SESSION TITLE: Pulmonary Vascular Disease Student/Resident Case Report Posters II
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: Vertebroplasties are performed for pain relief in patients with vertebral body fractures when architectural remodeling and stability is required. PMMA is a liquid cement used in vertebroplasties that solidifies within minutes of preparation. It is injected percutaneously into the fractured vertebral body under fluoroscopic radio-guidance. In rare instances, embolization of cement may occur, and is immediate after injection while the cement is still liquid. We here report a delayed presentation of PMMA embolization in a patient who presented with pleuritic chest pain 6 days after vertebroplasty.
CASE PRESENTATION: A 57-year-old male presented to the emergency department after a traumatic back injury with compression fractures of T11 and T12 vertebrae. He was admitted for a vertebroplasty and was discharged home the following day. He returned in 6 days with sudden onset of shortness of breath and pleuritic chest pain. His chest radiograph showed diffuse radio-opaque tubular densities in the lung fields. A computed tomographic (CT) scan of the chest showed irregular curvilinear opacities in multiple segmental branches of the pulmonary artery and an opacified right hemiazygous vein, consistent with PMMA embolization. The patient was anticoagulated and thoracic surgery was consulted to evaluate for surgical extraction of the embolized cement. It was decided not to operate due to diffuse and non-central location of the embolized cement.
DISCUSSION: Vertebroplasty is a common outpatient procedure and patients are discharged home the same day, after a brief period of bed rest. Pulmonary embolism of PMMA is a known complication of vertebroplasty reported to be between 0 to 4.8% in various studies. The majority are asymptomatic, while some develop symptoms during the procedure. Patients with underlying cardiac and pulmonary pathology are at highest risk for bad outcomes from PMMA embolization. A routine chest radiograph following vertebroplasty can identify embolized cement in the pulmonary vasculature immediately post-procedure.
CONCLUSIONS: We describe a patient who had an uneventful vertebroplasty and developed pulmonary symptoms related to PMMA embolization 6 days post-procedure. Most patients develop symptoms immediately but some may have a delayed presentation. The incidence of PMMA embolization is likely underestimated given asymptomatic cases. We recommend a chest radiograph in all patients post-vertebroplasty to identify cement pulmonary embolism.
Reference #1: Radcliff et al. Pulmonary cement embolization after kyphoplasty. Spine J. 2010 Oct;10(10):e1-5. PubMed PMID: 20868999.
Reference #2: Krueger et al. Management of pulmonary cement embolism after percutaneous vertebroplasty and kyphoplasty. Eur Spine J. 2009 Sep;18(9):1257-65. PubMed PMID: 19575243
Reference #3: Freitag et al. Pulmonary embolism caused by polymethylmethacrylate during percutaneous vertebroplasty in orthopaedic surgery. Acta Anaesthesiol Scand. 2006 Feb;50(2):248-51. PubMed PMID: 16430551
DISCLOSURE: The following authors have nothing to disclose: Bilal Jalil, Ali Saeed, Oleh Hnatiuk
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