The Efficacy of Anterior Spine Exposure by An Orthopedic Surgeon

Lateral approach to the lumbar spine: The utility of an access surgeon

Background

Lateral lumbar interbody fusions (LLIFs) utilize a retroperitoneal approach that avoids the intraperitoneal organs and manipulation of the anterior vasculature encountered in anterior approaches to the lumbar spine. The approach was championed by spinal surgeons; however, general/vasculature surgeons may be more comfortable with the approach.

Objective

The objective of this study was to compare short-term outcomes following LLIF procedures based on whether a spine surgeon or access surgeon performed the approach.

Materials and Methods

We retrospectively identified all one- to two-level LLIFs at a tertiary care center from 2011 to 2021 for degenerative spine disease. Patients were divided into groups based on whether a spine surgeon or general surgeon performed the surgical approach. The electronic medical record was reviewed for hospital readmissions and complication rates.

Results

We identified 239 patients; of which 177 had approaches performed by spine surgeons and 62 by general surgeons. The spine surgeon group had fewer levels with posterior instrumentation (1.40 vs. 2.00; P < 0.001) and decompressed (0.94 vs. 1.25, P = 0.046); however, the two groups had a similar amount of two-level LLIFs (29.9% vs. 27.4%, P = 0.831). This spine surgeon approach group was found to have shorter surgeries (281 vs. 328 min, P = 0.002) and shorter hospital stays Length of Stay (LOS) (3.1 vs. 3.6 days, P = 0.019); however, these differences were largely attributed to the shorter posterior fusion construct. On regression analysis, there was no statistical difference in postoperative complication rates whether or not an access surgeon was utilized (P = 0.226).

Conclusion

Similar outcomes may be seen regardless of whether a spine or access surgeon performs the approach for an LLIF.

Management of Vascular Complications during Anterior Lumbar Spinal Surgery Using Mini-Open Retroperitoneal Approach

BACKGROUND

Anterior retroperitoneal spine exposure has become increasingly performed for the surgical treatment of various spinal disorders. Despite its advantages, the procedure is not riskless and can expose to potentially life-threatening vascular lesions. The aim of this review is to report the vascular lesions that can happen during anterior lumbar spinal surgery using mini-open retroperitoneal approach and to describe their management.

METHODS

A systematic literature search was performed according to PRISMA to identify studies published in English between January 1980 and December 2019 reporting vascular complications during anterior lumbar spinal surgery with mini-open retroperitoneal approach. Three authors independently conducted the literature search on PubMed/Medline database using a combination of the following terms: "spinal surgery", "anterior lumbar surgery (ALS)", "anterior lumbar interbody fusion (ALIF)", "lumbar total disc replacement", "artificial disc replacement", "vascular complications", "vascular injuries". Vascular complications were defined as any peri-operative or post-operative lesions related to an arterial or venous vessel. The management of the vascular injury was extracted.

RESULTS

Fifteen studies fulfilled the inclusion criteria. Venous injuries were observed in 13 studies. Lacerations and deep venous thrombosis ranged from 0.8% to 4.3% of cases. Arterial lesions were observed in 4 studies and ranged from 0.4% to 4.3% of cases. It included arterial thrombosis, lacerations or vasospasms. The estimated blood loss was reported in 10 studies and ranged from 50 mL up to 3000 mL. Vascular complications were identified as a cause of abortion of the procedure in 2 studies, representing respectively 0.3% of patients who underwent ALS and 0.5% of patients who underwent ALIF.

CONCLUSION

Imaging pre-operative planning is of utmost importance to evaluate risk factors and the presence of anatomic variations in order to prevent and limit vascular complications. Cautions should be taken during the intervention when manipulating major vessels and routine monitoring of the limb oxygen saturation should be systematically performed for an early detection of arterial thrombosis. The training of the surgeon access remains a key-point to prevent and manage vascular complications during anterior lumbar spinal surgery with mini-open retroperitoneal.

Anterior Lumbar Interbody Fusion With and Without an "Access Surgeon": A Systematic Review and Meta-analysis

STUDY DESIGN

A systematic review and meta-analysis.

OBJECTIVE

The aim of this study was to investigate the outcomes of anterior lumber interbody fusion (ALIF) with and without an "access surgeon."

SUMMARY OF BACKGROUND DATA

Anterior approaches for spine operations have become increasingly popular but may often involve unfamiliar anatomy and territory for spine surgeons, potentially placing the patient at risk to a greater proportion of approach-related complications. Thus, many spine surgeons require or prefer the assistance of an "access surgeon" to perform the exposure. However, there has been much debate about the necessity of an "access surgeon."

METHODS

A systematic search of six databases from inception to April 2016 was performed by two independent reviewers. Meta-analysis was used to pool overall rates, and compare the outcomes of ALIF with an access surgeon and without.

RESULTS

A total of 58 (8028 patients) studies were included in this meta-analysis. The overall intraoperative complications were similar with and without an "access surgeon." The overall pooled rate of arterial injuries [no access 0.44% vs. access 1.16%, odds ratio (OR) 2.67, P < 0.001], retrograde ejaculation (0.41% vs. 0.96%, OR 2.34, P = 0.005), and ileus (1.93% vs. 2.26%, OR 2.45, P < 0.001) was higher with an "access surgeon." However, the overall pooled rates of peritoneal injury (0.44% vs. 0.16%, OR 0.36, P = 0.034) and neurological injury (0.99% vs. 0.11%, OR 0.11, P < 0.001) were lower with an "access surgeon." Total postoperative complications (5.95% vs. 4.08%, OR 0.67, P < 0.001) were lower with an "access surgeon" along with prosthesis complications (1.59% vs. 0.89%, OR 0.56, P < 0.001) and reoperation rates (2.28% vs. 1.31%, OR 0.57, P < 0.001).

CONCLUSION

Compared with no access surgeon, the use of an access surgeon was associated with similar intraoperative complication rates, higher arterial injuries, retrograde ejaculation, ileus, and lower prosthesis complications, reoperation rates, and postoperative complications. In cases wherein exposure may be difficult, support from an "access surgeon" should be available.

LEVEL OF EVIDENCE

1.

Surgical treatment of lumbosacral tuberculosis by one-stage debridement and anterior instrumentation with allograft through an extraperitoneal anterior approach

BACKGROUND

This study was aimed to investigate the clinical outcome of lumbosacral tuberculosis treatment by one-stage radical debridement with bone allograft reconstruction and anterior instrumentation via a retroperitoneal approach.

METHODS

We retrospectively analyzed a series of 43 patients with lumbosacral tuberculosis in whom the lumbosacral junction was exposed via an anterior midline retroperitoneal approach. After radical debridement, two parallel tricortical iliac crest bone allografts were placed to reconstruct the anterior column, and then anterior fixation was performed.

RESULTS

The mean follow-up period was 34 months (range, 24-91 months), during which no obvious loss of correction was observed. No case experienced recurrence, tuberculous peritonitis, erectile dysfunction, or retrograde ejaculation.

CONCLUSIONS

The midline retroperitoneal approach provides direct and safe access to lesions of lumbosacral tuberculosis. Two parallel structural iliac crest allografts and anterior instrumentation effectively stabilize the lumbosacral junction.

Access related complications during anterior exposure of the lumbar spine

The new millennium has witnessed the emergence of minimally invasive, non-posterior based surgery of the lumbar spine, in particular via lateral based methodologies to discectomy and fusion. In contrast, and perhaps for a variety of reasons, anterior motion preservation (non-fusion) technologies are playing a comparatively lesser, though incompletely defined, role at present. Lateral based motion preservation technologies await definition of their eventual role in the armamentarium of minimally invasive surgical therapies of the lumbar spine. While injury to the major vascular structures remains the most serious and feared complication of the anterior approach, this occurrence has been nearly eliminated by the use of lateral based approaches for discectomy and fusion cephalad to L5-S1. Whether anterior or lateral based, non-posterior approaches to the lumbar spine share certain access related pitfalls and complications, including damage to the urologic and neurologic structures, as well as gastrointestinal and abdominal wall issues. This review will focus on the recognition, management and prevention of these anterior and lateral access related complications.

Access related complications in anterior lumbar surgery performed by spinal surgeons

PURPOSE

Anterior lumbar surgery is a common procedure for anterior lumbar interbody fusion (ALIF) and artificial disc replacement (ADR). Our aim was to study the exposure related complications for anterior lumbar spinal surgery performed by spinal surgeons.

METHODS

A retrospective review was performed for 304 consecutive patients who underwent anterior lumbar spinal surgery over 10 years (2001-2010) at our institution. Each patient's records were reviewed for patients' demographics, diagnosis, level(s) of surgery, procedure and complications related to access surgery. Patients undergoing anterior lumbar access for tumour resection, infection, trauma and revision surgeries were excluded.

RESULTS

All patients underwent an anterior paramedian retroperitoneal approach from the left side. The mean age of patients was 43 years (10-73; 197 males, 107 females). Indications for surgery were degenerative disc disease (DDD 255), degenerative spondylolisthesis (23), scoliosis (18), iatrogenic spondylolisthesis (5) and pseudoarthrosis (3). The procedures performed were single level surgery--L5/S1 (n = 147), L4/5 (n = 62), L3/4 (n = 7); two levels--L4/5 and L5/S1 (n = 74), L3/4 and L4/5 (n = 4); three levels--L3/4, L4/5, L5/S1 (n = 5); four levels--L2/3, L3/4, L4/5, L5/S1 (n = 5). The operative procedures were single level ADR (n = 131), a single level ALIF (n = 87) with or without posterior fusion, two levels ALIF (n = 54), two levels ADR (n = 14), a combination of ADR/ALIF (n = 10), three levels ALIF (n = 1), three levels ADR/ALIF/ALIF (n = 1), ADR/ADR/ALIF (n = 2), four levels ALIF (n = 1) and finally 3 patients underwent a four level ADR/ADR/ALIF/ALIF. The overall complication rate was 61/304 (20 %). This included major complications (6.2 %)--venous injury requiring suture repair (n = 14, 4.6 %) and arterial injury (n = 5 [1.6 %], 3 repaired, 2 thrombolysed). Minor complications (13.8 %) included venous injury managed without repair (n = 5, 1.6 %), infection (n = 13, 4.3 %), incidental peritoneal opening (n = 12, 3.9 %), leg oedema (n = 2, 0.6 %) and others (n = 10, 3.3 %). We had no cases of retrograde ejaculation.

CONCLUSION

We report a very thorough and critical review of our anterior lumbar access surgeries performed mostly for DDD and spondylolisthesis at L4/5 and L5/S1 levels. Vascular problems of any type (24/304, 7.8 %) were the most common complication during this approach. The incidence of major venous injury requiring repair was 14/304 (4.6 %) and arterial injury 5/304 (1.6 %). The requirement for a vascular surgeon with the vascular injury was 9/304 (3 %; 5 arterial injuries; 4 venous injuries). This also suggests that the majority of the major venous injuries were repaired by the spinal surgeon (10/14, 71 %). Our results are comparable to other studies and support the notion that anterior access surgery to the lumbar spine can be performed safely by spinal surgeons. With adequate training, spinal surgeons are capable of performing this approach without direct vascular support, but they should be available if required.

Vascular injuries during anterior exposure of the thoracolumbar spine

BACKGROUND

The aim of this study was to evaluate the vascular injuries, repairs, and complications encountered during anterior thoracolumbar spine exposures.

METHODS

The medical records of patients undergoing anterior spine exposures from January 2004 to June 2010 were retrospectively analyzed.

RESULTS

A total of 269 anterior exposures were performed in 260 patients. The average patient age was 50.1 years, and the average body mass index was 29.0. Female patients represented 146 (54.3%) cases. Previous spinal surgery was noted in 145 (53.9%) cases, and 19 (7.1%) had previous anterior exposure. The median estimated blood loss (EBL) was 300 mL, and there were no postoperative mortalities. A vascular injury occurred in 37 cases (13.8%), with redo anterior exposure (n = 19, 52% vs. 11%; P < 0.001), previous spinal surgery (n = 145, 19% vs. 7%; P = 0.01), and diagnosis of a tumor (n = 14, 36% vs. 12.5%; P = 0.03) being associated with increased vascular injury. A vascular injury resulted in greater EBL (median: 800 mL vs. 300 mL; P < 0.001) and longer hospitalization (median: 7 days vs. 5 days; P = 0.04). Most frequently injured was the left common iliac vein (in 21 of the 37 [52.5%] injured cases). A vascular surgeon performed the exposure in 159 (59.1%) cases. There was a decrease in EBL (250 mL vs. 500 mL; P < 0.001), total incision time (290 minutes vs. 404 minutes; P = 0.002), and length of stay (5 days vs. 6.5 days; P < 0.001) as compared with the operations where the vascular surgeon was not involved in the exposure. These cases also had an increased incidence of any vascular injury (28 vs. 9; P = 0.04). There were no differences between groups regarding vascular injury type, repair type, or the incidence of deep venous thrombosis.

CONCLUSION

Collaboration between spine and vascular teams may result in decreased blood loss and consequently improved morbidity and length of hospital stay.

Analysis of intraoperative difficulties and management of operative complications in revision anterior exposure of the lumbar spine: a report of 25 consecutive cases

PURPOSE

After a first anterior approach to the lumbar spine, formation of adhesions of soft tissues to the spine increases the surgical difficulties and potential for iatrogenic injury during the revision exposure. The objective of this study was to identify the intraoperative difficulties and postoperative complications associated with revision anterior lumbar spine procedures in a single institution.

METHODS

This is a retrospective review of 25 consecutive anterior revision lumbar surgeries in 22 patients (7 men and 15 women) operated on between 1998 and 2011. Patients with trauma or malignancies were excluded. The mean age of the patients at the time of revision surgery was 56 years (range 20-80 years). The complications were analyzed depending on the operative level and the time between the index surgery and the revision.

RESULTS

Six major complications (five intraoperatively and one postoperatively) occurred in five patients (20 %): three vein lacerations (12 %) and two ureteral injuries (8 %), despite the presence of a double-J ureteral stent. The three vein damages were repaired or ligated by a vascular surgeon. One of the two ureteral injuries led to a secondary nephrectomy after end-to-end anastomosis failure; the other necessitated secondary laparotomy for small bowel obstruction.

CONCLUSIONS

Anterior revision of the lumbar spine is technically challenging and is associated with a high rate of vascular or urologic complications. Therefore, the potential complications of the procedure must be weighted against its benefits. When iterative anterior lumbar approach is mandatory, exposure should be performed by an access surgeon in specialized centers that have ready access to vascular and urologic surgeons.

Comparison of perioperative parameters and complications observed in the anterior exposure of the lumbar spine by a spine surgeon with and without the assistance of an access surgeon

BACKGROUND CONTEXT

The anterior approach to the spine is becoming an increasingly important avenue to treat spine conditions. Most of the literature reporting on the exposure uses an access surgeon assisting the spine surgeon to expose and prepare the spine for implant.

PURPOSE

To compare perioperative parameters and complications in anterior lumbar spine surgery with the exposure performed either by a spine surgeon or a general surgeon.

STUDY DESIGN

A retrospective cohort study comparing perioperative parameters and complications of anterior lumbar spine surgery.

METHODS

A retrospective review was completed on 96 consecutive patients who underwent anterior spine surgery between Levels L3 and S1 from 1995 to 2008. Patient and surgery characteristics including demographics, comorbidities, perioperative parameters, and complications were logged. In the first 56 consecutive patients, a general surgeon completed the exposure, with an additional patient who later had the exposure performed by a general surgeon because of extensive prior abdominal surgeries. In the next 39 patients, the orthopedic surgeon completed the exposure.

RESULTS

When the operation was performed solely by a spine surgeon, the estimated blood loss, operative time, and hospital stay was 204 mL, 2.80 hours, and 3.5 days, respectively. In the procedures completed with the aid of a general surgeon, it was found that the same parameters were 420 mL, 3.93 hours, and 4.7 days, respectively, and statistically significantly less in the group without the assistance of the general surgeon (p=.0007, p=.0003, and p=.0006, respectively). Fewer complications also were observed in that group (p<.00001). The most common complication was an ileus. Major complications including retrograde ejaculation, iliac vein bleeding, peritoneal rent requiring repair, dyspareunia, or scrotal/penile swelling were only observed in the group with the assistance of the general surgeon.

CONCLUSIONS

This study indicated that a spine surgeon can successfully and safely carry out the anterior exposure to the spine without the aid of an access surgeon.

Anterior Thoracolumbar Corpectomies: Approach Morbidity With and Without an Access Surgeon

BACKGROUND:

Anterior approaches for thoracolumbar corpectomies can have significant morbidity. Spine surgeons have historically performed their own anterior approaches, but recently access surgeons are being used more frequently.

OBJECTIVE:

To evaluate the morbidity rates of approaches performed by an access surgeon and by an approach-trained spinal neurosurgeon.

METHODS:

From 2004 to 2008, 46 patients undergoing anterior thoracolumbar corpectomies (levels T2-L5) by the senior author (D.C.) were identified and subdivided into 2 groups based on whether an access surgeon was involved. Nine patients were excluded, leaving 37 patients in the final analysis. Blood loss, operative times, length of hospital stay, complications, and neurological outcomes were evaluated.

RESULTS:

Eighteen patients had anterior spinal access by an approach-trained spinal neurosurgeon, and 19 patients underwent the approach by an access surgeon. Surgeries performed by the spinal neurosurgeon alone were comparable to those performed by an access surgeon with respect to operative time, days spent in the hospital, blood loss, complication rates, and improvement in neurological function.

CONCLUSION:

There appears to be no increased morbidity of anterior approaches performed by an approach-trained spinal neurosurgeon compared with approaches performed by an access surgeon in terms of operative time, complication rate, and improvement in neurological function.

Delayed-iatrogenic injury of the thoracic aorta by an anterior spinal instrumentation

We present a case of a 15-year-old girl who presented to us with an unusual low back pain. About 7 years ago, this patient had corrective surgery for her idiopathic left thoracolumbar scoliosis. Recent surgery revealed a laceration of the posterior wall of the thoracic aorta by an impending screw thread. This injury was repaired by the vascular surgeons and, subsequently, the patient had full recovery without any complications.

Major vascular injury during anterior lumbar spinal surgery: incidence, risk factors, and management

STUDY DESIGN

Retrospective chart review.

OBJECTIVE

To examine the incidence of major vascular injury during anterior lumbar spinal surgery, attempt to identify predisposing risk factors, and to discuss management techniques.

SUMMARY OF BACKGROUND DATA

Major vascular injury can be a catastrophic complication of anterior lumbar spinal surgery.

METHODS

Current procedural terminology codes were used to identify the occurrence of major vascular injury, defined as injury to the iliac vessels, vena cava, and aorta. Once identified, the office record, hospital chart, operative note, and diagnostic test results were reviewed in detail.

RESULTS

Three hundred forty-five operations were performed on 338 patients. Incidence of major vascular complication was 2.9% (10 of 345). There were 9 injuries of the common iliac vein and a single aortic injury. Risk factors identified in patients with major vascular injury were current or previous osteomyelitis or discogenic infection (n = 3), previous anterior spinal surgery (n = 2), spondylolisthesis (n = 2; 1 isthmic Grade II, 1 iatrogenic Grade II), large anterior osteophyte (n = 2), transitional lumbosacral vertebra (n = 1), and anterior migration of interbody device (n = 1). Lateral venorrhaphy by suture (n = 6) and hemoclip application (n = 2) was augmented by topical agents, which constituted the sole method of repair on 1 occasion. Magnetic resonance venography demonstrated iliac vein thrombosis in 1 patient.

CONCLUSION

Current or previous osteomyelitis or discogenic infection, previous anterior spinal surgery, spondylolisthesis, osteophyte formation, transitional lumbosacral vertebra and anterior migration of interbody device point to an increased risk of vascular injury during anterior lumbar spinal surgery. Careful handling of the vascular structures and liberal use of topical hemostatic agents can lead to control of hemorrhage and preservation of vascular patency. Routine postoperative surveillance for proximal deep vein thrombosis, by magnetic resonance venography of the pelvic veins and inferior vena cava, should be performed after venorrhaphy.

Open anterior approaches for lumbar spine procedures

With the advent of anterior lumbar interbody fusion (ALIF) and artificial discs as common procedures for the treatment many spinal problems such as pseudoarthrosis, degenerative disc disease and internal disc disruption from trauma, anterior exposure has become an increasingly popular procedure for the general, thoracic, urologic and vascular surgeon. Despite this, the body of literature describing this procedure is lacking. Dividing the approach for anterior spinal surgery into the thoracolumbar, mid-lumbar, and lumbosacral regions, we describe the basic techniques and anatomy needed to perform these open approaches, specifically, repairs of disc spaces T12-L2, L2-5, and L5-S1, respectively. The technique for the retroperitoneal approach will be discussed in detail; however, issues involved with indications for transperitoneal approach and technical "pearls" will also be discussed.

Revision open anterior approaches for spine procedures

BACKGROUND CONTEXT

Anterior exposure has become an increasingly popular procedure for the general and vascular surgeon due to the increased use of anterior lumbar interbody fusion and artificial disc replacement for the treatment of many spinal problems.

PURPOSE

Because of this increase, revision operations have become increasing necessary. Despite this, there is almost no literature dealing with the issues related to these complex revision operations.

STUDY DESIGN

A retrospective review of charts was performed on patients operated on from April 2002 until October 2004 in two tertiary care hospitals.

METHODS

In total, 218 open exposures for anterior lumbar spinal approaches were performed of which 9 patients required revision lumbar spinal operations. Seven patients were approached again anteriorly (78%), and 2 (22%) patients required a combined anterior and posterior approach.

RESULTS

The nine cases were the number of revision procedures performed over the 16-month period of this study. The average age was 44 overall (range, 25-89) and 53 (33-73) for the revision operations, p>.05. All revision operations attempted were successful. Seven (78%) of the secondary procedures could be approached retroperitoneally whereas 2 (22%) patients required transperitoneal approaches owing to the degree of adhesions. The average length until revision surgery was 13 months (range 6-24). No patients required early revision defined as surgery within 30 days from the primary surgery. Early complications occurred in 4 patients (44%), and included dural tear, median nerve dysthesia, left common femoral nerve palsy further complicated by prolonged postoperative ileus and retrograde ejaculation. Late complications occurred in one patient and consisted of a deep venous thrombosis and urinary tract infection. The average length of stay was 6 days (SD 2.7 days) (range 4-12) compared with 4 days (SD 2.3 days) (range 2-22) for the index operations, p>.05.

CONCLUSION

Revision anterior open exposure to the lumbar and lumbosacral vertebral bodies can be performed safely, but is associated with an increased rate of early complications. Nonetheless, these complications are self-limited and highlight the importance of a multidisciplinary approach in maximizing the various surgical skills of spine (orthopedic and neurosurgical) and exposure (vascular and general) surgeons in reducing serious complications in revision anterior lumbar spinal surgery.

Thoracolumbar fractures surgically treated by "in situ contouring"

This is a retrospective study on a series of 70 patients with thoracolumbar fractures (TL), surgically treated by the in situ bending technique (ISB). Its purpose is to show the performances and limits of the ISB technique for the early correction of post-traumatic spine deformities as well as to estimate the overall outcome in this series and to discuss the indications for anterior grafting. Although the management of limbs fractures is a cleared issue today, spine fractures management is still a matter of debate. Surgical treatment progresses fast, while indications, the fixation techniques, fracture reduction options, and associated grafting are still blurry. Seventy patients with TL fractures, mean age 40.3 years (20-80) were treated by posterior fusion with a standard construct and deformity reduction by means of the ISB technique. Mean follow-up was 30.7 months (12-78). Pre- and post-operative deformity was evaluated and the relative deformity as defined by Farcy's sagittal index (SIF) was analyzed. Thirty-eight patients underwent anterior interbody grafting. The pre-operative SIF decreased from 16.98 to 1.62 degrees (15.36 degrees decrease). Eighty percent of patients were normo- or hyper-corrected. The loss of correction during the follow-up occurred within the disc (SIF: -2.24 degrees , vertebral kyphosis 0.94 degrees , p<0.001), and was lower in patients who underwent secondary anterior grafting (-5.21 degrees vs.-1.18 degrees , p=0.002). Clinical outcome is good (Oswestry=29.75) and seems to be better in cases of double approach (20.71 vs. 37.,4, p=0.001). Sepsis occurred in ten cases, and two patients experienced construct dismounting. One patient had a retroperitoneal hematoma that required embolization. Seventy-one percent of operated patients went back to their previous work after surgery. Spine fractures deserve an efficient treatment. The ISB technique improves post traumatic kyphosis. This results is maintained at long term if the posterior fusion is associated with anterior grafting in cases where the correction within the disc exceeds 50% of the total correction.

Vascular injury and complication in neurosurgical spine surgery

Vascular injury is an uncommon, but not rare complication of spine surgery. The consequence of vascular injury may be quite devastating, but its incidence can be reduced by understanding the mechanisms of injury. Properly managing vascular injury can reduce mortality and morbidity of patients. A review of the literature was conducted to provide an update on the etiology and management of vascular injury and complication in neurosurgical spine surgery. The vascular injuries were categorized according to each surgical procedure responsible for the injury, i.e., anterior screw fixation of the odontoid fracture, anterior cervical spine surgery, posterior C1-2 arthrodesis, posterior cervical spine surgery, anterolateral approach for thoracolumbar spine fracture, posterior thoracic spine surgery, scoliosis surgery, anterior lumbar interbody fusion (ALIF), lumbar disc arthroplasty, lumbar discectomy, and posterior lumbar spine surgery. The incidence, mechanisms of injury, and reparative measures were discussed for each surgical procedure. Detailed coverage was especially given to vascular injury associated with ALIF, which may have been underestimated. The accumulation of anatomical knowledge and advanced imaging studies has made complex spine surgery safer and more reliable. It is not clear, however, whether the incidence of vascular injury has been reduced significantly in all procedures of spine surgery. Emerging new techniques, such as microendoscopic discectomy and lumbar disc arthroplasty, seem to be promising, but we need to keep in mind their safety issues, including vascular injury and complication.