Iliac Artery Injury During Lumbar Disc Hernia Surgery

Psoas Hematoma After Posterior Lumbar Interbody fusion: A Case Report and Literature Review

Introduction

This article introduced the management of a case with severe left lower extremity pain and forced hip flexion after posterior lumbar interbody fusion and a final diagnosis of left psoas hematoma.

Materials and methods

Here we reported a case of a 65-year-old female received posterior lumbar interbody fusion (PLIF) for L4-L5 spondylolisthesis and L4 instability. On the postoperative day one, the hemoglobin level decreased from 108 g/L to 78 g/L. Meanwhile, the patient presented low back pain and inner thigh radiating pain (VAS pain scale = 8). The pain was so severe that it could be barely relieved by keeping left hip in flexion position. On the postoperative day 6, the pain was still severe even after taking mecobalamin, ankylosaurus, dehydrant agents and central pain relievers(VAS pain scale = 9). Computed Tomography indicated a left intramuscular hematoma image extending down to the left iliac fossa. Active hemorrhage of lumbar segmental arterial was detected by B-ultrasound. The patient then received vascular embolization under angiography on the postoperative day 7.

Results

The pain in the low back and inner thigh were significantly relieved after the procedure (VAS3-4). On the postoperative day nineteen, the left hip can be fully extended, but the patient was still not able to stand on left leg without a walking stick. On the postoperative day 27, she was able to walk independently.

Discussion

The main reason for the complication was the second conical dilation channel slipped and entered the lateral side of the vertebral body along the transverse process. After timely embolization, pain was significantly relieved and muscle strength was improved.

Conclusions

Angiographic embolization is an effective treatment for psoas hematoma after posterior lumbar interbody fusion.

Rating the incidence of iatrogenic vascular injuries in thoracic and lumbar spine surgery as regards the approach: A PRISMA-based literature review

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.

Any Instrument in a Surgeon's Hand can be Fatal: Unusual Iliac Artery Injury in Lumbar Spinal Deformity Surgery

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.