Cement-augmented Pedicle Screw Research Articles

Ultrasonography-guided canal decompression combined with vertebroplasty and cement-augmented pedicle screw fixation for stage III Kümmell’s disease with neurological deficits: a retrospective cohort study

BackgroundPercutaneous vertebroplasty or kyphoplasty is the preferred procedure for stage I and II Kümmell’s diseases (KDs), but there exist controversies on the operative option of stage III KD. This study aimed at exploring the safety and efficacy of ultrasonography-guided canal decompression (UG-CD) combined with vertebroplasty and cement-augmented pedicle screw fixation (CA-PSF) for treating stage III KD with neurological deficit (ND).MethodsBetween September 2017 and December 2023, all patients who received the UG-CD combined with vertebroplasty and CA-PSF for managing stage III KD with NDs were reviewed retrospectively with their demographic and operation data, and complications recorded. Besides, the scores of Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI), together with imaging data including the kyphotic Cobb angle (KCA), wedge angle (WA), spinal canal area (SCA) at the narrowest level as well as anterior (AHR) and middle (MHR) height ratios were measured and compared between pre- and post-operation.ResultsA total of eleven patients with a mean age of 70.09 ± 2.98 years old were included in our study with their surgical time, hospitalization length, blood loss, and follow-up time being 150.91 ± 17.94 min, 202.09 ± 39.95 ml, 8.18 ± 1.17 days, and 16.91 ± 4.09 months, respectively. During the final follow-up, the KCA, WA, VAS scores, ODI scores, AHR, MHR, and SCA were significantly improved (P < 0.01). Intraoperatively, one case suffered a transient decrease in the motor evoked potential. Another case experienced a cerebrospinal fluid leakage postoperatively that was then successfully treated.ConclusionUG-CD combined with vertebroplasty and CA-PSF could be a feasible procedure for safely and effectively handling stage III KD with NDs.

Results of cement-augmented pedicle screw surgery in the treatment of thoracic and lumbar spine collapse in severe osteoporosis patients

Objective: This 2023 study aimed to assess pain relief, functional recovery, and kyphosis correction following pedicle screw surgery with cement augmentation in severe osteoporosis patients with vertebral collapse. Methods: Seventy-one patients underwent surgery and were evaluated for postoperative pain reduction (VAS score), functional improvement (ODI score), vertebral kyphosis angle, pre- and postoperative spinal curvature angles, and complications. Results: The study included 71 participants (13 males, 58 females; mean age 67.6±6.7 years). Trauma sources included falls (47.9%), heavy lifting (17%), and unclear mechanisms (35.2%). Mean hospital stay was 12±6.5 days. Preoperative, postoperative, and 1/6-month VAS scores were 8.7, 2.2, 1.5, 0.9 respectively (p&lt;0.001). ODI scores were 77.6, 52.8, 43.0, 37.9 respectively (p&lt;0.001). Kyphotic angle (vertebral body) decreased from preop 12.9° to postop 9.9°, 1/6 months 10.1° (p&lt;0.001); at surgical site, preop 15.4° to 1/6 months 11.9° (p&lt;0.001). Cement leakage occurred in 36.6% of cases, mostly asymptomatic, with distribution in the disc space (2.8%), blood vessels (8.5%), around vertebral body (12.7%), spinal canal (14.1%), and lungs (2.8%). Conclusion: Pedicle screw fixation with enhanced cement augmentation effectively manages severe osteoporotic vertebral compression fractures, providing significant pain relief, improved postoperative function, and spinal alignment. Symptomatic cement leakage is rare.

Tips and tricks for using cement augmentation of pedicle screws and vertebral body replacements—A literature review supported by two case reports

BackgroundThe prevalence of osteoporosis is escalating alongside an aging global population, increasing the demand for spinal surgeries, including those necessitating cement augmentation for enhanced construct stability. ObjectiveThis article delves into the nuanced application of cement augmentation techniques for pedicle screws and vertebral body replacements (VBR), aimed at optimizing surgical outcomes in osteoporotic spines. MethodDrawing from a comprehensive literature review according to important clinical and biomechanical studies and the authors’ clinical experiences, we elucidate strategies to mitigate complications and improve surgical efficacy. ResultsCement augmentation has shown promise in managing vertebral fractures and in securing pedicle screws within osteoporotic vertebrae, with the advent of polymethylmethacrylate (PMMA) bone cement marking a pivotal advancement in spinal surgery. We highlight intraoperative measures like the choice between pre-injecting cement and utilizing cannulated or fenestrated screws, emphasizing the importance of controlling cement viscosity to prevent leakage and embolism. Through two case reports, we demonstrate the practical application of endplate cementation following VBR. ConclusionWhile the use of cement augmentation poses certain risks, its judicious application—supported by evidence-based guidelines and surgical expertise—can substantially enhance the stability of spinal constructs in osteoporotic patients. This allows a reduction in instrumentation length by enhancing biomechanical stability concerning pullout, bending, and rotational forces. Furthermore, the incidence of endplate sintering following VBF can be significantly reduced. Future research, particularly on antibiotic-loaded PMMA, may further expand its utility and optimize its safety profile.

Biomechanical Effect of Different Posterior Fixation Techniques on Stability and Adjacent Segment Degeneration in Treating Thoracolumbar Burst Fracture With Osteoporosis: A Finite Element Analysis.

Finite element analysis. To investigate the biomechanical effect of four posterior fixation techniques on stability and adjacent segment degeneration in treating thoracolumbar burst fractures with osteoporosis. In terms of stability and adjacent segment degeneration, there remains no consensus or guidelines on the optimal technique for the treatment of thoracolumbar burst fractures in patients with osteoporosis. Images of CT scans were imported into MIMICS and further processed by Geomagic to build three-dimensional models of the T10-L5 region. A v-shaped osteotomy was performed on the L1 vertebral body to simulate a burst fracture in the setting of osteoporosis. Subsequently, four fixation techniques were designed using SolidWorks software. Range of motion (ROM) of the global spine, ROM distribution, ROM of adjacent segment, Von Mises stress on adjacent intervertebral disks, and facet joints were analyzed. Among the four groups, the cortical bone screw fixation (CBT) showed the highest global ROM at 1.86°, while long-segmented pedicle screw fixation (LSPS) had the lowest global ROM at 1.25°. The LSPS had the smallest percentage of ROM of fractured vertebral body to fixed segment at 75.04%, suggesting the highest stability after fixation. The maximum ROM of the adjacent segment was observed in the CBT at 1.32°, while the LSPS exhibited the smallest at 0.89°. However, the LSPS group experienced larger maximum stress on the adjacent intervertebral disks (9.60MPa) and facet joints (3.36MPa), indicating an increasing risk of adjacent segment disease. LSPS provided the greatest stability, while CBT provided the smallest amount of stability. However, the elevated stress on adjacent intervertebral disks and facet joints after LSPS fixation increased the possibility of adjacent segment degeneration. Cement-augmented pedicle screw fixation (CAPS) and combined cortical bone screw and pedicle screw fixation (CBT-PS) demonstrated significant biomechanical advantages in providing moderate fixation strength while reducing stress on the intervertebral disks and facet joints.

Comparison of cement-augmented pedicle screw and conventional pedicle screw for the treatment of lumbar degenerative patients with osteoporosis.

A retrospective cohort study. To compare the safety and clinical efficacy between using cement-augmented pedicle screws (CAPS) and conventional pedicle screws (CPS) for the treatment of lumbar degenerative patients with osteoporosis. Management of lumbar degenerative patients with osteoporosis undergoing spine surgery is challenging. The clinical efficacy and potential complications of the mid-term performance of the CAPS technique in the treatment of lumbar degenerative patients with osteoporosis remain to be evaluated. The data of 131 lumbar degenerative patients with osteoporosis who were treated with screw fixation from May 2016 to December 2019 were retrospectively analyzed in this study. The patients were divided into the following two groups according to the type of screw used: (I) the CAPS group (n = 85); and (II) the CPS group (n = 46). Relevant data were compared between two groups, including the demographics data, clinical results and complications. The difference in the VAS, ODI and JOA scores at three and 6months after the operation between the two groups was statistically significant (P < 0.05). At 12months after surgery and the final follow-up, a significant difference in the fusion rate was found between the two groups (P < 0.05). Four cemented screws loosening were observed in the CAPS group (loosening rate 4/384, 1.04%) and 15 screws loosening were observed in the CPS group (loosening rate 15/214, 7.01%). In the CAPS group, a total of 384 augmented screws were used, and cement leakage was observed in 25 screws (25/384, 6.51%), but no obvious clinical symptoms or serious complications were observed. Adjacent vertebral fractures occurred in six patients in the CAPS group and one in the CPS group. CAPS technique is an effective strategy for the treatment of lumbar degenerative patients with osteoporosis, with a higher fusion rate and lower screw loosening rate than CPS.

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.

Efficacy of cement-augmented pedicle screw fixation for osteoporotic mid-thoracic vertebral fractures.

Osteoporotic mid-thoracic vertebral fractures (OmTVF), often result in severe pain, and neurological deficits secondary to cord compression. Cement-augmented pedicle screw (CaPS) fixation with posterior spinal decompression (PSD) offers simultaneous decompression with stabilization of these osteoporotic vertebral fractures. The study involved 32 patients (2022-2023) with T8-T10 osteoporotic vertebral compression fractures resulting in cord compression. All patients underwent CaPS surgery with PSD. Pain reduction was measured using the visual analog scale (VAS), and outcomes with the Oswestry Disability Index, and the American Spinal Injury Association Grades. The local kyphotic angle was also tracked with computed tomography studies performed 1, 3, and 6 months post-operatively. The average pre-operative VAS score was 8.56 mm; this decreased at 1, 3, and 6 months post-operatively to 2.72 mm, 2.03 mm, and 1.44 mm, respectively. In addition, 31 of 32 patients fully recovered within 6 postoperative months. For 31 of 32 patients with T8-T10 osteoporotic vertebral fractures, CaPS fixation with PSD successfully alleviated pain and resulted in significant post-operative neurological recovery.

Cement Augmentation of Pedicle Screw Instrumentation: A Literature Review.

This literature review aimed to review the current understanding, indications, and limitations of pedicle screw instrumentation cement augmentation. Since they were first reported in the 1980s, pedicle screw cement augmentation rates have been increasing. Several studies have been published to date that describe various surgical techniques and the biomechanical changes that occur when cement is introduced through the screw-bone interface. This article provides a concise review of the uses, biomechanical properties, cost analysis, complications, and surgical techniques used for pedicle screw cement augmentation to help guide physician practices. A comprehensive review of the current literature was conducted, with key studies, and contributions from throughout history being highlighted. Patients with low bone mineral density are the most well-studied indication for pedicle screw cement augmentation. Many studies show that cement augmentation can improve pullout strength in patients with low bone mineral density; however, the benefit varies inversely with pathology severity and directly with technique. The various screw types are discussed, with each having its own mechanical advantages. Cement distribution is largely dependent on the filling method and volume of cement used. Cement composition and timing of cement use after mixing are critical considerations in practice because they can significantly alter the bone-cement and screw-cement interfaces. Overall, studies have shown that pedicle screw cement augmentation has a low complication rate and increased pullout strength, justifying its universal use in patients with a suboptimal bone-implant interface.

Application of cement-augmented pedicle screws in elderly patients with spinal tuberculosis and severe osteoporosis: a preliminary study.

Surgical management of elderly patients with spinal tuberculosis and severe osteoporosis is challenging. Cement-augmented pedicle screws (CAPS) have been specifically designed for elderly patients with osteoporotic spines. Herein, we investigated the feasibility of CAPS applied in elderly patients with spinal tuberculosis and severe osteoporosis. We retrospectively analyzed data of patients with spinal tuberculosis and severe osteoporosis between January 2017 and January 2021. Surgical data, including surgical duration and intraoperative blood loss, were recorded. Radiological parameters, such as correction of regional kyphotic angle and screw loosening, were also evaluated. Additionally, visual analog scores (VAS) and Oswestry disability index (ODI) were used to evaluate back pain and functional recovery, respectively. Erythrocyte sedimentation (ESR) and C-reactive protein (CRP) concentrations were detected to assess tuberculosis activity. The presence of complications and fusion rate was also assessed. A total of 15 patients were included in this study. The surgical duration was 263.0 ± 56.2min, with an average blood loss of 378.7 ± 237.0ml. The correction of regional kyphotic angle was 12.4° ± 15.0°, and it was well maintained until the final follow-up. The mean VAS decreased from 6.0 ± 1.2 points to 0.5 ± 0.6 points, and ODI reduced from 37.8% ± 7.6% to 8.3% ± 2.8% (P < 0.01). At the final follow-up, ESR and CRP levels were within normal range. Bony fusion occurred in all patients, with an average fusion duration of 8.8 ± 1.5months. No cases of pedicle screw pullout, screw loosening, or pseudoarthrosis occurred. Tuberculosis recurrence and dissemination were not observed during the follow-ups. CAPS fixation is an effective and safe technique to achieve solid fixation and favorable clinical outcomes in elderly patients with spinal tuberculosis and severe osteoporosis.

Treatment of stage Ⅱ-Ⅲ Kümmell disease with robot-assisted bone cement-augmented pedicle screw fixation

To evaluate the early clinical efficacy of robot-assisted percutaneous short-segment bone cement-augmented pedicle screw fixation in the treatment of stageⅡ-Ⅲ Kümmell disease. The clinical data of 20 patients with stageⅡ-Ⅲ Kümmell's disease who underwent robot-assisted percutaneous bone cement-augmented pedicle screw fixation between June 2017 and January 2021 were retrospectively analyzed. There were 4 males and 16 females, aged from 60 to 81 years old with an average age of (69.1±8.3) years. There were 9 cases of stageⅡand 11 cases of stage Ⅲ, all of which were single vertebral lesions, including 3 cases of T11, 5 cases of T12, 8 cases of L1, 3 cases of L2, and 1 case of L3. These patients did not exhibit symptoms of spinal cord injury. The operation time, intraoperative blood loss, and complications were recorded. The position of pedicle screws and the filling and leakage of bone cement in gaps were observed using postoperative CT 2D reconstruction. The data of the visual analogue scale (VAS), Oswestry disability index (ODI), kyphosis Cobb angle, wedge angle of the diseased vertebra, and anterior and posterior vertebral height on lateral radiographs were statistically analyzed preoperatively, 1 week postoperatively, and at the final follow-up. Twenty patients were followed up for 10 to 26 months, with an average follow-up of (16.0±5.1) months. All operations were successfully completed. The surgical duration ranged from 98 to 160 minutes, with an average of (122±24) minutes. The intraoperative blood loss ranged from 25 to 95 ml, with an average of (45±20) ml. There were no intraoperative vascular nerve injuries. A total of 120 screws were inserted in this group, including 111 screws at grade A and 9 screws at grade B according to the Gertzbein and Robbins scales. Postoperative CT indicated that the bone cement was well-filled in the diseased vertebra, and cement leakage occurred in 4 cases. Preoperative VAS and ODI were (6.05±0.18) points and (71.10±5.37)%, respectively, (2.05±0.14) points and (18.57±2.77)% at 1 week after operation, and (1.35±0.11) points and (15.71±2.12) % at final follow-up. There were significant differences between postoperative 1 week and preoperative, and between final follow-up and postoperative 1 week(P<0.01). Anterior and posterior vertebral height, kyphosis Cobb angle, and wedge angle of the diseased vertebra were(45.07±1.06)%, (82.02±2.11)%, (19.49±0.77) °, and (17.56±0.94) ° preoperatively, respectively, (77.00±0.99)%, (83.04±2.02)%, (7.34±0.56) °, and (6.15±0.52) ° at 1 week postoperatively, and (75.13±0.86)%, (82.39±0.45)%, (8.38±0.63) °, and (7.09±0.59) ° at the final follow-up. Robot-assisted percutaneous short-segment bone cement-augmented pedicle screw fixation demonstrates satisfactory short-term efficacy in treating stageⅡ-Ⅲ Kümmell's disease as an effective minimally invasive alternative. However, longer operation times and strict patient selection criteria are necessary, and long-term follow-up is required to determine its lasting effectiveness.

Cement Augmented Pedicle Screw Instrumentation in Pediatric Spine Surgery

Osteoporosis in pediatric patients is rare. Osteomalacia and osteoporosis are known to develop in syndromic or neuromuscular scoliosis children. Spinal deformity surgery for pediatric patients with osteoporosis is challenging, associated with pedicle screw (PS) failure and compression fractures. Cement augmentation of PS is one several measures to prevent screw failure. It provides additional pull-out strength to the PS in the osteoporotic vertebra. In 2010-2020, an analysis of pediatric patients who had cement augmentation of PS with a minimum follow-up of 2 years was performed. Radiological and clinical evaluations were analyzed. The study included 7 patients (4 girls, 3 boys) with a mean age of 13 years (range, 10-14 years) and mean follow-up of 3 years (range, 2-3 years). Only 2 patients underwent revision surgery. Total number of cement augmented PSs was 52 with an average of 7 per patient. Only 1 patient had lower instrumented vertebra vertebroplasty. There was no PS pull-out in the cement augmented levels, and there were no neurological deficits or pulmonary cement embolisms. One patient developed a PS pull-out in uncemented levels. Two patients developed compression fractures, one, with osteogenesis imperfecta, in the supra-adjacent levels (upper instrumented vertebra+ 1 and upper instrumented vertebra+ 2), and the other, with neuromuscular scoliosis, in the uncemented segments. In this study, all cement augmented PSs provided satisfactory radiological outcomes without PS pull-out and adjacent vertebral compression fracture. In pediatric spine surgery, in osteoporotic patients with a poor bone purchase, cement augmentation may be used, especially in high-risk patients with osteogenesis imperfecta, neuromuscular scoliosis, and syndromic scoliosis.

Asymptomatic Azygos Vein Cement Embolism: A Potential Risk of Cement Injection via Cannulated Screw: A case report

Objective: Vertebroplasty is a method that stabilizes the fracture and relieves pain by injecting cement into the vertebral body that has lost its height for some reason. Cement injection can also be done through kyphoplasty and cannulated screw. During the injection, protrusion of the cementum from the corpus is a complication that must be avoided in this procedure. Cement extending out of the corpus may cause pulmonary cement embolism (PCE) via the azygos vein. Case: A 76-year-old female patient was admitted to our clinic with the complaint of low back pain that had been going on for one year. The patient, who did not have motor or sensory deficits in the examination, described neurogenic claudication at 200 meters as well as sensitivity in the lumbar region. An osteoporotic collapse fracture in the L1 vertebra was detected in the patient's imaging. Transpedicular fixation, decompression, and cement-augmented pedicle screw were applied to the patient. After the operation, vena azygos cement embolism was detected in the thoracolumbar computed tomography (CT) scan conducted for follow-up. Although detailed tests were performed for pulmonary embolism (PCE), no findings were detected in the asymptomatic patient. During the follow-up examination after discharge, the patient did not report any respiratory complaints, pain in the lumbar region, or neurogenic claudication complaints. Conclusion: PCE may develop after cement leakage into the azygos vein during cement injection. Although most PCEs remain asymptomatic, sometimes serious or even fatal sequelae have been reported. Cement overflows not reflected in fluoroscopy during the procedure can be detected by post-procedure imaging, and patients can be protected from serious complications.

High Rate of Pulmonary Cement Embolism after Cement-Augmented Pedicle Screw Fixation: A 12-Year Single-Center Study.

The global trend toward increased life expectancy because of remarkable improvements in health care quality has drawn increased attention to osteoporotic fractures and degenerative spine diseases. Cement-augmented pedicle screw fixation has been established as the mainstay treatment for patients with poor bone quality. This study aimed to determine the number of patients with cement leakage and pulmonary cement embolism (PCE) as detected on thoracic computed tomography (CT), and to assess the potential risk factors for PCE. Patients undergoing cement-augmented pedicle screw placement in our institution between May 2008 and December 2020 were included. Data regarding baseline characteristics, complications, and cement leakage rates were collected. Indications for the performance of a postoperative thoracic CT due to the suspicion of PCE were intra- or postoperative complications, or postoperative oxygen supplementation. Moreover, PCE was accidently diagnosed because the thoracic CT was performed for medical reasons other than the suspicion of PCE (tumor staging, severe pneumonia, or exacerbated chronic pulmonary obstructive disease). A total of 104 patients with a mean age of 72.8 years (standard deviation of 6.7) were included. Of 802 screws, 573 were cement augmented. Of the 104 patients, 44 (42.3%) underwent thoracic CT scans to diagnose PCE; additionally, 67 (64.4%) demonstrated cement leakage, of whom 27 developed PCE and 4 were symptomatic. Cement-augmented thoracic screws were a risk factor for PCE (odds ratio: 1.5; 95% confidence interval: 1.2-2.1; p = 0.004). This study showed a high prevalence of cement leakage after cement-augmented pedicle screw insertion, with a relatively frequent incidence of PCE, as tracked by thoracic CT scans. Cement-augmented thoracic screw placement was a unique risk factor for PCE.

Cardiopulmonary Cement Embolism Following Cement-Augmented Pedicle Screw Fixation: A Narrative Review.

Fixation using cement-augmented pedicle screws (CAPS) is being increasingly performed. However, CAPS-associated cement leakage is a critical problem that can lead to cardiopulmonary cement embolism (CPCE). This narrative review aimed to explore the incidence of and risk factors and treatment strategies for CPCE and cement leakage-related complications after CAPS fixation. Data were extracted from each article, including characteristics of CPCE after CAPS fixation (incidence, location, diagnostic method and criteria, treatment, and outcome and prognosis). Overall, 28 case series and 14 case reports that met the inclusion criteria were included. Of the 1974 cases included in the review, CPCE was noted in 123, symptomatic CPCE in 35, and death in six, respectively. The frequencies of PCE and symptomatic PCE after CAPS fixation were 6% (range: 0-28.6%) and 1.3% (range: 0-26%), respectively. The range of frequencies of PCE and symptomatic PCE after CAPS fixation may have been wide because the definition of CPCE and data collection methods differed among the reports analyzed. Since PCE due to large cement emboli may be primarily related to the surgical technique, improved technique, such as minimizing the number of CAPSs by injecting low-volume high-viscosity cement at low velocity and pressure, and careful observation of cement leakage during CAPS insertion may reduce PCE associated with cement leakage. Spinal surgeons should pay more attention to the occurrence of CPCE during and after CAPS insertion, which can cause serious complications in some patients.

Reversed windshield-wiper effect leads to failure of cement-augmented pedicle screw: Biomechanical mechanism analysis by finite element experiment

The failure mode of cement-augmented pedicle screw (CAPS) was different from common pedicle screw. No biomechanical study of this failure mode named as “reversed windshield-wiper effect” was reported. To investigate the mechanisms underlying this failure mode, a series of finite element models of CAPS and PS were modified on L4 osseous model. Nine models were created according to the cement volume at 0.5 mL interval (range: 1–5 mL). Pullout load and cranio-caudal loads were applied on the screws. Stress and instantaneous rotation center (IRC) of the vertebra were observed. Under cranio-caudal load, the stress concentrated on the screw tip and pedicle region. The maximal stress (MS) at the screw tip region was +2.143 MPa higher than pedicle region. With cement volume increasing, the maximal stress (MS) at the screw tip region decreased dramatically, while MS at pedicle region was not obviously affected. As dose increased to 1.5 mL, the MS at pedicle region became higher than screw tip region and the maximal stress difference was observed at 3.5 mL. IRC of the vertebra located at the facet joint region in PS model. While IRC in CAPS models shifted anteriorly closer to the vertebral body with the increasing of cement volume. Under axial pull-out load, the maximal stress (MS) of cancellous bone in CAPS models was 29.53–50.04% lower than that 2.228 MPa in PS model. MS in the screw-bone interface did not change significantly with cement volume increasing. Therefore, the possible mechanism is that anterior shift of IRC and the negative difference value of MS between screw tip and pedicle region due to cement augmentation, leading to the screw rotate around the cement-screw complex as the fulcrum point.

Posterior instrumentation for osteoporotic fractures in the thoracic or lumbar spine: Cement-augmented pedicle screws vs hybrid constructs.

Cement-augmented pedicle screws (CPS) and hybrid construct (HC), consisting of pedicle screws and additional hooks, are common fixation methods for osteoporotic spine fracture. No study has compared surgical results of CPS and HC for treating osteoporotic spine fracture. The aim of the study was to compare surgical results using CPS or HC for osteoporotic fractures of the thoracic or lumbar spine. This retrospective cohort study included 84 patients who received surgical treatment with CPS (n = 43) or HC (n = 41) for osteoporotic spine fractures from January 2011 to December 2015, with a mean follow-up of 67 months. Sixty-five patients with neurological deficits received long posterior instrumentation, short posterior decompression, and posterolateral fusion. The 19 patients without neurologic deficits received long posterior instrumentation without posterior decompression and fusion. Radiographic, clinical, and neurologic outcomes were evaluated. The HC group had significantly shorter operative times (231 vs 258 minutes), greater blood loss (497 vs 427 mL), better immediate postoperative kyphosis reduction (10.6° vs 9.1°), and greater final reduction loss (9.8° vs 7.1°) than the CPS group. In both groups, significant loss of the kyphotic angle was apparent during follow-up. Improved ambulation after surgery occurred in 51.2% and 58.5% of patients in the CPS and HC groups, respectively. Neurologic function after surgery improved 0.5 and 0.7 grades in the CPS and HC groups, respectively. Implants failed in 2.3% and 2.4% of patients in the CPS and HC groups, respectively. The incidence of cement leakage from screw augmentation was 38.9%. The CPS and HC techniques for treating osteoporotic fractures of the thoracic or lumbar spine did not differ statistically in terms of improved radiologic and clinical outcomes, final neurologic and ambulatory function, or implant failure rates, making them equally comparable alternatives.

Comparison of pedicle screw fixation with or without cement augmentation for treating single-segment isthmic spondylolisthesis in the osteoporotic spine

The present study examined the necessity of cement-augmented pedicle screw fixation in osteoporotic patients with single-segment isthmic spondylolisthesis.Fifty-nine cases were reviewed retrospectively. Thirty-three cases were in the polymethylmethacrylate-augmented pedicle screw (PMMA-PS) group, and the other 26 cases were in the conventional pedicle screw (CPS) group. Evaluation data included operation time, intraoperative blood loss, hospitalization cost, hospitalization days, rates of fusion, screw loosening, bone cement leakage, visual analogue scale (VAS) scores, Oswestry disability index (ODI), lumbar lordosis (LL), pelvic tilt (PT) and sacral slope (SS).The operation time and blood loss in the CPS group decreased significantly compared to those in the PMMA-PS group. The average hospitalization cost of the PMMA-PS group was significantly higher than that of the CPS group. There was no significant difference in the average hospital stay between the 2 groups. The initial and last follow-up postoperative VAS and ODI scores improved significantly in the two groups. There were no significant differences in VAS and ODI between the 2 groups at each time point. The last postoperative spine-pelvic parameters were significantly improved compared with those preoperatively. In the PMMA-PS group, the fusion rate was 100%. The fusion rate was 96.15% in the CPS group. No significant difference was found between the two groups for the fusion rate. Nine patients in the PMMA-PS group had bone cement leakage. There was no screw loosening in the PMMA-PS group. There were 2 cases of screw loosening in the CPS group. There were no significant differences in screw loosening, postoperative adjacent segment fractures, postoperative infection or postoperative revision between the 2 groups. The use of PMMA-PS on a regular basis is not recommended in posterior lumbar interbody fusion for the treatment of single-segment isthmic spondylolisthesis with osteoporosis.

Novel Polyethylene Terephthalate Screw Sleeve Implant: Salvage Treatment in a Case of Spine Instability after Vertebroplasty Failure

The management of osteoporotic fractures is sometimes rather challenging for spinal surgeons, and considering the longer life expectancy induced by improved living conditions, their prevalence is expected to increase. At present, the approaches to osteoporotic fractures differ depending on their severity, location, and the patient's age. State-of-the-art treatments range from vertebroplasty/kyphoplasty to hardware-based spinal stabilization in which screw augmentation with cement is the gold standard. We describe the case of a 74-year-old man with an L5 osteoporotic fracture. The patient underwent a vertebroplasty (VP) procedure, which was complicated by a symptomatic cement leakage in the right L4-L5 neuroforamen. We urgently decompressed the affected pedicle via hemilaminectomy. At that point, the column required stability. The extravasation of cement had ruled out the use of cement-augmented pedicle screws but leaving the pedicular screws alone was not considered sufficient to achieve stability. We decided to cover the screws with a polyethylene terephthalate sleeve (OGmend®) to avoid additional cement leakage and to reinforce the screw strength required by the poor bone quality. In the evolving technologies used for spinal surgery, screws sleeve implants such as OGmend® are a useful addition to the surgeon's armamentarium when an increased pull-out strength is required and other options are not available.

Comparing the efficacy and safety of cement-augmented fenestrated pedicle screws and conventional pedicle screw in surgery for spinal metastases: a retrospective comparative cohort study.

The incidence of cancer patients with bone metastasis is increasing annually. With the advancement of medical treatment for malignant tumors, the survival time of patients with spinal metastases is gradually being prolonged, and adjacent segment vertebral metastases often occur after conventional pedicle screw (CPS) surgery, leading to spinal instability, pain and nerve function injury again, with repeated symptoms. Combined pedicle screw fixation can maintain or reconstruct the spinal stability. This study aimed to investigate the efficacy and safety of cement-augmented fenestrated pedicle screws in the posterior approach for spinal metastases by comparing with CPS. From January 2017 to August 2019, 52 patients with spinal metastases who underwent separation surgery and internal fixation via posterior approach were retrospectively enrolled. Cases were divided into the cement-augmented pedicle screw (CAPS) group (28 cases) and the CPS group (24 cases). The baseline data [age, gender, surgical sites, surgical segment, Tomita classification, Tomita score, Tokuhashi score, spinal instability neoplastic score (SINS)], surgical information, and local progression-free survival (PFS) time were compared between the two groups. Every patient was followed-up every 3 months with imaging examination. The visual analog scale (VAS) score and Frankel grade of the two groups were recorded before and 3 months after the operation were used to evaluate the efficacy. The operation time, the amount of intraoperative blood loss, the amount of bone cement injected in the pedicle screw group, and the complications of the surgery were recorded to evaluate the safety of CAPS. The baseline characteristics were comparable between the two group. Compared with the CPS group, the CAPS group showed significantly longer operation time (163±20 vs. 138±18 min, P<0.001) and lower VAS scores (2.93±1.33 vs. 4.17±1.34, P=0.002). Adjacent segment vertebral metastasis occurred in 10 cases (2 in the CAPS group and 8 in the CPS group, P=0.017). Internal implant failure occurred in 8 cases (1 in the CAPS group and 7 in the CPS group, P=0.011). Compared with the CPS group, the CAPS group had a significantly longer local PFS time (P<0.05). CAPS could be a safe and effective choice in surgery for spinal metastases with the posterior approach.