British Journal of Neurosurgery, April 2015; 29(2): 290 © 2014 The Neurosurgical Foundation ISSN: 0268-8697 print / ISSN 1360-046X online DOI: 10.3109/02688697.2014.978840
The “screwed aorta” after spinal deformity surgery Lee A. Tan, Sumeet K. Ahuja & Harel Deutsch
Br J Neurosurg Downloaded from informahealthcare.com by Nyu Medical Center on 04/25/15 For personal use only.
Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA A 26-year-old woman with prior T3–L4 spinal fusion for adolescent idiopathic scoliosis was incidentally found to have a malpositioned left T6 pedicle screw encroaching the descending thoracic aorta (Fig. 1A). Her scoliosis surgery was done 10 years ago at an outside institution and recent computed tomography (CT) showed solid bony fusion from T3 to L4. Intravascular ultrasound of the aorta showed severe distortion of the aortic wall with possible aortic penetration (Fig. 1B). Given the risk of pseudoaneurysm formation and delayed aortic rupture, she was taken to a hybrid operating room with endovascular capability for removal of the malpositioned thoracic pedicle screw. First, the patient was placed in supine position and two endovascular thoracic stents were successfully deployed to secure the segment of aorta affected by the pedicle screw. Subsequently, she was placed in prone position and the left T6 pedicle screw was exposed and removed after cutting the rod above and below the screw. She tolerated the procedure well and was discharged in a stable condition. Encroachment of the aorta by misplaced thoracic pedicle screws is an uncommon, but potentially fatal complication of spine surgery. The incidence is estimated to range from 0.29% to 1.5%.1,2 Most malpositioned pedicle screws are asymptomatic, therefore frequently undetected. However, symptomatic patients can present with acute bleeding, pseudoaneurysm formation, and delayed aortic rupture.3 Management strategies included open or endovascular
repair of the aorta, followed by removal of the malpositioned pedicle screws.1,4–6 A multidisciplinary approach can often offer good clinical outcome in patients affected by this rare complication. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References 1. Parker SL, Amin AG, Santiago-Dieppa D, et al. Incidence and clinical significance of vascular encroachment resulting from freehand placement of pedicle screws in the thoracic and lumbar spine: analysis of 6816 consecutive screws. Spine 2014;39:683–7. 2. Sarwahi V, Suggs W, Wollowick AL, et al. Pedicle screws adjacent to the great vessels or viscera: a study of 2132 pedicle screws in pediatric spine deformity. J Spinal Disord Tech. 2014;27:64–9. 3. Kakkos SK , Shepard AD. Delayed presentation of aortic injury by pedicle screws: report of two cases and review of the literature. J Vasc Surg 2008;47:1074–82. 4. Decker S, Omar M, Krettek C, Müller CW. Elective thoracotomy for pedicle screw removal to prevent severe aortic bleeding. World J Clin Cases 2014;2:100–3. 5. Clarke MJ, Guzzo J, Wolinsky J-P, Gokaslan Z, Black JH. Combined endovascular and neurosurgical approach to the removal of an intraaortic pedicle screw. J Neurosurg Spine 2011;15:550–4. 6. Akinrinlola A , Brinster DR. Endovascular treatment of a malpositioned screw in the thoracic aorta after anterior spinal instrumentation: the screwed aorta. Vasc Endovascular Surg 2013; 47:555–7.
Fig. 1. (A) CT angiogram demonstrating the malpositioned left T6 pedicle screw indenting the proximal descending aorta; (B) intravascular ultrasound demonstrating severe distortion of the aortic wall by the pedicle screw. Correspondence: Lee A. Tan, MD, Department of Neurosurgery, Rush University Medical Center, 1725 W. Harrison St. Suite 855, Chicago, IL 60612, USA. Tel: ⫹ 312-942-6644. Fax: ⫹ 312-563-3358. E-mail: [email protected] Received for publication 12 October 2014; accepted 15 October 2014
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The “screwed aorta” after spinal deformity surgery Lee A. Tan, Sumeet K. Ahuja & Harel Deutsch
Br J Neurosurg Downloaded from informahealthcare.com by Nyu Medical Center on 04/25/15 For personal use only.
Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA A 26-year-old woman with prior T3–L4 spinal fusion for adolescent idiopathic scoliosis was incidentally found to have a malpositioned left T6 pedicle screw encroaching the descending thoracic aorta (Fig. 1A). Her scoliosis surgery was done 10 years ago at an outside institution and recent computed tomography (CT) showed solid bony fusion from T3 to L4. Intravascular ultrasound of the aorta showed severe distortion of the aortic wall with possible aortic penetration (Fig. 1B). Given the risk of pseudoaneurysm formation and delayed aortic rupture, she was taken to a hybrid operating room with endovascular capability for removal of the malpositioned thoracic pedicle screw. First, the patient was placed in supine position and two endovascular thoracic stents were successfully deployed to secure the segment of aorta affected by the pedicle screw. Subsequently, she was placed in prone position and the left T6 pedicle screw was exposed and removed after cutting the rod above and below the screw. She tolerated the procedure well and was discharged in a stable condition. Encroachment of the aorta by misplaced thoracic pedicle screws is an uncommon, but potentially fatal complication of spine surgery. The incidence is estimated to range from 0.29% to 1.5%.1,2 Most malpositioned pedicle screws are asymptomatic, therefore frequently undetected. However, symptomatic patients can present with acute bleeding, pseudoaneurysm formation, and delayed aortic rupture.3 Management strategies included open or endovascular
repair of the aorta, followed by removal of the malpositioned pedicle screws.1,4–6 A multidisciplinary approach can often offer good clinical outcome in patients affected by this rare complication. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References 1. Parker SL, Amin AG, Santiago-Dieppa D, et al. Incidence and clinical significance of vascular encroachment resulting from freehand placement of pedicle screws in the thoracic and lumbar spine: analysis of 6816 consecutive screws. Spine 2014;39:683–7. 2. Sarwahi V, Suggs W, Wollowick AL, et al. Pedicle screws adjacent to the great vessels or viscera: a study of 2132 pedicle screws in pediatric spine deformity. J Spinal Disord Tech. 2014;27:64–9. 3. Kakkos SK , Shepard AD. Delayed presentation of aortic injury by pedicle screws: report of two cases and review of the literature. J Vasc Surg 2008;47:1074–82. 4. Decker S, Omar M, Krettek C, Müller CW. Elective thoracotomy for pedicle screw removal to prevent severe aortic bleeding. World J Clin Cases 2014;2:100–3. 5. Clarke MJ, Guzzo J, Wolinsky J-P, Gokaslan Z, Black JH. Combined endovascular and neurosurgical approach to the removal of an intraaortic pedicle screw. J Neurosurg Spine 2011;15:550–4. 6. Akinrinlola A , Brinster DR. Endovascular treatment of a malpositioned screw in the thoracic aorta after anterior spinal instrumentation: the screwed aorta. Vasc Endovascular Surg 2013; 47:555–7.
Fig. 1. (A) CT angiogram demonstrating the malpositioned left T6 pedicle screw indenting the proximal descending aorta; (B) intravascular ultrasound demonstrating severe distortion of the aortic wall by the pedicle screw. Correspondence: Lee A. Tan, MD, Department of Neurosurgery, Rush University Medical Center, 1725 W. Harrison St. Suite 855, Chicago, IL 60612, USA. Tel: ⫹ 312-942-6644. Fax: ⫹ 312-563-3358. E-mail: [email protected] Received for publication 12 October 2014; accepted 15 October 2014
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