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

An unexpected cause of intractable dysphagia after 20 years following cervical spine instrumentation using bone cement alone: a case report

Introduction and Importance

Postoperative dysphagia following anterior cervical discectomy fusion (ACDF) for cervical disc herniation is still poorly understood. Dysphagia after anterior spinal cervical approach is mild and transient. Here, the authors present a rare case suffering with severe progressive dysphagia for over 1 year after 20 years of ACDF due to expulsed bone cement abutting the esophagus which was successfully removed after reoperation.

Case Presentation

A 59-year-old homemaker female presented to us with a foreign body sensation in the throat 'globus pharyngeus' and progressive difficulty in swallowing for 1 year. She was previously operated for C5-C6 cervical intervertebral disc prolapse via ACDF using bone cement at another center. On examination, power in the left upper limb was MRC grade 3, and the left-hand grip was 25% only. MRI of the cervical spine showed increased prevertebral soft tissue space and a notable rectangular-shaped black prevertebral shadow at the C5-C6 level, causing esophageal compression. The patient underwent an exploration of previous ACDF surgery. Intraoperative findings revealed an extruded piece of bone cement of size ~2×1.5×1 cm3 at C5-C6 disc space level, compressing the esophagus. The yellowish extruded piece was removed and C5-C6 was reinforced with an anterior cervical plate with screws. The postoperative course was uneventful.

Clinical Discussion

The exact pathophysiology of dysphagia after ACF surgery remains unknown. In our case, there was an expulsion of the graft. The graft used was polymethyl methacrylate, commonly known as bone cement, which was placed 20 years back. Since polymethyl methacrylate is bioinert material, the graft may have expulsed from its site of placement and thus compressed the esophagus. Taking into consideration of the cost-effectiveness and maintenance of spinal mobility, few neurosurgeons believe that the application of bone cement in ACF surgery as a spacer is a safe and very cost-effective modality compared to modern expensive artificial disc.

Conclusion

Dysphagia after ACDF surgery is usually underrecognized. Although the serious complications after ACDF surgery are rare, dysphagia can cause prolonged morbidity to patients. Using bone cement alone for ACDF surgery may carry the risk of its anterior expulsion even after a long period of surgery.

Improvement in pain by using lidocaine combined with esketamine in elderly patients receiving local anaesthesia for percutaneous kyphoplasty: a randomized controlled study

BACKGROUND

Elderly patients often experience severe pain during percutaneous kyphoplasty under local anaesthesia. The aim of this work was to evaluate the effect of lidocaine combined with esketamine on pain improvement in elderly patients receiving local anaesthesia via percutaneous kyphoplasty.

METHODS

This prospective, randomized comparative trial was conducted on 66 elderly patients, aged 60-80 years, with an American Society of Anaesthesiologists (ASA) grade of I-III, I‒III and a BMI of 18.5-25 kg/m2, who underwent single-level lumbar percutaneous kyphoplasty under local anaesthesia. Patients were divided into two equal groups (33 per group). Group LE received 200 mg of 1% lidocaine and 25 mg of esketamine (total volume of 20 ml), and Group L received 200 mg of 1% lidocaine (total volume of 20 ml). Patient characteristics, surgery, VAS scores, MAP, HR, MOAA/S scores, patient satisfaction and related adverse reactions were compared for the groups. The VAS scores during and after surgery were considered the primary outcome.

RESULTS

There were statistically significant differences in the VAS score between the two groups at the following time points: channel establishment by the puncture needle, balloon dilation, bone cement injection and postoperative period (P < 0.05). The VAS score decreased in the LE group, but the MAP and HR were more stable, and the difference was statistically significant (P < 0.05). The difference in the MOAA/S score between the two groups was statistically significant (P < 0.05), and the MOAA/S score in the LE group decreased. The patient satisfaction level in the LE group was 100% and 48.48% in the L group (P < 0.05). There were no related complications or adverse reactions in either group.

CONCLUSION

The application of lidocaine combined with esketamine in local episcopal percutaneous vertebral kyphoplasty in elderly patients not only provides an effective analgesic effect but also improves surgical safety and patient comfort, which has important clinical value in promoting the optimization of surgical anaesthesia management in elderly patients.

TRIAL REGISTRATION

The study was registered at Chictr.org.cn with the number ChiCTR2400083466 on 06/12/2023.

Bioactive mineralized small intestinal submucosa acellular matrix/PMMA bone cement for vertebral bone regeneration

Polymethylmethacrylate (PMMA) bone cement extensively utilized for the treatment of osteoporotic vertebral compression fractures due to its exceptional handleability and mechanical properties. Nevertheless, the clinical application of PMMA bone cement is restricted by its poor bioactivity and excessively high modulus of elasticity. Herein, mineralized small intestinal submucosa (mSIS) was incorporated into PMMA to prepare a partially degradable bone cement (mSIS-PMMA) that provided suitable compressive strength and reduced elastic modulus compared to pure PMMA. The ability of mSIS-PMMA bone cement to promote the attachment, proliferation and osteogenic differentiation of bone marrow mesenchymal stem cells was shown through cellular experiments carried out in vitro, and an animal osteoporosis model validated its potential to improve osseointegration. Considering these benefits, mSIS-PMMA bone cement shows promising potential as an injectable biomaterial for orthopedic procedures that require bone augmentation.

High- versus low-viscosity cement vertebroplasty and kyphoplasty for osteoporotic vertebral compression fracture: a meta-analysis

BACKGROUND

To compare high- versus low-viscosity bone cement on the clinical outcomes and complications in patients with Osteoporotic vertebral compression fractures (OVCFs) who underwent percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP).

METHODS

PubMed, Embase, and the Cochrane Library were searched for papers published from inception up to February 2021 for potentially eligible studies comparing high- versus low-viscosity cement for PVP/PKP. The outcomes were the leakage rate, visual analog scale (VAS), and Oswestry Disability Index (ODI).

RESULTS

Eight studies (558 patients; 279 in each group) were included. The meta-analysis showed that the leakage rate was lower with high-viscosity cement than with low-viscosity cement (OR = 0.23, 95%CI 0.14-0.39, P < 0.001; I² = 43.5%, P_{heterogeneity} = 0.088); similar results were observed specifically for the disk space, paravertebral space, and peripheral vein, but there were no differences regarding the epidural space and intraspinal space. The VAS was decreased more significantly with high-viscosity cement than with low-viscosity cement (WMD = - 0.21, 95%CI - 0.38, - 0.04, P = 0.015; I² = 0.0%, P_{heterogeneity} = 0.565). Regarding the ODI, there was no difference between high- and low-viscosity cement (WMD = - 0.88, 95%CI - 3.06, 1.29, P = 0.426; I² = 78.3%, P_{heterogeneity} < 0.001).

CONCLUSIONS

There were lower cement leakage rates in PVP/PKP with high-viscosity bone cement than low-viscosity bone cement. The two groups have similar results in ODI, but the VAS scores favor high-viscosity bone cement. Therefore, the administration of high-viscosity bone cement in PVP/ PKP could be a potential option for improving the complications of leakage in OVCFs, while the clinical efficacy of relieving pain is not certain.

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.

Translation of a spinal bone cement product from bench to bedside

Spinal acrylic bone cements (ABCs) are used clinically for percutaneous vertebroplasty (PVP) and kyphoplasty (PKP) to treat osteoporotic vertebral compression fractures. Product translation of spinal ABC products followed the design control processes including design verification and validation. The bench to bedside translation of the first Chinese spinal ABC product (Alliment®, namely Alliment Cement) approved by National Medical Products Administration of China was investigated and another commercial product served as the control (Osteopal®V, namely Osteopal V Cement). Results of non-clinical bench performance verification tests of compression, bending and monomer release showed that the newly marketed Alliment Cement is similar to the Osteopal V Cement with properties of both meeting the criteria specified by standards. The Alliment Cement demonstrated good biocompatibility during the 26 weeks’ bone implantation test. Porcine cadaver validation tests further revealed that the Alliment Cement satisfied the needs for both PVP and PKP procedures. A post-approval, retrospective clinical investigation further demonstrated the safety and efficacy of the Alliment Cement, with a significant reduction of pain and the improved stability of the fractured vertebral bodies. A successful translation of biomaterial medical products needs close collaborations among academia, industry, healthcare professionals and regulatory agencies.

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Bench-to-bedside research of the first Chinese spinal acrylic bone cement product.

•Pre- & clinical investigations demonstrate the product's safety and efficacy.

•Translation of biomaterial medical products follows regulated processes.

Analysis on the Effect of Different Surgical Methods on the Treatment of Senile Osteoporotic Spinal Compression Fractures and the Influencing Factors of Complications

Osteoporotic fractures are a common type of fractures in the elderly, among which spinal compression fractures are more common. After the occurrence of fractures, due to the compression and burst of the vertebral body, this will lead to local kyphosis deformity and even affect the balance of the sagittal spine. In the past, conservative treatments were used for osteoporotic spinal compression fractures. Although it can relieve pain symptoms, it can easily lead to complications such as aggravation of osteoporosis and deep vein thrombosis of the lower extremities. At present, percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) are the main clinical surgical treatments, both of which are minimally invasive surgery, short operation time, effective pain relief, and rapid postoperative recovery. Although both of them are effective, there is still controversy over the efficacy of both in the treatment of osteoporotic spinal compression fractures. The purpose of this study was to investigate the efficacy of PVP and PKP in the treatment of elderly osteoporotic spinal compression fractures and to analyze the related factors that affect the occurrence of postoperative complications. The results show that both PVP and PKP can effectively improve the pain and dysfunction of elderly patients with osteoporotic spinal compression fracture, restoration of vertebral height, and correct kyphosis, but PKP has better effect and higher safety and is worth promoting. Postoperative complications of patients are related to their age, bone mineral density, use of hormones, and antiosteoporosis treatment.