Abdominal Vascular Injury During Lumbar Disc Sur gery. Case 1

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1 Chi nese Med i cal Jour nal (Taipei) 2001;64: Case Re port Abdominal Vascular Injury During Lumbar Disc Sur gery Huang-Ping Yu 1 Shu-Shya Hseu 1 Chun-Sung Sung 1 Hui-Cheng Cheng 2 Huey-Wen Yien 1 1 De part ment of An es the si ol ogy; 2 De part ment of Ra di ol ogy, Tai pei Vet erans Gen eral Hos pi tal; and De part ment of An es the si ol ogy, Na tional Yang-Ming Uni ver sity School of Med i cine, Tai pei, Tai wan, R.O.C. Key Words arteriovenous fis tula; intraoperative com pli ca tions; lum bar laminectomy; retroperitoneal hem or rhage Ma jor vas cu lar in jury is an un usual but well-recognized com pli ca tion of ver te bral disc sur gery. Iso lated ar te rial lac er a tion is the most com - mon type of this ves sel in jury in lum bar spine sur gery, with early man i - festation due to retroperitoneal hem or rhage. Two cases are de scribed that il lus trate the full spec trum of acute man i fes ta tion of such in ju ries. Two cases of acute hem or rhage due to ar te rial trauma were seen; one mor tal ity case was rec og nized dur ing the op er a tion and one sal vaged in the recovery room. In both cases unstable perioperative hemo dy - namics and post op er a tive dis tended ab do men were ob served. It is the purpose of this paper to report two cases and to dis cuss the morbid anat omy, di ag no sis of such vas cu lar in ju ries and an es thetic han dling of retroperitoneal hemorrhage. For anesthesiologists who are also drill workers while doing lumbar spinal or epidural anesthesia, these rare ca tas tro phes re mind us to pay spe cial at ten tion to the ver te bral vas cu lar (not only skel e tal) anat omy. [Chin Med J (Taipei) 2001;64: ] Since first re ported in 1945 by Lin ton and White at the Mas sa chu setts General Hospital, one ma jor vas cu lar in jury oc cur ring dur ing op er a tion for lum bar disk dis ease has be come rec og nized as an un usual but well-described com pli ca tion of such surgery. 1 As in other forms of vas cu lar trauma, in jury may cause lac er - a tion of a ma jor ves sel with early signs of acute blood loss, or may re sult in for ma tion of a false an eu rysm or arteriovenous fis tula that may of ten es cape de tec tion for long pe ri ods. The kind of iat ro genic vas cu lar in ju - ries could have full spec trum of clin i cal man i fes ta tions so that near-fatal ca tas tro phe can be held in the op er at - ing or re cov ery room. Knowl edge about this rare sur gi - cal com pli ca tion in tro duces us an es the si ol o gists the pos si ble tragic sce nario not only dis play ing in to tally vis i ble field of lum bar sur gery but also con sid er able in blinded tap ping of trau matic epidural an es the sia. Case 1 Case Reports A 69-year-old fe male was ad mit ted with a threeyear his tory of back pain ra di at ing down the right leg. Pre-operative com put er ized to mog ra phy showed spi - nal ste no sis at the level of L4-5 (Fig.1). An es the sia was in duced, phys i o log i cal mon i tor ing was hooked up, and the pa tient was prone po si tioned and drap ing as usual. Re moval of L 4-5 intervertebral disc was car - ried out un event fully, ex cept for an un ex plained drop in blood pres sure to 60 mmhg intraoperatively, as so - Re ceived: November 10, Ac cepted: July 6, Cor re spon dence to: Shu-Shya Hseu, MD, De part ment of An es the si ol ogy, Tai pei Vet erans Gen eral Hos pi tal, 201, Sec. 2, Shih-Pai Road, Tai pei 112, Tai wan. Fax: ; sshseu@vghtpe.gov.tw

2 650 Huang-Ping Yu, et al. Chi nese Med i cal Jour nal (Taipei) Vol. 64 No. 11 ci ated with tachy car dia. These ab nor mal i ties re - sponded well to vol ume re place ment (packed red blood cell trans fu sion 4 units). An es the si ol o gists set invasively intra-arterial blood pres sure (ABP) mon i - tor ing at this sit u a tion for fur ther eval u a tion but lower ABP level was noted. Sur geon did not find any sig nif - i cant blood loss in the sur gi cal field dur ing the perioperative pe riod. The to tal an es the sia time lasted for about 7 hours but the pa tient al most im me di ately waked up while she was turned to su pine po si tion and com plained leg pain. No ab nor mal ex ter nal bleed ing through drain age tub ing was noted. No leg pa ral y sis had been checked out. One hour post op er a tively, the pa tient com plained of in creased ab dom i nal pain. BP drop was found al though massive trans fu sion with packed red blood cell (PRBC) 14 units and crystalloid so lu tions was per formed. Phys i cal ex am i na tion re - vealed dif fuse ten der ness over the ab do men. Since both the ab dom i nal sonography and com put er ized to - mog ra phy con firmed retroperitoneal hematoma prob - a bly ooz ing from left iliac ar tery (Fig.2), the sur geons de cided to per form emer gent laparotomy sur gery to check bleed ing. At the op er a tion, a large de fect was seen in volv ing the left com mon iliac ar tery that could be pri mar ily re paired. A to tally 17,000 ml of blood loss dur ing ex plor atory op er a tion was noted and an - other 20 units of PRBC were trans fused. Post op er a - tive re cov ery was sat is fac tory and un event ful. Case 2 Fig. 1. The bulg ing of an nu lar fi bro sis re sult ing in mixed spi nal ste no sis at the level of L4-5. There is noth ing ex cept fat tis sue sur round ing to great ves sel. Fig. 2. Pres ence of a huge het er o ge neous mass (14 16 cm) in LLQ and ex tended along left retroperitoneal space into pararenal space at the level of L4-5 disc. A 58 -year-old male, hav ing suf fered from rup - tured L 4-5 disk with se vere low back pain and ra di a tion pain, was ad mit ted to un dergo disectomy sur gery. No any med i cal or sur gi cal his tory was avail able. Af ter in duc tion, the endotracheal intubation was per formed smoothly and gen eral an es the sia was main tained with isoflurane de liv ered in 50% N 2 O-O 2 mix ture. Prone po si tion and towel drap ing for lum bar disectomy was taken as usual. Though in at tempt to avoid ex ces sive depth pen e - tra tion, the or tho pae dic sur geon no ticed sud den loss of tis sue re sis tance while ap ply ing the pi tu itary rongeur in re mov ing inter- and peri-vertebral ma te ri - als ex ten sively. Rapid and pro fuse hem or rhage from sur gi cal field was found and the es ti mated blood loss was around 1,000 ml. Within a few min utes, pro - found hypotension with si nus tachy car dia was ob - served and per sisted de spite of ex ten sive in tra ve nous fluid re sus ci ta tion and car dio vas cu lar drug treat ment. Af ter sim ple clo sure of the sur gi cal wound the pa tient was im me di ately turned to su pine po si tion. Dis tended ab do men with mot tled lower limbs was no ticed. While the cen tral ve nous cath e ter was in serted via the right in ter nal jug u lar vein, the cen tral ve nous pres sure was down to only 1 mmhg. Af ter per sis tent fluid sup - ply, dopamine con tin u ous in fu sion and vasoactive

3 No vem ber 2001 Vas cu lar In jury Dur ing Sur gery 651 drug ther apy the sys tolic blood pres sure was raised to around 100 mmhg. Sur geons re sorted to ag gres sive med i cal treat ment at the in ten sive care unit in stead of emer gent ex plor atory sur gery. Un for tu nately the gen eral con di tions got worsen. Four hours later, vi tal signs could not be main tained even un der high dose vasoactive agent ther apy. The mot - tle area was ex tended cephaladly up to the lower ab do - men with cyanosis at the re gion from toes to the um bi li - cus. Air hun ger even with me chan i cal ven ti latory sup - port, severe metabolic acidosis and profound intraabdominal hemorrhage were found. Owing to lifethreatening and poor re sponse to med i cal treat ment the sur geons de cided to per form emer gent laparotomy sur - gery. Un der the com pre hen sive hemo dynamic mon i tor - ing of ra dial ar tery, pul mo nary ar tery and cen tral ve nous pres sures, con tin u ous fluid and blood com po nent re sus - ci ta tion and vasoactive drug ther apy, the car diac, or tho - pae dic and gen eral sur geons co op er ated to per form the emer gent life-saving sur gery. As the field of laparotomy was draped, dis tended ab do men was eas ily dis cern ible. Mas sive blood flooded out of ab do men shortly af ter lap - arotomy with acute car dio vas cu lar col lapse. Tear of right iliac ar tery was found. Even with cardio pulmonary re - suscitation, the pa tient ex pired due to se vere hem or - rhagic shock with car dio vas cu lar col lapse. Discussion Ab dom i nal vas cu lar in jury dur ing lum bar spine sur gery is an un usual and rather weird event. Though the re ported in ci dence of ab dom i nal great ves sel in - jury in back sur gery is rare, the un rec og nized events are far more than ex pected. Sev eral au thors have re - ported and re viewed the vas cu lar in jury in spine sur - gery. 2-6 Gertzbein et al. 7 re ported a 2.4% in ci dence of vas cu lar in jury com pli ca tion in lum bar spine sur gery while Rajaraman et al. 8 re ported a 6.7% in ci dence in an te rior lum bar interbody fu sion sur gery. Such in ju - ries oc cur even in ex pe ri enced sur geons with gen tle technique. Al though the vas cu lar in jury in lum bar spine sur - gery is un com mon, it could turn to be a ca tas tro phe with fa tal out come. As the lon gev ity of gen eral pop u - la tion is pro longed and the ad vance ment in neu ro sur - gery is pro moted, pa tients un der go ing lum bar spine sur gery and the ex tent of sur gi cal ex plo ra tion are greatly in creased. It is im por tant for us to keep alert about the pos si bil ity of vas cu lar com pli ca tion dur ing lum bar spine sur gery and be fa mil iar with the clin i cal ex pres sion and man age ment of these events. The aorta bi fur cates in the retroperitoneum just to the left of the midline at the level of the body of the fourth lum bar ver te bra in 75-80% of pa tients. The com - mon iliac ar ter ies pass down ward and lateralward across the L4-5 disk space. The com mon iliac veins pass up - ward to meet above the L4-5 disk space to form the in fe - rior vena cava to the right of the midline. The left com - mon iliac vein passes up ward and me dialward across the fifth lum bar ver te bral body and the L4-5 disk space, where it is crossed by the right com mon iliac ar tery, which es sen tially fixes it. 9,10 The prox im ity of the iliac ar ter ies, iliac veins and in fe rior vena cava to the re gion of the L4-5 disk space, where a broad vas cu lar belt is formed, sug gests why the ma jor ity of in ju ries oc cur in these ves sels and at this disk space. This also ex plains the oc cur rence of fis tula for ma tion be tween the right com mon iliac ar tery and left com mon iliac vein. (Fig. 3) The ex act lo ca tion of ves sel in jury de pends on sev eral fac tors, in clud ing the op er ated disk space, in - di vid ual an a tomic vari a tion, and the pierc ing an gle of ex plor ing in stru ment (e.g. rongeur). The ma jor ity of Fig. 3. The prox im ity of the bi fur ca tion of the aorta and the for ma tion of the in fe rior vena cava to the L4-5 disk space cre ates a broad vas cu lar band at this site. The left com mon iliac vein passes be neath the right com mon iliac ar tery where it is rel a tively fixed. A prob ing in stru ment, e.g., a pi tu itary rongeur, may eas ily pro duce a vas cu lar in jury. (A: fron tal view. B: sagittal view.)

4 652 Huang-Ping Yu, et al. Chi nese Med i cal Jour nal (Taipei) Vol. 64 No. 11 re ported in ju ries have fol lowed op er a tion on the L4-5 disk space and have in volved in jury to the com mon iliac ves sels. 5,6,11 Intra-abdominal great ves sels, such as aorta, in fe rior vena cava, com mon iliac ar tery and vein, in ter nal iliac ar tery and vein, lum bar ar tery, and me dial sa cral ves sels, have been re ported to suf fer from vas cu lar in jury dur ing or af ter lum bar spine sur - gery. 6,9,12-19 Con cern ing about the in ci dence of intraabdominal ves sel in jury Jarstfer et al. 6 an nounced that the right com mon iliac ar tery was in jured most fre - quently, but Birkeland et al. 9 sug gested that it was the left com mon iliac ar tery in jured most fre quently be - cause it lay im me di ately an te rior to the fourth lum bar intervertebral disc. The ra tio of ar te rial or ve nous in - jury alone to artreriovenous fis tula for ma tion was re - ported from 1.2:1 to 9.2:1. 6 Arteriovenous fis tu las oc - curred in about 25 per cent of pub lished cases of ves sel in jury; sev eral went un rec og nized for as long as nine years af ter lum bar-disk sur gery. 20 Intra-abdominal vas cu lar in ju ries dur ing lum bar disectomy might ex press as: (1) lac er a tion of great ves sel with or with out im me di ate shock, (2) par tial in - jury of vas cu lar wall with de layed hem or rhage or throm bo sis, and (3) an eu rysm or arteriovenous fis tula for ma tion. These vas cu lar com pli ca tions have led to a va ri ety of clin i cal ap pear ance, even with cat a strophic con se quences. The mas sive blood loss from ex - sanguination re quires med i cal treat ment with pro fuse blood trans fu sion or even emer gent laparotomy sur - gery to stop bleed ing. To make the di ag no sis of vas cu lar in jury in lum - bar spine sur gery, we must keep in mind the pos si bil - ity of this com pli ca tion. Higher than 50% of mor tal ity rate for acute ar te rial in ju ries re sult ing from lum bar disc sur gery were re ported by many au thors. 2,4,6,11,12 Should there were (1) un usual rate of pro fuse bleed ing from the op er a tion field, (2) un sta ble homo dy nam ic or even shock which could not be ex plained with perioperative blood loss, or (3) dis tended ab do men, we should sus pect the pos si bil ity of vas cu lar in jury. In both of our pa tients, un sta ble perioperative hemo - dynamics and post op er a tive dis tended ab do men were ob served. If the clin i cal con di tion is sta ble, or if the di - ag no sis of vas cu lar in jury is es tab lished, angiography or ab dom i nal com put er ized to mog ra phy can be help - ful and de fin i tive. It may prove nec es sary and ad vis - able to pro ceed with ab dom i nal ex plo ra tion sim ply on the ba sis of clin i cal sus pi cion. Should the pa tient s vi - tal signs were ex tremely un sta ble and could not be main tained un der med i cal treat ment, emer gent lap - arotomy should be per formed im me di ately. Bass et al. 13 sug gested that the ab dom i nal sur gi cal ex plo ra tion should be prompted im me di ately as the vas cu lar in - jury was noted dur ing lum bar spine sur gery or in the re cov ery room. Only prompt and ag gres sive treat ment can im prove the out come of vas cu lar com pli ca tion in lum bar disc sur gery. Once the in di ca tion of emer gent ex plor atory lap - arotmy is es tab lished, set greater-bore ve nous lines and more blood com po nents than ex pected for the bleed ing are usu ally pro vided deep in site and pro - found in vol ume. The ex plo ra tion should never start un til ev ery thing was ready at hands. For mas sive bleed ing and trans fu sion is highly pos si ble in the great ves sel sur gery, it is ab so lutely nec es sary to warm the trans fused blood com po nents and con tin u ous mon i tor the body tem per a ture. It is also help ful in crit i cal pe - riod to work out the mas sive trans fu sion al go rithm for each op er at ing the ater, in clud ing se quenc ing the rea - son able com bi na tion of blood com po nents and check - out list of co ag u la tion func tion. In con clu sion, in the tran si tional pe riod of sur gi - cal prac tic ing, not only sur geons but also we an es the - si ol o gists should learn well the re lated an a tomic knowl edge for new ser vice and even the rare com pli - ca tions. Only when we keep alert to the pos si bil ity that back sur gery could pro duce the lac er a tion in jury of ab dom i nal ves sel, then the near-fatal ca tas tro phes may have the chance to re solve to make a happy end - ing. Setup of cri sis res o lu tion pro to cols, such as mas - sive trans fu sion al go rithm to se quence the rea son - able com bi na tion of blood com po nents and check out list of co ag u la tion func tion, is quite ben e fi cial in the crit i cal pe riod. Acknowledgments We thank Miss Mei-Chen Yu for her prep a ra tion of the sketch for us.

5 No vem ber 2001 Vas cu lar In jury Dur ing Sur gery 653 References 1. Lin ton RR, White PD. Arteriovenous fis tula be tween the right com mon iliac ar tery and the in fe rior vena cava: a re port of a case of its oc cur rence fol low ing an op er a tion for a rup - tured intervertebral disk with cure by op er a tion. Arch Surg 1945;50: Harbison SP. Ma jor vas cu lar com pli ca tions of intervertebral disc sur gery. Ann Surg 1954;140: DeSaussure RL. Vas cu lar in jury co in ci dent to disc sur gery. J Neurosurg 1959;16: Hohf RP. Ar te rial in ju ries oc cur ring dur ing or tho pae dic op - er a tions. Clin Orthop 1963;28: Hildreth DH, Turcke DA. Postlaminectomy arteriovenous fis tula. Sur gery 1977;81: Jarstfer BS, Rich NM. The chal lenge of arteriovenous fis tula for ma tion fol low ing disk sur gery: a col lec tive re view. J Trauma 1976;16: Gertzbein SD, Betz R, Clements D. Errico T, Hammerberg K, Rob bins S, et al. Semirigid in stru men ta tion in the man - age ment of lum bar spi nal con di tions com bined with cir - cumfer ential fu sion. A multicenter study. Spine 1996;21: Rajaraman V, Vingan R, Roth P, Heary RF, Conklin L, Jacobs GB. Vis ceral and vas cu lar com pli ca tions re sult ing from an te - rior lum bar interbody fu sion. J Neurosurg 1999;91(suppl 1): Birkeland IW, Tay lor TKF. Ma jor vas cu lar in ju ries in lum bar disk sur gery. J Bone Joint Surg 1969;51B: Seeley SF, Hughes CW, Jahnke EJ. Ma jor ves sel dam age in lum bar disk op er a tion. Sur gery 1954;35: Birkeland IW, Tay lor TKF. Ma jor vas cu lar in ju ries in lum bar disc sur gery. J Bone Joint Surg 1969;51A: Holscher EC. Vas cu lar and vis ceral in ju ries dur ing lum - bar-disc sur gery. J Bone Joint Surg 1968;50A: Bass J, Lach J, Fegelman RH. Vas cu lar in ju ries dur ing lum - bar laminectomy. Am Surg 1980;46: Smith DW, Law rence BD. Vas cu lar com pli ca tions of lum bar de com pres sion laminectomy and foraminotomy. A unique case and re view of the lit er a ture. Spine 1991;16: Kiev J, Dupont JR, Kerstein MD. In jury of a me dial sa cral ves sel dur ing lum bar laminectomy. Ann Vasc Surg 1996;10: Ezra E, Richenberg JL, Smellei WAB. Ma jor vas cu lar in jury dur ing lum bar laminectomy. J Soc Med 1996;89: Brewster DC, May ARL, Dar ling C, Abbott WM, Moncure C. Vari able man i fes ta tions of vas cu lar in jury dur ing lum bar disk sur gery. Arch Surg 1979;114: May ARL, Brewster DC, Dar ling RC, Browse NL. Arte - riovenous fis tula fol low ing lum bar disc sur gery. Br J Surg 1981;68: Boyd DP, Farha GJ. Arteriovenous fis tula and iso lated vas - cu lar in ju ries sec ond ary to intervertebral disk sur gery. Re - port of four cases and re view of the lit er a ture. Ann Surg 1965;161: Hildreth DH, Turcke DA. Postlaminectomy arteriovenous fis tula. Sur gery 1977;81: