Mechanical Cavity Creation with Curettage and Vacuum Suction (Q-VAC) in Lytic Vertebral Body Lesions with Posterior Wall Dehiscence and Epidural Mass before Cement Augmentation

Abstract

Background and Objectives: We describe a novel technique for percutaneous tumor debulking and cavity creation in patients with extensive lytic lesions of the vertebral body including posterior wall dehiscence prior to vertebral augmentation (VA) procedures. The mechanical cavity is created with a combination of curettage and vacuum suction (Q-VAC). Balloon kyphoplasty and vertebral body stenting are used to treat neoplastic vertebral lesions and might reduce the rate of cement leakage, especially in presence of posterior wall dehiscence. However, these techniques could theoretically lead to increased intravertebral pressure during balloon inflation with possible mobilization of soft tissue tumor through the posterior wall, aggravation of spinal stenosis, and resultant complications. Creation of a void or cavity prior to balloon expansion and/or cement injection would potentially reduce these risks. Materials and Methods: A curette is coaxially inserted in the vertebral body via transpedicular access trocars. The intravertebral neoplastic soft tissue is fragmented by multiple rotational and translational movements. Subsequently, vacuum aspiration is applied via one of two 10 G cannulas that had been introduced directly into the fragmented lesion, while saline is passively flushed via the contralateral cannula, with lavage of the fragmented solid and fluid-necrotic tumor parts. Results: We applied the Q-VAC technique to 35 cases of thoracic and lumbar extreme osteolysis with epidural mass before vertebral body stenting (VBS) cement augmentation. We observed extravertebral cement leakage on postoperative CT in 34% of cases, but with no clinical consequences. No patients experienced periprocedural respiratory problems or new or worsening neurological deficit. Conclusion: The Q-VAC technique, combining mechanical curettage and vacuum suction, is a safe, inexpensive, and reliable method for percutaneous intravertebral tumor debulking and cavitation prior to VA. We propose the Q-VAC technique for cases with extensive neoplastic osteolysis, especially if cortical boundaries of the posterior wall are dehiscent and an epidural soft tissue mass is present.

Stent screw–assisted internal fixation (SAIF): clinical report of a novel approach to stabilizing and internally fixating vertebrae destroyed by malignancy

“…Bilateral screws were utilized in 18/36 levels (50%), and unilateral screws were used in 18/36 levels (50%). Cavity creation in the VB with Q-VAC 35 was performed in 29/36 levels.…”

“…When deemed necessary, cavity creation was performed utilizing curettage and vacuum suction (Q-VAC technique). 35 Following transpedicular implant of the VBS(s) and placement of uni-or bilateral pedicular screws, cement augmentation was performed through the screw(s) with high-viscosity polymethyl methacrylate (PMMA; Verta-Plex HV, Stryker) under real-time fluoroscopy.…”

“…adjacent trabecular bone whenever possible. Techniques utilized to limit PMMA leakage and/or displacement of the soft tissue include the creation of a cavity, 8,10,35 the use of high-viscosity PMMA, 3,10 the containment effect of the VBS mesh, 9 and real-time fluoroscopic control during cement injection. These approaches were considered particularly relevant, as these patients had highly destructive lesions typically with a dehiscent posterior wall and the frequent coexistence of an epidural mass.…”

Clinical Rationale of Using Steerable Technologies for Radiofrequency Ablation Followed by Cavity Creation and Cement Augmentation in the Treatment of Painful Spinal Metastases

“…In spinal metastatic disease, the trabecular structure is infiltrated by the presence of tumor tissue in the vertebral body, contributing to a higher intervertebral pressure. Balloon expansion and following cement injection alone may mobilize the tumoral tissue and facilitate extraosseous and epidural tumor spread [ 20 ]. In particular, simultaneous bilateral ablation with two steerable RFA probes articulated over the midline is useful for generating optimal thermodynamics given the diffuse and hyper-vascular nature of tumors, especially those of renal cell carcinoma, hepatocellular carcinoma, thyroid carcinoma, and melanoma.…”

Letter to the Editor. Stent screw–assisted internal fixation and combined radiofrequency ablation and vertebroplasty for stabilization and local tumor control

“…2020;32(4):507-518). Stent screw-assisted internal fixation (SAIF) is a new percutaneous minimally invasive technique that provides vertebral body reconstruction with a 360° internal fixation for vertebral bodies in cases of osteoporotic and pathological fractures 1,2 and allows for restoration of the load-bearing capacity of severe osteolytic vertebra. 3 We wish to make the following comments:…”