Treatment of Complications in Vertebroplasty and Kyphoplasty

1
Treatment of Complications in Vertebroplasty and
Kyphoplasty

• J.J. Verlaan
• Dept. Orthopaedics
• University Medical Center Utrecht
• The Netherlands

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Introduction Overview

• Aim of this Lecture
• The Good Part of Vertebroplasty Kyphoplasty
• The not so Good Part
• Preventing Complications
• What Can Go Wrong?
• Suggested Treatment
• Conclusions

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Aim of Lecture

• To inform about the prevalent causes for major
  complications in vertebroplasty and kyphoplasty
• To present the clinical impact and incidence of
  major complications
• To suggest treatment of major complications based
  on current knowledge

4
The Good Part

• Vertebroplasty
• Intravertebral cement injection
• Invented 1984 (H. Deramond)
• Local / general anesthesia
• Osteoporotic fracture, metastases
• 80-90 successful (pain ??)
• Cement leakage 0.9-87.9
• Relatively simple
• gt 600.000 procedures
• Few serious complications

• Kyphoplasty
• Intravertebral cement injection after inflation
  bone tamps
• First application 1999
• General anesthesia
• Osteoporotic fracture, metastases
• 85-90 succesful (pain ??)
• Cement leakage 2.6-33.0
• More demanding
• gt 460.000 procedures
• Few serious complications

Taylor et al. Eur Spine J 2007 McGirt et al.
Spine J 2009
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The not so Good Part

• Minor complications
• hematoma / superficial infection
• rib fracture
• cement leakage in surrounding soft tissues
• intradiscal cement leakage ( ? chance for
  adjacent level fracture)
• neuralgia after epidural cement leakage
• asymptomatic pulmonary cement embolism
• Major complications
• neurological deficit (weakness / paralysis lower
  extremities)
• symptomatic pulmonary cement embolism
• death

Taylor et al. Eur Spine J 2007 McGirt et al.
Spine J 2009
6
The not so Good Part
Spinal Canal Stenosis after Vertebroplasty M
Hochegger et al. Clinical Radiology 2005
Acute Paraplegia After Vertebroplasty Caused by
Epidural Hemorrhage A Case Report C Birkenmaier
et al. JBJS(Am) 2007
Successful Management of a Large Pulmonary Cement
Embolus After Percutaneous Vertebroplasty A Case
Report K François et al. Spine 2003
Inferior Vena Cava Syndrome Following
Percutaneous Vertebroplasty with
Polymethylmethacrylate F Kao et al. Spine 2008
Cerebral Arterial Embolization of Cement during
Intraoperative Vertebroplasty R Scroop et al.
AJNR 2002
Palacos im Herzen B Schoenes et al. Anaesthesist
2007
Multiple Cardiac Perforations and Pulmonary
Embolism caused by Cement Leakage after
Percutaneous Vertebroplasty S Lim et al. Eur J
Cardiothorac Surg 2008
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The not so Good Part
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The not so Good Part
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The not so Good Part
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The not so Good Part
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The not so Good Part
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Preventing Leakage

• Correct needle placement

• Use best imaging device available
• Inject highest viscosity cement possible
• large diameter, short needles, (no cement guns)
• Use small volume (1mL) incremental injection
• immediately stop in case of leakage

• Do not fill entire vertebral body
• currently 2-4 ml recommended, preferably
  endplate-to-endplate
• Avoid multi-level procedures

Loeffel et al. Spine 2008 Verlaan et al.
Biomaterials 2006
13
Impact and Incidence

• Major complications relatively rare (lt1)
• increasing number of procedures performed
• adopted by increasing number of (less
  experienced) clinicians
• Almost always related to cement leakage
• cardiopulmonary circulation / compression of
  neural structures
• Sometimes requiring
• emergency surgical removal of intravascular
  cement
• spinal decompression
• admittance intensive care / mechanical
  ventilation (death gt 20)

Lee et al. Spine 2009 McGirt et al. Spine J 2009
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Impact and Incidence

• Major complications not so rare (gt1) ?
• increasing number of procedures performed
• adopted by increasing number of (less
  experienced) clinicians
• Almost always related to cement leakage
• cardiopulmonary circulation / compression of
  neural structures
• Sometimes requiring
• emergency surgical removal of intravascular
  cement
• spinal decompression
• admittance intensive care / mechanical
  ventilation (death gt 20)

Lee et al. Spine 2009 McGirt et al. Spine J 2009
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Impact and Incidence

• Meta-analysis on complications (Lee et al. Spine
  2009)
• Cement leakage after vertebroplasty
• asymptomatic 3078 / 4097 75
• symptomatic 76 / 5067 1.5
• Cement leakage after kyphoplasty
• asymptomatic 184 / 1297 14
• symptomatic 1 / 1568 0.06
• Systematic review of literature (McGirt et al.
  Spine J 2009)
• vertebroplasty neurological deficit lt0.6,
  cement embolism lt0.9
• kyphoplasty neurological deficit lt0.2,
  cement embolism lt0.4

Lee et al. Spine 2009 McGirt et al. Spine J 2009
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What Can Go Wrong?

• Perform routine vertebroplasty / kyphoplasty
• Uneventful procedure
• Check on your patient few hours post-OP

respiratory insufficiency
neurological deficit
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What Can Go Wrong?

• Perform routine vertebroplasty / kyphoplasty
• Uneventful procedure
• Check on your patient few hours post-OP

respiratory insufficiency
neurological deficit
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Neurological Deficit

• Mechanical compression of neural structures
• Severity depending on location and volume
• spinal canal
• foraminal (radicular symptoms)
• Exothermic polymerization (probably) not relevant
• convective heat dissipation CSF / circulation
• Polymethyl methacrylate (PMMA) nonresorbable
• Dexamethason / analgesics not indicated
• Emergency surgical intervention

Deramond et al. Bone 1999 Verlaan et al. JBMR 2003
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Suggested Treatment

• Computed tomography / (MRI)
• localization and extent cement extravasation
• planning for spinal instrumentation
• Decompression affected levels / removal cement
• Fusion of segments depending on affected levels
• prepare for less purchase in osteoporotic/metastat
  ic bone
• consider (pre-existent) adjacent level collapse
• Close observation of clinical course
• improvement neurological symptoms
• Early consultation Dept. rehabilitation

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What Can Go Wrong?

• Perform routine vertebroplasty / kyphoplasty
• Uneventful procedure
• Check on your patient few hours post-OP

respiratory insufficiency
neurological deficit
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What Can Go Wrong?

• Perform routine vertebroplasty / kyphoplasty
• Uneventful procedure
• Check on your patient few hours post-OP

respiratory insufficiency
neurological deficit
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Pulmonary Embolism

• Which patient becomes symptomatic?
• preoperative condition patient
• amount of cement leaked into pulmonary system
• mean diameter of cement embolus gt 2 mm?
• blocked venous system by cement or subsequent
  thrombotic process?
• Effect of PMMA cement on coagulation
• release of TGF-ß after contact platelet rich
  plasma (tissue repair)
• no hemolytic activity
• no effect on intrinsic pathway (APTT)
• no effect on extrinsic pathway (INR)
• no modifying effects on antithrombotic properties

Kim et al. Radiology 2009 Cenni et al.
Biomaterials 2001
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Suggested Treatment

• Supply oxygen!
• Computed tomography (ventilation/perfusion)
• extent pulmonary embolism
• localization and extent cement extravasation
• Observation on Intensive Care Unit
• Intubation / mechanical ventilation when
  indicated
• Role anticoagulation / thrombolytics yet unclear
• Incidental surgical removal of cement embolus
• Early consultation Dept. cardiopulmonary surgery

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Conclusions

• Vertebroplasty and Kyphoplasty safe techniques
• Major complications do occur check your patient!
• Prevalence serious complications underestimated
• Neurological deficit warrants emergency surgery
• Do not delay or treat with steroids / analgesics
• Respiratory insufficiency warrants ICU admittance
• Role thrombolytics / anticoagulants yet unclear

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Thank You
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