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FIGURE 9 Sixty-eight-year-old man with multiple myeloma. (A) Sagittal T1-weighted magnetic resonance (MR) image showing vertebral fracture with signal intensity changes of T12 and L1 and chronic collapse of T11, L2, L3, and L4. An area of signal void is seen into L1 vertebral body. (B) Fat.Sat.Fast Spin Echo image showing high signal intensity of L1 vertebral collapse with an anterior and central area of signal void and diffuse high signal intensity of T12. (C, D) Anteroposterior (C) and lateral (D) radiographs showing intravertebral needle placement through a bilateral transpedicu-lar approach during vertebroplasty. Needle tips are placed at the posterior edge of the signal void area to allow filling of the intravertebral cleft with cement. (E, F) Anteroposterior (E) and lateral (F) radiographs during vertebroplasty showing complete filling of the intravertebral cleft with cement without significant extravertebral cement leakage. (G) Transverse computed tomography (CT) image showing complete filling of the L1 intravertebral cleft. There is a small anterior venous cement leakage. (H) Transverse CT image through the pedicles of L1 showing cement reflux along the needle track.

If possible, needle tip is brought below a nonfractured endplate, which minimizes the risk of disk leakage. When the VC is not too severe, placement of the needle tip is avoided in the mid-height of the vertebral body where venous drainage is abundant. A correct site for needle penetration of the neural arch at the beginning of the procedure is critical in order to make a single path in the vertebra, which minimizes the risk of cement extravasation along a previous needle track. Several attempts are often necessary to find the optimal site for bone panetration and to achieve an accurate needle placement. Very often, the needle tip slides over the irregular cortex of the neural arch. Turning the bevel of the

FIGURE 10 Diagram comparing the bilateral (A) and unilateral (B) transpedicular vertebral cement filling. Intervertebral disk and venous cement leakages are more likely to occur with the unilateral technique, because the needle tip has to be placed in the central part of the vertebral body where compression is more severe and intraosseous veins more abundant. Point of skin puncture for the bilateral approach is 5 mm lateral and 5 mm cranial to the superolateral edge of the vertebral body on an anteroposterior radiograph (A) and slightly more lateral (8-10 mm) for the unilateral approach (B).

FIGURE 10 Diagram comparing the bilateral (A) and unilateral (B) transpedicular vertebral cement filling. Intervertebral disk and venous cement leakages are more likely to occur with the unilateral technique, because the needle tip has to be placed in the central part of the vertebral body where compression is more severe and intraosseous veins more abundant. Point of skin puncture for the bilateral approach is 5 mm lateral and 5 mm cranial to the superolateral edge of the vertebral body on an anteroposterior radiograph (A) and slightly more lateral (8-10 mm) for the unilateral approach (B).

needle may help to penetrate the cortex at the appropriate site. The needle should be advanced slowly while verifying frequently its position on both AP and lateral views.

7. The medial border of the pedicle should not be crossed on the AP view before it has crossed the posterior cortex of the vertebral body on the lateral view (Fig. 11), unless there is a risk of breakthrough of this medial cortex and reflux cement into the spinal canal (Fig. 12).

8. Once the needle is in the vertebral body, making a hole in the anterior cortex with the needle tip or a biopsy cannula should be avoided because it can create a potential site of cement leakage (Fig. 13).

9. The round shape of the vertebral body should be kept in mind. Therefore, a needle may appear to be contained within the vertebral body on both the AP and lateral views while it has actually crossed the anterior cortex (Fig. 13).

10. In severe VCs with separation of the vertebral body into an anterior and a posterior part, the needle tip is advanced very anteriorly into the anterior part of the vertebral body (Fig. 14). The vertebral body will fill from anterior to posterior (10). In cases of vacuum phenomenon or fracture cleft or gap, it is important to place the needle tip in or very close to the vacuum area to be able to fill it with cement. Filling the cleft or gap with cement is probably critical to obtain pain relief and stabilization.

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Dealing With Back Pain

Dealing With Back Pain

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