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Indications & Contraindications
When SpineJack is preferred over kyphoplasty
Indications
- Acute osteoporotic VCF with significant height loss (>30%) — VADs (including SpineJack) emerged specifically for cases of significant vertebral height loss where balloon kyphoplasty is inadequate
- Young patients where durable height restoration is desired — titanium implant remains in situ indefinitely; balloon kyphoplasty deflates before cement, allowing partial height recollapse
- Traumatic fractures — SpineJack indicated for compression fractures from osteoporotic, traumatic, and tumor-related causes; level range T5–L5
- Primary or secondary bone tumors — SpineJack can be used with appropriate oncologic indication alongside cementoplasty for tumor stabilization
- Cases where kyphosis correction is a priority — SpineJack provides up to 40% height gain and significant kyphotic angle reduction (mean 11–24 degrees in published series)
Contraindications
- Absolute: Retropulsed fragments causing neurologic deficit (surgery) · Active spinal infection / osteomyelitis · Uncorrectable coagulopathy · PMMA allergy
- Relative: Posterior wall disruption with canal compromise — device expansion may worsen retropulsion · Spinal instability requiring surgical fixation · Severe osteoporosis with very low bone density (device may not achieve purchase)
- OsseoFix absolute contraindication note: Retropulsed fragments and dural sac/cord compression are absolute contraindications for OsseoFix — similar caution applies to all VADs
SpineJack vs. Balloon Kyphoplasty — Key Advantages
- Durable height restoration: SpineJack remains in situ permanently — balloon deflation before cement in kyphoplasty allows partial cavity collapse; SpineJack maintains full expansion
- Mechanical (not hydraulic) expansion: Craniocaudal expansion is controlled mechanically — provides predictable force application; balloon expansion is hydraulic and less directional
- Superior height restoration and kyphosis correction: Preliminary and multicenter studies (Noriega et al, SAKOS study, Spine J 2019) show SpineJack non-inferior to kyphoplasty for pain with superior height restoration
- 81.5% pain relief at 48 hours in Noriega et al registry study (n=108); 90%+ decrease in analgesia use at 12 months
- Cost: Most expensive of the three options; requires implant-specific instrumentation
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Pre-Procedure Checklist
Imaging, labs, implant planning, antibiotics
MRI spine with STIR. Confirm bone marrow edema = active fracture. Assess degree of height loss, fracture morphology, and kyphotic deformity. STIR hyperintensity confirms treatment benefit; no edema in chronic fracture = low response likelihood.
CT spine — mandatory for SpineJack planning. Quantify vertebral height loss (pre-procedure CT: measure anterior, central, and posterior heights). Assess posterior wall integrity. Measure pedicle width to confirm bilateral transpedicular access feasibility. Document kyphotic angle (Cobb angle) for post-procedure comparison. Post-procedure CT used to confirm height restoration and cement distribution.
Select appropriate SpineJack device size. SpineJack is available in a 5-mm diameter implant inserted via a working cannula. Select device length based on vertebral body dimensions from pre-procedure CT. Implant-specific instrumentation required — confirm availability before scheduling.
Labs. INR ≤1.5, platelets ≥50K. CBC, BMP. As an implant procedure: type and screen recommended.
Prophylactic antibiotics — REQUIRED (implant). Cefazolin 1g IV within 60 minutes of incision. Penicillin allergy: clindamycin 600 mg IV or vancomycin 15 mg/kg IV. Repeat dose if procedure >3 hours.
Anesthesia plan. General anesthesia commonly used (implant placement requires precise, controlled patient positioning and longer procedure time vs. vertebroplasty). MAC acceptable for selected patients with good pain tolerance in prone position.
Consent — implant-specific risks. Discuss: device malposition, failure to achieve adequate height restoration, cement leak around device, implant not FDA-approved at all centers (verify regulatory status), infection (implant), adjacent fracture, need for surgical removal if complication (rare).
Multidisciplinary discussion for complex cases. Per published VAD literature — tumor cases, multi-level fractures, or spinal instability warrant multidisciplinary spine team discussion prior to SpineJack placement.
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Relevant Anatomy
Bilateral access, implant workspace, expansion mechanics
Transpedicular / Parapedicular Access
- Bilateral approach mandatory: SpineJack requires bilateral implant placement — two cannulae, two devices, simultaneous expansion
- Standard transpedicular approach (pedicle width ≥4–5 mm); parapedicular approach for narrower pedicles
- Level range: T5–L5 (VBS system); SpineJack generally applied T4–L5
- Working cannula (implant-specific trocar) advanced to posterior one-third of vertebral body — confirmed on lateral fluoroscopy
SpineJack Device Anatomy
- Titanium implant, 5 mm diameter in collapsed state; expands craniocaudally via mechanical compression of the device handle
- Expansion creates a cavity in the vertebral body within which SpineJack resides — analogous to balloon kyphoplasty cavity but implant remains
- Mechanical (not hydraulic) expansion = operator-controlled, directional craniocaudal force — compacts trabecular bone vertically
- PMMA injected through the working cannula simultaneously on both sides, filling the cavity around the in-situ implant
- Device locked in expanded position before cement injection — ensures height is maintained during cementing
Drill Path & Template
- After working cannula placed at posterior one-third of vertebral body: inner trocar replaced with guidewire, then bone drill (reamer)
- Drill advances to desired implant position — terminates just short of the anterior vertebral body cortex
- Drill removed; template device "cleans" the desired implant site and confirms dimensions
- Process repeated on contralateral side before any device insertion
- Both implant expanders inserted through working cannulae, expanded simultaneously under fluoroscopy
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Technique
Default RadCall approach · share your own below
Supplies
Biplanar fluoroscopy (C-arm)
SpineJack implant system (Stryker) — bilateral set
Implant-specific working cannulae (5-mm device)
Guidewire (implant-specific)
Bone drill / reamer
Template device (site preparation)
SpineJack expander tool (mechanical)
Implant-specific PMMA cement
1 mL Luer-lock syringes (cement delivery)
Cefazolin 1g IV (antibiotic)
ChloraPrep
Sterile drapes
1% lidocaine
18G spinal needle (level marking)
Steps — SpineJack Vertebral Augmentation
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Prophylactic antibiotics & positioning
Administer cefazolin 1g IV within 60 minutes prior to skin incision. Patient prone on radiolucent table. Biplanar fluoroscopy configured. Confirm correct vertebral level with marking needle. Prep and drape widely. Review pre-procedure CT for pedicle dimensions and degree of height loss.
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Bilateral pedicle entry — working cannulae
Local anesthesia (1% lidocaine) to skin and periosteum bilaterally. Make bilateral stab incisions. Advance implant-specific working cannulae through both pedicles using the "owl eye" technique on AP fluoroscopy. Confirm on lateral: cannula tip should reach the posterior one-third of the vertebral body — not crossing the posterior wall at this stage.
▶ Bilateral pedicular access — SpineJack approach
Bilateral pedicular cannulae: same access as kyphoplasty — confirm pedicle wall integrity before advancing; SpineJack requires accurate midline trajectory.
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Guidewire and bone drill (reamer)
Remove inner trocar from working cannula. Insert implant-specific guidewire. Over the guidewire, advance bone drill (reamer) to desired position. Drill terminates just short of the anterior vertebral body cortex — confirm on lateral fluoroscopy. Drilling creates the channel for the SpineJack implant. Remove drill.
▶ Reamer creating SpineJack cavity
Reamer advancing to create SpineJack seating cavity — lateral confirms instrument tip position anterior to posterior cortex before device insertion.
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Template device — site preparation
Insert the template device through the working cannula to "clean" the desired implant site. The template ensures appropriate dimensions and removes loose debris from the drilled channel. Confirm template position under lateral fluoroscopy. Remove template. Repeat steps 3–4 on contralateral side before device insertion.
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Insert SpineJack expanders bilaterally
Insert SpineJack implant expanders through both working cannulae simultaneously. Confirm position under lateral and AP fluoroscopy — expanders should be in the correct craniocaudal position within the vertebral body. Both devices must be in satisfactory position before expansion begins.
▶ SpineJack expanders — bilateral deployment
Bilateral SpineJack expanders deployed — simultaneous mechanical expansion restores vertebral height; device locks in expanded position before cement injection.
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Simultaneous mechanical expansion — height restoration
Expand both devices simultaneously using the mechanical expander tool. Expansion is craniocaudal — the device compresses the fracture cleft open, restoring height. Monitor continuously with intermittent fluoroscopy on lateral view. STOP expansion if: end-plate breach visualized, no further height gain despite continued expansion (limit reached), or superior end-plate flattening noted. Goal: restore near-normal vertebral body height.
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Lock devices in expanded position
Once target height achieved: lock both SpineJack devices in their expanded position using the locking mechanism (per manufacturer instructions). This is a critical step — the device must be locked before cement injection to prevent height recollapse. Remove expander tool; working cannulae and locked devices remain in situ.
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Simultaneous PMMA cement injection
Mix implant-specific PMMA cement to paste consistency. Inject cement simultaneously on both sides through the working cannulae under continuous biplanar fluoroscopy. Cement fills the cavity created by the SpineJack devices and around the implants. STOP immediately at any sign of posterior leak, foraminal filling, or venous runoff. Standard volumes per level; fill confirmed by AP and lateral fluoroscopy.
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Cannula removal & final imaging
Once cement polymerizes (1–2 min): remove working cannulae. SpineJack implants remain permanently in situ. Apply pressure at skin entry sites. Post-procedure AP control projection to confirm implant positioning and cement distribution. Post-procedure CT recommended to confirm height restoration, implant position, and exclude canal encroachment.
▶ Post-SpineJack — cement fill and height restoration
Final fluoroscopy: SpineJack devices with surrounding PMMA cement — confirm vertebral height restoration and absence of cement extravasation.
Vertebral Body Stenting (VBS) System — Alternative VAD
- VBS (DePuy Synthes): Expandable titanium stent deployed using the same balloon as conventional kyphoplasty — stent remains expanded in place after balloon removal (unlike conventional kyphoplasty where only cement remains)
- Bipedicular approach; suitable for T5–L5 compression fractures
- After balloon inflation and stent expansion: balloon is removed but stent stays — PMMA injected through same cannula into stent cavity
- Evidence shows greater vertebral height reduction after VBS vs. standard kyphoplasty (stent holds height after balloon removal)
- Significant pain reduction and height restoration maintained at 12 months in published series
- Mechanism: Hydraulic (balloon-based) vs. SpineJack mechanical — both leave permanent implant; different engineering approach
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Troubleshooting
Problem
Device does not expand / insufficient height gain
Likely cause: Chronic fracture with sclerotic bone, very dense trabecular architecture, or device positioned in wrong location (e.g., in the fracture endplate rather than in trabecular bone).
Next step: Confirm device tip position on lateral fluoroscopy — ensure both implants are within trabecular bone at the same level and aimed at the fracture cleft. Attempt additional expansion force. If maximum expansion reached without adequate height gain: lock device in partially expanded position and proceed with cement. Partial restoration still provides pain relief and structural stabilization.
Problem
Asymmetric expansion — one device advances faster
Likely cause: Asymmetric fracture morphology, one device in denser bone, or slight difference in starting positions.
Next step: Monitor both devices simultaneously on AP fluoroscopy during expansion. Slow the advancing device and apply more force on the lagging side to achieve symmetric height restoration. Small asymmetries are acceptable — do not force symmetric expansion at the cost of superior end-plate breach.
Problem
Cement leak around device
Likely cause: Posterior cortical breach, cement injected at too low viscosity, or fracture line extending to posterior cortex.
Next step: Stop injection immediately. Wait for polymerization at leak site (1–2 min). Resume cautiously if leak self-seals. The SpineJack implant should provide additional containment vs. vertebroplasty — persistent posterior leak despite locked implant suggests unrecognized posterior wall compromise. Post-procedure CT mandatory.
Problem
Superior end-plate breakthrough during expansion
Likely cause: Excessive expansion force, device positioned too cranially, or weakened end-plate from tumor/osteoporosis.
Next step: Stop expansion immediately. Lock device at current position. Assess extent of end-plate disruption on fluoroscopy. Intradiscal cement filling is a risk during subsequent cement injection — monitor carefully and stop if intradiscal filling seen on AP fluoroscopy. Post-procedure CT will characterize extent of end-plate involvement.
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Complications
Implant-Related Complications
- Device malposition: Implant too posterior (canal risk) or too anterior (cortical breach) — confirmed on post-procedure CT; surgical removal in rare symptomatic cases
- Implant migration: Rare with proper technique; risk higher in very osteoporotic bone
- Infection (deep implant infection): Rare but serious; prophylactic antibiotics mandatory. Requires prolonged antibiotics or explantation if confirmed
- End-plate disruption: Aggressive expansion may breach end plate; intradiscal cement risk
Cement & Procedure Complications
- Cement extravasation: Epidural, foraminal, intradiscal, venous/PE — same spectrum as vertebroplasty and kyphoplasty; reduced but not eliminated by implant containment
- Adjacent vertebral fracture: Stiffened augmented level increases adjacent level stress — counsel patients
- Failed height restoration: Chronic/sclerotic fractures; partial restoration still provides pain relief
- Neurologic injury: Rare; from cement epidural leak or device malposition — emergent surgical consult if new deficit
Emergent Escalation Triggers
- New neurologic deficit post-procedure → emergent spine surgery consult + CT spine
- Hypoxia / chest pain post-procedure → CT chest angiography (cement PE)
- Fever + back pain after 48–72h → CBC, CRP, blood cultures; consider implant infection
- Severe unremitting pain escalation → CT spine (epidural collection or device malposition)
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Post-Procedure Care
Recovery & Monitoring
- Recover supine 1–2 hours; complete neurologic exam before discharge
- Ambulation on post-procedure day 1 — demonstrated in published SpineJack case series
- Pain score documented at 24–48 hours; expected significant improvement
- Case series: pain reduction from 6.5/10 pre-procedure to 1/10 post-procedure day 1; kyphotic angle reduced by 11–24 degrees
- Most patients discharged same day or post-procedure day 1 (institutional preference)
Imaging & Follow-up
- Post-procedure CT to confirm implant positioning, height restoration, and cement distribution — mandatory for implant procedures
- Upright weight-bearing AP and lateral X-ray at 1 month to confirm maintained height (key advantage of SpineJack: height durability)
- Resume anticoagulation: 24 hours post-procedure
- Osteoporosis management: bisphosphonates, denosumab, or teriparatide — essential to prevent adjacent fractures
- Physical therapy referral for core strengthening and fall prevention
- Report fever, new neurologic symptoms, or new acute back pain immediately
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Critical Pearls
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Lock the device BEFORE injecting cement: This is the most critical SpineJack-specific step. Cement injected before locking the device in expanded position will not maintain height — the device could be pushed into a sub-optimal position by injection pressure. Lock both implants, confirm position fluoroscopically, then proceed with cement.
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Simultaneous bilateral expansion is essential: Expand both devices at the same time under AP and lateral fluoroscopy. Sequential expansion risks asymmetric height gain and lateral vertebral displacement. The bilateral simultaneous approach creates a symmetric craniocaudal force distribution across the fracture cleft.
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Antibiotics are required — not optional: SpineJack is an implant procedure. Cefazolin 1g IV prophylaxis within 60 minutes of incision is mandatory. This differentiates SpineJack from vertebroplasty and balloon kyphoplasty, which do not routinely require antibiotics. Document antibiotic administration in the procedure note.
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Drill terminates short of anterior cortex: Over-drilling risks anterior cortical breach with cement leakage anteriorly into the paravertebral soft tissue or, at lumbar levels, into the retroperitoneum. Confirm drill tip position on lateral fluoroscopy — always maintain a 2–3 mm gap from the anterior cortex.
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SpineJack advantage over balloon kyphoplasty — implant stays: When a balloon is deflated before cement injection, the trabecular cavity can partially collapse. The SpineJack occupies the cavity permanently — cement fills around a stable implant scaffold. This is the mechanism of superior durable height restoration.
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Post-procedure upright X-ray at 1 month: Unlike vertebroplasty, where height gain is minimal and cement is the sole structural element, SpineJack outcomes should be documented with upright weight-bearing radiographs. Height maintenance over time validates implant performance and guides counseling.
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VADs are "third generation" — require specific training and equipment: SpineJack, VBS, and OsseoFix each have distinct instrumentation, implant-specific trocars, and technique requirements. Do not attempt with vertebroplasty equipment or improvised alternatives. Industry representative proctoring recommended for initial cases at new centers.
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Related Resources
References, comparison table, related procedures, VAD devices
Vertebral Augmentation Comparison
| Feature | Vertebroplasty | Balloon Kyphoplasty | SpineJack |
|---|---|---|---|
| Mechanism | Direct cement injection | Balloon inflation creates cavity, then cement | Titanium implant expands craniocaudally, then cement |
| Height restoration | Minimal | Moderate; partial recollapse possible | Superior — up to 40%; durable (implant permanent) |
| Cement leak risk | Highest (direct injection into cancellous bone) | Lower (contained cavity) | Low (implant scaffold contains cement) |
| Sedation | MAC / Local | MAC / General | General / MAC |
| Antibiotics | Not routine | Not routine | Cefazolin 1g IV — required |
| Implant remains | No | No (balloon removed) | Yes — titanium; permanent |
| Cost | Lowest | Moderate | Highest |
| Best for | VCF without significant height loss; malignant fractures; low-cost centers | Fractures with >15% height loss; intact posterior wall | Significant height loss; young patients; durable restoration; tumor cases |
| Follow-up imaging | CT (optional) | CT + upright XR at follow-up | CT (mandatory) + upright XR at 1 month |
Vertebral Augmentation Devices (VADs) Overview
| Device | Manufacturer | Mechanism | Level Range | Notes |
|---|---|---|---|---|
| SpineJack | Stryker Corp. | Mechanical — craniocaudal expansion | T4–L5 | SAKOS trial (non-inferior to BKP, superior height restoration) |
| VBS (Vertebral Body Stenting) | DePuy Synthes | Hydraulic (balloon) — stent expands, balloon removed | T5–L5 | Greater height retention than standard BKP after balloon removal |
| OsseoFix | Alphatec Spine | Mechanical compression of trabecular bone via titanium mesh | T6–L5 | Less PMMA required; interlocking bone-titanium effect; absolute CI: retropulsed fragments |
Primary Reference
Prologo JD, Ray CE Jr., eds. Advanced Pain Management in Interventional Radiology: A Case-Based Approach. Thieme; 2024. DOI: 10.1055/b000000387
Chapter 18 (Dalili et al — Osteoporotic Fracture III: Vertebral Augmentation Devices)
Additional references: Noriega et al, Spine J 2019 (SAKOS study — SpineJack vs. BKP) · Noriega et al, BioMed Res Int 2015 (108 SpineJack registry, 1-year results) · Vanni et al, J Spine Surg 2016 (third-generation VADs) · Werner et al, J Bone Joint Surg Am 2013 (VBS vs. kyphoplasty RCT) · Disch & Schmoelz, Spine 2014 (VBS augmentation model)