Expert’s comment concerning Grand Rounds case entitled “Intracardiac bone cement embolism as a complication of vertebroplasty: management strategy” by Hatzantonis C, Czyz M, Pyzik R, Boszczyk BM. (Eur Spine J; 2016. doi:10.1007/s00586-016-4695-x)

Asymptomatic Intracardiac Cement Embolism Following Kyphoplasty

Cement extravasation can occur during vertebral body augmentation such as kyphoplasty and vertebroplasty with diverse presentation and resultant treatment. The cement can embolize through venous vasculature to the thorax where it poses a potential threat to the cardiovascular and pulmonary systems. A thorough risk-benefit analysis should be conducted to select the appropriate treatment course. We present an asymptomatic case of cement extravasation to the heart and lungs during kyphoplasty.

The Correlation Between the Diffusion Coefficient of Bone Cement and Efficacy in Percutaneous Vertebroplasty

This study investigated the effect of bone mineral density (BMD) on the diffusion coefficient (DC) of bone cement in percutaneous vertebroplasty (PVP) and the correlation between the DC and the efficacy after PVP. This was a retrospective study of PVP cases with follow-up longer than 12 months. The cases were assigned to 3 groups according to the BMD: BMD decrease group, osteoporosis group, and severe osteoporosis group. The 3 groups were compared regarding bone cement injection volume (IV), diffusion volume (DV), DC, visual analog scale (VAS) score, Oswestry Disability Index (ODI) score, and vertebral height loss ratio (VHLR). The correlation between DC and BMD, IV, DV, and VHLR was analyzed. The least significant difference test was used for comparison among the 3 groups, and the Pearson correlation coefficient was used for correlation analysis. There were a total of 132 cases, including 34 males and 98 females with a mean age of 76.5±9.6 years. The DV was larger than the IV in each group (P<.05). There was no statistically significant difference in the IV, VAS score, and ODI among the 3 groups (P>.05). However, there were significant differences in the DC and VHLR among the 3 groups (P<.05). Correlation analysis showed that there were significant correlations between BMD and IV (-0.716), BMD and DC (0.754), IV and DV (0.502), and IV and DC (-0.666) (P<.01). Scatter plot showed that the correlation between IV and BMD was r=0.716, R²=0.513, and the correlation between DC and BMD was r=0.754, R²=0.568. The DV was larger than the IV in PVP, and BMD was closely related to the DC. The higher the BMD, the higher the DC. Short-term follow-up revealed that the DC was inversely proportional to the VHLR. [Orthopedics. 2021;44(1):e95-e100.].

[Intracardiac and Pulmonary Cement Embolism after Percutaneous Vertebroplasty]

The article presents a clinical case of embolism with bone cement of the right ventricle of the heart and pulmonary artery after percutaneous vertebroplasty in a patient aged 63 years. According to the results of a comprehensive examination using ultrasound and x-ray methods, three foreign bodies were found: in the right ventricle cavity, in the trunk of the pulmonary artery, in the branches of the left pulmonary artery. Considering the stable condition, normal blood oxygen saturation, the lack of influence of formations on intracardiac hemodynamics, it was decided to refrain from surgery, since the risk of intervention exceeded the possible benefit. Conservative treatment tactics and dynamic observation were chosen. The literature data on the frequency of such events and tactics of management of these patients are presented.

Cement cardiac embolism following kyphoplasty noted on thoracic imaging

Asymptomatic polymethyl methacrylate cardiac embolism is an uncommon complication of kyphoplasty. We report a case of a 56-year-old female with an incidentally noted radiopaque foreign body in the right ventricular cavity on chest x-ray following kyphoplasty. In this report, we discuss how to differentiate between the potential intracardiac foreign bodies and how to establish the diagnosis of polymethyl methacrylate embolism. Once diagnosed, the management of these patients remains controversial.

Presentation and management of symptomatic central bone cement embolization

BACKGROUND CONTEXT

With more cement augmentation procedures done, the occurrence of serious complications is also expected to rise. Symptomatic central cement embolization is a rare but very serious complication. Moreover, the pathophysiology and treatment of intrathoracic cement embolism remain controversial.

PURPOSE

In this case series, we are trying to identify various presentations and suggest our emergent management scheme for symptomatic central cement embolization.

PATIENT SAMPLE

Retrospective case series of nine patients with symptomatic central cement embolism identified after vertebroplasty with 24 months of follow-up. Level IV.

OUTCOME MEASURES

The degree of dyspnea measured by the New York Heart Association (NYHA) score and/or death related to cement embolism induced cardio/respiratory failure at the final follow-up at 24 months.

METHODS

The nine patients, eight females, and one male had a mean age of 70.25 years (range 65-78 years) and were operated between January 2004 and December 2014. They had percutaneous vertebroplasty for osteoporotic non-traumatic and malignant vertebral collapse of dorsal and lumbar vertebrae. Post-vertebroplasty dyspnea and stitching chest pain were striking in the nine patients. After exclusion of cardiac ischemia and medical pulmonary causes for dyspnea, we identified radiopaque lesions on the chest X-ray. Further echocardiography and high-resolution chest CT were performed for optimal localization. Emergent heart surgery was performed in two patients: interventional therapy was conducted in one patient, while the remaining six patients were conservatively treated by anticoagulation. The management decision was taken in the setting of an interdisciplinary meeting depending on localization, fragmentation, and clinical status.

RESULTS

All patients of this series showed gradual improvement and an uneventful hospital stay. During our 24-month follow-up phase, eight patients showed no subsequent cardiological and/or respiratory symptoms (NYHA I). However, one mortality due to advanced malignancy occurred. Preoperative anemia was the only common intersecting preoperative parameter among these nine patients.

CONCLUSIONS

After cement augmentation, close clinical monitoring is mandatory. A chest CT is pivotal in determining the interdisciplinary management approach in view of the availability of necessary expertise, facilities and the location of the cement emboli whether accessible by cardiac or vascular surgical means. The clinical presentation and its timing may vary and the patient may be seen subsequently by other health care providers obligating a wide-spread awareness for this serious entity among health care providers for this age group as spine surgeons, family and emergency room doctors, and institutional or home-care nurses. Most symptomatic central cement emboli may be treated conservatively.