Vascular injury complicating lumbar disc surgery. A systematic review.

OBJECTIVES: to review the literature concerning the early and late vascular complications of lumbar disc surgery. METHODS: using the MEDLINE database, we reviewed all reports of vascular complications associated with surgical excision of a prolapsed disc via a posterior approach reported in the English literature since 1965. RESULTS: we identified 98 cases of vascular complications for an incidence of 1-5 in 10000 disc operations. Early presentation is shock due to rupture of a large retroperitoneal vessel. Late complications include development of pseudoaneurysms and arteriovenous fistulas. Treatment of a vascular tear consisted mainly of primary suturing of the injured vessel. The preferred method for arteriovenous fistula and pseudoaneurysm repair was suturing from within the arterial lumen along with interposition grafting. Recently, endovascular techniques have been recommended, lowering the high morbidity and mortality related to conventional repair. CONCLUSION: iatrogenic vascular injury during lumbar disc surgery, although rare, should be suspected if signs of circulatory instability are noted or if lumbar pain, leg oedema or high output cardiac failure develop months to years following such surgical procedures. However, these symptoms may arise during or immediately after surgery, requiring immediate intervention.     

Vascular injury and complication in neurosurgical spine surgery

Summary 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.     

Injury to major abdominal vessels during posterior lumbar interbody fusion. A case report and review of the literature

Background contextNumerous cases of injury to major abdominal vessels during the excision of a lumbar herniated disc have been reported, but no cases of injury during interbody fusion by a posterior approach have been described.PurposeTo report on an injury to common iliac vessels during a posterior lumbar interbody fusion (PLIF) and discuss the causes and possible preventive measures.Study designA unique case report and a review of the literature.MethodsThe hospital chart and autopsy report of a single patient were analyzed.ResultsA 52-year-old woman with L4–L5 disc degeneration underwent PLIF. During scraping of the vertebral end plates, there was a sudden increase in blood flow from the disc space, however not copious, with no changes of vital parameters. When the patient was placed supine, severe hypotension and abdominal distension led to strongly suspect a lesion to abdominal vessels. At laparotomy, carried out by a vascular surgeon, a vast retroperitoneal hematoma was evacuated and the vascular lesions were repaired. Postoperatively, the patient continued to lose blood from the abdominal drains and after 4 hours, she was reoperated by another vascular surgeon, who found a diffuse hemorrhage from the small vessels in the surgical field. Soon after the surgery the patient died.ConclusionsThe lesions were produced by a shaver used for scraping the vertebral end plates. The absence of abundant bleeding from the disc space was possibly because of the compression of the iliac vessels by the pads of the frame on which the patient was lying. The causes of the lesions and possible prevention of similar injuries are analyzed.     

Large Vessel Injury following Operation for a Herniated Lumbar Disc

Major vascular injury can occur during an operation for a herniated lumbar disc due to the intimate anatomical relation between the lumbar vertebrae and major vessels. Although occurrence is infrequent, it is associated with high morbidity and mortality. Diagnosis is suspected when early signs of retroperitoneal hemorrhage appear, but may often be delayed for weeks or years. Formation of a pseudoaneurysm or an arteriovenous (A-V) fistula may be of gradual onset and produce initially only a few symptoms. We report here six cases of large vessel injury, which consisted of active bleeding from an injured common iliac artery, or a pseudoaneurysm of the common iliac artery with or without an A-V fistula that occurred following an operation for a herniated lumbar disc and was successfully treated by radiologic intervention and/or surgery. Angiography with the intention of intervention is considered the first step of treatment for a large vessel injury following an operation for a herniated lumbar disc at the level between fourth and fifth lumbar or between fifth lumbar and first sacral intervertebral space.     

Vascular complications of lumbar disc surgery. Case report.

Four patients were successfully treated for vascular complications associated with lumbar disc surgery, one as an emergency case and three from 1 to 3 months postoperatively. Acute complications are often identified by severe bleeding. Knowledge of the anatomy is essential for appropriate surgical repair, which may consist of patch-graft angioplasty or graft interposition. Treatment of late complications (usually arteriovenous fistula or false aneurysm) is often impeded by adhesions. Fistula repair is performed from inside the artery. Precautions against vascular complications during lumbar disc surgery are discussed.     

Amaurosis after spine surgery: survey of the literature and discussion of one case

Postoperative vision loss (POVL) associated with spine surgery is a well known, albeit very rare complication. POVL incidence after spinal surgery ranges from 0.028 to 0.2%; however, due to the increase in number and duration of annual complex spinal operations, the incidence may increase. Origin and pathogenesis of POVL remain frequently unknown. A 73-year-old patient presented with lumbar disc herniation with associated neurological deficits after conservative pre-treatment at a peripheral hospital. Known comorbidities included arterial hypertension, moderate arterial sclerosis, diabetes mellitus type 2, mildly elevated blood lipids and treated prostate gland cancer. During lumbar spine surgery in modified prone position the patient presented with an acute episode of severe hypotension, which required treatment with catecholamines and Trendelenburg positioning. Three hours postoperatively, a visual loss in the right eye occurred, resulting in a complete amaurosis. Antihypertensive medication, arteriosclerosis and intraoperative hypotension are possible causes for the POVL. Intraoperative administration of catecholamines and Trendelenburg positioning for treatment of systemic hypotension might further compromise ocular perfusion. In patients with comorbidities compromising arterial blood pressure, blood circulation and microcirculation, POVL must be considered as a severe postoperative complication. It is recommended to inform patients about such complications and obtain preoperative informed consent regarding POVL. Any recent modification of antihypertensive medication must be reported and analysed for potential intraoperative hemodynamic consequences, prior to spine surgery in prone position.     

Rupture of aorta and inferior vena cava during lumbar disc surgery

Summary Major vascular injury during lumbar disc surgery has been recognized as an unusual but well described complication. A potentially fatal outcome can be avoided by a high index of suspicion and an early diagnosis.We present a rare case of aortic and inferior vena caval injury in a 50-year-old female patient undergoing intervertebral disc surgery at lumbar one and two levels. A quick diagnosis and prompt management resulted in a favourable outcome for the patient.     

腰椎间盘突出症手术失败的再手术治疗

目的:本文报告20例腰椎间盘突出症手术失败再手术的病人,目的在于分析手术失败的原因和再手治疗的有关问题。方法:回顾1989年至1996年间的1218例腰椎间盘突出症手术病人,选择其中20例因初次手术失败而接受再次手术的病人,对其再手术的原因和手术治疗进行回顾性研究。结果:初次手术失败的原因主要是突出间盘切除不全和术后发生疤痕性椎管狭窄,另外,马尾损伤、腰椎骨质增生、软骨板破裂及腰骶神经节椎管内异位畸形等亦是手术失败的原因。结论:作者强调首次手术应采用开窗术进行椎管减压和髓核摘除。再次手术难度较大,但病变显露应从正常解剖部位开始,仔细地去除疤痕和其它致病因素,以免神经根或神经组织的损伤。     

Surgery for lumbar disc herniation during pregnancy

STUDY DESIGN: The case reports of three pregnant patients with lumbar disc herniation causing cauda equina syndrome or severe neurologic deficits are presented to illustrate that disc surgery during gestation is a safe method of management. OBJECTIVE: To emphasize the importance of recognizing and definitively treating lumbar disc displacement causing neurologic deficits during pregnancy. SUMMARY OF BACKGROUND DATA: The advent of magnetic resonance imaging and modern surgical techniques for treatment of lumbar disc displacement allows safe management of this condition at any stage of gestation. A review of the literature on the risks of nonobstetric surgery and the risks of delaying disc surgery until delivery shows that operating at any stage during gestation for severe neurologic deficit secondary to lumbar disc displacement is justified. METHODS: A review of the literature on the use of magnetic resonance imaging scan and nonobstetric surgery during pregnancy was performed. Three case reports of the authors' patients who had lumbar disc displacement with cauda equina syndrome or severe neurologic deficit are presented. Patients were placed prone on a four-poster frame, and an epidural anesthetic agent was administered. A one-level hemilaminectomy, partial facetectomy, and disc excision were performed in all three cases. RESULTS: The methods used for diagnosis and surgical treatment of three patients with disc herniation during pregnancy resulted in a satisfactory outcome for both mother and child. The medical literature supports surgical intervention in pregnant patients with cauda equina syndrome and severe and/or progressive neurologic deficit(s) from lumbar disc displacement at any state of gestation. CONCLUSION: Although extremely rare, cauda equina syndrome and severe and/or progressive neurologic deficit caused by lumbar disc displacement can occur during pregnancy. The prevalence of symptomatic lumbar disc herniation during pregnancy may be on the increase because of the increasing age of patients who are becoming pregnant. These cases showed, and the literature confirms, that pregnancy at any stage is no contraindication to magnetic resonance imaging scan, epidural and/or general anesthesia, and surgical disc excision.     

Iatrogenic vascular injuries following lumbar disc surgery. Case report and review of the literature

Iatrogenic vascular injuries are unusual complications of lumbar disc surgery. The incidence of such injuries is very low but probably underestimated because clinical manifestations may be extremely variable depending on the extension of trauma whether artery or vein are injured or both. Diagnosis is suspected when early signs of retroperitoneal hemorrhage appear, but may often be delayed for weeks or years because formation of a pseudoaneurysm or an arteriovenous fistula which may be of gradual onset and produce only a few symptoms at the onset. Prompt diagnosis and aggressive treatment can hope to improve current mortality of more than 50%. A case of venous and arterial injury is reported, successfully operated on with an original technique of ilio-caval patching to avoid caval ligation. A review of the literature shows the predisposing factors and complex anatomy of such injuries, the clinical picture and the management of the emergency.     

Endovascular repair of iliac artery injury complicating lumbar disc surgery

Vascular injury as a complication of disc surgery was first reported in 1945 by Linton and White. It is a rare but potentially fatal complication. The high mortality rate (40–100%) is attributed to a combination of rapid blood loss and the failure to recognise the cause of the deteriorating patient. Early diagnosis and treatment is essential. Treatment has traditionally been by open vascular surgical repair, however with modern imaging and endovascular techniques, minimally invasive treatment should be considered first line in patients who are stable. We present the case of a 51-year-old woman who sustained common iliac artery injury during lumbar spinal surgery that was treated successfully using a covered stent.

     

Percutaneous Endoscopic Lumbar Discectomy for Lumbar Disc Herniation Using an Endoscopic Staining: A Technical Note

Symptomatic lumbar disc herniation (LDH) is widely treated using percutaneous endoscopic lumbar discectomy (PELD). In the present PELD surgery, performing decompression under endoscope still takes a long time to explore the rupture site of annulus fibrosus, resulting in prolonged operation time and over‐invasion of the undegenerated annulus fibrosus. A wide range of intraoperative exploration also induces an iatrogenic injury of the normal annulus fibrosus, even aggravating intervertebral disc degeneration, which may lead to early postoperative recurrence in severe case. Hence, it is important to seek a precise decompression in PELD surgery. Under this kind of realization, more spinal surgeons possibly choose a disc staining before performing decompression. However, the classical disc staining technique still has its shortcomings. First of all, an appropriate dose of staining cannot be accurately mastered, even induces unqualified staining effect. Second, the duration of surgery and the times of fluoroscopy will be increased. Finally, what surgeons see under the endoscope is the staining result but not the staining process. Hence, this is accomplished more effectively by designing procedures that perform fully visible disc staining under spinal endoscope. There is no specific research to discuss the technique note of endoscopic staining in PELD surgery. We have come up with a new original technology of endoscopic staining with methylene blue injection in PELD for treatment of LDH.     

Emergency diagnosis with spiral CT angiography in case of suspected ventral perforation following lumbar disc surgery

BACKGROUND: Ventral perforation and vascular lesions are rare but life-threatening complications in lumbar disc surgery. In some cases, however, it remains unclear from the clinical situation whether a laparotomy is necessary to save the patient. The goal of this study is to demonstrate the value of spiral CT (computed tomography) angiography for emergency vascular diagnosis in two cases. METHODS: Spiral CT angiography with an intravenous bolus contrast medium injection and reconstruction with images in sagittal, coronal, and oblique planes was performed. RESULTS: Spiral CT angiography confirms or excludes a vascular lesion, as demonstrated in two case reports. CONCLUSION: In unclear cases when ventral perforation in lumbar disc surgery is suspected, the need for emergency laparotomy can be confirmed quickly by noninvasive spiral CT angiography.     

Courbe d’apprentissage pour la chirurgie de la hernie discale lombaire

Background and purposeVarious techniques are available for lumbar disc surgery. But failure and severe adverse events still occur during such procedures. Recent work concluded that the use of microscope was not mandatory for such procedures.MethodsThe first 70 spinal procedures for lower limb radicular syndrome by a surgeon at the beginning of this activity where studied. Particular interest was paid on adverse events, especially complications and failures.ResultAverage duration of surgery (50 min) and rate of reoperation (six reoperations needed out of 65 patients, five of them by the same surgeon) where, as expected, a bit higher than published in experienced hands. But no battered-root syndrome, injury to neighboring structures or other severe complication was observed. Noteworthy is that no patient was neurologically worsened by surgery.ConclusionsIf the use of microscope may not be needed for lumbar disc open surgery in experienced hands, we strongly advice surgeons at the beginning of their practice to use it. At least, to avoid unforgiving mistakes such as picking out the root instead of the herniation.     

Ureteric injury after lumbosacral discectomy: a case report and review of the literature

Herein, a case of ureteric injury was inflected during lumbo-sacral laminectomy is reported to be added to the previously published 15 cases. Ureteric injury is a rare complication that may be encountered during lumbar disc surgery. We traced 15 cases that were published in literatures allover the past years with different management techniques. To the best of our knowledge, we report the first case that was treated by ileal ureteric replacement. Special attention should be paid regarding ureteric injury during surgery. Despite rare incidence of such injury with laminectomy, there were some reportable complications. So, surgeons should be aware of prediction, early diagnosis, and possible management alternatives for such injuries to safe patients from unsuspected handicapping.     

Hypotension during thoracic surgery under combined general and high thoracic epidural anesthesia

High thoracic epidural anesthesia (TEA) is increasingly often used in combination with general anesthesia for major thoracic and abdominal surgery. TEA leads to sympatholysis of cardiac efferences leading to improved myocardial oxygen balance, which is in part due to vasodilation of atherosclerotic coronary vessels. To provide the full benefit of TEA, it is important to extend it as patient-controlled epidural analgesia in the postoperative period. If adequate vascular volume is maintained, hypotension is less frequent after TEA than after lumbar epidural anesthesia. However, in combination with general anesthesia, it may be more frequent and more severe. Treatment of hypotension is sometimes difficult and may require the use of nonadrenergic vasoconstrictors (eg, vasopressin). Copyright © 2000 by W.B. Saunders Company     

Cauda equina lesions as a complication of spinal surgery

Although the most common aetiology of cauda equina lesions is lumbar intervertebral disc herniation, iatrogenic lesions may also be the cause. The aim of this study was to identify and present patients in whom cauda equina lesions occurred after spinal surgery. From the author’s series of patients with cauda equina lesions, those with the appearance of sacral symptoms after spinal surgery were identified. To demonstrate lesions more objectively, electrodiagnostic studies were performed in addition to history and clinical examination. Imaging studies were also reviewed. Of 69 patients from the series, 11 patients in whom a cauda equina lesion developed after spinal surgery were identified. The aetiology comprised surgery for herniated intervertebral disc in 5 (4 performed by a single surgeon), spinal stenosis surgery in 4, and postoperative lumbar epidural haematoma in 2 patients (each performed by a different surgeon). Proportion of spinal surgeries with this complication varied from 0 to 6.6‰ in different centres. Patients with iatrogenic cauda equina lesion were significantly older (p < 0.001), and reported more severe urinary, but similar bowel and sexual symptoms compared to other patients in the series. In conclusion the study identified spinal surgery as the cause of approximately 15% of cauda equina lesions. More than a third of lesions developed after procedures performed by a single surgeon. Most of the remaining lesions could probably be avoided by better surgical technique (e.g. the use of a high-speed drill instead of a Kerrison rongeur in patients with severe spinal stenosis), or prevented by closer postoperative monitoring (e.g. in patients with postoperative lumbar epidural haematoma).     

Does minimally invasive lumbar disc surgery result in less muscle injury than conventional surgery? A randomized controlled trial

The concept of minimally invasive lumbar disc surgery comprises reduced muscle injury. The aim of this study was to evaluate creatine phosphokinase (CPK) in serum and the cross-sectional area (CSA) of the multifidus muscle on magnetic resonance imaging as indicators of muscle injury. We present the results of a double-blind randomized trial on patients with lumbar disc herniation, in which tubular discectomy and conventional microdiscectomy were compared. In 216 patients, CPK was measured before surgery and at day 1 after surgery. In 140 patients, the CSA of the multifidus muscle was measured at the affected disc level before surgery and at 1 year after surgery. The ratios (i.e. post surgery/pre surgery) of CPK and CSA were used as outcome measures. The multifidus atrophy was classified into three grades ranging from 0 (normal) to 3 (severe atrophy), and the difference between post and pre surgery was used as an outcome. Patients’ low-back pain scores on the visual analogue scale (VAS) were documented before surgery and at various moments during follow-up. Tubular discectomy compared with conventional microdiscectomy resulted in a nonsignificant difference in CPK ratio, although the CSA ratio was significantly lower in tubular discectomy. At 1 year, there was no difference in atrophy grade between both groups nor in the percentage of patients showing an increased atrophy grade (14% tubular vs. 18% conventional). The postoperative low-back pain scores on the VAS improved in both groups, although the 1-year between-group mean difference of improvement was 3.5 mm (95% CI; 1.4–5.7 mm) in favour of conventional microdiscectomy. In conclusion, tubular discectomy compared with conventional microdiscectomy did not result in reduced muscle injury. Postoperative evaluation of CPK and the multifidus muscle showed similar results in both groups, although patients who underwent tubular discectomy reported more low-back pain during the first year after surgery.     

Clinical neuroprotection and secondary neuronal injury mechanisms

Anaesthetists and intensive care physicians commonly encounter brain injuries in their clinical practice. Cerebral insults may arise from traumatic brain injury, may follow cardiothoracic, vascular or major orthopaedic surgery, and are seen in medical conditions including subarachnoid haemorrhage, central nervous system infection, epilepsy and stroke. In all cases, neuronal injury may lead to severe disability or death; however, aggressive early treatment to prevent the mechanisms that lead to irreversible ischaemia and neuronal cell destruction can result in improvements in patient morbidity and mortality. Neuroprotection involves intervention initiated before the onset of an ischaemic event in an attempt to modify the cascade of biological events that follow ischaemia and thus limit permanent cell damage. Neuroresuscitation, on the other hand, refers to treatment aimed at restoring blood flow to cells that have already become exposed to an ischaemic insult.     

Iatrogenic vascular injury during to lumbar disc surgery

Summary We report two patients who sustained vascular injury while undergoing intervertebral disc surgery at the lumbar four and five level. Each patient suffered from massive bleeding and shock, urgent laparatomy was performed, and the vascular injuries were successfully primarily repaired. The experience prompted us to review reports in the literature since 1965 of vascular complications associated with surgical excision of hernia disc via a posterior approach. From our analysis, we highlight the clinical features and management, emphasising that rapid diagnosis and immediate intervention can result in a favourable outcome, as in our patients.