Iatrogenic Iliac Artery Injury

Iatrogenic Iliac Artery Injury

Vascular complications, which we rarely encounter during lumbosacral stabilization surgeries, can be life-threatening if they are not treated quickly. These arterial injuries occur during screw insertion. The presentation with the common iliac artery injury during the decortication process in transverse processes with ‘Pedicle awl‘ will be the first case in the literature as far as Koban et al. know.

Iatrogenic vascular laceration is a rare but well-known complication of posterior lumbar disc surgery (PLUDS).

In a study, the incidence of iatrogenic major vascular injuries in lumbar discectomy was 1 in 1249 operations (0.08%) 1)

Akhaddar et al. performed a review of the literature to evaluate the management of this life-threatening complication. A total of 54 papers containing 100 cases of vascular laceration following PLUDS between 1969 and 2018 were analyzed with their representative case with a left common iliac artery (CIA) laceration during a posterior approach for a far lateral L4-L5 disc herniation. There were 54 females and 35 males (12 cases with unreported gender) with ages ranging from 20 to 72 years. The most commonly involved spinal level was L4-L5 (n = 67). The duration from the causative surgery to the symptom of the vascular injury ranged from 0 to 50 h (mean, 7.3 h). Only 47.3% of patients underwent postoperative imaging and the most commonly injured vessel was the CIA (n = 49). Vascular repair, open surgery, and/or an endovascular procedure was performed in 95 patients. The most frequent complications were deep venous thrombosis in the leg and pulmonary emboli, where a complete recovery was seen in 75.3% of patients. The mortality rate was 18.8%. In hemodynamically unstable cases, an emergent exploratory laparotomy was life-saving even without vascular imaging, although angiography with/without endovascular intervention may be used in stable patients 2).


Sealing of common iliac artery or abdominal aortic lesions as a complication of lumbar-disc surgery with a stent graft is effective and is suggested as an excellent alternative to open surgery for iatrogenic great-vessel injuries, particularly in critical conditions 3)

Bojarski et al. presented the case of a 57-year-old patient who received surgery for critical degenerative lumbal spinal stenosis on the L4-L5 level. The diagnosis was based on strong right sciatica and neurogenic claudication. A bilateral laminotomy from the right and a microdiscectomy were performed. During surgery, no bleeding from the intervertebral space was observed and blood pressure was low but stable from the beginning. After surgery, the patient was in good general and neurological condition, without preoperative right-sided sciatica. Within a few hours after the operation, the circulatory and respiratory systems were stable with normal saturation and the patient did not report shortness of breath. Paleness of the skin and mucous membranes was observed. Follow-up morphology tests performed at 6 and 10.5 hours after surgery showed a decrease in the level of erythrocytes. The patient had palpable tenderness in the left hypochondriac region. Suspicion of bleeding into the abdominal cavity from arteries or iliac veins was stated. Immediately, an angio-computed tomography (CT) of the abdominal cavity was performed, which confirmed the presence of a hematoma in the peritoneal space and a pseudoaneurysm of the left iliac artery. The patient was urgently transported to the Vascular Surgery Clinic, where a Y-type covered stent was implanted percutaneously into both iliac arteries. After the procedure, there were symptoms of ischaemia in the left lower extremity and intermittent claudication. A Doppler study showed signs of narrowing at the stent level on the left side. The patient was reoperated after a CT check-up and a second stent was implanted into the left iliac artery, which allowed vasodilation and true flow in the artery.

Suggest that both the neurosurgeon and anaesthesiologist should have been aware of the possibility of such a rare but life-threatening complication as iliac vessel damage during lumbar discectomy surgery. A quick diagnosis and implementation of a proper procedure reduces the high mortality rate caused by this complication. In cases of a sudden unjustified drop in blood pressure during lumbar discectomy, an immediate laparotomy should be performed to find and repair the site of laceration of a vessel. In patients who are stable hemodynamically, performing an angio-CT function of the abdominal cavity is suggested and the damaged artery should be treated with a covered stent 4).


LUMBOSACRAL DECOMPRESSION AND STABILIZATION SURGERY WAS PERFORMED IN A 57-YEAR-OLD PATIENT WITH L1-S1 Spinal stenosis and scoliosis. After the stabilization process was completed; while decorticating the transverse processes with ‘pedicle awl‘, the tool fell to the paravertebral region and then active arterial hemorrhage was observed on the surgical site. Hemostasis was achieved in the surgical field, but a rapid progressive drop was observed in the patient’s blood pressure. The surgery was quickly terminated and the patient was turned to the supine position. Vascular surgeons opened the abdomen with midline laparotomy and approximately 2600 cc hematoma was evacuated from the retroperitoneum. The 5 mm defect in the left common iliac artery was repaired by primary suturing. The patient had no problem in postoperative follow-up and was discharged on the 10th postoperative day.

In these complications that we rarely encounter in lumbosacral stabilization surgeries, perioperative findings should be evaluated well, and rapid intervention should be made in cases where vascular injury is considered. One must remember that every tool used during surgery can be dangerous even in an experienced hand 5).


A 31 year old woman was admitted to the neurosurgery department with L5 right-sided sciatica and an associated radiculopathy, and paraesthesia of the first toe of the right foot. She had previously undergone surgical correction of a L4 – L5 lumbar disc herniation, as well as a left oophorectomy and chemotherapy for ovarian neoplasia. A right L5 hemilaminectomy associated with right L5 – S1 foraminotomy and L5 – S1 discectomy was performed with the patient in the ventral position. The procedure was carried out without any apparent complications. In the first three post-operative days the patient complained persistently of orthostatic hypotension and a drop in haemoglobin was observed. Computed tomography angiography revealed what appeared to be a complete transection of the right common iliac artery and vein, with active haemorrhage, and a large pseudoaneurysm. Immediate surgery was carried out with reconstruction consisting of a 9 mm Dacron graft interposed in the right common iliac artery, as well as ligation of the right common iliac vein, which was not amenable to repair. The post-operative period was uneventful. The patient was discharged on day 13 with normal lower limb pulses and mild oedema of the right lower limb, controlled with elastic compression stockings.

Iatrogenic injuries of the large abdominal vessels during spinal surgery is rare but serious. Close patient surveillance and remaining vigilant for these life threatening vascular lesions are crucial in the peri-operative period of spinal surgery 6).


1)

Denli Yalvac ES, Balak N. The probability of iatrogenic major vascular injury in lumbar discectomy. Br J Neurosurg. 2020 Jun;34(3):290-298. doi: 10.1080/02688697.2020.1736261. Epub 2020 Mar 9. PMID: 32148105.
2)

Akhaddar A, Alaoui M, Turgut M, Hall W. Iatrogenic vascular laceration during posterior lumbar disc surgery: a literature review. Neurosurg Rev. 2021 Apr;44(2):821-842. doi: 10.1007/s10143-020-01311-5. Epub 2020 May 12. PMID: 32399729.
3)

Canaud L, Hireche K, Joyeux F, D’Annoville T, Berthet JP, Marty-Ané C, Alric P. Endovascular repair of aorto-iliac artery injuries after lumbar-spine surgery. Eur J Vasc Endovasc Surg. 2011 Aug;42(2):167-71. doi: 10.1016/j.ejvs.2011.04.011. Epub 2011 May 17. PMID: 21592826.
4)

Bojarski P, Solonynko B, Stapinska-Syniec A, Sobstyl M, Nazarewski S. Rare iatrogenic iliac artery injury during lumbar disc surgery – a case report. Pol Merkur Lekarski. 2021 Apr 18;49(290):150-152. PMID: 33895764.
5)

Koban O, Akar E, Öğrenci A, Yilmaz M, Dalbayrak S. Any Instrument in Surgeon’s Hand Can Be Fatal: Unusual İliac Artery Injury in Lumbar Spinal Deformity Surgery [published online ahead of print, 2020 Aug 7]. World Neurosurg. 2020;S1878-8750(20)31749-6. doi:10.1016/j.wneu.2020.07.217
6)

Moutinho M, Silvestre L, Belo D, Soares T, Pedro LM. Complete Disruption of The Iliac Vessels During Spinal Surgery With Delayed Presentation. EJVES Short Rep. 2019;43:33-36. Published 2019 May 23. doi:10.1016/j.ejvssr.2019.04.008

Traumatic brain injury epidemiology

Traumatic brain injury epidemiology

Traumatic brain injury (TBI) is a critical public health and socio-economic problem throughout the world, making epidemiological monitoring of incidence, prevalence and outcome necessary.

It is one of leading causes of mortality and disability worldwide and is estimated to surpass many diseases by 2020 1) 2).

It is the leading cause of mortality and morbidity in children 3).

Nonaccidental head injury, as seen in domestic child abuse cases, is often associated with spine injury, and spinal subdural hematoma is the most frequent diagnosis. While spinal epidural hematomas are a rare occurrence, the incidence of spontaneous epidural hematomas occurring in nonaccidental head injury patients is even lower 4).


In 2019, relevant articles and registries were identified via systematic review; study quality was higher in the high-income countries (HICs) than in the low- and middle-income countries (LMICs). Sixty-nine million (95% CI 64-74 million) individuals worldwide are estimated to sustain a TBI each year. The proportion of TBIs resulting from road traffic accidents was greatest in Africa and Southeast Asia (both 56%) and lowest in North America (25%). The incidence of RTA was similar in Southeast Asia (1.5% of the population per year) and Europe (1.2%). The overall incidence of TBI per 100,000 people was greatest in North America (1299 cases, 95% CI 650-1947) and Europe (1012 cases, 95% CI 911-1113) and least in Africa (801 cases, 95% CI 732-871) and the Eastern Mediterranean (897 cases, 95% CI 771-1023). The LMICs experience nearly 3 times more cases of TBI proportionally than HICs.

Sixty-nine million (95% CI 64-74 million) individuals are estimated to suffer TBI from all causes each year, with the Southeast Asian and Western Pacific regions experiencing the greatest overall burden of disease. Head injury following road traffic collision is more common in LMICs, and the proportion of TBIs secondary to road traffic collision is likewise greatest in these countries. Meanwhile, the estimated incidence of TBI is highest in regions with higher-quality data, specifically in North America and Europe 5).

Traumatic brain injury (TBI) is a public health problem in Ethiopia. We need more knowledge about the epidemiology and neurosurgical management of TBI patients to identify possible focus areas for quality improvement and preventive efforts.

In a prospective cross-sectional study (2012-2016) at the four teaching hospitals in Addis Ababa, Ethiopia. All surgically treated TBI patients were included, and details on clinical presentation, injury types, and trauma causes were registered.

They included 1087 patients (mean age 29 years; 8.7% females; 17.1% < 18 years of age). Only 15.5% of TBIs were classified as severe (Glasgow Coma Scale (GCS) score 3-8). Depressed skull fracture (DSF; 44.9%) and epidural hematoma (EDH; 39%) were the most frequent injuries. Very few patients were polytraumatized (3.1%). Assault was the most common injury mechanism (69.9%) followed by road traffic accidents (RTA; 15.8%) and falls (8.1%). More than 80% of patients came from within 200 kms of the hospitals, but the median time to admission was 24 hours. Most assault victims (80.4%) were injured more than 50 kms from the hospitals, whereas 46% of RTA victims came from the urban area. Delayed admission was associated with higher GCS scores and non-severe TBI (p < 0.01).

The injury panorama delayed admission, and few operations for severe TBI are linked to a substantial patient selection both before and after hospital admission. The results also suggest that there should be a geographical framework for tailored guidelines, preventive efforts, and development of prehospital and hospital services 6).

Sun et al. conducted a nationally representative door-to-door survey in the general population across all age groups in 31 provinces in mainland China in 2013.

All participants were reviewed for a history of physician-diagnosed TBI by trained investigators using a structured questionnaire. TBI survivors were considered as prevalent cases at the prevalent time. The present study also examined the odds of TBI as a function of sex, age, and other demographical variables using logistic regression model. + Of 583,870 participants, 2,673 individuals had suffered from a TBI during their past life, yielding a weighted prevalence of being 442.4 (95% CI 342.2-542.6) per 100,000 person. The TBI prevalence increased with increasing age. The present study observed the multiadjusted ORs of TBI were 1.9 (95% CI 1.8-2.1) for the male, 1.9 (95% CI 1.2-3.1) for the farmers, 1.9 (95% CI 1.2-3.3) for the retiree or homemakers, 3.4 (95% CI 1.5-7.7), and 2.8 (95% CI 1.1-6.6) for those whose education were primary school and high school, respectively. The most common external cause was road traffic accidents among those who were aged 18-34 years old and those whose educational levels were middle school in both genders.

The results indicate TBI was substantially prevalent among Chinese population and underscore the need to develop national strategies to improve the safe education on road and traffic of TBI in rural residents and some subgroup population 7).

Every 15 seconds someone suffers a traumatic brain injury (TBI) in the United States. TBI causes more deaths in males <35 years old than all other diseases combined, and it is estimated that 2% of the U.S. population lives with TBI-associated disability. Despite extensive research and success in animal studies, successful drug therapies have proved elusive in clinical trials 8).

The Centers for Disease Control and Prevention (CDC) estimate that more than 1.7 million each year in USA sustain TBI. Of these, approximately 1.4 million are treated and released from emergency centers, 275,000 are hospitalized, 80,000 suffer long-term disability and 52,000 die 9) ,and another 235,000 are hospitalized for non-fatal TBI 10).

Incidence of TBI in all industrialized countries is comparable to the U.S., with estimates ranging from 150 to more than 300 per 100,000

Annual incidence of approximately 250-600 patients per 100,000, and mortality of 17 cases per 100,000.

It is one of the most common causes of death in ordinary accidents, natural disasters, or warfare.

These injuries frequently occur outside, leaving injured individuals exposed to environmental temperature extremes before they are transported to a hospital.

Each year, approximately 100,000 patients require neurosurgical evacuation of an intracranial hematoma in the United States 11).

There are strong and demographically stable associations between TBI and substance use. These associations may not only increase the odds of injury but impair the quality of post injury recovery 12).

The exact incidence is unavailable in India.

From August 2012 to May 2013 at Department of Neurosurgery, S.C.B. Medical College, Cuttack, Odisha, India. All the pertinent details from case records of hundred and forty-seven children <15 years with TBI were analyzed. Follow-up was done for 6 months at outpatients department.

Age wise, incidence and severity of TBI is more common in 10-15 years. Males outnumber females with a male: female ratio 2.19:1. Overall, road traffic accident (RTA) is the commonest mode of injury. Assault is not uncommon (7.48% cases). Falls is common in <5 years while RTA is common in 5-15 years. The extradural hematoma was the most common injury pattern; however, surgical consideration was maximal for fracture skull. Overall mortality was 7.48%. Diffuse axonal injury has the maximum individual potential for mortality. We noticed excellent recovery in 68.7%, disabilities in 17.68%, and persistent vegetative state in 5.45% cases.

TBI in children carries good outcome, if resuscitated and referred early to a neurotrauma center, and managed subsequently on an individualized basis with a well-organized team approach. Severe TBI in children has a poor outcome 13).

Traumatic brain injury (TBI) is a common reason for presentation at the emergency department (ED) and hospital admission in Europe.

In total, 28 epidemiological studies on TBI from 16 European countries were identified in the literature. A great variation was found in case definitions and case ascertainment between studies. Falls and road traffic accidents (RTA) were the two most frequent causes of TBI, with falls being reported more frequently than RTA 14).

In 2006 it was difficult to reach a consensus on all epidemiological findings across the 23 published European studies because of critical differences in methods employed across the reports 15).

Traumatic brain injury epidemiology in Spain

2015

A search was conducted in the PubMed electronic database using the terms: epidemiology, incidence, brain injur*, head injur* and Europe. Only articles published in English and reporting on data collected in Europe between 1990 and 2014 were included. In total, 28 epidemiological studies on TBI from 16 European countries were identified in the literature. A great variation was found in case definitions and case ascertainment between studies. Falls and road traffic accidents (RTA) were the two most frequent causes of TBI, with falls being reported more frequently than RTA. In most of the studies a peak TBI incidence was seen in the oldest age groups. In the meta-analysis, an overall incidence rate of 262 per 100,000 for admitted TBI was derived.

Interpretation of published epidemiologic studies is confounded by differences in inclusion criteria and case ascertainment. Nevertheless, changes in epidemiological patterns are found: falls are now the most common cause of TBI, most notably in elderly patients. Improvement of the quality of standardised data collection for TBI is mandatory for reliable monitoring of epidemiological trends and to inform appropriate targeting of prevention campaigns 16).

A coordinated strategy to evaluate this public health problem in Romania would first of all rely on a related advanced monitoring system, to provide precise information about the epidemiology, clinical and paraclinical data, but concerning the social and economic connected consequences, too 17).

see Traumatic brain injury in skiers.


1)

Hyder AA, Wunderlich CA, Puvanachandra P, Gururaj G, Kobusingye OC. The impact of traumatic brain injuries: A global perspective. NeuroRehabilitation 2007;22:341-53. Back to cited text no. 1
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Lopez AD, Murray CC. The global burden of disease, 1990-2020. Nat Med 1998;4:1241-3.
3)

K. S. Quayle, D. M. Jaffe, N. Kuppermann et al., “Diagnostic testing for acute head injury in children: when are head computed tomography and skull radiographs indicated?” Pediatrics, vol. 99, no. 5, article e11, 1997.
4)

Rangwala SD, Birk DM, Tobin MK, Hahn YS, Nikas DC. Spontaneous Resolution of Spinal Epidural Hematoma Resulting from Domestic Child Abuse: Case Report. Pediatr Neurosurg. 2016 Sep 20. [Epub ahead of print] PubMed PMID: 27644085.
5)

Dewan MC, Rattani A, Gupta S, Baticulon RE, Hung YC, Punchak M, Agrawal A, Adeleye AO, Shrime MG, Rubiano AM, Rosenfeld JV, Park KB. Estimating the global incidence of traumatic brain injury. J Neurosurg. 2018 Apr 1:1-18. doi: 10.3171/2017.10.JNS17352. [Epub ahead of print] PubMed PMID: 29701556.
6)

Laeke T, Tirsit A, Kassahun A, Sahlu A, Debebe T, Yesehak B, Masresha S, Deyassa N, Moen BE, Lund-Johansen M, Sundstrøm T. Prospective study of surgery for traumatic brain injury in Addis Ababa, Ethiopia: Trauma causes, injury types and clinical presentation. World Neurosurg. 2021 Feb 7:S1878-8750(21)00184-4. doi: 10.1016/j.wneu.2021.02.003. Epub ahead of print. PMID: 33567370.
7)

Sun D, Jiang B, Ru X, Sun H, Fu J, Wu S, Wang L, Wang L, Zhang M, Liu B, Wang W; for the NESS-China investigators. Prevalence and Altered Causes of Traumatic Brain Injury in China: A Nationwide Survey in 2013. Neuroepidemiology. 2019 Dec 18:1-8. doi: 10.1159/000501911. [Epub ahead of print] PubMed PMID: 31851999.
8)

Maas, A. I. R., Menon, D. K., et al. (2012). “Re-orientation of clinical research in traumatic brain injury: report of an international workshop on comparative effectiveness research.” Journal of Neurotrauma 29(1): 32-46.
9)

Faul M, Xu L, Wald MM & Coronado VG. (2010). Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths 2002–2006. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control
10)

Corrigan JD, Selassie AW, Orman JA. The epidemiology of traumatic brain injury. J Head Trauma Rehabil 2010; 25: 72–80.
11)

Feinberg M, Mai JC, Ecklund J. Neurosurgical Management in Traumatic Brain Injury. Semin Neurol. 2015 Feb;35(1):50-56. Epub 2015 Feb 25. PubMed PMID: 25714867.
12)

Ilie G, Mann RE, Hamilton H, Adlaf EM, Boak A, Asbridge M, Rehm J, Cusimano MD. Substance Use and Related Harms Among Adolescents With and Without Traumatic Brain Injury. J Head Trauma Rehabil. 2014 Nov 25. [Epub ahead of print] PubMed PMID: 25427256.
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Satapathy MC, Dash D, Mishra SS, Tripathy SR, Nath PC, Jena SP. Spectrum and outcome of traumatic brain injury in children <15 years: A tertiary level experience in India. Int J Crit Illn Inj Sci. 2016 Jan-Mar;6(1):16-20. PubMed PMID: 27051617.
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Peeters W, van den Brande R, Polinder S, Brazinova A, Steyerberg EW, Lingsma HF, Maas AI. Epidemiology of traumatic brain injury in Europe. Acta Neurochir (Wien). 2015 Oct;157(10):1683-96. doi: 10.1007/s00701-015-2512-7. Epub 2015 Aug 14. PubMed PMID: 26269030.
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Tagliaferri F, Compagnone C, Korsic M, Servadei F, Kraus J. A systematic review of brain injury epidemiology in Europe. Acta Neurochir (Wien). 2006 Mar;148(3):255-68; discussion 268. Review. PubMed PMID: 16311842.
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Popescu C, Anghelescu A, Daia C, Onose G. Actual data on epidemiological evolution and prevention endeavours regarding traumatic brain injury. J Med Life. 2015 Jul-Sep;8(3):272-7. Review. PubMed PMID: 26351526; PubMed Central PMCID: PMC4556905.

Pediatric traumatic brain injury guidelines

Pediatric traumatic brain injury guidelines

see Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition

In a systematic review and guideline appraisal for pediatric clinical practice guidelines (CPGs) concerning the acute management of Pediatric Traumatic Brain Injury. Targeted guideline creation specific to the pediatric population has the potential to improve the quality of acute TBI clinical practice guidelines (CPGs).

Furthermore, it is crucial to address the applicability of a guideline to translate the CPG from a published manuscript into clinically relevant local practice tools and for resource limited practice settings 1).

Guidelines for Diagnosing and Managing Pediatric Concussion

Guidelines.


Thromboprophylaxis in Traumatic brain injury:

Low-molecular-weight heparin (LMWH) prophylaxis in pediatric traumatic brain injury appears to be more effective than unfractionated heparin (UH) in preventing venous thromboembolism (VTE). Large, multicenter prospective studies are warranted to confirm the superiority of LMWH over UH in pediatric patients with traumatic brain injury. Moreover, outcomes of VTE prophylaxis in the very young remain understudied; therefore, dedicated studies to evaluate this population are needed 2).


1)

Appenteng R, Nelp T, Abdelgadir J, Weledji N, Haglund M, Smith E, Obiga O, Sakita FM, Miguel EA, Vissoci CM, Rice H, Vissoci JRN, Staton C. A systematic review and quality analysis of pediatric traumatic brain injury clinical practice guidelines. PLoS One. 2018 Aug 2;13(8):e0201550. doi: 10.1371/journal.pone.0201550. eCollection 2018. PubMed PMID: 30071052; PubMed Central PMCID: PMC6072093.
2)

van Erp IA, Gaitanidis A, El Moheb M, Kaafarani HMA, Saillant N, Duhaime AC, Mendoza AE. Low-molecular-weight heparin versus unfractionated heparin in pediatric traumatic brain injury. J Neurosurg Pediatr. 2021 Feb 12:1-6. doi: 10.3171/2020.9.PEDS20615. Epub ahead of print. PMID: 33578391.
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