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LETTER TO EDITOR
Year : 2015  |  Volume : 63  |  Issue : 2  |  Page : 257-258

Anaphylaxis during percutaneous kyphoplasty for an osteoporotic vertebral fracture


Department of Neurosurgery, G B Pant Hospital, New Delhi, India

Date of Web Publication5-May-2015

Correspondence Address:
L D Sathyanarayana
Department of Neurosurgery, G B Pant Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.156297

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How to cite this article:
Sathyanarayana L D, Sinha S. Anaphylaxis during percutaneous kyphoplasty for an osteoporotic vertebral fracture. Neurol India 2015;63:257-8

How to cite this URL:
Sathyanarayana L D, Sinha S. Anaphylaxis during percutaneous kyphoplasty for an osteoporotic vertebral fracture. Neurol India [serial online] 2015 [cited 2019 Oct 22];63:257-8. Available from: http://www.neurologyindia.com/text.asp?2015/63/2/257/156297


Sir,

The aim of balloon kyphoplasty is to reduce excessive vertebral compression due to a vertebral body fracture. This is done by distention of a balloon inserted into the vertebral body prior to the injection of polymethylmethacrylate (PMMA). The procedure may be needed in compression fractures that result in greater than 70% reduction of the original vertebral height. [1],[2],[3],[4] The diagnosis of an osteoporotic fracture is based on clinical and radiological observations including the Dual X-Ray Absorptiometry (DEXA) scan. Accordingly, it may be considered as a minimally invasive intervention for the treatment of vertebral body pain.

A female patient, aged 76 years, was admitted with a history of pain in the thoracolumbar region for 8 months. It was incapacitating enough to prevent her from standing and walking. Analgesics only gave her a transient relief in her symptoms. She had a history of allergic reaction to non-steroid anti-inflammatory medication and to sulfonamides. She had a localized tenderness at the level of the thoracic (T)12 vertebra. Her basic laboratory assessment, including her coagulation profile, was normal. Her magnetic resonance imaging (MRI) showed a compression fracture of the T12 vertebra due to osteoporosis. There was an overall reduced bone density. She was planned for a transpedicular kyphoplasty to relieve her of her pain. The procedure was carried out in prone position under general anesthesia in view of her elderly age and the possibility of her being non-co-operative during the procedure. A small skin incision was made at the entry point and a transpedicular needle was introduced until the anterior third of the vertebral body. A C-arm image intensifier was used for the intra-procedural image guidance. By expanding the balloon, the endplate was lifted and a cavity was formed within the vertebra. The balloon was removed and deployment of the PMMA mixture was carried out in a controlled manner within this cavity. Venous embolization of the material was prevented by injecting a slightly firmer mixture of PMMA under radioscopic control. No leakage into the epidural space occurred. The patient, however, developed a sudden fall in her blood pressure within minutes after the PMMA was injected into the collapsed vertebra. Her end tidal (ET) CO2 fell rapidly and she started developing fever and a red rash all over her body. She soon had an impalpable pulse, an unrecordable blood pressure and a progressive bradycardia. A timely cardiac massage, and administration of steroids, antihistamines and adrenaline revived her. The patient was resuscitated and could soon be extubated. She appreciated the pain relief following the procedure and was mobilized the next day. She was placed on calcium and vitamin D 3 supplementation and was discharged on the fourth postoperative day.

The fundamental principle of kyphoplasty is to percutaneously inject a rapidly hardening substance (i.e. the PMMA) into the vertebral body. [5] It aims at restoring the height of the fractured vertebral body and the correction of local kyphosis. The mechanism responsible for pain relief after a kyphoplasty is not known but may involve rendering the peripheral nerve endings insensitive or achieving mechanical stabilization of the vertebral body micro-fractures. [6]

PMMA is made by mixing a polymer powder with a liquid monomer. The bone cement injection is performed under continuous lateral radiographic guidance. [5],[6],[7],[8] The complications include a pedicle fracture, fat embolism, pulmonary embolization, cement leakage into the spinal canal and paraplegia. Severe anaphylactic shock during cement injection can occur as a consequence of extravasation of the toxic cement monomer. [1],[2],[3] In our patient, the anaphylactic shock was due to a severe allergic reaction to the cement monomer. The fact that our patient underwent her procedure under general anesthesia wherein she was already intubated and had well-secured intravenous lines considerably helped in her rapid resuscitation.

In order to minimize the risk of extravasation of the PMMA into the vascular system, it is strongly recommended that the cement be injected when it has achieved the consistency of a toothpaste. A venography should be performed before injecting the cement in order to obviate the possibility of a rapid shunting of contrast from the vertebra to the inferior vena cava. [1] If the venogram detects a continuous and rapid shunting of the dye, then the fistula should be occluded by polyvinyl alcohol particles or a gelatin sponge pledget prior to injection of the PMMA cement.

 
  References Top

1.
Vasconcelos C, Gailloud P, Beauchamp N, Heck D, Murphy K. Is percutaneous vertebroplasty without pretreatment venography safe? Evaluation of 205 consecutives procedures. Am J Neuroradiol. 2002;23:913-917.  Back to cited text no. 1
    
2.
Patel V, Allen D, Morley A, Malhotra R. Features and management of an acute allergic response to acrylic ocular prostheses. Orbit 2009;28:339-341.  Back to cited text no. 2
    
3.
Jensen J, Trap B, Skydsgaard K. Delayed contact hypersensitivity and surgical glove penetration with acrylic bone cements. Acta Orthop Scand 1991;62:24-28.  Back to cited text no. 3
    
4.
Muthukumar N. Biopsy of osteoporotic vertebral compression fractures. Neurol India, 2013;61:569-571.  Back to cited text no. 4
    
5.
Hwan TH. Percutaneous vertebroplasty: Current concepts and local experience. Neurol India 2005;53:475-482.  Back to cited text no. 5
    
6.
Siddall PJ, Cousins MJ. Spinal pain mechanisms. Spine 1997;22:98-104.  Back to cited text no. 6
    
7.
Zhang L, Li J, Yang H, Luo Z, Zou J. Histological evaluation of bone biopsy results during PVP or PKP of vertebral compression fractures. Oncol Lett 2013;5:135-8.  Back to cited text no. 7
    
8.
Mueller CW Mueller, Berlemann U. Kyphoplasty: Chances and limits. Neurol India 2005;53:451-457.  Back to cited text no. 8
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