Chapter 2258: 2181 Jinxed Mouth

Many procedures in the Orthopedics Department, like interventional surgery, need to be performed under X-ray.

C-arm X-ray fluoroscopy positions the L2 vertebral body and bilateral pedicle, the assistant begins disinfection and lays the sterile surgical drape.

The position was set without issue; before the surgery, Tian Jiaoshou explained the entire Shou Bing process to the assistant.

After administering 1% lidocaine local anesthesia, Tian Jiaoshou made incisions of about 0.5 cm at each marked point on the patient's second lumbar vertebra.

Under fluoroscopic guidance, bilateral puncture was performed using a styleted puncture needle at the lateral superior margin of the bilateral L2 pedicles, inserting the needle at approximately a 10° angle.

Skilled in the procedure, for a surgeon of Tian Jiaoshou's caliber, this level of difficulty in Shou Bing presents virtually no challenge.

Under C-arm X-ray fluoroscopy, after the needle tip entered the pedicle, the stylet was removed and a guidewire inserted; the guidewire was advanced to the anterior one-third of the vertebral body, the puncture needle was withdrawn, and a working sheath was placed.

After drilling to the midpoint of the vertebral body, the hand drill and guidewire were removed, and a balloon was inserted through the working sheath; fluoroscopy showed good balloon position, and as the balloon was gradually inflated, C-arm X-ray fluoroscopy revealed the vertebral body height had been restored close to normal.

Tian Jiaoshou removed the balloon, and the assistant had already prepared the bone cement.

One minute thirty seconds later, bone cement was slowly injected through the working sheath under C-arm fluoroscopy.

As the Shou Bing neared completion, Tian Jiaoshou injected bone cement while closely watching its image.

"The operation here must be meticulous and careful," Tian Jiaoshou said while injecting bone cement, explaining to the assistant.

"What is the biggest complication of injecting bone cement?" Tian Jiaoshou asked.

"Bone cement leakage," the assistant replied.

Tian Jiaoshou is of the more academic type, lacking a rough-and-tumble air, seeming like a southerner.

For the doctors training under him, Tian Jiaoshou asks many questions during every Shou Bing.

As a trainee doctor, one is initially unaccustomed, but one cannot possibly be left speechless by Tian Jiaoshou's simple questions on the operating table.

Though studying and memorizing are tough for trainee doctors, their progress is swift.

"Uncertain," Tian Jiaoshou said while slowly injecting bone cement, explaining: "The most serious complication is pulmonary artery embolism. Bone cement leakage is common; because the patient has osteoporosis, 73% of patients show no reaction after leakage."

Tian Jiaoshou did not continue, because the patient was under local anesthesia; if he spoke too severely, causing the patient tension and possibly a heart attack, that would be needlessly creating trouble for himself.

"As long as you're careful, just avoid letting the injection needle's tip touch the nutrient artery and vein," Tian Jiaoshou said after injecting 2 ml of bone cement. "Under normal circumstances, this is a low-risk Shou Bing. Next, you will perform the procedure yourself, with me assisting on the side."

Hearing Tian Jiaoshou say that, the patient felt fortunate, thinking his luck seemed good, eager for Tian Jiaoshou to perform the procedure personally.

When about 2.5 mL of bone cement had been injected, Tian Jiaoshou paused.

Fluoroscopy showed an upward-extending strip-like "bone cement X-ray contrast agent" shadow appearing on the right paraspinal margin of the vertebral body's anterior edge; the image resembled a small worm, continually crawling.

"Uh..." Tian Jiaoshou was speechless, saying leakage is leakage—did I just jinx myself with my mouth?

"It's fine, it's fine," Tian Jiaoshou reassured himself.

Literature reports that the incidence of venous leakage of bone cement accounts for about 24% of bone cement leakages, and venous leakage leads to pulmonary embolism in 4.6%–6.8% of cases; most are small pulmonary emboli without obvious clinical symptoms.

Only 0.4%–0.9% of pulmonary embolism patients develop clinical symptoms.

This probability is so low that there's hardly any need to worry.

In clinical practice, Tian Jiaoshou has also encountered bone cement leakage and even cases leading to pulmonary embolism.

Most patients are fine after resting a while, with no special complications; postoperative management is minimal and does not affect anything.

Tian Jiaoshou comforted himself and gave himself encouragement—nothing will happen, nothing will happen.

Through continuous C-arm dynamic fluoroscopy, the contrast agent's shadow was observed shifting, passing through the right atrium and right ventricle, finally lodging in the right lung.

Tian Jiaoshou had stopped the operation; he helplessly watched the bone cement enter the right lung, his hands going numb.

"Damn it! How did I encounter a pulmonary embolism?" The ever-temperate Tian Jiaoshou cursed inwardly; now he could only pray the patient shows no clinical symptoms.

Performing Shou Bing, no one can avoid the occurrence of complications.

No matter how careful, no matter how thorough the preoperative preparation, it cannot be avoided.

Those who have no incidents are those who perform few Shou Bing! This is a consensus in the medical field; once a certain number of Shou Bing are performed, one will inevitably face various complications.

For example... today's pulmonary embolism.

"Any discomfort?" Tian Jiaoshou asked softly as he saw the bone cement reach the right lung.

"No," the patient replied, "Everything's fine, Professor Tian, you did a great job—I don't feel any pain at all."

Tian Jiaoshou sighed inwardly, wondering if he had done well.

The Shou Bing should have been fine, but a complication arose—how could I brazenly claim I did well?

The patient's images show bone cement entering the right lung, yet clinically there are no pulmonary embolism symptoms.

Tian Jiaoshou considered that the bone cement had overflowed from the vertebral body, entered the paraspinal vein, and migrated to the lung, causing multifocal embolism of the pulmonary arterioles.

Let's terminate the procedure; if we stubbornly continue, even something fine could become problematic.

He immediately stopped injecting bone cement and sutured the incision.

Afterward, Tian Jiaoshou personally assisted the patient to lie flat, fearing that the assistant's mishandling could worsen the patient's fracture or cause other accidents.

There have already been enough accidents; the fewer, the better.

The patient was turned from prone to supine, given oxygen and ECG monitoring, and venous access was established.

For asymptomatic bone cement pulmonary embolism patients, there is no universally accepted treatment domestically or abroad; currently, the tendency is to avoid prophylactic anticoagulants and only closely monitor the condition via follow-up.

Although the Shou Bing failed, as long as the patient is unharmed, there cannot be a major problem. Tian Jiaoshou felt somewhat uneasy, closely monitoring the patient's condition.

While closely monitoring the condition, Tian Jiaoshou urgently requested the Respiratory Medicine and Cardiothoracic Surgery departments to come to the Operating Room for a consultation.

After one hour of observation, the patient showed no discomfort symptoms. The Respiratory Medicine and Cardiothoracic Surgery departments also advised against excessive intervention, simply to observe any changes and discuss further if needed.

Intraoperatively, after the patient suffered a pulmonary embolism, there were no signs of dyspnea, tachypnea, increased respiratory rate, or other manifestations of impaired intra-pulmonary gas exchange.

Tian Jiaoshou felt he was somewhat fortunate; at least the patient had no issues.

Just the Shou Bing failed; afterward, he must explain much to the family, seeking the patient's family's understanding, and absolutely avoid causing a medical dispute.