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Vascular Complications
leaks. Direct repair may be technically difficult because of the landmarks. Once an injury is identified during surgery, bone
friable nature of the ducts wall. If the injury is noted after sur- wax can be used to tamponade the bleeding. Placement of the
gery, lymphangiography can be used to localize the injury. A screw may provide additional tamponade. If the bleeding
drain to decompress the chyle flow can be placed via interven- cannot be controlled, it may be necessary to expose and ligate
tional radiology techniques. Postoperatively, oral feeding the artery. A postoperative angiogram should be obtained if
should be withheld, and the patient should be placed on low- there is any concern about residual bleeding after surgery.
fat parenteral nutrition until the leak has resolved. Octreotide
or etilefrine may be helpful in slowing the rate of the leak.
Patients should be monitored for septicemia and fungemia, THORACIC SPINE
and prophylactic antibiotics should be considered. Operative
intervention, if needed, can be performed after the injury has ANATOMY
been localized via lymphangiography, and the duct may be
ligated with double ligation as described above. The spine and the great vessels are closely related in the tho-
racic cavity. The aorta travels along the left side of the chest and
passes posterior to the pulmonary vessels (Fig. 150.5). In
POSTERIOR PROCEDURES
patients with scoliosis, the position of the aorta tends to shift
The vertebral artery is the primary vascular structure at risk farther posteriorly and laterally with increasing Cobb angles
during posterior cervical surgery, especially during instrumen- (Fig. 150.6). The vena cava is on the right and passes anterior
tation of the C1 and C2 vertebral levels. As described previ- to the pulmonary vessels. Additionally, there are several smaller
ously, after exiting the C2 foramen transversarium, the artery vessels at risk during thoracic spine surgery. The azygos vein is
travels medially and posteriorly behind the ring of C1 before located in close proximity to the right side of the vertebral bod-
entering the base of the skull through the foramen magnum. ies of the thoracic spine. The thoracic duct is positioned ante-
The limits of careful dissection have been reported as between rior to the spine between the aorta and azygos veins. It crosses
12 and 15 mm from midline; the distance is less in children.3,11 to the left side of the chest anterior to the T5 vertebral body.
The artery is at greater risk along the superior margin of C1. The segmental arteries arise from the aorta and travel along
Numerous methods for instrumentation of the suboccipital the midportion of the vertebral body. Posteriorly, they divide to
cervical spine have been described. Wiring techniques have a contribute to the anterior spinal and intercostal arteries.
relatively low risk for vascular injury, whereas C1 to C2 transarticu- Numerous anastomoses connect these arteries. The intercostal
lar screws have a relatively high risk of vascular injury [4.1% to veins branch from the azygos and hemiazygos and pass along
8%].22,30 Vascular injury with transarticular screws is more likely in the inferior aspects of the ribs. These perforating vessels also
patients with a narrow isthmus. Usually, the left side is larger, and serve to tether the larger vessels to the spine.
therefore safer, than the right. Placement of C1 lateral mass
screws can lead to substantial bleeding from the epidural plexus
ANTERIOR PROCEDURES
that overlies the starting point for the screw. Additionally, over-
zealous dissection cephalad to the arch of C1 places the vertebral The anterior thoracic spine can be approached from the right
artery at risk. C2 pedicle screws are relatively safe, but a lateral or left side with thoracotomy or thorascopic techniques. The
breach of the screw can place the artery at risk.1 wall of the aorta is thicker than the vena cava and therefore
Instrumentation of the subaxial cervical spine also puts the easier and safer to manipulate. Therefore, many surgeons pre-
vertebral artery at risk. The level of risk depends on the technique fer a left-sided approach. It is important to note, however, that
used for placement of the screws and whether or not screws are the left-sided approach places the pericardial structures at
bicortical. Heller et al16 reviewed 654 lateral mass screws placed in greater risk than does a right-sided approach. In cases of defor-
78 patients and found no evidence of vertebral artery injury. mity, it may be advantageous to approach from the convexity of
Abumi et al1 reviewed cervical pedicle screws retrospectively in the curve. During dissection, care should be taken to preserve
45 patients (183 screws) and prospectively in 189 patients the segmental arteries that supply the spinal cord (Table 150.2).
(669 screws). They reported 13 screws that were described as at In a series of more than 1,000 patients undergoing anterior
risk on postoperative radiographs and one episode of vertebral thoracic spinal procedures, Winter et al29 reported no inci-
artery injury with no subsequent sequelae. Kast et al17 examined dence of neurologic sequelae. To preserve the collateral blood
postoperative computed tomography scans for 16 patients flow, they suggested that, when ligation is necessary, the arteries
(94 pedicle screws) and found 4 screws that compromised the should be ligated unilaterally at the level of the middle of the
vertebral artery canal by more than 25%. None of those patients vertebral body and that ligation should be performed on the
were noted to have had any vascular complications. convexity of the scoliotic curve. In addition, to preserve the
Prevention of injury to the vertebral artery requires a com- perfusion pressure, anesthesia should avoid making the patient
prehensive understanding of the anatomy. Before surgery, hypotensive. The Artery of Adamkiewicz, the major vascular
imaging studies should be reviewed to evaluate for aberrant supply to the lower portion of the spinal cord, usually is located
anatomy of the artery. All preoperative magnetic resonance on the left side and can arise anywhere from T5 to L2. Most
imaging studies should be reviewed in the axial and sagittal commonly, it is found between T9 and T12.23 Although ligation
planes, with specific attention to mapping the course of the ver- of this artery has been associated with neurologic complica-
tebral artery. For cases that involve complex deformity or instru- tions after vascular procedures on the aorta, Burrington et al6
mentation at the C1 and/or C2 levels, a preoperative computed have shown that the artery can be ligated safely as long as the
tomography scan should also be considered. For accurate screw collateral circulation is preserved.
placement, there should be adequate exposure to ensure full Overall, injury during anterior thoracic surgery is relatively
visualization of the starting point and regional anatomic rare, but it may be secondary to an errant retractor, bur, or other
instrument. Sucato et al26 evaluated 106 screws placed thoras- vertebral body, possibly leading to vascular injury (Table 150.3)
copically in 14 patients with scoliosis. They found that 14.2% of (Fig. 150.7). Suk et al27 reviewed 4,600 screw placements and
the screws were located adjacent to the aorta and that 12.3% of found a 1.5% rate of malposition. Kim et al18 reported a 6.2%
the screws deformed the aorta. There were no complications rate of moderate cortical breech in 3,204 screw placements.
related to these screws. Kuklo et al19 found that 26% of anterior There were no vascular complications reported in either series.
screws placed at the apex of scoliotic curves were within 2 mm of
the aorta but that none of these deformed the aorta. Prevention
of injury requires adequate visualization and careful placement
of instruments. Injury to the great vessels requires immediate Structures at Risk During a
control of the bleeding and an emergent intraoperative vascular TABLE 150.2
Anterior Thoracic Approach
surgery consultation. The anesthesiologist will need to provide
aggressive hemodynamic stabilization. Aorta
Vena cava (superior and inferior)
Pulmonary arteries and veins
POSTERIOR PROCEDURES Segmental vessels
Azygos and hemiazygos veins
If placed inaccurately in the thoracic spine, a pedicle screw
Thoracic duct
can penetrate the anterior or anterolateral cortex of the
A B
Figure 150.6. Axial computed tomography images showing the changing posi-
tion of the aorta in a patient with scoliosis. (A) Position at the T4 level. Note how
the aorta shifts more posterior and lateral at the apex of the curve (B) and then
returns to its more normal anatomic position in the lower thoracic region after
passing the apex of the curve (C). Reprinted with permission from Kuklo TR,
Lehman RA, Lenke LG. Structures at risk following anterior instrumented spinal
fusion for thoracic adolescent idiopathic scoliosis. J Spinal Disord Tech
C
2005;18S:S58S64.
The aorta is at greater risk in patients with scoliosis, particu- (Fig. 150.8). The aorta and vena cava usually bifurcate into the
larly with a lateral breech at the concavity of the curve: Kuklo iliac vessels at the L4 level. The common iliac arteries and veins
et al19 reported 96.3% accuracy in patients with more than 90 bifurcate into the internal and external vessels at S1, with the
of scoliosis. Screws that are noted to be malpositioned intraop- internal vessels branching off medially. The left iliac vein passes
eratively should be removed and repositioned. Placement of posterior and medial to the common iliac artery. The right
an endovascular shunt prior to screw removal may help mini- common iliac artery passes below and medial to the left iliac
mize the risks associated with screw removal. vein. Aberrant anatomy is believed to be relatively common in
this region. The median sacral artery originates at the bifurca-
tion of the aorta and passes over the sacral promontory. The
LUMBAR SPINE iliolumbar vein is a branch of the common iliac vein, is often
found anterior to the L5 level, and can be injured during
ANATOMY retraction or surgery at the L5 level.
The aorta and vena cava travel through the chest into the abdo-
men anterior and slightly anterolateral to the lumbar spine ANTERIOR PROCEDURES
The vascular structures of the abdomen and pelvis are at risk
during dissection and retraction during anterior procedures
Structures at Risk During a (Table 150.4). The instruments used for anterior lumbar sur-
TABLE 150.3 gery are often long, and slight movements in the surgeons
Posterior Thoracic Approach
hand may translate to larger ones in the operative field. The
Aorta L5-S1 disc is usually located below the level of the bifurcation
Vena cava
of the great vessels. Access to the L4 to L5 and more caudal
Segmental vessels
levels may require mobilization of the great vessels or use of a