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Insa Janssen Yu-Mi Ryang Jens Gempt Stefanie Bette Julia Gerhardt Jan S. Kirschke Bernhard Meyer 《The spine journal》2017,17(6):837-844
Background
Cement-augmented pedicle screw instrumentation (CAPSI) of the thoracolumbar spine is indicated in osteoporosis or osteopenia to improve pullout strength and biomechanical stability of pedicle screws (PS). Only a few studies report on the incidence of pulmonary cement embolism or other complications associated with CAPSI.Purpose
The aim of this retrospective study was to assess the rate of CAPSI-associated complications.Study Design
Retrospective cohort study.Patient Sample
Patients who underwent CAPSI due to spinal tumors or degenerative spine disease.Outcome Measures
Cement leakage, pulmonary cement embolism (PCE), mortality rate.Methods
Our clinical database was reviewed for patients who underwent CAPSI between January 2012 and June 2015. A total of 165 patients (mean age 71±11.2; range: 46 to 93 years; m=62, f=103) were included. Indications were osteoporotic fractures (n=40), spinal metastases (n=57), degenerative (n=49) or infectious spine disease (n=5), and traumatic vertebral fractures (n=14) with an associated osteoporosis. Every patient received between 2 and 21 (mean 8±3.3) cement-augmented pedicle screws in the thoracolumbar and lumbosacral spine. Both intraoperative cement leakage in prevertebral veins, the inferior vena cava, and/or pulmonary arteries, and leakage detected on postoperative imaging were evaluated. We assessed the incidence of clinically symptomatic and asymptomatic events.Results
In 29 of 31 patients with intraoperative suspicion of cement leakage into prevertebral veins or the inferior vena cava on lateral fluoroscopy, which were without hemodynamic relevance, cement extrusion was confirmed on postoperative X-ray or computed tomography (CT) scan. In three of eight patients with suspicion of PCE, PCE was verified on thoracic CT. Four patients experienced life-threatening intraoperative hemodynamic reactions, either due to cement embolism (n=2; 1.2%) or anaphylactic shock (n=2; 1.2%) with need for intraoperative cardiopulmonary resuscitation in three cases. Two patients died due to fulminant PCE. Three patients with dyspnea 1 day after surgery were also confirmed with PCE on chest CT. In five patients, an asymptomatic PCE was found incidentally on postoperative imaging. In addition, 68 patients with cement leakage into prevertebral veins or the ascending cava vein were found incidentally on postoperative spine X-ray or CT. Two of 10 patients with intraspinal epidural cement leakage required revision surgery. One hundred ten of 165 patients (66.7%) had clinically asymptomatic cement leakage. Thirteen patients had PCE (7.9%), of whom five (3.0%) were symptomatic. Two patients experienced intraoperative cement-induced anaphylaxis (1.2%). The overall symptomatic complication rate was 5.5% (n=9). The 30-day mortality rate was 1.8% (n=3).Conclusions
CAPSI bears a high risk of asymptomatic cement leakage. The risk for associated severe complications was also relatively high and probably underestimated considering the retrospective nature of the present study. A strict indication for cement augmentation, especially in patients with cardiac predisposition, should be the consequence. We doubt that technical aspects of cement application and/or different types of cement are capable of reducing the risk of these complications substantially. 相似文献2.
Potential risks of using cement-augmented screws for spinal fusion in patients with low bone quality
M. Martín-Fernández A. López-Herradón A.R. Piñera F. Tomé-Bermejo J.M. Duart M.D. Vlad M.G. Rodríguez-Arguisjuela L. Alvarez-Galovich 《The spine journal》2017,17(8):1192-1199
Background Context
Dramatic increases in the average life expectancy have led to increases in the variety of degenerative changes and deformities observed in the aging spine. The elderly population can present challenges for spine surgeons, not only because of increased comorbidities, but also because of the quality of their bones. Pedicle screws are the implants used most commonly in spinal surgery for fixation, but their efficacy depends directly on bone quality. Although polymethyl methacrylate (PMMA)-augmented screws represent an alternative for patients with osteoporotic vertebrae, their use has raised some concerns because of the possible association between cement leakages (CLs) and other morbidities.Purpose
To analyze potential complications related to the use of cement-augmented screws for spinal fusion and to investigate the effectiveness of using these screws in the treatment of patients with low bone quality.Study Design
A retrospective single-center study.Patient Sample
This study included 313 consecutive patients who underwent spinal fusion using a total of 1,780 cement-augmented screws.Methods and Outcome Measures
We analyzed potential complications related to the use of cement-augmented screws, including CL, vascular injury, infection, screw extraction problems, revision surgery, and instrument failure. There are no financial conflicts of interest to report.Results
A total of 1,043 vertebrae were instrumented. Cement leakage was observed in 650 vertebrae (62.3%). There were no major clinical complications related to CL, but two patients (0.6%) had radicular pain related to CL at the S1 foramina. Of the 13 patients (4.1%) who developed deep infections requiring surgical debridement, two with chronic infections had possible spondylitis that required instrument removal. All patients responded well to antibiotic therapy. Revision surgery was performed in 56 patients (17.9%), most of whom had long construction. A total of 180 screws were removed as a result of revision. There were no problems with screw extraction.Conclusions
These results demonstrate the efficacy and safety of cement-augmented screws for the treatment of patients with low bone mineral density. 相似文献3.
目的 探讨椎体退变性腰椎侧弯(DLS)患者骨质疏松的发生率和分布规律,为骨水泥螺钉的选择性使用提供参考。方法 回顾性分析2015年1月—2019年9月北京大学第三医院骨科接受手术治疗的95例DLS患者的临床和影像学资料,其中男20例、女75例,年龄(63.3±6.5)岁。于脊柱X线全长片上测量患者Cobb角、冠状平衡距离(CBD)值,统计患者冠状位失衡分型例数。选择患者主弯和代偿弯内椎体前缘皮质后方2 mm、椎体中部和椎骨后缘皮质前方2 mm三个层面的CT冠状面重建图像,于椎体松质骨部分选择最大可能的椭圆形区域作为骨密度Hounsfield units(HU)值测量兴趣区,取三个层面测量的平均值作为相应椎体的骨密度HU值,同样方法分别测量椎体凸、凹侧的HU值;以L1≤110 HU作为骨质疏松的诊断标准,观察患者骨质疏松发生率,并按观察结果将患者分为正常骨密度组和骨质疏松组两组,进而对比两组患者临床基线资料。观察全组患者主弯与代偿弯内椎体HU值,以及主弯和代偿弯内各椎体及其凸凹两侧骨质疏松的发生情况。结果 全组95例患者Cobb角为25.5°±11.1°,CBD为(22.8±18.7)mm,冠状位失衡为A型者74例、B型12例、C型9例。骨密度正常58例(61.1%),骨质疏松37例(38.9%);女性骨质疏松的发生率45.3%(34/75),高于男性的15.0%(3/20),差异有统计学意义(χ2=6.110, P＜0.05)。正常骨密度组和骨质疏松组患者的年龄、体质量指数、Cobb角、CBD、侧弯方向、冠状位失衡分型比较,差异均无统计学意义(P值均＞0.05)。主弯与代偿弯内椎体HU值:L1为(122.2±45.0)HU、稳定椎为(124.7±44.8)HU、中立椎为(120.9±42.9)HU、上端椎为(124.3±46.1)HU、顶椎(134.4±49.4)HU、下端椎(153.3±63.8)HU、L5椎(169.8±75.8)HU。主弯内各椎体的骨质疏松发生率分别与L1椎体比较,差异均无统计学意义(P值均>0.05);而代偿弯内L5椎体的骨质疏松发生率则低于主弯的L1椎体,分别为17.9%(17/95)和38.9%(37/95),差异有统计学意义(χ2=10.349,P＜0.05)。L5椎体、下端椎、顶椎的凸侧骨质疏松发生率高于凹侧,差异均有统计学意义(P值均＜0.01);而上端椎、中立椎、稳定椎凸凹两侧骨质疏松的发生率比较,差异均无统计学意义(P值均＞0.05)。结论 DLS患者中骨质疏松发生率为38.9%,女性患者的发生率更高。代偿弯内椎体骨质疏松发生率低于主弯内椎体,L5椎、下端椎和顶椎凸侧是骨质疏松的好发部位。 相似文献
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Tong-Zhou Liang Hai-Peng Zhu Bo Gao Yan Peng Wen-Jie Gao 《World Journal of Clinical Cases》2021,9(13):3120-3129
BACKGROUNDWe report a case of Intracardiac, pulmonary, and intravenous cement embolism after cement-augmented pedicle screw instrumentation in treating spondylolisthesis underlying osteoporotic bone, which was successfully managed by conservative treatment. We describe the treatment and outcome of the patient, hoping to shed light on the management of bone cement embolism.CASE SUMMARYA 67-year-old female suffered from progressive low back pain and numbness in lower extremities for 30 years. She was diagnosed with L4 and L5 spondylolisthesis, spinal stenosis, and osteoporosis. The patient underwent spinal canal decompression, an interbody fusion of L4/5 and L5/S1, cement-augmented pedicle screw instrumentation in L4-L5 segments, and regular pedicle screw in S1 segments. Three days postoperatively, a sudden drop in oxygen saturation occurred. Computerized tomography scan confirmed Intracardiac, pulmonary, and intravenous embolism. The patient was treated conservatively by continuous low-flow oxygen inhalation, anti-coagulation, and antibiotic therapy for 1 mo and continued anticoagulation treatment for 6 mo. The patient showed no further symptoms in a 30-mo follow-up.CONCLUSIONIntracardiac, pulmonary cement embolism after cement-augmented pedicle screw instrumentation is extremely rare. Careful clinical and radiographic evaluation is required in multiple sites of bone cement embolism. Conservative treatment may be a primary consideration in scattered emboli without life-threatening conditions, but a clinical decision should be made on an individualized basis. 相似文献
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目的:比较腰椎后路单/双节段融合固定时普通椎弓根螺钉(pedicle screw,PS)固定和骨水泥强化椎弓根螺钉(cement-augmented pedicle screw,CAPS)固定对邻近节段退变(adjacent segments degeneration,ASD)的影响。方法:选取1例正常男性志愿者的腰骶部CT扫描数据,建立L3～S1的完整有限元模型。验证完整模型的有效性后,通过三维扫描仪扫描空心及实心椎弓根螺钉,构建较为仿真的三维螺钉模型,再分别建立L5～S1、L4～S1的PS固定和CAPS固定模型。在L3椎体上表面施加载400N的垂直向下载荷模拟人体自身重力,同时在L3椎体上表面于不同方向施加7.5N·m力矩,模拟脊柱前屈、后伸、左右侧弯和左右旋转等生理活动,比较模型间固定节段上位相邻近节段的椎间盘/小关节Von Mises应力极值和上位相邻节段活动度(ROM)的差异。结果:模型的有效性验证显示完整模型在各个方向上的ROM与已发表的尸体研究类似。在单节段固定时,PS固定的相邻椎间盘/小关节Von Mises应力极值和椎间ROM均略小于CPAS固定组。在双节段固定时,PS固定组相邻椎间盘/小关节Von Mises应力极值和ROM均小于CPAS固定组。两种固定方式中相邻节段椎间盘的应力分布规律基本类似,均分布在纤维环的外侧缘。结论:相比于PS固定,CAPS固定会增加相邻节段椎间盘/小关节的应力和椎间ROM,且在双节段固定时更为明显,可能会加速相邻节段的退变。 相似文献
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