INTRODUCTION: Balloon kyphoplasty is a recently introduced procedure for the treatment of vertebral compression fractures, especially from osteoporosis, tumors and burst fractures. With the increase in frequency of procedures being performed more complications from kyphoplasty are seen. The risk of pulmonary embolism ranges from 3.5% to 23% for osteoporotic fractures. We report a case of an asymptomatic cement pulmonary embolism following a balloon kyphoplasty procedure.
CASE PRESENTATION: An 82 year old woman was admitted for a dorsal spine wound infection and was found to have an abnormal chest x-ray. She has a past medical history of osteoporosis, hypertension, hypercholesterolemia and multiple vertebral compression fractures for which she had undergone a kyphoplasty of L3 and L4 8 weeks prior to admission. She had no respiratory complaints or weight loss. Oxygen saturation was 98% on room air. Her lung exam was clear to auscultation bilaterally. The only significant physical finding was related to her back where she had a foul smelling wound. Chest x-ray revealed multiple tubular filling defects in the right and left pulmonary arteries in comparison to her chest x-ray pre-kyphoplasty which was normal. Subsequently, a CT scan of her chest was performed which showed multiple filling defects with HU of 2600 consistent with pulmonary cement embolism.
DISCUSSION: This case presents a case of post kyphoplasty pulmonary cement embolism. Although most leaks are asymptomatic there are case reports of fatalities. Cement leakage is the most frequent complication after percutaneous kyphoplasty. Due to the risk for radiation exposure, chest x-rays after kyphoplasty are not usually performed. In asymptomatic peripheral cement embolism the recommendation is to follow clinically and not anticoagulate. In cases of central or peripheral symptomatic cement embolism it is recommended to anticoagulate for 6 months.
CONCLUSIONS: Physicians should be aware of the possibility of cement embolism following both kyphoplasty and vertebroplasty. A routine chest x-ray post-procedure may be of value in evaluating the incidence of pulmonary cement embolism. As with our patient, most cases are without respiratory complaints and there is no need to start anticoagulation for asymptomatic cement embolism when diagnosed on chest x-ray. However, the recommendation for treatment of symptomatic cement embolism is anticoagulation. Diagnosis of cement embolism on a routine post-kyphoplasty chest x-ray may initiate appropriate treatment earlier including close clinical follow up for incidental asymptomatic emboli.
Reference #1 Kruger 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; 18:1257-1265
Reference #2 Radcliff K et al. Pulmonary cement embolism after kyphoplasty: a case report and review of the literature. The Spine Journal 2010;10 e1-e5
DISCLOSURE: The following authors have nothing to disclose: George Apergis, Mara Lagzdins, Ali Soueidan
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