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Erschienen in: European Journal of Trauma and Emergency Surgery 5/2013

01.10.2013 | Original Article

Intraoperative PEEP-ventilation during PMMA-injection for augmented pedicle screws: improvement of leakage rate in spinal surgery

verfasst von: A. El Saman, A. Kelm, S. Meier, A. L. Sander, K. Eichler, I. Marzi, H. Laurer

Erschienen in: European Journal of Trauma and Emergency Surgery | Ausgabe 5/2013

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Abstract

Background

Within the last two decades the use of polymethylmethacrylate (PMMA) in the treatment of osteoporotic vertebral fractures has been established widely. Several techniques of cement application in spinal surgery have been described. Besides classical vertebroplasty, kyphoplasty and related techniques that reinforce stability of the fractured vertebral body itself, augmentation of pedicle screws became an issue in the past 10 years. Aim of this technique is strengthening of the implant-bone-interface and the prevention of loosening and failure of posterior instrumentation in limited bone quality due to osteoporosis. PMMA use in spinal surgery always bears the risk of cement leakage and cement embolism. There are only few publications dealing with cement leakage in pedicle screw augmentation. We examined our cohort concerning incidence and type of leakage in comparison to the literature. In particular, we evaluated a possible role of intrathoracic pressure during cementation procedure.

Patients and methods

In this retrospective study 42 patients were included. Mean age was 74 (57–89) years. 311 fenestrated, augmented screws were analyzed postoperatively concerning leakage and subsequent pulmonary embolism of cement particles. Overall, there was a leakage rate of 38.3 %, and 28.6 % of patients showed pulmonary embolism of PMMA. During surgery, patients were in part ventilated with a positive end-expiratory pressure (PEEP) of 15 cmH2O during cement injection. These individuals showed significantly less leakage locally as well as less PMMA-emboli in the pulmonary circulation in contrast to patients ventilated without increased PEEP.

Conclusion

PEEP elevation during administration of PMMA via fenestrated pedicle screws is reducing the leakage rate in spinal surgery. These beneficial effects warrant further evaluation in prospective studies.
Literatur
1.
Zurück zum Zitat Aebli N, Krebs J, Schwenke D, Davis G, Theis JC. Cardiovascular changes during multiple vertebroplasty with and without vent-hole: an experimental study in sheep. Spine (Phila Pa 1976). 2003;28(14):1504–11 discusion 11–12. Aebli N, Krebs J, Schwenke D, Davis G, Theis JC. Cardiovascular changes during multiple vertebroplasty with and without vent-hole: an experimental study in sheep. Spine (Phila Pa 1976). 2003;28(14):1504–11 discusion 11–12.
2.
Zurück zum Zitat Aebli N, Krebs J, Davis G, Walton M, Williams MJ, Theis JC. Fat embolism and acute hypotension during vertebroplasty: an experimental study in sheep. Spine (Phila Pa 1976). 2002;27(5):460–6.CrossRef Aebli N, Krebs J, Davis G, Walton M, Williams MJ, Theis JC. Fat embolism and acute hypotension during vertebroplasty: an experimental study in sheep. Spine (Phila Pa 1976). 2002;27(5):460–6.CrossRef
3.
Zurück zum Zitat Bohner M, Gasser B, Baroud G, Heini P. Theoretical and experimental model to describe the injection of a polymethylmethacrylate cement into a porous structure. Biomaterials. 2003;24(16):2721–30.PubMedCrossRef Bohner M, Gasser B, Baroud G, Heini P. Theoretical and experimental model to describe the injection of a polymethylmethacrylate cement into a porous structure. Biomaterials. 2003;24(16):2721–30.PubMedCrossRef
4.
Zurück zum Zitat Boger A, Benneker LM, Krebs J, Boner V, Heini PF, Gisep A. The effect of pulsed jet lavage in vertebroplasty on injection forces of PMMA bone cement: an animal study. Eur Spine J. 2009;18(12):1957–62. doi:10.1007/s00586-009-1079-5.PubMedCrossRef Boger A, Benneker LM, Krebs J, Boner V, Heini PF, Gisep A. The effect of pulsed jet lavage in vertebroplasty on injection forces of PMMA bone cement: an animal study. Eur Spine J. 2009;18(12):1957–62. doi:10.​1007/​s00586-009-1079-5.PubMedCrossRef
5.
6.
Zurück zum Zitat Benneker LM, Heini PF, Suhm N, Gisep A. 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 (Phila Pa 1976). 2008;33(23):E906–10. doi:10.1097/BRS.0b013e318183bb6d.CrossRef Benneker LM, Heini PF, Suhm N, Gisep A. 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 (Phila Pa 1976). 2008;33(23):E906–10. doi:10.​1097/​BRS.​0b013e318183bb6d​.CrossRef
7.
Zurück zum Zitat Benneker LM, Krebs J, Boner V, Boger A, Hoerstrup S, Heini PF, et al. Cardiovascular changes after PMMA vertebroplasty in sheep: the effect of bone marrow removal using pulsed jet-lavage. Eur Spine J. 2010;19(11):1913–20. doi:10.1007/s00586-010-1555-y.PubMedCrossRef Benneker LM, Krebs J, Boner V, Boger A, Hoerstrup S, Heini PF, et al. Cardiovascular changes after PMMA vertebroplasty in sheep: the effect of bone marrow removal using pulsed jet-lavage. Eur Spine J. 2010;19(11):1913–20. doi:10.​1007/​s00586-010-1555-y.PubMedCrossRef
9.
Zurück zum Zitat Yeom JS, Kim WJ, Choy WS, Lee CK, Chang BS, Kang JW. Leakage of cement in percutaneous transpedicular vertebroplasty for painful osteoporotic compression fractures. J Bone Joint Surg Br. 2003;85(1):83–9.PubMedCrossRef Yeom JS, Kim WJ, Choy WS, Lee CK, Chang BS, Kang JW. Leakage of cement in percutaneous transpedicular vertebroplasty for painful osteoporotic compression fractures. J Bone Joint Surg Br. 2003;85(1):83–9.PubMedCrossRef
11.
Zurück zum Zitat Aebli N, Goss BG, Thorpe P, Williams R, Krebs J. In vivo temperature profile of intervertebral discs and vertebral endplates during vertebroplasty: an experimental study in sheep. Spine (Phila Pa 1976). 2006;31(15):1674–8. doi:10.1097/01.brs.0000224193.52587.d8 discussion 9.CrossRef Aebli N, Goss BG, Thorpe P, Williams R, Krebs J. In vivo temperature profile of intervertebral discs and vertebral endplates during vertebroplasty: an experimental study in sheep. Spine (Phila Pa 1976). 2006;31(15):1674–8. doi:10.​1097/​01.​brs.​0000224193.​52587.​d8 discussion 9.CrossRef
12.
Zurück zum Zitat Galovich LA, Perez-Higueras A, Altonaga JR, Orden JM, Barba ML, Morillo MT. Biomechanical, histological and histomorphometric analyses of calcium phosphate cement compared to PMMA for vertebral augmentation in a validated animal model. Eur Spine J. 2011;20(Suppl 3):376–82. doi:10.1007/s00586-011-1905-4.PubMedCrossRef Galovich LA, Perez-Higueras A, Altonaga JR, Orden JM, Barba ML, Morillo MT. Biomechanical, histological and histomorphometric analyses of calcium phosphate cement compared to PMMA for vertebral augmentation in a validated animal model. Eur Spine J. 2011;20(Suppl 3):376–82. doi:10.​1007/​s00586-011-1905-4.PubMedCrossRef
14.
Zurück zum Zitat Verlaan JJ, Oner FC, Slootweg PJ, Verbout AJ, Dhert WJ. Histologic changes after vertebroplasty. J Bone Joint Surg Am. 2004;86(A(6)):1230–8.PubMed Verlaan JJ, Oner FC, Slootweg PJ, Verbout AJ, Dhert WJ. Histologic changes after vertebroplasty. J Bone Joint Surg Am. 2004;86(A(6)):1230–8.PubMed
15.
Zurück zum Zitat Verlaan JJ, Oner FC, Verbout AJ, Dhert WJ. Temperature elevation after vertebroplasty with polymethyl-methacrylate in the goat spine. J Biomed Mater Res B Appl Biomater. 2003;67(1):581–5. doi:10.1002/jbm.b.20002.PubMedCrossRef Verlaan JJ, Oner FC, Verbout AJ, Dhert WJ. Temperature elevation after vertebroplasty with polymethyl-methacrylate in the goat spine. J Biomed Mater Res B Appl Biomater. 2003;67(1):581–5. doi:10.​1002/​jbm.​b.​20002.PubMedCrossRef
20.
21.
Zurück zum Zitat Amendola L, Gasbarrini A, Fosco M, Simoes CE, Terzi S, De Iure F, et al. Fenestrated pedicle screws for cement-augmented purchase in patients with bone softening: a review of 21 cases. J Orthop Traumatol. 2011;12(4):193–9. doi:10.1007/s10195-011-0164-9.PubMedCrossRef Amendola L, Gasbarrini A, Fosco M, Simoes CE, Terzi S, De Iure F, et al. Fenestrated pedicle screws for cement-augmented purchase in patients with bone softening: a review of 21 cases. J Orthop Traumatol. 2011;12(4):193–9. doi:10.​1007/​s10195-011-0164-9.PubMedCrossRef
24.
Zurück zum Zitat Temple JD, Ludwig SC, Ross WK, Marshall WK, Larsen L, Gelb DE. Catastrophic fat embolism following augmentation of pedicle screws with bone cement : a case report. J Bone Joint Surg Am. 2002;84(A(4)):639–42.PubMed Temple JD, Ludwig SC, Ross WK, Marshall WK, Larsen L, Gelb DE. Catastrophic fat embolism following augmentation of pedicle screws with bone cement : a case report. J Bone Joint Surg Am. 2002;84(A(4)):639–42.PubMed
25.
Zurück zum Zitat Rollinghoff M, Siewe J, Eysel P, Delank KS. Pulmonary cement embolism after augmentation of pedicle screws with bone cement. Acta Orthop Belg. 2010;76(2):269–73.PubMed Rollinghoff M, Siewe J, Eysel P, Delank KS. Pulmonary cement embolism after augmentation of pedicle screws with bone cement. Acta Orthop Belg. 2010;76(2):269–73.PubMed
27.
Zurück zum Zitat Bullmann V, Schmoelz W, Richter M, Grathwohl C, Schulte TL. Revision of cannulated and perforated cement-augmented pedicle screws: a biomechanical study in human cadavers. Spine (Phila Pa 1976). 2010;35(19):E932–9. doi:10.1097/BRS.0b013e3181c6ec60.CrossRef Bullmann V, Schmoelz W, Richter M, Grathwohl C, Schulte TL. Revision of cannulated and perforated cement-augmented pedicle screws: a biomechanical study in human cadavers. Spine (Phila Pa 1976). 2010;35(19):E932–9. doi:10.​1097/​BRS.​0b013e3181c6ec60​.CrossRef
28.
Zurück zum Zitat Anselmetti GC, Manca A, Kanika K, Murphy K, Eminefendic H, Masala S, et al. Temperature measurement during polymerization of bone cement in percutaneous vertebroplasty: an in vivo study in humans. Cardiovasc Intervent Radiol. 2009;32(3):491–8. doi:10.1007/s00270-009-9509-7.PubMedCrossRef Anselmetti GC, Manca A, Kanika K, Murphy K, Eminefendic H, Masala S, et al. Temperature measurement during polymerization of bone cement in percutaneous vertebroplasty: an in vivo study in humans. Cardiovasc Intervent Radiol. 2009;32(3):491–8. doi:10.​1007/​s00270-009-9509-7.PubMedCrossRef
32.
Zurück zum Zitat Rankin JS, Olsen CO, Arentzen CE, Tyson GS, Maier G, Smith PK, et al. The effects of airway pressure on cardiac function in intact dogs and man. Circulation. 1982;66(1):108–20.PubMedCrossRef Rankin JS, Olsen CO, Arentzen CE, Tyson GS, Maier G, Smith PK, et al. The effects of airway pressure on cardiac function in intact dogs and man. Circulation. 1982;66(1):108–20.PubMedCrossRef
Metadaten
Titel
Intraoperative PEEP-ventilation during PMMA-injection for augmented pedicle screws: improvement of leakage rate in spinal surgery
verfasst von
A. El Saman
A. Kelm
S. Meier
A. L. Sander
K. Eichler
I. Marzi
H. Laurer
Publikationsdatum
01.10.2013
Verlag
Springer Berlin Heidelberg
Erschienen in
European Journal of Trauma and Emergency Surgery / Ausgabe 5/2013
Print ISSN: 1863-9933
Elektronische ISSN: 1863-9941
DOI
https://doi.org/10.1007/s00068-013-0319-x

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