Create an account and get 3 free clips per day.
Chapters
Outline of the Procedure | Treatment of Vertebral Compression Fractures Physician Education
Outline of the Procedure | Treatment of Vertebral Compression Fractures Physician Education
2017angleanteriorcementcenterchapterfull videomeritnoindexpedicleposteriorprojectionthoracicvertebral
Pedicle Needle Placement & Insertion | Treatment of Vertebral Compression Fractures Physician Education
Pedicle Needle Placement & Insertion | Treatment of Vertebral Compression Fractures Physician Education
2017cadaverschaptercortexfacetfull videolateralmedialmeritneedleneedlesnoindexobliquepediclesoftvisualization
Needle Placement | Treatment of Vertebral Compression Fractures Physician Education
Needle Placement | Treatment of Vertebral Compression Fractures Physician Education
2017anglebeveledchaptercortexfacetfull videomeritmidlinenoindexobliquepediclevertebral
Positioning Cannula in the Cortex | Treatment of Vertebral Compression Fractures Physician Education
Positioning Cannula in the Cortex | Treatment of Vertebral Compression Fractures Physician Education
2017anteriorchapterdopplerfull videohammerlateralmeritneedlenoindexpediclesoundvertebral
Pedicle Needle Placement & Insertion 2 | Treatment of Vertebral Compression Fractures Physician Education
Pedicle Needle Placement & Insertion 2 | Treatment of Vertebral Compression Fractures Physician Education
2017angleanteriorarterybeambuttockcalcificationchapterconefull videoglutealhurtsmeritnoindexsacrumsplenic
Injection of Cement | Treatment of Vertebral Compression Fractures Physician Education
Injection of Cement | Treatment of Vertebral Compression Fractures Physician Education
2017anteriorbenigncementchapterfull videoinjectmeritnoindexsyringevertebral
Familiarising Yourself with Cement & Syringe | Treatment of Vertebral Compression Fractures Physician Education
Familiarising Yourself with Cement & Syringe | Treatment of Vertebral Compression Fractures Physician Education
2017angioplastyaugmentationcalibrationcementchapterfull videoinjectmeritnoindexsyringe
Injecting the Cement | Treatment of Vertebral Compression Fractures Physician Education
Injecting the Cement | Treatment of Vertebral Compression Fractures Physician Education
2017anatomicanteriorbenignbluecementchaptercontinuedispersionendpointfull videograyinjectkyphoplastymeritmyelomanoindexsuperiorthrombosevertebralvertebroplasty
Transcript

- Okay, so we're going to look at the vertebral body. You're going to have pedicles and spinous process, right? And we're going to divide it into anterior middle thirds. And we want to wind up here, so we're going to begin at a point here that allows us to land there. You're going to begin, usually around 10,

and probably translate, depending on the shape of the fracture, down to around four p.m. kind of location, or four o'clock or whatever. Okay, you're going to gradually go down. And you look all the way in the posterior projection until you get down to this point.

And then you switch to lateral. You always have to remember the vertebral body is concave, circumferentially. So if you're going really straight and you're out here, you could wind up out here. And you'll only know as you inject

cement in the lateral projection when the cement starts to be kind of amorphous and blobby. And in fact, it's just filling up and down. Okay, so be conscious, particularly in the thoracic spine, that if you go really far forward, you can pooch out the front of the vertebral body.

So we look at that. You see three lovely pedicles on one side. And say we pick the middle vertebral body, it's shaped a bit like a jelly bean. It's got that characteristic little notch on the outside lateral aspect.

I'm going to angle this way a little bit. And if I just want to see, oh. - [Assistant] The brakes on this are not good. - [Instructor] Okay, so I'm just going to angle. So now we're truly AP. Going to center that by just pulling the whole machine

over towards me a little bit. I'll actually go back towards you. Go back towards you, okay. All right, so that's T12. And those are big pedicles for T12. Sometimes T12 is quite grass-like and they're quite elegant.

And if somebody's got a scoliosis, they'll be thinner on one side than the other. The side of the scoliosis that's convex will have thinner pedicles than the side that is concave. But the weight bearing is on the concave side.

will have thinner pedicles than the side that is concave. But the weight bearing is on the concave side. So if I try and make that pedicle as big as possible

by angling this way, it's actually not working. We better go back here. That's pretty good, and then angle a little bit to put it in the vertebral body middle, like that, cool. - You try and get the end plates parallel? - I want to get the pedicle as big as possible

and get an obliquity that lets me get down to the midline of the vertebral body. So let's see where this nice person is. Come back over, angle a little bit this way. Okay, and can you mag up on that, please, Joe? - You're looking at this one, yes?

- [Instructor] Yeah. - Let's just try and go up there, exit it. - [Assistant] Clear on there. - [Instructor] Okay, I'm going to put it back over there. - [Assistant] It's a little machine, you get a flare every time it changes setting.

- [Instructor] Okay, so somewhere around here, you know, And if you use a beveled needle like the M2 or this shape, it's really just a nail and you can drive it anywhere you want. If you use a, sorry, if you use a diamond tip, you can shove anywhere.

If you use one of these, remember that fascia is oblique. And if you go in on fast, the facet , it'll slip. So you got to turn this so the blade of it is actually going to catch my glove. So in this, I would go in that way to grip that slippy periosteum.

And then just push it a little bit into the periosteum, 'cause the periosteum is soft. And then you feel the more firm cortex beneath it. There you go. - I have a question for you, Kieran. - [Kieran] Can you get the scalpel down there?

- You've talked about going oblique from the 10 o'clock to four o'clock. But normally I would oblique the angle more, so that I can be going down the barrel. You're oblique less so you got a big pedicle, but now you're working in the third dimension

that you can't necessarily see. - [Kieran] Yeah, you get used it. Let's just see what it's like. Do you want to go ahead and do that? - Yeah, yeah. - Go ahead. - [Student] So I'm going to use the diamond.

- [Kieran] Okay sure, you can use the diamond. Yeah, yeah, yeah. And you need a needle holder. - Yes. - Can I grab the towel down there, that, and use it as needle holder? Okay.

And most importantly, do not stick yourself in the hand or anywhere else with these needles, 'cause cadavers, they have Clostridia and other things in them, and you can get terrible cellulitis and face infections if you do that. Most of the time people stick themselves

when they're taking needles out, not putting them in. Arty's done this hundreds of times. - Yeah, so this is the hardest part of the whole thing. So that looks-- - Do you feel it? - [Student] Yeah, I do, so it isn't soft. - [Kieran] Is it really soft?

- [Student] Really soft, yeah. - [Kieran] So do it, what I'd suggest is just move that up a little bit so you get more visualization of the bone. Okay, you might want to just walk down to a little over there, you know? - [Student] A little laterally?

- [Kieran] A little lateral, and yeah. Now it's made a little hole, somewhere around there, but a little lower, even like two millimeters lower. That's great, yeah. Is the bone really soft? - Yeah.

- [Kieran] Okay, sometimes the bone is so soft it feels like wet paper bag and you just kind of marvel-- - [Student] So am I too lateral there? - [Kieran] If you're, are you in bone? - I think so, yes, I think so. - [Kieran] Okay, then I would give it some taps.

- It's so soft I can just, it. - [Kieran] Just gently tap. Oh, yeah. (hammer tapping) Can I take a look? Okay, so I would keep going. (hammer tapping)

Take a look. I think it might be slipping down the side of the pedicle. I think it was, take a look now. I might, yeah. I think what actually happened was, you know when you're at a bar and you put your elbow

on the bar and it slips off? I've heard this happens, but sometimes

So if I try and make that pedicle as big as possible

by angling this way, it's actually not working. We better go back here. That's pretty good, and then angle a little bit to put it in the vertebral body middle, like that, cool. - You try and get the end plates parallel? - I want to get the pedicle as big as possible

and get an obliquity that lets me get down to the midline of the vertebral body. So let's see where this nice person is. Come back over, angle a little bit this way. Okay, and can you mag up on that, please, Joe? - You're looking at this one, yes?

- [Instructor] Yeah. - Let's just try and go up there, exit it. - [Assistant] Clear on there. - [Instructor] Okay, I'm going to put it back over there. - [Assistant] It's a little machine, you get a flare every time it changes setting.

- [Instructor] Okay, so somewhere around here, you know, And if you use a beveled needle like the M2 or this shape, it's really just a nail and you can drive it anywhere you want. If you use a, sorry, if you use a diamond tip, you can shove anywhere.

If you use one of these, remember that fascia is oblique. And if you go in on fast, the facet , it'll slip. So you got to turn this so the blade of it is actually going to catch my glove. So in this, I would go in that way to grip that slippy periosteum.

And then just push it a little bit into the periosteum, 'cause the periosteum is soft. And then you feel the more firm cortex beneath it. There you go. - I have a question for you, Kieran. - [Kieran] Can you get the scalpel down there?

- You've talked about going oblique from the 10 o'clock to four o'clock. But normally I would oblique the angle more, so that I can be going down the barrel. You're oblique less so you got a big pedicle, but now you're working in the third dimension

that you can't necessarily see. - [Kieran] Yeah, you get used it. Let's just see what it's like. Do you want to go ahead and do that?

- Yeah, yeah. - Go ahead. - [Student] So I'm going to use the diamond.

- [Kieran] Okay sure, you can use the diamond. Yeah, yeah, yeah. And you need a needle holder. - Yes. - Can I grab the towel down there, that, and use it as needle holder? Okay.

And most importantly, do not stick yourself in the hand or anywhere else with these needles, 'cause cadavers, they have Clostridia and other things in them, and you can get terrible cellulitis and face infections if you do that. Most of the time people stick themselves

when they're taking needles out, not putting them in. Arty's done this hundreds of times. - Yeah, so this is the hardest part of the whole thing. So that looks-- - Do you feel it? - [Student] Yeah, I do, so it isn't soft. - [Kieran] Is it really soft?

- [Student] Really soft, yeah. - [Kieran] So do it, what I'd suggest is just move that up a little bit so you get more visualization of the bone. Okay, you might want to just walk down to a little over there, you know? - [Student] A little laterally?

- [Kieran] A little lateral, and yeah. Now it's made a little hole, somewhere around there, but a little lower, even like two millimeters lower. That's great, yeah. Is the bone really soft? - Yeah.

- [Kieran] Okay, sometimes the bone is so soft it feels like wet paper bag and you just kind of marvel-- - [Student] So am I too lateral there? - [Kieran] If you're, are you in bone? - I think so, yes, I think so. - [Kieran] Okay, then I would give it some taps.

- It's so soft I can just, it. - [Kieran] Just gently tap. Oh, yeah. (hammer tapping) Can I take a look? Okay, so I would keep going. (hammer tapping)

Take a look. I think it might be slipping down the side of the pedicle. I think it was, take a look now. I might, yeah. I think what actually happened was, you know when you're at a bar and you put your elbow

on the bar and it slips off? I've heard this happens, but sometimes the needle will do the same thing, I'm told. Okay, so now you have to straighten up a lot to stay away from that medial wall. (hammer tapping)

Yeah, I would, you can crank a little more. (hammer tapping) Good, take a look. Okay, so you can see the medial wall very clearly there. (hammer tapping) Okay, yes.

(hammer tapping) From the sound, it's still quite firm, isn't it? - Yeah, so you can, you talked about hearing a sound. - [Kieran] Do you want to go laterally and see how deep you are? - Yes. - But this also confirms that we were

kind of paravertebral earlier. We probably would have gone into it. If you think of what is lateral to the pedicle. There's nothing you can hurt, lateral to the pedicle. There's some blood vessels there. (machinery humming)

- [Man] But I do think we could do it later. - [Assistant] Readjust engaging. - Yeah, still a long way to go. - Okay, go back. (machinery humming) In fact, the bone is much denser.

- Yes. - Yes. (machinery humming) - Let's get that obliquely right there. Okay, so that's a-- - [Student] That's a different obliquity then. - But it shows you why the sound

is so high pitched. It's actually the sound of cortex, you know? So let's go back to where we were, and we'll try and get a good position. All right, I think. Okay, what I would do would be I would bring it up that way.

And I might actually just screw it a bit, like that. Let's see where we are now. Okay, 'cause we can move around quite a bit. Look, that's very safe, right there. I would just give it a good thump. (hammer tapping)

Yep, more cowbell. (hammer tapping) (laughing) - I think I'm somewhere. - Did something change? - It feels loose. - Get more lateral. - Okay, you're good, just more cowbell.

- Okay, I think we should look lateral now. - Sure. The sound has dropped, hasn't it? - Yes, yeah, yeah. - It's kind of cool. It's like having Dopplers and color Dopplers, you know?

- Yeah, as you say, the key is just getting in the right place. So I kind of be sure that I'm really in before I get too aggressive with making that big of a hole. - But once you're in that, then it's so safe. Yeah, cool. - You're home free now.

- So now I can advance from here. - [Kieran] Yeah, and the hammer I use is a little lighter than that one. It's about half that weight. And hammering is more controlled than pushing with your... - Should he switch over to the beveled needle now,

to get some directional control? - [Student] But I'm going in the right direction. - Yeah, I suppose it's-- - [Kieran] But this is it, I wouldn't go any further forward, 'cause I want to make a point here. So this has a changeable stylet.

Look where the needle is now. It looks fine, right? - [Student] Yeah, just down and past. - [Kieran] But in fact, the needle is, there we go, all the way back there. - [Assistant] That's seven millimeters.

- [Kieran] Yeah, so you actually need to be a bit further forward than you think with this design. - Okay, so now we're going to just rotate and angle towards me. (machinery humming) - Too much? - Why don't you use this side? Okay, go back.

- Yeah, so let's move the whole. No, no, not the angle, the whole device. - So you start moving, depending on how-- - [Assistant] Right, you want it to center? - No, towards us. - [Assistant] No, no, don't move the...

- 80, 90 degrees. - So the angle is too steep? You want me to un-angle a bit? - [Kieran] Let's take a look, probably. That's pretty good, actually. - [Assistant] Yeah, it's a nice big target. - I don't want you to hurt yourself.

- [Assistant] Thank you. - [Kieran] I think there's something else in the aorta there. So one of the things you do prior to loading cement and injecting it is you register in your own head all the apparent locations of calcium.

'Cause there's nothing worse than being in the middle of an injection and suddenly you see that and go, "Shit." And you lose three, four minutes trying to figure out, did something awful happen? So you do your own visual subtraction, pulse junctions,

splenic artery calcitations, renal artery calcitations, level it's in the lung, all that stuff. (hammer tapping) (machines beeping and murmuring in background) (hammer tapping) - Should we see what it looks like lateral,

or should I correct it? - [Kieran] Sure, why not, and then see if we can correct it. - Let's go to lateral. (machine whirring and beeping) - The chisel selection is based...? - Just kind of listening to your own,

so I was kind of taught where the factor is but if it doesn't hurt the area then-- - But still there's a correlation, cross section of data. - Not even, does it hurt here, here, or here, as a factor, whereas I would say, if it hurts here...

(hammer tapping) - All right, put another one in the other side. I wouldn't go any further forward. - I see where the cannula is there. - Yeah. - Your Spidey-sense is tingling again?

- [Kieran] You're perfect. - Good, thank you. - [Kieran] Okay, would you want to? - Sure, you've done this before, have you? - Yeah, once or twice. - Put in the other, and then we'll inject cement,

and then the other three, four people will do it.

the needle will do the same thing, I'm told. Okay, so now you have to straighten up a lot to stay away from that medial wall. (hammer tapping)

Yeah, I would, you can crank a little more. (hammer tapping) Good, take a look. Okay, so you can see the medial wall very clearly there. (hammer tapping) Okay, yes.

(hammer tapping) From the sound, it's still quite firm, isn't it? - Yeah, so you can, you talked about hearing a sound. - [Kieran] Do you want to go laterally and see how deep you are? - Yes. - But this also confirms that we were

kind of paravertebral earlier. We probably would have gone into it. If you think of what is lateral to the pedicle. There's nothing you can hurt, lateral to the pedicle. There's some blood vessels there. (machinery humming)

- [Man] But I do think we could do it later. - [Assistant] Readjust engaging. - Yeah, still a long way to go. - Okay, go back. (machinery humming) In fact, the bone is much denser.

- Yes. - Yes. (machinery humming) - Let's get that obliquely right there. Okay, so that's a-- - [Student] That's a different obliquity then. - But it shows you why the sound

is so high pitched. It's actually the sound of cortex, you know? So let's go back to where we were, and we'll try and get a good position. All right, I think. Okay, what I would do would be I would bring it up that way.

And I might actually just screw it a bit, like that. Let's see where we are now. Okay, 'cause we can move around quite a bit. Look, that's very safe, right there. I would just give it a good thump. (hammer tapping)

Yep, more cowbell. (hammer tapping) (laughing) - I think I'm somewhere. - Did something change? - It feels loose. - Get more lateral. - Okay, you're good, just more cowbell.

- Okay, I think we should look lateral now. - Sure. The sound has dropped, hasn't it? - Yes, yeah, yeah. - It's kind of cool. It's like having Dopplers and color Dopplers, you know?

- Yeah, as you say, the key is just getting in the right place. So I kind of be sure that I'm really in before I get too aggressive with making that big of a hole. - But once you're in that, then it's so safe. Yeah, cool. - You're home free now.

- So now I can advance from here. - [Kieran] Yeah, and the hammer I use is a little lighter than that one. It's about half that weight. And hammering is more controlled than pushing with your... - Should he switch over to the beveled needle now,

to get some directional control? - [Student] But I'm going in the right direction. - Yeah, I suppose it's-- - [Kieran] But this is it, I wouldn't go any further forward, 'cause I want to make a point here. So this has a changeable stylet.

Look where the needle is now. It looks fine, right? - [Student] Yeah, just down and past. - [Kieran] But in fact, the needle is,

there we go, all the way back there. - [Assistant] That's seven millimeters.

- [Kieran] Yeah, so you actually need to be a bit further forward than you think with this design. - Okay, so now we're going to just rotate and angle towards me. (machinery humming) - Too much? - Why don't you use this side? Okay, go back.

- Yeah, so let's move the whole. No, no, not the angle, the whole device. - So you start moving, depending on how-- - [Assistant] Right, you want it to center? - No, towards us. - [Assistant] No, no, don't move the...

- 80, 90 degrees. - So the angle is too steep? You want me to un-angle a bit? - [Kieran] Let's take a look, probably. That's pretty good, actually. - [Assistant] Yeah, it's a nice big target. - I don't want you to hurt yourself.

- [Assistant] Thank you. - [Kieran] I think there's something else in the aorta there. So one of the things you do prior to loading cement and injecting it is you register in your own head all the apparent locations of calcium.

'Cause there's nothing worse than being in the middle of an injection and suddenly you see that and go, "Shit." And you lose three, four minutes trying to figure out, did something awful happen? So you do your own visual subtraction, pulse junctions,

splenic artery calcitations, renal artery calcitations, level it's in the lung, all that stuff. (hammer tapping) (machines beeping and murmuring in background) (hammer tapping) - Should we see what it looks like lateral,

or should I correct it? - [Kieran] Sure, why not, and then see if we can correct it. - Let's go to lateral. (machine whirring and beeping) - The chisel selection is based...? - Just kind of listening to your own,

so I was kind of taught where the factor is but if it doesn't hurt the area then-- - But still there's a correlation, cross section of data. - Not even, does it hurt here, here, or here, as a factor, whereas I would say, if it hurts here...

(hammer tapping) - All right, put another one in the other side. I wouldn't go any further forward. - I see where the cannula is there. - Yeah. - Your Spidey-sense is tingling again?

- [Kieran] You're perfect. - Good, thank you. - [Kieran] Okay, would you want to? - Sure, you've done this before, have you? - Yeah, once or twice. - Put in the other, and then we'll inject cement,

and then the other three, four people will do it. - [Assistant] Okay, so I'll mix it now. - [Instructor] So take the filter off, and then come off, like that. Normally what I'll do is I'll attach this, so we don't lose the cement, because...

So this is the multiplying syringe, so it can generate a lot of pressure compared to just a simple hand syringe. What this does, is it will actually pressurize this master syringe and it'll push into the syringe. - [Student] And this is just your standard

angioplasty pressure device? - This is something that you'll find with your, you know, with your, you know, your eltex

- [Assistant] Okay, so I'll mix it now. - [Instructor] So take the filter off, and then come off, like that. Normally what I'll do is I'll attach this, so we don't lose the cement, because...

So this is the multiplying syringe, so it can generate a lot of pressure compared to just a simple hand syringe. What this does, is it will actually pressurize this master syringe and it'll push into the syringe. - [Student] And this is just your standard

angioplasty pressure device? - This is something that you'll find with your, you know, with your, you know, your eltex with the little needle and more. - Want some more? - Normally I wet my hands a little bit,

so go ahead and stick your fingers in that. So yeah, this is all personal preference, one thing I will tell you though, when I ask you to wipe it, go ahead and wipe it, okay? One, two, three wipe it. So you'll see that all you have to do in order

to stop the cement flow, is pull this clutch. - Right that releases - Releases the pressure. - Of the system, you don't have to pull back or anything. So this is a locking cannula, you'll see it's blue to blue, you put it in here. There's a lock-in with the blue lure.

- And how far does that protrude? - Ten millimeters. - Ten mills. - So that's one centimeter. So the stylet is seven millimeters. - So Murray's going through the anterior wall, probably.

- You can back both of those. If you want to back. - So is that anterior, or is that okay? - You're good. So in dead people, cement tends to extravasate more than in living people, right,

because they're cold, whereas in the living, it will begin to polymerize. So you might see more veins. Remember we talked earlier about density. - [Student] Yeah.

- [Instructor] I think those two densities are aortic, right, it's not cement. - [Instructor] What about this stuff up there, did anybody notice? - [Student] I think that's glue, it's not you. - [Instructor] I think that's where some of your cement

went right off the get-go. - Just go lateral and take a look, okay? Sorry, go AP, take a look. - [Student] So I did, and I released the load beams. Just in the middle of it. - So, there's some crossing,

there's a little bit I think, just, just going to take, just going to angle it this way. You're actually good. - [Student] Yeah, it looks good. Is there something besides there, on the...? - [Instructor] I'm not sure.

I don't know. It's a much lower density than than the cement, but let's just continue to inject back here, okay? Thank you very much. (machine whirring and beeping)

Thank you. But that would be something that we would have kind of pre-registered in our minds, because we just lost two minutes. - [Student] So again, there was a dispersion, so in my vast series of kypho-lines,

I find I can get way more cement in. - [Instructor] Yeah. - [Student] Endplate to endplate, as opposed to my experience with vertebroplasty, where I get far less cement in, and again, so whatever that means.

- [Instructor] How do the patients do? Is there something near to the anterior inferior aspect of that vertebral body now? - [Student] Yeah. - [Instructor] All right, just for anatomic reasons, let's continue, get a sense of it.

- [Student] It's good to know where we're at. - There's definitely something down there. - [Instructor] Do you feel it's safe to continue to inject? You know how much cross-thinning has occurred, is it going to continue to get to a higher plane? Are there tectonic plates of pressure in that vertebra

that will prevent this from getting to your endplate? - [Student] It's not getting. - [Instructor] It's beginning to go up there now, isn't it? We see it, physically see it ascend. - Do you feel the pressure? - [Student] Some, some.

- You're getting a downward vibe, aren't you? - Oh you're right, oh, that's 400. - [Instructor] So Bob, how much do you mix of the eight? - We mix 10, and there's 9 deliverable, but these are the demo kit, so we only have seven. - [Instructor] Right, can you mix another one

so we can do the other four levels. - [Student] So now, they're real light, so it's almost like there may be some extravasate anterio-inferiorally, is that a problem? - [Instructor] I don't think it's real. Yeah, I'm not sure it's real.

- [Student] If that was real, is that a problem, would you stop? - [Instructor] I would stop and let it compose, and then I would continue. - [Instructor] Which, I mean, is brilliant, you have such a long working time.

- Yeah. - [Instructor] With this cement. - The other thing that is kind of fun that we didn't talk about is, this is clearly a benign vertebral body, it's not malignant disease. There's a fractal pattern to malignancy

that's irregular, whereas in the benign disease you get this modulous distribution of cohesive cement, but in myeloma, it looks like a moth with even legs. Clearly abnormal. What could be cool now, is just to go A-P now,

this, that line, let's just see what's going on. - [Student] Oh, actually, some of it is coming out the other side. - It's blood. - That's blood, yeah. - [Student] Oh yeah, so I've gotten a lot of cross...

- [Instructor] And that was a little thing that was just. - [Student] I see. So how bad is that? - [Instructor] That's fine, that's fine. Wouldn't worry about it at all. I've seen a lot of those things.

- [Student] You feel, like in real life, this would be, I mean, you'd stop? I mean, you've got pretty good filling. - [Instructor] Yeah, we're done.

with the little needle and more. - Want some more? - Normally I wet my hands a little bit,

so go ahead and stick your fingers in that. So yeah, this is all personal preference, one thing I will tell you though, when I ask you to wipe it, go ahead and wipe it, okay? One, two, three wipe it. So you'll see that all you have to do in order

to stop the cement flow, is pull this clutch. - Right that releases - Releases the pressure. - Of the system, you don't have to pull back or anything. So this is a locking cannula, you'll see it's blue to blue, you put it in here. There's a lock-in with the blue lure.

- And how far does that protrude? - Ten millimeters. - Ten mills. - So that's one centimeter. So the stylet is seven millimeters. - So Murray's going through the anterior wall, probably.

- You can back both of those. If you want to back. - So is that anterior, or is that okay? - You're good. So in dead people, cement tends to extravasate more than in living people, right,

because they're cold, whereas in the living, it will begin to polymerize. So you might see more veins. Remember we talked earlier about density. - [Student] Yeah.

- [Instructor] I think those two densities are aortic, right, it's not cement. - [Instructor] What about this stuff up there, did anybody notice? - [Student] I think that's glue, it's not you. - [Instructor] I think that's where some of your cement

went right off the get-go. - Just go lateral and take a look, okay? Sorry, go AP, take a look. - [Student] So I did, and I released the load beams. Just in the middle of it. - So, there's some crossing,

there's a little bit I think, just, just going to take, just going to angle it this way. You're actually good. - [Student] Yeah, it looks good. Is there something besides there, on the...? - [Instructor] I'm not sure.

I don't know. It's a much lower density than than the cement, but let's just continue to inject back here, okay? Thank you very much. (machine whirring and beeping)

Thank you. But that would be something that we would have kind of pre-registered in our minds, because we just lost two minutes. - [Student] So again, there was a dispersion, so in my vast series of kypho-lines,

I find I can get way more cement in. - [Instructor] Yeah. - [Student] Endplate to endplate, as opposed to my experience with vertebroplasty, where I get far less cement in, and again, so whatever that means.

- [Instructor] How do the patients do? Is there something near to the anterior inferior aspect of that vertebral body now? - [Student] Yeah. - [Instructor] All right, just for anatomic reasons, let's continue, get a sense of it.

- [Student] It's good to know where we're at. - There's definitely something down there. - [Instructor] Do you feel it's safe to continue to inject?

You know how much cross-thinning has occurred, is it going to continue to get to a higher plane? Are there tectonic plates of pressure in that vertebra

that will prevent this from getting to your endplate? - [Student] It's not getting. - [Instructor] It's beginning to go up there now, isn't it? We see it, physically see it ascend. - Do you feel the pressure? - [Student] Some, some.

- You're getting a downward vibe, aren't you? - Oh you're right, oh, that's 400. - [Instructor] So Bob, how much do you mix of the eight? - We mix 10, and there's 9 deliverable, but these are the demo kit, so we only have seven. - [Instructor] Right, can you mix another one

so we can do the other four levels. - [Student] So now, they're real light, so it's almost like there may be some extravasate anterio-inferiorally, is that a problem? - [Instructor] I don't think it's real. Yeah, I'm not sure it's real.

- [Student] If that was real, is that a problem, would you stop? - [Instructor] I would stop and let it compose, and then I would continue. - [Instructor] Which, I mean, is brilliant, you have such a long working time.

- Yeah. - [Instructor] With this cement. - The other thing that is kind of fun that we didn't talk about is, this is clearly a benign vertebral body, it's not malignant disease. There's a fractal pattern to malignancy

that's irregular, whereas in the benign disease you get this modulous distribution of cohesive cement, but in myeloma, it looks like a moth with even legs. Clearly abnormal. What could be cool now, is just to go A-P now,

this, that line, let's just see what's going on. - [Student] Oh, actually, some of it is coming out the other side. - It's blood. - That's blood, yeah. - [Student] Oh yeah, so I've gotten a lot of cross...

- [Instructor] And that was a little thing that was just. - [Student] I see. So how bad is that? - [Instructor] That's fine, that's fine. Wouldn't worry about it at all. I've seen a lot of those things.

- [Student] You feel, like in real life, this would be, I mean, you'd stop? I mean, you've got pretty good filling. - [Instructor] Yeah, we're done.

Disclaimer: Content and materials on Medlantis are provided for educational purposes only, and are intended for use by medical professionals, not to be used self-diagnosis or self-treatment. It is not intended as, nor should it be, a substitute for independent professional medical care. Medical practitioners must make their own independent assessment before suggesting a diagnosis or recommending or instituting a course of treatment. The content and materials on Medlantis should not in any way be seen as a replacement for consultation with colleagues or other sources, or as a substitute for conventional training and study.