Departments of Neurosurgery, New York University School of Medicine, NY, NY, USA.
J Neurosurg Spine. 2010 Sep;13(3):403-6. doi: 10.3171/2010.3.SPINE09657.
Pedicle screws placed in the thoracic, lumbar, and sacral spine occasionally come in contact with the aorta, vena cava, or iliac vessels. When such screws are seen on postoperative imaging in an asymptomatic patient, the surgeon must decide whether it is riskier to revise the screw or to observe it. The authors hypothesized that the incidence of screw placement causing perioperative vessel injury is low and, further, that screws placed in contact with major vessels do not always result in vessel injury.
A retrospective review of the operative records of 182 consecutive patients undergoing thoracic, lumbar, and lumbosacral pedicle screw fusion was performed to determine the frequency of intraoperative vessel injury. Postoperative imaging for 107 patients was available to determine the incidence of screws in contact with major vessels. Charts were examined to determine if any adverse sequelae had resulted from malpositioned screws. Patient outcomes were documented.
There were no intraoperative vessel injuries or deaths in 182 consecutive operations. One hundred seven patients with available postoperative films had 680 pedicle screws placed between T-3 and the sacrum during 115 operations. No patient had arterial screw penetration or deformation on postoperative imaging. Thirty-three of the 680 inserted screws were in contact with a major vessel on routine postoperative imaging. The contacted vessels included the aorta (4 cases), the iliac artery (7 cases), and the iliac veins (22 cases). Patients were followed up until death or November 2009, for a mean follow-up of 44 months (median 44 months, range 5-109 months). None of the patients with vessel contact was noted to suffer symptoms or sequelae as a result of vessel contact. Radiographic follow-up as long as 50 months after surgery revealed no detectable vessel abnormality at the contacted site.
Placing pedicle screws in contact with major vessels is a known risk of spinal surgery. The risk of repositioning a screw in contact with a major vessel but causing no symptoms must be weighed against the relative risk of leaving it in place.
胸椎、腰椎和骶椎的椎弓根螺钉偶尔会与主动脉、腔静脉或髂血管接触。对于无症状患者的术后影像学检查，如果发现这些螺钉，外科医生必须决定修正螺钉是否风险更大，还是观察它更安全。作者假设，螺钉放置导致围手术期血管损伤的发生率较低，而且，与大血管接触的螺钉并不总是导致血管损伤。
对 182 例连续行胸、腰、腰骶椎弓根螺钉融合术的患者的手术记录进行回顾性分析，以确定术中血管损伤的频率。107 例患者有术后影像学资料，以确定与主要血管接触的螺钉的发生率。检查图表以确定螺钉位置不当是否导致任何不良后果。记录患者的转归。
在 182 例连续手术中，无术中血管损伤或死亡。107 例术后有影像学资料的患者在 115 次手术中，T3 到骶骨之间共置入 680 枚椎弓根螺钉。术后影像学检查未见动脉螺钉穿透或变形。在常规术后影像学检查中，33 枚置入的螺钉与主要血管接触。接触的血管包括主动脉（4 例）、髂动脉（7 例）和髂静脉（22 例）。患者随访至死亡或 2009 年 11 月，平均随访时间为 44 个月（中位数 44 个月，范围 5-109 个月）。接触血管的患者均未出现因血管接触而导致的症状或后遗症。术后最长达 50 个月的影像学随访未发现接触部位有可察觉的血管异常。
椎弓根螺钉与大血管接触是脊柱手术的已知风险。重新定位与大血管接触但无症状的螺钉的风险必须与将其留在原位的相对风险进行权衡。
