CASE REPORT

Unusual Presentation of Infected Vertebroplasty with DelayedCement Dislodgment in an Immunocompromised Patient: CaseReport and Review of Literature

Wei-Che Lin Æ Chen-Hsiang Lee Æ Shih-Hao Chen ÆChun-Chung Lui

Received: 10 May 2007 / Accepted: 25 September 2007 / Published online: 13 December 2007

� Springer Science+Business Media, LLC 2007

Abstract Percutaneous vertebroplasty has been estab-

lished as a safe and effective treatment for compression

fractures of osteoporotic vertebrae. Complications of ver-

tebroplasty, such as infection or anterior cement extrusion,

are rare. Herein, we report an unusual presentation in an

immunocompromised patient with an insidious infection of

the disk. This infection resulted in dislodgment of the

cement inferiorly and a compression fracture of the adja-

cent vertebra 6 months after vertebroplasty. We discuss the

significance of this case and compare it with 7 others found

in the literature.

Keywords Cement � Complication � Infected spondylitis �Polymethylmethacrylate � Vertebroplasty

Introduction

Vertebroplasty is a well-developed treatment for painful

compression fractures of osteoporotic vertebrae [1]. In

more than 90% of cases, there is rapid relief from pain as

the vertebral height is restored [2]. Complications of ver-

tebroplasty are uncommon, as reported incidences range

from 1% to 3% in osteoporotic fractures [2]. Infection

occurring after vertebroplasty is rare; to our knowledge,

only 7 cases have been described in the literature [1, 3–7].

We report a case of cement dislodgment as an unusual

presentation of vertebroplasty infection. We also review

the English language literature to compare the etiologies

and treatment implications of this presentation.

Case Report

A 65-year-old woman with adrenal insufficiency had

severe lower back pain for 1 month. Plain radiographs and

magnetic resonance imaging (MRI) revealed a compres-

sion fracture with an air- and fluid-filled cleft in the T12

vertebra (Fig. 1). Physical examination demonstrated

marked tenderness on palpation of the posterior spinous

process of T12 (score of 8 of 10 on a visual analog scale).

The patient’s pain was refractory to medical treatment;

therefore, vertebroplasty was scheduled.

Two weeks before the procedure, the patient was given

parenteral cefuroxime 750 mg every 8 hr to treat a urinary

tract infection caused by Escherichia coli. The infection

resolved after a 2-week course of the antibiotic. The

patient’s condition stabilized. Her white blood cell (WBC)

count was 7,500 cells/mm3 (normal range 3,000–10,500

cells/mm3). Antibiotic prophylaxis was not administered

before surgery.

W.-C. Lin � C.-C. Lui (&)

Department of Diagnostic Radiology, Chang Gung Memorial

Hospital, Kaohsiung Medical Center, Chang Gung University

College of Medicine, 123 Ta-Pei Road Niao-Sung Hsiang,

Kaohsiung 83305, Taiwan

e-mail: lchung@adm.cgmh.org.tw

W.-C. Lin

e-mail: u64lin@yahoo.com.tw

C.-H. Lee

Division of Infectious Disease Chang Gung Memorial Hospital,

Kaohsiung Medical Center, Chang Gung University College of

Medicine, 123 Ta-Pei Road Niao-Sung Hsiang, Kaohsiung

83305, Taiwan

S.-H. Chen

Department of Orthopedics Chang Gung Memorial Hospital,

Kaohsiung Medical Center, Chang Gung University College of

Medicine, 123 Ta-Pei Road Niao-Sung Hsiang, Kaohsiung

83305, Taiwan

123

Cardiovasc Intervent Radiol (2008) 31:S231–S235

DOI 10.1007/s00270-007-9234-z

Vertebroplasty was preformed by means of a unipedic-

ular approach, with strict sterile conditions in an

interventional radiology suite (Fig. 2). We used 8 ml of

polymethylmethacrylate, which was conformed to a cleft-

fill pattern in the T12 vertebra. Postoperative computed

tomography (CT) scans confirmed that none of the cement

had leaked. After the procedure, the patient’s backache

improved dramatically, and she was discharged 3 days after

the procedure.

Six months after the procedure, the patient began to

have progressively worsening pain (score of 7 or 10 on a

visual analog scale) at the T12 level. The pain was asso-

ciated with numbness in both lower extremities.

Radiography and MRI revealed loosening and dislodgment

of the cement from the inferior aspect. The disk space at

the T12-L1 level had collapsed. MRI depicted heteroge-

neous signal intensity, and the nucleus and annulus could

not be distinguished clearly. We also noted a compression

fracture of the adjacent L1 vertebra, as well as severe

degeneration of endplates of the L3, L4, and L5 vertebrae.

A protruding bony fragment caused posterior compression

of the spinal cord at the T12-L1 level (Fig. 3).

The patient was afebrile, and her WBC count was 8,800

cells/mm3 with 75% segmented neutrophils. Her erythro-

cyte sedimentation rate was 28 mm/hr (normal \30 mm/

hr), and her C-reactive protein concentration was 1.04 mg/

dl (normal\0.8 mg/dl). Radiographs depicted no evidence

of osteomyelitis, diskitis, or abscess formation.

Two months later, the patient was admitted for spinal

decompression and fixation because the muscular strength

in both her legs had deteriorated (from grade 5 to grade 3).

After debridement, anterior interbody fusion was per-

formed with a 3.2 cm strut bony graft from the humerus.

During the operation, it was noted that the cement had

loosened; this complication was associated with inflam-

matory necrosis of the tissue and collapse of the L1 and L2

vertebrae. Acinetobacter species were isolated from the

necrotic tissue. An infectious disease specialist was con-

sulted, and the patient was given parenteral ciprofloxacin

400 mg every 12 hr. Posterior instrumentation was inserted

2 weeks later.

After surgical intervention, the patient’s back pain and

muscle weakness improved, and the kyphotic deformity

was corrected. She was discharged home 8 days later. At

the time of discharge, her WBC count was 3,900 cells/mm3

with 82% segmented neutrophils. Her erythrocyte sedi-

mentation rate was 40 mm/hr.

Oral antibiotic with ciprofloxacin 1000 mg/day was

continued for 4 months until the patient’s C-reactive pro-

tein level and erythrocyte sedimentation rate were within

normal limits.

Fig. 1 Plain radiograph A and sagittal T2-weighted MR image Brevealed a compression fracture with an air- and fluid-filled cleft

within the T12 vertebra

Fig. 2 Lateral radiography after vertebroplasty showed good depo-

sition of the cement from anterior to posterior margins of the T12

vertebra. The contour and anterior height of the L1 vertebra were

unremarkable

S232 W.-C. Lin et al.: Unusual Presentation of Infected Vertebroplasty

123

Two years later, during the most recent follow-up visit,

the patient was able to ambulate with a walker.

Discussion

Percutaneous vertebroplasty has become a common option

for the treatment of osteoporotic compression fractures

because of its high success rate and ability to relieve pain

effectively [1, 2]. Although rare, complications have

occurred. These are mainly related to unexpected deposi-

tion of the cement [8, 9]. Most such complications occur

immediately and can be prevented. However, delayed

complications, such as infection (Table 1) [1, 3–7] or

cement migration related to aseptic loosening, are rare and

unpredictable [10, 11]. In our case, infection manifested in

an extremely uncommon way, with chronic septic loosen-

ing of the cement. Early recognition of this complication

was difficult given the absence of obvious signs of infec-

tion. Delayed complications may result in ongoing back

pain and a need for further decompression procedures.

Infected vertebroplasty is suspected when patients

present with typical clinical symptoms and signs of infec-

tion, such as back pain, fever, and leukocytosis. It can be

confirmed with appropriate imaging evaluation. However,

the common radiologic changes may not be present in all

cases. We observed osteosclerosis of the bone surrounding

the intravertebral cleft filled with cement rather than

osteolysis. MRI showed no definite bone marrow edema or

destruction that suggested active infection. This presenta-

tion was unusual for spondylitis and was easily overlooked.

The dual effect of a low-virulence pathogen (an Acineto-

bacter organism) [12] and long-term steroid use accounted

for the insidious onset of infection and loosening of the

cement.

Loosening of a cemented vertebra is a multifactorial

phenomenon [13]. Two reported cases of cement dislodg-

ment after vertebroplasty were aseptic, and both surgeries

were performed in a vertebra with a large cleft [10, 11].

This situation usually happens early during follow-up

because an injection of polymethylmethacrylate into a

cystic cavity should considerably reduce interdigitation

with the surrounding bone compared with an injection into

intact trabecular bone [11]. Anterior cortical defects are

usually seen in wedge-type compression fractures and

further increase the likelihood of anterior dislodgment of

the cement [14]. In our patient, the destructive endplate and

degenerative disk changes caused by insidious infection

did not contribute enough mechanical strength to support

the loosening cement. The mechanical load was transferred

directly through the cement into the vertebra below and

caused adjacent compression fractures.

Infection rates after vertebroplasty are low. To our

knowledge, only 7 cases have been described in the liter-

ature [1, 3–7]. Bacteria were identified in 5. Most cases

were associated with an episode of systemic infection

before vertebroplasty, and half the patients were immu-

nocompromised (Table 1). These patients may be

predisposed to develop spondylitis, especially at sites

where foreign bodies are retained after a hematogenously

spreading infection occurs.

Infected vertebroplasty can occur early or late. The

isolated pathogens are usually low-virulence bacteria, such

as coagulase-negative Staphylococcus organisms, Staphy-

lococcus epidermidis, or Acinetobacter species [12, 15].

The infections caused by these pathogens usually develop

several months after the procedure. Because of poor vas-

cularity, the injected cement is prone to colonization by

pathogens from transient bacteremia or directly from the

surgical site. Contrary to common expectations, infections

due to hospital-acquired and skin-colonizing species tend

to occur early. One postvertebroplasty wound infection

caused by Enterobacter species and another infection

caused by polymicrobial pathogens developed within 2

weeks.

Routine use of prophylactic antibiotics during verteb-

roplasty is still a controversial issue. Lidwell [16] has

Fig. 3 A, B. Six months after vertebroplasty, progressive low back

pain and bilateral lower extremity numbness brought the patient to

our clinic again. The lateral radiograph A and sagittal T2-weighted

MR image with fat saturation B revealed loosening and inferior

dislodgment of the cement. Obvious sclerotic changes at the superior

endplate of L1 vertebra and wedge-shaped compression fracture were

noted. Furthermore, the spinal stenosis was more severe than 6

months previously

W.-C. Lin et al.: Unusual Presentation of Infected Vertebroplasty S233

123

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S234 W.-C. Lin et al.: Unusual Presentation of Infected Vertebroplasty

123

stated that 95% of periprosthetic infections that occur

during the first year after artificial joint replacement are

due to intraoperative contamination of the prosthesis by

airborne bacteria. In contrast to arthroplasty, vertebroplasty

involves a relatively small surgical wound and short pro-

cedural time. These differences may lower the risk of

exposure to airborne bacteria. Yu and colleagues [3]

reported an infection rate of less than 0.5% with the pro-

phylactic administration of antibiotics. Although direct

contamination during the procedure or spread from an

adjacent infection could not be excluded in our case or in

others, strategies such as the use of gentamicin-loaded

cement [17] or antibiotic prophylaxis could be considered,

especially in vulnerable patients.

At our institution, antibiotics are now prophylactically

administrated before procedures are performed in high-risk

patients, and active infection is considered a contraindi-

cation for vertebroplasty. Previous lack of these practices

may have accounted for half of the patients (including

ours) in whom a preceding infection led to infectious

complications after vertebroplasty. We believe that most

postvertebroplasty infections can be prevented with careful

selection of candidates, strict adherence to aseptic proce-

dures, and adequate antibiotic prophylaxis.

Although infection after vertebroplasty can initially be

managed with antibiotics, we know of only 1 case in which

this approach achieved satisfactory results [6]. Most cases

require extensive debridement and reconstruction. Spaces

can potentially be created between the bone cement and

necrotic bone. These spaces are inaccessible to systemic

antibiotics and, therefore, make eradication of the pathogen

difficult. In most patients, vertebrectomy is warranted to

remove the infected bone-cement complex; this procedure

is followed by interbody fusion for stabilization.

Conclusion

Vertebroplasty is a safe procedure for treating symptomatic

compression fractures of osteoporotic vertebrae. Immuno-

compromise and uncontrolled systemic infection before

vertebroplasty increase the risk of wound infection after-

ward, and great caution should be exercised in this

situation. Insidious infection should be suspected if unusual

complications, such as inferior extrusion of the cement and

destruction of the endplate and disk, occur in the context of

these risk factors, even in the absence of local or systemic

signs of infection. A combination of appropriate antibiotic

therapy and early surgical debridement to remove the

infected tissue can achieve satisfactory results.

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