Cardiopulmonary Cement Embolism Following Cement-Augmented Pedicle Screw Fixation: A Narrative Review

Abstract

Fixation using cement-augmented pedicle screws (CAPS) is being increasingly performed. However, CAPS-associated cement leakage is a critical problem that can lead to cardiopulmonary cement embolism (CPCE). This narrative review aimed to explore the incidence of and risk factors and treatment strategies for CPCE and cement leakage-related complications after CAPS fixation. Data were extracted from each article, including characteristics of CPCE after CAPS fixation (incidence, location, diagnostic method and criteria, treatment, and outcome and prognosis). Overall, 28 case series and 14 case reports that met the inclusion criteria were included. Of the 1974 cases included in the review, CPCE was noted in 123, symptomatic CPCE in 35, and death in six, respectively. The frequencies of PCE and symptomatic PCE after CAPS fixation were 6% (range: 0-28.6%) and 1.3% (range: 0-26%), respectively. The range of frequencies of PCE and symptomatic PCE after CAPS fixation may have been wide because the definition of CPCE and data collection methods differed among the reports analyzed. Since PCE due to large cement emboli may be primarily related to the surgical technique, improved technique, such as minimizing the number of CAPSs by injecting low-volume high-viscosity cement at low velocity and pressure, and careful observation of cement leakage during CAPS insertion may reduce PCE associated with cement leakage. Spinal surgeons should pay more attention to the occurrence of CPCE during and after CAPS insertion, which can cause serious complications in some patients.

Keywords: cardiopulmonary embolism; cement embolism; cement-augmented fenestrated pedicle screw; cement-augmented pedicle screw; fenestrated pedicle screw; pulmonary embolism.

Figure 1

Fenestrated screws (a) Expedium Verse^Ⓡ spinal system and Vertecem V+^Ⓡ cement (DePuy Synthes Products, Inc., Raynham, MA, USA), (b) Case illustration: preoperative lumbar X-ray, 82-year-old man with L1 vertebral fracture pseudarthrosis in the osteoporotic spine (T= −2SD). (c) Case illustration: postoperative lumbar X-ray. L1vertebroplasty and T12-L2 posterior fusion with cement-augmented fenestrated screws was performed.