Simultaneous Combined Major Arterial and Lumbar Plexus Injury During Primary Extra Lateral Interbody Fusion: Case Report and Review of the Literature

Abstract

Extra lateral interbody fusion (XLIF) has been established in recent years as an effective approach to address degenerative lumbar disc disease (DLDD). Although neurological and vascular complications during XLIF have been reported, to our knowledge, a combination of simultaneous vascular and neurovascular complication during XLIF has not been reported to date. A 72-year-old female patient was admitted to our orthopaedic department because of back pain associated with severe neuropathic radicular pain to her both lower extremities, incomplete paraplegia and low back fistula with serous secretion for several weeks. She had been wheelchair bound since nine years before her admission in our department when she had her initial XLIF operation in another institution. Intraoperatively, an aorta lesion occurred, which was emergently addressed, along with lumbar plexus injury. Since then, she had an extensive history of subsequent operations that ended with a T10-S1 posterior lumbar fusion, with no improvement of her neurological condition, complicated by hardware-induced infection. She underwent her last operation in our department; removal of the posterior lumbar construct and extensive debridement of the posterior lumbar spine. We present this rare case and we perform an extensive literature review. Although XLIF has been established in recent years, the report of major vascular injuries, although rare, has questioned its safety profile. Spine surgeons should be aware of catastrophic major neurovascular complications associated with this procedure and be prepared to address them.

Perspective; high frequency of intraoperative errors due to extreme, oblique, and lateral lumbar interbody fusions (XLIF, OLIF, LLIF): Are they “safe”?

“…Varying frequencies of major vascular injuries/surgical errors have been reported during XLIF (0% up to 1.8%), OLIF (up to 3.2%), and LLIF (up to 2%) [ Table 1 ]. [ 2 , 4 , 5 , 10 , 16 - 18 , 20 ]…”

“…In an effort to limit major vascular injuries occurring during XLIF, OLIF, and LLIF procedures, multliple authors recommended obtaining preoperative radiological studies to document the anatomy of the lumbar great vessels [ Table 1 ]. [ 1 , 2 , 4 , 5 , 10 , 16 - 18 , 20 ] Alkadhim et al . (2015) emphasized that; “Understanding the vascular anatomy of the lateral and anterior lumbar spine is paramount for successfully and safely executing the LLIF procedure” [ Table 1 ].…”

“…3 of which were at L45); 1 injury resulted in a mortality, 1 resulted in shock due to a retroperitoneal hematoma, and there were 2 common iliac vein injuries (in one case also involving a lumbar plexus injury) [ Table 1 ]. [ 2 , 4 , 16 , 17 ] In one case report, Assina et al . (2014) observed a major vessel injury that occurred during a L45 MI XLIF that resulted in the patient’s death.…”

“…[ 2 - 4 , 10 , 12 , 16 - 18 ] The 5 case studies involved 4 acute great vessel injuries occurring during XLIF/MI XLIF warranting immediate intraoperative repairs, plus one additional report of an acute bowel perforation. [ 2 - 4 , 16 , 17 ] In 2011, Rodgers et al . found that 11 (1.8%) of 600 patients undergoing XLIF required additional surgery.…”

Vascular injury risk stratification for lateral lumbar interbody fusion (LLIF) at L4–L5: a morphometric study using magnetic resonance imaging

“…Assina et al reported a fatal case involving extensive lacerations to the inferior vena cava (IVC) and both common iliac veins (CIVs) related to anterior longitudinal ligament (ALL) retractor migration during an L4–L5 LLIF from a right-sided approach ( 22 ). Buric et al described a right CIV injury that occurred during Cobb elevator dissection of the L4–L5 disc from the L4 inferior end plate during a right-sided LLIF approach, while Mousafeiris et al reported an aortic laceration and right common iliac artery (CIA) injury during the cage placement at L4–L5 from a left-sided approach ( 23 , 24 ). Kueper et al reported one case of an abdominal aorta injury during a L3–L5 LLIF ( 25 ).…”