Skip to main content

Bone marrow washout for multilevel vertebroplasty in multiple myeloma spinal involvement. Technical note.



Vertebral involvement is found in a high percentage of multiple myeloma (MM) patients, often requiring multilevel surgical treatment to reduce pain and disability and to receive prompt access to oncological care. We describe the clinical use of washout technique for multilevel vertebroplasty in MM patients with diffuse spinal involvement. The aim of this technique is to reduce the risk of pulmonary fat embolism after cement injection and possibly to increment the amount of cement and treated levels in one surgical stage.


Three patients were treated with the washout technique prior to multilevel vertebroplasty for thoracolumbar diffuse spinal involvement in multiple myeloma. We describe the surgical technique and review the pertinent literature.


The technique is clinically safe and effective in reducing pain, without significant complications. Two six-level vertebroplasties were performed in one case, allowing a larger amount of cement injected and a prompt start of the oncological treatment.


Multilevel vertebroplasty in MM patients with diffuse spinal involvement carries the advantages of reducing pain, avoid repeated surgeries and faster return to oncological regimen. Cardiovascular complications, including pulmonary embolism, are rare but can have fatal consequences. It is mainly due to bone marrow mobilization during cement injection and the risk increases with the amount of cement injected and the number of treated levels. Despite multilevel treatment at the same stage, we did not observe any significant complication in our series. Further studies are needed to confirm the preliminary results of this technique.

Graphical abstract

These slides can be retrieved under electronic supplementary material.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3


  1. 1.

    Gerszten PC, Welch WC (2000) Current surgical management of metastatic spinal disease. Oncology 14(7):1013–1024. discussion 1024, 1029–1030

    CAS  PubMed  Google Scholar 

  2. 2.

    Khan O, Brinjikji W, Kallmes DF (2014) Vertebral augmentation in patients with multiple myeloma: a pooled analysis of published case series. Am J Neuroradiol 35(1):207–210

    Article  CAS  PubMed  Google Scholar 

  3. 3.

    Erdem E, Samant R, Malak S, Culp W, Brown A, Peterson L, Lensing S, Barlogie B (2013) Vertebral augmentation in the treatment of pathologic compression fractures in 792 patients with multiple myeloma. Leukemia 27(12):2391

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. 4.

    Aebli N, Krebs J, Schwenke D, Davis G, Theis J-C (2003) Pressurization of vertebral bodies during vertebroplasty causes cardiovascular complications: an experimental study in sheep. Spine 28(14):1513–1519

    PubMed  Google Scholar 

  5. 5.

    Hussein M, Vrionis F, Allison R, Berenson J, Berven S, Erdem E, Giralt S, Jagannath S, Kyle R, LeGrand S (2008) The role of vertebral augmentation in multiple myeloma: international Myeloma Working Group Consensus Statement. Leukemia 22(8):1479

    Article  CAS  PubMed  Google Scholar 

  6. 6.

    Benneker LM, Heini PF, Suhm N, Gisep A (2008) The effect of pulsed jet lavage in vertebroplasty on injection forces of polymethylmethacrylate bone cement, material distribution, and potential fat embolism: a cadaver study. Spine 33(23):E906–E910

    PubMed  Google Scholar 

  7. 7.

    Boger A, Benneker LM, Krebs J, Boner V, Heini PF, Gisep A (2009) The effect of pulsed jet lavage in vertebroplasty on injection forces of PMMA bone cement: an animal study. Eur Spine J 18(12):1957

    Article  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Hoppe S, Elfiky T, Keel MJB, Aghayev E, Ecker TM, Benneker LM (2016) Lavage prior to vertebral augmentation reduces the risk for cement leakage. Eur Spine J 25:3463–3469

    Article  PubMed  Google Scholar 

  9. 9.

    Benneker LM, Krebs J, Boner V, Boger A, Hoerstrup S, Heini PF, Gisep A (2010) Cardiovascular changes after PMMA vertebroplasty in sheep: the effect of bone marrow removal using pulsed jet-lavage. Eur Spine J 19(11):1913–1920

    Article  PubMed  PubMed Central  Google Scholar 

  10. 10.

    Boszczyk BM, Bierschneider M, Hauck S, Beisse R, Potulski M, Jaksche H (2005) Transcostovertebral kyphoplasty of the mid and high thoracic spine. Eur Spine J 14(10):992–999.

    Article  PubMed  Google Scholar 

  11. 11.

    Roodman G (2009) Pathogenesis of myeloma bone disease. Leukemia 23(3):435

    Article  CAS  PubMed  Google Scholar 

  12. 12.

    Lecouvet FE, Vande Berg BC, Maldague BE, Michaux L, Laterre E, Michaux J-L, Ferrant A, Malghem J (1997) Vertebral compression fractures in multiple myeloma. Part I. Distribution and appearance at MR imaging. Radiology 204(1):195–199

    Article  CAS  PubMed  Google Scholar 

  13. 13.

    Chen L-H, Hsieh M-K, Niu C-C, Fu T-S, Lai P-L, Chen W-J (2012) Percutaneous vertebroplasty for pathological vertebral compression fractures secondary to multiple myeloma. Arch Orthop Trauma Surg 132(6):759–764

    Article  PubMed  Google Scholar 

  14. 14.

    Gangi A, Guth S, Imbert JP, Marin H, Dietemann J-L (2003) Percutaneous vertebroplasty: indications, technique, and results. Radiographics 23(2):e10–e10

    Article  PubMed  Google Scholar 

  15. 15.

    Audat ZA, Hajyousef MH, Fawareh MD, Alawneh KM, Odat MA, Barbarawi MM, Alomari AA, Jahmani RA, Khatatbeh MA, Assmairan MA (2016) Comparison if the addition of multilevel vertebral augmentation to conventional therapy will improve the outcome of patients with multiple myeloma. Scoliosis Spinal Disord 29(11):47

    Article  Google Scholar 

  16. 16.

    Mellor A, Soni N (2001) Fat embolism. Anaesthesia 56(2):145–154

    Article  CAS  Google Scholar 

  17. 17.

    Wiles MD, Nowicki RW, Hancock SM, Boszczyk B (2009) Anaesthesia for vertebroplasty and kyphoplasty. Curr Anaesth Crit Care 20(1):38–41

    Article  Google Scholar 

  18. 18.

    Syed MI, Jan S, Patel NA, Shaikh A, Marsh RA, Stewart RV (2006) Fatal fat embolism after vertebroplasty: identification of the high-risk patient. AJNR Am J Neuroradiol 27(2):343–345

    CAS  PubMed  Google Scholar 

  19. 19.

    Heini P, Orler R (2004) Vertebroplasty in severe osteoporosis. Technique and experience with multi-segment injection. Der Orthopade 33(1):22–30

    Article  CAS  PubMed  Google Scholar 

  20. 20.

    Katonis P, Hadjipavlou A, Souvatzis X, Tzermiadianos M, Alpantaki K, Simmons JW (2012) Respiratory effects, hemodynamic changes and cement leakage during multilevel cement balloon kyphoplasty. Eur Spine J 21(9):1860–1866.

    Article  PubMed  PubMed Central  Google Scholar 

  21. 21.

    Mailli L, Filippiadis DK, Brountzos EN, Alexopoulou E, Kelekis N, Kelekis A (2013) Clinical outcome and safety of multilevel vertebroplasty: clinical experience and results. Cardiovasc Intervent Radiol 36(1):183–191.

    Article  Google Scholar 

  22. 22.

    Zhang JJ, Zhou Y, Hu HY, Sun YJ, Wang YG, Gu YF, Wu CG, Shen Z, Yao Y (2017) Safety and efficacy of multilevel vertebroplasty for painful osteolytic spinal metastases: a single-centre experience. Eur Radiol 27(8):3436–3442.

    Article  PubMed  Google Scholar 

  23. 23.

    Zhan Y, Jiang J, Liao H, Tan H, Yang K (2017) Risk factors for cement leakage after vertebroplasty or kyphoplasty: a meta-analysis of published evidence. World Neurosurg 101:633–642

    Article  PubMed  Google Scholar 

  24. 24.

    Hoppe S, Wangler S, Aghayev E, Gantenbein B, Boger A, Benneker LM (2016) Reduction of cement leakage by sequential PMMA application in a vertebroplasty model. Eur Spine J 25(11):3450–3455

    Article  PubMed  Google Scholar 

  25. 25.

    Mohamed R, Silbermann C, Ahmari A, Bohner M, Becker S, Baroud G (2010) Cement filling control and bone marrow removal in vertebral body augmentation by unipedicular aspiration technique: an experimental study using leakage model. Spine 35(3):353–360

    Article  PubMed  Google Scholar 

  26. 26.

    La Maida GA, Giarratana LS, Acerbi A, Ferrari V, Mineo GV, Misaggi B (2012) Cement leakage: safety of minimally invasive surgical techniques in the treatment of multiple myeloma vertebral lesions. Eur Spine J 21(1):61–68

    Article  PubMed Central  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Corrado Lucantoni.

Ethics declarations

Conflict of interest

None of the authors has any potential conflict of interest.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (PPTX 585 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Hershkovich, O., Lucantoni, C., Kapoor, S. et al. Bone marrow washout for multilevel vertebroplasty in multiple myeloma spinal involvement. Technical note.. Eur Spine J 28, 1455–1460 (2019).

Download citation


  • Multiple myeloma
  • Vertebroplasty
  • Fat pulmonary embolism
  • Vertebral washout
  • Lavage