Extravertebral cement leakage at percutaneous kyphoplasty in patients with osteoporotic vertebral compression fractures





kyphoplasty, osteoporosis, extravertebral cement leakage, bone cement


Objective. Investigation of the frequency, peculiarities and clinical signs of extravertebral cement leakage (ECL) during baloon kyphoplasty in patients with osteoporotic vertebral compression fractures (OVCF).

Material and methods. A retrospective analysis of 24 patients with OVCF, aged 57 to 82 years (average 71 years old), 19 females and 5 males; 47 vertebral bodies treated. MSCT and all available intrascopic examinations data were evaluated. Doubtful signs were interpreted as ECL. Cement extravasations were divided for leakage into venous plexuses (VP) and through cortical bone defects (CBD).

Results. ECL were found in 48.9 % of cases; in one patient bone cement was determined in small branches of the pulmonary artery. The frequencies of ECL into the venous plexuses and through cortical defects were approximately the same (27.6 and 31.9 %, respectively), combined distribution — 4.2 %. Leakage into the intervertebral discs (17 %) probably did not cause adjacent vertebral fractures. Clinical symptoms were detected only for cement distribution into the epidural and radicular veins (25 %, 1 of 4 cases) and trough CBD into the vertebral canal (1 case). Cement embolism of the pulmonary arteries (1 patient) were not accompanied by TEPA.

Conclusions. MSCT after kyphoplasty provides precise identification of presence and the features of ECL. Complications of ECL occur predominantly when cement enters the vertebral canal or intervertebral venous plexuses, but there are potential high risks for cement distribution into major venous vessels. ECL itself should not be considered as a complication of kyphoplasty.

Author Biographies

Sergii M. Lysenko, Clinical Hospital “Feofaniya”

Neurosurgery Center

Roman Y. Ilyuk, Clinical Hospital “Feofaniya”

Neurosurgery Center

Andrii L. Lytvynenko, Clinical Hospital “Feofaniya”

Neurosurgery Center

Oleksandr V. Klymenko, Clinical Hospital “Feofaniya”; Shupyk National Medical Academy of Postgraduate Education, Kyiv

Center of Pain;
Department of Neurology #1

Andriy V. Ashykhmin, National Cancer Institute, Kyiv

Research Department of Radiology

Oleksandr M. Voznyak, Clinical Hospital “Feofaniya”; Shupyk National Medical Academy of Postgraduate Education

Neurosurgery Center;
Department of Neurosurgery


1. Acaroğlu E, Nordin M, Randhawa K, Chou R, Cфtй P, Mmopelwa T, Haldeman S. The Global Spine Care Initiative: a summary of guidelines on invasive interventions for the management of persistent and disabling spinal pain in low- and middle-income communities. Eur Spine J. 2018 Sep;27(Suppl 6):870-878. [CrossRef] [PubMed]

2. Schupfner R, Stoevelaar HJ, Blattert T, Fagan D, Fransen P, Marcia S, Schils F, Siddiqi MA, Anselmetti GC. Treatment of Osteoporotic Vertebral Compression Fractures: Applicability of Appropriateness Criteria in Clinical Practice. Pain Physician. 2016 Jan;19(1):E113-20. [PubMed] http://www.painphysicianjournal.com/current/pdf?article=MjQ4OA %3D %3D&journal=93

3. Jensen ME, Evans AJ, Mathis JM, Kallmes DF, Cloft HJ, Dion JE. Percutaneous polymethylmethacrylate vertebroplasty in the treatment of osteoporotic vertebral body compression fractures: technical aspects. AJNR Am J Neuroradiol. 1997 Nov-Dec;18(10):1897-904. [PubMed] http://www.ajnr.org/content/ajnr/18/10/1897.full.pdf

4. Cotten A, Boutry N, Cortet B, Assaker R, Demondion X, Leblond D, Chastanet P, Duquesnoy B, Deramond H. Percutaneous vertebroplasty: state of the art. Radiographics. 1998 Mar-Apr;18(2):311-20; discussion 320-3. [CrossRef] [PubMed]

5. Venmans A, Klazen CA, van Rooij WJ, de Vries J, Mali WP, Lohle PN. Postprocedural CT for perivertebral cement leakage in percutaneous vertebroplasty is not necessary--results from VERTOS II. Neuroradiology. 2011 Jan;53(1):19-22. [CrossRef] [PubMed] [PubMed Central]

6. 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 Jan;85(1):83-9. [CrossRef] [PubMed]

7. Schmidt R, Cakir B, Mattes T, Wegener M, Puhl W, Richter M. Cement leakage during vertebroplasty: an underestimated problem? Eur Spine J. 2005 Jun;14(5):466-73. [CrossRef] [PubMed] [PubMed Central]

8. Semaan H, Obri T, Bazerbashi M, Paull D, Liu X, Sarrouj M, Elgafy H. Clinical outcome and subsequent sequelae of cement extravasation after percutaneous kyphoplasty and vertebroplasty: a comparative review. Acta Radiol. 2018 Jul;59(7):861-868. [CrossRef] [PubMed]

9. Taylor RS, Taylor RJ, Fritzell P. Balloon kyphoplasty and vertebroplasty for vertebral compression fractures: a comparative systematic review of efficacy and safety. Spine (Phila Pa 1976). 2006 Nov 1;31(23):2747-55. [CrossRef] [PubMed]

10. Hulme PA, Krebs J, Ferguson SJ, Berlemann U. Vertebroplasty and kyphoplasty: a systematic review of 69 clinical studies. Spine (Phila Pa 1976). 2006 Aug 1;31(17):1983-2001. [CrossRef] [PubMed]

11. Wang CH, Ma JZ, Zhang CC, Nie L. Comparison of high-viscosity cement vertebroplasty and balloon kyphoplasty for the treatment of osteoporotic vertebral compression fractures. Pain Physician. 2015 Mar-Apr;18(2):E187-94. [PubMed]

12. Sebaaly A, Rizkallah M, Bachour F, Atallah F, Moreau PE, Maalouf G. Percutaneous cement augmentation for osteoporotic vertebral fractures. EFORT Open Rev. 2017 Jun 22;2(6):293-299. [CrossRef] [PubMed] [PubMed Central]

13. Gu CN, Brinjikji W, Evans AJ, Murad MH, Kallmes DF. Outcomes of vertebroplasty compared with kyphoplasty: a systematic review and meta-analysis. J Neurointerv Surg. 2016 Jun;8(6):636-42. [CrossRef] [PubMed]

14. Buchbinder R, Johnston RV, Rischin KJ, Homik J, Jones CA, Golmohammadi K, Kallmes DF. Percutaneous vertebroplasty for osteoporotic vertebral compression fracture. Cochrane Database Syst Rev. 2018 Nov 6;11:CD006349. [CrossRef] [PubMed]

15. Vaccaro AR, Oner C, Kepler CK, Dvorak M, Schnake K, Bellabarba C, et al.; AOSpine Spinal Cord Injury & Trauma Knowledge Forum. AOSpine thoracolumbar spine injury classification system: fracture description, neurological status, and key modifiers. Spine (Phila Pa 1976). 2013 Nov 1;38(23):2028-37. [CrossRef] [PubMed]

16. Schnake KJ, Schroeder GD, Vaccaro AR, Oner C. AOSpine Classification Systems (Subaxial, Thoracolumbar). J Orthop Trauma. 2017 Sep;31 Suppl 4:S14-S23. [CrossRef] [PubMed]

17. Thйron J, Moet J. Spinal Phlebography:Lumbar and Cervical Techniques. Berlin: Springer-Verlag; 1978. 168 p.

18. Palm HG, Riesner HJ, Lang P, Haentzsch M, Friemert B, Hackenbroch C. Diagnostic Accuracy of Fluoroscopy, Radiography, and Computed tomography in Detecting Cement Leakage in Kyphoplasty. J Neurol Surg A Cent Eur Neurosurg. 2018 Nov;79(6):502-510. [CrossRef] [PubMed]

19. Takahashi S, Kitagawa H, Ishii T. Intraoperative pulmonary embolism during spinal instrumentation surgery. A prospective study using transoesophageal echocardiography. J Bone Joint Surg Br. 2003 Jan;85(1):90-4. [CrossRef] [PubMed]

20. Jamjoom B, Patel S, Bommireddy R, Klezl Z. Impact of the quantity of intradiscal cement leak on the progression of intervertebral disc degeneration. Ann R Coll Surg Engl. 2017 Sep;99(7):529-533. [CrossRef] [PubMed] [PubMed Central]

21. Gaughen JR Jr, Jensen ME, Schweickert PA, Kaufmann TJ, Marx WF, Kallmes DF. Relevance of antecedent venography in percutaneous vertebroplasty for the treatment of osteoporotic compression fractures. AJNR Am J Neuroradiol. 2002 Apr;23(4):594-600. [PubMed] http://www.ajnr.org/content/ajnr/23/4/594.full.pdf

22. Greene DL, Isaac R, Neuwirth M, Bitan FD. The eggshell technique for prevention of cement leakage during kyphoplasty. J Spinal Disord Tech. 2007 May; 20(3):229-32. [CrossRef] [PubMed]

23. Elnoamany H. Percutaneous vertebroplasty: a new serial injection technique to minimize cement leak. Asian Spine J. 2015 Dec;9(6):855-62. [CrossRef] [PubMed] [PubMed Central]

24. Gonschorek O, Hauck S, WeiЯ T, Bьhren V. Percutaneous vertebral augmentation in fragility fractures-indications and limitations. Eur J Trauma Emerg Surg. 2017 Feb;43(1):9-17. [CrossRef] [PubMed]

25. Xiao H, Yang J, Feng X, Chen P, Li Y, Huang C, Liang Y, Chen H. Comparing complications of vertebroplasty and kyphoplasty for treating osteoporotic vertebral compression fractures: a meta-analysis of the randomized and non-randomized controlled studies. Eur J Orthop Surg Traumatol. 2015 Jul;25 Suppl 1:S77-85. [CrossRef] [PubMed]



How to Cite

Lysenko, S. M., Ilyuk, R. Y., Lytvynenko, A. L., Klymenko, O. V., Ashykhmin, A. V., & Voznyak, O. M. (2018). Extravertebral cement leakage at percutaneous kyphoplasty in patients with osteoporotic vertebral compression fractures. Ukrainian Neurosurgical Journal, (4), 38–44. https://doi.org/10.25305/unj.142087



Original articles