Paraplegia complicating percutaneous vertebroplasty for osteoporotic vertebral fracture: case report

Abstract

-We report a case of spinal cord and root compression during percutaneous transpedicular polymethylmethacrylate vertebroplasty (PTPV) for a compression fracture due to osteoporosis. Sudden onset of excruciating pain in the distribution of the right sixth intercostal nerve with hyperemia along its path, prompted the interruption of the procedure. Under narcotic sedation the patient was taken to the ICU and 10mg of dexamethasone was administered intravenously. Few hours later she developed paraplegia with preservation of light touch and a CT scan and MRI showed epidural extravasation of polymethylmethacrylate with spinal cord and root compression. Surgical decompression was followed by neurological recovery. The cement could be removed after been thinned out by high speed drill, with microsurgical technique, through a wide three level laminectomy of D5 to D7. Extravasation of cement is commonly encountered in PTPV and most of the time it is asymptomatic. Root compression may require surgical intervention if nonresponsive to steroid treatment. Cord compression is less often seen and requires emergency surgery. The cement does not adhere to the duramater and it can be removed easily.KEY WORDS: spinal fracture, polymethylmethacrylate, osteoporosis, vertebroplasty, paraplegia.Remoção cirúrgica de polimetilmetacrilato epidural como complicação de vertebroplastia percutânea para tratamento de fratura com compressão de vértebra dorsal osteoporótica: relato de caso RESUMO -Relatamos um caso de compressão medular e radicular durante vertebroplastia percutanea transpedicular com polimetilmetacrilato (VPTP) para tratamento de fratura com compressão por osteoporose. O início súbito de dor lancinante na distribuição do 6º nervo intercostal direito, com hiperemia ao longo de seu trajeto, determinou a interrupção do procedimento. Sob sedação com narcóticos, a paciente foi levada ao CTI, sendo administrados 10mg de dexametazona por via endovenosa. Após algumas horas, ela desenvolveu paraplegia com preservação do tato, e a TC e a RM mostraram extravazamento epidural de polimetilmetacrilato com compressão medular e radicular. Descompressão cirúrgica resultou em recuperação neurológi-ca. O cimento foi removido após ter sua espessura diminuída com o uso de broca de alta rotação, usando técnica microcirúrgica através de laminectomia ampla de tres níveis de T5 a T7. Extravazamento de cimento é comumente encontrado em VPTP, sendo assintomático na maioria das vezes. Compressão radicular pode requerer intervenção cirúrgica se não responsiva ao tratamento com corticosteróides. Compressão medular é vista com menos frequência e requer cirurgia de emergência. O cimento não adere à dura-máter e pode ser removido facilmente.

Current concepts of percutaneous balloon kyphoplasty for the treatment of osteoporotic vertebral compression fractures: Evidence-based review

“…Many patients with these cement leaks need to return to the operating room for emergent decompression and stabilization. [36][37][38][39][40][41] …”

Percutaneous vertebroplasty: a comparison between the procedure using the traditional and the new side-opening cannula for osteoporotic vertebral fracture

“…Leakage of bone cement is one of the main potential complications following percutaneous cement injection, especially vertebroplasty [13][14][15]17,18 . Polymethyl methacrylate may exit the vertebral body through deficiencies, fractures in the vertebral cortex, or by injection of cement into the vertebral venous system 25 .…”

“…These complications include those related to needle insertion and those associated to cement leakage, either locally or distally. The cement may leak laterally to the soft tissues in the lateral aspect of the vertebra, into the adjacent disc space, and posteriorly, where it may involve the exiting nerve root or the spinal canal, that may lead to neurologic complications needing urgent surgical intervention [13][14][15] . Cement leakage during vertebroplasty is a common occurrence, at frequencies of 11-73% for OVF, the majority of which is asymptomatic.…”

Percutaneous vertebroplasty complications

“…Most cases are clinically silent if not for post-procedure CT. The prevalence may be as high as 40% 812–14. Chiras et al15 reported paraplegia due to cement-related spinal cord compression to occur in only 0.4% of patients.…”