Skip to main content
SpringerLink
Log in

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

  • Original Article
  • Published:
European Journal of Trauma and Emergency Surgery Aims and scope Submit manuscript

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. 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.

    Google Scholar 

  2. 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.

    Article  Google Scholar 

  3. 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.

    Article  PubMed  CAS  Google Scholar 

  4. 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.

    Article  PubMed  Google Scholar 

  5. Boger A, Wheeler KD, Schenk B, Heini PF. Clinical investigations of polymethylmethacrylate cement viscosity during vertebroplasty and related in vitro measurements. Eur Spine J. 2009;18(9):1272–8. doi:10.1007/s00586-009-1037-2.

    Article  PubMed  CAS  Google Scholar 

  6. 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.

    Article  Google Scholar 

  7. 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.

    Article  PubMed  Google Scholar 

  8. Heini PF, Orler R. Vertebroplastik bei hochgradiger Osteoporose. Orthopade. 2004;33(1):22–30. doi:10.1007/s00132-003-0574-3.

    Article  PubMed  CAS  Google Scholar 

  9. 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.

    Article  PubMed  CAS  Google Scholar 

  10. Laurer H, Sander A, Wutzler S, Nau C, Marzi I. Traumatic vertebral body fractures and osteoporosis: value of cement augmentation. Orthopade. 2010;39(7):704–10. doi:10.1007/s00132-010-1601-9.

    Article  PubMed  CAS  Google Scholar 

  11. 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.

    Article  Google Scholar 

  12. 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.

    Article  PubMed  Google Scholar 

  13. Lai PL, Tai CL, Chen LH, Nien NY. Cement leakage causes potential thermal injury in vertebroplasty. BMC Musculoskelet Disord. 2011;12:116. doi:10.1186/1471-2474-12-116.

    Article  PubMed  CAS  Google Scholar 

  14. 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  Google Scholar 

  15. 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.

    Article  PubMed  Google Scholar 

  16. Gstottner M, Angerer A, Rosiek R, Bach CM. Quantitative volumetry of cement leakage in viscosity-controlled vertebroplasty. J Spinal Disord Tech. 2011;. doi:10.1097/BSD.0b013e31823f62b1.

    Google Scholar 

  17. Krappinger D, Kastenberger TJ, Schmid R. Augmented posterior instrumentation for the treatment of osteoporotic vertebral body fractures. Oper Orthop Traumatol. 2012;24(1):4–12. doi:10.1007/s00064-011-0098-7.

    Article  PubMed  CAS  Google Scholar 

  18. Liu D, Wu ZX, Gao MX, Wan SY, Shi L, Fu SC, et al. A new method of partial screw augmentation in sheep vertebrae in vitro: biomechanical and interfacial evaluation. J Spinal Disord Tech. 2011;24(5):318–24. doi:10.1097/BSD.0b013e3181fee4c8.

    Article  PubMed  Google Scholar 

  19. Chang MC, Liu CL, Chen TH. Polymethylmethacrylate augmentation of pedicle screw for osteoporotic spinal surgery: a novel technique. Spine (Phila Pa 1976). 2008;33(10):E317–24. doi:10.1097/BRS.0b013e31816f6c73.

    Article  Google Scholar 

  20. Sawakami K, Yamazaki A, Ishikawa S, Ito T, Watanabe K, Endo N. Polymethylmethacrylate augmentation of pedicle screws increases the initial fixation in osteoporotic spine patients. J Spinal Disord Tech. 2012;25(2):E28–35. doi:10.1097/BSD.0b013e318228bbed.

    Article  PubMed  Google Scholar 

  21. 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.

    Article  PubMed  Google Scholar 

  22. Kafchitsas K, Geiger F, Rauschmann M, Schmidt S. Cement distribution in vertebroplasty pedicle screws with different designs. Orthopade. 2010;39(7):679–86. doi:10.1007/s00132-010-1603-7.

    Article  PubMed  CAS  Google Scholar 

  23. Bullmann V, Liljenqvist UR, Rodl R, Schulte TL. Pedicle screw augmentation from a biomechanical perspective. Orthopade. 2010;39(7):673–8. doi:10.1007/s00132-010-1602-8.

    Article  PubMed  CAS  Google Scholar 

  24. 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  Google Scholar 

  25. 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  Google Scholar 

  26. Schoenes B, Bremerich DH, Risteski PS, Thalhammer A, Meininger D. Cardiac perforation after vertebroplasty. Anaesthesist. 2008;57(2):147–50. doi:10.1007/s00101-007-1276-8.

    Article  PubMed  CAS  Google Scholar 

  27. 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.

    Article  Google Scholar 

  28. 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.

    Article  PubMed  Google Scholar 

  29. Gravius S, Kraska N, Maus U, Mumme T, Berdel P, Weisskopf M. Intravertebral pressure during vertebroplasty: an in vitro study. Z Orthop Unfall. 2009;147(1):43–7. doi:10.1055/s-2008-1039114.

    Article  PubMed  CAS  Google Scholar 

  30. Gainnier M, Michelet P, Thirion X, Arnal JM, Sainty JM, Papazian L. Prone position and positive end-expiratory pressure in acute respiratory distress syndrome. Crit Care Med. 2003;31(12):2719–26. doi:10.1097/01.CCM.0000094216.49129.4B.

    Article  PubMed  Google Scholar 

  31. Luecke T, Pelosi P. Clinical review: positive end-expiratory pressure and cardiac output. Crit Care. 2005;9(6):607–21. doi:10.1186/cc3877.

    Article  PubMed  Google Scholar 

  32. 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.

    Article  PubMed  CAS  Google Scholar 

Download references

Conflict of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Author information

Authors and Affiliations

  1. Department of Trauma, Hand, and Reconstructive Surgery, University Hospital of the Johann Wolfgang Goethe-University, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany

    A. El Saman, A. Kelm, S. Meier, A. L. Sander, I. Marzi & H. Laurer

  2. Department of Diagnostic and Interventional Radiology, University Hospital of the Johann Wolfgang Goethe-University, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany

    K. Eichler

Authors
  1. A. El Saman
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. A. Kelm
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. S. Meier
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. A. L. Sander
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. K. Eichler
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. I. Marzi
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. H. Laurer
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to A. El Saman.

Rights and permissions

Reprints and permissions

About this article

Cite this article

El Saman, A., Kelm, A., Meier, S. et al. Intraoperative PEEP-ventilation during PMMA-injection for augmented pedicle screws: improvement of leakage rate in spinal surgery. Eur J Trauma Emerg Surg 39, 461–468 (2013). https://doi.org/10.1007/s00068-013-0319-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00068-013-0319-x

Keywords

Search

Navigation