Safety of Cement Distribution Patterns in Metastatic Vertebral Tumors: A Retrospective Study

Incidence of Cement Leakage and Potential Risk Factors in Surgery for Spinal Metastasis: A Systematic Review and Meta-Analysis

OBJECTIVES

The current meta-analysis was performed to gather available evidence regarding the incidence and risk factors of cement leakage (CL) in patients undergoing surgical procedures for spinal metastasis.

METHODS

Two authors independently searched the PubMed, Embase, and CENTRAL databases. Clinical studies reporting the incidence or risk factors of CL were included for analysis. The primary outcome analyzed was the incidence of various types of CL. Random-effects or fixed-effects single-proportion meta-analyses were conducted to pool the available evidence, based on the heterogeneity test. Subgroup analyses were conducted based on surgical procedures (percutaneous vertebroplasty, percutaneous kyphoplasty, and others). Risk factors of CL were synthesized narratively to identify the most commonly accepted factors.

RESULTS

A total of 26 studies, involving 2551 patients, were included. The number of operated spine segments was reported in 23 studies, accounting for 4101 vertebrae. The pooled incidences of general, intradiscal, paravertebral, spinal canal, and intravascular CLs were 0.18 (95% confidence interval [CI], 0.11-0.28), 0.14 (95% CI, 0.08-0.21), 0.13 (95% CI, 0.06-0.21), 0.11 (95% CI, 0.05-0.19), and 0.12 (95% CI, 0.08-0.17), respectively. Subgroup analyses revealed significantly different incidences of general CL (0.37 vs. 0.06 vs. 0.09, P < 0.01), intradiscal CL (0.22 vs. 0.06 vs. 0.12, P < 0.01), paravertebral CL (0.25 vs. 0.03 vs. 0.06, P < 0.01), and vascular CL (0.14 vs. 0.03 vs. 0.15, P < 0.01) among the three groups. Posterior wall disruption, pathologic fracture, and the number of treated vertebral levels were the most commonly identified independent risk factors for general CL. Posterior wall disruption was determined as a common significant risk factor for spinal canal CL.

CONCLUSIONS

This review provides insights into the incidence and risk factors associated with CL in surgical procedures for spinal metastasis. Understanding these risk factors can contribute to the development of tailored strategies aimed at minimizing CL occurrence and optimizing surgical outcomes for patients undergoing spinal metastatic surgery.

The influence of diverse bone cement distribution patterns for metastatic vertebral lesions after bilateral percutaneous kyphoplasty

Objective

To investigate the influence of diverse bone cement distribution patterns in patients with metastatic vertebral lesions after bilateral percutaneous kyphoplasty (PKP).

Methods

Fifty-nine patients with single-level metastatic vertebral lesions who received bilateral PKP were retrospectively reviewed. According to the different bone cement distribution patterns, patients were divided into confluent (n = 35, CF) and separated (n = 24, SP) groups. Indicators including visual analogue scale (VAS), Oswestry Disability Index (ODI), vertebral body height (VBH) variation, quality of life (QoL), and related complications were reviewed and compared between the two groups.

Results

No statistically significant differences were observed between the two groups in age, sex, types of lesions, locations of lesions, posterior vertebral body and/or pedicle involvement, percentage of vertebral invasion, procedure duration or cement volume (p > 0.05). There was significant improvement in VAS, ODI, VBH and QoL at any follow-up examination (p < 0.05) compared with those preoperatively. The CF group exhibited better pain relief in VAS scores than did the SP group just at 3 days and 1 month after PKP (p < 0.05). There were no significant differences between the two groups in VAS scores at 3 months or 1 year after PKP (p > 0.05). No statistically significant differences were observed between the two groups in terms of ODI, VBH or QoL (p > 0.05). There was no statistically significant difference in the incidence of complications between the two groups (p > 0.05).

Conclusions

More rapid pain relief was achieved with confluent rather than separated bone cement distribution patterns in PKP for patients with metastatic vertebral lesions.

The Palliative Care in the Metastatic Spinal Tumors. A Systematic Review on the Radiotherapy and Surgical Perspective

Spine represents the most common site for metastatic disease involvement. Due to the close relationship between the spinal cord and critical structures, therapeutical management of metastatic spinal cord disease remains challenging. Spinal localization can lead to neurological sequelae, which can significantly affect the quality of life in patients with a limited life expectancy. The authors conducted a systematic literature review according to PRISMA guidelines in order to determine the impact of the most updated palliative care on spinal metastases. The initial literature search retrieved 2526 articles, manually screened based on detailed exclusion criteria. Finally, 65 studies met the inclusion criteria and were finally included in the systematic review. In the wide scenario of palliative care, nowadays, recent medical or surgical treatments represent valuable options for ameliorating pain and improving patients QoL in such this condition.

Separation surgery for metastatic epidural spinal cord compression: A qualitative review

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Separation surgery is a new concept for metastatic spinal cord compression treatment.

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Stereotactic radiosurgery increased local control, overcoming radio-resistance’s idea.

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The surgery goal shifted towards creating targets for radiations avoiding cord damages.

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Minimal invasive strategies could allow quick return to systemic therapies.

Introduction

The new concept of separation surgery has changed the surgical paradigms for the treatment of metastatic epidural spinal cord compression (MESCC), shifting from aggressive cytoreductive surgery towards less invasive surgery with the aim to achieve circumferential separation of the spinal cord and create a safe target for high dose Stereotactic Body Radiation Therapy (SBRT), which turned out to be the real game-changer for disease’s local control.

Discussion

In this review a qualitative analysis of the English literature has been performed according to the rating of evidence, with the aim to underline the increasingly role of the concept of separation surgery in MESCC treatment. A review of the main steps in the evolution of both radiotherapy and surgery fields have been described, highlighting the important results deriving from their integration.

Conclusion

Compared with more aggressive surgical approaches, the concept of separation surgery together with the advancements of radiotherapy and the use of SBRT for the treatment of MESCC showed promising results in order to achieve a valuable local control while reducing surgical related morbidities and complications.

Vertebral body cemented stents combined with posterior stabilization in the surgical treatment of metastatic spinal cord compression of the thoracolumbar spine

Background

Extensile interventions to provide anterior spinal column support in metastatic spinal cord compression (MSCC) surgery incur added morbidity in this surgically frail group of patients. We present our preliminary results of posterior spinal decompression and stabilization coupled with vertebral body cemented stents for anterior column support in MSCC.

Methods

Fourteen patients underwent posterior spinal decompression and pedicle screw construct along with vertebral body stenting (VBS) technique for reconstruction and augmentation of the vertebral body. The primary in all except one was solid organ malignancy and 10 patients (71%) were treatment naïve. The mean revised Tokuhashi score was 10.7 ± 2.7 and the mean spinal instability neoplastic score was 9.6 ± 1.9. All vertebral body lesions were purely lytic and were associated with a cortical defect in the posterior wall.

Results

A mean 5.3 ± 2.7 ml low-viscosity polymethyl methacrylate bone cement was injected within the stent at each compression level. No cement extrusion posteriorly was noted in any case from intraoperative fluoroscopy or postoperative radiographs. Five patients died at a mean 6.8 months (range 1-15 months), while the remaining patients have a mean survival of 18 months. Neither further revision surgical intervention nor any neurological deterioration was noted in any patient, who all continued to be ambulatory. The mean postoperative Core Outcome Measures Index score for 11 patients was 4.03 (standard deviation 3.11, 95% confidence interval (1.93-6.12).

Conclusion

In lytic vertebral body lesions with posterior wall erosions, cemented VBS technique adds to the surgical armamentarium in MSCC surgery showing promising early results without added complications.