Cement pulmonary embolism after vertebroplasty

Risk factor analysis of pulmonary cement embolism during percutaneous vertebroplasty or kyphoplasty for osteoporotic vertebral compression fractures

Objective

The purpose of this research is to evaluate the risk factors and incidence of pulmonary cement embolism (PCE) during percutaneous vertebroplasty (PVP) or kyphoplasty (PKP) for osteoporotic vertebral compression fractures (OVCFs) based on postoperative computed tomography (CT).

Methods

A total of 2344 patients who underwent PVP or PKP due to OVCFs in our spine center were analyzed retrospectively. According to the detection of postoperative pulmonary CT, the patients were divided into two groups: pulmonary cement embolism group (PCE group) and non-pulmonary cement embolism group (NPCE group). Demographic data in both groups were compared using the χ² test for qualitative data and the unpaired t test for quantitative data. Multiple logistic regression analysis was carried out to identify risk factors that were significantly related to the PCE resulting from cement leakage.

Results

PCE was found in 34 patients (1.9% 34/1782) with pulmonary CT examination after operation. There was no statistically significant difference in the parameters such as age, gender, body mass index (BMI), and cement volume in the two groups. Patients with three or more involved vertebrae had a significantly increased risk to suffer from PCE than those with one involved vertebra (p=0.046 OR 2.412 [95% CI 1.017–5.722]). Patients who suffered thoracic fracture had a significantly increased risk to suffer from PCE than those who suffered thoracolumbar fracture (p=0.001 OR 0.241 [95% CI 0.105–0.550]). And significantly increased PCE risk also was observed in thoracic fracture compared with lumbar fracture patients (p=0.028 OR 0.094 [95% CI 0.114–0.779]). The risk of PCE within 2 weeks after fracture was significantly higher than that after 2 weeks of fracture (p=0.000 OR 0.178 [95% CI 0.074–0.429]). Patients who underwent PVP surgery had a significantly increased PCE risk than those who underwent PKP surgery (p=0.001 OR 0.187 [95% CI 0.069–0.509]).

Conclusion

The real incidence of PCE is underestimated due to the lack of routine postoperative pulmonary imaging examination. The number of involved vertebrae, fracture location, operation timing, and operation methods are independent risk factors for PCE.

Cement pulmonary embolism after percutaneous vertebroplasty in a patient with cushing's syndrome: A case report

BACKGROUND

Vertebroplasty is a procedure most commonly used for vertebral compression fractures. Although it is a relatively safe procedure, complications have been reported. Cement embolism is seen in 2.1%-26% of patients after percutaneous vertebroplasty.

CASE PRESENTATION

a 38-year-old male who was diagnosed with cushing's syndrome, underwent percutaneous vertebroplasty for his thoracic osteoporotic compression fractures. 24-hours following vertebroplasty, he presented to emergency department with acute-onset dyspnea and chest pain. Chest radiography showed an opaque linear lesion in left pulmonary artery which was suggestive of cement embolism. Pulmonary spiral CT-scan further confirmed the diagnosis. The patient's symptoms improved over time, and warfarin was started with close cardiopulmonary assessments for indicators of cement embolus removal.

CONCLUSION

in patients with pulmonary cement embolism, conservative treatment may be recommended rather than a surgical removal except when the obstruction is extensive enough to cause hemodynamic changes. Given that all the related studies have suggested that pulmonary thromboembolism can occur as a complication due to bone cement leakage, discovering new cement alternatives and/or injection devices, seems beneficial.

Biomechanical behavior of novel composite PMMA-CaP bone cements in an anatomically accurate cadaveric vertebroplasty model

Vertebral compression fractures are caused by many factors including trauma and osteoporosis. Osteoporosis induced fractures are a result of loss in bone mass and quality that weaken the vertebral body. Vertebroplasty and kyphoplasty, involving cement augmentation of fractured vertebrae, show promise in restoring vertebral mechanical properties. Some complications however, are reported due to the performance characteristics of commercially available bone cements. In this study, the biomechanical performance characteristics of two novel composite (PMMA-CaP) bone cements were studied using an anatomically accurate human cadaveric vertebroplasty model. The study involves mechanical testing on two functional cadaveric spinal unit (2FSU) segments which include monotonic compression and cyclical fatigue tests, treatment by direct cement injection, and microscopic visualization of sectioned vertebrae. The 2FSU segments were fractured, treated, and mechanically tested to investigate the stability provided by two novel bone cements; using readily available commercial acrylic cement as a control. Segment height and stiffness were tracked during the study to establish biomechanical performance. The 2FSU segments were successfully stabilized with all three cement groups. Stiffness values were restored to initial levels following fatigue loading. Cement interdigitation was observed with all cement groups. This study demonstrates efficient reinforcement of the fractured vertebrae through stiffness restoration. The pre-mixed composite cements were comparable to the commercial cement in their performance and interdigitative ability, thus holding promise for future clinical use. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2067-2074, 2017.

Cardiac Perforation and Multiple Emboli After Percutaneous Vertebroplasty

Percutaneous vertebroplasty is a minimally invasive technique for treating vertebral compression fractures and tumors. Although percutaneous vertebroplasty is considered a relatively safe and technically simple procedure, it is also associated with life-threatening complications as a result of cement leakage, including cardiac perforation and pulmonary embolism. A 63-year-old woman underwent percutaneous vertebroplasty for an L3 vertebral fracture and had cement leaks into the inferior vena cava, pulmonary arteries, and right heart chambers, with a free wall perforation. Surgical removal of the cement emboli was recommended as a result of apparent penetration of the ventricle and the fragile nature of polymethyl methacrylate. A cardiopulmonary bypass was immediately performed via a right atriotomy. A foreign body 10 cm in length was removed from the right atrium and ventricle. Arteriotomies were then performed, and 4 cement filaments were retrieved from the pulmonary arteries. The inferior vena cava was also surgically opened, allowing extraction of a cement fragment that was 12 cm long. The postoperative course was uneventful, and the patient fully recovered. This is the first report of the migration of a cement fragment larger than 10 cm that had migrated and embedded in the heart chamber. This report showed that imaging analysis is valuable when cement leakage is detected during percutaneous vertebroplasty and can be used to avoid serious complications and improve patient outcomes.

Venous extravasation and polymethylmethacrylate pulmonary embolism following fluoroscopy-guided percutaneous vertebroplasty

Percutaneous vertebroplasty has gained widespread popularity and demonstrated clinical efficacy in the treatment of spinal osteoporotic compression fractures and pathologic osteolytic lesions. Despite its rapid pain relief and safety, this minimally invasive intervention has exhibited some rare complications over the past decade. In this case study, we describe a patient with an uncommon complication of polymethylmethacrylate (PMMA) cement pulmonary embolism following fluoroscopy-guided percutaneous vertebroplasty for treatment of pain associated with an osteoporotic vertebral fracture. We present this case to highlight that vertebroplasty is not risk-free and that knowledge of such potentially severe complication is necessary for prevention and optimal operative outcomes.

Controversial issues in kyphoplasty and vertebroplasty in malignant vertebral fractures

BACKGROUND

Kyphoplasty (KP) and vertebroplasty (VP) have been successfully employed in the treatment of pathological vertebral fractures.

METHODS

A critical review of the medical literature was performed and controversial issues were analyzed.

RESULTS

Evidence supports KP as the treatment of choice to control fracture pain and the possible restoration of sagittal balance, provided that no overt instability or myelopathy is present, the fracture is painful and other pain generators have been excluded, and positive radiological findings are present. Unilateral procedures yield similar results to bilateral ones and should be pursued whenever feasible. Biopsy should be routinely performed and 3 to 4 levels may be augmented in a single operation. Higher cement filling appears to yield better results. Radiotherapy is complementary with KP and VP but must be individualized.

CONCLUSIONS

In cases of painful cancer fractures, if overt instability or myelopathy is not present, unilateral KP should be pursued, whenever feasible, followed by radiotherapy. The technological advances in hardware and biomaterials, as well as combining KP with other modalities, will help ensure a safe and more effective procedure. Address.

Controversial issues in kyphoplasty and vertebroplasty in osteoporotic vertebral fractures

Kyphoplasty (KP) and vertebroplasty (VP) have been successfully employed for many years for the treatment of osteoporotic vertebral fractures. The purpose of this review is to resolve the controversial issues raised by the two randomized trials that claimed no difference between VP and SHAM procedure. In particular we compare nonsurgical management (NSM) and KP and VP, in terms of clinical parameters (pain, disability, quality of life, and new fractures), cost-effectiveness, radiological variables (kyphosis correction and vertebral height restoration), and VP versus KP for cement extravasation and complications profile. Cement types and optimal filling are analyzed and technological innovations are presented. Finally unipedicular/bipedicular techniques are compared. Conclusion. VP and KP are superior to NSM in clinical and radiological parameters and probably more cost-effective. KP is superior to VP in sagittal balance improvement and cement leaking. Complications are rare but serious adverse events have been described, so caution should be exerted. Unilateral procedures should be pursued whenever feasible. Upcoming randomized trials (CEEP, OSTEO-6, STIC-2, and VERTOS IV) will provide the missing link.