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Transient Thermal Sympathectomy as Possible Mechanism for Hypotension after Kyphoplasty: A Case Report

Soto, Eliezer; Galperin, Mark; Portenoy, Russell, K.

doi: 10.1097/AJP.0000000000000031
Case Report: PDF Only

Background: Vertebroplasty and kyphoplasty are minimally invasive treatments for vertebral compression fractures. Although infrequent, both transitory and persistent adverse effects have been reported. They range from asymptomatic to severe neurologic deficits which are caused directly by polymethylmethacrylate (PMMA) leakage or may be related to local or general reactions not due to PMMA leakage. Transitory hypotension after the procedure has been observed, but the characteristics and etiology of this phenomenon are not defined.

Objective: To describe a case of prolonged hypotension after kyphoplasty and suggest a possible mechanism.

Methods: Six months after L2 kyphoplasty, a 63 year old woman with severe osteoporosis developed a new back pain due to compression fracture of L1 and compression deformity of the superior L3 endplate. The patient underwent bilateral kyphoplasty at the L1 and L3 levels. She developed persistent hypotension for approximately 46 hours immediately after the procedure. Common causes of hypotension were ruled out and the event resolved spontaneously.

Results: Based on the needle placement, the temporal relationship between the procedure and blood pressure change, and the lack of other identifiable causes, thermal sympathectomy from heating of the PMMA adjacent to the paravertebral sympathetic chain is proposed as a potential mechanism.

Limitations: Single case report based on clinical observation.

Discussion: Prolonged hypotension can complicate kyphoplasty at upper lumbar levels. Two days of severe hypotension has not been described as a complication of kyphoplasty. Although the mechanism is unknown, a transient thermal sympathectomy may be the cause.

Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, New York, USA

Statement of Authorship: This statement is to declare that this manuscript is an original contribution, not previously published, and it is not been considered for publication elsewhere.

Disclaimer: There was no external funding in the preparation of this manuscript.

Notifications of Conflicts of Interest and Ethical Adherence: Drs. Eli Soto and Mark Galperin have no conflicts of interest to report. Dr. Russell K. Portenoy served as consultant for Arsenal Medical Inc., Pfizer, Grupo Ferrer, Transcept Pharma and Xenon. Dr. Russell K. Portenoy also received departmental educational/research grants from Allergan, Ameritox, Boston Scientific, Covidien Mallinckrodt Inc., Endo Pharmaceuticals, Forest Labs, K-Pax Pharmaceuticals, Medtronic, Otsuka Pharma, ProStrakan, Purdue Pharma, Salix and St. Jude Medical. We have adhere to standard ethical parameters for the development of this manuscript.

Reprints: Eliezer Soto, MD, DABPM, Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, First Ave at 16th Street, New York, NY 10003 (e-mail:

Received January 16, 2013

Accepted September 5, 2013

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