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A7029 - Broken Bones and Pulmonary Stones- A Rare Case of Pulmonary Embolism
Author Block: S. Kothari1, A. Milas2, M. Sunbuli3; 1Internal Medice, University of Illinois Chicago/Advocate Christ, Oak Lawn, IL, United States, 2Internal Medicine, University of Illinois Chicago/Advocate Christ, Oak Lawn, IL, United States, 3Pulmonology and Critical Care, Advocate Christ, Oak Lawn, IL, United States.
The treatment of conventional pulmonary embolism has become well studied with a multitude of therapies being offered. There however remains a paucity of literature regarding treatment guidelines for patients with cement pulmonary embolism after orthopedic surgery. Today we would like to present a unique approach to the management of these patients.
The patient is a 65-year-old female with past medical history of chronic obstructive pulmonary disease, hyperlipidemia and compression fractures of the lumbosacral spine who recently underwent cementing and fusion three weeks prior at an outside facility. The patient was discharged for rehabilitation and subsequently went home. She began to develop progressive shortness of breath and presented to the emergency department for evaluation. Angiographic CT imaging of the chest demonstrated multiple subsegmental areas of bone cement pulmonary emboli, mainly in the right upper lobe, without evidence of traditional thromboembolic disease. Arterial blood gas was drawn and showed chronic carbon dioxide elevation that was well compensated, and it was thought that her dyspnea was largely due to cement emboli. Beta-natriuretic peptide was mildly elevated at 148 pg/mL but echocardiogram did not show evidence of right ventricular strain. The patient was treated with lovenox as a bridge to Coumadin and was discharged home.
Percutaneous vertebroplasty is a non-invasive treatment approach for the management of compression fractures. Polymethyl methacrylate is injected into the vertebral body which helps provide pain relief by stabilizing the fracture. A rare complication of this procedure is the leakage of this ‘cement’ into vasculature leading to deposition of the material in the pulmonary arteries. It was once thought that this was a rare complication, but recent literature suggests that more patients are presenting with this incidental finding on chest imaging. Our case is unique in that our patient developed symptoms likely attributed to cement embolization several weeks after her intervention, which raises the concern of possible migration of the clot. Typical management includes anticoagulation with Coumadin for a short six-month course. We would like to stress the importance of keeping this entity in the differential for someone who presents with acute onset shortness of breath in the setting of recent spinal manipulation. We also encourage the use of postoperative chest x-rays in appropriate patients as a screening tool, as well as periodic echocardiograms to evaluate for right ventricular strain.