Table 32:

Complication Case Reports Involving Kyphoplasty for Cancer-Related Vertebral Compression Fractures

Author, Year Country	Patient and Primary Malignancy	Clinical History	Operator Interventions and Treated Spinal Levels	Adverse Event	Outcome
Cruz et al, 2014188 Canada	48-year-old female Melanoma	History of diffuse metastatic melanoma in the axial skeleton, liver, lungs and subsequently multifocal spinal metastases; unprovoked acute back pain, refractory to opioids and NSAIDs and unable to walk; cancer was judged to be inoperable	Interventional neuroradiology KP at T10; MRI revealed complete replacement of the marrow of the VB by tumour, focal cortical disruption of the posterior vertebral body wall, and soft-tissue extension of the tumour into the epidural space; the VCF was < 50% of original vertebral height, with bulging of the posterior wall into the spinal canal; there were 2 small metastases in the T6 and T9; KP was immediately followed by SRS (24 Gy in 2 fractions) to T10	Tumour extravasation following KP: during the procedure, minor posterior epidural venous cement leaks and some migration of cement along the path of the left cannula into the pedicle occurred; an MRI 2 months post-procedure suggested the tumour had spread cranially and caudally to T9 and T11; there was an opening of the basilar vein where the tumour also propagated to the posterior aspect of the T9 VB	There was no other disease progression in the spine, suggesting that tumour migration through the venous system accounted for the unusual spread to the adjacent level; the patient died 6 months later of extraspinal metastases
	73-year-old male Non-small-cell lung cancer	History of non-small cell lung cancer; sudden unprovoked mechanical back pain that was refractory to opioids and NSAIDs; cancer was judged to be inoperable	Interventional neuroradiology KP was performed for T9 VCF followed by conventional radiotherapy (20 Gy at 5 daily fractions); target was not amenable to SRS due to inadequate targeting precision; the VCF had > 50% height loss, bulging of anterior and posterior wall, complete replacement of the vertebral body marrow with tumour extending to both pedicles and paravertebral soft tissues, and focal disruption of the posterior wall	Tumour extravasation following KP: 2½ weeks following KP, the patient had recurrent back and bilateral flank pain; a 4-week follow-up MRI showed anterior subligamentous tumour spread to the immediate adjacent cranial and caudal vertebral levels, extension into the paravertebral soft tissues beyond the boundaries of the T9 VB, and involvement of the pedicles along the path of the KP cannulas; the disease spread was considered to be due to increased VB internal pressure, disruption of the tissue during balloon inflation and cement application, forcing the soft-tissue tumour beyond the vertebral bony boundaries through cortical defects and involving adjacent levels through subligamentous spread	Despite palliative conventional radiotherapy, the patient died a month later due to progression of systemic disease
Elshinawy et al, 2005197 United States	62-year-old male Multiple myeloma	A long history of multiple myeloma and prostate cancer, coronary artery disease, and PE; warfarin was discontinued before surgery	Surgery KP under general anaesthesia for VCFs at 3 levels (L1, L2, L3) for severe pain resulting from osteoporotic fractures	Bone cement PE: towards the end of the cement injection, a small vein of the left side of L2 indicated cement had entered the paravertebral venous system; although injection was stopped, cement was visualized entering the systemic venous system; fever (38.4° C, 101.1° F) and tachycardia (heart rate 110 beats per minute) developed without blood pressure or respiration changes; a chest radiograph showed linear, tortuous radiopaque density over the right medial hemithorax, and a chest CT showed new metallic density anteriorly along the right main pulmonary artery representing a cement PE	The patient was treated with supportive care and intravenous antibiotics for presumed pneumonia; fever and tachycardia resolved within 24 hours without respiratory symptoms, and warfarin was resumed; follow-up radiographs continue to show pulmonary cement embolus
Esmende et al, 2013198 United States	65-year-old male Oral carcinoma	History of metastatic squamous-cell carcinoma of the tongue	Orthopedic surgery KP for VCF at T9	Spinal cord compression after KP for cancer-related VCF requiring surgical intervention: immediately following the procedure, the patient developed progressive bilateral lower-extremity numbness and weakness; CT and MRI revealed cement in the T9 vertebral body and retropulsion of the tumour mass into the ventral spinal canal	Emergent posterolateral decompression with T9 vertebrectomy, anterior reconstruction T8–T10 and posterior instrumented spinal fusion were performed; full strength, sensation, and ambulation were recovered post-operatively
Langdon et al, 2009200 United Kingdom	53-year-old male Renal cell carcinoma with pulmonary metastases	MRI-identified metastases on anterior half of T10; no fracture seen, but superior and inferior end plate indentations were present	Orthopedic surgery KP at T10	New fracture occurrence behind the cement: 2 days following prophylactic KP for imminent fracture, VAS increased to 8/10 and an MRI scan with T1-weighted images and edema on the STIR sequence detected a fracture behind the cement	The patient was managed conservatively; pain resolved within 7 days, and the patient remained free of pain at 14-month follow-up
Tran et al, 2013199 Germany	68-year-old female Etiology NR	Presented with acute chest pain and dyspnea a day after KP	Neurosurgery KP at 2 VB levels (L4, L3)	Cement embolism migration in the venous system and perforation of right ventricle causing cardiac tamponade: 2 days after KP, a coronary angiogram showed no coronary artery disease, but a radio-opacified structure was detected on the right side of the heart; shortly after the angiogram, the patients’ hemodynamic status deteriorated developing into cardiac shock; echocardiography showed diffuse moderate pericardial effusion and urgent pericardial drainage (400 mL) was performed; CT showed a cement embolus that had perforated the right ventricle, causing pericardial tamponade	Using a snare catheter and a percutaneous approach, the cement material was removed from the right ventricle to the vena femoralis communis via the inferior vena cava; because of its fragile nature, the cement was removed surgically from the venous circulation; the patient's course was uneventful at 3-month follow-up

Abbreviations: CT, computed tomography; KP, kyphoplasty; L, lumbar; MRI, magnetic resonance imaging; NR, not reported; NSAID, non-steroidal anti-inflammatory drug; PE, pulmonary embolism; SRS, stereotactic radiosurgery; STIR, short tau inversion recovery; T; thoracic; VAS, visual analogue scale; VB, vertebral body; VCF, vertebral compression fracture.