Cement Leakage

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Cement extravasation is a very frequent occurrence in vertebroplasty. It has been reported to occur in 38% (2) to 72.5% of cases (3) in malignant collapses, and in 30% (4), 59.5% (5), and 65% of the cases (6) in osteoporotic VC. Fortunately, it is well tolerated in the large majority of patients. However, cement extravasation is also the main source of clinical complications. Cement may leak into a large variety of anatomical compartments including needle track and the prevertebral soft tissue in 6% (7) to 52.5% (3) of the cases, and the spinal canal in up to 37.5% of the cases (3). It may also leak into the intervertebral disk in 5% (7) to 25% (8), prevertebral veins in 5% (3) to 16.6% (9), and epidural veins in 16.5% of the cases (7), with metameric artery, inferior vena cava (2,10), aorta and lungs also being reported.

Cement leakage in the prevertebral soft tissue is almost always asymptomatic (Fig. 1) except in two cases of transitory femoral neuropathy related to PMMA leakage into the psoas muscle (3,9). It may be secondary to preexistent cortical destruction or cortical breakthrough at time of biopsy preceding the vertebroplasty. Due to the round shape of the vertebral body, a needle may pass through the anterior cortex even though it appears to be within the vertebral body, both on anteroposterior (AP) and lateral views.

Cement leakage into the spinal canal is frequent when destruction of the posterior cortex of the vertebral body is present. In patients in whom a soft-tissue mass has developed in the anterior part of the spinal canal, such as malignant diseases and aggressive hemangiomas, the cement commonly fills the intraspinal soft-tissue mass (Fig. 2). Cement leakage into the spinal canal is usually well tolerated if there is enough residual space for the thecal sac.

Cement leakage into the foramen (Fig. 3) is less frequent because the transpedicular approach is preferred to the classical posterolateral approach, which crosses the foramen. Both foraminal and spinal canal cement leakage may be due to breakthrough of the medial or inferior cortex of the vertebral pedicle at the time of approach.

Intervertebral disk leakage is a frequent occurrence (Fig. 4) especially in cases of severe VC. Peh et al. reported 35% disk leakage in a series of severe VC and found that the leakage onset was not dependant on the shape of the VC (gibbus deformity, vertebra plana, and

FIGURE 1 Metastatic disease: cement extravasation in the prevertebral soft tissue.

FIGURE 2 Aggressive hemangioma. (A, B) Preoperative computed tomography (CT) scan: presence of a tumoral extension in the left part of the spinal canal (A) and left intervertebral foramen (B). (C, D) Postvertebroplasty CT scan: the cement replaces the tumoral mass and extends into the spinal canal (C) and left intervertebral foramen (D).

FIGURE 2 Aggressive hemangioma. (A, B) Preoperative computed tomography (CT) scan: presence of a tumoral extension in the left part of the spinal canal (A) and left intervertebral foramen (B). (C, D) Postvertebroplasty CT scan: the cement replaces the tumoral mass and extends into the spinal canal (C) and left intervertebral foramen (D).

FIGURE 3 Fifty-year-old man with a very painful metastatic involvement of T5 with slight vertebral collapse due to a cutaneous basocellular carcinoma of the face: lateral (A) and anteroposterior (B) radiographs after vertebroplasty showing filling of T5 vertebra with polymethylmethacrylate. There is cement leakage into the left T5-T6 foramen. Despite the cement leakage, the patient experienced no nerve root pain after the procedure.

FIGURE 3 Fifty-year-old man with a very painful metastatic involvement of T5 with slight vertebral collapse due to a cutaneous basocellular carcinoma of the face: lateral (A) and anteroposterior (B) radiographs after vertebroplasty showing filling of T5 vertebra with polymethylmethacrylate. There is cement leakage into the left T5-T6 foramen. Despite the cement leakage, the patient experienced no nerve root pain after the procedure.

H-shape) (10). Intervertebral disk leakage is asymptomatic, but may have mechanical long-term consequences on adjacent vertebrae (11).

Venous cement leakage is very frequent (Figs. 5-7). It is not serious on its own but carries a risk of pulmonary embolism. Venous leakage may extend into the inferior vena cava without clinical symptoms (2,9). Padovani et al. reported a case of pulmonary embolism with a favorable outcome (12). Scroop et al. reported a case of paradoxical cerebral arterial embolization of PMMA together with pulmonary embolism of PMMA in a 78-year-old woman after multilevel intraoperative vertebroplasty for spinal fixation surgery (13). Multiple pulmonary emboli of PMMA precipitated pulmonary hypertension and right-to-left shunting into the venous circulation through a patent foramen ovale (13). This occurred because of failure to recognize venous migration of cement during the procedure. Aebli et al. in an experimental study on vertebroplasty in sheep, found in one sheep a string of cement wrapped into an ovoid shape approximately 3 cm long, in a main pulmonary artery (14).

Finally, arterial leakage may occur in highly vascularized lesions, with high intralesional pressure at time of cement injection, which results in reflux of cement into the metameric artery and even the aorta (Fig. 8).

FIGURE 4 Sixty-four-year-old man with mixed sclerotic and lytic vertebral collapse of L2 due to metastatic disease (primary not found): lateral (A) and anteroposterior (B) radiographs during vertebroplasty using a bilateral transpedicular approach. There is cement leakage into the L2-L3 intervertebral disk. Due to the mostly sclerotic nature of the lesion, cement injection required high pressure, which may explain cement leakage into the intervertebral disk.

FIGURE 4 Sixty-four-year-old man with mixed sclerotic and lytic vertebral collapse of L2 due to metastatic disease (primary not found): lateral (A) and anteroposterior (B) radiographs during vertebroplasty using a bilateral transpedicular approach. There is cement leakage into the L2-L3 intervertebral disk. Due to the mostly sclerotic nature of the lesion, cement injection required high pressure, which may explain cement leakage into the intervertebral disk.

FIGURE 5 Multiple myeloma. Vertebroplasty at three vertebral levels: postvertebroplasty computed tomography-reformated image showing cement leakage into the prevertebral veins.

FIGURE 8 Metastatic leiomyosarcoma of T9. (A) Preoperative transverse computed tomography (CT) scan showing pseudoangiomatous appearance with intravertebral parallel bone channels. (B) Preoperative axial magnetic resonance (MR) postgadolinium T1-weighted MR scan showing intense enhancement of the intravertebral bony channels prevertebral and epidural soft-tissue masses. (C) Postvertebroplasty lateral radiograph showing cement extravasation in the prevertebral soft tissue and posteriorly into the spinal canal. (D) Postoperative transverse scan showing extravasation of cement into the prevertebral soft tissue and posterior aspect of the spinal canal through the intravertebral body channels. (E) Axial CT scan showing extravasation of cement in the prevertebral soft tissue and a small drop of cement into the aorta.

FIGURE 8 Metastatic leiomyosarcoma of T9. (A) Preoperative transverse computed tomography (CT) scan showing pseudoangiomatous appearance with intravertebral parallel bone channels. (B) Preoperative axial magnetic resonance (MR) postgadolinium T1-weighted MR scan showing intense enhancement of the intravertebral bony channels prevertebral and epidural soft-tissue masses. (C) Postvertebroplasty lateral radiograph showing cement extravasation in the prevertebral soft tissue and posteriorly into the spinal canal. (D) Postoperative transverse scan showing extravasation of cement into the prevertebral soft tissue and posterior aspect of the spinal canal through the intravertebral body channels. (E) Axial CT scan showing extravasation of cement in the prevertebral soft tissue and a small drop of cement into the aorta.

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