Delayed presentation of aortic injury by pedicle screws: Report of two cases and review of the literature

Objectives: Perforation of the aorta by pedicle screws is a rare but serious complication of spine fixation surgery. This article reviews the clinical presentation and management of this complication. Methods: Presented are two cases of thoracic aorta perforation by a pedicle screw and a review of the appropriate literature performed using a MEDLINE search. Results: Literature review identified eight additional patients. In most cases, aortic perforation was recognized and managed within 18 months of the spine surgery. Clinical presentation included acute bleeding, necessitating urgent exploration in two patients, and pseudoaneurysm formation in five cases, two of which were infected. Depending on the extent of aortic damage and the presence or absence of infection, management ranged from endovascular grafting, to screw burring with closure of the perforation site, to aortic reconstruction with a tube graft and complete orthopedic hardware removal. Outcome was favorable in all patients who were operated on. Conclusions: The small number of reported cases indicates either the rarity of this complication or unawareness of its existence. The true incidence of this complication is probably under-reported. Orthopedic and vascular surgeons should be aware of this potentially fatal problem. Prevention remains the best treatment. Once encountered, a variety of techniques are available to manage this complication with reasonable outcome.