Case Presentation: A Caucasian male in his early 60s with metastatic pancreatic cancer presented to the urgent care with complaints of neck pain. He recently underwent kyphoplasty at the level of T3-T4 two weeks prior. He noticed a growing lump in his neck that grew over the last two days and associated with excruciating pain. The patient stated that the pain was in the lower neck region, throbbing in nature, with no improvement with postural changes of his head. He denied any recent falls or trauma to the area. He denied chest pain, shortness of breath, or syncope. His vitals were unremarkable: blood pressure 123/64 mmHg, heart rate of 78 beats per minute, respiratory rate of 16 breaths a minute, and oxygen saturation of 96 percent on room air. On physical exam, there was no focal point of tenderness that was elicited. He was given intravenous hydromorphone for acute pain control. He underwent computed tomography (CT) of the neck and thorax with intravenous contrast. (Figure 1) It showed the presence of a cement embolus at the bifurcation of the right main pulmonary artery. After discussion with neurosurgery, the patient was not started on anticoagulation as he was hemodynamically stable with no respiratory complaints. His pain improved with pain medication and he was discharged home. He was followed up by his oncologist two days later and had resolution of the pain.
Discussion: We present a case of incidental finding of cement embolism post kyphoplasty that presented as neck pain. Percutaneous vertebroplasty/kyphoplasty is an interventional procedure consisting of the injection of radiopaque bone cement into a vertebral body to promote vertebral stabilization resulting in pain relief [1]. The procedure is utilized in patients with osteoporotic vertebral collapse or more commonly in malignancies with severe pain due to destruction of the vertebral body [2]. Some of the complications of kyphoplasty include cement leakages, pulmonary embolism, and spinal canal stenosis [1]. Cement leakage is thought to be caused by excessive pressure while injecting the material. The cement drains from the basivertebral veins via the inferior vena cava to the pulmonary artery. Pulmonary embolism can occur in up to 26% of patients. Krueger et. al showed a significant amount of symptomatic pulmonary embolism occurring post kyphoplasty, with patients complaining of a wide severity of symptoms, from few hours of dyspnea to severe hypoxia and death [3]. Identification even without acute intervention may alleviate patient anxiety and facilitate closer follow-up [4]. Treatment is based on the location of the embolism and the patient’s symptoms; options include surgical removal, anticoagulation, or observation [5]. Pulmonary cement embolism rarely requires intervention since most cases remain asymptomatic [2]. Radiating neck pain has been rarely described as a complication. In our patient, the pain must have occurred due to inflammation from the leaked cement in the surrounding areas.
Conclusions: This case shows the importance for hospitalists to consider pulmonary embolism when patients present with neck pain with no identifiable cause. Patients with pulmonary embolism may present with a referred jaw, neck, or shoulder pain due to converging somatic and visceral afferent nerves entering the cervical spine. Management of cement embolism is not as standardized compared to that of thromboembolism as it is based on symptoms. Ultimately, it warrants a collaboration with neurosurgery and the patient to decide upon the best path of action.
