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Vascular injury following disc surgery
Brief Reports
Vascular Injury Following Disc Surgery DAVID J. DULA, MD, RONALD FIERRO, MD, HARLEN GESSNER, MD, WILLIAM S. SNOVER, MD The case of a patient who suffered a vascular injury following lumbar disk surgery is presented. She presented to the emergency department for evaluation of hypotension and congestive heart failure, which occurred acutely several days after her surgery. At anglography, a large A:V fistula was demonstrated between the aorta and vena cava. The diagnosis and pathophysiology of this complication of lumbar disc surgery is discussed. (Am J Emerg Med 1986;4:406-408)
Emergency physicians must be familiar with the complications of surgical procedures, as post-operative patients commonly present to the emergency department when problems occur. Patients who present to the emergency department with persistent pain since the time of their surgery probably reflect poor patient selection by the surgeon and have other musculoskeletal or functional causes for their pain. Pain occurring several weeks after disk surgery after an initial good result should alert the physician to a possible disk-space infection. Other complications that may occur include muscle spasm, atelectasis, urinary retention, intestinal ileus, injury to neural elements, deep venous thrombosis, intestinal perforation, bladder or ureteral perforation, and vascular injury.1-9 Vascular injury may result in serious cardiovascular compromise, and it must be accurately identified and diagnosed if mortality is to be prevented. Although the exact incidence of this lesion is difficult to determine, a survey of physicians performing disc surgery yielded 106 vascular complications.* The morbidity of this complication and its associated high mortality rate make it an important problem for physicians who may care for these patients in the post-operative period. This is a case report of a patient who suffered from
From the Department of Emergency Medicine, ical Center, Danville, Pennsylvania 17822. Manuscript received uary 30, 1986. Address
reprint
Key Words:
requests
6, 1985; revision
Med-
accepted
Jan-
to Dr. Dula.
Disc, surgery,
0735-6757186 $00.00 406
October
Geisinger
+ .25
vascular
injury,
vertebra.
acute hypotension following disk surgery and who presented to our emergency department for evaluation. CASEREPORT A 35year-old woman who had been in good health was admitted to a hospital for elective surgery for a herniated LS disk. At the time of surgery, there was no notable intraoperative bleeding from the wound site; however, her hemoglobin was noted to have fallen after surgery from 14.0 to 8.6 g/d1 over three days. The patient also developed respiratory distress and was noted to have patchy infiltrates on a chest X-ray film (Fig. 1). She had a low-grade fever to 38.3”C and was given erythromycin for suspected pneumonitis. She failed to respond, and five days post-operatively, she was transferred to Geisinger Medical Center for further evaluation of these post-operative complications. On arrival to our emergency department, the patient appeared to be in significant respiratory distress with a respiratory rate of 36/min, a temperature of 36S”C, a blood pressure of 150/50 mm Hg, and a pulse of 128 beats/min. She appeared ashen and was diaphoretic; however, she was alert and complained only of being weak, short of breath, and in some pain in her back from her recent surgery. Results of examination of her head, ears, eyes, nose, and throat were normal. Her cardiac examination revealed a very rapid pulse; however, no murmurs or gallops were appreciated, and no cardiac enlargement was detected. Examination of the chest revealed good breath sounds bilaterally. There were rales at both bases, however, and the remainder of the chest examination results were clear. Examination of her abdomen revealed it to be soft; there were no masses or organomegaly. Bowel sounds were active. There was a loud machine-like bruit noted in the periumbilical region. Examination of the extremities revealed that the femoral and popliteal pulses were intact: however, the posterior tibia1 pulses were detected by the Doppler technique only, and the dorsalis pedis pulse could not be appreciated even with the Doppler technique. Neurological examination results were normal. Laboratory tests revealed arterial blood gases on 41 of nasal prongs with a pH of 7.5 1, a Pco2 of 30 mm Hg, a P, of 80 mm Hg, and a bicarbonate level of 24 mmoUl. Her electrolytes showed a sodium level of 143 mEq/l, a chloride level of 108 mEq/l, and a potassium level of 5.3 mEq/l. Her bicarbonate level was 27 mmol/l, blood urea nitrogen (BUN) was 70 mmol/l, and creatinine was 0.6 mg/dl. Blood sugar level was 116 mg/dl, leukocyte
DULA ET AL n VASCULAR
FIGURE 1 (nbove). radiograph. FIGURE 2 (right). aortocaval fistula.
Patchy infiltrates are demonstrated Emergency
INJURY FOLLOWING
DISC SURGERY
on chest
angiography demonstrates
a large
count was 18,300 cells/mm3, and hemoglobin was 8.6 g/dl. Platelet count was adequate. There were 75 segments, 3 bands, 13 lymphocytes, and 9 monocytes. Because of the patient’s acute changes postoperatively and the loud abdominal bruit, it was thought that the patient may have had vascular injury secondary to her disk removal. The patient underwent emergency angiography, and a large aortocaval tistula was demonstrated (Fig. 2). The patient was immediately taken to the operating room where the cardiovascular surgeons repaired the fistula. The patient experienced rapid improvement of her respiratory insufficiency and her hypotension postoperatively with a blood pressure of 140/90 mm Hg in the recovery room. She was subsequently discharged from the hospital 12 days after her surgery in an ambulatory condition and remained in a stable condition during her subsequent follow-up.
rhage and/or thrombosis, 3) false aneurysm, 4) A-V fistula, 5) septic rupture of the blood vessels associated with injury and infection, and 6) injury resulting in peripheral vascular disease.* Most of these injuries are recognized in the operating room as evidenced by sudden hypotension during the operative procedure; however, more a subtle injury may go undetected.2-7 Bleeding through the interspace at the time of surgery occurs in less than 50% of these cases, so a change in blood pressure during surgery despite insignificant blood loss at the wound site must arouse suspicion that such an injury may have occurred.5 Our patient
DISCUSSION Vascular
complications
from
disk
surgery
are un-
common; only 106 cases have been reported erature.2 WhitelO
in the litin 1945 by Linton and
It was first described who developed in a patient
progressive dyspnea and cardiac decompensation nine months after disk surgery and was found to have an A-V fistula. The exact incidence of this injury is unknown but can be estimated to occur in one of every several
thousand cases of lumbar disk surgery.2T4 The mechanism of injury is direct mechanical trauma to the blood vessels during disc removal (Fig. 3). The types of injury that may occur include 1) laceration of the abdominal aorta or vena cava with immediate shock, 2) partial avulsion of the vessel wall with delayed hemor-
FIGURE 3. Direct mechanical trauma to the blood vessels is the mechanism of injury during disc removal. 407
AMERICAN
JOURNAL
OF EMERGENCY
MEDICINE
w Volume
4, Number
had no recorded excessive blood loss during surgery, and for this reason, probably did not alert the surgeon to such a lesion. The location of the vascular injury as noted in a retrospective study demonstrates that the left iliac artery is the most commonly injured arterial structure, whereas the right iliac vein is the most common vein that is injured.1’2 Of those patients with a delayed diagnosis, 45 percent had A-V fistulas.’ In this study, 11 cases involve the common iliac artery and vein resulting in a tistula, and there is only a 9% mortality rate. The clinical presentation of these vascular injuries may include signs of shock, a palpable abdominal mass, a thrill in the abdomen, diminished femoral pulses, a bruit, and a wide pulse pressure.2*4 Symptoms following the creation of an A-V fistula may be delayed for several years as patients may slowly develop signs of hemodynamic compromise. Our patient presented with respiratory failure and decreased blood pressure as a result of the high-cardiacoutput congestive failure from the A-V fistula. The occurrence of high-output congestive heart failure is a known complication of A-V fistula, and its occurrence as a result of disk surgery has been described as a common feature of this lesion.3,4 The treatment for this condition is urgent operative repair as soon as the diagnosis is suspected. If the diagnosis is obvious from the patient’s presentation in the operating room, it should be repaired at that time. l-7 If the diagnosis is in question, and the patient is stable, angiography, CT scan, or ultrasonography may be helpful to delineate the lesion and the type of treatment that may be necessary. Mortality rates range widely, depending on the type of injury that occurs.2 Venous injury, associated with the lowest mortality rate, may be frequently undetected, and it resolves spontaneously.1*2*4 Arterial injuries with free intraperitoneal bleeding are the most life-threatening, whereas other types of injuries will have mortality rates depending on the degree of injury and the timing of the operative repair.‘,2,4 The overall rate of mortality from A-V fistula is 9- 11%.4 Our patient presented with congestive heart failure and hypotension that occurred several days after surgery and became progressively worse. The patient also had a loud abdominal bruit, which led us to suspect the complication of an A-V fistula. Aortography docu-
408
5 M September
1986
mented the lesion, and urgent operative repair was carried out. The patient’s high-output congestive heart failure and hypotension resolved once the surgical repair was carried out. CONCLUSION This case demonstrates a rare but serious complication of lumbar disk surgery. Only 106 cases of this type of injury have been reported, with 58 arteriovenous tears and 48 A-V fistulas. When A-V fistulas occur, delayed clinical presentation is not uncommon; however, it is important for emergency physicians to keep this injury in mind whenever patients present with complications following disk surgery. Vascular injuries should be suspected whenever there are unexplained episodes of hypotension or congestive heart failure, especially in the presence of an abdominal bruit. Accurate diagnosis of this condition may be a life-saving measure in patients presenting with such injuries. Angiography may be necessary to document the lesion, and operative repair is required to correct the lesion. REFERENCES 1. Stokes JM. Vascular complications of disk surgery. J Bone Joint Surg 1968;5OA:394-399. 2. DeSaussure RL. Vascular injury coincident to disk surgery. J Neurosurg 1958;15:222-229. J Am Osteo3. Wood JP. Lumbar disk surgery: Complications. path Assoc 1974;74:234-239. 4. Birkeland IW, Taylor TK. Major vascular injuries in lumbar disk surgery. J Bone Joint Surg 1969;518:4-19. 5. Lie TA, Desmet HL. Major vascular injuries following operations for protruded lumbar disk: Psychiat neurol neurochir 1968;71:71-75. 6. Brewster DC, May AR, Darling RC, et al. Variable manifestations of vascular injury during lumbar disk surgery. Arch Surg 1979;114:1026-1030. 7. Holscher EC. Vascular visceral injuries during lumbar disk surgery. J Bone Joint Surg 1968;5OA:383-393. 8. Youmans JR. Neurological surgery, 2nd edition. Philadelphia: W. B. Saunders Co., 1982:2548-2550. RH, Rengachary SS. Neurosurgery. New York: 9. Wilkins McGraw-Hill Co., 1985:2257-2260. 10. Linton RR, White PD. Arteriovenous fistula between the right common iliac artery in the inferior vena cava. Report of a case of its occurrence following an operation for ruptured intervertebral disk with cure by operation. Arch Surg 1945;50:6-13.
Vascular Injury Following Disc Surgery DAVID J. DULA, MD, RONALD FIERRO, MD, HARLEN GESSNER, MD, WILLIAM S. SNOVER, MD The case of a patient who suffered a vascular injury following lumbar disk surgery is presented. She presented to the emergency department for evaluation of hypotension and congestive heart failure, which occurred acutely several days after her surgery. At anglography, a large A:V fistula was demonstrated between the aorta and vena cava. The diagnosis and pathophysiology of this complication of lumbar disc surgery is discussed. (Am J Emerg Med 1986;4:406-408)
Emergency physicians must be familiar with the complications of surgical procedures, as post-operative patients commonly present to the emergency department when problems occur. Patients who present to the emergency department with persistent pain since the time of their surgery probably reflect poor patient selection by the surgeon and have other musculoskeletal or functional causes for their pain. Pain occurring several weeks after disk surgery after an initial good result should alert the physician to a possible disk-space infection. Other complications that may occur include muscle spasm, atelectasis, urinary retention, intestinal ileus, injury to neural elements, deep venous thrombosis, intestinal perforation, bladder or ureteral perforation, and vascular injury.1-9 Vascular injury may result in serious cardiovascular compromise, and it must be accurately identified and diagnosed if mortality is to be prevented. Although the exact incidence of this lesion is difficult to determine, a survey of physicians performing disc surgery yielded 106 vascular complications.* The morbidity of this complication and its associated high mortality rate make it an important problem for physicians who may care for these patients in the post-operative period. This is a case report of a patient who suffered from
From the Department of Emergency Medicine, ical Center, Danville, Pennsylvania 17822. Manuscript received uary 30, 1986. Address
reprint
Key Words:
requests
6, 1985; revision
Med-
accepted
Jan-
to Dr. Dula.
Disc, surgery,
0735-6757186 $00.00 406
October
Geisinger
+ .25
vascular
injury,
vertebra.
acute hypotension following disk surgery and who presented to our emergency department for evaluation. CASEREPORT A 35year-old woman who had been in good health was admitted to a hospital for elective surgery for a herniated LS disk. At the time of surgery, there was no notable intraoperative bleeding from the wound site; however, her hemoglobin was noted to have fallen after surgery from 14.0 to 8.6 g/d1 over three days. The patient also developed respiratory distress and was noted to have patchy infiltrates on a chest X-ray film (Fig. 1). She had a low-grade fever to 38.3”C and was given erythromycin for suspected pneumonitis. She failed to respond, and five days post-operatively, she was transferred to Geisinger Medical Center for further evaluation of these post-operative complications. On arrival to our emergency department, the patient appeared to be in significant respiratory distress with a respiratory rate of 36/min, a temperature of 36S”C, a blood pressure of 150/50 mm Hg, and a pulse of 128 beats/min. She appeared ashen and was diaphoretic; however, she was alert and complained only of being weak, short of breath, and in some pain in her back from her recent surgery. Results of examination of her head, ears, eyes, nose, and throat were normal. Her cardiac examination revealed a very rapid pulse; however, no murmurs or gallops were appreciated, and no cardiac enlargement was detected. Examination of the chest revealed good breath sounds bilaterally. There were rales at both bases, however, and the remainder of the chest examination results were clear. Examination of her abdomen revealed it to be soft; there were no masses or organomegaly. Bowel sounds were active. There was a loud machine-like bruit noted in the periumbilical region. Examination of the extremities revealed that the femoral and popliteal pulses were intact: however, the posterior tibia1 pulses were detected by the Doppler technique only, and the dorsalis pedis pulse could not be appreciated even with the Doppler technique. Neurological examination results were normal. Laboratory tests revealed arterial blood gases on 41 of nasal prongs with a pH of 7.5 1, a Pco2 of 30 mm Hg, a P, of 80 mm Hg, and a bicarbonate level of 24 mmoUl. Her electrolytes showed a sodium level of 143 mEq/l, a chloride level of 108 mEq/l, and a potassium level of 5.3 mEq/l. Her bicarbonate level was 27 mmol/l, blood urea nitrogen (BUN) was 70 mmol/l, and creatinine was 0.6 mg/dl. Blood sugar level was 116 mg/dl, leukocyte
DULA ET AL n VASCULAR
FIGURE 1 (nbove). radiograph. FIGURE 2 (right). aortocaval fistula.
Patchy infiltrates are demonstrated Emergency
INJURY FOLLOWING
DISC SURGERY
on chest
angiography demonstrates
a large
count was 18,300 cells/mm3, and hemoglobin was 8.6 g/dl. Platelet count was adequate. There were 75 segments, 3 bands, 13 lymphocytes, and 9 monocytes. Because of the patient’s acute changes postoperatively and the loud abdominal bruit, it was thought that the patient may have had vascular injury secondary to her disk removal. The patient underwent emergency angiography, and a large aortocaval tistula was demonstrated (Fig. 2). The patient was immediately taken to the operating room where the cardiovascular surgeons repaired the fistula. The patient experienced rapid improvement of her respiratory insufficiency and her hypotension postoperatively with a blood pressure of 140/90 mm Hg in the recovery room. She was subsequently discharged from the hospital 12 days after her surgery in an ambulatory condition and remained in a stable condition during her subsequent follow-up.
rhage and/or thrombosis, 3) false aneurysm, 4) A-V fistula, 5) septic rupture of the blood vessels associated with injury and infection, and 6) injury resulting in peripheral vascular disease.* Most of these injuries are recognized in the operating room as evidenced by sudden hypotension during the operative procedure; however, more a subtle injury may go undetected.2-7 Bleeding through the interspace at the time of surgery occurs in less than 50% of these cases, so a change in blood pressure during surgery despite insignificant blood loss at the wound site must arouse suspicion that such an injury may have occurred.5 Our patient
DISCUSSION Vascular
complications
from
disk
surgery
are un-
common; only 106 cases have been reported erature.2 WhitelO
in the litin 1945 by Linton and
It was first described who developed in a patient
progressive dyspnea and cardiac decompensation nine months after disk surgery and was found to have an A-V fistula. The exact incidence of this injury is unknown but can be estimated to occur in one of every several
thousand cases of lumbar disk surgery.2T4 The mechanism of injury is direct mechanical trauma to the blood vessels during disc removal (Fig. 3). The types of injury that may occur include 1) laceration of the abdominal aorta or vena cava with immediate shock, 2) partial avulsion of the vessel wall with delayed hemor-
FIGURE 3. Direct mechanical trauma to the blood vessels is the mechanism of injury during disc removal. 407
AMERICAN
JOURNAL
OF EMERGENCY
MEDICINE
w Volume
4, Number
had no recorded excessive blood loss during surgery, and for this reason, probably did not alert the surgeon to such a lesion. The location of the vascular injury as noted in a retrospective study demonstrates that the left iliac artery is the most commonly injured arterial structure, whereas the right iliac vein is the most common vein that is injured.1’2 Of those patients with a delayed diagnosis, 45 percent had A-V fistulas.’ In this study, 11 cases involve the common iliac artery and vein resulting in a tistula, and there is only a 9% mortality rate. The clinical presentation of these vascular injuries may include signs of shock, a palpable abdominal mass, a thrill in the abdomen, diminished femoral pulses, a bruit, and a wide pulse pressure.2*4 Symptoms following the creation of an A-V fistula may be delayed for several years as patients may slowly develop signs of hemodynamic compromise. Our patient presented with respiratory failure and decreased blood pressure as a result of the high-cardiacoutput congestive failure from the A-V fistula. The occurrence of high-output congestive heart failure is a known complication of A-V fistula, and its occurrence as a result of disk surgery has been described as a common feature of this lesion.3,4 The treatment for this condition is urgent operative repair as soon as the diagnosis is suspected. If the diagnosis is obvious from the patient’s presentation in the operating room, it should be repaired at that time. l-7 If the diagnosis is in question, and the patient is stable, angiography, CT scan, or ultrasonography may be helpful to delineate the lesion and the type of treatment that may be necessary. Mortality rates range widely, depending on the type of injury that occurs.2 Venous injury, associated with the lowest mortality rate, may be frequently undetected, and it resolves spontaneously.1*2*4 Arterial injuries with free intraperitoneal bleeding are the most life-threatening, whereas other types of injuries will have mortality rates depending on the degree of injury and the timing of the operative repair.‘,2,4 The overall rate of mortality from A-V fistula is 9- 11%.4 Our patient presented with congestive heart failure and hypotension that occurred several days after surgery and became progressively worse. The patient also had a loud abdominal bruit, which led us to suspect the complication of an A-V fistula. Aortography docu-
408
5 M September
1986
mented the lesion, and urgent operative repair was carried out. The patient’s high-output congestive heart failure and hypotension resolved once the surgical repair was carried out. CONCLUSION This case demonstrates a rare but serious complication of lumbar disk surgery. Only 106 cases of this type of injury have been reported, with 58 arteriovenous tears and 48 A-V fistulas. When A-V fistulas occur, delayed clinical presentation is not uncommon; however, it is important for emergency physicians to keep this injury in mind whenever patients present with complications following disk surgery. Vascular injuries should be suspected whenever there are unexplained episodes of hypotension or congestive heart failure, especially in the presence of an abdominal bruit. Accurate diagnosis of this condition may be a life-saving measure in patients presenting with such injuries. Angiography may be necessary to document the lesion, and operative repair is required to correct the lesion. REFERENCES 1. Stokes JM. Vascular complications of disk surgery. J Bone Joint Surg 1968;5OA:394-399. 2. DeSaussure RL. Vascular injury coincident to disk surgery. J Neurosurg 1958;15:222-229. J Am Osteo3. Wood JP. Lumbar disk surgery: Complications. path Assoc 1974;74:234-239. 4. Birkeland IW, Taylor TK. Major vascular injuries in lumbar disk surgery. J Bone Joint Surg 1969;518:4-19. 5. Lie TA, Desmet HL. Major vascular injuries following operations for protruded lumbar disk: Psychiat neurol neurochir 1968;71:71-75. 6. Brewster DC, May AR, Darling RC, et al. Variable manifestations of vascular injury during lumbar disk surgery. Arch Surg 1979;114:1026-1030. 7. Holscher EC. Vascular visceral injuries during lumbar disk surgery. J Bone Joint Surg 1968;5OA:383-393. 8. Youmans JR. Neurological surgery, 2nd edition. Philadelphia: W. B. Saunders Co., 1982:2548-2550. RH, Rengachary SS. Neurosurgery. New York: 9. Wilkins McGraw-Hill Co., 1985:2257-2260. 10. Linton RR, White PD. Arteriovenous fistula between the right common iliac artery in the inferior vena cava. Report of a case of its occurrence following an operation for ruptured intervertebral disk with cure by operation. Arch Surg 1945;50:6-13.