Management of a periaortic spinal pedicle screw in a patient with adult presentation thoracic scoliosis.

ABSTRACT

Introduction: Vascular injury due to direct contact with malpositioned pedicle screws is perhaps the most devastating complication associated with screw instrumentation. While frank perforation of major vessels warrants urgent open or endovascular repair, the management of pedicle screws in close vicinity of large vessels is unclear. We present a systematic multi-disciplinary approach to manage a patient with a periaortic pedicle screw. Case Report A 20-year-old female underwent posterior scoliosis correction and spinal fusion for an adult thoracic scoliosis with spinal instrumentation extending from T3-T12. In the immediate post-operative period, an episode of acute desaturation prompted a computed tomography pulmonary angiography (CTPA) to rule out pulmonary embolism. While CTPA demonstrated an enlarged right side of the heart (corresponding to a large atrial septal defect as evident on 2D-ECHO), an incidental lateral breech at the left T10 pedicle screw level was also identified with the screw tip in close proximity to the aorta. At this time, cardiac management was prioritized and a successful atrial septal defect repair procedure was performed. After recovery from the cardiac procedure, a plan was formulated with a multidisciplinary team to remove the pedicle screw. To determine the exact position of the screw tip in relation to the aorta, an angiogram and an intravascular ultrasound were done which showed no evidence of intra-luminal extension of the screw tip. In addition, a transesophageal ultrasound was performed and this ruled out any extra-luminal contact with the aorta. Subsequently, the spinal instrumentation was removed safely with the vascular surgeon and interventional radiologist being on standby. Conclusion: The authors suggest the removal of spinal pedicle screws in proximity to major vessels and describe an algorithm for this. Thorough pre-operative planning and detailed vascular imaging, as well as a multidisciplinary approach resulting in a clear surgical plan are critical to allow safe removal of such implants.