Elsevier

World Neurosurgery

Volume 137, May 2020, Pages e286-e290
World Neurosurgery

Original Article
Venous Drainage of Lumbar Vertebral Bodies: Anatomic Study with Application to Kyphoplasty, Vertebroplasty, and Pedicle Screw Complications

https://doi.org/10.1016/j.wneu.2020.01.174Get rights and content

Background

Bone cement augmentation with polymethylmethacrylate is a reliable method for stabilizing osteoporotic compression fractures and improving fixation of pedicle screws. However, cement extrusion into the vertebral venous system can result in pulmonary cement embolism. The goal of this anatomic study was to identify the relationship between the internal/external vertebral plexus and neighboring abdominal caval system.

Methods

Thirty-two lumbar vertebral levels were used in this study. Anterior abdominal dissection was performed to access the lumbar vertebral bodies through the peritoneal cavity, and a 16-gauge needle was placed into the center of each lumbar vertebral body at its anterior aspect. Fluoroscopy was used to confirm if the needle was correctly placed. Next, latex and/or continuous air injections were performed into each lumbar vertebral level (L1-L5). Observations confirmed if the latex or air traveled into the inferior vena cava. In addition, the spinal canal was opened to see if any latex was found to enter inside the vertebral canal in cadavers injected with the latex.

Results

Latex or air was found to flow into the inferior vena cava at all the lumbar vertebral levels. The latex/air was not observed in the spinal canal in any specimen.

Conclusions

An exact knowledge of the lumbar vertebral venous anatomy is essential when procedures that could affect the vertebral venous system are involved. Its complexity and anatomic variability necessitate such an understanding to better prevent/understand possible complications associated with polymethylmethacrylate extrusion.

Introduction

Minimally invasive bone cement application using either kyphoplasty or vertebroplasty is used to strengthen or stabilize fractured bone and relieve postoperative pain. The efficacy of these techniques has been reported in many studies.1, 2, 3, 4, 5 With the injection of bone cement (polymethylmethacrylate: PMMA) into the vertebral body, cement leakage has been reported to occur in between 11% and 73% of patients.6,7 Most often, the cement leakage is asymptomatic, but severe complications associated with the application of PMMA into the vertebral body have been reported.5,8,9 Neural injuries can be caused by the exothermic reaction of PMMA or direct mechanical compression. The more life-threatening complications occur when PMMA migrates into the pulmonary arteries due to cement leakage into segmental and/or paravertebral veins, which further drain into the azygos, hemiazygos, and accessory hemiazygos veins or directly into the inferior vena cava (IVC), causing pulmonary cement embolism.10,11 Besides the technical aspects of PMMA application into the vertebral body, cement leakage in patients occurs, among other things, due to variations in the intraosseous and vertebral venous systems of the vertebral bodies.10

Anatomically, the vertebral venous system is divided into 3 interconnected parts: the internal and external vertebral venous plexuses and basivertebral veins (Figure 1).

For example, the basivertebral veins lie primarily inside the vertebral bodies. They comprise the venous vessels and channels within the vertebra communicating anteriorly with the anterior external vertebral venous plexus through small connections and are connected posteriorly with the anterior internal vertebral plexuses via transverse branches. These interconnections may be responsible for cement leakage via the basivertebral veins, which has been reported in up to 60% of patients during vertebroplasty.10 However, besides the many open connections of the vertebral venous plexus to the vertebral body, its large volume and valveless connections to abdominal veins (e.g., lumbar veins) may also play an important role for cement leakage after kyphoplasty, vertebroplasty, or pedicle screw placement where cement is used.10,12,13

Therefore the goal of this study was to clarify the relationship between the bony venous plexuses of the lumbar vertebrae and vertebral venous plexus and inferior vena cava.

Section snippets

Materials and Methods

Thirty-two lumbar vertebral levels from 7 fresh-frozen Caucasian cadaveric torsos derived from 4 females and 3 males were used in this study. The mean age at death for specimens was 73.3 ± 15.2 years (range 46–86 years). Three lumbar vertebral levels (L1 from a 79-year-old specimen at death and L1 and L2 from an 85-year-old specimen at death) were not available in this study.

Anterior abdominal dissection through the peritoneal cavity was performed to access the lumbar vertebral bodies in the

Results

The latex injected into the lumbar bodies flowed into the IVC in 17 out of 17 vertebral levels (100%). The air placed in the lumbar body traveled into the IVC in 15 out of 15 vertebral levels (100%) (Figure 2). Latex was not observed in the spinal canal in any specimen. Air filled the entire IVC, iliac veins, and tributaries of the IVC (e.g., renal veins up to the heart in all specimens and from each of the vertebral levels). Insufflated air was not observed flowing out any of the injected

Discussion

Vertebroplasty and kyphoplasty have gained popularity among many clinicians worldwide as these techniques have been found to be useful for the relief of back pain, especially in osteoporotic fractures.10 With increasing use of bone cement, complications due to extravertebral extrusion of PMMA have been reported. As mentioned earlier, cement leakage rates can be high14,15 but occur in at least 40% of patients in most studies.16, 17, 18, 19

In most studies, cement leakage is thought to have

Conclusions

This anatomic study offers further clarification concerning the venous connections between the lumbar VVS and abdominal veins and serves as additional data when considering surgical procedures that inject bone cement into the vertebral bodies. On the basis of our findings, injections into the lumbar vertebral bodies drain specifically into the inferior vena cava system and not internally into the vertebral venous plexus of the vertebral canal.

CRediT authorship contribution statement

Joe Iwanaga: Conceptualization, Data curation, Formal analysis, Writing - original draft. Tarush Rustagi: Data curation, Writing - original draft. Basem Ishak: Data curation, Formal analysis, Writing - original draft. Jaspreet Johal: Data curation, Formal analysis, Writing - original draft. Glen David: Data curation, Formal analysis. Miguel Angel Reina: Formal analysis, Writing - review & editing. Aaron S. Dumont: Supervision, Writing - review & editing. R. Shane Tubbs: Conceptualization, Data

Acknowledgments

The authors would like to thank those who donated their body for the advancement of medical education and research.

References (35)

  • J.M. Lane et al.

    Minimally invasive options for the treatment of osteoporotic vertebral compression fractures

    Orthop Clin North Am

    (2002)
  • I. Janssen et al.

    Risk of cement leakage and pulmonary embolism by bone cement-augmented pedicle screw fixation of the thoracolumbar spine

    Spine

    (2017)
  • J.M. Mathis et al.

    Percutaneous vertebroplasty: a developing standard of care for vertebral compression fractures

    Am J Neuroradiol

    (2001)
  • C. Chen et al.

    Comparing pain reduction following kyphoplasty and vertebroplasty: a meta-analysis of randomized and non-randomized controlled trials

    Der Orthopade

    (2017)
  • M. Dohm et al.

    A randomized trial comparing balloon kyphoplasty and vertebroplasty for vertebral compression fractures due to osteoporosis

    Am J Neuroradiol

    (2014)
  • J.B. Gill et al.

    Comparing pain reduction following kyphoplasty and vertebroplasty for osteoporotic vertebral compression fractures

    Pain Physician

    (2007)
  • N.B. Watts et al.

    Treatment of painful osteoporotic vertebral fractures with percutaneous vertebroplasty or kyphoplasty

    Osteoporos Int

    (2001)
  • S.R. Garfin et al.

    New technologies in spine: kyphoplasty and vertebroplasty for the treatment of painful osteoporotic compression fractures

    Spine

    (2001)
  • S. Fadili Hassani et al.

    Intracardiac cement embolism during percutaneous vertebroplasty: incidence, risk factors and clinical management

    Eur Radiol

    (2019)
  • R.J. Groen et al.

    Anatomical and pathological considerations in percutaneous vertebroplasty and kyphoplasty: a reappraisal of the vertebral venous system

    Spine

    (2004)
  • R. Schmidt et al.

    Cement leakage during vertebroplasty: an underestimated problem?

    Euro Spine J

    (2005)
  • K.D. Harrington

    Major neurological complications following percutaneous vertebroplasty with polymethylmethacrylate: a case report

    J Bone Joint Surg Am

    (2001)
  • P. De Negri et al.

    Treatment of painful osteoporotic or traumatic vertebral compression fractures by percutaneous vertebral augmentation procedures: a nonrandomized comparison between vertebroplasty and kyphoplasty

    Clin J Pain

    (2007)
  • G. Voggenreiter et al.

    [Results of balloon kyphoplasty in the treatment of osteoporotic vertebral compression fractures]

    Der Unfallchirurg

    (2008)
  • A. Venmans et al.

    Frequency and outcome of pulmonary polymethylmethacrylate embolism during percutaneous vertebroplasty

    Am J Neuroradiol

    (2008)
  • M.B. Pitton et al.

    CT-guided vertebroplasty: analysis of technical results, extraosseous cement leakages, and complications in 500 procedures

    Euro Radiol

    (2008)
  • N. Tanigawa et al.

    Cement leakage in percutaneous vertebroplasty for osteoporotic compression fractures with or without intravertebral clefts

    Am J Roentgenol

    (2009)
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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.

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