1. Painful VCFs: How and When to Treat Them?

2. Agenda Background on VCFs Diagnosis New Information on Treatment Options A New, Implant-based Approach Case Studies Summary and Conclusions

3. Background 750,000 Vertebral Compression Fractures (VCFs) in US each year caused by osteoporosis Osteoporosis causes twice as many spinal fractures than hip fractures Yet VCFs often go undiagnosed and untreated Estimated that two-thirds of VCFs are never diagnosed  Many patients dismiss their back pain as a sign of aging and/or arthritis

4. Similar Mortality in Hip Fracture and VCF Patients Source: International Osteoporosis Foundation: Vertebral Fracture Initiative

5. Balanced Force Concentration Force Transmission Biomechanics of Kyphosis: “Kyphosis begets Kyphosis”

6. VCFs Increase Risk of Subsequent Fragility Fracture Source: International Osteoporosis Foundation: Vertebral Fracture Initiative

7. Consequences of Kyphosis Deformity Debilitation Disability Depression Death Source: International Osteoporosis Foundation: Vertebral Fracture Initiative

8. Diagnosis Patients may experience either:  Sudden onset of severe, “knifelike" back pain  Chronic or gradual onset of back pain that worsens when standing or walking Courtesy of Nucleus Medical Art, Inc. Additional symptoms of multiple VCFs:  Eventual loss of height, as much as six inches over time  Kyphosis (curved back), commonly called a dowager’s hump  Stomach complaints  Hip pain  Breathing problems

9. Treatment of Symptomatic VCFs Treatment options:  Bed rest for severe pain  Prolonged pain and rest leads to loss of function and possible loss of independence  Analgesics and opoids  Physical therapy  Bracing  Steroid injections  Minimally Invasive Vertebral Augmentation  Vertebroplasty  Balloon kyphoplasty Source: International Osteoporosis Foundation: Vertebral Fracture Initiative

10. FREE Study Shows Benefits of BKP Treatment FREE: Fracture REduction Evaluation Study  300 patient, multicenter, randomized, controlled study designed to compare BKP to non-surgical care for acute VCF patients Trial results were published in The Lancet and demonstrated  BKP patients had improved outcomes in terms of pain reduction, quality of life, function and mobility compared to non-surgical care  BKP had increased rates of new fractures (33%) compared to non-surgical care (25%) at one year Efficacy and safety of balloon kyphoplasty compared with non-surgical care for vertebral compression fracture (FREE) Study, Wardlaw D, Cummings SR, Van Meirhaeghe J, et al. Lancet. 2009 Mar 21;373(9668):1016-24. Epub 2009 Feb 24.

11. FREE Study Shows Benefits of Earlier BKP Treatment On average, the BKP patients in FREE were treated at 5.6 weeks By one month post-treatment, compared to non- surgical patients, BKP patients experienced:  Greater improvement on most measures Findings suggest that BKP may be considered earlier to provide faster pain relief and improved function.

12. Vertebral Augmentation: Room for Improvement Unmet needs: Decrease:  New fracture risk  Cement leakage Improve:  Kyphotic angle correction  Deployment predictability 10 years of very little innovation in vertebral augmentation Until Now: a new implant-based approach

13. About the Implant-based Approach Structurally-supportive Implant  Stabilize the bone while using less cement  Predictable implant structure Approximates natural bone characteristics  Made of medical polymer  Provides flexible, structural support Implanted over removable guidewire, then filled with bone cement

14. Kiva in Action Insert Kiva Animation

15. Impressive Clinical Evidence Supports Implant In three separate comparative studies, Kiva has been demonstrated to meet or exceed the performance of BKP 1 2 3. In one or more of these studies, as compared to BKP, Kiva was shown to:  Reduce rate of adjacent level fractures  Improve kyphotic angle restoration  Reduce rate of cement leakage into surrounding tissue  Reduce cement volume 1 KAST IDE Study: The Kiva System as a Vertebral Augmentation Treatment – A Safety and Effectiveness Trial 2 Otten, Pflugmacher, et al. Pain Physician Journal, October 2013 3 Korovessis et al. Spine, February 2013

16. StudyPublicationSizeResults KAST (Kiva System as a Vertebral Augmentation Treatment – A Safety and Effectiveness Trial) Presented at Society for Interventional Radiology 2014 Scientific Meeting, March 26, 2014 300 patients Improvement in pain and function were similar to balloon kyphoplasty Reduced rate of adjacent level fractures as compared to balloon kyphoplasty - per protocol population* Reduced rate of extravasation as compared to balloon kyphoplasty - as reported by Investigators* Significant reduction in cement volume over balloon kyphoplasty* *Posterior probability of superiority was > 90% Balloon Kyphoplasty versus Kiva Vertebral Augmentation. Comparison of Two Techniques for Osteoporotic Vertebral Body Fractures Spine Feb. 15, 2013 168 patients Significant restoration of the Gardner angle in patients treated with Kiva, whereas ballon kyphoplasty did not meet significance Lower extravasation rates with Kiva Lower cement volume with Kiva VAS, ODI, and SF-36 were similar Comparison of Balloon Kyphoplasty with the New Kiva VCF System for the Treatment of Vertebral Compression Fractures Pain Physician Journal Sept./Oct. 2013 52 patients Significantly lower rate of new fractures following treatment with Kiva Pain improvement was significantly better with Kiva at 6 months Mean cement used was less than half with Kiva

17. Additional Implications of KAST Patients in both the Kiva and kyphoplasty group showed substantial improvements over baseline  Although Kiva showed distinct advantages ● Patients treated as early as 2 weeks post onset of pain demonstrated marked improvement by 7 days post intervention.

18. Kiva Case from KAST

19. Sample Kiva Case Courtesy of Wayne Olan, MD, Director of Interventional & Endovascular Neurosurgery George Washington University Medical Center

20. Summary: Vertebral Fractures… Are the most common osteoporotic fractures Increase the risk of subsequent VCFs by 5-fold and the risk of other fragility fractures (including hip) by 2- to 4-fold Multiple VCFs:  Have similar mortality to hip fractures and so we need to be vigilant in diagnosis and treatment  Are associated with significant morbidity, even if they do not come to clinical attention Source: International Osteoporosis Foundation: Vertebral Fracture Initiative

21. Three Takeaways 1. FREE study showed benefits of vertebral augmentation over non-surgical care. 2. New clinically proven, implant-based approach to vertebral augmentation meets or exceeds the performance of BKP. 3. There is clinical evidence showing the benefits of treating acute VCF patients earlier than 6 weeks with vertebral augmentation.

22. Questions?