Sven Hoppe1, Sebastian Wangler2, Emin Aghayev3, Benjamin Gantenbein4, Andreas Boger5, Lorin M Benneker2. 1. Department of Orthopedic Surgery and Traumatology, Inselspital Bern, Bern University Hospital, 3010, Bern, Switzerland. svenhoppe@gmail.com. 2. Department of Orthopedic Surgery and Traumatology, Inselspital Bern, Bern University Hospital, 3010, Bern, Switzerland. 3. Institute for Evaluative Research in Medicine, University of Bern, Bern, Switzerland. 4. Institute for Surgical Technology and Biomechanics, University of Bern, Bern, Switzerland. 5. Ansbach University of Applied Science, Ansbach, Germany.
Abstract
PURPOSE: Leakage is the most common complication of percutaneous cement augmentation of the spine. The viscosity of the polymethylmethacrylate (PMMA) cement is strongly correlated with the likelihood of cement leakage. We hypothesized that cement leakage can be reduced by sequential cement injection in a vertebroplasty model. METHODS: A standardized vertebral body substitute model, consisting of aluminum oxide foams coated by acrylic cement with a preformed leakage path, simulating a ventral vein, was developed. Three injection techniques of 6 ml PMMA were assessed: injection in one single step (all-in-one), injection of 1 ml at the first and 5 ml at the second step with 1 min latency in-between (two-step), and sequential injection of 0.5 ml with 1-min latency between the sequences (sequential). Standard PMMA vertebroplasty cement was used; each injection type was tested on ten vertebral body substitute models with two possible leakage paths per model. Leakage was assessed by radiographs using a zonal graduation: intraspongious = no leakage and extracortical = leakage. RESULTS: The leakage rate was significantly lower in the "sequential" technique (2/20 leakages) followed by "two-step" (15/20) and "all-in-one" (20/20) techniques (p < 0.001). The RR for a cement leakage was 10.0 times higher in the "all-in-one" compared to the "sequential" group (95 % confidence intervals 2.7-37.2; p < 0.001). CONCLUSIONS: The sequential cement injection is a simple approach to minimize the risk for leakage. Taking advantage of the temperature gradient between body and room temperature, it is possible to increase the cement viscosity inside the vertebra while keeping it low in the syringe. Using sequential injection of small cement volumes, further leakage paths are blocked before further injection of the low-viscosity cement.
PURPOSE: Leakage is the most common complication of percutaneous cement augmentation of the spine. The viscosity of the polymethylmethacrylate (PMMA) cement is strongly correlated with the likelihood of cement leakage. We hypothesized that cement leakage can be reduced by sequential cement injection in a vertebroplasty model. METHODS: A standardized vertebral body substitute model, consisting of aluminum oxide foams coated by acrylic cement with a preformed leakage path, simulating a ventral vein, was developed. Three injection techniques of 6 ml PMMA were assessed: injection in one single step (all-in-one), injection of 1 ml at the first and 5 ml at the second step with 1 min latency in-between (two-step), and sequential injection of 0.5 ml with 1-min latency between the sequences (sequential). Standard PMMA vertebroplasty cement was used; each injection type was tested on ten vertebral body substitute models with two possible leakage paths per model. Leakage was assessed by radiographs using a zonal graduation: intraspongious = no leakage and extracortical = leakage. RESULTS: The leakage rate was significantly lower in the "sequential" technique (2/20 leakages) followed by "two-step" (15/20) and "all-in-one" (20/20) techniques (p < 0.001). The RR for a cement leakage was 10.0 times higher in the "all-in-one" compared to the "sequential" group (95 % confidence intervals 2.7-37.2; p < 0.001). CONCLUSIONS: The sequential cement injection is a simple approach to minimize the risk for leakage. Taking advantage of the temperature gradient between body and room temperature, it is possible to increase the cement viscosity inside the vertebra while keeping it low in the syringe. Using sequential injection of small cement volumes, further leakage paths are blocked before further injection of the low-viscosity cement.
Authors: Ioannis D Papanastassiou; Frank M Phillips; Jan Van Meirhaeghe; James R Berenson; Gunnar B J Andersson; Gary Chung; Brent J Small; Kamran Aghayev; Frank D Vrionis Journal: Eur Spine J Date: 2012-04-29 Impact factor: 3.134
Authors: Sven Hoppe; Tarek Elfiky; Marius Johann Baptist Keel; Emin Aghayev; Timo Michael Ecker; Lorin Michael Benneker Journal: Eur Spine J Date: 2015-08-15 Impact factor: 3.134
Authors: Nicolas Plais; Charles Mengis; Jesús Manuel Gallego Bustos; Felix Tomé-Bermejo; Alejandro Peiro-Garcia; America Novoa Buitrago; Luis Alvarez-Galovich Journal: Int J Spine Surg Date: 2021-09-22