Management of major vascular injury during pedicle screw instrumentation of thoracolumbar spine

Aleem K. Mirza, Mohammed Ali Alvi, Ryan M. Naylor, Panagiotis Kerezoudis, William E. Krauss, Michelle J. Clarke, Daniel L. Shepherd, Ahmad Nassr, Randall R De Martino, Mohamad Bydon

Research output: Contribution to journalArticle

8 Citations (Scopus)

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.

Original languageEnglish (US)
Pages (from-to)53-59
Number of pages7
JournalClinical Neurology and Neurosurgery
Volume163
DOIs
StatePublished - Dec 1 2017

Fingerprint

Vascular System Injuries
Spine
Back Pain
Thoracic Aorta
Anatomy
Technology
Iliac Vein
Phlebography
False Aneurysm
Infection
Chronic Pain
Stents
Aorta
Leg
Angiography
Fever
Arteries
Pedicle Screws
Hemorrhage
Transplants

Keywords

  • Aorta
  • Iliac vein
  • Interbody fusion
  • Lumbar spine
  • Multidisciplinary
  • Pedicle screw
  • Screw abutment
  • Screw perforation
  • Spine surgery
  • Thoracic spine
  • Vascular injury
  • Venography

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology

Cite this

Mirza, A. K., Alvi, M. A., Naylor, R. M., Kerezoudis, P., Krauss, W. E., Clarke, M. J., ... Bydon, M. (2017). Management of major vascular injury during pedicle screw instrumentation of thoracolumbar spine. Clinical Neurology and Neurosurgery, 163, 53-59. https://doi.org/10.1016/j.clineuro.2017.10.011

Management of major vascular injury during pedicle screw instrumentation of thoracolumbar spine. / Mirza, Aleem K.; Alvi, Mohammed Ali; Naylor, Ryan M.; Kerezoudis, Panagiotis; Krauss, William E.; Clarke, Michelle J.; Shepherd, Daniel L.; Nassr, Ahmad; De Martino, Randall R; Bydon, Mohamad.

In: Clinical Neurology and Neurosurgery, Vol. 163, 01.12.2017, p. 53-59.

Research output: Contribution to journalArticle

Mirza, AK, Alvi, MA, Naylor, RM, Kerezoudis, P, Krauss, WE, Clarke, MJ, Shepherd, DL, Nassr, A, De Martino, RR & Bydon, M 2017, 'Management of major vascular injury during pedicle screw instrumentation of thoracolumbar spine', Clinical Neurology and Neurosurgery, vol. 163, pp. 53-59. https://doi.org/10.1016/j.clineuro.2017.10.011
Mirza, Aleem K. ; Alvi, Mohammed Ali ; Naylor, Ryan M. ; Kerezoudis, Panagiotis ; Krauss, William E. ; Clarke, Michelle J. ; Shepherd, Daniel L. ; Nassr, Ahmad ; De Martino, Randall R ; Bydon, Mohamad. / Management of major vascular injury during pedicle screw instrumentation of thoracolumbar spine. In: Clinical Neurology and Neurosurgery. 2017 ; Vol. 163. pp. 53-59.
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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.",
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AU - Mirza, Aleem K.

AU - Alvi, Mohammed Ali

AU - Naylor, Ryan M.

AU - Kerezoudis, Panagiotis

AU - Krauss, William E.

AU - Clarke, Michelle J.

AU - Shepherd, Daniel L.

AU - Nassr, Ahmad

AU - De Martino, Randall R

AU - Bydon, Mohamad

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N2 - 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.

AB - 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.

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KW - Pedicle screw

KW - Screw abutment

KW - Screw perforation

KW - Spine surgery

KW - Thoracic spine

KW - Vascular injury

KW - Venography

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