Name:
FOCUS25824video11
Description:
FOCUS25824video11
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/9040eb06-40c7-452f-b7f1-833ec3d62a63/videoscrubberimages/Scrubber_1.jpg?sv=2019-02-02&sr=c&sig=GrZIiMo2rVvfN2V4GznhQ0x9f9qRY%2FV9jC7TrYVOLXM%3D&st=2026-05-13T19%3A53%3A14Z&se=2026-05-13T23%3A58%3A14Z&sp=r
Duration:
T00H07M37S
Embed URL:
https://stream.cadmore.media/player/9040eb06-40c7-452f-b7f1-833ec3d62a63
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/9040eb06-40c7-452f-b7f1-833ec3d62a63/11. 25-29.mp4?sv=2019-02-02&sr=c&sig=UsaoW8XtJLqQuFfKlsRJ9PBDqMMxCf1c%2Fslm3IPBX1E%3D&st=2026-05-13T19%3A53%3A14Z&se=2026-05-13T21%3A58%3A14Z&sp=r
Upload Date:
2025-12-11T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
SPEAKER: Here, we'll be presenting
SPEAKER: an anterior lumbar interbody fusion complication case. A 57-year-old male with a past medical history of L5–S1 osteomyelitis, hypertension, diabetes, and end-stage renal disease was transferred from an outside hospital for evaluation of a possible spinal epidural abscess. The patient was being treated with IV antibiotics for left endophthalmitis. On exam, he was afebrile with low back tenderness and no other neurological abnormalities.
SPEAKER: On reviewing the preoperative images— we're looking at the x-ray of the lumbar spine in the neutral position and flexion-extension— we notice a destruction of the lumbar L5–S1 endplates. On reviewing the CT of the lumbar spine on sagittal and axial cuts, we notice intervertebral disc space loss and irregularities in the endplates, as well as a concern of a paraspinal fluid collection there.
SPEAKER: Based on the imaging findings, there was a concern of a possible epidural abscess as well. The other diagnostic considerations for this patient were comorbidities of hypertension, diabetes, and end-stage renal disease, and he was on hemodialysis. We also consulted the nephrology team and the infectious diseases team. We recommended for this patient an interior L5–S1 discectomy, debridement, and reconstruction with an iliac bone graft followed by a stage 2 posterior nonsegmented instrumented fusion at L5–S1 with pedicle screws.
SPEAKER: Our rationale was the severe back pain the patient had and the extensive destruction of his endplates and disc space, as well as the early spinal canal compromise. We discussed with the patient the risks of the surgical procedure, which included infection, bleeding, CSF leak, nerve injury, vascular injury, failed fusion, and chronic pain. We anticipated in this surgery that it would be hard to optimize the patient given all his comorbidities, and we anticipated if a vascular injury would occur intraoperatively, the exposure surgeon would be present to promptly manage the injury.
SPEAKER: Going through the case events, the patient was brought into the operating room where the exposure surgeon proceeded with the retroperitoneal approach. A lower transverse incision was made, and dissection continued until the iliac artery and lumbar spine were exposed. Meticulous hemostasis was achieved. The spine surgeon then performed the L5–S1 disc debridement, partial corpectomy, and fusion with iliac bone graft and additional autograft.
SPEAKER: Meticulous hemostasis was then reconfirmed by the exposure surgeon, and the surgical site was closed. Here we'll be showing an anterior lumbar interbody fusion exposure. Patient was positioned supine, and a lower transverse incision was made. Dissection was continued to expose down to the lumbar spine. Here is a figure showing the view with the iliac vessels, as well as the L5–S1 disc space and the median sacral artery and vein.
SPEAKER: Here are our retractors placed. A needle is placed in the L5–S1 disc space to localize. You can see the vessels on both sides pointed on with our suction. The vessels are going to be retracted. Here's a new figure after sacrificing the median sacral vein and artery. Here you can see after performing the discectomy and the empty disc space.
SPEAKER: And you can see the vessels on the right and the left. Once meticulous hemostasis was achieved, the peritoneum, fascia, and skin were closed and approximated. On postoperative day 1, the patient complained of dyspnea and mild incisional pain. On physical exam, the patient had left inguinal and flank area tenderness and fullness. No neurological abnormalities were noted.
SPEAKER: His hemoglobin and hematocrit were decreasing, and the patient was transfused with 2 units of blood. He continued to be hemodynamically unstable on postoperative day 2 with high suspicion for retroperitoneal hematoma, requiring transfusion of 3 more units of blood. On postoperative day 3, the patient stabilized, which enabled us to get a CT scan of his abdomen, showing a large left retroperitoneal hematoma.
SPEAKER: On postoperative day 4, the patient continued to be stable, and we proceeded with the staged posterior fusion. The patient tolerated the procedure well, and the rest of his hospital stay was uncomplicated. Here we can see on the CT of the abdomen the coronal and axial cuts, so we are able to illustrate the retroperitoneal hematoma on the left side. The hematoma is close to the left femoral nerve and lumbar plexus.
SPEAKER: If left lower extremity deficits, weakness, or sensory loss was endorsed, then further evaluation and intervention for possible nerve compromise would have begun. In this case, the patient did not endorse neurological abnormalities. Regarding the clinical outcomes, the high clinical suspicion and prompt management led to a quick patient stabilization. The patient received multiple blood transfusions and was discharged to a long-term rehab facility on postop day 11 from his ALIF.
SPEAKER: A follow-up visit at 8.5 weeks showed that the patient had made a significant clinical recovery. His abdomen was no longer tender and undescended. He was improving in his ability to ambulate, which he had much difficulty doing prior to surgery, leading to an improved outcome of the patient. Further analysis of the complication: to understand that there are opportunities to improve. Even if an experienced exposure surgeon performed the ALIF exposure, vascular injuries can still occur.
SPEAKER: Although intraoperatively there may be no signs of bleeding detected on inspection, if postoperatively a patient shows signs of hemodynamic instability, then a complication associated with an ALIF should be considered. The specific lesson in this case: although there were no signs of vascular injury prior to ALIF closure, a delayed vascular injury presented itself.
SPEAKER: Complications associated with vascular injuries should be highly considered in postoperative ALIF patients who demonstrate signs of clinical instability. Vascular injuries will most often be identified during removal of the retractable blades, although they may not immediately present themselves intraoperatively. Consider letting the wound rest for a few minutes after the retractors have been removed to observe any vascular injuries prior to closure.
SPEAKER: Here, we are demonstrating a figure of a theory of what might have happened to this patient, showing a vascular injury occurring in the left common iliac vein during an ALIF procedure. In patients with a high risk for developing postoperative vascular injuries, such as retroperitoneal hematomas, preoperative vascular assessment should be performed to determine feasibility of the operation and risk for vascular complications.
SPEAKER: High-risk patients include patients with coexisting peripheral vascular disease or severe atherosclerosis. Including an experienced exposure surgeon can mitigate the risk for vascular injury and development of postoperative hematoma. Close monitoring of postoperative hemoglobin level in serial abdominal exams can lead to early identification and management of postoperative hematomas.
SPEAKER:
SPEAKER:
SPEAKER: or invasively, including embolization and surgical intervention, depending on the etiology and clinical condition of the patient. Stable patients can be managed with supportive care, including close monitoring and pelvic binding. Unstable patients should be considered for surgical exploration with continued hemodynamic instability or a pulsatile expanding hematoma.
SPEAKER: All patients should have adequate resuscitation with blood products.
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