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Amelioration of chronic neuropathic pain and motor deficit following removal of lumbar vertebroplasty intradural cement
Clinical Neurology and Neurosurgery 115 (2013) 836–838
Contents lists available at SciVerse ScienceDirect
Clinical Neurology and Neurosurgery journal homepage: www.elsevier.com/locate/clineuro
Case report
Amelioration of chronic neuropathic pain and motor deficit following removal of lumbar vertebroplasty intradural cement José D. Carrillo-Ruiz a,b,∗ , Julio C. Soto-Barraza a , Aníbal Fuentes-Manzo a , Alicia Kassian c , Guillermo Becerra-Escobedo a , Francisco Velasco a , Alejandro Frade-García a,b a
Stereotactic and Functional Neurosurgery and Radiosurgery of Mexico General Hospital, Mexico City, Mexico Neuroscience Department of Anahuac University, Mexico c Pain and Algology Clinic, Mexico General Hospital, Mexico b
a r t i c l e
i n f o
Article history: Received 1 February 2012 Received in revised form 3 August 2012 Accepted 4 August 2012 Available online 1 September 2012 Keywords: Methyl-methacrylate cement Percutaneous vertebroplasty Neuropathic pain Intradural complication
1. Introduction
2. Case report
Percutaneous vertebroplasty (PVP) is a procedure employed to repair vertebral fractures of different etiologies (related to trauma, tumors, osteoporotic bones, etc.) caused by a partial or total collapse of the vertebrae, which in most cases produces intense somatic pain [1]. The purpose of this procedure is to reduce spine instability by injecting polimethyl-methacrylate (PMMA) into the vertebrae for re-expansion in order to ameliorate the pain. Although this surgical procedure is minimally invasive, inherent complications may occur when PMMA is injected into the intradural space, particularly in the case of compression of the spinal cord and nerves [2–4]. The objective of this paper is discuss the case of a patient reporting PMMA intradural leakage, which caused radiculopathy in the lumbar zone, accompanied by chronic neuropathic pain, sensorial disturbances and paresis in the right leg. Surgical removal of the intradural cement resulted in a marked improvement of the patient’s motor and sensory symptoms.
A 56-year-old female with a seven-year-history of lumbar pain which developed after a fall, was referred to our pain clinic. Immediately following the accident, her MRI showed a fracture of the superior platform of the L1 vertebra. She underwent a vertebroplasty procedure 4 years later in attempt to relief her back pain. Unfortunately, the patient did not have immediately spinal image studies following this surgery. Subsequently, she developed severe neuropathic pain in right inguinal area, accompanied by numbness and paresthesias, as well as hypoesthesia in her right foot and motor deficit in her right pelvic limb, reporting a 4/5 muscular strength. CT and MRI studies of the patient’s lumbar spine demonstrated PMMA leakage into the spinal canal at L1 (Figs. 1 and 2), after which, the patient developed a progressively incapacitating, dull, burning-like pain which increased when standing or walking, with maximum intensity in the lumbar region, extending to the right leg, with an intensity of 8/10 on the Visual Analogue Score (VAS). She had been prescribed several medications including Tramadol (300 mg/day), Gabapentin (900 mg/day), and Carbamazepine (900 mg/day), aside from having several local lumbar nerve blocks, none of which provided significant relief of her pain. We evaluated the case and decided to remove the PMMA using a posterior approach, in attempt to relief the pressure on possible nerve roots as well as lumbar spinal cord compression. One level laminectomy plus midlevel of the superior and inferior adjacent laminae (Fig. 3a) was performed. Following the
∗ Corresponding author at: Periférico Sur 3070-780, Col. Héroes de Padierna, CP 10700 México, DF, Mexico. E-mail address: [email protected] (J.D. Carrillo-Ruiz). 0303-8467/$ – see front matter © 2012 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.clineuro.2012.08.004
J.D. Carrillo-Ruiz et al. / Clinical Neurology and Neurosurgery 115 (2013) 836–838
837
Fig. 1. Thoraco-lumbar spine CT scan image (AP and lateral projections) shows PMMA in the spinal canal at L1 level (white arrow).
Fig. 2. Thoraco-lumbar T2 weighted lateral MRI images demonstrated a burst fracture at L1 vertebral body and PMMA between the lumbar nerve roots.
Fig. 3. Intraoperative pictures showing: (a) lumbar laminectomy and extradural exploration, (b) dural opening and lumbar nerve roots, (c) PMMA extraction from intradural space, sparing lumbar nerve roots.
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J.D. Carrillo-Ruiz et al. / Clinical Neurology and Neurosurgery 115 (2013) 836–838
laminectomy, an inspection of the dura showed no evidence of a previous lesion. In fact, the color of the dura coincided with that of the healthy region. Nevertheless, a discrete, hard prominence could be perceived by touch. On opening the dura, a cement fragment was visibly adhered to the inner laminae of the dura. It was carefully removed to avoid any collateral damage to the dura or nerve roots. A thin piece of PMMA, 3.0 cm × 0.7 cm, was extracted without injuring the surrounding tissues or the cauda equine (Fig. 3b and c). Following the surgery, the patient reported a rapid recovery of muscular strength. The neuropathic pain in her leg, dorsal and inguinal areas disappeared, and her numbness improved. However, hypoesthesia on her external foot surface remained. She continued to participate in a physical therapy program. These findings remain consistent after three years of follow-up. 3. Discussion Extradural PMMA leakage after vertebroplasty is a complication which may occur after a simple procedure, in turn, leaving the patient with severe side effects. There are other published cases [1,4], reporting neurological symptoms following cement injection, including alteration of sensitivity, pain and hypoesthesia of nerves root dermatomes, and important motor abnormalities with severe weakness and even paraplegia, which may persist even after immediate decompression of the spinal canal. Intradural leakage involving spinal cord and lumbar roots were reported in 2001 by Harrington et al. [5], as well as additional cases [2,6] including female patients between the ages of 66 and 90 with osteoporotic vertebral fractures including low thoracic and high lumbar levels (T11-L2). Neurological deficits included intense lumbar neuropathic pain, accompanied by hypoesthesia and paresthesias in legs and toes, as well as motor alterations from claudication to severe weakness (1/5 to 2/5). Shapiro’s case also reports symptoms of urinary and fecal incontinence, which was the only case resolved by surgical intervention 12 h after cement leakage [6]. The other two patients were treated with medication and physiotherapy. These patients showed partial improvement in pain and weakness but the problem of incontinence was not modified. Follow-ups ranged between 12 weeks and 1 year. Only two cases of mixed extra and intradural PMMA leakage have been published. One case, involving a 79-year-old woman, described by Teng et al. [4] in 2006, and another of a 49-year-old man, by Sabuncuoglu et al. [3] in 2008, with similar neurological deficits, showing principally motor symptoms. Surgery was immediately performed in both cases, which resulted in motor improvement in one case [3] but not in the other [4]. Most reports available in the literature coincide that neurological complications from PVP are rare. However, when they appear, their effects may be devastating and permanent, depending on the specific location of the PMMA leakage in the spinal canal and the surgical success of removing the cement. Other reports describe cases of neurological symptoms immediately following PVP with leakage into the spinal canal, where the material was surgically removed within hours of the procedure. This case describes a patient treated several years after PVP, with an identified leak of PMMA in the spinal canal 3 years following the procedure, who complained of neuropathic pain and motor deficit. She was treated by our neurosurgical service many years after a posterior decompressive approach with the removal of the PMMA material from the intradural compartment, which resulted
in the immediate amelioration of pain. Exactly how the cement entered the intradural space in this patient is unknown; however one hypothesis is that when the puncture was performed, the needle was introduced into the bone, surpassing the posterior limit of the vertebrae, which damaged the dura with an evident intradural tear of the cement. She continued to show improvement 30 months afterward and continued to participate in a rehabilitation program. This is a unique case in which one patient manifested a progressive neurological deficit due to the presence of cement in the intradural space inducing neuropathic pain of adjacent nerve roots. Three other cases of this unusual complication have been reported in literature, in two of which PMMA removal was performed a few hours after PVP. In the patient discussed in this case, the cement remained in contact with the nerve for 3 years, producing progressive neuropathic pain and sensory changes which disappeared after removal the material, except for the hypoesthesia. Given that this patient was at risk for greater loss of leg mobility, and the etiology of the neuropathic pain was the cement, it was the unanimous decision of the physicians involved to remove the fragment. In brief, it is important to note that improvement of neuropathic pain, dysesthesia and muscular weakness in lower extremities may occur after delayed cement removal. Some authors purport that it is impossible to reverse sensorial damage after PMMA leakage, secondary to nerve injury. Nonetheless, this was not true in the case presented here, despite the fact that chronic neurological deficits may occur after surgery and rehabilitation. Our patient’s muscular strength has weakened, visible in a discrete limitation of her gait. 4. Conclusion It is best to take preventative measures to avoid PMMA leakage into the spinal canal when performing vertebroplasty. This can be achieved by positioning the patient correctly, using a fluoroscopy which permits a clear observation of vertebrae and intervertebral spaces, and positioning the tip of the needle following a vertebral tap to avoid possible leakage into the posterior vertebral body wall, and thus, cement injection into the spinal canal. It is imperative that medical personnel performing PVP be trained to identify and immediately deal with this complication properly if it arises. The staff should be trained not only to perform percutaneous procedures, but also to perform open surgery using spinal cord and nerve roots decompression. All in all, it is promising to note that in the case of a cement leak in the PVP procedures, there is the potential alternative to resolve mishaps, years after the procedure, as this paper has shown. References [1] Lee BJ, Lee SR, Yoo TY. Paraplegia as a complication of percutaneous vertebroplasty with polymethylmethacrylate. Spine 2002;27(19):E419–22. [2] Chen YJ, Tan TS, Chen WH, Chen CC, Lee TS. Intradural cement leakage: a devastatingly rare complication of vertebroplasty. Spine 2006;31(12):E379–82. [3] Sabuncuo˘glu H, Dinc¸er D, Güc¸lü B, Erdo˘gan E, Hatipo˘glu HG, Ozdo˘gan S, et al. Intradural cement leakage: a rare complication of percutaneous vertebroplasty. Acta Neurochirurgica 2008;150(8):811–5. [4] Teng MM, Cheng H, Ho DM, Chang CY. Intraspinal leakage of bone cement after vertebroplasty: a report of 3 cases. American Journal of Neuroradiology 2006;27(1):2249. [5] Harrington KD. Major neurological complications following percutaneous vertebroplasty with polymethylmethacrylate: a case report. Journal of Bone and Joint Surgery 2001;83:1070–3. [6] Shapiro S, Abel T, Purvines S. Surgical removal of epidural and intradural polymethylmethacrylate extravasation complicating percutaneous vertebroplasty for an osteoporotic lumbar compression fracture. Journal of Neurosurgery 2003;98(1 Suppl.):90–2 [Case report].
Contents lists available at SciVerse ScienceDirect
Clinical Neurology and Neurosurgery journal homepage: www.elsevier.com/locate/clineuro
Case report
Amelioration of chronic neuropathic pain and motor deficit following removal of lumbar vertebroplasty intradural cement José D. Carrillo-Ruiz a,b,∗ , Julio C. Soto-Barraza a , Aníbal Fuentes-Manzo a , Alicia Kassian c , Guillermo Becerra-Escobedo a , Francisco Velasco a , Alejandro Frade-García a,b a
Stereotactic and Functional Neurosurgery and Radiosurgery of Mexico General Hospital, Mexico City, Mexico Neuroscience Department of Anahuac University, Mexico c Pain and Algology Clinic, Mexico General Hospital, Mexico b
a r t i c l e
i n f o
Article history: Received 1 February 2012 Received in revised form 3 August 2012 Accepted 4 August 2012 Available online 1 September 2012 Keywords: Methyl-methacrylate cement Percutaneous vertebroplasty Neuropathic pain Intradural complication
1. Introduction
2. Case report
Percutaneous vertebroplasty (PVP) is a procedure employed to repair vertebral fractures of different etiologies (related to trauma, tumors, osteoporotic bones, etc.) caused by a partial or total collapse of the vertebrae, which in most cases produces intense somatic pain [1]. The purpose of this procedure is to reduce spine instability by injecting polimethyl-methacrylate (PMMA) into the vertebrae for re-expansion in order to ameliorate the pain. Although this surgical procedure is minimally invasive, inherent complications may occur when PMMA is injected into the intradural space, particularly in the case of compression of the spinal cord and nerves [2–4]. The objective of this paper is discuss the case of a patient reporting PMMA intradural leakage, which caused radiculopathy in the lumbar zone, accompanied by chronic neuropathic pain, sensorial disturbances and paresis in the right leg. Surgical removal of the intradural cement resulted in a marked improvement of the patient’s motor and sensory symptoms.
A 56-year-old female with a seven-year-history of lumbar pain which developed after a fall, was referred to our pain clinic. Immediately following the accident, her MRI showed a fracture of the superior platform of the L1 vertebra. She underwent a vertebroplasty procedure 4 years later in attempt to relief her back pain. Unfortunately, the patient did not have immediately spinal image studies following this surgery. Subsequently, she developed severe neuropathic pain in right inguinal area, accompanied by numbness and paresthesias, as well as hypoesthesia in her right foot and motor deficit in her right pelvic limb, reporting a 4/5 muscular strength. CT and MRI studies of the patient’s lumbar spine demonstrated PMMA leakage into the spinal canal at L1 (Figs. 1 and 2), after which, the patient developed a progressively incapacitating, dull, burning-like pain which increased when standing or walking, with maximum intensity in the lumbar region, extending to the right leg, with an intensity of 8/10 on the Visual Analogue Score (VAS). She had been prescribed several medications including Tramadol (300 mg/day), Gabapentin (900 mg/day), and Carbamazepine (900 mg/day), aside from having several local lumbar nerve blocks, none of which provided significant relief of her pain. We evaluated the case and decided to remove the PMMA using a posterior approach, in attempt to relief the pressure on possible nerve roots as well as lumbar spinal cord compression. One level laminectomy plus midlevel of the superior and inferior adjacent laminae (Fig. 3a) was performed. Following the
∗ Corresponding author at: Periférico Sur 3070-780, Col. Héroes de Padierna, CP 10700 México, DF, Mexico. E-mail address: [email protected] (J.D. Carrillo-Ruiz). 0303-8467/$ – see front matter © 2012 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.clineuro.2012.08.004
J.D. Carrillo-Ruiz et al. / Clinical Neurology and Neurosurgery 115 (2013) 836–838
837
Fig. 1. Thoraco-lumbar spine CT scan image (AP and lateral projections) shows PMMA in the spinal canal at L1 level (white arrow).
Fig. 2. Thoraco-lumbar T2 weighted lateral MRI images demonstrated a burst fracture at L1 vertebral body and PMMA between the lumbar nerve roots.
Fig. 3. Intraoperative pictures showing: (a) lumbar laminectomy and extradural exploration, (b) dural opening and lumbar nerve roots, (c) PMMA extraction from intradural space, sparing lumbar nerve roots.
838
J.D. Carrillo-Ruiz et al. / Clinical Neurology and Neurosurgery 115 (2013) 836–838
laminectomy, an inspection of the dura showed no evidence of a previous lesion. In fact, the color of the dura coincided with that of the healthy region. Nevertheless, a discrete, hard prominence could be perceived by touch. On opening the dura, a cement fragment was visibly adhered to the inner laminae of the dura. It was carefully removed to avoid any collateral damage to the dura or nerve roots. A thin piece of PMMA, 3.0 cm × 0.7 cm, was extracted without injuring the surrounding tissues or the cauda equine (Fig. 3b and c). Following the surgery, the patient reported a rapid recovery of muscular strength. The neuropathic pain in her leg, dorsal and inguinal areas disappeared, and her numbness improved. However, hypoesthesia on her external foot surface remained. She continued to participate in a physical therapy program. These findings remain consistent after three years of follow-up. 3. Discussion Extradural PMMA leakage after vertebroplasty is a complication which may occur after a simple procedure, in turn, leaving the patient with severe side effects. There are other published cases [1,4], reporting neurological symptoms following cement injection, including alteration of sensitivity, pain and hypoesthesia of nerves root dermatomes, and important motor abnormalities with severe weakness and even paraplegia, which may persist even after immediate decompression of the spinal canal. Intradural leakage involving spinal cord and lumbar roots were reported in 2001 by Harrington et al. [5], as well as additional cases [2,6] including female patients between the ages of 66 and 90 with osteoporotic vertebral fractures including low thoracic and high lumbar levels (T11-L2). Neurological deficits included intense lumbar neuropathic pain, accompanied by hypoesthesia and paresthesias in legs and toes, as well as motor alterations from claudication to severe weakness (1/5 to 2/5). Shapiro’s case also reports symptoms of urinary and fecal incontinence, which was the only case resolved by surgical intervention 12 h after cement leakage [6]. The other two patients were treated with medication and physiotherapy. These patients showed partial improvement in pain and weakness but the problem of incontinence was not modified. Follow-ups ranged between 12 weeks and 1 year. Only two cases of mixed extra and intradural PMMA leakage have been published. One case, involving a 79-year-old woman, described by Teng et al. [4] in 2006, and another of a 49-year-old man, by Sabuncuoglu et al. [3] in 2008, with similar neurological deficits, showing principally motor symptoms. Surgery was immediately performed in both cases, which resulted in motor improvement in one case [3] but not in the other [4]. Most reports available in the literature coincide that neurological complications from PVP are rare. However, when they appear, their effects may be devastating and permanent, depending on the specific location of the PMMA leakage in the spinal canal and the surgical success of removing the cement. Other reports describe cases of neurological symptoms immediately following PVP with leakage into the spinal canal, where the material was surgically removed within hours of the procedure. This case describes a patient treated several years after PVP, with an identified leak of PMMA in the spinal canal 3 years following the procedure, who complained of neuropathic pain and motor deficit. She was treated by our neurosurgical service many years after a posterior decompressive approach with the removal of the PMMA material from the intradural compartment, which resulted
in the immediate amelioration of pain. Exactly how the cement entered the intradural space in this patient is unknown; however one hypothesis is that when the puncture was performed, the needle was introduced into the bone, surpassing the posterior limit of the vertebrae, which damaged the dura with an evident intradural tear of the cement. She continued to show improvement 30 months afterward and continued to participate in a rehabilitation program. This is a unique case in which one patient manifested a progressive neurological deficit due to the presence of cement in the intradural space inducing neuropathic pain of adjacent nerve roots. Three other cases of this unusual complication have been reported in literature, in two of which PMMA removal was performed a few hours after PVP. In the patient discussed in this case, the cement remained in contact with the nerve for 3 years, producing progressive neuropathic pain and sensory changes which disappeared after removal the material, except for the hypoesthesia. Given that this patient was at risk for greater loss of leg mobility, and the etiology of the neuropathic pain was the cement, it was the unanimous decision of the physicians involved to remove the fragment. In brief, it is important to note that improvement of neuropathic pain, dysesthesia and muscular weakness in lower extremities may occur after delayed cement removal. Some authors purport that it is impossible to reverse sensorial damage after PMMA leakage, secondary to nerve injury. Nonetheless, this was not true in the case presented here, despite the fact that chronic neurological deficits may occur after surgery and rehabilitation. Our patient’s muscular strength has weakened, visible in a discrete limitation of her gait. 4. Conclusion It is best to take preventative measures to avoid PMMA leakage into the spinal canal when performing vertebroplasty. This can be achieved by positioning the patient correctly, using a fluoroscopy which permits a clear observation of vertebrae and intervertebral spaces, and positioning the tip of the needle following a vertebral tap to avoid possible leakage into the posterior vertebral body wall, and thus, cement injection into the spinal canal. It is imperative that medical personnel performing PVP be trained to identify and immediately deal with this complication properly if it arises. The staff should be trained not only to perform percutaneous procedures, but also to perform open surgery using spinal cord and nerve roots decompression. All in all, it is promising to note that in the case of a cement leak in the PVP procedures, there is the potential alternative to resolve mishaps, years after the procedure, as this paper has shown. References [1] Lee BJ, Lee SR, Yoo TY. Paraplegia as a complication of percutaneous vertebroplasty with polymethylmethacrylate. Spine 2002;27(19):E419–22. [2] Chen YJ, Tan TS, Chen WH, Chen CC, Lee TS. Intradural cement leakage: a devastatingly rare complication of vertebroplasty. Spine 2006;31(12):E379–82. [3] Sabuncuo˘glu H, Dinc¸er D, Güc¸lü B, Erdo˘gan E, Hatipo˘glu HG, Ozdo˘gan S, et al. Intradural cement leakage: a rare complication of percutaneous vertebroplasty. Acta Neurochirurgica 2008;150(8):811–5. [4] Teng MM, Cheng H, Ho DM, Chang CY. Intraspinal leakage of bone cement after vertebroplasty: a report of 3 cases. American Journal of Neuroradiology 2006;27(1):2249. [5] Harrington KD. Major neurological complications following percutaneous vertebroplasty with polymethylmethacrylate: a case report. Journal of Bone and Joint Surgery 2001;83:1070–3. [6] Shapiro S, Abel T, Purvines S. Surgical removal of epidural and intradural polymethylmethacrylate extravasation complicating percutaneous vertebroplasty for an osteoporotic lumbar compression fracture. Journal of Neurosurgery 2003;98(1 Suppl.):90–2 [Case report].