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Tsalimas G, Pappa E, Zygogiannis K, Antonopoulos S, Kakridonis F, Chatzikomninos I. Cement leakage and pulmonary embolism by bone cement-augmented pedicle screw fixation of the thoracolumbar spine - A case report. Surg Neurol Int 2024; 15:290. [PMID: 39246758 PMCID: PMC11380811 DOI: 10.25259/sni_506_2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Accepted: 07/25/2024] [Indexed: 09/10/2024] Open
Abstract
Background Few studies discuss the complication of pulmonary cement embolism (PCE) due to cement augmented pedicle screw instrumentation (CAPSI) of the thoracolumbar spine. Case Description A 62 female with a history of multiple myeloma and Sjogren's syndrome on chronic steroids developed an osteoporotic L1 compression fracture and underwent posterior stabilization with a T10-L4 CAPSI. However, postoperatively, the patient developed a surgical site infection and a PCE, resulting in severe respiratory compromise and death 1 month later. Conclusion When performing a T10-L4 thoracolumbar CAPSI (i.e., augmented pedicle screw instrumentation of the thoracolumbar spine) to address an L1 osteoporotic compression fracture, a 62 year old patient developed a life ending multi organ deficiency due to sepsis together with a PCE.
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Affiliation(s)
- Georgios Tsalimas
- Department of Spine Surgery and Scoliosis, KAT General Hospital, Kifisia, Athens, Greece
| | - Eleni Pappa
- Department of Spine Surgery and Scoliosis, KAT General Hospital, Kifisia, Athens, Greece
| | | | - Spiridon Antonopoulos
- Department of Spine Surgery and Scoliosis, KAT General Hospital, Kifisia, Athens, Greece
| | - Fotios Kakridonis
- Department of Spine Surgery and Scoliosis, KAT General Hospital, Kifisia, Athens, Greece
| | - Ioannis Chatzikomninos
- Department of Spine Surgery and Scoliosis, KAT General Hospital, Kifisia, Athens, Greece
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Milaras N, Baikoussis NG, Dourvas P, Kosmopoulou S, Sideris S. Dyspnea After Spinal Surgery and a Troubling X-Ray: A Case of Cement Embolism. JACC Case Rep 2024; 29:102425. [PMID: 39157572 PMCID: PMC11328781 DOI: 10.1016/j.jaccas.2024.102425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 05/22/2024] [Accepted: 05/29/2024] [Indexed: 08/20/2024]
Abstract
An older woman developed dyspnea after instrumented lumbar spinal fusion surgery. During clinical work-up, a chest radiography revealed a U-shaped object within the cardiac silhouette. Further imaging confirmed that the object was entrapped in the tricuspid subvalvular apparatus. Surgery was performed for removal of the object, which was later identified as cement (polymethyl methacrylate). Cement extravasation and embolism are well-known but rarely clinically significant complications after spinal surgery.
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Affiliation(s)
- Nikias Milaras
- Department of Cardiology, General Hospital of Athens Hippocration, Athens, Greece
| | - Nikolaos G. Baikoussis
- Department of Cardiothoracic Surgery, General Hospital of Athens Hippocration, Athens, Greece
| | - Panagiotis Dourvas
- Department of Cardiology, General Hospital of Athens Hippocration, Athens, Greece
| | | | - Skevos Sideris
- Department of Cardiology, General Hospital of Athens Hippocration, Athens, Greece
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Hu Y, Chen X, Chu Z, Tian Q, Luo L, Gan Z, Zhong J, Yuan Z, Zhu B, Dong W. Micro-Computed Tomography Analysis and Histological Observation of the Screw-Bone Interface of Novel Porous Scaffold Core Pedicle Screws and Hollow Lateral Hole Pedicle Screws: A Comparative Study in Bama Pigs. World Neurosurg 2024:S1878-8750(24)01263-4. [PMID: 39059721 DOI: 10.1016/j.wneu.2024.07.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2024] [Accepted: 07/17/2024] [Indexed: 07/28/2024]
Abstract
OBJECTIVE Screw loosening is a common complication of pedicle screw internal fixation surgery. This study aimed to investigate whether the application of a porous scaffold structure can increase the contact area between screws and bone tissue by comparing the bone ingrowth and screw-bone interface of porous scaffold core pedicle screws (PSCPSs) and hollow lateral hole pedicle screws (HLHPSs) in the lumbar spine of Bama pigs. METHODS Sixteen pedicle screws of both types were implanted into the bilateral pedicles of the L1-4 vertebrae of 2 Bama pigs. All Bama pigs were sacrificed and the lumbar spine was freed into individual vertebrae at 16 weeks postoperatively. After the vertebrae were made into screw-centered specimens, micro-computed tomography analysis and histological observation were performed to assess the screw-bone interface and bone growth around and within the screws. RESULTS We found that the bone condition around PSCPSs and HLHPSs did not show significant differences on micro-computed tomography three-dimensional reconstruction images. CT transverse views showed different bone growth inside the 2 screws. In PSCPSs, bone tissue was seen to fill the internal pores and was evenly distributed around each strut. Inside HLHPSs, bone growth was confined to 1 side of the screw and did not fill the entire cavity. Osteometric analysis showed that bone volume fraction and trabecular number, the parameters representing bone mass, were higher in PSCPSs than in HLHPSs. These differences were not statistically significant (P > 0.05). Histological observations visualized that the osseointegration within PSCPSs was superior to that of HLHPSs, and the tight integration of bone tissue with the porous scaffold resulted in a larger screw-bone integration area in PSCPSs than in HLHPSs. CONCLUSIONS Compared with HLHPSs, PSCPSs possessing a porous scaffold core could promote bone ingrowth and osseointegration, resulting in an effective enhancement of the combined area of the screw-bone interface.
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Affiliation(s)
- Yong Hu
- Department of Spine Surgery, Ningbo No. 6 Hospital of Ningbo University, Ningbo, China.
| | - Xijiong Chen
- Health Science Center, Ningbo University, Ningbo, China
| | - Zhentao Chu
- Health Science Center, Ningbo University, Ningbo, China
| | - Quanliang Tian
- Department of Spine Surgery, Qianxinan Autonomous Prefecture Hospital of TCM, Xingyi, China
| | - Linwei Luo
- Health Science Center, Ningbo University, Ningbo, China
| | - Zhiwei Gan
- Health Science Center, Ningbo University, Ningbo, China
| | - Jianbin Zhong
- Department of Spine Surgery, Ningbo No. 6 Hospital of Ningbo University, Ningbo, China
| | - Zhenshan Yuan
- Department of Spine Surgery, Ningbo No. 6 Hospital of Ningbo University, Ningbo, China
| | - Bingke Zhu
- Department of Spine Surgery, Ningbo No. 6 Hospital of Ningbo University, Ningbo, China
| | - Weixin Dong
- Department of Spine Surgery, Ningbo No. 6 Hospital of Ningbo University, Ningbo, China
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Hu Y, Chen X, Chu Z, Luo L, Gan Z, Zhong J, Yuan Z, Zhu B, Dong W. Biomechanical Properties of Novel Porous Scaffold Core and Hollow Lateral Hole Pedicle Screws: A Comparative Study in Bama Pigs. Orthop Surg 2024; 16:1718-1725. [PMID: 38766934 PMCID: PMC11216838 DOI: 10.1111/os.14091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 04/09/2024] [Accepted: 04/23/2024] [Indexed: 05/22/2024] Open
Abstract
OBJECTIVE Screw loosening is a common complication of internal fixation of pedicle screw. Therefore, the development of a pedicle screw with low loosening rate and high biosafety is of great clinical significance. This study aimed to investigate whether the application of a porous scaffold structure can improve the stability of pedicle screws by comparing the biomechanical properties of novel porous scaffold core pedicle screws (PSCPSs) with those of hollow lateral hole pedicle screws (HLHPSs) in a porcine lumbar spine. METHODS Thirty-two pedicle screws of both types were implanted bilaterally into the L1-4 vertebrae of four Bama pigs, with our newly designed PSCPSs on the right and HLHPSs on the left. All the Bama pigs were sacrificed 16 weeks postoperatively, and the lumbar spine was freed into individual vertebrae. Biomechanical properties of both the pedicle screws were evaluated using pull-out tests, as well as cyclic bending and pull-out tests, while the mechanical properties were assessed using three-point bending tests. The data generated were statistically analyzed using paired-sample t-tests and two independent sample t-tests. RESULTS We found that the maximal pull-out forces before and after cyclic bending of the PSCPSs (1161.50 ± 337.98 N and 1075.25 ± 223.33 N) were significantly higher than those of the HLHPSs (948.38 ± 194.32 N and 807.13 ± 242.75 N) (p < 0.05, p < 0.05). In 800 cycles of the bending tests, neither PSCPS nor HLHPS showed loosening or visible detachment, but their maximal pull-out forces after cyclic bending tests decreased compared to those in cycles without cyclic bending tests (7.43% and 14.89%, respectively), with no statistical significance (p > 0.05 and p > 0.05, respectively). Additionally, both screws buckled rather than broke in the three-point bending tests, with no statistically significant differences between the maximal bending load and modulus of elasticity of the two screws (p > 0.05 and p > 0.05, respectively). CONCLUSIONS Compared with the HLHPSs, the PSCPSs have greater pull-out resistance and better fatigue tolerance with appropriate mechanical properties. Therefore, PSCPSs theoretically have significant potential for clinical applications in reducing the incidence of loosening after pedicle screw implantation.
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Affiliation(s)
- Yong Hu
- Department of Spine SurgeryNingbo No. 6 HospitalNingboChina
| | - Xijiong Chen
- Health Science CenterNingbo UniversityNingboChina
| | - Zhentao Chu
- Health Science CenterNingbo UniversityNingboChina
| | - Linwei Luo
- Health Science CenterNingbo UniversityNingboChina
| | - Zhiwei Gan
- Health Science CenterNingbo UniversityNingboChina
| | - Jianbin Zhong
- Department of Spine SurgeryNingbo No. 6 HospitalNingboChina
| | - Zhenshan Yuan
- Department of Spine SurgeryNingbo No. 6 HospitalNingboChina
| | - Bingke Zhu
- Department of Spine SurgeryNingbo No. 6 HospitalNingboChina
| | - Weixin Dong
- Department of Spine SurgeryNingbo No. 6 HospitalNingboChina
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Wang Y, Zhou C, Yin H, Song D. Comparison of cement-augmented pedicle screw and conventional pedicle screw for the treatment of lumbar degenerative patients with osteoporosis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1609-1617. [PMID: 38363348 DOI: 10.1007/s00590-024-03849-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 01/25/2024] [Indexed: 02/17/2024]
Abstract
STUDY DESIGN A retrospective cohort study. OBJECTIVE To compare the safety and clinical efficacy between using cement-augmented pedicle screws (CAPS) and conventional pedicle screws (CPS) for the treatment of lumbar degenerative patients with osteoporosis. Management of lumbar degenerative patients with osteoporosis undergoing spine surgery is challenging. The clinical efficacy and potential complications of the mid-term performance of the CAPS technique in the treatment of lumbar degenerative patients with osteoporosis remain to be evaluated. PATIENTS AND METHODS The data of 131 lumbar degenerative patients with osteoporosis who were treated with screw fixation from May 2016 to December 2019 were retrospectively analyzed in this study. The patients were divided into the following two groups according to the type of screw used: (I) the CAPS group (n = 85); and (II) the CPS group (n = 46). Relevant data were compared between two groups, including the demographics data, clinical results and complications. RESULTS The difference in the VAS, ODI and JOA scores at three and 6 months after the operation between the two groups was statistically significant (P < 0.05). At 12 months after surgery and the final follow-up, a significant difference in the fusion rate was found between the two groups (P < 0.05). Four cemented screws loosening were observed in the CAPS group (loosening rate 4/384, 1.04%) and 15 screws loosening were observed in the CPS group (loosening rate 15/214, 7.01%). In the CAPS group, a total of 384 augmented screws were used, and cement leakage was observed in 25 screws (25/384, 6.51%), but no obvious clinical symptoms or serious complications were observed. Adjacent vertebral fractures occurred in six patients in the CAPS group and one in the CPS group. CONCLUSIONS CAPS technique is an effective strategy for the treatment of lumbar degenerative patients with osteoporosis, with a higher fusion rate and lower screw loosening rate than CPS.
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Affiliation(s)
- Yazhou Wang
- Department of Orthopedics, Shanghai Songjiang District Central Hospital, Shanghai, China
- Department of Orthopedics, Shanghai General Hospital of Nanjing Medical University, Shanghai, China
| | - Chenghao Zhou
- Department of Orthopedics, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, 650 New Songjiang Road, Songjiang District, Shanghai, 200080, China
| | - Huabin Yin
- Department of Orthopedics, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, 650 New Songjiang Road, Songjiang District, Shanghai, 200080, China
| | - Dianwen Song
- Department of Orthopedics, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, 650 New Songjiang Road, Songjiang District, Shanghai, 200080, China.
- Department of Orthopedics, Shanghai General Hospital of Nanjing Medical University, Shanghai, China.
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Lenga P, Bajwa AA, Schneider T, Iwanaga J, Tubbs RS, Kiening KL, Unterberg AW, Ishak B. High Rate of Pulmonary Cement Embolism after Cement-Augmented Pedicle Screw Fixation: A 12-Year Single-Center Study. J Neurol Surg A Cent Eur Neurosurg 2024; 85:117-125. [PMID: 36828012 DOI: 10.1055/s-0043-1761943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
BACKGROUND The global trend toward increased life expectancy because of remarkable improvements in health care quality has drawn increased attention to osteoporotic fractures and degenerative spine diseases. Cement-augmented pedicle screw fixation has been established as the mainstay treatment for patients with poor bone quality. This study aimed to determine the number of patients with cement leakage and pulmonary cement embolism (PCE) as detected on thoracic computed tomography (CT), and to assess the potential risk factors for PCE. METHODS Patients undergoing cement-augmented pedicle screw placement in our institution between May 2008 and December 2020 were included. Data regarding baseline characteristics, complications, and cement leakage rates were collected. Indications for the performance of a postoperative thoracic CT due to the suspicion of PCE were intra- or postoperative complications, or postoperative oxygen supplementation. Moreover, PCE was accidently diagnosed because the thoracic CT was performed for medical reasons other than the suspicion of PCE (tumor staging, severe pneumonia, or exacerbated chronic pulmonary obstructive disease). RESULTS A total of 104 patients with a mean age of 72.8 years (standard deviation of 6.7) were included. Of 802 screws, 573 were cement augmented. Of the 104 patients, 44 (42.3%) underwent thoracic CT scans to diagnose PCE; additionally, 67 (64.4%) demonstrated cement leakage, of whom 27 developed PCE and 4 were symptomatic. Cement-augmented thoracic screws were a risk factor for PCE (odds ratio: 1.5; 95% confidence interval: 1.2-2.1; p = 0.004). CONCLUSIONS This study showed a high prevalence of cement leakage after cement-augmented pedicle screw insertion, with a relatively frequent incidence of PCE, as tracked by thoracic CT scans. Cement-augmented thoracic screw placement was a unique risk factor for PCE.
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Affiliation(s)
- Pavlina Lenga
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Awais Akbar Bajwa
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Till Schneider
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Joe Iwanaga
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, Louisiana, United States
| | - R Shane Tubbs
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, Louisiana, United States
| | - Karl L Kiening
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Andreas W Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Basem Ishak
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
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Yu W, Jiang X, Zhang H, Yao Z, Zhong Y, Tang F, Cai D. The incidence and risk factors for extensive epidural cement leakage in cement-augmented pedicle screw fixation: a multicenter retrospective study. Arch Orthop Trauma Surg 2024; 144:1013-1020. [PMID: 38078951 DOI: 10.1007/s00402-023-05149-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 11/17/2023] [Indexed: 02/28/2024]
Abstract
INTRODUCTION In cement-augmented pedicle screw fixation (CAPSF), epidural cement leakage (CL) is a frequently reported complication with the potential for neural injury, especially when it is extensive. To date, there has been no reports discussing basivertebral foramen morphology and pedicle screw placement, which is critical in the analysis of the risk of extensive epidural CL. Thus, this study aimed to identify the incidence and risk factors for extensive epidural CL in osteoporotic patients with CAPSF. MATERIALS AND METHODS 371 osteoporotic patients using 1898 cement-augmented screws were included. Preoperative computed tomography (CT) was utilized to characterize basivertebral foramen morphology. Following CAPSF, the severity of epidural CL, the implantation position of pedicle screw and cement extension within the vertebral body were determined by postoperative CT. In this study, significant risk factors for extensive epidural CL were identified through logistic regression analysis. RESULTS There were 19 patients (5.1%) and 32 screws (1.7%) with extensive epidural CL. Nine patients (involving 19 screws) had neurological symptoms. The independent risk factors for patients with extensive epidural CL were decreased BMD and increased number of augmented screws. Significant predictors for extensive epidural CL were a magistral type of basivertebral foramen, more volume of cement injected, solid screw, a shallower screw implantation, and the smaller distance between the tip of the screw and the midline of vertebral body. CONCLUSION Extensive epidural CL risk was significant in CAPSF when a magistral basivertebral foramen was present; solid screws and more volume of cement were used; and screw tip was implanted shallower or closer to the midline.
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Affiliation(s)
- Weibo Yu
- Department of Orthopaedics, The Third Affiliated Hospital of Southern Medical University, West Zhongshan Road 183, Guangzhou, 510520, Guangdong, People's Republic of China
- Department of Spinal Surgery, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Xiaobing Jiang
- Department of Spinal Surgery, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Haiyan Zhang
- Department of Orthopaedics, The Third Affiliated Hospital of Southern Medical University, West Zhongshan Road 183, Guangzhou, 510520, Guangdong, People's Republic of China
| | - Zhensong Yao
- Department of Spinal Surgery, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Yuanming Zhong
- Department of Orthopaedics, The First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning, Guangxi, People's Republic of China
| | - Fubo Tang
- Department of Orthopaedics, The First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning, Guangxi, People's Republic of China
| | - Daozhang Cai
- Department of Orthopaedics, The Third Affiliated Hospital of Southern Medical University, West Zhongshan Road 183, Guangzhou, 510520, Guangdong, People's Republic of China.
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Wang Y, Yang L, Li C, Sun H. A Biomechanical Study on Cortical Bone Trajectory Screw Fixation Augmented With Cement in Osteoporotic Spines. Global Spine J 2023; 13:2115-2123. [PMID: 35042407 PMCID: PMC10538326 DOI: 10.1177/21925682211070826] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
STUDY DESIGN A biomechanical study. OBJECTIVE To evaluate the efficacy and feasibility of cement-augmented cortical bone trajectory (CBT) screw fixation. METHODS Forty-nine CBT screws were inserted into lumbar vertebrae guided by three-dimensionally printed templates, and then injected with 0, .5, or 1.0 mL of polymethylmethacrylate. The screw placement accuracy, cement dispersion, and cement leakage rate were evaluated radiologically. Biomechanical tests were performed to measure the axial pull-out strength and torque value. RESULTS Overall, 83.67% of the screws were inserted without pedicle perforation. In the 1.0 mL group, cement dispersed into the pedicle zone and formed a concentrated mass more often than in the .5 mL group, but not significantly more often (P > .05). The total cement leakage rate was 18.75%. Compared with the control group, the torque value was slightly higher in the .5 mL group (P = .735) and significantly higher in the 1.0 mL group (P = .026). However, there was no significant difference between the .5 and 1.0 mL groups (P = .431). The maximal pull-out force (Fmax) was increased by 52.85% and 72.73% in the .5 and 1.0 mL groups, respectively, compared with the control group (P < .05). However, the difference was not significant between the 2 cemented groups (P = .985). CONCLUSIONS Cement augmentation is a useful method for increasing CBT screw stability in osteoporotic spines. The cement injection volume is recommended to be 1 mL for each screw, and the cement should disperse into the vertebral body than the pedicle zones.
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Affiliation(s)
- Yuetian Wang
- Department of Orthopedics, Peking University First Hospital, Beijing, China
| | - Lei Yang
- Center for Health Science and Engineering (CHSE), School of Health Sciences and Biomedical Engineering, Hebei University of Technology, Tianjin, China
| | - Chunde Li
- Department of Orthopedics, Peking University First Hospital, Beijing, China
| | - Haolin Sun
- Department of Orthopedics, Peking University First Hospital, Beijing, China
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Yu W, Liang D, Yao Z, Zhang H, Zhong Y, Tang Y, Jiang X, Cai D. The Potential Impact of Basivertebral Foramen Morphology and Pedicle Screw Placement on Epidural Cement Leakage With Cement-Augmented Fenestrated Pedicle Screw Fixation: A Multicenter Retrospective Study of 282 Patients and 1404 Augmented Screws. Neurosurgery 2023; 93:66-74. [PMID: 36749094 DOI: 10.1227/neu.0000000000002373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/24/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Epidural cement leakage (CL) is a common complication in cement-augmented fenestrated pedicle screw fixation (CAFPSF) with the potential for neural injury. However, there are no reports discussing basivertebral vein morphology and pedicle screw placement, which are critical in the analysis of the risk of epidural CL after CAFPSF. OBJECTIVE To identify the incidence and risk factors of epidural CL in osteoporotic patients during CAFPSF. METHODS Two hundred and eighty-two osteoporotic patients using 1404 cement-augmented fenestrated screws were included. Preoperative computed tomography (CT) was used to characterize the morphology of posterior cortical basivertebral foramen. After CAFPSF, the severity of epidural CL, the implantation position of the screw tip, and cement extension within the vertebral body were determined by postoperative CT scans. In this study, significant risk factors for epidural CL were identified through logistic regression analysis. RESULTS In total, 28 patients (18.8%) and 108 screws (7.7%) had epidural CL and 7 patients (13 screws) experienced neurological symptoms. Although local epidural CL was generally not clinically significant, extensive epidural leakage posed a higher risk of neurological symptoms. Significant predictors for extensive epidural CL were a magistral type of basivertebral foramen and the smaller distance between the tip of the screw and the posterior wall of the vertebral body. CONCLUSION In osteoporotic patients receiving CAFPSF, epidural CL is relatively common. The morphology of basivertebral foramen should be taken into account when planning a CAFPSF procedure. It is important to try and achieve a deeper screw implantation, especially when a magistral type of basivertebral foramen is present.
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Affiliation(s)
- Weibo Yu
- Department of Orthopaedics, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - De Liang
- Department of Spinal Surgery, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, People's Republic of China
| | - Zhensong Yao
- Department of Spinal Surgery, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, People's Republic of China
| | - Haiyan Zhang
- Department of Orthopaedics, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Yuanming Zhong
- Department of Orthopaedics, The First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning, Guangxi, People's Republic of China
| | - Yongchao Tang
- Department of Spinal Surgery, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, People's Republic of China
| | - Xiaobing Jiang
- Department of Spinal Surgery, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, People's Republic of China
| | - Daozhang Cai
- Department of Orthopaedics, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong, People's Republic of China
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Spicher A, Lindtner RA, Zegg MJ, Schmid R, Hoermann R, Schmoelz W. Pedicle screw augmentation in posterior constructs of the thoracolumbar spine: How many pedicle screws should be augmented? Clin Biomech (Bristol, Avon) 2023; 106:106010. [PMID: 37245280 DOI: 10.1016/j.clinbiomech.2023.106010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 05/16/2023] [Accepted: 05/19/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUNDS To evaluate the effects of different pedicle screw augmentation strategies on screw loosening and adjacent segment collapse at the proximal end of long-segment instrumentation. METHODS Eighteen osteoporotic (9 male, 9 female donors; mean age: 74.7 ± 10.9 [SD] years) thoracolumbar multi-segmental motion segments (Th11 - L1) were assigned as follows: control, one-level augmented screws (marginally), and two-level augmented screws (fully augmented) groups (3 × 6). Pedicle screw placement was performed in Th12 and L1. Cyclic loading in flexion started with 100-500 N (4 Hz) and was increased by 5 N every 500 cycles. Standardized lateral fluoroscopy images with 7.5 Nm loading were obtained periodically during loading. The global alignment angle was measured to evaluate the overall alignment and proximal junctional kyphosis. The intra-instrumental angle was used to evaluate screw fixation. FINDINGS Considering screw fixation as a failure criterion, the failure loads of the control (683 N), and marginally (858 N) and fully augmented (1050 N) constructs were significantly different (ANOVA p = 0.032).Taking the overall specimen alignment as failure criteria, failure loads of the three groups (control 933 ± 271.4 N, marginally 858 N ± 196 N, and full 933 ± 246.3 N were in the same range and did not show any significance (p = 0.825). INTERPRETATION Global failure loads were comparable among the three groups and unchanged with augmentation because the adjacent segment and not the instrumentation failed first. Augmentation of all screws showed significant improved in screw anchorage.
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Affiliation(s)
- Anna Spicher
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Austria
| | | | - Michael Josef Zegg
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Austria
| | - Rene Schmid
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Austria
| | - Romed Hoermann
- Division of Clinical and Functional Anatomy, Department of Anatomy, Histology and Embryology, Medical University of Innsbruck, Innsbruck, Austria
| | - Werner Schmoelz
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Austria.
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Morimoto T, Kobayashi T, Hirata H, Tsukamoto M, Yoshihara T, Toda Y, Mawatari M. Cardiopulmonary Cement Embolism Following Cement-Augmented Pedicle Screw Fixation: A Narrative Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020407. [PMID: 36837608 PMCID: PMC9964565 DOI: 10.3390/medicina59020407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/14/2023] [Accepted: 02/18/2023] [Indexed: 02/22/2023]
Abstract
Fixation using cement-augmented pedicle screws (CAPS) is being increasingly performed. However, CAPS-associated cement leakage is a critical problem that can lead to cardiopulmonary cement embolism (CPCE). This narrative review aimed to explore the incidence of and risk factors and treatment strategies for CPCE and cement leakage-related complications after CAPS fixation. Data were extracted from each article, including characteristics of CPCE after CAPS fixation (incidence, location, diagnostic method and criteria, treatment, and outcome and prognosis). Overall, 28 case series and 14 case reports that met the inclusion criteria were included. Of the 1974 cases included in the review, CPCE was noted in 123, symptomatic CPCE in 35, and death in six, respectively. The frequencies of PCE and symptomatic PCE after CAPS fixation were 6% (range: 0-28.6%) and 1.3% (range: 0-26%), respectively. The range of frequencies of PCE and symptomatic PCE after CAPS fixation may have been wide because the definition of CPCE and data collection methods differed among the reports analyzed. Since PCE due to large cement emboli may be primarily related to the surgical technique, improved technique, such as minimizing the number of CAPSs by injecting low-volume high-viscosity cement at low velocity and pressure, and careful observation of cement leakage during CAPS insertion may reduce PCE associated with cement leakage. Spinal surgeons should pay more attention to the occurrence of CPCE during and after CAPS insertion, which can cause serious complications in some patients.
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12
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Schneider A, Gavriil A, Köhler G. [Postoperative ventricular tachycardia]. Med Klin Intensivmed Notfmed 2023; 118:242-245. [PMID: 36629873 DOI: 10.1007/s00063-022-00988-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 12/17/2022] [Accepted: 12/21/2022] [Indexed: 01/12/2023]
Affiliation(s)
- Andreas Schneider
- Klinik für Anästhesiologie und Operative Intensivmedizin, Kliniken Maria Hilf GmbH, Viersener Str. 450, 41063, Mönchengladbach, Deutschland.
| | - Athina Gavriil
- Klinik für Kardiologie, Kliniken Maria Hilf GmbH, Mönchengladbach, Deutschland
| | - Gerald Köhler
- Klinik für Orthopädie und Unfallchirurgie, Kliniken Maria Hilf GmbH, Mönchengladbach, Deutschland
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13
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Wang Y, Liu C, Liu H, Fu H, Li C, Yang L, Sun H. A Novel Calcium Phosphate-Based Nanocomposite for Augmentation of Cortical Bone Trajectory Screw Fixation. Int J Nanomedicine 2022; 17:3059-3071. [PMID: 35844971 PMCID: PMC9278980 DOI: 10.2147/ijn.s365149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 06/26/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose To evaluate the effect of cement augmentation of cortical bone trajectory (CBT) screws using a novel calcium phosphate–based nanocomposite (CPN). Material and Methods CBT screws were placed into cadaveric lumbar vertebrae. Depending on the material used for augmentation, they were divided into the following three groups: CPN, polymethylmethacrylate (PMMA), and control. Radiological imaging was used to evaluate the cement dispersion. Biomechanical tests were conducted to measure the stability of CBT screws. A rat cranial defect model was used to evaluate biodegradation and osseointegration of the CPN. Results After cement augmentation, the CPN tended to disperse into the distal part of the screws, whereas PMMA remained limited to the proximal part of the screws (P < 0.05). As for cement morphology, the CPN tended to form a concentrated mass, whereas PMMA arranged itself as a scattered cement cloud, but the difference was not significant (P > 0.05). The axial pullout test showed that the average maximal pullout force (Fmax) of CPN-augmented CBT screws was similar to that of the PMMA group (CPN, 1639.56 ± 358.21 N vs PMMA, 1778.45 ± 399.83 N; P = 0.745) and was significantly greater than that of the control group (1019.01 ± 371.98 N; P < 0.05). The average torque value in the CPN group was higher than that in the control group (CPN, 1.51 ± 0.78 N∙m vs control, 0.97 ± 0.58 N∙m) and lower than that in the PMMA group (1.93 ± 0.81 N∙m), but there were no statistically significant differences (P > 0.05). The CPN could be biodegraded and gradually replaced by newly formed bone tissue after 12 weeks in a rat cranial defect model. Conclusion The biocompatible CPN could be a valuable augmentation material to enhance CBT screw stability.
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Affiliation(s)
- Yuetian Wang
- Department of Orthopedics, Peking University First Hospital, Beijing, People's Republic of China
| | - Chun Liu
- Medical Research Centre, Changzhou Second People's Hospital Affiliated to Nanjing Medical University, Jiangsu, People's Republic of China
| | - Huiling Liu
- Institute of Orthopedics, Department of Orthopedics, Soochow University, Suzhou, People's Republic of China
| | - Haoyong Fu
- Department of Orthopedics, Peking University First Hospital, Beijing, People's Republic of China
| | - Chunde Li
- Department of Orthopedics, Peking University First Hospital, Beijing, People's Republic of China
| | - Lei Yang
- Institute of Orthopedics, Department of Orthopedics, Soochow University, Suzhou, People's Republic of China.,Center for Health Sciences and Engineering (CHSE), School of Health Sciences and Biomedical Engineering, Hebei University of Technology, Tianjin, People's Republic of China
| | - Haolin Sun
- Department of Orthopedics, Peking University First Hospital, Beijing, People's Republic of China
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14
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Wang Y, Yang L, Li C, Sun H. The Biomechanical Properties of Cement-Augmented Pedicle Screws for Osteoporotic Spines. Global Spine J 2022; 12:323-332. [PMID: 33611971 PMCID: PMC8907649 DOI: 10.1177/2192568220987214] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
STUDY DESIGN This is a broad, narrative review of the literature. OBJECTIVE In this review, we describe recent biomechanics studies on cement-augmented pedicle screws for osteoporotic spines to determine which factors influence the effect of cement augmentation. METHODS A search of Medline was performed, combining the search terms "pedicle screw" and ("augmentation" OR "cement"). Articles published in the past 5 years dealing with biomechanical testing were included. RESULTS Several factors have been identified to impact the effect of cement augmentation in osteoporotic spines. These include the type of augmentation material, the volume of injected cement, the timing of augmentation, the severity of osteoporosis, the design of the pedicle screw, and the specific augmenting technique, among others. CONCLUSIONS This review elaborates the biomechanics of cement-augmented pedicle screws, determines which factors influence the augmentation effect, and identifies the risk factors of cement leakage in osteoporotic bone, which might offer some guidance when using this technique in clinical practice. Further, we provide information about newly designed screws and recently developed augmentation materials that provide higher screw stability as well as fewer cement-related complications.
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Affiliation(s)
- Yuetian Wang
- Department of Orthopedics, Peking University First
Hospital, Beijing, China
| | - Lei Yang
- Center for Health Science and
Engineering(CHSE), School of Materials Science and Engineering, Hebei University of
Technology, Tianjin, China
| | - Chunde Li
- Department of Orthopedics, Peking University First
Hospital, Beijing, China
| | - Haolin Sun
- Department of Orthopedics, Peking University First
Hospital, Beijing, China,Haolin Sun, Peking University First
Hospital, Beijing 100034, China.
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15
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Improved fixation stability for repairing pedicle screw loosening using a modified cement filling technique in porcine vertebrae. Sci Rep 2022; 12:2739. [PMID: 35177724 PMCID: PMC8854567 DOI: 10.1038/s41598-022-06724-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 02/04/2022] [Indexed: 01/20/2023] Open
Abstract
Polymethylmethacrylate (PMMA) has been applied clinically and biomechanically repair loose pedicle screws. Controversies have arisen over data due to uncontrolled cement properties, various locations and sizes of fenestrated holes in repair screws, irregular holes and different bone densities of specimens. In this study, the pullout strength was compared for two techniques, the modified technique to use PMMA to augment a threaded hole and the traditional technique with retrograde injection of a PMMA filling, for standard loose screws in porcine vertebrae. Both techniques provided statistically significant results for sufficiently randomized specimens and experimental procedures. The difference in the pullout strength between conical and cylindrical screws for the aforementioned cement augmentation techniques was also investigated. Twenty-four single-level fresh-frozen lumbar vertebrae from L1 to L6 were harvested from four mature pigs. A total of 0.8 ml of PMMA was retrograde injected into screw holes with a 5.5 mm diameter, followed by insertion of a 5.0 mm diameter repair screw in the traditional group (n = 12). A stiff threaded PMMA hole was created with a 4.5 mm tapping screw before insertion of repair screws in the modified group (n = 12). Two screw geometries were randomly assigned as cylindrical (n = 6) and conical (n = 6) in each group. The correlations between filling techniques, screw geometries and axial pullout strength were analyzed. An appropriate screw trajectory and insertion depth were confirmed using X-ray imaging prior to pullout testing in both groups. For a given screw geometry (cylindrical or conical), the pullout force of the modified group was significantly higher than that of the traditional group. There was no significant difference in the pullout force between the screw geometries for a given filling technique. The cement augmentation technique is far more influential than the screw outer geometry. The modified PMMA technique created a greater anchor force than the traditional method and could be an alternative for revision of pedicle screw loosening.
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Gomez FA, Herrera OM, Gaona JLV, Reyes CAF, Gutiérrez MLC, Saenz LCM. Pulmonary cement embolism following transpedicular screws placement for thoracolumbar fractures. Surg Neurol Int 2021; 12:495. [PMID: 34754545 PMCID: PMC8571380 DOI: 10.25259/sni_817_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 08/25/2021] [Indexed: 11/09/2022] Open
Abstract
Background Symptomatic pulmonary cement embolism in patients undergoing thoracic transpedicular fenestrated screw placement is rare. Here, we have added a 64-year-old female undergoing transpedicular screw placement for a T11 fracture who developed a pulmonary cement embolism intraoperatively and add this case to 13 others identified in the literature. Case Description A 64-year-old female presented with a type "C", ASIA "E" T11 fracture. The thoracolumbar pedicle screw fixation was supplemented with bone cement due to her underlying severe osteoporosis. During the fluoroscopy-guided supplementation with bone cement, a leak through the paravertebral venous system was noted. Thirty minutes later, the patient acutely developed extreme respiratory failure and required mechanical ventilation for the next 2 days. The diagnosis of pulmonary embolism due to bone cement was confirmed on a contrast computed tomography study of the chest. Conclusion Symptomatic pulmonary cement embolization supplementing transpedicular screws placement for osteoporotic bone is rare. Here, we present a 64-year-old female who during transpedicular fixation of a T11 fracture developed an acute pulmonary embolism from the bone cement resulting in the need for 2 days of postoperative artificial ventilation.
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Affiliation(s)
- Fernando Alvarado Gomez
- Department of Spine Surgery, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Omar Marroquín Herrera
- Department of Spine Surgery, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Jorge L Villán Gaona
- Department of Spine Surgery, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Carlos A Fuentes Reyes
- Department of Spine Surgery, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | | | - Luis C Morales Saenz
- Department of Spine Surgery, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
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Zhang J, Wang G, Zhang N. A meta-analysis of complications associated with the use of cement-augmented pedicle screws in osteoporosis of spine. Orthop Traumatol Surg Res 2021; 107:102791. [PMID: 33338677 DOI: 10.1016/j.otsr.2020.102791] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 07/30/2020] [Accepted: 08/20/2020] [Indexed: 02/03/2023]
Abstract
PURPOSE Our study aimed to provide updated and comprehensive evidence on the complications associated with the use of cement-augmented pedicle screws (CAPS) in osteoporosis patients undergoing spinal instrumentation. METHODS Databases of PubMed, Embase, Ovoid, and Google Scholar were screened from January 2000-February 2020 for studies reporting complications of CAPS in osteoporosis patients. Pooled estimates (with 95% confidence intervals) were calculated. RESULTS Twenty studies were included. The pooled risk of screw loosening, screw breakage and screw migration was 2.0% (0.2%-4.9%), 0.6% (0%-2.0%) and 0.2% (0%-1.2%) respectively. On pooling of data from 1277 patients, we found the risk of all cement leakage to be 21.8% (6%-43.1%). However, data from 1654 patients indicated the risk of symptomatic cement leakage was 1.2% (0.6%-1.9%). The incidence of pulmonary embolism was 3.0% (0.5%-6.8%) while the risk of symptomatic pulmonary embolism was 0.8% (0.2%-1.5%). Pooled risk of neurovascular complications was 1.6% (0.3%-3.6%), adjacent compression fracture was 3.3% (1.2%-6.2%) and infectious complications was 3.1% (1.1%-5.7%). There were high heterogeneity and variability in the study outcomes. CONCLUSION The incidence of screw-related complications like loosening, breakage, and migration with the use of CAPS in spinal instrumentation of osteoporotic patients is low. The risk of cement leakage is high and variable but the incidence of symptomatic cement leakage and related neurovascular or pulmonary complications is low. Further studies using homogenous methods of reporting are needed to strengthen current evidence. LEVEL OF EVIDENCE II, Systematic Review and Meta-analysis.
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Affiliation(s)
- Jinlong Zhang
- Department of Orthopedics, Shengli Oilfield Central Hospital, No.31, Jinan Road, 257000 Dongying City, Shandong Province, China
| | - Guohua Wang
- Department of Orthopedics, Shengli Oilfield Central Hospital, No.31, Jinan Road, 257000 Dongying City, Shandong Province, China.
| | - Nannan Zhang
- Department of Orthopedics, Shengli Oilfield Central Hospital, No.31, Jinan Road, 257000 Dongying City, Shandong Province, China
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Gomes de Farias LDP, Richter I, Mouallem ARE, Baptista LDPS. Cardiac Embolization of Polymethylmethacrylate after Thoracolumbar Spinal Arthrodesis. Radiol Cardiothorac Imaging 2021; 3:e210125. [PMID: 34778783 PMCID: PMC8581580 DOI: 10.1148/ryct.2021210125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 08/16/2021] [Accepted: 08/31/2021] [Indexed: 06/13/2023]
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19
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Yagi M, Ogiri M, Holy CE, Bourcet A. Comparison of clinical effectiveness of fenestrated and conventional pedicle screws in patients undergoing spinal surgery: a systematic review and meta-analysis. Expert Rev Med Devices 2021; 18:995-1022. [PMID: 34503387 DOI: 10.1080/17434440.2021.1977123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Pedicle screws are commonly used for spinal procedures for fusion stability, which is particularly important in osteoporotic patients, who are at an increased risk of requiring revision procedures. AREAS COVERED A systematic review and meta-analysis were conducted to compare clinical effectiveness of conventional pedicle screws (CPS) vs fenestrated pedicle screws (FPS) in patients undergoing spinal surgery. Primary outcomes included screw loosening, revision surgeries (involving an implant) and reoperations (not involving intervention on an implant) in patients treated with CPS vs FPS, sub-stratified by with and without osteoporosis. Secondary outcomes included changes in pain scores. Forty-eight studies with 8,302 patients were included, with 1,565 (19.18%) treated with FPS and 6,710 (80.82%) treated with CPS. FPS was associated with a lower risk of screw loosening (p = 0.001) vs CPS. In the general population, there was a non-significant trend of lower revision rate, but no difference in reoperation rate, between patients treated with FPS vs CPS. In osteoporotic patients, revision rates were significantly lower for FPS vs CPS (p = 0.009). EXPERT OPINION This review suggests that FPS are effective for surgical fixation and reduce rates of screw loosening, and in osteoporotic patients, revision surgeries, compared to CPS.
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Affiliation(s)
- Mitsuru Yagi
- Department of Orthopedic Surgery, Keio University School of Medicine, Japan
| | - Mami Ogiri
- Division of the Chief Medical Officer, Johnson & Johnson K.K. Medical Company, Chiyoda, Tokyo, Japan
| | - Chantal E Holy
- Medical Devices, Johnson and Johnson Limited, New Brunswick, NJ, USA
| | - Anh Bourcet
- Health Economics & Market Access, Johnson & Johnson Medical Asia Pacific, Singapore, Singapore
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20
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Guo H, Li J, Ma Y, Guo D, Liang D, Zhang S, Tang Y. Long-Term Outcomes of Peripheral Pulmonary Cement Embolism in Patients with Polymethylmethacrylate Augmentation: A Case Series with a Minimum Follow-Up of Five Years. World Neurosurg 2021; 155:e315-e322. [PMID: 34419660 DOI: 10.1016/j.wneu.2021.08.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/10/2021] [Accepted: 08/11/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Pulmonary cement embolism (PCE) is a rare but lethal complication. However, few long-term follow-up studies have investigated PCE after polymethylmethacrylate augmentation. This study aimed to investigate both the clinical and imaging outcomes of patients with PCE during a follow-up period of at least 5 years. METHODS A total of 1460 patients were initially included in this retrospective study. After exclusion, the clinical and imaging data were analyzed for selected patients, including the augmented level, location and length of the PCE, symptoms, therapy, migration and disintegration of the embolism, foreign body reaction, and status at follow-up. RESULTS Twelve female patients (age range, 56-88 years) with PCE and more than 5 years of follow-up (range, 5-13 years) were eventually included. All emboli were found in subsegment pulmonary arteries and were classified as peripheral PCE. Although 2 patients experienced transient symptoms after surgery, the majority of patients (84.6%) were asymptomatic during follow-up. No other reported emboli were observed during the follow-up period. The imaging data showed that the cement embolus could remain in the initial position throughout the long-term follow-up. In terms of the length of the PCE, there was no statistically significant difference between the values post-operation and at the last follow-up time (P > 0.05). CONCLUSIONS Patients with peripheral PCE do not develop known late complications. Moreover, polymethylmethacrylate can remain stable and inert in the pulmonary vasculature over the long term. Routine prophylactic anticoagulation may not be necessary for patients with peripheral PCE during follow-up.
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Affiliation(s)
- Huizhi Guo
- The First Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, Guangdong, People's Republic of China; Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, People's Republic of China
| | - Jinglan Li
- The First Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, Guangdong, People's Republic of China
| | - Yanhuai Ma
- The First Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, Guangdong, People's Republic of China; Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, People's Republic of China
| | - Danqing Guo
- The First Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, Guangdong, People's Republic of China
| | - De Liang
- Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, People's Republic of China
| | - Shuncong Zhang
- Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, People's Republic of China
| | - Yongchao Tang
- Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, People's Republic of China.
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21
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Ehresman J, Pennington Z, Elsamadicy AA, Hersh A, Lubelski D, Lehner K, Cottrill E, Schilling A, Lakomkin N, Ahmed AK, Lo SF, Sciubba DM. Fenestrated pedicle screws for thoracolumbar instrumentation in patients with poor bone quality: Case series and systematic review of the literature. Clin Neurol Neurosurg 2021; 206:106675. [PMID: 34020324 DOI: 10.1016/j.clineuro.2021.106675] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 04/27/2021] [Accepted: 05/02/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To describe the results of a single-surgeon series and systematically review the literature on cement-augmented instrumented fusion with fenestrated pedicle screws. METHODS All patients treated by the senior surgeon using fenestrated screws between 2017 and 2019 with a minimum of 6-months of clinical and radiographic follow-up were included. For the systematic review, we used PRISMA guidelines to identify all prior descriptions of cement-augmented instrumented fusion with fenestrated pedicle screws in the English literature. Endpoints of interest included hardware loosening, cement leakage, and pulmonary cement embolism (PCE). RESULTS Our series included 38 patients (mean follow-up 14.8 months) who underwent cement-augmented instrumentation for tumor (47.3%), deformity/degenerative disease (39.5%), or osteoporotic fracture (13.2%). Asymptomatic screw lucency was seen in 2.6%, cement leakage in 445, and pulmonary cement embolism (PCE) in 5.2%. Our literature review identified 23 studies (n = 1526 patients), with low reported rates of hardware loosening (0.2%) and symptomatic PCE (1.0%). Cement leakage, while common (55.6%), produced symptoms in fewer than 1% of patients. Indications for cement-augmentation in this cohort included: spine metastasis with or without pathologic fracture (n = 18; 47.3%), degenerative spine disease or fixed deformity with poor underlying bone quality (n = 15; 39.5%), and osteoporotic fracture (n = 5; 13.2%). CONCLUSION Cement-augmented fusion with fenestrated screws appears to be a safe, effective means of treating patients with poor underlying bone quality secondary to tumor or osteoporosis. High-quality evidence with direct comparisons to non-augmented patients is needed.
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Affiliation(s)
- Jeff Ehresman
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
| | - Zach Pennington
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; Department of Neurosurgery, Mayo Clinic, Rochester, MN 55905, USA.
| | - Aladine A Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Andrew Hersh
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Kurt Lehner
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Ethan Cottrill
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Andrew Schilling
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Nikita Lakomkin
- Department of Neurosurgery, Mayo Clinic, Rochester, MN 55905, USA
| | - A Karim Ahmed
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Sheng-Fu Lo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY 11030, USA.
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22
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Liang TZ, Zhu HP, Gao B, Peng Y, Gao WJ. Intracardiac, pulmonary cement embolism in a 67-year-old female after cement-augmented pedicle screw instrumentation: A case report and review of literature. World J Clin Cases 2021; 9:3120-3129. [PMID: 33969099 PMCID: PMC8080748 DOI: 10.12998/wjcc.v9.i13.3120] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/04/2021] [Accepted: 03/03/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND We report a case of Intracardiac, pulmonary, and intravenous cement embolism after cement-augmented pedicle screw instrumentation in treating spondylolisthesis underlying osteoporotic bone, which was successfully managed by conservative treatment. We describe the treatment and outcome of the patient, hoping to shed light on the management of bone cement embolism.
CASE SUMMARY A 67-year-old female suffered from progressive low back pain and numbness in lower extremities for 30 years. She was diagnosed with L4 and L5 spondylolisthesis, spinal stenosis, and osteoporosis. The patient underwent spinal canal decompression, an interbody fusion of L4/5 and L5/S1, cement-augmented pedicle screw instrumentation in L4-L5 segments, and regular pedicle screw in S1 segments. Three days postoperatively, a sudden drop in oxygen saturation occurred. Computerized tomography scan confirmed Intracardiac, pulmonary, and intravenous embolism. The patient was treated conservatively by continuous low-flow oxygen inhalation, anti-coagulation, and antibiotic therapy for 1 mo and continued anticoagulation treatment for 6 mo. The patient showed no further symptoms in a 30-mo follow-up.
CONCLUSION Intracardiac, pulmonary cement embolism after cement-augmented pedicle screw instrumentation is extremely rare. Careful clinical and radiographic evaluation is required in multiple sites of bone cement embolism. Conservative treatment may be a primary consideration in scattered emboli without life-threatening conditions, but a clinical decision should be made on an individualized basis.
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Affiliation(s)
- Tong-Zhou Liang
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510289, Guangdong Province, China
| | - Hai-Peng Zhu
- Department of Orthopedics, Guangdong Women and Children Hospital, Guangzhou 511400, Guangdong Province, China
| | - Bo Gao
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510289, Guangdong Province, China
| | - Yan Peng
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510289, Guangdong Province, China
| | - Wen-Jie Gao
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510289, Guangdong Province, China
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Massaad E, Rolle M, Hadzipasic M, Kiapour A, Shankar GM, Shin JH. Safety and efficacy of cement augmentation with fenestrated pedicle screws for tumor-related spinal instability. Neurosurg Focus 2021; 50:E12. [PMID: 33932920 DOI: 10.3171/2021.2.focus201121] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 02/16/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Achieving rigid spinal fixation can be challenging in patients with cancer-related instability, as factors such as osteopenia, radiation, and immunosuppression adversely affect bone quality. Augmenting pedicle screws with cement is a strategy to overcome construct failure. This study aimed to assess the safety and efficacy of cement augmentation with fenestrated pedicle screws in patients undergoing posterior, open thoracolumbar surgery for spinal metastases. METHODS A retrospective review was performed for patients who underwent surgery for cancer-related spine instability from 2016 to 2019 at the Massachusetts General Hospital. Patient demographics, surgical details, radiographic characteristics, patterns of cement extravasation, complications, and prospectively collected Patient-Reported Outcomes Measurement Information System Pain Interference and Pain Intensity scores were analyzed using descriptive statistics. Logistic regression was performed to determine factors associated with cement extravasation. RESULTS Sixty-nine patients underwent open posterior surgery with a total of 502 cement-augmented screws (mean 7.8 screws per construct). The median follow-up period for those who survived past 90 days was 25.3 months (IQR 10.8-34.6 months). Thirteen patients (18.8%) either died within 90 days or were lost to follow-up. Postoperative CT was performed to assess the instrumentation and patterns of cement extravasation. There was no screw loosening, pullout, or failure. The rate of cement extravasation was 28.9% (145/502), most commonly through the segmental veins (77/145, 53.1%). Screws breaching the lateral border of the pedicle but with fenestrations within the vertebral body were associated with a higher risk of leakage through the segmental veins compared with screws without any breach (OR 8.77, 95% CI 2.84-29.79; p < 0.001). Cement extravasation did not cause symptoms except in 1 patient who developed a symptomatic thoracic radiculopathy requiring decompression. There was 1 case of asymptomatic pulmonary cement embolism. Patients experienced significant pain improvement at the 3-month follow-up, with decreases in Pain Interference (mean change 15.8, 95% CI 14.5-17.1; p < 0.001) and Pain Intensity (mean change 28.5, 95% CI 26.7-30.4; p < 0.001). CONCLUSIONS Cement augmentation through fenestrated pedicle screws is a safe and effective option for spine stabilization in the cancer population. The risk of clinically significant adverse events from cement extravasation is very low.
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Patel S, Parola R, Rosinski CL, Nunna RS, Mehta AI. Fenestrated Pedicle Screws in Spinal Oncology: Technique and Comparative Retrospective Analysis. Int J Spine Surg 2021; 15:113-118. [PMID: 33900964 DOI: 10.14444/8015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The use of spinal stabilization with decompression has been shown to improve survival, spinal stability, and ambulatory status in patients with metastatic spinal tumors. However, the poor bone quality typically seen in these patients can prevent adequate stabilization. Fenestrated pedicle screws permit augmented fixation via injection of bone cement into the vertebral body upon screw placement, potentially mitigating the difficulties in achieving adequate stabilization in these patients. OBJECTIVE To compare surgical outcomes of posterior spinal fusion in patients with cancerous spinal lesions between polymethyl methacrylate cement-augmented fenestrated screws and standard pedicle screws. METHODS A total of 19 consecutive patients with cancerous spinal lesions receiving posterior spinal fusion (PSF) with pedicle screws from a single surgeon were retrospectively reviewed for demographic information, comorbidities, surgical parameters, and outcomes. RESULTS Ten patients underwent PSF with cement augmentation, whereas 9 underwent standard PSF. There was no significant difference in demographics, comorbidities, or surgical characteristics. Operative time was significantly greater in the cement-augmented group (302 ± 100 minutes vs 203 ± 55 minutes; P = .015). There was no significant difference in rates of operation or readmission between the cohorts nor was there any significant difference in discharge disposition. There was 1 case of surgical site infection (in a patient with a fenestrated screw) and no cases of cement extravasation. No instances of mechanical hardware failure were recorded. CONCLUSIONS Fenestrated screws confer similar risk profiles as nonfenestrated screws for posterior spinal fusion in patients with spinal cancer. However, fenestrated screws may affect operative time, radiation exposure, and impose risk of cement extravasation. Cement-augmented fenestrated pedicle screws may be a viable option for patients with poor bone quality associated with metastatic disease without significantly increased rates of surgical complications. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Saavan Patel
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Rown Parola
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Clayton L Rosinski
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Ravi S Nunna
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Ankit I Mehta
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
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Rodriguez-Arguisjuela M, Martin-Piñeiro B, Cuéllar-Bobadilla C, Leal-Caramanzana V, Heili-Frades S, Mahíllo-Fernandez I, Mengis CL, Gallego-Bustos J, Peiro A, Garzon-Márquez FM, Tomé-Bermejo F, Alvarez-Galovich L. Lung injury in patients age 75 years and older with the use of polymethylmethacrylate fenestrated pedicle screws. Spine J 2021; 21:430-437. [PMID: 33259968 DOI: 10.1016/j.spinee.2020.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 10/12/2020] [Accepted: 11/14/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Pulmonary complications in patients age 75 years and older who undergo spinal fusion may have catastrophic consequences. The use of augmentation techniques with polymethylmethacrylate (PMMA) have been associated with pulmonary damage. The use of fenestrated pedicle screws augmented with PMMA may increase the risk of lung injury in this population. PURPOSE To investigate whether the use of PMMA-augmented screws is correlated with increased lung injury in patients undergoing instrumented lumbar spinal fusion. STUDY DESIGN A nonrandomized, prospective, case-controlled clinical study was carried out. PATIENT SAMPLE We included 50 consecutive patients: 25 classifieds as patients who required PMMA-augmented screws in lumbar spinal fusion, and 25 classifieds as control participants because they underwent uncemented instrumented spinal fusion. OUTCOME MEASURES We compare the incidence of the event, lung damage, in both groups by measuring a series of parameters: arterial blood gas, transesophageal echocardiography, urinary desmosine, and chest radiograph. The epidemiological parameters analyzed were age, sex, body mass index, status as a smoker, and number of cement leaks. METHODS Changes in pulmonary damage markers were described in both groups of patients, comparing postsurgery values with baseline values. In control participants, each change was evaluated for the total number of patients. All changes are indicated in this report by mean differences for quantitative variables and by differing proportions for qualitative variables, with 95% confidence intervals provided for all values. RESULTS There was an increase in postinstrumentation PaO2 (arterial partial pressure of oxygen) in both groups, probably related to the use of mechanical ventilation and recruitment maneuvers. Even though the group that required augmentation had lower baseline levels, the difference between groups was not statistically significant. On transesophageal echocardiographs, we observed scattered small, snowflake-like emboli, and bright echo signals appeared in the right atrium during PMMA injection. Signal density was constant but gradually faded away when PMMA injection ended. No participants in the group without augmentation had radiological complications. Overall, desmosine levels increased in both groups, and the rise was similar in both. There was a slight average increase in urine desmosine levels after instrumentation and progressively continues to rise until 24 hours after instrumentation, with a subsequent decrease at 72 hours. Comparing the two groups, we found no statistically significant differences at any time. CONCLUSIONS We were not able to identify a significant difference in urine desmosine levels associated with the augmentation of with fenestrated pedicle screws with PMMA. Despite comparing patients age 75 years or older with a younger group, we found no clinical, analytical, or gasometric data indicating lung damage in patients who had augmentation.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Felix Tomé-Bermejo
- Hospital General de Villalba, Orthopedic Department, Collado Villalba, 28400 Madrid, Spain
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Guo HZ, Guo DQ, Tang YC, Liang D, Zhang SC. Selective cement augmentation of cranial and caudal pedicle screws provides comparable stability to augmentation on all segments in the osteoporotic spine: a finite element analysis. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1384. [PMID: 33313129 PMCID: PMC7723578 DOI: 10.21037/atm-20-2246] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background Cement-augmented pedicle screw instrumentation (CAPSI) has been proven to significantly increase the biomechanical stability in the osteoporotic lumbar spine. However, besides the merits, it is responsible for the inevitable cement leakage growing with more instrumented segments and volumes involved. This study aimed to compare the biomechanical performance of pedicle screws augmented on all segments with those augmented only on the cranial and caudal vertebrae selectively. Methods The finite element model of L3-S1 was modeled with the CT data of a healthy volunteer, the solid/fenestrated pedicle screws from micro-CT scans of physical screws, and bone cement from the CT scans of a postoperative patient with CAPSI. Three different augmented strategies for pedicle screws were taken into consideration: augmentation at each pedicle trajectory (Model A), selective augmentation at the cranial and caudal pedicle trajectories (Model B), and pedicle trajectories without augmentation (Model C). A total of six surgical models were constructed: Models A, B, and C were subdivided into double segmental fusion from L4 to S1 (Models A1, B1, and C1) and multi-segment fusion from L3 to S1 (Models A2, B2, and C2). The Range of motion (ROM), stress on the cage, and stress on the fixed segments were compared among the six models. Results The ROM at the fusion segments decreased in all instrumentation models. The ROMs of Model B and Model A are similar in each direction, while that of Model C is significantly larger. The differences in the ROMs between Model A and Model B were noted to be less than 0.1°. Compared with Models A1 and A2, the peak Von Mise stress on the cage-endplate interface and pedicle screws were slightly higher in Models B1 and B2. In contrast, the stress of Models C1 and C2 increased significantly. The compressive stress was concentrated in the screw head, the cranial and caudal screws, and rods. Conclusions The selective augmentation of pedicle screws is capable of providing reliable stability in short-segment posterior fixation (2- or 3-level). It could be a potential optimal procedure to minimize the associated complications of CAPSI.
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Affiliation(s)
- Hui-Zhi Guo
- The First Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, Guangzhou, China.,Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Dan-Qing Guo
- The First Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yong-Chao Tang
- Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - De Liang
- Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Shun-Cong Zhang
- The First Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, Guangzhou, China.,Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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Effect of Fenestrated Pedicle Screws with Cement Augmentation in Osteoporotic Patients Undergoing Spinal Fusion. World Neurosurg 2020; 143:e351-e361. [PMID: 32771604 DOI: 10.1016/j.wneu.2020.07.154] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 07/20/2020] [Accepted: 07/21/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Osteoporosis is a well-known risk factor for instrumentation failure and subsequent pseudoarthrosis after spinal fusion. In the present systematic review, we analyzed the biomechanical properties, clinical efficacy, and complications of cement augmentation via fenestrated pedicle screws in spinal fusion. METHODS We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Reports appearing in the PubMed database up to March 31, 2020 were queried using the key words "cement," "pedicle screw," and "osteoporosis." We excluded non-English language studies, studies reported before 2000, studies that had involved use of cement without fenestrated pedicle screws, nonhuman studies, technical reports, and individual case reports. RESULTS Twenty-five studies met the inclusion criteria. Eleven studies had tested the biomechanics of cement-augmented fenestrated pedicle screws. The magnitude of improvement achieved by cement augmentation of pedicle screws increased with the degree of osteoporosis. The cement-augmented fenestrated pedicle screw was superior biomechanically to the alternative "solid-fill" technique. Fourteen studies had evaluated complications. Cement extravasation with fenestrated screw usage was highly variable, ranging from 0% to 79.7%. However, cement extravasation was largely asymptomatic. Thirteen studies had assessed the outcomes. The use of cement-augmented fenestrated pedicles decreased screw pull out and improved fusion rates; however, the clinical outcomes were similar to those with traditional pedicle screw placement. CONCLUSIONS The use of cement-augmented fenestrated pedicle screws can be an effective strategy for achieving improved pedicle screw fixation in patients with osteoporosis. A potential risk is cement extravasation; however, this complication will typically be asymptomatic. Larger comparative studies are needed to better delineate the clinical efficacy.
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Tang YC, Guo HZ, Guo DQ, Luo PJ, Li YX, Mo GY, Ma YH, Peng JC, Liang D, Zhang SC. Effect and potential risks of using multilevel cement-augmented pedicle screw fixation in osteoporotic spine with lumbar degenerative disease. BMC Musculoskelet Disord 2020; 21:274. [PMID: 32345282 PMCID: PMC7189525 DOI: 10.1186/s12891-020-03309-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 04/22/2020] [Indexed: 02/07/2023] Open
Abstract
Background The increase of augmented level and bone cement dose are accompanied by the rising incidence of cement leakage (CL) of cement-augmented pedicle screw instrumentation (CAPSI). But the effect and potential risks of the application of CAPSI to osteoporotic lumbar degenerative disease (LDD) have not been studied in the case of multilevel fixation. This study aimed to investigate the effectiveness and potential complications of using multilevel CAPSI for patients with osteoporotic LDD. Methods A total of 93 patients with multilevel LDD were divided into the CAPSI group (46 subjects) and the conventional pedicle screw (CPS) group (47 subjects), including 75 cases for three levels and 18 cases for four levels. Relevant data were compared between two groups, including baseline data, clinical results, and complications. Results In the CAPSI group, a total of 336 augmented screws was placed bilaterally. The CL was observed in 116 screws (34.52%). Three cemented screws (0.89%) were found loosened during the follow-up and the overall fusion rate was 93.47%. For perioperative complications, two patients (4.35%) experienced pulmonary cement embolism (PCE), one patient augmented vertebral fracture, and three patients (6.52%) wound infection. And in the CPS group, thirty-three screws (8.46%) suffered loosening in cranial and caudal vertebra with a fusion rate of 91.49%. The operation time and hospital stay of CAPSI group were longer than the CPS group, but CAPSI group has a lower screw loosening percentage (P<0. 05). And in terms of blood loss, perioperative complications, fusion rate, and VAS and ODI scores at the follow-up times, there were no significant differences between the two groups. Conclusions Patients with osteoporotic LDD underwent multilevel CPS fixation have a higher rate of screw loosening in the cranial and caudal vertebra. The application of cemented pedicle screws for multilevel LDD can achieve better stability and less screw loosening, but it also accompanied by longer operating time, higher incidence of CL, PCE and wound infections. Selective cement augmentation of cranial and caudal pedicle screws may be a worthy strategy to decrease the complications.
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Affiliation(s)
- Yong-Chao Tang
- Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Hui-Zhi Guo
- The 1st Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, People's Republic of China
| | - Dan-Qing Guo
- The 1st Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, People's Republic of China
| | - Pei-Jie Luo
- Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China.,The 1st Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, People's Republic of China
| | - Yong-Xian Li
- Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China.,The 1st Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, People's Republic of China
| | - Guo-Ye Mo
- Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China.,The 1st Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, People's Republic of China
| | - Yan-Huai Ma
- Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China.,The 1st Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, People's Republic of China
| | - Jian-Cheng Peng
- Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China.,The 1st Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, People's Republic of China
| | - De Liang
- Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Shun-Cong Zhang
- Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China. .,The 1st Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, People's Republic of China.
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Rahimizadeh A, Hassani V, Soufiani H, Rahimizadeh A, Karimi M, Asgari N. Symptomatic pulmonary cement embolism after pedicle screw polymethylmethacrylate cement augmentation: A case report and review. Surg Neurol Int 2020; 11:18. [PMID: 32123606 PMCID: PMC7049880 DOI: 10.25259/sni_592_2019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 01/08/2020] [Indexed: 12/18/2022] Open
Abstract
Background: In osteoporotic patients, a useful technique for significantly enhancing the strength of a pedicle screw is augmentation with polymethylmethacrylate cement. However, a rare complication of this procedure is a symptomatic pulmonary cement embolism. Case Description: A pedicle screw cement augmentation was performed in a middle-aged female for the failed back syndrome. When she developed symptomatic pulmonary cement emboli, she was successfully managed with conservative measures, including anticoagulation. Conclusion: Despite the increased use of cement augmentation for pedicle screw placement and the relatively high incidence of cement leakage into the prevertebral venous system, symptomatic cement pulmonary embolism remains rare. The management of such symptomatic CPE should be evaluated and treated based on both the size and location of the embolism. Here, we presented this case while reviewing three symptomatic and four asymptomatic cases from the literature.
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Affiliation(s)
- Abolfazl Rahimizadeh
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Valiollah Hassani
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Housain Soufiani
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Ava Rahimizadeh
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Mona Karimi
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Naser Asgari
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran
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Venous Drainage of Lumbar Vertebral Bodies: Anatomic Study with Application to Kyphoplasty, Vertebroplasty, and Pedicle Screw Complications. World Neurosurg 2020; 137:e286-e290. [PMID: 32014549 DOI: 10.1016/j.wneu.2020.01.174] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 01/21/2020] [Accepted: 01/22/2020] [Indexed: 11/22/2022]
Abstract
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.
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Wang W, Liu C, Li J, Li H, Wu J, Liu H, Li C, Zhou Y. Comparison of the fenestrated pedicle screw and conventional pedicle screw in minimally percutaneous fixation for the treatment of spondylolisthesis with osteoporotic spine. Clin Neurol Neurosurg 2019; 183:105377. [DOI: 10.1016/j.clineuro.2019.105377] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 05/10/2019] [Accepted: 05/22/2019] [Indexed: 11/26/2022]
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