Asian Cardiovasc Thorac Ann 2001;9:53-55
© 2001 Asia Publishing EXchange Pte Ltd
Aortic Injury From Thoracic Vertebral Stabilization Instrument
Oktay Burma, MD,
Ali Rahman, MD,
Ahmet Çekirdekçi, MD,
Ihsan Sami Uyar, MD,
Cahide Topsakal, MD,1
Department of Thoracic and Cardiovascular Surgery
1 Department of Neurosurgery Firat University School of Medicine Elazi , Turkey
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For reprint information contact: Oktay Burma, MD Tel: 90 424 238 8080 Fax: 90 424 238 8096 email: oko{at}hotmail.com Department of Thoracic and Cardiovascular Surgery, Firat University School of Medicine, Fevzi Cakmak Mah, Elazi 23200, Turkey.
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Abstract
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A case of delayed postoperative thoracic aortic rupture from erosion by a spinal fixation device is described to call attention to this potential catastrophe. Appropriate management and prevention of this complication is discussed.
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Introduction
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Since the 1980s, spinal fixation with screws has become common.1 Problems arising from neurological and infectious conditions top the list of complications following spinal fixation. Major vascular injury during spinal surgery is a rare but well-known complication.2 To prevent this usually fatal complication, a fixation prosthesis near a major vascular structure should be carefully monitored. Sharing information about encountered complications is very important as it enables other surgeons to be aware of the condition.3 To this end, we report a case of thoracic aortic rupture resulting from a spinal prosthesis used for thoracic vertebral stabilization.
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Case Report
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A 45-year-old woman was admitted to the neurology clinic with weakness of both lower extremities. Paraplegia developed on the fourth day. Computed tomography and magnetic resonance imaging showed a mass with extra-osseous metastasis in the corpus of the fourth thoracic vertebra (Figure 1
). Surgery was decided and during the operation, a solid mass measuring 3 x 4 cm was detected near the descending thoracic aorta. The mass was at the level of the fourth thoracic vertebra, surrounded by and involving the parietal pleura, showing destruction of the vertebral corpus but not invading the aorta. The tumor mass was totally excised and removed with a margin of the surrounding tissue. Vertebrectomy and partial lami-nectomy were carried out. Histopathology of the tumor mass indicated malign chordoma. Pieces taken from the fifth costa were placed in the vertebrectomy area. A vertebral stabilization plate (Codman Anterior Cervical Plate System, 98 mm; Johnson & Johnson Professional, Inc., Raynham, MA, USA) was fixed using 3 screws at each end. Following hemostasis, the parietal pleura was detached and used to separate the aorta from the plate. However, the aorta could not be completely separated due to a large defect in the parietal pleura. The thoracic wall was closed. Apical and basal drains were removed on the third and fifth postoperative day, respectively, as there was no significant drainage and no problems in the early postoperative period.
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Figure 1. Magnetic resonance image of the spinal channel showing a mass with extraosseous metastasis in the corpus of the fourth thoracic vertebra.
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However, dyspnea, chest and back pain appeared on the eighth postoperative day. Arterial blood pressure fell from 130/80 to 80/40 mm Hg, and the hematocrit decreased to 28% from 40% on the first postoperative day. Radiography indicated left-sided hemothorax. Two units of fresh whole blood were transfused, and the patient underwent an exploration thoracotomy after she had been stabilized. Approximately 2 L of blood was found in the left hemithorax. A 1 x 2 mm smooth-edged laceration with active pulsatile arterial bleeding was seen in the aorta in the area next to the screws in the upper end of the vertebral stabilization plate. The aortic tear was repaired primarily with 2/0 polypropylene suture pledgetted with vascular material. The tightness of the screws was tested; there was no movement, therefore, the instrument was left in position. An oval-shaped piece of polytetrafluoroethylene (PTFE) felt (GoreTex; WL Gore, Elkton, MD, USA) was cut to the dimensions of the instrument (5 x 7 cm) and attached to the adjacent pleural tissue to prevent further laceration of the aortic wall due to friction (Figure 2). There was no problem in the postoperative period. Basal and apical drains were removed after 3 and 4 days, respectively. The thoracotomy sutures were removed after 10 days. Neurological examination showed that the patient was much improved. Her incomplete neural deficit (paraplegia with some preserved sensory functions, Frankel grade B) improved to useful motor function (Frankel grade D). She was discharged with a corset. In the follow-up period of one year, no significant problem was detected.
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Discussion
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The application of screws for fixation in spinal surgery was first carried out in the lumbosacral joint by King4 in 1948. Since then, bone screws have been widely used to treat spinal disorders.1 However, reports of outcome, especially of complications, are limited. Complications arising from vertebral stabilization include those related to surgical exploration, those related to decompression, usually requiring adjacent discectomy, and problems resulting from the stabilization technique.3 Neurological disorders and infections are the most common com-plications.3 Problems concerning the visceral organs and vascular structures have also been observed; vascular problems following posterior discectomy vary from 0.17% to 12%.2 Vascular complications are encountered most frequently during surgery in the cervical area, nearly all are due to rupture and related bleeding.2 To prevent such complications, the anatomy of the patient's vascular structures should be previously determined; thin-slice computed tomography scanning might be useful for this purpose.5
Anterior metal implants are reported to be more dangerous in thoracic vertebral stabilization as they can lead to rupture of adjacent structures such as bronchi, aorta, or heart. Therefore, the classical posterolateral approach is recommended in such circumstances.6 However, in cases like that of our patient requiring tumor resection, the anterior approach may be required. It has been emphasized that blunt instruments should be used to avoid neurological and vascular complications, smoothing of rough surfaces of bone edges is also important, as well as covering with flaps by interposition of autogenic materials such as muscular structures from omentum or chest wall.1 Nevertheless, if there is invasion of the pleura or sur-rounding tissues by a tumor, these applications may not be easy, and synthetic materials such as Teflon or PTFE felt might be considered. PTFE felt is very inert, causing limited perigraft reaction. PTFE has been successfully used as a graft in vascular surgery and for pericardial closure.7 It was also reported that PTFE can be used as a limiting barrier for scar adhesion after laminectomy.8
Potential problems in thoracic spinal surgery, especially using the anterior approach, include pneumothorax, hemopneumothorax, hiatal hernia from inappropriate diaphragmatic repair, and serious respiratory problems.3 The possibility of hemorrhage should be considered when images suggesting hematoma are seen in the operative region postoperatively and there is a sudden change in the patient's condition. In a previous report, prosthetic material used in spinal reconstruction perforated the thoracic aorta, leading to a fatal aortoesophageal fistula.3 In the case described here, it was observed that the aortic injury was self-limiting. If it had not been treated in time, pseudo-aneurysm formation may have occurred.
This case highlights the risk of aortic injury following spinal instrumentation using an anterior thoracic approach. The surface of the stabilization device must be covered with pleura and adjacent tissues. If there is insufficient adjacent tissue, we suggest that Teflon or PTFE felt be used to form a barrier.
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References
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Harada Y, Imai Y, Kurosawa H, Hoshino S, Nacano K. Long-term results of the clinical use of an expanded polytetrafluoroethylene surgical membrane as a pericardial substitute. J Thorac Cardiovasc Surg 1988;96:811–5.[Abstract]
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DiFazio FA, Nichols JB, Pope MH, Frymoyer JW. The use of expanded polytetrafluoroethylene as an interposition membrane after lumbar laminectomy. Spine 1995;20: 986–91.[Medline]
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Abstract
Introduction
