Neurological deficit due to cement extravasation following a vertebral augmentation procedure

Case report

Restricted access

The authors endeavor to highlight the surgical management of severe neurological deficit resulting from cement leakage after percutaneous vertebroplasty and to systematically review the literature on the management of this complication.

A patient presented after a vertebroplasty procedure for traumatic injury. A CT scan showed polymethylmethacrylate leakage into the right foramina at T-11 and L-1 and associated central stenosis at L-1. He underwent decompression and fusion for removal of cement and stabilization of the fracture segment. In the authors' systematic review, they searched Medline, Scopus, and Cochrane databases to determine the overall number of reported cases of neurological deficit after cement leakage, and they collected data on symptom onset, clinical presentation, surgical management, and outcome.

After surgery, despite neurological recovery postoperatively, the patient developed pneumonia and died 16 days after surgery. The literature review showed 21 cases of cement extravasation with neurological deficit. Ultimately, 15 patients had resolution of the postoperative deficit, 5 had limited change in neurological status, and 2 had no improvement.

Cement augmentation procedures are relatively safe, but certain precautions should be taken to avoid such complications including high-resolution biplanar fluoroscopy, considering the use of a local anesthetic, and controlling the location of cement spread in relationship to the posterior vertebral body. Immediate surgical intervention with removal of cement provides good results with complete recovery in most cases.

Abbreviations used in this paper:BKP = balloon kyphoplasty; PMMA = polymethylmethacrylate; PVP = percutaneous vertebroplasty.

Article Information

Address correspondence to: Gursukhman Sidhu, M.B.B.S., Rothman Institute, Thomas Jefferson University, 925 Chestnut Street, Philadelphia, Pennsylvania 19107. email: Gursukh

Please include this information when citing this paper: published online May 3, 2013; DOI: 10.3171/2013.4.SPINE12978.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    A: Preoperative midsagittal CT image demonstrating PMMA filling the posterior aspect of the spinal canal between T-11 and L-1. B: Preoperative axial CT image at the T12–L1 disc space revealing right neural foramen compression (arrow). C: Preoperative axial CT image at L-1 demonstrating partial filling of the posterior vertebral body by PMMA (arrow). There is greater than 50% central stenosis being caused by the extravasated cement.

  • View in gallery

    Axial CT image of the chest showing PMMA emboli within a pulmonary arterial branch (arrow).

  • View in gallery

    Anteroposterior radiograph (A), axial CT scans of T-12 (B) and L-1 (C), and midsagittal CT image (D) of the lumbar spine after removal of epidural bone cement, decompression, and placement of instrumentation.

  • View in gallery

    Flow chart illustrating study selection.



Al-Nakshabandi NA: Percutaneous vertebroplasty complications. Ann Saudi Med 31:2942972011


Becker SMeissner JTuschel AChavanne AOgon M: Cement leakage into the posterior spinal canal during balloon kyphoplasty: a case report. J Orthop Surg (Hong Kong) 15:2222252007


Boger ABisig ABohner MHeini PSchneider E: Variation of the mechanical properties of PMMA to suit osteoporotic cancellous bone. J Biomater Sci Polym Ed 19:112511422008


Boonen SVan Meirhaeghe JBastian LCummings SRRanstam JTillman JB: Balloon kyphoplasty for the treatment of acute vertebral compression fractures: 2-year results from a randomized trial. J Bone Miner Res 26:162716372011


Bouza CLopez TMagro ANavalpotro LAmate JM: Efficacy and safety of balloon kyphoplasty in the treatment of vertebral compression fractures: a systematic review. Eur Spine J 15:105010672006


Bouza CLópez-Cuadrado TCediel PSaz-Parkinson ZAmate JM: Balloon kyphoplasty in malignant spinal fractures: a systematic review and meta-analysis. BMC Palliat Care 8:122009


Buchbinder ROsborne RHEbeling PRWark JDMitchell PWriedt C: A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med 361:5575682009


Buchbinder ROsborne RHEbeling PRWark JDMitchell PWriedt CJ: Efficacy and safety of vertebroplasty for treatment of painful osteoporotic vertebral fractures: a randomised controlled trial [ACTRN012605000079640]. BMC Musculoskelet Disord 9:1562008


Chen JKLee HMShih JTHung ST: Combined extraforaminal and intradiscal cement leakage following percutaneous vertebroplasty. Spine (Phila Pa 2976) 32:E358E3622007


Chen LHLai PLChen WJ: Current status of vertebroplasty for osteoporotic compression fracture. Chang Gung Med J 34:3523592011


Chen YJTan TSChen WHChen CCLee TS: Intradural cement leakage: a devastatingly rare complication of vertebroplasty. Spine (Phila Pa 2976) 31:E379E3822006


Chew CCraig LEdwards RMoss JO'Dwyer PJ: Safety and efficacy of percutaneous vertebroplasty in malignancy: a systematic review. Clin Radiol 66:63722011


Cosar MSasani MOktenoglu TKaner TErcelen OKose KC: The major complications of transpedicular vertebroplasty. A review. J Neurosurg Spine 11:6076132009


Cotten ADewatre FCortet BAssaker RLeblond DDuquesnoy B: 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 200:5255301996


Docampo ECiria MSerra-Burgés JBlanch JPérez Edo LCarbonell J: [Risk factors of new fractures after vertebroplasty.]. Med Clin (Barc) 133:17192009. (Span)


Eck JCNachtigall DHumphreys SCHodges SD: Comparison of vertebroplasty and balloon kyphoplasty for treatment of vertebral compression fractures: a meta-analysis of the literature. Spine J 8:4884972008


Eckel TSOlan W: Vertebroplasty and vertebral augmentation techniques. Tech Vasc Interv Radiol 12:44502009


Fourney DRSchomer DFNader RChlan-Fourney JSuki DAhrar K: Percutaneous vertebroplasty and kyphoplasty for painful vertebral body fractures in cancer patients. J Neurosurg 98:1 Suppl21302003


Hadjipavlou AGTzermiadianos MNKatonis PGSzpalski M: Percutaneous vertebroplasty and balloon kyphoplasty for the treatment of osteoporotic vertebral compression fractures and osteolytic tumours. J Bone Joint Surg Br 87:159516042005


Harrington KD: Major neurological complications following percutaneous vertebroplasty with polymethylmethacrylate: a case report. J Bone Joint Surg Am 83-A:107010732001


Hulme PAKrebs JFerguson SJBerlemann U: Vertebroplasty and kyphoplasty: a systematic review of 69 clinical studies. Spine (Phila Pa 1976) 31:198320012006


Kallmes DFComstock BAHeagerty PJTurner JAWilson DJDiamond TH: A randomized trial of vertebroplasty for osteoporotic spinal fractures. N Engl J Med 361:5695792009


Kasperk CNoldge GGrafe IMeeder PHuber FNawroth P: [Indications and results of kypho- and vertebroplasty.]. Internist (Berl) 49:12062008. (Ger)


Katonis PHadjipavlou ASouvatzis XTzermiadianos MAlpantaki KSimmons JW: Respiratory effects, hemodynamic changes and cement leakage during multilevel cement balloon kyphoplasty. Eur Spine J 21:186018662012


Krueger ABliemel CZettl RRuchholtz S: Management of pulmonary cement embolism after percutaneous vertebroplasty and kyphoplasty: a systematic review of the literature. Eur Spine J 18:125712652009


Laredo JDHamze B: Complications of percutaneous vertebroplasty and their prevention. Skeletal Radiol 33:4935052004


Lee BJLee SRYoo TY: Paraplegia as a complication of percutaneous vertebroplasty with polymethylmethacrylate: a case report. Spine (Phila Pa 1976) 27:E419E4222002


Lieberman IReinhardt MK: Vertebroplasty and kyphoplasty for osteolytic vertebral collapse. Clin Orthop Relat Res 415 SupplS176S1862003


Long SSMorrison WBParker L: Vertebroplasty and kyphoplasty in the United States: provider distribution and guidance method, 2001–2010. AJR Am J Roentgenol 199:135813642012


Lopes NMLopes VK: Paraplegia complicating percutaneous vertebroplasty for osteoporotic vertebral fracture: case report. Arq Neuropsiquiatr 62:3B8798812004


Luo JDaines LCharalambous AAdams MAAnnesley-Williams DJDolan P: Vertebroplasty: only small cement volumes are required to normalize stress distributions on the vertebral bodies. Spine (Phila Pa 1976) 34:286528732009


Ma XLXing DMa JXXu WGWang JChen Y: Balloon kyphoplasty versus percutaneous vertebroplasty in treating osteoporotic vertebral compression fracture: grading the evidence through a systematic review and meta-analysis. Eur Spine J 21:184418592012


Mousavi PRoth SFinkelstein JCheung GWhyne C: Volumetric quantification of cement leakage following percutaneous vertebroplasty in metastatic and osteoporotic vertebrae. J Neurosurg 99:1 Suppl56592003


Papanastassiou IDPhillips FMVan Meirhaeghe JBerenson JRAndersson GBChung G: Comparing effects of kyphoplasty, vertebroplasty, and non-surgical management in a systematic review of randomized and non-randomized controlled studies. Eur Spine J 21:182618432012


Park SYModi HNSuh SWHong JYNoh WYang JH: Epidural cement leakage through pedicle violation after balloon kyphoplasty causing paraparesis in osteoporotic vertebral compression fractures—a report of two cases. J Orthop Surg 5:542010


Patel AAVaccaro ARMartyak GGHarrop JSAlbert TJLudwig SC: Neurologic deficit following percutaneous vertebral stabilization. Spine (Phila Pa 1976) 32:172817342007


Ploeg WTVeldhuizen AGThe BSietsma MS: Percutaneous vertebroplasty as a treatment for osteoporotic vertebral compression fractures: a systematic review. Eur Spine J 15:174917582006


Raffo CSLauerman WC: Predicting morbidity and mortality of lumbar spine arthrodesis in patients in their ninth decade. Spine (Phila Pa 1976) 31:991032006


Ratliff JNguyen THeiss J: Root and spinal cord compression from methylmethacrylate vertebroplasty. Spine (Phila Pa 1976) 26:E300E3022001


Ross IBFineman I: Delayed neurologic complications of vertebral bone cement injections. Can J Neurol Sci 37:1251272010


Sabuncuoğlu HDinçer DGüçlü BErdoğan EHatipoğlu HGOzdoğan S: Intradural cement leakage: a rare complication of percutaneous vertebroplasty. Acta Neurochir (Wien) 150:8118152008


Shapiro SAbel TPurvines S: Surgical removal of epidural and intradural polymethylmethacrylate extravasation complicating percutaneous vertebroplasty for an osteoporotic lumbar compression fracture. Case report. J Neurosurg 98:1 Suppl90922003


Sonmez EYilmaz CCaner H: Development of lumbar disc herniation following percutaneous vertebroplasty. Spine (Phila Pa 1976) 35:E93E952010


Taylor RSFritzell PTaylor RJ: Balloon kyphoplasty in the management of vertebral compression fractures: an updated systematic review and meta-analysis. Eur Spine J 16:108511002007


Taylor RSTaylor RJFritzell P: Balloon kyphoplasty and vertebroplasty for vertebral compression fractures: a comparative systematic review of efficacy and safety. Spine (Phila Pa 1976) 31:274727552006


Teng MMCheng HHo DMChang CY: Intraspinal leakage of bone cement after vertebroplasty: a report of 3 cases. AJNR Am J Neuroradiol 27:2242292006


Walter JHaciyakupoglu EWaschke AKalff REwald C: Cement leakage as a possible complication of balloon kyphoplasty—is there a difference between osteoporotic compression fractures (AO type A1) and incomplete burst fractures (AO type A3.1)? Acta Neurochir (Wien) 154:313–3191)?. Acta Neurochir (Wien) 154:3133192012


Wegener BZolyniak NGülecyüz MFBüttner Avon Schulze Pellengahr CSchaffer V: Heat distribution of polymerisation temperature of bone cement on the spinal canal during vertebroplasty. Int Orthop 36:102510302012


Wenger MMarkwalder TM: Cement leakage and the need for prophylactic fenestration of the spinal canal during vertebroplasty. J Bone Joint Surg Am 84-A:6896902002. (Letter)


Wu CCLin MHYang SHChen PQShih TT: Surgical removal of extravasated epidural and neuroforaminal polymethylmethacrylate after percutaneous vertebroplasty in the thoracic spine. Eur Spine J 16:Suppl 33263312007


Yang SCChen WJYu SWTu YKKao YHChung KC: Revision strategies for complications and failure of vertebroplasties. Eur Spine J 17:9829882008




All Time Past Year Past 30 Days
Abstract Views 98 98 15
Full Text Views 85 85 22
PDF Downloads 205 205 18
EPUB Downloads 0 0 0


Google Scholar