Radiological changes, infections and neurological complications after reverse shoulder arthroplasty related to different design types and their rates: Part II

Early reported complication rates with the Grammont-type reverse shoulder arthroplasty (RSA) were very high, up to 24%. A ‘problem’ is defined as an intraoperative or postoperative event that is not likely to affect the patient’s final outcome, such as intraoperative cement extravasation and radiographic changes. A ‘complication’ is defined as an intraoperative or postoperative event that is likely to affect the patient’s final outcome, including infection, neurologic injury and intrathoracic central glenoid screw placement. Radiographic changes around the glenoid or humeral components of the RSA are very frequently observed and described in the literature. High complication rates related to the Grammont RSA design led to development of non-Grammont designs which led to a dramatic fall in the majority of complications. The percentage of radiological changes after RSA is not negligible and remains unsolved, despite a decrease in its occurrence in the last decade. However, such changes should be now considered as simple problems because they rarely have a negative influence on the patient’s final outcome, and their prevalence has dramatically decreased. With further changes in indications and designs for RSA, it is crucial to accurately track the rates and types of complications to justify its new designs and increased indications. Cite this article: EFORT Open Rev 2021;6:1109-1121. DOI: 10.1302/2058-5241.6.210040

Delayed neurological deficits caused by cement extravasation following vertebroplasty: a case report

Delayed neurological deficits secondary to percutaneous vertebroplasty caused by cement leakage is a rare condition. Although cement extravasation during percutaneous vertebroplasty is not uncommon, most cases are clinically asymptomatic, and symptomatic cement extravasation that requires surgical excision is rarely reported. Herein, a case of L4 radiculopathy secondary to cement leakage is reported that involved the delayed onset of neurological symptoms. The patient was treated using a minimally invasive transforaminal endoscopic approach. The clinical and imaging findings and treatment methods are discussed.

Single-center outcomes for percutaneous pedicle screw fixation in metastatic spinal lesions: can spontaneous facet fusion occur?

OBJECTIVE Survival of cancer patients continues to improve with systemic treatment advancements, leading to an increase in cancer-related complications such as pathological spinal fractures. In this study, the authors aimed to evaluate the outcome of percutaneous stabilization with cement augmentation of the pedicle screws in the management of patients with metastatic cancer to the spine. METHODS The authors reviewed a retrospective case series of 74 patients with symptomatic pathological spine fractures treated with cement-augmented pedicle screws implanted with a percutaneous technique. The mean imaging follow-up was 11.3 months. Data on demographics, clinical outcomes, and complications were collected. Cement extravasation, spinal hardware integrity, and fusion rates were assessed on CT scans. RESULTS Among 50 patients with follow-up imaging, 23 patients (46%) showed facet joint fusion. The length of segmental stabilization was not a significant predictor of the occurrence of fusion. Pre- or postoperative radiation therapy, postoperative chemotherapy, and the location of spinal lesions did not have a statistically significant effect on the occurrence of fusion. Patients older than 60 years of age were more likely to have fusion across facet joints compared with younger patients. There was a significant difference in the mean visual analog scale pain score, with 6.28 preoperatively and 3.41 postoperatively, regardless of fusion status (p < 0.001). Cement extravasation was seen in 51% of the cohort, but in all instances, patients remained asymptomatic. Most importantly, the incidence of hardware failure was low (4%). CONCLUSIONS Percutaneous fixation with cement-augmented pedicle screws in patients with pathological spine fractures provides an improvement in mechanical back pain, with a low incidence of failure, and in some patients, spontaneous facet fusion was observed. Further research is necessary with regard to both short-term benefits and long-term outcomes.

Safety and efficacy of cement augmentation with fenestrated pedicle screws for tumor-related spinal instability

OBJECTIVE Achieving rigid spinal fixation can be challenging in patients with cancer-related instability, as factors such as osteopenia, radiation, and immunosuppression adversely affect bone quality. Augmenting pedicle screws with cement is a strategy to overcome construct failure. This study aimed to assess the safety and efficacy of cement augmentation with fenestrated pedicle screws in patients undergoing posterior, open thoracolumbar surgery for spinal metastases. METHODS A retrospective review was performed for patients who underwent surgery for cancer-related spine instability from 2016 to 2019 at the Massachusetts General Hospital. Patient demographics, surgical details, radiographic characteristics, patterns of cement extravasation, complications, and prospectively collected Patient-Reported Outcomes Measurement Information System Pain Interference and Pain Intensity scores were analyzed using descriptive statistics. Logistic regression was performed to determine factors associated with cement extravasation. RESULTS Sixty-nine patients underwent open posterior surgery with a total of 502 cement-augmented screws (mean 7.8 screws per construct). The median follow-up period for those who survived past 90 days was 25.3 months (IQR 10.8–34.6 months). Thirteen patients (18.8%) either died within 90 days or were lost to follow-up. Postoperative CT was performed to assess the instrumentation and patterns of cement extravasation. There was no screw loosening, pullout, or failure. The rate of cement extravasation was 28.9% (145/502), most commonly through the segmental veins (77/145, 53.1%). Screws breaching the lateral border of the pedicle but with fenestrations within the vertebral body were associated with a higher risk of leakage through the segmental veins compared with screws without any breach (OR 8.77, 95% CI 2.84–29.79; p < 0.001). Cement extravasation did not cause symptoms except in 1 patient who developed a symptomatic thoracic radiculopathy requiring decompression. There was 1 case of asymptomatic pulmonary cement embolism. Patients experienced significant pain improvement at the 3-month follow-up, with decreases in Pain Interference (mean change 15.8, 95% CI 14.5–17.1; p < 0.001) and Pain Intensity (mean change 28.5, 95% CI 26.7–30.4; p < 0.001). CONCLUSIONS Cement augmentation through fenestrated pedicle screws is a safe and effective option for spine stabilization in the cancer population. The risk of clinically significant adverse events from cement extravasation is very low.

Thorned heart. Description of a near-fatal cardiac embolism after percutaneous Vertebroplasty

Cement extravasation is a rather common complication of vertebroplasty, which can be observed in up to 30-40% of patients undergoing this procedure, further associated with venous leakage occurring in up to 24% of cases. Pulmonary embolism may eventually develop once the cement migrates within the pulmonary artery, and is the most common complication of cement extravasation (involving ~4.6% of patients). Intra-cardiac cement embolism is considerably less frequent, but is a potentially fatal complication, mostly managed with cardiac surgery. We describe here a rare case of near-fatal cardiac cement embolism, with a large fragment perforating the right ventricle and reaching the pericardium, who presented to the Emergency Department (ED) for syncope. The patient, who displayed this severe complication after a vertebroplasty procedure performed for osteoporotic compression fracture, needed cardiac surgery.

Incidence and Clinical Risk of Cement Extravasation in Adult Patients Undergoing Prophylactic Vertebroplasty During Surgical Spine Reconstruction

INTRODUCTION Many have advocated for the use of prophylactic vertebroplasty in adult spinal reconstructions as a means of reducing complications related to poor bone quality, including proximal junctional kyphosis. Although numerous studies have evaluated the effectiveness of prophylactic vertebroplasty, none have evaluated safety. The purpose of this study was to measure the incidence and clinical severity of cement extravasation in adult patients undergoing prophylactic vertebroplasty as part of a spinal reconstruction procedure. METHODS Consecutive adult patients treated with prophylactic vertebroplasty during a spinal reconstruction procedure were reviewed over a 46 mo time period. Spine reconstruction was defined as any procedure involving 6 or more levels of fusion or a 3-column osteotomy. Patients without postoperative computed tomography (CT) scan were excluded. Cement extravasation was graded using a novel grading system. Chi-square analyses and Fisher's exact tests were performed to identify independent predictors of cement extravasation. RESULTS A total of 34 patients met the inclusion and exclusion criteria, comprising 112 vertebral bodies (VBs). All 34 patients (100%) had CT evidence of cement extravasation. In all 103 out of 112 VBs (92.0%) demonstrated cement extravasation and 13 VBs (11.6%) in 9 patients (26.5%) had cement extending to the vena cava, end-organs, or causing spinal canal stenosis. Upper thoracic vertebrae (C7-T6) had significantly higher rates of clinically worrisome extravasation than lower thoracic-lumbar (T7-L5) vertebrae (P = .004). Two patients who underwent upper thoracic vertebroplasty suffered potentially devastating complications: one patient had an oxygen desaturation and a postoperative CT scan demonstrating cement in the heart and lungs. The second patient lost motor evoked potentials due to cement-induced spinal canal stenosis. No permanent clinical sequelae resulted from these events. CONCLUSION Although no patients in this study suffered known long-term consequences of prophylactic vertebroplasty, 11.4% of patients had cement extravasation that threatened end-organs or neural elements. Upper thoracic vertebrae appear to pose a much higher risk for clinically dangerous cement extravasation.

Utility of Cement Augmentation via Percutaneous Fenestrated Pedicle Screws for Stabilization of Cancer-Related Spinal Instability

BACKGROUND Cancer patients experience pathological fractures and the typical poor bone quality frequently complicates stabilization. Methods for overcoming screw failure include utilization of fenestrated screws that permit the injection of bone cement into the vertebral body to augment fixation. OBJECTIVE To evaluate the safety and efficacy of cement augmentation via fenestrated screws. METHODS A retrospective chart review of patients with neoplastic spinal instability who underwent percutaneous instrumented stabilization with cement augmentation using fenestrated pedicle screws. Patient demographic and treatment data and intraoperative and postoperative complications were evaluated by chart review and radiographic evaluation. Prospectively collected patient reported outcomes (PRO) were evaluated at short (2- &lt;6 mo) and long term (6-12 mo). RESULTS Cement augmentation was performed in 216 fenestrated pedicle screws in 53 patients. Three patients required reoperation. One patient had an asymptomatic screw fracture at 6 mo postoperatively that did not require intervention. No cases of lucency around the pedicle screws, rod fractures, or cement extravasation into the spinal canal were observed. Eight cases of asymptomatic, radiographically-detected venous extravasation were found. Systemic complications included a pulmonary cement embolism, a lower extremity deep vein thrombosis, and a postoperative mortality secondary to pulmonary failure from widespread metastatic pulmonary infiltration. Significant improvement in PRO measures was found in short- and long-term analysis. CONCLUSION Cement augmentation of pedicle screws is an effective method to enhance the durability of spinal constructs in the cancer population. Risks include cement extravasation into draining blood vessels, but risk of clinically significant extravasation appears to be exceedingly low.

Diagnostic Accuracy of Fluoroscopy, Radiography, and Computed Tomography in Detecting Cement Leakage in Kyphoplasty

Purpose Cement leakage is a typical complication of kyphoplasty for vertebral fractures. It is unclear if cement application intraoperatively can be improved by using other techniques of visualization and which kind of postoperative imaging should be recommended to detect cement extravasation accurately. Objective To compare the rates of cement leakage detected by intraoperative fluoroscopy, postoperative radiography, and postoperative computed tomography (CT) in a retrospective study. Patients and Methods The study included 78 patients (60 women and 18 men; 115 vertebral bodies) who were treated with two kinds of kyphoplasty. The patients underwent intraoperative fluoroscopy and postoperative radiography and CT. After surgery, the images were evaluated to compare cement leakage rates and locations in the three visualization techniques. Leakage locations were described as epidural, intradiskal, extravertebral, or intravascular. Results Compared with CT, intraoperative fluoroscopy regularly detected intradiskal leakage (75%) but had a considerably lower sensitivity for visualizing epidural (21%), extravertebral (31%), and intravascular (51%) cement leakages. A comparison of radiography and CT showed that radiography had a high sensitivity for detecting intradiskal (82%) and intravascular (70%) cement extrusions but a lower sensitivity in identifying epidural (42%) and extravertebral (50%) leaks. Therefore, the CT scan overall was best in detecting location and accuracy. Conclusion CT detected more cement leaks than any of the other investigated techniques, especially epidural, extravertebral, and intravascular cement leakages. To achieve the best accuracy, only CT provides complete information.