Preoperative Embolization of Hypervascular Spinal Metastases Using Percutaneous Direct Injection with n-Butyl Cyanoacrylate: Technical Case Report

Abstract

Intraoperative blood loss constitutes a major cause of perioperative morbidity in surgical decompression and reconstruction of highly vascular spinal metastatic tumors. We propose a technique for embolization of highly vascular vertebral metastases using percutaneous direct injection using n-butyl cyanoacrylate (NBCA) instead of polymethylmethacrylate to complement preoperative transarterial embolization and to minimize operative blood loss. Five patients with renal cell carcinoma metastases to the spine (one cervical, one thoracic, and three lumbar) underwent embolization by percutaneous direct injection of the affected vertebrae with a mixture of NBCA and iodized oil to supplement transarterial embolization with polyvinyl alcohol particles and fibered platinum coils. This was achieved via a transpedicular approach in four cases and by direct vertebral body puncture in one case. The percutaneous NBCA direct injection procedure was technically successful in all cases and was not associated with neurological or medical complications. All patients underwent subsequent vertebrectomy and spinal instrumentation. Surgical resection was performed with lower than expected blood loss and with a subjective improvement in tumor tissue handling and dissection. The extent of tumor devascularization can be improved by supplementing transarterial embolization with NBCA direct injection to decrease operative blood loss and increase the safety of surgical resection and stabilization of highly vascular spinal metastases.