Polymethylmethacrylate Pulmonary Embolism Following Kyphoplasty

Abstract

We report a case of polymethylmethacrylate cement pulmonary embolism (PE) that occurred two days following a minimally invasive kyphoplasty procedure. Our patient developed non-specific rib pain postoperatively followed by dyspnea, prompting presentation to the emergency department. The polymethylmetacrylate cement was visualized on initial chest radiograph and further characterized using computed tomography. The patient was admitted and anticoagulation started, later having an uncomplicated hospital course. The polymethylmethacrylate cement has a well-documented history of leakage and other postoperative complications. Cement PE, while rare, can present similarly to a thrombotic PE and requires adequate long-term anticoagulation with close follow-up.

Full text

UC Irvine
Clinical Practice and Cases in Emergency Medicine
Title
Polymethylmethacrylate Pulmonary Embolism Following Kyphoplasty
Permalink
https://escholarship.org/uc/item/5295w6gj
Journal
Clinical Practice and Cases in Emergency Medicine, 3(3)
ISSN
2474-252X
Authors
Morris, Oliver
Mathai, Josephin
Weller, Karl
Publication Date
2019
DOI
10.5811/cpcem.2019.4.42324
License
CC BY 4.0
Peer reviewed
eScholarship.org Powered by the California Digital Library
University of California

Clinical Practice and Cases in Emergency Medicine 226 Volume III, no. 3: August 2019
Case RepoRt
Polymethylmethacrylate Pulmonary Embolism
Following Kyphoplasty
Oliver Morris, DO
Josephin Mathai, DO
Karl Weller, DO
Section Editor: Christopher Sampson, MD
Submission history: Submitted January 13, 2019; Revision received March 22, 2019; Accepted April 2, 2019
Electronically published May 20, 2019
Full text available through open access at http://escholarship.org/uc/uciem_cpcem
DOI: 10.5811/cpcem.2019.4.42324
We report a case of polymethylmethacrylate cement pulmonary embolism (PE) that occurred two
days following a minimally invasive kyphoplasty procedure. Our patient developed non-specic rib
pain postoperatively followed by dyspnea, prompting presentation to the emergency department. The
polymethylmetacrylate cement was visualized on initial chest radiograph and further characterized
using computed tomography. The patient was admitted and anticoagulation started, later having an
uncomplicated hospital course. The polymethylmethacrylate cement has a well-documented history
of leakage and other postoperative complications. Cement PE, while rare, can present similarly to
a thrombotic PE and requires adequate long-term anticoagulation with close follow-up. [Clin Pract
Cases Emerg Med. 2019;3(3):226-228.]
INTRODUCTION
Vertebral compression fractures make up approximately
one half of all osteoporotic fractures in the United States
(U.S.), affecting over 700,000 people per year.1 Patients with
compression fractures often experience severe pain that may
limit mobility, increase morbidity, and can be a signicant
source of healthcare resource utilization. Multiple treatment
modalities have been used including medical management,
pain management, physical therapy, bracing, and surgery. The
surgical therapies consist of minimally invasive techniques
such as percutaneous balloon kyphoplasty and vertebroplasty,
where a cement polymer is injected into the vertebrae to
stabilize the osseous structure. There are estimated to be over
25,000 kyphoplasty and vertebroplasty procedures performed
in the U.S. each year, and they can be associated with severe
intra- and postoperative complications.2 This case report
highlights one of the rarer but often more severe complications,
polymethylmethacrylate (PMMA) pulmonary embolism (PE).
CASE REPORT
A 43-year-old male construction worker with a history
of chronic back pain and recent kyphoplasty two days prior,
presented to the emergency department (ED) for the second
time that day for dyspnea. The patient had been seen in the ED
earlier in the day by another provider for nonspecic lower back
and ank pain that was medically treated with improvement of
St. Lucie Medical Center, Department of Emergency Medicine, Port St. Lucie, Florida
symptoms. A few hours after arriving home, the patient became
dyspneic and returned to the ED for evaluation.
On physical examination, he appeared to be mildly
tachypneic. His blood pressure was 105/71 millimeters of
mercury, pulse 86 beats per minute (BPM), respiratory rate
20 breaths per minute, and oxygen saturation of 95% on room
air. He did not appear to be in respiratory distress with no
accessory muscle use. Lungs were clear to auscultation but
mildly diminished. He exhibited no wheezing, rhonchi, or
rales. The heart sounds were regular, with no audible murmur.
Abdomen was soft and nontender, with positive bowel sounds.
There was no midline spinal tenderness. He had several well-
healing, non-erythematous paraspinal puncture wounds from
the kyphoplasty procedure two days prior. The rest of his
physical exam was unremarkable.
Initial workup consisted of basic metabolic panel, complete
blood count, troponin, electrocardiogram (ECG) and a chest
radiograph (CXR). When we applied the Wells criteria for PE,
the patient scored 1.5 for having had a surgery in the previous
four weeks. This score put him in the low-risk group with a 1.3%
chance of PE.1 The ECG showed a normal sinus rhythm at 85
BPM. The CXR revealed pulmonary cement embolism with mild
vascular crowding and atelectasis at the lung bases (Image 1).
With this nding, a computed tomography angiography of the
chest was ordered, which revealed cement in distal pulmonary
arteries consistent with cement emboli along with patchy,

Volume III, no. 3: August 2019 227 Clinical Practice and Cases in Emergency Medicine
Morris et al. Polymethylmethacrylate PE Following Kyphoplasty
Image 1. Chest radiograph of a 43-year-old male depicting
multiple hyperdense opacities (arrows) with vascular crowding
and atelectasis at lung bases.
Image 2. Computed tomographic angiogram of the chest of
a 43-year-old male depicting hyperdense material in distal
pulmonary arteries (arrows) consistent with cement emboli.
ground-glass opacity worrisome for inltrate (Image 2). The
patient was immediately treated with heparin and admitted to the
hospital for continued management. While there, he was treated
according to guidelines for thrombotic PEs and started on six-
month warfarin therapy. He was discharged home two days later.
DISCUSSION
Kyphoplasty and vertebroplasty are two common surgical
techniques used in stabilization and repair of vertebral
compression fractures. The procedures are similar in that
they use a cement, such as PMMA, which is injected into the
vertebral body and allowed to harden. Kyphoplasty differs
by rst employing a balloon that is inated in the vertebral
body prior to the cement injection. This allows for height
restoration of the affected vertebrae. The procedures themselves
are minimally invasive, but the efcacy of kyphoplasty and
vertebroplasty in osteoporotic vertebral fractures continues to
be controversial. Two randomized, placebo-controlled trials
found no signicant benet over conservative management.2,3,4,5
In 2010, as part of its clinical practice guidelines, the American
Academy of Orthopaedic Surgeons strongly recommended
against vertebroplasty for patients who present with an
osteoporotic spinal compression. Since taking that stance, there
have been several newer, unblinded trials and meta-analyses
published that contradict the initial ndings..
6,7,8
Cement extravasation is the most common and well-
known complication of both vertebroplasty and kyphoplasty
CPC-EM Capsule
What do we already know about this clinical
entity?
Polymethymethacrylate pulmonary
embolism is a rare but known complication
of kyphoplasty. It has been reported
in orthopaedic literature but rarely in
emergency medicine.
What makes this presentation of disease
reportable?
There have been very few reports of this
disease entity in emergency medicine
literature, so increasing awareness of post-
kyphoplasty complications is essential.
What is the major learning point?
The novelty of this disease, along with the
morbidity and mortality if left untreated,
makes early recognition important.
How might this improve emergency
medicine practice?
Early recognition of polymethylmethacrylate
pulmonary embolism can lead to better
patient outcomes.

Clinical Practice and Cases in Emergency Medicine 228 Volume III, no. 3: August 2019
Polymethylmethacrylate PE Following Kyphoplasty Morris et al.
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with rates as high as 41% and 18%, respectively.9,10 This
leakage can cause damage to surrounding nerve and tissues,
irritation of nerve roots, PE, and even reports of cardiac
tamponade. The literature research revealed that the risk
of PE ranges from 3.5-23%, with vertebroplasty leakages
being more common and more signicant..
11 Treatment in
these cases has not been well dened, but the consensus is
to proceed according to guidelines of thrombotic PEs. Initial
heparinization and six months of continuous warfarin therapy
is recommended in symptomatic peripheral and asymptomatic
central PE along with admission for clinical observation and
close follow-up. In rare instances of central symptomatic PE,
surgical embolectomy may be considered..
11
CONCLUSION
This report highlights the importance of recognizing
cement PE in a postoperative kyphoplasty patient presenting
for non-specic chest complaints in an otherwise healthy
individual and minimal PE risk factors.
Documented patient informed consent and/or Institutional Review
Board approval has been obtained and led for publication of this
case report.
Address for Correspondence: Oliver J. Morris, DO, St. Lucie Medical
Center, Department of Emergency Medicine, 1800 SE Tiffany Ave,
Port St. Lucie, FL 34652. Email: oliver.morris@hcahealthcare.com.
Conicts of Interest: By the CPC-EM article submission agreement,
all authors are required to disclose all afliations, funding sources
and nancial or management relationships that could be perceived
as potential sources of bias. The authors disclosed none.
Copyright: © 2019 Morris et al. This is an open access article
distributed in accordance with the terms of the Creative Commons
Attribution (CC BY 4.0) License. See: http://creativecommons.org/
licenses/by/4.0/