Zusammenfassung
Hintergrund
Im Zuge eines Aufschwungs der sog. mikroinvasiven Verfahren hat die Stabilisierung osteoporotischer Wirbelkörper durch die Einspritzung von Knochenzement gewisse Bedeutung erlangt. Dazu wird der Wirbel via Pedikel punktiert und dünnflüssiges Palacos® unter hohem Druck injiziert.
Material und Methoden
Es wird über den Fall eines 60-jährigen Mannes berichtet, der leblos in seinem Fahrzeug mit laufendem Motor aufgefunden wurde. Es bestand keine Einleitung von Abgasen in das Wageninnere. Bei der Obduktion fand sich ein nicht mehr frischer Infarkt der Herzhinterwand bei einem Herzgewicht von 840 g (Körpermasse 128,5 kg) als Todesursache. Zusätzlich bestanden Verschlüsse von Lumbalvenen, die bis in die V. cava inferior reichten. Die Verschlüsse waren durch eine weiße, derbe, nichtschneidbare Masse bedingt. Bei weiterer Präparation fand sich im Hilusbereich der rechten Pulmonalarterie eine geflechtartige Ansammlung streifenartiger, bis zu 2,5 cm langer und 2 mm durchmessender Fragmente desselben Materials. Die Präparation der Wirbelsäule ergab eine Durchsetzung des 2. und 3. Lendenwirbelkörpers mit einem festen weißlichen Material. Über der oberen Lendenwirbelsäule war eine narbige Hauteinziehung sichtbar. Aus der Vorgeschichte war eine Vertebroplastie wegen Osteoporose vor mehr als einem Jahr bekannt.
Ergebnisse
Im gegenständlichen Fall war es bei der Injektion in den Wirbelkörper offensichtlich zu einer venösen Embolisation des injizierten Materials via V. cava inferior bis in den rechten Lungenhilus gekommen, die klinisch unbemerkt geblieben war. Ein Beitrag zum Todesmechanismus wäre nur als zusätzliche kardiale Dauerbelastung bei erheblichen Vorschäden zu diskutieren.
Schlussfolgerung
Die Injektion dünnflüssigen Palacos®' unter hohem Druck in reich vaskularisierte Räume beinhaltet mithin ein nennenswertes Risiko für eine embolische Verschleppung des Materials.
Abstract
Background
In the wake of an upsurge in so-called microinvasive procedures, the stabilization of osteoporotic vertebral bodies by injection of bone cement has gained a certain level of importance. In this procedure the pedicle is punctured and low viscosity Palacos® is injected under high pressure.
Material and methods
This article reports on the case of a 60-year-old man who was found dead in his vehicle with the engine running but there was no connection between the exhaust pipe and the vehicle interior. The autopsy revealed a posterior wall myocardial infarction which was no longer fresh with a heart weight of 840 g (body weight 128.5 kg) as the cause of death. Additionally, there were occlusions of the lumbar veins which extended to the inferior vena cava and consisted of a white, dense non-sliceable mass. Furthermore, this same material could be found in the hilar region of the right pulmonary artery in the form of a network-like collection of streak-like fragments measuring up to 2.5 cm in length and 2 mm in width. Preparation of the spinal column revealed an infiltration of the vertebral bodies L2 and L3 with a solid white material and a scar-like skin retraction was visible above the upper lumbar spine. The medical history documented that a vertebroplasty had been carried out for osteoporosis more than 1 year ago.
Results
In the current case it was obvious that the injection into the spinal column resulted in embolization of the injected material via the inferior vena cava up to the hilus of the right lung, which had remained clinically unnoticed. A contribution to the mode of death would only be feasible as an additional cardiac load on top of substantial pre-existing damage.
Conclusion
The injection of low viscosity Palacos® under high pressure into richly vascularized areas therefore represents a substantial risk for embolic entrainment of the material.
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R. Amberg, G. Kernbach-Wighton und B. Madea geben an, dass kein Interessenkonflikt besteht.
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Amberg, R., Kernbach-Wighton, G. & Madea, B. Palacos®-Embolisation nach Vertebroplastie. Rechtsmedizin 25, 556–560 (2015). https://doi.org/10.1007/s00194-015-0009-6
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DOI: https://doi.org/10.1007/s00194-015-0009-6