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NI FEATURE: FACING ADVERSITY…TOMORROW IS ANOTHER DAY! - LETTER TO EDITOR
Year : 2017  |  Volume : 65  |  Issue : 2  |  Page : 375-376

Extraosseous cement leakage after vertebroplasty producing intractable low back pain


Department of Neurology, Aster Medcity, Kochi, Kerala, India

Date of Web Publication10-Mar-2017

Correspondence Address:
Boby V Maramattom
Department of Neurology, Aster Medcity, Kochi, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/neuroindia.NI_591_16

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How to cite this article:
Maramattom BV. Extraosseous cement leakage after vertebroplasty producing intractable low back pain. Neurol India 2017;65:375-6

How to cite this URL:
Maramattom BV. Extraosseous cement leakage after vertebroplasty producing intractable low back pain. Neurol India [serial online] 2017 [cited 2017 Mar 26];65:375-6. Available from: http://www.neurologyindia.com/text.asp?2017/65/2/375/201864


Sir,

Vertebroplasy is a well-established procedure for vertebral angiomas, osteolytic metastases, and osteoporotic compression fractures. The procedure entails passing a cannula into the vertebral body and injecting bone cement. Polymerization of the cement stabilizes the fractured body and reduces pain. The cement is made up of methylmethacrylate (MMA), the rapid curing of which in 2–5 minutes provides immediate mechanical strength as well as blocks the sensory nerve endings in the vertebral body, thereby alleviating pain.[1] This process is highly exothermic and has the capacity to increase local tissue temperatures by >20°C causing thermal injury, if extravasated.[2] I would like to highlight a rare complication of vertebroplasty resulting in local muscle injury and persistent pain.

A 70-year-old lady was admitted with low backache of 1 month duration. Her pain was band-like, around the mid-abdomen and radiated down to both legs, right > left. She had a history of fall 2 years ago followed by numbness in toes. There was no history of fever or loss of weight. On examination, she had lumbar spinal tenderness and her movements were slowed due to pain. Her motor power and reflexes were normal, and she had minimal sensory impairment in her soles. Magnetic resonance imaging (MRI) of the spine showed a mild levocurvature of the lumbar spine centered at L3, with compression fractures, biconcave deformities, and significant vertebral height loss at L2-L4 vertebral bodies. The involved vertebral bodies showed short tau inversion recovery (STIR) hyperintensity at the L2 and L3 bodies with abnormal contrast enhancement along the endplates. There was no retropulsion at any level. Computed tomography (CT) of the lumbosacral spine confirmed generalized osteopenia and compression fractures at L2-L4 levels. The posterior elements were intact and there was no retropulsion. There was a fracture line along the superior endplate of the L3 vertebral body. Air pockets were observed in the L2 vertebral body (the vacuum phenomenon or the vacuum cleft sign).[3] She was extensively investigated to rule out an infectious spondylitis. Her inflammatory parameters and serology for tuberculosis and  Brucellosis More Details were negative. She improved only minimally with bisphosphonates and calcium. Hence, an L2, 3, 4 vertebroplasty with balloon kyphoplasty was performed after 1 month because of persistent pain (Numeric pain scale score 8/10). After the procedure, her pain improved by 30%, although she had mild residual pain in the right iliac crest. Ten days later, she came back with worsening pain in the right lumbar region. She was unable to get up from the bed or turn over due to pain (pain scale score 10/10). This pain was nonradiating and its character was different from her previous pain. Examination revealed severe right paraspinal lumbar tenderness with severe pain during flexion of the right hip and psoas stretch test (Cope's psoas test). There were no focal neurological deficits. X-ray LS spine showed an oval locule of extravasated cement at the L3 level on the right side [Figure 1].
Figure 1: X-ray LS spine; anteroposterior and lateral views showing post-vertebroplasty images. Arrow points to the extravasated cement

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A repeat MRI spine showed post-vertebroplasty hypointensities on T1 and T2 sequences within the vertebral bodies. There was a small [3 cm × 0.8 cm] locule of low signal within the right psoas muscle, suggestive of extravasated bone cement. The right-sided right iliopsoas and quadratus lumborum muscles showed T2 high signals and prominent enhancement following contrast [Figure 2] and [Figure 3].
Figure 2: Coronal MRI images. Panel A:T1 with contrast images, B:T2-weighted fat saturated image (Arrow points at locule of cement) C:T1-weighted images with fat saturation. (Arrow points at locule of cement), D:T1-weighted image with fat saturation (Arrow indicates Quadratus lumborum muscle)

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Figure 3: Axial MRI images. Panel A: T1-weighted images, B:T2-weighted images, C: T2-weighted turbo spin echo-fast spin echo image, D: T1-postcontrast image. Arrows show the located extravasated cement in the right psoas muscle with muscle edema

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She was unwilling for surgical exploration and complained of severe pain for another 2 months.

Pain relief is rapidly obtained in 70% of patients after a vertebroplasty for compression fractures.[4] The rapid polymerization of MMA into PMMA provides rapid structural integrity and analgesia. However, it is an exothermic reaction that releases an equivalent of ~57 kJ per 100 g of MMA. The local rise in temperature within the bone cement varies from 70–120°C in in vitro studies.[5]In vivo studies have shown a range of rise of temperature of 3–17°C with a maximum temperature of 48°C that lasts for approximately 2–3 minutes.[6] There is a rapid concentric reduction of heat within the cement locule with temperatures of 68.1 ± 3.4°C at the vertebral center (lasting ~220 seconds), cooling off to ~45°C at the periphery. Thus, bone cement contained within the vertebral body is benign, whereas extravasated cement has a high likelihood of causing local tissue injury.[2]

Although extravertebral cement leaks (ECL) are common after vertebroplasty, the vast majority are clinically asymptomatic. ECL can result in neurological sequelae with nerve root compression (radiculopathy) or extradural compression (myelopathy). Embolism of bone cement via the paravertebral veins may result in occlusion of the inferior vena cava or pulmonary embolism in rare cases.[7],[8]

In a large series utilizing a CT scan to detect post-vertebroplasty leakage, the frequency of extraosseus leaks ranged from 55–82%.[9],[10] The most common sites of extraosseous leak were the intervertebral disc spaces (25%), epidural venous plexus (16%), posterior wall leaks (2.6%), neural foraminal leaks (1.6%), and combinations.[4] However, the actual procedure related morbidity was very low (<3%).

To date, no case of local muscle injury has been reported in literature. In our case, the ECL leak into the Psoas major muscle on the right side must have resulted in thermal injury to the neighbouring muscles (Psoas and Quadratus lumborum), causing persistent severe spontaneous and provoked pain after the vertebroplasty. Persistent pain after vertebroplasty should include a search for extraosseous leak with muscle injury.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 » References Top

1.
Jay B, Ahn SH. Vertebroplasty. Semin Intervent Radiol 2013;30:297-306.  Back to cited text no. 1
    
2.
Lai PL, Tai CL, Chen LH, Nien NY. Cement leakage causes potential thermal injury in vertebroplasty. BMC Musculoskelet Disord 2011;12:116.  Back to cited text no. 2
    
3.
Resnick D, Niwayama G, Guerra J Jr, Vint V, Usselman J. Spinal vacuum phenomena: Anatomical study and review. Radiology 1981;139:341-8.  Back to cited text no. 3
    
4.
Garfin SR, Yuan HA, Reiley MA. New technologies in spine: Kyphoplasty and vertebroplasty for the treatment of painful osteoporotic compression fractures. Spine 2001;26:1511-5.  Back to cited text no. 4
    
5.
DiPisa JA, Sih GS, Berman AT. The temperature problem at the bone-acrylic cement interface of the total hip replacement. Clin Orthop 1976;121:95-8.  Back to cited text no. 5
    
6.
Reckling FW, Dillon WL. The bone-cement interface temperature during total joint replacement. J Bone Joint Surg 1977;59:80-2.  Back to cited text no. 6
    
7.
Athreya S, Mathias N, Rogers P, Edwards R. Retrieval of cement embolus from inferior vena cava after percutaneous vertebroplasty. Cardiovasc Intervent Radiol 2009;32:817-9.  Back to cited text no. 7
    
8.
Choe DH, Marom EM, Ahrar K, Truong MT, Madewell JE. Pulmonary embolism of polymethyl methacrylate during percutaneous vertebroplasty and kyphoplasty. AJR Am J Roentgenol 2004;183:1097-102.  Back to cited text no. 8
    
9.
Pitton MB, Herber S, Koch U, Oberholzer K, Drees P, Düber C. CT-guided vertebroplasty: Analysis of technical results, extraosseous cement leakages, and complications in 500 procedures. Eur Radiol 2008;18:2568-78.  Back to cited text no. 9
    
10.
Martin DJ, Rad AE, Kallmes DF. Prevalence of extravertebral cement leakage after vertebroplasty: Procedural documentation versus CT detection. Acta Radiol 2012;53:569-72.  Back to cited text no. 10
    


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