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RADIOLOGY QUIZ
Year : 2021  |  Volume : 38  |  Issue : 3  |  Page : 277-279  

Clinical context: A man with abnormal imaging following kyphoplasty


1 Department of Pulmonary and Critical Care, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
2 Department of Pulmonary and Critical Care, Veterans Affairs Hospital, Salem, Virginia, USA

Date of Submission10-Aug-2020
Date of Acceptance18-Oct-2020
Date of Web Publication30-Apr-2021

Correspondence Address:
Dr. Venkateswara K Kollipara
Virginia Tech Carilion School of Medicine, Roanoke, Virginia
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/lungindia.lungindia_654_20

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How to cite this article:
Kollipara VK, Agarwal A. Clinical context: A man with abnormal imaging following kyphoplasty. Lung India 2021;38:277-9

How to cite this URL:
Kollipara VK, Agarwal A. Clinical context: A man with abnormal imaging following kyphoplasty. Lung India [serial online] 2021 [cited 2021 May 8];38:277-9. Available from: https://www.lungindia.com/text.asp?2021/38/3/277/315302




   Case Top


A 76-year-old man with a history of severe chronic obstructive lung disease on 2 L home oxygen, former smoker with 40 pack-years (quit in 2005), atrial fibrillation, and right lower lobe non-small cell lung cancer (T1aN0M0, Stage IA) status post cyber knife therapy in 2016 presented with chief complaint of lower back pain. Patients lung cancer recurred in 2017 with positive station 7 lymph node and received chemo-radiation. Magnetic resonance imaging (MRI) showed benign burst fractures of T8 and T9 vertebrae. He had kyphoplasty of T7, 8, and 9 vertebrae. During kyphoplasty, following complications were noted [Figure 1] and [Figure 2].
Figure 1: Images 1 and 2

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Figure 2: Images (3-6): Arrows showing cement embolism in the azygous vein on fluoroscopy (Image 3) and noncontrast computed tomography chest (Images 4-6)

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   Questions Top


  1. What is the abnormality detected on fluoroscopy and computed tomography (CT) chest during the procedure [Figure 1] and [Figure 2]?



   Answer Top


  • Abnormality: Cement embolism into azygos vein (images with arrow marks below). During the procedure, it was observed the cement material extravasated into the azygous vein. CT chest was done which confirmed the finding. The patient denied any chest pain or shortness of breath post procedure.



   Discussion Top


Pulmonary cement embolism (PCE) refers to the embolization of polymethyl methacrylate (PMMA) into the lungs. PMMA is a rapidly settling acrylic cement that is often used in vertebroplasty. Its reported incidence is thought to be around 3.5%–23% for osteoporotic fractures.[1]

Patients can be asymptomatic or can present with chest pain, dyspnea, arrhythmia, and collapse. Noncontrast CT of the chest is the imaging of choice to diagnose PCE. There are no guidelines in the treatment of PCE due to its rarity. Cardiopulmonary complications associated with kyphoplasty include PCE, arrhythmias, cardiac perforation, pulmonary infarction, and cardiac arrest. Treatment depends on the symptoms and location of PCE. Cardiac surgery or percutaneous removal for central embolism (embolectomy), and 3–6 months of anticoagulation is recommended by most experts based on the symptoms and risks of cardiopulmonary complications. Reason for anticoagulation is for the thrombogenic potential of cement, which can lead to progressive occlusion of pulmonary arteries. Based on previous case reports and series, at least 3–6 months of anticoagulation is recommended to avoid additional thrombosis and to give time for the cement to endothelialized which might prevent progression of the occlusion.[2] Our patient was admitted overnight for observation. Follow-up CT chest showed stable azygos vein cement embolism; therefore, he was discharged home on apixaban which was also indicated for atrial fibrillation.

To give a general recommendation for avoiding cement embolisms, the bone cement used should have a viscous, toothpaste-like consistency. There is hard evidence in the experimental work that viscosity of the bone cement is one crucial parameter regarding the risk for leakage.[3],[4] The injection should be stopped as soon as one of the personnel present during the procedure realizes that there is paravertebral or intravenous cement extravasation. Both kyphoplasty and vertebroplasty procedures should be done under fluoroscopy or CT monitoring by experienced proceduralists. Routine chest radiograph following every vertebroplasty is recommended to prevent serious delayed cardiopulmonary complications.[5],[6]

The risk for PCE seems to be higher in vertebroplasty than in kyphoplasty and in the treatment of some malignant lesions because of more frequent cortical destruction of the vertebral body and higher vascularization associated with some malignant tumors.[5] Some authors reported the use of a preinjection venogram and injection of sclerosing agents into the vertebral body before vertebroplasty to close the venous channels to prevent (or reduce the risk of) this complication.[1]

Follow-up

Repeat CT chest after 1 month showed progression of his right lower lobe lung cancer, mild progression of cement into superior vena cava and focal discontinuity proximally. He was scheduled for cement retrieval with moderate sedation through internal jugular approach. However, given the progression of his lung cancer, while on immunotherapy (Durvalumab), he opted for hospice care.

Take home points

  1. Although rare, PCE is a life-threatening complication and should be in differential diagnosis in patients presenting with worsening respiratory symptoms after vertebroplasty or kyphoplasty procedure
  2. Routine chest radiograph should be obtained following all vertebroplasty and kyphoplasty to prevent serious delayed cardiopulmonary complications
  3. Noncontrast CT chest is the imaging of choice to diagnose PCE
  4. Treatment depends on the symptoms and location of PCE. Therapeutic anticoagulation for 3–6 months is recommended to avoid additional thrombosis and to give time for the cement to endothelialized which might prevent the progression of the occlusion.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Krueger 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;18:1257-65.  Back to cited text no. 1
    
2.
Righini M, Sekoranja L, Le Gal G, Favre I, Bounameaux H, Janssens JP. Pulmonary cement embolism after vertebroplasty. Thromb Haemost 2006;95:388-9.  Back to cited text no. 2
    
3.
Baroud G, Crookshank M, Bohner M. High-viscosity cement significantly enhances uniformity of cement filling in vertebroplasty: An experimental model and study on cement leakage. Spine (Phila Pa 1976) 2006;31:2562-8.  Back to cited text no. 3
    
4.
Bohner M, Gasser B, Baroud G, Heini P. Theoretical and experimental model to describe the injection of a polymethylmethacrylate cement into a porous structure. Biomaterials 2003;24:2721-30.  Back to cited text no. 4
    
5.
Geraci G, Lo Iacono G, Lo Nigro C, Cannizzaro F, Cajozzo M, Modica G. Asymptomatic bone cement pulmonary embolism after vertebroplasty: Case report and literature review. Case Rep Surg 2013;2013:591432.  Back to cited text no. 5
    
6.
Wang LJ, Yang HL, Shi YX, Jiang WM, Chen L. Pulmonary cement embolism associated with percutaneous vertebroplasty or kyphoplasty: A systematic review. Orthop Surg 2012;4:182-9.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2]



 

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