Fat Embolism Syndrome and Cardiopulmonary Arrest Survival Following Elective Posterior Spinal Fusion

Introduction: Fat embolism syndrome (FES) is a rare complication that is most associated with long bone and pelvic fractures. Severe cases can cause acute right ventricular (RV) failure and cardiopulmonary collapse. We report a rare case of severe FES following posterior spinal fusion and survival without mechanical circulatory support (MCS).


Description: A 70-year-old woman underwent elective T9-L3 fusion with T12 corpectomy, screw fixation, and allograft augmentation. Postoperatively, she developed rapid atrial fibrillation, hypoxia and hypotension. Echocardiography revealed new, severe RV dilation and dysfunction with elevated RV and pulmonary artery (PA) pressures, no pericardial effusion, and CT angiogram excluded pulmonary embolism. Three days later, she developed increasing lethargy and confusion requiring intubation with ensuing cardiac arrest. She was transferred to a tertiary-care center and arrived hypotensive on three vasopressors, febrile, and hypoxic despite inhaled prostacyclin and maximum ventilator support. Her exam was notable for a diffuse petechial rash and workup showed kidney and liver dysfunction, thrombocytopenia, coagulopathy and ECG without acute ischemia. Additionally, chest radiograph revealed bilateral infiltrates while hemodynamics showed elevated PA and right atrial pressures with normal pulmonary capillary wedge pressures. Max-dose inhaled epoprostenol, antibiotics, inotropes, and diuretics were started. Considering her history and presentation, as well as positive scores on both Schonfeld’s criteria (15 points) and Gurd and Wilson’s criteria (2 major and 4 minor criteria present), she was diagnosed with FES. CT surgery was consulted and MCS not pursued. Her hemodynamics and hypoxia slowly improved with aggressive supportive care and after 37 days hospitalized, she was discharged to a skilled nursing facility.


Discussion: There is one previous case report describing a patient with FES confirmed via autopsy following posterior spinal fusion with screw fixation and allograft augmentation. Our case report describes a patient with severe FES and cardiopulmonary collapse following a similarly executed spinal fusion who survived without MCS. This case highlights that, although rare, severe FES is a potential complication of posterior spinal fusions and survival is possible.