Selections of Bone Cement Viscosity and Volume in Percutaneous Vertebroplasty: A Retrospective Cohort Study

Enhanced bone cement distribution in percutaneous vertebroplasty using a curved guide wire: a propensity score matching analysis

BACKGROUND

Osteoporotic vertebral compression fractures (OVCF) severely affect the quality of life in the aged population. Percutaneous vertebroplasty (PVP) alleviates pain and stabilizes vertebrae, but suboptimal bone cement distribution can cause complications. Hence, this study aimed to clarify whether a new technique for PVP, using a curved guide wire, enhances the distribution of bone cement and improves clinical outcomes in patients with OVCF.

METHODS

Patients with single-segment OVCF underwent PVP or curved guide wire percutaneous vertebroplasty (C-PVP). Propensity score matching (PSM) was employed to balanced the baseline characteristics. The primary outcomes were the visual analog scale (VAS) and Oswestry disability index (ODI) scores. The secondary outcomes included assessments of bone cement distribution, bone cement injection volume, radiological parameters, and general clinical results. Additionally, Complications and adverse events were documented.

RESULTS

After PSM analysis, each group comprised 54 patients, which significantly reduced baseline differences. The C-PVP group showed better clinical outcomes compared to the traditional PVP group. One month after surgery, the C-PVP group had significantly lower VAS and ODI scores (p < 0.001). These improvements persisted at six months and the final follow-up. Additionally, bone cement distribution scores were better (p < 0.001), injection volume was higher (p = 0.03), leakage was less frequent (p = 0.02), and adjacent vertebral fractures occurred less frequently (p = 0.04) in the C-PVP group. Radiological parameters and overall clinical outcomes revealed no significant differences between the two groups.

CONCLUSION

The use of curved guide wire in PVP significantly improves bone cement distribution and injection volume, resulting in better clinical efficacy in patients with OVCF.

[Translated article] Truths and myths about augmentation techniques in the treatment of fragility fractures

The main event of osteoporosis is fragility fractures. Vertebral compression fractures are the most commonly fragility fracture related to osteoporosis. Our goal is to review the available literature to confirm or deny concepts learned about spinal cementation and adapt our clinical practice according to scientific evidence. In the complex world of spine surgery, constant innovations seek to improve the quality of life of patients. Among these, vertebral augmentation has emerged as an increasingly popular technique, but often shrouded in myths and misunderstandings. In this systematic review, we will thoroughly explore the truths behind vertebral augmentation, unravelling common myths and providing a clear insight into this technique. As specialists in the field, it is crucial to understand the reality surrounding these interventions to offer our patients the best possible information and make informed decisions.

Combined vertebroplasty and pedicle screw insertion for vertebral consolidation: feasibility and technical considerations

PURPOSE

To assess the feasibility and technical accuracy of performing pedicular screw placement combined with vertebroplasty in the radiological setting.

METHODS

Patients who underwent combined vertebroplasty and pedicle screw insertion under combined computed tomography and fluoroscopic guidance in 4 interventional radiology centers from 2018 to 2023 were retrospectively assessed. Patient demographics, vertebral lesion type, and procedural data were analyzed. Strict intra-pedicular screw positioning was considered as technical success. Pain score was assessed according to the Visual Analogue Scale before the procedure and in the 1-month follow-up consultation.

RESULTS

Fifty-seven patients (38 men and 19 women) with a mean age of 72.8 (SD = 11.4) years underwent a vertebroplasty associated with pedicular screw insertion for the treatment of traumatic fractures (29 patients) and neoplastic disease (28 patients). Screw placement accuracy assessed by post-procedure CT scan was 95.7% (89/93 inserted screws). A total of 93 pedicle screw placements (36 bi-pedicular and 21 unipedicular) in 32 lumbar, 22 thoracic, and 3 cervical levels were analyzed. Mean reported procedure time was 48.8 (SD = 14.7) min and average injected cement volume was 4.4 (SD = 0.9) mL. A mean VAS score decrease of 5 points was observed at 1-month follow-up (7.7, SD = 1.3 versus 2.7, SD = 1.7), p < .001.

CONCLUSION

Combining a vertebroplasty and pedicle screw insertion is technically viable in the radiological setting, with a high screw positioning accuracy of 95.7%.

Truths and myths about augmentation techniques in the treatment of fragility fractures

The main event of osteoporosis is fragility fractures. Vertebral compression fractures are the most commonly fragility fracture related to osteoporosis. Our goal is to review the available literature to confirm or deny concepts learned about spinal cementation and adapt our clinical practice according to scientific evidence. In the complex world of spine surgery, constant innovations seek to improve the quality of life of patients. Among these, vertebral augmentation has emerged as an increasingly popular technique, but often shrouded in myths and misunderstandings. In this systematic review, we will thoroughly explore the truths behind vertebral augmentation, unraveling common myths and providing a clear insight into this technique. As specialists in the field, it is crucial to understand the reality surrounding these interventions to offer our patients the best possible information and make informed decisions.

Advancements in poly(methyl Methacrylate) bone cement for enhanced osteoconductivity and mechanical properties in vertebroplasty: A comprehensive review

The evolution of polymethyl methacrylate (PMMA) based bone cement (BC) from plexiglass to a biomaterial has revolutionized the joint and vertebral arthroplasties field. This widely used grouting material possesses exceptional properties for medical applications, including excellent biocompatibility, impressive mechanical strength, and favorable handling characteristics. PMMA-based BC is preferred in challenging conditions such as osteoporotic vertebral compression fractures, scoliosis, vertebral hemangiomas, spinal metastases, and myelomas, where it is crucial in withstanding stress. This review aims to comprehensively analyze the available reports and guide further research toward enhanced formulations of vertebral BC, focusing on its osteoconductive and mechanical properties. Furthermore, the review emphasizes the significant impact of BC's mechanical properties and osteoconductivity on the success and longevity of vertebroplasty procedures.

New Research Progress of Modified Bone Cement Applied to Vertebroplasty

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

A novel puncture approach via point "O" for percutaneous kyphoplasty in patients with L4 or L5 osteoporotic vertebral compression fracture

This study introduced a novel point "O" puncture approach for percutaneous kyphoplasty (PKP) in patients with L4 or L5 osteoporotic vertebral compression fracture (OVCF) and evaluated its clinical and radiographic outcomes. Between September 2019 and December 2020, we compared the clinical and radiographic outcomes in 31 cases (36 vertebrae) using the "O" entry point PKP intervention (O-PKP) and 31 cases (37 vertebrae) using transverse the process-pedicle approach PKP intervention (T-PKP). No serious postoperative complications were observed in any of the participants. Only two T-PKP patients experienced intervertebral disc space leakage. Compared with the T-PKP patients, the O-PKP patients showed shorter operative time and fluoroscopy times (P < 0.05), comparable blood loss and cement volume (P > 0.05), improved VAS and ODI scores at the final follow-up (P < 0.05), better increases in the vertebral compression ratio (P < 0.05), comparable Cobb angle (P > 0.05), comparable anteroposterior bone cement distribution, enhanced bilateral bone cement distribution (P < 0.05), and larger sagittal and transverse angles (P < 0.05). Herein, O-PKP was indicated for patients with L4 or L5 OVCF. This puncture approach showed significant advantages over T-PKP not only in terms of pain relief, surgery and fluoroscopy times but also in the puncture angle, vertebral reconstruction, and symmetrical cement distribution.

Safety and Efficacy of Bone Cement (Spinofill®) for Vertebroplasty in Patients with Osteoporotic Compression Fracture : A Preliminary Prospective Study

Objective

Although several commercialized bone cements are used during percutaneous vertebroplasty (PVP) for patients with osteoporotic vertebral compression fracture (OVCF), there are no reports using domestic products from South Korea. In this study, we investigated the safety and efficacy of Spinofill^® (Injecta Inc., Gunpo, Korea), a new polymethyl methacrylate product.

Methods

A prospective, single-center, and single-arm clinical trial of 30 participants who underwent PVP using Spinofill^® for painful thoracolumbar OVCF was performed with 6-months follow-up. Clinical and surgical outcomes included the Visual analog scale (VAS), Korean-Oswestry disability index (K-ODI), and Odom’s criteria, complication rate, and recurrence rate. Radiological outcomes were evaluated by measuring the findings of postoperative computed tomography and simple radiograph.

Results

The pain of VAS (from 8.95±1.05 to 4.65±2.06, p<0.001) and the life quality based on K-ODI (from 33.95±5.84 to 25.65±4.79, p<0.001) improved significantly, and successful patient satisfaction were achieved in 20 patients (66.7%) 1 day after surgery. These immediate improvements were maintained or more improved during the follow-up. There was no surgery- or product-related complications, but OVCF recurred in two patients (6.7%). Favorable cement interdigitation was reported in 24 patients (80.0%), and extra-vertebral cement leakage was reported in 13 patients (43.0%). The mean vertebral height ratio (from 60.49%±21.97% to 80.07%±13.16%, p<0.001) and segmental kyphotic angle (from 11.46°±8.50° to 7.79°±6.08°, p=0.002) improved one day after surgery. However, these short-term radiological findings somewhat regressed at the end.

Conclusion

The overall outcomes of PVP using Spinofill^® were as favorable as those of other conventionally used products.

Intervertebral bridging ossification after kyphoplasty in a Parkinson’s patient with Kummell’s disease: A case report

BACKGROUND

The short-term therapeutic efficacy of kyphoplasty on Kummell’s disease is obvious. However, postoperative refracture and adjacent vertebral fracture occur occasionally and are difficult to treat. Parkinson's disease (PD) is a pathological disorder associated with heterotopic ossification. In a patient with PD, an intervertebral bridge was formed in a short period of time after postoperative refracture and adjacent vertebral fracture, providing new stability.

CASE SUMMARY

A 78-year-old woman had been suffering from PD for more than 10 years. Three months before operation, she developed lower back pain and discomfort. The visual analog scale (VAS) score was 9 points. Preoperative magnetic resonance imaging indicated collapse of the L2 vertebra. Kyphoplasty was performed and significantly decreased the severity of intractable pain. The patient’s VAS score for pain improved from 9 to 2. Fifty days postoperatively, the patient suddenly developed severe back pain, and the VAS score was 9 points. X-ray showed L2 vertebral body collapse, slight forward bone cement displacement, L1 vertebral compression fracture, and severe L1 collapse. The patient was given calcium acetate capsules 0.6 g po qd and alfacalcidol 0.5ug po qd, and bed rest and brace protection were ordered. After conservative treatment for 2 mo, the patient's back pain was alleviated, and the VAS score improved from 9 to 2. Computed tomography at the 7-mo follow-up indicated extensive callus formation around the T12-L2 vertebrae and intervertebral bridging ossification, providing new stability.

CONCLUSION

Kyphoplasty is currently a conventional treatment for Kummell's disease, with definite short-term effects. However, complications still occur in the long term, and these complications are difficult to address; thus, the treatment needs to be selected carefully. To avoid refracture, an interlaced structure of bone cement with trabeculae should be created to the greatest extent possible during the injection of bone cement. Surgical intervention may not be urgently needed when a patient with PD experiences refracture and adjacent vertebral fracture, as a strong bridge may help stabilize the vertebrae and relieve pain.

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

Background

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

Case Presentation

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

Conclusions

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

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

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