European Spine Journal

, Volume 27, Issue 10, pp 2584–2592 | Cite as

Presentation and management of symptomatic central bone cement embolization

  • Ahmed Samir BarakatEmail author
  • Tamer Owais
  • Mohamed Alhashash
  • Mootaz Shousha
  • Hesham El Saghir
  • Bernward Lauer
  • Heinrich Boehm
Original Article


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.


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.


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.


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.


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.


Vertebral cement leakage Pulmonary cement emboli and central symptomatic bone embolization Open heart and minimally invasive heart surgery Radiological interventionist Conservative treatment 


Compliance with ethical standards

Conflict of interest

The authors declare that there are no conflicts of interest regarding this work.


There is no private or public funding source regarding this work.

Human and animal rights statement

This article does not contain any studies with human participants or animals performed by any of the authors. The surgical, as well as the conservative treatment modalities described in this manuscript, are well established and profoundly documented elsewhere in the relevant literature.


  1. 1.
    Yeom JS, Kim WJ, Choy WS, Lee CK, Chang BS, Kang JW (2003) Leakage of cement in percutaneous transpedicular vertebroplasty for painful osteoporotic compression fractures. J Bone Joint Surg Br 85:83–89CrossRefGoogle Scholar
  2. 2.
    Vasconcelos C, Gailloud P, Beauchamp NJ, Heck DV, Murphy KJ (2002) Is percutaneous vertebroplasty without pretreatment venography safe? Evaluation of 205 consecutives procedures. AJNR Am J Neuroradiol 23:913–917PubMedGoogle Scholar
  3. 3.
    Venmans A, Klazen CH, Lohle PNM, Van Rooij WJ, Verhaar HJJ, De Vries J, Mali WPTM (2010) Percutaneous vertebroplasty and pulmonary cement embolism: results from VERTOS II. Am J Neuroradiol 31:1451–1453. doi: 10.3174/ajnr.A2127 CrossRefPubMedGoogle Scholar
  4. 4.
    Lim SH, Kim H, Kim HK, Baek M-J (2008) Multiple cardiac perforations and pulmonary embolism caused by cement leakage after percutaneous vertebroplasty. Eur J Cardiothorac Surg 33:510–512. doi: 10.1016/j.ejcts.2007.12.012 CrossRefPubMedGoogle Scholar
  5. 5.
    Gosev I, Nascimben L, Huang P-H, Mauri L, Steigner M, Mizuguchi A, Shah AM, Aranki SF (2013) Right ventricular perforation and pulmonary embolism with polymethylmethacrylate cement after percutaneous kyphoplasty. Circulation 127:1251–1253. doi: 10.1161/CIRCULATIONAHA.112.144535 CrossRefPubMedGoogle Scholar
  6. 6.
    Owens WD, Felts JA, Spitznagel EL (1978) ASA physical status classifications: a study of consistency of ratings. Anesthesiology 49:239–243CrossRefGoogle Scholar
  7. 7.
    Criteria Committee, New York Heart Association I (1964) Diseases of the heart and blood vessels. Nomenclature and criteria for diagnosis, 6th edn. Little Brown, BostonGoogle Scholar
  8. 8.
    Abdul-Jalil Y, Bartels J, Alberti O, Becker R (2007) Delayed presentation of pulmonary polymethylmethacrylate emboli after percutaneous vertebroplasty. Spine (Phila Pa 1976) 32:E589–E593. doi: 10.1097/BRS.0b013e31814b84ba CrossRefGoogle Scholar
  9. 9.
    Choe DH, Marom EM, Ahrar K, Truong MT, Madewell JE (2004) Pulmonary embolism of polymethyl methacrylate during percutaneous vertebroplasty and kyphoplasty. AJR Am J Roentgenol 183:1097–1102. doi: 10.2214/ajr.183.4.1831097 CrossRefPubMedGoogle Scholar
  10. 10.
    Wang L, Yang H, Shi Y, Jiang W, Chen L (2012) Pulmonary cement embolism associated with percutaneous vertebroplasty or kyphoplasty: a systematic review. Orthop Surg 4:182–189. doi: 10.1111/j.1757-7861.2012.00193.x CrossRefPubMedGoogle Scholar
  11. 11.
    Llanos RA, Viana-Tejedor A, Abella HR, Fernandez-Avilés F (2013) Pulmonary and intracardiac cement embolism after a percutaneous vertebroplasty. Clin Res Cardiol 102:395–397. doi: 10.1007/s00392-013-0542-9 CrossRefPubMedGoogle Scholar
  12. 12.
    Krueger A, Bliemel C, Zettl R, Ruchholtz S (2009) Management of pulmonary cement embolism after percutaneous vertebroplasty and kyphoplasty: a systematic review of the literature. Eur Spine J 18:1257–1265. doi: 10.1007/s00586-009-1073-y CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Jang JS, Lee SH, Jung SK (2002) Pulmonary embolism of polymethylmethacrylate after percutaneous vertebroplasty: a report of three cases. Spine (Phila Pa 1976) 27:E416–E418. doi: 10.1097/01.BRS.0000025696.28544.96 CrossRefGoogle Scholar
  14. 14.
    Tozzi P, Abdelmoumene Y, Corno AF, Gersbach PA, Hoogewoud H-M, von Segesser LK (2002) Management of pulmonary embolism during acrylic vertebroplasty. Ann Thorac Surg 74:1706–1708CrossRefGoogle Scholar
  15. 15.
    Henderson R (2017) Expert’s comment concerning Grand Rounds case entitled “Intracardiac bone cement embolism as a complication of vertebroplasty: management strategy” by Hatzantonis C, Czyz M, Pyzik R, Boszczyk BM. (Eur Spine J; 2016. doi:10.1007/s00586-016-4695-x). Eur Spine J. doi: 10.1007/s00586-017-5089-4 CrossRefPubMedGoogle Scholar
  16. 16.
    Kim YJ, Lee JW, Park KW, Yeom J-S, Jeong HS, Park JM, Kang HS (2009) Pulmonary cement embolism after percutaneous vertebroplasty in osteoporotic vertebral compression fractures: incidence, characteristics, and risk factors. Radiology 251:250–259. doi: 10.1148/radiol.2511080854 CrossRefPubMedGoogle Scholar
  17. 17.
    Baumann A, Tauss J, Baumann G, Tomka M, Hessinger M, Tiesenhausen K (2006) Cement embolization into the vena cava and pulmonal arteries after vertebroplasty: interdisciplinary management. Eur J Vasc Endovasc Surg 31:558–561. doi: 10.1016/j.ejvs.2005.11.008 CrossRefPubMedGoogle Scholar
  18. 18.
    Peh WCG, Gilula LA (2003) Additional value of a modified method of intraosseous venography during percutaneous vertebroplasty. AJR Am J Roentgenol 180:87–91. doi: 10.2214/ajr.180.1.1800087 CrossRefPubMedGoogle Scholar
  19. 19.
    Groen RJM, du Toit DF, Phillips FM, Hoogland PVJM, Kuizenga K, Coppes MH, Muller CJF, Grobbelaar M, Mattyssen J (2004) Anatomical and pathological considerations in percutaneous vertebroplasty and kyphoplasty: a reappraisal of the vertebral venous system. Spine (Phila Pa 1976) 29:1465–1471CrossRefGoogle Scholar
  20. 20.
    Bhatia C, Barzilay Y, Krishna M, Friesem T, Pollock R (2006) Cement leakage in percutaneous vertebroplasty: effect of preinjection gelfoam embolization. Spine (Phila Pa 1976) 31:915–919. doi: 10.1016/j.spinee.2005.05.035 CrossRefGoogle Scholar
  21. 21.
    Hoppe S, Wangler S, Aghayev E, Gantenbein B, Boger A, Benneker LM (2015) Reduction of cement leakage by sequential PMMA application in a vertebroplasty model. Eur Spine J 25:3450–3455. doi: 10.1007/s00586-015-3920-3 CrossRefPubMedGoogle Scholar
  22. 22.
    Moreland DB, Landi MK, Grand W (2001) Vertebroplasty: techniques to avoid complications. Spine J 1:66–71. doi: 10.1016/S1529-9430(01)00013-4 CrossRefPubMedGoogle Scholar
  23. 23.
    Qin Y, Ye J, Wang P, Gao L, Jiang J, Wang S, Shen H (2016) Evaluation of the biphasic calcium composite (BCC), a novel bone cement, in a minipig model of pulmonary embolism. J Biomater Sci Polym Ed 27:317–326. doi: 10.1080/09205063.2015.1128240 CrossRefPubMedGoogle Scholar
  24. 24.
    Liodakis E, Bergeron SG, Zukor DJ, Huk OL, Epure LM, Antoniou J (2015) Perioperative complications and length of stay after revision total hip and knee arthroplasties: an analysis of the NSQIP database. J Arthroplasty 30:1868–1871. doi: 10.1016/j.arth.2015.05.029 CrossRefPubMedGoogle Scholar
  25. 25.
    Aynardi M, Jacovides CL, Huang R, Mortazavi SMJ, Parvizi J (2013) Risk factors for early mortality following modern total hip arthroplasty. J Arthroplasty 28:517–520. doi: 10.1016/j.arth.2012.06.040 CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany 2017

Authors and Affiliations

  1. 1.Department of Spinal SurgeryZentralklinik Bad BerkaBad BerkaGermany
  2. 2.Department of Cardiac SurgeryZentralklinik Bad BerkaBad BerkaGermany
  3. 3.Department of CardiologyZentralklinik Bad BerkaBad BerkaGermany
  4. 4.Department of Orthopedics and Spinal SurgeryAlexandria University HospitalsAlexandriaEgypt
  5. 5.Department of Cardiothoracic SurgeryCairo UniversityCairoEgypt
  6. 6.Department of Orthopedics and TraumatologyCairo UniversityCairoEgypt

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