# Percutaneous Vertebral Augmentation OR Training OR training for left transpedicular vertebroplasty and kyphoplasty of an L1 osteoporotic wedge fracture By Jamil Shaikh Topic: Human Body & Medicine [Open the interactive Jig](https://ask.jig.com/j/CbucgyKEeG02) ## Transcript ### 1. L1 osteoporotic compression fracture Patient prone, posterior elements up\. L1 shows an anterior wedge: anterior height down about a third, posterior wall intact\. T12 and L2 are faded; the thecal sac fills the canal\. Access is left transpedicular\. Choose the technique; it carries through every step\. Insets: AP left \(operator orientation, patient left on the left\), lateral right \(posterior up, cranial right\)\. Drag empty space to turn the view\. ### 2. 1 · True AP Square the C\-arm to L1 before any needle\. Correct rotation until the spinous process sits midway between the pedicles, and tilt cranial or caudal until each endplate is a single sharp line\. A rotated or tilted beam moves the apparent medial pedicle wall\. Watch the AP inset: the doubled endplates merge and the spinous process centres\. ### 3. 2 · Dock at 10 o'clock After local anaesthetic to the periosteum, dock the 11G needle tip on the superolateral margin of the left pedicle oval, at 10 o'clock on AP\. Starting lateral gives room to converge medially before the medial wall\. The right pedicle equivalent is 2 o'clock\. ### 4. 3 · Engage the cortex Seat the diamond\-tip stylet in the dorsal cortex with controlled mallet taps on the T\-handle\. On lateral, keep the trajectory parallel to the endplates; on AP, keep the tip inside the pedicle ring\. Re\-check both projections every few millimetres of advance\. ### 5. 4 · Traverse the pedicle Advance through the pedicle with alternating AP and lateral checks\. Safety rule: on AP the tip must not cross the medial pedicle wall until the lateral view shows it past the posterior vertebral body wall\. Here both landmarks are reached together\. Toggle the pitfall to see a medial breach: tip medial on AP while still within the pedicle on lateral\. ### 6. 5 · Final tip position Advance to the anterior third of the body on lateral, near the midline on AP\. Kyphoplasty: exchange the stylet, place the working cannula, open a channel with the hand drill, then inflate the balloon tamp with contrast under fluoroscopy\. Inflate slowly; stop at cortical contact, the pressure limit or adequate height\. Restoration is partial\. ### 7. 6 · Mix PMMA Mix the PMMA powder and MMA monomer, then wait until the cement reaches toothpaste consistency: it holds a peak and no longer drips\. Load the delivery device\. Thin cement leaks; thick cement fills by interdigitation\. Working time depends on product and room temperature; follow the IFU\. ### 8. 7 · Inject under lateral fluoro Inject in small increments under lateral fluoroscopy\. Fill from the anterior third, endplate to endplate, across the midline\. Stop as cement approaches the posterior quarter of the body or appears in a vein, the disc or the canal\. Toggle the pitfall to see venous leak into the basivertebral and paravertebral veins\. ### 9. 8 · Stylet, rotate, withdraw Reinsert the stylet to clear cement from the cannula, rotate to shear the column at the tip, and withdraw under fluoroscopy\. Leaving cement in the cannula drags a tail through the pedicle and soft tissue\. Toggle the pitfall to see a cement tail along the needle track\. ### 10. 9 · Recover supine Turn the patient supine once the cement has cured\. Keep them flat for the recovery period, document lower\-limb strength and sensation, and watch for new pain, dyspnoea or neurological change\. Recovery time and discharge criteria follow local protocol\. ### 11. The kit, exploded Tap any part to see what it does\. The access needle is shown exploded: T\-handle, stylets and 11G cannula\. Kyphoplasty adds the working cannula, hand drill, balloon tamp and inflation syringe\. The selected part is outlined in orange; its role appears in the panel\. ### 12. Your Role You are scrubbed\. Hand the operator the next instrument for the chosen technique by tapping it on the back table\. A correct pass travels to the field tip first; a wrong one is refused with the reason\. Change the technique at the first step or step 5 to rehearse the other sequence\. ### 13. Q1 · Before the needle On a true AP of L1, where should the spinous process project? ### 14. Q2 · Docking point Where do you dock on the left pedicle oval on AP? ### 15. Q3 · The safety rule On AP the tip reaches the medial pedicle wall\. What must the lateral show before you continue? ### 16. Q4 · Trajectory On lateral, how should the needle run while engaging the cortex? ### 17. Q5 · Final tip Where is the final tip for a unipedicular approach? ### 18. Q6 · Kyphoplasty Which sequence follows the access needle in kyphoplasty? ### 19. Q7 · Cement When is PMMA ready to inject? ### 20. Q8 · Injection Cement appears in the basivertebral vein on lateral\. What do you do? ### 21. Q9 · Withdrawal What prevents a cement tail along the needle track? ### 22. Q10 · Breach sign On AP the tip is medial to the pedicle wall while lateral shows it still in the pedicle\. What is at risk?