Renal cement embolism during percutaneous vertebroplasty.
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Percutaneous vertebroplasty (PVP) is an effective treatment for lesions of the vertebral body that involves a percutaneous injection of polymethylmethacrylate (PMMA). Although PVP is considered to be minimally invasive, complications can occur during the procedure. We encountered a renal embolism of PMMA in a 57-year-old man that occurred during PVP. This rare case of PMMA leakage occurred outside of the anterior cortical fracture site of the L1 vertebral body, and multiple tubular bone cements migrated to the course of the renal vessels via the valveless collateral venous network surrounding the L1 body. Although the authors could not explain the exact cause of the renal cement embolism, we believe that physicians should be aware of the fracture pattern, anatomy of the vertebral venous system, and careful fluoroscopic monitoring to minimize the risks during the PVP. (+info)
Surgical removal of extravasated epidural and neuroforaminal polymethylmethacrylate after percutaneous vertebroplasty in the thoracic spine.
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Although extravasations of polymethylmetharylate during percutaneous vertebroplasty are usually of little clinical consequence, surgical decompression is occasionally required if resultant neurologic deficits are severe. Surgical removal of epidural polymethylmetharylate is usually necessary to achieve good neurologic recovery. Because mobilizing the squeezed spinal cord in a compromised canal can cause further deterioration, attempts to remove epidural polymethylmetharylate in the thoracic region need special consideration. A 66-year-old man had incomplete paraparesis and radicular pain on the chest wall after percutaneous vertebroplasty for osteoporotic compression fracture of T7. Radiological studies revealed polymethylmetharylate extravasations into the right lateral aspect of spinal canal that caused marked encroachment of the thecal sac and right neuroforamina. Progressive neurologic deficit and poor responses to medical managements were observed; therefore, surgical decompression was performed 4 months later. After laminectomy and removal of facet joints and T7 pedicle on the affected side, extravasated polymethylmetharylate posterior and anterior to the thecal sac was completely removed without retracting the dura mater. Spinal stability was reconstructed by supplemental spinal instrumentation and intertransverse arthrodesis with banked cancellous allografts. Myelopathy and radicular pain gradually resolved after decompression surgery. The patient was free of sensory abnormality and regained satisfactory ambulation two years after surgical decompression. (+info)
Percutaneous vertebroplasty at C2: case report of a patient with multiple myeloma and a literature review.
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Percutaneous vertebroplasty (PVP) of the axis is a challenging procedure which may be performed by a percutaneous or a transoral approach. There are few reports of PVP at the C2 level. We report a case of unstable C2 fracture treated with the percutaneous approach. The fracture was the first manifestation of multiple myeloma in a previously healthy 47-year-old woman. After local radiotherapy and chemotherapy, the fracture was still unstable and the patient had been continuously wearing a stiff cervical collar for 9 months. Complication-free PVP resulted in pain relief and stabilization and use of the cervical collar could be discontinued. At 18 months follow-up the patient remained free from pain, the fracture was stable and she had returned to work. The purpose of this article is to present the technical facts and to highlight the benefits and potential complications of the procedure. The technical characteristics of the procedure, the indication and results of the present case are discussed together with previously reported cases of PVP treatment at C2. (+info)
Balloon kyphoplasty in the management of vertebral compression fractures: an updated systematic review and meta-analysis.
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This systematic review updates the understanding of the evidence base for balloon kyphoplasty (BKP) in the management of vertebral compression fractures. Detailed searches of a number of electronic databases were performed from March to April 2006. Citation searches of included studies were undertaken and no language restrictions were applied. All controlled and uncontrolled studies were included with the exception of case reports. Prognostic factors responsible for pain relief and cement leakage were examined using meta-regression. Combined with previous evidence, a total of eight comparative studies (three against conventional medical therapy and five against vertebroplasty) and 35 case series were identified. The majority of studies were undertaken in older women with osteoporotic vertebral compression fractures with long-term pain that was refractory to medical treatment. In direct comparison to conventional medical management, patients undergoing BKP experienced superior improvements in pain, functionality, vertebral height and kyphotic angle at least up to 3-years postprocedure. Reductions in pain with BKP appeared to be greatest in patients with newer fractures. Uncontrolled studies suggest gains in health-related quality of life at 6 and 12-months following BKP. Although associated with a finite level of cement leakage, serious adverse events appear to be rare. Osteoporotic vertebral compression fractures appear to be associated with a higher level of cement leakage following BKP than non-osteoporotic vertebral compression fractures. In conclusion, there are now prospective studies of low bias, with follow-up of 12 months or more, which demonstrate balloon kyphoplasty to be more effective than medical management of osteoporotic vertebral compression fractures and as least as effective as vertebroplasty. Results from ongoing RCTs will provide further information in the near future. (+info)
Results, experience and technical points learnt with use of the SKy Bone Expander kyphoplasty system for osteoporotic vertebral compression fractures: a prospective study of 40 patients with a minimum of 12 months of follow-up.
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To describe our centre's results, experience and technical points learnt with the SKy Bone Expander System for osteoporotic vertebral compression fractures (VCFs). Forty consecutive patients with painful single level T12 or L1 osteoporotic VCF who had failed conservative management for more than 3 months had 40 single level SKy Bone Expander kyphoplasties performed. Using local anaesthesia with patients in a prone, hyper-lordotic position, a unilateral, percutaneous, intra-pedicular approach was employed. Once correctly positioned, the SKy Bone Expander was expanded, creating a void. It was subsequently contracted, removed and bone cement injected. Pre-kyphoplasty and 12-month post-kyphoplasty radiological and functional outcomes were recorded. Statistical analysis was by Wilcoxon Signed Ranks Test. Median percentage increase in anterior, middle and posterior vertebral body heights at 12-month post-operative was 51.25% [inter-quartile range (IQR) 17.21-93.22], 52.29% (IQR 26.50-126.17) and 9.84% (IQR 4.94-19.26) respectively, while median percentage decrease in kyphotic angle was 30.77% (IQR 17.06-46.61). There was no significant vertebral body correction loss at 12-month post-operative. Visual analogue score, North American Spine Society and Short Form-36 scores for physical functioning and bodily pain scores improved by medians of 5.0 (IQR 3.0-8.0), 1.45 (IQR 0.68-2.90), 20.5 (IQR 0.0-40.8) and 10.0 (IQR 0.0-20.0) respectively. All P-values were <0.001. There were eight adjacent/remote level VCFs, three cases of cement extravasation and one case of the SKy Bone Expander being unable to be contracted and withdrawn from the vertebral body. It was left in situ. This is the first reported incidence of such a complication. The SKy Bone Expander System appears to be a viable alternative to balloon tamp kyphoplasty. Important technical considerations include proper device positioning within the vertebral body before expansion, single use of devices, familiarity with salvage procedure and injection of bone cement under close image intensifier guidance to prevent cement extravasation. (+info)
C2/C3 pathologic fractures from polyostotic fibrous dysplasia of the cervical spine treated with percutaneous vertebroplasty.
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We will discuss a potential role of percutaneous vertebroplasty (PVP) in the management of patients with severe fibrous dysplasia of the spine with multiple cervical lesions and C2-C3 pathologic fractures that may not be a good surgical candidate. Polyostotic fibrous dysplasia involvement of the cervical spine is rare. Review of literature indicates only few reported cases of surgical management with one case of mortality indicating increased risks associated with surgical intervention. While PVP is commonly used for the treatment of osteoporotic thoracolumbar vertebral compression fractures, its role in vertebral stabilization for fibrous dysplasia has not been reported. A 35-year-old man with McCune-Albright syndrome and severe polyostotic fibrous dysplasia of C2 and C3 vertebrae presented with severe neck pain, radiculopathy, quadriparesis and myelopathy. The lesion had pathologic fractures, and there was an os odontoideum with cervical cord atrophy at the C1 level. After discussing need for aggressive surgical management and potential complications, we offered PVP due to surgical risks involved. PVP was performed with a posterolateral transpedicular approach without complication. The patient had remarkable improvement in clinical relief of neck pain and improvement of myelopathic symptoms at 1-year follow-up. We present a case that illustrates a potential use of PVP in the management of a patient with symptomatic spinal fibrous dysplasia with associated pathologic fractures who was poor surgical candidate. (+info)
Posterior 360-degree stabilisation of the upper thoracic spine: a technical note.
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PURPOSE: To describe a technique involving posterior 360-degree stabilisation of the upper thoracic spine: spinal cord decompression, posterior vertebral body replacement, and then posterior instrumentation and intercostal posterolateral vertebral stabilisation. METHODS: Three men and 4 women aged 41 to 77 (mean, 58) years underwent posterior 360-degree stabilisation of the upper thoracic spine. Their indications for surgery were bone metastasis (n=5), burst fracture (n=1), and osteoporotic collapse with cord compression (n=1). Their clinical and radiological findings and treatment outcomes were retrospectively reviewed. RESULTS: Pain status of all patients improved after surgery: 4 had severe and 3 had mild pain preoperatively; in 3 pain became minimal and 4 had none postoperatively. All patients except one had Frankel/American Spinal Injury Association scores of E after surgery indicating complete recovery of sensory and motor function. There were no complications related to surgery or instrumentation construct. At the time of review, one patient had died of old age 8.6 years after surgery and another from local recurrence and lung metastasis 5.7 years after surgery. All other patients were living. CONCLUSION: One-stage posterior 360-degree stabilisation and vertebral body replacement is a useful technique for upper thoracic spine surgery. (+info)
Adjacent vertebral failure after vertebroplasty: a biomechanical study of low-modulus PMMA cement.
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PMMA is the most common bone substitute used for vertebroplasty. An increased fracture rate of the adjacent vertebrae has been observed after vertebroplasty. Decreased failure strength has been noted in a laboratory study of augmented functional spine units (FSUs), where the adjacent, non-augmented vertebral body always failed. This may provide evidence that rigid cement augmentation may facilitate the subsequent collapse of the adjacent vertebrae. The purpose of this study was to evaluate whether the decrease in failure strength of augmented FSUs can be avoided using low-modulus PMMA bone cement. In cadaveric FSUs, overall stiffness, failure strength and stiffness of the two vertebral bodies were determined under compression for both the treated and untreated specimens. Augmentation was performed on the caudal vertebrae with either regular or low-modulus PMMA. Endplate and wedge-shaped fractures occurred in the cranial and caudal vertebrae in the ratios endplate:wedge (cranial:caudal): 3:8 (5:6), 4:7 (7:4) and 10:1 (10:1) for control, low-modulus and regular cement group, respectively. The mean failure strength was 3.3 +/- 1 MPa with low-modulus cement, 2.9 +/- 1.2 MPa with regular cement and 3.6 +/- 1.3 MPa for the control group. Differences between the groups were not significant (p = 0.754 and p = 0.375, respectively, for low-modulus cement vs. control and regular cement vs. control). Overall FSU stiffness was not significantly affected by augmentation. Significant differences were observed for the stiffness differences of the cranial to the caudal vertebral body for the regular PMMA group to the other groups (p < 0.003). The individual vertebral stiffness values clearly showed the stiffening effect of the regular cement and the lesser alteration of the stiffness of the augmented vertebrae using the low-modulus PMMA compared to the control group (p = 0.999). In vitro biomechanical study and biomechanical evaluation of the hypothesis state that the failure strength of augmented functional spine units could be better preserved using low-modulus PMMA in comparison to regular PMMA cement. (+info)