Department of Neurosurgery, Institute of Psychiatry and Neurology, Warsaw, Poland.
Pol Merkur Lekarski. 2021 Apr 18;49(290):150-152.
Damage to large abdominal vessels during lumbar discectomy surgery is a rare but life-threatening complication.
The authors present the case of a 57-year-old patient who received surgery for critical degenerative lumbal spinal stenosis on the L4-L5 level. The diagnosis was based on strong right sciatica and neurogenic claudication. A bilateral laminotomy from the right and a microdiscectomy were performed. During surgery, no bleeding from the intervertebral space was observed and blood pressure was low but stable from the beginning. After surgery, the patient was in good general and neurological condition, without preoperative right-sided sciatica. Within a few hours after the operation, the circulatory and respiratory systems were stable with normal saturation and the patient did not report shortness of breath. Paleness of the skin and mucous membranes was observed. Follow-up morphology tests performed at 6 and 10.5 hours after surgery showed a decrease in the level of erythrocytes. The patient had palpable tenderness in the left hypochondriac region. Suspicion of bleeding into the abdominal cavity from arteries or iliac veins was stated. Immediately, an angio-computed tomography (CT) of the abdominal cavity was performed, which confirmed the presence of a hematoma in the peritoneal space and a pseudoaneurysm of the left iliac artery. The patient was urgently transported to the Vascular Surgery Clinic, where a Y-type covered stent was implanted percutaneously into both iliac arteries. After the procedure, there were symptoms of ischaemia in the left lower extremity and intermittent claudication. A Doppler study showed signs of narrowing at the stent level on the left side. The patient was reoperated after a CT check-up and a second stent was implanted into the left iliac artery, which allowed vasodilation and true flow in the artery.
The authors suggest that both the neurosurgeon and anaesthesiologist should have been aware of the possibility of such a rare but life-threatening complication as iliac vessel damage during lumbar discectomy surgery. A quick diagnosis and implementation of a proper procedure reduces the high mortality rate caused by this complication. In cases of a sudden unjustified drop in blood pressure during lumbar discectomy, an immediate laparotomy should be performed to find and repair the site of laceration of a vessel. In patients who are stable hemodynamically, performing an angio-CT function of the abdominal cavity is suggested and the damaged artery should be treated with a covered stent.
腰椎间盘切除术手术过程中损伤大的腹部血管是一种罕见但危及生命的并发症。
作者报告了一例 57 岁患者，因 L4-L5 水平严重退行性腰椎管狭窄症接受手术治疗。诊断基于强烈的右侧坐骨神经痛和神经性跛行。进行了双侧从右侧椎板切开术和微椎间盘切除术。手术过程中，椎间无出血，血压从一开始就低但稳定。手术后，患者一般情况和神经状况良好，术前无右侧坐骨神经痛。手术后几小时内，循环和呼吸系统稳定，饱和度正常，患者无呼吸急促。观察到皮肤和粘膜苍白。手术后 6 小时和 10.5 小时进行的形态学随访检查显示红细胞水平下降。患者左季肋区有压痛。怀疑动脉或髂静脉内出血。立即进行腹部血管计算机断层扫描（CT），证实腹膜腔内有血肿和左侧髂动脉假性动脉瘤。患者紧急运往血管外科诊所，在该处通过经皮将 Y 型覆膜支架植入双侧髂动脉。手术后，左侧下肢出现缺血症状和间歇性跛行。多普勒研究显示左侧支架水平有狭窄迹象。在 CT 检查后对患者进行了再次手术，并在左侧髂动脉内植入第二个支架，这使得动脉扩张并恢复了真流。
作者建议神经外科医生和麻醉师都应该意识到腰椎间盘切除术手术过程中损伤大的腹部血管这种罕见但危及生命的并发症的可能性。快速诊断和实施适当的程序可以降低这种并发症引起的高死亡率。在腰椎间盘切除术中突然出现血压不明原因下降的情况下，应立即进行剖腹手术，以找到并修复血管撕裂部位。对于血流动力学稳定的患者，建议进行腹部血管 CT 血管造影功能检查，并使用覆膜支架治疗受损动脉。
