A CASE OF LUMBAR RADICULOPATHY FOLLOWING
VERTEBRAL AUGMENTATION
Kirk Sheplay MD*, Denaeya Easley-Terrones**, Christopher Trower MD***
*ODU/EVMS PM&R Residency **EVMS Medical School ***Wake Forest Pain FellowshipIntroduction
•Vertebral augmentation such as percutaneous vertebroplasty and balloon kyphoplasty have been shown to be an effective treatment for acute or subacute osteoporotic vertebral compression fractures.
•The procedure is done through a transpedicular approach into the vertebral body where polymethyl methacrylate is pressurized to fill the fracture, which improve pain symptoms, increase functionality, and enhance the fractured vertebrae's stability.
•Recent literature has shown improvement in patient outcomes and increase in mobility with these procedures.
•Although vertebral augmentation has many benefits, complications still arise due to inappropriate patient selection, cement extravasation, infection, and/or damage to surrounding structures.
•We report a patient status post sacroplasty presenting with radiculopathy secondary to extravasation of cement impinging on the right L5 nerve root.
Case Report
•Our patient is a female who presented with chronic low back pain with bilateral leg weakness for 3 years.
•MRI showed moderate T6 compression fracture, sacral insufficiency fracture, and mild L5 compression fracture.
•She underwent L5 and T6 kyphoplasties using a bi-pedicular approach.
•The patient returned a few weeks later with unchanged back pain and underwent a sacroplasty.
•Since the procedure, she had severe weakness in her right toe and severe and debilitating radiating pain down her right leg.
•An initial CT scan showed extravasation of cement from the right sacrum into her anterior sacral wall into the retroperitoneal space.
•MRI scan confirmed that the extravasation of cement was impinging on her right L5 nerve root.
•She also underwent an EMG/NCS which revealed a right L5 radiculopathy.
•The patient elected to have the extravasated cement surgically removed, which resolved her symptoms.
Discussion
•The most common complications of cement augmentation include infection, bleeding, vasovagal and allergic reactions.
•More serious complications include: extravasation, cement embolism, adjacent vertebral fractures, and neurologic injury.
•The incidence of cement extravasation ranges from 18% to 88% of cases and most common site includes the end plate, disk, paravertebral space, and epidural space.
•Cement embolism occurs as a monomer that polymerizes in distant sites or as small fragments of polymerized cement. A systematic review showed the incidence of cement embolism ranged from 2% to 26%.
•After cement augmentation, there is risk of fracture at the adjacent vertebral body. In a meta-analysis comparing conservative care to vertebroplasty, approximately 20% of patients experienced a new fracture at 6 to 12 months after the procedure.
•Neurological injury related to cement extravasation into the epidural space is rare. A literature review in 2013 on the overall number of reported cases of neurological deficit after cement leakage showed 21 cases of cement extravasation with neurological deficit.
•Vertebral augmentation procedures are relatively safe, but certain precautions should be taken to avoid such complications including high-resolution biplanar fluoroscopy, the use of a local anesthetic, and controlling the location of cement spread in relationship to the posterior vertebral body.
References
Martin DJ, Rad AE, Kallmes DF: Prevalence of extravertebral cement leakage after vertebroplasty: Procedural documentation versus CT detection. Acta Radiologica 2012;53:569-572.
Wang Lj, Yang Hl, Shi Yx, Jiang Wm, Chen L: Pulmonary cement embolism associated with percutaneous vertebroplasty or kyphoplasty: A systematic review. Orthopaedic Surg 2012;4:182-189.
Anderson PA, Froyshteter AB, Tontz WL: Meta-analysis of vertebral augmentation compared with conservative treatment for osteoporotic spinal fractures. J Bone Mineral Res 2013;28:372-382.
Sidhu GS, Kepler CK, Savage KE, Eachus B, Albert TJ, Vaccaro AR. Neurological deficit due to cement extravasation following a vertebral augmentation procedure. J Neurosurg Spine. 2013;19(1):61-70.
Kim HS, Kim SH, Ju CI, Kim SW, Lee SM, Shin H. The role of bone cement augmentation in the treatment of chronic symptomatic osteoporotic compression fracture. J Korean Neurosurg Soc. 2010;48(6):490-495.
