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Today we are honored to welcome Dr. Majid Khan for a lecture

0:53

on vertebral augmentation past present and

0:56

future.

0:57

Dr. Khan present completed his Radiology residence

1:00

residency at numc Stony

1:03

Brook University and is subspecialty training and

1:06

neuro radiology at Johns Hopkins University. He is

1:09

at present on the neuroradiology and

1:12

Interventional Radiology staff at Johns Hopkins University.

1:16

Dr. Khan is a nationally and internationally recognized expert

1:19

and spine tumor ablation and spine

1:22

cement augmentation procedures. He's published

1:25

extensively on these areas and has been invited to

1:28

lecture preside over panels run workshops and

1:31

moderate sessions at many national and international conferences.

1:35

At the end of the lecture join Dr. Khan in a

1:38

Q&A session where he will address questions you may have on today's topic.

1:42

Please remember to use the Q&A feature to submit your questions so

1:45

we can get to as many as we can before our time

1:48

is up with that. We're ready to begin. Today's lecture Dr.

1:51

Khan. Please take it from here.

1:53

Thank you, Ashley for your client introduction.

1:57

Good morning. Good afternoon, wherever you

2:00

are in the country.

2:01

So let's get started about where people

2:05

augmentation where we were and where

2:08

we are and where we are hopefully going to be in

2:11

future.

2:14

These are my disclosures.

2:17

So today what I'm going to talk about is mostly

2:20

going to be relevant with in

2:23

regards to benign compression fractures. We do vertical augmentation

2:26

for pathological fractures for traumatic fractures, but

2:29

overwhelmingly what I'm going to talk today will

2:32

be with in relation with the

2:35

benign fractures and we know osteoporosis is

2:39

perhaps the most important cause of more people

2:42

fractures.

2:44

So normal bone as you

2:47

can see, this is the healthy bone with sinusoidal cavities and

2:50

the trabecular pattern osteoporosis literally

2:53

means porous bones or bone that

2:56

is full of holes. And when you look at the picture, you

2:59

can see that the sinusital cavities have

3:02

enlarged and the trabecular

3:05

Pattern has significantly thinned out giving the

3:08

typical appearance to the bone that we are used to see.

3:12

This is another microscopic picture

3:15

of the trabecular cavities in

3:18

normal bone and compared to the osteoporotic Bone.

3:21

You can see in the picture below how enlarged the

3:24

sinusoidal cavities within the trabecular bones

3:27

are and if you look at the cortical bone also that also shows similar

3:30

loss of the osseus material

3:33

and and you can see porous looking

3:36

cortical margins of the bone.

3:40

overall 700,000 vertical

3:43

compression fractures happen in US

3:47

70,000 of these patients with

3:50

vertical compression fractures will end up

3:53

getting hospitalized with an average

3:56

length of stay for about eight days. So

3:59

you can imagine just a fracture. We

4:02

normally don't think about what it will

4:05

fractures leading to such extensive length of

4:08

stay in the hospitals, but it happens.

4:12

now we know previously we used to think that it is a diagnosis

4:15

of females only,

4:18

but now we know that

4:20

25% of the males will also

4:23

sustain osteoporosis and can develop

4:26

compression fractures due

4:29

to osteoporosis.

4:33

So

4:34

looking at the silver tsunami that wants osteoporosis

4:37

was called and still is if

4:40

you look at the numbers back in 2010.

4:45

Americans age 50 and more

4:48

made up about 54% 99% of

4:52

the population back in 2010 and more

4:55

than half of that population had osteoporosis

4:58

and osteopenia, which total was

5:01

about 17% of the entire population.

5:05

But now we have will be increasing this number

5:08

by about 27% of

5:11

up to about 20 30

5:14

and it will go even higher so this is

5:17

a big elephant that is that is sitting in the room for us.

5:20

If you're a numbered person and really want

5:23

to know the dollar amount that

5:26

is being spent on this diagnosis. This

5:29

is a very alarming slide at

5:32

least to me that I saw that the total

5:35

amount of money that is spent on

5:38

patience with osteoporosis. That's that's Total

5:41

Care of osteoporosis hospitalization inpatient

5:44

outpatient care. You can

5:47

see it's about 4.8 billion dollars

5:50

compare it to my cartilage and

5:53

stroke.

5:54

So it's much higher than even typically

5:58

what we think about are the biggest

6:01

money guzzlers when it comes to Patient Care

6:04

and inpatient and as spending dollar

6:07

amount these

6:09

on specific diagnosis

6:12

This is one of my patients. I just wanted to show you

6:15

the sequence of events that happened in

6:18

this patient's life. So 51 year

6:22

old female back in 2009 had a

6:25

low dexa score so had

6:28

a mild osteopenia. Nothing was

6:31

done for this patient in 2016. She

6:34

sustained and L1 and L2

6:37

fracture. She had an upper respiratory track infection had

6:40

about of coughing and fractured her bones.

6:43

She was 58. Then nothing was really done to

6:46

address her problem at that point. Also 2018.

6:49

She develops two

6:52

more fractures a T10 and a t11

6:55

fracture and you had to be cognizant of the fact that

6:58

each fracture is a sentinel event in this

7:01

diagnosis and can be definitely prevented

7:04

if specific care is

7:07

given to the patient as specific points and then

7:10

and then finally in 2019 when I

7:13

saw her she had another fracture of

7:16

T12 vertebra so multiple compression

7:19

fractions, which really could have been avoided had she

7:22

had

7:24

Proper care diagnostics test would have been done

7:27

no recent decks are comparing the numbers

7:30

to her previous dexa scan and nothing was

7:33

really you done to reduce her fracture risks.

7:38

So we really

7:41

all of us get old, but we shouldn't be really getting like older

7:44

older and osteoporosis and fractures definitely make

7:47

us old.

7:51

This is literally the comments that

7:54

I have heard in my clinic from patients

7:57

that I have seen over the years.

8:00

Most importantly, especially with female you

8:03

you hear this a lot that I'm losing High.

8:09

Talking to elderly patients either who live alone or

8:12

as a couple and losing the

8:15

ability to drive to do all these

8:18

different chores that they are used to do has have

8:21

a devastating effect on their

8:24

life because they are they're doing everything by

8:27

by themselves without getting any

8:30

help from anywhere.

8:33

I have heard this many many times in

8:36

this day and age.

8:40

Osteoporosis should be known to every person especially

8:43

people over 50 years of age, but

8:46

I tell you this is this is something that's that's consistently

8:49

heard from our

8:52

patients day in and day out that I have no

8:55

idea about osteoporosis. Nobody told me to be on calcium or

8:58

other treatment modalities and if I

9:01

had known it earlier this everything would not

9:04

have happened to me very very consistent a

9:07

symptom

9:10

that I hear from these patients.

9:13

Okay, Imaging of osteoporosis. We know we

9:16

get plain rated graphs. We have these

9:19

ghost vertebras. I literally

9:22

tell my patients that I can see through your vertebras. They

9:25

are so thinned out and this is just an

9:28

example of that. It's not much difference looking

9:31

at soft issues compared to these obvious bones

9:34

in this patient.

9:36

Healthy bone on a CT should

9:39

look like this. It should be quite dense. And this is the parents

9:42

of osteoporosis on CT with a

9:45

compression fracture. They saw this is your typical Ghost

9:48

Warrior. You can see some increased fatty

9:52

content of the vertical bodies thicken trabeculate

9:55

all so at times and loss of trabecular pattern in

9:58

some parts of the word evil bodies.

10:02

So we can make a diagnosis of osteoporosis

10:05

on CT, but it's not consistent differentiating

10:08

normal

10:11

bone from osteopenia / osteoporosis.

10:15

Is can be done reliably most of

10:18

the times but differentiating osteopenia from

10:21

osteoporosis can be hard on grayscale CT

10:24

Imaging. So back in 2019. We

10:27

came up with this color enhanced detection

10:30

where we did a retrospective study by

10:33

putting this CED on abdominal

10:36

CTS that are done routinely and to

10:39

see if we can compare it to the patient's Dex

10:42

scan and what results we get and

10:45

and it had really

10:48

good results and we were able to put colors

10:51

on the bone on CT and able to make a

10:54

diagnosis of osteopenia osteoporosis

10:57

or normal bone within two seconds.

11:01

And so these are the grayscale Imaging and this

11:04

is the colored detection images that have been Port where

11:07

the red being osteoporosis and green being normal

11:10

bone. We followed

11:14

it up actually with our prospective study validating

11:17

the colored enhanced

11:20

detection. And again, it had very very

11:23

good correlation with the Texas scan.

11:27

MRI

11:30

in especially for an Interventional list who is

11:33

treating these osteoporotic compression fractures

11:36

can be very very useful. If you

11:39

have your own Clinic, you're looking at your patient and

11:42

examining the patient really we

11:45

do not need an MRI if I have point tenderness at

11:48

a particular location. My x-ray is showing a compression

11:51

fracture and my patient is also telling me that the pain is

11:54

maximum at this location.

11:56

We don't but unfortunately some of

11:59

the insurance companies really will

12:02

want you to get an MRI before you

12:05

intervene on a patient's fracture. So

12:08

most of the practices will have some

12:11

cross-sectional Imaging either CT or

12:14

preferably MRI that you will have to get and

12:17

and really MRI helps you to age a

12:20

fracture if you see in the Dima, you know, it's it's a Subacute

12:23

or a chronic. I mean a cute fracture and

12:26

helps you differentiate in a patient with

12:29

multilevel fractures a chronic fracture from more acute

12:32

fractures, but really you're not treating an

12:35

MRI and it's many many times. I have

12:38

had patience who had just subtle changes

12:41

on the stir image on an MRI right

12:44

next to a word and Broad that had

12:47

big time and Demon there and in the

12:50

body and the patient when I saw the patient and the clinic

12:53

they were complaining of more localized pain.

12:56

That Subacute fracture rather than in the acute

12:59

fracture. So so you really treating

13:02

the patient and not always the MRI MRI helps.

13:05

Of course, I'm not saying that you should not get it but it's

13:08

it's very helpful, but more helpful is when you

13:12

examine the patient and when you know what the patient is telling

13:15

you

13:16

So we do get a lot of lots and

13:19

lots of MRI in these patients. So we came up

13:22

with this vertebral bone quality

13:25

score, which is the vbq score

13:28

based on MRI and we compared this to

13:31

dexa scan and

13:34

and wanted to see how this BBQ score

13:37

will be able to predict the fragility fractures

13:40

independent of the bone mineral density.

13:43

We we actually published few papers based on

13:46

the BBQ scores. It was actually one

13:49

of the outstanding papers that was in mass in

13:52

2020.

13:53

And it showed really good correlation with

13:56

the dexa scan and predicting patients with

13:59

osteopenia and osteoporosis. So basically we just

14:02

did a signal intensity from L1 to

14:05

L4. We divided it by signal intensity of the CSF and

14:08

came up with the vbq score. And as

14:11

I said, it really helped us because we get

14:14

MRI right left and centered in most patients. So

14:17

this is something that can be very easily quickly done

14:20

in patients and you come up

14:23

with a score if the patient doesn't have a Texas can

14:26

and all that.

14:27

So now we have a patient who has an established

14:30

fracture. We have image the patient whatever

14:33

Imaging you have obtained on that patient, and now

14:36

we have to take care of the patient. So there

14:39

are multiple

14:42

services that are involved in treatment

14:45

of these patients right from primary care. You have

14:48

the medicine guys, you have the nursing staff

14:51

the physical therapist. They usually

14:54

come up from the Ed orthopedic surgeon

14:57

neurosurgeons. And then we have the Interventional Radiologists.

15:00

Also getting involved in the treatment

15:03

of such patients.

15:05

So in intervention Radiology, we

15:08

treat the vertebral compression

15:11

fractures by doing vertical augmentation.

15:15

I just wanted to touch on the research

15:18

that has been done in this realm

15:21

because most of the

15:24

people will come up with some controversial papers

15:27

that came out in 2009 in

15:31

an egm Journal which

15:34

is probably the biggest impact factor journal

15:37

and it had a huge implication on

15:40

the practice of doing what

15:43

people augmentation two trials

15:46

actually came out Bush binder from published

15:49

in 2009 and invest trial

15:52

in also 2009 were

15:55

published saying that

15:58

what Hebrew classy specifically more deeper plasty compared

16:01

to a sham procedure and they said that multiple class.

16:04

He had no benefit over a

16:07

sham procedure.

16:09

Looking at this graph you the the

16:12

numbers of vertebroplasty or augmentation that

16:15

was done before the 2009 paper. There was

16:18

a humongous dip about 35% dip

16:21

in the number of procedures that

16:24

were done post 2009 up

16:27

to almost 2012 2014

16:30

when the

16:33

numbers started to pick back up again.

16:38

So what's the literature since those

16:41

two Landmark trials that

16:44

that got published in the negm?

16:48

Just to give you an idea about 4,000 articles have

16:51

been published on vertebroplasty in about two

16:54

thousand on klephoplasty two Mega

16:57

Montana analysis have been done

17:00

off 2500 patients included 52 level

17:03

one and level two articles. There

17:06

were actually certain

17:09

things that were found in

17:12

the bush binder study that came out in

17:15

2009 and it has been downgraded

17:18

now from a level one to a level two

17:21

based on certain flaws in

17:24

the in the setup of those

17:27

of those trials.

17:31

This is the few few examples

17:34

of few people that came out and this

17:37

this the conclusion here is really alarming that

17:40

about 35% reduction in mortality

17:43

risk at up to four years for patient undergoing

17:46

kyphoplasty one compared on and

17:49

when compared on emergent basis.

17:52

And zampini also found the same exact

17:55

almost 48% lower risk in patients.

17:58

So big implication papers like this.

18:04

The conclusion of some of the papers was that

18:07

the because of the decrease in the number of

18:10

augmentations that were done.

18:13

It in turn the five-year period following 2009

18:16

was associated with elevated mortality

18:19

in patients with vertical compression fractures

18:22

slash osteoporosis.

18:24

So the mortality actually went up

18:27

pushed those 2009 papers.

18:30

So these were the two papers that were published in 2009 comparing

18:33

vertebral palsy with sham?

18:36

These are the three papers that were published later

18:39

on using the same sham procedures

18:42

and all three of them proved that

18:46

vertebral palsy had better results pain

18:49

pollution compared to a sham procedure

18:52

and just this was a free trial that was

18:55

statistically significant in almost all the

18:58

parameters that were used in 2019.

19:01

These are

19:04

very high impact papers. Just I just wanted you guys to take

19:07

a look look at the number of patients that were

19:10

involved from the Medicare data two million

19:13

one million and almost all of them showed that doing

19:16

augmentation

19:19

was better than non-surgical management

19:22

of these patients so much has

19:25

been done since 2009. I know

19:28

some of some of the some of the our surgical colleagues

19:31

still are

19:34

referencing those 2009 papers,

19:37

but those of you who want to set up spine practice

19:40

should really read up

19:43

on these new papers that have come out

19:46

which are clearly showing a benefit of doing

19:50

augmentation over.

19:53

Non-surgical management and this is

19:56

a landmark paper from my good friend Joshua Hirsch

19:59

from Mass General that came

20:02

out which which really showed that

20:05

you need to do.

20:07

15 vertical augmentation

20:10

procedures to save one life and

20:13

about 12 procedures say

20:16

one life at five years and compare

20:19

it to almost 22 management

20:22

patients non-surgically to say one life and

20:25

24. So almost double in the

20:28

non-surgical arm compared to the augmentation arm.

20:31

This was this is a really Landmark

20:34

paper that that because no other people really shows the

20:37

mortality benefit long term

20:40

mortality benefit of these procedures and this this

20:43

paper clearly showed that there is significant mortality

20:46

benefit by doing this these augmentations

20:51

Okay.

20:52

So now we get the

20:55

patient in our clinic and we start to discuss with our

20:58

patients about where

21:01

people augmentation. So so what do I

21:04

tell my patient when they first come up in my clinic about

21:07

when I have assessed them? What am

21:10

I? What am I offering to my patients?

21:13

So

21:14

We are either doing vertebroplasty. We are either doing balloon

21:17

kyphoplasty or we can do an implant

21:20

kyphoplasty for such patients and the patient always.

21:23

Tend to ask hey, what's the difference? Why am

21:26

I why you telling me that I'll get Kai full

21:29

over vertebral or an implant or balloon type

21:32

of plasty. So we all know that when

21:35

you inject cement directly into the word table body

21:38

whether you're doing it through one pericle or

21:41

you're doing it from both particles it is what you were plasticity.

21:44

If you put a balloon in create a cavity and then

21:47

put the cement in a pre-created cavity. It

21:50

is a balloon kyphoplasty. And then the implant

21:53

is where you put a titanium implant in the world people

21:56

body and then you inflate that implant in the body to

21:59

restore the fracture height.

22:02

That's the implant type of plasticity. Of course,

22:05

really I if the vertebra has

22:08

just lost minimal height. I will do whatever plasti if

22:11

it's a mild to moderate fracture. I

22:14

may do balloon car for plasticity versus

22:17

an implant guy for plasticity, but if it's a

22:20

moderate to severe fracture and I can

22:23

fit

22:23

An implant in that vertebra, I will do

22:26

an implant kyphoplasty because you want to raise the

22:29

height of the vertebral body also, but having

22:33

said that the main aim of

22:36

doing this is pain palliation. So almost all of

22:39

these have shown to decrease your your

22:42

pain by at least four to five

22:45

if not more points on visual analog

22:48

Pain Scale.

22:51

So going back into the percutaneous final

22:54

procedures in 1934. Actually

22:57

ball Earnest or ball

23:00

was the first person who started to do image

23:03

guided procedures. So pretty much

23:06

this is exactly what we do to this

23:09

day.

23:11

He actually if you look at these diagram he is

23:14

coming in for a particular and coming along

23:17

the inferior aspect of that neurophoramine. I

23:20

just avoid the nerve and what we do

23:23

now, we mostly we try to come transpendicular but

23:26

this was back in 1934 and pretty

23:29

much the technique is still the

23:32

same exactly the same what he

23:35

did back then.

23:37

Next we came

23:40

up with what to put in the word table

23:43

body or in the osseous structures, and

23:46

that was because what happened in

23:49

the acrylic acid was used back in 1843 then

23:52

in 1887 1877. We

23:55

had a German chemist.

23:59

Look at the polymerization of the methyl metac

24:02

relate to polymethyl metaculate and solidification of

24:05

that and that's what was used later

24:08

on in plastic sheet in plexiglass

24:11

that we don't normally now

24:14

see in our cars and some of our musical instruments

24:17

in our in our we used to

24:20

see that in our planes all the plexiglass that was

24:23

used.

24:24

In the World War Two because of

24:27

all the injuries that happened especially the craniofacial injuries

24:30

that happened to patients with

24:33

deformities and all that actually cranioplasty with

24:37

these acrylic plates. Where were used for

24:40

this facial deformities back then.

24:45

People have also used pmma pass

24:48

for corpactamine these

24:51

days now we see these big fancy corepectomy

24:54

cages. Once you do a vertebraectomy,

24:57

but back then they used to put

25:00

a a cast of pmma in

25:03

the working directime side,

25:06

and it was used for those surgical Maneuvers

25:09

also. So the

25:13

first warmer plasti, if you look at the history was actually

25:16

done done in France in 1984 Gatlinburg

25:19

and Dara morn

25:22

with the two guys who perform this this was actually

25:25

a guy who had aggressive C2 Hemangioma,

25:28

and

25:31

the surgeons did not want to operate on

25:34

the patient.

25:36

Patient was having excruciating pain. So

25:39

that's when they

25:42

thought of doing this percutaneously they went in

25:45

through the trans oral route. And these are

25:48

these are actually the original images.

25:51

You can see the needle coming in through the trans oral

25:54

route into the C2 vertebra, and then they have filled it with

25:57

pmma and the patient had dramatic relief

26:00

after they injected about three

26:03

cc's of cement into the C2 vertebra.

26:08

They did seven cases of

26:11

aggressive human geomas after

26:14

that with protein properties vertebroplasty.

26:19

These these are just some notes from

26:22

their original paper and it

26:25

was it was really fascinating to read them that they

26:28

said their radiotherapy is the usual treatment for for

26:32

such patients, but it couldn't be done because it

26:35

was close to the spinal cord and now these days with

26:38

sbrt and all the other things we take everything for granted.

26:41

But this was this was in

26:44

their original paper how they how they came up with this.

26:48

So whatever plastic coming to us was actually

26:51

in 1993 a paper

26:56

was presented at asnr by the dermann

26:59

group from France. And then

27:02

three of these our greats John Mathis

27:05

Legion and they actually went to

27:08

France and they learned what he were plasticity

27:11

from the Des Moines group and then they came back to

27:14

University of Virginia in 1993 and

27:17

started doing more detroplasty

27:20

and reported a case

27:23

series was reported in 1997 actually

27:26

about working with

27:29

plastic.

27:31

they used to make the cement

27:34

on their own so you can imagine

27:37

these days again we take its

27:39

So much for granted. We have

27:42

really good cement thick whisk of cement and

27:45

back then they had to mix everything right on the table people who

27:49

do this a lot in and day out can can realize how

27:53

much of a pain it would have been back then

27:56

but so and we owe a lot these guys

27:59

what we're doing today. All the fancy things

28:02

was because of what they did back then

28:05

and they were they

28:08

else came up with this idea of adding barium to

28:11

the cement so that the cement can actually be

28:14

seen

28:18

A very nicely as a cement goes into the world. You do

28:21

body. Okay, so now going

28:24

Talking a little bit about the indications of doing the

28:27

vertebroplasty. So if you have a painful osteoporotic

28:30

or a traumatic fracture, which is

28:33

refractor to Medical therapy, it is

28:36

indicated. If you have a pathological fracture be

28:39

it from metastasis from

28:42

any solid tumor multiple, myeloma, we do

28:45

cement augmentation.

28:48

Imagine what he will demand you must more. So aggressive hemangiomas.

28:52

We do it if patient has criminals phenomenon

28:55

osteonecrosis. This is a really good procedure to do.

28:58

And sometimes patients with chronic fractures

29:01

who have ongoing compression and have

29:05

a painful back. We we

29:08

tend to do this procedure.

29:11

Traumatic fractures were are done

29:14

more. So in by our

29:17

European colleagues, but now spine Jack

29:20

has gotten FDA approval in

29:23

us all so because

29:26

most of the insurance companies would not cover vertebral

29:29

augmentation in traumatic fractures in

29:32

us, but hopefully that will change now with with

29:35

the implantic.

29:40

So this is just few examples of bipedicular approach

29:44

what everblasty as I said that when you do a word even plaster

29:47

you just get the needles in and start putting

29:50

the cement in straight away in that compressed

29:53

bone. And so this is an example of a bipedicular two

29:56

needles have gone in and that's cement

29:59

going into that compressed vertebra.

30:02

Uh, so it's it's as I

30:05

said, it's it's done very commonly, very routinely one

30:08

of the things about about people plasty

30:11

is that because you have not created a cavity. So if

30:14

there is good bit of impedance in the

30:17

bone the pressure inside the bone is very high. You

30:20

may not be able to get a whole lot of cement into

30:23

that vertebra. So you have

30:26

to keep that in mind also.

30:30

This is a unipendicular axis.

30:33

Now many instruments have come

30:36

from many companies which will let

30:39

you get in from only one pedicle. And

30:42

then you have a curved needle that you can

30:45

cross over to the contralateral side and start putting

30:48

cement in the word evil body. And here

30:51

you can see we have vertebra play now almost here and

30:54

we coming in we just threaded this

30:57

curved needle right across that planer and

31:00

then we started putting cement starting at the

31:03

contralateral side. And then we keep on pulling our

31:06

curved needle back so that you spread the contrast

31:09

completely from one pericle to the

31:12

ipsilateral pedicle filling up the water.

31:15

This is a something that

31:18

these curved needles really help you

31:21

with is that put the curb needle

31:24

in I have crossed the midline here. Then I went I can

31:27

I can curve it up. I can curve it down. So here

31:30

I started putting cement by curving the

31:33

needle up. So I put the cement underneath the Superior in plate,

31:36

which is the end play that is fractured probably nine out

31:39

of 10 times and then I curved it down and put

31:42

cement along the inferior aspect also and

31:45

completely filling up the working problem

31:48

with cement.

31:50

With the unipendicular access if

31:53

you're doing multiple level contiguous levels. I

31:56

usually do three or at the most score levels

31:59

in one setting you can see very

32:02

nicely that you can alternate the

32:05

entry of the needles into the vertical bodies.

32:08

If you were doing bipedicular, this would not have been

32:11

possible because the needles touch each other and you will not

32:14

be able to put four needles perhaps at

32:17

the same time if the fractures are moderate to

32:20

severe and very close to each other. So that's another distinct advantage

32:23

that you get by doing a unipendicular access.

32:27

Bipedicular kyphoplasty very similar

32:30

to the excesses the same just like you do

32:33

the vertebroplasty but here now you put a balloon in

32:36

the vertebra you inflate the balloon create a

32:39

cavity in the vertebra deflate the balloon and then you put the

32:42

cement in that pre-created cavity. So

32:45

the advantage that kyphoplasty gives you is that you can

32:48

put more cement more cement goes into

32:51

the vertebra under less pressure. So the chances of

32:54

cement extravization are less

32:57

theoretically compared to a more deeper plasty

33:00

at times. So here you can see the balloons

33:03

are going in here. I have inflated the balloons the

33:06

balloon touch the midline. This is called the kissing balloon

33:09

technique. That's typically how it

33:12

should be and then you deflate the

33:15

balloon and then you put the cement in crossing the midline.

33:18

You have to cross the midline. You cannot put cinnamon only

33:21

and one side of the vertebra because that

33:24

probably did more disservice to the patient.

33:27

And helping the patient if you have cement only on

33:30

one side.

33:32

Similarly now companies have come

33:35

up with this unipedicular kyphoplasty. So

33:38

it's it's very useful because if you

33:41

can get away with doing anything from

33:44

one particle, why do you want to puncture the

33:47

patient twice? So so it's it's been it

33:50

decreases the table time. It decreases the

33:53

radiation to the patient to the operator table time

33:57

is decreased and it's it's

34:02

these days a lot depends on the table time. So it's it's

34:05

definitely helpful and and the results are pretty

34:08

much the same comparing a unipolecular

34:11

to a bipedicular kyphoplasty.

34:14

So here you can see that come in.

34:17

This is the balloon that

34:20

has crossed the midline again. You have to make sure that

34:23

your cement and balloon go into the midline. So

34:26

that's very important because you don't want to be on the epsilateral or

34:29

the contralateral half of the word. You have to be in the

34:32

midline. So that's what we have done. This is how it

34:35

looks on the lateral view. This is

34:38

the balloon should be in the interior middle third

34:41

of the word abroad. That's another important thing because you don't

34:44

want your cement coming into the posterior column because posterior column

34:47

doesn't take any part in

34:50

the axial dissipation of force.

34:54

And here we have inflated the balloon right

34:57

in the middle of the vertebra. We are in the anterior third

35:00

of the vertebral body on the lateral and then we start deflated the

35:03

balloon and started putting cement in as we

35:06

did in that unit particular pathoplasting.

35:09

If for some reason you want to

35:12

do this with CT guidance, you

35:15

can absolutely do that. This is one of my patients who had

35:18

Frozen shoulders. So we tried to do it

35:21

under fluoroscopy, but her arms were she could

35:24

not lift her arms up. So we had to

35:27

do her in CT and you can see that

35:30

this is this is actually a pathologic fracture. You can see this

35:33

politic Legion involving the vertebra here. We

35:36

are coming in. We have put the balloon right across there here balloons

35:39

getting inflated cement going

35:42

in cement going in and this is the post picture

35:45

on the same patient with the cement well and

35:48

truly in place within the vertical body without any evidence

35:51

of extract.

35:54

Okay. So the first generation when

35:57

we started all this of course medical management

36:00

and vertebroplasty then

36:03

the second generation is when we when Kai

36:06

phone came up with this balloons and

36:10

we started to think about balloon kyphoplasty. But

36:13

all along we were thinking that how can

36:16

we raise the height of a fractured

36:19

word about that was the heart process and and those

36:22

of us who have been doing this for many many years.

36:25

We have we have used many many devices over

36:28

over the years just

36:31

With This Heart of we need

36:35

to restore the height of the word rather than just getting in

36:38

there and putting some cement so that the word doesn't compress

36:41

any further than it already has there are

36:44

many devices have come into the market and some did

36:47

not survive the test of time and kind of

36:50

went away, but definitely there are many devices

36:53

that are still on the

36:54

It I think the the biggest one of

36:57

them now at present is this spine Jack

37:01

that is consistently being used

37:04

to restore the height in the vertigo bodies.

37:07

This is an awesome fix device that

37:10

we use like literally like

37:13

almost 40 will stance that we put in here you

37:16

can see that inflating the stand underneath the superior and

37:19

plate and then putting cement in that

37:22

stand. It's not available in the

37:25

market now.

37:26

Optimesh was another one that we used the

37:29

cement used to come out from the

37:32

mesh itself and really is not

37:35

used in practice keyword devices is is still in

37:38

practice. It's still available and we still

37:41

use it. The good thing about Kiva is that you

37:44

put these the introduced revire in and

37:47

then you thread this peak over the

37:50

wire and when you have that in the water table

37:53

body, the cement actually only comes out from the

37:56

inside of this peak rather than coming from

37:59

the outside. So all the cement is contained within

38:02

this peak and this can

38:05

be used for patients with that

38:08

logical fractures and completely broken bodies. So

38:11

here you can see that keyword device

38:15

has been used very nicely and after

38:18

we put the cement a good fill is

38:21

considered to be and played to end play it

38:24

and from the inside of the pericle from one side to

38:26

side of the pedicle to the other side and you can see very nicely

38:29

the cement is in place there with the

38:32

use of the keyboard device.

38:34

This is a patient with

38:37

severe pain visual analog

38:40

brain score of 10 on 10 and just few

38:43

steps you want to be again, very close

38:46

to the superior and play it because the devices go

38:49

going to open in a caudal fashion. So

38:52

you have to give yourself room and the device

38:55

room to open quarterly. And that's what we are doing.

38:58

Now the the wires are you survives

39:01

have been put in so this is the wire all the

39:04

way in and then we put the

39:07

peak or the sheet over the wire make

39:10

sure that it is sitting snugly on

39:13

both AP and lateral views and

39:16

then you put cement in and this is the post City in

39:19

that patient.

39:22

Spine Jack or the implant citroblasty is

39:25

being done now to consistently being

39:29

used in patients to restore multiple

39:32

body height. Of course, as I said pen paliation is

39:35

number one goal in the in such patients,

39:38

but this device is used to

39:41

restore height and and you can

39:44

see with these videos when we put them

39:47

in how nicely you can Elevate the

39:50

fractured end plates and restore the height

39:53

of the vertebra and in some cases.

39:56

We have almost restored in back to pre

39:59

fracture Heights and and the

40:02

patient has had really good relief.

40:06

So this is these are just few examples. This is a fracture

40:09

right here. This is the jack that has been put in

40:12

place and completely inflated in the vertebra. And this

40:15

is the post picture. So if you compare the pre and the post

40:18

there has been significant height gain.

40:21

This is a patient 88 year old with osteoporosis.

40:24

MRI was done here. Really? You

40:27

can't even see where the fracture is. But this was actually a

40:30

T12 fracture CT shows

40:33

a little better than MRI here. You can see a little bit of a

40:36

retropulpture of the posterior cortex patient was managed conservatively. But

40:39

oh after

40:42

a week, you could see an ongoing compression and

40:45

the patient was complaining of significant pain which

40:48

improved a little bit compared to

40:51

a week ago. So patient was again put in

40:54

a corset and

40:58

with narcotic, analgesia

41:02

And was sent home.

41:05

The brace and the narcotics for three weeks patients pain

41:08

did not get any better. But the patient was now almost

41:11

completely immobile was living and

41:14

sleeping in his recliner. And this

41:17

is two weeks after you

41:20

can see where the fracture was barely seen.

41:23

Now, you can see at least a moderate compression fracture. So

41:26

at that point patient was sent over to me and

41:29

this is when I put the patient on the table, so it's almost a

41:32

plane on now by the time patient was

41:35

on my table.

41:37

So I usually like in a case such

41:40

as this we want to restore some height for

41:43

this word Russo I decided to put in this implant. So

41:46

this is just the steps

41:49

of putting the implant in and you can see the

41:52

implants are going in and now we are inflating the

41:55

implants in the patient and this is

41:58

the pre.

42:00

Image of the patient and this is the post image

42:03

or almost almost double triple the

42:06

height of the the word that was compressed and

42:09

the patient had complete pain relief within 48 hours

42:12

and was very happy with

42:15

the results. So typically as I

42:18

said for me if there's a moderate to severe compression

42:21

fracture, I will use these implants because

42:24

the aim is a impaliation and

42:27

be to restore as much height

42:30

of that those compressed vertebras as much

42:33

as we can another example

42:36

Austria product fracture 10 or

42:39

10 pain they were not that bad we decided

42:42

to go because these are junctional Level fractures

42:45

T12 L1 fractures. We went in with the

42:48

spine Jacks and you can see right there.

42:51

So this is the pre-picture and this is the post picture you can

42:54

see almost normal normal height restoration

42:57

prefracial level at

43:00

Levels in the patient did very very well with his

43:03

pain with a vascore of zero.

43:07

So I've talked a lot about height restoration

43:11

why it's not only

43:14

that we want the images that we do

43:17

Post procedural to look pretty with good

43:20

height restoration and everybody say, oh you give

43:23

so much of height to the patient and blah blah. It definitely

43:26

has a basis to this and and the basis to that

43:29

is when we talk about what people fractures we

43:32

really talk and concentrate only on

43:35

the bone. We forget a very very important

43:38

other factor or constituent of

43:41

the spine. That is the disc.

43:44

And and research has shown us

43:47

that.

43:48

You need normal vertebral height

43:51

to maintain your normal introdiscal pressure.

43:55

And as long as your interdiscal pressure and

43:58

your word evil body height is normal you transfer

44:01

your axial load

44:04

from one vertebra into the other vertebra.

44:08

Across the disc at the

44:11

level of the nucleus.

44:13

Nucleus is really spongy. That's the

44:16

job of the nucleus that it transmits the

44:19

weight very easily to the next level.

44:22

So when you fracture, so so that's that's your blue

44:25

line with the normal fracture.

44:27

When you fracture a vertebrate that has

44:30

an indirect bearing on the introdiscal pressure

44:33

and and we know that the introdiscal pressure

44:36

Falls a lot when you develop for people

44:39

compression fractures, and that's the interdiscal pressure

44:42

once the vertebra fracture. So

44:45

what happens with this is that once you do

44:48

that?

44:49

The fulcrum of the axial

44:52

load transforms from

44:55

the middle of the vertebra to the from the

44:58

nucleus into the annulus and the annulus

45:01

is not made to transmit that

45:04

axial load from one vertebra into

45:07

the other vertebra. And that's what predisposes

45:10

the adjacent vertebral

45:13

level for fracture.

45:16

A lot of people will will say that hey

45:19

by putting cement in one vertebra are we

45:22

not putting the other adjacent vertebra at risk? Absolutely. There's

45:25

no denying that fact that post

45:28

cementation you have you can

45:31

dwell up adjacent level fractions,

45:34

but

45:35

there's no denying the fact also that if you

45:38

don't do anything your adjacent vertebra is

45:42

also at risk for developing fracture just

45:45

because of this factor that I told you

45:48

that the falkir moves from the middle column to the interior column

45:51

from the nucleus to the anonymous

45:54

fibrosis and and the predisposition

45:57

of interior level fractured based on this is

46:00

higher than the predisposition after

46:03

cement injection and and the

46:06

third line the yellow line that you're seeing

46:09

is that after the height has been restored the

46:12

interdiscal pressure really comes up. It

46:15

doesn't go all the way to normal, but it's still much

46:18

much better than when the fracture had happened with

46:21

the interdisco pressure plummeting almost to

46:24

zero Baseline here.

46:26

So that's that's the whole.

46:28

Evidence behind and and the

46:31

thought process behind height

46:34

Restoration in these in these fractured

46:37

vertebrates.

46:39

So we actually did a study

46:42

on spinejack and compared it

46:45

to the safety

46:48

profile and everything pain palliation adjacent

46:51

level fractures and it was published in

46:54

21, and and we found that spinejet definitely did

46:57

much better than the other vertebroplasty in

47:02

regards to pain-paliation And in regards to development of

47:05

adjacent level practice.

47:08

Portable body stents are also

47:11

there and this is this is a prime example of that

47:14

here. You can see again. The stents have been put in

47:17

you inflate The Stance very nicely in the vertebra and

47:20

then you put the cement in those stents,

47:23

which is the thing why

47:26

we do this say for example comparing this

47:29

tent to balloon kind of class. You would say that it's it's

47:32

no different from balloon guy for plastic. You should balloon cry

47:35

for plastian was very similar. But remember when

47:38

we do the balloon kyphoplasty you inflate the

47:41

balloons you kind of push the superior end plate

47:44

up, but then you have to deflate the

47:47

balloons to get the balloons out and when you

47:50

deflate the balloon, so any

47:53

Good bit of height restoration that you had obtained by

47:56

inflating those balloon. The end plates

47:59

really come back to rest at their original height

48:02

and then you put the cement in

48:05

and you do get elevation of the N

48:08

Play depending upon how much cement you are able to put in but it's

48:11

not as consistent as you see with

48:14

these implant kyphoplasties because the implants are

48:17

used to attain the

48:20

height restoration and they are kept in place there

48:23

and then the cement is put Within These implants

48:26

and so the height restoration definitely is

48:29

met much better and because it's better sustained

48:33

by the implants rather than getting the

48:36

height restoration with the cement. That is the concept

48:39

of balloon craft plasticity.

48:42

Uh Now new new devices

48:45

are coming in the market

48:48

in which you can stabilize the vertebral Body

48:51

by putting cement in and then you have these Peak

48:54

implants and almost like Pericles screws

48:57

that you can keep in place so that

49:00

you augment both the the interior column

49:03

as well as augment the posterior column and one

49:06

such is is this restart

49:09

that that we are using now and

49:12

in a normal spine 60% of

49:15

the axial load is the anterior column in 40%

49:18

is by the posterior column. I mean older age group

49:21

The more pressure is is along

49:24

the interior portable body. Hence the

49:27

increase incidence of fracturing the

49:30

the portable body rather than the posterior element.

49:33

So with the idea is that with the

49:36

use of reach these struts you

49:39

can you can pretty much balance it out back

49:42

to the normal spine of the

49:45

younger days in such patients and

49:48

have you started to use this more in patients

49:51

with pathological fractures where the pedicles are involved so

49:54

that you have some element of structural stability

49:58

within that involved Medical.

50:02

And this is just an example of restruct here.

50:06

You can see augmentation of the vertebral body and then these

50:09

dots they're seeing this is the the struts

50:12

that have been left in place in the posterior

50:15

column right here.

50:17

So what are the future directions? Where

50:20

are we heading now? So now a lot

50:23

of research is being done because we've been using pmms

50:26

cement for like decades and decades. Nothing

50:29

has changed really much in

50:32

regards to what type of cement we use from

50:35

our PMs. And but now

50:38

a lot of research is being done

50:41

in which we are thinking of impregnating

50:44

our cement with antimicotic agents

50:47

these titanium. Micro Spurs This

50:50

phosphonates locally for treatment of pathological fractures.

50:53

So a lot is being done in

50:56

this realm now and hopefully one day we

50:59

will have these drug looting cement that

51:03

we will use rather than our simple pmma

51:06

cement bone cement radioisotopes

51:09

is being thought about all so

51:12

and research that

51:15

can be used especially

51:17

In certain cancers, there are

51:21

certain chemotherapeutic agents that can be used with

51:24

bone cement because few Studies have shown that

51:27

bone cement actually eludes out

51:30

from the cement for about three weeks.

51:33

So there are certain chemotherapeutic

51:36

agents that make a radio

51:39

resistant tumor more radio sensitive. So

51:42

we're we're thinking about mixing those

51:46

with our cement and hopefully hopefully so that

51:49

sbrt or other radiation use

51:52

can be much better

51:55

in patient with the radio resistant humor. So

51:58

are this is also being research

52:01

now there are companies that have come up who are

52:04

more.

52:06

Thinking in terms of Osteo integration of the

52:09

bone cement and putting in bone grafts in

52:12

that that integrated into

52:15

the Osteo structures and help in healing of

52:18

the vertebral body. And this is one such case where you

52:21

can see this models nor fractured vertebration

52:24

was having pain and this is the after these

52:27

beads were

52:30

put in this is 12 months later. You're seeing

52:33

this osteoporil 100% alograph

52:36

bone implant that was put in and you

52:39

can see nice Osteo integration at about 12

52:42

months of the bone with these beads. So

52:45

that's that's hopefully the future in

52:48

this area. As I

52:51

said titaniums micro spares have been

52:54

put in they've been also in the in

52:57

the research world and still being research,

53:00

but that's something hopefully we'll get to

53:03

see in future with our

53:06

augmentations

53:09

With that, I think we are we have

53:13

five seven minutes for any question answers. Thank

53:16

you for your attention and

53:19

and if you have any questions

53:22

Please go ahead.

53:27

Dr. Khan, you can go ahead and open up that Q&A box. Okay

53:30

a couple in there for you. Okay. So the

53:33

first question is how can we differentiate between

53:36

pathologic fracture and osteoporotic fracture

53:40

in an old lady?

53:43

So

53:46

sometimes it can be hard on your

53:49

routine and atomic Imaging.

53:51

We know that on routine and

53:55

atomic Imaging BH CT

53:58

or be it MRI, we have

54:01

certain characteristics of pathologic fracture convex

54:04

bulging of the posterior cortex

54:07

is something that goes with a

54:10

malignant pathologic fracture. If

54:13

you have involvement of the Pericles that on

54:17

especially on MRI, if you have signal changes that go into

54:20

the Pericles bilaterally that is something that favors pathologic

54:23

fractures. If you have a pet of

54:26

spinal Mass be it in

54:29

the ventral epidural space or the enteral lateral aspect

54:32

of the vertebral bodies all of those favorable pathological

54:36

compression fractures what having said that

54:39

at times it is extremely hard to differentiate

54:42

if you don't have these features and you just

54:45

have mild moderate compression fracture. It is

54:48

very hard on routine. Anatomical Imaging.

54:52

But if we do have some suspicion of patient

54:55

has remote history of cancer or something like that

54:58

here at our

55:01

practice. We have Incorporated Advanced spinal

55:04

Imaging where we do diffusion and

55:07

perfusion imaging now and that really helps us

55:10

better understand what anatomical

55:13

Imaging really does not so that's something that

55:16

should be incorporated in in

55:20

clinical practice now, especially in academic

55:23

centers. I think that's something that

55:26

needs to be done. If you're not able to do that. Then

55:29

the only way to answer that question is by doing a biopsy and

55:32

most of the time I do send a biopsy if I'm

55:35

treating a new fracture and there is some history of

55:38

remote history of cancer or the history

55:42

is not clear cut. We always end up the biopsy.

55:46

The next one is what shall be done to reduce occurrence

55:49

of osteoporosis or osteopenia before

55:52

happening.

55:54

very very good question and that's why if you

55:57

are in the potentialist and you or if you're wanting to

56:00

become a spine interventionalist the days

56:04

of

56:06

Treating a patient and then shoving the

56:09

patient back to their referrals is long gone.

56:13

So you have to have your own Clinic where

56:16

you see these patients and so when

56:19

I assess these patients, we have a discussion with

56:22

these patients about osteoporosis. And if they

56:26

have their PCP or they

56:29

are have an endocrinologist or a rheumatologist who

56:32

can take care of their osteoporosis. I had

56:35

multiple occasion where the patient never even had

56:38

a Texas scan down. So we make sure that we tell the

56:42

patient to get a Texas scan and then based on

56:45

the results and all we make referral to

56:48

either an endocrinologist or a rheumatologist or

56:51

talk to

56:54

their PCP so that these patients are

56:57

started on bone strengthening

57:00

agents for treatment of their osteoporosis. Otherwise,

57:03

you'll be just chasing one

57:06

fracture to the next fracture as I showed in the timeline on

57:10

one of my patients. We do a lot like five fractures.

57:13

six seven years

57:15

So yeah, look at these patients treat

57:18

these patients in your clinic refer them to

57:21

the appropriate Physicians who can take care of osteoporosis.

57:25

Is the spine jet MRI compatible? If

57:28

so at what time interval?

57:30

So the company will says that

57:34

it is it is.

57:36

Conditional approval of spine Jack but

57:39

we have got MRI for this study

57:42

that I showed. I pretty much did MRI within

57:45

24 to 48 hours after putting the Jacks in

57:48

so they are completely Mr. Compatible

57:51

and you can you can image them right away half

57:54

replacement if need be they shouldn't

57:57

be a problem with that. But but they come up with this disclaimer

58:00

that they are our conditional.

58:03

What is your comment about using plates

58:06

to fix vertical fractures?

58:11

Using plates like quite don't

58:14

understand plates.

58:17

Is is are you

58:20

talking about the acdf or because typically

58:24

if it's a surgical fracture,

58:27

they they

58:30

put in trans-pedical screws or they do

58:33

laminectomies.

58:37

If you can elaborate more on what you mean by

58:40

surgical plates so I can probably answer that question

58:43

much better.

58:47

Why does water table augmentation increase the risk

58:50

of adjacent level fracture great question

58:53

again. One of the reasons

58:56

is because as I said, we till now

58:59

pretty much we have been putting in pmma and

59:02

the pmma has a very high tensile resistant.

59:06

It is much much.

59:09

Stronger than the inherent bone, especially if

59:12

you're doing an osteoporotic weak

59:15

bone. So that's that's when

59:18

because of the difference in

59:21

the tensile strength of the bone in a

59:24

severely osteoporotic patient that that

59:27

may put adjacent level

59:30

at at risk. Sometimes you

59:33

may have cases where there has been extravization of

59:36

cement into the disk space. And that's one I

59:39

tell my fellows that you had to be very careful not

59:42

extroversating contrast into the

59:45

disc space because if the contrast goes into the disk space touches the

59:48

inferior end plate or the spirit and plate of the

59:51

adjacent vertebra, obviously those those word

59:54

impress will be at at a higher risk for fracture

59:57

than the normal.

60:03

What is the treatment policy in US regarding

60:06

extensive osteoporosis in female symptomatic

60:09

only at one level? How

60:12

do you

60:14

how do you follow up in view of stress on

60:17

the adjacent vertebra?

60:21

So as I said, usually

60:24

the photo of our patients either to endocrinologists or

60:29

rheumatologists who can take care of but most of the time patients

60:32

will will get a the bone

60:36

a bisphosphonates. Now you

60:39

can get monthly six monthly and you

60:42

can get yearly injections. We tend

60:45

to follow these patients with the dexa scan and see overall

60:48

improvement over time with these

60:51

scans, but most of the time of course you

60:54

have you have you're taking your vitamin Ds your calciums, but

60:57

in severe osteoporosis, you you end

61:00

up taking these bones strengthening

61:03

agent. So to say is fascinates

61:06

so and and

61:09

being managed either six monthly on a

61:12

yearly basis now.

61:14

Can these procedures be used to correct?

61:17

A scoliosis? No, scoliosis are

61:21

definitely needs to be created and

61:24

I mean traded surgically especially if

61:27

it's a

61:28

moderate to severe you need to put rods and

61:31

screws osteotomies need need to be

61:34

done. So this is this is that's not

61:37

an indication for doing. What you belong.

61:40

You I guess

61:44

that's it. That's it, Dr.

61:47

Khan. Thank you so much for your lecture today and thanks

61:50

to everybody for participating in new conference.

61:54

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62:15

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62:18

lecture will be given by Dr. Barbara Pauley past

62:21

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62:24

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62:27

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62:36

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