1
|
Alomari S, Planchard R, Lo SFL, Witham T, Bydon A. Aortic injury in spine surgery……What a spine surgeon needs to know. Neurosurg Rev 2021; 44:3189-3196. [PMID: 33851267 DOI: 10.1007/s10143-021-01527-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/23/2021] [Accepted: 03/15/2021] [Indexed: 11/28/2022]
Abstract
Aortic injury is a rare, yet underreported and underestimated complication of spine surgery. Anatomical relation between the aorta and the spine changes under physiological (positional) as well as pathological (deformity) conditions, which puts the aorta at risk of injury during spine surgery. Clinical presentation of aortic injury ranges from asymptomatic perforation of the aorta to acute fatal bleeding. Although several diagnostic methods have been reported, CT-angiography remains an important diagnostic study. Several advancements in the open and the endovascular surgical management have been reported to be successfully used in the management of aortic injury following spine surgery. Management approach of malpositioned screws abutting the aorta is still controversial. Anatomical knowledge and understanding of the previously reported mechanisms of aortic injury are important to be integrated in the preoperative planning process. If the complication occurs, time-to- recognition and to-appropriate-management are important factors for predicting mortality. If unrecognized and untreated in the acutely injured patients, mortality can approach 100%.
Collapse
Affiliation(s)
- Safwan Alomari
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ryan Planchard
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sheng-Fu Larry Lo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Timothy Witham
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ali Bydon
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Department of Neurological Surgery, Johns Hopkins Hospital, 600 North Wolfe Street, Meyer 5-109, Baltimore, MD, 21287, USA.
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
Valič M, Žižek D, Špan M, Mihalič R, Mohar J. Malpositioned pedicle screw in spine deformity surgery endangering the aorta: report of two cases, review of literature, and proposed management algorithm. Spine Deform 2020; 8:809-817. [PMID: 32170660 DOI: 10.1007/s43390-020-00094-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 02/11/2020] [Indexed: 12/20/2022]
Abstract
STUDY DESIGN Case reports and review of the literature with a proposed management algorithm. OBJECTIVES To report two cases of a potential vascular complication due to an incorrectly placed pedicle screw (PS) during spine deformity surgery. Relevant literature regarding the management of vascular complications is reviewed, and an evidence-based management algorithm is proposed. Aortic lesions represent a rare but potentially life-threatening complications with spine deformity and revision surgery, significantly increasing the risk. A management algorithm for an aortic lesion in the case of a malpositioned PS has not yet been published. METHODS Case 1: An 18-year-old female with proximal thoracic spinal non-instrumented fusion underwent a revision corrective procedure due to a progressive right-sided thoracolumbar compensatory curve. However, postoperative computed tomography (CT) performed to evaluate the position of the PS revealed malposition of the left T9 PS, which was abutting the descending aorta with CT angiography excluding the perforation of the aorta. Case 2: A 17-year-old male was scheduled for correction of Lenke 3-C-N adolescent idiopathic scoliosis. Postoperative routine evaluation with low-dose CT revealed a left T9 PS paravertebral malposition, and subsequent CTA demonstrated that the thread of the PS was in contact with the descending thoracic aorta and an unlikely hemodynamically significant vessel injury. RESULTS Successful removal of both malpositioned PS was performed. In the first case, a cardiovascular surgeon attended the operation if an urgent thoracotomy was needed, and in the second case, additional video-assisted thoracoscopic control of the aorta was performed during PS removal. CONCLUSIONS Preoperative imaging in spinal surgery is essential to avoid major vascular and other complications when placing PS, especially in thoracic deformities. When a potential major vessel complication emerges, an interdisciplinary approach and an appropriate management algorithm are mandatory to make the best clinical decisions. LEVEL OF EVIDENCE 4.
Collapse
Affiliation(s)
- Matej Valič
- Department of Spine Surgery, Valdoltra Orthopedic Hospital, Jadranska cesta 31, 6280, Ankaran, Slovenia
| | - David Žižek
- Department of Cardiology, University Medical Centre Ljubljana, Zaloška cesta 7, 1000, Ljubljana, Slovenia
| | - Matjaž Špan
- International Center for Cardiovascular Diseases - MC Medicor, Polje 40, 6310, Izola, Slovenia
| | - René Mihalič
- Department of Spine Surgery, Valdoltra Orthopedic Hospital, Jadranska cesta 31, 6280, Ankaran, Slovenia
| | - Janez Mohar
- Department of Spine Surgery, Valdoltra Orthopedic Hospital, Jadranska cesta 31, 6280, Ankaran, Slovenia. .,Chair of Orthopedics, Faculty of Medicine, University of Ljubljana, Zaloška cesta 9, 1000, Ljubljana, Slovenia.
| |
Collapse
|
4
|
Is the Risk of Aorta Injury or Impingement Higher During Correction Surgery in Patients with Severe and Rigid Scoliosis? World Neurosurg 2020; 139:e626-e634. [PMID: 32339734 DOI: 10.1016/j.wneu.2020.04.065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 04/08/2020] [Accepted: 04/09/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate the position of the aorta relative to the spine and the risk of aortic injury during correction surgery in patients with idiopathic severe and rigid scoliosis (main curve Cobb angle >90° and flexibility <30%). METHODS Twenty-seven patients with severe right thoracic/thoracolumbar scoliosis were recruited. The entry point-aorta distance (EAD), the left pedicle-aorta angle (α), the left aorta angle (β), and the vertebral rotation angle (γ) were measured from 4 vertebrae above (A4) to 4 below (B4) the apical vertebra (Apex) to quantify the spatial relationship between aorta and spine. We simulated the pedicle screw misplacement with variable direction error, length, and diameter to analyze the potential risk of aortic injury. RESULTS The aorta shifted laterally and posteriorly as it descended from A4 and moved back medially and anteriorly from Apex. The potential risk of aortic injury increased with the augment of direction error and/or length of the screw, but the tendency was not significant with the augment of diameter. The risk peaked at A4, A3, and B2, when the screw length was 40 mm and diameter was 5.0 mm, and the direction error was 30°, whereas the risk was lowest at the apical level 14.3% (0%-40.7%) in any scenarios. CONCLUSIONS In patients with severe and rigid scoliosis, the aorta shifted more laterally and posteriorly, and the injury risk was lower at the apical level, compared with moderate scoliosis. Most potential risks can be minimized by careful preoperative planning and the assistance of intraoperative navigation or robotics.
Collapse
|
5
|
Does the Severity of the Curve in Lenke 1 and 2 Adolescent Idiopathic Scoliosis Patients Affect the Distance and Position of the Aorta From Vertebra? Spine (Phila Pa 1976) 2019; 44:785-792. [PMID: 30475346 DOI: 10.1097/brs.0000000000002945] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective study of a prospectively-collected data. OBJECTIVE To determine whether the severity of the curve magnitude in Lenke 1 and 2 Adolescent Idiopathic Scoliosis (AIS) patients affects the distance and position of the aorta from the vertebra. SUMMARY OF BACKGROUND DATA There were studies that looked into the position of the aorta in scoliotic patients but none of them documented the change in distance of the aorta to the vertebra in relation to the magnitude of the scoliosis. METHODS Patients with Lenke 1 and 2 AIS who underwent posterior spinal fusion using pedicle screw construct and had a preoperative computed tomography (CT) scan performed were recruited. The radiological parameters measured on preoperative CT scan were: Aortic-Vertebral Distance (AVD), Entry-Aortic Distance (EAD), Aortic-Vertebral angle (AVA), Pedicle Aorta angle/Aortic Alpha angle (α angle), and Aortic Beta angle (β angle). RESULTS Thirty-nine patients were recruited. Significant moderate to strong positive correlation was found between AVD and Cobb angle from T8 to T12 vertebrae (r = 0.360 to 0.666). The EAD was generally small in the thoracic region (T4-T10) with mean EAD of less than 30 mm. Among all apical vertebrae, the mean AVD was 5.9 ± 2.2 mm with significant moderate-strong positive correlation to Cobb angle (r = 0.580). The mean α angle was 37.7 ± 8.7° with significant weak positive correlation with Cobb angle (r = 0.325). CONCLUSION The larger the scoliotic curve, the aorta was located further away from the apical vertebral wall. The aorta has less risk of injury from the left lateral pedicle screw breach in larger scoliotic curve at the apical region. The distance from the pedicle screw entry point to the wall of the aorta was generally small (less than 30 mm) in the thoracic region (T4-T10). LEVEL OF EVIDENCE 4.
Collapse
|
6
|
Mirza AK, Alvi MA, Naylor RM, Kerezoudis P, Krauss WE, Clarke MJ, Shepherd DL, Nassr A, DeMartino RR, Bydon M. Management of major vascular injury during pedicle screw instrumentation of thoracolumbar spine. Clin Neurol Neurosurg 2017; 163:53-59. [PMID: 29073499 DOI: 10.1016/j.clineuro.2017.10.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 10/05/2017] [Accepted: 10/15/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Vascular injury is a rare complication of spinal instrumentation. Presentation can vary from immediate hemorrhage to pseudoaneurysm formation. In the literature, surgical approach to repair has varied based on anatomy, acuity of diagnosis, infection, and available technology. In this manuscript, we aim to describe our institutional experience with vascular injuries in thoraco-lumbar spine surgery. PATIENTS AND METHODS We report our institutional experience of three cases of vascular injury secondary to pedicle screw misplacement and their management, as well as a review of the literature. RESULTS The first case had a history of previous instrumentation and presented with back pain and fever. The patient was taken for instrumentation exploration via a posterior approach. Aortic violation was discovered at T6 intraoperatively during instrumentation removal and the patient underwent emergent endovascular repair. The second case presented with chronic back pain after multiple prior posterior fusions and CT angiogram showing screw perforation on the aorta at T10. The patient underwent elective endovascular repair with synchronous removal of the instrumentation. The third case presented with radicular leg pain 6 months after L4-S1 posterior lumbar interbody fusion, with CT scan demonstrating the left S1 screw abutting the L5 nerve root and common iliac vein. The patient underwent elective instrumentation revision with intraoperative venography. CONCLUSION Major vascular injury is a known complication of spinal surgery, especially if it involves instrumentation with pedicle screws. Treatment approach has evolved with the advancement of endovascular technology; however, open surgery remains an option when anatomy or infection is prohibitive. In the elective setting, preoperative planning with attention to surgical approach, positioning, and contingencies, should occur in a multidisciplinary fashion. Repair with an aortic stent-graft cuff may minimize unnecessary coverage of the descending thoracic aorta and intercostal arteries.
Collapse
Affiliation(s)
- Aleem K Mirza
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Mohammed Ali Alvi
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Ryan M Naylor
- Mayo Clinic School of Medicine, Rochester, MN, USA; Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Panagiotis Kerezoudis
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - William E Krauss
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Daniel L Shepherd
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Ahmad Nassr
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Randall R DeMartino
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Mohamad Bydon
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
7
|
Sevuk U, Mesut A, Kiraz I, Kose K, Ayaz F, Erkul A. Delayed Presentation of Aortic Injury by a Thoracic Pedicle Screw. J Card Surg 2016; 31:220-30. [PMID: 26864154 DOI: 10.1111/jocs.12718] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Delayed presentation of a thoracic aortic injury is an extremely rare complication after spine surgery. We report a case of delayed presentation of a thoracic aortic injury with a vertebral pedicle screw after posterior spinal surgery without periaortic hematoma, hemorrhage or pseudoaneurysm formation and review the relevant literature.
Collapse
Affiliation(s)
- Utkan Sevuk
- Department of Cardiovascular Surgery, Diyarbakir Gazi Yasargil Education and Research Hospital, Diyarbakir, Turkey
| | - Abdullah Mesut
- Department of Neurosurgery, Diyarbakir Gazi Yasargil Education and Research Hospital, Diyarbakir, Turkey
| | - Ilker Kiraz
- Department of Neurosurgery, Diyarbakir Gazi Yasargil Education and Research Hospital, Diyarbakir, Turkey
| | - Kaan Kose
- Department of Cardiovascular Surgery, Diyarbakir Gazi Yasargil Education and Research Hospital, Diyarbakir, Turkey
| | - Firat Ayaz
- Department of Cardiovascular Surgery, Diyarbakir Gazi Yasargil Education and Research Hospital, Diyarbakir, Turkey
| | - Aylin Erkul
- Department of Anesthesiology, Diyarbakir Obstetrics and Gynecology Hospital, Diyarbakir, Turkey
| |
Collapse
|