Anterior approaches to the lumbosacral spine were first popularized by Hodgson et al1 in the early 20th century as a means of treating crippling tuberculous lesions of the spine. Since then, anterior lumbosacral surgery has evolved to encompass all aspects of spine surgery, including trauma, deformity, and in especially increasing numbers, degenerative conditions. Its theoretical advantages include increasing correction of spinal deformities, improved fusion rates, direct access to the interbody space, and potential lessening of the exposure-related morbidity of posterior approaches. Anterior lumbosacral surgery, however, carries with it certain definite risks, one of the most critical of which is injury to the surrounding vasculature. Because increasing numbers of surgeons are using an anterior approach to the lumbosacral spine, it is important for both the patient and the surgeon to understand the risks, patterns, and outcomes of injury to the vascular structures associated with this direct anterior exposure (and access) to the lumbar spine. The purpose of this review, therefore, is to attempt to answer the following 4 clinical questions:
- What is the incidence of vascular injury (direct and indirect) in anterior lumbosacral procedures?
- What are the consequences and clinical outcomes of vascular injury?
- What factors contribute to this vascular injury during anterior access?
- Are there effective measures to decrease the incidence of intraoperative vascular injury in anterior lumbosacral spine procedures?
Materials and Methods
Electronic Literature Database.
The literature search is outlined in detail elsewhere.2 We conducted a systematic search in Medline, EMBASE, and the Cochrane Collaboration Library for literature published from January 1993 through December 2008. We limited our results to humans and to articles published in the English language. Reference lists of key articles were also systematically checked.
To answer our first study question, we attempted to identify studies specifically designed to evaluate the incidence or frequency of vascular injury in elective anterior lumbosacral spine surgery. To determine the consequences of vascular injury in anterior lumbosacral spine surgery patients (study question no. 2), we attempted to identify studies that specifically evaluated outcomes for this event. To determine which factors contribute to this injury (study question no. 3), we attempted to identify studies that evaluated risk factors for vascular injury in anterior lumbosacral spine approaches. To address study question no. 4, we attempted to identify studies that measured the effect of an intervention or prevention strategy to decrease the incidence of intraoperative vascular injury in anterior lumbosacral spine surgery. Exclusions included editorials, review articles without quantitative data, case reports, and non-English-written studies (Figure 1).
Each retrieved citation was reviewed by 2 independently working reviewers (J.R.D. and D.F.). Most articles were excluded on the basis of information provided by the title or abstract. Citations that seemed to be appropriate or those that could not be excluded unequivocally from the title and abstract were identified, and the corresponding full-text reports were reviewed by the 2 reviewers. Any disagreement between them was resolved by consensus. From the included articles, the following data were extracted: study design, patient demographics, surgical approach, diagnosis, surgical treatment rendered, rate or number of documented events of vascular injury, and risk factors for as well as consequences of this complication.
Level of evidence ratings were assigned to each article independently by 2 reviewers using the criteria set by The Journal of Bone and Joint Surgery. American Volume (J Bone Joint Surg Am)3 for diagnostic studies and modified to delineate criteria associated with methodologic quality and described elsewhere.2
The rate of vascular injuries was reported as the proportion of patients experiencing a vascular injury, deep vein thrombosis, or pulmonary emboli. Data were summarized in tables and, where possible, pooled rates were calculated, weighted by sample size. Qualitative analysis was performed considering 3 domains: quality of studies (level of evidence), quantity of studies (the number of published studies similar in patient population, condition treated, and outcome assessed), and consistency of results across studies (whether the results of the different studies lead to a similar conclusion).4 We judged whether the body of literature represented a minimum standard for each of the 3 domains using the following criteria: for study quality, at least 80% of the studies reported needed to be rated as a level of evidence I or II; for study quantity, at least 3 published studies were needed, which were adequately powered to answer the study question; and for study consistency, at least 70% of the studies had to have consistent results. The overall strength of the body of literature was expressed in terms of the impact that further research may have on the results. An overall strength of “high” means that further research is very unlikely to change our confidence in the estimate of effect. The overall strength of “moderate” is interpreted as further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. A grade of “low” means that further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate, whereas “very low” means that any estimate of effect is very uncertain.2
We identified 88 articles or reports from our literature search reporting on vascular injury secondary to anterior lumbosacral spine surgery. From these potential articles or reports, we judged 51 to undergo full-text review. After full-text review, we excluded 11 for the following reasons: 9 studies did not meet the inclusion criteria (included infection, tumor or trauma condition, reported on posterior approach only), and 2 studies did not report data on vascular injury. The selection process is summarized in Figure 2.
All of the remaining 40 articles provide information on frequencies of vascular injury. Nine are prospective studies, 2 graded as level of evidence I,5,6 7 graded as level of evidence II,7–13 and 31 are retrospective studies graded as level of evidence III.14–44 Five of the studies also reported on risk factors associated with vascular injury7,18,19,26,36 (Supplemental Digital Content, available at: http://links.lww.com/BRS/A421; further details on the level of evidence and the study characteristics for each study can be found in Tables 1 and 2, respectively).
Question 1. What Is the Incidence of Vascular Injury (Direct and Indirect) in Anterior Lumbosacral Procedures?
The incidence of vascular injury after anterior lumbosacral surgery ranged from 0% to 18%, with the highest rates being reported in the early to mid 1990s (Figure 3). Rates also depended on patient demographics, the surgical approach, and the number and level of the lumbar spine exposed. Twenty-eight studies reported frequencies of vascular injury among patients who underwent anterior lumbosacral surgery via an open technique5–7,10–12,14, 15,19–23, 26,28–30,32,34,36–38,40–45 (Table 1). The rate of venous injury ranged from 0.0% to 18.1% whereas the rate of arterial injury ranged from 0.0% to 5.0%. Among patients receiving a mini-open technique, the rate of venous injury ranged from 0.0% to 3.9%, whereas that of arterial injury was 0.0% to 5.6% in 9 studies.6,8,9,13,18,22,27,29,35 Ten studies reported the incidence of vascular injuries using a thoracoscopic or laparoscopic technique.8,9,20,22,24,27,31,33–35 The rate of venous injury reported during this technique ranged from 2.1% to 8.6% whereas the arterial injury rate ranged from 0.0% to 5.0%. The left common iliac vein was the vessel injured most frequently, followed by the inferior vena cava and iliolumbar vein. Most venous injuries occurred during retraction of the great vessels.
Question 2. What Are the Consequences and Clinical Outcomes of Vascular Injury?
Eleven studies addressed the consequences and patient outcomes after vascular injury. Primary suture of the laceration after manual compression of the bleeding site was effective in treating most vascular injuries, and patient outcome after vascular injury was not adversely affected. However, there are occasional reports of vascular injury in which large amounts of bleeding, the nature of the injury, and subsequent repair attempts resulted in residual morbidity. Brau et al18 reported such a case in which direct repair of the inferior vena cava was not possible. His group conducted a retrospective cohort study on 1310 consecutive patients who underwent anterior lumbar interbody fusion (ALIF) or total disc replacement using a mini-open, retroperitoneal approach. The rate of major venous laceration was reported as 1.5% (19 of 1310) though “major” was undefined by the authors. Sixteen injuries were to the left common iliac vein, 1 to the bifurcation of the inferior vena cava and 2 to the right iliolumbar veins. Blood loss ranged from 100 to 3000 mL. In 10 of the 16 common iliac vein lacerations, the injury occurred during exposure. In the other 6, the injury occurred either during the arthrodesis or during removal of the insertion instruments. Seventeen of the 19 venous injuries occurred at L4–L5. For the vena cava injury, direct repair was not possible, resulting in ligation. The patient consequently experienced mild chronic edema of both lower extremities. Further, in 2 cases in obese patients, the scheduled arthrodesis was aborted because of excessive bleeding from right lumbar veins. Both were reported to have undergone successful posterior fusions. None of the patients reported late sequelae attributable to the vein injuries or required transfusion. An additional 6 (0.46%) patients were identified as having left iliac artery thrombosis, 4 in the left iliac artery, and 2 had embolized down to the bifurcation of the common femoral artery. After successful thrombectomy‘ on 4 patients, 1 developed a compartment syndrome that required fasciotomies. In the other 2 patients, after failed attempts at thrombectomy, 1 patient required an axillofemoral bypass and another had a femorofemoral bypass and later developed compartment syndrome. Both patients with compartment syndrome eventually recovered; however, a 3/5 muscular deficit of the extensors in the left lower leg resulted.
Mahvi and Zdeblick31 reviewed 20 consecutive patients with degenerative disc disease who underwent ALIF with placement of BAK implants via a laparoscopic retroperitoneal approach. Nineteen patients had a single-level L5–S1 fusion, and 1 had a 2-level L4–L5 and L5–S1 fusion. Vascular complications included an injury to the middle sacral artery (1 of 20, 5.0%) and an injury to the left common iliac vein (1 of 20, 5.0%). Both of these patients were converted to open approach to repair the injury. Neither of the patients required transfusion, and both conversions resulted in excellent outcomes. These 2 patients with open conversions stayed in the hospital for 4 days, whereas all other patients with laparoscopic surgeries were discharged home at an average of 1.7 days after surgery.
Kulkarni et al29 reported on 220 ALIF procedures performed via: (a) the minimally invasive muscle-sparing retroperitoneal (mini-ALIF) approach (n = 95) or (b) the hypogastric-midline-transperitoneal approach (n = 125). Arterial thrombosis occurred in 2.3% (5 of 220) of the cases; 3 via retroperitoneal approach (2 left common iliac artery and common femoral artery and 1 left common iliac artery) and 2 via transperitoneal approach (1 left common iliac artery and 1 right common iliac artery). Arterial vasospasm was reported in 2 (0.9%) patients in the retroperitoneal group. One (0.5%) occlusive intimal tear of the left common iliac vein occurred in the transperitoneal group. All 8 cases with vascular complications involved surgery at the L4–L5 level. One (0.5%) of the patients, who developed a left common iliac artery thrombosis after spinal access via the retroperitoneal approach, developed rhabdomyolysis resulting in fatal acidosis.
Brewster et al19 performed a retrospective cohort study of intraoperative and postoperative complications in 128 consecutive patients who underwent low anterior lumbar spinal fusion. Retroperitoneal exposure was achieved in 125 (97%) patients, whereas conversion to transperitoneal exposure was necessary in 3 patients secondary to adhesive disease from prior laparotomies. There were 7 (5.4%) intraoperative vein injuries and 1 (0.8%) postoperative pulmonary embolism. Vein injury was not associated with an increased length of hospital stay (3 ± 1.4 days for vein injury vs. 2.3 ± 1.1 day for no injury). No studies, including the well-controlled prospectively randomized studies on disc arthroplasty and fusions, evaluated or reported the impact of vascular injury and repair on patient-reported functional outcomes (short form-36, Oswestry Disability Index, etc.). Seven additional studies15,17,23–25,32,39 reported no sequelae or deaths associated with anterior lumbosacral spinal procedures.
Question 3. What Factors Contribute to This Vascular Injury During Anterior Access?
Vascular injury is more commonly reported after L4–L5 exposure than other levels. Brau et al's18 evaluation of 1310 consecutive patients identified 6 as having left iliac artery thrombosis (0.5%), all of whom had the L4–L5 level exposed. Hamdan et al26 performed a retrospective cohort study to evaluate the incidence of arterial and venous injuries in 480 consecutive patients who underwent anterior fusion of the lumbar spine. Vascular injury was defined as any case in which a suture was required to control bleeding. Exposure of L4–L5 was associated with an increased rate of vascular injury. Of the 318 patients who had exposure of L4–L5, 44 (13.8%) experienced a vascular injury, whereas in the remaining 162 patients, 9 (5.6%) experienced a vascular injury. No other factors predicted risk of major vascular injury. On the other hand, Brewster et al,19 in their retrospective cohort study of 128 consecutive patients, found that procedures involving L4 were not associated with an increase in frequency of vein injuries (5.6% involving L4 vs. 5.3% not involving L4).
One study has suggested that implant characteristics might play a role in injury to the vasculature. In a prospective randomized multicenter trial, Sasso et al7 compared the safety and efficacy of the INTER FIX device, a cylindrical threaded titanium cage, with a femoral ring allograft (control). A total of 140 patients at 13 study sites underwent single-level ALIF through a transperitoneal or retroperitoneal approach for treatment of symptomatic degenerative disc disease. Seventy-eight patients were randomized to the INTER FIX device treatment arm, and 62 patients were randomized to the control group. Among patients receiving the threaded cage, 11.5% sustained a vascular injury compared with 3.2% in the nonthreaded device group. The relative increase in risk of vascular injury among those implanted with a threaded device was confirmed in a second study by Sasso et al,36 a retrospective cohort study in which they assessed complications associated with threaded and nonthreaded devices in 471 consecutive patients who underwent ALIF surgery. Threaded devices (n = 228) included both titanium cages and allograft bone dowels. Nonthreaded devices (n = 243) included femoral ring allograft spacers and iliac crest autograft blocks that were inserted after a block discectomy without the aid of reamers or working channels. Vascular injury occurred in 3.1% of the threaded and 0.4% in the nonthreaded devices (3 iliac artery injuries occurred: 2 in patients with a threaded device and 1 in an individual with a nonthreaded device; and 5 venous injuries occurred, all in patients with threaded devices). The authors suggested that the use of large implantation tools used for placement of the threaded fusion device may have required more retraction force, resulting in the higher incidence of vascular injury.
Another factor that may play a role would be revision approaches to the lumbosacral junction. Three studies reported vascular injury after anterior access in revision surgery. Nguyen et al16 reviewed 14 consecutive patients undergoing anterior removal of interbody devices and noted a high rate of vascular injury (8 of 14, 57%). The index approach for 5 patients had been anterior and, for 9 patients, posterior via PLIF or TLIF. Four (80%) of the 5 anterior patients had their original implants replaced anteriorly, whereas 4 (44%) of 9 underwent revision posterior placement. Eight patients had single-level surgery at L4–L5; all patients in the ALIF (4 of 4) and PLIF (2 of 2) treatment groups and no patients in the TLIF (0 of 2) treatment groups sustained 1 or more vascular injuries.
Wagner et al39 reported on 21 anterior surgeries in 19 patients for displaced implant or removal of a Charité artificial disc. Three patients had bilevel explantation; 2 had staged removal of the device at 2 levels whereas 1 patient had simultaneous removal of the prostheses at 2 levels. The average time to removal from the index procedure was 7 months (range, 9 days to 4 years). Three of the 12 procedures at L5–S1 were completed through the same retroperitoneal approach as the index procedure. The remaining 9 prostheses were exposed from a contralateral retroperitoneal approach. L4–L5 prostheses were accessed from the original approach in 4 patients, and from a lateral, transpsoas exposure in 5 patients. One device was removed from L3–L4 via a left lateral transpsoas approach. Nineteen of the 22 prostheses were converted to ALIF. Only 1 patient who had a transperitoneal approach to revise L5–S1 sustained an iliac vein injury (5%), which occurred during removal of the prosthesis. This was repaired without sequelae.
Brau et al17 report on 62 consecutive patients having revision anterior surgery for either failed ALIF or ADR. Twenty-three patients had the same level revised and 39 patients had adjacent-level surgery. There were 6 vascular injuries (9.6%); 3 venous and 3 arterial. All 3 arterial injuries occurred while approaching L3–L4 after L4–S1 prior fusion or disc replacement. The venous injuries (n = 3) occurred while approaching the index procedure level or levels. All had the injuries repaired without sequelae.
Question 4. Are There Effective Measures to Decrease the Incidence of Intraoperative Vascular Injury in Anterior Lumbosacral Spine Procedures?
We found no studies comparing the effect of the position of the patients on the operating table (supine vs. lateral), incision (paramedian vs. flank), handling of abdominal muscles (muscle-cutting vs. muscle-splitting), or the presence of an access surgeon on the incidence or consequence of vascular injury. However, there is some suggestion that the rate of vascular injury may be associated with the type and approach of surgery. Comparing studies published after 1997, the pooled rate of vascular injury in patients receiving a laparoscopic or thoracoscopic procedure (4.2%) was roughly twice that of those receiving an open (2.2%) or mini-open (2.0%) procedure (Figure 4). Those receiving a transperitoneal approach were significantly more likely to have a vascular injury (3.6%) compared with a retroperitoneal approach (1.9%), P = 0.005 (Figure 5).
The overall strength of evidence with respect to incidence of vascular injury after anterior spine surgery is “low,” that is, further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. The overall strength of evidence for effective recommendations is “very low,” that is, any estimate of effect is very uncertain (Table 2).
The anterior approach to the lumbosacral spine is a valuable exposure in the treatment of a plethora of pathologic conditions, such as debridement in the case of infection and tumor removal, decompression of the neural elements, reconstruction for deformity, and discectomy for fusion and total disc arthroplasty. The rate of spine surgery has continued to increase over the past 3 decades. The number of anterior approaches has also increased.46 Although the purpose of this review was to study the nature of vascular injury during these approaches, the surgeon performing anterior lumbosacral spine surgery should be aware of the potential challenges and associated complications of this exposure to minimize the threat of adverse outcomes to their patients.
The consequences of vascular injury during an anterior approach, in most cases, fortunately seem to be of little or no lasting clinical consequences. The majority of patients were reported to have experienced no adverse outcomes. However, in a small number of patients, the consequences of a vascular injury can be devastating. The reports include fatal acidosis from rhabdomyolysis, compartment syndrome, massive blood loss, which may prompt surgeons to abort the case, transfusion, and thrombosis with or without pulmonary embolism.
It seems that there is a trend for increased risk of vascular injury with an L4–L5 approach, revision surgery, use of threaded interbody devices, an approach via a transperitoneal exposure, and use of laparoscopic technique. When the expected degree of vascular mobilization is greater, depending on specific implant technology, a computed tomography (CT) angiogram may assist in some of the preoperative planning. Datta et al47 described their use of a preoperative CT angiogram to help them more accurately define the prevertebral vascular anatomy. They went on to say in their personal experience, 21% of these CT angiograms directly influenced their surgical decision-making.47 Significant vascular anomalies (large central sacral arteries, tortuous vessels, retroaortic renal arteries, and duplicate femoral veins) were seen in 11.8% of patients. Atherosclerotic disease, which can be a risk factor for arterial thrombosis and thromboembolic shower, was seen in 17% of the patients (Figure 6). CT angiography seemed to clarify the anatomy for the authors and aided in some decision-making; however, its use has not yet been validated, and its use in terms of outcome measures has not been quantified.
The reported overall frequency of vascular injury in anterior lumbosacral surgery fortunately seems to be relatively low (<5%) since 1997 onward, which may be a reflection of greater surgeon experience or more formalized training with these dissections. As a result, larger study populations would be needed to identify a number of variables and risk factors potentially associated with intraoperative vascular injury. One limitation of this report is the small sample size of the studies included. We attempted to overcome this by pooling rates when possible. However, we could not control for the possible confounding effects of factors that may influence the rate of vascular injury, such as approach (retroperitoneal or transperitoneal), type of surgery (open, mini-open, or laparoscopic), indication (primary or revision), patient factors (obesity, intra-abdominal scarring from nonspine surgery) level of surgery, and number of levels requiring surgery. To correctly identify factors associated with vascular injury, a large prospective multicenter study would be needed to gather sample size sufficient to adjust for a multitude of variables.
Despite the low level of evidence with respect to incidence of vascular injury after anterior spine surgery, the threat is real, and the surgeon performing the exposure should be prepared to address injuries should they occur. We found no studies comparing different strategies to reduce the incidence of vascular injury using the anterior approach to the lumbosacral spine. Although we await the identification and testing of potentially effective measures, we recommend that surgeons have adequate training and experience with regards to manipulation, mobilization, and retraction of the vasculature at risk, and the techniques of both venous and arterial repair. For those surgeons not experienced in the techniques of vascular manipulation and repair, involvement of an access surgeon should be considered. CT angiogram is a valuable tool to accurately define the vascular prevertebral anatomy. For those cases that present an increased risk, such as exposure of the L4–L5 level, morbid obesity, vascular calcifications, congenital deformities, prior retroperitoneal access, radiation, revision surgery, using the transperitoneal approach or laparoscopic technique, an access surgeon is a valuable resource.
- The reported incidence of vascular injury in anterior lumbosacral surgery remains low, with reports being <5%.
- The consequences of injury seem rare, but may include thrombosis, pulmonary embolism, and increased hospital stay.
- Exposure and surgery at L4–L5 may be associated with a higher risk of injury than that at L5–S1, though the data are not consistent.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.spinejournal.com).
The authors thank Ms. Nancy Holmes, RN, for her administrative assistance and Mr. Jeff Hermsmeyer, BS, and Ms. Erika Ecker for their assistance in searching the literature, abstracting data, and proofing.
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