Iliac-Cava Complication after L4–L5 Discectomy

Abstract

Introduction Lumbar discectomy is one of the most often performed surgical technique at spinal level. The appearance of post discectomy complications is uncommon, being even rarer the vascular ones. Materials and Methods In this paper we present the case of a woman who underwent L4-L5 discectomy, left L5 foraminotomy and interspinous UniWallis implant at this level through posterior longitudinal approach. Four weeks after surgery, the patient presented symptoms of right heart failure and systolic-diastolic murmur on aortic area with abdominal and lumbar clear dominance. The CT scan revealed the presence of a right iliac-cava fistula that was treated by endovascular surgery with success. Results Postdiscectomy vascular complications are very uncommon (from 0.04 to 0.14%). However, they are potentially fatal for patients. For this reason they should be suspected, identified and treated as soon as possible. In this case, the potential cause could had been a damage at baseline wall of the right iliac artery. This could produce a pseudoaneurysm that progressed overtime and eroded the wall of the vein cava adjacent leading to a right iliac-cava fistula formation due to the blood flow pressure. This justifies the start of the characteristic symptoms. However, one of the peculiarities and particularities of this case is that the clinic started 4 weeks after surgery, not having found in the literature publications with these characteristics until this moment. Even though, it has been described the formation of an aneurysm at 5 -6 weeks after trauma in Vascular Surgery. Moreover, postdiscectomy vascular complications have been reported more frequently in the L4-L5 space, being more frequent lesion in the right iliac artery. In this case, the disc level and laterality agree with the most frequent complication, although approaching has been done by left side. On the other hand, the anterior approaching has the highest rates of vascular complication in spine surgery, but in our case the approaching has been done by left posterior incision. Conclusions Postdiscectomy lumbar vascular complications represent a vital risk to the patient. For this reason they must be taken into account for prompt diagnosis and treatment. These complications can be asymptomatic during hospitalization and postoperative and be revealed several weeks later. Posterior approaches in lumbar spine surgery are not exempt from vascular complications, since they frequently occur by anterior approach. This case highlights the importance of taking into account these vascular complications despite the posterior approach as well as after initial satisfactory postoperative course.