ePostersLive by SCIGEN TECHNOLOGIES
14 posters, 
1 sessions, 
64 authors, 
20 institutions

3

Delayed presentation of a thoracic aortic injury by a vertebral pedicle screw: a case report.

Thursday, 22 September, 2011 - 12:20
Board

The placement of pedicle screws into vertebral bodies involves several risks against neurological and vascular structures. We describe a case of pedicle screw penetration in the descending thoracic aorta.
Part of Session

Vascular Surgery

Your rating: None Average: 4.5 (2 votes)

Full Text

Introduction

The placement of pedicle screws into vertebral bodies involves several risks against neurological and vascular structures. We describe a case of pedicle screw penetration in the descending thoracic aorta.Case Report

  • A 55years old man, victim of a motorcycle accident, presented multiple rib and a T6 A.2.1 and T7 A.3.2.1 fractures according to Margel classification. A posterior instrumented arthrodesis was performed, with the implantation of T3, T4, T5, T8, T9 pedicular screws and 2 longitudinal rods. Two misplaced screws in T4 and T5 had not penetrated the left side of the vertebral body and had exited the lateral pedicle cortex. The T4 screw was in closely proximity to the posterior-medial wall of the thoracic aorta (Fig.1).
  • After 6 months a CTA suggested T4 screw had penetrated the thoracic aortic wall (Fig.2), without contrast medium extravasations. An anterior column insufficiency and local kyphosisi were identified. An arthrodesis revision with the left T4 and T5 screw removal was proposed to restore the spinal stability and to avoid future aortic complications.
  • It was performed through a simultaneous left and posterior thoracotomy approach (4th intercostals space incision and 5th left rib excision). The descending thoracic aorta was exposed. Isolation and ligation of two intercostals arteries pairs allowed aortic mobilization to expose the posterior wall. Simultaneously, by a midline posterior incision the spine hardware was exposed. After the aortic clamping the T4 screw was removed. A 4 mm posterior-medial wall lesion and the communicating hole between T4 and the aorta was noted. It was repaired with 3 interrupted 4-0 felt-pledget polypropylene sutures. The left T4 and T5 screws were not replaced, a resection of T6 and T7 body was performed followed by an anterior column reconstruction using the previously removed rib.
  • The patient stayed in the intensive care unit 48 hours. The post operative course was without any complications and he was discharged home in a good clinical condition on the 6th day. A 6 months CTA showed the absence of aortic complications and the good spinal stability.

Discussion

  • There are some controversies regards the necessity of vertebral pedicle screw removing when it touches vessels in asymptomatic patients.
  • In our case, the T4 and T5 screw misplacement was identified in the immediately post-operative CT but the screw placed in T4 did not penetrate it. We speculate that with the pulsing movement of the vessel, the screw gradually entered the aorta’s wall.
  • An alternative option is the endovascular repair but the need to reconstruct the anterior spinal column (spine instability with chronic pain) justified our open approach also to the aortic lesion.
  • Thoracotomy associated to a simultaneous posterior spine approach is a good option because it provides direct access to repair the vessel lesion and to make the spine stabilization.

-Fig.1: RX and CT one week after the first arthrodesis treatment: the T4 screw was in closely proximity to the posterior-medial wall of the thoracic aorta (fig.1).

-Fig. 2: six months CTA shows T4 screw had penetrated into the thoracic aortic wall