A 79 year old female with history of osteoporosis, remote breast cancer s/p mastectomy and radiation therapy, and history of multiple vertebral compression fractures presented to the hospital three days after kyphoplasty of T10 vertebral body with the chief complaint of chest discomfort since her procedure. Patient described chest discomfort as a chest wall pain associated with mild shortness of breath when taking deep inspiration. Patient reported being ambulatory since the time of her procedure, and reported no personal or family history of clotting disorder. Patient’s initial vital signs were BP 106/55, PR 72, RR 17, O2 99% on room air. Physical exam was unremarkable. A basic metabolic panel and a complete blood count were within normal limits. A troponin was negative and EKG was normal sinus rhythm at 70 BPM. Given concern for a pulmonary embolism post-procedure, a D-dimer was done and found to be elevated to 8.42 ug/mL. A CT angiogram was then performed and revealed scattered hyperdensities of higher attenuation than contrast in the pulmonary arterial tree, consistent with cement embolism (CE).
The patient was admitted to the hospital for close cardiac monitoring and monitoring of chest pain symptoms. Patient’s symptoms and oxygentation status remained well controlled. An echo was performed and revealed no evidence of right heart strain. After discussion with patient and family regarding anti-coagulation, it was decided not to anticoagulate the patient. The patient was discharged home, and at follow up appointment one month later, had no further chest pain or shortness of breath symptoms.
Discussion: Kyphoplasty is a minimally invasive procedure that stabilizes the fractured vertebral body via percutaneous injections of a cement-like material, polymethyl methacrylate (PMMA). The procedure is done in an effort to provide effective long term pain relief and extended fracture free survival. Low pressure injections of high viscosity PMMA has helped minimize the risk of cement leakage. However, CE is reported to occur in 3.5-23% of all cases. While CE is typically an incidental finding in asymptomatic patients, it can present as dry cough, dyspnea, chest pain, hypoxia, arrhythmia and hypotension. Asymptomatic patients are typically observed, and those with cardiovascular and pulmonary complications are managed with anticoagulation or embolectomy.
Conclusions: As kyphoplasty becomes an increasingly utilized intervention, physicians must become familiar with the signs and symptoms of, and maintain a high clinical suspicion for CE in patients who have recently undergone the procedure and present with symptoms concerning for a pulmonary embolism. The clinical presentation is highly variable, often sub-clinical, and can occur up to months following the procedure. Treatment should be tailored to individual patient based on symptoms, clinical findings, and severity of clot burden.
To cite this abstract:Rosen H, Luger D, Lam W. Back Reconstruction Leading to Cement Embolism. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 671. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/back-reconstruction-leading-to-cement-embolism/. Accessed May 27, 2019.