Utilization of Cone Beam CT during Vertebral Augmentation

Learning Objectives: Illustrate the utility of cone-beam CT in altering intraprocedural management in percutaneous vertebral augmentation through a series of challenging cases.

Background: Spinal compression fractures can result in debilitating pain for many people, whether due to osteoporosis, trauma, or osseous metastatic disease. Percutaneous vertebral augmentation (PVA), including vertebroplasty, kyphoplasty, and now other novel implantable devices, has been an effective and minimally invasive treatment modality resulting in pain reduction, improved quality of life, and biomechanical restoration.{1-2} Traditionally, PVA is achieved under fluoroscopic guidance,{3} however, the advent of intraprocedural cone-beam CT (CBCT) with or without needle guidance may further reduce complications and lead to improved technical proficiency with potentially better outcomes.{4}

Clinical Findings/Procedure Details: A series of cases will be presented demonstrating how CBCT altered intraprocedural management resulting in a more optimal and durable procedural outcome. We will highlight cases of cement deposition variation with unipedicular approach, assessment of appropriate Kirschner wire placement in vertebra plana cases, and guidance for vertebral lesion biopsy.

For cases of unipedicular access, a curved balloon system is used to reach the contralateral hemivertebra. While unipedicular approach can reduce procedure time and radiation dose, this technique may result in a paucity of cement deposition in the contralateral posterior quadrant. CBCT can easily illustrate this pitfall, ultimately necessitating contralateral pedicle access to attain uniform vertebral body cement deposition. Conversely, excessive cement deposition leading to extavertebral leak or intravasation can readily be identified and quantified.{5}

Severe vertebra plana cases are challenging as interposition of Kirshner wires between the end plates may be unclear under fluoroscopy alone. CBCT provides three-dimensional characterization to ensure proper wire placement prior to implementation of an implantable device, such as Spine Jack. {6}

Lastly, CBCT can aid in suspected vertebral body lesion biopsy prior to augmentation. While needle trajectory in relation to a vertebral body targeted lesion may be opaque under fluoroscopy, CBCT provides greater detail allowing for a higher likelihood of adequate specimen yield.

Conclusion and/or Teaching Points: The utilization of CBCT can be an effective tool for improved technical proficiency in PVA, altering and enhancing intraprocedural management to achieve durable and optimal results in select cases.