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Fu S, Ju G, Dai X, Li H, Huang A. Severe major vessel injury during peadicle screw removal: a case report. Front Surg 2023; 10:1187801. [PMID: 37383382 PMCID: PMC10293790 DOI: 10.3389/fsurg.2023.1187801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 05/22/2023] [Indexed: 06/30/2023] Open
Abstract
Introduction Pedicle screw fixation (PSF) has been the standard therapy for the treatment of various spinal diseases. Although complications are identified regularly, iatrogenic vascular injury is one of the rare but life-threatening complications. In this literature, we describe the first case of inferior vena cava (IVC) injury during pedicle screw removal. Case description A 31-year-old man was treated by percutaneous pedicle screw fixation for an L1 compression fracture. After a year, the fracture healed well and hardware removal surgery was performed. During the procedure, the hardware on the right was removed unremarkably except for the L2 pedicle screw which slipped into the retroperitoneum because of the improper technique. The CT angiogram revealed the screw had breached the anterior cortex of the L2 vertebral body and penetrated the IVC. After multidisciplinary cooperation, the defect of IVC was reconstructed and the L2 screw was removed from the posterior approach in the end. Result The patient recovered well and was discharged after 3 weeks without further events. The removal of the contralateral implants was unremarkable at 7 months postoperatively. At the 3-year follow-up, the patient returned to his normal daily activity without any complaints. Conclusion Although pedicle screw removal is a rather simple procedure, severe complications may have occurred from this procedure. Surgeons should keep vigilant to avoid the complication noted in this case.
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Affiliation(s)
- ShengYu Fu
- Department of Orthopaedic, The Affiliated Taizhou People’s Hospital of Nanjing Medical University, Taizhou, China
- Postgraduate School, Dalian Medical University, Dalian, China
| | - Gang Ju
- Department of Orthopaedic, The Affiliated Taizhou People’s Hospital of Nanjing Medical University, Taizhou, China
| | - Xiang Dai
- Department of Vascular Surgery, The Affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou, China
| | - Haijun Li
- Department of Orthopaedic, The Affiliated Taizhou People’s Hospital of Nanjing Medical University, Taizhou, China
| | - Aibing Huang
- Department of Orthopaedic, The Affiliated Taizhou People’s Hospital of Nanjing Medical University, Taizhou, China
- Postgraduate School, Dalian Medical University, Dalian, China
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Hsu FC, Chen CS, Yao YC, Lin HH, Wang ST, Chang MC, Liu CL, Chou PH. Shorter screw lengths in dynamic Dynesys fixation have less screw loosening: From clinical investigation to finite-element analysis. J Chin Med Assoc 2023; 86:330-337. [PMID: 36729417 DOI: 10.1097/jcma.0000000000000864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The dynamic Dynesys Stabilization System preserves lumbar mobility at instrumented levels. This study investigated the effect of screw length on screw loosening (SL) after dynamic Dynesys fixation and screw displacement during lumbar motion, using clinical investigation and finite-element (FE) analysis. METHODS Clinical data of 50 patients with degenerative spondylolisthesis treated with decompression and Dynesys fixation in 2011 were analyzed retrospectively. Horizontal sliding displacement and vertical displacement of screw tips at L4 were analyzed postoperatively using displacement-controlled FE analysis at the L4-L5 level with screw lengths 45 (long screw), 36 (median screw), and 27 (short screw), and 6.4 mm in diameter, under flexion, extension, lateral bending, and rotation. RESULTS In 13 patients (13/50, 26%), 40 screws (40/266, 15%) were loose at mean follow-up of 101.3 ± 4.4 months. Radiographic SL at 35, 40, 45, and 50 mm were 7.7%, 10.7%, 12.1%, and 37.5%, respectively, regardless of the fixation level ( p = 0.009). FE analysis revealed that the long screw model with corresponding longer lever arm had maximal horizontal sliding displacement under all directions and maximal vertical displacement, except for lateral bending. CONCLUSION Shorter screws in Dynesys fixation may help avoid dynamic SL. Clinically, 50 mm screws showed the greatest SL and median screw screws demonstrated the least displacement biomechanically.
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Affiliation(s)
- Fang-Chi Hsu
- Department of Physical Therapy and Assistive Technology, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Chen-Sheng Chen
- Department of Physical Therapy and Assistive Technology, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Yu-Cheng Yao
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Hsi-Hsien Lin
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Shih-Tien Wang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Ming-Chau Chang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chien-Lin Liu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Po-Hsin Chou
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
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He S, Bi Y, Ye C, Peng D, Xiao J, Wei H. Interdisciplinary Surgical Treatments and Long-Term Outcomes of Lumbar Spinal Tumors With Retroperitoneal Involvements: A Retrospective Case Series Study. Front Oncol 2022; 11:720432. [PMID: 35004269 PMCID: PMC8733943 DOI: 10.3389/fonc.2021.720432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 11/23/2021] [Indexed: 12/02/2022] Open
Abstract
Purpose Surgical treatments are technically challenging for lumbar spinal tumor (LST) with extensive retroperitoneal involvements. Our study aimed to report the experience and outcomes concerning interdisciplinary surgical collaborations in managing such LSTs. Patients and Methods Nine patients underwent interdisciplinary surgical treatments which were performed by specialists, namely, spinal, vascular, and urinary surgeries. Data on clinical characteristics were collected, and the Visual Analogue Scale (VAS) and the Japanese Orthopaedic Association Score (JOAS) were used in the evaluation before and after surgery. The postoperative complications and the long-term outcomes were reported as well. Results The interdisciplinary work included double J catheter indwelling (n = 9), nephrostomy (n = 5), replacement of the common iliac vein (n = 2), abdominal aorta repair (n = 3), and vital vessel repair (n = 8). The early-stage complications included complaints of moderate low back pain and slight implant shift (n = 1, 11.1%) and tardive ureterodialysis (n = 1, 11.1%). The 3- and 5-year disease-free survival rates were 76.2 ± 14.8 and 50.8 ± 23.0%, respectively, during the mean follow-up of 34.6 ± 17.9 months (range, 9.5–68.7). Besides this, more blood loss was associated with recurrent and metastatic tumor status (p = 0.043) and surgery time >5 h (p = 0.023). Remarkable pain relief and favorable quality of life were achieved based on the postoperative VAS (3.3 ± 0.9, p < 0.001) and JOAS (16.6 ± 0.5, p < 0.001). Conclusions The treatments of LSTs with wide-range retroperitoneal involvements require interdisciplinary surgical collaborations to lower the risks and improve the long-term outcomes. High-quality prospective cohort studies with large samples are warranted to establish general surgical protocols in managing LSTs with extensive retroperitoneal involvements.
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Affiliation(s)
- Shaohui He
- Spinal Tumor Center, Department of Orthopaedic Oncology, No. 905 Hospital of People's Liberation Army (PLA) Navy, Changzheng Hospital, The Second Military Medical University, Shanghai, China
| | - Yifeng Bi
- Spinal Tumor Center, Department of Orthopaedic Oncology, No. 905 Hospital of People's Liberation Army (PLA) Navy, Changzheng Hospital, The Second Military Medical University, Shanghai, China
| | - Chen Ye
- Spinal Tumor Center, Department of Orthopaedic Oncology, No. 905 Hospital of People's Liberation Army (PLA) Navy, Changzheng Hospital, The Second Military Medical University, Shanghai, China
| | - Dongyu Peng
- Spinal Tumor Center, Department of Orthopaedic Oncology, No. 905 Hospital of People's Liberation Army (PLA) Navy, Changzheng Hospital, The Second Military Medical University, Shanghai, China.,Department of Orthopaedic Surgery, Chengdu Military General Hospital, Chengdu, China
| | - Jianru Xiao
- Spinal Tumor Center, Department of Orthopaedic Oncology, No. 905 Hospital of People's Liberation Army (PLA) Navy, Changzheng Hospital, The Second Military Medical University, Shanghai, China
| | - Haifeng Wei
- Spinal Tumor Center, Department of Orthopaedic Oncology, No. 905 Hospital of People's Liberation Army (PLA) Navy, Changzheng Hospital, The Second Military Medical University, Shanghai, China
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Baldwin KD, Kadiyala M, Talwar D, Sankar WN, Flynn JJM, Anari JB. Does intraoperative CT navigation increase the accuracy of pedicle screw placement in pediatric spinal deformity surgery? A systematic review and meta-analysis. Spine Deform 2022; 10:19-29. [PMID: 34251607 DOI: 10.1007/s43390-021-00385-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 07/03/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE Although pediatric spinal deformity correction using pedicle screws has a very low rate of complications, the long-term consequences of screw malposition is unknown. CT navigation has been proposed to improve screw accuracy. The aim of this study was to determine whether intraoperative navigation during pedicle screw placement in pediatric scoliosis makes screw placement more accurate. We also examined radiation exposure, operative time blood loss and complications with and without the use of CT navigation in pediatric spinal deformity surgery. METHODS A systematic review of the literature was conducted. After screening, 13 articles were qualitatively and quantitatively analyzed to be used for the review. A random effects meta-analysis using REML methodology was employed to compare outcomes of screw accuracy, estimated blood loss, radiation exposure, and surgical duration. RESULTS Screws placed with CT navigation surgery were three times as likely to be deemed "acceptable" compared with screws placed with freehand and 2D fluoroscopy assistance, twice as likely to be "perfect", and only 1/3 as likely to be potentially unsafe (all p value < 0.01). EBL was not significantly different between groups; however, operative time was roughly thirty minutes longer on average. Random effects analysis showed no significant difference in effective dose radiation while using CT navigation (p = 0.06). CONCLUSION This systematic review of the literature demonstrates that intraoperative navigation results in more accurate pedicle screw placement compared to non-navigated techniques. We found that blood loss was similar in navigated and non-navigated surgery. Operative time was found to be approximately a half hour longer on average in navigated compared to non-navigated surgery. Effective radiation dose trended higher in navigated cases compared to non-navigated cases but did not reach statistical significance.
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Affiliation(s)
- Keith D Baldwin
- Division of Orthopaedics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Manasa Kadiyala
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Divya Talwar
- Division of Orthopaedics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Wudbhav N Sankar
- Division of Orthopaedics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - John Jack M Flynn
- Division of Orthopaedics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jason B Anari
- Division of Orthopaedics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Tharp P, King RW, Frankel BM, Wooster MD. Thoracic Endovascular Aortic Repair for Iatrogenic Injury of the Thoracic Aorta. J Endovasc Ther 2021; 29:813-817. [PMID: 34894824 DOI: 10.1177/15266028211065968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Address iatrogenic injury to the descending thoracic aorta by breached spinal screws through a novel approach of concomitant spinal screw removal and thoracic endovascular repair (TEVAR) placement. CASE REPORT A 36-year-old female with idiopathic scoliosis underwent T4 to L3 bilateral pedicle instrumentation with spinal fusion and correction of scoliosis deformity. Ten months post-operative, she continued to complain of mid-thoracic pain; computed tomography (CT) angiography revealed protrusion of the left T5 and T6 transpedicular screws into her descending thoracic aorta by 3 and 5 mm, respectively. She was taken to the odds ratio (OR) in a combination case with vascular and neurosurgery. Positioned in the right lateral decubitus position, TEVAR was successfully deployed while neurosurgery concurrently removed the invading spinal screws via posterior spinal exposure. Neurosurgery then completely revised the spinal hardware during the same operation. The patient progressed well throughout the remainder of her hospital stay and was discharged on postoperative day 4. Two-year angiography demonstrated a well-placed TEVAR with no extravasation or aortic abnormality. CONCLUSIONS In the setting of iatrogenic aortic injury due to pedicle screws, concomitant TEVAR and spinal screw removal is a safe and feasible treatment option that allows for spinal reconstruction to occur without multiple trips to the operating room.
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Affiliation(s)
- Peyton Tharp
- College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Ryan W King
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Bruce M Frankel
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - Mathew D Wooster
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC, USA
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Giotta Lucifero A, Gragnaniello C, Baldoncini M, Campero A, Savioli G, Tartaglia N, Ambrosi A, Luzzi S. Rating the incidence of iatrogenic vascular injuries in thoracic and lumbar spine surgery as regards the approach: A PRISMA-based literature review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:3172-3190. [PMID: 34410504 DOI: 10.1007/s00586-021-06956-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 08/02/2021] [Accepted: 08/06/2021] [Indexed: 02/08/2023]
Abstract
PURPOSE To assess the rate, timing of diagnosis, and repairing strategies of vascular injuries in thoracic and lumbar spine surgery as their relationship to the approach. METHODS PubMed, Medline, and Embase databases were utilized for a comprehensive literature search based on keywords and mesh terms to find articles reporting iatrogenic vascular injury during thoracic and lumbar spine surgery. English articles published in the last ten years were selected. The search was refined based on best match and relevance. RESULTS Fifty-six articles were eligible, for a cumulative volume of 261 lesions. Vascular injuries occurred in 82% of instrumented procedures and in 59% during anterior approaches. The common iliac vein (CIV) was the most involved vessel, injured in 49% of anterior lumbar approaches. Common iliac artery, CIV, and aorta were affected in 40%, 28%, and 28% of posterior approaches, respectively. Segmental arteries were injured in 68% of lateral approaches. Direct vessel laceration occurred in 81% of cases and recognized intraoperatively in 39% of cases. CONCLUSIONS Incidence of iatrogenic vascular injuries during thoracic and lumbar spine surgery is low but associated with an overall mortality rate up to 65%, of which less than 1% for anterior approaches and more than 50% for posterior ones. Anterior approaches for instrumented procedures are at risk of direct avulsion of CIV. Posterior instrumented fusions are at risk for injuries of iliac vessels and aorta. Lateral routes are frequently associated with lesions of segmental vessels. Suture repair and endovascular techniques are useful in the management of these severe complications.
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Affiliation(s)
- Alice Giotta Lucifero
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, Neurosurgery Unit, University of Pavia, Polo Didattico "Cesare Brusotti", Viale Brambilla, 74, 27100, Pavia, Italy
| | - Cristian Gragnaniello
- Department of Neurological Surgery, University of Illinois at Chicago, Il 1200 W Harrison St, Chicago, IL, 60607, USA
| | - Matias Baldoncini
- Laboratory of Neuroanatomic Microsurgical-LaNeMic-II Division of Anatomy, School of Medicine, University of Buenos Aires, CABA C1053, Buenos Aires, Argentina
| | - Alvaro Campero
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, T4000, Tucumán, Argentina.,Department of Neurological Surgery, Hospital Padilla, T4000, Tucumán, Argentina
| | - Gabriele Savioli
- Emergency Department, Fondazione IRCCS Policlinico San Matteo, Viale C. Golgi, 19, 27100, Pavia, Italy.,PhD School in Experimental Medicine, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia Polo Didattico "Cesare Brusotti", Viale Brambilla, 74, 27100, Pavia, Italy
| | - Nicola Tartaglia
- Department of Medical and Surgical Sciences, University of Foggia, Italy Via A.Gramsci 89/91, 71100, Foggia, Italy
| | - Antonio Ambrosi
- Department of Medical and Surgical Sciences, University of Foggia, Italy Via A.Gramsci 89/91, 71100, Foggia, Italy
| | - Sabino Luzzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, Neurosurgery Unit, University of Pavia, Polo Didattico "Cesare Brusotti", Viale Brambilla, 74, 27100, Pavia, Italy. .,Department of Surgical Sciences, Neurosurgery Unit, Fondazione IRCCS Policlinico San Matteo, Viale C. Golgi, 19, 27100, Pavia, Italy.
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Koban O, Akar E, Öğrenci A, Yilmaz M, Dalbayrak S. Any Instrument in a Surgeon's Hand can be Fatal: Unusual Iliac Artery Injury in Lumbar Spinal Deformity Surgery. World Neurosurg 2020; 143:276-279. [PMID: 32777398 DOI: 10.1016/j.wneu.2020.07.217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 07/28/2020] [Accepted: 07/30/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Vascular complications, which we rarely encounter during lumbosacral stabilization surgeries, can be life-threatening if they are not treated quickly. These arterial injuries occur during screw insertion. Our presentation with the common iliac artery injury during the decortication process in transverse processes with the "pedicle awl" will be the first case in the literature to our knowledge. CASE DESCRIPTION Lumbosacral decompression and stabilization surgery was performed in a 57-year-old patient with L1-S1 spinal stenosis and scoliosis. After the stabilization process was completed, while decorticating the transverse processes with the pedicle awl, the tool fell to the paravertebral region, and then active arterial hemorrhage was observed at the surgical site. Hemostasis was achieved in the surgical field, but a rapid progressive drop was observed in the patient's blood pressure. The surgery was quickly terminated, and the patient was turned to the supine position. Vascular surgeons opened the abdomen with a midline laparotomy, and approximately 2600 mL hematoma was evacuated from the retroperitoneum. The 5-mm defect in the left common iliac artery was repaired by primary suturing. The patient had no problem in postoperative follow-up and was discharged on the 10th postoperative day. CONCLUSIONS In these complications that we rarely encounter in lumbosacral stabilization surgeries, perioperative findings should be well evaluated, and rapid intervention should be made in cases in which vascular injury is considered. One must remember that every tool used during surgery can be dangerous even in an experienced hand.
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Affiliation(s)
- Orkun Koban
- Department of Neurosurgery, Okan University, Istanbul, Turkey
| | - Ezgi Akar
- Haydarpaşa Numune Training and Research Hospital, Istanbul, Turkey.
| | - Ahmet Öğrenci
- Department of Neurosurgery, Okan University, Istanbul, Turkey
| | - Mesut Yilmaz
- Department of Neurosurgery, Neurospinal Academy, Istanbul, Turkey
| | - Sedat Dalbayrak
- Department of Neurosurgery, Okan University, Istanbul, Turkey
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Patel SA, McDonald CL, Reid DBC, DiSilvestro KJ, Daniels AH, Rihn JA. Complications of Thoracolumbar Adult Spinal Deformity Surgery. JBJS Rev 2020; 8:e0214. [PMID: 32427777 DOI: 10.2106/jbjs.rvw.19.00214] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Adult spinal deformity (ASD) is a challenging problem for spine surgeons given the high risk of complications, both medical and surgical.
Surgeons should have a high index of suspicion for medical complications, including cardiac, pulmonary, thromboembolic, genitourinary and gastrointestinal, renal, cognitive and psychiatric, and skin conditions, in the perioperative period and have a low threshold for involving specialists.
Surgical complications, including neurologic injuries, vascular injuries, proximal junctional kyphosis, durotomy, and pseudarthrosis and rod fracture, can be devastating for the patient and costly to the health-care system. Mortality rates have been reported to be between 1.0% and 3.5% following ASD surgery. With the increasing rate of ASD surgery, surgeons should properly counsel patients about these risks and have a high index of suspicion for complications in the perioperative period.
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George K, Burke S, Park S, Suarez L, Riesenburger R. Presentation and management of IVC and iliac vein encroachment by lumbar pedicle screws: a case-report. J Surg Case Rep 2020; 2020:rjaa040. [PMID: 32201557 DOI: 10.1093/jscr/rjaa040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 02/14/2020] [Indexed: 11/13/2022] Open
Abstract
Pedicle screws are commonly used in spinal surgeries and are relatively safe, with venous complications occurring rarely. We report a patient with imaging following a L4-5 fusion that showed indentation of the inferior vena cava and right common iliac vein by the right L4 and L5 pedicle screws. She underwent revision surgery in which the hardware was removed and no bleeding was observed. Intraoperative venogram confirmed vascular integrity and absence of indentation on the venous structures following screw removal. The patient recovered without complications. Venous contact by pedicle screws should be treated on a case-by-case basis in a multidisciplinary approach with vascular surgery. We discuss a treatment algorithm for the operative management of this problem.
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Affiliation(s)
- Keith George
- Department of Neurosurgery, Tufts Medical Center, Boston, MA, USA
| | - Shane Burke
- Department of Neurosurgery, Tufts Medical Center, Boston, MA, USA
| | - Sandra Park
- Department of Vascular Surgery, Tufts Medical Center, Boston, MA, USA
| | - Luis Suarez
- Department of Vascular Surgery, Tufts Medical Center, Boston, MA, USA
| | - Ron Riesenburger
- Department of Neurosurgery, Tufts Medical Center, Boston, MA, USA
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Monzio-Compagnoni N, Aseni P, Romani F. Emergency Aortic Control for Pedicle Screw Misplacement During Spinal Fixation. Ann Vasc Surg 2020; 66:669.e1-669.e3. [PMID: 31923600 DOI: 10.1016/j.avsg.2020.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 12/28/2019] [Accepted: 01/01/2020] [Indexed: 11/16/2022]
Abstract
Aortic iatrogenic injuries during spinal instrumentation are rare but carry a high risk of mortality. In this report, we describe the case of a 26-year-old man with traumatic vertebral fracture and subsequent spinal cord injury who underwent posterior vertebral fixation at our trauma center. The neurosurgical procedure was complicated by the misplacement of a spinal pedicle screw, which almost penetrated the descending thoracic aorta. To avoid a possibly fatal bleeding, we safely removed the pedicle screw with the help of a prophylactic proximal compliant aortic balloon ready to be inflated in case of hemorrhage. Follow-up computed tomography scan did not detect any defect of the aortic wall, nor any sign of bleeding. After a 15-month follow-up, the patient is alive and in good physical conditions, with little residual neurologic deficit due to the spinal trauma.
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Affiliation(s)
| | - Paolo Aseni
- Emergency Medicine Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Federico Romani
- Vascular Surgery Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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Abstract
STUDY DESIGN Survey analysis among spine surgeons. OBJECTIVE To identify current consensus and discrepancies in managing adverse intraoperative events among spine surgeons. SUMMARY OF BACKGROUND DATA Major intraoperative events are not commonly the subject of formal medical training, in part due to the relative paucity of their occurrence and in part due to an insufficient evidence base. Given the clinical impact of appropriate complication management, it is important to identify where surgeons may be able to improve decision making when choosing interventions. METHODS A survey was created including five hypothetical unpredicted scenarios affecting different organ systems to assess the respondents' preferred reactions. The five clinical vignettes that were selected by the researchers involved: 1) loss of spinal signals in neuro-monitoring, 2) prone position cardiac arrest, 3) prone position hypoxia during thoracic corpectomy and instrumentation, 4) supine cervical vertebral artery injury, and 5) sudden onset hypotension in major prone position reconstructive spine surgery. Twenty-eight surveys (Spine Fellows n = 11; Spine surgeon Faculty n = 17) were completed and returned to the investigators. Results were sorted and ranked according to the frequency each action was identified as a top five choice. RESULTS Following formal statistical evaluation loss of signals in neuro-monitoring had the statistically significantly most uniform response while the scenario involving cardiac compromise had the most heterogeneous. Many "best" responses had near or complete consensus while some "distractor" possibilities that could harm a patient were also selected by the respondents. CONCLUSION The heterogeneity of responses in the face of "disaster scenario" intraoperative events shows there is room for more thorough and directed education of spine surgeons during training. As surgical teaching moves toward increased use of patient simulation and situational learning, these vignettes hopefully serve to provide direction for training future spine surgeons on how best to approach difficult situations. LEVEL OF EVIDENCE 4.
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Moutinho M, Silvestre L, Belo D, Soares T, Pedro LM. Complete Disruption of The Iliac Vessels During Spinal Surgery With Delayed Presentation. EJVES Short Rep 2019; 43:33-36. [PMID: 31193961 PMCID: PMC6545402 DOI: 10.1016/j.ejvssr.2019.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/25/2019] [Accepted: 04/27/2019] [Indexed: 11/28/2022] Open
Abstract
Introduction The posterior approach to the lumbar spine is most commonly used to treat lumbar spine pathology. Vascular complications, although rare, have a high mortality rate. This is the report of an arterial lesion complicating a L5 hemilaminectomy and its surgical resolution. The need to remain vigilant for this condition, which requires prompt diagnosis and treatment, is emphasised. Report A 31 year old woman was admitted to the neurosurgery department with L5 right-sided sciatica and an associated radiculopathy, and paraesthesia of the first toe of the right foot. She had previously undergone surgical correction of a L4 – L5 lumbar disc herniation, as well as a left oophorectomy and chemotherapy for ovarian neoplasia. A right L5 hemilaminectomy associated with right L5 – S1 foraminotomy and L5 – S1 discectomy was performed with the patient in the ventral position. The procedure was carried out without any apparent complications. In the first three post-operative days the patient complained persistently of orthostatic hypotension and a drop in haemoglobin was observed. Computed tomography angiography revealed what appeared to be a complete transection of the right common iliac artery and vein, with active haemorrhage, and a large pseudoaneurysm. Immediate surgery was carried out with reconstruction consisting of a 9 mm Dacron graft interposed in the right common iliac artery, as well as ligation of the right common iliac vein, which was not amenable to repair. The post-operative period was uneventful. The patient was discharged on day 13 with normal lower limb pulses and mild oedema of the right lower limb, controlled with elastic compression stockings. Discussion Iatrogenic injuries of the large abdominal vessels during spinal surgery is rare but serious. Close patient surveillance and remaining vigilant for these life threatening vascular lesions are crucial in the peri-operative period of spinal surgery. This type of computed tomography angiography images are rare. Vascular lesions resulting from a posterior approach to the lumbar spine are uncommon. These lesions are often fatal and this case serves as a warning to other surgeons and anaesthetists.
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Affiliation(s)
- Mariana Moutinho
- Departamento de Coração e Vasos, Serviço de Cirurgia Vascular, Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Universidade de Lisboa, Portugal
| | - Luís Silvestre
- Departamento de Coração e Vasos, Serviço de Cirurgia Vascular, Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Universidade de Lisboa, Portugal
| | - Diogo Belo
- Serviço de Neurocirurgia, Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Universidade de Lisboa, Portugal
| | - Tony Soares
- Departamento de Coração e Vasos, Serviço de Cirurgia Vascular, Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Universidade de Lisboa, Portugal
| | - Luís Mendes Pedro
- Departamento de Coração e Vasos, Serviço de Cirurgia Vascular, Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Universidade de Lisboa, Portugal
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13
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Suh SW, Kim GU, Lee HN, Yang JH, Chang DG. Delayed presentation of infected common iliac artery pseudoaneurysm caused by malpositioned pedicle screw after minimally invasive scoliosis surgery. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:68-72. [PMID: 31089815 DOI: 10.1007/s00586-019-06005-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 05/09/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE To report delayed onset common iliac artery perforation and infected pseudoaneurysm caused by malpositioned pedicle screw after minimally invasive scoliosis surgery (MISS). METHODS A 21-year-old female was referred to our hospital with a 1-week history of abrupt right-sided low back pain, lower abdominal pain, and fever with a history of MISS using cannulated pedicle screws 18 months earlier. Paravertebral arterial erosion with pseudoaneurysm and retroperitoneal and paraspinal abscess were suspected. RESULTS We performed resection of the pseudoaneurysm, vascular repair of right common iliac artery by angioplasty with a bovine patch and removal of implant. At 6 months after the last surgery, she had no limitations or problems in her daily activities with no recurrence of low back pain, abdominal pain, or fever as well as without loss of deformity. CONCLUSIONS Our case showed that misplaced pedicle screws can cause potentially fatal complications, such as infected pseudoaneurysm, even in the late postoperative period.
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Affiliation(s)
- Seung-Woo Suh
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Guro-Dong, Guro-Gu, Seoul, 152-703, Republic of Korea
| | - Gang-Un Kim
- Department of Orthopaedic Surgery, Sanggye Paik Hospital, College of Medicine, Inje University, 1342, Dongil-Ro, Nowon-Gu, Seoul, 01757, Republic of Korea
| | - Hoon-Nyun Lee
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Guro-Dong, Guro-Gu, Seoul, 152-703, Republic of Korea
| | - Jae Hyuk Yang
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Guro-Dong, Guro-Gu, Seoul, 152-703, Republic of Korea
| | - Dong-Gune Chang
- Department of Orthopaedic Surgery, Sanggye Paik Hospital, College of Medicine, Inje University, 1342, Dongil-Ro, Nowon-Gu, Seoul, 01757, Republic of Korea.
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14
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Latka K, Zurawel R, Maj B, Olbrycht T, Chowaniec J, Latka D. Iatrogenic lumbar artery pseudoaneurysm after lumbar transpedicular fixation: Case report. SAGE Open Med Case Rep 2019; 7:2050313X19835344. [PMID: 30858976 PMCID: PMC6404053 DOI: 10.1177/2050313x19835344] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 02/12/2019] [Indexed: 12/03/2022] Open
Abstract
Only a few cases of iatrogenic lumbar injury have been reported in the
literature. A 58-year-old male with severe back pain was admitted to our
department. The patient was qualified for the transpedicular stabilization with
interbody fixation at L4/L5 and L5/S1 levels. On the first day after surgery,
the patient was mobile and reported significant pain relief. He was discharged
the same day. After 2 weeks, the patient returned with severe right lower
abdominal pain and radicular pain in his right leg. He was administered to the
Neurology Department where the presence of a lumbar muscle hematoma and lumbar
artery pseudoaneurysm were discovered. He was transferred to the Vascular
Surgery Department where aortography was performed and the pseudoaneurysm was
embolized. After few days, the patient’s overall condition improved
significantly. Eight weeks after surgery, he was pain-free. Our case shows how
initially innocuous symptoms may be the result of serious complications.
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Affiliation(s)
- Kajetan Latka
- Department of Neurosurgery, Opole University Hospital, Opole, Poland
| | - Robert Zurawel
- Department of General and Vascular Surgery, Opole University Hospital, Opole, Poland
| | - Boguslaw Maj
- Department of Neurosurgery, Opole University Hospital, Opole, Poland
| | - Tomasz Olbrycht
- Department of Neurosurgery, Opole University Hospital, Opole, Poland
| | - Jacek Chowaniec
- Department of Neurosurgery, Opole University Hospital, Opole, Poland
| | - Dariusz Latka
- Department of Neurosurgery, Opole University Hospital, Opole, Poland
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15
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Iatrogenic Lumbar Artery Injury in Spine Surgery: A Literature Review. World Neurosurg 2019; 122:266-271. [DOI: 10.1016/j.wneu.2018.10.219] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 10/26/2018] [Accepted: 10/29/2018] [Indexed: 12/14/2022]
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