Abstract
Introduction Based on 27 years of peripheral vascular surgery practice and 21 years of experience in performing anterior lumbar spine approaches the author will make recommendations for management of the more common complications of the approach to the lumbar spine.
Methods A database of 2020 cases performed since August of 1997 has been evaluated to determine the best way to manage the complications of the approach encountered in that time period.
Results 6 patients had left iliac artery thrombosis (0.29%) and 24 had major vein lacerations (1.1%). Two patients developed compartment syndrome and two other patients required arterial reconstruction. One of the patients had ureteral injury. None of the patients had retrograde ejaculation, lymphoedema, bowel injury or neurological injury. Left iliac artery thrombosis is best managed by immediate thrombectomy using balloon catheters, either via the main incision of via a left femoral incision. The diagnosis is clinical and the patient should not be taken to the radiology department for diagnostic angiography. Avoidance of delay is important in preventing compartment syndrome. If ischemia is present for 4 hours or more a prophylactic fasciotomy may be indicated. For patients with intimal disruption or atherosclerosis, in whom thrombectomy fails, arterial reconstruction or stenting may be necessary and is best left to a vascular surgeon. Venous lacerations can be repaired using 5-0 monofilament sutures. Lacerations of 5mm or less that are not easily accessible can be treated with hemostatic agents and pressure. For major disruptions of the iliac veins or inferior vena cava ligation of these vessels is an acceptable option. Proximal and distal control of vessels during exposure is not necessary and may actually lead to a higher incidence of arterial thrombosis. Control of bleeding can usually be obtained by pressure with sponge sticks or balloon catheters. The sympathetic fibres run with the peritoneum and retrograde ejaculation can be avoided by carefully elevating the peritoneum away from the promontory with blunt dissection while exposing L5-S1. The ureter similarly runs with the peritoneum and should be lifted away with it to prevent devascularization. Lymphedema is due to the disruption of the lymphatics while mobilising the iliac vessels. It is very rare and unavoidable. Injury to the genito-femoral nerve is avoided by identifying it over the psoas muscle and preserving it from injury. Bowel injury is prevented by staying retroperitoneal.
Discussion Anterior exposure to the lumbar spine carries with it a low complication rate, but these complications can have significant negative results. Prompt recognition and management of these complications will result in lower overall morbidity.
The abstracts were prepared by Professor Bruce McPhee. Correspondence should be addressed to him at Orthopaedics Division, The University of Queensland, Clinical Sciences Building, Royal Brisbane & Women’s Hospital, Herston, Qld, Australia
