puncture

• The patient is positioned prone or in lateral decubitus on the CT table.
• The entry point and the pathway are selected on the CT scan.
• After positioning the patient, under neuroleptanalgesia and local anesthesia. The 10 or 14-gauge vertebroplasty needle is safely guided under CT.
• The approach is
  • anterolateral in the cervical level.
  • The optimal approach is transpedicular in both thoracic and lumbar levels
  • but the intercostovertebral route can be used in the thoracic level and the posterolateral route in the lumbar level.

Figure 7b. Transpedicular

Figure 7c. Transpedicular

Figure 7d. Intercostovertebral route

• The use of CT for planning of the pathway and positioning of the needle allows a medial positioning of the needle tip in the anterior third of the vertebral body. In this way, a controlateral access is seldom necessary to obtain a good vertebral filling.
• Cortical perforation can require the aid of a surgical hammer.

Figure 7e. Puncture surgical hammer.

Figure 7f. Puncture .

Figure 7j. vertebral body biopsy.

Figure 7k. Fluoroscopy control, vertebral body biopsy.

• The vertebroplasty needle bevel: The aim of this bevel is to allow precise course correction of the needle inside bone tissue by changing the bevel direction. Hammering will lead the needle on the course determined by the bevel direction. According to the bevel tip direction (right, left, up or down) the course of the needle will be modified . This technique allows an optimal placement of the vertebroplasty needle.
• When the needle is in the optimal position (needle tip in the anterior third of the vertebral body or in the anterior portion of the tumor), the imaging mode is switched to fluoroscopy.
• Vertebral body biopsy If a vertebral body biopsy is needed it can be performed in the same operating time as vertebroplasty. After puncture a 18 gauge biopsy needle ( Ostycut® ) is used under fluoroscopy in coaxial mode to the Optimed® vertebroplasty needle to perform the samplings.
• Vertebral venography Vertebral venography is only performed in hypervascularized lesions with overflow of blood. In the other cases, the contrast media is washed out too slowly and can interfere with the injection of the glue.

Figure 7i. Puncture, the use of vertebroplasty needle bevel.