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 Table of Contents  
CASE REPORTS
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 243-249

Symptomatic epidural cement leakage after percutaneous vertebroplasty: A case report of successful management by surgical excision with literature review


1 Department of Spine Surgery, Zydus Hospitals and Healthcare Research Private Limited, Zydus Hospital Road, Thaltej, Ahmedabad, Gujarat, India
2 Gujarat Spine Clinic, Skylark Tower, Satellite, Ahmedabad, Gujarat, India

Date of Submission29-Sep-2020
Date of Decision17-May-2021
Date of Acceptance20-May-2021
Date of Web Publication16-Jul-2021

Correspondence Address:
Hitesh N Modi
Department of Spine Surgery, Zydus Hospitals and Healthcare Research Private Limited, Zydus Hospital Road, Thaltej, Ahmedabad 380015, Gujarat.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ISJ.ISJ_78_20

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  Abstract 

The purpose of this case report was to present successfully treated case of symptomatic cement leakage after percutaneous vertebroplasty procedure (PVP) with technical tips to avoid such injury and to present literature review. PVP is a simple solution to treat osteoporotic vertebral compression fracture (OVCF) if it is performed with right indications. Cement leak into spinal canal during PVP can lead to catastrophic accident and cause severe neurological deficit that requires an urgent exploration and removal of cement. To avoid medial pedicle breach, there should be a definitive guideline during PVP. An 81-year-old lady had PVP after injury for OVCF at D12. She developed severe neurological deficit immediately after the procedure; however, she was managed conservatively. On presentation to us, urgent investigations with CT scan revealed cement leak into spinal canal from medial pedicle breach extending from D10-12 level with severe cord compression. Her surgery was performed with wide laminectomy at D10-D12 levels with transpedicular stabilization D9-L2 along with neuromonitoring. Cement mass was isolated from the dura and removed achieving decompression of the cord. Postoperatively, patient showed significant neurological improvement and walked independently with the help of stick in three months. In conclusion, although PVP is a convenient solution for painful OVCF, care must be taken while considering this option such as timing, insertion of needle, viscosity of cement, and C-arm monitoring. If neurological deficit occurs, urgent CT scan for the diagnosis and exploration with removal of cement with or without stabilization is mandatory.

Keywords: Epidural cement leak, neurologic deficit, removal of cement, urgent CT scan, vertebroplasty


How to cite this article:
Modi HN, Shrestha U, Bhandari N, Patel UD. Symptomatic epidural cement leakage after percutaneous vertebroplasty: A case report of successful management by surgical excision with literature review. Indian Spine J 2021;4:243-9

How to cite this URL:
Modi HN, Shrestha U, Bhandari N, Patel UD. Symptomatic epidural cement leakage after percutaneous vertebroplasty: A case report of successful management by surgical excision with literature review. Indian Spine J [serial online] 2021 [cited 2021 Dec 4];4:243-9. Available from: https://www.isjonline.com/text.asp?2021/4/2/243/321583




  Introduction Top


Osteoporotic vertebral compression fracture (OVCF) is a common condition among elderly population. It can occur after a trivial fall during household activities and cause severe back pain that restricts daily activities. Percutaneous vertebroplasty procedure (PVP) is a commonly recommended, minimally invasive procedure that can be performed under local anesthesia with successful results. PVP is performed for vertebral fractures caused by osteoporotic, traumatic, or neoplastic conditions, which manifest as mechanical back pain not relieved by medications or conservative trial.[1],[2],[3] It can also be useful in painful vertebral hemangiomas and other clinical conditions with good clinical results.[4],[5] However, despite good clinical outcome with PVP, complications are not uncommon. Literature mentioned a number of complications such as cement leakage in surrounding veins, paravertebral muscles, intervertebral disc, spinal canal, neural foramina, and extremely rare intradural.[6],[7],[8] It also increases the risk of adjacent level fracture[9] or uncommon infection. There are systemic complications reported with PVP such as pulmonary cement embolism,[10] fat embolism, cardiac damage,[11] renal embolism, arterial embolism, convulsions,[12] and epidural hemorrhage.[8]

Literature mentions that PVP, although a minimally invasive procedure, must be carried out with adequate safety and care because of its devastating complications. Cement leakage into the spinal canal is one of such catastrophic complications, which can cause permanent neurological deficits and make the patient bedridden for the rest of their life.[13],[14] It is an emergency when such complication happens and often requires a difficult surgical procedure to remove leaked cement, decompress the cord, and hopefully recover neurological complication.[13] Here, we report an interesting case of circumferentially leaked vertebroplasty cement into the spinal canal, causing paraparesis. The purpose was to report a successful outcome by surgery with removal of cement mass and to highlight the most common mistakes causing such complication.


  Case Report Top


An 81-year-old female patient was referred to us with a history of recent onset paraparesis after PVP three days back at a peripheral center. She had a history of trivial fall in the house while doing household work and sustained an injury to her back. She had pain around dorsolumbar region, making her unable to stand or sit due to severe pain. However, there was no weakness or numbness in the lower extremities. She had a history of diabetes and hypertension. She had a history of left hip hemiarthoplasty following a fracture four years back. The patient was taken to the local hospital and investigated in the form of X-ray and MRI after the injury [Figure 1]A and B. She was diagnosed with compression fracture at D12 with fluid collection in the fracture line on MRI. She was admitted and explained about the vertebroplasty procedure. Because of the severity of the pain, she immediately agreed to PVP under local anesthesia. She communicated that during the procedure, she felt sudden onset burning sensation with heaviness in both legs during cement injection. Once the procedure was over, she noticed that she could not move her legs, for which she was reassured. However, she was not able to move both legs till the next day, along with numbness below her waist with dribbling micturition. She was catheterized and further managed conservatively for two days without any improvement. Therefore, the patient took discharge and presented to us for further treatment. On presentation, she had paraparesis in both lower extremities with power 1/5 bilaterally. Sensations were decreased below the level of D10 (umbilicus), and knee and ankle jerks were absent. Her Babinski sign was upgoing. She was catheterized and she did not have feeling while passing stool. She was immediately investigated and her X-ray showed uniform filling of vertebroplasty cement at D12 with increased opacity till D10 in the midline on anteroposterior film [Figure 2]A. Her CT scan revealed epidural cement leakage from the right side and causing significant compression of the spinal cord. Cement mass was seen both anterior and posterior to the cord extending till D10 level [Figure 2]B. She was additionally investigated in the form of MRI that exhibited the complete block of cerebrospinal fluid flow from D10 to D12 level because of spinal cord compression by epidural cement leakage [Figure 2]C. Hence, she was diagnosed with symptomatic epidural cement leakage with cord compression at D10–D12 with paraparesis after vertebroplasty at D12. She was explained about her condition, and emergency surgery was planned. During the surgery, we performed transpedicular stabilization from D9 to L2 level, followed by wide laminectomies from D10 to D12. A large piece of epidurally leaked cement was found from D10 to 12 level on the right and posteriorly, which was causing compression over the cord [Figure 3]A. After carefully isolating the cement mass, it was detached from the dura and removed completely from the posterior and right side [Figure 3]B. We removed the entire 5.5 × 1.5 cm large cement mass during surgery [Figure 3]C. There was no dural leak or thermal injury seen on the dura [Figure 3]D. We did not try to mobilize the cord to go anteriorly for retrieval of anterior cement mass. This entire surgery was monitored using intraoperative neuromonitoring (IONM) with free-running electromyogram. After the removal of posteriorly leaked cement mass, motor-evoked-potential signal showed improvement in both amplitude and latency. Therefore, we did not try to remove anteriorly leaked cement. Posterolateral fusion was performed using autografts from spinous processes and laminae removed. Postoperatively, the patient exhibited a gradual improvement in her neurology. Her power in lower extremities improved to grade 3/5 with improved sensations bilaterally within three days of surgery. She was able to stand and walk few steps with the help of assisted physiotherapy after four days of surgery. Her postoperative X-ray suggested satisfactory fixation and location of vertebroplasty cement in D12 [Figure 4]. She was discharged after one week, and her power was grade 4/5 in both lower extremities and mild hypoesthesia below D10. Her catheter was removed after three weeks, and she was able to pass urine after removal of the catheter. She also regained sensations while passing stool. She was able to walk with the help of a tripod in one month and with the help of a stick in three months after her surgery.
Figure 1: A: X-ray and B: MRI pictures of an 81-year-old lady after injury showing compression fracture D12 with fracture fluid in the fracture site. There is no significant compression of the cord on the MR-myelogram

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Figure 2: PVP images of A: x-ray, B: CT scan, and C: MRI of dorsolumbar spine suggested cement leakage into spinal canal from the right side and extending till D10–D12 level, causing significant compression of cord on MR-myelogram

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Figure 3: Intraoperative pictures of revision surgery suggested A: long mass of epidurally leaked cement mass from D10 to D12 level, which was B: isolated from the dura carefully, and C: removed piece of cement mass measuring 5.5 × 1.5 cm. After the completion of decompression, D: dura seems intact without any cerebrospinal fluid leak or thermal injury

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Figure 4: Postoperative AP and lateral x-ray images of dorsolumbar spine show adequate decompression and fixation of the spine with transpedicular stabilization. Some part of anteriorly displaced cement was not removed to prevent injury to the cord

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  Discussion Top


PVP is a simple and clinically rewarding solution for the treatment of painful OVCF.[15] However, it may cause a catastrophic complication if the cement leaks into the spinal canal, causing severe compression.[14],[16] Here, we report a case of epidural leak of cement causing severe weakness in both lower extremities immediately after PVP. This emphasizes that care should be taken during PVP even if it is very easy and rewarding.[17] In our case, there are several points that need to be discussed to avoid such a devastating complication with PVP and its treatment. It also shows that once the patient develops neurological deficit after PVP, early intervention may offer favourable result.

Literature mentions several indications for PVP; however, it is often divided about the timing of the procedure. Wong and McGirt mentioned that there is no standard timeline for conservative treatment of OVCF, and therefore, the fracture should be within the subacute phase at the time of PVP.[18] On the other hand, Mathis, et al. in their review wrote that timing for PVP must be individualized. They mentioned that early interventions for PVP might be indicated because of the possibility of a continued collapse of the fractured vertebra during the lengthy period of nonoperative therapy.[17] Teng, et al. proposed that there should be adequate opacification in the vertebra before consideration of PVP.[19] It proves that there may be higher chances of cement leakage if performed in a fresh fracture. Inour case, PVP was performed within one day of injury without a conservative trial. We believe PVP should not be performed in a fresh fracture to avoid such a catastrophic complication. We think PVP should be performed after two to three weeks of injury in cases of OVCF and if the pain does not improve despite adequate conservative trial.

The second point to consider is regarding the process during PVP itself. The entry point of a needle into the pedicle should be considered extremely important as wrong entry can breach the medial pedicle cortex and result in cement leakage. Ryu, et al. mentioned that epidural cement leak tends to happen less when the pedicle entry is taken through unilateral pedicle rather than bilateral pedicles.[20] Teng, et al. emphasized that constant effort to prevent the needle from breaking the medial wall of the pedicle or passing through the spinal canal should be maintained rather than uni- or bipedicular entry.[19] Pateder, et al. shared a technical tip while making an entry into the pedicle and vertebral body. They suggested the use of the C-arm in both anteroposterior (AP) and lateral plane; when the trocar is midway across the vertebral body, it should be midway between pedicle and spinous process.[21] If it is closer to the spinous process, the chance of pedicle breach is higher. We believe that when the trocar is touching the oval shape of the pedicle for the entry, it should have the pedicle on lateral aspect at 3 or 9 o’clock position, and when it advances till the middle of the oval shape into the pedicle, it should have crossed pedicle and rest on the posterior vertebral body on the lateral image. When the trocar further advances till anterior 1/3rd of the vertebral body in the lateral C-arm image, it should touch the medial pedicle wall on AP image. This is the ideal way to prevent the lateral and medial breach of the pedicle and thereby reducing the chances of an epidural leak [Figure 5]A–D. Therefore, high-quality fluoroscopic imaging and accurate placement of trocar cannula are a must to avoid collateral damage according to the standards of care during PVP.[17] Once the trocar is placed accurately into the pedicles, cement should not be injected in a liquid phase. Additionally, the use of high-viscosity cement should be preferred over low-viscosity cement to reduce the chances of leakage.[22] The consistency of cement should be paste-like or doughy, which does not dissociate from the syringe tip under its own weight when tested in the open air before injection.[23] Moreover, the intermittent release of pressure while injecting cement is necessary to avoid the fast flow of cement into the vertebral body and causing a leak to surrounding tissues.[17],[19] The use of low-pressure injection and higher viscosity cement allows a controlled flow of cement. The amount of cement injected must be monitored in real-time under fluoroscopy, and the cement flow must be stopped once the posterior vertebral body is reached or leakage starts to occur.[24],[25] In our case, there might be a possibility that the pedicle breach happened during entry, continuous C-arm monitoring was not followed, and cement might have been injected in the liquid phase causing the complication. There may be another possibility of cement leakage happening from posterior vertebral body fracture in our case. Therefore, it is advisable to perform a preoperative CT scan to check if there is any fracture extending into the posterior vertebral body. If the fracture line is extending into the posterior vertebral body, PVP should be avoided.
Figure 5: IITV images with the matched schematic presentation of a vertebroplasty procedure regarding technical tips for needle insertion to avoid medial pedicle breach. A shows the entry into the pedicle by seeing its oval shape from its lateral aspect under C-arm and inserting a needle at a 3 or 9 o’clock position. B shows the insertion of needles slightly inside from the lateral aspect of the oval shape of pedicle; the needle should not cross the posterior border of the vertebral body and should remain within the path of the pedicle in lateral IITV image. C shows further continuation of needle insertion in AP image, and one should stop once it just reaches the medial pedicle wall, and check IITV lateral image. D shows the needle reaching the medial pedicle wall in AP plane; the needle should cross the middle of the vertebral body in the lateral image to start injecting cement

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If a complication does develop, immediate diagnosis with imaging followed by exploration and removal of compressing cement mass is of utmost necessity. Once the patient develops a neurological deficit immediately after PVP, an urgent CT scan with or without MRI is recommended.[6] Literature mentioned that a CT scan is a more efficient way to detect cement leakage into spinal canal rather than an X-ray.[26] Yeom, et al. have described three types of cement leakage after PVP.[27] They mentioned type B, type S, and type C leakages that correspond to leakage through the basivertebral vein, segmental vein, and cortical defect, respectively. In the present case, it seems type C defect has caused this complication, as anterior vertebral body filling with cement was adequate on postoperative x-ray. We used a CT scan to identify cement leakage in our case, which is recommended in several reports.[13],[27],[28] We also suggest that preprocedural CT scan is always advisable before consideration of PVP in cases of OVCF to identify posterior cortical defect at the fracture line. If it is present, PVP can be avoided. Kita, et al. reported a case of circumferentially leaked cement in epidural space at T6–7 level in a 77-year-old man. The patient developed paraparesis immediately after PVP that required exploration along with removal of cement. They initially conducted a cadaver study to verify that cement remains separate from the dura and can be detached from the dural surface. They removed small eight pieces of cement using a high-speed burr. We have, however, first isolated the cement mass as a whole throughout the entire length of mass after obtaining wide laminectomy from D10 to 12. Once it was isolated, we could easily remove the cement mass as a whole [Figure 3]A–D. Additionally, there was no dural tear or leak found, suggesting cerebrospinal fluid and dura actually protect spinal cord from thermal injury or necrosis of the cord.[29] This is the most positive finding of our case, suggesting acting fast and removing the compressing mass for better recovery. According to published reports, patients with incomplete paraplegia that was treated urgently usually had good postoperative recovery.[30],[31] In our case, the patient had significant weakness (power 1/5); however, she had some preserved sensations with flickering of power left suggesting incomplete paraplegia. Therefore, even though she presented after three days, we treated her on an urgent basis and she showed good neurological recovery. Once we remove cement after laminectomy, should we proceed with stabilizing the spine or not can be a question as well as a query. There is some literature that supports urgent decompression with transpedicular stabilization,[14],[32],[33],[34] while others favor decompression only.[19],[23],[30] On the other hand, a few reports have treated it using minimally invasive and endoscopic techniques if cement leakage is small and compressing the lumbar root.[28],[35] In our case, we preferred to stabilize the spine as we performed wide laminectomies at D10–12 level to retrieve large cement mass. During wide laminectomy, some parts of facet joints were also sacrificed to see if there is any foraminal leakage of cement also. This was another reason to proceed with stabilization of the spine. Additionally, there was some cement left anterior to the dura to prevent injury to the cord by mobilization. Therefore, by transpedicular stabilization, we ensured solid fixation preventing further movements at the level, and thereby, avoiding any possibility of damage by friction between cement and dura. Performing the whole procedure under IONM additionally gave us an indirect guide about adequate decompression of the canal after removal of posterior and right-sided cement leakage. And therefore, anteriorly leaked cement was not removed to avoid possible neurological injury caused by cord mobilization. We would like to emphasize the importance of IONM in such complications to achieve adequate decompression during the surgery.


  Conclusion Top


Although PVP is a convenient solution for painful OVCF, care must be taken while considering this option such as timing, insertion of a needle, viscosity of cement, C-arm monitoring. Unfortunately, if a neurological deficit happens, an urgent CT scan for the diagnosis and exploration with the removal of cement leakage with or without stabilization is mandatory for recovery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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