Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 59, Num. 2, 2011, pp. 307-308

Neurology India, Vol. 59, No. 2, March-April, 2011, pp. 307-308

Letter to Editor

Undetected iliac artery injury presenting as acute intraoperative hypotension during lumbar disc surgery

KR Madhusudan Reddy, Smita Vimala, GS Umamaheswara Rao

Department of Neuroanaesthesia, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India

Correspondence Address: K R Madhusudan Reddy, Department of Neuroanaesthesia, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India, krmsr2000@yahoo.com

Date of Submission: 09-Dec-2010
Date of Decision: 11-Dec-2010
Date of Acceptance: 11-Dec-2010

Code Number: ni11088

PMID: 21483147

DOI: 10.4103/0028-3886.79165

Sir,

Vascular injury during lumbar disc surgery is rare but can be catastrophic. We report the occurrence of iliac artery injury resulting in persistent hypotension during lumbar discectomy and the successful management of this complication.

A 29-year-old man weighing 60 kg presented with low backache of 6 months duration. Magnetic resonance imaging revealed prolapsed disc at L4-L5 level. He was scheduled for fenestration and discectomy. Standard anesthetic technique and monitoring were performed. During microdiscectomy, there was a sudden drop in the blood pressure (BP) from 108/72 mmHg to 60/42 mmHg. BP was restored to the previous level with rapid infusion of fluids and mephenteramine. No bleeding from the operative field was noted and systolic BP remained between 85 and 100 mmHg. Postoperative abdominal ultrasonography revealed localized collection near the operative site. Contrast-enhanced computed tomography scan demonstrated a leak from the right iliac artery at L4-L5 level and formation of pseudoaneurysm [Figure - 1]a. Angiogram confirmed the findings, and the complication was treated successfully by endovascular stenting [Figure - 1]b.

The incidence of vascular injury during lumbar spine surgery is about 0.0001%-0.0005%. ^[1] The most common injury is that of right iliac artery at L4--L5 level. This occurs due to the accidental penetration of the anterior longitudinal ligament (ALL), while removing the disc fragments. Increased abdominal pressure in prone position compresses the vessels in the retroperitoneal space against the vertebral bodies, rendering them immobile and prone to injury. Other factors that make vessels vulnerable during spinal surgeries include congenital anomalies of the spine and great vessels, acquired conditions, arteriosclerosis, re-do surgery, degeneration of ALL, sharp instruments and improper estimation of disc space. ^[2] The most common presentation is acute hypotension without evidence of operative site bleeding. The tough ALL produces self-sealing effect, causing bleeding into the retroperitoneal space rather than the operative site. In an unstable patient, emergency laparotomy might be required. Karakovic et al. have described the use of intraoperative angiography and coil embolization of the bleeding vessel to control the hemorrhage. ^[3] The tamponade effect produced by the prone position might have maintained hemodynamic stability. To conclude, acute intraoperative hypotension without operative field blood loss during lumbar disc surgery should alert the possibility of this rare complication. If its detection is missed, then the later presentations would be falling hemoglobin level and abdominal distension. This report also highlights the utility of endovascular treatment to arrest continued bleeding and manage pseudoaneurysm formation.

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