Wednesday, 13 May 2015

xrayoftheweek 19: can you spot the problem?

This is the #xrayoftheweek, an abdominal x-ray. Two questions for you:
1. Which procedure(s) has this patient had in the past?
2. What complication can you see?

For bonus marks, which single imaging test would you like to see next?

Other than a cholecystectomy, this person has had a vertebroplasty (the full name is a percutaneous vertebroplasty). This is an interventional radiology procedure in which cement, mixed with contrast, is injected into vertebral bodies. It has been shown to improve symptoms in osteoporotic and malignant vertebral body collapse. Known complications of the procedure include leak of the cement, into the foraminal, epidural and prevertebral spaces, and the effect of these depends on the volume of leak. 

A potentially more serious complication is extravasation into the paravertebral veins, as seen on this x-ray. The linear vertical densities are cement filling the paravertebral veins, seen more clearly on this reconstructed CT image:

If limited to this degree of extravasation, there is no clinical consequence. However, this is a route to the right side of the heart and therefore for pulmonary embolism. Cement pulmonary emboli may be detected on post-procedure chest x-rays or CT, and may be asymptomatic if small. Reports of cerebral embolism and cardiac perforation have been published. This article summarises the complications of vertebroplasty.

I have also posted this case, with a scrollable CT stack, on Radiopaedia.



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