An orthopedic surgery expert witness opines on a case where a patient was left with chronic pain as a result of cement extravasion following a kyphoplasty. This case involves a fifty-one-year-old female patient with a past medical history of hypertension, hyperthyroidism and back pain. The patient presented to her primary care physician complaining of worsening back pain. The physician initially managed the patient’s condition with conservative treatment and non-steroidal anti-inflammatory drugs for pain relief. When conservative management proved ineffective and the back pain continued to worsen the primary care physician referred the patient to an orthopedic surgeon for further evaluation. She was seen shortly thereafter by the surgeon. He ordered a CT scan of the patient’s spine. The scan revealed extensive lytic expansile lesions in the transverse and spinous processes of vertebral bodies of L3, 4, 5, as well as in the posterior elements of L2 and L1. A pathologist was consulted who diagnosed the patient with fibrous dysplasia and the treating orthopedic surgeon performed a subsequent kyphoplasty. The surgery appeared to go well with no complications during the procedure. However, in the immediate post-operative period she complained of severe pain and her condition began to decline drastically. The patient was taken for an MRI which indicated that significant extravasated cement was present in the spinal canal. The patient was returned to the operating room by the treating physician the following day to remove the excess cement. The patient was left with severe pain in her left leg and numbness as a result of the original procedure.
Question(s) For Expert Witness
- What could have been done to prevent the surgical cement from extravasating into the spinal canal during the kyphoplasty?
Expert Witness Response E-007022
There are a number of different surgical techniques that orthopedic surgeons can employ in order to minimize the risk of cement extravasation. For example, the surgeon may consider altering the cement viscosity to make it less “runny” or injecting it under low pressure but the bottom line is that cement augmentation is relatively contraindicated for fractures which exhibit disruption of the posterior cortex which I imagine was the case with this patient.
I have a great deal of experience performing kyphoplasty surgery. Cement extravasation is a recognized complication of these types of procedures although it has never happened to any of the patients I have treated. Further review of this patient is warranted to assess whether or not the treating surgeon’s actions constituted a deviation from the standard of care. On the surface, it appears that this patient was not a good candidate for cement augmentation and her surgeon exercised poor judgment in eletcting her for this procedure.