A Case Report for a Mortality Following Kyphoplasty: Suggested Method of Prevention

Study design: A case report and review of literature. Objective: To discuss the implementation of a bilateral cannula venting technique to prevent perioperative mortality and morbidity related to kyphoplasty. Summary of background data: Several authors have suggested various recommendations for techniques to lower complications related to kyphoplasty, such as specific cement types, consistencies, volumes, and intravertebral pressures. However, there are few commentaries regarding venting during kyphoplasty as a method to reduce complications, such as embolism. Methods: A 69-year-old male suffered acute cardiac decompensation and arrest during a kyphoplasty procedure, ultimately resulting in his death. Results: Autopsy report from the coroner’s office revealed the cause of death as a pulmonary fat and bone marrow embolism. In response to this event, the attending physician and his partners began venting during the kyphoplasty procedure, using a bilateral cannula technique. Conclusion: The bilateral venting modification has been adopted as the standard of practice with the senior author and his local colleagues. Since implementing this technique, the group of surgeons has successfully performed over 1000 kyphoplasty surgeries without any resulting in perioperative mortality or morbidity.