Presentation and management of symptomatic central bone cement embolization.
BACKGROUND CONTEXT
With more cement augmentation procedures done, the occurrence of serious complications is also expected to rise. Symptomatic central cement embolization is a rare but very serious complication. Moreover, the pathophysiology and treatment of intrathoracic cement embolism remain controversial.


PURPOSE
In this case series, we are trying to identify various presentations and suggest our emergent management scheme for symptomatic central cement embolization.


PATIENT SAMPLE
Retrospective case series of nine patients with symptomatic central cement embolism identified after vertebroplasty with 24 months of follow-up. Level IV.


OUTCOME MEASURES
The degree of dyspnea measured by the New York Heart Association (NYHA) score and/or death related to cement embolism induced cardio/respiratory failure at the final follow-up at 24 months.


METHODS
The nine patients, eight females, and one male had a mean age of 70.25 years (range 65-78 years) and were operated between January 2004 and December 2014. They had percutaneous vertebroplasty for osteoporotic non-traumatic and malignant vertebral collapse of dorsal and lumbar vertebrae. Post-vertebroplasty dyspnea and stitching chest pain were striking in the nine patients. After exclusion of cardiac ischemia and medical pulmonary causes for dyspnea, we identified radiopaque lesions on the chest X-ray. Further echocardiography and high-resolution chest CT were performed for optimal localization. Emergent heart surgery was performed in two patients: interventional therapy was conducted in one patient, while the remaining six patients were conservatively treated by anticoagulation. The management decision was taken in the setting of an interdisciplinary meeting depending on localization, fragmentation, and clinical status.


RESULTS
All patients of this series showed gradual improvement and an uneventful hospital stay. During our 24-month follow-up phase, eight patients showed no subsequent cardiological and/or respiratory symptoms (NYHA I). However, one mortality due to advanced malignancy occurred. Preoperative anemia was the only common intersecting preoperative parameter among these nine patients.


CONCLUSIONS
After cement augmentation, close clinical monitoring is mandatory. A chest CT is pivotal in determining the interdisciplinary management approach in view of the availability of necessary expertise, facilities and the location of the cement emboli whether accessible by cardiac or vascular surgical means. The clinical presentation and its timing may vary and the patient may be seen subsequently by other health care providers obligating a wide-spread awareness for this serious entity among health care providers for this age group as spine surgeons, family and emergency room doctors, and institutional or home-care nurses. Most symptomatic central cement emboli may be treated conservatively.
['Barakat|Ahmed Samir|AS|0000-0002-6778-2364', 'Owais|Tamer|T|', 'Alhashash|Mohamed|M|', 'Shousha|Mootaz|M|', 'El Saghir|Hesham|H|', 'Lauer|Bernward|B|', 'Boehm|Heinrich|H|']
D000368:Aged D001843:Bone Cements D004617:Embolism D005260:Female D006801:Humans D008297:Male D013902:Radiography, Thoracic D012189:Retrospective Studies D014057:Tomography, X-Ray Computed D054854:Vertebroplasty
Conservative treatment Open heart and minimally invasive heart surgery Pulmonary cement emboli and central symptomatic bone embolization Radiological interventionist Vertebral cement leakage