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.

Eike I Piechowiak,Maurizio Isalberti,Alessandro Cianfoni,Joshua A Hirsch,Marco Pileggi,Daniela Distefano

doi:10.3390/medicina55100633

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.

Highlights

Percutaneous vertebral augmentation (VA) with vertebroplasty (PVP), balloon kyphoplasty (BKP), or vertebral body stenting (VBS) is often performed in patients with painful, fractured, or at-risk-of-fracture neoplastic spinal lytic lesions
While leakage rate might be reduced by the use of high-viscosity cement [9] and/or by balloon kyphoplasty [10], especially in presence of posterior wall lytic dehiscence and soft tissue epidural mass, both balloon expansion and cement injection might instead extrude tumoral tissue outside of the vertebral body, worsening a central canal stenosis [11] or facilitating extraosseous disease spread [12]
The aim of this study is to describe a new percutaneous image-guided minimally invasive technique for mechanical nonthermal intravertebral tumor debulking and cavity creation in vertebral body lytic lesion

Summary

Introduction

Percutaneous vertebral augmentation (VA) with vertebroplasty (PVP), balloon kyphoplasty (BKP), or vertebral body stenting (VBS) is often performed in patients with painful, fractured, or at-risk-of-fracture neoplastic spinal lytic lesions. While leakage rate might be reduced by the use of high-viscosity cement [9] and/or by balloon kyphoplasty [10], especially in presence of posterior wall lytic dehiscence and soft tissue epidural mass, both balloon expansion and cement injection might instead extrude tumoral tissue outside of the vertebral body, worsening a central canal stenosis [11] or facilitating extraosseous disease spread [12]. 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 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. We observed extravertebral cement leakage on postoperative CT in 34% of cases, but with no clinical consequences

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Discussion

Conclusion