Vascular injury is the main complication of the posterior approach in thoracic and lumbosacral spinal surgery. While vascular injury is rare, it can result in massive potentially life-threatening intraoperative hemorrhage.1,3,5–7 Most vascular complications occur intraoperatively, immediately postoperative, or as delayed pseudoaneurysms during the long-term postoperative period.3,8 Vascular injury may lead to acute hemorrhage, pseudoaneurysm, or arteriovenous fistula.9 Most of these injuries are venous, but arterial injuries have also been reported at an incidence ranging from 0.45% to 1.5%.4 Venous injuries are primarily lacerations accompanied by hemorrhage and are caused by branch vessel avulsions during mobilization and retraction.10
The theoretical and actual distances in the thoracic segments were similar in male and female subjects. However, in the lumbar segments, the theoretical and actual distances were significantly greater in males than in females. The paravertebral vessels may be at higher risk of injury in female subjects during posterior lumbar spinal procedure and warrant particular caution. However, without a large case-control study, the specific relationship between gender and paravertebral vascular injury remains unknown. Among the known case reports, Olcay et al19 described the case of a woman who experienced a left common iliac artery laceration during spinal surgery. Chao et al20 described a male subject with rupture of a pseudoaneurysm in the right common iliac artery after spinal surgery to treat intervertebral disc herniation. In a case study by Lopera et al,21 the arterial injuries caused by misplacement of fixation screws were reportedly similar between the six male and female subjects. Other studies have found that the surgical window in lower lumbar procedures is larger in males than in females; a more exposed approach can be used in male subjects, which decreases the risk of damage and postoperative complications.22 As we observed, course of the lumbar paravertebral vessels is variable, especially at L4/L5. Therefore, careful planning is required in surgery of the lumbar spine. The right and left common iliac arteries are frequently injured intraoperatively according to a previous report (43% and 29% of subjects, respectively).23 The iliac artery is also reportedly prone to injury during surgery.24 A literature review showed that these lesions are more frequent after surgeries performed at L4-L5 than at L5-S1.25 These iatrogenic vascular injuries require immediate and aggressive treatment.26 Understanding the course and anatomy of the paravertebral vessels can reduce vascular complications. Early diagnosis and surgical repair of these injuries may decrease morbidity and mortality.
Radiologic methods provide a more intuitive and accurate reflection of the paravertebral vessel course and its relationship to the thoracic and lumbar vertebrae, and provides a useful basis for surgical planning. However, our analysis was mainly descriptive, and the vascular windows of the thoracolumbar spine were not measured on fresh cadaveric specimens, which is a limitation of our study. Measurement of these parameters in cadavers is impossible as an adequate sample size cannot be procured, and the cost would be prohibitive. Additionally, distortion errors may be caused by tissue shrinkage after formalin fixation. Thus the present study, does offer certain limitations. However, this study is only a preliminary study. We are also planning to perform a multi-center clinical study in the future in various regions of China to expand the sample size and validate our findings.
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