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Case Report
2021
:12;
495
doi:
10.25259/SNI_817_2021

Pulmonary cement embolism following transpedicular screws placement for thoracolumbar fractures

Department of Spine Surgery, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia.
Corresponding author: Omar Marroquín Herrera, Department of Spine Surgery, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia. dr.omarmhspine@gmail.com
Licence

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Gomez FA, Herrera OM, Gaona JV, Reyes CF, Gutiérrez MC, Saenz LM. Pulmonary cement embolism following transpedicular screws placement for thoracolumbar fractures. Surg Neurol Int 2021;12:495.

Abstract

Background:

Symptomatic pulmonary cement embolism in patients undergoing thoracic transpedicular fenestrated screw placement is rare. Here, we have added a 64-year-old female undergoing transpedicular screw placement for a T11 fracture who developed a pulmonary cement embolism intraoperatively and add this case to 13 others identified in the literature.

Case Description:

A 64-year-old female presented with a type “C”, ASIA “E” T11 fracture. The thoracolumbar pedicle screw fixation was supplemented with bone cement due to her underlying severe osteoporosis. During the fluoroscopy-guided supplementation with bone cement, a leak through the paravertebral venous system was noted. Thirty minutes later, the patient acutely developed extreme respiratory failure and required mechanical ventilation for the next 2 days. The diagnosis of pulmonary embolism due to bone cement was confirmed on a contrast computed tomography study of the chest.

Conclusion:

Symptomatic pulmonary cement embolization supplementing transpedicular screws placement for osteoporotic bone is rare. Here, we present a 64-year-old female who during transpedicular fixation of a T11 fracture developed an acute pulmonary embolism from the bone cement resulting in the need for 2 days of postoperative artificial ventilation.

Keywords

Fenestrated transpedicular screws
Polymethylmethacrylate
Pulmonary embolism
Thoracolumbar fracture

INTRODUCTION

Polymethylmethacrylate (PMMA) bone cement improves immediate stability and increases pullout resistance from 173% to 244% for patients with osteoporosis undergoing thoracic fracture transpedicular fixation.[4,14,19]

Potential locations of bone cement leakage include perivertebral, disc intracanalicular, foraminal, local perivertebral venous system cement leakage, and critically, as in this case, leakage to the central vascular system with migration to the cardiac or pulmonary system with risk of pulmonary embolism (2.1–26%).[2,3,8,17,18]

The presence of pulmonary embolism correlates with instrumentation of >7 levels.[16] Notably, patients with anterior or posterior wall fractures or burst fractures and accompanying cortical destruction are at increased risk of pulmonary cement embolization.[8]

CASE REPORT

A 64-year-old female with osteoporosis, presented with a non-penetrating T11 traumatic spinal injury as a result of falling backwards downstairs. The computed tomography (CT) scan showed a T11, AO spine C classification, without a neurological deficit, ASIA – E [Figure 1].

Figure 1:: (a) Computed tomography, sagittal view, transverse fracture of T11, subluxation of the vertebral body. (b) T2-weighted magnetic resonance imaging, sagittal view, injury of the posterior ligament complex. (c) Computed axial tomography, axial view, double image of vertebral laminae due to subluxation.

Surgery

Three days later, she underwent a T11 hemilaminectomy to remove an epidural hematoma with T9 - T10 (5.5 mm × 40 mm screws) to T12 - L1 (6.5 mm × 45 mm screws) transpedicular instrumented fusion. Vertebral body augmentation with 1.5 mL of PMMA bone cement per transpedicular screw (distally fenestrated) was performed due to her underlying osteoporosis. When the fourth screw was placed, fluoroscopy showed leakage of PMMA cement into the paravertebral system [Figure 2]. We briefly stopped applying bone cement, but then resumed its application when we observed no intraoperative cardiorespiratory compromise. Fracture reduction was then performed with bilateral 5.5 mm × 36 cm rod placement. The intraoperative arterial blood gas showed respiratory acidosis with a moderate “oxygenation disorder” (pH, 7.31; pO2, 100 mmHg; pCO2, 48 mmHg; HCO3, 24 mEq/L; O2 saturation, 96%; PaO2/FiO2, 178 mmHg; lactate, 1 mmol/L, hemoglobin 11.5 g/dL). Thirty minutes after transfer to the recovery room, however, she suddenly developed hypoxemia with oxygen saturation of 45%, requiring ventilatory support.

Figure 2:: (a) Intraoperative, instrumental placement for cement application. (b) Fluoroscopy, sagittal view, transpedicular screw placement. (c) Augmentation begins, bone cement at the level of the vertebral body. (d) Suspected bone cement leakage through the paravertebral venous system.

The CT angiogram of the chest documented a cement pulmonary embolism [Figure 3]. She remained intubated for the next 2 days and was started on low molecular weight heparin 4 days postoperatively. Nine days later, she had a postoperative Chest X-ray that showed a radiopaque image in the right lung associated with cement emboli [Figure 4]. She was then discharged without supplemental oxygen or on anticoagulation.

Figure 3:: Computed axial tomography Angiography, (a-c) Coronal, sagittal, and axial view (yellow circle), respectively where high density material is observed in the paravertebral venous system, is suggestive of cement embolus. (d) Presence of the high density material occupying the lumen of the subsegmental arterial vessels, in the apicoposterior segment of both upper lobes, anterior segment of the right upper lobe, lingula lobe, middle lobe, posterior and medial basal, segment of the right lower lobe.
Figure 4:: Follow-up at 1 week after surgery. Instrumentation with transpedicular screws at T9, T10, T12 and L1 with polymethylmethacrylate augmentation. (a) Anteroposterior view, radiopaque image in right lung associated with cement emboli. (b) sagittal view radiopaque image which is correlated with cement leakage through the paravertebral venous system.

DISCUSSION

Symptomatic pulmonary embolism due to bone cement utilized to perform transpedicular screw fixation is rare, occurring in 1.4% of isolated cases.[6,7,9,11,13,20] Currently, ten publications have reported 13 cases of patients with symptomatic pulmonary embolism due to bone cement.[1,5,9-12,14-16,20] Most of the patients reported were over 64 years of age and had instrumentation of the lumbar spine [Table 1]. Of the 13 cases, one had a fatal outcome, and two required open embolectomy; Where pulmonary cement embolisms involve main arterial trunks or are located in cardiac cavities but the patient is asymptomatic, anticoagulation is recommended for 6 months.[1,5,10,12,15] In this case, due to clinical improvement and lack of level A evidence, the cardiology department did not recommend continuing anticoagulation. Follow-up was performed 15 days, 1 month, and 6 months after discharge.

Table 1:: Case Reports of Symptomatic Pulmonary Embolism After Transpedicular Cemented Screw Instrumentation.

CONCLUSION

PMMA cementation continues to be a used in osteoporotic patients to increase pull-out resistance when placing transpedicular screws for thoracolumbar fractures/ fusions. Although cement leakage resulting in symptomatic pulmonary embolization following cemented PMMA transpedicular screw fixation is rare, it should be aggressively diagnosed and medically managed in every patient individually by an interdisciplinary team.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

REFERENCES

  1. , , , , , . Life-threatening cardiac perforation after posterior spondylodesis. Ann Thorac Surg. 2017;104:e355-7.
    [Google Scholar]
  2. , , . Pulmonary embolism with vertebral augmentation procedures. Case Rep Pulmonol. 2013;2013:785307.
    [Google Scholar]
  3. , , , , . Pulmonary embolism of polymethyl methacrylate during percutaneous vertebroplasty and kyphoplasty. AJR Am J Roentgenol. 2004;183:1097-102.
    [Google Scholar]
  4. , , , , , . Different pedicle osteosynthesis for thoracolumbar vertebral fractures in elderly patients. Eur Spine J. 2018;27:198-205.
    [Google Scholar]
  5. . Abnormal chest X-ray and computed tomography post-lumbar fusion. J Nurse Pract. 2015;11:276-8.
    [Google Scholar]
  6. , . Pulmonary bone cement embolism following pedicle screw instrumentation with bone cement augmentation for a burst fracture of l1 in a non-osteoporotic spine. Acta Med Philipp. 2013;47:76-9.
    [Google Scholar]
  7. , , . Cement embolism into the venous system after pedicle screw fixation: Case report, literature review, and prevention tips. Orthop Rev (Pavia). 2013;5:24.
    [Google Scholar]
  8. , , , . Management of pulmonary cement embolism after percutaneous vertebroplasty and kyphoplasty: A systematic review of the literature. Eur Spine J. 2009;18:1257-65.
    [Google Scholar]
  9. , , , , . Intracardiac, pulmonary cement embolism in a 67-year-old female after cement-augmented pedicle screw instrumentation: A case report and review of literature. World J Clin Cases. 2021;9:3120-9.
    [Google Scholar]
  10. , . Pulmonary cement embolism after segmental polymethyl methacrylate-augmented pedicle screw fixation. J Turk Spinal Surg. 2012;23:233-40.
    [Google Scholar]
  11. , , , , , . Symptomatic pulmonary cement embolism after pedicle screw polymethylmethacrylate cement augmentation: A case report and review. Surg Neurol Int. 2020;11:1-4.
    [Google Scholar]
  12. , , , . Pulmonary palacos embolism: A case report. Thorac Cardiovasc Surg. 2010;58:437-9.
    [Google Scholar]
  13. , , , . Pulmonary cement embolism after augmentation of pedicle screws with bone cement. Acta Orthop Belg. 2010;76:269-73.
    [Google Scholar]
  14. , , , , , , . Effect and potential risks of using multilevel cement-augmented pedicle screw fixation in osteoporotic spine with lumbar degenerative disease. BMC Musculoskelet Disord. 2020;21:274.
    [Google Scholar]
  15. , . Pulmonary cement embolism after pedicle screw vertebral stabilization. J Emerg Trauma Shock. 2012;5:272-3.
    [Google Scholar]
  16. , , , , , , . Pulmonary cement embolism following cement-augmented fenestrated pedicle screw fixation in adult spinal deformity patients with severe osteoporosis (analysis of 2978 fenestrated screws) Eur Spine J. 2018;27:2348-56.
    [Google Scholar]
  17. , , , , . Frequency and outcome of pulmonary polymethylmethacrylate embolism during percutaneous vertebroplasty. AJNR Am J Neuroradiol. 2008;29:1983-5.
    [Google Scholar]
  18. , , , , . Pulmonary cement embolism associated with percutaneous vertebroplasty or kyphoplasty: A systematic review. Orthop Surg. 2012;4:182-9.
    [Google Scholar]
  19. , , , , . Efficacy of novel-concept pedicle screw fixation augmented with calcium phosphate cement in the osteoporotic spine. J Orthop Sci. 2005;10:56-61.
    [Google Scholar]
  20. , , , , , , . Fatal extensive bone cement embolism: Histological findings confirmed by Fourier transform infrared spectroscopy. Forensic Sci Int. 2013;229:e23-5.
    [Google Scholar]
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