Calcium Phosphate Cement Leakage During Balloon Kyphoplasty Causing Incomplete Paraplegia: Case Report and Review of the Literature

Bone cement leakage is the most common, however, it can have potentially disastrous complications during vertebroplasty and balloon kyphoplasty (BK). Polymethylmethacrylate (PMMA) is the most commonly used bone filler, however, calcium phosphate (CP) has been successfully used in spine surgery as a vertebral filler because it is not associated with exothermal reaction and is biologically very close to the vertebral bone. CP leakage during vertebral augmentation is extremely rare.
A 72-year-old woman with an A2/AO type fracture of L1-vertebra underwent a transpedicular BK at the L1-vertebra with CP plus short segment pedicle screw construct (T12-L2) by minimally invasive surgery (MIS). Continuous neuromonitoring and fluoroscopy were used in this case, although no pathological signs were recorded because of the low radiopacity of CP. Two days later, incomplete paraplegia was presented due to intra and extradural cement leakage. The patient underwent an emergency T12-L2 wide decompression for removal of an epidural leak of CP plus durotomy for intradural CP removal. After removal of the cement, there was improvement of neurologic function. CP leakage should have occurred because of a violation of the medial right pedicle wall by the BK trockar and subsequently CP injection both intra and extradural. Since no direct intraoperative nerve root injury occurred, there was no pathologic sign during intraoperative neuromonitoring.
PMMA leakage is well documented in the literature as a common complication during BK. Calcium phosphate leakage during vertebral augmentation is rare. Furthermore, delayed onset of neurologic deficit due to CP leakage has never been reported in the current literature. Spine surgeons and interventional radiologists should always be aware of this potential disastrous complication.