Postprocedural CT for perivertebral cement leakage in percutaneous vertebroplasty is not necessary--results from VERTOS II

Risk of new vertebral compression fractures and serious adverse effects after vertebroplasty: a systematic, critical review and meta-analysis of randomized controlled trials

BACKGROUND

Osteoporotic vertebral fractures (OVFs) significantly impact morbidity, mortality, functionality, and quality of life. Vertebroplasty, a widely utilized treatment for OVFs, has its efficacy and safety debated due to varying outcomes reported across clinical trials and meta-analyses. This study aims to critically review and conduct a meta-analysis of randomized controlled trials (RCTs) focusing on the safety of vertebroplasty, specifically its association with serious adverse effects and the development of new vertebral fractures, while exploring potential confounders.

METHODS

We conducted a systematic review and meta-analysis by searching PubMed, Web of Science, and EMBASE. The search was updated to February 23, 2024. We included published RCTs comparing vertebroplasty to conservative treatment (CT) or placebo/active control, focusing on new fractures and serious adverse effects. The primary outcomes were "incidence of new fractures" and "serious adverse effects". We applied the Dersimonian-Laird method with a random effects model to estimate risk ratios (RRs) of the primary outcomes, using the I2 statistic to assess heterogeneity among studies. Sensitivity analyses were conducted when significant heterogeneity was detected. Subgroup analyses were performed based on the characteristics of the control groups, risk of bias based on The Cochrane Risk of Bias Tool 2, time from fracture onset, and multicentric versus single-center trials.

RESULTS

In total, 14 RCTs encompassing 1,413 patients were analyzed. High and unclear risk of bias were observed in 15 and 25 items, respectively. No significant difference was observed in the incidence of new vertebral fractures between vertebroplasty and the control groups [RR =1.05, 95% confidence interval (CI): 0.71-1.56; I2=55%; P<0.01]. However, vertebroplasty was associated with a significantly lower incidence of serious adverse effects (RR =0.53, 95% CI: 0.31-0.91; I2=0%; P=0.93). Subgroup analyses revealed no significant differences based on control types, risk of bias, or number of institutions involved. Notably, early vertebroplasty (within 6 weeks of symptom onset) showed a protective effect against new vertebral fractures (RR =0.60, 95% CI: 0.38-0.92; I2=0%; P=0.53). The sensitivity analysis showed that one study influenced the observed heterogeneity but did not significantly modify the pooled estimate.

CONCLUSIONS

Vertebroplasty is not associated with an increased risk of developing new vertebral fractures and may reduce the risk of serious adverse effects compared to placebo or CT. Early intervention post-fracture appears beneficial. However, the limited number and quality of RCTs call for further high-quality studies.

Deep learning-based multimodal image analysis predicts bone cement leakage during percutaneous kyphoplasty: protocol for model development, and validation by prospective and external datasets

Background

Bone cement leakage (BCL) is one of the most prevalent complications of percutaneous kyphoplasty (PKP) for treating osteoporotic vertebral compression fracture (OVCF), which may result in severe secondary complications and poor outcomes. Previous studies employed several traditional machine learning (ML) models to predict BCL preoperatively, but effective and intelligent methods to bridge the distance between current models and real-life clinical applications remain lacking.

Methods

We will develop a deep learning (DL)-based prediction model that directly analyzes preoperative computed tomography (CT) and magnetic resonance imaging (MRI) of patients with OVCF to accurately predict BCL occurrence and classification during PKP. This retrospective study includes a retrospective internal dataset for DL model training and validation, a prospective internal dataset, and a cross-center external dataset for model testing. We will evaluate not only model's predictive performance, but also its reliability by calculating its consistency with reference standards and comparing it with that of clinician prediction.

Discussion

The model holds an imperative clinical significance. Clinicians can formulate more targeted treatment strategies to minimize the incidence of BCL, thereby improving clinical outcomes by preoperatively identifying patients at high risk for each BCL subtype. In particular, the model holds great potential to be extended and applied in remote areas where medical resources are relatively scarce so that more patients can benefit from quality perioperative evaluation and management strategies. Moreover, the model will efficiently promote information sharing and decision-making between clinicians and patients, thereby increasing the overall quality of healthcare services.

Risk factors for new vertebral compression fracture after vertebroplasty and efficacy of osteoporosis treatment: A STROBE-compliant retrospective study

Vertebroplasty (VP) effectively treats vertebral compression fractures (VCFs). However, the issue of secondary new VCFs (SNVCFs) after VP is yet to be addressed. Therefore, identification of risk factors for SNVCFs after VP may aid the development of strategies to minimize SNVCF risk. This study aimed to retrospectively evaluate risk factors for SNVCFs after VP, including those associated with the type of anti-osteoporotic treatment administered after VP. Data from 128 patients who underwent single-level VP were collected and reviewed. Patients were divided into 2 groups: those with (n = 28) and without (n = 100) SNVCF within 1 year of VP. We collected the following patient data: age, sex, site of compression fracture, medical history, bone mineral density (BMD), history of long-term steroid use, history of osteoporosis drug use, duration between fracture and VP, VP implementation method (unilateral or bilateral), cement usage in VP, cement leakage into the disc, compression ratio before VP, pre- and postoperative recovery ratio of the lowest vertebral body height, and kyphotic angle of fractured vertebrae. These data were analyzed to identify factors associated with SNVCFs after VP and to investigate the effects of the type of anti-osteoporotic treatment administered for SNVCFs. SNVCFs occurred in 28 patients (21.9%) within 1 year of VP. Logistic regression analysis identified BMD, cement leakage into the disc, and long-term steroid use to be significantly associated with the occurrence of SNVCFs. The group treated with zoledronate after VP had a significantly reduced SNVCF incidence compared with the group treated with calcium (P < .001). In addition, the zoledronate group had a lower SNVCF incidence compared with the groups treated with alendronate (P = .05), selective estrogen receptor modulators (P = .26), or risedronate (P = .22). This study showed that low BMD, presence of an intradiscal cement leak, and long-term steroid use were risk factors for developing SNVCFs following VP. Additionally, among osteoporosis treatments prescribed for VP, zoledronate may be the preferred choice to reduce the risk of SNVCFs.

Complications of Percutaneous Vertebroplasty: A Pictorial Review

Percutaneous vertebroplasty is a minimally invasive treatment technique for vertebral body compression fractures. The complications associated with this technique can be categorized into mild, moderate, and severe. Among these, the most prevalent complication is cement leakage, which may insert into the epidural, intradiscal, foraminal, and paravertebral regions, and even the venous system. The occurrence of a postprocedural infection carries a notable risk which is inherent to any percutaneous procedure. While the majority of these complications manifest without symptoms, they can potentially lead to severe outcomes. This review aims to consolidate the various complications linked to vertebroplasty, drawing from the experiences of a single medical center.

High-viscosity versus low-viscosity cement for the treatment of vertebral compression fractures: A meta-analysis of randomized controlled trials

BACKGROUND

High viscosity cement (HVC) and low viscosity cement (LVC) have been used to treat osteoporotic vertebral compression fractures (OVCFs). Our study was to assess the safety and efficacy of HVC and LVC in treating OVCFs.

METHODS

We searched the electronic database for randomized controlled trials of HVC and LVC to treat OVCFs. Random-effects model was performed to pool the outcomes about operation time, visual analogue scale (VAS), bone cement injection volume, oswestry disability index (ODI), bone cement leakage and adjacent vertebral fractures.

RESULTS

Twelve randomized trials were included in the meta-analysis. The 2 groups had similar changes in terms of bone cement injection volume, ODI and adjacent vertebral fractures. The HVC group showed shorter operation time and better VAS score improvement. The bone cement leakage rate of the HVC group was significantly better than LVC group (P < .00001).According to the location of bone cement leakage, in the leakages of the veins (P < .00001), the intervertebral disc (P < .00001), the paravertebral area (P = .003) and the intraspinal space (P = .03), the HVC group were significantly better than the LVC group.

CONCLUSIONS

In terms of bone cement injection volume, ODI and adjacent vertebral fractures, the 2 group are equivalent. HVC had a shorter operation time, lower bone cement leakage rate and better VAS score improvement, compared with LVC.

Risk factors for secondary fractures to percutaneous vertebroplasty for osteoporotic vertebral compression fractures: a systematic review

BACKGROUND

Osteoporotic vertebral compression fracture (OVCF) is one of the most common fragile fractures, and percutaneous vertebroplasty provides considerable long-term benefits. At the same time, there are many reports of postoperative complications, among which fracture after percutaneous vertebroplasty is one of the complications after vertebroplasty (PVP). Although there are many reports on the risk factors of secondary fracture after PVP at home and abroad, there is no systematic analysis on the related factors of secondary fracture after PVP.

METHODS

The databases, such as CNKI, Wan Fang Database and PubMed, were searched for documents on secondary fractures after percutaneous vertebroplasty published at home and abroad from January 2011 to March 2021. After strictly evaluating the quality of the included studies and extracting data, a meta-analysis was conducted by using Revman 5.3 software.

RESULTS

A total of 9 articles were included, involving a total of 1882 patients, 340 of them diagnosed as secondary fractures after percutaneous vertebroplasty.

CONCLUSION

The additional history of fracture, age, bone mineral density (BMD), bone cement leakage, intravertebral fracture clefts and Cobb Angle might be risk factors related to secondary fractures after percutaneous vertebroplasty for osteoporotic vertebral compression fractures. The height of vertebral anterior and body mass index (BMI) were not correlated.

Vertebral augmentation reduces the 12-month mortality and morbidity in patients with osteoporotic vertebral compression fractures

OBJECTIVES

To investigate the 12-month all-cause mortality and morbidity in patients with osteoporotic vertebral compression fractures (OVCFs) undergoing vertebroplasty/balloon kyphoplasty (VP/BKP) versus non-surgical management (NSM).

METHODS

Following a Medline and EMBASE search for English language articles published from 2010 to 2019, 19 studies reporting on mortality and morbidity after VP/BKP in patients with OVCFs were selected. The 12-month timeline was set due to the largest amount of data availability at such time interval. Estimates for each study were reported as odds ratios (OR) along with 95% confidence intervals (CI) and p values. Fixed or random-effects meta-analyses were performed. All tests were based on a two-sided significance level of 0.05.

RESULTS

Pooled OR across 5 studies favored VP/BKP over NSM in terms of 12-month all-cause mortality (OR: 0.81 [95% CI: 0.46-1.42]; p = .46). Pooled OR across 11 studies favored VP/BKP over NSM in terms of 12-month all-cause morbidity (OR: 0.64 [95% CI: 0.31-1.30]; p = .25). Sub-analysis of data dealing with 12-month infective morbidity from any origin confirmed the benefit of VP/BKP over NSM (OR: 0.23 [95% CI, 0.02-2.54]; p = .23).

CONCLUSION

Compared to NSM, VP/BKP reduces the 12-month risk of all-cause mortality and morbidity by 19% and 36%, respectively. Moreover, VP/BKP reduces by 77% the 12-month risk of infection from any origin.

KEY POINTS

• Compared to non-surgical management, vertebral augmentation reduces the 12-month risk of all-cause mortality by 19% and all-cause morbidity by 36%. • Vertebral augmentation reduces the 12-month risk of infection morbidity from any origin by 77%.

A meta-analysis of the secondary fractures for osteoporotic vertebral compression fractures after percutaneous vertebroplasty

To identify the risk factors of the secondary fractures for osteoporotic vertebral compression fractures (OVCFs) after percutaneous vertebroplasty (PVP).We conducted a search of relevant articles using Cochrane Library, PubMed, Medline, Science Direct, Embase, the Web of Science and other databases. The time range we retrieved from establishment of the electronic database to November 2017. Gray studies were found in the references of included literature reports. STATA version 11.0 (Stata Corporation, College Station, Texas) was used to analyze the pooled data.Fourteen studies involving 1910 patients, 395 of whom had fracture secondary to the surgery were included in this meta-analysis. The result of meta-analyses showed the risk factors of the secondary fractures for OVCFs after PVP was related to bone mineral density (BMD) [95%CI (-0.650, -0.164), SMD=-0.407, P=.001], cement leakage ((RR=0.596, 95%CI (0.444,0.798), P = .001)), and kyphosis after primary operation ((SMD=0.741, 95%CI (0.449,1.032), P = .000)), but not to gender, age, body mass index, cement volume, thoracolumbar spine, and cement injection approaches.Bone mineral density, cement leakage, and kyphosis after primary operation are the risk factors closely correlative to the secondary fracture after PVP. There have not been enough evidences to support the association between the secondary fracture and gender, age, body mass index, cement volume, thoracolumbar spine, and cement injection approaches.

Basivertebral foramina of true vertebrae: morphometry, topography and clinical considerations

PURPOSE

Basivertebral foramina (BVF) are openings of the posterior wall of vertebral body (VB) that lead to basivertebral canals (BVC), where homonymous neurovascular bundle courses. BVF and BVC are implicated with spinal fractures, vertebral augmentation and basivertebral nerve radiofrequency ablation. Despite their essential clinical impact, knowledge of BVF precise anatomy is scarce. The current study describes in detail the BVF typical morphological and topographical anatomy, morphometry and variants.

METHODS

In total, 1561 dried true vertebrae of 70 Greek spines of known gender and age were examined. BVF number, location, shape and size (in foramina > 1 mm), BVF distance from VB rims and pedicles, as well as VB morphometry (diameters, heights and distance between pedicles) were studied. Ten spines were re-examined by computed tomography and BVC depth and shape were recorded. Correlations and differences were statistically analyzed.

RESULTS

C₁ lack BVF (3.4%). One BVF was found in 45.1%, two in 36.9%, three in 3.8% and four BVF in 0.6%. Multiple small (< 1 mm) foramina were observed in 10.1%. Asymmetry was detected in 12.3%. C₂ and T₁₀-L₁ presented typical pattern, whereas C₃ and T₂ had the greatest variability. BVF were significantly closer to the upper rim in C₂ and T₁₀-L₄ and to the lower rim in C₇-T₄, T₆-T₈ and L₅. The mean BVC depth was 12-21.8% of the VB anteroposterior diameter.

CONCLUSION

BVF number, shape, size and topography are described, in detail, per vertebral level. The provided morphological classification and the created cumulative BVF topographic graphs should assist in clinical practice and surgery.

Risk factors for cement leakage and nomogram for predicting the intradiscal cement leakage after the vertebra augmented surgery

Background

Vertebral augmentation is the first-line treatment for the osteoporosis vertebral compression fractures. Bone cement leakage is the most common complication of this surgery. This study aims to assess the risk factors for different types of cement leakage and provides a nomogram for predicting the cement intradiscal leakage.

Methods

We retrospectively reviewed 268 patients who underwent vertebral augmentation procedure between January 2015 and March 2019. The cement leakage risk factors were evaluated by univariate analysis. Different types of cement leakage risk factors were identified by the stepwise logistic analysis. We provided a nomogram for predicting the cement intradiscal leakage and used the concordance index to assess the prediction ability.

Results

A total of 295 levels of vertebrae were included, with a leakage rate of 32.5%. Univariate analysis showed delayed surgery and lower vertebral compression ratio were the independent risk factors of cement leakage. The stepwise logistic analysis revealed percutaneous vertebroplasty was a risk factor in vein cement leakage; delayed surgery, preoperative compression ratio, and upper endplate disruption were in intradiscal cement leakage; age, preoperative fracture severity, and intravertebral vacuum cleft were in perivertebral soft tissue cement leakage; no factor was in spinal canal cement leakage. The nomogram for intradiscal cement leakage had a precise prediction ability with an original concordance index of 0.75.

Conclusions

Delayed surgery and more vertebral compression increase the risk of cement leakage. Different types of cement leakage have different risk factors. We provided a nomogram for precise predicting the intradiscal cement leakage.

Revisiting the Vertebral Venous Plexus-A Comprehensive Review of the Literature

The venous drainage of the vertebral and paravertebral regions is important for a better understanding of hematogenous disease spread. Moreover, the spine surgeon must be well acquainted with this anatomy to minimize intraoperative and postoperative complications. A comprehensive review of the vertebral venous plexus (Batson plexus) was performed with a concentration on the clinical and surgical correlations of this venous network.

Novel Surgical Strategy for Treating Osteoporotic Vertebral Fractures with Cord Compression

OBJECTIVES

Treatment for osteoporotic vertebral fracture (OVF) with cord compression is challenging and it usually requires surgical interventions to decompress nerves and restore spinal sequences. To describe a novel surgical strategy for treating OVFs with cord compression.

METHODS

This is a single-center retrospective analysis. The inclusion criteria were Frankel grade C-E, single level T10 -L2 . Between January 2008 and December 2016, a total of 56 OVF patients (47 females and nine males, with an average age of 72 years (66-88 years), comprising of eight grade C, 23 grade D, and 25 grade E patients) were enrolled. The treatment algorithm included preoperative evaluation by MRI, extension CT, and radiography to classify the OVFs as type 1.1 (reducible, stable; n = 13), type1.2 (reducible, unstable; n = 16), type 2 (irreducible; n = 19) or type 2M (modifier; n = 8). Vertebroplasty (VP)/kyphoplasty (KP) was applied in type 1.1. VP/KP with posterior fixation and posterolateral fusion was applied in type 1.2. And additional laminectomy/osteotomy was used in type 2, except in a modifier group (2M) where same procedure as applied for type 1.2 was used. VAS, ODI, Cobb angle, Frankel functional grade, and complications were recorded.

RESULTS

Thirteen cases were classified as type 1.1, 16 cases as type 1.2, 19 cases as type 2, and eight cases as type 2M. The follow-up period was 38.9 months (range, 24-108 months). All patients were followed-up in at least 24 months, in which time four patients died, two patients were lost at the last follow-up, and 50 patients completed the full study. The total VAS and ODI improved from 8 (7, 9) and 75.5% (67.2%, 80.0%) preoperatively to 2 (1, 3) and 31% (24.0%, 37.0%) on conclusion, respectively (P < 0.01). The local kyphotic angle was corrected from 22.3° (17.1°, 33. 8°) preoperatively to 10.4° (6.4°, 15.3°) on conclusion (P < 0.01). Twenty-three patients had achieved neurological recovery on conclusion (42E, 8D, P < 0.01). Asymptotic cement leakage was observed in 17/56 cases (30.4%), 6/56 in the affected vertebra (10.7%), and 24/330 in the screw trajectory (7.3%). At 2 years postoperatively, 11 new VFs had occurred in nine patients (16.1%), including VFs in nine adjacent segments that all occurred within 1 year after surgery. No cement migration or implant failure was noted.

CONCLUSION

The novel surgical strategy for treating OVFs with cord compression consists of the most tailored and least invasive treatment for each patient. The positive mid- and long-term clinical and radiological outcomes observed could represent a step forward in devising the proposed algorithm.

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.

Pulmonary cement embolism following balloon kyphoplasty: The impact of a procedural complication in a new era for lung cancer management

Pulmonary cement embolism (PCE) is a recognized complication of balloon kyphoplasty, a vertebral augmentation technique that stabilizes vertebral compression fractures, alleviating associated pain. Balloon kyphoplasty is particularly relevant when patients with advanced stages of cancer present with longer survival times, and therefore benefit from such augmentation techniques to improve pain and prevent additional complications. The embolization of cement to pulmonary vasculature may be unnoticed given the frequent absence of symptoms and routine imaging tests following the procedure. The present study reports the case of a 58-year-old female with stage IV lung cancer with a painful compression L3 fracture who underwent balloon kyphoplasty with no initially reported complications. The patient maintained the usual respiratory symptoms; therefore, the diagnosis was only made in a routine CT scan 3 months after the surgery. A literature review of PCE is performed, integrating the current evidence regarding diagnosis, therapeutics, prognosis and prevention. Certain poorly clarified aspects are identified as potential investigation starting points.

Bone-filling mesh container versus percutaneous kyphoplasty in treating Kümmell's disease

Kümmell's disease (eponymous name for osteonecrosis and collapse of a vertebral body due to ischemia and non-union of anterior vertebral body wedge fractures after major trauma) cannot heal spontaneously. Bone-filling mesh container (BFMC) can significantly relieve pain, help the correction of kyphosis, and may prevent cement leakage. This pilot study may provide the basis for the design of future studies.

PURPOSE

To compare the effectiveness and safety of BFMC and percutaneous kyphoplasty (PKP) for treatment of Kümmell's disease.

METHODS

From August 2016 to May 2018, 40 patients with Kümmell's disease were admitted to Guizhou Provincial People's Hospital. Among them, 20 patients (20 vertebral bodies) received PKP (PKP group) and the other 20 received BFMC (BFMC group). Operation time, Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), Cobb's angle changes, and related complications were recorded.

RESULTS

All patients underwent operations successfully. VAS scores and ODI of both groups at each postoperative time point were lower than preoperatively, with statistically significant difference (p < 0.05). Postoperative Cobb's angle of both groups postoperatively was lower than preoperatively (p < 0.05). Cement leakage occurred in eight vertebrae (8/20) in the PKP group and in one vertebra (1/20) in the BFMC group. No complications such as pulmonary embolism, paraplegia, or perioperative death occurred during operation in both groups. Adjacent vertebral refractures occurred in five patients (5/20) in the PKP group and in four patients (4/20) in the BFMC group, with no significant difference in the incidence rate of refractures in both groups but the material is too small to verify statistically.

CONCLUSIONS

Both PKP and BFMC technologies can significantly relieve pain and help the correction of kyphosis while treating Kümmell's disease. Moreover, the BMFC may prevent cement leakage.

Application of Cement-Injectable Cannulated Pedicle Screw in Treatment of Osteoporotic Thoracolumbar Vertebral Compression Fracture (AO Type A): A Retrospective Study of 28 Cases

OBJECTIVE

To evaluate safety and effectiveness of the novel polymethyl methacrylate-augmented bone cement-injectable cannulated pedicle screw (CICPS) in patients with thoracolumbar vertebral compression fractures (AO type A) associated with osteoporosis.

METHODS

We conducted a retrospective cohort study of 28 patients treated for osteoporosis-related thoracolumbar vertebral body compression fracture at our facility between 2011 and 2015. Treatment involved posterior thoracolumbar fusion or lumbar fusion using CICPS. Treatment effectiveness was evaluated using visual analog scale and Oswestry Disability Index scores, degree of fracture reduction, and correction of kyphosis. The safety of CICPS was mainly assessed in terms of intraoperative and postoperative complications. Radiography, computed tomography, and magnetic resonance imaging outcomes were also assessed.

RESULTS

All 28 patients had severe osteoporosis. The visual analog scale score at final follow-up (0.50 ± 0.69) was significantly (P < 0.001) lower compared with before surgery (4.93 ± 1.30). The Oswestry Disability Index score had also decreased from 57.39% ± 14.46% to 6.83% ± 15.38% at final follow-up (P < 0.001). Radiologic evaluation of vertebral height and Cobb angle showed good fracture reduction and satisfactory correction of kyphosis (preoperative vs. final follow-up, P < 0.001). There were no instances of screw loosening or symptomatic complications except for a few cases of cement leakage from CICPS (10.3%; cement leakage most common in AO type A3.3).

CONCLUSIONS

The use of CICPS and polymethyl methacrylate is an effective and safe surgical technique for management of osteoporosis-related vertebral fractures (AO type A), with good clinical outcomes and low complications rates.

Phase I/II trial of combined kyphoplasty and intraoperative radiotherapy in spinal metastases

BACKGROUND CONTEXT

Spinal metastases occur in 30%-50% of patients with systemic cancer. The primary goals of palliation are pain control and prevention of local recurrence.

PURPOSE

This study aimed to test the safety and efficacy of a combined modality approach consisting of kyphoplasty and intraoperative radiotherapy (Kypho-IORT).

STUDY DESIGN/SETTING

Kyphoplasty and intraoperative radiotherapy was a prospective, single-center phase I/II trial. Patients were enrolled in a classical 3+3 scheme within the initial phase I, where Kypho-IORT was applied using a needle-shaped 50 kV X-ray source at three radiation dose levels (8 Gy in 8-mm, 8 Gy in 11-mm, and 8 Gy in 13-mm depth). Thereafter, cohort expansion was performed as phase II of the trial. The trial is registered with clinicaltrials.gov, number NCT01280032.

PATIENT SAMPLE

Patients aged 50 years and older with a Karnofsky Performance Status of at least 60% and with one to three painful vertebral metastases confined to the vertebral body were eligible to participate.

OUTCOME MEASURES

The primary end point was safety as per the occurrence of dose-limiting toxicities. The secondary end points were pain reduction, local progression-free survival (L-PFS), and overall survival (OS).

METHODS

Pain was measured using the visual analog scale (VAS) and local control was assessed in serial computed tomography or magnetic resonance imaging scans.

RESULTS

None of the nine patients enrolled in the phase I showed dose-limiting toxicities at any level and thus, 52 patients were subsequently enrolled into a phase II, where Kypho-IORT was performed at various dose levels. The median pain score significantly dropped from 5 preoperatively to 2 at the first postoperative day (p<.001). Of 43 patients who reported a pre-interventional pain level of 3 or more, 30 (69.8%) reported a reduction of ≥3 points on the first postoperative day. A persistent pain reduction beyond the first postoperative day of ≥3 points was seen in 34 (79.1%) patients. The 3, 6, and 12 month L-PFS was excellent with 97.5%, 93.8%, and 93.8%. The 3, 6, and 12 months OS was 76.9%, 64.0%, and 48.4%.

CONCLUSION

Kyphoplasty and intraoperative radiotherapy is safe and immediately provided sustained pain relief with excellent local control rates in patients with painful vertebral metastases.

Comparison of high- and low-viscosity cement in the treatment of vertebral compression fractures: A systematic review and meta-analysis

BACKGROUND

High-viscosity cement (HVC) has been gradually applied in percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP). Although HVC has been reported to reduce cement leakage, different opinions exist. To assess the complications of HVC in cement leakage in the treatment of vertebral compression fractures and to evaluate the clinical effect of HVC compared with low-viscosity cement (LVC).

METHODS

EMBASE, PubMed, Science Direct, Google Scholar and Cochrane Library databases were comprehensively searched from their inception to August 2017. Two researchers independently searched for articles and reviewed all retrieved studies. Forest plots were used to illustrate the results. The Q-test and I statistic were employed to evaluate between-study heterogeneity. Potential publication bias was assessed by funnel plot.

RESULTS

HVC reduced the occurrence of cement leakage (risk ratio (RR) = 0.38, 95% confidence interval (CI) = 0.29 to 0.51, P < 0.00001), especially in the disc space (RR = 0.45, 95% CI = 0.45 to 0.80, P = 0.007) and the vein (RR = 0.54, 95% CI = 0.35 to 0.85, P = 0.008) but not in the intraspinal space (RR = 0.48, 95% CI = 0.19 to 1.23, P = 0.13) or the paravertebral area (RR = 0.63, 95% CI = 0.32 to 1.22, P = 0.17). No significant differences in the visual analogue scale (VAS), Oswestry Disability Index (ODI), injected cement volume or adjacent vertebral fracture were noted between HVC and LVC (P > 0.05).

CONCLUSION

Compared with LVC, HVC results in a reduced incidence of cement leakage for the treatment of vertebral compression fractures, especially in the disc space and vein but not in the intraspinal space or the paravertebral area. In addition, HVC yields the same satisfactory clinical effect as LVC.

Cement leakage in pedicle screw augmentation: a prospective analysis of 98 patients and 474 augmented pedicle screws

OBJECTIVE Loosening and pullout of pedicle screws are well-known problems in pedicle screw fixation surgery. Augmentation of pedicle screws with bone cement, first described as early as 1975, increases the pedicle-screw interface and pullout force in osteoporotic vertebrae. The aim of the present study was to identify cement leakage and pulmonary embolism rates in a large prospective single-center series of pedicle screw augmentations. METHODS All patients who underwent cement-augmented pedicle screw placement between May 2006 and October 2010 at the authors' institution were included in this prospective cohort study. Perivertebral cement leakage and pulmonary cement embolism were evaluated with a CT scan of the area of operation and with a radiograph of the chest, respectively. RESULTS A total of 98 patients underwent placement of cement-augmented pedicle screws; 474 augmented screws were inserted in 237 vertebrae. No symptomatic perivertebral cement leakage or symptomatic pulmonary cement embolism was observed, but asymptomatic perivertebral cement leakage was seen in 88 patients (93.6%) and in 165 augmented vertebrae (73.3%). Cement leakage most often occurred in the perivertebral venous system. Clinically asymptomatic pulmonary cement embolism was found in 4 patients (4.1%). CONCLUSIONS Perivertebral cement leakage often occurs in pedicle screw augmentation, but in most cases, it is clinically asymptomatic. Cement augmentation should be performed under continuous fluoroscopy to avoid high-volume leakage. Alternative strategies, such as use of expandable screws, should be examined in more detail for patients at high risk of screw loosening.

Cement leakage and complication of liposarcoma spinal metastasis during vertebral augmentation procedure: a case report

Background

Liposarcoma is a malignant tumor of soft tissue. Myxoid/round cell liposarcoma has a tendency to spread to extrapulmonary sites but the spine is an unusual location even for metastasis. Metastatic bone tumors in the spine are painful. The vertebral body augmentation procedures for treating painful metastatic spinal lesions are minimally invasive and are good alternatives to open surgery.

Case presentation

A 41-year-old Turkish man was treated with radiofrequency tumor ablation and percutaneous vertebral augmentation for spinal metastasis. Asymptomatic perivertebral and segmental veins' cement leakage was detected on perioperative X-ray radiograms; at the follow-up computed tomography scan, no further migration of any cement material was seen, and his postoperative course was uneventful.

Conclusions

The risk of cement leakage and embolism is increased with the treatment of some malignant lesions. The frequency of local leakage of bone cement is relatively high. Patients undergoing percutaneous vertebral augmentation of malignant spinal metastases need close monitoring. There is no agreement on the treatment strategy.

Percutaneous Vertebroplasty: A New Serial Injection Technique to Minimize Cement Leak

Study Design

This is a prospective cohort study.

Purpose

This study discusses a new technique for injecting cement in the affected vertebrae.

Overview of Literature

Since introduction of vertebroplasty to clinical practice, the cement leak is considered the most frequent and hazardous complication. In literature, the cement extravasation occurred in 26%-97% of the cases.

Methods

A hundred and twenty-three patients underwent vertebroplasty using the serial injection technique. The package of the cement powder and the solvent was divided into five equal parts. Each part of the powder and the solvent was mixed as a single dose and injected to the affected vertebra. The duration between subsequent injections was 10 minutes. Each injection consisted of 1-1.5 mL of cement.

Results

This new technique gives the surgeon enough time to make multiple separate injections using the same package. The time interval between injections hardens the cement just enough so that it does not get displaced by the next cement injection. This technique gives time to the preceding injected cement to seal off the cracks and cavities in the vertebra, and subsequently leads to a significant decrease in cement leak (p<0.001), as compared to literature.

Conclusions

This study demonstrates a previously unreported technique for vertebroplasty that adds more safety to the procedure by significantly decreasing cement leak. It also makes the surgeon more relaxed due to time intervals, giving him more self-confidence whilst performing the procedure.

The clinical comparative study on high and low viscosity bone cement application in vertebroplasty

OBJECTIVE

To investigate the clinical effect of high and low viscosity bone cement in vertebroplasty for treatment of osteoporotic vertebral compression fractures.

METHODS

40 cases of patients with osteoporotic thoracolumbar compression fractures admitted into department of orthopeadics in our hospital were reviewed. All patients were divided into high viscosity bone cement group (20 cases) and low viscosity bone cement group (20 cases). Visual Analog Score (VAS), Oswestry Dability Index (ODI), injured vertebral height restoration (Cobb Angle) and bone cement leakage rate, subsequent fracture rate of vertebrae body with or without surgical treatment were measured.

RESULTS

Compared with the low viscosity bone cement group, the VAS score, ODI score and Cobb angle of high viscosity bone cement group had a statistical difference (P<0.05). The postoperative complications in high viscosity bone cement group were lower than those in low viscosity bone cement group (P<0.05).

CONCLUSION

Compared with low viscosity bone cement, bone cement leakage rate reduced obviously in high viscosity bone cement with good clinical effect and prognosis in vertebroplasty for treatment of osteoporotic thoracolumbar compression fractures.

Minimally Invasive Technique for PMMA Augmentation of Fenestrated Screws

Purpose. To describe the minimally invasive technique for cement augmentation of cannulated and fenestrated screws using an injection cannula as well as to report its safety and efficacy. Methods. A total of 157 cannulated and fenestrated pedicle screws had been cement-augmented during minimally invasive posterior screw-rod spondylodesis in 35 patients from January to December 2012. Retrospective evaluation of cement extravasation and screw loosening was carried out in postoperative plain radiographs and thin-sliced triplanar computed tomography scans. Results. Twenty-seven, largely prevertebral cement extravasations were detected in 157 screws (17.2%). None of the cement extravasations was causing a clinical sequela like a new neurological deficit. One screw loosening was noted (0.6%) after a mean follow-up of 12.8 months. We observed no cementation-associated complication like pulmonary embolism or hemodynamic insufficiency. Conclusions. The presented minimally invasive cement augmentation technique using an injection cannula facilitates convenient and safe cement delivery through polyaxial cannulated and fenestrated screws during minimally invasive screw-rod spondylodesis. Nevertheless, the optimal injection technique and design of fenestrated screws have yet to be identified. This trial is registered with German Clinical Trials DRKS00006726.

Clinical outcome after the use of a new craniocaudal expandable implant for vertebral compression fracture treatment: one year results from a prospective multicentric study

The purpose of this prospective multicentric observational study was to confirm the safety and clinical performance of a craniocaudal expandable implant used in combination with high viscosity PMMA bone cement for the treatment of vertebral compression fractures. Thirty-nine VCFs in 32 patients were treated using the SpineJack minimally invasive surgery protocol. Outcome was determined by using the Visual Analogue Scale for measuring pain, the Oswestry Disability Index for scoring functional capacity, and the self-reporting European Quality of Life scores for the quality of life. Safety was evaluated by reporting all adverse events. The occurrence of cement leakages was assessed by either radiographs or CT scan or both. Statistically significant improvements were found regarding pain, function, and quality of life. The global pain score reduction at 1 year was 80.9% compared to the preoperative situation and the result of the Oswestry Disability Index showed a decrease from 65.0% at baseline to 10.5% at 12 months postoperatively. The cement leakage rate was 30.8%. No device- or surgery-related complications were found. This observational study demonstrates promising and persistent results consisting of immediate and sustained pain relief and durable clinical improvement after the procedure and throughout the 1-year follow-up period.

Analysis of related factors on the deformity correction of balloon kyphoplasty

BACKGROUND AND PURPOSE

Balloon kyphoplasty is a minimally invasive surgical approach for treating vertebral compression fractures, including osteoporotic vertebral compression fractures. The purpose of this study was to determine the effect of balloon inflation and postural reduction on balloon kyphoplasty for the deformity correction of vertebral compression fractures and to explore the correlative factors affecting the deformity correction.

MATERIALS AND METHODS

A retrospective study of 72 patients (75 levels) who had undergone balloon kyphoplasty was conducted. Imaging data and clinical features were collected and analyzed. Independent-samples t test analysis was used to find the possible factors affecting deformity correction.

RESULTS

Postural correction in the overextending position significantly increased anterior middle vertebral height, kyphotic angle, and Cobb angle (each P < .05). There was no significant difference in anterior, middle vertebral height, kyphotic angle, and Cobb angle between postural reduction and balloon dilation (each P > .05). The improvement on the Visual Analog Scale was notable (P < .05). Among a variety of factors, the fracture type (wedge type and biconcave type) affected both the height restoration (P = .003) and kyphotic angle reduction (P = .007). The bone cement injected volume was related to height restoration (P = .011) and kyphotic angle reduction (P = .018).

CONCLUSIONS

Balloon inflation was useless for deformity correction. The deformity correction was attributed to postural reduction with cement strengthening. The most significant factors affecting deformity correction were the fracture type and bone cement injected volume.

[Experiences with cement leakage after balloon kyphoplasty]

BACKGROUND

Kyphoplasty is associated with a low incidence of cement leakage and this usually tends to be clinically asymptomatic. However, there is a potential for life-threatening complications from extraspinal leakage resulting in vascular, cardiac and pulmonary embolisms. A total of eight cases of open surgical thrombectomy for cardiopulmonary cement leakage have been published in the current literature to date. Besides the description of a consecutive series with special reference to extraspinal cement leakage this article presents the results after successful endovascular removal of intravenous cement fragments following kyphoplasty in two patients.

MATERIALS AND METHODS

In 46 cases following balloon kyphoplasty the number and amount of extraspinal venous cement leakage was retrospectively determined using computed tomography (CT). The number of cement embolisms into the pulmonary venous system was differently revealed for patients showing no extravertebral leakage or leakage only into the external vertebral venous plexus compared to leakage into the major venous vessels, azygos and hemiazygos vein or inferior vena cava.

RESULTS

In 8 out of 046 cases (17.4 %) leakage into the external vertebral venous plexus was detected. In 5 out of 8 cases without involvement of the azygos/hemiazygos vein or inferior vena cava no pulmonary cement embolism was detected. In 3 out of 8 cases the inferior vena cava or azygos/hemiazygos vein was reached and additionally asymptomatic peripheral pulmonary cement embolism was induced in these cases. In two cases harboring residual intravasal cement fragments treatment was successful using endovascular extraction techniques.

CONCLUSIONS

A computed tomography scan after kyphoplasty is recommended for all cases. If there is involvement of the inferior vena cava or the azygos/hemiazygos vein an additional CT scan of the chest should follow, even in asymptomatic cases. Residual intravasal cement fragments are safely extractable using endovascular techniques.

Prevalence of extravertebral cement leakage after vertebroplasty: procedural documentation versus CT detection

BACKGROUND

Reported incidence of extravertebral cement leakage after vertebroplasty varies widely across studies.

PURPOSE

To retrospectively compare the relative detection rates of extravertebral leakage noted under intra-procedural fluoroscopic surveillance, postprocedure plain radiographs, and postprocedure computed tomography (CT) in a cohort of patients undergoing vertebroplasty.

MATERIAL AND METHODS

With IRB approval, we retrospectively identified 181 patients with 277 levels treated with percutaneous vertebroplasty among a total of 1255 patients undergoing vertebroplasty between 1999 and 2010 who had subsequently undergone a CT examination that included the treated level(s). Categories of leakage were paravertebral, end plate, epidural, and prevertebral venous leakage. CT-detected leak rates were then compared to those noted on the vertebroplasty procedure reports and the archived fluoroscopic images for this same cohort using Pearson's χ(2) test.

RESULTS

One hundred and forty-nine (82%, 95% CI 76-87%) of 181 patients demonstrated evidence of some type of leakage on CT at one or more treated levels. Sixty-two (34%, 95% CI 28-42%) and seventy-seven (50%, 95% CI 43-57%) of 149 CT-detected leaks were reported in the procedural dictation or detected on plain radiography (P = 0.01 and 0.006, respectively). The most common type of leakage noted on CT was end plate (n = 81, 45%, 95% CI 38-52%), followed by paravertebral (n = 64, 35%, 95% CI 29-43%), epidural (n = 36, 20%, 95% CI 15-26%), and prevertebral venous (n = 32, 18%, 95% CI 13-24%).

CONCLUSION

Cement leakage after vertebroplasty is common and is often not reported by operators in procedural dictations. CT detects substantially more leaks than plain radiography.