A 73–year–old man with atrial fibrillation, and multiple myeloma was admitted with severe back pain secondary to multiple lumbar osteoporotic vertebral compression fractures (VCF). Four kyphoplasties (KP) were performed, providing significant pain relief. He presented 8 months later with pneumonia, and was incidentally found on a contrast–enhanced computed tomography scan of the chest to have a linear mass in the right atrium and extending into the right ventricle. A transthoracic echocardiogram confirmed the location of the linear mass and showed movement with systole. It was evident that he had suffered a venous embolism of PMMA from his prior KP. A 63–year–old woman with atrial fibrillation and a prior unprovoked pulmonary embolism presented after a fall with back pain secondary to an acute T12 fracture. She failed inpatient pain management, developing encephalopathy before achieving adequate pain control. Her warfarin was held for vertebroplasty (VP), which was done without incident. She was bridged with enoxaparin and discharged to a skilled facility where her warfarin titration was problematic. She was readmitted on full dose enoxaparin and warfarin, INR 2.7, with hypovolemic shock and a 25 × 5 × 13 cm hematoma in the posterior right chest wall, along the track of the prior VP.
Two blinded randomized trials in 2009 compared VP to a sham procedure in patients with painful vertebral fractures. Patients in either group had equivalent results regarding pain control and degree of disability, questioning the true efficacy of VP. This contrasts prior studies, including meta–analyses, all supporting VP and KP over medical management in the short term. However – none of these studies involved a sham procedure, including a randomized controlled trial comparing KP favorably to medical management.
The patients in these two case reports survived, with the first person never displaying any symptoms. The second patient presented critically ill, and required a 10 day hospitalization. Patients with multiple myeloma and those on warfarin are at higher risk for complications. Hospitalists should carefully consider whether the risks in patients with multiple co–morbidities outweigh the potential benefits of a procedure possibly equivalent to placebo.
Figure 1Contrast–enhanced computed tomography showing an embolized fragment of polymethylmethacrylate in the right atrium extending into the right ventricle.
Figure 2CT scan of the chest without contrast demonstrating a 25 × 5 × 13 cm hematoma in the posterior right chest wall beneath the trapezius muscle and internal to the scapula.