Intercostal artery hemorrhage with hemothorax following combined lateral and posterior lumbar interbody fusion: a case report

Abstract

Introduction Lateral lumbar interbody fusion (LLIF) is a safe treatment for degenerative spine conditions. However, risk of complications such as vascular injuries remains. We report a unique case of an intercostal artery (ICA) hemorrhage with hemothorax following LLIF. Case presentation One hour after a right-sided LLIF L3-4 with posterior decompression L2-4 and L3-5 instrumentation, the patient became hypotensive, anemic and required vasopressor support. Evaluation revealed a right-sided hemothorax, which was caused by a bleeding intercostal artery, laterally at the 10th intercostal space. A lateral thoracotomy was performed to stop the bleeding. After vessel ligation and placement of two chest tubes, the patients' hemodynamics improved. The patient remained intubated overnight and was extubated on the first postoperative day. Discussion Vascular injury is a rare complication of LLIF procedures. Most vascular injuries are segmental vessel lacerations, which resolve postoperatively. This is the first case description of ICA bleeding associated with LLIF surgery. Spontaneous ICA bleeding exists, but surgeons should be aware of careful handling in patients with vascular risk factors, especially with regard to patient positioning required in certain spinal surgical approaches. Timely vascular injury identification is critical for hemostasis and clinical management.

Lethal intercostal artery injury after a fall

“…Clinical presentations of ICA injury include chest pain, dyspnea, hypotension, and increased pleural fluid (4,5). Three main causes of ICA injury have been identifiedspontaneous, traumatic, and iatrogenic (6,7). Spontaneous ICA hemorrhage is often associated with specific underlying diseases, such as neurofibromatosis type 1, systemic lupus erythematosus, and coagulopathy (7-9).…”

“…Although extremely rare, spontaneous ruptured ICA resulted from cirrhosis or aneurysm has also been reported (5,(10)(11)(12). Trauma, the most common cause of ICA hemorrhage, can be caused by either blunt or penetrating thoracic injury (4,7,9). Iatrogenic causes of ICA injury include the complications with thoracentesis, pleural biopsy, chest tube insertion, and liver biopsy (4,7).…”

Anterior Spinal Surgery Requiring Thoracotomy for Post-Operative Hematoma Removal: Two Case Reports

“…The origin of the hemothorax after anterior thoracolumbar surgery includes epidural vessel rebleeding, bleeding from the osteotomy site, pulmonary parenchymal laceration, and vascular injury. Spontaneous intercostal artery hemorrhage has also been reported, although it is rare [ 13 ].…”