From Spine to Lungs: Investigating the Dangerous Pulmonary Cement Embolism

Abstract Introduction: Vertebroplasty is a minimally invasive procedure where bone cement is percutaneously injected directly into a fractured vertebral body. This procedure is relatively safe with complications usually including infection and cement leakage into epidural space. Patients that experience these complications are usually asymptomatic, but leakage of cement may lead to severe consequences. Case Discussion: This is a case of a 42-year-old woman with past medical history of hypothyroidism, rheumatoid arthritis, pulmonary fibrosis and osteoporosis secondary to steroid use, that presented with worsening shortness of breath. Patient with long history of interstitial lung disease secondary to severe rheumatoid arthritis that has been treated with steroids which caused osteoporosis with compression fractures. She underwent vertebroplasty procedure to help stabilize vertebral bodies and alleviate pain. Patient subsequently developed worsening shortness of breath. At examination, patient only had bibasilar Velcro-like crackles which correlated with her history of interstitial lung disease. Pulmonary function tests showed improvement of lung volumes compared to previous tests. Echocardiogram was done with findings of normal ejection fraction and no pulmonary hypertension. Chest computed tomography scan without contrast was then performed and reported vertebroplasty changes with cement noted from T6 to T12, with cement noted outside the T6 vertebral body on the left at sub-pleural space with area measuring 2.4cm x 1.2cm, bilateral changes of pulmonary fibrosis unchanged from previous imaging, and bilateral peripheral and central radiopaque emboli at pulmonary arterial circulation consistent with pulmonary cement embolism. Patient was referred for pulmonary transplant. Also recommended to have further evaluation for steroid-sparing agents to avoid worsening of osteoporosis. Discussion: Cement extravasation is not common and may be a severe complication after vertebroplasty procedure. It can result in pulmonary cement embolism, which presents with symptoms like a traditional acute pulmonary embolism, including chest pain, dyspnea, palpitations, cough, and hemoptysis. Our patient presented with worsening dyspnea which was masked by her history of interstitial lung disease. With this case presentation, we want to bring awareness of this rare entity that needs to be suspected in patients that undergo vertebroplasty and present with dyspnea. There are currently no standardized guidelines regarding the management of pulmonary cement embolism. Patients may need to be referred for lung transplant to avoid further complications.