Cement leakage during vertebroplasty: an underestimated problem?

Abstract

Overall, vertebroplasty has a low complication rate. Nevertheless, severe complications can occur. The majority of these are related to cement extrusion. The rate of cement leakage is often obtained by X-ray, with only a single leak registration per vertebra. Detection rate of leaks in comparison with CT and inter-observer reliability for X-ray is, in large parts, unknown. We conducted this study to determine the value of fluoroscopy and X-ray used to detect cement leakage as compared to CT scans. Intraoperative findings in lateral fluoroscopy by the surgeon, and postoperative findings in X-rays by two orthopaedic surgeons, were compared with CT scans for the same study group. Multiple cement leakage was considered, and agreement rate was determined. The detection rate for leaks was 34% for lateral X-ray and 48% for lateral and AP view. Additional AP views only enhanced the detection of leaks in the segmental veins. The agreement rate between fluoroscopy/X-ray and CT scans ranged between 66% and 74%, while inter-observer reliability showed only fair agreement. The rate of cement leaks in vertebroplasty is high if multiple leaks are considered in CT scans. Detection rates using X-rays are low and complicated by only fair inter-observer agreement. Leaks in the basivertebral veins are frequently misinterpreted and can lead to severe complications. Therefore, CT scans should be obtained to calculate the exact leakage rate and to assess persistent or new pain occurring postoperatively.

Changes in the drug release pattern of fresh and set simvastatin-loaded brushite cement

“…The materials were fully injectable, with a clinically relevant extrusion force ( Figure 3) [39,41] and did not show signs of filter pressing or phase separation. The injected cement exhibited a uniform ball-like shape (Figure 4), and while there is no literature data on specific sphericity values of CPC cements, it could be assumed that this shape would be beneficial in terms of a reduced risk for leakage in clinical applications such as vertebroplasty [55], as has been the hypothesis for PMMA cements [40,56,57].…”

Surgical removal of extravasated epidural and neuroforaminal polymethylmethacrylate after percutaneous vertebroplasty in the thoracic spine

“…With radiologic study, leakage of PMMA is usually detected on intraoperative fluoroscopic images or postoperative radiographs. The detection rate is low with fluoroscopy and radiography than that with CT [22]. Despite the high rate of PMMA leakage, extrusions of PMMA cement are usually clinically asymptomatic [7,8,25,27].…”

“…Extravasations of PMMA into the epidural space of the spinal canal account for 22-38% of all detected PMMA leakages associated with PVP [7,21,22,27]. Because PMMA leaks out of the vertebral bodies through different routes, various patterns of cement distribution can be observed and result in neurologic complications.…”

“…Patients with incomplete paraparesis after complicated PVP may have severe disability if surgical decompression is not performed [1,7,13]. Laminectomy or laminotomy alone does not achieve adequate neural decompression to facilitate good recovery from incomplete paraparesis caused by extravasated PMMA cement [22]. Good recovery is usually reported in patients with incomplete paraparesis who undergo surgical removal of epidural cement [20,22,23].…”

“…Although PVP is validated as a safe and effective procedure, several complications have been reported. Among them, extravasations of PMMA cement is the most prevalent and occurs in 11-81% of PVP cases described in the literature [1,2,4,5,7,9,13,22,27]. Although extravasations of PMMA cement could be reduced by increase of the cement viscosity [3] and are usually of little clinical consequence [7,8,25,27], it can result in severe neurologic complications that require surgical decompression [7,17,[20][21][22][23][24]26].…”