867 - Pulmonary Cement Embolism after Spinal Fusion: A Case Report

Case Diagnosis: Pulmonary cement embolism (PCE)

Case Description: Patient is a 33-year-old male with history of metastatic angiosarcoma who presented with shortness of breath and chest/ back pain. He was found to have a T12 pathologic compression fracture and underwent T11-L1 fusion, after which he was admitted to the inpatient rehabilitation unit for deconditioning and debility. Hospital course was significant for new onset tachycardia and O2 requirement, limiting his physical therapy to bed level. CT chest angiography demonstrated hyperdense material within the main pulmonary artery and its branches and in the veins around the lumbar spine likely representing PCE. No surgical or percutaneous intervention was recommended, and he was subsequently placed on anticoagulation then started on metoprolol to prevent tachycardia-induced cardiomyopathy.

Discussions: Spinal fusion, a surgical procedure to connect two or more bones in the spine, reinforces structure and stability. In spinal fusion, pedicle screws are placed above and below the vertebrae being fused. Cement augmentation is a technique used to increase the stability of pedicle screws in poor quality bone, as seen in this case. The risk for PCE after pedicle screw augmentation is 0.8%. Presentation can be variable, ranging from asymptomatic to dyspnea, chest pain, or rarely, acute respiratory distress syndrome. Changes in vital signs such as O2 desaturation, new onset tachycardia, or hypotension and any symptoms such as shortness of breath, cough, lightheadedness/dizziness, or irregular heartbeat should warrant further workup. Treatment depends on the amount of cement embolized and severity of symptoms, although most cases are treated nonoperatively with anticoagulation.

Conclusions: This case documents a very rare complication of PCE after pedicle screw augmentation with cement in spinal fusion. Vital signs and patient presentation should be closely monitored as presentation of can be largely variable, and delay in diagnosis can impact the patient’s ability to participate and progress in therapy.