Cement leakage during vertebroplasty: an underestimated problem?

Abstract

Overall, vertebroplasty has a low complication rate. Nevertheless, severe complications can occur. The majority of these are related to cement extrusion. The rate of cement leakage is often obtained by X-ray, with only a single leak registration per vertebra. Detection rate of leaks in comparison with CT and inter-observer reliability for X-ray is, in large parts, unknown. We conducted this study to determine the value of fluoroscopy and X-ray used to detect cement leakage as compared to CT scans. Intraoperative findings in lateral fluoroscopy by the surgeon, and postoperative findings in X-rays by two orthopaedic surgeons, were compared with CT scans for the same study group. Multiple cement leakage was considered, and agreement rate was determined. The detection rate for leaks was 34% for lateral X-ray and 48% for lateral and AP view. Additional AP views only enhanced the detection of leaks in the segmental veins. The agreement rate between fluoroscopy/X-ray and CT scans ranged between 66% and 74%, while inter-observer reliability showed only fair agreement. The rate of cement leaks in vertebroplasty is high if multiple leaks are considered in CT scans. Detection rates using X-rays are low and complicated by only fair inter-observer agreement. Leaks in the basivertebral veins are frequently misinterpreted and can lead to severe complications. Therefore, CT scans should be obtained to calculate the exact leakage rate and to assess persistent or new pain occurring postoperatively.

Fig. 1

a Sagittal CT reconstruction showing posterior wall fragment. Black line level corresponding to transverse CT scan in b

Fig. 2

Type S leak via the segmental vein (white arrow)

Fig. 3

a Type B leak Although cement does not reach the posterior vertebral wall, leakage in the vein has occurred. b Sagittal CT reconstruction showing cement distribution in the spinal canal (arrow)

Fig. 4

a CT and b X-ray with type C leak arrow indicates cement in the intervertebral disc

Fig. 5

Type B leak (black arrow) with crossing of pedicle border and reflow of cement towards pedicle with no leak (white arrow)

Fig. 6

CT corresponding to Fig. 1 after PVP, showing small leak by iatrogenic pedicle wall erosion. Filling only anterior and middle part of the vertebra, with no leak through posterior wall fracture