Removal of a large cement embolus from the right pulmonary artery 4 years after kyphoplasty: Consideration of thrombogenicity

Polymethylmethacrylate Pulmonary Embolism Following Vertebroplasty

Polymethylmethacrylate (PMMA) is a commonly used substrate in vertebroplasty procedures. Well-known for its dependable strength and relative lack of toxic side effects, PMMA administration is useful for the stabilization of vertebral bodies in the setting of common spinal pathologies such as osteoporosis. Unfortunately, as the popularity of vertebroplasty has increased, so has the incidence of a potentially lethal complication of the procedure, PMMA pulmonary embolism. Extravasation of PMMA from the vertebral body into the adjacent vasculature can provide a route through which PMMA may travel until it becomes lodged in the pulmonary vasculature, thereby forming a PMMA pulmonary embolism. While the vast majority of PMMA embolism cases are relatively mild, others are severe and demand swift recognition and potentially life-saving intervention. Despite the increasing incidence of PMMA embolism, a clear algorithm for management does not yet exist. Controversy abounds regarding the most effective strategies to diagnose and manage patients with PMMA embolism. Described is a case of delayed diagnosis of a PMMA embolism in a patient who underwent percutaneous vertebroplasty for an osteoporotic vertebral body fracture. Multiple visits to the emergency department (ED) for chest discomfort or cough after the vertebroplasty eventually led to cross-sectional imaging that revealed the diagnosis. Her acute symptoms resolved with conservative management. Given that her final outcome was positive with no long-term morbidity, the aim of this report is to explore the current treatment algorithms for PMMA embolism and to consider whether or not this patient would have been managed differently had the correct diagnosis been uncovered earlier.

Utility of Cement Augmentation via Percutaneous Fenestrated Pedicle Screws for Stabilization of Cancer-Related Spinal Instability

BACKGROUND

Cancer patients experience pathological fractures and the typical poor bone quality frequently complicates stabilization. Methods for overcoming screw failure include utilization of fenestrated screws that permit the injection of bone cement into the vertebral body to augment fixation.

OBJECTIVE

To evaluate the safety and efficacy of cement augmentation via fenestrated screws.

METHODS

A retrospective chart review of patients with neoplastic spinal instability who underwent percutaneous instrumented stabilization with cement augmentation using fenestrated pedicle screws. Patient demographic and treatment data and intraoperative and postoperative complications were evaluated by chart review and radiographic evaluation. Prospectively collected patient reported outcomes (PRO) were evaluated at short (2- <6 mo) and long term (6-12 mo).

RESULTS

Cement augmentation was performed in 216 fenestrated pedicle screws in 53 patients. Three patients required reoperation. One patient had an asymptomatic screw fracture at 6 mo postoperatively that did not require intervention. No cases of lucency around the pedicle screws, rod fractures, or cement extravasation into the spinal canal were observed. Eight cases of asymptomatic, radiographically-detected venous extravasation were found. Systemic complications included a pulmonary cement embolism, a lower extremity deep vein thrombosis, and a postoperative mortality secondary to pulmonary failure from widespread metastatic pulmonary infiltration. Significant improvement in PRO measures was found in short- and long-term analysis.

CONCLUSION

Cement augmentation of pedicle screws is an effective method to enhance the durability of spinal constructs in the cancer population. Risks include cement extravasation into draining blood vessels, but risk of clinically significant extravasation appears to be exceedingly low.

Pulmonary cement embolism following balloon kyphoplasty: The impact of a procedural complication in a new era for lung cancer management

Pulmonary cement embolism (PCE) is a recognized complication of balloon kyphoplasty, a vertebral augmentation technique that stabilizes vertebral compression fractures, alleviating associated pain. Balloon kyphoplasty is particularly relevant when patients with advanced stages of cancer present with longer survival times, and therefore benefit from such augmentation techniques to improve pain and prevent additional complications. The embolization of cement to pulmonary vasculature may be unnoticed given the frequent absence of symptoms and routine imaging tests following the procedure. The present study reports the case of a 58-year-old female with stage IV lung cancer with a painful compression L3 fracture who underwent balloon kyphoplasty with no initially reported complications. The patient maintained the usual respiratory symptoms; therefore, the diagnosis was only made in a routine CT scan 3 months after the surgery. A literature review of PCE is performed, integrating the current evidence regarding diagnosis, therapeutics, prognosis and prevention. Certain poorly clarified aspects are identified as potential investigation starting points.

Calcium Hydroxylapatite Pulmonary Embolism after Percutaneous Injection Laryngoplasty

Injection medialization laryngoplasty is a procedure that has many advantages in treating vocal fold paralysis; however, undesired complications can occur. We experienced a case of a pulmonary embolism, suspected in a patient who had undergone an injection laryngoplasty with calcium hydroxylapatite (CaHA). The patient suffered dyspnea after undergoing the injection laryngoplasty. Chest embolism computed tomography (CT) scan revealed a new lesion of enhancing materials at the pulmonary vasculature in the right upper lobe. The CaHA embolism was suspected, and the patient was treated with warfarin for 12 months. The patient's symptom of dyspnea nearly disappeared and a follow up chest embolism CT scan revealed no signs of the previous lesion. Thus, we would like to report this rare case along with a review of the literature.

Surgical techniques and clinical evidence of vertebroplasty and kyphoplasty for osteoporotic vertebral fractures

Osteoporotic vertebral fracture is a disease condition with high morbidity and mortality, whose prevalence rises with mean increase in the life span. Conventional treatments for an osteoporotic vertebral fracture include bed rest, pain medication and brace implementation, but if the patient's pain is severe, cement augmentation procedures, including vertebroplasty and kyphoplasty, are performed. Vertebroplasty and kyphoplasty are relatively easy procedures that have been reported to be effective in controlling acute pain. But, the risk of complication and additional adjacent segment fracture and their superiority over conventional treatment remain debatable. Therefore, the authors have summarized the procedures, complications, and clinical evidence of vertebroplasty and kyphoplasty in this review.

Vertebral Augmentation for Osteoporotic Compression Fractures

Vertebral augmentation procedures such as vertebroplasty and kyphoplasty were developed to reduce pain and improve quality of life for patients with osteoporotic vertebral compression fractures. However, the use of vertebral augmentation has been debated and questioned since its inception. This article addresses some of these issues.

Pulmonary Cement Embolism following Percutaneous Vertebroplasty

Percutaneous vertebroplasty is a minimal invasive procedure that is applied for the treatment of osteoporotic vertebral fractures. During vertebroplasty, the leakage of bone cement outside the vertebral body leads to pulmonary cement embolism, which is a serious complication of this procedure. Here we report a 48-year-old man who was admitted to our hospital with dyspnea after percutaneous vertebroplasty and diagnosed as pulmonary cement embolism.

Pulmonary embolism with vertebral augmentation procedures

With the prevalence of an aging American population on the rise, osteoporotic vertebral fractures are becoming a common occurrence, resulting in an increase in vertebral augmentation procedures and associated complications such as cement leakage, vertebral compressions, and pulmonary embolism. We describe a patient who presented with respiratory distress three years following kyphoplasty of the lumbar vertebra. Computed tomography (CT) angiogram of the chest confirmed the presence of polymethylmethacrylate (PMMA) cement in the lung fields and pulmonary vessels. We conducted a systematic review of the published literature identifying effective management strategies for the treatment of vertebroplasty-associated pulmonary embolism.

Intracardiac foreign body (bone cement) after percutaneous vertebroplasty

Percutaneous vertebroplasty is a relatively easy and minimally invasive procedure used in treating vertebral fractures. However, the procedure has many complications, one of which is bone cement leakage, which happens frequently. Leakage to the paravertebral venous system, in particular, may lead to especially devastating consequences. Here we report a case of a 65-year-old male patient with an intracardiac foreign body (bone cement) that generated a perforation on the right ventricle, and result in hemopericardium after percutaneous vertebroplasty. We performed open heart surgery to remove the foreign body.

Vertebroplasty in Patients with Tumour-Related Vertebral Fractures: Is Rehabilitation Needed?

For about 20 years, vertebroplasty has been used to achieve relief from pain and improve function in eligible patients affected by vertebral fractures. The procedure is also performed in patients with tumours of the vertebral body. The aim of this study was to investigate, by means of a literature review, correlations between vertebroplasty and the need for rehabilitation after patients with tumour-related vertebral fractures were operated on. This review was based on literature from the US National Library of Medicine, National Institutes of Health (PubMed), using the following Medical Subject Headings (MeSH) terms: "vertebroplasty," "surgical procedures minimally invasive," "bone neoplasm," "spine," "postoperative care," "rehabilitation," and "exercise." In total, 14 citations were retrieved: potentially relevant studies were identified by searching titles and abstracts, and then the full text of the selected articles was reviewed. From this review, the postoperative course of vertebroplasty today does not strictly indicate the need for rehabilitation.