Major vascular injury during anterior lumbar spinal surgery - Incidence, risk factors, and management

Study Design. Retrospective chart review. Objective. To examine the incidence of major vascular injury during anterior lumbar spinal surgery, attempt to identify predisposing risk factors, and to discuss management techniques. Summary of Background Data. Major vascular injury can be a catastrophic complication of anterior lumbar spinal surgery. Methods. Current procedural terminology codes were used to identify the occurrence of major vascular injury, defined as injury to the iliac vessels, vena cava, and aorta. Once identified, the office record, hospital chart, operative note, and diagnostic test results were reviewed in detail. Results. Three hundred forty-five operations were performed on 338 patients. Incidence of major vascular complication was 2.9% ( 10 of 345). There were 9 injuries of the common iliac vein and a single aortic injury. Risk factors identified in patients with major vascular injury were current or previous osteomyelitis or discogenic infection (n = 3), previous anterior spinal surgery ( n = 2), spondylolisthesis ( n = 2; 1 isthmic Grade II, 1 iatrogenic Grade II), large anterior osteophyte ( n = 2), transitional lumbosacral vertebra ( n = 1), and anterior migration of interbody device ( n = 1). Lateral venorrhaphy by suture ( n = 6) and hemoclip application ( n = 2) was augmented by topical agents, which constituted the sole method of repair on 1 occasion. Magnetic resonance venography demonstrated iliac vein thrombosis in 1 patient. Conclusion. Current or previous osteomyelitis or discogenic infection, previous anterior spinal surgery, spondylolisthesis, osteophyte formation, transitional lumbosacral vertebra and anterior migration of interbody device point to an increased risk of vascular injury during anterior lumbar spinal surgery. Careful handling of the vascular structures and liberal use of topical hemostatic agents can lead to control of hemorrhage and preservation of vascular patency. Routine postoperative surveillance for proximal deep vein thrombosis, by magnetic resonance venography of the pelvic veins and inferior vena cava, should be performed after venorrhaphy.