Dose-dependent epidural leakage of polymethylmethacrylate after percutaneous vertebroplasty in patients with osteoporotic vertebral compression fractures

Abstract

<jats:p content-type="fine-print"><jats:italic>Object.</jats:italic> The use of polymethylmethacrylate (PMMA) cement by percutaneous injection in cases requiring vertebroplasty provides pain relief in the treatment of osteoporotic vertebral compression fractures. A retrospective study was performed to assess what caused PMMA cement to leak into the epidural space and to determine if this leakage caused any changes in its therapeutic benefits.</jats:p> <jats:p content-type="fine-print"><jats:italic>Methods.</jats:italic> Polymethylmethacrylate was injected into 347 vertebral compression fractures in 159 patients. The cement leaked into the epidural space in 92 (26.5%) of 347 treated vertebrae in 64 (40.3%) of the 159 patients, as demonstrated on postoperative computerized tomography scanning. Epidural leakage of PMMA cement occurred more often when injected above the level of T-7 (p = 0.001) than below. The larger the volume of PMMA injected the higher the incidence of epidural leakage (p = 0.03). Using an injector also increased epidural leakage (p = 0.045). The position of the needle tip within the vertebral body and the pattern of venous drainage did not affect epidural leakage of the cement. Leakage of PMMA into the epidural space reduced the pain relief expected after vertebroplasty. The immediate postoperative visual analog scale scores were higher (and therefore reflective of less pain relief) in patients in whom epidural PMMA leakage occurred (p = 0.009). Three months postoperatively, the authors found the highest number of patients presenting with pain relief, including those in the group with epidural leakage, and at this follow-up stage there were no significant differences between the two groups.</jats:p> <jats:p content-type="fine-print"><jats:italic>Conclusions.</jats:italic> The authors found that epidural leakage of PMMA after percutaneous vertebroplasty was dose dependent. The larger amount of injected PMMA, the higher the incidence of leakage. Injecting vertebral levels above T-7 also increased the incidence of epidural leakage. Epidural leakage of PMMA may attenuate only the immediate therapeutic effects of vertebroplasty.</jats:p>

Comparing effects of kyphoplasty, vertebroplasty, and non-surgical management in a systematic review of randomized and non-randomized controlled studies

“…The lower rate of cement extravasation after BKP is consistent with previous studies [15,18,[49][50][51][52]. A number of factors may have contributed to the heterogeneity in the VP group: procedural technique, variation in considering extravasation as a complication [51], different postoperative radiological follow-up (plain films vs. computed tomography [51,53]), cement viscosity (inverse relationship [52]), cement pressure [49], fracture level (higher extravasation rates above T7), and cement volume (dose dependent [54]). The optimum cement amount per level has not been established, and cement volume does not seem to correlate well with either clinical success [55] or restoration of vertebral stiffness or strength [56,57].…”

Short segment pedicle screw instrumentation and augmentation vertebroplasty in lumbar burst fractures: an experience

“…As proposed by some authors that the fractured and impressed endplate increases the chance of intrusion of the intervertebral disc in the corpus which can cause subsequent spine deformity [19,21]. The possibilities of vertebroplasty to reduce the endplate impression are limited and can only be achieved by building pressure on the cement, which is strongly associated with an increase in cement leakage that can result in spinal cord compression and pulmonary embolism [33][34][35]. The use of inflatable bone tamps in the treatment of osteoporotic compression fractures has received a lot of attention the last few years [36][37][38]42].…”

Surgical removal of extravasated epidural and neuroforaminal polymethylmethacrylate after percutaneous vertebroplasty in the thoracic spine

“…Extravasations of PMMA into the epidural space of the spinal canal account for 22-38% of all detected PMMA leakages associated with PVP [7,21,22,27]. Because PMMA leaks out of the vertebral bodies through different routes, various patterns of cement distribution can be observed and result in neurologic complications.…”

“…Among them, extravasations of PMMA cement is the most prevalent and occurs in 11-81% of PVP cases described in the literature [1,2,4,5,7,9,13,22,27]. Although extravasations of PMMA cement could be reduced by increase of the cement viscosity [3] and are usually of little clinical consequence [7,8,25,27], it can result in severe neurologic complications that require surgical decompression [7,17,[20][21][22][23][24]26].…”