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CHAPTER

150 Gregory Gebauer


A. Jay Khanna

Vascular Complications

INTRODUCTION The vertebral arteries arise from the subclavian arteries


bilaterally, pass anterior to the C7 transverse process, and enter
The close anatomic relationship between the major neurologic into the osseous foramen transversarium at the C6 level (Fig.
and vascular structures in the body places any patient undergo- 150.2). The arteries travel through the foramen transversarium
ing spine surgery at risk for vascular injury. Such injuries can accompanied by sympathetic nerve fibers and an extensive
range from minor bleeds that can obscure the surgical field to venous plexus. The foramen protects the artery at the level of
a major injury resulting in substantial blood loss and even the vertebral body; at the level of the intervertebral disc, the
death. Management of vascular complications in spine, or any artery is relatively unprotected except for the uncinate process
other, surgery starts with prevention. A thorough knowledge of medially. As the artery progresses more cranially through the
anatomy and careful technique during dissection, retraction, spine, the diameter of the foramen decreases, as does the dis-
and the placement of spinal instrumentation are essential. tance from the foramen to the posterior border of the vertebral
Once an injury has occurred, the surgeon must be familiar with body, thus placing the artery at greater risk for injury at the
the techniques and strategies for the management of these higher vertebral levels. At the C1 level, the artery exits the fora-
complications. In this chapter, we describe the anatomic struc- men and travels posteriorly and medially to enter the foramen
tures at risk for anterior and posterior approaches to the cervi- magnum and join with the contralateral artery to form the basi-
cal, thoracic, and lumbar spine; review the relative risks of lar artery and then the posterior component of the Circle of
injury; and provide general and specific strategies for the pre- Willis (Fig. 150.3). The minimal safe distance for dissection
vention and treatment of these injuries. from the midline has been reported as 15 mm,3 although
Ebraheim et al11 have suggested more conservative measure-
ments of 12 mm along the inferior margin of C1 and 8 mm
along the superior margin. Aberrant vertebral artery anatomy
CERVICAL SPINE
is relatively common. A hypoplastic or absent artery is present
in 15% of the population, and a tortuous artery or one with an
ANATOMY
abnormal course has been reported in up to 2.7% of the popu-
The thoracic duct and five major vascular structures are at risk lation.8 Bruneau et al5 reported a 12.4% rate of unilateral
during cervical spine surgery (Fig. 150.1): carotid arteries abnormal arteries and a 0.8% incidence of bilateral anomalies
(internal and external), jugular veins (internal and external), (Fig. 150.4).
superior thyroid artery, inferior thyroid artery, and vertebral The thoracic duct is at risk during high thoracic and low
arteries. The carotid artery branches off from the aortic arch cervical procedures. It enters the base of the neck to the left of
on the left and from the brachiocephalic artery on the right. the esophagus, crosses over the subclavian artery at the T1 level,
It travels proximally through the anterolateral neck in the and empties into the superior vena cava in the upper mediasti-
carotid sheath, along with the internal jugular vein and the num on the right side of the chest.
vagus nerve. At the level of the superior border of the thyroid
cartilage, the carotid artery divides into the internal and exter-
ANTERIOR PROCEDURES
nal carotid arteries, with the internal artery continuing
cephalad to provide the anterior contribution to the Circle of Anterior cervical procedures put many of the major vascular
Willis. The external carotid artery provides circulation to the structures of the neck at risk for direct and indirect injury
head, face, and neck. The superior and inferior thyroid arter- (Table 150.1). Although direct injury to the carotid artery is
ies are important not only as a source of potential bleeding but possible, it is rare. Thrombosis of the internal carotid artery has
also because of their close anatomic relationship to major been reported7 and is believed to be related to retraction of the
nerves. The superior thyroid artery is a branch of the external vessels during the surgery. Emboli from these thrombosed ves-
carotid artery and crosses the neck at the level of C3 to C4. It sels can produce hemiparalysis. Increased age, the presence of
is often found in close proximity to the superior laryngeal atherosclerosis, and lengthy duration of retraction are risk fac-
nerve. The inferior thyroid artery, a branch of the thyrocervi- tors for the development of thrombosis.7
cal trunk of the subclavian artery, is usually seen at the C6 to Prevention of carotid artery injuries requires careful dissec-
C7 level and is located in close proximity to the recurrent tion during the approach to the anterior cervical spine. The
laryngeal nerve. surgeon should confirm that the artery is palpable lateral to the
1598

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Chapter 150 Vascular Complications 1599

Figure 150.1. Artist sketches of the


anatomy of the anterior cervical spine.
(A) Axial image of the anatomy of the neck
and the surgical plane most commonly used
to approach the cervical spine. Note the
close relationship of the carotid sheath.
(B) The vascular anatomy at the cervicotho-
racic junction. Note the close relationship
of the inferior thyroid artery and the
recurrent laryngeal nerve. (C) Vascular
anatomy at the more superior cervical lev-
els. Note the close relationship between the
superior thyroid artery and the superior
laryngeal nerve. Reprinted with permission
from Rao R, Bagaria V. Anterior approaches
to the cervical and cervicothoracic spine.
Orthopaedic Knowledge Online. American
Academy of Orthopaedic Surgeons,
December 19, 2005. C

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1600 Section XIV Complications

Figure 150.2. Anatomy of the vertebral artery as seen on a reconstructed image


from a computed tomography angiogram showing the vascular anatomy of the cer-
vical spine. (A) The common carotid artery, (B) the external carotid artery, (C) the
internal carotid artery, (D) the vertebral artery, and (E) the superior laryngeal
artery.

Figure 150.3. Artist sketches of the anatomy of the


vertebral artery and the occipitocervical junction. Axial
(A) and coronal (B) illustrations of the course of the ver-
tebral artery as it passes over C1, into the vertebral artery
groove, and through the foramen magnum to contribute
to the Circle of Willis. Reprinted with permission from
Ebraheim NA, Xu R, Ahmad M, et al. The quantitative
anatomy of the vertebral artery groove of the atlas and its
relation to the posterior atlantoaxial approach. Spine
B 1998;23:320323.

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Chapter 150 Vascular Complications 1601

terization. Care must be taken to avoid the nerves that accom-


pany these two vessels (the superior laryngeal nerve with the
superior thyroid artery and the recurrent laryngeal nerve with
the inferior thyroid artery).
The incidence of vertebral artery injury during anterior
procedures has been reported to be between 0.3%13 and 0.5%.25
Risk factors for injury include aberrant anatomy, loss of midline
orientation, previous radiation, and presence of osteomyelitis
or tumor altering the osseous anatomy.25 Injury can occur
during decompression via a bur, during screw placement, or
from retraction. The artery is at greater risk for injury during
corpectomy than during discectomy. Injury to this artery can
result in substantial blood loss [3004500 mL].25 In addition,
ischemic and embolic cerebrovascular accidents have been
reported.15 Late-presenting complications from injury can
include pseudoaneurysm, late-onset hemorrhage, and arterio-
venous malformation.9
Daentzer et al9 reviewed 29 cases of vertebral artery injury;
five resulted in a permanent neurologic deficit and three
resulted in death. Smith et al,25 in a series of 10 patients,
reported six cases of neurologic deficit: transient C5 paralysis
Figure 150.4. Aberrant anatomy of the vertebral artery as seen on (two), cerebellar ataxia (two), quadriplegia (one), and
axial computed tomography images of a tortuous vertebral artery
within the foramen transversarium. Reprinted with permission from
Wallenburg ataxia (one). The injury in nine of the 10 cases was
Curylo, LJ, Mason, HC, Bohlman HH, et al. Tortuous course of the attributed to use of the bur.
vertebral artery and anterior cervical decompression: a cadaveric and Care while using the bur during anterior cervical decom-
clinical case study. Spine 2000;25:28602864. pression is essential for the prevention of vertebral artery injury.
The bur should be kept perpendicular to the surgical field.
Maintenance of midline orientation is also necessary to avoid
plane of dissection. Once the spine is exposed, overzealous excessive lateral burring. The uncovertebral joints can be used
retraction should be avoided, and the retractors should be as a guide for the lateral extent of decompression. Osteophytes
released intermittently during the course of the procedure. should be noted and removed if necessary to maintain orienta-
During the preoperative evaluation, auscultation of the neck tion. Marking the midline of the superior and inferior vertebral
for the presence of a bruit may be useful for identifying patients bodies may help keep midline orientation. Smith et al25 recom-
at risk for carotid artery thrombosis. Ultrasound may be useful mended decompressing only to the edge of the longus colli
in at-risk patients to determine the laterality of the approach or muscles. Intraoperative fluoroscopy or radiographs can be used
determine if it would be more prudent to use a posterior to confirm location relative to midline during the procedure.
approach. During surgery, the anesthesiologist can palpate the Radiopaque contrast agent placed into the corpectomy defect
superficial temporal artery to monitor for possible occlusion. may allow better visualization of the distance to the vertebral
Direct injuries to the carotid artery should be repaired pri- artery.
marily. If injury does occur, an intraoperative vascular surgery Once an injury to the vertebral artery has been identified, it
consultation should be strongly considered. Vascular surgery is essential to minimize and stop the bleeding and to prevent
should also be consulted if thrombosis of the carotid artery is ischemia and the formation of emboli. In general, distal inju-
noted intraoperatively. Treatment of postoperatively identified ries are easier to control than proximal ones. To obtain control
thromboses should include anticoagulation and possibly neu- of the artery, the osseous structures surrounding the artery,
rology and vascular surgery consultations. including the anterior margin of the vertebral foramen, are
The superior and inferior thyroid arteries are often encoun- removed. Next, proximal and distal control is achieved with the
tered during anterior cervical surgery. The superior thyroid use of vessel loops. Dissection of the artery is then completed,
artery is often present at the C3 to C4 level, and the inferior and the laceration is repaired with suture. If direct repair is not
artery is usually seen at the C6 to C7 level. Bleeding from these possible, the artery can be ligated proximally and distally to the
arteries can generally be controlled with ligation or electrocau- zone of injury. The risk of cerebrovascular infarct after ligation,
assuming a normal contralateral vessel, is reported to be 3.1%
for the left side and 1.8% for the right side.28 Ligation of only
the proximal portion of the artery has been associated with an
Structures at Risk During increased risk of delayed embolization, hemorrhage, and
TABLE 150.1 an Anterior Cervical fistula formation.25 If local control cannot be obtained by liga-
Approach tion or repair, the wound can be packed, and the artery can be
embolized via interventional radiology techniques.
Carotid arteries (internal and external) Injuries to the thoracic duct are relatively rare. Damage to
Jugular veins (internal and external)
the duct can result in chylomediastinum or a chylous pleural
Thyroid arteries (superior and inferior)
effusion. Minor injuries to the duct usually heal spontaneously.
Vertebral arteries
Thoracic duct (low cervical and high thoracic levels) If a severe injury is noted intraoperatively, double ligation can
be performed with surgical clips. Fibrin glue may help seal

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1602 Section XIV 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

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Chapter 150 Vascular Complications 1603

Figure 150.5. Artist sketches of


the anatomy of the thoracic spine
encountered during left-side (A) and
right-side (B) thoracotomies for
access to the thoracic spine.
Reprinted with permission from Rao
R, Bagaria V. Anterior approaches to
the thoracolumbar spine. Orthopae-
dic Knowledge Online. American
Academy of Orthopaedic Surgeons,
December 19, 2005. B

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

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1604 Section XIV Complications

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

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Chapter 150 Vascular Complications 1605

lateral approach. When necessary, segmental vessels should be


ligated over the anterior portion of the vertebral body to avoid
injury to the collateral and foraminal circulation.
Commonly injured vessels during anterior lumbar surgery
include the left common iliac vein, the inferior vena cava,
and the iliolumbar vein. Arterial injuries are less common
than venous injury. The most frequently injured artery is the
common iliac artery.20 The incidence of major vascular injury
during an open approach to the anterior spine has been
reported to be as high as 15.6%.4 Minimally invasive tech-
niques also involve risk to the abdominal vasculature. Escobar
et al12 reported the incidence of injury to be 3.7% when using
video-assisted techniques and 8.7% when using a minimally
open surgical technique. Risk factors for injury include smok-
ing, a history of vascular disease, and previous abdominal
surgery.20
In addition to direct injury, there is also the risk of throm-
bosis from extended retraction. Such extended retraction
and the associated potential for thrombosis can lead to
ischemia of the limb, deep venous thrombosis, and poten-
tially pulmonary embolism. Brau et al4 reported 6 episodes of
Figure 150.7. Axial computed tomography image of a thoracic
thrombosis in 1315 patients undergoing anterior lumbar
pedicle screw with a lateral wall breach impacting to the thoracic
aorta. Reprinted with permission from Minor ME, Morrissey NJ, interbody fusion, resulting in an incidence of 0.45%. Of these
Peress R, et al. Endovascular treatment of an iatrogenic thoracic aortic patients, four required thrombectomy, two required a
injury after spinal instrumentation: case report. J Vasc Surg bypass-type procedure, and two developed a compartment
2004;39:893896. syndrome.

Figure 150.8. Artists sketch of the lumbar


spine anatomy encountered during an anterior
approach. Reprinted with permission from Rao
R, Bagaria V. Anterior approaches to the thora-
columbar spine. Orthopaedic Knowledge Online.
American Academy of Orthopaedic Surgeons,
December 19, 2005.

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1606 Section XIV Complications

Structures at Risk During Risk Factors for Vascular


TABLE 150.6
TABLE 150.4 an Anterior Lumbar Complications10
Approach
Patient Factors Surgeon Factors
Aorta
Iliac arteries (internal and external) Aberrant anatomy (e.g., Improper patient positioning,
Inferior vena cava vertebral or vascular resulting in rotation, or
Iliac veins (internal and external) anomalies) increased abdominal pressure
Median sacral artery Gaps or deficiency in annulus Plunging/deep protrusion of
Iliolumbar vein or ligaments instruments
Thoracic duct Obesity Loss of midline orientation
Previous surgery/adhesions Extensive retraction
Previous irradiation Failure to study or interpret
adequately the preoperative
POSTERIOR PROCEDURES imaging studies
Vascular disease
The placement of the pedicle screws in the lumbar spine is
believed to the relatively safe with regard to vascular injury
(Table 150.5). Lonstein et al21 reported that 2.8% of 4,790
pedicle screws were found to have penetrated the anterior cor-
tex of the vertebral body but that none of those injuries resulted SPECIAL CONSIDERATIONS
in any major complications.
Discectomy and posterior and transforaminal lumbar inter- BONE GRAFT HARVEST
body arthrodesis procedures place the anterior vessels at risk
The superior gluteal artery is at risk during posterior iliac
for injury. The left iliac artery is the most commonly injured
crest bone graft harvest. This artery is a branch of the internal
vessel because of its close relationship to the L4 to L5 disc
iliac artery that passes through the sciatic notch (Fig. 150.9).
space.14 Other vessels prone to injury are the right iliac artery,
Injury can result from deep placement of retractors, curettes,
inferior vena cava, aorta, and iliac veins; the incidence of such
or osteotomes. The artery may retract into the pelvis, making
injury ranges from 1.6 to 46 in 10,000.14,24 Increased risk of
localization difficult. To visualize and obtain control of this
injury has been associated with patient and surgeon factors
artery, it may be necessary to enlarge the notch or detach
(Table 150.6). Clinically, these injuries can be difficult to diag-
some of the gluteus musculature. Angiography and emboliza-
nose. They are mostly easily discovered by the presence of brisk
tion can also be considered. Injury to the superior gluteal
bleeding from the disc space, but this sign is unreliable, and
the absence of bleeding does not preclude injury. Severe injury
may result in hypotension and signs of acute blood loss, but it
may also be missed during the normal resuscitative efforts of
the anesthesiologist. Delayed presentation of these injuries may
include increased abdominal distention and discomfort, nau-
sea, and vomiting14symptoms than can be confused with
more typical postoperative symptoms. Vigilance is necessary for
the diagnosis of such injuries. Once an injury is suspected,
angiography may be useful in confirming the diagnosis. The
potential for death from these injuries is high, especially if the
bleeding is not quickly brought under control and the patient
is aggressively resuscitated. Late complications may include
arteriovenous fistula and aneurysm.
Acute, intraoperative treatment of these injuries often
requires an emergent vascular surgery consultation. If the
patient is unstable, aggressive fluid resuscitation must be per-
formed while the patient is repositioned supine and an emer-
gency laparotomy is performed. Stable patients or those in
whom the vascular injury is diagnosed postoperatively may be
candidates for angiography and possible embolization or endo-
vascular stenting.

Structures at Risk During a


TABLE 150.5 Figure 150.9. Artists sketch of the anatomy of the superior glu-
Posterior Lumbar Approach teal artery. Note the position of the artery as it exits the sciatic notch.
This artery is at risk during posterior iliac crest bone graft. PSIS, pos-
Aorta
terior superior iliac spine. Reprinted with permission from Ebraheim
Iliac arteries (internal and external)
NA, Elgafy H, Xu R. Bone-graft harvesting from the iliac and fibular
Inferior vena cava
donor site: techniques and complications. J Am Acad Orthop Surg
Iliac veins (internal and external)
2001;9(3):210218.

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Chapter 150 Vascular Complications 1607

artery can be prevented by limiting the depth of the dissec- REFERENCES


tion and visualizing the portions of the ilium that are to be
1. Abumi K, Shono Y, Ito M, et al. Complications of pedicle screw fixation in reconstructive
harvested. surgery of the cervical spine. Spine 2000;25:962969.
2. Biafora SJ, Mardjetko SM, Butler JP, et al. Arterial injury following percutaneous vertebral
augmentation. A case report. Spine 2006;31:E84E87.
VERTEBROPLASTY/KYPHOPLASTY 3. Bono CM, Liu PC, Yuan HA, et al. Anatomy and approaches. In: Bono CM, Garfin SR, eds.
Orthopaedic surgery essentials: spine. Philadelphia: Lippincott Williams & Wilkins,
Although vertebroplasty and kyphoplasty are considered mini- 217234: 2004.
mally invasive and low-risk procedures, they do carry a risk for 4. Brau SA, Delamarter RB, Schiffman ML, et al. Vascular injury during anterior lumbar
surgery. Spine J 2004;4:409412.
vascular injury.2 The segmental arteries may be injured during 5. Bruneau M, Cornelius JF, Marneffe V, et al. Anatomical variations of the V2 segment of the
the placement of the trocar and working cannula during these vertebral artery. Neurosurgery 2006;59:ONS-20ONS-24.
6. Burrington JD, Brown C, Wayne ER, et al. Anterior approach to the thoracolumbar spine.
procedures. The diagnosis can be made if pulsatile bleeding is Technical considerations. Arch Surg 1976;111:456463.
noted at the surgical site. Embolization can be used to control 7. Chozick BS, Watson P, Greenblatt SH. Internal carotid artery thrombosis after cervical
the bleeding. Kyphoplasty and vertebroplasty have the poten- corpectomy. Spine 1994;19:22302232.
8. Curylo LJ, Mason HC, Bohlman HH, et al. Tortuous course of the vertebral artery and
tial to cause pulmonary embolism and fat embolism. Although, anterior cervical decompression. A cadaveric and clinical case study. Spine 2000;25:
to our knowledge, there have been no definitive studies, the 28602864.
incidence of vascular complication after these procedures is 9. Daentzer D, Deinsberger W, Boker DK. Vertebral artery complications in anterior
approaches to the cervical spine: report of two cases and review of literature. Surg Neurol
believed to be low. 2003;59:300309.
10. Dosoglu M, Is M, Pehlivan M, et al. Nightmare of lumbar disc surgery: iliac artery injury.
Clin Neurol Neurosurg 2006;108:174177.
11. Ebraheim NA, Xu R, Ahmad M, et al. The quantitative anatomy of the vertebral artery
CONCLUSION groove of the atlas and its relation to the posterior atlantoaxial approach. Spine
1998;23:320323.
12. Escobar E, Transfeldt E, Garvey T, et al. Video-assisted versus open anterior lumbar spine
Vascular injury during spine surgery is a rare but potentially fusion surgery. A comparison of four techniques and complications in 135 patients. Spine
devastating complication. During cervical procedures, the ver- 2003;28:729732.
tebral and carotid arteries are the major at-risk structures. Care 13. Golfinos JG, Dickman CA, Zabramski JM, et al. Repair of vertebral artery injury during
anterior cervical decompression. Spine 1994;19:25522556.
should be taken during dissection and retraction to avoid injury 14. Goodkin R, Laska LL. Vascular and visceral injuries associated with lumbar disc surgery:
to the carotid artery. During dissection, it is important to feel medicolegal implications. Surg Neurol 1998;49:358370.
15. Graham JJ. Complications of cervical spine surgery. A five-year report on a survey of the
regularly for the carotid pulse to confirm the correct plane of membership of the Cervical Spine Research Society by the Morbidity and Mortality Com-
the dissection. Retractors should be released periodically to mittee. Spine 1989;14:10461050.
minimize the risk of thrombosis associated with prolonged 16. Heller JG, Silcox DH III, Sutterlin CE III. Complications of posterior cervical plating. Spine
1995;20:24422448.
retraction. 17. Kast E, Mohr K, Richter HP, et al. Complications of transpedicular screw fixation in the
The vertebral artery is most at risk in anterior procedures cervical spine. Eur Spine J 2006;15:327334.
during removal of the disc space and use of the burr. 18. Kim YJ, Lenke LG, Bridwell KH, et al. Free hand pedicle screw placement in the thoracic
spine: is it safe? Spine 2004;29:333342.
Maintenance of midline orientation and careful control of 19. Kuklo TR, Lehman RA Jr, Lenke LG. Structures at risk following anterior instrumented spinal
instruments is essential. If this artery is injured, packing and fusion for thoracic adolescent idiopathic scoliosis. J Spinal Disord Tech 2005;18:S58S64.
20. Kulkarni SS, Lowery GL, Ross RE, et al. Arterial complications following anterior lumbar
hemostatic agents should be used to gain control. If these mea- interbody fusion: report of eight cases. Eur Spine J 2003;12:4854.
sures are not successful, direct repair of the artery should be 21. Lonstein JE, Denis F, Perra JH, et al. Complications associated with pedicle screws. J Bone
attempted. The vertebral artery can also be injured during Joint Surg Am 1999;81:15191528.
22. Madawi AA, Casey ATH, Solanki GA, et al. Radiological and anatomical evaluation of the
placement of posterior instrumentation. These injuries can be atlantoaxial transarticular screw fixation technique. J Neurosurg 1997;86:961968.
controlled with packing and placement of the screws. If injury 23. Mirovsky Y, Hod-Feins R, Agar G, et al. Avoiding neurologic complications following liga-
is noted on one side, instrumentation should not be inserted tion of the segmental vessels during anterior instrumentation of the thoracolumbar spine.
Spine 2007;32:275280.
on the contralateral side for fear of injuring both of the verte- 24. Ramirez LF, Thisted R. Complications and demographic characteristics of patients under-
bral arteries. The surgeon should examine preoperative imag- going lumbar discectomy in community hospitals. Neurosurgery 1989;25:226230.
25. Smith MD, Emery SE, Dudley A, et al. Vertebral artery injury during anterior decompres-
ing and be aware of the relatively high prevalence of aberrant sion of the cervical spine. A retrospective review of ten patients. J Bone Joint Surg Br
anatomy of the vertebral artery. Additional caution should be 1993;75:410415.
observed in the area of the occipitocervical junction. 26. Sucato DJ, Kassab F, Dempsey M. Analysis of screw placement relative to the aorta and
spinal canal following anterior instrumentation for thoracic idiopathic scoliosis. Spine
Surgery on the thoracic and lumbar spine places the aorta, 2004;29:554559.
vena cava, iliac vessels, and iliolumbar vein at risk. Major injury 27. Suk SI, Kim WJ, Lee SM, et al. Thoracic pedicle screw fixation in spinal deformities. Are
to these vessels may require an emergent vascular surgery con- they really safe? Spine 2001;26:20492057.
28. Thomas GI, Anderson KN, Hain RF, et al. The significance of anomalous vertebral-basilar
sultation and aggressive resuscitation with fluids and blood artery communication in operations on the heart and great vessels. An illustrative case with
products. Although posterior surgery is relatively safe, perfora- review of the literature. Surgery 1959;46:747757.
29. Winter RB, Lonstein JE, Denis F, et al. Paraplegia resulting from vessel ligation. Spine
tion of the anterior cortex of the vertebral body can put the 1996;21:12321233.
vascular structures at risk. Screws noted to be too long should 30. Wright NM, Lauryssen C. Vertebral artery injury in C12 transarticular screw fixation:
be revised. results of a survey of the AANS/CNS section on disorders of the spine and peripheral
nerves. J Neurosurg 1998;88:634640.

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