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Zhou S, Han H, Zhang Y, Shu C, Luo M. Endovascular repair for thoracic aortic pseudoaneurysm induced by pedicle screw implantation: a case report with 8 years follow-up. J Cardiothorac Surg 2024; 19:326. [PMID: 38849846 PMCID: PMC11157916 DOI: 10.1186/s13019-024-02820-w] [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: 02/21/2024] [Accepted: 05/25/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND Pedicle screw instrument surgeries can result in the development of aortic pseudoaneurysm, which is a rare yet potentially severe complication; therefore, the purpose of this work is to describe the case of pseudoaneurysm of the thoracic aorta caused by the severe migration of a pedicle screw after surgery. CASE PRESENTATION We herein report a patient who underwent endovascular repair for the pseudoaneurysm of the descending thoracic aorta following thoracic vertebral fixation surgery. A 28-80 mm covered stent was initially inserted through the right femoral artery, and intraoperative aortography revealed a minor extravasation of contrast material. Subsequently, an additional 28-140 mm covered stent was implanted. The patient recovered well during the 8-year follow-up period. CONCLUSIONS Vascular complications resulting from spinal surgery are severe and rare, necessitating early diagnosis and intervention.
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Affiliation(s)
- Shufen Zhou
- State Key Laboratory of Cardiovascular Disease, Center of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
- The Second Hospital of Jilin University, Changchun, 130041, China
| | - Hui Han
- State Key Laboratory of Cardiovascular Disease, Center of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Yidan Zhang
- State Key Laboratory of Cardiovascular Disease, Center of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Chang Shu
- State Key Laboratory of Cardiovascular Disease, Center of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Mingyao Luo
- State Key Laboratory of Cardiovascular Disease, Center of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China.
- Department of Vascular Surgery, Henan Cardiovascular Disease Center, Central-China Branch of National Center for Cardiovascular Diseases, Fuwai Central-China Hospital, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, 450046, China.
- Department of Vascular Surgery, Fuwai Yunnan Cardiovascular Hospital, Affiliated Cardiovascular Hospital of Kunming Medical University, Kunming, 650102, China.
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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%.
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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.
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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.
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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.
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Egea-GÁmez RM, FerreÑo-MÁrquez D, DE Benito FernÁndez L, Losada-ViÑas J, GonzÁlez-DÍaz R. Thoracic Aortic Pseudoaneurysm Due to Screw Dislodgment Following Anterior Spinal Approach. Complex Surgical Management of Both Issues: A Case Report and Review of Literature. Int J Spine Surg 2020; 14:397-402. [PMID: 32699763 DOI: 10.14444/7052] [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] [Indexed: 11/20/2022] Open
Abstract
A few descriptions about anterior thoracic arthrodesis causing thoracic aortic pseudoaneurysms due to late screw loosening are mentioned in the literature. We report a case that describes a hybrid approach complicated with an aortic injury when removing a screw from the aortic wall. A 57-year-old man was initially operated on for scoliosis due to poliomyelitis using dorsal thoracolumbar in situ fusion at an early age. At adulthood, the patient complained of spinal cord compression and severe myelopathy due to D9-D10 nonunion, and the patient required a double surgical approach. Almost a year later, he was diagnosed with a thoracic aneurysm caused by late screw loosening from the anterior plate. A hybrid approach was used to treat the aortic pseudoaneurysm (endograft stent) and for anterior vertebral hardware removal (rethoracotomy). Although an aortic stent was covering the aortic lumen, during the open part of the procedure, an aortic injury took place when removing the screw, requiring quick cross clamping and repair. Anterior vertebral hardware removal after a previous anterior spinal approach is a technically highly demanding procedure. As unexpected life-threatening complications can occur, this procedure should be performed in a setting with the capacity for both endovascular and open aortic repair.
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Affiliation(s)
- Rosa M Egea-GÁmez
- Department of Orthopaedic Surgery, Spinal Unit, Hospital Universitario Niño Jesús, Madrid, Spain
| | | | | | - Jose Losada-ViÑas
- Department of Orthopaedic Surgery, Hospital Fundación Alcorcón, Madrid, Spain
| | - Rafael GonzÁlez-DÍaz
- Department of Orthopaedic Surgery, Spinal Unit, Hospital Universitario Niño Jesús, Madrid, Spain
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Reliability and Usefulness of Intraoperative 3-Dimensional Imaging by Mobile C-Arm With Flat-Panel Detector. Clin Spine Surg 2017; 30:E64-E75. [PMID: 28107246 DOI: 10.1097/bsd.0b013e3182a357ad] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Reliability and agreement study. OBJECTIVE To assess the reliability of intraoperative 3-dimensional imaging with a mobile C-arm (3D C-arm) equipped with a flat-panel detector. SUMMARY OF BACKGROUND DATA Pedicle screws are widely used in spinal surgery. Postoperative computed tomography (CT) is the most reliable method to detect screw misplacement. Recent advances in imaging devices have enabled surgeons to acquire 3D images of the spine during surgery. However, the reliability of these imaging devices is not known. METHODS A total of 203 screws were used in 22 consecutive patients who underwent surgery for scoliosis. Screw position was read twice with a 3D C-arm and twice with CT in a blinded manner by 2 independent observers. Screw positions were classified into 4 categories at every 2 mm and then into 2 simpler categories of acceptable or unacceptable. The degree of agreement with respect to screw positions between the double readings was evaluated by κ value. With unanimous agreement between 2 observers regarding postoperative CT readings considered the gold standard, the sensitivity of the 3D C-arm for determining screw misplacement was calculated. RESULTS A total 804 readings were performed. For the 4-category classification, the mean κ value for the 2 interobserver readings was 0.52 for the 3D C-arm and 0.46 for CT. For the 2-category classification, the mean κ value for the 2 interobserver readings was 0.80 for the 3D C-arm and 0.66 for CT. The sensitivity, specificity, positive predictive value, and negative predictive value of intraoperative imaging with the 3D C-arm were 70%, 95%, 44%, and 98%, respectively. With respect to screws with perforation ≥4 mm, the sensitivity was 83%. No revision surgery was performed. CONCLUSIONS Intraoperative imaging with a 3D C-arm was reliable for detecting screw misplacement and helpful in decreasing the rate of revision surgery for screw misplacement.
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Bischoff MS, Meisenbacher K, Schmack B, Tanner M, Goldschmidt H, Kasperk C, Hyhlik-Dürr A, Böckler D. [Prevention of aortic erosion by a bone cement skid : Thoracic endovascular aortic repair following kyphoplasty]. DER ORTHOPADE 2016; 45:994-997. [PMID: 27709244 DOI: 10.1007/s00132-016-3342-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The underlying case report describes the successful endovascular prevention of an aortic injury by a bone cement skid after kyphoplasty. The intervention was performed in order to prohibit fatal aortic rupture or embolisation and underlines the role of vascular surgery techniques in interdisciplinary clinical networks.
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Affiliation(s)
- M S Bischoff
- Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland.
| | - K Meisenbacher
- Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - B Schmack
- Klinik für Herzchirurgie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M Tanner
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - H Goldschmidt
- Klinik für Innere Medizin V, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - C Kasperk
- Klinik für Innere Medizin I, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - A Hyhlik-Dürr
- Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - D Böckler
- Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
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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.
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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
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Ziegler JD, Polly DW, Andrade RS. Hemoptysis Due to Anterior Scoliosis Implants: A Case Report. JBJS Case Connect 2016; 6:e20. [PMID: 29252726 DOI: 10.2106/jbjs.cc.o.00116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
CASE A twenty-five-year-old man presented with recurrent episodes of hemoptysis requiring hospitalization and interventional embolization. Instrumentation that had been implanted ten years previously for anterior spinal correction and fusion to treat adolescent idiopathic scoliosis adjoined the medial border of the right lung. The instrumentation eroded the lung during respiration, which prompted the formation of adhesions and fibrosis. Because of the risk of additional hemoptysis events, we performed revision thoracotomy, removal of the spinal instrumentation, and partial lobectomy. CONCLUSION This rare and serious complication underscores the importance of meticulous surgical technique to ensure proper implant placement and of vigilant monitoring for late iatrogenic injury.
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Affiliation(s)
- Jacob D Ziegler
- Department of Orthopaedic Surgery (J.D.Z. and D.W.P. Jr.) and Section of Thoracic and Foregut Surgery, Department of Surgery (R.S.A.), University of Minnesota, Minneapolis, Minnesota
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Pillai ST, Schoenhagen P, Subrahmanyan L, Mukherjee SK, McNamara RL, Elefteriades J, Svensson LG. Aortic dissection associated with penetration of a spinal pedicle screw: a case report and review of the literature. J Card Surg 2014; 29:377-81. [PMID: 24707982 DOI: 10.1111/jocs.12327] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
A 30-year-old male underwent a corrective posterior instrumented spinal fusion for scoliosis. Six years later, he was found to have an aortic dissection after aortic penetration of a spinal pedicle screw. We review the literature, including diagnostic modalities, and treatment decision-making for this unusual complication.
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Affiliation(s)
- Saila T Pillai
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Heart and Vascular Institute, Cleveland, Ohio
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Safety of pedicle screws and spinal instrumentation for pediatric patients: comparative analysis between 0- and 5-year-old, 5- and 10-year-old, and 10- and 15-year-old patients. Spine (Phila Pa 1976) 2014; 39:541-9. [PMID: 24430718 DOI: 10.1097/brs.0000000000000202] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE To investigate the safety of pedicle screws and constructs for infantile and juvenile patients with spinal deformity. SUMMARY OF BACKGROUND DATA Few studies have examined the safety and complication rates associated with the usage of pedicle screw for children younger than 10 years. METHODS Radiographical and clinical data were collected of patients treated with pedicle screws at a single institution. Patients were divided into 2 groups based on age (0-5 yr old, 5-10 yr) and compared with an older cohort of 10- to 15-year-old patients. Patient demographics, screw adjustment, and complication data were collected for each group. Outcomes were analyzed using analysis of variance (P < 0.05). RESULTS In total, 5054 pedicle screws were analyzed: 176 in the 0- to 5-year-old group (31 patients), 659 in the 5- to 10-year-old group (68 patients), and 4219 in the 10- to 15-year-old group (234 patients). Mean follow-up was 3.1 ± 1.8 years (range, 3 mo-9 yr). There were 7 pedicle screw-associated complications (3 required revision surgery). Overall pedicle screw-associated complication rates were 2.1% per patient and 0.1% per screw. There were no neurological complications associated with misplacement of a pedicle screw. The pedicle screw-associated complication rates per patient and per screw were 3.2% and 0.6% in the 0- to 5-year-old group, 2.9% and 0.3% in the 5- to 10-year-old group, and 1.7% and 0.1% in the 10- to 15-year-old group (P > 0.05). The 5- to 10-year-old group had a significantly higher overall surgically related complication rate (34%) than the 0- to 5-year-old group (7%) and the 10- to 15-year-old group (6%) (P = 0.005), primarily due to the "growth friendly" constructs common in this age group. CONCLUSION Pedicle screws can be used for infantile or juvenile patients, although complication rates associated with pedicle screws tended to be slightly higher in the younger groups.
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Fukuda W, Aoki C, Daitoku K, Taniguchi S, Fukuda I. Screw in the aorta: minimally invasive graft replacement for chronic aortic erosion by spinal instrument. Ann Thorac Cardiovasc Surg 2012; 19:320-2. [PMID: 23232300 DOI: 10.5761/atcs.cr.12.01914] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Intra-and early post-operative aortic injury by pedicle screw is not a rare complication in orthopedic surgery, but aortic penetration by a screw head over a long time period is considered as an uncommon case. There are various surgical management options for thoracic aortic injury caused by malpositioned spinal instruments. We report a case of a patient who underwent minimally invasive graft replacement of the descending thoracic artery for pedicle screw penetration.
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Affiliation(s)
- Wakako Fukuda
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
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12
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Colvard BD, Anaya-Ayala JE, Smolock CJ, Lumsden AB, Reardon MJ, Davies MG. Hybrid approach for removal of an errant intra-vascular pedicle spinal fixation screw in the thoracic aorta. J Vasc Surg 2012; 56:201-4. [PMID: 22503180 DOI: 10.1016/j.jvs.2011.12.084] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2011] [Revised: 12/21/2011] [Accepted: 12/30/2011] [Indexed: 12/21/2022]
Abstract
Late presentation of aortic injuries secondary to internal fixation hardware is uncommon and generally associated with pseudoaneurysm formation. We herein present a case of transmural migration of a pedicle screw into the descending thoracic aorta, which was revealed incidentally by computed tomography scan after almost 4 years of hardware implantation. Approximately 75% of the pedicle screw was exposed to the bloodstream, and was successfully removed using endovascular segmental exclusion to avoid aortic cross-clamping and an open approach via left thoracotomy. This case illustrates the successful repair of an iatrogenic aortic injury using a hybrid technique.
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Affiliation(s)
- Benjamin D Colvard
- Department of Cardiovascular Surgery, Methodist DeBakey Heart & Vascular Center, The Methodist Hospital, Houston, TX, USA
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