Pulmonary cement emboli after kyphoplasty

Abstract

CaseA 37-year-old woman with estrogen/progesterone receptorpositive breast cancer with metastases to the lungs, liver,and lumbar spine, being treated with vinorelbine, initiallypresented to this hospital with severe lower back pain. Atthe time of presentation, multiplanar magnetic resonanceimaging of the spine after the administration of intravenousgadolinium demonstrated anterior wedge compressiondeformities of the L1 and L2 vertebral bodies (Fig. 1). Thepatient underwent bilateral transpedicular kyphoplasty,without evidence of cement extravasation (Fig. 2). Onemonth later, after an uneventful recovery, the patientreturned to this hospital with pleuritic chest pain, shortnessof breath, and generalized weakness for 4 days. On phys-ical examination, the patient was tachycardic with a heartrate of 115 beats per min, with diffuse chest wall tender-ness and diminished breath sounds at the bilateral lungbases. Laboratory testing demonstrated an elevatedD-dimer of 1,700 ng/mL (normal reference range less than250 ng/mL). A portable chest radiograph demonstrated apossible serpiginous linear density within the left lung,without evidence of pneumonia, pleural effusions, orpneumothorax (Fig. 3). Given the patient’s pleuritic chestpain, shortness of breath, and tachycardia, history of met-astatic disease, and elevated D-dimer, computed tomogra-phy of the chest with pulmonary angiography protocol wascompleted to evaluate for pulmonary emboli. Analysis ofthe study demonstrated numerous linear hyperdensitiesthroughout the arterial tree, consistent with pulmonarycement emboli from the prior kyphoplasty as well asmultiple hypodense filling defects representing associatedthrombi (Fig. 4). The patient was admitted to the MedicalOncology Service, where she was started on enoxaparin,and eventually discharged with plans to continue vinorel-bine treatments. On return clinic visits 1 month later, thepatient reported complete resolution of chest pain, short-ness of breath, and weakness, with mild improvement inback pain.DiscussionVertebral body compression fractures are common,occurring at a rate of 500 per 100,000 in patients aged50–54 and 2,960 per 100,000 in patients older than 85, andprompting numerous emergency department visits per year[1]. Initial treatment consists of conservative measuresincluding analgesia, bed rest, and bracing. Further man-agement of intractable pain from vertebral compressionfractures may be undertaken with vertebroplasty and kyp-hoplasty, although these procedures remain somewhatcontroversial. Vertebroplasty and kyphoplasty are associ-ated with a variety of complications including infection,