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Cawley DT, Divani K, Shafafy R, Devitt A, Molloy S. When spinal instrumentation revision is not an option: Salvage vertebral augmentation with polymethylmethacrylate for mechanical complications: A systematic review. BRAIN & SPINE 2023; 3:101726. [PMID: 37383448 PMCID: PMC10293288 DOI: 10.1016/j.bas.2023.101726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/23/2023] [Accepted: 03/01/2023] [Indexed: 06/30/2023]
Abstract
Intoduction Mechanical complications from spinal fusion including implant loosening or junctional failure result in poor outcomes, particularly in osteoporotic patients. While the use of percutaneous vertebral augmentation with polymethylmethacrylate (PMMA) has been studied for augmentation of junctional levels to offset against kyphosis and failure, its deployment around existing loose screws or in failing surrounding bone as a salvage percutaneous procedure has been described in small case series and merits review. Research Question How effective and safe is the use of PMMA as a salvage procedure for mechanical complications in failed spinal fusion?. Materials and Methods Systematic search of online databases for clinical studies using this technique. Results 11 studies were identified, only consisting of two case reports and nine case series. Consistent improvements were observed in pre- to post-operative VAS and with sustained improvements at final follow-up. The extra- or para-pedicular approach was the most frequent access trajectory. Most studies cited difficulties with visibility on fluoroscopy, using navigation or oblique views as a solution for this. Discussion and Conclusions Percutaneous cementation at a failing screw-bone interface stabilises further micromotion with reductions in back pain. This rarely used technique is manifested by a low but increasing number of reported cases. The technique warrants further evaluation and is best performed within a multidisciplinary setting at a specialist centre. Notwithstanding that underlying pathology may not be addressed, awareness of this technique may allow an effective and safe salvage solution with minimal morbidity for older sicker patients.
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Affiliation(s)
- Derek T. Cawley
- Mater Private Hospital, Dublin, 1, Ireland
- Dept of Spinal Surgery, University of Galway, Ireland
| | | | - Roozbeh Shafafy
- Dept of Spinal Surgery, RNOH Stanmore, Brockley Hill, Stanmore, HA7 4LP, UK
| | - Aiden Devitt
- Dept of Spinal Surgery, University of Galway, Ireland
| | - Sean Molloy
- Dept of Spinal Surgery, RNOH Stanmore, Brockley Hill, Stanmore, HA7 4LP, UK
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Barzilai O, McLaughlin L, Lis E, Yamada Y, Bilsky MH, Laufer I. Outcome analysis of surgery for symptomatic spinal metastases in long-term cancer survivors. J Neurosurg Spine 2019; 31:285-290. [PMID: 31026814 DOI: 10.3171/2019.2.spine181306] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 02/06/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE As patients with metastatic cancer live longer, an increased emphasis is placed on long-term therapeutic outcomes. The current study evaluates outcomes of long-term cancer survivors following surgery for spinal metastases. METHODS The study population included patients surgically treated at a tertiary cancer center between January 2010 and December 2015 who survived at least 24 months postoperatively. A retrospective chart and imaging review was performed to collect data regarding patient demographics; tumor histology; type and extent of spinal intervention; radiation data, including treatment dose and field; long-term sequelae, including local tumor control; and reoperations, repeat irradiation, or postoperative kyphoplasty at a previously treated level. RESULTS Eighty-eight patients were identified, of whom 44 were male, with a mean age of 61 years. The mean clinical follow-up for the cohort was 44.6 months (range 24.2-88.3 months). Open posterolateral decompression and stabilization was performed in 67 patients and percutaneous minimally invasive surgery in 21. In the total cohort, 84% received postoperative adjuvant radiation and 27% were operated on for progression following radiation. Posttreatment local tumor progression was identified in 10 patients (11%) at the index treatment level and 5 additional patients had a marginal failure; all of these patients were treated with repeat irradiation with 5 patients requiring a reoperation. In total, at least 1 additional surgical intervention was performed at the index level in 20 (23%) of the 88 patients: 11 for hardware failure, 5 for progression of disease, 3 for wound complications, and 1 for postoperative hematoma. Most reoperations (85%) were delayed at more than 3 months from the index surgery. Wound infections or dehiscence requiring additional surgical intervention occurred in 3 patients, all of which occurred more than a year postoperatively. Kyphoplasty at a previously operated level was performed in 3 cases due to progressive fractures. CONCLUSIONS Durable tumor control can be achieved in long-term cancer survivors surgically treated for symptomatic spinal metastases with limited complications. Complications observed after long-term follow-up include local tumor recurrence/progression, marginal tumor control failures, early or late hardware complications, late wound complications, and progressive spinal instability or deformity.
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Affiliation(s)
| | | | | | - Yoshiya Yamada
- 3Radiation Oncology, Memorial Sloan Kettering Cancer Center; and
| | - Mark H Bilsky
- Departments of1Neurosurgery
- 4Department of Neurological Surgery, Weill Cornell Medical College, New York, New York
| | - Ilya Laufer
- Departments of1Neurosurgery
- 4Department of Neurological Surgery, Weill Cornell Medical College, New York, New York
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Cianfoni A, Giamundo M, Pileggi M, Huscher K, Shapiro M, Isalberti M, Kuhlen D, Scarone P. Spinal Instrumentation Rescue with Cement Augmentation. AJNR Am J Neuroradiol 2018; 39:1957-1962. [PMID: 30213804 DOI: 10.3174/ajnr.a5795] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 07/23/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE Altered biomechanics or bone fragility or both contribute to spine instrumentation failure. Although revision surgery is frequently required, minimally invasive alternatives may be feasible. We report the largest to-date series of percutaneous fluoroscopically guided vertebral cement augmentation procedures to address feasibility, safety, results and a variety of spinal instrumentation failure conditions. MATERIALS AND METHODS A consecutive series of 31 fluoroscopically guided vertebral augmentation procedures in 29 patients were performed to address screw loosening (42 screws), cage subsidence (7 cages), and fracture within (12 cases) or adjacent to (11 cases) the instrumented segment. Instrumentation failure was deemed clinically relevant when resulting in pain or jeopardizing spinal biomechanical stability. The main study end point was the rate of revision surgery avoidance; feasibility and safety were assessed by prospective recording of periprocedural technical and clinical complications; and clinical effect was measured at 1 month with the Patient Global Impression of Change score. RESULTS All except 1 procedure was technically feasible. No periprocedural complications occurred. Clinical and radiologic follow-up was available in 28 patients (median, 16 months) and 30 procedures. Revision surgery was avoided in 23/28 (82%) patients, and a global clinical benefit (Patient Global Impression of Change, 5-7) was reported in 26/30 (87%) cases at 1-month follow-up, while no substantial change (Patient Global Impression of Change, 4) was reported in 3/30 (10%), and worsening status (Patient Global Impression of Change, 3), in 1/30 (3%). CONCLUSIONS Our experience supports the feasibility of percutaneous vertebral augmentation in the treatment of several clinically relevant spinal instrumentation failure conditions, with excellent safety and efficacy profiles, both in avoidance of revision surgery and for pain palliation.
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Affiliation(s)
- A Cianfoni
- From the Departments of Neuroradiology (A.C., M.P., M.I.) .,Department of Neuroradiology (A.C.), Inselspital, Bern, Switzerland
| | - M Giamundo
- Neurosurgery (M.G., D.K., P.S.), Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - M Pileggi
- From the Departments of Neuroradiology (A.C., M.P., M.I.)
| | - K Huscher
- Department of Neurosurgery (K.H.), Hôpital du Valais, Sion, Switzerland
| | - M Shapiro
- Department of Radiology (M.S.), New York University Langone Medical Center, New York, New York
| | - M Isalberti
- From the Departments of Neuroradiology (A.C., M.P., M.I.)
| | - D Kuhlen
- Neurosurgery (M.G., D.K., P.S.), Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - P Scarone
- Neurosurgery (M.G., D.K., P.S.), Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
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Fu TS, Li YD. Fluoroscopy-guided percutaneous vertebroplasty for symptomatic loosened pedicle screw and instrumentation-associated vertebral fracture: an evaluation of initial experiences and technical note. J Neurosurg Spine 2018; 28:364-371. [PMID: 29327973 DOI: 10.3171/2017.7.spine17625] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE For symptomatic loosened pedicle screws and instrumentation-associated vertebral fracture, extensive surgery to remove the pedicle screws and extend the instrumentation, along with the reinsertion of more pedicle screws, is usually the treatment of choice. After such a surgery, however, similar complications will still be encountered. In this study the authors propose minimally invasive percutaneous cement augmentation under fluoroscopic guidance as a salvage procedure that eliminates the inherent risks of conventional extensive surgery. METHODS The records for 10 consecutive patients who had undergone fluoroscopy-guided percutaneous cement augmentation for loosened pedicle screws and instrumentation-associated vertebral fractures were reviewed. The procedures, performed with the patients under local anesthesia, were basically similar to vertebroplasty except for the preexisting pedicle screws. The trocar was inserted under fluoroscopic guidance, along the path of the loosened pedicle screw, using the latero-pedicular approach. The visual analog scale (VAS) and radiographic images were used for clinical outcome assessment at 3, 6, and 12 months after surgery. RESULTS The mean follow-up period was 14.3 months. The mean postoperative hospital stay was 1.2 days. There was neither cement leakage into the posterior neuroforamen nor neurological complication in this series. The mean VAS score improved from 5.9 preoperatively to 2.5 at the last follow-up (p = 0.02). Eight patients obtained satisfactory results and 2 needed revision open surgery. CONCLUSIONS The results demonstrate that minimally invasive fluoroscopy-guided percutaneous vertebroplasty is technically feasible and can be performed safely and effectively for symptomatic loosened pedicle screws and instrumentation-associated vertebral fracture.
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Abstract
STUDY DESIGN Cadaveric model. OBJECTIVES To compare the effect of PEEK versus conventional implants on scatter radiation to a simulated tumor bed in the spine SUMMARY OF BACKGROUND DATA.: Given the highly vasculature nature of the spine, it is the most common place for bony metastases. After surgical treatment of a spinal metastasis, adjuvant radiation therapy is typically administered. Radiation dosing is primarily limited by toxicity to the spinal cord. The scatter effect caused by metallic implants decreases the accuracy of dosing and can unintentionally increase the effective dose seen by the spinal cord. This represents a dose-limiting factor for therapeutic radiation postoperatively. METHODS A cadaveric thorax specimen was utilized as a metastatic tumor model with two separate three-level spine constructs (one upper thoracic and one lower thoracic). Each construct was examined independently. All four groups compared included identical posterior instrumentation. The anterior constructs consisted of either: an anterior polyether ether ketone (PEEK) cage, an anterior titanium cage, an anterior bone cement cage (polymethyl methacrylate), or a control group with posterior instrumentation alone. Each construct had six thermoluminescent detectors to measure the radiation dose. RESULTS The mean dose was similar across all constructs and locations. There was more variability in the upper thoracic spine irrespective of the construct type. The PEEK construct had a more uniform dose distribution with a standard deviation of 9.76. The standard deviation of the others constructs was 14.26 for the control group, 19.31 for the titanium cage, and 21.57 for the cement (polymethyl methacrylate) construct. CONCLUSION The PEEK inter-body cage resulted in a significantly more uniform distribution of therapeutic radiation in the spine when compared with the other constructs. This may allow for the application of higher effective dosing to the tumor bed for spinal metastases without increasing spinal cord toxicity with either fractionated or hypofractionated radiotherapy. LEVEL OF EVIDENCE N/A.
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Virk MS, Han JE, Reiner AS, McLaughlin LA, Sciubba DM, Lis E, Yamada Y, Bilsky M, Laufer I. Frequency of symptomatic vertebral body compression fractures requiring intervention following single-fraction stereotactic radiosurgery for spinal metastases. Neurosurg Focus 2017; 42:E8. [DOI: 10.3171/2016.10.focus16359] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
The purpose of this study was to determine the rate of symptomatic vertebral body compression fractures (VCFs) requiring kyphoplasty or surgery in patients treated with 24-Gy single-fraction stereotactic radiosurgery (SRS).
METHODS
This retrospective analysis included all patients who had been treated with 24-Gy, single-fraction, image-guided intensity-modulated radiation therapy for histologically confirmed solid tumor metastases over an 8-year period (2005–2013) at Memorial Sloan Kettering Cancer Center. Charts and imaging studies were reviewed for post-SRS kyphoplasty or surgery for mechanical instability. A Spinal Instability Neoplastic Score (SINS) was calculated for each patient both at the time of SRS and at the time of intervention for VCF.
RESULTS
Three hundred twenty-three patients who had undergone single-fraction SRS between C-1 and L-5 were included in this analysis. The cumulative incidence of VCF 5 years after SRS was 7.2% (95% CI 4.1–10.2), whereas that of death following SRS at the same time point was 82.5% (95% CI 77.5–87.4). Twenty-six patients with 36 SRS-treated levels progressed to symptomatic VCF requiring treatment with kyphoplasty (6 patients), surgery (10 patients), or both (10 patients). The median time to symptomatic VCF was 13 months. Seven patients developed VCF at 11 levels adjacent to the SRS-treated level. Fractured levels had no evidence of tumor progression. The median SINS changed from 6.5 at SRS (interquartile range [IQR] 4.3–8.8) to 11.5 at stabilization (IQR 9–13). In patients without prior stabilization at the level of SRS, there was an association between the SINS and the time to fracture.
CONCLUSIONS
Five years after ablative single-fraction SRS to spinal lesions, the cumulative incidence of symptomatic VCF at the treated level without tumor recurrence was 7.2%. Higher SINSs at the time of SRS correlated with earlier fractures.
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Affiliation(s)
- Michael S. Virk
- Departments of 1Neurological Surgery,
- 2Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York; and
| | | | | | | | - Daniel M. Sciubba
- 5Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Eric Lis
- 6Radiology, Memorial Sloan Kettering Cancer Center
| | | | - Mark Bilsky
- Departments of 1Neurological Surgery,
- 2Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York; and
| | - Ilya Laufer
- Departments of 1Neurological Surgery,
- 2Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York; and
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