title: Radiographic and histologic findings of vertebral augmentation using polymethylmethacrylate in the primate spine: percutaneous vertebroplasty versus kyphoplasty.
abstract: METHODS
  Animal study.
  
  
  OBJECTIVE
  To investigate the gross behavior and the histologic effect(s) of polymethylmethacrylate (PMMA) in primate vertebral bodies after percutaneous vertebroplasty and kyphoplasty.
  
  
  BACKGROUND
  PMMA is known to induce thermal osteonecrosis in exposed bone during tumor surgery and total joint arthroplasty, and barium sulfate as well as PMMA are known to induce a foreign body reaction, but the effects of PMMA on vertebral cancellous bone have not been well documented. Furthermore, little is known about the mechanisms of cement extravasation that occasionally occur during these procedures. Lastly, it is not known if differences exist between vertebroplasty and kyphoplasty with regards to the above occurrences.
  
  
  METHODS
  Six living, elderly, female baboons were used in this study. Seven vertebrae from T12 to L6 were investigated in each animal. Two levels underwent vertebroplasty, two underwent kyphoplasty, and one underwent cavity creation only without cement augmentation in each animal. Three animals were killed at 24 hours and three at 26 weeks after surgery. The specimens were examined macroscopically for cement migration, and histologically for evidence of thermal necrosis, foreign body reaction, cement migration, and intravascular extravasation.
  
  
  RESULTS
  Small zones of osteonecrosis were observed histologically at the bone-cement interface in only two kyphoplasty (2 of 6) and two vertebroplasty specimens (2 of 5) at 26 weeks after surgery. All of these necrotic segments of bone were associated with new bone formation. Foreign body reactions were observed in all specimens at 26 weeks after surgery, yet none of them was associated with bone resorption. The incidence of cement leak into the spinal canal and adjacent soft tissues was 6 of 11 and 4 of 11 in vertebroplasty specimens and 5 of 12 and 3 of 12 in kyphoplasty specimens, respectively. There was no statistical difference in the incidence of cement leakage into the spinal canal (P = 0.54) and adjacent soft tissues (P = 0.55) between vertebroplasty and kyphoplasty specimens. The incidence of intravascular cement was significantly greater in vertebroplasty (11 of 12, 91%) than in kyphoplasty (5 of 12, 42%) (P = 0.013).
  
  
  CONCLUSIONS
  PMMA caused relatively little necrotic exothermal effect. The presence of PMMA with barium sulfate induces a mild foreign body reaction. The use of a balloon tamp creates a void by displacing pieces of bone, which may result in a lower incidence of intravascular cement leak.
authors.affiliation: Cleveland Clinic Spine Institute, Cleveland, OH 44195, USA.
authors.forename: Daisuke
authors.initials: D
authors.lastname: Togawa
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Kovacic
authors.forename: Thomas W
authors.initials: TW
authors.lastname: Bauer
authors.forename: Mary Kay
authors.initials: MK
authors.lastname: Reinhardt
authors.forename: Darrel S
authors.initials: DS
authors.lastname: Brodke
authors.forename: Isador H
authors.initials: IH
authors.lastname: Lieberman
mesh_terms: D000818:Animals; D001843:Bone Cements / Q000009:adverse effects*; D015519:Bone Density; D017587:Diskectomy, Percutaneous / Q000379:methods; D005260:Female; D008159:Lumbar Vertebrae / Q000000981:diagnostic imaging / Q000187:drug effects* / Q000473:pathology; D023421:Models, Animal; D019637:Orthopedic Procedures / Q000009:adverse effects; D016348:Osseointegration / Q000187:drug effects; D010020:Osteonecrosis / Q000139:chemically induced / Q000473:pathology; D010215:Papio; D011109:Polymethacrylic Acids / Q000009:adverse effects*; D011859:Radiography; D013904:Thoracic Vertebrae / Q000000981:diagnostic imaging / Q000187:drug effects* / Q000473:pathology
chemical_list: D001843:Bone Cements; D011109:Polymethacrylic Acids; C030613:polymethacrylic acid