Elsevier

World Neurosurgery

Volume 101, May 2017, Pages 633-642
World Neurosurgery

Literature Review
Risk Factors for Cement Leakage After Vertebroplasty or Kyphoplasty: A Meta-Analysis of Published Evidence

https://doi.org/10.1016/j.wneu.2017.01.124Get rights and content

Background

Cement leakage is the most common complication of vertebroplasty and kyphoplasty. So far, the reported risk factors remain conflicting because of limited data and lack of uniform measurement and evaluation. Here, we performed a systematic review and meta-analysis of potential risk factors for cement leakage after vertebroplasty or kyphoplasty.

Methods

Relevant literature was retrieved using PubMed, EMBASE, Cochrane Controlled Trial Register, and MEDLINE with no language restriction, supplemented by a hand search of the reference lists of selected articles. A fixed-effects model was used if homogeneity existed among included studies; otherwise, a random-effects model was used. The results were presented with weighted mean difference for continuous outcomes and odds ratio (OR) for dichotomous outcomes with a 95% confidence interval (CI).

Results

Twenty-two studies consisting of 2872 patients with 4187 vertebrae were included in the meta-analysis. The incidences of cement leakage for percutaneous vertebroplasty and percutaneous balloon kyphoplasty were 54.7% and 18.4%, respectively. The significant risk factors for new vertebral compression fractures were intravertebral cleft (OR, 1.40; 95% CI, 1.09–1.78; P < 0.01), cortical disruption (OR, 5.56; 95% CI, 1.84–16.81; P < 0.01), cement viscosity (OR, 3.32; 95% CI, 1.36–8.07; P < 0.01) and injected cement volume (weighted mean difference, 0.59; 95% CI, 0.02–1.17; P < 0.05). Age, sex and fracture type, operation level, and surgical approach were not significant risk factors.

Conclusions

The results of this meta-analysis suggest that patients with intravertebral cleft, cortical disruption, low cement viscosity, and high volume of injected cement may be at high risk for cement leakage after vertebroplasty or kyphoplasty. Rigorous patient selection and individual therapeutic strategy irrespective of age, sex and fracture type, operation level, and surgical approach may reduce the occurrence of cement leakage. Given the inherent limitation of the meta-analysis, more large sample–sized randomized controlled trials are needed to further validate the present findings.

Introduction

Percutaneous vertebroplasty (PVP), first introduced by Galibert et al. in 1987, has been widely used as a minimally invasive surgery for painful osteoporotic vertebral compression fracture (OVCF) and benign and malignant spinal tumor.1, 2 Although PVP is an effective and safe procedure that provides quick pain relief and rapid recovery, the surgical technique has some complications.3, 4 Among them, cement leakage is the most common. Leakage has been reported to occur in 30%–65% of patients with osteoporotic vertebral collapse and in 38%–72.5% of patients with malignant collapse.5, 6, 7 Although it is generally of no clinical symptoms, sometimes it can lead to serious complications including neurologic deficit,8 new vertebral compression fracture,9 and even fetal consequences such as pulmonary embolism.10, 11

Numerous previous studies have investigated risk factors for cement leakage after PVP or percutaneous balloon kyphoplasty (PKP), including intravertebral cleft (IVC).12, 13, 14, 15, 16 cortical disruption,17, 18, 19 cement viscosity,20, 21, 22 and injected cement volume.23 However, these studies were limited by either a small sample size or a limited number of potential risk factors investigated. Furthermore, some of the results were conflicting rather than conclusive. For instance, Potet et al.24 concluded that injected cement volume was associated with cement leakage, whereas Mirovsky et al.25 found that there was no association between them.

To obtain more precise and useful information that will be helpful to offer individualized treatment modality and reduce the occurrence of cement leakage, we aimed to perform a systematic review and meta-analysis of risk factors for cement leakage after PVP or PKP.

Section snippets

Search Strategy and Study Selection

We searched for studies published between January 1960 and September 2016 that identified risk factors for cement leakage after PVP or PKP. The databases included PubMed, EMBASE, Cochrane Controlled Trial Register, and MEDLINE with no language restriction. The following search terms were used: 1) cement leakage OR cement leak OR leakage OR leak; 2) vertebroplasty OR kyphoplasty OR VP OR PVP OR PKP OR augmentation; 1) and 2). In addition, the reference lists of the included studies were manually

Study Identification and Selection

Using the outlined search strategy, 1194 articles were obtained. By screening the titles and abstracts, 1154 references were excluded because they were irrelevant studies, case reports, or reviews. Full texts of the remaining 40 studies were retrieved for review. Two relevant studies were identified by hand searching the references of previous studies and systematic reviews. Seventeen studies were excluded after elaborative full-text reading because they were irrelevant studies, duplicates, or

Discussion

To the best of our knowledge, the study is the first comprehensive meta-analysis to evaluate risk factors for cement leakage after PVP or PKP. By systemically reviewing and combining the published evidence, our meta-analysis has shown that IVC, cortical disruption, cement viscosity, and injected cement volume, but not age, sex and fracture type, operation level, and surgical approach, were significant risk factors for cement leakage. Moreover, the incidence of cement leakage was relatively

Conclusions

Multiple risk factors for cement leakage after PVP or PKP including disease-related factors and procedure-related factors were identified in the meta-analysis. The incidence of cement leakage that might lead to severe complications is considerable. Rigorous patient selection and individually optimal therapeutic strategy may reduce the occurrence of cement leakage. Because most of the studies included in the meta-analysis are retrospective, more large sample–sized RCTs are warranted to further

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

    Yi Zhan and Jianzhong Jiang contributed equally to this work.

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