Epidural Cement Leakage Research Articles

Biportal Endoscopic Paraspinal Decompression for Epidural Cement Leakage Removal: A Technical Note

ObjectiveWe aimed to preliminarily explore the efficacy and safety of unilateral biportal endoscopy (UBE) for the treatment of epidural cement leaks. We report a patient who underwent epidural cement leakage removal and achieved endoscopic spinal decompression. MethodsA 67-year-old female patient underwent biportal endoscopic paraspinal decompression following percutaneous vertebroplasty for an osteoporotic fracture that resulted in neurologic impairment due to epidural cement leakage. A transforaminal biportal endoscopic surgery was performed to remove the leaked cement, and the left L1 and bilateral L2 nerves were decompressed. ResultsThe patient’s postoperative clinical course was uneventful. ConclusionsA paraspinal approach that avoids a posterior approach reduces the need to remove stabilizing facet bone, is truly minimally invasive and does not involve an instrumented fusion, maybe a helpful addition in the minimally invasive spine surgeon’s armamentarium.

Anatomic distribution of basivertebral foramen with a magistral form in vertebral bodies of T10~L5 and its clinical significance for extensive epidural cement leakage in cement-augmented pedicle screw fixation: a multicenter case–control study

BackgroundThere are no reports discussing anatomic distribution of basivertebral foramen (BVF) in the osteoporotic vertebral body, which is critical in the analysis of the risk of epidural cement leakage (ECL) after cement-augmented pedicle screw fixation (CAPSF).Methods371 osteoporotic patients using 1898 cement-augmented screws were included. Preoperative computed tomography (CT) was used to determine the frequency, width, height, and depth of magistral BVF in T10~L5. Additionally, we measured the distance between BVF and the left/right borders of vertebral body as well as the distance between BVF and upper/lower endplates. Following CAPSF, the severity of ECL and the position of pedicle screws were determined by postoperative CT. Finally, significant risk factors for extensive ECL were identified through binary logistic regression analysis.ResultsOf 2968 vertebral bodies ranging from T10 to L5, 801 (42.2%) had a magistral BVF. From T10 to L5, the frequency of magistral BVF appeared to gradually increase. The magistral BVF was much closer to the upper endplate and the depth accounted for about a quarter of anteroposterior diameter of vertebral body. Overall, there were 19 patients (5.1%) and 32 screws (1.7%) with extensive ECL, nine of whom had neurological symptoms. The independent risk factors for extensive ECL were the magistral BVF (OR = 8.62, P < 0.001), more volume of cement injected (OR = 1.57, P = 0.031), reduced distance from screw tip to vertebral midline (OR = 0.76, P = 0.003) and vertebral posterior wall (OR = 0.77, P < 0.001) respectively.ConclusionWhen planning a CAPSF procedure, it is important to consider anatomical distribution of BVF and improve screw implantation methods.

The incidence and risk factors for extensive epidural cement leakage in cement-augmented pedicle screw fixation: a multicenter retrospective study.

In cement-augmented pedicle screw fixation (CAPSF), epidural cement leakage (CL) is a frequently reported complication with the potential for neural injury, especially when it is extensive. To date, there has been no reports discussing basivertebral foramen morphology and pedicle screw placement, which is critical in the analysis of the risk of extensive epidural CL. Thus, this study aimed to identify the incidence and risk factors for extensive epidural CL in osteoporotic patients with CAPSF. 371 osteoporotic patients using 1898 cement-augmented screws were included. Preoperative computed tomography (CT) was utilized to characterize basivertebral foramen morphology. Following CAPSF, the severity of epidural CL, the implantation position of pedicle screw and cement extension within the vertebral body were determined by postoperative CT. In this study, significant risk factors for extensive epidural CL were identified through logistic regression analysis. There were 19 patients (5.1%) and 32 screws (1.7%) with extensive epidural CL. Nine patients (involving 19 screws) had neurological symptoms. The independent risk factors for patients with extensive epidural CL were decreased BMD and increased number of augmented screws. Significant predictors for extensive epidural CL were a magistral type of basivertebral foramen, more volume of cement injected, solid screw, a shallower screw implantation, and the smaller distance between the tip of the screw and the midline of vertebral body. Extensive epidural CL risk was significant in CAPSF when a magistral basivertebral foramen was present; solid screws and more volume of cement were used; and screw tip was implanted shallower or closer to the midline.

Symptomatic epidural cement leakage after percutaneous vertebroplasty: A case report of successful management by surgical excision with literature review

The purpose of this case report was to present successfully treated case of symptomatic cement leakage after percutaneous vertebroplasty procedure (PVP) with technical tips to avoid such injury and to present literature review. PVP is a simple solution to treat osteoporotic vertebral compression fracture (OVCF) if it is performed with right indications. Cement leak into spinal canal during PVP can lead to catastrophic accident and cause severe neurological deficit that requires an urgent exploration and removal of cement. To avoid medial pedicle breach, there should be a definitive guideline during PVP. An 81-year-old lady had PVP after injury for OVCF at D12. She developed severe neurological deficit immediately after the procedure; however, she was managed conservatively. On presentation to us, urgent investigations with CT scan revealed cement leak into spinal canal from medial pedicle breach extending from D10-12 level with severe cord compression. Her surgery was performed with wide laminectomy at D10-D12 levels with transpedicular stabilization D9-L2 along with neuromonitoring. Cement mass was isolated from the dura and removed achieving decompression of the cord. Postoperatively, patient showed significant neurological improvement and walked independently with the help of stick in three months. In conclusion, although PVP is a convenient solution for painful OVCF, care must be taken while considering this option such as timing, insertion of needle, viscosity of cement, and C-arm monitoring. If neurological deficit occurs, urgent CT scan for the diagnosis and exploration with removal of cement with or without stabilization is mandatory.

Cement leakage following percutaneous kyphoplasty in a patient after a posterior lumbar fusion: a case report

BackgroundPercutaneous kyphoplasty (PKP) has become an important minimally invasive surgical technique for fracture stabilization and pain relief in patients with vertebral compression fractures. However, intraspinal cement leakage following PKP is a serious postoperative complication that can lead to morbidity and mortality.Case presentationWe describe an uncommon case of epidural leakage of bone cement in an 81-year-old woman who underwent posterior lumbar decompression and fusion from L3–5 4 years prior and had an unremarkable postoperative course. The patient was admitted to Peking Union Medical College Hospital with complaints of muscle weakness and severe low back pain radiating to the left thigh 1 week after PKP of L5 due to an acute osteoporotic compression fracture. Computed tomographic imaging revealed massive leakage of cement into the spinal canal at L5-S1, and therefore, surgical decompression and removal of epidural cement were performed carefully without causing a dural tear. She improved remarkably and no neurologic deterioration was observed in the postoperative period during the one-year follow-up.ConclusionsWe present the rare reported case, to our knowledge, of epidural cement leakage after PKP at the segment of internal fixation and discuss the most likely etiologies and preventive measures for this condition.

Epidural Cement Leakage During Kyphoplasty Leading to Radiculopathy

Epidural Cement Leakage During Kyphoplasty Leading to Radiculopathy

Percutaneous Vertebral Augmentation for Osteoporotic Vertebral Compression Fracture in the Midthoracic Vertebrae (T5-8): A Retrospective Study of 101 Patients with 111 Fractured Segments

Data reporting percutaneous vertebroplasty (PVP) or percutaneous balloon kyphoplasty (PKP) application to the midthoracic vertebrae remain limited. This study aimed to summarize our experiences and explore the efficacy and safety of PVP or PKP in dealing with osteoporotic vertebral compression fracture (OVCF) in the midthoracic vertebrae. Patients receiving PVP or PKP for midthoracic OVCF in our institution from January 2015 to January 2018 were retrospectively enrolled. All patients were grouped according to cement augmentation procedure types, surgical approaches, and puncture routes. All patients underwent a postoperative follow-up of 2-36 months. Visual analog scale (VAS) and ECOG Scale of Performance Status scores were evaluated pre- and postoperatively. Cement distribution and rate of cement leakage were assessed by radiographs. Associations of these variables and clinical scores and radiographic indices were analyzed. A total of 101 consecutive patients with 111 fractured centrums were enrolled. Both VAS and ECOG Scale of Performance Status scores of all patients decreased significantly after the operation, and progressively decreased at the final follow-up. The cement distribution of the bipedicular group was significantly better than the unipedicular group, but the total leakage rate of the former (71.7%) was significantly higher than the latter (43.1%). The rate of epidural cement leakage in the PKP group (5.4%) was significantly lower than that of the PVP group (20.3%), whereas the left puncture group (28.6%) was significantly higher than that of the right puncture group (2.7%). PKP and a bipedicular approach can help improve cement distribution and reduce the epidural cement leakage rate and therefore should be preferred over PVP or a unipedicular approach in OVCF of the midthoracic vertebrae.

Percutaneous Endoscopic Retrieval of Intraspinal Cement Leakage: Technical Note

We sought to preliminarily explore the efficacy and safety of percutaneous endoscopic spinal surgery for epidural cement leakage. We report a case series of patients who underwent percutaneous retrieval of leaked epidural cement and achieved spinal decompression under endoscopy. Five patients with neurologic impairment due to epidural cement leakage after percutaneous vertebroplasty were treated with percutaneous endoscopic spinal decompression. Computed tomography reconstruction and 3-dimensional imaging were used to evaluate the extruded material. During follow-up at 3, 6, and 12 months postoperatively, all patients were advised to undergo plain radiograph and computed tomography examinations. The leaked epidural cement was successfully removed in all patients under percutaneous endoscopy through a unilateral or bilateral approach. At the 12-month follow-up, the visual analog scale score of all patients improved. In addition, the neurologic function of each patient improved to at least 1 grade level, as evaluated using the American Spinal Injury Association. According to the modified MacNab criteria, 2 patients had excellent recovery, whereas the other 3 patients had good recovery. We described a novel and minimally invasive procedure to ameliorate intractable epidural cement extrusion. As an alternative to conventional laminectomy, percutaneous endoscopic retrieval achieved the targeted decompression without damaging the posterior lamina. Moreover, the whole operation was performed under regional anesthesia accompanied with dexmedetomidine sedation, allowed real-time neural function evaluation, and had lower risks of anesthesia-related complications, compared with general anesthesia.

Risk of cement leakage and pulmonary embolism by bone cement-augmented pedicle screw fixation of the thoracolumbar spine

BackgroundCement-augmented pedicle screw instrumentation (CAPSI) of the thoracolumbar spine is indicated in osteoporosis or osteopenia to improve pullout strength and biomechanical stability of pedicle screws (PS). Only a few studies report on the incidence of pulmonary cement embolism or other complications associated with CAPSI. PurposeThe aim of this retrospective study was to assess the rate of CAPSI-associated complications. Study DesignRetrospective cohort study. Patient SamplePatients who underwent CAPSI due to spinal tumors or degenerative spine disease. Outcome MeasuresCement leakage, pulmonary cement embolism (PCE), mortality rate. MethodsOur clinical database was reviewed for patients who underwent CAPSI between January 2012 and June 2015. A total of 165 patients (mean age 71±11.2; range: 46 to 93 years; m=62, f=103) were included. Indications were osteoporotic fractures (n=40), spinal metastases (n=57), degenerative (n=49) or infectious spine disease (n=5), and traumatic vertebral fractures (n=14) with an associated osteoporosis. Every patient received between 2 and 21 (mean 8±3.3) cement-augmented pedicle screws in the thoracolumbar and lumbosacral spine. Both intraoperative cement leakage in prevertebral veins, the inferior vena cava, and/or pulmonary arteries, and leakage detected on postoperative imaging were evaluated. We assessed the incidence of clinically symptomatic and asymptomatic events. ResultsIn 29 of 31 patients with intraoperative suspicion of cement leakage into prevertebral veins or the inferior vena cava on lateral fluoroscopy, which were without hemodynamic relevance, cement extrusion was confirmed on postoperative X-ray or computed tomography (CT) scan. In three of eight patients with suspicion of PCE, PCE was verified on thoracic CT. Four patients experienced life-threatening intraoperative hemodynamic reactions, either due to cement embolism (n=2; 1.2%) or anaphylactic shock (n=2; 1.2%) with need for intraoperative cardiopulmonary resuscitation in three cases. Two patients died due to fulminant PCE. Three patients with dyspnea 1 day after surgery were also confirmed with PCE on chest CT. In five patients, an asymptomatic PCE was found incidentally on postoperative imaging. In addition, 68 patients with cement leakage into prevertebral veins or the ascending cava vein were found incidentally on postoperative spine X-ray or CT. Two of 10 patients with intraspinal epidural cement leakage required revision surgery. One hundred ten of 165 patients (66.7%) had clinically asymptomatic cement leakage. Thirteen patients had PCE (7.9%), of whom five (3.0%) were symptomatic. Two patients experienced intraoperative cement-induced anaphylaxis (1.2%). The overall symptomatic complication rate was 5.5% (n=9). The 30-day mortality rate was 1.8% (n=3). ConclusionsCAPSI bears a high risk of asymptomatic cement leakage. The risk for associated severe complications was also relatively high and probably underestimated considering the retrospective nature of the present study. A strict indication for cement augmentation, especially in patients with cardiac predisposition, should be the consequence. We doubt that technical aspects of cement application and/or different types of cement are capable of reducing the risk of these complications substantially.

The Potential Impact of Venobasillar System Morphology and Applied Technique on Epidural Cement Leakage with Percutaneous Vertebroplasty

Background: Bone cement leakage during vertebroplasty is a frequently reported complication with the potential for neural injury. Objective: To assess risk factors for epidural cement leakage during vertebroplasty. Setting: Neurosurgical department of a scientific research institute. Study Design: This is a prospective cross-sectional randomized trial. Methods: Seventy-five patients with intractable pain due to low energy vertebral compression fractures between T11 and L5 were treated with vertebroplasty at 150 vertebral levels. Preoperative computed tomography (CT) scans were utilized to characterize vertebral parameters including the type of nutrient foramena in the posterior vertebral cortex. Following vertebroplasty, distance from the needle tracts to the midline and the presence and type of any epidural cement leakage were determined. Using logistic regression analysis, significant risk factors for cement leakage were determined. Results: A smaller distance between the tip of the needle and the midline and a magistral type of venobasillar system were found to be significant risk factors for epidural cement leakage (P &lt; 0.0001). Use of a bipedicular vs. monopedicular technique did not significantly affect the rate of epidural cement leakage (P = 0.3869). Limitations: This study is limited because of the relatively small number of patients and the lack of any patients who had clinical consequences as a result of extensive epidural cement leakage. Conclusion: The type of venobasillar system should be taken into account when planning a vertebroplasty procedure as a magistral type of venobasillar system is associated with the increased rate of epidural cement leakage. It is important to try and achieve a large distance between the needle tip and the midline, especially when a magistral type of venobasillar system is present, to reduce the risk of epidural cement leakage. Key words: Vertebroplasty, intracanal cement leakage, low energy vertebra fracture

Ascending tonic clonic seizure syndrome after percutaneous vertebroplasty.

Background Context. Cement leakage is not a rare complication of vertebroplasty, but ascending tonic clonic seizure syndrome is exceptionally rare. We herein report the first case to our knowledge of this complication related to vertebroplasty. Purpose. We herein report the first case of ascending tonic clonic seizure syndrome following epidural cement leakage after percutaneous vertebroplasty in a patient with multiple osteoporotic compression fractures. Study Design. Case report. Methods. A 64-year-old woman with T8, T10, L2, and L4 osteoporotic compression fractures underwent percutaneous vertebroplasty using polymethylmethacrylate. 40 minutes after the procedure the patient started suffering back and leg pain, having repetitive myoclonic jerks lasting 15 seconds of the lower extremities, spasm of the back, dyspnea, sinus tachycardia, hypoxemia, and metabolic acidosis. Results. The patient recovered completely due to a combination of early effective resuscitation and considered definitive management. Conclusions. Percutaneous vertebroplasty with polymethylmethacrylate is relatively safe but has few dangerous complications, which should be prevented by a meticulous technique and excellent image quality.

Kyphoplasty for the Treatment of Very Severe Osteoporotic Vertebral Compression Fracture

A retrospective evaluation of the clinical outcome and technical feasibility of kyphoplasty for the treatment of very severe osteoporotic vertebral compression fracture (vsOVCF). Patients with vsOVCF were treated with kyphoplasty and followed-up for 1 year. Vertebral body height variation, kyphotic angle, back pain (visual analogue scale [VAS]) and Oswestry disability index (ODI) were evaluated preoperatively, postoperatively, 1 month, 3 months and 1 year after treatment. In total, 35 patients (49 vertebrae) were treated with kyphoplasty. There were no cases of spinal or extraspinal injury, infection, bleeding, pulmonary embolism, epidural cement leakage, stroke or cardiac arrest as a result of treatment. There were significant postoperative improvements in all outcome measures (vertebral body height variation, kyphotic angle, VAS and ODI); these improvements were maintained during the follow-up period. Kyphoplasty is an effective and minimally invasive procedure for the treatment of vsOVCF.

Epidural cement leakage through pedicle violation after balloon kyphoplasty causing paraparesis in osteoporotic vertebral compression fractures - a report of two cases

Kyphoplasty is advantageous over vertebroplasty in terms of better kyphosis correction and diminished risk of cement extravasations. Literature described cement leakage causing neurological injury mainly after vertebroplasty procedure; only a few case reports show cement leakage with kyphoplasty without neurological injury or proper cause of leakage. We present a report two cases of osteoporotic vertebral compression fracture treated with kyphoplasty and developed cement leakage causing significant neurological injury. In both cases CT scan was the diagnostic tool to identify cause of cement leakage. CT scan exhibited violation of medial pedicle wall causing cement leakage in the spinal canal. Both patients displayed clinical improvement after decompression surgery with or without instrumentation. Retrospectively looking at stored fluoroscopic images, we found that improper position of trocar in AP and lateral view simultaneously while taking entry caused pedicle wall violation. We suggest not to cross medial pedicle wall in AP image throughout the entire procedure and keeping the trocar in the center of pedicle in lateral image would be the most important precaution to prevent such complication. Our case reports adds the neurological complications with kyphoplasty procedure and suggested that along with other precautions described in the literature, entry with trocar along the entire procedure keeping the oval shape of pedicle in mind (under C-arm) will probably help to prevent such complications.

The major complications of transpedicular vertebroplasty

Vertebroplasty is a well-known technique used to treat pain associated with vertebral compression fractures. Despite a success rate of up to 90% in different series, the procedure is often associated with major complications such as cord and root compression, epidural and subdural hematomas (SDHs), and pulmonary emboli, as well as other minor complications. In this study, the authors discuss the major complications of transpedicular vertebroplasty and their clinical implications during the postoperative course. Vertebroplasty was performed in 12 vertebrae of 7 patients. Five patients had osteoporotic compression fractures, 1 had tumoral compression fractures, and 1 had a traumatic fracture. Two patients had foraminal leakage, 1 had epidural leakage, 1 had subdural cement leakage, 2 had a spinal SDH, and the last had a split fracture after the procedure. Three patients had paraparesis (2 had SDHs and 1 had epidural cement leakage), 3 had root symptoms, and 1 had lower back pain. Two of the 3 patients with paraparesis recovered after evacuation of the SDH and subdural cement; however, 1 patient with paraparesis did not recover after epidural cement leakage, despite cement evacuation. Two patients with foraminal leakage and 1 with subdural cement leakage had root symptoms and recovered after evacuation and conservative treatment. The patient with the split fracture had no neurological symptoms and recovered with conservative treatment. Transpedicular vertebroplasty may have major complications, such as a spinal SDH and/or cement leakage into the epidural and subdural spaces, even when performed by experienced spinal surgeons. Early diagnosis with CT and intervention may prevent worsening of these complications.

One-stage single balloon multiple expansions percutaneous kyphoplasty: report of 18 cases

To observe the effect and safety of one-stage single balloon multiple expansions percutaneous kyphoplasty (PKP) in treatment of osteoporotic vertebral compressive fracture (OVCF) and spinal tumor. One-stage single balloon multiple expansions PKP was performed on 18 patients, 5 males and 13 females, aged 68.77 (44 - 80), with 45 vertebrae, including 11 case of OVCF (with 29 diseased vertebrae), 11 cases of multiple vertebral fracture (with 19 diseased vertebrae), 5 cases of multiple myeloma (with 12 diseased vertebrae), and 2 case of spinal metastatic tumor (with 4 diseased vertebrae), the vital signs were record during operation. Pain relief and functional recovery were evaluated with visual analogue pain scale (VAS) and Oswestry disability index (ODI) scaling, and restoration of vertebral height and Cobb angle were evaluated by X-ray examination. Follow-up was conducted by telephone survey or clinic consults for 12.3 months (6 - 18 months). Operation was successfully performed on all patients with an operative time of 29.3 min (55 - 127 min) per vertebra. The average pressure of the balloon expansion was 165 Psi (87 - 210 Psi), and the average balloon expanded volume was 3.25 ml (1.5 - 4 ml). A balloon was expanded 2 approximately 5 times in one operation with the average of 2.94 expanded times. The bone cement volume injected was 3.95 ml (2 - 8.5 ml) per vertebra. Epidural cement leakage was seen in 1 vertebra in 1 case and paraspinal leakage was seen in two vertebrae in 1 case. The VAS and ODI scoring of these patients were both decreased significantly after operation. Both the anterior height and midline height of vertebrae were significantly improved. The pain relief and functional recovery were substantial and maintained to the last follow-up without any re-collapse or adjacent level fracture. one-stage single balloon multiple expansions PKP is effective, economic and safe in treatment of multi-level OVCF and spinal tumor.

Transcostovertebral kyphoplasty of the mid and high thoracic spine

While Kyphoplasty is increasingly becoming a recognised minimally invasive treatment option for osteoporotic vertebral fractures and neoplastic vertebral collapse, the experience in the treatment of vertebrae of the mid (T5-8)- and high (T1-4) thoracic levels is limited. The slender pedicle morphology restricts the transpedicular approach at these levels, necessitating extrapedicular placement techniques. Fifty five vertebrae of 32 consecutive patients were treated with kyphoplasty at levels ranging from T2-T8 for vertebral fractures (27 patients) or osteolytic collapse (5 patients). All procedures were performed through the transcostovertebral approach under fluoroscopic guidance. The radioanatomical landmarks of this minimally invasive approach were consistently identified and strictly adhered to. One fracture required open instrumentation due to posterior column injury in addition to kyphoplasty. Identification of specific radioanatomical landmarks allowed precise tool introduction in all cases without intraspinal or paravertebral malplacement. Average operating time for patients with osteoporotic fractures was 30 min per level (range 13-60 min) and 52 min per level (range 35-95 min) in neoplastic cases. Biopsy yield in patients with known or suspected malignancies was 100%. Epidural cement leakage was detected in one patient with pedicular osteolysis. Perforation of the lateral vertebral cortex during balloon inflation occurred in another patient. Both intraoperative complications were without clinical significance. Kyphoplasty in mid- to -high thoracic levels is possible via the transcostovertebral route under fluoroscopic guidance. Strict adherence to a stepwise protocol of tool introduction following defined radioanatomical landmarks is mandatory for the safe completion of this minimally invasive technique.

Microsurgical interlaminary vertebro- and kyphoplasty for severe osteoporotic fractures.

Percutaneous vertebro- and kyphoplasty have become established methods for the treatment of uncomplicated osteoporotic vertebral fractures. In the setting of severe fractures involving fragmentation of the posterior wall and neural compromise, however, decompressive surgery cannot be performed and epidural cement leakage is poorly controlled. A microsurgical interlaminary approach for vertebro- and kyphoplasty was developed to allow spinal decompression and control of the spinal canal during augmentation. Interlaminary vertebro- or kyphoplasty was performed in 24 patients with osteoporotic fractures involving neural compression or posterior wall fragmentation. After unilateral microsurgical fenestration, decompression of the spine, and gentle mobilization of the thecal sac, vertebro- or kyphoplasty was performed directly through the posterior wall of the fractured vertebral body. Cement was injected under microscopic and fluoroscopic control, with the option of immediate exploration of the exposed spinal canal. Thirty-four levels (T-8 to L-5) were treated. Mean blood loss was less than 100 ml and augmentation added 10 to 40 minutes to the entire procedure. Cement leakage associated with the kyphoplasty procedure was less than that in vertebroplasty. There were no major complications. One patient was lost to follow up. Clinical outcome was good or excellent in 17 of the 23 patients available for follow-up (1 to 31-month) evaluation. The present microsurgical interlaminary approach for vertebro- and kyphoplasty enables treatment of severe osteoporotic fractures involving fragmentation of the posterior wall and neural compromise. Decompressive surgery is possible and the risk of epidural cement leakage is controlled intraoperatively. This technique can be regarded as a procedure on the treatment continuum between percutaneous augmentation and conventional open reconstruction.