Surgical Removal of Circumferentially Leaked Polymethyl Methacrylate in the Epidural Space of the Thoracic Spine after Percutaneous Vertebroplasty

Abstract

Background The major complication of percutaneous vertebroplasty (PVP) using polymethyl methacrylate (PMMA) is epidural leakage of PMMA that damages the spinal cord.

Methods This is a case report.

Result A 77-year-old man presented to our institution with a 6-month history of muscle weakness and an intolerable burning sensation of both lower limbs after PVP with PMMA for thoracic compression fracture at T7 at another hospital. His past medical history was significant for hypertension. He had no history of smoking and alcohol. Computed tomography revealed massive leakage of PMMA into the T6 and T7 spinal canal circumferentially surrounding the spinal cord that caused marked encroachment of the thecal sac. Magnetic resonance images revealed cord compression and intramedullary signal change from T6 to T7 level. After we verified that the leaked PMMA could be easily detached from the dura mater in the cadaveric lumbar spine, surgical decompression and removal of epidural PMMA was performed. The leaked PMMA was carefully thinned down with a high-speed diamond burr. Eight pieces of PMMA were detached from the dura mater easily without causing a dural tear. No neurologic deterioration was observed in the postoperative period. The burning sensation resolved, but the muscle weakness remained unchanged. One and a half years postoperatively, the muscle weakness has improved to ⅘ on the manual muscle strength test, but he could not walk without an aid because of spasticity.

Conclusion This report demonstrates the catastrophic epidural extrusion of PMMA following PVP. Extravasated PMMA can be removed through a working space created by means of laminectomy and subtraction of the affected pedicle. Spine surgeons should recognize the possible neurologic complications of PVP and be prepared to treat them using suitable approaches.

Keywords

percutaneous vertebroplasty - cement leakage - neurologic deficit - surgical removal

• References

• 1 Galibert P, Deramond H, Rosat P, Le Gars D. Preliminary note on the treatment of vertebral angioma by percutaneous acrylic vertebroplasty [in French]. Neurochirurgie 1987; 33 (02) 166-168
• 2 Cotten A, Dewatre F, Cortet B. , et al. Percutaneous vertebroplasty for osteolytic metastases and myeloma: effects of the percentage of lesion filling and the leakage of methyl methacrylate at clinical follow-up. Radiology 1996; 200 (02) 525-530
• 3 Ryu KS, Park CK, Kim MC, Kang JK. Dose-dependent epidural leakage of polymethylmethacrylate after percutaneous vertebroplasty in patients with osteoporotic vertebral compression fractures. J Neurosurg 2002; 96 (1, Suppl): 56-61
• 4 Schmidt R, Cakir B, Mattes T, Wegener M, Puhl W, Richter M. Cement leakage during vertebroplasty: an underestimated problem?. Eur Spine J 2005; 14 (05) 466-473
• 5 Yeom JS, Kim WJ, Choy WS, Lee CK, Chang BS, Kang JW. Leakage of cement in percutaneous transpedicular vertebroplasty for painful osteoporotic compression fractures. J Bone Joint Surg Br 2003; 85 (01) 83-89
• 6 Teng MM, Cheng H, Ho DM, Chang CY. Intraspinal leakage of bone cement after vertebroplasty: a report of 3 cases. AJNR Am J Neuroradiol 2006; 27 (01) 224-229
• 7 Harrington KD. Major neurological complications following percutaneous vertebroplasty with polymethylmethacrylate: a case report. J Bone Joint Surg Am 2001; 83-A [phone]
• 8 Garfin SR, Reilley MA. Minimally invasive treatment of osteoporotic vertebral body compression fractures. Spine J 2002; 2 (01) 76-80
• 9 Becker S, Meissner J, Tuschel A, Chavanne A, Ogon M. Cement leakage into the posterior spinal canal during balloon kyphoplasty: a case report. J Orthop Surg (Hong Kong) 2007; 15 (02) 222-225
• 10 Nussbaum DA, Gailloud P, Murphy K. A review of complications associated with vertebroplasty and kyphoplasty as reported to the Food and Drug Administration medical device related web site. J Vasc Interv Radiol 2004; 15 (11) 1185-1192
• 11 Lee BJ, Lee SR, Yoo TY. Paraplegia as a complication of percutaneous vertebroplasty with polymethylmethacrylate: a case report. Spine 2002; 27 (19) E419-E422
• 12 Shapiro S, Abel T, Purvines S. Surgical removal of epidural and intradural polymethylmethacrylate extravasation complicating percutaneous vertebroplasty for an osteoporotic lumbar compression fracture. Case report. J Neurosurg 2003; 98 (1, Suppl): 90-92
• 13 Ratliff J, Nguyen T, Heiss J. Root and spinal cord compression from methylmethacrylate vertebroplasty. Spine 2001; 26 (13) E300-E302
• 14 Lin BJ, Li CC, Ma HI. Intradural cement leakage after percutaneous vertebroplasty. Turk Neurosurg 2015; 25 (06) 940-942