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