geons have the better, because outcomes improve
with the increased ability to steer the placement of
the balloon.
The technology of the balloons themselves has
also progressed quite nicely. They're now much less
likely to burst, and surgeons are able to inflate them
to much higher pounds per square inch. We've gone
from having to make multiple instrument exchanges
to using an all-in-one device. There have also been
advances in the tip of the trocar, which is now
directional and beveled.
Improvements over time
Balloon kyphoplasty was first per-
formed only in hospital settings
while the patient was under general
anesthesia. It has since moved into
ambulatory surgery centers and then
about five years started becoming
more prevalent in office settings. In
ASCs and offices, anesthesiologists
use conscious sedation — typically
propofol — to anesthetize patients.
The percutaneous procedure takes
30 minutes to an hour for each verte-
bral level to complete and up to
three levels can be repaired in a sin-
gle procedure. It's performed with
the patient in the prone position. A
small incision is made directly over
the pedicle of the vertebral body
that's fractured. Surgeons place
instrumentation into the vertebral
body and then inflate the balloon,
which creates a cavity. The balloon
is withdrawn and the PMMA acrylic
is injected. The PMMA is mixed with
barium that allows surgeons to see
the placement of the PMMA.
Surgical facilities or office-based
settings must be outfitted with a radi-
olucent OR table that can be adjusted
to various heights, a radiographic C-
arm and the appropriate lead-based
gear for the surgeon to protect his
eyes and thyroid. Vendors who sell
the balloons and PMMA offer training
sessions for the OR support staff who assist in per-
forming the procedure.
Patient selection is key
Once you've determined that the patient is a candi-
date for the procedure, it's critical that you deal
with the patient holistically and treat the patient's
underlying disease that may have been a contribut-
ing factor to the fracture. The first step is to make
sure they're being treated for — or at least evaluat-
ed for — osteoporosis. I sometimes defer to the
7 2 • O U T P A T I E N T S U R G E R Y M A G A Z I N E • A U G U S T 2 0 2 0
BONE CEMENT An acrylic is injected into the vertebral body to repair compression fractures in older patients with
osteoporosis. This photo shows a successful kyphoplasty procedure done on a 100-year-old woman.
