Intraoperative fat embolism syndrome associated with implantation of titanium sacroiliac joint fusion implants: a report of two cases

Abstract

Background: For patients undergoing long-construct fusion surgeries, simultaneous sacroiliac joint (SIJ) fusion is a growing trend in spine surgery. Some options for posterior SIJ fusion include 3D-printed triangular titanium implants or self-harvesting SIJ screws. Both implants require fixation within the sacrum and ileum. Fat embolism syndrome is a rare but known complication of lumbar pedicle instrumentation but has never been reported in association with SIJ fusion, regardless of implant type. We report the first two known cases of fat embolism associated with placement of SIJ fusion devices during long construct posterior spine fusion.

Case description: Case 1-a 50-year-old female with multiple previous spine surgeries complicated by osteomyelitis/diskitis that was successfully eradicated, underwent T10-pelvis posterior spinal fusion (PSF), L4 pedicle-subtracting-osteotomy, and bilateral SIJ fusion. During implantation of each SIJ fusion device, the patient's hemodynamic status deteriorated necessitating vasopressor support, intravenous fluid bolus, and hyperventilation, but quickly resolved. The case was completed without further issue, and she had an uneventful post-operative course. Case 2-a 71-year-old female with a past medical history of ankylosing spondylitis, previous L2-L5 PSF, rheumatoid arthritis on chronic steroids, underwent a T9-pelvis PSF, bilateral SIJ fusion, L4 pedicle subtraction osteotomy, T10-L1 Smith Peterson osteotomies. After implantation of the second SIJ fusion device, she became hypotensive and tachycardic, pulses were absent, and cardiopulmonary resuscitation was initiated. Pulses returned quickly, the index surgery was terminated, and she was transferred to the intensive care unit (ICU). In the ICU she was quickly weaned off the ventilator on post-operative day 1. On post-operative day 4, the patient returned to the operating room for completion of the surgery and had an extended, but uneventful, recovery afterwards.

Conclusions: We report on the first two known cases of fat embolism syndrome occurring immediately after implantation of SIJ fusion devices. Spine surgeons should be aware of this rare, but potentially fatal, complication. Collaboration with the anesthesia team and optimization of the patient's hemodynamic status prior to implantation may help prevent catastrophic complications.

Keywords: Fat embolism syndrome; case report; intraoperative fat embolism; sacroiliac joint fusion (SIJ fusion).

Figure 1

Preoperative standing anterior-posterior and lateral X-rays of case 1.

Figure 2

Post-operative biplanar X-rays of case 1.

Figure 3

Timeline of case 1. PSF, posterior spinal fusion; PLIF, posterior lumbar interbody fusion; I&D, incision and drainage; PSO, pedicle subtracting osteotomy; SIJ, sacroiliac joint.

Figure 4

Pre-operative anterior-posterior and lateral X-rays of case 2.

Figure 5

Post-operative day 3 biplanar X-rays for case 2.

Figure 6

Timeline of case 2. TLIF, transforaminal lumbar interbody fusion; PSF, posterior spinal fusion; PSO, pedicle subtracting osteotomy; PCO, posterior column osteotomy; SIJ, sacroiliac joint; ICU, intensive care unit; POD, post-operative day.