RESEARCH—HUMAN—CLINICAL STUDIES

The Potential Impact of Basivertebral Foramen Morphology and

Pedicle Screw Placement on Epidural Cement Leakage With
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Cement-Augmented Fenestrated Pedicle Screw Fixation: A Multicenter

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Retrospective Study of 282 Patients and 1404 Augmented Screws

Weibo Yu, MD*, De Liang, MM‡, Zhensong Yao, MD‡, Haiyan Zhang, MD*, Yuanming Zhong, MD§, Yongchao Tang, MD‡,
Xiaobing Jiang, MD‡, Daozhang Cai, MD *
*Department of Orthopaedics, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong, People’s Republic of China; ‡Department of Spinal Surgery, The
First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, People’s Republic of China; §Department of Orthopaedics, The First Affiliated
Hospital of Guangxi University of Chinese Medicine, Nanning, Guangxi, People’s Republic of China
Correspondence: Xiaobing Jiang, MD, Department of Spinal Surgery, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Airport Rd 16, Guangzhou
510405, China. Email: 975401145@qq.com; Daozhang Cai, MD, Department of Orthopaedics, The Third Affiliated Hospital of Southern Medical University, West Zhongshan Rd 183,
Guangzhou 510520, China. Email: osteoporosis1985@126.com

Received, September 29, 2022; Accepted, November 24, 2022; Published Online, February 7, 2023.

© Congress of Neurological Surgeons 2023. All rights reserved.

BACKGROUND: Epidural cement leakage (CL) is a common complication in cement-augmented fenestrated pedicle
screw fixation (CAFPSF) with the potential for neural injury. However, there are no reports discussing basivertebral vein
morphology and pedicle screw placement, which are critical in the analysis of the risk of epidural CL after CAFPSF.
OBJECTIVE: To identify the incidence and risk factors of epidural CL in osteoporotic patients during CAFPSF.
METHODS: Two hundred and eighty-two osteoporotic patients using 1404 cement-augmented fenestrated screws
were included. Preoperative computed tomography (CT) was used to characterize the morphology of posterior cortical
basivertebral foramen. After CAFPSF, the severity of epidural CL, the implantation position of the screw tip, and cement
extension within the vertebral body were determined by postoperative CT scans. In this study, significant risk factors for
epidural CL were identified through logistic regression analysis.
RESULTS: In total, 28 patients (18.8%) and 108 screws (7.7%) had epidural CL and 7 patients (13 screws) experienced
neurological symptoms. Although local epidural CL was generally not clinically significant, extensive epidural leakage
posed a higher risk of neurological symptoms. Significant predictors for extensive epidural CL were a magistral type of
basivertebral foramen and the smaller distance between the tip of the screw and the posterior wall of the vertebral body.
CONCLUSION: In osteoporotic patients receiving CAFPSF, epidural CL is relatively common. The morphology of ba-
sivertebral foramen should be taken into account when planning a CAFPSF procedure. It is important to try and achieve a
deeper screw implantation, especially when a magistral type of basivertebral foramen is present.
KEY WORDS: Cement-augmented fenestrated pedicle screw fixation, Osteoporotic patients, Epidural cement leakage

Neurosurgery 93:66–74, 2023 https://doi.org/10.1227/neu.0000000000002373

ince the introduction of pedicle screw fixation for the for those with osteoporosis, have become well-known problems.1,2

S treatment of degenerative diseases, fracture, tumor, and spinal

deformity, loosening and pullout of pedicle screws, especially
ABBREVIATIONS: AP, anterior-posterior; BMD, bone mineral density;
BMI, body mass index; CAFPSF, cement-augmented fenestrated
pedicle screw fixation; CL, cement leakage; CT, computed tomography;
OR, odds ratio; PMMA, polymethylmethacrylate.
Supplemental digital content is available for this article at neurosurgery-online.
com.
Hence, it has been a challenging task for spine surgeons to perform a
successful pedicle screw fixation in elderly patients with osteoporosis.
A common technique for strengthening pedicle screws is to use
polymethylmethacrylate (PMMA), and in vitro and clinical studies
have shown that PMMA has been quite effective.1-4 A principal risk
of such a technique is epidural cement leakage (CL).5-7 Such leakage
is relatively common and carries the potential for temporary or
permanent loss of neurological functioning. The frequency of this
complication varies depending on the initial condition, such as
osteoporosis, and the dose of cement injected.5,6

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In pedicle screw augmentation, Hu et al6 divided CL into 3
areas: anterior–lateral (involving the anterior and/or anterior–
lateral to anterior half of the vertebral body), posterior–lateral
(involving the posterior–lateral to posterior half of the vertebral
body), and epidural leakage (involving the spinal canal). Although
anterior–lateral and posterior–lateral leakages were generally not
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clinically significant, epidural leakage has been reported to have a
higher risk of neurological injury. Some risk factors for epidural
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CL have been identified including lower bone mineral density
(BMD) and cement distribution morphology.6 Nonetheless, that
study did not investigate the association between leakage and
other possible risk factors, such as cement injection volume per
screw and the position of pedicle screw in the vertebral body. To
our knowledge, the incidence, the severity, and risk factors of
epidural CL in osteoporotic patients treated with cement-
augmented fenestrated pedicle screw fixation (CAFPSF) have
not been reported in the previous literature.
METHODS
This study was designed to be performed retrospectively at 3 medical
centers between January 2014 and May 2022. This study was performed
in accordance with the Code of Ethics of the World Medical Association
(Declaration of Helsinki). After approval from the ethics committee of
the primary research institution, approval from each local institutional
research ethical board or the director of the respective sites was obtained.
In our study, all participants received written and oral information before
giving written consent.
Selection of Patients
We retrospectively reviewed 345 consecutive osteoporotic patients
who underwent CAFPSF at 3 medical centers, whereas 58 of them were
excluded because of incomplete clinical data (n = 19), spinal infection
(n = 3), and spinal metastases (n = 36). The BMD of each vertebral body
was measured using dual-energy x-ray absorptiometry. T-Score values less
than 2.5 were set as the criteria for osteoporosis. Finally, 282 patients
(39 males and 243 females), with an average age of 66.50 ± 8.85 years and
T-scores of 3.27 ± 0.91, were enrolled, among whom osteoporotic
vertebral fractures were diagnosed in 13 patients, lumbar spondylolis-
thesis in 126 patients, degenerative scoliosis in 49, and lumbar spinal
stenosis in 94 (Supplemental Figure 1, http://links.lww.com/NEU/
D604). In most cases, patients underwent standard posterior lumbar
interbody fusion, including laminectomy, discectomy, posterior instru-
mentation, and interbody fusion, except for osteoporotic vertebral
fracture patients, who only underwent posterior instrumentation, de-
compressive laminectomy, and open posterolateral fusion. In our study,
the cement-augmented pedicle screws located at the segments of the
fractured vertebral body were excluded to prevent biased effects. Finally,
there were 1404 cement-augmented fenestrated pedicle screws. An av-
erage operation took 260.27 ± 61.75 minutes, the blood loss averaged
722.70 ± 582.50 mL, and hospital stay averaged 19.32 ± 7.41 days.
Operative Procedure
All operations were performed under general anesthesia. Patients were
in a prone position, and screw placement was performed according to the
NEUROSURGERY
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EPIDURAL CEMENT LEAKAGE
technique described by Mueller et al7 and Ulusoy et al.8 Besides eval-
uating the patients’ BMD, the experienced surgeons decided whether to
perform augmentation when manual findings during tapping indicated
that mechanical strength of implanted screws might be insufficient. A
freehand placement of fenestrated screws (DTPSTM, Dream STS) was
performed on the osteoporotic spine. The pedicle screws (6.5 or 7.5 mm
in diameter and 40 or 45 mm in length) had a distal end with 4 holes and
a cannulation diameter of 2.5 or 3.0 mm. After the verification of the
screw position, 0.1-mL increments of bone cement (DePuy AcroMed)
were injected under lateral fluoroscopic guidance. The injection of bone
cement would be stopped if bone cement reached the posterior vertebral
body line or if apparent CL was noted below the endplates or anterior
cortex of the vertebral body. In all 3 medical centers, PMMA preparation
and application followed a standardized protocol provided by the
company. Consequently, 30 seconds were required to mix powder and
liquid, 30 seconds were needed to fill the application device, and 300
seconds must elapse before using cement. The mean amounts of cement
injected in each pedicle screw were 2.15 mL (range, 0.6-5 mL). Three
more than 13 years experienced spinal surgeons performed the opera-
tions. The technique does not require a steep learning curve.
Preoperative and Postoperative Computed Tomography
Evaluation and Data Collection
All enrolled patients underwent a noncontrast computed tomography
(CT) scan (Siemens SOMATOM PLUS 4) with a tube current of 240
mA, 120 Kilovolt Peak, and Pitch 1 on preoperative and first postop-
erative day. The scans used a slice thickness of 3 mm, covering a scan area
of 50 cm. Imaging characteristics were recorded including the mor-
phology of basivertebral foramen in the midportion of the posterior wall of
the vertebral body, the position of the screw tip in the mediolateral direction
of the vertebral body, the screw depth in the anterior-posterior direction of
the vertebral body, and cement extension within the vertebral body.
Depending on whether the posterior nutrition foramina were magistral (a
large, single centrally located foramen with a width/height of ≥5 mm) or
dispersed (multiple small nutrient foramina), basivertebral foramina were
classified into 2 types (Figure 1). Furthermore, the position of the screw tip
in the mediolateral direction of the vertebral body was defined as the vertical
distance between the screw tip and the midline of the vertebral body. The
screw depth in the anterior-posterior direction of the vertebral body was
defined as the vertical distance between the tip of the screw and the posterior
wall of the vertebral body (Figure 2A). The cement extension within the
vertebral body was divided into 4 zones6: zone 1 corresponded to the
anterior third, zone 2 to the middle third, zone 3 to the posterior third, and
zone 4 to the pedicle area (Figure 2B). Finally, the severity of epidural CL
was also observed and divided into 2 groups: group 1, local epidural leakage
(cement meniscus only at the nutrition foramen) (Figure 3A) and group 2,
extensive epidural leakage (cement mass exceeding the range of the nutrition
foramen in the posterior wall of the vertebral body or canal leakage mea-
suring more than 2-mm thick) (Figure 3B). All the radiological parameters
would be measured twice by 2 independent experienced spinal surgeons
with over 10 years of experience, who were blinded to the identity of the
participants, design, and hypotheses of the study throughout data. In the
case of disagreement, a third experienced radiologist was involved in the
decision-making process to manage bias.
In addition, the following data were collected: age, sex, body mass
index, BMD, the number of augmented screws, the level of augmented
screws (thoracic or lumbosacral spine), blood loss, and operative time.
Data are available on reasonable request.
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FIGURE 1. The morphology of basivertebral foramen in the posterior vertebral cortex in coronal and axial
computed tomography images. A and B, A magistral type of basivertebral foramen (a large, single centrally located
foramen with a width/height of ≥5 mm). C and D, A disperse type of basivertebral foramen (multiple small
nutrient foramina).

Statistical Analysis
All the statistical analyses in this study were performed using SPSS
25.0 (SPSS, Inc) and R Software version 3.6.2. Significant differences
were identified when the P value was < .05. Means and SD were used
to express qualitative characteristics of groups. The differences be-
tween the groups were assessed using univariate analysis for variables
with symmetrical distributions and the nonparametric Wilcoxon test
for variables with other distributions. Fisher’s exact test was used to
assess the statistical significance of dichotomous variables. We used
binary logistic regression analysis and receiver operating characteristic
curves to determine independent risk factors and critical values,
respectively.
RESULTS
There were 53/282 (18.8%) patients who developed epidural
CL, whereas 108/1404 (7.7%) augmented screws were involved.
The levels treated were from T10 to S1, and Figure 4 illustrates
the distribution of pedicle screws and epidural CL.
Extensive epidural CL was observed in 13 patients (involving
23 screws), 6 patients (10 screws) of whom were asymptomatic.
However, 7 patients (13 screws) of those 13 patients presented
with neurological symptoms because of nerve compression caused
by CL, 4 of whom experienced mild postoperative sciatica and
recovered after conservative treatment; 2 of whom received excess
cement removal during the same surgical procedure without
severe neurological sequelae of paralysis, but did experience
sensory complaints such as burning, tingling, and numbness in
the distal lower extremities and got complete disappearance after
conservative treatment within 3 months after the operation; and
only 1 of whom had neurological injury and required a revised
surgery for total laminectomy at the L1/L2 level on the second
postoperative day (Figure 5), but continued to complain of
weakness and numbness in his right leg within a 1-year follow-up.

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FIGURE 2. A, The location of pedicle screw implantation in the mediolateral (red line) and anterior-posterior
(green line) directions of the vertebral body on axial CT scan. B, Cement distribution within the vertebral body
was divided into 4 zones on CT axial view. CT, computed tomography.

Local epidural CL was observed in 40 patients (involving 85
screws) although all patients were asymptomatic. In addition, no
patient observed in our study suffered from pulmonary cement
embolisms.
A magistral type of basivertebral foramen was observed in 622
(44.3%) of the 1404 augmented screws, and of these, 17 (2.7%)
demonstrated extensive epidural CL. A disperse type of basi-
vertebral foramen was observed in 782 (55.7%) of the 1404
augmented screws; of these, 6 (0.8%) demonstrated extensive
epidural leakage. These differences were analyzed using Fisher’s
exact test and found to be statistically significant with a P value
of .002.
The independent risk factors for patients with epidural CL were
decreased BMD (odds ratio [OR] = 0.56, P = .019) and more
number of augmented screws (OR = 1.59, P = .002). Based on a
logistic regression analysis, screws with epidural CL were asso-
ciated with 5 independent factors, including a magistral type of
basivertebral foramen (OR = 2.27, P = .002), more volume of
cement injected (OR = 2.40, P < .001), the smaller distance
between the screw tip and the midline of the vertebral body (OR =
0.64, P < .001), the smaller distance between the tip of the screw
and the posterior wall of the vertebral body (OR = 0.64, P < .001),
and cement extension into the pedicle area (OR = 4.08, P < .001)
(Table 1).

FIGURE 3. A, Local epidural CL on the axial CT image (cement meniscus only at the nutrition foramen).
B, Extensive epidural CL on the axial CT image (cement mass exceeding the range of the nutrition foramen in
the posterior wall of the vertebral body or canal leakage measuring more than a thickness of 2 mm). CL,
cement leakage; CT, computed tomography.

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FIGURE 4. The distribution of pedicle screws related to epidural CL. A,
Distribution of pedicle screws with and without epidural CL. B, Distribution of
pedicle screws with different types of epidural CL. CL, cement leakage.
Although local epidural CL was generally not clinically sig-
nificant, extensive epidural leakage posed a higher risk of neu-
rological symptoms. Thus, we identified risk factors associated
with extensive epidural leakage as well. Binary logistic regression
analysis showed that 2 factors had a significant association with
extensive epidural leakage, including a magistral type of basi-
vertebral foramen (OR 6.84; 95% CI 2.18-21.48; P = .001) and
the smaller distance between the tip of the screw and the posterior
wall of the vertebral body (OR 0.75; 95% CI 0.62-0.92; P = .005)
(Table 2). The area under the curve of the estimated general
model for extensive epidural leakage was 0.787 (95% CI 0.685-
0.890) with a sensitivity of 69.6% and a specificity of 75.6%,
which was the highest when compared with each independent risk
factor (Figure 6). The predictive value of the estimated general
model was 74.5% (percent of correctly predicted values for de-
pendent variables). The adequate calibration for the estimated
regression model was further supported by the Hosmer–Leme-
show P-value of .893.
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DISCUSSION
Interpretation
CL into the spinal canal is a common complication with
CAFPSF and has a higher risk of developing neurological defi-
cits.1-5 Unfortunately, most cases of epidural CL cannot be
prevented or detected by fluoroscopic guidance because post-
operative CT findings are much higher than those detected by
intraoperative fluoroscopy.9,10 Therefore, it is necessary to have
thorough understanding of the preoperative factors that can be
used to predict the risk of epidural CL and pedicle screw
placement that can be used to reduce the rate of epidural CL.
Epidural CL has been classified in previous studies by its
thickness, including the studies by Hu et al6 and Georgy et al,11
and it is unclear, however, whether this grading system has any
clinical significance. Finally, our study focused on extensive
epidural CL because of the risk of neurological compromise as-
sociated with this type of leakage.
BMD may also play an important role in epidural CL. Similar
to many previous studies,5,6,12 this research also indicated that
low BMD was closely related to epidural CL after CAFPSF
treatment for osteoporotic patients. Hu et al6 suggested that
patients with lower BMD had thinner trabeculae in the vertebral
body, in which mobile cement might be able to pass through more
intertrabeculae space. The bone cement might extend more easily
to basivertebral vein and spread through the vein network into the
spinal canal.12 Therefore, it is necessary to take extra precaution
during cement injections for CAFPSF in patients with severe
osteoporosis.
In our study, more number of augmented screws are considered
another risk factor for patients with epidural CL. The findings of
previous study reported by Guo et al,5 who conducted a retro-
spective analysis of 202 patients, provided strong support for our
conclusions. Ulusoy et al8 demonstrated that 7 more levels and 14
augmented screws could significantly increase risk of symptomatic
pulmonary cement embolism (PCE). In their study, they concluded
that fewer number of CAFPSF should be used and CAFPSF should
be applied only to critical regions in the most proximal level, most
distal level, and thoracolumbar junction to prevent the occurrence of
symptomatic PCE. This view is supported by our results, which
suggest that fewer levels (3.05 ± 1.59) and augmented screws (4.97 ±
1.56) may explain the absence of PCE after CAFPSF.
Another important risk factor for epidural CL is cement ex-
tension into the pedicle area. In previous studies, injection of
PMMA along the entire length of the screw resulted in the
strongest pullout strength.13 Approximately 60% of the pullout
strength of pedicle screws can be attributed to the pedicle area,
which means the more zones (especially the pedicle area) are used
in the pedicle area, the stronger the pullout strength. However,
cement extension into the pedicle area significantly increased the
spinal canal leakage rate (21.34%, 19 of 89 screws) compared with
without cement extension into the pedicle area (5.7%, 70/1226).
Finally, our hypothesis is that the ideal cement extension should
not exceed the posterior wall of the vertebral body, which may
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FIGURE 5. In the presence of magistral basivertebral foramen, A and B, postoperative computed tomography
scans demonstrate C and D, that the screw is inserted relatively shallowly and close to the midline of the
vertebral body, resulting in extensive epidural cement leakage with neurological injury.

balance biomechanical strength with spinal canal leakage risk
perfectly.
In addition, our analysis data also showed that there was a
positive correlation between the applied cement volume and the
likelihood of epidural leakage. According to previous studies, it is
also a risk factor for epidural leakage in percutaneous vertebral
augmentation when there is a large amount of bone cement,
resulting in an increase in injection pressure, a possibility of
secondary venous wall rupture, and pressed cement into the
basivertebral vein.14 Based on literature, the amount of cement
used per screw varies between 1.8 and 3.0 mL,5,7 similar to the
amount used in this study. The purchasing strength is not in-
creased by injecting more cement than 2.8 mL per screw, ac-
cording to biomechanical studies.15 To reduce the risk of epidural
leakage, we believe that 1.5 to 2 mL per pedicle screw is a good
amount to use.7
In our study, pedicle screw placement also had a significant
association with epidural CL, and in cases where the depth of the
screw tip was smaller or the screw tip was closer to the midline,
epidural CL was more likely to occur. Furthermore, we
identified risk factors associated with extensive epidural CL,
and an analysis of binary logistic regression showed that only
the smaller distance between the screw tip and the posterior
wall of the vertebral body was significantly associated with
extensive epidural CL. Besides, the morphology of posterior
cortical basivertebral foramen has been added as another
clinically significant factor, with a magistral type of basi-
vertebral foramen being significantly associated with a much
higher risk of extensive epidural CL. We believe that anatomic
characteristics of the basivertebral vein might play a major role
in the cause. It originates in the ventral third of the vertebral
body and converges posteriorly to drain into the ventral part of
the internal venous plexus. When screws are inserted too
shallowly and a magistral type of basivertebral foramen is
present, more volume of cement injected may easily enter the
magistral basivertebral system and be transferred to the ventral

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TABLE 1. Using Binary Logistic Regression Analysis to Judge Independent Risk Factors for Epidural CL

Factors Leakage Nonleakage OR (95% CI) P values

For patients with epidural leakage
Age (y)a 68.34 ± 10.65 66.07 ± 8.35 1.01 (0.97-1.05) .581
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Sex (female/male) 45/8 198/31 0.85 (0.47-3.83) .723

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BMIa 22.17 ± 3.17 22.87 ± 3.40 1.03 (0.91-1.16) .135

BMD (T score)a 3.51 ± 0.51 3.22 ± 0.97 0.56 (0.34-0.91) .019b

Operative time (min)a 273.17 ± 57.93 257.28 ± 62.35 1.00 (0.99-1.01) .349

No. of augmented screws 5.49 ± 0.91 4.85 ± 1.65 1.59 (1.18-2.15) .002b

Blood loss (mL)a 623.01 ± 428.31 745.76 ± 611.14 1.00 (0.99-1.01) .169

For implanted screws with epidural leakage

Type of basivertebral foramen (magistral/dispersed) 47/61 575/721 2.27 (1.37-3.78) .002b

Volume of cement injected (mL)a 2.59 ± 1.06 2.12 ± 0.74 2.40 (1.81-3.18) <.001b

Distance between the screw tip and the midline of the vertebral body (mm)a 3.89 ± 1.71 5.72 ± 2.28 0.64 (0.57-0.73) <.001b

Screw depth in the AP direction of the vertebral body (mm)a 20.85 ± 3.07 24.77 ± 3.13 0.64 (0.59-0.70) <.001b

Cement extension into the pedicle area (yes/no) 19/89 70/1226 4.08 (1.97-8.47) <.001b

Augmented vertebra (thoracic/lumbosacral) 2/106 38/1258 0.59 (0.11-3.19) .546

AP, anterior-posterior; BMD, bone mineral density; BMI, body mass index; CL, cement leakage; OR, odd ratio.
a
Quantitative variables are expressed as mean ± SD.
b
P<0.05.

epidural space through these veins, compromising the neural
elements in the spinal canal.5,16,17
Limitations
There are still some limitations in this study. First, we adopted a
multicenter retrospective study, but selection bias and technical
and interpretational bias among surgeons are inevitable, and
further prospective study is needed. Second, in our study, most of
the pedicle screw tip’s position could be identified either directly
or by adjusting the window level and width on postoperative CT
scans. However, a small proportion of screw tip’s position was still
invisible, and we determined the position of the screw tip based on
the lengths of intraoperatively implanted screws. Although it
might lead to some potential bias in comparison with direct

TABLE 2. Using Binary Logistic Regression Analysis to Judge Independent Risk Factors for Extensive Epidural Leakage

95% CI of OR

Factors B OR Lower bound Upper bound P values

BMD (T score)a 0.385 1.470 0.411 5.251 .553
Type of basivertebral foramen (magistral/dispersed) 1.922 6.835 2.175 21.482 .001b

Volume of cement injected (mL)a 0.440 1.553 0.848 2.845 .154

a
Distance between the screw tip and the midline of the vertebral body (mm) 0.010 1.010 0.749 1.362 .946
a
Screw depth in the AP direction of the vertebral body (mm) 0.282 0.754 0.620 0.916 .005b

Cement extension into the pedicle area (yes/no) 0.181 1.199 0.312 4.598 .792

AP, anterior-posterior; BMD, bone mineral density; OR, odd ratio.

a
Quantitative variables are expressed as mean ± SD.
b
P<0.05.

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FIGURE 6. Receiver operating characteristic curves and area under the curve
(AUC) (the estimated general model, the morphology of posterior cortical
basivertebral foramen, and the screw depth in the vertebral body).
detection of the screw tip’s position, we believe that final results
would not be significant. Third, there are numerous types of
fenestrated pedicle screws with differing core diameters, sizes,
numbers, and locations of radial holes,18,19 which may contribute
to epidural leakage. However, our study included only 1 type of
fenestrated pedicle screw to prevent biased effects caused by
different types of fenestrated pedicle screws.
CONCLUSION
In osteoporotic patients receiving CAFPSF, epidural CL is
relatively common. The morphology of basivertebral foramen
should be taken into account when planning a CAFPSF procedure.
It is important to try and achieve a deeper screw implantation,
especially when a magistral type of basivertebral foramen is present.
Funding
Weibo Yu received funding from the Guangxi Natural Science Foundation
Program, China (2019GXNSFBA185025). This study did not receive any funding
or financial support.
Disclosures
The authors have no personal, financial, or institutional interest in any of the
drugs, materials, or devices described in this article.
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NEUROSURGERY
© Congress of Neurological Surgeons 2023. Unauthorized reproduction of this article is prohibited.
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Supplemental digital content is available for this article at neurosurgery-online.com.
Supplemental Figure 1. Flow diagram of the analytic cohort selected from the
database.
COMMENTS
T he authors have submitted a multicenter, retrospective review of 282
osteoporotic patients undergoing placement of 1404 fenestrated
pedicle screws to determine risk factors associated with epidural leakage of
cement. Distribution of cement was determined via CT scans and cat-
egorized as either local or extensive (mass effect within the spinal canal).
VOLUME 93 | NUMBER 1 | JULY 2023 | 73
 YU ET AL
Epidural leakage was identified in 18.8% (53) of patients and 7.7% (108) of
screws. Extensive leakage was identified in 13 patients (23 screws), with 7
thought to develop neurological sequelae. Based on their analysis, the authors
identified a “magistral type” basivertebral foramen (single large foramen) and
decreased distance between the screw tip and the posterior cortical wall as
independent risk factors for extensive epidural leakage. The authors conclude
Downloaded from http://journals.lww.com/neurosurgery by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0h
that when utilizing fenestrated pedicle screws supplement with cement in
osteoporotic patients, the configuration of the basivertebral foramen is
considered and an attempt to maximize screw length is attempted.
CywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 10/04/2023
The authors are to be commended for exploring a difficult clinical
scenario that can be problematic under the best of circumstances. Uti-
lization of cement can prove to be an effective adjunct, which, however, is
associated with the potential complication of cement leakage into the
epidural space with possible neurological compromise. To date, several
criteria, such as decreased BMD and an increased number of screws, have
been identified as potential risk factors for epidural dement leakage. The
74 | VOLUME 93 | NUMBER 1 | JULY 2023
© Congress of Neurological Surgeons 2023. Unauthorized reproduction of this article is prohibited.
authors’ observations support these previous findings and have identified
2 additional risk factors, the configuration of the basivertebral foramen
and proximity of the screw type to the posterior cortical wall, as inde-
pendent risk factors that may lead to concerning epidural cement leakage.
The presence of a large basivertebral foramen may exacerbate the in-
creased risk associated with decreased BMD, as a point of least resistance
for cement to escape into the epidural space.
Although this manuscript suffers from several limitations, for instance,
the retrospective study design and subjective surgeon interpretation to
determine necessity of cement augmentation, it provides novel infor-
mation to stimulate further research. At the very least, these additional
risk factors should be taken into account when considering cement
augmentation in the osteoporotic patient.
Michael G. Kaiser
Ridgewood, New Jersey, USA
neurosurgery-online.com