Fatal Intracardiac Embolism Following Cement-Augmented Pedicle Screw Instrumentation: A Case Report

Cement-augmented pedicle screw instrumentation (CAPSI) is a widely used surgical technique for spinal stabilization and decompression, particularly in patients with poor bone quality. Although generally considered safe, cement extravasation can result in severe complications, including neurological injury and embolic events involving pulmonary or cardiac structures. Intracardiac cement embolism is a rare but potentially fatal occurrence.

A 67-year-old man with a history of hypertension and advanced renal cancer under palliative care presented with a 1-week history of severe lumbar pain radiating to the right lower limb, accompanied by progressive weakness in both legs. Magnetic resonance imaging revealed an infiltrative soft tissue mass extending from T12 to L2 with spinal canal compression and metastatic-appearing sacroiliac bone lesions. The patient underwent open posterior decompression with CAPSI using polymethylmethacrylate. Within 24 h postoperatively, he developed acute dyspnea and oppressive retrosternal chest pain. A contrast-enhanced chest CT revealed hyperdense material consistent with cement within the inferior vena cava, pulmonary arteries, and right ventricle, with perforation of the posterior ventricular wall and extravasation into the anterior esophageal wall. Transesophageal echocardiography confirmed a 53-mm linear, hyperechoic structure spanning the right atrium and perforating the anterior leaflet of the tricuspid valve, resulting in significant tricuspid regurgitation. A second cement fragment, located outside the atrial cavity, was associated with a mild pericardial effusion. Surgical intervention was recommended but declined by the patient. He subsequently developed obstructive shock due to cardiac tamponade and died.

This case highlights a rare but catastrophic complication of CAPSI. Accidental cement migration into the venous system can lead to cardiac perforation, even after an apparently uneventful surgical procedure. Prompt clinical suspicion and multimodal imaging are critical to identifying and managing this potentially fatal condition.