Surgical removal of epidural and intradural polymethylmethacrylate extravasation complicating percutaneous vertebroplasty for an osteoporotic lumbar compression fracture

Abstract

<jats:p content-type="fine-print">✓ The authors report the case of patient with a lumbar vertebral body osteoporotic compression fracture who underwent percutaneous transpedicular polymethylmethacrylate (PMMA)—assisted vertebroplasty in whom extravasation of the cement into the spinal canal caused immediate neurological deterioration.</jats:p> <jats:p content-type="fine-print">Lateral lumbar radiography and computerized tomography scanning demonstrated the presence of intraspinal PMMA. The patient suffered severe low-back pain, left-sided sciatica, and profound left L2–4 distribution weakness and numbness. She underwent immediate L-2 laminectomy, the extra- and intradural PMMA was removed, and instrumentation-assisted lateral mass fusion was performed. The patient recovered without incident and her neurological deficit improved.</jats:p> <jats:p content-type="fine-print">Extravasation of cement into the spinal canal, neural foramen, paraspinal veins, or disc space has been reported in 11 to 73% of percutaneous transpedicular PMMA-assisted vertebroplasty procedures. It is disturbing that more than one group of authors has documented symptomatic spinal canal PMMA extravasation and that the patients were left severely handicapped because of a stated fear that surgery to remove the cement would be difficult and make them worse. The results achieved in this case refute that published notion. It is important to document that decompressive surgery and PMMA removal from the spinal canal are easy and can lead to immediate neurological improvement. With the increasing popularity of percutaneous transpedicular PMMA-assisted vertebroplasty, the authors suspect that more of these cases will be seen.</jats:p>

Surgical removal of extravasated epidural and neuroforaminal polymethylmethacrylate after percutaneous vertebroplasty in the thoracic spine

“…Despite the high rate of PMMA leakage, extrusions of PMMA cement are usually clinically asymptomatic [7,8,25,27]. However, several reports describe the extravasation of PMMA cement into the spinal canal, where it caused severe neurologic complications including complete paralysis and incomplete paraparesis [13,17,20,23].…”

“…A large amount of PMMA cement can extrude into the spinal canal and obliterate large cross-sectional areas of the spinal canal. Major neurologic complications may occur in this distribution pattern of PMMA leakage [13,17,23,24]. When epidural leakage of PMMA leads to neurologic complications, the initial severity of the neurologic deficit and the treatment modalities influence the patient's possibility of recovery and final neurological status.…”

“…Laminectomy or laminotomy alone does not achieve adequate neural decompression to facilitate good recovery from incomplete paraparesis caused by extravasated PMMA cement [22]. Good recovery is usually reported in patients with incomplete paraparesis who undergo surgical removal of epidural cement [20,22,23]. Furthermore, those who have had a good recovery from incomplete paraparesis were all surgically treated on the same day or on the day after the PVP procedures causing the complication.…”

“…By mobilizing the thecal sac, extravasated PMMA cement anterior or posterior to the thecal sac of the lumbar spine can be completely removed in a posterior decompression operation [22,23]. In the cervical and thoracic spine, mobilizing the squeezed spinal cord in a stenotic spinal canal can cause further neurologic deterioration.…”

“…Among them, extravasations of PMMA cement is the most prevalent and occurs in 11-81% of PVP cases described in the literature [1,2,4,5,7,9,13,22,27]. Although extravasations of PMMA cement could be reduced by increase of the cement viscosity [3] and are usually of little clinical consequence [7,8,25,27], it can result in severe neurologic complications that require surgical decompression [7,17,[20][21][22][23][24]26].…”