gms | German Medical Science

67th Annual Meeting of the German Society of Neurosurgery (DGNC)
Joint Meeting with the Korean Neurosurgical Society (KNS)

German Society of Neurosurgery (DGNC)

12 - 15 June 2016, Frankfurt am Main

Risk of cement extravasation and pulmonary embolism by bone cement augmented pedicle screw fixation of the thoracolumbar spine

Meeting Abstract

  • Insa Janssen - Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Germany
  • Yu-Mi Ryang - Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Germany
  • Jens Gempt - Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Germany
  • Julia Gerhardt - Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Germany
  • Bernhard Meyer - Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Germany

Deutsche Gesellschaft für Neurochirurgie. 67. Jahrestagung der Deutschen Gesellschaft für Neurochirurgie (DGNC), 1. Joint Meeting mit der Koreanischen Gesellschaft für Neurochirurgie (KNS). Frankfurt am Main, 12.-15.06.2016. Düsseldorf: German Medical Science GMS Publishing House; 2016. DocMO.14.03

doi: 10.3205/16dgnc076, urn:nbn:de:0183-16dgnc0760

Published: June 8, 2016

© 2016 Janssen et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License. See license information at http://creativecommons.org/licenses/by/4.0/.


Outline

Text

Objective: Cement augmented pedicle screw instrumentation (CAPSI) of the thoracolumbar spine is indicated in osteoporosis or osteopenia to improve pullout strength and biomechanical stability of pedicle screws. Only few studies report on the incidence of pulmonary cement embolism or other complications associated with CAPSI. Aim of this retrospective study was to assess the rate of CAPSI associated complications.

Method: Our clinical database was reviewed for patients who underwent CAPSI between January 2012 and May 2015. A total of 155 patients (mean age 71 ± 11,3; range: 48- 93 yrs; m= 57, f=98) were identified. Indications were osteoporotic fractures (n= 38), spinal metastases (n=56), degenerative (n= 46) or infectious spine disease (n= 15). Every patient received between 4 and 14 cement augmented pedicle screws. Both intraoperative cement extravasation in prevertebral veins, the inferior vena cava and/or pulmonary arteries and extravasation detected on postoperative imaging were evaluated. We assessed the incidence of clinically symptomatic and asymptomatic patients.

Results: In 29 cases there was intraoperative suspicion of cement extravasation on lateral fluoroscopy without hemodynamic relevance. In 18 of these cases postoperative x- ray or CT scan confirmed cement extravasation in prevertebral veins or the inferior vena cava. Eight of these patients had suspicion of pulmonary cement embolism (PCE) and received thoracic CT. PCE was verified in 3 cases. 4 patients experienced relevant intraoperative hemodynamic reactions due to cement embolism (n=2; 1,3%) or anaphylactic shock (n=2; 1.3%) with need of intraoperative CPR. The 2 anaphylactic patients recuperated fully, the other 2 patients deceased within 48 hours after surgery due to fulminant PCE, which was verified on postoperative chest CT. Three patients with dyspnea one day after surgery were also confirmed with PCE on Chest CT. In an additional 34 cases without intraoperative suspicion of cement extravasation cement extrusion in prevertebral veins was found incidentally on postoperative imaging (spine x ray or spine CT) without clinical sequelae. All in all 49 patients (31.6%) had clinically asymptomatic cement extravasation. Ten patients were confirmed with PCE (6.5%) of whom only 5 (3.2%) were clinically symptomatic. Two patients experienced intraoperative cement induced anaphylaxia (1.3%). The overall complication rate was 7.7% (n=12). The mortality rate 1.3% (n=2).

Conclusions: CAPSI bears a high risk of asymptomatic cement extravasation. The risk for associated complications was relatively high. Complications however, were severe. Thorough consideration of the indication for cement augmentation and slow and careful intraoperative cement augmentation under serial lateral fluoroscopy might reduce the risk of cement associated complications.