A63-36 A Hard Diagnosis, Cement Pulmonary Embolism Following Routine Kyphoplasty

Abstract Introduction A cement pulmonary embolism refers to the migration of bone cement routinely used in kyphoplasty or vertebroplasty into the pulmonary arterial circulation. Although extravasation of cement has been reported in 11% to 73% of vertebroplasty procedures, and less commonly with kyphoplasty procedures, it is rarely clinically relevant. The incidence of extravasation resulting in cement pulmonary embolism has also been described as lower, ranging from 2% to 26%, and is typically an incidental finding on chest x-ray or CT imaging in asymptomatic patients. If present, symptoms begin days to weeks post-procedure and include chest pain, dyspnea, cough, and rarely cardiopulmonary compromise. Recommended management for asymptomatic, peripheral cement pulmonary emboli is typically conservative management as there is no high-quality evidence supporting anticoagulation for incidentally found cement pulmonary emboli. For symptomatic patients, anticoagulation with direct oral anticoagulants (DOACs) is generally initiated for a duration of three months; however, there is a lack of data from randomized trials to guide this approach. Rarely, cement pulmonary emboli may require more invasive interventions such as a pulmonary wedge resection. Case Description A 57-year-old woman with a history of chronic back pain and multiple spinal surgeries was initially admitted for extension of her fusion from T9 to T11, revision of T9-pelvis posterior instrumented spinal fusion, and kyphoplasty of T8. Her spinal surgery was uncomplicated; however, she developed persistent postoperative hypoxia requiring 4 L/min along with intermittent chest pain. These symptoms lead to obtaining a CTA chest to evaluate for a new pulmonary embolism. The CTA chest was noted to have new multifocal hyperdense filling defects in the bilateral segmental and subsegmental pulmonary vasculature with the exception of the left lower lobe, consistent with cement emboli (Figure 1). The Pulmonary Embolism Response Team (PERT) was consulted for assistance and ultimately decided to initiate therapeutic anticoagulation with enoxaparin 1mg/kg given she was symptomatic with the plan to transition to rivaroxaban on discharge and recommendation to complete three months total treatment duration. Discussion Although cement pulmonary embolism following routine vertebroplasty or kyphoplasty is an uncommon complication typically identified incidentally on imaging, it should remain on the differential for any patient who develops symptoms post operatively as described in the case above. Treatment typically involves anticoagulation for at least three months to reduce the risk of thrombus formation on the cement embolus; however, literature supporting this approach is limited and the quality of evidence remains low. This abstract is funded by: None