Vertebral Augmentation Techniques , 1st Edition

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Contributors

Alaa Abd-Elsayed, MD, MPH, CPE, FASA Gabrielle Frisenda, MD

Medical Director, UW Health Pain Services Department of Anesthesia and Critical Care
Medical Director, UW Pain Clinic University of Chicago
Division Chief, Chronic Pain Management Chicago, Illinois
Department of Anesthesiology United States
University of Wisconsin
Madison, Wisconsin Manuchehr Habibi, MD
United States Department of Anesthesiology
University of Wisconsin School of Medicine and
Mohammad H. Bawany, MD Public Health
Department of Emergency Medicine Madison, Wisconsin
University of Wisconsin School of Medicine and United States
Public Health
Madison, Wisconsin Nasir Hussain, MD, MSc
United States Department of Anesthesiology
The Ohio State University, Wexner Medical Center
Clayton Busch, MD Columbus, Ohio
Department of Anesthesiology United States
The Ohio State University, Wexner Medical Center
Columbus, Ohio Navdeep S. Jassal, MD
United States Assistant Clinical Professor
Department of Neurology/Pain
Ahish Chitneni, DO University of South Florida
Department of Rehabilitation and Regenerative Tampa, Florida
Medicine United States
New York-Presbyterian Hospital -Columbia and
Cornell Ahmed Malik
New York, New York University of Chicago
United States Chicago, Illinois
United States
Pooja Chopra, MD
Pain Management Physician Tariq Malik, MD
Bux Pain Management Associate Professor
Danville, Kentucky Anesthesia and Critical Care
United States University of Chicago
Chicago, Illinois
Kenneth J. Fiala, BS United States
University of Wisconsin School of Medicine and
Public Health
Madison, Wisconsin
United States

vi
 Contributors vii

Genevieve Marshall, DO Ahmed M. Raslan, MD

Department of Physical Medicine and Rehabilitation Vice Chair for Clinical Affairs
Zucker School of Medicine at Hofstra/Northwell Department of Neurological Surgery
Health Oregon Health & Science University
Long Island, New York Portland, Oregon
United States United States

Joshua M. Martens, BS Lucas Vannoy, DO

University of Wisconsin School of Medicine and Department of Anesthesiology
Public Health University of Wisconsin School of Medicine and
Madison, Wisconsin Public Health
United States Madison, Wisconsin
United States
David J. Mazur-Hart, MD
Department of Neurological Surgery Ognjen Visnjevac, MD
Oregon Health & Science University Chief, Spine Pain Program, Bloor Pain Specialists
Portland, Oregon Anesthesiologist & Pain Management Physician,
United States Cleveland Clinic Canada and Bloor Pain Specialists;
Assistant Clinical Professor (Adjunct)
Kailash Pendem, MD Department of Anesthesiology
Department of Physical Medicine and Rehabilitation Faculty of Health Sciences
University of Florida McMaster University
Gainesville, Florida Hamilton, Ontario
United States Canada
Keth Pride, MD Nasser K. Yaghi, MD
Assistant Professor Department of Neurological Surgery
Department of Anesthesiology Oregon Health & Science University
University of Wisconsin School of Medicine and Portland, Oregon
Public Health United States
Madison, Wisconsin
United States
Preface

Vertebral augmentation is an advanced procedure per- This book provides a definitive guide for practitio-
formed by pain physicians, interventional radiologists, ners performing vertebral augmentation, incorporat-
and spine surgeons. Over time, revolutionary changes ing detailed figures and perspectives from leaders in
in equipment, technique, and equipment have dra- the field to maximize the conveyance of currently
matically altered the performance of these procedures. practiced techniques.
Vertebral augmentation is a profoundly critical pro- I would like to thank the authors and publisher for
cedure that requires thoughtful patient selection and their support and dedication in bringing this guide to
a thorough understanding of procedural indications, practitioners.
contraindications, and optimal maximization of im-
provements in procedural outcomes. Alaa Abd-Elsayed, MD, MPH, CPE, FASA

viii
Contents

1. Vertebral Anatomy, 1 7. Vertebral Augmentation Using Expandable

Mohammad H. Bawany, Ognjen Visnjevac, Intravertebral Implants, 59
and Alaa Abd-Elsayed Pooja Chopra, Kailash Pendem, Genevieve Marshall,
and Navdeep S. Jassal
2. Patient Selection for Vertebral Augmentation, 25
Manuchehr Habibi, Kenneth J. Fiala, and 8. Radiofrequency Ablation for Metastatic Bone
Alaa Abd-Elsayed
Lesions With Vertebral Augmentation, 67
Gabrielle Frisenda, Tariq Malik, and Ahmed Malik
3. Perioperative Care for Vertebral Augmentation, 29
Alaa Abd-Elsayed and Ahish Chitneni
9. Basivertebral Nerve Ablation, 83
Alaa Abd-Elsayed and Ahish Chitneni
4. Vertebroplasty/Kyphoplasty: Transpedicular
Approach, 31 10. Outcome Measurement for Vertebral
Lucas Vannoy and Keth Pride
Augmentation, 89
Manuchehr Habibi, Joshua M. Martens,
5. Balloon Augmentation, 45 and Alaa Abd-Elsayed
David J. Mazur-Hart, Nasser K. Yaghi,
and Ahmed M. Raslan
Index, 93
6. Vertebral Augmentation With Osteotome, 53
Clayton Busch, Nasir Hussain, and Alaa Abd-Elsayed

ix
 Chapter 1

Vertebral Anatomy
Mohammad H. Bawany, Ognjen Visnjevac, and Alaa Abd-Elsayed

A detailed understanding of spinal anatomy is requisite cervical spine, also known as the craniocervical
to performing spinal procedures. The spine consists of junction. In total, 33 bones make up the entire
bones, ligaments, discs, blood vessels, and nerves. vertebral column. Of these bones, 24 are individu-
ally separate though linked to each other through
Bony Structures and Ligaments joints and ligaments to provide both support
and flexibility. The lower nine bones are fused
of the Spine
in adults and make up the sacrum and coccyx
The bony components of the spine, or vertebrae, (Fig. 1.1).1 This chapter will focus on the upper
begin at the transition from the skull to the 24 vertebrae.

C1 (atlas) C1

C2 (axis)
Cervical
vertebrae

C7
C7
T1 T1

Thoracic
vertebrae

T12 T12

L1 L1

Lumbar
vertebrae

L5
L5

Sacrum

Coccyx

Anterior Posterior lateral

Fig. 1.1 Anterior, posterior, and lateral views of bony structures of the spine. (From Cleveland Clinic Center for Medical Art & Photography

© 2011–2015. All rights reserved. With permission.)

1
2 Vertebral Augmentation Techniques

The upper 24 vertebrae can be divided into 7 including L5 sacralization, which is incorporation
cervical, 12 thoracic, and 5 lumbar. Accurate and of the L5 vertebral body into the sacrum (Fig. 1.2).2
consistent numbering of vertebrae is critical in The vertebrae are arranged such that, when in
guiding interventions. Therefore, it is important to the upright position, they make naturally occurring
note anatomical variants that may be encountered, curves. These curves assist in the spine’s ability to

Fig. 1.2 Sacralization. L5 fuses fully or partially into the sacrum, on one or both sides. Sacralization is a congenital anomaly. (From Doo AR, Lee J,


Yeo GE, et al. The prevalence and clinical significance of transitional vertebrae: a radiologic investigation using whole spine spiral three-dimensional computed
tomographic images. Anesth Pain Med. 2020;15(1):103-110, Fig. 2.)
 1 Vertebral Anatomy 3

distribute vertical compressive forces. When viewed While there are structural variations, most of the
from the side, the cervical and lumbar spines vertebrae are composed of an anterior part and a pos-
appear concave, known as lordosis, whereas the terior part. The anterior part of a vertebra contains
thoracic spine appears convex, known as kyphosis the vertebral body. Externally, it is made of a hard
(Fig. 1.3).3 shell of compact bone; internally, it consists of

Right lateral view Anterior view

S Axis S
Atlas
P A R L
Cer vical Cervical
cur vature

I vertebrae I
(7)
cic cur vature

Thoracic
vertebrae
(12)
Thora

Lum
bar c
urvature

Intervertebral
foramina

Lumbar
vertebrae
(5)
e
tur
ral curva
Sa c

Sacrum

A B Coccyx

Fig. 1.3 Natural curvature of the spine. (From Patton K, Thibodeau G, Douglas M. Essentials of Anatomy and Physiology. Elsevier; 2012: 161, Fig. 9.10.)

4 Vertebral Augmentation Techniques

marrow-containing trabecular bone, which is inner- in load bearing and are discussed later. The posterior
vated by the sinuvertebral and basivertebral nerves part of a vertebra contains the vertebral arch, which in-
(Fig. 1.4).4 cludes the pedicle, lamina, spinous process, transverse
Each vertebral body is separated by intervertebral process, and superior and inferior articular processes,
discs that sit between adjacent vertebrae. These discs aid which form the facet or zygapophyseal joints (Fig. 1.5).5

Vertebral Vertebral
arch body

Nucleus pulposus
Annulus fibrosis

Intervertebral disc

Endplate region

Trabecular centrum
Cortical shell

Cartilage endplate
Vertebral endplate

Fig. 1.4 Vertebral structure. (Left) A vertebra is split into the vertebral arch posteriorly and vertebral body anteriorly. (Right) The body is made up
of trabecular bone surrounded by a cortical shell. Superiorly and inferiorly is the end-plate region, atop which sits the intervertebral disc. (Modified


from Auger JD, Frings N, Wu Y, et al. Trabecular architecture and mechanical heterogeneity effects on vertebral body strength. Curr Osteoporos Rep.
2020;18:716-726, Fig. 1.)
SAP

TP

PI
B P

IAP SP
L
Fig. 1.5 Lumbar vertebra, superior view (left) and lateral view (right). B, Vertebral body; C, spinal canal; IAP, inferior articulating process; L, lamina;
P, pedicle; PI, pars interarticularis; SAP, superior articulating process; SP, spinous process; TP, transverse process. (Modified from Manjila SV, Mroz, TE,


Steinmetz MP. Lumbar Interbody Fusions, 1st ed. Elsevier; 2018. chap 3, 19-21, Figs. 3.1 and 3.2.)
 1 Vertebral Anatomy 5

The pedicles connect the vertebral body to the The laminae connect the transverse processes to
transverse processes as well as the laminae, together the spinous process and form the roof of the spinal
creating the arch, which helps encase the spinal canal through which the spinal cord travels. The spi-
cord. Nerve roots exit inferior to each pedicle; nous process is the point for muscle and ligament at-
thus, the pedicle is a key anatomical landmark to tachment, notably, those muscles used for extension of
identify during needle placement for interventional the vertebral column.3 The articular processes also
procedures.6 With fluoroscopic imaging, pedicles project from the laminae and allow a vertebra to ar-
appear as rounded areas of increased bone density ticulate with the vertebrae above and below it to form
(Fig. 1.6).7 the zygapophyseal, or facet, joints (Fig. 1.7).8

Fig. 1.6 The “Scotty dog” in lumbar oblique projections that assists in identifying fluoroscopic landmarks. (A) Fluoroscopic image with needle in
position for a supra-neural transforaminal epidural steroid injection. (B) How the anatomical landmarks create the “Scotty dog” outline and eye.
IAP, Inferior articular process—front and back legs; IEP, inferior endplate; LAM, lamina—body; P, pedicle—eye; PI, pars interarticularis—neck;
SAP, superior articular process—ear; SEP, superior endplate; SP, spinous process—tail. (From Furman MB. Atlas of Image-Guided Spinal Procedures.


2nd ed. Elsevier; 2018:chap 3, 27-65, Fig. 3.20.)

Fig. 1.7 Facet joints in lateral view. (From Mahadevan V. Anatomy of the vertebral column. Surgery (Oxford). 2018;36(7):327-332, Fig. 4.)

6 Vertebral Augmentation Techniques

Cortical rim

Vertebral Cancellous
body bone

Pedicle
Transverse process

Facet joints
Spondylolysis
Lamina Spinal canal

Spinous process

A B C

Pars
Interarticularis Spondylolysis

Spondylolisthesis

Fig. 1.8 Top (left and right) showing a defect in the pars interarticularis (PI), termed spondylolysis. Bottom showing sagittal views of the spine
with the intact PI (A), pars defect (B), or spondylolysis, and anterior displacement of the L5 vertebral body (C), or spondylolisthesis. (Modified from


Chakravarthy V, Patel A, Kemp W, Steinmetz M. Surgical treatment of lumbar spondylolisthesis in the elderly. Neurosur Clin N Am. 2019;30(3):341-352.)

The thicker portion of the lamina that acts as the ability of the cervical spine. C1 attaches the skull to
junction connecting the spinous processes to the supe- the spine. It is unlike the other vertebrae in that it
rior and inferior articular processes on a single vertebra lacks a vertebral body and a spinous process. It is
is known as the pars interarticularis. It is prone to “pars shaped like a ring: two lateral masses are connected
defects,” or fractures known as spondylolysis, which can by an anterior and posterior arch. The anterior arch
lead to the displacement of a vertebral body, known as comes to a midpoint that contains the dorsal facet,
spondylolisthesis (Fig. 1.8). Spondylolisthesis can result which allows for a connection with the dens on
in nerve root compression.9 the vertebral body of C2, allowing C1 to pivot the
skull.11,12 The posterior arch of C1 contains the pos-
terior tubercle at its midpoint, which serves as the
Cervical Spine
origin for the rectus capitis posterior minor muscle,
The superior-most vertebra, C1, is termed the atlas. which assists head and neck extension.3,10
The second, C2, is termed the axis (Fig. 1.9).10 In the posterior portion of each posterior arch is a
Together, they account for most of the rotational groove in which the vertebral artery and first cervical
 1 Vertebral Anatomy 7

Fig. 1.9 The C1 (left) and C2 (right) vertebrae. (From Bazira PJ. Clinically applied anatomy of the vertebral column. Surgery. 2021;39(6):315-323, Fig. 4.)


Fig. 1.10 Features of typical cervical vertebrae from C3 to C6. The C7 vertebra is distinguished in that it has a monofid spinous process and no
foramen transversarium. (From Bazira PJ. Clinically applied anatomy of the vertebral column. Surgery. 2021;39(6):315-323, Fig. 3.)


spinal nerve are found. Injecting in this region can be prominent bony landmark for palpation. It is also the
technically challenging. The posterior cavity of the attachment for several suboccipital muscles and the
atlas formed by the anterior and posterior arches con- ligamentum nuchae (nuchal ligament), which extends
tains the spinal cord. The lateral masses of C1 contain from the external occipital protuberance to the C7
the superior articular processes/facets that connect it spinous process.
to the occiput, or skull base, and inferior articular The lower cervical vertebrae (C3–C7) adopt the
processes that connect it to C2. more usual vertebral structure detailed previously, but
The C2 vertebra, or the axis, is composed of a body they are distinguished (except for C7) by the presence
that contains a vertical pillar of bone, the dens, which of a perforation in each transverse process, termed the
articulates with C1 above. The inferior facets are lo- foramen transversarium, that transmits the vertebral
cated at the junction of the pedicles and laminae.10 artery and sympathetic plexuses (Fig. 1.10).10 Further,
The spinous process of C2 is bifid and provides a the spinous processes of C3 to C6 are bifid, whereas
8 Vertebral Augmentation Techniques

the spinous process of C7 is monofid. The spinal canal sternum. A primary function of the thoracic spine, in con-
of the cervical vertebrae is triangular; its anterior bor- nection with the ribs and sternum, is protection of thoracic
der is the vertebral body, its lateral borders are the organs, including the heart and lungs. The bodies of the
pedicles, and its posterior border is the laminae. The thoracic spine vertebrae are unique in that their upper and
transverse process in the cervical vertebrae is unique lower lateral borders house areas, known as demi-facets,
not only because it contains the foramen transversar- for articulation with the heads of the ribs (Fig. 1.11).13
ium but also in that it gives off two tubercles, anterior The posterior arches of the thoracic vertebrae con-
and posterior, that attach the scalene muscles used for tain the same components as those seen in Fig. 1.5:
lateral neck flexion. The anterior tubercle of C6 is the vertebral foramen, pedicles, superior and inferior
notable in that it is termed the carotid tubercle and is articular processes, spinous processes, and transverse
immediately posterior to the carotid artery.3 processes. The spinous processes of thoracic vertebrae
are more acutely slanted caudad.
There are usually 12 ribs on each side of the thoracic
Thoracic Spine vertebra. Ribs 1 to 7 are true ribs in that they connect
The thoracic region is the least mobile area of the spine, to the costal cartilage of the sternum anteriorly; ribs
partly due to stability provided by the rib cage and 8 to 12 are false ribs in that their costal cartilages are

Spine
Lamina
Transverse
process

Spinal Superior
canal articular
process

Body

Superior
articular process
Transverse
Rib facet process

Rib facet
Body

Inferior
articular
Rib facet process
Spine

Fig. 1.11 Thoracic vertebra superior view (top) and lateral view (bottom). The characteristic feature of thoracic vertebrae is the presence of rib
facets/demi-facets, joints that articulate with ribs. (GD Cramer, SA Darby Basic and clinical anatomy of the spine, spinal cord, and ANS (2nd ed.),


Elsevier Mosby, St Louis (2005))

 1 Vertebral Anatomy 9

connected to the rib above. Ribs 11 and 12 are also spinous processes are near horizontal, making for
floating ribs, which do not project anteriorly. large interlaminar spaces that are easily visualized
using a fluoroscopic approach during interventions
(Fig. 1.13).8,14
Lumbar Spine
Five vertebrae compose the lumbar portion of the
Ligaments of the Spine
spine. The vertebral bodies are large, and the poste-
rior arch, formed by the pedicles, laminae, and ar- Ligaments of the spine, from most superficial to deep
ticular processes, encloses the vertebral foramen. starting dorsally, are the supraspinous ligament, the in-
These vertebrae are unique in their lack of costal terspinous ligament, the ligamentum flavum, the poste-
facets and foramen transversaria (Fig. 1.12). The rior longitudinal ligament, and the anterior longitudinal

Small, narrow

Large, wide

Fig. 1.13 Interlaminar window size and shape (outlined in yellow) of the
lumbar vertebrae. Fluoroscopic views make it apparent that there is a
noticeable size difference between the visibility of the thoracic and lumbar
interlaminar windows. (From Shin KH. Percutaneous full-endoscopic interlami-


Fig. 1.12 Superior views of typical cervical (top), thoracic (middle), and nar lumbar spine surgery. In: Kim J-S, Lee JH, Ahn Y, eds. Endoscopic Procedures
lumbar (bottom) vertebrae. A common architectural design with unique on the Spine. Springer Singapore; 2020:chap 15, 185-209, Fig. 15.1.)
variations can be appreciated. (From Mahadevan V. Anatomy of the verte-


bral column. Surgery (Oxford). 2018;36(7):327-332, Fig. 2.)

10 Vertebral Augmentation Techniques

ligament (Fig. 1.14).8 The supraspinous ligament is a The posterior and anterior longitudinal ligaments
fibrous band that joins the tips of the spinous processes are composed of layers; the deep layer connects adja-
and ends between L4 and L5. The interspinous liga- cent vertebrae, whereas the superficial layers can ex-
ments connect adjacent spinous processes from roots to tend fibers over three vertebrae. The posterior longi-
apices. The ligamentum flavum begins in C1 to C2 su- tudinal ligament begins at C2 and extends inferiorly to
periorly and extends to L5 to S1 inferiorly.15 It connects the sacrum. It is fused to the posterior annulus fibrosis
adjacent laminae and forms the dorsal boundary of the of the intervertebral discs, making up the anterior
epidural space. With age, the ligamentum flavum loses border of the spinal canal. A major function of this
elasticity and thickens, potentially causing spinal canal ligament is to prevent posterior disc herniation into
stenosis.16,17 the spinal canal. The anterior longitudinal ligament is

Ligamentum flavum

Intertransverse
ligament

Facet
capsulary
ligament
Posterior
longitudinal
ligament
Interspinous
ligament

Supraspinous Anterior
ligament longitudinal
ligament

Fig. 1.14 Vertebral column showing vertebral ligaments. (Left) Bisected view showing the supraspinous ligament, interspinous ligament, and liga-
mentum flavum. (Right) Anterior view showing the supraspinous ligament, interspinous ligament, ligamentum flavum, posterior longitudinal ligament,
and anterior longitudinal ligament. (Modified from Mahadevan V. Anatomy of the vertebral column. Surgery (Oxford). 2018;36(7):327-332, Fig. 5.)