Cardiac Perforation Caused by Bone Cements as a Complication of Cement Augmented Pedicle Screw Fixation Using the Fenestrated Pedicle Screw: A Case Report

Abstract

Cement-augmented fenestrated pedicle screw fixation is becoming more popular for osteoporotic patients. Although several reports have been published on leakage-related problems with bone cement, no cases of cardiac perforation after cement-augmented pedicle screw fixation have been reported. We present a case of cardiac perforation after cement-augmented fenestrated pedicle screw fixation. A 67-year-old female was admitted to our hospital with complaints of dyspnea and chest pain after lumbar surgery. She had been treated with L4–5 lumbar interbody fusion and percutaneous pedicle screw fixation with bone cement augmentation seven days earlier for degenerative spondylolisthesis. The right chest pain was observed a day after the surgery; she was treated conservatively but it did not improve for 7 days after surgery. Chest computed tomography (CT) revealed a hemothorax and a large sharp bone cement fragment that perforated the right atrium. Bone cement can be removed with thoracotomy surgery. We have to be aware of cement leakage through the normal venous drain system around the vertebral body. We also have to consider a detailed cardiac workup, which may include chest CT or echocardiography, if a patient complains of chest pain or dyspnea after cement augmentation.

Percutaneous Endovascular Retrieval of Large Cement Leakage into the Right Atrium Following Cement-Augmented Pedicle Screw Instrumentation

“…They identified 68 cases with cement leakage into paravertebral veins or the ascending vena cava and 13 patients with pulmonary cement embolism (7.9%), of whom five (3.0%) were symptomatic. In addition, a case of cardiac perforation caused by bone cement, closely resembling our situation, was reported as a complication of CAPS, 6 wherein the authors reported the presence of a sharp and large fragment (4.5-cm-sized and needle-shaped). In their case, the authors detected cement leakage 7 days after spine surgery and performed anterolateral thoracotomy under one-lung ventilation for its removal.…”

Bone cement embolism penetrating both the aorta and the right atrium after percutaneous vertebroplasty: Thermal rather than mechanical injury?

“…Most cardiac perforations occurred in the right atrium 4 and ventricle. 5 However, in our case, perforations were found in both the right atrial wall and the aorta facing the right atrial wall. The leading cause of cardiac tamponade and hypotension in this case was aortic bleeding.…”

Cardiopulmonary Cement Embolism Following Cement-Augmented Pedicle Screw Fixation: A Narrative Review

“…Two major types of CAPS were found depending on the screw type: Conventional solid screws: cement-brushed solid screw inserted [ 19 ] or solid screw inserted after vertebroplasty [ 4 , 5 , 6 , 7 , 8 , 9 , 10 , 20 , 21 , 22 , 23 ]. Fenestrated screws ( Figure 1 ): these can be cemented after screw placement [ 11 , 12 , 13 , 14 , 15 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 ]. …”

“…However, while CAPS is being increasingly used, post-CAPS cement leakage is a considerable problem. Cement leakage into the spinal canal can cause spinal cord compression symptoms, including neurologic deficits and pain, while leakage into the epidural vein, vena cava, right atrium, pulmonary artery, or multiple lung arterioles can cause cardiac or pulmonary cement embolism (PCE) [ 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 ]. Since both embolisms have the same pathology, this study included cardiopulmonary cement embolisms after CAPS as CPCE.…”

“…Heat associated with cement polymerization can also cause neurological damage [ 18 ]. However, only a few publications have reported the incidence of CPCE or CAPS-related complications, most in the form of case reports [ 2 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 ]. CPCE rates reported in past studies showed a wide prevalence range because it does not have a standard definition, and different studies used different methods to evaluate cement embolism [ 2 ].…”