Valič Matej, Žižek David, Špan Matjaž, Mihalič René, Mohar Janez
Department of Spine Surgery, Valdoltra Orthopedic Hospital, Jadranska cesta 31, 6280, Ankaran, Slovenia.
Department of Cardiology, University Medical Centre Ljubljana, Zaloška cesta 7, 1000, Ljubljana, Slovenia.
Spine Deform. 2020 Aug;8(4):809-817. doi: 10.1007/s43390-020-00094-5. Epub 2020 Mar 13.
Case reports and review of the literature with a proposed management algorithm.
To report two cases of a potential vascular complication due to an incorrectly placed pedicle screw (PS) during spine deformity surgery. Relevant literature regarding the management of vascular complications is reviewed, and an evidence-based management algorithm is proposed. Aortic lesions represent a rare but potentially life-threatening complications with spine deformity and revision surgery, significantly increasing the risk. A management algorithm for an aortic lesion in the case of a malpositioned PS has not yet been published.
Case 1: An 18-year-old female with proximal thoracic spinal non-instrumented fusion underwent a revision corrective procedure due to a progressive right-sided thoracolumbar compensatory curve. However, postoperative computed tomography (CT) performed to evaluate the position of the PS revealed malposition of the left T9 PS, which was abutting the descending aorta with CT angiography excluding the perforation of the aorta. Case 2: A 17-year-old male was scheduled for correction of Lenke 3-C-N adolescent idiopathic scoliosis. Postoperative routine evaluation with low-dose CT revealed a left T9 PS paravertebral malposition, and subsequent CTA demonstrated that the thread of the PS was in contact with the descending thoracic aorta and an unlikely hemodynamically significant vessel injury.
Successful removal of both malpositioned PS was performed. In the first case, a cardiovascular surgeon attended the operation if an urgent thoracotomy was needed, and in the second case, additional video-assisted thoracoscopic control of the aorta was performed during PS removal.
Preoperative imaging in spinal surgery is essential to avoid major vascular and other complications when placing PS, especially in thoracic deformities. When a potential major vessel complication emerges, an interdisciplinary approach and an appropriate management algorithm are mandatory to make the best clinical decisions.
病例报告及文献综述，并提出管理算法。
报告两例脊柱畸形手术中椎弓根螺钉（PS）放置不当导致的潜在血管并发症。回顾了有关血管并发症管理的相关文献，并提出了基于证据的管理算法。主动脉病变是脊柱畸形和翻修手术中罕见但可能危及生命的并发症，会显著增加风险。尚未有关于PS位置不当情况下主动脉病变的管理算法发表。
病例1：一名18岁女性，近端胸椎非器械融合，因进行性右侧胸腰段代偿性曲线接受翻修矫正手术。然而，术后为评估PS位置而进行的计算机断层扫描（CT）显示左T9 PS位置不当，CT血管造影显示其紧靠降主动脉，排除了主动脉穿孔。病例2：一名17岁男性计划矫正Lenke 3-C-N青少年特发性脊柱侧凸。术后低剂量CT常规评估显示左T9 PS椎旁位置不当，随后的CTA显示PS螺纹与降主动脉接触，且不太可能存在血流动力学显著的血管损伤。
成功取出两枚位置不当的PS。在第一例中，如果需要紧急开胸手术，心血管外科医生参与了手术；在第二例中，在取出PS期间进行了额外的电视辅助胸腔镜下主动脉控制。
脊柱手术中的术前影像学检查对于放置PS时避免重大血管和其他并发症至关重要，尤其是在胸椎畸形中。当出现潜在的大血管并发症时，必须采用多学科方法和适当的管理算法来做出最佳临床决策。
4级。
