PULMONARY CEMENT EMBOLISM FOLLOWING VERTEBRAL KYPHOPLASTY

Abstract

SESSION TITLE: Global Case Report Posters SESSION TYPE: Global Case Reports PRESENTED ON: October 18-21, 2020 INTRODUCTION: Percutaneous vertebroplasty or kyphoplasty is a minimal invasive procedure that is applied for the treatment of vertebral fracture. The leakage of bone cement outside the vertebral body leads to pulmonary cement embolism (PCE). Although PCE is mostly asymptomatic, clinicians should be aware of the possibility of respiratory manifestations that can occur after the vertebral augmentation procedure. CASE PRESENTATION: A 49-year-old female with a past medical history of asthma presented to the emergency department for dyspnea and pleuritic chest pain. Two days prior, the patient underwent vertebral kyphoplasty of her T10 vertebrae for a compression fracture resulting from a fall. Given her recent surgery and a positive d-dimer, a computed topography of the chest was performed revealing bilateral segmental PCE. The patient was admitted overnight for observation. Since the patient remained vitally stable and was in no acute distress, she was discharged with no further treatment. The patient presented to the emergency department on two separate occasions over the next three days with dyspnea and pleuritic chest pain. She continued to remain vitally stable, but was referred to the pulmonary clinic for recommendations regarding PCE. During her evaluation in the pulmonary clinic she continued to have dyspnea and pleuritic chest pain, but she remained vitally stable without hypoxia. Upon review of systems the patient reported cough, dizziness, and back pain. She was started on six months of anticoagulation therapy for symptomatic peripheral PCE. On six weeks follow up visit her dizziness resolved and dyspnea and cough had improved. DISCUSSION: Transvertebral cement leakages into surrounding tissues and paravertebral veins are common complications after percutaneous vertebroplasty and kyphoplasty. Majority of patients are asymptomatic and PCE may be found incidentally on follow-up chest imaging. Alternatively, patients may present with symptoms including dyspnea, tachycardia, dizziness, chest pain, cough, or hemoptysis. Deaths due to PCE are rare but reported. Uncommonly, acute respiratory distress syndrome has also been reported. In cases of symptomatic peripheral or asymptomatic central embolisms, it is recommended to follow standard treatment guidelines for pulmonary thromboembolism. With limited cases reported there is no clear therapeutic protocol that has been accepted as a standard for treatment. CONCLUSIONS: Patients with respiratory symptoms after vertebroplasty should be evaluated carefully in terms of PCE. The rarity of this disease limits the ability to perform randomized trials to determine the best treatment option. Our case adds to the literature given her symptomatic improvement with anticoagulation. Reference #1: Krueger A, Bliemel C, Zettl R, Ruchholtz S. Management of pulmonary cement embolism after percutaneous vertebroplasty and kyphoplasty: a systematic review of the literature. Eur Spine J. 2009;18(9):1257–1265. Reference #2: Ignacio JMF, Ignacio KHD. Pulmonary embolism from cement augmentation of the vertebral body. Asian Spine J. 2018;12(2):380–387. Reference #3: Wang LJ. Pulmonary cement embolism associated with percutaneous vertebroplasty or kyphoplasty: a systematic review. Orthop Surg. 2012 Aug;4(3):182-9. DISCLOSURES: No relevant relationships by Sarah Hadique, source=Web Response No relevant relationships by Alicia Hinerman, source=Web Response No relevant relationships by Rachel Leonard, source=Web Response