SpineUniverse Case Study Library

Unipedicular Kyphoplasty and Targeted Cement Placement for T12 Fracture

AVAmax® vertebral balloon and AVAflex® vertebral augmentation needle

This case study is brought to you by:
What is this?


The patient is an active 82-year-old female with a history of osteoporosis. She presents with severe back pain that suddenly developed and has troubled her the past six to eight weeks. The patient felt no radicular pain.

She is undergoing pharmacologic management of osteoporosis and has no other health problems. The patient is a non-smoker.


She exhibited point tenderness to percussion and palpation.

Pre-treatment Images

Sagittal lumbar MRI demonstrated acute superior endplate fracture (Fig. 1) of the T12 vertebral body with associated bone swelling.

sagittal MRI demonstrates T12 fractureFigure 1


Acute superior endplate fracture; T12

Suggest Treatment

Indicate how you would treat this patient by completing the following brief survey. Your response will be added to our survey results below.

Selected Treatment

  • Unipedicular access was achieved under biplanar fluoroscopy and a biopsy performed. The biopsy was benign.
  • Kyphoplasty was then performed using the AVAmax system (AVAmax® Advanced Vertebral Augmentation System, CareFusion, Waukegan, IL) vertebral balloon to create a void in the vertebral body, reducing extravasation risk. (Fig. 2A)
  • Targeted cement delivery was then performed using an AVAflex® curved needle (AVAmax® Advanced Vertebral Augmentation System, CareFusion, Waukegan, IL). (Fig. 2B)
  • Four cubic centimeters of polymethylmethacrylate cement (PMMA) were delivered into the superior endplate fracture lines and the anterior portion of the vertebral body.

intra-operative image, kyphoplasty using AVAmax vertebral balloonFigure 2A

intra-operative image, kyphoplasty using the AVAflex curved needleFigure 2B

The patient tolerated the 20-minute procedure without complication. She reported immediate pain relief.

Post-operative imaging (Fig. 3) demonstrated complete fill of the superior endplate fracture, as well as interdigitation of cement throughout the vertebral body, providing structural support. No cement extravasation was observed.

post-operative image, kyphoplasty treatment of T12 fractureFigure 3

Surgeon’s Treatment Rationale
CareFusion’s AVAmax system provided a unilateral approach to stabilize the fracture with the balloon and curved needle combination.

The procedure was performed on an outpatient basis at a cost lower than the general cost of traditional kyphoplasty.


During the patient’s 6-month follow-up, she is pain free.


Promotional material provided by CareFusion.

The physician author of this case has been compensated for his illustration by CareFusion.

1500 Waukegan Road
McGaw Park, Il 60085

Case Discussion

This case demonstrates the evolution of treating vertebral compression fracture over the years. In the 1980s, vertebroplasty was the only treatment available using dissimilar types of needles to inject bone cement into different parts of the body. In the 1990s, the development of kyphoplasty enabled balloon placement to reduce the fracture from the inside and create a cavity before cement injection.

The AVAmax system combines the benefits of the available devices in the market. First, it allows a unipedicular approach that definitely saves time for pedicle targeting. After access is obtained using the AVAmax system, the surgeon can decide on continuing the procedure using a vertebroplasty or kyphoplasty approach. Finally, the AVAflex curved needle allows targeted cement deposition and leakage avoidance.

Author's Response

Dr. Georgy's delineation of vertebroplasty and kyphoplasty is appreciated. While both of these procedures have advanced vertebral augmentation, in my experience, the AVAmax system provides a better surgical experience than other available products.

Like some of my colleagues, I was skeptical -- Why should I change a procedure that has worked well all this time? Frankly, three facts about the CareFusion system gave me pause.

1. Curved needle affords unilateral approach
2. Radiation exposure is reduced
3. Targeted cement delivery

The beauty of the AVAmax system is it's a one-sided, unilateral1 approach – a clear advantage over traditional kyphoplasty. Depending on the shape of the fracture, the AVAflex curved needle and its trajectory enables you to cross the midline to the opposite side of the vertebral body without making a second incision. The curved needle works easily with vertebroplasty or kyphoplasty. In addition, the curved needle is "associated with shorter procedure duration and reduced fluoroscopy time".2 Furthermore, the curved needle allows targeted cement delivery to optimize cement distribution and reduce the risk of cement leakage.

Radiation exposure is a valid concern to all surgeons. During spine surgery and conventional vertebroplasty and kyphoplasty your hands are irradiated. The dilemma of hand irradiation has been reported on by many including Rampersaud3, Singer4, and Ortiz5. The Ortiz5 study evaluated vertebral fracture augmentation using vertebroplasty and kyphoplasty to assess whether modifying the cement delivery method would reduce radiation exposure. Further research by Ortiz6 and Luchs7 revealed that cement injection facilitated by an extension tube allowed reduced radiation exposure.

Rosioreanu8 presented research at American Society of Spine Radiology and revealed the average fluoro time for vertebroplasty was 11.2 minutes averaging 5.2 minutes for needle positioning and 6 minutes to deliver cement. Respectfully, kyphoplasty was 13.2 minutes averaging 8.5 minutes for needle positioning and 4.7 minutes for cement injection. At one point, I was ready to give up kyphoplasty because of the radiation exposure. Using the AVAmax cement delivery system minimizes my risks and I'm very comfortable performing these procedures.

1. Hunt CH, Kallmes DF, Thielen KR. A unilateral vertebroplasty approach using a curved injection cannula for directed, site-specific vertebral body filling. J Vasc Interv Radiol. 2009;20(4):553-5. Accessed February 7, 2011. http://www.ncbi.nlm.nih.gov/pubmed/19246209

2. Saxena A, Hakimelahi R, Jha RM, et al. The safety and effectiveness of a curved needle for vertebral augmentation: comparison with traditional techniques. J Vas Interv Radiol. 2010;21(10):1548-53. Accessed February 7, 2011. http://www.ncbi.nlm.nih.gov/pubmed/20801677

3. Rampersaud YR, Foley KT, Shen AC, et al. Radiation exposure to the spine surgeon during fluoroscopically assisted pedicle screw insertion. Spine. 2000;Oct 15;25(20):2637-45. Accessed February 7, 2011. http://www.ncbi.nlm.nih.gov/pubmed/11034650

4. Singer G. Occupational Radiation Exposure to the Surgeon. J Am Acad Orthop Surg. 2005;13(1):69-76. Accessed February 7, 2011. http://www.jaaos.org/cgi/content/abstract/13/1/69

5. Ortiz AO, Natarajan V, Gregorius DR, Pollack S. Significantly Reduced Radiation Exposure to Operators during Kyphoplasty and Vertebroplasty Procedures: Methods and Techniques. AJNR Am J Neuroradiol. 2006;27(5):989-94. Accessed February 7, 2011. http://www.ajnr.org/cgi/content/abstract/27/5/989

6. Ortiz O, Gregorius D, Koehler, Natarajan V. Use of a longer extension tube reduces operator radiation exposure during vertebroplasty. Presented at the American Society of Spine Radiology (ASSR), February 2003. Accessed February 7, 2011. http://theassr.org/abstract/use-of-a-longer-extension-tube-reduces-operator-radiation-exposure-during-vertebroplasty/

7. Luchs JS, Rosioreanu A, Gregorius D, et al. Radiation Safety During Spine Interventions. Presented at the American Society of Spine Radiology (ASSR), February 2003. Accessed February 7, 2011. http://theassr.org/?s=Radiation+Safety+During+Spine+Interventions

8. Rosioreanu A, Ortiz O, Natarajan V, et al. Radiation Exposure Levels During Spine Interventional Procedures: A Comparison Between Vertebroplasty and Kyphoplasty. Presented at the American Society of Spine Radiology (ASSR), February 2003. Accessed February 7, 2011. http://theassr.org/?s=Radiation+Exposure+Levels+During+Spine+Interventional+Procedures%3A+A+Comparison+Between+Vertebroplasty+and+Kyphoplasty

Visit the AVAmax® Advanced Vertebral Augmentation System Resource for Surgeons


Get new patient cases delivered to your inbox

Sign up for our healthcare professional eNewsletter, SpineMonitor.
Sign Up!