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.
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Acknowledgments
We thank Synthes GmbH, Oberdorf, Switzerland for providing PMMA cement for the study.
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The authors have no commercial associations or sources of support that might pose a conflict of interest.
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Sven Hoppe and Sebastian Wangler have contributed equally to the manuscript and share first authorship.
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Hoppe, S., Wangler, S., Aghayev, E. et al. Reduction of cement leakage by sequential PMMA application in a vertebroplasty model. Eur Spine J 25, 3450–3455 (2016). https://doi.org/10.1007/s00586-015-3920-3
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DOI: https://doi.org/10.1007/s00586-015-3920-3