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Acute Paraplegia After Vertebroplasty in an Eighty-two-Year-Old Woman1
An eighty-two-year-old woman with intractable back pain was transferred to our service from another hospital. A diagnosis of osteoporosis had been made following multiple vertebral fractures that had occurred approximately one year before and from which she had fully recovered after treatment with oral analgesics, calcium, vitamin D, and use of a brace. When renewed back pain developed, she first had received outpatient therapy with a variety of orally administered analgesics, including opioids for about five weeks, and oral alendronate (70 mg once per week). At the time of transfer to our department, she was receiving high doses of narcotic analgesics both orally and intravenously, but she was still immobilized because of pain. The maximum pain was in an area of enhanced signal intensity on magnetic resonance imaging consistent with bone marrow edema in the twelfth thoracic and first lumbar vertebrae. There was no associated pain or enhanced signal intensity in the other, also deformed, vertebrae. After failure of an intensified noninvasive treatment regimen including intravenous patient-controlled analgesia with piritramide (a strong synthetic opioid) and the use of a rotationally stable custom brace for another seven days, the patient provided informed consent for vertebroplasty. She had comorbidities, which were arterial hypertension and a history of transient ischemic attacks, for which she was taking 100 mg of aspirin per day. The use of aspirin was discontinued five days prior to the procedure. The patient had no history or clinical signs of a bleeding disorder, and the preoperative prothrombin time, partial thromboplastin time, international normalized ratio, and platelet counts were within normal range. A bleeding time was not performed preoperatively. Prior to the start of the procedure, a hypertensive episode (blood pressure of 220/110 mm Hg) was treated with sublingual nitroglycerin and nifedipine. When the blood pressure returned to 180/90, the procedure was begun under biplanar fluoroscopic control after the administration of local anesthesia with a total of 20 mL of 0.5% bupivacaine and under constant monitoring that included a single-channel electrocardiogram and measurement of the heart rate, blood pressure, and peripheral oxygen saturation. The passage of the trocar needle through the left pedicle into L1 was not problematic, but the left pedicle of T12 could not be entered easily and access was then obtained through the right pedicle of T12. Cement augmentation was performed with use of standard polymethylmethacrylate cement and an applicator kit (Biomet, Berlin, Germany). There was no visible cement extravasation into the spinal canal, but there was filling of a short venous segment (Fig. 1). Immediately after the procedure, the patient was hemodynamically stable and almost completely free of pain. The postoperative neurological examination demonstrated normal findings.
Fig. 1 |
Fig. 1 Anteroposterior and lateral plain radiographs made immediately after vertebroplasty. Both vertebrae are sufficiently filled, and there is no visible cement extravasation into the spinal canal. There is a short venous segment on the left anterior side of L1 that is filled with cement (arrow).
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Thirty minutes later, the patient reported pain in the anterior part of the leg bilaterally. Within fifteen minutes, the pain had increased and paresthesias and weakness began developing first in the left and then in the right leg. A computed tomography scan was performed immediately (Figs. 2 and 3), but only a slight amount of cement extravasation into the epidural veins was noted. Since the intraspinal structures could not be clearly distinguished, a magnetic resonance imaging scan was acquired (Fig. 4).
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