Fatal pulmonary cement embolism following percutaneous vertebroplasty (PVP)

doi:10.1016/j.forsciint.2004.06.010

Forensic Science International

Volume 149, Issue 1, 20 April 2005, Pages 35-38

https://doi.org/10.1016/j.forsciint.2004.06.010 Get rights and content

Abstract

A case of fatal pulmonary embolism with acrylic cement occuring during a percutaneous vertebroplasty on account of a fracture of L1 is described. Autopsy confirmed the presence of large amounts of surgical cement in the paravertebral venous system and in the pulmonary arteries. This rare complication occurred because perivertebral venous cement migration was not recognized during vertebroplasty. To our knowledge, this is the first case of fatal pulmonary embolism caused by surgical cement following a percutaneous vertebroplasty.

Introduction

The technique of percutaneous transpedicular polymethylmethacrylate (PMMA)-assisted vertebroplasty was developed by Galibert et al. [1]. Initial and ongoing successful treatment of aggressive vertebral hemangiomas and painful osteolytic vertebral tumors [1], [2], [3], [4], [5], [6], [7], [8] paved the way for new indications such as refractory vertebral body compression fractures secondary to osteoporosis [5], [6], [7], [8], [9], [10].

Percutanous transpedicular PMMA-assisted vertebroplasty involves the percutaneous injection of polymethylmethacrylate directly into the fractured vertebral body via a transpedicular approach. According to literature, the average injected amount of acrylic cement ranges between 5.4 [11] and 7.1 ml [9].

Despite the minimal invasiveness of this technique, complications can occur during or after the treatment, even though the rate appears to be low. The majority of complications consist of local processes such as infection or cement leakage into the spinal canal or into the perivertebral venous system [9], [11]. Further complications are related to the initial vertebral disease rather than to the operative intervention. As a rare complication, single rib fractures during the procedure were described [9]. Grave complications, such as fatal pulmonary failure in the immediate postoperative period, have been reported on and were due to fat or thrombotic tissue embolism [12]. In comparison, embolism caused by the cement itself remained asymptomatic [13], [14].

Section snippets

Case report

An 81-year-old woman was hospitalized for traumatic intertrochanteric hip fracture and a fracture of the first lumbar vertebra. On account of the femoral fracture, osteosynthesis utilizing a dynamic hip screw was performed.

Due to continued pain and immobilization of the patient, surgical intervention was decided upon.

A percutaneous vertebroplasty of TH 12, L1 and L2 was performed under general anaesthesia 7 days after the initial trauma. The intervention lasted approximately 20 min. According to

Discussion

Percutaneous vertebroplasty is a common minimal-invasive operative method for stabilisation of vertebral fractures, consisting of injection of a small amount of surgical cement into the fractured vertebral body. The complication rate is considered as low. Complications such as hemorrhage at the puncture site, local infection and pulmonary embolism [9], [11] have been reported on.

The major complication observed in this technique is cement extravasation into the venous system and into the spinal

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Risk factors for pulmonary cement embolism associated with percutaneous vertebral augmentation: A systematic review and meta-analysis
2022, International Journal of Surgery
Citation Excerpt :
Details of PCE were presented in Tables 2 and 3. According to the 9-srat NOS, 7 studies (Kim YJ, 2009 [16]; Potet J, 2013 [17]; Venmans A, 2010 [18]; Mansour A, 2018 [9]; Zou D, 2021 [24]; Hsieh MK, 2019 [25]; Barragán-Campos HM 2006 [26]) were considered to be of low quality, with NOS <6. In turn, 6 studies (Bliemel C, 2013 [15]; Duran C, 2007 [19]; Kang HR, 2020 [20]; Luetmer MT, 2011 [21]; Venmans A, 2008 [23]; Choe DH 2004 [27])) were of relatively high quality, with NOS ≥6.
Pulmonary cement embolism (PCE) was a rare but fatal complication for percutaneous vertebral augmentation (PVA). Thus we did a systematic review and meta-analysis of cohort studies to investigate the risk factors for PCE after PVA.
We systematically searched PubMed, EMBASE, Cochrane library, Google Scholar, web of science, and ClinicalTrial.gov from the establishment of the database to September 2021. All eligible studies assessing the risk factors for PCE after PVA were incorporated. Dichotomous data was calculated by risk difference (RD) from Mantel-Haenszel method (M − H method); continuous data was analyzed by mean difference (MD) from Inverse-Variance method (I–V method). All variables were taken as measure of effect by fixed effect model. Heterogeneity, sensitivity, and publication bias analyses were also performed.
This study totally included 13 studies. According to the Newcastle-Ottawa Scale (NOS), 7 studies were considered as low quality, with NOS< 6. The others were of relatively high quality, with NOS≥6. 144/6251 patients (2.3%) had PCE after PVA. percutaneous vertebroplasty (PVP) (RD = 0.02, 95%CI: [0.01, 0.04], Z = 3.70, P < 0.01), thoracic vertebra (RD = 0.03, 95%CI: [0.01, 0.05], Z = 3.53, P < 0.01), higher cement volume injected per level (MD = 0.23, 95%CI: [0.05, 0.42], Z = 2.44, P = 0.01), more than three vertebrae treated per session (MD = −0.05, 95%CI: [-0.08, −0.02], Z = 3.65, P < 0.01), venous cement leakage (RD = 0.07, 95%CI: [0.03, 0.11], Z = 3.79, P < 0.01) were more likely to cause PCE.
This study showed that risk factors for PCE included PVP, thoracic vertebra, higher cement volume injected per level, more than three vertebrae treated per session, venous cement leakage. As a serious complication, PCE should be paid attention and avoided.
Kyphoplasty-related paradoxical cerebral arterial embolism. Case presentation and topic review
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Delayed pulmonary embolism from vertebral reinforcement material. Clinical and medico-legal considerations of a case
2021, Revista Espanola de Medicina Legal
La vertebroplastia y la cifoplastia son procedimientos de punción percutáneos que precisan de la inyección de cemento en el soma de una vértebra fracturada, con el fin de refuerzo y alivio del dolor. Con ocasión de un caso de cifoplastia del soma de L2 que desarrolló una infrecuente embolización diferida de cemento a la arteria pulmonar, se revisa la literatura y analizan los principales problemas médico-legales de estas complicaciones. Se subraya la necesidad de un consentimiento informado detallando la frecuencia y riesgos de estas complicaciones, así como un adecuado control radiológico postoperatorio, no solo local, sino torácico. Igualmente, se enfatiza la posibilidad de repetir el estudio radiológico local y torácico, ante cualquier cambio de la morfología de la fuga local o desaparición de la fuga local, ante la posibilidad de migraciones tardías.
Vertebroplasty and kyphoplasty are percutaneous puncture procedures that require the injection of cement into the soma of a fractured vertebra for reinforcement and pain relief.
As the result of a case of kyphoplasty of the soma of L2 that developed a rare, delayed embolization of cement to the pulmonary artery, we undertook a literature review, and the main medico-legal problems of these complications were analysed.
The need for informed consent is stressed, detailing the frequency and risks of these complications, as well as adequate postoperative local and chest X-ray control. Likewise, the possibility is highlighted of repeat local and chest X-rays in the event of any change in the morphology of local leakage or disappearance of local leakage in the event of late migration.
Incidence and Clinical Risk of Cement Extravasation in Adult Patients Undergoing Prophylactic Vertebroplasty During Surgical Spine Reconstruction
2020, World Neurosurgery
Citation Excerpt :
Prophylactic vertebroplasty in this context can broadly be defined as any cement augmentation of a vertebral body (VB) for the purpose of preventing PJK or PJF secondary to VB fracture or pedicle screw failure. Although vertebroplasty is generally thought to be safe, there are numerous reports of devastating complications arising from this technique when performed percutaneously for the isolated treatment of VB compression fractures.12-38 These complications result from cement extravasation into the spinal canal, neural foramina, or perivertebral venous system.
To measure the incidence and severity of cement extravasation in adult patients undergoing prophylactic vertebroplasty as part of a spinal reconstruction procedure.
Consecutive adult patients treated with prophylactic vertebroplasty during a spinal reconstruction procedure were reviewed over a 46-month period. Patients without a postoperative computed tomography scan were excluded. Spine reconstruction was defined as any procedure involving ≥6 levels of fusion or a 3-column osteotomy. Cement extravasation was graded using a novel grading system. Fisher exact tests were performed to identify independent predictors of cement extravasation.
Inclusion and exclusion criteria were met by 34 patients comprising 112 vertebral bodies (VB). All 34 patients (100%) had computed tomography evidence of cement extravasation. Of 112 VBs, 103 (92.0%) demonstrated cement extravasation. Thirteen VBs (11.6%) in 9 patients (26.5%) had cement extending to the vena cava or end-organs or cement causing spinal canal stenosis (grade 4 and 5 extravasation). No permanent clinical sequelae were found in these 9 patients. Upper thoracic vertebrae (C7-T6) had significantly higher rates of grade 4 and 5 extravasation than lower thoracic–lumbar vertebrae (T7-L5) (P = 0.004).
Although no patients in this study experienced known long-term consequences of prophylactic vertebroplasty, 26.5% of patients had cement extravasation that threatened end-organs or neural elements. These results prompted us to change our practice from cementing upper thoracic VBs to using hooks instead. Cement injection is associated with serious risks and should be performed selectively. Larger prospective studies are needed to verify these results.
Fatal cardiac perforation and pulmonary embolism of leaked cement after percutaneous vertebroplasty
2019, Journal of Forensic and Legal Medicine
Percutaneous vertebroplasty consists of percutaneous injection of polymethylmethacrylate (PMMA) via a transpedicular approach for the treatment of collapsed osteoporotic or metastatic vertebrae. Even if percutaneous vertebroplasty is considered to be minimally invasive, threatening complications can occur. Cement leakage is the most common complication of percutaneous vertebroplasty. Rigorous patient selection and individual therapeutic strategy may reduce the occurrence of leakage, in particular the risk of cement entry into the venous system and the spinal canal is the potent major hazard of this technique. Cement pulmonary and cardiac embolism are reported in literature as a cause of unexpected death after percutaneous vertebroplasty. Authors report a fatal case of pulmonary cement embolization occurred after vertebroplasty with haemopericardium, due to the perforation of the right atrium wall from a cement solidified fragment. A complete post mortem examination documented the presence of multiple cement fragments in the pulmonary arteries and transmural perforation of the wall of the right atrium by a whitish needle-like foreign body. Pulmonary microembolization was observed under polarized light.
Inferior vena cava injury during percutaneous vertebroplasty: a rare cause of fatal pulmonary thromboembolism
2023, Forensic Science, Medicine, and Pathology

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View full text

Fatal pulmonary cement embolism following percutaneous vertebroplasty (PVP)

Abstract

Introduction

Section snippets

Case report

Discussion

Radiol. Clin. North Am.

Bone

Bone

Biomaterials

Preliminary note on the treatment of vertebral angioma by percutaneous acrylic vertebroplasty

Neurochirurgie

Percutaneous acrylic vertebroplasty as a treatment of vertebral angioma as well as painful and debilitating diseases

Chirurgie

Percutaneous vertebroplasty for osteolytic metastases and myeloma: effects of the percentage of lesion filling and the leakage of methyl methacrylate at clinical follow-up

Radiology

Spinal metastases: indications for and results of percutaneous injection of acrylic surgical cement

Radiology

Percutaneous vertebral surgery. Technics and indications

J. Neuroradiol.

Percutaneous vertebroplasty: state of the art

Radiographics