Delayed Hemorrhage Followed by Vertebral Artery Injury during Cervical Anterior Controllable Antedisplacement and Fusion Surgery: Case Report and Literature Review

Abstract

Background: Vertebral artery injury (VAI) during cervical spine surgery is rare. Anterior controllable ante-displacement and fusion (ACAF) surgery is a novel technique for treating degenerative cervical spine disorders, especially ossification of the posterior longitudinal ligament. To date, there have been no reports of VAI during cervical ACAF surgery. Here, we report a rare case of perioperative complication of VAI during ACAF surgery. The available English literature that provides treatment instructions were reviewed.Case Presentation: A patient diagnosed with mixed ossification of the posterior longitudinal ligament (OPLL) underwent ACAF surgery from C2-C6. Two level transverse foramina were ruptured, and severe bleeding was encountered during ACAF osteotomy. Hemostatic tamponade was performed using bone waxes. The patient had delayed hemorrhage on postoperative day 6. Emergence angiography revealed two vertebral artery pseudoaneurysms in the ruptured transverse foramina. A balloon-expandable covered stent was deployed to treat the pseudoaneurysm. The patient recovered without complications. Conclusion:ACAF surgery is a good choice for multiple-level OPLL disease, but special attention should be paid to VAI in the perioperative period. Intraoperative tamponade with bone wax and postoperative digital subtraction angiography (DSA) are effective in preventing disaster-related hemorrhage.

Incidence of vertebral artery injury in patients undergoing cervical spine trauma surgery in correlation with surgical approach: A review

“…In 2021, An TY et al [ 32 ] reviewed the literature on iatrogenic vertebral artery injury and observed increased intraoperative risk during vertebral exposure, decompression, or instrument insertion. Yongjun T and colleagues, in 2022 [ 33 ] reviewing literature regarding late bleeding owing to vertebral artery injury in ACAF technique, underlined that intraoperative local packing with bone graft for bleeding control is the optimum method. They also advocated performing preoperative imaging to discern possible vascular variations and calculate the distance from the transverse foramen and its relationship with the posterior longitudinal ligament.…”

“…[ 26 ] As claimed by Yongjun T et al, who studied the incidence of iatrogenic injury in spinal fusion with the ACAF technique, besides perceiving the anatomical variation of the vessel, the calculation of the distance of the vertebral artery from the transverse foramen and its relationship with the posterior longitudinal ligament is of momentous gravity. [ 33 ] Although literature accentuates the essential requirement for preoperative knowledge of the anatomy and course of the vertebral artery, the imaging technique of choice remains contentious. It is even worth mentioning that according to Tan La et al, preoperative ignorance of vertebral artery anatomy is associated with an upraised incidence of injury at a rate of 35%.…”

Multiple Myeloma Treatment Challenges: A Case Report of Vertebral Artery Pseudoaneurysm Complicating Occipitocervical Arthrodesis and a Review of the Literature

“…Known risks from the posterior spine approach are due to complex regional vascular neural anatomy and may generate neurological or vascular complications, especially those associated with early or late vertebral artery injury, either of which can be fatal if not quickly recognized. Therefore, it is crucial to prevent this complication and know how to investigate it upon suspicion of vertebral artery (VA) injury [12][13][14][15][16]. Imaging studies play a fundamental role in determining the course of treatment [17].…”