Warning line for preventing bone cement leakage in the surgery of percutaneous kyphoplasty for osteoporotic vertebral compression fractures

doi:10.21203/rs.3.rs-5032086/v1

Background

With the increasing aging of society, osteoporotic fractures have gradually become a serious problem affecting the quality of life of elderly individuals. Osteoporotic vertebral compression fractures (OVCFs) are the most common complication of osteoporosis. Percutaneous kyphoplasty (PKP) has achieved good clinical efficacy in the treatment of OVCFs. However, how to reduce the bone cement leakage rate and improve safety during PKP surgery remains an urgent issue to be addressed in clinical practice. Therefore, the aim of this study was to identify a line, called the “warning line”, to determine whether there is leakage of bone cement during PKP surgery.

Methods

From February 2018 to September 2022, patients with OVCFs treated with PKP by a single surgeon at our center were included in the study. After screening from intraoperative X-ray images, we selected patients whose bone cement diffusion reached the posterior margin of the vertebral body, resulting in a total of 88 patients and 106 vertebral bodies. Clinical general data were recorded. Postoperative three-dimensional CT scans were used to assess bone cement leakage at the posterior margin. Vertebral bodies with bone cement reaching the apex of the posterior margin depression without leakage were designated Group A, whereas those with leakage were designated Group B. We compared the age, bone density, balloon pressure, contrast dose, and bone cement volume between the two groups. The posterior vertebral wall was divided into three equal parts in the postoperative three-dimensional CT scans, and the leakage rates at different positions of the posterior vertebral wall were analysed. Lateral X-ray images were used in Group A. Line a was marked as the posterior vertebral margin. Line b was marked as the apex of cement diffusion, parallel to line a. Line c was marked as the anterior vertebral margin. Line b was designated the warning line, and the ratio of ab/ac was calculated.

Results

All 88 patients successfully underwent surgery, with a significant decrease in the postoperative VAS score. No neurological complications occurred in any patient. On the basis of three-dimensional CT images of the 106 vertebral bodies, the posterior vertebral wall cement leakage rate was 58.5%. There were 44 vertebral bodies in Group A and 62 in Group B. No significant differences were found between the two groups in terms of age, bone density, balloon pressure, contrast dose, or cement volume (P > 0.05). In the sagittal images of the three-dimensional CT images, the bone cement leakage rates in the upper third, middle third, and lower third of the posterior vertebral wall were 25%, 61.1%, and 66.7%, respectively, with statistically significant differences in leakage rates at different positions (P < 0.05). In Group A, the ab/ac ratio in the lateral X-ray images was 6.8 ± 2.17%, indicating that the warning line was approximately 6.8% of the sagittal diameter from the posterior vertebral margin.

Conclusions

PKP is a relatively safe treatment for OVCFs. Most bone cement leakage occurs in the middle and lower thirds of the posterior vertebral wall. When the apex of cement diffusion remains anterior to the warning line in PKP surgery, the posterior vertebral wall cement leakage rate is low.

Percutaneous kyphoplasty (PKP)

Osteoporotic vertebral compression fractures (OVCFs)

Bone cement leakage

Warning line

With the increasing aging of society, osteoporotic fractures have gradually become a serious problem affecting the quality of life of the elderly. Osteoporotic vertebral compression fractures (OVCF) are the most common complication of osteoporosis, with approximately 1.4 million patients diagnosed with OVCFs each year^[1]. In recent years, numerous clinical studies have confirmed the good clinical efficacy of percutaneous kyphoplasty (PKP) in treating OVCF, and PKP has been widely used for this purpose. However, bone cement leakage remains the main complication of PKP surgery^{[2, 3]}. Although most bone cement leakages are asymptomatic, some can lead to catastrophic outcomes. For example, intravertebral canal leakage of bone cement could cause varying degrees of damage to the spinal cord and nerves due to direct compression or the exothermic reaction during cement polymerization, resulting in complete or incomplete paralysis. Additionally, intravascular leakage of bone cement into the bloodstream can lead to embolization of vital organs, such as pulmonary embolism^{[4, 5]}. Therefore, reducing the leakage rate of bone cement and improving the safety of PKP surgery remains an urgent clinical issue.

Previous studies have systematically analyzed high-risk factors for intravertebral canal leakage of bone cement. Vertebra-related factors include fracture morphology, the degree of vertebral collapse, cortical defects, vertebral fissures, and vertebral venous foramina; surgery-related factors include the amount of bone cement injected and the viscosity of the bone cement^{[3, 6, 7]}. In the surgery of PKP, if the possibility of bone cement leakage can be predicted in advance through X-ray fluoroscopic images, the risk of intravertebral canal leakage of bone cement can be significantly reduced.

Recent studies have found that the anatomical features of the posterior vertebral wall depression may hinder the judgment of intraoperative bone cement intravertebral canal leakage. Thus, it is suggested that in X-ray lateral fluoroscopic images, the dispersion of bone cement should not exceed the posterior one-sixth of the vertebral body^[8]. However, in actual PKP surgeries, we found significant differences in bone cement dispersion trends due to varying internal conditions of fractured vertebrae. To achieve adequate dispersion of bone cement within the vertebrae, surgeons often inject bone cement beyond this limit. Whether this increases the incidence of intravertebral canal leakage of bone cement has not yet been reported. Additionally, studies have shown that the incidence of neurological complications is very low in cases of intravertebral canal leakage of bone cement^[9-11].

Therefore, the purposes of this study are: 1. To screen cases where bone cement dispersion approaches the posterior edge of the vertebrae in intraoperative X-ray fluoroscopy images and to observe postoperative spinal CT to calculate the actual incidence of posterior wall leakage of bone cement; 2. To select cases where bone cement dispersion reaches the apex of the posterior edge depression in postoperative spinal CT axial images without leakage and to measure the distance between the posterior edge of bone cement dispersion and the posterior edge of the vertebral body in corresponding intraoperative X-ray lateral fluoroscopic images. The aim is to explore the warning line for posterior bone cement dispersion in intraoperative X-ray images in the surgery of PKP.

Patients

The study subjects were selected from patients with OVCF who underwent PKP surgery in our research institute between February 2018 and September 2022. Inclusion criteria: (1) Osteoporotic thoracic or lumbar vertebral compression fractures, with a bone density T-score ≤ -1.0; (2) No preoperative neurological symptoms; (3) Disease duration ≤ 3 weeks; (4) Clear history of low back pain with visual analog scale (VAS) ≥ 4; (5) Surgery performed by the same surgeon using unilateral puncture PKP; (6) Intraoperative X-ray fluoroscopy lateral images showing bone cement dispersion reaching or approaching the posterior vertebral edge, measured by two doctors. Exclusion criteria: (1) Surgically confirmed infectious or pathological fractures; (2) Congenital vertebral anomalies (e.g., hemivertebrae or congenital fusion vertebrae); (3) Presence of preoperative neurological symptoms; (4) Non-osteoporotic vertebral fractures; (5) Inability to clearly identify the posterior vertebral wall for any reason; (6) Old vertebral fractures or fractures with a disease duration > 3 weeks. A total of 88 cases (106 vertebral bodies) meeting these criteria were included.

Surgery

Patients were positioned prone, and local anesthesia was administered at the puncture site. Under X-ray fluoroscopy, the puncture needle and cannula were carefully inserted into the vertebral body. The puncture process should avoid areas close to cortical defects, especially the posterior vertebral wall. Balloon expansion and high-viscosity cement injection were performed under X-ray fluoroscopy, starting approximately 1 minute and 30 seconds after mixing. The cement dispersion was closely monitored, and injection was stopped if the cement approached or exceeded the posterior vertebral edge. Finally, the cement delivery device and cannula were removed, and the incision was compressed for hemostasis and covered with a dressing. All procedures were performed by the same surgeon using a unilateral puncture technique. Intraoperative X-ray fluoroscopy was used to ensure symmetrical pedicles in the anteroposterior view and parallel endplates in both the anteroposterior and lateral views.

Data collections

Record clinical baseline data during the perioperative period, including age, gender, bone density, surgical segment, balloon pressure, contrast dose, and bone cement volume. Record VAS before and after surgery, and postoperative neurological complications.

Radiological measurement and indicators

All 88 patients underwent three-dimensional CT scans of the thoracic/lumbar spine after PKP surgery. The thoracic/lumbar CT Dicom data were imported into the workstation for reconstruction. All intraoperative X-ray and CT scans images were collected. Firstly, the patients among which bone cement dispersion approached the posterior vertebral edge were identified from intraoperative X-ray fluoroscopy images. Secondly, postoperative three-dimensional CT axial images were used to statistically analyze the actual posterior vertebral wall leakage. Thirdly, these patients without leakage at the apex of the posterior edge dispersion were classified as Group A; those patients with leakage were classified as Group B.

Based on the intraoperative X-ray lateral fluoroscopy images, the posterior vertebral wall was divided into three equal parts. Depending on the position of the bone cement dispersion in the sagittal view, the patients were divided into: Group I: dispersion edge in the upper third; Group II: dispersion edge in the middle third; Group III: dispersion edge in the lower third. The number of patients in each group was counted, and the posterior vertebral wall leakage was statistically analyzed using three-dimensional CT reconstruction. The leakage rate of bone cement in each subgroup was calculated.

In the intraoperative X-ray lateral fluoroscopy image, line a represents the posterior vertebral edge, and line b is a parallel line through the apex of the bone cement dispersion's posterior edge, and line c is the anterior vertebral edge line. Line b is defined as the warning line for bone cement posterior dispersion. The distance ab between line a and line b and the distance ac between line a and line c were measured (Figure 1) . In the reconstructed CT axial images, the cortical apex on both sides of the posterior vertebral edge were identified and connected to form line d. Line e and line f were drawn parallel to line d through the apex of the posterior vertebral depression and the anterior vertebral edge, respectively. The distance de between line e and line d and the distance df between lines f and line d were measured (Figure 1). The ratios were calculated: ab/ac for X-ray images and de/df for CT axial images. The relationship between ab/ac and de/df was compared.

Fig 1: a. In the intraoperative X-ray lateral fluoroscopy image, line a represents the posterior vertebral edge, and line b is a parallel line through the apex of the bone cement dispersion's posterior edge, and line c is the anterior vertebral edge line[dl1] ; b. In the reconstructed CT axial images, the cortical apex on both sides of the posterior vertebral edge were identified and connected to form line d. Line e and line f were drawn parallel to line d through the apex of the posterior vertebral depression and the anterior vertebral edge, respectively.

Statistical analysis

Statistical analysis was performed using SPSS 19.0 software. Measurement data were first tested for normality. If the samples conformed to a normal distribution, an independent samples t-test or analysis of variance (ANOVA) was used to compare the mean values across groups to determine if there were statistically significant differences. The significance level was set at α=0.05.

General information

From February 2018 to September 2022, a total of 88 patients (19 males and 69 females) meeting the inclusion criteria were enrolled, encompassing 106 vertebra. All patients underwent unilateral approach PKP surgery without any neurological complication postoperatively, and completed the relevant preoperative and postoperative imaging examinations. The average age of the patients was 73.58±9.59 years (range 52-89 years), with a bone mineral density(BMD) T-score of -3.59±0.86 (range -2.5 to -5.7). The distribution of fracture segments was as follows: T5 (1 case), T6 (2 cases), T7 (2 cases), T9 (4 cases), T10 (4 cases), T11 (13 cases), T12 (31 cases), L1 (17 cases), L2 (22 cases), L3 (6 cases), and L4 (4 cases). There were 73 cases of single-segment fractures and 15 cases of double or multiple segment fractures. The preoperative VAS score was 5.69±1.15, and the postoperative VAS score was 1.20±0.79 (Table 1).

Table 1 Clinical general data of all patients

	General Data
Total number		88
Male		19
Female		69
Vertebra		106
Mean age		73.58±9.59
Mean BMD		-3.59±0.86
Fracture segment
T5		1
T6		2
T7		2
T9		4
T10		4
T11		13
T12		31
L1		13
L2		22
L3		6
L4		4
Single-segment fracture		73
Double or multiple segment fractures Preoperative VAS score Postoperative VAS score P(VAS)		15 5.69±1.15 1.20±0.79 0.00*

*P＜0.05

Incidence of bone cement leakage

Postoperative CT 3D reconstruction imaging revealed that there were 44 cases in Group A and 62 cases in Group B, with an overall incidence of posterior vertebral wall cement leakage of 58.5%. There were no statistically significant differences between the two groups in terms of gender, age, bone density, balloon pressure, contrast agent volume, and bone cement injection volume (P>0.05) (Table 2).

Table 2 Comparison between groupA and Group B

	Age	BMD	Balloon pressure	Contrast agent volume	bone cement volume
Group A	72.12±9.51	-3.76±0.79	189.03±48.33	2.85±0.62	3.68±1.14
Group B	74.18±9.61	-3.52±0.88	190.00±39.11	2.83±0.52	3.47±1.00
(F value, P)	(0.000, 0.317) *	(0.105, 0.187) *	(1.790, 0.914) *	(0.840, 0.811) *	(1.295, 0.331) *

*P＞0.05

According to the postoperative three-dimensional CT scans, the posterior vertebral wall was divided into three equal parts. All 106 vertebral bodies were divided into three groups based on the diffusion of bone cement in the posterior wall of the vertebral body: Group I (upper 1/3), Group II (middle 1/3), and Group III (lower 1/3). There were 8 vertebral bodies in Group I, with 2 vertebral bodies of posterior vertebral wall leakage, resulting in a leakage rate of 25%. Group II comprised 95 vertebral bodies, with 58 vertebral bodies of posterior vertebral wall leakage, resulting in a leakage rate of 61.1%. Group III consisted of 3 vertebral bodies, with 2 vertebral bodies of posterior vertebral wall leakage, resulting in a leakage rate of 66.7%. There were statistically significant differences in leakage rates among the three groups (P<0.05). There were no statistically significant differences among the groups in terms of gender, age, bone density, balloon pressure, contrast agent volume, and bone cement injection volume (P>0.05) (Table 3).

Table 3 Comparison among group I, II and III

	Age	BMD	Balloon pressure	Contrast agent volume	bone cement volume
Group I	76.00±8.90	-3.90±0.93	202.50±58.98	2.56±0.50	3.44±1.40
Group II	73.02±9.57	-3.57±0.86	188.00±40.41	2.85±0.55	3.52±1.02
Group III	85.00±2.65	-3.53±0.91	210.00±30.06	3.00±0.00	4.17±1.04
(F value, P)	(2.623, 0.077) *	(0.562, 0.572) *	(0.805, 0.450) *	(1.185,0.310) *	(0.590, 0.566) *

*P＞0.05

Warning line in the surgery of PKP

For the 44 vertebral body in group A without bone cement leak, the ab/ac ratio was calculated to be (6.8±2.17)% in the intraoperative X-ray lateral images. In the postoperative three-dimensional CT reconstruction axial image, the de/df ratio was calculated to be (11.19±3.47)%, which showed a statistically significant difference compared to the ab/ac ratio (P<0.05). Therefore, in PKP surgery, the location of the warning line for preventing bone cement leakage is considered to be approximately 6.8% of the sagittal diameter from the posterior edge of the vertebral body.

OVCFs are a common type of fragility fracture caused by decreased bone mass. Surgical treatment is a primary approach[2, 3], aiming to quickly alleviate back pain, end prolonged bed rest, reduce the incidence of complications such as lower limb venous thrombosis, pneumonia, and pressure sores, and prevent muscle weakness or atrophy due to long-term bed rest, which can further exacerbate bone loss and osteoporosis. Among surgical treatments, PKP is widely applied for osteoporotic vertebral fractures[2, 4]. Compared with traditional open surgery, PKP is advantageous because of its shorter duration, less trauma, minimal bleeding, and rapid symptom relief.

Cement leakage remains the main complication of PKP, with an incidence rate of 25% reported in the literature[12]. Leakage into blood vessels or the spinal canal can lead to severe complications, including pulmonary embolism and spinal cord or nerve damage, significantly affecting surgical outcomes and reducing patients' quality of life[13–15]. Therefore, to increase surgical safety, many risk factors for cement leakage have been identified, such as low bone density, hypertension, degree of vertebral compression, presence of vertebral fissures, and cement viscosity[16, 17]. However, there is limited research on the early detection and prevention of leakage during surgery. It is challenging to detect early leakage through intraoperative X-ray fluoroscopic lateral views[18]. Wang et al. [7] noted that the anatomical feature of the posterior vertebral wall appearing arch shaped and concave inwards on axial CT images makes it difficult to detect cement leakage in a timely and accurate manner through X-ray fluoroscopy during surgery unless CT scans are performed intraoperatively. Yeom et al. [18] reported that only 7% of intrathecal cement leakage could be detected via lateral views and suggested that cement injection be stopped immediately when it reaches one-fifth of the vertebral body via intraoperative fluoroscopy. However, this indicator is subjectively defined and not an objective measurement.

In this study, cases where cement dispersion just reached the posterior edge without leakage were screened via axial postoperative spinal CT images. Measurements of CT axial images and intraoperative fluoroscopic lateral views revealed that the postoperative fluoroscopic measurement results were significantly smaller than the CT measurements were, indicating statistical significance. Zhang et al. [8] precisely measured the depth of the posterior vertebral concavity via CT. We believe that CT measurements cannot fully represent intraoperative fluoroscopic images because of differences in defining the posterior vertebral edge between the two imaging methods. Intraoperative X-ray fluoroscopic images are more intuitive and immediately useful for reference during surgery. Therefore, on the basis of our study results, we suggest that in intraoperative X-ray fluoroscopic lateral views, the warning line for cement dispersion is approximately 6.8% of the sagittal diameter from the posterior vertebral edge.

In actual cases, further observation of postoperative CT and X-ray images revealed that when the posterior vertebral wall was divided into thirds, cement leakage occurred mainly in the middle and lower thirds, with the lowest incidence in the upper third. These findings suggest that the vertebral venous foramen is a high-risk area for posterior vertebral wall cement leakage. Li et al. [19] reported that the presence of the vertebral venous foramen and relatively sparse trabeculae make the middle region of the vertebral body mechanically weakest. During vertebral compression, the central trabeculae are most severely damaged, with the largest intertrabecular distance, thus resulting in the highest leakage rate. In some cases, although the degree of cement dispersion exceeded the posterior vertebral edge, further observation of axial postoperative CT images revealed that the cement did not leak into the spinal canal but rather dispersed into the pedicle, possibly explaining the lower incidence of upper third leakage. Therefore, when cement dispersion exceeds the warning line in the middle and lower thirds of the vertebral body, there is a greater risk of posterior wall leakage.

PKP is relatively safe for treating OVCFs. The warning line for bone cement dispersion is approximately 6.8% from the posterior edge of the vertebral body. Most leaks occur in the middle and lower thirds, so caution is needed when bone cement dispersion exceeds the warning line in these areas. This study has certain limitations. First, this was a single-center retrospective study, and further validation through large-scale, multicenter research is needed. Second, the clarity of intraoperative fluoroscopic images is limited, leading to some measurement errors. Additionally, the morphology of fractured vertebrae may differ from that of normal vertebrae.

PKP is a relatively safe treatment for OVCFs. In this study, the incidence of posterior vertebral wall cement leakage was 58.5%. Most bone cement leakage occurs in the middle and lower thirds of the posterior vertebral wall. Intraoperative X-ray fluoroscopic lateral measurements suggest that the warning line for cement dispersion is approximately 6.8% of the sagittal diameter from the posterior vertebral edge. When the apex of cement diffusion remains anterior to the warning line in PKP surgery, the posterior vertebral wall cement leakage rate is low. The warning line can effectively help prevent bone cement leakage and related complications during PKP surgery. Further analysis of the imaging results indicated that when cement dispersion exceeds the warning line in the middle and lower thirds of the vertebral body, there is a greater risk of posterior wall leakage.

OVCFs

Osteoporotic vertebral compression fractures

PKP

Percutaneous kyphoplasty

VAS

visual analogue scale

ANOVA

Analysis of variance

Acknowledgements

We would like to thank all the participants in the studies.

Authors’ contributions

LDY contributed to the study design, the writing of the paper, and drafting of the manuscript. TLM participated in the design of the study and the writing of the paper. SQJ performed the surgeries. ZXN reviewed and edited the manuscript. WXR collected and analyzed the data. All authors read and approved the final manuscript.

Funding

None.

Availability of data and materials

All data used and analyzed during this study are available from the corresponding author upon reasonable request.

Ethics approval and consent to participate

This research was approved by the ethics committee of the Chaoyang Hospital Affiliated to Capital Medical University. And agreement to participate was given by the participants. Because of the retrospective nature of the study, informed consent was waived.

Consent for publication

Written informed consent for publication of their clinical details and/or clinical images was obtained from the patient/parent/guardian/relative of the patient.

Competing interests

The authors declare that they have no competing interests.

Gauthier A, Kanis JA, Jiang Y, et al. Epidemiological burden of postmenopausal osteoporosis in the UK from 2010 to 2021: estimations from a disease model[J]. Arch Osteoporos. 2011;6:179–88. https://doi.org/10.1007/s11657-011-0063-y.
Semaan H, Obri T, Bazerbashi M et al. Clinical outcome and subsequent sequelae of cement extravasation after percutaneous kyphoplasty and vertebroplasty: a comparative review[J]. Acta Radiol 2018,59(7):861–8. https://doi.org/10.1177/0284185117732599
Huang SH, Zhu XW, Xiao D, et al. Therapeutic effect of percutaneous kyphoplasty combined with anti-osteoporosis drug on postmenopausal women with osteoporotic vertebral compression fracture and analysis of postoperative bone cement leakage risk factors: a retrospective cohort study[J]. J Orthop Surg Res. 2019;14(1):452. https://doi.org/10.1186/s13018-019-1499-9.
Fadili Hassani S, Cormier E, Shotar E et al. Intracardiac cement embolism during percutaneous vertebroplasty: incidence, risk factors and clinical management[J]. Eur Radiol,2019,29(2):663–73. https://doi.org/10.1007/s00330-018-5647-0
Shridhar P, Chen Y, Khalil R, et al. A Review of PMMA Bone Cement and Intra-Cardiac Embolism[J]. Materials(Basel). 2016;9(10):821. https://doi.org/10.3390/ma9100821.
Ren H, Feng T, Cao J, et al. A Retrospective Study to Evaluate the Effect of Dynamic Fracture Mobility on Cement Leakage in Percutaneous Vertebroplasty and Percutaneous Kyphoplasty in 286 Patients with Osteoporotic Vertebral Compression Fractures[J]. Med Sci Monit. 2022;28e935080. https://doi.org/10.12659/MSM.935080.
Wang C, Fan S, Liu J, et al. Basivertebral foramen could be connected with intravertebral cleft: a potential risk factor of cement leakage in percutaneous kyphoplasty[J]. Spine J. 2014;14(8):1551–8. https://doi.org/10.1016/j.spinee.2013.09.025.
Zhang S, Wang GJ, Wang Q, et al. A mysterious risk factor for bone cement leakage into the spinal canal through the Batson vein during percutaneous kyphoplasty: a case control study[J]. BMC Musculoskelet Disord. 2019;20(1):423. https://doi.org/10.1186/s12891-019-2807-6.
Hsieh MK, Kao FC, Chiu PY, et al. Risk factors of neurological deficit and pulmonary cement embolism after percutaneous vertebroplasty[J]. J Orthop Surg Res. 2019;14(1):406. https://doi.org/10.1186/s13018-019-1459-4.
Tang C, Tang X, Zhang W, et al. Percutaneous mesh-container-plasty for osteoporotic thoracolumbar burst fractures: A prospective, nonrandomized comparative study[J]. Acta Orthop Traumatol Turc. 2021;55(1):22–7. https://doi.org/10.5152/j.aott.2021.20045.
Yin P, Li Z, Zhu S, et al. The treatment of osteoporotic thoraco-lumbar burst fractures by unilateral percutaneous kyphoplasty: A prospective observation study[J]. Eur J Pain. 2020;24(3):659–64. https://doi.org/10.1002/ejp.1516.
Phillips FM, Todd Wetzel F, Lieberman I, et al. An in vivo comparison of the potential for extravertebral cement leak after vertebroplasty and kyphoplasty[J]. Spine (Phila Pa 1976). 2002;27(19):2173–8. https://doi.org/10.1097/00007632-200210010-00018.
Harrington KD. Major neurological complications following percutaneous vertebroplasty with polymethylmethacrylate: a case report[J]. J Bone Joint Surg Am. 2001;83(7):1070–3. https://doi.org/10.2106/00004623-200107000-00014.
Yoo KY, Jeong SW, Yoon W, et al. Acute respiratory distress syndrome associated with pulmonary cement embolism following percutaneous vertebroplasty with polymethylmethacrylate[J]. Spine (Phila Pa 1976). 2004;29(14):E294–297. https://doi.org/10.1097/01.brs.0000131211.87594.b0.
Lee ST, Chen JF. Closed reduction vertebroplasty for the treatment of osteoporotic vertebral compression fractures. Technical note[J]. J Neurosurg. 2004;100(4 Suppl Spine):392–6. https://doi.org/10.3171/spi.2004.100.4.0392.
Rho YJ, Choe WJ, Chun YI. Risk factors predicting the new symptomatic vertebral compression fractures after percutaneous vertebroplasty or kyphoplasty[J]. Eur Spine J. 2012;21(5):905–11. https://doi.org/10.1007/s00586-011-2099-5.
Li M, Zhang T, Zhang R, et al. Systematic Retrospective Analysis of Risk Factors and Preventive Measures of Bone Cement Leakage in Percutaneous Kyphoplasty[J]. World Neurosurg. 2023;171:e828–836. https://doi.org/10.1016/j.wneu.2022.12.117.
Yeom JS, Kim WJ, Choy WS, et al. Leakage of cement in percutaneous transpedicular vertebroplasty for painful osteoporotic compression fractures[J]. J Bone Joint Surg Br. 2003;85(1):83–9. https://doi.org/10.1302/0301-620x.85b1.13026.
Li S, Wang C, Shan Z, et al. Trabecular Microstructure and Damage Affect Cement Leakage From the Basivertebral Foramen During Vertebral Augmentation[J]. Spine (Phila Pa 1976). 2017;42(16):E939–948. https://doi.org/10.1097/BRS.0000000000002073.

No competing interests reported.

Warning line for preventing bone cement leakage in the surgery of percutaneous kyphoplasty for osteoporotic vertebral compression fractures

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions

Figures

Background

Materials and methods

Results

General information

Discussion

Conclusions

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1