British Journal of Neurosurgery
ISSN: 0268-8697 (Print) 1360-046X (Online) Journal homepage: http://www.tandfonline.com/loi/ibjn20
Traumatic lumbar artery rupture after lumbar spinal fracture dislocation causing hypovolemic shock: An endovascular treatment Jong-Pil Eun & Young-Min Oh To cite this article: Jong-Pil Eun & Young-Min Oh (2015): Traumatic lumbar artery rupture after lumbar spinal fracture dislocation causing hypovolemic shock: An endovascular treatment, British Journal of Neurosurgery, DOI: 10.3109/02688697.2015.1039490 To link to this article: http://dx.doi.org/10.3109/02688697.2015.1039490
Published online: 11 May 2015.
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Date: 05 November 2015, At: 15:19
British Journal of Neurosurgery, 2015; Early Online: 1–3 © 2015 The Neurosurgical Foundation ISSN: 0268-8697 print / ISSN 1360-046X online DOI: 10.3109/02688697.2015.1039490
SHORT REPORT
Traumatic lumbar artery rupture after lumbar spinal fracture dislocation causing hypovolemic shock: An endovascular treatment Jong-Pil Eun & Young-Min Oh
Downloaded by [Australian National University] at 15:19 05 November 2015
Department of Neurosurgery, Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Korea We recently observed a patient who developed a retroperitoneal hemorrhage with hemodynamic instability following a fracture dislocation of the lumbar vertebra and was treated successfully with endovascular embolization.
Abstract Recently, we observed a case of lumbar artery injury after trauma, which was treated by endovascular embolization. A 67-year-old woman who was injured in a traffic accident was brought to the emergency room. She was conscious and her hemodynamic condition was stable, but she had paraplegia below L1 dermatome. Contrast-enhanced computed tomography scan of abdomen and pelvis revealed fracture dislocation of L3/4 along with retroperitoneal hematomas. However, there was no evidence of traumatic injury in both thoracic and abdominal cavity. At that time, her blood pressure suddenly decreased to 60/40 mmHg and her mental status deteriorated. Also, her hemoglobin level was 5.4 g/dl. While her hemodynamic condition stabilized with massive fluid resuscitation including blood transfusion, an angiography was immediately performed to look for and embolize site of retroperitoneal hemorrhage. On the angiographic images, there was an active extravasation from ruptured left 3rd lumbar artery, and we performed complete embolization with GELFOAM and coil. Lumbar artery injury after trauma is rare and endovascular treatment is useful in case of hemodynamic instability.
Case report A 67-year-old woman who was injured in a traffic accident was brought to the emergency room. She was conscious and her hemodynamic condition was stable, but she had paraplegia below L1 dermatome. Contrast-enhanced computed tomography (CT) scan of abdomen and pelvis revealed fracture dislocation of L3/4 along with extravasation of the contrast media (Fig. 1a and b). However, there was no evidence of traumatic injury in both thoracic and abdominal cavity. At that time, her blood pressure suddenly decreased to 60/40 mmHg and her mental status deteriorated. Also, her hemoglobin level was 5.4 g/dl. While her hemodynamic condition stabilized with massive fluid resuscitation including blood transfusion, an angiography was immediately performed to look for and embolize site of retroperitoneal hemorrhage. On the angiographic images, there was an active extravasation from ruptured left 3rd lumbar artery (Fig. 2a), and we performed complete embolization with GELFOAM and coil (Fig. 2b). After the procedure, her hemodynamic status and clinical condition gradually improved. The retroperitoneal hematoma reduced on 5th day of hospitalization. The patient then underwent open reduction and screw fixation for fracture dislocation of L3/4 vertebrae. Then the patient was transferred to the department of rehabilitation and able to stand with walker.
Keywords: hypovolemic shock; lumbar artery; spinal fracture; trauma
Introduction Although there are some reports about iatrogenic lumbar artery injury after invasive procedures, lumbar artery injury after trauma is a rare cause of significant retroperitoneal hemorrhage.1 Since retroperitoneal hemorrhage can induce hypovolemic shock, early detection and suspicion of lumbar artery injury are important. Treatment for this injury is either surgery or endovascular embolization. Since surgery often fails to identify the bleeder, endovascular treatment is preferred for lumbar artery injury.1 Lumbar artery injury is a rare and often overlooked cause of retroperitoneal hemorrhage after spinal trauma.
Discussion A lumbar artery injury after lumbar spinal fracture is a rare cause of significant retroperitoneal hemorrhage. The cause of lumbar artery injuries may be induced by shearing forces during rotation, flexion distraction, or fracture dislocation
Correspondence: Young-Min Oh, Department of Neurosurgery, Chonbuk National University Medical School/Hospital, Gunjiro 20, Deokjin-gu, Jeonju 561–712, Korea. Tel: 82-63-250–1870. Fax: 82-63-277–3273. E-mail: [email protected] Received for publication 26 January 2015; accepted 6 April 2015
1
Downloaded by [Australian National University] at 15:19 05 November 2015
2 J.-P. Eun & Y.-M. Oh
Fig. 1. (a) Lumbar radiography shows lumbar fracture dislocation on L3/4. (b) Contrast-enhanced CT scan of abdomen and pelvis revealed extravasation of the contrast media (arrow).
injury. Also, fracture of body or a transverse process may be responsible for direct laceration and avulsion of a lumbar artery. Most of hemorrhages associated with vertebral fractures mainly occur from the azygos vein, external vertebral venous plexus, and intercostal artery. In these cases, spontaneous hemostasis usually occurs. However, because lumbar arteries are branched directly from the aorta, the lumbar artery injury is high-pressure bleeding and can cause a massive retroperitoneal hematoma.2 Therefore, early diagnosis of a lumbar artery is important. In our case, hemodynamic status of the patient worsened shortly after the trauma and CT images revealed L3/4 fracture dislocation injury with multiple transverse process fractures. So we suspected the bleeding from lumbar artery injuries and decided to perform angiography and embolization. The presence of lumbar vertebral fracture, lower rib fracture, or transverse process fracture suggests an associated retroperitoneal hematoma. There are some reports about the management of a hemodynamically unstable patient with a large retroperitoneal hematoma. Because of diffuse vascular injuries and inability
to obtain effective proximal control, surgical hemostasis is often difficult to achieve, resulting in a high reported mortality. Yuan et al.3 reported that two patients with lumbar artery injury underwent concomitant retroperitoneal exploration during other emergency surgery, but both surgeries failed to identify the bleeder, and both patients eventually required angiography. Therefore, they do not recommend concomitant retroperitoneal exploration during other emergency surgery if lumbar artery injury is suspected. On the contrary, many authors have reported high technical success rates for endovascular embolization for lumbar artery injury.1,3 We also performed complete embolization with GELFOAM and coil. We suggest that endovascular embolization is less invasive than surgical management and effective for the treatment of intractable bleeding following compression or burst fractures of the spine.
Conclusion A lumbar artery injury after lumbar spinal fracture is a rare cause of significant retroperitoneal hemorrhage and can
Fig. 2. Angiographic image. (a) There was an active extravasation from ruptured left 3rd lumbar artery. (b) We performed complete embolization with GELFOAM and coil.
Traumatic lumbar artery rupture 3 induce hypovolemic shock. In this case, it is important for clinicians to recognize the possibility of lumbar artery injury. Endovascular treatment is effective in case of hemodynamic instability.
Downloaded by [Australian National University] at 15:19 05 November 2015
Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper.
References 1. Yuan KC, Hsu YP, Wong YC, et al. Management of complicated lumbar artery injury after blunt trauma. Ann Emerg Med 2011;58:531–5. 2. Morita S, Tsuji T, Fukushima T, et al. Arterial embolization of an extrapleural hematoma from a dislocated fracture of the lumbar spine: A case report. Scand J Trauma Resusc Emerg Med 2009;17:27. 3. Boufi M, Bordon S, Dona B, et al. Unstable patients with retroperitoneal vascular trauma: An endovascular approach. Ann Vasc Surg 2011;25:352–8.
ISSN: 0268-8697 (Print) 1360-046X (Online) Journal homepage: http://www.tandfonline.com/loi/ibjn20
Traumatic lumbar artery rupture after lumbar spinal fracture dislocation causing hypovolemic shock: An endovascular treatment Jong-Pil Eun & Young-Min Oh To cite this article: Jong-Pil Eun & Young-Min Oh (2015): Traumatic lumbar artery rupture after lumbar spinal fracture dislocation causing hypovolemic shock: An endovascular treatment, British Journal of Neurosurgery, DOI: 10.3109/02688697.2015.1039490 To link to this article: http://dx.doi.org/10.3109/02688697.2015.1039490
Published online: 11 May 2015.
Submit your article to this journal
Article views: 29
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ibjn20 Download by: [Australian National University]
Date: 05 November 2015, At: 15:19
British Journal of Neurosurgery, 2015; Early Online: 1–3 © 2015 The Neurosurgical Foundation ISSN: 0268-8697 print / ISSN 1360-046X online DOI: 10.3109/02688697.2015.1039490
SHORT REPORT
Traumatic lumbar artery rupture after lumbar spinal fracture dislocation causing hypovolemic shock: An endovascular treatment Jong-Pil Eun & Young-Min Oh
Downloaded by [Australian National University] at 15:19 05 November 2015
Department of Neurosurgery, Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Korea We recently observed a patient who developed a retroperitoneal hemorrhage with hemodynamic instability following a fracture dislocation of the lumbar vertebra and was treated successfully with endovascular embolization.
Abstract Recently, we observed a case of lumbar artery injury after trauma, which was treated by endovascular embolization. A 67-year-old woman who was injured in a traffic accident was brought to the emergency room. She was conscious and her hemodynamic condition was stable, but she had paraplegia below L1 dermatome. Contrast-enhanced computed tomography scan of abdomen and pelvis revealed fracture dislocation of L3/4 along with retroperitoneal hematomas. However, there was no evidence of traumatic injury in both thoracic and abdominal cavity. At that time, her blood pressure suddenly decreased to 60/40 mmHg and her mental status deteriorated. Also, her hemoglobin level was 5.4 g/dl. While her hemodynamic condition stabilized with massive fluid resuscitation including blood transfusion, an angiography was immediately performed to look for and embolize site of retroperitoneal hemorrhage. On the angiographic images, there was an active extravasation from ruptured left 3rd lumbar artery, and we performed complete embolization with GELFOAM and coil. Lumbar artery injury after trauma is rare and endovascular treatment is useful in case of hemodynamic instability.
Case report A 67-year-old woman who was injured in a traffic accident was brought to the emergency room. She was conscious and her hemodynamic condition was stable, but she had paraplegia below L1 dermatome. Contrast-enhanced computed tomography (CT) scan of abdomen and pelvis revealed fracture dislocation of L3/4 along with extravasation of the contrast media (Fig. 1a and b). However, there was no evidence of traumatic injury in both thoracic and abdominal cavity. At that time, her blood pressure suddenly decreased to 60/40 mmHg and her mental status deteriorated. Also, her hemoglobin level was 5.4 g/dl. While her hemodynamic condition stabilized with massive fluid resuscitation including blood transfusion, an angiography was immediately performed to look for and embolize site of retroperitoneal hemorrhage. On the angiographic images, there was an active extravasation from ruptured left 3rd lumbar artery (Fig. 2a), and we performed complete embolization with GELFOAM and coil (Fig. 2b). After the procedure, her hemodynamic status and clinical condition gradually improved. The retroperitoneal hematoma reduced on 5th day of hospitalization. The patient then underwent open reduction and screw fixation for fracture dislocation of L3/4 vertebrae. Then the patient was transferred to the department of rehabilitation and able to stand with walker.
Keywords: hypovolemic shock; lumbar artery; spinal fracture; trauma
Introduction Although there are some reports about iatrogenic lumbar artery injury after invasive procedures, lumbar artery injury after trauma is a rare cause of significant retroperitoneal hemorrhage.1 Since retroperitoneal hemorrhage can induce hypovolemic shock, early detection and suspicion of lumbar artery injury are important. Treatment for this injury is either surgery or endovascular embolization. Since surgery often fails to identify the bleeder, endovascular treatment is preferred for lumbar artery injury.1 Lumbar artery injury is a rare and often overlooked cause of retroperitoneal hemorrhage after spinal trauma.
Discussion A lumbar artery injury after lumbar spinal fracture is a rare cause of significant retroperitoneal hemorrhage. The cause of lumbar artery injuries may be induced by shearing forces during rotation, flexion distraction, or fracture dislocation
Correspondence: Young-Min Oh, Department of Neurosurgery, Chonbuk National University Medical School/Hospital, Gunjiro 20, Deokjin-gu, Jeonju 561–712, Korea. Tel: 82-63-250–1870. Fax: 82-63-277–3273. E-mail: [email protected] Received for publication 26 January 2015; accepted 6 April 2015
1
Downloaded by [Australian National University] at 15:19 05 November 2015
2 J.-P. Eun & Y.-M. Oh
Fig. 1. (a) Lumbar radiography shows lumbar fracture dislocation on L3/4. (b) Contrast-enhanced CT scan of abdomen and pelvis revealed extravasation of the contrast media (arrow).
injury. Also, fracture of body or a transverse process may be responsible for direct laceration and avulsion of a lumbar artery. Most of hemorrhages associated with vertebral fractures mainly occur from the azygos vein, external vertebral venous plexus, and intercostal artery. In these cases, spontaneous hemostasis usually occurs. However, because lumbar arteries are branched directly from the aorta, the lumbar artery injury is high-pressure bleeding and can cause a massive retroperitoneal hematoma.2 Therefore, early diagnosis of a lumbar artery is important. In our case, hemodynamic status of the patient worsened shortly after the trauma and CT images revealed L3/4 fracture dislocation injury with multiple transverse process fractures. So we suspected the bleeding from lumbar artery injuries and decided to perform angiography and embolization. The presence of lumbar vertebral fracture, lower rib fracture, or transverse process fracture suggests an associated retroperitoneal hematoma. There are some reports about the management of a hemodynamically unstable patient with a large retroperitoneal hematoma. Because of diffuse vascular injuries and inability
to obtain effective proximal control, surgical hemostasis is often difficult to achieve, resulting in a high reported mortality. Yuan et al.3 reported that two patients with lumbar artery injury underwent concomitant retroperitoneal exploration during other emergency surgery, but both surgeries failed to identify the bleeder, and both patients eventually required angiography. Therefore, they do not recommend concomitant retroperitoneal exploration during other emergency surgery if lumbar artery injury is suspected. On the contrary, many authors have reported high technical success rates for endovascular embolization for lumbar artery injury.1,3 We also performed complete embolization with GELFOAM and coil. We suggest that endovascular embolization is less invasive than surgical management and effective for the treatment of intractable bleeding following compression or burst fractures of the spine.
Conclusion A lumbar artery injury after lumbar spinal fracture is a rare cause of significant retroperitoneal hemorrhage and can
Fig. 2. Angiographic image. (a) There was an active extravasation from ruptured left 3rd lumbar artery. (b) We performed complete embolization with GELFOAM and coil.
Traumatic lumbar artery rupture 3 induce hypovolemic shock. In this case, it is important for clinicians to recognize the possibility of lumbar artery injury. Endovascular treatment is effective in case of hemodynamic instability.
Downloaded by [Australian National University] at 15:19 05 November 2015
Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper.
References 1. Yuan KC, Hsu YP, Wong YC, et al. Management of complicated lumbar artery injury after blunt trauma. Ann Emerg Med 2011;58:531–5. 2. Morita S, Tsuji T, Fukushima T, et al. Arterial embolization of an extrapleural hematoma from a dislocated fracture of the lumbar spine: A case report. Scand J Trauma Resusc Emerg Med 2009;17:27. 3. Boufi M, Bordon S, Dona B, et al. Unstable patients with retroperitoneal vascular trauma: An endovascular approach. Ann Vasc Surg 2011;25:352–8.
