Thoracic Vertebral Screw Impingement on the Aorta in an In Vivo Bovine Model

Faro, Fran D; Farnsworth, Christine L.; Shapiro, Gary S.; Mohamad, Fazir; White, Klane K.; Breisch, Eric; Mahar, Andrew; Tomlinson, Tucker; Bawa, Maneesh; Gomez, Mark A.; Newton, Peter O.

doi:10.1097/01.brs.0000184587.25330.40

Cited by 34 publications

(30 citation statements)

References 14 publications

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“…More commonly, however, they present as a pseudoaneurysm and a possible delayed hemorrhage, which can present weeks to months later. 4,7,8,11,12 In addition, the presentation of these pseudoaneurysms can be extremely variable and are often asymptomatic, making diagnosis incidental during routine reimaging. 13,14 Chronic irritation of the aortic wall due to the pulsations of the aorta against a metallic object is felt to lead to eventual perforation or pseudoaneurysm formation.…”

Section: Discussionmentioning

confidence: 97%

“…13,14 Chronic irritation of the aortic wall due to the pulsations of the aorta against a metallic object is felt to lead to eventual perforation or pseudoaneurysm formation. 11,15 Given that proximity of a screw tip to the aortic wall has been reported in up to 12% of spinal cases, delayed injury to the aorta represents a real concern. 16,17 Repair of such injuries to the aorta traditionally involved a thoracotomy or laparotomy, with direct repair of the injured segment.…”

Section: Discussionmentioning

confidence: 99%

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Endovascular solutions to arterial injury due to posterior spine surgery

Loh

Maldonaldo

Rockman

et al. 2012

Journal of Vascular Surgery

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Iatrogenic arterial injury is an uncommon but recognized complication of posterior spinal surgery. The spectrum of injuries includes vessel perforation leading to hemorrhage, delayed pseudoaneurysm formation, and threatened perforation by screw impingement on arterial vessels. Repair of these injuries traditionally involved open direct vessel repair or graft placement, which can be associated with significant morbidity. We identified five patients with iatrogenic arterial injury during or after posterior spinal surgery between July 2004 and August 2009 and describe their endovascular treatment. Intraoperative arterial bleeding was encountered in two patients during posterior spinal surgery. The posterior wounds were packed, temporarily closed, and the patient was placed supine. In both patients, angiography demonstrated arterial injury necessitating repair. Covered stent grafts were deployed through femoral cutdowns to exclude the areas of injury. In three additional patients, postoperative computed tomography imaging demonstrated pedicle screws abutting/penetrating the thoracic or abdominal aorta. Angiography or intravascular ultrasound imaging, or both, confirmed indention/perforation of the aorta by the screw. Aortic stent graft cuffs were deployed through femoral cutdowns to cover the area of aortic contact before hardware removal. All five patients did well and were discharged home in good condition. Endovascular repair of arterial injuries occurring during posterior spinal procedures is feasible and can offer a safe and less invasive alternative to open repair.

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Section: Discussionmentioning

confidence: 97%

Section: Discussionmentioning

confidence: 99%

Endovascular solutions to arterial injury due to posterior spine surgery

Loh

Maldonaldo

Rockman

et al. 2012

Journal of Vascular Surgery

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“…Mere impingement by a fixation screw can lead to aortic wall thinning and the potential for eventual erosion. 32 Proximity of the screw tip to aortic wall has been reported in 2% to 12% of cases. [33][34][35] Because the natural history of screws abutting the aorta remains unknown, the clinical significance and proper treatment of this entity are unclear.…”

Section: Discussionmentioning

confidence: 99%

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

Kakkos

Shepard

2008

Journal of Vascular Surgery

132

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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.

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“…Faro et al [1] studied the influence of indentation of the aorta by a screw in their bovine model and found that the major impingement of vertebral screws on the aorta caused acute and chronic histopathologic and biomechanical changes in the vessel wall. Though sequelae of moderate to mild indentation of the aorta have not yet been known, screws will stay inside the body for over tens of years in this young population.…”

Section: Discussionmentioning

confidence: 99%

New parameters to represent the position of the aorta relative to the spine for pedicle screw placement

et al. 2010

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Parameters of the position of the aorta in previous reports were determined for anterior surgery. This study evaluated the relative position of the aorta to the spine by new parameters, which could enhance the safety of pedicle screw placement. Three parameters were defined in a new Cartesian coordinate system. We selected an entry point of a left pedicle screw as the origin. The transverse plane was determined to include both the bases of the superior facet and to be parallel to the upper endplate of the vertebral body. A line connecting the entry points of both sides was defined as the X-axis. The angle formed by the Yaxis and a line connecting the origin and the center of the aorta was defined as the left pedicle-aorta angle. The length of a line connecting the origin and the aorta edge was defined as the left pedicle-aorta distance. Distance from the edge of the aorta to the X-axis was defined as the pedicular line-aorta distance. These parameters were measured preoperatively in 293 vertebral bodies of 24 patients with a right thoracic curve. We simulated the placement of the pedicle screw with variable length and with some direction error. We defined a warning pedicle as that when the aorta enters the expected area of the screw.Sensitivity analysis was performed to find the warning pedicle ratio in 12 scenarios. The left pedicle-aorta angle averaged 29.7°at the thoracic spine and -16.3°at the lumbar spine; the left pedicle-aorta distance averaged 23.7 and 55.2 mm; the pedicular line-aorta distance averaged 18.3 and 51.0 mm, respectively. The ratio of warning pedicles was consistently high at T4-5 and T10-12. When a left pedicle screw perforates an anterior/lateral wall of the vertebral body, the aorta may be at risk. These new parameters enable surgeons to intuitively understand the position of the aorta in surgical planning or in placement of a pedicle screw.

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Thoracic Vertebral Screw Impingement on the Aorta in an In Vivo Bovine Model

Cited by 34 publications

References 14 publications

Endovascular solutions to arterial injury due to posterior spine surgery

Endovascular solutions to arterial injury due to posterior spine surgery

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

New parameters to represent the position of the aorta relative to the spine for pedicle screw placement

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