Pulmonary cement emboli post vertebroplasty

Case contributed by Daniel MacManus

Presentation

CTPA requested by clinical team to exclude pulmonary embolus for a patient with new tachycardia and decreased oxygen saturations one week post spinal surgery.

Patient Data

Age: 60 years
Gender: Female

On the bone windows (1st stack) multiple curvilinear high-density deposits causing filling defects are seen throughout the lower lobe segmental and subsegmental pulmonary arteries bilaterally.

Features consistent with acrylic cement emboli post vertebroplasty. The vertical linear high density adjacent to the T9 vertebra represents cement extravasation in a paravertebral vein.

On the arterial soft tissue window (second stack) the high-density in the right lower lobe segmental pulmonary artery is associated with surrounding clot formation proximally.

Other findings:

Left pleural effusion with associated atelectasis. Left mastectomy. Surgical clips within the left axilla. Lytic appearance to posterior left second rib, sclerotic anterior left third rib.

Background:

Metastatic left breast cancer, managed with mastectomy and left axillary lymph node dissection followed by chemoradiation.

Recurrence with T10-L3 pathological fractures and canal stenosis requiring lumbar L3/L4 percutaneous stabilization, T10 corpectomy and fusion.

Bone window thick MIP reconstruction (annotated)

ct

Bone windowed thick MIP reconstruction to highlight location of cement emboli and associated pulmonary thromboembolism.

The supine projection highlights the right-sided hilar and lower zone curvilinear opacities reflecting the acrylic cement emboli.

Other:

Posterior spinal fixation with rods and pedicle screws in the lower thoracic and upper lumbar spine. Previous corpectomy T10 vertebra. Surgical clips noted in the left axilla. The tip of the right-sided PICC projects over the junction of the right atrium and SVC.

Case Discussion

Cement emboli can be one complication following vertebroplasty. Cement leak into the paravertebral veins is a potentially serious complication as these vessels are a direct route to the right side of the heart and pulmonary arteries.

The reported incidence of cement embolism ranges widely, from 2.1% to 26% 1. Caution is required when injecting cement to prevent spillage into the venous system, foraminal/epidural spaces or surrounding soft tissues.

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