Symptomatic pulmonary cement embolism after pedicle screw polymethylmethacrylate cement augmentation: A case report and review
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran.
DOI:10.25259/SNI_592_2019Copyright: © 2020 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Abolfazl Rahimizadeh, Valiollah Hassani, Housain Soufiani, Ava Rahimizadeh, Mona Karimi, Naser Asgari. Symptomatic pulmonary cement embolism after pedicle screw polymethylmethacrylate cement augmentation: A case report and review. 07-Feb-2020;11:18
How to cite this URL: Abolfazl Rahimizadeh, Valiollah Hassani, Housain Soufiani, Ava Rahimizadeh, Mona Karimi, Naser Asgari. Symptomatic pulmonary cement embolism after pedicle screw polymethylmethacrylate cement augmentation: A case report and review. 07-Feb-2020;11:18. Available from: https://surgicalneurologyint.com/surgicalint-articles/9865/
Background: In osteoporotic patients, a useful technique for significantly enhancing the strength of a pedicle screw is augmentation with polymethylmethacrylate cement. However, a rare complication of this procedure is a symptomatic pulmonary cement embolism.
Case Description: A pedicle screw cement augmentation was performed in a middle-aged female for the failed back syndrome. When she developed symptomatic pulmonary cement emboli, she was successfully managed with conservative measures, including anticoagulation.
Conclusion: Despite the increased use of cement augmentation for pedicle screw placement and the relatively high incidence of cement leakage into the prevertebral venous system, symptomatic cement pulmonary embolism remains rare. The management of such symptomatic CPE should be evaluated and treated based on both the size and location of the embolism. Here, we presented this case while reviewing three symptomatic and four asymptomatic cases from the literature.
Keywords: Cement augmentation, Cement pulmonary emboli, Complication, Failed back syndrome, Pedicle screw, Polymethylmethacrylate
For nearly two decades, polymethylmethacrylate (PMMA) augmentation of pedicle screws in osteoporotic patients has been performed to improve pullout strength. One of the very rare but serious complications is symptomatic pulmonary cement embolism (PCE).[
A middle-aged female underwent surgery for failed back syndrome requiring additional decompression and instrumentation [
One of the most serious complications of pedicle screw PMMA augmentation is cement leakage into the inferior vena cava or azygos vein with subsequent migration through the pulmonary arteries into the lungs (e.g., PCE).[
Risk factors and prevention
The occurrence of PCE during pedicle screw PMMA augmentation depends on the viscosity of cement at the time of its delivery. The increased force attributed to the rapid injection of low viscous cement (dough-like) likely contributes to a higher incidence of PCE, while the reduced delivery rate of toothpaste-like cement results in a smaller incidence of leakage.[
Clinical picture of PCE
The clinical picture of a symptomatic PCE is similar to that of a thrombotic PE; the cardinal features include tachycardia, dyspnea, hypotension, and loss of consciousness that may result in cardiorespiratory arrest and death.[
With PCE, echocardiography may demonstrate changes in pulmonary artery pressure and right ventricular dilatation. The chest X-ray and CT for both symptomatic and asymptomatic PCE may be visualized as large tubular, branching (serpentine), or multiple small densities/opacities.[
Asymptomatic subjects with small cement particles in the lung fields require no treatment, while those with symptomatic thrombotic pulmonary emboli require emergent anticoagulation, for example, 5000 units of heparin and IV push followed by 1000 units/h.[
Symptomatic PCE is a rare, potentially catastrophic complication of augmenting pedicle screw instrumentation with PMMA. Rapidly injected low-viscous cement significantly contributes to cement leakage. If studies (X-ray, chest CT, and CT angiography) demonstrate cement in the inferior vena cava, one should be aware of its potential for embolization into the lungs (e.g., PCE).
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