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Lenga P, Bajwa AA, Schneider T, Iwanaga J, Tubbs RS, Kiening KL, Unterberg AW, Ishak B. High Rate of Pulmonary Cement Embolism after Cement-Augmented Pedicle Screw Fixation: A 12-Year Single-Center Study. J Neurol Surg A Cent Eur Neurosurg 2024; 85:117-125. [PMID: 36828012 DOI: 10.1055/s-0043-1761943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
BACKGROUND The global trend toward increased life expectancy because of remarkable improvements in health care quality has drawn increased attention to osteoporotic fractures and degenerative spine diseases. Cement-augmented pedicle screw fixation has been established as the mainstay treatment for patients with poor bone quality. This study aimed to determine the number of patients with cement leakage and pulmonary cement embolism (PCE) as detected on thoracic computed tomography (CT), and to assess the potential risk factors for PCE. METHODS Patients undergoing cement-augmented pedicle screw placement in our institution between May 2008 and December 2020 were included. Data regarding baseline characteristics, complications, and cement leakage rates were collected. Indications for the performance of a postoperative thoracic CT due to the suspicion of PCE were intra- or postoperative complications, or postoperative oxygen supplementation. Moreover, PCE was accidently diagnosed because the thoracic CT was performed for medical reasons other than the suspicion of PCE (tumor staging, severe pneumonia, or exacerbated chronic pulmonary obstructive disease). RESULTS A total of 104 patients with a mean age of 72.8 years (standard deviation of 6.7) were included. Of 802 screws, 573 were cement augmented. Of the 104 patients, 44 (42.3%) underwent thoracic CT scans to diagnose PCE; additionally, 67 (64.4%) demonstrated cement leakage, of whom 27 developed PCE and 4 were symptomatic. Cement-augmented thoracic screws were a risk factor for PCE (odds ratio: 1.5; 95% confidence interval: 1.2-2.1; p = 0.004). CONCLUSIONS This study showed a high prevalence of cement leakage after cement-augmented pedicle screw insertion, with a relatively frequent incidence of PCE, as tracked by thoracic CT scans. Cement-augmented thoracic screw placement was a unique risk factor for PCE.
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Affiliation(s)
- Pavlina Lenga
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Awais Akbar Bajwa
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Till Schneider
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Joe Iwanaga
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, Louisiana, United States
| | - R Shane Tubbs
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, Louisiana, United States
| | - Karl L Kiening
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Andreas W Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Basem Ishak
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
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Liu YY, Xiao J, He L, Yin X, Song L, Zhou R, Zeng J, Liu P, Dai F. Risk factor analysis of bone cement leakage for polymethylmethacrylate-augmented cannulated pedicle screw fixation in spinal disorders. Heliyon 2023; 9:e15167. [PMID: 37089395 PMCID: PMC10113860 DOI: 10.1016/j.heliyon.2023.e15167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 03/25/2023] [Accepted: 03/28/2023] [Indexed: 04/05/2023] Open
Abstract
Objective To investigate the risk factors of cement leakage (CL) for polymethylmethacrylate-augmented cannulated pedicle screw (CPS) in spinal degenerative diseases and provided technical guidance for clinical surgery. Methods This study enrolled 276 patients with spinal degenerative disease and osteoporosis who were augmented using CPSs (835 screws in total) from May 2011 to June 2018 in our hospital. The patients' age, sex, bone mineral density (BMD), diagnosis, augmented positions, number of CPS implanted, and CL during surgery were recorded. CL was observed by postoperative computed tomography (CT) and was classified by Yeom typing. Results A total of 74 (74/835, 8.9%) CPSs in 64 patients leaked (64/276, 23.2%). CL was significantly correlated with the number and position of screws (P < 0.05), but not with sex, age, and BMD (P > 0.05). The position, number of CPSs, fracture, degenerative scoliosis, ankylosing spondylitis, and revision surgery were risk factors for CL (P < 0.05). Augmentation of the thoracic vertebral body, fracture, and ankylosing spondylitis were independent risk factors for Type S. Augmentation of the lumbar vertebral body, lumbar disc herniation, and lumbar spondylolisthesis were independent risk factors for Type B (P < 0.05). Conclusions CL has a high incidence in clinical practice. High-risk factors for leakage should be addressed to avoid serious complications. Particularly, it is necessary to develop alternative solutions once CPSs can't be used in surgery caused by CL.
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Affiliation(s)
- Yao-yao Liu
- Department of Spine Surgery, Daping Hospital, Army Medical Center of PLA, Chongqing, 400042, PR China
| | - Jun Xiao
- Guangzhou Rocket Force Special Service Convalescent Center, Guangzhou, 510515, PR China
| | - Lei He
- Department of Orthopedics, Southwest Hospital of Army Medical University, PLA, Chongqing, 400038, PR China
| | - Xiang Yin
- Department of Spine Surgery, Daping Hospital, Army Medical Center of PLA, Chongqing, 400042, PR China
| | - Lei Song
- Department of Orthopedics, Southwest Hospital of Army Medical University, PLA, Chongqing, 400038, PR China
| | - Rui Zhou
- Department of Orthopedics, Southwest Hospital of Army Medical University, PLA, Chongqing, 400038, PR China
| | - Jing Zeng
- Guangzhou Rocket Force Special Service Convalescent Center, Guangzhou, 510515, PR China
| | - Peng Liu
- Department of Spine Surgery, Daping Hospital, Army Medical Center of PLA, Chongqing, 400042, PR China
- Corresponding author. Department of Spine surgery, Daping Hospital, Army Medical Center of PLA, No. 10 Changjiang Road, Yuzhong District, Chongqing, 400042, PR China.
| | - Fei Dai
- Department of Orthopedics, Southwest Hospital of Army Medical University, PLA, Chongqing, 400038, PR China
- Corresponding author. Department of Orthopedics, Southwest Hospital of Army Medical University, PLA, No. 30 Gaotanyan Street, Shapingba District, Chongqing, 400038, PR China.
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Morimoto T, Kobayashi T, Hirata H, Tsukamoto M, Yoshihara T, Toda Y, Mawatari M. Cardiopulmonary Cement Embolism Following Cement-Augmented Pedicle Screw Fixation: A Narrative Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020407. [PMID: 36837608 PMCID: PMC9964565 DOI: 10.3390/medicina59020407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/14/2023] [Accepted: 02/18/2023] [Indexed: 02/22/2023]
Abstract
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.
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Piccirilli E, Cariati I, Primavera M, Triolo R, Gasbarra E, Tarantino U. Augmentation in fragility fractures, bone of contention: a systematic review. BMC Musculoskelet Disord 2022; 23:1046. [PMID: 36457070 PMCID: PMC9717408 DOI: 10.1186/s12891-022-06022-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 11/24/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Osteoporosis is a complex multifactorial disease characterized by reduced bone mass and microarchitectural deterioration of bone tissue linked to an increase of fracture risk. Fragility fractures occur in osteoporotic subjects due to low-energy trauma. Osteoporotic patients are a challenge regarding the correct surgical planning, as it can include fixation augmentation techniques to reach a more stable anchorage of the implant, possibly lowering re-intervention rate and in-hospital stay. METHODS The PubMed database and the Google Scholar search engine were used to identify articles on all augmentation techniques and their association with fragility fractures until January 2022. In total, we selected 40 articles that included studies focusing on humerus, hip, spine, and tibia. RESULTS Literature review showed a quantity of materials that can be used for reconstruction of bone defects in fragility fractures in different anatomic locations, with good results over the stability and strength of the implant anchorage, when compared to non-augmented fractures. CONCLUSION Nowadays there are no recommendations and no consensus about the use of augmentation techniques in osteoporotic fractures. Our literature review points at implementing the use of bone augmentation techniques with a specific indication for elderly patients with comminuted fractures and poor bone quality.
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Affiliation(s)
- Eleonora Piccirilli
- grid.413009.fDepartment of Orthopaedics and Traumatology, “Policlinico Tor Vergata” Foundation, Viale Oxford 81, 00133 Rome, Italy ,grid.6530.00000 0001 2300 0941Department of Clinical Sciences and Translational Medicine, “Tor Vergata” University of Rome, Via Montpellier 1, 00133 Rome, Italy
| | - Ida Cariati
- grid.6530.00000 0001 2300 0941Department of Clinical Sciences and Translational Medicine, “Tor Vergata” University of Rome, Via Montpellier 1, 00133 Rome, Italy
| | - Matteo Primavera
- grid.413009.fDepartment of Orthopaedics and Traumatology, “Policlinico Tor Vergata” Foundation, Viale Oxford 81, 00133 Rome, Italy
| | - Rebecca Triolo
- grid.413009.fDepartment of Orthopaedics and Traumatology, “Policlinico Tor Vergata” Foundation, Viale Oxford 81, 00133 Rome, Italy
| | - Elena Gasbarra
- grid.413009.fDepartment of Orthopaedics and Traumatology, “Policlinico Tor Vergata” Foundation, Viale Oxford 81, 00133 Rome, Italy
| | - Umberto Tarantino
- grid.413009.fDepartment of Orthopaedics and Traumatology, “Policlinico Tor Vergata” Foundation, Viale Oxford 81, 00133 Rome, Italy ,grid.6530.00000 0001 2300 0941Department of Clinical Sciences and Translational Medicine, “Tor Vergata” University of Rome, Via Montpellier 1, 00133 Rome, Italy
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Han X, Zhang Y, Wang Z, Zhao M. Case report: Cement entrapped in the inferior vena cava filter after pedicle screw augmentation. Front Cardiovasc Med 2022; 9:892025. [PMID: 36247486 PMCID: PMC9560782 DOI: 10.3389/fcvm.2022.892025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 08/29/2022] [Indexed: 11/16/2022] Open
Abstract
Background Cement leakage into the inferior vena cava (IVC) is one of the most common complications associated with cement vertebroplasty, and can lead to potentially life-threatening complications such as pulmonary cement embolism (PCE). Implantation of an IVC filter is effective in the prevention of fatal pulmonary embolism. Here, we present an extremely rarely case of cement entrapped in an IVC filter after pedicle screw augmentation, and discuss all similar cases reported in the literature. Case presentation A 70-year-old female presented with significant back and lower extremities pain and was unable to walk. MRI of the lumbar spine revealed an osteoporotic compression fracture of the L1–L3. She underwent cement-augmented pedicle screws implanted at the L1 and L3 vertebral bodies. A retrievable IVC filter was implanted due to the presence of calf vein thrombosis before cement vertebroplasty. Cement leaked into the IVC and was trapped by the filter, rendering the filter unretrievable using a conventional method. The asymptomatic patient received rivaroxaban 20 mg daily for anticoagulant postoperatively and lifelong anticoagulation was administered to prevent secondary IVC and cemented filter thrombosis. Methods A literature search was conducted utilizing the PUBMED/MEDLINE using the following terms: “vertebroplasty,” “complication,” “bone cement,” and “inferior vena cava (IVC),” or “inferior vena cava (IVC) filter.” All relevant articles published in English or in other languages with English abstracts since 1962 were included. Results A total of 36 articles were retrieved according to the search strategy. Only 6 out of these 36 studies contained information regarding the inferior vena cava filter and cement. Of the patients, 85.7% (36/42) reported in the literature whose gender was known were female and 14.3% were male. 28.5% (45/158) patients with pulmonary arterial and cardiovascular complications. Conclusion Cement embolization occurring in the IVC filter is rare. Accurate knowledge about the lumbar vertebral venous anatomy and skillful operation during vertebral cementoplasty should be required in clinical practice.
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Zhang J, Wang G, Zhang N. A meta-analysis of complications associated with the use of cement-augmented pedicle screws in osteoporosis of spine. Orthop Traumatol Surg Res 2021; 107:102791. [PMID: 33338677 DOI: 10.1016/j.otsr.2020.102791] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 07/30/2020] [Accepted: 08/20/2020] [Indexed: 02/03/2023]
Abstract
PURPOSE Our study aimed to provide updated and comprehensive evidence on the complications associated with the use of cement-augmented pedicle screws (CAPS) in osteoporosis patients undergoing spinal instrumentation. METHODS Databases of PubMed, Embase, Ovoid, and Google Scholar were screened from January 2000-February 2020 for studies reporting complications of CAPS in osteoporosis patients. Pooled estimates (with 95% confidence intervals) were calculated. RESULTS Twenty studies were included. The pooled risk of screw loosening, screw breakage and screw migration was 2.0% (0.2%-4.9%), 0.6% (0%-2.0%) and 0.2% (0%-1.2%) respectively. On pooling of data from 1277 patients, we found the risk of all cement leakage to be 21.8% (6%-43.1%). However, data from 1654 patients indicated the risk of symptomatic cement leakage was 1.2% (0.6%-1.9%). The incidence of pulmonary embolism was 3.0% (0.5%-6.8%) while the risk of symptomatic pulmonary embolism was 0.8% (0.2%-1.5%). Pooled risk of neurovascular complications was 1.6% (0.3%-3.6%), adjacent compression fracture was 3.3% (1.2%-6.2%) and infectious complications was 3.1% (1.1%-5.7%). There were high heterogeneity and variability in the study outcomes. CONCLUSION The incidence of screw-related complications like loosening, breakage, and migration with the use of CAPS in spinal instrumentation of osteoporotic patients is low. The risk of cement leakage is high and variable but the incidence of symptomatic cement leakage and related neurovascular or pulmonary complications is low. Further studies using homogenous methods of reporting are needed to strengthen current evidence. LEVEL OF EVIDENCE II, Systematic Review and Meta-analysis.
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Affiliation(s)
- Jinlong Zhang
- Department of Orthopedics, Shengli Oilfield Central Hospital, No.31, Jinan Road, 257000 Dongying City, Shandong Province, China
| | - Guohua Wang
- Department of Orthopedics, Shengli Oilfield Central Hospital, No.31, Jinan Road, 257000 Dongying City, Shandong Province, China.
| | - Nannan Zhang
- Department of Orthopedics, Shengli Oilfield Central Hospital, No.31, Jinan Road, 257000 Dongying City, Shandong Province, China
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Yagi M, Ogiri M, Holy CE, Bourcet A. Comparison of clinical effectiveness of fenestrated and conventional pedicle screws in patients undergoing spinal surgery: a systematic review and meta-analysis. Expert Rev Med Devices 2021; 18:995-1022. [PMID: 34503387 DOI: 10.1080/17434440.2021.1977123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Pedicle screws are commonly used for spinal procedures for fusion stability, which is particularly important in osteoporotic patients, who are at an increased risk of requiring revision procedures. AREAS COVERED A systematic review and meta-analysis were conducted to compare clinical effectiveness of conventional pedicle screws (CPS) vs fenestrated pedicle screws (FPS) in patients undergoing spinal surgery. Primary outcomes included screw loosening, revision surgeries (involving an implant) and reoperations (not involving intervention on an implant) in patients treated with CPS vs FPS, sub-stratified by with and without osteoporosis. Secondary outcomes included changes in pain scores. Forty-eight studies with 8,302 patients were included, with 1,565 (19.18%) treated with FPS and 6,710 (80.82%) treated with CPS. FPS was associated with a lower risk of screw loosening (p = 0.001) vs CPS. In the general population, there was a non-significant trend of lower revision rate, but no difference in reoperation rate, between patients treated with FPS vs CPS. In osteoporotic patients, revision rates were significantly lower for FPS vs CPS (p = 0.009). EXPERT OPINION This review suggests that FPS are effective for surgical fixation and reduce rates of screw loosening, and in osteoporotic patients, revision surgeries, compared to CPS.
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Affiliation(s)
- Mitsuru Yagi
- Department of Orthopedic Surgery, Keio University School of Medicine, Japan
| | - Mami Ogiri
- Division of the Chief Medical Officer, Johnson & Johnson K.K. Medical Company, Chiyoda, Tokyo, Japan
| | - Chantal E Holy
- Medical Devices, Johnson and Johnson Limited, New Brunswick, NJ, USA
| | - Anh Bourcet
- Health Economics & Market Access, Johnson & Johnson Medical Asia Pacific, Singapore, Singapore
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Wagner A, Haag E, Joerger AK, Gempt J, Krieg SM, Wostrack M, Meyer B. Cement-Augmented Carbon Fiber-Reinforced Pedicle Screw Instrumentation for Spinal Metastases: Safety and Efficacy. World Neurosurg 2021; 154:e536-e546. [PMID: 34339894 DOI: 10.1016/j.wneu.2021.07.092] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/18/2021] [Accepted: 07/19/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate the complication rates and long-term implant failure rates in a monocentric study of a consecutive cohort of patients with thoracolumbar spinal metastases after posterior instrumentation with a fenestrated carbon fiber-reinforced poly-ether-ether-ketone (CFRP) pedicle screw system. METHODS We retrospectively reviewed demographics, Karnofsky Performance Status Scale scores, complications, and implant failure rates. RESULTS Between June 2016 and November 2019, 51 consecutive patients underwent cement-augmented CFRP pedicle screw instrumentation at our institution. Mean age was 68 years (standard deviation 10.5), the median preoperative Karnofsky Performance Status Scale of 80 increased to 90 postoperatively (P = 0.471). Most common primary entities were breast (25.5%), lung (15.7%), and prostate (13.7%) cancers. Of 428 placed screws, 293 (68.5%) were augmented with polymethylmethacrylate, a mean 6 per patient (standard deviation ±2). Screws were inserted via a minimally invasive system technique in 54.9% of cases. In total, 11.8% of patients had immediate postoperative sequelae related to the cement. Pulmonary cement embolisms were noted in 3 patients, 2 had paravertebral extravasation, and 1 had an embolism into a segmental artery. Of these 6, 2 patients with pulmonary embolisms reported related symptoms. Follow-up was available for 80.4%. After a mean 9.8 months, screw loosening was noted in 11.8% of cases on computed tomography, although it was asymptomatic in all but 1 patient. Screw pull-out did not occur. Neither cement-related (P = 0.353) nor general complication rates (P = 0.507) differed significantly between open and minimally invasive system techniques. CONCLUSIONS Percutaneous cement-augmented CFRP pedicle screw instrumentation facilitates artifact-reduced postoperative imaging, while maintaining a risk profile and implant failure rates comparable to conventional metallic instrumentation.
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Affiliation(s)
- Arthur Wagner
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany.
| | - Elena Haag
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany
| | - Ann-Kathrin Joerger
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany
| | - Sandro M Krieg
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany
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