Anatomical and pathological considerations in percutaneous vertebroplasty and kyphoplasty: a reappraisal of the vertebral venous system.
OBJECTIVE
To focus attention of the clinician on the anatomy and (patho)physiology of the vertebral venous system, so as to offer a tool to better understand and anticipate (potential) complications that are related to the application of percutaneous vertebroplasty and kyphoplasty.


BACKGROUND
Percutaneous vertebroplasty and kyphoplasty are newly developed, minimally invasive techniques for the relief of pain and for the strengthening of bone in vertebral body lesions. With the clinical implementation of these techniques, a number of serious neurologic and cardiopulmonary complications have been reported in the international medical literature. Most complications appear to be related to the extrusion of bone cement into the vertebral venous system.


METHODS
The literature about complications of percutaneous vertebroplasty and kyphoplasty is reviewed, and the anatomic and (patho)physiologic characteristics of the vertebral venous system are reported. Based on what is currently known from the anatomy and physiology of the vertebral venous system, the procedures of percutaneous vertebroplasty and kyphoplasty are analyzed, and suggestions are made to improve the safety of these techniques.


CONCLUSIONS
Thorough knowledge of the anatomic and (patho)physiologic characteristics of the vertebral venous system is mandatory for all physicians that participate in percutaneous vertebroplasty and kyphoplasty. To reduce the risk of cement extrusion into the vertebral venous system during injection, vertebral venous pressure should be increased during surgery. This can be achieved by operating the patient in the prone position and by raising intrathoracic venous pressure with the aid of the anesthesiologist during intravertebral instrumentation and cement injection. Intensive theoretical and practical training, critical patient selection, and careful monitoring of the procedures, also taking into account patient positioning and intrathoracic and intra-abdominal pressures, will help to facilitate low morbidity outcomes in these very promising minimally invasive techniques.
Groen
Rob J M
RJ
Department of Neurosurgery, University Hospital Groningen, Grongingen, The Netherlands. r.j.m.groen@nchir.azg.nl
du Toit
Don F
DF
Phillips
Frank M
FM
Hoogland
Piet V J M
PV
Kuizenga
Karel
K
Coppes
Maarten H
MH
Muller
Christo J F
CJ
Grobbelaar
Marie
M
Mattyssen
Johannes
J
D001794:Blood Pressure; D001843:Bone Cements / Q000009:adverse effects* / Q000627:therapeutic use; D003131:Combined Modality Therapy; D003392:Cranial Sinuses / Q000033:anatomy & histology; D004617:Embolism / Q000209:etiology / Q000517:prevention & control; D005119:Extravasation of Diagnostic and Therapeutic Materials / Q000209:etiology* / Q000517:prevention & control; D005598:Fractures, Spontaneous / Q000209:etiology / Q000517:prevention & control; D018056:Hemorheology; D006801:Humans; D015552:Injections, Intralesional; D007738:Kyphosis / Q000209:etiology / Q000601:surgery / Q000628:therapy*; D010024:Osteoporosis / Q000150:complications / Q000517:prevention & control / Q000601:surgery / Q000628:therapy; D019904:Polymethyl Methacrylate / Q000008:administration & dosage / Q000009:adverse effects* / Q000627:therapeutic use; D016684:Prone Position; D012306:Risk; D013115:Spinal Canal / Q000098:blood supply; D013122:Spinal Diseases / Q000601:surgery / Q000628:therapy*; D013131:Spine / Q000098:blood supply*; D014680:Veins / Q000033:anatomy & histology; D014684:Venae Cavae / Q000033:anatomy & histology
D001843:Bone Cements; D019904:Polymethyl Methacrylate