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Although single or multilevel ACDF have utilized iliac crest autograft for decades, the implant industry now offers multiple alternative grafting and spacer devices; allografts, cages, polyether-etherketone PEEK amongst others. While most studies have focused on fusion rates and clinical outcomes following ACDF, few have analyzed the "value-added" of these various constructs e.
The author found no clinically significant differences in cervical spine fusion outcomes between autograft and cages, despite an up to fold difference in cost among various constructs. The author concluded that iliac crest autograft utilized for single or multilevel ACDF is associated with the highest fusion, lowest complication rates, and significantly lower costs compared with allograft, cages, PEEK, or other grafts.
As spinal surgeons and institutions become more cost conscious, we will have to account for the "value added" of these increasingly expensive graft constructs. Kersten et al stated that polyetheretherketone PEEK cages have been widely used during the past decade in patients with degenerative disorders of the cervical spine.
Their radiolucency and low elastic modulus make them attractive attributes for spinal fusion compared with titanium and bone graft. Still, limitations are seen such as pseudoarthrosis, subsidence, and migration of the cages.
The authors stated that limited evidence on the clinical outcome of PEEK cages is found in the literature other than noncomparative cohort studies with only a few randomized controlled trials.
The systematic review included all randomized controlled trials and prospective and retrospective nonrandomized comparative studies with a minimum follow-up of 6 months and all noncomparative cohort studies with a long-term follow-up of more than 5 years.
The primary outcome variable was clinical performance. Secondary outcome variables consisted of radiographic scores.
A total of studies were identified, of which 10 studies were included. These comprised two randomized controlled trials, five prospective comparative trials, and three retrospective comparative trials. The authors found minimal evidence for better clinical and radiographic outcome for PEEK cages compared with bone grafts in the cervical spine.
No differences were found between PEEK, titanium, and carbon fiber cages. The authors stated that future studies are needed to improve methodology to minimize bias. The Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and Congress of Neurological Surgeons Ryken et al, conducted a systematic review to determine the efficacy of cervical interbody grafting techniques.
Abstracts were reviewed and studies that met the inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence Classes I-III. Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network.
The authors found that autograft bone harvested from the iliac crest, allograft bone from either cadaveric iliac crest or fibula, or titanium cages and rectangular fusion devices, with or without the use of autologous graft or substitute, have been successful in creating arthrodesis after 1- or 2-level anterior cervical discectomy with fusion Class II.
Alternatives to autograft, allograft, or titanium cages include polyetheretherketone cages and carbon fiber cages Class III. Polyetheretherketone cages have been used successfully with or without hydroxyapatite for anterior cervical discectomy with fusion.
The authors concluded that current evidence does not support the routine use of interbody grafting for cervical arthrodesis. Multiple strategies for interbody grafting have been successful with Class II evidence supporting the use of autograft, allograft, and titanium cages.
Class III evidence suggests that the surgeon consider the increased rate of subsidence with allograft but also understand that subsidence does not correlate with clinical outcome. Class III evidence also suggests that the surgeon factor in the incidence of donor pain and decrease in patient satisfaction reported with the harvest of autograft iliac crest graft. Polymethyl-methylmethacrylate may be considered to preserve intervertebral distraction after discectomy, but is a poor fusion substrate Class II.
All of the above options appear to have similar clinical outcomes equivalent to the use of bone. A Senate Finance Committee Report focusing on Infuse, one substitute for bone graft, noted that company officials inserted language into studies that promoted the substitute as a better technique than the autograft technique by emphasizing the pain associated with the autograft technique.
Chemonucleolysis is a procedure that involves the dissolving of the gelatinous cushioning material in an intervertebral disk by the injection of chymopapain or other enzyme.
The AHCPR evidence-based guideline on the management of acute back pain and the medical literature supports the use of chemonucleolysis CNL with chymopapain as a safe and effective alternative to surgical disc excision in the majority of patients who are candidates for surgery for intractable sciatica due to herniated nucleus pulposus HNP.
Chemonucleolysis involves the enzymatic degradation of the nucleus pulposus, and has been shown to be more effective than percutaneous discectomy since it can be successfully performed for protruded and extruded discs, just as long as the herniated disc material is still in continuity with the disc of its origin.
Facet injections, also known as facet blocks, are injections of a local anesthetic, with or without a steroid medication, into the facet joints or around the nerve supply the medial branch nerve to the joints. Facet injections may be given for diagnostic purposes to determine if the facet joint is the source of pain or it may be performed to treat facet pain that has previously been detected. The injections are fluoroscopically guided.
If the pain is relieved, the physician will know that the facet joint appears to be the source of pain. Facet denervation may also follow a successful diagnostic facet block. Degenerative changes in the posterior lumber facet joints have been established as a source of LBP that may radiate to the leg. Pain impulses from the medial branches of lumbar dorsal rami can be interrupted by blocking these nerves with anesthetic facet block or coagulating them with a radiofrequency wave radiofrequency facet denervation.
Typically, facet joint blocks are performed as a part of a work-up for back or neck pain Wagner, Pain relief following a precise injection of local anesthetic confirms the facet joint as the source of pain. Based on the outcome of a facet joint nerve block, if the patient gets sufficient relief of pain but the pain recurs, denervation of the facet joint may be considered. A number of uncontrolled studies have suggested positive effects of facet injections on chronic back pain Wagner, However, randomized controlled trials RCTs have failed to demonstrated a benefit.
A number of systematic evidence reviews and evidence-based guidelines have evaluated the literature on facet injections for chronic back pain.
Guidelines from the American Pain Society Chou et al, stated: "We found good or fair evidence that An assessment by the Canadian Agency for Drugs and Technologies in Health Zakaria et al, concluded: "According to the RCTs [randomized controlled trials] completed to date, FJIs [facet joint injections] with local anesthetics or steroids have not been proven to be superior to placebo for the treatment of chronic LBP [low back pain].
Steroid FJIs have not been proven to be superior to local anesthetic FJIs in the treatment of chronic neck pain secondary to a motor vehicle accident. The studies are limited. A Cochrane systematic evidence review found no clear differences between facet joint glucocorticoid and placebo injections Staal et al, A review in UpToDate Chou, stated: "Evidence is unavailable, unreliable, or contradictory regarding the effectiveness of glucocorticoid injections for other sites, including We suggest not performing these procedures for chronic low back pain".
Sacroiliac SI joint injections are performed by injecting a local anesthetic, with or without a steroid medication, into the SI joints. If the pain is relieved, the physician will know that the SI joint appears to be the source of pain.
All procedures were performed using an FL or US apparatus. Subjects were randomly assigned to either the FL or US group. Immediately after the SIJ injections, fluoroscopy was applied to verify the correct placement of the injected medication and intravascular injections.
Treatment effects and functional improvement were compared at 2 and 12 weeks after the procedures. The verbal numeric pain scale and Oswestry Disability Index ODI improved at 2 and 12 weeks after the injections without statistical significances between groups. Of 55 US-guided injections, 48 Vascularization around the SIJ was seen in 34 of 55 patients. Among the 34 patients, 7 had vascularization inside the joint, 23 had vascularization around the joint, and 4 had vascularization both inside and around the joint; 3 cases of intravascular injections occurred in the FL group.
The authors concluded that the US-guided approach may facilitate the identification and avoidance of the critical vessels around or within the SIJ. Function and pain relief significantly improved in both groups without significant differences between groups.
The US-guided approach was shown to be as effective as the FL-guided approach in treatment effects. However, diagnostic application in the SIJ may be limited because of the significantly lower accuracy rate Radiofrequency ablation may also be referred to as RFA, percutaneous radiofrequency neuroablation, radiofrequency coagulation, radiofrequency denervation, radiofrequency lesioning, radiofrequency neuroablation, radiofrequency neurotomy or rhizotomy [articular rhizolysis] involves the use of radiofrequency energy to denervate a nerve.
One of the most commonly performed neuroablative procedures is facet denervation, which is the destruction or interruption of a facet joint nerve to relieve chronic pain in the cervical, thoracic or lumbar region of the spine.
Facet joints of the spine have joint capsules that are supplied by a branch of the posterior ramus of the spinal nerve.
Percutaneous radiofrequency facet denervation, also known as radiofrequency facet joint rhizotomy or facet neurotomy, involves selective denervation using radiofrequency under fluoroscopic guidance. As a method of neurolysis, radiofrequency facet denervation has been shown to be a very safe procedure and can offer relief for many patients with mechanical LBP in whom organic pathology, most commonly a herniated lumbar disc, has been eliminated.
According to the literature, it offers advantages over conventional neurolytic agents e. Because there are no reliable clinical signs that confirm the diagnosis, successful relief of pain by injections of an anesthetic agent into the joints are necessary before proceeding with radiofrequency facet denervation.
Results from many studies have shown that radiofrequency facet denervation results in significant excellent or good pain relief, reduced use of pain medication, increased return-to-work, and is associated with few complications. Success rate, however, depends on a careful selection of patients.
Neuroablative techniques in pain management consist of several surgical and non-surgical methods to denervate a nerve. The goal of denervation is to "shut off" the pain signals that are sent to the brain from the joints and nerves.
An additional objective is to reduce the likelihood of, or to delay, any recurrence by selectively destroying pain fibers without causing excessive sensory loss, motor dysfunction or other complications. Laser ablation involves the use of laser to denervate a nerve. There is a lack of published evidence of laser facet denervation for lumbar facet pain. Chemical neurolysis also referred to as chemical ablation, chemical denervation or chemodenervation involves injection of neurolytic agents [eg, phenol, alcohol or hypertonic saline] to denervate a nerve.
The use of chemical facet injections such as alcohol, phenol and hypertonic saline has been proposed as an option for lumbar facet pain. However, there is a lack of published data to support the safety and effectiveness of this technique. Pedicle screw fixation systems consist of steel or titanium plates that are longitudinally inter-connected and anchored to adjacent vertebrae using bolts, hooks, or screws.
Pedicle screw fixation in the spine is used to produce a rigid connection between 2 or more adjacent vertebrae in order to correct deformity and to stabilize the spine, thereby reducing pain and any neurological deficits. It is most often used in the lumbosacral spine from L1 though S1, and may also be used in the thoracic spine.
Excision of tissues compressing the spinal cord posterior decompression is a common treatment for patients with herniated or subluxed vertebrae spondylolisthesis , degenerative intervertebral discs, certain types of vertebral fractures, or spinal tumors.
Spinal instability following decompression may be sufficiently severe to require stabilization by bony fusion arthrodesis of affected and adjacent vertebrae using implanted autologous bone grafts.
Following placement of the graft, sufficient mechanical stability to allow its incorporation may be provided by combinations of various surgically implanted hooks, rods, or wires.
However, severe instability may require surgical implantation of plates or rods anchored to vertebral pedicles using screws pedicle screw fixation systems in order to provide rigid 3-column fixation and minimize the risk of incomplete fusion pseudoarthrosis or pseudarthrosis or loss of alignment during fusion.
The current medical literature suggests that rigid fixation of the lumbar spine with pedicle screws improves the chances of successful fusion as compared with patients with lumbar spine fusion not supplemented with internal fixation. Internal fusion and fixation are major operative procedures with significant risks and according to the available literature should be reserved for patients with spinal instability associated with neurological deficits, major spinal deformities, spinal fracture, spinal dislocation or complications of tumor.
Spinal fusion and pedicle screw fixation has been shown not to be effective for the treatment of isolated chronic back pain, and surgery is not advocated to treat this diagnosis in the absence of instability or neurological deficits. In July , the FDA re-classified into Class II the pedicle screw spinal systems intended to provide immobilization and stabilization of spinal segments in skeletally mature patients as an adjunct to fusion in the treatment of the following acute or chronic instabilities or deformities of the thoracic, lumbar, and sacral spine: degenerative spondylolisthesis with objective evidence of neurological impairment, fracture, dislocation, scoliosis, kyphosis, spinal tumor, and failed previous fusion pseudarthrosis.
Pedicle screw systems intended for any other uses are considered post-amendment Class III devices for which pre-market approval is required. A spine cage, also known as an interbody cage, is a small hollow cylindrical device, usually made of titanium, with perforated walls. The device is placed in the disc space between 2 vertebrae to restore lost disc height resulting from a collapsed disc and to relieve pressure on nerve roots.
Unlike pedicle screws, both of these fusion devices are permanent implants, as the literature describes bone growing into and through the implant. The safety and effectiveness of these fusion devices have not been established in 3 or more levels to be fused, previous fusion attempt at the involved level s , spondylolisthesis or retrolisthesis of Grade II or greater.
Although the BAK has received FDA approval for implantation laparoscopically, studies performed for FDA approval demonstrated significantly greater incidence of complications from anterior spinal reconstructive surgery using a laparoscopic approach than using an open approach.
Furthermore, patients with laparoscopically implanted BAK fusion devices were followed for only 6 months; thus, the long-term stability of laparoscopically implanted BAK cages is unknown. Thus, coverage of laparoscopic endoscopic implantation of the BAK should be denied as experimental and investigational. See discussion of anterior endoscopic spinal reconstructive surgery above. In a retrospective, database review, Pirkle and colleagues analyzed the rate of nonunion in patients treated with structural allograft and intervertebral cages in anterior cervical discectomy and fusion ACDF.
These investigators carried out a retrospective analysis of 6, patients registered in the PearlDiver national database through Humana Insurance from to All ACDF patients with anterior plating who were active in the database for at least 1 year were included in the study.
Patients with a fracture history within 1 year of intervention, past arthrodesis of hand, foot, or ankle, or a planned posterior approach were excluded from the study. Patients were stratified by number of levels treated, tobacco use, and diabetic condition.
Nonunion rates of structural allograft and intervertebral cage groups after 1 year were compared using Chi-squared analyses. A total of 4, patients were included in the allograft group, while 2, were included in the cage group. Overall nonunion rates were significantly higher in the cage group 5. When controlling for confounders, increased rates of nonunion were consistently observed in the cage group, achieving statistical significance in 25 of the 26 analyses.
The authors concluded that the increased rate of nonunion associated with intervertebral cages may suggest the superiority of allograft over cages in ACDF. The authors noted that with any large database, there are weaknesses. The reliability of the reporting and coding was dependent upon multiple sources in an administrative data registry.
These researchers were unable to obtain radiographic evidence of nonunion for individual patients and instead relied on the diagnosis codes for nonunion, an important assumption they have made in this study.
As this was an observational database study, these investigators were also unable to determine the constitution of each cage placed, whether that be PEEK, titanium, mesh, or porous material. In this analysis, the authors stratified their initial population to account for the 3 most likely confounding variables for nonunion. It was entirely possible that other confounding variables exist and this may affect the analysis.
Even with this large database, the nonunion patients whittled down to less than 11 patients in some sub-analyses. One of the limitations of PearlDiver was when patient population size was less than 11, the true number was not revealed because of the potential for patient identification. The authors encountered this in some of their sub-analyses and this limited their ability to analyze the data, particularly where they attempted to control for multiple confounders.
These researchers stated that future studies utilizing other data sources with sufficient sample size may be of value in further investigation. However, the PearlDiver data have been widely utilized in peer-reviewed publication. To-date, this study is the largest comparative study examining the fusion rates of ACDF using cages and structural bone graft.
These data suggested that allograft, when available, may be a superior option than the use of a cage in achieving arthrodesis in the cervical spine. Key points in this study: Both structural allograft and intervertebral cage groups experienced high fusion rates.
When comparing nonunion rates, these data suggested the superiority of allograft in ACDF. While the use of a cage and non-structural bone graft material remains an important surgical option, the use of allograft, when donor bone is available, may be preferable in achieving solid arthrodesis. Percutaneous polymethylmethacrylate vertebroplasty PPV is a therapeutic, interventional radiologic procedure, which consists of the injection of an acrylic bone cement usually methyl methacrylate into a cervical, thoracic or lumbar vertebral body lesion for the relief of pain and the strengthening of bone.
The procedure is performed under fluoroscopic guidance with local anesthesia and moderate sedation. This procedure is being used for patients with lytic lesions due to bone metastases, aggressive hemangiomas, or multiple myeloma, and for patients who have medically intractable debilitating pain resulting from osteoporotic vertebral collapse.
An alternative to traditional bone cement is Cortoss Bone Augmentation Material. Cortoss is an injectable, non-resorbable synthetic material that functions as a strengthening agent for injection into vertebral bodies with compression fractures. In these reports, pain relief was apparent within 1 to 2 days after injection, and appeared to persist for at least several months up to several years.
While experimental studies and preliminary clinical results suggest that percutaneous vertebroplasty can also strengthen the vertebral bodies and increase mobility, it remains to be proven whether this procedure can prevent additional fractures in the injected vertebrae.
In addition, the duration of effect was not known; there were no long-term follow-up data on most of these patients, and these data may be difficult to obtain and interpret in patients with an underlying malignant process because disease progression may confound evaluation of the treatment effect. Complications were relatively rare, although some studies reported a high incidence of clinically insignificant leakage of bone cement into the paravertebral tissues.
In a few cases, the leakage of polymer caused compression of spinal nerve roots or neuralgia. Several instances of pulmonary embolism were also reported. The FDA notified healthcare professionals about complications related to the use of polymethylmethacrylate bone cement to treat osteoporotic compression fractures of the spine using vertebroplasty and kyphoplasty.
Reported complications, such as soft tissue damage and nerve root pain and compression, are related specifically to the leakage of bone cement. Other reported complications include pulmonary embolism, respiratory and cardiac failure, and death.
Percutaneous vertebroplasty is an in-patient procedure because it may cause compression of adjacent structures and require emergency decompressive surgery. In addition, radiation therapy or concurrent surgical interventions, such as laminectomy, may also be required in patients with compression of the spinal cord due to ingrowth of a tumor. An assessment of percutaneous vertebroplasty by the National Institute for Clinical Excellence NICE, concluded that "current evidence on the safety and efficacy of percutaneous vertebroplasty appears adequate".
However, 2 subsequently published RCTs published in the New England Journal of Medicine have found no significant benefit with vertebroplasty. In the Investigational Vertebroplasty Safety and Efficacy Trial INVEST , Kallmes et al reported that pain and disability outcomes at 1 month in a group of patients who underwent vertebroplasty were similar to those in a control group that underwent a sham procedure.
In the other trial, Buchbinder et al measured pain, quality of life, and functional status at 1 week and at 1, 3, and 6 months after sham and active vertebroplasty and found there were no significant between-group differences at any time point. The Society for Interventional Radiology SIR, had identified a number of issues in interpreting these studies, including potential biases in patient selection, the use of vertebroplasty in older greater than 3 months fractures, and a potentially inadequate amount of polymethylmethacrylate PMMA that was injected into the vertebrae.
The SIR concluded: "We recognize the value of randomized controlled trials and evidence-based medicine.
But based on the above-discussed weakness in the studies and the degree of discordance between the outcomes of these studies, prior studies and experience, we believe it is premature and possibly incorrect — to conclude that vertebroplasty is no better than a control sham procedure trigger point, facet injection. In a retrospective study, He and colleagues examined if a repeat percutaneous vertebroplasty PV is effective on pain-relief at the vertebral levels in patients who had previously undergone PV.
Of the procedures of PV performed in patients with osteoporotic vertebral compression fractures from October to June in the authors' institute, 15 vertebrae in 15 patients with unrelieved pain in 4 to 32 days after an initial PV were treated with a repeat vertebroplasty.
The clinical outcomes were assessed by measurements of visual analog scale VAS , and the imaging features were analyzed pre- and post-procedure. The mean volume of polymethylmethacrylate injected in each vertebra was 4. During the first month of follow-up after repeat PV in this series, a mean VAS scores of the pain level was reduced from 8.
No serious complications related to the procedures occurred, however asymptomatic polymethylmethacrylate leakage around vertebrae was demonstrated on radiograph or computed tomography in 2 patients. The authors concluded that the outcomes of this series suggested that repeat PV is effective at the same vertebral levels in patients without pain-relief who underwent previous PV. Absent or inadequate filling of cement in the unstable fractured areas of the vertebral body may be responsible for the unrelieved pain after the initial PV.
An accompanying editorial by Kallmes of the afore-mentioned article stated that "[u]nfortunately, limitations in the current study likely preclude definitive answers, but still the series may help focus future studies". Furthermore, Kallmes is still somewhat concerned about the safety of the repeat procedure. Absolute contraindications to percutaneous vertebroplasty or kyphoplasty balloon-assisted vertebroplasty include, but may not be limited to, the following:.
Relative contraindications to percutaneous vertebroplasty include, but may not be limited to, the following:. Kyphoplasty also known as balloon-assisted vertebroplasty is a minimally-invasive orthopedic procedure, which has been developed to restore bone height lost due to painful osteoporotic compression fractures. It is a modification of the vertebroplasty procedure, and involves the insertion of 1 or 2 balloon devices into the fractured vertebral body.
Once inserted, the surgeon inflates the balloon s to create a cavity and to compact the deteriorated bone with the intent to restore vertebral height. The balloon s are then removed and the newly created cavity is filled with the surgeon's choice of bone filler material, creating an internal cast for the fractured area.
The Kiva VCF Treatment System is an implantable device which has been proposed for use with a vertebroplasty or kyphoplasty procedure for reduction and treatment of spinal fractures.
PMMA bone cement is used to fill the implant once it is placed. An assessment of balloon kyphoplasty by the National Institute for Health and Clinical Excellence NICE, concluded that "[c]urrent evidence on the safety and efficacy of balloon kyphoplasty for vertebral compression fractures appears adequate to support the use of this procedure provided that normal arrangements are in place for consent, audit and clinical governance".
The NICE assessment reviewed 3 non-randomized studies, 2 of which compared balloon kyphoplasty with conventional medical care physical and analgesic therapy and 1 which compared the procedure with vertebroplasty. All 3 studies found that patients who had undergone balloon kyphoplasty had improved pain scores compared with the control group at a maximum follow-up of 24 months.
The assessment noted that the specialist advisors to NICE expressed uncertainties about whether the improvements following balloon kyphoplasty reduced pain and height restoration are maintained in the long term.
Other potential complications of kyphoplasty include infection, allergy, and spinal cord or nerve root injury caused by incorrect needle placement. Based on the results of an assessment, the Ontario Ministry of Health and Long Term Care reached the following conclusions about balloon kyphoplasty: "There are currently two methods of cement injection for the treatment of osteoporotic VCFs.
These are vertebroplasty and balloon kyphoplasty. Although no RCT has been conducted to compare the two techniques, the existing evidence shows that balloon kyphoplasty is a reasonable alternative to vertebroplasty, given the lower reported peri-operative and long-term complications of balloon kyphoplasty".
Wardlaw et al reported positive results with kyphoplasty compared with non-surgical care in a non-blinded, multi-center RCT.
The investigators reported that the frequency of adverse events did not differ between groups. There were 2 serious adverse events related to kyphoplasty hematoma and urinary tract infection ; other serious adverse events such as myocardial infarction and pulmonary embolism did not occur peri-operatively and were not related to procedure.
The California Technology Assessment Forum Karliner, concluded that balloon kyphoplasty meets CTAF criteria for safety, effectiveness and improvement in health outcomes for the treatment of recent less than 3 month old osteoporotic vertebral compression fractures confirmed by MRI.
Sacroplasty is a variation of the vertebroplasty technique, and involves the injection of polymethylmethacrylate cement into sacral insufficiency fractures for stabilization. Under fluoroscopic guidance, PMMA is injected into the sacrum at the fracture site, in an attempt to stabilize the fracture.
Symptomatic improvement may require up to 12 months. Treatment includes limited weight-bearing and bed rest, oral analgesics, and sacral corsets. Significant mortality and morbidity are associated with pelvic insufficiency fractures. Percutaneous sacroplasty is being developed as an alternative treatment for SIF patients.
Frey et al reported on a prospective observational cohort study of the safety and efficacy of sacroplasty in consecutive osteoporotic patients with SIFs. Each procedure was performed under intravenous conscious sedation using fluoroscopy. Two bone trochars were inserted between the sacral foramen and sacroiliac joint through which 2 to 3 ml of polymethylmethacrylate was injected.
A total of 37 patients, 27 females, were treated. Mean age was All patients were available at each follow-up interval except 1 patient who died due to unrelated pulmonary disease before the 4-week follow-up. The investigators reported that mean VAS score at baseline was 7. The investigators found that improvement at each interval and overall was statistically significant using the Wilcoxon Rank Sum Test.
One case of transient S1 radiculitis was encountered. The investigators concluded that sacroplasty appears to be a safe and effective treatment for painful SIF. Limitations of this study include its small size, limited duration of follow-up, and lack of control group.
Most occurrences, however, are asymptomatic Cortet et al, Vesselplasty uses a porous polyethylene terephthalate balloon to create both a cavity and contain the cement, thereby, allowing only a small amount of cement to permeate into the vertebral body. Flors et al evaluated the use of vesselplasty to treat symptomatic vertebral compression fractures VCFs in 29 patients. All patients had been undergoing medical therapy for 1 or more painful VCFs.
Pain, mobility, and analgesic use scores were obtained, and restoration of vertebral body height was evaluated. A 2-tailed paired Student's t test was used to compare differences in the mean scores for levels of pain, mobility, and analgesic use before and after the procedure and to evaluate changes in vertebral body height. Seven of the 29 patients had fractures in more than 1 level, for a total of 37 procedures.
The average pain score before treatment was 8. The average mobility score before treatment was 2. The average analgesic use score before treatment was 3. There was no evidence of clinical complications. The authors concluded that vesselplasty offers statistically significant benefits in improvements of pain, mobility, and the need for analgesia in patients with symptomatic VCFs, thus providing a safe alternative in the treatment of these fractures.
While vesselplasty appears to be a promising new technique for VCFs, there is insufficient evidence of its safety and effectiveness. Prospective, randomized, controlled studies with a larger number of patients and long-term follow-up are needed. Epiduroscopy involves insertion of a fiberoptic camera through the sacral hiatus into the lower epidural space, which is then guided upwards towards the lower lumbar discs and nerve roots.
Footing design where all parts of the footing are connected together. Concrete runs continuously from one section of the footing to the next with no breaks or gaps. This helps the footing resist movement during earthquakes or other types of earth movement. An oven designed to clean materials that may have splashed or spilled inside it as it cooks.
Continuous-cleaning ovens are typically lower quality. See self-cleaning oven and convection oven. Cut or formed break in a concrete part designed to control where the fracturing occurs as the concrete expands and contracts. Ideally the fracturing and movement should occur along the control joint and not elsewhere. An oven which uses circulating hot air to accelerate cooking time.
See continuous-cleaning oven and self-cleaning oven. Chemical that is created when copper is exposed to the atmosphere. Copper oxide is not an insulator and creates no hazard. A block that projects from the face of a wall a short distance and provides support for other weight. Test sample of concrete, usually twelve inches high and six inches in diameter When properly cured, the core sample may be used to determine the strength of the concrete.
Decorative piece that is placed between the vertical side casing and the horizontal top casing. Also see base block. Decorative exterior trim installed at the intersection of the roof and the top of the wall. May be made of wood, plastic, metal, molded stucco, or molded synthetic stucco. Roofing sheet often made out of galvanized steel or fiberglass. Shaped in alternating ridges and valleys. Damage to an item or surface that only affects the way an item looks and does not effect the way the item functions.
For example, a small crack in drywall usually indicates cosmetic damage to the drywall finish but does not indicate structual damage to the wall framing beneath. Also see structural damage. Effect created by a force that is acting in opposition to another force; for example, the weight of an overhead door is counterbalanced by springs making it feel lighter when opened.
Installed any time flashing comes in contact with a surface finish that does not overlap it, such as masonry. With masonry, it can be a piece of sheet metal secured into the masonry joint and extending out over the base flashing.
Horizontal layer or row of masonry units in a wall. See also rowlock, soldier course, and sailor course. Specialty tile trim piece used to trim corners in a tile surface. See cap mold, tile base, and double bullnose. In the Coverage Limits window you can view the limits original, new, and overages of the selected coverage, as well as make adjustments to the policy limit insured. You can assign multiple coverages to a type of loss.
You can also assign a separate policy limit insured and deductible to each coverage. Building that has an area between the soil and the bottom of the first floor that is large enough for a person to crawl in. A crawl space structure does not have a basement so the sewer lateral can run through the foundation wall rather than under the footings. In reference to concrete, cream is the thin layer of fine mixture that comes to the surface of concrete when the course aggregate is pushed down with a concrete finishing tool such as a gandy or bull float.
Used with fitting in PB pipe. The PB pipe is pressed firmly around the fitting with the crimp ring. Rafter that runs from a hip rafter to a valley rafter.
A cripple rafter never reaches the wall top plate or the ridge board. Short studs that are used to fill the gap under the window sill and between the header and the top plate if there is a gap. Also used in a nonbearing wall to fill the space above the door opening and the top plate when no header is required.
Almost no lumber is chalkline straight since it will bow slightly along its length. The upward bow is called the crown of the board. See camber. When a wall is assembled on the floor, the framer places the crown of the stud upward. When the wall is stood in place, the convex or crown side of the stud is the "front," and the convex side of the stud is the "back. A three-dimensional volume measurement equal to the amount contained by a cube that is one foot wide, one foot long, and one foot high.
A three-dimensional volume measurement equal to the amount contained by a cube that is one yard wide, one yard long, and one yard high. Each cubic yard contains 27 cubic feet. Type of solid plastic material usually mixed with a pattern that imitates a type of stone. Cultured marble countertops are probably the most common type but cultured granite is also common. Cultured materials are also used to make tub and shower surrounds.
See plastic laminate countertop, solid surface countertop, solid plastic countertop, wood block countertop, cultured marble countertop, stone countertop, and tile countertop.
The most common type of cultured countertop, it contains swirls and color variations that imitate the look of marble. See plastic laminate counter top, solid surface counter top, solid plastic counter top, wood block counter top, cultured counter top, stone counter top, and tile counter top. Masonry units made from man-made materials such as plaster or plastic.
Cultured stone is shaped and colored to resemble natural stone but is much lighter weight. Vent positioned at the ridge line. Cupolas are often in the shape of a small house or dome, topped with a weathervane.
Some cupolas are installed for decoration only and are nonfunctional. Milled cabinets that are built for a specific kitchen to match specified dimensions and a specified design. See built-in cabinets, milled cabinets, and mass produced cabinets.
Carpet pile in which the ends are looped, both ends are attached to the carpet backing, then the centers of the loops are cut. See pile and loop pile. Piece of metal inside the flue that opens and closes. The damper should remain open when the fireplace is in use to allow combustion gases to escape through the flue and into the atmosphere. When not in use, the damper should be closed to prevent exterior air and small animals from entering the structure.
Process of coating the parts of the foundation system that will be below the soil level with a moisture resistant material. This helps the foundation to resist the absorption or penetration of groundwater during short term exposure. Not the same as waterproofing. On the Dashboard window, you can open recent projects and create new projects without searching through the entire Projects List.
In the Projects Preview pane, you can view the sketch or notes of a selected project. With the Backup feature of Xactware you can back up your estimates, valuations, price lists, macros, and other important files. In the event that it becomes necessary to reformat your hard drive or reinstall Xactimate, you can retrieve your data.
For this reason, it is important to frequently back up all valuable data. If you regularly back up important data, you can restore lost or damaged files using the Xactimate restore feature. It is critical that you restore your data using the same version number of Xactimate that you used to back up the data. Restoring data from different versions of Xactimate could result in damaged or lost data. With the data transfer feature, you can transfer projects, price lists, contacts, macros, and other information between Xactware users.
In order to transfer data from one user to another, both users need to be registered and using the same Xactimate profile. Permanent load consisting of all building parts and built-in fixtures that will be supported by a structural part.
An expression of distance in feet and decimal portions of feet rather than feet and inches. For example: 6. If a damaged carpet were to be replaced, depreciation would be higher for an older carpet that had nearly achieved it's life expectancy. Person who recommends aesthetically pleasing combinations of shapes and shades for the interior or the exterior of a building.
One of the five basic views found on a plan. A detail is a close-up i. Person who improves land, preparing the land for building on it by providing such improvements as roads, sidewalks, and connections for sewer, water, electricity, and gas.
The developer may subdivide the land into building lots. Reinforcing member that is attached at an angle to provide lateral strength to another member such as a rafter. Installation where wood strips are installed in a pattern that runs diagonally to at least one of the walls.
See straight wood floor installation and herringbone wood floor installation. The process of drawing a floor plan and sometimes elevations which include dimensions and other important information such as the location of doors, windows, outlets, switches, and so forth.
A straight line segment that passes through the center of a circle and terminates at the outer edges of the circle. It is the longest line segment that will fit inside a circle. The diameter is equal to twice the length of the radius. You can see the Digital Images window by choosing the camera button on the Quick access toolbar. Made from dimensional lumber usually available in rough cut or surfaced finishes.
See header. Dimensions are the measurements of a room or object. From plans, dimensions can be determined using the measurement on the drawing and the scale of the drawing or by reading the dimensions printed on the drawing.
The amount of labor expended directly on a finished task, excluding breaks, set-up, clean-up, etc. The highest level of efficiency that can be achieved when all labor waste factors are excluded.
On the Control Center Document Modules tab, you can view, create and modify company headers and model statements. Insulating material placed around the door jamb where the slab meets the jamb or door stop when closed. The door gasket is used on exterior doors. Trim attached to the JAMB which prevents a door slab from swinging past the jamb. Projection from a sloped roof plane; usually contains a window or vent and provides additional interior space.
Specialty trim piece with rounded corners on both sides. See cap mold, cove piece, and tile base. Window unit that may be opened by sliding the upper sash downward or the lower sash upward. A method for using the ladder to climb a lower roof section, then pulling the ladder onto the roof for use when climbing a second higher roof section.
Stick of wood or metal which fits into corresponding holes to attach two pieces of material together. Vertical pipe that carries water from the gutter, along the side of the structure to the ground or drainage system. Person who translates the ideas provided to them by an architect or designer into accurate plans that may be used for construction. A series of pipes through which waste is released into the soil after it has been treated in the septic tank.
The size of the drain field depends on the number of people being serviced by the system and the ability of the soil to absorb liquid. Any edge that is shaped so that the water drips off of it onto the ground and not onto the part below. A loop that is made in the drop wires just in front of the weather head.
The drip loop prevents water from dripping down the wires and into the weather head. Shiplap siding with special shaping on its face; for example, it may have a rounded face to look like logs. Wire that connects the transformer to the structure. The drop wire for a residential structure usually contains a current carrying lead and a neutral. Machine used in the manufacture of composition shingles that is designed to allow air to circulate around roofing material to dry the material.
A term used to denote the stage of construction when the inside of the structure is protected from weather. Generally it is the point when all exterior doors and windows are in place and roof felt has been placed over the roof sheathing.
Process used to remove moisture from lumber. The moisture content in the lumber is reduced to about the average amount it will maintain when used in building construction. After drying, many lumber mills seal the lumber with stain or wax to prevent them from absorbing moisture again.
Surface drying and kiln drying are two methods used for drying lumber. Interior wall finish using mostly non-flammable materials. While drywall actually refers to any interior finish made from plaster or gypsum board, in common usage it usually refers to a finish made from gypsum board.
Door that contains two half slabs mounted one above the other. Each slab is attached to the jamb with hinges and may swing independently of the other.
Also known as a stable door. Piece of land, usually a narrow strip along the perimeter of the lot, that others have a right to use and access, typically for the placement of utilities. Horizontal roof edge off of which precipitation drips.
This edge is extended beyond the exterior wall. Shingeles made from lumber whose annual rings form at least a forty-five degree angle at the face. A group of outlets or other electrical devices that connect to a fuse box or breaker panel through a common lead.
Elevation is an eye-level view of a surface on the building. The process of securing a structure from weather and unwanted entry. Damaged doors and windows or other easily accessible openings are typically covered with plywood and opening in the roof are typically covered with plastic.
A two-part resin that, when mixed, forms a tight cross-linked polymer. Epoxy forms a hard, tough surface that is highly resistant to corrosion.
Concrete finish made by spreading an epoxy adhesive over cured concrete, then aggregate is placed over the epoxy which glues the aggregate to the underlying concrete. The process of injecting epoxy resin into a concrete crack. A good epoxy joint is usually stronger than the concrete it replaces. Displays the totals for all equipment costs for the activity. Hardened glass which has been sandblasted or otherwise engraved to form a pattern or design in the glass.
A cabinet hinge which is mortised into the back of the door on one side and attached to the cabinet box on the other side. Once installed, it can be adjusted in a variety of directions.
The European style cabinet door hinge was designed for use on the frameless style cabinets that were developed in Europe after World War II, but is also found on some higher quality framed style cabinets. Also called a six way adjustable hinge and a recessed hinge. See standard cabinet door hinge. System which cools by drawing air through moist filters which transfers moisture into the air and cools the air.
Evaporative coolers are effective only in regions with relatively low humidity. Person who moves the soil out of the area where footings, foundations, or utility lines will be placed and backfills the soil around these parts once they are in place.
On the Exceptions menu you can apply tax rules to specific line items under specific circumstances. You can also designate certain line items as being non-taxable. In order to create an exceptions list, you must first create exception items. Exception items are line items that are grouped together so that they can be taxed in the same way.
Foam which contains small beads with air voids around the beads. When used as insulation expanded foam should only be installed above grade. Concrete finish in which the top layer or surface cream is removed to expose the aggregate beneath, or aggregate is pressed into the surface of the concrete after screeding is complete.
Foam which is smooth, with no beads or voids. Because extruded foam will not absorb water, it can be installed as insulation above or below grade. A frame placed over the cabinet box against which the doors and drawers will rest. The face frame is made from vertical stiles and horizontal rails. To drive a nail into the face of the board so that it will be visible on the finished product. See also blind nailing. A pre-built firebox assembly that includes a heat exchanger, air movement equipment, and the flue assembly.
Also called a zero clearance fireplace. Non-structural, decorative tread and riser assembly which is placed over the structural tread and riser when carpet will run down the center of a stair. False tread and risers are typically stain-grade wood which give the appearance of higher grade wood treads and risers at a lower cost.
Exterior horizontal trim piece that covers the vertical edge of the rafter tails. It can also be called the finish fascia because it is installed over the rough fascia. Connects the meter base to the breaker panel s or fuse box es. Usually contains four cables that are twisted together.
Used in compression fittings, the ferrule is a ring that slides over the top of a pipe. The ferrule is tapered on the top and is compressed between the fitting and a threaded nut. Shingle made from a combination of wood fiber and Portland cement. Glass filaments which are formed by pulling or spinning molten glass into random lengths. Fiberglass does not easily burn.
The amount of material, including waste, that will be required in the field in order to complete the job. Small piece of decorative wood that fills Oak Dowel Shear Strength 00 the space between balusters in a bottom rail.
Review by the building inspector after the interior and exterior construction is complete, to check for any problems which may endanger the health or safety of the building occupants.
In most areas a certificate indicating that the final inspection has been successfully completed is required before the home can be occupied. Joint which uses small tapered projections fingers which interlace to join two pieces of material. May refer to the plumbing, electrical, carpentry, or HVAC work that is visible when construction is complete.
Final coat of any material on a surface. The third coat of common stucco is the finish coat and contains the texture and may contain the pigment. If the finish coat does not contain pigment, the surface of the stucco must be painted when dry.
For stucco, see also scratch coat and brown coat. Any electrical part that will be installed after the walls and ceiling are finished. A nail with a smaller shank for its length than other types of nails. The head on the finish nail is also smaller and able to sink below the surface of the wood. Finish nails are primarily used in finishing work. Piece of material installed to block the spread of fire from one side of it into wood framing members on the other side.
The fire is forced to burn through it before it can reach another part of the framing system. Process in which drywall is finished to provide fire protection only and not to provide a smooth finish wall. Firetaped drywall has tape embedded along all joints which are then covered with one additional layer of mud.
Fasteners are also covered with mud. Wall which has been designed to resist the spread of fire. Fire walls in homes are typically required between the garage and living space.
Fire walls are usually rated by the hours they are designed to resist the spread of fire. A typical residential firewall rating is one hour. The interior of a fireplace system built of heat-resistant materials which contains the fire and radiates heat in the room. Can be made from a variety of materials including special Fire brick, prefabricated masonry panels or metal.
Masonry unit made from clay that is formed and then baked at a high enough temperature to cause a partial melting or glazing on the surface. This glaze provides a seal which protects the brick from moisture. Flexible tape that is used to pull electrical wire through conduit.
The fish tape is pushed through the conduit, the electrical wires are fastened to the end and pulled through the conduit. Term used for exterior decking material. Refers to the one and one-quarter or "five-quarter" thickness of the material. Type of stone which splits easily into slabs known as flags and is commonly used on floors. Parallel edges on a steel beam that are perpendicular to the center web of the beam.
Any piece of material, usually metal or plastic, installed to prevent water from penetrating into the structure around doors, windows, chimneys, and roof edges. Shingles made from lumber whose annual rings form less than a forty-five degree angle at the face. A flat, thin plywood panel used in a frame and panel cabinet door. See frame and panel cabinet door, slab cabinet door and raised panel.
Roof style that appears flat but actually has a slight slope to allow drainage of precipitation. Tile shingle with a flat surface. The surface of flat tiles often have a grain simulation and the sides are usually rabbeted and grooved. Roof or floor truss with horizontal top and bottom chords reinforced with diagonal members between them. Type of plastic laminate countertop with no integral backsplash, a flat smooth surface, and usually a square front edge.
Flat-laid countertops can be fabricated in a shop or on site. See plastic laminate countertop and postformed countertop. A large piece of lumber cut out of a log that is then sawn into boards or veneer strips. Hand tool used to provide an even texture to concrete or plaster surfaces before they set.
Heavy, smooth asphalt coating mopped over the cap sheet of a multiple ply membrane roof to provide a smooth surface. The flood coat must be protected from sun damage by painting it with a UV coat or by covering it with aggregate. Structure which sits atop columns which raise the main floor above the flood plane.
Also known as plan view. Floor plan is a view as though you are looking directly down on a building with the top removed so you can see the layout of the floor including walls and fixtures. Includes the framing support members such as floor joists or floor trusses and the sheathing that provides the floor system surface.
May be used instead of regular joists or I-joists. Floor trusses are generally placed on wider centers, are deeper and more expensive than other joists. Floor trusses are designed to allow plumbing, electrical, and heating runs to be placed inside of them instead of below them like is often required in other joists. Pipe that is sized, insulated, and positioned to carry combustible gases up and away from the structure.
Cap placed on the top opening of the flue in such a way as to permit proper ventilation of the inner chambers of the flue pipe and at the same time prevent moisture or small animals from entering the flue. Door with a flat, smooth face with no panels or decoration. Flush doors may have a solid core or a hollow core. Casing that contains a series of round called flutes along its length.
Fluted casing is designed to look like fluted columns. Gable rafter which is located under the overhang part of the roof sheathing on the gable end.
It is not directly supported by the exterior wall. Also sometimes referred to as the barge rafter or barge board. Base upon which the structure will stand, it rests on the soil. A footing ultimately supports all of the weight of the structure, it is a structural part. Heating system that uses a fan to push heated air through ducts to vents throughout the structure. Brand name of a common type of plastic laminate material. The term formica is often used in the industry when referring to plastic laminate.
This structural part rests on the footing and supports the exterior walls and floor system. A foundation is usually constructed out of concrete, block or treated lumber. Piece of lumber usually redwood or treated that is used between the foundation and the framing.
It is attached to the foundation with anchor bolts. Inspection of the rough-in of four trades including framing, plumbing, HVAC, electric. This inspection must be completed before the walls or ceilings are covered. A composition shingle that has been torn by the impact from a hailstone.
The fractures often radiate out from the center of the hailstone impact in a spider web pattern. Also see bruised composition shingles and granular loss. A cabinet door which consists of a frame that surrounds a panel. The panel may be glass, a veneered plywood flat panel, or a solid wood raised panel.
See slab cabinet door. Cabinet style in which a face frame is attached to the cabinet box. See frameless style cabinets. Term to denote that the building framing has been completed to the point that it is ready for the roof system to be built.
Cabinet style which has no face frame attached to the cabinet box. Often called a European style cabinet because it was developed in Europe during the reconstruction following World War II as an alternative to the more labor-intensive framed style cabinet. See framed style cabinet. Members which connect the bottoms of opposing rafters together to prevent them from moving outward. Ceiling joists are commonly used as framing ties.
A faucet designed to supply water to the outside of the structure without danger of freezing in cold temperatures. The faucet is located on the outside of the structure but the valve portion is located inside the heated structure.
Horizontal trim piece installed at the top of the exterior wall, covering the joint between the soffit and the exterior wall. The frieze board is often ornately decorated. The maximum depth that frost is expected to penetrate into the soil during the coldest part of winter.
Fair rental value coverage is insurance that pays the loss of rental income on rental property, minus expenses, when that rental income cannot continue because property rented to others or held for rental is damaged by a peril covered in the insurance policy. Backsplash which runs from the countertop to the bottom of the upper cabinet.
See backsplash and block backsplash. A structure that has a basement level, the floor of which is usually positioned below ground level under the main level. Hardware attached between a cabinet drawer and the cabinet box which allows the drawer to be pulled completely out of the cabinet box.
Any cabinet that runs the full height from the floor to the level of the upper unit. See lower unit, vanity cabinet, and upper unit. Also called furr strips, they are often used on the interior of block or concrete walls. Furring strips can be made from either metal or wood. They are fastened to the walls, ceiling, or floor system generally for the purpose of providing a surface to which the ceiling or wall covering may be easily attached.
Truss used at the ends of a gable roof. It has vertical members which are spaced to allow convenient attachment of the exterior wall sheathing. Roof style consisting of two sides that slope in opposite directions down from the peak or ridge. The roof ends form an inverted V and are filled in with triangular shaped gable end walls.
Vents placed in the gable ends of the roof. Gable vents facilitate the flow of air in the attic while protecting it from insects and the weather. Each side has two sections, the lower section having a steeper slope than the upper section.
The gambrel roof is often used on barns. Also known as a mansard roof. Truss used to make a gambrel roof, functions in the same way as a gable truss. Traditionally used in the U. Tool which uses a screen to press the course aggregate downward while leaving the fine aggregate at the surface. Flat gandy is dropped lightly over the entire surface. Rolling gandy uses a screen shaped like a barrel and is rolled across the entire surface.
Widely used in residential construction, its use is discouraged by many structural engineers because it can severely damage the concrete unless used skillfully. Refers to the thickness of metal. A heavier gauge means that the metal is thicker but it is noted by a smaller number. Main line items that represent more specific line items that can be placed or associated within a category i.
Scientist who performs the necessary calculations to determine the types and sizes of footings which must be used to ensure safe and proper support of the building by the soil. Also called a Soils engineer. Large horizontal beam which may be used to provide structural support at specific bearing points along its length. A girder is held up in position by columns or a bearing wall. Tile shingle with a color glaze compound put on its surface that produces a smooth and shiny face.
Glazed clay tiles are baked. Glazed concrete tiles dry chemically. Glaze usually adds significantly to the cost of clay tiles, but adds only moderately or not at all to the cost of concrete tiles. Tile which come in a variety of sizes but are usually about 4" by 4" and typically have a high gloss or matte glaze applied to the finish surface. See ceramic mosaic tile and quarry tile.
Hardware attached between a cabinet drawer and the cabinet box which holds the drawer in a level position as the drawer is pulled out of and pushed into the cabinet box. See full extension glide. Short for glue-laminated beam, it is made of several layers of dimensional lumber glued together so that the joints in each layer are overlapped by other layers to provide strength.
Glue-lam beams always have a slight arch or bow called a camber. They are always installed so the camber is up. A long, curving handrail piece that is used to step down and make a long vertical transition between handrail parts on a stair balustrade.
See top rail, volute, one-quarter turn, and balustrade. Concrete beam that rests on grade ie: on the soil but is supported by piers or columns rather than the soil directly underneath. A grade beam may appear to be a footing or short foundation wall unless one inspects carefully enough to discover the connections to the top of the piers or columns underneath. Stake which is placed in the ground and marked at the point where the grade should be found once the building part is in place.
Grade stakes are often placed and marked to indicate where the top of the concrete will be located once the pour is complete. Grade stakes used as a guide for establishing the final level of the concrete are usually pulled out and their holes filled with wet concrete once the wet concrete has been leveled at the proper grade.
Granular loss occurs when mineral granules embedded in a composition shingle are loosened by the impact from a hailstone when the hailstone does not bruise or fracture the shingle. See fractured composition shingles and bruised composition shingles. Molding that fits over a single pane to make it appear as if the window unit has many separate lights. Also see muntin.
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Vuqar
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