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Tummala et al. Postoperative complications of spinal surgery

are chronic in nature due to baseline pathophysiology hematoma, and myelopathy.
involving atherosclerotic changes in the aorta. Risk
factors like hyperlipidemia, hypertension, diabetes On physical examination, he was alert and oriented.
would aggravate the underlying chronic condition. [1] There was no point tenderness noted on palpation of
Acute cases are rare and are usually related to acute the back. Abdomen was soft on palpation and normal
thrombus occlusion. bowel sounds heard without any tenderness. In the
neurological examination, there was a loss of sensation
Injuries of the thoracic and abdominal aorta after to fine and crude touch in both lower extremities up to
spine surgery are rare but may result in severe life- the mid thighs (L2-S1) and 4/5 power with +2 reflexes
threatening complications. Acute and chronic vascular (patellar and ankle). The motor and sensory system
injuries such as perforations leading to major bleeding of L1 distribution were normal. Babinski’s sign was
or hematoma formation, erosions or pseudoaneurysm present bilaterally. Rectal sphincter tone was normal.
formation are some of the vascular complications of The patient had no sensory or motor deficits in the
lower spinal surgeries. [2-4] However, most injuries are upper extremities. I-XII cranial nerves intact. Vitals
delayed due to chronic irritation of the aortic wall. were stable.

The majority of spinal surgery complications highlight Review of operative note revealed, that anterior
neurological sequelae, while vascular issues are less aspect of lumbosacral spines was reached by the
frequent. Post spinal surgery Leriche’s syndrome surgeon through retroperitoneal approach, following
[5]
often misdiagnosed because of overlapping symptoms left paramedian incision. Exposure of the disks was
of pseudo-claudication from spinal canal stenosis. accomplished after mobilization of left iliac vessels to
We highlight a case of acute Leriche’s syndrome after the right side and retraction by a malleable retractor.
anterior lumbar interbody fusion (ALIF) surgery, and its During disk removal and positioning the cages, the
presentation. major vessels were mobilized to right side and protected
by the retractor. No direct injury to any vessels or
CASE REPORT excessive bleeding leading to hematoma was noted
intraoperatively. The operative time was approximately
A 58-year-old male patient presented to the hospital 4 h. Routine blood works including complete blood
3 weeks after ALIF surgery at L2-S1, performed count with differentiation, complete metabolic profile,
due to lumbar spinal stenosis. He reported sudden erythrocyte sedimentation rate, C-reactive protein,
numbness, tingling and weakness of both lower creatinine kinase were normal.
extremities from the waist down. He had none of
these lower extremity symptoms before surgery. Prior Due to a strong suspicion of complications from
to his visit to our Emergency Department (ED), he was recent spinal surgery computed tomography (CT) of
discharged from two EDs in last 48 h with the diagnosis the thoracolumbar spine was ordered which showed
of diskitis. Review of the system included new onset anterior interbody fusion changes at L2-S1 with intact
leg claudication but no rest pain. The patient had hardware. Mild to moderate multilevel central canal
the blood pressure of 140/95 mmHg, a heart rate of narrowing was noted in CT scan, which was secondary
80 beats/min and a respiratory rate of 16 breaths/min, to scar tissue in the anterior epidural recesses,
whereas laboratory tests were inconspicuous. His consistent with recent surgical history. The imaging
past medical history was significant for osteoarthritis, study ruled out any critical central canal stenosis,
chronic back pain, and hypertension. There was no prior acute lumbar osseous injury or paraspinal abscess.
history of peripheral vascular disease, coronary artery There was not enough evidence of myelopathy and
disease, hypercoagulable state or prior thrombosis radiculopathy from the CT and blood works, explaining
formation. Only past surgical history included an the symptoms. His condition did not improve despite
operative history of ALIF of L2-S1, 3 weeks prior to steroid treatment as well. Then we started looking
presentation for lumbar spinal stenosis. He was a for vascular causes. CT angiography of abdomen
chronic smoker with 30 pack year’s history. There and pelvis was performed, which ruled out intramural
was no associated fever, abdominal pain, nausea, hematoma or aortic dissection. However, there was
vomiting, bladder or bowel incontinence. Initially, all an extensive aortoiliac atherosclerotic disease with
his symptoms were attributed to post-surgical changes long segment occlusive thrombosis of the infrarenal
leading to pseudo-claudication and other symptoms. abdominal aorta by a crescentic mural thrombus
At this point, our differentials for sudden sensory and [Figures 1 and 2].
motor deficit in lower extremities were spinal cord
compression, spinal cord abscess, retroperitoneal As part of acute thrombosis work up, hypercoagulable
156 Vessel Plus ¦ Volume 1 ¦ September 26, 2017