Dr. Finkenberg demonstrates the kyphoplasty procedure, which is the restoring of the original height and angle of kyphosis of a fractured vertebra.
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First let’s look at the spine. In the lumbar spine region typically at the thoracolumbar junction is where we see many of our osteoporotic compression fractures, but they are typically in the very anterior part of the vertebrae here. What tends to happen is that with a flexion maneuver or fall, the osteoporotic bone tends to compress anteriorly, and as it does that you get a wedge effect to the vertebrae. Some people say, “I have a hunched-over back and I walk in a flex forwards position,” and frequently that’s due to multiple vertebrae having that anterior compression fracture, the anterior being up here where my finger is pointing now. So when we see these types of fractures, X-rays obviously are taken first, and when that X-ray is completed and we see what appears to be a fracture, we have several choices. If the patient is able to undergo an MRI scan, that scan is particularly helpful in helping us tell how new the fracture is. Fractures that have been present for years will continue to show the compression but in reality are not the cause of the person’s pain at that time. So when we get an MRI of the lumbar or thoracic spine and you look on specific images, we call them T2 and STIR images, they tend to show increased uptake in the vertebrae of those fractured vertebrae, and that to us represents an acute or subacute fracture. In demonstrating the procedure, it’s usually done in a prone position. It can be done under local anesthetic as well as general anesthesia. What we do is have the patient lying on their stomach, which is prone, and we anesthetize the area that we plan to do the injection as well as clear it of any bacteria by prepping the area. Once that’s complete we make small incisions, the size of a pencil, and we introduce trocars. Those trocars are guided by fluoroscopy which is a type of radiographic equipment, and it allows us to see where we are placing the trocar in the vertebrae and we get pictures from the side as well as from the front. Once that trocar is in place, then we have the ability to pass this balloon inside the vertebra under radiographic imaging, and we can tell whether it’s exactly in the vertebra where we want it to be. Once it’s inside, we can blow up a small balloon within the vertebra to create a void. I like this procedure in the sense that it allows us to create the void first so we have the ability to place the cement in, in a more viscous or thick character. By being thicker, I think you decrease your chances of pulmonary embolism and complications. So I am going to try to blow up this balloon here to give you an idea as to what this looks like, and then you will see what is going on inside the vertebra. So with the balloon blown up like this and filled with fluid that has radiographic material in it, we can see that 2 ccs, 3 ccs of fluid is filling in the balloon and creating a nice void for us. This can be done unilaterally, meaning from one side, or bilaterally. Once again, with the radiographic equipment we are able to place it without causing any neurologic injuries. Once that procedure is finished, the balloon is collapsed and pulled back out, and bone cement is placed down trocars into the void that we created in the bone. When we are finished, a picture something like this will occur on the X-ray, and you can see within the vertebral body there are spaces filled with white cement, and that, as I mentioned earlier, gets very hard within 20 minutes, and from that point on it’s just a matter of closing the small incisions on the skin, getting final X-rays, and transferring the patient out of the operating room.
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