The Journal of Bone and Joint Surgery (American). 2008;90:349-356.
doi:10.2106/JBJS.G.00058
© 2008 The Journal of Bone and Joint Surgery, Inc.
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Influence of Bone Marrow Fat Embolism on Coagulation Activation in an Ovine Model of Vertebroplasty

Jörg Krebs, DVM, PhD1, Stephen J. Ferguson, PhD, PD1, Simon P. Hoerstrup, MD2, Ben G. Goss, PhD3, André Haeberli, PhD4 and Nikolaus Aebli, MD, PhD5

1 MEM Research Center, Institute for Surgical Technology and Biomechanics, Medical Faculty, University of Bern, Stauffacherstrasse 78, 3014 Bern, Switzerland. E-mail address for J. Krebs: jorg.krebs{at}memcenter.unibe.ch
2 Cardiovascular Surgery Research, University of Zürich, Rämistrasse 100 8091 Zürich, Switzerland
3 AO Spine Research Centre, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, QLD 4102, Australia
4 Department for Clinical Research, Thrombosis and Hemostasis Group, University of Bern, Murtenstrasse 35, 3010 Bern, Switzerland
5 Department for Orthopaedic Surgery, Swiss Paraplegic Centre, 6207 Nottwil, Switzerland

Investigation performed at the MEM Research Center, Institute for Surgical Technology and Biomechanics, Medical Faculty, University of Bern, Bern, Switzerland

Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the Wesley Foundation, Brisbane, Australia; the AO Foundation, Davos, Switzerland; and AOSpine, Dübendorf, Switzerland (SRN 02/105). Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Background: Intraoperative cardiovascular deterioration as a result of pulmonary embolization of bone marrow fat is a potentially serious complication during vertebroplasty. The release of fatty material and thromboplastin from the bone marrow cavity during vertebroplasty may activate the coagulation cascade resulting in thrombogenesis, and pharmacological prophylaxis may therefore prevent cardiovascular complications. Thus, the effects of bone marrow fat embolism on coagulation activation during vertebroplasty were investigated with use of an animal model.

Methods: Polymethylmethacrylate was injected into three lumbar vertebrae of six sheep in order to force bone marrow fat into the circulation. Invasive blood pressures and heart rate were recorded continuously until sixty minutes after the last injection. Cardiac output, arterial and mixed venous blood gas parameters, and coagulation parameters were measured at selected time-points. Postmortem lung biopsy specimens were assessed for the presence of intravascular fat.

Results: Embolization of bone marrow fat resulted in a sudden and dramatic increase in mean pulmonary arterial pressure and a decrease in mean arterial blood pressure. There were no significant changes in any coagulation parameter from before the injection to after the injection. Intravascular fat and bone marrow cells were present in all lung lobes.

Conclusions: Injection of polymethylmethacrylate into vertebral bodies caused embolization of bone marrow fat with subsequent transient cardiovascular deterioration, but no changes in coagulation parameters were observed. Thromboembolism did not contribute to the observed cardiovascular changes.

Clinical Relevance: Cardiovascular complications as a result of bone marrow fat embolism should be considered in patients undergoing vertebroplasty. Vertebroplasty with use of polymethylmethacrylate does not appear to activate the coagulation system or cause thromboembolism.


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