Vertebral Body Lavage before Vertebra/Kyphoplasty Significantly Reduces Cement Leakage in a Clinical Setting

Abstract

Introduction Vertebra/kyphoplasty is an established treatment option for painful vertebral compression fractures. Cement leakage is the most frequent adverse event for this procedure that can result in serious, sometimes fatal, complications. We have shown in an experimental cadaveric as well as in a large animal model that lavage of the vertebral body before cement injection can remove bone marrow and significantly reduced injection pressure, cement leakage, and pulmonary fat embolism.1,2,3 In this study, we examined the effects of a simplified lavage technique in a clinical setting. Methods Retrospective radiological analysis of cement leakage and distribution of a cohort that underwent lavage before vertebral augmentation; cases without lavage were used as control group. Lavage was performed by rinsing the vertebrae with 100 mL Ringer solution, which was alternatingly injected through one filling cannula while aspirating the bone marrow via the contralateral cannula. For all augmentations, the same cement and filling cannulas were used under identical external conditions. Filling pattern, occurrence of cement leakage as well as type (venous, cortical defect, disc) and extend of the leakage was assessed from biplanar radiographs. Results In a 1-year period (2012–2013) the lavage technique was applied in 138 vertebrae. The control group consisted of 105 vertebrae; patient's characteristics, fracture types, and locations were comparable to the treatment group. The lavage group showed significantly lower leakage rates for the venous and disc type as compared with the standard technique group (venous 12.3 vs. 30.5%, disc 15.9 vs. 60% [both p < 0.001]; cortical defect 10.1 vs. 15.2% [ p = 0.23]). Venous cement extrusions were, in general, shorter after lavage ( p = 0.08) and extrusions larger than 10 mm were only observed in the control group (0 vs. 12.5%). Cement filling pattern (aiming for end plate-to-end plate filling) was significant better in the lavage group ( p = 0.001). According to the multivariate analysis, nonlavaged vertebra have a 3.57 times higher likelihood for a venous leakage than a lavaged one ( p = 0.0009). Discussion The results of this retrospective data analysis show clearly that lavage before vertebra/kyphoplasty can reduce occurrence and severity of cement leakage under clinical condition. The technique is simple and the increase in OR time (range, 10–30 seconds) and costs (< 1$) are insignificant. References Benneker LM, Heini PF, Suhm N, Gisep A. The effect of pulsed jet lavage in vertebroplasty on injection forces of polymethylmethacrylate bone cement, material distribution, and potential fat embolism: a cadaver study. Spine (Phila Pa 1976) 2008;33(23) E906-E910 Boger A, Benneker LM, Krebs J, Boner V, Heini PF, Gisep A. The effect of pulsed jet lavage in vertebroplasty on injection forces of PMMA bone cement: an animal study. Eur Spine J 2009;18(12) 1957-1962 Benneker LM, Krebs J, Boner V, Boger A, Hoerstrup S, Heini PF, Gisep A. Cardiovascular changes after PMMA vertebroplasty in sheep: the effect of bone marrow removal using pulsed jet-lavage. Eur Spine J 2010;19(11) 1913-1920. P070.