Pulmonary embolism caused by cement leakage after percutaneous kyphoplasty: a case report

Risk factors for pulmonary cement embolism associated with percutaneous vertebral augmentation: A systematic review and meta-analysis

BACKGROUND

Pulmonary cement embolism (PCE) was a rare but fatal complication for percutaneous vertebral augmentation (PVA). Thus we did a systematic review and meta-analysis of cohort studies to investigate the risk factors for PCE after PVA.

METHODS

We systematically searched PubMed, EMBASE, Cochrane library, Google Scholar, web of science, and ClinicalTrial.gov from the establishment of the database to September 2021. All eligible studies assessing the risk factors for PCE after PVA were incorporated. Dichotomous data was calculated by risk difference (RD) from Mantel-Haenszel method (M - H method); continuous data was analyzed by mean difference (MD) from Inverse-Variance method (I-V method). All variables were taken as measure of effect by fixed effect model. Heterogeneity, sensitivity, and publication bias analyses were also performed.

RESULTS

This study totally included 13 studies. According to the Newcastle-Ottawa Scale (NOS), 7 studies were considered as low quality, with NOS< 6. The others were of relatively high quality, with NOS≥6. 144/6251 patients (2.3%) had PCE after PVA. percutaneous vertebroplasty (PVP) (RD = 0.02, 95%CI: [0.01, 0.04], Z = 3.70, P < 0.01), thoracic vertebra (RD = 0.03, 95%CI: [0.01, 0.05], Z = 3.53, P < 0.01), higher cement volume injected per level (MD = 0.23, 95%CI: [0.05, 0.42], Z = 2.44, P = 0.01), more than three vertebrae treated per session (MD = -0.05, 95%CI: [-0.08, -0.02], Z = 3.65, P < 0.01), venous cement leakage (RD = 0.07, 95%CI: [0.03, 0.11], Z = 3.79, P < 0.01) were more likely to cause PCE.

CONCLUSION

This study showed that risk factors for PCE included PVP, thoracic vertebra, higher cement volume injected per level, more than three vertebrae treated per session, venous cement leakage. As a serious complication, PCE should be paid attention and avoided.

Cardiac Perforation Caused by Cement Embolism after Percutaneous Vertebroplasty: A Report of Two Cases

Background

Percutaneous vertebroplasty (PVP) is a minimally invasive surgical technique in which polymethyl methacrylate (PMMA) is injected into the weakened vertebral body to strengthen it. However, this procedure is associated with various complications, the most common being cement leakage. Cardiac perforation caused by cement escape into the venous system is another complication, which is rare but potentially life‐threatening even if not treated promptly.

Case Presentation

Here, we report two elderly patients who developed cardiac perforation caused by cement escape into veins following PVP. Both patients had a history of severe osteoporosis. On admission, they presented with lower back pain and limited movement. MRI revealed vertebral bodies compression fracture in both patients. Considering the advanced age of the patients, PVP was performed to avoid the risk of potential complications associated with nonoperative therapy. Unfortunately, the rare and fatal postoperative complication, cardiac perforation caused by cement escape into veins, occurred in both patients. Emergency open‐heart surgery was performed to remove cement material and repair the heart, both patients recovered well and were discharged.

Conclusions

Although PVP is a safe and minimally invasive surgical technique, it is associated with various serious complications as seen in the present cases. We therefore recommend that surgeons should be aware of such complications. Appropriate timing of surgical operation, meticulous surgical procedures, early intraoperative and postoperative monitoring of cement leakage may improve outcomes of patients with such complications.

Delayed Symptomatic Pulmonary Embolism Secondary to Bone Cement After Percutaneous Vertebroplasty

BACKGROUND

Percutaneous vertebroplasty (PVP) is a common procedure performed on patients suffering from osteoporotic compression fractures. Complications of the bone cement escaping both locally as well as systemically into pulmonary circulation leading to pulmonary embolism (PE) have been reported in ≤26% of patients.

CASE REPORT

A 57-year-old woman presented to the emergency department with complaints of chest pain, fever, and cough. The patient had a history of an outpatient PVP from compression fractures of T5 and T7 performed 25 days before her presentation. She was in moderate respiratory distress and placed on bilateral positive airway pressure with improvement of her respiratory status. Laboratory results were remarkable for an elevated D-dimer, normal B-type natriuretic peptide, and decreased pH on venous blood gas. Pulmonary computed tomography angiography demonstrated bone cement PE in both the left lower lobe and a right middle lobe pulmonary artery. She was admitted to the hospital with improvement of her respiratory status with supportive treatment only. She was discharged after a 4-day hospital stay but died unexpectedly in her sleep 38 days after discharge. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: PVP is a common procedure that carries a risk of PE from bone cement embolization. Most of these events occur during the procedure, making the diagnosis obvious. However, delayed presentations from weeks to years have been reported. The emergency physician should consider bone cement embolization in the differential diagnosis in any patient with chest pain and shortness of breath that also has a history of PVP.

Safety and Efficacy Studies of Vertebroplasty with Dual Injections for the Treatment of Osteoporotic Vertebral Compression Fractures: Preliminary Report

PURPOSE

To evaluate the clinical safety and efficacies of percutaneous vertebroplasty (PVP), percutaneous vertebroplasty with dual injections (PVPDI), and percutaneous kyphoplasty (PKP) for the treatment of osteoporotic vertebral compression fractures (OVCFs), a retrospective study of 90 patients with OVCFs who had been treated by PVP (n = 30), PVPDI (n = 30), and PKP (n = 30) was conducted in this work.

METHODS

The clinical efficacies of these three treatments were evaluated by comparing their PMMA cement leakages, cement patterns, height restoration percentages, wedge angles, visual analogue scales, and Oswestry disability index (ODI) at the pre- and postoperative time points.

RESULTS

Ten percent, 6.7%, and 0% of patients had PMMA leakage in PVP, PVPDI, and PKP groups, respectively. Three (solid, trabecular, and mixed patterns), two (trabecular and mixed patterns), and two (solid and mixed patterns) types of cement patterns were observed in PVP, PVPDI, and PKP groups, respectively. PVP and PVPDI treatments had similar and less height restoration ability than PKP treatment. All the PVP, PVPDI, and PKP treatments had significant and similar ability in pain relief and functional recovery ability for the treatment of OVCFs. Microfractures after the surgery occurred after PVP and PKP treatments.

CONCLUSION

These results indicate minimally invasive techniques were effective methods for the treatment of OVCFs. Moreover, these initial outcomes suggest PVPDI treatment has great value and is worth promoting vigorously in orthopedics clinics.

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.

Safety and Efficacy Studies of Vertebroplasty, Kyphoplasty, and Mesh-Container-Plasty for the Treatment of Vertebral Compression Fractures: Preliminary Report

To evaluate the clinical safety and efficacies of percutaneous vertebroplasty (PVP), percutaneous kyphoplasty (PKP), and percutaneous mesh-container-plasty (PMCP) for the treatment of vertebral compression fractures (VCFs), a retrospective study of 90 patients with VCFs who had been treated by PVP (n = 30), PKP (n = 30), and PMCP (n = 30) was conducted. The clinical efficacies of these three treatments were evaluated by comparing their PMMA cement leakages, cement patterns, height restoration percentages, wedge angles, visual analogue scales (VAS), and oswestry disability index (ODI) at the pre- and post-operative time points. 6.67%, 3.33%, and 0% of patients had PMMA leakage in PVP, PKP, and PMCP groups, respectively. Three (solid, trabecular, and mixed patterns), two (solid and mixed patterns), and one (mixed patterns) types of cement patterns were observed in PVP, PKP, and PMCP groups, respectively. PKP and PMCP treatments had better height restoration ability than PVP treatment. PVP, PKP, and PMCP treatments had significant and similar ability in pain relief and functional recovery ability for the treatment of VCFs. These results indicate minimally invasive techniques were effective methods for the treatment of VCFs. Moreover, these initial outcomes suggest PMCP treatment may be better than both PVP treatment and PKP treatment.

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.

Biomechanical evaluation of the primary stability of pedicle screws after augmentation with an innovative bone stabilizing system

INTRODUCTION

In today's aging population, diminished bone quality often affects the outcome of surgical treatment. This occurs especially when surgical implants must be fixed to bone, as it occurs when lumbar fusion is performed with pedicle screws. Besides Polymethylmethacrylate (PMMA) injection, several techniques have been developed to augment pedicle screws. The aim of the current study was to evaluate the primary stability of an innovative system (IlluminOss™) for the augmentation of pedicle screws in an experimental cadaveric setup. IlluminOss™ is an innovative technology featuring cement with similar biochemical characteristics to aluminum-free glass-polyalkenoate cement (GPC).

MATERIALS AND METHODS

IlluminOss™ was inserted transpedicularly via a balloon/catheter system in 40 human cadaveric lumbar vertebrae. For comparability, each vertebra was treated bilaterally with pedicle screws, augmented and non-augmented. The maximum failure load during pull out test was documented by a universal material testing machine.

RESULTS

The results showed significantly higher failure loads for the augmented pedicle screws (Median 555.0 ± 261.0 N, Min. 220.0 N, Max. 1,500.0 N), compared to the native screws (Median 325.0 ± 312.1 N, Min. 29.0 N, Max. 1,400.0 N).

CONCLUSIONS

Based on these data, we conclude the IlluminOss™ system can be used to augment primary screw stability regarding axial traction, compared to native screws. The IlluminOss™ monomer offers ease of control for use in biological tissues. In contrast to PMMA, no relevant heat is generated during the hardening process and there is no risk of embolism. Further studies are necessary to evaluate the usefulness of the IlluminOss™ system in the in vivo augmentation of pedicle screws in the future.