Pulmonary Cement Embolism Research Articles

Cemented in place: kyphoplasty-associated pulmonary cement embolism: a case report

BackgroundKyphoplasty-associated cement extravasation into surrounding tissue and vasculature can lead to life-threatening complications. We present a rare case of significant inferior vena cava cement burden that resulted in pulmonary embolism.Case presentationA 74-year-old Caucasian woman with a history of severe osteoporosis, recurrent falls, and spinal compression fracture status post-kyphoplasty of the L4–L5 vertebrae, presents to the emergency department 2 days post-vertebral kyphoplasty due to chest pain, back pain, and dyspnea. Computed tomography of the chest and abdomen showed a metallic density within the inferior vena cava extending superiorly approximately 10 cm from the vertebral L5 level. She was also found to have right lower lobe pneumonia. The patient finished a 10-day course of antibiotics and was discharged home with a 1-month long course of anticoagulation with apixaban per recommendations of a multidisciplinary team consisting of Hematology/Oncology, Interventional Radiology, Vascular Surgery, and Orthopedic Surgery. Unfortunately, the patient was readmitted a month later with shortness of breath. Work up was notable for an influenza type A infection and computed tomography findings of pulmonary cement embolism. The respiratory distress was resolved with supportive care. Despite pulmonary cement burden, the multidisciplinary care team recommended no further anticoagulation. Patient was discharged home with close clinical follow-up and 6 months has since passed at the time of this report without reported complications.ConclusionsA large cement burden in the inferior vena cava leading to pulmonary cement embolism is a rare event. A high burden of cement predisposes development of pulmonary embolism. A short course of anticoagulation may only be needed for asymptomatic patients.

Clinical case of pulmonary cement embolism and adjacent fractures as a complication after vertebroplasty

Introduction: Osteoporosis is a skeleton disease with reduction in bone mass and disruption of the bone microstructure. A rare secondary form is pregnancy-associated osteoporosis. The standard method for determining bone density is DEXA measurement (dual X-ray absorptiometry). With the radiofrequency echographic multi spectrometry (REMS) method this is done using ultrasound without radiation exposure. Osteoporosis often leads to pathological fractures of the vertebrae. In case of severe pain and immobilization vertebroplasty is considered standard procedure. However, it can have side effects such as cement leakage into surrounding tissue, pulmonary embolism and adjacent fractures.
 Case: We present a 27-year-old female patient with compression fractures of the Th8 and Th12 5 months after labour. DEXA measurements showed values of the T-score at hip neck -2,5 SD (total) and -3,5 SD (L1-L4) at spine. The fractures of the Th8 and Th12 were then treated with vertebroplasty. A post-operative CT showed cement leakage and extravasation, as well as bilateral cement embolism of the proximal branches of the pulmonary arteries and progression of the height loss of Th5, Th7 and L1.
 Discussion: Pulmonary cement embolism is a rare complication of vertebroplasty. Cement leakage is more frequent complication, although most of the time asymptomatic. These risks of complications make the alternative conservative treatment worth considering before proceeding to surgical interventions. Only after failure to achieve adequate pain management kyphoplasty or vertebroplasty should be considered, due to the risks of prolonged immobilization of the patient leading to further bone and muscle loss.
 Conclusion: Pregnancy associated osteoporosis is very rare. The radiation free REMS method is suitable for pregnant women. Vertebroplasty offers pain relief and rapid mobilization of the patient. However, it poses a risk of numerous complications. The osteoporotic fractures of the vertebrae are usually stable and a conservative treatment prior to surgical interventions should always be considered.

Cement Pulmonary Embolism during Cemented Total Hip Arthroplasty: A Case Report and Review of Literature

Fractures of the femoral neck are the most frequent in elderly patients. They represent the most prevalent pathology in traumatology. Their incidence increases with age due to osteoporosis and the tendency to fall. Treatment is by cemented or uncemented arthroplasty. The use of polymethylmetacrylate cement provides primary stabilization of the implant and compensates for the poor bone quality in the elderly. However, the use of cement is not without complications and cement pulmonary embolism is one of the most serious complications. We report the case of a 64- year-old patient admitted to the Department of Orthopaedic and Traumatologic Surgery for a femoral neck fracture classified as Garden 2 and who underwent cemented arthroplasty complicated by cement pulmonary embolism and death.

Cement pulmonary embolism as a complication of percutaneous vertebroplasty in a patient with follicular lymphoma

Vertebroplasty involves injecting a cement polymer, often polymethylmethacrylate (PMA), into the vertebral body under imaging guidance to increase stability. However, the high vascularization and anatomical network of the paravertebral and extradural venous plexuses can allow the migration of cement particles into the systemic venous circulation regardless of whether spinal compression or fractures occur during or are present prior to the treatment. This case report presents a 42-year-old female patient who visited the emergency room with symptoms of cough, nasal obstruction, rhinorrhea, and dyspnea and had a history of follicular non-Hodgkin’s lymphoma under rituximab treatment. Imaging revealed a cement embolism in the pulmonary artery tree, most likely caused by prior vertebroplasty. Anticoagulation was started despite the lack of hypoxemia due to the inorganic character of the embolic substance and the patient’s immunosuppressed status. The embolic debris was still present on subsequent imaging, but the patient’s condition remained stable, with some signs of illness remission. This case highlights the importance of considering cement embolism as a possible vertebroplasty complication and the importance of properly assessing and managing such cases, particularly in patients with underlying medical issues, as well as the need for the development of a standard protocol of sequential chest X-rays after the procedure and possible alternatives to PMA.

Pulmonary cement embolism: a complication following vertebroplasty - a case report with brief review of literature

BackgroundA minimally invasive treatment for vertebral compression fractures is vertebroplasty. In spite of its relative safety, complications have been reported. It is a relatively uncommon complication among these that patients experience massive cement pulmonary embolism. Polymethyl methacrylate (PMMA) can cause embolization in the pulmonary arteries. One of the most common cements used in vertebroplasty is PMMA, a type of acrylic cement. Pulmonary cement embolism can occur if cement leaks into the perivertebral veins and then the pulmonary arteries (Barbero et al., Radiol Med 113:101–13, 2008). Occasionally, the patient will show no symptoms at all, while other times they will experience dyspnea, chest pain, or acute respiratory distress syndrome. A 54-year-old male who underwent vertebroplasty developed pulmonary cement embolism is the patient in our case report.Case presentationA 54-year-old male had complaints of breathlessness for 1 week and left lower limb and lower back pain associated with swelling of the lower limbs for 20 days. The patient is an operated case of osteoporotic compression fractures of D6, D11, L1, L3, and L5 vertebroplasty 3 years back. Subsequently, computed tomography pulmonary angiography was performed and diagnosed with partial embolization of the distal peripheral branches of the bilateral pulmonary arteries by the vertebroplasty material.ConclusionVertebroplasty and kyphoplasty are the most prevalent procedures used to inject bone cement (PMMA) into the vertebral column in order to treat osteoporosis. With vertebroplasty, the possibility of embolization increases. In vertebral osteoporosis, the primary advantage is a reduction in pain and vertebral body collapse. Pulmonary cement embolization causes chest discomfort and shortness of breath. Sometimes, acute respiratory distress syndrome is present (Yoo et al., Spine (Phila Pa 1976) 29:E294–7, 2004). After the operation, these symptoms rarely arise. Symptoms often appear weeks, months, or years after the surgery (Habib et al., Heart Lung 41:509-11, 2012). Through this case report, we discuss the complication following vertebroplasty and their management guidelines.

Cement pulmonary embolism as a complication of percutaneous vertebroplasty

Percutaneous Vertebroplasty (PV) involves the injection of Poly Methylmeth Acrylate (PMA) Bone Cement (BC) into the vertebral body

Risk factors for pulmonary cement embolism after percutaneous vertebroplasty and radiofrequency ablation for spinal metastases.

Pulmonary cement embolism is a rare but underestimated complication of vertebroplasty due to the relative lack of study and examination. This study aims to investigate the incidence of pulmonary cement embolism in patients with spinal metastasis who undergo PVP with RFA and to analyze the relative risk factors. A total of 47 patients were retrospectively included and classified into pulmonary cement embolism (PCE) group and non-pulmonary cement embolism (NPCE) group by comparing pre- and postoperative pulmonary CT scan images. The demographic and clinical information of the patients was obtained. Demographic data in the two groups were compared using the chi-square test for qualitative data and the unpaired t test for quantitative data. Multiple logistic regression analysis was used to identify risk factors related to pulmonary cement embolism. Pulmonary cement embolism was detected in 11 patients (23.4%), and all patients were asymptomatic and followed up regularly. Risk analysis showed that multiple segments (≥3, p=0.022), thoracic vertebrae (p=0.0008), and unipedicular puncture approach (p=0.0059) were risk factors for pulmonary cement embolism. There was a high incidence of pulmonary cement embolism if bone cement leaked into the para vertebral venous plexus in the thoracic vertebra (p<0.0001). Vein leakage of cement was related to the integrity of the vertebral cortex. The number of involved vertebrae, lesion location, and puncture approach are independent risk factors for pulmonary cement embolism. There was a high incidence of pulmonary cement embolism if bone cement leaked into the para vertebral venous plexus in the thoracic vertebra. Surgeons should consider these factors when formulating therapeutic strategies.

Bone Cement Emboli after Arthroplasty: Is It Possible? A Case Report and Literature Review

Background: Polymethylmethacrylate (PMMA) has been extensively used as bone cement in orthopedic procedures. Pulmonary cement embolisms (PCEs) are supposed to originate from cement extravasation into the basivertebral veins before draining into the inferior vena cava and eventually becoming lodged in the pulmonary capillaries. Few cases of bone cement embolism have been reported. This study reported a case of pulmonary embolism (PE) after thoracolumbar fixation and kyphoplasty and reviewed the current literature.&#x0D; Case Report: We presented an 81-year-old woman who had undergone thoracolumbar vertebroplasty three months before admission and became symptomatic due to PE after total knee arthroplasty (TKA).&#x0D; Conclusion: This case illustrates that clinicians must be aware of the probable occurrence of respiratory distress syndrome in patients with a history of vertebroplasty.

CT features and risk factors of pulmonary cement embolism after vertebroplasty or kyphoplasty in patients with vertebral compression fracture: a retrospective cohort study.

Pulmonary cement embolism (PCE) caused by cement leakage is one of the complications of percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP). The aim of our study was to explore the imaging features on computed tomography (CT) and analyze the risk factors of PCE in patients with a vertebral compression fracture to compare the incidences of PCE caused by PVP and PKP. In this single-center, retrospective study, 373 patients (96 males and 277 females; mean age 76.2±9.4 years) from January 2017 to December 2020 who underwent PVP or PKP for treatment of vertebral compression fracture in the China-Japan Friendship Hospital were retrospectively included. Their clinical data were recorded, and their postprocedural chest CT scans were reviewed and evaluated for PCE. Of the 373 patients, 258 patients underwent PVP while the other 115 underwent PKP. PCE was found on the postprocedural chest CT scans in 64 patients (17.2%), including 47 patients with PVP and 17 patients with PKP. The incidence of PCE of PVP and PKP was similar (χ2=0.660; P=0.460). The typical CT findings of PCE were multiple linear or branching radiopaque densities in pulmonary arteries. The upper lobes of bilateral lungs were the most frequently involved. In addition, postprocedural chest CT demonstrated that 103 cases had cement emboli in the azygos vein, and 8 cases had cement emboli in the inferior vena cava. Binary logistic regression analysis demonstrated that PVP or PKP in the T9 vertebra [odds ratio (OR) =4.222; 95% CI: 1.490-11.966] and cement emboli in the azygos vein (OR =7.647; 95% CI: 3.937-14.856) or the inferior vena cava (OR =42.701; 95% CI: 7.525-242.302) were the risk factors of PCE. The incidence of PCE during PVP or PKP was 17.2%. Postprocedural chest CT clearly showed PCE as branching hyperdense or radiopaque lesions confined within the pulmonary artery courses. PVP or PKP in the T9 vertebra and cement emboli in the azygos vein or the inferior vena cava were risk factors for PCE.

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.

Pulmonary artery bone cement embolization resulting from percutaneous vertebroplasty.

Pulmonary artery bone cement embolization resulting from percutaneous vertebroplasty.

Analysis of medical malpractice litigation following vertebral augmentation therapy in China from 2008 to 2018.

The first case of vertebral augmentation therapy in mainland China was reported in 2000. Since then, it has been widely used in China as a minimally invasive procedure to treat vertebral compression fractures. However, the characteristics of malpractice litigation involving vertebral augmentation therapy remains unclear. This study aims to analyze the characteristics of medical malpractice litigation involving vertebral augmentation therapy in mainland China for the past 10 years. Two online legal databases were queried for court verdicts involving vertebral augmentation therapy from Jan 2009 to Dec 2018 in mainland China. Each case file was then thoroughly reviewed and data pertaining to defendants, plaintiffs, case outcomes, allegations, and verdicts were abstracted, and descriptive analyses were performed. Level of evidence: LEVEL III. A total of 96 cases were enrolled for final analysis. The number of claims increased by five times during the past 10 years. More than two thirds (67.7%, n = 65) of the cases underwent percutaneous vertebroplasty, and 22.9% (n = 22) underwent percutaneous kyphoplasty, the rest (9.4%, n = 9) remained undefined. Paralysis was alleged in 35.4% of cases (n = 34), followed by significant physical injury (34.4%, n = 33). Cement leakage to spinal canal (44.8%, n = 43) is the most commonly cited reason for litigation, followed by incomplete informed consent (42.7%, n = 41), accidental dural puncture (20.8%, n = 20), unsatisfactory clinical outcome (18.8%, n = 18), and misdiagnosis (12.5%, n = 12). Acute pulmonary cement embolism (4.2%, n = 4), wrong-level vertebrae procedure (3.1%, n = 3) and postoperative infection (2.1%, n = 2) were less common causes for concern. Doctors successfully defended themselves only in 8 (8.3%) cases, which resulted in no indemnity payment. The rest 88 (91.7%) cases were closed with a mean verdict payout of 361,580 Yuan (51,654 US dollars). There is a quickly rising trend in the number of medical malpractice litigation involving vertebral augmentation therapy in China. Identifying the most common reasons for litigation and summarizing their characteristics may help decrease litigation rate and improve the patient experience.

MANAGEMENT OF PULMONARY CEMENT EMBOLI AFTER KYPHOPLASTY

MANAGEMENT OF PULMONARY CEMENT EMBOLI AFTER KYPHOPLASTY

CEMENTING THE SIDE EFFECTS OF KYPHOPLASTY: CEMENT EMBOLI IN THE CARDIOPULMONARY SYSTEM

CEMENTING THE SIDE EFFECTS OF KYPHOPLASTY: CEMENT EMBOLI IN THE CARDIOPULMONARY SYSTEM

Pulmonary cement embolism is frequently observed but not a contributing factor for death in patients with cemented total hip and knee arthroplasty: a postmortem study

PurposeBone cement is frequently used for implant fixation in orthopaedic surgery. The occurrence of pulmonary cement embolism (PCE) in hip and knee arthroplasty has been described previously, but the exact extent and frequency have not been adequately studied. A postmortem cohort provides a unique opportunity for a more detailed analysis of this phenomenon.MethodsThrough retrospective analysis of whole-body computed tomography (CT) scans and autopsy protocols, we identified 67 cases with previous cemented total hip or knee arthroplasties. A grading system originally developed for PCE after cemented spine procedures was used. Findings were compared with two control groups: 35 individuals with previous cementless total joint arthroplasty as well as 25 individuals without evidence of prostheses.ResultsPCE was detected in 46.3% of the cases: grade 1 (31.3%), grade 2 (10.5%), and grade 3 (4.5%). No statistically significant difference was found between hip and knee arthroplasties in terms of PCE frequency. Importantly, none of the autopsy reports listed PCE as a cause of death or a contributing factor for the patients’ death. In the two control groups, only one case per group was classified as grade 1 PCE, while the remaining cases did not show any evidence of PCE.ConclusionThe presented data reveal a high frequency of PCE in hip and knee arthroplasties, which is almost identical to previous findings in patients with cement-augmented interventions in the spine. This way, our results underline the relevance of PCE after arthroplasty, suggesting an adaptation of surgical methods to minimize this complication.

Pulmonary Infarction and Acute Respiratory Distress Syndrome Resulted from Small Amount of Peripheral Pulmonary Cement Embolism following Cement-Augmented Pedicle Screw Fixation: A Rare Case and Literature Review

The information about symptomatic pulmonary cement embolism (PCE) following vertebroplasty and cement-augmented pedicle screw fixation is limited. To our knowledge, this is the first reported case of severe acute respiratory distress syndrome (ARDS) caused by a relatively small amount of peripheral PCE, which resulted in mortality.

Risk Factors for Pulmonary Cement Embolism (PCE) After Polymethylmethacrylate Augmentation: Analysis of 32 PCE Cases

ObjectivePulmonary cement embolism (PCE) is an underestimated but potentially fatal complication after cement augmentation. Although the treatment and follow-up of PCE have been reported in the literature, the risk factors for PCE are so far less investigated. This study aims to identify the preoperative and intraoperative risk factors for the development of PCE. MethodsA total of 1,373 patients treated with the polymethylmethacrylate (PMMA) augmentation technique were retrospectively included. Patients with PCE were divided into vertebral augmentation group and screw augmentation group. Possible risk factors were collected as follows: age, sex, bone mineral density, body mass index, diagnosis, comorbidity, surgical procedure, type of screw, augmented level, number of augmented vertebrae, fracture severity, presence of intravertebral cleft, cement volume, marked leakage in the paravertebral venous plexus, and periods of surgery. Binary logistic regression analyses were used to analyze independent risk factors for PCE. ResultsPCE was identified in 32 patients, with an incidence rate of 2.33% (32 of 1,373). For patients who had undergone vertebral augmentation, marked leakage in the paravertebral venous plexus (odds ratio [OR], 1.2; 95% confidence interval [CI], 0.1–10.3; p=0.000) and previous surgery (OR, 16.1; 95% CI, 4.2–61.0; p=0.007) were independent risk factors for PCE. Regarding patients who had undergone screw augmentation, the marked leakage in the paravertebral venous plexus (OR, 4.2; 95% CI, 0.5–37.3; p=0.004) was the main risk factor. ConclusionMarked leakage in the paravertebral venous plexus and previous surgery were significant risk factors related to PCE. Paravertebral leakage and operator experience should be concerned when performing PMMA augmentation.

Percutaneous Cementoplasty for the Pelvis in Bone Metastasis: 12-Year Experience.

BackgroundIn advanced cancer patients, pelvic bone metastasis often causes pain and gait disturbance. The use of percutaneous bone cement [polymethylmethacrylate (PMMA)] injection for pain management and strengthening in pelvic bone metastasis has rarely been reported. To evaluate this method, we aimed to determine surgical outcomes and complications over a long-term follow-up period using a large patient group.Patients and MethodsWe retrospectively collected data from 178 patients who underwent percutaneous cementoplasty for pelvic metastatic lesions, 201 in total. Surgical outcomes evaluated included pain reduction and improvement of ambulation. Mortality within 1 month after procedure and pulmonary embolism caused by thrombus, fat, tumor emboli, or bone cement were investigated as surgical complications. For long-term survivors, pain relapse and mechanical failure were analyzed. The mean follow-up period was 12.6 months, and there were 159 fatalities at last follow-up.ResultsThe mean regional pain numerical rating scale scores decreased from 6.1 preoperatively to 2.4 1 month after procedure (p < 0.01). Gait function was maintained, worsened, and uncheckable in 68%, 24%, and 8% of patients, respectively, 1 month after procedure. Of long-term survivors followed up for > 12 months (n = 53), there were no significant changes in serial plain radiographs, and regional pain aggravation was observed in 9%. Pulmonary cement embolism and bone cement implantation syndrome was observed in 11% and 10%, respectively. However, all patients with these complications were asymptomatic.ConclusionsPercutaneous cement injection into the pelvis is a feasible and safe palliative surgical option for patients with advanced malignancy in terms of pain reduction and maintenance of ambulatory function under regional anesthesia.