PULMONARY CEMENT EMBOLISM AFTER PERCUTANEOUS VERTEBROPLASTY AND TRANSPEDICULAR SCREW FIXATION WITH BONE CEMENT: POTENTIAL RISK FACTORS

Objective. To analyze cases of pulmonary cement embolism and to determine possible causes of the complication.

Material and Methods. A heterogeneous group of 49 patients was retrospectively analyzed. Vertebroplasty was prescribed to the patients for restoration of vertebral support ability after osteoporotic compression fractures and hemangiomas, and as an auxiliary manipulation for transpedicular fixation of the osteoporotic spine. Thoracic computed tomography was performed and pulmonary cement embolism was revealed in the early or late postoperative periods.

Results. Pulmonary cement embolism was revealed in 7 (14 %) patients, two of them presented with massive pulmonary cement embolism. In one case it was caused by excessive injection of cement, and in the other - by anomalous anastomosis. In one case, the vertebroplasty was cancelled taking into account the results of venospodilography.

Conclusion. Attempts of maximum filling of the vertebral body and inadequate assessment of intertrabecular space volume, as well as anomalous anastomoses between the major blood vessels may cause clinically significant massive pulmonary embolism. Venospondylography performed before vertebroplasty may reveal the features of venous drainage of the vertebral body, which are the risk factors for massive cement embolism. 

1. Akinola B, Lutchman L, Barker P, Rai A. Pulmonary cement embolism during cement augmentation of pedicle screw fixation: a case report. J Orthop Surg. 2010;18:364-366.

2. Blinc A, Bozic M, Vengust R, Stegnar M. Methyl-methacrylate bone cement surface does not promote platelet aggregation or plasma coagulation in vitro. Thromb Res. 2004;114:179-184.

3. Cadeddu C, Nocco S, Secci E, Deidda M, Pirisi R, Mercuro G. Echocardiographic accidental finding of asymptomatic cardiac and pulmonary embolism caused by cement leakage after percutaneous vertebroplasty. Eur J Echocardiogr. 2009;10:590-592. DOI: 10.1093/ejechocard/jep030.

4. Calabresi P, Abelmann WH. Porto-caval and porto-pulmonary anastomoses in Laennec’s cirrhosis and in heart failure. J Clin Invest. 1957;36:1257-1265. DOI: 10.1172/JCI103523.

5. Cohen J, Lane T. Right intra-atrial and ventricular polymethylmethacrylate embolus after balloon kyphoplasty. Am J Med. 2010;123:e5-e6. DOI: 10.1016/j.amjmed.2010.01.037.

6. Galibert P, Deramond H, Rosat P, Le Gars D. [Preliminary note on the treatment of vertebral angioma by percutaneous acrylic vertebroplasty]. Neurochirurgie. 1987;33:166-168. In French.

7. Glenn WW. Circulatory bypass of the right side of the heart. IV. Shunt between superior vena cava and distal right pulmonary artery; report of clinical application. N Engl J Med. 1958;259:117-120.

8. Hagans I, Markelov A, Makadia M. Unique venocaval anomalies: case of duplicate superior vena cava and interrupted inferior vena cava. J Radiol Case Rep. 2014;8:20-26. DOI: 10.3941/jrcr.v8i1.1354.

9. Kellman GM, Alpern MB, Sandler MA, Craig BM. Computed tomography of vena caval anomalies with embryologic correlation. Radiographics. 1988;8:533-556.

10. Kim YJ, Lee JW, Park KW, Yeom JS, Jeong HS, Park JM, Kang HS. Pulmonary cement embolism after percutaneous vertebroplasty in osteoporotic vertebral compression fractures: incidence, characteristics, and risk factors. Radiology. 2009;251:250-259. DOI: 10.1148/radio1.2511080854.

11. Luetmer MT, Bartholmai BJ, Rad AE, Kallmes DF. Asymptomatic and unrecognized cement pulmonary embolism commonly occurs with vertebroplasty. AJNR Am J Neuroradiol. 2011;32:654-657. DOI: 10.3174/ajnr.A2368.

12. Marchand P, Gilroy JC, Wilson VH. An anatomical study of the bronchial vascular system and its variations in disease. Thorax. 1950;5:207-221.

13. Mehbod A, Aunoble S, Le Huec JC. Vertebroplasty for osteoporotic spine fracture: prevention and treatment. Eur Spine J. 2003;12:S155-S162. DOI: 10.1007/s00586-003-0607-y.

14. Nieuwenhuijse MJ, Bollen L, van Erkel AR, Dijkstra PD. Optimal intravertebral cement volume in percutaneous vertebroplasty for painful osteoporotic vertebral compression fractures. Spine. 2012;37:1747-1755. DOI: 10.1097/BRS.0b013e318254871c.

15. Rothermich MA, Buchowski JM, Bumpass DB, Patterson GA. Pulmonary cement embolization after vertebroplasty requiring pulmonary wedge resection. Clin Orthop Relat Res. 2014;472:1652-1657. DOI: 10.1007/s11999-014-35-06-0.

16. Snellen HA, van Ingen HC, Hoefsmit EC. Patterns of anomalous pulmonary venous drainage. Circulation. 1968;38:45-63. DOI: 10.1016/0735-1097(92)90064-T.

17. Venmans A, Klazen CA, Lohle PN, van Rooij WJ, Verhaar HJ, de Vries J, Mali WP. Percutaneous vertebroplasty and pulmonary cement embolism: results from VERTOS II. AJNR Am J Neuroradiol. 2010;31:1451-1453. DOI: 10.3174/ajnr.A2127.