Anatomical and Pathological Considerations in Percutaneous Vertebroplasty and Kyphoplasty: A Reappraisal of the Vertebral Venous System

Abstract

Thorough knowledge of the anatomic and (patho)physiologic characteristics of the vertebral venous system is mandatory for all physicians that participate in percutaneous vertebroplasty and kyphoplasty. To reduce the risk of cement extrusion into the vertebral venous system during injection, vertebral venous pressure should be increased during surgery. This can be achieved by operating the patient in the prone position and by raising intrathoracic venous pressure with the aid of the anesthesiologist during intravertebral instrumentation and cement injection. Intensive theoretical and practical training, critical patient selection, and careful monitoring of the procedures, also taking into account patient positioning and intrathoracic and intra-abdominal pressures, will help to facilitate low morbidity outcomes in these very promising minimally invasive techniques.

Respiratory effects, hemodynamic changes and cement leakage during multilevel cement balloon kyphoplasty

“…For example, a drop in ABP or changes in blood gases in an old osteoporotic patient can be easily misconstrued as result of cardiopulmonary disease [4]. Several authors have blamed PMMA toxicity for cardiopulmonary complications during cement augmentation procedures and suggest the use of less toxic, non-PMMA bone cement [12,13].…”

“…This allows the anesthesiologist to elevate intrathoracic and intra-abdominal pressures (i.e., venous pressure), when inflating the balloons or inserting the cement, to avoid undesirable cardiorespiratory changes. However, high intrathoracic pressure may dramatically impair venous return to the heart leading to hemodynamic collapse, especially in elderly and cardiopulmonary compromised patients [4]. The raise of intrathoracic and intra-abdominal pressure technique should be applied very briefly and only during balloon inflation and cement insertion.…”

“…Augmentation of more than one vertebral body is reported as a risk factor for increasing the incidence of embolic phenomena [2]. Although PMMA toxicity has been ascribed for cardiopulmonary events, there is evidence that the potential cardiovascular complications during balloon kyphoplasty are highly related to increased interosseous pressure within the vertebral bodies rather than the PMMA toxicity itself [3,4].…”

Perispinal etanercept: a new therapeutic paradigm in neurology

“…Batson's plexus is an extensive inter connected plexus of veins that surrounds the spine and is distributed along the entire length of the spine, from the sacrum to the neck, communicating freely with the pelvic and prostatic venous plexuses caudally and with the cerebral venous system via extensive interconnections at the base of the cranium [23,[40][41][42]. Among the unique features of Batson's plexus is the fact that it lacks venous valves, so flow within this system is bidirectional [23,[40][41][42]87,88]. The functional and anatomic continuity of the vertebral venous system with the cerebral venous system led this author to select the name 'cerebrospinal venous system' to designate the combination of the cerebral venous system with the vertebral venous plexus [40].…”

Effects of cement augmentation on the mechanical stability of multilevel spine after vertebral compression fracture

“…The procedure involves fluoroscopicor CT-guided injection of acrylic cement, usually polymethylmethacrylate (PMMA) into the fractured vertebral body via a transpedicular or extrapedicular approach (11). As the incidence of vertebral compression fractures continues to rise as our population ages (12), cement augmentation will no doubt be performed more extensively, and more information is needed about this relatively new procedure.…”