Risk factors for pulmonary cement embolism associated with percutaneous vertebral augmentation: A systematic review and meta-analysis

High-density pulmonary lesions: Review in chest imaging

High-density pulmonary lesions are frequently seen in chest imaging, and it is important to identify their different causes. Radiologists must be able to distinguish between common and rare conditions in order to provide the best diagnosis and treatment. This article provides an overview of the various causes and imaging features of high-density lesions in the lungs. The lesions are classified into various categories, such as pulmonary nodules, inflammatory conditions, deposition diseases, contrast-related lesions, and thoracic devices. A clear understanding of these categories can help radiologists accurately diagnose and manage high-density pulmonary lesions encountered in practice.

Endovascular treatment of a large bone cement pulmonary embolism: Case report

We report a case of endovascular treatment of bone cement embolism after percutaneous vertebroplasty. The patient underwent percutaneous vertebroplasty for acute L1 compression fracture. Two weeks later, the patient developed symptoms of pulmonary embolism. Computed tomography pulmonary angiogram confirmed the presence of a bone cement foreign body in the pulmonary artery. Endovascular treatment was performed, and the cement embolism was caught, pulled to the level of the iliac vein, and fixed with stents. At the 1-year follow-up, the patient did not have any complaints, postoperative computed tomography pulmonary angiogram showed no obvious manifestations of pulmonary embolism, and angiography showed that the bone cement was fixed in place and that the iliac veins were normal.

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

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

Kyphoplasty is associated with reduced mortality risk for osteoporotic vertebral compression fractures: a systematic review and meta-analysis

BACKGROUND

Vertebral augmentation, such as vertebroplasty (VP) or kyphoplasty (KP), has been utilized for decades to treat OVCFs; however, the precise impact of this procedure on reducing mortality risk remains a topic of controversy. This study aimed to explore the potential protective effects of vertebral augmentation on mortality in patients with osteoporotic vertebral compression fractures (OVCFs) using a large-scale meta-analysis.

MATERIALS AND METHODS

Cochrane Library, Embase, MEDLINE, PubMed and Web of Science databases were employed for literature exploration until May 2023. The hazard ratios (HRs) and 95% confidence intervals (CIs) were utilized as a summary statistic via random-effect models. Statistical analysis was executed using Review Manager 5.3 software.

RESULTS

After rigorous screening, a total of five studies with substantial sample sizes were included in the quantitative meta-analysis. The total number of participants included in the study was an 2,421,178, comprising of 42,934 cases of vertebral augmentation and 1,991,244 instances of non-operative management. The surgical intervention was found to be significantly associated with an 18% reduction in the risk of mortality (HR 0.82; 95% CI 0.78, 0.85). Subgroup analysis revealed a remarkable 71% reduction in mortality risk following surgical intervention during short-term follow-up (HR 0.29; 95% CI 0.26, 0.32). Furthermore, KP exhibited a superior and more credible decrease in the risk of mortality when compared to VP treatment.

CONCLUSIONS

Based on a comprehensive analysis of large samples, vertebral augmentation has been shown to significantly reduce the mortality risk associated with OVCFs, particularly in the early stages following fractures. Furthermore, it has been demonstrated that KP is more reliable and effective than VP in terms of mitigating mortality risk.

The incidence and risk factors for extensive epidural cement leakage in cement-augmented pedicle screw fixation: a multicenter retrospective study

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.

Anatomic distribution of basivertebral foramen with a magistral form in vertebral bodies of T10~L5 and its clinical significance for extensive epidural cement leakage in cement-augmented pedicle screw fixation: a multicenter case-control study

BACKGROUND

There are no reports discussing anatomic distribution of basivertebral foramen (BVF) in the osteoporotic vertebral body, which is critical in the analysis of the risk of epidural cement leakage (ECL) after cement-augmented pedicle screw fixation (CAPSF).

METHODS

371 osteoporotic patients using 1898 cement-augmented screws were included. Preoperative computed tomography (CT) was used to determine the frequency, width, height, and depth of magistral BVF in T10~L5. Additionally, we measured the distance between BVF and the left/right borders of vertebral body as well as the distance between BVF and upper/lower endplates. Following CAPSF, the severity of ECL and the position of pedicle screws were determined by postoperative CT. Finally, significant risk factors for extensive ECL were identified through binary logistic regression analysis.

RESULTS

Of 2968 vertebral bodies ranging from T10 to L5, 801 (42.2%) had a magistral BVF. From T10 to L5, the frequency of magistral BVF appeared to gradually increase. The magistral BVF was much closer to the upper endplate and the depth accounted for about a quarter of anteroposterior diameter of vertebral body. Overall, there were 19 patients (5.1%) and 32 screws (1.7%) with extensive ECL, nine of whom had neurological symptoms. The independent risk factors for extensive ECL were the magistral BVF (OR = 8.62, P < 0.001), more volume of cement injected (OR = 1.57, P = 0.031), reduced distance from screw tip to vertebral midline (OR = 0.76, P = 0.003) and vertebral posterior wall (OR = 0.77, P < 0.001) respectively.

CONCLUSION

When planning a CAPSF procedure, it is important to consider anatomical distribution of BVF and improve screw implantation methods.

Analysis of Potential Risk Factors for Cement Leakage into Paraspinal Veins after Vertebroplasty for Acute Osteoporotic Vertebral Fractures Based on a 3D Reconstruction Technique: A Retrospective Matched Case-Control Study

OBJECTIVE

Pulmonary embolism, cardiac embolism, and even cerebral embolism due to paraspinal vein leakage (PVL) are increasingly reported, and their risk factors need to be adequately investigated for prevention. To this end, this study investigated the correlation of the distribution and morphological characteristics of fracture lines with the occurrence of PVL after percutaneous vertebroplasty (PVP), which has not been previously reported.

METHODS

Patients with acute single-segment thoracolumbar osteoporotic vertebral compression fractures (OVCFs) treated with PVP at our institution from January 2019 to July 2022 were selected for a matched case-control study. The case and control groups included those with and without PVL, respectively, matched at a 1:1 ratio based on general clinical characteristics. Additionally, fracture map and heatmap analysis was performed in both groups. In addition to the general clinical characteristics, the vertebral height ratio, puncture angle, delivery rate, and indexes were assessed via the three-dimensional CT reconstruction fracture line mapping technique, namely, the distribution of fracture lines, fracture line length, main fracture line shape, location of fracture line involvement, and number of fracture line branches, were compared between the two groups. The Wilcoxon rank-sum test, t tests, analysis of variance, and conditional logistic regression were used for statistical analysis.

RESULTS

Among 658 patients with OVCFs, 54 who did and 54 who did not develop PVL were included in this study. Significant differences in the puncture angle, fracture line distribution (MR-1, ML-2, MM-2, MR-2, ML-3, MM-3, LL-1, LM-1, LL-2, LM-2), fracture line involvement of the posterior wall, total fracture line length, and main fracture line length were found between the two groups (p < 0.05). Logistic univariate analysis showed significant differences in the puncture angle, fracture line distribution (MR-1, ML-2, MM-2, MR-2, ML-3, MM-3, LL-1, LL-2, LM-2, LL-3), total fracture line length, main fracture line length, and fracture line involvement of the posterior wall between the two groups (p < 0.05). Logistic multifactorial analysis showed that the fracture line distribution (UR-3, ML-3, LM-2, LR-2) and main fracture line length were independent risk factors for the development of PVL in both groups. In addition, the fracture maps and heatmaps showed a greater degree of fracture line encapsulation and more extensive involvement in the middle and lower regions of the vertebral body in the PVL group than in the control group.

CONCLUSIONS

Through a three-dimensional computed tomography reconstruction-based fracture line mapping technique, this study revealed for the first time that the distribution of fracture lines (UR-3, ML-3, LM-2, LR-2) and main fracture line length were independent risk factors for PVL after PVP in patients with acute single-segment thoracolumbar OVCFs. In addition, we hypothesized that the fracture line-vein traffic branch that may appear within 2 weeks after injury in acute OVCF patients may be one of the mechanisms influencing the above potential independent risk factors associated with PVL.

Risk Factors for Hidden Blood Loss Associated with Vertebroplasty or Kyphoplasty for Osteoporotic Vertebral Compression Fracture: A Systematic Review and Meta-Analysis

OBJECTIVE

Hidden blood loss (HBL), as a perioperative complication of percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP), affects the quality of life of older adults with poor health status, but it is often ignored by clinical surgeons. The purpose of this study was to discuss the risk factors for perioperative HBL through meta-analysis.

METHODS

We systematically searched PubMed, Embase, Cochrane Library, Web of Science, Scopus, Google Scholar, Chinese National Knowledge Infrastructure, and Wan Fang from establishment of the database to September 2022. All eligible studies regarding risk factors for HBL after PVP or PKP were included. Heterogeneity was assessed using the χ2 test and I2 statistic percentages. If I2 >50% or P < 0.1, the random-effect model was used; otherwise, the fixed-effect model was used. Data were analyzed with Revman 5.4 and Stata 16.0.

RESULTS

Eleven studies involving 1506 patients were included and the average HBL of PKP and PVP was 278.57 mL and 276.12mL. The results showed that bone cement leakage (P < 0.0001), thoracic vertebra (P < 0.00001), bilateral surgical approach (P = 0.0008), ≥2 fracture segments (P < 0.00001), vertebral body height loss rate (≥1/3) (P < 0.00001), and vertebral body height restoration rate (≥1/3) (P < 0.00001) were risk factors for increased HBL. Diabetes (P = 0.12) and hypertension (P = 0.52) were not significantly associated with HBL.

CONCLUSIONS

The findings of this meta-analysis suggested that fracture level, surgical approach, number of fracture levels, cement leakage, vertebral height loss and restoration rate were significant risk factors for HBL, which had certain guiding significance for clinical surgeons to take reasonable measures to deal with this complication.

Cardiopulmonary Cement Embolism Following Cement-Augmented Pedicle Screw Fixation: A Narrative Review

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.