Bone marrow washout for multilevel vertebroplasty in multiple myeloma spinal involvement. Technical note

Effect of unilateral pulsed jet lavage prior to vertebroplasty on the intravertebral pressure and cement distribution

Background

Percutaneous vertebroplasty is the most common treatment for osteoporotic vertebral compression fracture. However, the morbidity of vertebroplasty-related complications, such as cement leakage, remains high. We tested a new technique of unilateral pulsed jet lavage and investigated its effect on the intravertebral pressure and bone cement distribution.

Methods

Thirty lumbar vertebrae (L1-L5) from six cadaver spines were randomly allocated into two groups (with and without irrigation). Prior to vertebroplasty, pulsed jet lavage was performed through one side of the pedicle by using a novel cannula with two concentric conduits to remove the fat and bone marrow of the vertebral bodies in the group with irrigation. The control group was not irrigated. Then, standardized vertebroplasty was performed in the vertebral bodies in both groups. Changes in the intravertebral pressure during injection were recorded. Computed tomography (CT) was performed to observe the cement distribution and extravasations, and the cement mass volume (CMV) was calculated.

Results

During cement injection, the average maximum intravertebral pressure of the unirrigated group was higher than that of the irrigated group (4.92 kPa versus 2.22 kPa, P < 0.05). CT scans showed a more homogeneous cement distribution with less CMV (3832 mm³ vs. 4344 mm³, P < 0.05) and less leakage rate (6.7% vs. 46.7%, P < 0.05) in the irrigated group than in the control group.

Conclusions

Unilateral pulsed jet lavage can reduce intravertebral pressure and lower the incidence of cement leakage during vertebroplasty. An enhanced bone cement distribution can also be achieved through this lavage system.

Mechanical Cavity Creation with Curettage and Vacuum Suction (Q-VAC) in Lytic Vertebral Body Lesions with Posterior Wall Dehiscence and Epidural Mass before Cement Augmentation

Background and Objectives: We describe a novel technique for percutaneous tumor debulking and cavity creation in patients with extensive lytic lesions of the vertebral body including posterior wall dehiscence prior to vertebral augmentation (VA) procedures. The mechanical cavity is created with a combination of curettage and vacuum suction (Q-VAC). Balloon kyphoplasty and vertebral body stenting are used to treat neoplastic vertebral lesions and might reduce the rate of cement leakage, especially in presence of posterior wall dehiscence. However, these techniques could theoretically lead to increased intravertebral pressure during balloon inflation with possible mobilization of soft tissue tumor through the posterior wall, aggravation of spinal stenosis, and resultant complications. Creation of a void or cavity prior to balloon expansion and/or cement injection would potentially reduce these risks. Materials and Methods: A curette is coaxially inserted in the vertebral body via transpedicular access trocars. The intravertebral neoplastic soft tissue is fragmented by multiple rotational and translational movements. Subsequently, vacuum aspiration is applied via one of two 10 G cannulas that had been introduced directly into the fragmented lesion, while saline is passively flushed via the contralateral cannula, with lavage of the fragmented solid and fluid-necrotic tumor parts. Results: We applied the Q-VAC technique to 35 cases of thoracic and lumbar extreme osteolysis with epidural mass before vertebral body stenting (VBS) cement augmentation. We observed extravertebral cement leakage on postoperative CT in 34% of cases, but with no clinical consequences. No patients experienced periprocedural respiratory problems or new or worsening neurological deficit. Conclusion: The Q-VAC technique, combining mechanical curettage and vacuum suction, is a safe, inexpensive, and reliable method for percutaneous intravertebral tumor debulking and cavitation prior to VA. We propose the Q-VAC technique for cases with extensive neoplastic osteolysis, especially if cortical boundaries of the posterior wall are dehiscent and an epidural soft tissue mass is present.

Percutaneous Vertebral Body Augmentations: The State of Art

Osteoporotic compression fractures of the vertebral body can result in pain and long-term morbidity, including spinal deformity, with increased risk of mortality resulting from associated complications. Conservative management includes opioids and other analgesics, bed rest, and a back brace. For patients with severe and disabling pain, vertebral augmentation (vertebroplasty and kyphoplasty) is often considered, with these procedures endorsed by multiple professional societies, and provides immediate structural support, and stabilizes and reinforces the weakened bone structure. The purpose of this article is to review the vertebral biomechanics, indications and contraindications, and techniques of performing successful vertebral augmentation.