Cardiac Perforation and Multiple Emboli After Percutaneous Vertebroplasty

Case report: Cement entrapped in the inferior vena cava filter after pedicle screw augmentation

Background

Cement leakage into the inferior vena cava (IVC) is one of the most common complications associated with cement vertebroplasty, and can lead to potentially life-threatening complications such as pulmonary cement embolism (PCE). Implantation of an IVC filter is effective in the prevention of fatal pulmonary embolism. Here, we present an extremely rarely case of cement entrapped in an IVC filter after pedicle screw augmentation, and discuss all similar cases reported in the literature.

Case presentation

A 70-year-old female presented with significant back and lower extremities pain and was unable to walk. MRI of the lumbar spine revealed an osteoporotic compression fracture of the L1–L3. She underwent cement-augmented pedicle screws implanted at the L1 and L3 vertebral bodies. A retrievable IVC filter was implanted due to the presence of calf vein thrombosis before cement vertebroplasty. Cement leaked into the IVC and was trapped by the filter, rendering the filter unretrievable using a conventional method. The asymptomatic patient received rivaroxaban 20 mg daily for anticoagulant postoperatively and lifelong anticoagulation was administered to prevent secondary IVC and cemented filter thrombosis.

Methods

A literature search was conducted utilizing the PUBMED/MEDLINE using the following terms: “vertebroplasty,” “complication,” “bone cement,” and “inferior vena cava (IVC),” or “inferior vena cava (IVC) filter.” All relevant articles published in English or in other languages with English abstracts since 1962 were included.

Results

A total of 36 articles were retrieved according to the search strategy. Only 6 out of these 36 studies contained information regarding the inferior vena cava filter and cement. Of the patients, 85.7% (36/42) reported in the literature whose gender was known were female and 14.3% were male. 28.5% (45/158) patients with pulmonary arterial and cardiovascular complications.

Conclusion

Cement embolization occurring in the IVC filter is rare. Accurate knowledge about the lumbar vertebral venous anatomy and skillful operation during vertebral cementoplasty should be required in clinical practice.

A novel "three-dimensional-printed individual guide template-assisted percutaneous vertebroplasty" for osteoporotic vertebral compression fracture: a prospective, controlled study

BACKGROUND

Conventional percutaneous vertebroplasty (PVP) are mainly guided by C-arm fluoroscopy, and it usually leads to excessive X-ray radiation exposure to patients, surgeons, and anesthetists. Moreover, multi-time fluoroscope may prolong the operation time. 3D-printed template could help minimize fluoroscopy shot times and fluoroscopy dosage during operation, and shorten operation time. We perform this study to compare the efficacy and accuracy of PVP assisted by "three-dimensional printed individual guide template" versus conventional PVP.

METHOD

Patients who suffered acute painful single segment osteoporotic vertebral compression fracture(OVCF) needed operative treatment were randomly assigned into three-dimensional printing individual guide template-assisted percutaneous vertebroplasty group (group A) or conventional PVP guided by C-arm fluoroscopy group (group B) at a 1:1 ratio. Fluoroscopy times for puncture points (FTPP), total radiation dosages (TRD), total fluoroscopy time (TFT), and total operation time (TOT) were recorded as the main evaluation factors to evaluate the two operation procedures.

RESULTS

A total of 36 acute painful single segment OVCF patients were successfully operated on, and each group has 18 patients. None of the patients presented symptomatic complications. The surgical success rate in group A was 94.4%(17/18), one patient in the group A was failed and then operated by conventional procedure. FTPP (1.8 ± 0.8 in group A vs 5.2 ± 1.9 in group B, P < 0.05), TRD (4.9 ± 0.9 mGy vs 7.9 ± 1.6 mGy, P < 0.05), TFT (16.7 ± 2.9 vs 26.6 ± 5.3, P < 0.05), and total operation time (19.4 ± 2.4 min vs 27.8 ± 4.0 min, P < 0.05) were presented statistically difference in the two groups. The incidence of cement leakage occurred in group A (3/18, 16.7%) was less than that occurred in group B (7/18, 38.9%) (P > 0.05).

CONCLUSIONS

Compared with the conventional PVP, "three-dimensional-printed individual guide template-assisted PVP" could minimize fluoroscopy shot times during operation and fluoroscopy dosage, shorten operation time, and is a more precise and feasible operation method.

TRIAL REGISTRATION

The present study was registered with the Chinese Clinical Trial Registry (ChiCTR) ( http://www.chictr.org.cn ), and its registration no. is ChiCTR1900024283.

Cardiac Perforation Caused by Bone Cements as a Complication of Cement Augmented Pedicle Screw Fixation Using the Fenestrated Pedicle Screw: A Case Report

Cement-augmented fenestrated pedicle screw fixation is becoming more popular for osteoporotic patients. Although several reports have been published on leakage-related problems with bone cement, no cases of cardiac perforation after cement-augmented pedicle screw fixation have been reported. We present a case of cardiac perforation after cement-augmented fenestrated pedicle screw fixation. A 67-year-old female was admitted to our hospital with complaints of dyspnea and chest pain after lumbar surgery. She had been treated with L4-5 lumbar interbody fusion and percutaneous pedicle screw fixation with bone cement augmentation seven days earlier for degenerative spondylolisthesis. The right chest pain was observed a day after the surgery; she was treated conservatively but it did not improve for 7 days after surgery. Chest computed tomography (CT) revealed a hemothorax and a large sharp bone cement fragment that perforated the right atrium. Bone cement can be removed with thoracotomy surgery. We have to be aware of cement leakage through the normal venous drain system around the vertebral body. We also have to consider a detailed cardiac workup, which may include chest CT or echocardiography, if a patient complains of chest pain or dyspnea after cement augmentation.

"Targeted Percutaneous Vertebroplasty" Versus Traditional Percutaneous Vertebroplasty for Osteoporotic Vertebral Compression Fracture

Objective. In this randomized, nonblinded, controlled study, the feasibility and precision of "targeted percutaneous vertebroplasty" ("targeted PVP") for osteoporotic vertebral compression fracture (OVCF) was evaluated. Methods. A total of 42 patients, aged 50 to 87 years, with OVCF were randomly divided into 2 groups: A and B. Group A underwent "targeted PVP," and group B underwent traditional PVP with the guidance of C-arm fluoroscopy. Fluoroscopy times for skin puncture points (FTSPP), total radiation doses (TRD), total fluoroscopy times (TFT), and operation time were set as the main evaluation indicators. Results. FTSPP (1.52 ± 0.51 in group A vs 6.62 ± 2.58 in group B, U < .001), TRD (6.26 ± 1.51 in group A vs 11.32 ± 4.21 in group B, P < .001), TFT (16.57 ± 2.79 in group A vs 26.05 ± 6.18 in group B, P < .001), and operation time (20.05 ± 3.38 in group A vs 25.43 ±5.11 in group B, U < .001) were statistically different in the 2 groups. The incidence of cement leakage that occurred in group A (1/21, 4.76%) was significantly less than that in group B (9/21, 42.9%, P < 0.05). Conclusions. "Targeted PVP" may achieve (1) less skin positioning fluoroscopy times, less total fluoroscopy times and dose, shorter operation time, which is more precise than traditional PVP; (2) less incidence of cement leakage; and (3) visualization of the fractured vertebra, which is probably more valuable for the treatment of complicated OVCF patients.

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.

Life-Threatening Cardiac Perforation After Posterior Spondylodesis

This reports presents a case of a 62-year-old woman with hemorrhagic hypovolemic shock, respiratory distress, and pericardial effusion secondary to right atrial perforation caused by a cement embolus after dorsal spondylodesis. Despite optimal intensive care support for a supposed pulmonary embolism, the patient's condition markedly deteriorated. On delayed embolus recognition by contrast-enhanced computed tomography and transesophageal echocardiography, she had to undergo cardiac surgery. Cardiac involvement is a rare but important complication, with few cases described after vertebroplasty and none after spondylodesis. In our case, diagnosis before perforation would have allowed an endovascular approach, thereby avoiding open heart surgery.