Intracardiac cement embolism during percutaneous vertebroplasty: incidence, risk factors and clinical management

Cardiac cement embolism and asymptomatic pulmonary embolism caused by percutaneous vertebroplasty for osteoporotic vertebral fracture: a case report

Background

As society ages, the incidence of osteoporotic vertebral compression fractures steadily rises. Procedures like percutaneous kyphoplasty (PKP) and percutaneous vertebroplasty (PVP) have proven effective in significantly relieving pain in patients with these fractures. While PKP and PVP are minimally invasive, complications can still occur. However, most complications are not clinically significant, with cement leakage being the most common.

Case presentation

We present the case of a patient with an osteoporotic vertebral compression fracture who underwent percutaneous kyphoplasty (PKP) and percutaneous vertebroplasty (PVP). On the night following the procedure, the patient experienced transient discomfort in the chest, which resolved on its own. A chest CT scan the next day revealed a 5 cm arc-shaped high-density shadow near the right atrium, along with multiple high-density lung spots. After consulting with cardiothoracic surgery, interventional vascular surgery, and radiology experts, and discussing options with the patient and their family, a thoracotomy was recommended to remove the bone cement from the heart. However, the attempt was unsuccessful. Despite this, the patient made a good recovery and was successfully discharged.

Conclusions

Vascular leakage of bone cement is a potentially life-threatening complication of PKP/PVP, and it warrants careful attention.

Percutaneous Vertebroplasty versus Nonoperative Treatment of Osteoporotic Vertebral Fractures: A Meta-Analysis of Randomized Controlled Trials

Osteoporotic vertebral fractures frequently result in pain and decreased quality of life (QoL). The management of these fractures remains a topic of debate. Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we analyzed randomized controlled trials comparing percutaneous vertebroplasty (PV) with non-operative treatment (non-OT). The outcomes of interest included pain, QoL, cement leakage, and new osteoporotic vertebral fractures after 1 year. Compared to non-OT regarding pain relief, PV yielded significant improvement at 1-2 weeks, 1 month, 6 months (standard mean difference [SMD] = -0.67 (6/14; 95% confidence interval [CI]: -1.29 to -0.06; I2 = 92%, random effects) and 1 year (mean difference = -1.07 (4/14; 95% CI: -1.97 to -0.18; I2 = 97%, random effects). For QoL, notable improvements were observed at 1 week (standard mean difference = -2.10 (5/14; 95% CI: -3.77 to -0.42; I2 = 98%, random effects) and 3 months (mean difference = -1.58 (4/14; 95% CI: -3.07 to -0.09; I2 = 96%, random effects), with 1 month, 6 months and 1 year being inconclusive. A cement leakage rate of 42% (10/14; 95% CI: 25% to 59%; I2 = 99%, random effects) was found. Further, PV did not significantly heighten the risk of new fractures within a year (odds ratio = 1.26 (6/14; 95% CI: 0.63 to 2.53; I2 = 74%, random effects). PV emerges as a promising intervention for specific time intervals regarding pain relief, especially in the extended-term analysis, and QoL, especially in the short-term analysis, compared to non-OT. However, clinicians must consider cement leakage risks. Heterogeneity among studies underscores careful patient selection.

Pulmonary embolism and intracardiac foreign bodies caused by bone cement leakage: a case report and literature review

Percutaneous vertebroplasty (PVP) is a surgical procedure that involves injecting polymethylmethacrylate (PMMA) bone cement into the diseased vertebrae to rapidly relieve pain and strengthen the vertebrae. We reported a 73-year-old patient who underwent percutaneous vertebroplasty (PVP) surgery for thoracolumbar vertebral compression fracture. After the surgery, the patient experienced symptoms such as chest tightness and dyspnea. Further examination revealed multiple high-density foreign bodies in the blood vessels/heart and concomitant multi-organ dysfunction. It was considered that the multi-organ embolism was caused by bone cement leakage. The patient improved after undergoing surgical treatment and anticoagulant therapy.

Percutaneous Vertebroplasty for Cervical Symptomatic Hemangiomas and Spinal Metastases: A Case Series and Literature Review

OBJECTIVE

Percutaneous vertebroplasty (PVP) is a commonly used technique for the treatment of spinal diseases, but it is rarely employed for cervical lesions. This study presents a case series and a literature review to evaluate the efficacy of cervical PVP.

METHODS

From August 2013 to January 2023, 14 patients underwent cervical PVP in the author's institution. The mean postoperative follow-up time was 20.3 ± 12.1 months (ranging from 5 to 41 months). The pain status and quality of life were assessed preoperatively, postoperatively, and during follow-up using the Visual Analog Scale and Neck Disability Index. Additionally, complications that occurred during the study period were documented.

RESULTS

The series of cases included 9 cases of hemangiomas and 5 cases of spinal metastases. The common symptom was axial pain in the neck. All patients were successfully treated with PVP. Visual analog scale scores decreased from 6.6 ± 0.8 preoperatively to 1.9 ± 0.8 at 24 hours postoperatively and to 2.4 ± 1.2 at the last follow-up (P < 0.01). Neck Disability Index decreased from 22.3% ± 8.9% preoperatively to 7.6% ± 8.1% at 24 hours postoperatively and to 6.0% ± 7.2% at 12-month follow-up (P < 0.01). After the operation, a case of dysphagia occurred, but no major complications were observed during the follow-up period.

CONCLUSIONS

Cervical PVP via the anterolateral approach is a safe option for the treatment of cervical symptomatic hemangiomas and spinal metastases with limited invasiveness. It is effective in relieving pain and improving quality of life.

Incidence of Cement Leakage and Potential Risk Factors in Surgery for Spinal Metastasis: A Systematic Review and Meta-Analysis

OBJECTIVES

The current meta-analysis was performed to gather available evidence regarding the incidence and risk factors of cement leakage (CL) in patients undergoing surgical procedures for spinal metastasis.

METHODS

Two authors independently searched the PubMed, Embase, and CENTRAL databases. Clinical studies reporting the incidence or risk factors of CL were included for analysis. The primary outcome analyzed was the incidence of various types of CL. Random-effects or fixed-effects single-proportion meta-analyses were conducted to pool the available evidence, based on the heterogeneity test. Subgroup analyses were conducted based on surgical procedures (percutaneous vertebroplasty, percutaneous kyphoplasty, and others). Risk factors of CL were synthesized narratively to identify the most commonly accepted factors.

RESULTS

A total of 26 studies, involving 2551 patients, were included. The number of operated spine segments was reported in 23 studies, accounting for 4101 vertebrae. The pooled incidences of general, intradiscal, paravertebral, spinal canal, and intravascular CLs were 0.18 (95% confidence interval [CI], 0.11-0.28), 0.14 (95% CI, 0.08-0.21), 0.13 (95% CI, 0.06-0.21), 0.11 (95% CI, 0.05-0.19), and 0.12 (95% CI, 0.08-0.17), respectively. Subgroup analyses revealed significantly different incidences of general CL (0.37 vs. 0.06 vs. 0.09, P < 0.01), intradiscal CL (0.22 vs. 0.06 vs. 0.12, P < 0.01), paravertebral CL (0.25 vs. 0.03 vs. 0.06, P < 0.01), and vascular CL (0.14 vs. 0.03 vs. 0.15, P < 0.01) among the three groups. Posterior wall disruption, pathologic fracture, and the number of treated vertebral levels were the most commonly identified independent risk factors for general CL. Posterior wall disruption was determined as a common significant risk factor for spinal canal CL.

CONCLUSIONS

This review provides insights into the incidence and risk factors associated with CL in surgical procedures for spinal metastasis. Understanding these risk factors can contribute to the development of tailored strategies aimed at minimizing CL occurrence and optimizing surgical outcomes for patients undergoing spinal metastatic surgery.

Analysis of Prognostic Factors in Osteoporotic Patients Who Were Treated with Percutaneous Vertebroplasty for Refracture After Vertebral Augmentation

OBJECTIVE

To retrospectively analyze prognostic factors in osteoporotic patients who treated with percutaneous vertebroplasty for refracture after vertebral augmentation.

METHODS

A retrospective analysis was performed of 61 patients with refractures after vertebral augmentation who received percutaneous vertebroplasty treatment again from January 2019 to December 2021. Based on the presence of back pain at the last follow-up, 17 patients were placed in the pain group, and 44 patients were placed in the pain-free group. The following covariates were reviewed: age; bone mineral density; bone cement dosage; bone cement leakage; body mass index; and rate of anterior vertebral height (AVH) loss in the target before surgery, 1 week after surgery, and at last follow-up. Patients were assessed using visual analogue scale score and Oswestry Disability Index.

RESULTS

Binary logistic regression analysis revealed that the rate of AVH loss after surgery was associated with postoperative back pain. According to the receiver operating characteristic curve analysis, the area under the curve of AVH loss rate at 1 week after surgery was 0.6845, and the cutoff value was 0.18; the area under the curve of AVH loss rate at the last follow-up was 0.7306, and the cutoff value was 0.2815. Kaplan-Meier survival analysis showed that patients with lower AVH loss rates had lower incidence of postoperative back pain and better prognosis.

CONCLUSIONS

Occurrence of postoperative back pain was strongly associated with AVH loss after surgery. Patients with a lower rate of AVH loss had a lower incidence of postoperative back pain and a better prognosis.

Impact of Cytogenetic Abnormalities, Induction and Maintenance Regimens on Outcomes After High-Dose Chemotherapy and Autologous Stem Cell Transplantation in Patients With Newly Diagnosed Multiple Myeloma: A Decade-Long Real-World Experience

Background

High-dose chemotherapy and autologous stem cell transplant (HDT-ASCT) has become a standard of care for transplant eligible newly diagnosed multiple myeloma (NDMM) patients. While cytogenetic abnormalities have been shown to affect outcomes after HDT-ASCT in clinical trials, these trials often exclude or underrepresent elderly patients with comorbidities and those belonging to ethnic minorities. We describe our institutional experience highlighting the impact of high-risk cytogenetic abnormalities (HRCAs) on outcomes after HDT-ASCT for NDMM patients.

Methods

A total of 449 patients with NDMM who underwent HDT-ASCT between February 2012 and August 2022 were included in this retrospective analysis. HRCAs included the presence of one or more of: deletion 17p, t(14;16), t(4;14), and amplification 1q. Survival analyses, including progression-free survival (PFS) and overall survival (OS), were performed using Kaplan-Meier estimator.

Results

With a median follow-up of 29 (1 - 128) months for the entire patient population, the best overall response rate for the patients with HRCAs was lower compared to those with standard risk cytogenetics (90% vs. 96%; P = 0.01). Patients with HRCAs had an inferior PFS compared to patients with standard-risk cytogenetics (29 vs. 58 months; P < 0.001) without a difference in OS (70 months vs. not reached; P = 0.13).

Conclusions

In a multivariable analysis adjusting for factors including age, race, and comorbidities, HRCAs, non-lenalidomide-based maintenance, non-proteasome inhibitor-based maintenance, and age greater than 65 were associated with inferior PFS. Amongst these factors, only non-lenalidomide-based maintenance was associated with inferior OS.

Extensive Intracardiac Cement Embolism in a Patient Undergoing Workup for Bone Marrow Transplant

Cement emboli are a well-established complication of kyphoplasties and vertebroplasties and can easily be mistaken for wires. While kyphoplasties are commonly performed for vertebral fractures caused by metastases from malignancies such as multiple myeloma, the implication of cement emboli in bone marrow transplant (BMT) patients is not well documented. Our patient presented with an incidental intracardiac cement embolism found while undergoing workup for BMT. He was managed conservatively, but transplant workup was put on hold until the embolism could be removed due to the risks associated with cement emboli. The significance of cement emboli in immunocompromised patients needs to be further investigated.

Advances in materials used for minimally invasive treatment of vertebral compression fractures

Vertebral compression fractures are becoming increasingly common with aging of the population; minimally invasive materials play an essential role in treating these fractures. However, the unacceptable processing-performance relationships of materials and their poor osteoinductive performance have limited their clinical application. In this review, we describe the advances in materials used for minimally invasive treatment of vertebral compression fractures and enumerate the types of bone cement commonly used in current practice. We also discuss the limitations of the materials themselves, and summarize the approaches for improving the characteristics of bone cement. Finally, we review the types and clinical efficacy of new vertebral implants. This review may provide valuable insights into newer strategies and methods for future research; it may also improve understanding on the application of minimally invasive materials for the treatment of vertebral compression fractures.

Comprehensive evaluation and advanced modification of polymethylmethacrylate cement in bone tumor treatment

Bone tumors are invasive diseases with a tendency toward recurrence, disability, and high mortality rates due to their grievous complications. As a commercial polymeric biomaterial, polymethylmethacrylate (PMMA) cement possesses remarkable mechanical properties, injectability, and plasticity and is, therefore, frequently applied in bone tissue engineering. Numerous positive effects in bone tumor treatment have been demonstrated, including biomechanical stabilization, analgesic effects, and tumor recurrence prevention. However, to our knowledge, a comprehensive evaluation of the application of the PMMA cement in bone tumor treatment has not yet been reported. This review comprehensively evaluates the efficiency and complications of the PMMA cement in bone tumor treatment, for the first time, and introduces advanced modification strategies, providing an objective and reliable reference for the application of the PMMA cement in treating bone tumors. We have also summarized the current research on modifications to enhance the anti-tumor efficacy of the PMMA cement, such as drug carriers and magnetic hyperthermia.

New Research Progress of Modified Bone Cement Applied to Vertebroplasty

Percutaneous vertebroplasty and percutaneous kyphoplasty are effective methods to treat acute osteoporotic vertebral compression fractures that can quickly provide patients with pain relief, prevent further height loss of the vertebral body, and help correct kyphosis. Many clinical studies have investigated the characteristics of bone cement. Bone cement is a biomaterial injected into the vertebral body that must have good biocompatibility and biosafety. The optimization of the characteristics of bone cement has become of great interest. Bone cement can be mainly divided into 3 types: polymethyl methacrylate, calcium phosphate cement, and calcium sulfate cement. Each type of cement has its own advantages and disadvantages. In the past 10 years, the performance of bone cement has been greatly improved via different methods. The aim of our review is to provide an overview of the current progress in the types of modified bone cement and summarize the key clinical findings.

Asymptomatic Intracardiac Cement Embolism Following Kyphoplasty

Cement extravasation can occur during vertebral body augmentation such as kyphoplasty and vertebroplasty with diverse presentation and resultant treatment. The cement can embolize through venous vasculature to the thorax where it poses a potential threat to the cardiovascular and pulmonary systems. A thorough risk-benefit analysis should be conducted to select the appropriate treatment course. We present an asymptomatic case of cement extravasation to the heart and lungs during kyphoplasty.

Current status and challenges of percutaneous vertebroplasty (PVP)

A narrative review regarding percutaneous vertebroplasty (PVP) for osteoporotic vertebral fracture (OVF) is provided herein, addressing the epidemic of OVF in Japan, the latest response to the criticism of PVP for OVFs, the indications and potential risks of PVP for OVFs, and a future perspective for PVP. Each year in Japan, approximately 32,000 patients aged 55 years or older suffer from chronic low back pain for several months to several years due to a compression fracture. PVP is one of the surgical treatments for an OVF, and it is less invasive compared to the traditional open surgery. PVP is suitable for OVF patients who have difficulty walking as assessed by the modified Yokoyama's activities of daily living (ADL) scoring system, and for patients with Kummell's disease diagnosed by CT and MRI examinations. Serious adverse events related to PVP occur in 1.1-3.3% of the cases, but direct deaths from PVP are extremely rare at less than 1%. Recent studies demonstrated that OVF patients treated with PVP are less likely to die after the treatment than non-surgically treated patients, which conflicts with the Cochran reviews' conclusion not supporting PVP for OVFs. Novel robotic systems and procedure-support devices are being developed, providing a next step toward fully automated PVP procedures.

Use of a 3D-printed body surface percutaneous puncture guide plate in vertebroplasty for osteoporotic vertebral compression fractures

BACKGROUND

Percutaneous vertebroplasty (PVP) has been used widely to treat osteoporotic vertebral compression fractures (OVCFs). However, it has many disadvantages, such as excessive radiation exposure, long operation times, and high cement leakage rates. This study was conducted to explore the clinical effects and safety of the use of a three-dimensional (3D)-printed body-surface guide plate to aid PVP for the treatment of OVCFs.

METHODS

This prospective cohort study was conducted with patients with OVCFs presenting between October 2020 and June 2021. Fifty patients underwent traditional PVP (group T) and 47 patients underwent PVP aided by 3D-printed body-surface guide plates (3D group). The following clinical and adverse events were compared between groups: the puncture positioning, puncture, fluoroscopy exposure and total operation times; changes in vertebral height and the Cobb angle after surgery relative to baseline; preoperative and postoperative visual analog scale and Oswestry disability index scores; and perioperative complications (bone cement leakage, neurological impairment, vertebral infection, and cardiopulmonary complications.

RESULTS

The puncture, adjustment, fluoroscopy, and total operation times were shorter in the 3D group than in group T. Visual analog scale and Oswestry disability index scores improved significantly after surgery, with significant differences between groups (both p < 0.05). At the last follow-up examination, the vertebral midline height and Cobb angle did not differ between groups. The incidence of complications was significantly lower in the 3D group than in group T (p < 0.05).

CONCLUSION

The use of 3D-printed body-surface guide plates can simplify and optimize PVP, shortening the operative time, improving the success rate, reducing surgical complications, and overall improving the safety of PVP.

Venous injection of a triphasic calcium-based implant in a sheep model of pulmonary embolism demonstrates minimal acute systemic effects

PURPOSE

Implant leakage is the most common complication of vertebral augmentation. Alternative injectable materials must demonstrate intravascular safety comparable to or better than polymethyl methacrylate (PMMA). This study assessed the systemic effects of a triphasic calcium-based implant or PMMA injected directly into the femoral vein in a large animal model designed to mimic severe intravascular implant leakage.

METHODS

Six skeletally mature female sheep were randomly assigned (n = 3) to either the PMMA or the triphasic implant (AGN1, composition: calcium sulfate, β-tricalcium phosphate, brushite) treatment group. Femoral veins of each sheep were directly injected with 0.5 mL of implant material to mimic leakage volumes reported during PMMA vertebroplasty. To compare acute systemic effects of the materials, cardiovascular parameters, laboratory coagulation markers, and calcium and sulfate serum levels were monitored for 60 min after implant injection. Thrombotic and embolic events were evaluated by radiologic imaging, necropsy, and histopathology.

RESULTS

Heart rate, systemic arterial blood pressure, arterial oxygenation, arterial carbon dioxide content, and coagulation markers remained within physiological range after either AGN1 or PMMA injection. No blood flow interruption in the larger pulmonary vessels was observed in either group. Lung histopathology revealed that the severity of thrombotic changes after AGN1 injection was minimal to slight, while changes after PMMA injection were minimal to massive.

CONCLUSION

Acute systemic effects of intravascular AGN1 appeared to be comparable to or less than that of intravascular PMMA. Furthermore, in this preliminary study, the severity and incidence of pulmonary histological changes were lower for AGN1 compared to PMMA.

Life-threatening intracardiac cement embolisms after percutaneous kyphoplasty: a case report and literature review

BACKGROUND

Percutaneous kyphoplasty is a popular technique in the treatment of osteoporotic vertebral fractures, but intracardiac cement embolism can be a life-threatening complication.Case presentation: The authors present a case involving a patient who developed dyspnea and chest tightness after percutaneous kyphoplasty. Echocardiography and chest computed tomography confirmed several foreign bodies in the right atrium and pulmonary arteries causing cardiac perforation and pericardial tamponade. Conservative treatment was administered, and the patient died of respiratory and heart failure.

CONCLUSIONS

The present case highlights that surgical removal may be the first-choice treatment for symptomatic intracardiac cement embolism.

Cement leakage in percutaneous vertebroplasty for spinal metastases: a retrospective study of risk factors and clinical outcomes

Objective

The objective of this research was to investigate the risk factors of cement leakage in patients with metastatic spine tumors following percutaneous vertebroplasty (PVP).

Methods

Sixty-four patients with 113 vertebrae were retrospectively reviewed. Various clinical indexes, including age, sex, body mass index (BMI), smoking history, drinking history, chemotherapy history, radiotherapy history, primary cancer, location, other metastases, collapse, posterior wall defects, the laterality of injection, and the injected cement volume were analyzed as potential risk factors. Multivariate analyses were conducted to identify the independent risk factors.

Results

The cement leakage was found 64 in 113 treated vertebrae (56.63%), in which the incidence of each type was shown as below: spinal canal leakage 18 (15.93%), intravascular leakage around the vertebrae 11 (9.73%), and intradiscal and paravertebral leakage 35 (30.97%). Tomita classification (P = 0.019) and posterior wall destruction (P = 0.001) were considered strong risk factors for predicting cement leakage in general. The multivariate logistic analysis showed that defects of the posterior wall (P = 0.001) and injected volume (P = 0.038) were independently related to the presence of spinal canal leakage. The postoperative visual analog scale (VAS) and activities of daily living (ADL) scores showed significant differences compared with the pre-operative parameters (P < 0.05). No significant differences were found in every follow-up time between the leakage group and the non-leakage group for pain management and improvement of activities in daily life.

Conclusion

In our study, Tomita classification and the destruction of the posterior wall were independent risk factors for leakage in general. The defects of the posterior wall and injected volume were independently related to the presence of spinal canal leakage. The PVP procedure can be an effective way to manage the pain.

High viscosity bone cement vertebroplasty versus low viscosity bone cement vertebroplasty in the treatment of mid-high thoracic vertebral compression fractures

BACKGROUND CONTEXT

As science and technology have advanced, novel bone cements with numerous formulated ingredients have greatly evolved and been commercialized for vertebroplasty. Recently, viscosity has been a focus to achieve better clinical outcomes and fewer complications. Meanwhile, the experience in the treatment of mid (T7-9) to high (T4-6) thoracic vertebral compression fractures is limited.

PURPOSE

The objective of this study was to identify the different outcomes between high-viscosity bone cement (HVBC) and low-viscosity bone cement (LVBC) used to repair mid (T7-9)- and high (T4-6)- thoracic vertebral compression fractures.

STUDY DESIGN/SETTING

This study was a single-center, retrospective cohort study PATIENT SAMPLE: A consecutive series of 107 patients with a total of 144 vertebrae was included.

OUTCOME MEASURES

The anterior vertebral height (AVH), middle vertebral height (MVH), posterior vertebral height (PVH), local kyphotic angle (KA), Cobb angle (CA), and other associated parameters were evaluated radiologically at several time points-preoperative, surgery day 0, postoperative day 1, and 6-month follow-up. Pain evaluation was assessed by using a visual analog scale (VAS) before and 6 months after the procedure.

METHODS

The patients were divided into two groups according to the viscosity of the bone cement used, and plain film and magnetic resonance imaging (MRI) of the vertebrae were used to calculate parameters. The patient characteristics; bone cement brand; changes in AVH, MVH, PVH, KA, CA, and VAS; and complications of each patient were recorded and then analyzed.

RESULTS

Both groups showed increased vertebral body height, corrected KA, and CA after vertebroplasty. There were no significant differences between the HVBC and LVBC groups (ΔAVH: 2.19±2.60 vs. 2.48±3.09, p=.555; ΔMVH: 1.25±3.15 vs. 1.89±2.58, p=.192; ΔKA: -5.46±4.58 vs -5.37±4.47, p=.908; and ΔCA: -4.22±4.23 vs. -4.56±5.17, p=.679). There were significant preoperative to postoperative and preoperative to follow-up changes in AVH (HVBC, p=.012 and .046, respectively; LVBC, p=.001 and .015, respectively); a significant preoperative to postoperative change in MVH (HVBC, p=.045; LVBC, p=.001); and significant preoperative to postoperative and preoperative to follow-up changes in KA and CA (KA: HVBC, p=0.000 and .003, respectively; LVBC, p=.000 and .000, respectively; CA: HVBC, p=.017 and .047, respectively; LVBC, p=.006 and .034, respectively). The volume of cement injected was significantly higher with HVBC (3.66±1.36 vs. 3.11±1.53, p=.024), and the use of HVBC was associated fewer cases with cement leakage (26 vs. 45, p=.002). Furthermore, there was no difference between the groups in the incidence of adjacent fracture. Both groups showed an improved VAS score at follow-up, with statistically greater improvement in the HVBC group (2.40±1.53 vs. 3.07±1.69, p=.014). Moreover, significantly fewer patients with a VAS score ≥ 3 were found in the HVBC group (22 vs. 39, p=.004) CONCLUSIONS: HVBC and LVBC are safe and effective to treat mid-to-high level thoracic vertebral compression fractures. Compared with LVBC, HVBC shows less cement leakage, a greater injection volume, and better postoperative pain relief.

Percutaneous Kyphoplasty Versus Percutaneous Vertebroplasty for Neurologically Intact Osteoporotic Kümmell's Disease: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

Percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) are minimally invasive techniques widely used for the treatment of neurologically intact osteoporotic Kümmell's disease (KD), but which treatment is preferable remains controversial. Therefore, this study aimed to shed light on this issue.

METHODS

Six databases were searched for all relevant studies based on the PRISMA guidelines. Two investigators independently conducted a quality assessment, extracted the data and performed all statistical analyses.

RESULTS

Eight studies encompassing 438 neurologically intact osteoporotic KD patients met the inclusion criteria. Compared to PVP, PKP was associated with greater improvement in the short- and long-term Cobb angle [SMD = -0.37, P = 0.007; SMD = -0.34, P = 0.012], short-term anterior vertebral height [SMD = 0.43, P = 0.003] and long-term middle vertebral height [SMD = 0.57, P = 0.012] and a lower cement leakage rate [SMD = 0.50, P = 0.003] but produced more consumption (cement injection volume, operative time, fluoroscopy times, intraoperative blood loss and operation cost). However, there were no differences between the 2 procedures in the short- and long-term VAS and ODI scores, long-term anterior vertebral height, overall complications or new vertebral fractures.

CONCLUSIONS

Both procedures are equally effective for neurologically intact KD in terms of the clinical outcomes, with the exception of a lower cement leakage risk and better radiographic improvement for PKP but greater resource consumption. Based on the evidence available, good clinical judgment should be exercised in the selection of patients for these procedures.

A case report of intracardiac bone cement embolization after posterior decompression and cement-enhanced pedicle screw fixation for osteoporosis and lumbar degeneration

RATIONALE

Bone cement leakage is a common complication of percutaneous kyphoplasty (PKP) and percutaneous vertebroplasty (PVP) surgery and has also been reported in posterior decompression and cement-enhanced pedicle screw fixation. When bone cement leaks through the venous system, it will have serious consequences and even endanger the life of the patient, especially when the bone cement causes intracardiac embolism.

PATIENT CONCERNS

A 70-year-old woman developed chest tightness and decreased blood oxygen saturation following posterior decompression and cement-enhanced pedicle screw fixation.

DIAGNOSIS

After the patient was given symptomatic treatment, the symptoms were not relieved, the high-sensitivity troponin I level continued to rise, the electrocardiogram results were abnormal, and chest computed tomography (CT) revealed multiple flaky and strip-shaped dense shadows in the heart.

INTERVENTION

The patient underwent removal of foreign bodies from the heart under cardiopulmonary bypass and tricuspid valvuloplasty, removal of intracardiac bone cement, and repair of the tricuspid valve and chordae.

OUTCOME

The patient recovered well postoperatively and was discharged from the hospital after 3 weeks. There were no intracardiac foreign bodies observed on chest CT after the operation.

LESSONS

For patients with cardiopulmonary discomfort after posterior decompression and bone cement-enhanced pedicle screw fixation, in view of the limitations of radiographic examination, we recommend performing chest CT examination to confirm the diagnosis. For patients with intravascular foreign body embolism, multidisciplinary team joint treatment saves lives.

Cardiac Perforation Caused by Cement Embolism after Percutaneous Vertebroplasty: A Report of Two Cases

Background

Percutaneous vertebroplasty (PVP) is a minimally invasive surgical technique in which polymethyl methacrylate (PMMA) is injected into the weakened vertebral body to strengthen it. However, this procedure is associated with various complications, the most common being cement leakage. Cardiac perforation caused by cement escape into the venous system is another complication, which is rare but potentially life‐threatening even if not treated promptly.

Case Presentation

Here, we report two elderly patients who developed cardiac perforation caused by cement escape into veins following PVP. Both patients had a history of severe osteoporosis. On admission, they presented with lower back pain and limited movement. MRI revealed vertebral bodies compression fracture in both patients. Considering the advanced age of the patients, PVP was performed to avoid the risk of potential complications associated with nonoperative therapy. Unfortunately, the rare and fatal postoperative complication, cardiac perforation caused by cement escape into veins, occurred in both patients. Emergency open‐heart surgery was performed to remove cement material and repair the heart, both patients recovered well and were discharged.

Conclusions

Although PVP is a safe and minimally invasive surgical technique, it is associated with various serious complications as seen in the present cases. We therefore recommend that surgeons should be aware of such complications. Appropriate timing of surgical operation, meticulous surgical procedures, early intraoperative and postoperative monitoring of cement leakage may improve outcomes of patients with such complications.

Trends and regional variation in vertebroplasty and kyphoplasty in Switzerland: a population-based small area analysis

Regional variation in procedure use often reflects the uncertainty about the risks and benefit of procedures. In Switzerland, regional variation in vertebroplasty and balloon kyphoplasty rates was high, although the variation declined between 2013 and 2018. Substantial parts of the variation remained unexplained, and likely signal unequal access and differing physician opinion.

PURPOSE

To assess trends and regional variation in percutaneous vertebroplasty (VP) and balloon kyphoplasty (BKP) use across Switzerland.

METHODS

We conducted a population-based analysis using patient discharge data from all Swiss acute care hospitals for 2013-2018. We calculated age/sex-standardized mean procedure rates and measures of variation across VP/BKP-specific hospital areas (HSAs). We assessed the influence of potential determinants of variation using multilevel regression models with incremental adjustment for demographics, cultural/socioeconomic, health, and supply factors.

RESULTS

We analyzed 7855 discharges with VP/BKP from 31 HSAs. The mean age/sex-standardized procedure rate increased from 16 to 20/100,000 persons from 2013 to 2018. While the variation in procedure rates across HSAs declined, the overall variation remained high (systematic component of variation from 56.8 to 6.9 from 2013 to 2018). Determinants explained 52% of the variation.

CONCLUSIONS

VP/BKP procedure rates increased and regional variation across Switzerland declined but remained at a high level. A substantial part of the regional variation remained unexplained by potential determinants of variation.

Bedside echocardiography for diagnosis of intracardiac cement embolism after percutaneous vertebroplasty: A case report

This case report is to demonstrate that a female patient had suddenly become unconscious 14 hours after percutaneous vertebroplasty. Bedside echocardiogram showed that the patient had a strong echo in the right heart with a small amount of pericardial effusion. CT showed high density in the distal branches of both pulmonary arteries and a high density in the right heart. With the help of that, the doctor made the diagnosis of intracardiac cement embolism in a very short time. The bone cement in the heart was removed under emergency cardiopulmonary bypass, then the patient was discharged smoothly.

Prediction of early vascular cement leakage following percutaneous vertebroplasty in spine metastases: the Peking University First Hospital Score (PUFHS)

BACKGROUND

Cement leakage into venous blood posed significant challenge to surgeons. The aim of the study was to create a Peking University First Hospital Score (PUFHS) which could evaluate the probability of vascular cement leakage among spine metastases patients following percutaneous vertebroplasty.

METHODS

The study retrospectively enrolled 272 spine metastases patients treated with percutaneous vertebroplasty. We randomly extracted all enrolled patients as the training or validation group and baseline characteristic comparison was assessed between the two groups. Creation of the PUFHS was performed in the training group and validation of the PUFHS was performed in the validation group.

RESULTS

Of all the 272 patients, the total number of included vertebrae was 632 and the median treated levels were 2 per patient. Vascular cement leakage occurred in 26.47% (72/272) of patients. The baseline characteristics were comparable between the two groups (P > 0.05). Three risk predictors (primary cancer types, number of treated vertebrae levels, and vertebrae collapse) were included in the PUFHS. The area under the receiver operating characteristic curve (AUROC) of the PUFHS was 0.71 in the training group and 0.69 in the validation group. The corresponding correct classification rates were 73.0 and 70.1%, respectively. The calibration slope was 0.78 (95% confidence interval[CI]: 0.45-1.10) in the training group and 1.10 (95% CI: 0.73-1.46) in the validation group. The corresponding intercepts were 0.06 (95% CI: - 0.04-0.17) and - 0.0079 (95% CI: - 0.11-0.092), respectively.

CONCLUSIONS

Vascular cement leakage is common among spine metastases after percutaneous vertebroplasty. The PUFHS can calculate the probability of vascular cement leakage, which can be a useful tool to inform surgeons about vascular cement leakage risk in advance.

Cement Pulmonary Embolism Due to Percutaneous Vertebroplasty

BACKGROUND

Bone cement is an uncommon cause of foreign-body pulmonary embolism.

CASE PRESENTATION

A 65-year-old woman with wheeze presented with multiple linear opacities with bone density on chest x-ray. She reported percutaneous vertebroplasty 4 months prior. Non-- contrast chest computerized tomography showed peripheral cement emboli in the pulmonary arteries. The patient received conservative treatment.

CONCLUSION

Clinicians should be aware of this potential complication following vertebroplasty. It is necessary to perform a chest x-ray after the procedure.

Risk factors for thoracolumbar pain following percutaneous vertebroplasty for osteoporotic vertebral compression fractures

OBJECTIVE

To explore possible risk factors for poor outcomes following percutaneous vertebroplasty (PV) for painful osteoporotic compression fractures of thoracolumbar vertebra.

METHODS

This was a retrospective review of data from patients who underwent PV at our institution over a ten-year period to evaluate the association between possible risk factors and thoracolumbar pain (T11-L2). According to the difference between pre- and post-operative visual analogue scale (VAS) scores for pain, patients were separated into poor relief (PR; <4) and good relief (GR; ≥4) of pain.

RESULTS

Of the 750 patients identified, 630 (PR group, n =310; GR group, n = 320) fulfilled the eligibility criteria. Multivariate binary logistic analysis showed that bone mineral density (BMD), >2 fractured vertebral bodies, maldistribution of bone cement, <5 ml bone cement injected into a single vertebral body and thoracolumbar fascia injury prior to surgery were independent risk factors associated with thoracolumbar pain following PV.

CONCLUSION

Although prospective controlled studies are required to confirm our results, this review suggests that the above factors should be taken into account when selecting patients for PV.

Unexpected pacemaker lead in an 84-year-old patient

An elderly patient with a history of atrial fibrillation presented to our emergency room. Previous medical records from another hospital described a pacemaker lead in the echocardiography although the patient had no known history of a pacemaker implantation. Finally, by close examination, chest X-ray, and computed tomography, we found that a kyphoplasty of the spine had caused a so-called palacos embolism, which had repeatedly been mistaken for a pacemaker lead. Unusually, there were no further signs of kyphoplasty material in the pulmonary veins. As the patient was asymptomatic and the embolism caused only moderate tricuspid regurgitation, a conservative treatment was agreed on.

Epidemiology and detection of cement leakage in patients with spine metastases treated with percutaneous vertebroplasty: A 10-year observational study

•

Cement leak is common for percutaneous vertebroplasty in metastatic spinal disease.

•

A proposed and validated algorithm can screen patients with high cement leak risk.

•

The algorithm included four significant characteristics.

•

The validation group AUROC was 0.69, and the goodness-of-fit test P-value was 0.50.

Objectives

To investigate the epidemiology of cement leaks and further develop an algorithm to detect the high risk of cement leaks among advanced cancer patients with metastatic spinal disease treated with percutaneous vertebroplasty.

Methods

This study retrospectively analyzed 309 patients with metastatic spinal disease treated with percutaneous vertebroplasty. Patients were randomly divided into a training group and a validation group. In the training group, 13 potential characteristics were analyzed for their abilities to predict cement leaks. Discal cement leakage and paravertebral cement leakage were excluded from the analysis. Those characteristics identified as having significant predictive value were used to develop a predictive algorithm. Internal validation of the algorithm was performed based on discrimination and calibration qualities.

Results

Overall, cement leaks occurred in 61.17% (189/309) patients. Among the 13 characteristics analyzed, younger age (P = 0.03), extravertebral bone metastases (P = 0.02), increased number of treated vertebrae levels (P < 0.01), and cortical osteolytic destruction in the posterior wall (P = 0.01) were included in the algorithm. This algorithm generates a score between 0 and 16 points, with higher scores indicating a higher risk of cement leakage. The area under the receiver operating characteristic curve (AUROC) value for the algorithm was 0.75 in the training group and 0.69 in the validation group. The mean correct classification rates for the training and validation groups were 73.5% and 64.9%, respectively, and the corresponding P-values of the goodness-of-fit test were 0.70 and 0.50.

Conclusions

Cement leaks are common in patients with metastatic spinal disease treated with percutaneous vertebroplasty. The present study proposed and internally validated an algorithm that can be used to screen patients at high risk of cement leakage.

Snare or Scalpel: Challenges of intracardiac cement embolism retrieval

Intracardiac cement embolism (ICE) after percutaneous vertebroplasty is a rare, but dangerous complication, and guiding principles for its management are not well described. The management of this present case of ICE offers insight to facilitate the treatment decision making process in symptomatic patients requiring extraction.

Percutaneous vertebroplasty with high- versus low-viscosity bone cement for osteoporotic vertebral compression fractures

Objective

There is no consensus on the best choice between high- and low-viscosity bone cement for percutaneous vertebroplasty (PVP). This study aimed to compare the clinical and radiological outcomes and leakage between three cements with different viscosities in treating osteoporotic vertebral compression fractures.

Methods

This is a prospective study comparing patients who were treated with PVP under local anesthesia: group A (n = 99, 107 vertebrae) with high-viscosity OSTEOPAL V cement, group B (n = 79, 100 vertebrae) with low-viscosity OSTEOPAL V cement, and group C (n = 88, 102 vertebrae) with low-viscosity Eurofix VTP cement. Postoperative pain severity was evaluated using the visual analog scale. Cement leakage was evaluated using radiography and computed tomography.

Results

There was no significant difference in the incidence of cement leakage between the three groups (group A 20.6%, group B 24.2%, group C 20.6%, P = 0.767). All three groups showed significant reduction in postoperative pain scores but did not differ significantly in pain scores at postoperative 2 days (group A 2.01 ± 0.62, group B 2.15 ± 0.33, group C 1.92 ± 0.71, P = 0.646). During the 6 months after cement implantation, significantly less reduction in the fractured vertebral body height was noticed in group B and group C than in group A (group A 19.0%, group B 8.1%, group C 7.3%, P = 0.009).

Conclusions

Low-viscosity cement has comparable incidence of leakage compared to high-viscosity cement in PVP for osteoporotic vertebral compression fractures. It also can better prevent postoperative loss of fractured vertebral body’s height.

Safety of vertebral augmentation with cranio-caudal expansion implants in vertebral compression fractures with posterior wall protrusion

OBJECTIVES

Vertebral augmentation (VA) has become routinely used in vertebral compression fractures (VCFs). VCFs are often associated with posterior wall protrusions (PWPs), which theoretically contraindicates vertebroplasty due to a higher risk of neurological complications. The latest generation of VA devices uses intravertebral cranio-caudal expandable implants to improve the correction of structural deformities but could also be used to prevent further PWP during cement injection. The aim of this study was to evaluate the safety of VA with expandable implant for VCFs with PWP.

METHODS

All consecutive patients treated with expandable implants were considered eligible for inclusion if they met the following criteria: (1) non-neurological VCF, (2) considered unstable (A3-A4 in AOSpine classification), (3) significant PWP (> 2 mm), (4) back pain with a visual analogue scale (VAS) ≥ 4. PWPs were independently measured by two investigators; Pearson's statistics were used for interobserver reproducibility.

RESULTS

Fifty-one consecutive patients, with a mean age of 75 ± 8.3 years (range, 50-92), were included. There was a slight decrease between mean preoperative (6.7 mm ± 2.2 mm) and postoperative (6.5 mm ± 2.2 mm) PWP (p = 0.02), with an excellent interobserver reproducibility (Pearson correlation coefficient = 0.92). A mean kyphosis reduction of 34.9% (± 28.4) was observed (p < 0.001). Forty-two patients (82.4%) had significant pain improvements (mean preoperative VAS = 6.9 [± 1.7] versus 3.1 [± 2.0] postoperatively [p < 0.001]). Secondary adjacent level fractures were noted in 16 patients (31.4%), with a reduction of that risk down to 18.8% if a preventive adjacent vertebroplasty was performed, without reaching the significance threshold (p = 0.14).

CONCLUSIONS

VA with expandable implants appeared safe for non-neurological VCFs with PWP, while allowing satisfactory pain relief.

KEY POINTS

• Vertebral augmentation with cranio-caudal expandable implants is safe for non-neurological vertebral compression fractures with posterior wall protrusions. • Vertebral augmentation with cranio-caudal expandable implants might increase the occurrence of secondary adjacent level fractures. • Adjacent level vertebroplasty might be helpful to prevent secondary adjacent level fractures.

Cement leakage following percutaneous kyphoplasty in a patient after a posterior lumbar fusion: a case report

BACKGROUND

Percutaneous kyphoplasty (PKP) has become an important minimally invasive surgical technique for fracture stabilization and pain relief in patients with vertebral compression fractures. However, intraspinal cement leakage following PKP is a serious postoperative complication that can lead to morbidity and mortality.

CASE PRESENTATION

We describe an uncommon case of epidural leakage of bone cement in an 81-year-old woman who underwent posterior lumbar decompression and fusion from L3-5 4 years prior and had an unremarkable postoperative course. The patient was admitted to Peking Union Medical College Hospital with complaints of muscle weakness and severe low back pain radiating to the left thigh 1 week after PKP of L5 due to an acute osteoporotic compression fracture. Computed tomographic imaging revealed massive leakage of cement into the spinal canal at L5-S1, and therefore, surgical decompression and removal of epidural cement were performed carefully without causing a dural tear. She improved remarkably and no neurologic deterioration was observed in the postoperative period during the one-year follow-up.

CONCLUSIONS

We present the rare reported case, to our knowledge, of epidural cement leakage after PKP at the segment of internal fixation and discuss the most likely etiologies and preventive measures for this condition.

Venous Drainage of Lumbar Vertebral Bodies: Anatomic Study with Application to Kyphoplasty, Vertebroplasty, and Pedicle Screw Complications

BACKGROUND

Bone cement augmentation with polymethylmethacrylate is a reliable method for stabilizing osteoporotic compression fractures and improving fixation of pedicle screws. However, cement extrusion into the vertebral venous system can result in pulmonary cement embolism. The goal of this anatomic study was to identify the relationship between the internal/external vertebral plexus and neighboring abdominal caval system.

METHODS

Thirty-two lumbar vertebral levels were used in this study. Anterior abdominal dissection was performed to access the lumbar vertebral bodies through the peritoneal cavity, and a 16-gauge needle was placed into the center of each lumbar vertebral body at its anterior aspect. Fluoroscopy was used to confirm if the needle was correctly placed. Next, latex and/or continuous air injections were performed into each lumbar vertebral level (L1-L5). Observations confirmed if the latex or air traveled into the inferior vena cava. In addition, the spinal canal was opened to see if any latex was found to enter inside the vertebral canal in cadavers injected with the latex.

RESULTS

Latex or air was found to flow into the inferior vena cava at all the lumbar vertebral levels. The latex/air was not observed in the spinal canal in any specimen.

CONCLUSIONS

An exact knowledge of the lumbar vertebral venous anatomy is essential when procedures that could affect the vertebral venous system are involved. Its complexity and anatomic variability necessitate such an understanding to better prevent/understand possible complications associated with polymethylmethacrylate extrusion.

Safety and effectiveness of cervical vertebroplasty: report of a large cohort and systematic review

PURPOSE

To evaluate retrospectively safety and effectiveness of cervical vertebroplasty (cVP) based on a single-center large cohort.

MATERIALS AND METHODS

All cVP performed at a single center from January 2001 to October 2014 were included and reviewed. Procedure-related complications (minor and major) were systematically recorded. Effectiveness in terms of analgesia was evaluated using a semi-quantitative grading scale at 1-month follow-up. Risk factors for the occurrence of a procedure-related complication or cement leakage, as well as factors influencing pain relief at 1-month follow-up, were evaluated using a multivariate analysis.

RESULTS

One hundred and forty cVP procedures (176 vertebrae) were performed in 130 consecutive patients (88 female, 42 male; mean age = 56 years) during the inclusion period. Among the treated lesions, 80% were bone metastases (mostly from breast cancer), 8% were related to hematological malignancies, and 12% were non-malignant lesions. One fatal complication (0.7%) was related to cement migration in the vertebrobasilar system. Three cervical hematomas were recorded, one of them requiring prolonged oral intubation. The overall rate of major complications was 1.5%. At 1 month, pain reduction was observed in 76% of the cases. Additional surgical fixation was required in 6.1% of the cases. cVP of more than one vertebra during the same session was an independent risk factor for procedure-related complications.

CONCLUSION

Cervical vertebroplasty is a safe technique with an acceptable major complication rate. Its effectiveness in terms of pain relief is good at mid-term follow-up.

KEY POINTS

• Cervical vertebroplasty (cVP) is a safe procedure with a low rate of major complications (1.5%). • cVP provides pain relief in 76% of the cases. • Additional fixation surgery is rarely required after cVP (6.1% of the cases).

Analgesia of percutaneous thermal ablation plus cementoplasty for cancer bone metastases

Background

The purpose of this study was to review recent research related to the analgesic effect of ablation therapy combined with cementoplasty, as well as to identify the duration of analgesic effect and risk for cement leaks.

Methods

A systematic literature search using PubMed, Web of Science, and annual meeting proceedings of the oncology society and other organizations were conducted.

Results

Twelve retrospective studies met the inclusion criteria. Four of the studies included in the review assessed the changes immediately after treatment. Five studies were subjected to analyses of analgesic effect of combined percutaneous thermal ablation and Cementoplasty at 24 weeks after treatment. Incidences of leakage of bone cement during surgery were detected in 4 out of 12 studies. The change of mean pain scores at 1 days, at 1 week, and at 4 weeks, 12 weeks, and 24 weeks after treatment were -3.90 (95% CI: -4.80 to -3.00), -4.55 (95% CI:-5.46 to -3.64), -4.78 (95% CI: -5.70 to -3.86), -5.16 (95% CI: -6.39 to -3.92), and -5.91 (95% CI: -6.63 to -5.19). The relative risk of cement leakage was 0.10 (95% CI: -6.63 to -5.19).

Conclusions

Our systematic review suggested that thermal ablation combined with cementoplasty could be a safe and effective intervention for the management of bone metastases-induced pain.

Complex spine deformities in young patients with severe osteogenesis imperfecta: current concepts review

The severity of osteogenesis imperfecta (OI), the associated reduced quality and quantity of collagen type I, the degree of bone fragility, ligamentous laxity, vertebral fractures and multilevel vertebral deformities all impair the mechanical integrity of the whole spinal architecture and relate to the high prevalence of progressive kyphoscoliotic deformities during growth. Bisphosphonate therapy may at best slow down curve progression but does not seem to lower the prevalence of deformities or the incidence of surgery. Brace treatment is problematic due to pre-existing chest wall deformities, stiffness of the curve and the brittleness of the ribs which limit transfer of corrective forces from the brace shell to the spine. Progressive curves entail loss of balance, chest deformities, pain and compromise of pulmonary function and eventually require surgical stabilization, usually around puberty. Severe vertebral deformities including deformed, small pedicles, highly brittle bones and chest deformities, short deformed trunks and associated issues like C-spine and cranial base abnormalities (basilar impressions, cervical kyphosis) as well as deformed lower and upper extremities are posing multiple peri- and intraoperative challenges. Hence, an early multidisciplinary approach (anaesthetist, pulmonologist, paediatric orthopaedic spine surgeon) is mandatory. This paper was written under the guidance of the Spine Study Group of the European Paediatric Orthopaedic Society. It highlights the most pertinent information given in the current literature and various practical aspects on surgical care of spine deformities in young OI patients based on the personal experience of the contributing authors.