Abdominal vascular injury caused by lumbar reoperation surgery：a case report

doi:10.21203/rs.3.rs-3416687/v1

Download PDF

Case Report

Abdominal vascular injury caused by lumbar reoperation surgery：a case report

https://doi.org/10.21203/rs.3.rs-3416687/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

Purpose

We report a case of pedicle screw injury to the abdominal inferior vena cava （IVC）during lumbar reoperation.

Methods

A 67-year-old man was hospitalized again for low back pain and numbness in his lower limbs. The imaging results of the patient's re-hospitalization showed that the L4/5 intervertebral space was not fused, and the L5 bilateral pedicle screw was broken. When we removed the fractured pedicle screw on the left side, the screw was accidentally pushed to the abdomen. Fortunately, the patient 's blood pressure did not show a progressive decrease.

Results

We decisively made open exploration of the left approach to him, and successfully removed the pedicle screw. At the same time, we made bone graft and internal fixation of the L4/5 intervertebral space, and the patients had satisfactory recovery during and after the operation.

Conclusion

Abdominal vascular injury is a rare but fatal complication of posterior lumbar surgery. Lumbar revision surgery is complex, and surgeons must consider it carefully before surgery. Oblique Lumbar Interbody Fusion（OLIF）surgery can meet both lumbar revision and abdominal vascular exploration

Vascular injury

Lumbar reoperation

Pedicle screw breakage

OLIF

The first retroperitoneal vascular injury in lumbar surgery was reported in 1945 [1].Iatrogenic abdominal vascular injury related to posterior lumbar surgery with an incidence of around 0.01–0.05% is not a frequently occurring problem [2], while the mortality was up to 10–65% [3]. In various posterior lumbar surgery, abdominal vascular injury was more common in lumbar disc resection, and can be also found during interbody fusion [4]. Vascular injury caused by pedicle screw fixation has also been reported[5]. However, the injury of the inferior vena cava caused by the removal of internal fixation in spinal revision has not been reported. This article reports an unusual case of inferior vena cava injury caused by the removal of broken pedicle screws during lumbar reoperation.

A 67-year-old man was hospitalized again due to low back pain and paresthesia of both lower limbs. Four years ago, he was performed posterior decompression fusion and internal fixation for lumbar spinal stenosis at L3-4 and L4-5 levels in our hospital. The imaging examination after hospitalization showed that the intervertebral space at the L4-5 level did not achieve bone fusion, and the pedicle screw in the L5 vertebral body was broken(Fig. 1). On the fourth day after his hospitalization, we decided to give him a revision surgery. Our surgical plan is to remove the broken pedicle screw from the posterior lumbar spine, and then re-intervertebral bone graft and re-fixed the vertebral body.

When we tried to remove the broken pedicle screw, something shocking happened. The broken screw was accidentally pushed to the abdomen (Fig. 2). Fortunately, the patient’s blood pressure did not present a progressive decline in blood at that time. Anesthesia monitoring of the patient 's vital signs is stable. We decisively decided to give up the removal of the fractured pedicle screw on the right side, then we added a pedicle screw on the right side to strengthen the fixation on the right side. We changed the patient 's position and used the oblique lateral approach of the abdomen. Firstly, we explored the screws into the abdomen. We are extremely lucky. Since the broken screw has almost pierced the other side of the left inferior vena cava, (Fig. 3), there is no serious consequence of massive hemorrhage. Vascular surgeons helped us successfully remove the broken pedicle screws (Fig. 4). Moreover, they sutured the damaged inferior vena cava blood vessel wall, and the blood vessel returned to normal blood flow after the suture was completed.

Finally, we cleaned the gap between L4 and L5 vertebral bodies and filled the patient 's own iliac bone into the approach space while protecting the blood vessels. Pedicle screw fixation was performed on the left side of L4 and L5 vertebrae. The whole operation lasted for 7.5 hours, and the patient finally recovered to our satisfaction. The symptoms of low back pain and lower limb nerve symptoms were significantly relieved, and the X-ray was reviewed after operation (Fig. 5). After 30 days of hospitalization, he was discharged smoothly, and he is currently followed up regularly after surgery.

Abdominal vascular injury during posterior lumbar surgery is common in lumbar discectomy and intervertebral graft placement[6].The pituitary rongeur is the usual cause of injury during disc surgery. During disc removal, the rongeur may slip through the anterior longitudinal ligament and enter the retroperitoneal space of the abdominal cavity. A deep bite can then injure the major vessels[7]. Cases of vascular injury were also reported, which occurred during the placement of pedicle screws[5, 8]. In the posterior internal fixation surgery, vascular injury is theoretically due to the screw tip incorrectly close to the blood vessel wall[9]. However, no cases of abdominal vascular injury caused by screws were reported during spinal reoperation.

This article reported an unusual case of injury to the inferior vena cava caused by the removal of a broken pedicle screw during a lumbar spine reoperation. We analyzed the following reasons. First, we can learn that the patient got hurt at the L5 level and the left iliac vein. Anatomically, the abdominal blood vessels were close to the anterior border of the vertebra, and if the anterior longitudinal ligament is penetrated, the blood vessels would be easily damaged[10]. For degenerative lumbar disease, L4–L5 and L5–S1 are the most common surgical levels. Since AA and IVC bifurcate at L4 level[10], surgical procedures such as pedicle screwing and pituitary rongeur probing may cause major vascular injury here [11], especially to the left CIA and CIV [12]. We combined with the risk factors reported in the literature [2, 13], the risk factors of our cases are as follows. (1) Previous history of lumbar surgery may lead to retroperitoneal vascular and vertebral adhesion. (2) Chronic disc disease leading to degeneration of the annulus fibrosus and anterior longitudinal ligament. (3) The prone position compresses the ventral side and shortens the distance between the retroperitoneal blood vessels and the vertebral body.

Our case is a revision surgery for lumbar spinal stenosis. J.c.Le Huec et al [14]. reviewed revision cases after spinal stenosis surgery. They realized that revision surgery after spinal stenosis surgery is a very large subject, involving many clinical situations. They also understand that TLIF and PLIF techniques make revision surgery difficult. Because the attachment of fibrous tissue around the cage increases the risk of dural tear when the implant is removed. It may be very difficult to remove the broken screw through posterior approach. It is recommended that the posterior approach should not be used to remove the implant, because there is a high risk of nerve injury [15].

For this case, we are very lucky. We had to choose the oblique lumbar interbody fusion (OLIF) to remove the screw and lumbar lateral fixation fusion. If our initial surgical option was an anterior surgical revision, it may be a reasonable choice. OLIF was first proposed by Michael Mayer in 1977, mainly through the anterior approach between the aorta and the lumbar muscle into the intervertebral disc space [16]. It is suitable for the treatment of segmental instability caused by long-term intervertebral fusion after lumbar spine surgery [17].

This is a rare adverse event. Spinal revision surgery is complex and requires careful and scientific planning by surgeons before surgery. OLIF surgery can take into account both lumbar revision and abdominal vascular exploration.

Funding The research wasn’t supported by any funding.

Competing interests The authors declare no competing interests.

Authors' contributions Jia Yang wrote the manuscript. Jia-Nan Dong collected the data. Jia-Le Zheng, and Li-Kai Pang did the date analysis.Zhong-Ning Cui revised the manuscript, and decided to submit the manuscript for publication.

Availability of data and material The data presented in this study as well as the cognitive tasks used during the surgery are available on request from the corresponding author.

Code availability Not applicable.

Ethical approval The manuscript is written in accordance with the 1964 WMA Declaration of Helsinki.

Consent to participate Written informed consent has been obtained from the patient to publish this paper.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creative commons. org/ licenses/ by/4. 0/.

Linton RR, White PD. Arteriovenous fistula between the right common iliac artery and the inferior vena cava. Report of a case of its occurrence following an operation for a ruptured intervertebral disc with cure by operation. Arch Surg. 1945;50:6–13.
Papadoulas S, Konstantinou D, Kourea HP, Kritikos N, Haftouras N, Tsolakis JA. Vascular injury complicating lumbar disc surgery. A systematic review. Eur J Vasc Endovasc Surg. 2002;24(3):189 – 95. 10.1053/ejvs.2002.1682. PMID: 12217278.
Szolar DH, Preidler KW, Steiner H, Riepl T, Flaschka G, Stiskal M, Moelleken S, Norman D. Vascular complications in lumbar disk surgery: report of four cases. Neuroradiology. 1996;38(6):521-5. 10.1007/BF00626086. PMID: 8880709.
Postacchini R, Cinotti G, Postacchini F. Injury to major abdominal vessels during posterior lumbar interbody fusion. A case report and review of the literature. Spine J. 2013;13(1):e7–11. 10.1016/j.spinee.2012.11.016. Epub 2012 Dec 6. PMID: 23219458.
Yen CY, Yang SC, Chen HS, Tu YK. Endovascular retrieval of a migrating pedicle screw within the inferior vena cava after instrumented spinal surgery: case report. J Neurosurg Spine. 2018;28(2):215–9. Epub 2017 Nov 24. PMID: 29171788.
Inamasu J, Guiot BH. Vascular injury and complication in neurosurgical spine surgery. Acta Neurochir (Wien). 2006;148(4):375 – 87. 10.1007/s00701-005-0669-1. PMID: 16322906.
Kaygin MA, Halici U. Our clinical experiences of vascular injuries due to lumbar disc surgeries. Vascular. 2022;30(3):555–558. doi: 10.1177/17085381211021671. Epub 2021 Jun 9. PMID: 34102928.
Kwinta BM, Myszka AM, Bigaj MM, Dragan MR, Kenig J, Krzyżewski RM. Iatrogenic Common Iliac Vessel Injury During Routine Degenerative Lumbar Spine Surgery: Report of 2 Cases and Review of Literature. World Neurosurg. 2020;137:111–8. Epub 2020 Feb 14. PMID: 32006736.
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. Eur Spine J. 2021;30(11):3172–90. 10.1007/s00586-021-06956-4. Epub 2021 Aug 19. PMID: 34410504.
Liu B, Ye K, Gao S, Liu K, Feng H, Zhou F, Tian Y. The summary of experience of abdominal vascular injury related to posterior lumbar surgery. Int Orthop. 2019;43(9):2191–8. 10.1007/s00264-018-4262-7. Epub 2019 Jan 14. PMID: 30643934.
Skippage P, Raja J, McFarland R, Belli AM. Endovascular repair of iliac artery injury complicating lumbar disc surgery. Eur Spine J. 2008;17(2):228–31. 10.1007/s00586-007-0470-3. Epub 2007 Aug 22. PMID: 17712578; PMCID: PMC2525903.
Olcay A, Keskin K, Eren F. Iliac artery perforation and treatment during lumbar disc surgery by simple balloon tamponade. Eur Spine J. 2013;22(Suppl 3):350–2. 10.1007/s00586-012-2436-3. Epub 2012 Jul 18. PMID: 22805757; PMCID: PMC3641250.
Jung HS, Kim DJ, Kim HS, Lee HK, Choi SJN, Chung SY. Vascular Complications Related to Posterior Lumbar Disc Surgery. Vasc Specialist Int. 2017;33(4):160–5. 10.5758/vsi.2017.33.4.160. Epub 2017 Dec 31. PMID: 29354627; PMCID: PMC5754066.
Le Huec JC, Seresti S, Bourret S, Cloche T, Monteiro J, Cirullo A, Roussouly P. Revision after spinal stenosis surgery. Eur Spine J. 2020;29(Suppl 1):22–38. 10.1007/s00586-020-06314-w. Epub 2020 Jan 29. PMID: 31997016.
Murase S, Oshima Y, Takeshita Y, Miyoshi K, Soma K, Kawamura N, Kunogi J, Yamazaki T, Ariyoshi D, Sano S, Inanami H, Takeshita K, Tanaka S. Anterior cage dislodgement in posterior lumbar interbody fusion: a review of 12 patients. J Neurosurg Spine. 2017;27(1):48–55. doi: 10.3171/2016.12.SPINE16429. Epub 2017 May 5. PMID: 28475020.
Mayer HM. A new microsurgical technique for minimally invasive anterior lumbar interbody fusion. Spine (Phila Pa 1976). 1997;22(6):691-9; discussion 700. 10.1097/00007632-199703150-00023. PMID: 9089943.
Mehren C, Korge A. Minimally invasive anterior oblique lumbar interbody fusion (OLIF). Eur Spine J. 2016;25(Suppl 4):471–472. 10.1007/s00586-016-4465-9. PMID: 26914094.

No competing interests reported.

Download PDF

Version 1

posted

You are reading this latest preprint version

Abdominal vascular injury caused by lumbar reoperation surgery：a case report

Status:

Version 1

Abstract

Figures

Introduction

Case presentation

Discussion

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1