Abstract
Introduction and importance
To describe an unusual case with herniated disc caused by bone cement leaking to disc space after kyphoplasty.
Case presentation
We reported a 72-year-old woman with L4 osteoporotic compression fracture. New-onset of left sciatica, numbness and intermittent claudication suffered her immediate after kyphoplasty. Herniated disc caused by bone cement leaking to disc space after kyphoplasty. The patient was post decompressive operation of L34 and the symptoms subsided well then.
Clinical discussion
Percutaneous vertebroplasty (PVP) was a common procedure today. Especially to back pain caused by osteoporotic fracture, reported pain relief rate was satisfactory. Current studies about bone cement leakage showed kyphoplasty less than vertebroplasty. However, for the mechanism and stress effect of balloon expansion, new weak points and cracks over endplate was created, which may cause bone cement leakage to disc space and related symptoms.
Conclusion
Kyphoplasty was a common, effective and minimal invasive operation for patients with compression fracture of spine. Cement leakage to intervertebral disc space was generally asymptomatic, but it should be avoided as much as possible. The leakage could affect the stability and weight-bearing of spinal column. Accelerated degenerative process of disc would be found and newly herniated disc would be noted. It should be ceased the procedure when relative amount of bone cement leakage to disc space during kyphoplasty.
Keywords: Herniated disc, Osteoporosis, Compression fracture, Kyphoplasty, Vertebroplasty, Leakage
Highlights
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Kyphoplasty as a common, effective procedure for compression fracture
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Bone cement leakage in kyphoplasty less than vertebroplasty
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Bone cement leakage affect spine stability
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Herniated disc from bone cement leaking to disc space might cause annoying symptoms
1. Introduction
Kyphoplasty was a common, effective and minimal invasive operation for patients with osteoporotic compression fracture of spine. The operation was generally satisfactory which pain subsided and exertion increase. Bone cement leakage was a common complication, however, it was not resulted in serious consequences. Current studies about bone cement leakage showed kyphoplasty less than vertebroplasty. We reported a 72-year-old woman with L4 osteoporotic compression fracture. New-onset of left sciatica, numbness and intermittent claudication suffered her immediate after kyphoplasty. Delay onset of herniated disc caused by bone cement leaking to disc space had confirmed. Cement leakage to intervertebral disc space was generally asymptomatic, but it should be avoided as much as possible. The leakage could affect the stability and weight-bearing of spinal column with accelerated degenerative process of disc and newly herniated disc would be noted. It should be ceased the procedure when relative amount of bone cement leakage to disc space during kyphoplasty. This case report has been reported in line with the SCARE Criteria [1].
2. Presentation of case
We reported a 72-year-old female with severe low back pain while exertion. Symptoms improved after lying down. The symptoms localized over buttock area and not extending to lower limbs. She had history of receiving L2 kyphoplasty due to traumatic history weeks ago. Image survey showed L4 compression fracture. The patient was post kyphoplasty over L4 (Fig. 1). The back pain improved well then. However, she complained tenderness and numbness over left lower limb immediately after the procedure. Intermittent claudication suffered her as well. Follow-up MRI showed bone cement leakage in L3–4 disc space causing herniated disc, left side (Fig. 2). Which was compatible with clinical symptoms. The patient was post decompressive operation of L3–4 and the symptoms subsided well then.
Fig. 1.
Kyphoplasty over L4 compressed vertebral body was done. Bone cement leakage through ruptured cortex into L3/4 disc space. Besides, we could notice the patient with sacral lumbarization.
Fig. 2.
Bone cement leakage to disc space of L3/4. Which cause L3/4 herniated disc of L3/4 level, Left ventral area of dural sac, with spinal stenosis.
3. Discussion
Percutaneous vertebroplasty (PVP) was a common procedure today. Especially to back pain caused by osteoporotic fracture, reported pain relief is achieved in approximately 70%–100% [2], [3]. However, cement leakage could often be found with reported rates between 11% and 73% [2], [3], [4]. The leakage could be found mostly at venous plexus, extended out of the bone cortex to intradiscal space, epidural, foraminal and paravertebral areas [5], [6], [7], [8]. Severe complications related to spinal stenosis even needed emergent surgical intervention.
Cement leaking to disc space was common seen around 25% to 41% of patients after vertebroplasty [5], [9]. There were no significant relationship between age, sex, type of fracture, amount of deformity, fracture location in the vertebral column and cement leakage [5]. The shape of the vertebral collapse (gibbus, vertebra plana, H shape) was not associated with cement leakage [10]. However, it should be aware of needle tip penetrating through the intact endplate while advancing [5]. Besides, if continuation of vacuum clefts extending into the disc space, the risk of cement leakage into these area would increase [5]. Though most intervertebral leakage to disc space was asymptomatic initially, long-term mechanical consequences on adjacent vertebrae were noticed [11]. During previous studies, the bone cement and related augmentation would increase stiffness of the motion segment and related loading pressure to nucleus [14], [15] Adjacent body fracture and herniated disc might be observed through cement leakage [12], [13]. Besides, bone cement leakage to intradiscal space was found being risk factors of new compression Fractures in adjacent vertebrae after percutaneous vertebroplasty [12], [16].
In our case, we done balloon kyphoplasty then cement injection. The leakage rate of kyphoplasty was 5 to 30% [17], [18], [19], On the other hand, vertebroplasty from 31 to 96% [17], [20], [21]. The leakage rate showed less of kyphoplasty comparing to pure vertebroplasty. However, for the mechanism and stress effect of balloon expansion, new weak points and cracks over endplate was created, which may cause bone cement leakage to disc space. The leakage cement affected the weight-bearing system of previous disc space. Increased intra-disc pressure which accelerated degenerative process, causing herniated disc and symptoms associated with spinal stenosis and radiculopathy.
4. Conclusion
Kyphoplasty was a common, effective and minimal invasive operation for patients with compression fracture of spine. The leakage rate of bone cement showed lower of kyphoplasty than vertebroplasty. However, it should be cautious while needle advancing and during balloon expansion. Previous intact but weak endplate of vertebral body might be crushed. Cement leakage to intervertebral disc space was generally asymptomatic, but it should be avoided as much as possible. The leakage could affect the stability and weight-bearing of spinal column. Accelerated degenerative process of disc would be found and newly herniated disc would be noted.
Provenance and peer review
Not commissioned, externally peer-reviewed.
Source of funding
The research did not receive and specific grant form funding agencies in the public, commercial, or not-for-profit sectors.
Ethical approval
This paper as a case report, therefore does not require ethics approval.
Consent
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.
Author contribution
Shih-Wei Tzeng: study concept design, data collection, data analysis or interpretation, literature review, writing the paper.
Ching-Lin Chen: main neurosurgical provider for the patient, operator and the lead of this project. Concept and design of the manuscript, revisions of the manuscript, and final approval of the version to be published.
Research registration
N/a.
Guarantor
Ching-Lin Chen
Declaration of competing interest
Shih-Wei Tzeng declares no conflict of interest.
Ching-Lin Chen declares no conflict of interest.
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