allow for that. The goal needs to be identifying when you're leaking and to minimize symptomatic/dangerous leaks.

Great tips. Any idea if the vetebroplasty kit comes with an osteotome?

 

[cameroncarter]

In surprised by this. Kypho pays much better, IS better, and is safer. Have you considered just moving it to in-office?

I’m pretty new and the bosses want to only offer this in ASC where there’s surgical/anesthesia support.

Tell me more about payment- is Kypho payment in ASC really better than for vertebroplasty??

 

[Ferrismonk]

I’m pretty new and the bosses want to only offer this in ASC where there’s surgical/anesthesia support.

Tell me more about payment- is Kypho payment in ASC really better than for vertebroplasty??

On my phone, but this is a screenshot from ASIPP.

 

[cameroncarter]

On my phone, but this is a screenshot from ASIPP.

Ferris- you’re great, thanks!

I’m not quite sure what my ASC was getting at then…are the kypho kits that much more expensive than the vert kits??

 

[lobelsteve]

is there any risk of going so slow the MMA hardens during the procedure and you can’t remove the sheath?

Yes. Yes there is. And it was not fun.

 

[BobBarker]

kypho kits are more expensive but you should be able to get one for $1500 or less.

 

[cameroncarter]

kypho kits are more expensive but you should be able to get one for $1500 or less.

medtronic?

 

[powermd]

medtronic?

Check out IZI. Best pricing I've seen.

 

[DrMDAware]

For a full discussion please look at Spine Jack. I’ve never done one but I know it gets mentioned in the same discussions as kypho, vertroplasty

 

[cameroncarter]

For a full discussion please look at Spine Jack. I’ve never done one but I know it gets mentioned in the same discussions as kypho, vertroplasty

I think that’s even more expensive/ can anyone comment?

 

[Orin]

I think that’s even more expensive/ can anyone comment?

It is more expensive. I like it for some cases with retropulsion or clear end plate fractures as the force displacement in cranial/caudal rather than a balloon, but if you're hurting for money, I would focus on a cheap balloon system.

 

[RoloTomassi]

I think that’s even more expensive/ can anyone comment?

Quite a bit more if I recall. There's a special TPT reimbursement that helps offset but compared to kypho it's a wash at best. Given the extra time I would say it's a smaller margin.

 

[Orin]

Yes. Yes there is. And it was not fun.

Is this the access cannula or a nitinol sheath? I have had it harden while injecting to the point I needed a fresh batch, but never had one get stuck.

There is a tool called a cast spreader which I have found useful for when introducers/wires are stuck, but I also don't work out much

 

[BobBarker]

I think you should be able to get the Medtronic essentials down below $1500 especially with it being used in an ASC.

 

[SC Tian]

I think you should be able to get the Medtronic essentials down below $1500 especially with it being used in an ASC.

It is roughly $1100, only one balloon, better than vertebroplasty, needs to be familiar with unilateral approach, and do multiple level kypho with one system.

 

[DrMDAware]

I think that’s even more expensive/ can anyone comment?

Right. So when you negotiate put the price of the spine Jack on the table so comparatively the other two systems look like a steal.

 

[Asclepius186]

Yes. Yes there is. And it was not fun.

Please tell us more.

 

[lobelsteve]

Please tell us more.

10+ years ago. Office based kypho. Mixer broke. Had to use older technique of filling Verteport (any injecting needle that goes in the 10-11G kypho needle). Use a stylet to push cement in. Refill and replace. Had minor extravasation and let it sit 60 seconds to harden. Did not twist the inner needle enough. The ball of cement was stuck on the needle in the vertebral body and was moving in the cavity created. Patient on oral sedation only. Able to go into right sided pedicle and add cement to stabilize the ball and twist out left sided needle. Lots of pain produced. Got job done but admitted to hospital for pain control post-op and babied her for a few days. CT looked good, like I didn't mess it up and crap my pants.

 

[Asclepius186]

10+ years ago. Office based kypho. Mixer broke. Had to use older technique of filling Verteport (any injecting needle that goes in the 10-11G kypho needle). Use a stylet to push cement in. Refill and replace. Had minor extravasation and let it sit 60 seconds to harden. Did not twist the inner needle enough. The ball of cement was stuck on the needle in the vertebral body and was moving in the cavity created. Patient on oral sedation only. Able to go into right sided pedicle and add cement to stabilize the ball and twist out left sided needle. Lots of pain produced. Got job done but admitted to hospital for pain control post-op and babied her for a few days. CT looked good, like I didn't mess it up and crap my pants.

Does not sound fun. Smart thinking to access other pedicle and add cement there. Nice cautionary tale to keep those cannulae/needle spinning if stopping and waiting.