Thoracic aortic injury as a complication of spinal surgery: A new case and systematic review (1991-2024)

Abstract

Background

Iatrogenic thoracic aortic injury (TAI) is a rare but well-recognized complication of spine surgery, lacking standardized treatment guidelines due to its rarity and variability of manifestations.

Methods

We present a new case of TAI successfully managed with endovascular repair and systematically reviewed 52 articles (1991-2024) reporting 64 cases, including demographics, surgical indications, injury patterns, and treatments.

Results

A 53-year-old man with a T7 fracture underwent posterior spinal instrumentation and developed chest pain due to a combination of impingement and screw penetration into the thoracic aorta and was treated with thoracic endovascular aortic repair (TEVAR) and removal of pedicle screws. The review (n = 64; mean age, 50 years; 48% male and 48% female) identified vertebral fractures (42.2%), spinal deformities (31.3%), and posterior approaches (70%) as predominant risk factors. Injuries included thoracic aorta penetration (53%), impingement (21.9%), combined injuries (21.9%), and other rare events (3.2%), with median diagnosis at 31 to 34 months. Treatments comprised TEVAR (51.6%), open repair (31.3%), and conservative management (17.2%). Posterior approaches significantly increased injury risk (P < .001).

Conclusions

TAI often presents late, requiring surveillance. TEVAR is effective, although open repair remains vital in select cases. This review informs management strategies for this rare complication.

Iatrogenic injuries to major vessels during or following spine surgery are exceptionally rare, with an estimated incidence of less than 0.01%.^1,2 Injuries specifically affecting the thoracic aorta are even less common.³ Such complications most commonly originate from the mispositioning of pedicle screws (PSs) during spinal fixation, a technique routinely employed to stabilize thoracic spinal conditions, encompassing fractures, deformities, or neoplastic processes. The anatomical juxtaposition of the thoracic aorta to the vertebral column—frequently separated by mere millimeters—substantially heightens the susceptibility to mechanical trauma arising from screw malpositioning or postoperative migration.4, 5, 6 In contrast to the comparatively well-documented vascular injuries associated with lumbar spinal procedures, involving the abdominal aorta or iliac vessels,7, 8, 9, 10, 11, 12, 13, 14, 15 thoracic-specific injuries remain sparsely chronicled, predominantly emerging in the literature as isolated case reports. This limited documentation obfuscates their true prevalence and impedes the formulation of evidence-based management paradigms. Clinical detection of thoracic aortic injury (TAI) is remarkably challenging, particularly in cases involving late manifestations. The identification of TAI presents formidable diagnostic challenges, particularly in instances of delayed clinical manifestation. The interplay of factors—such as the methodological approach to spinal instrumentation, the underlying mechanism of injury (eg, impingement, penetration, or laceration), the temporal emergence of symptoms, and the heterogeneity of atypical clinical signs—complicates the patient’s presentation and hinders injury recognition. In chronic phases, the diagnostic effort is even more arduous due to the nonspecific nature of the symptoms, which may remain latent for months or years following the initial intervention. Although acute perforation of the aorta, accompanied by hemorrhage or overt clinical signs, necessitates urgent surgical intervention, the optimal management of impingement without vascular breach remains contentious and unresolved. This study presents a novel case of TAI successfully managed through endovascular repair, accompanied by a systematic review of 64 cases (including one institutional case and 63 published cases)16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40^,41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67 to analyze demographics, injury patterns, and therapeutic strategies. Our aims are to delineate risk factors, diagnostic timelines, and treatment options, offering evidence-based recommendations for vascular and spinal surgeons.

Case report

A 53-year-old male patient presented to the emergency department following a motor vehicle accident, exhibiting a constellation of injuries, including an unstable fracture of the T7 vertebra and paraplegia secondary to spinal cord compression. Urgent posterior spinal instrumentation was performed using fluoroscopy-guided freehand placement of two stabilizing rods and eight PSs distributed across the T6 to T9 vertebral levels (two screws per level) (Fig 1). The procedure transpired without intraoperative complications. Within hours post-surgery, the patient manifested moderate-to-severe thoracic pain, initially presumed to stem from operative trauma and concomitant neurologic insult. The persistence of symptoms despite robust analgesic therapy prompted a computed tomography evaluation on postoperative day 14, which revealed impingement of the left T6 PS (Fig 2) and penetration of the left T7 PS through the posterior wall of the thoracic aorta, in the absence of hematoma, pseudoaneurysm formation, or pleural effusion (Fig 3, Fig 4, Fig 5). Subsequent engagement of the vascular and endovascular surgical teams led to the prioritization of thoracic endovascular aortic repair (TEVAR) as the therapeutic modality of choice (Fig 6, Fig 7, Fig 8). A single 28 × 28 × 100 mm GORE C-TAG thoracic stent was meticulously deployed to encompass both sites of screw-related injury, followed by the uneventful extraction of the offending screws. The intervention culminated in the complete amelioration of the patient’s thoracic pain, permitting discharge 48 hours thereafter, contingent upon an angiotomographic assessment that demonstrated no evidence of vascular extravasation (Figs 9 and 10). The patient gave full permission for the publication of his case.

Fig 1.

Postoperative thoracic spine computed tomography X-ray scan demonstrating the standard posterior fusion construct (T6-T9). Notice bilateral pedicle screws (PSs) (2 per level) with dual titanium rods (white arrows).

Fig 2.

(A) Computed tomography angiogram in the axial plane at the T6 vertebral level reveals the left T6 pedicle screw (PS) projecting anterior to the vertebral body, with cortical violation and direct abutment of the screw tip against the posteromedial aspect of the descending aorta (white arrow); (B) Axial images confirm left T7 PS violation including: lateral cortical breach (white arrow) and posteromedial aortic wall penetration (red arrow).

Fig 3.

Preoperative computed tomography angiography (sagittal reconstruction), T6-T7 levels demonstrating left T6 pedicle screw (PS) indenting the posterior aortic wall (white arrow), with maintained wall integrity and left T7 PS exhibiting full-thickness aortic wall penetration (red arrow), with intraluminal position confirmed on multiplanar reconstruction.

Fig 4.

Digital subtraction aortography shows successful endovascular repair: implanted thoracic stent graft completely covering the impingement and penetration sites at the T6-T7 levels, and no evidence of contrast extravasation or endoleak.

Fig 5.

Digital subtraction aortography prior to pedicle screws (PSs) extraction: detail of the proximity of the tip of the T6 pedicle screw (T6-PS) with the outer wall of the endoprosthesis (white arrows) and extrinsic compression by the T7 pedicle pedicle screw (T7-PS) with preserved graft integrity causing focal deformation of the endoprosthesis (red arrow). There was no associated contrast extravasation or flow limitation.

Fig 6.

Postoperative computed tomography angiography (axial and sagittal reconstructions) 2 shows successful endovascular repair with intact thoracic stent graft, fully 3 covering the T6-T7 penetration sites, and the path of the extracted pedicle screws (PSs) (red arrow).

Fig 7.

Postoperative computed tomography angiography (sagittal reconstruction) shows successful endovascular repair with intact thoracic stent graft, fully covering the T6-T7 penetration sites, and extracted pedicle screws (PSs).

Fig 8.

Among the indications for spinal surgery, spinal fractures and deformities were the most common.

Fig 9.

Levels of approach in spinal fusion: most cases of vascular injury occurred in fusion of the thoracolumbar segment of the spine, followed by surgical approach of only the thoracic segment of the spine.

Fig 10.

Aortic injuries occurred most frequently at the T6 and T11 levels, followed by T10 and T5. More than half of the injuries occurred at these four levels.

Literature review

This systematic review was conducted in strict accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. An exhaustive literature search was undertaken across PubMed, Google Scholar, and the Cochrane Library, spanning the period from November 1, 2024, to February 20, 2025, utilizing the Boolean search terms: “thoracic aorta” AND “injury” AND “spine surgery” AND (“screw penetration” OR “screw malposition”). Inclusion was restricted to English-language studies elucidating thoracic aortic injuries resulting from spinal surgery, with a particular focus on therapeutic interventions. Studies were excluded if they pertained to nonthoracic vascular injuries, thoracic aortic injuries unrelated to spinal procedures, or stent graft deployments absent confirmed injury. Data concerning injury typology, surgical methodology, clinical manifestations, and management approaches were meticulously extracted by two independent reviewers. Statistical analyses, encompassing descriptive metrics (percentages, medians, interquartile ranges [IQRs]) and inferential tests (χ², Mann-Whitney U), were executed using SPSS version 28.0, with a threshold for statistical significance established at P < .05.

Results

From a corpus of 52 articles published between 1991 and 2024, data were collated on 64 patients (63 derived from the literature, 1 from an institutional record): 31 males (48.4%), 31 females (48.4%), and two of unspecified gender (3.2%), with a mean age of 50 years (range, 15-77 years). Age remained unreported in four instances (6.2%). A comprehensive summary of clinical characteristics is provided in the Table. Surgical indications included vertebral fractures (42.2%), spinal deformities (31.2%), infectious etiologies (9.4%), neoplastic disorders (10.9%), and rare pathologies (4.7%, such as eosinophilic granuloma, n = 1); one case (1.6%) lacked documentation (Fig 11). Procedures included thoracolumbar fusion in 34 patients (53%), thoracic-only instrumentation in 26 (41%), and cervicothoracic or thoracosacral interventions in four (6%). Posterior surgical approaches predominated, accounting for 70% of injuries (45/64), in contrast to 30% from anterior approaches (19/64), a disparity substantiated by statistical significance (χ² = 12.25; P < .001). TAIs were localized to a single spinal fusion level in 38 cases (59%), spanned two distinct levels in 11 cases (17%), and were unspecified in 15 cases (24%). The T6 vertebral level demonstrated the greatest propensity for injury (25%), followed by T11 (12.5%), T5 (9.3%), and T10 again (9.3%), with further details delineated. Injuries manifested asymptomatically in 46.9% of cases (30/64) and symptomatically in 53.1% (34/64). In the group of 34 symptomatic patients, clinical manifestations included persistent or emerging pain (67.6%; 23/34), hemorrhage (17.6%; 6/34), or neurologic impairments (5.9%, 2/34) or systemic manifestations (5.9%, 2/34). Median diagnostic intervals were 33.8 months (IQR, 15.2-52.4 months) for asymptomatic cases and 30.6 months (IQR, 12.8-60.2 months) for symptomatic cases, with no significant divergence (U = 432, P = .72). Injury classifications encompassed isolated penetration in 53% (34/64), impingement in 21.9% (14/64), and composite injuries (eg, penetration concurrent with pseudoaneurysms) in 21.9% (14/64), alongside infrequent occurrences of laceration and dissection (1.6% each). Therapeutic strategies included TEVAR in 51.6% of cases (33/64; 30 standalone, 3 with adjunctive measures), open surgical repair in 31.3% (20/64), and conservative management in 17.2% (11/64). Reintervention was necessitated in two TEVAR cases, though this did not achieve statistical significance relative to open repair (P = .09, Fisher’s exact test).

Table.

Characteristics and technical details of cases collected from the literature

Author year	Age, years/sex	Indication	Procedure/approach	Time to presentation after SF and reason	TAI and repair	Spinal repair
Sokolić et al,16 1991	16/female	Scoliosis	T5-L1 SF/anterior	4-month follow-up/pain	T5 PS penetration + false aneurysm/primary suture repair	PS removal/no revision
Matsuzaki et al,17 1993	52/male	Kyphoscoliosis	T6-T9 SF/anterior	6-month follow-up/incidental CT finding	T6 PS penetration/aortic resection and tube graft replacement	PS burring
Choi et al,18 2001	50/male	Kyphoscoliosis	TL-SF/posterior	11-month follow-up/pain	T6 PS penetration + false aneurysm/aortic resection and tube graft replacement	PS removal/no revision
Ohnishi et al,19 2001	53/male	T11 fracture	T10-T12 SF + T11 corpectomy/anterior	20-month follow-up/pain	PS penetration + false aneurysm/false aneurysm resection + primary patch repair	PS removal/no revision
Minor et al,20 2004	77/male	Scoliosis	TL-SF/posterior	30-day follow-up/incidental CT finding	T5 PS penetration/TEVAR	PS removal/no revision
Jarrahnejad et al,21 2005	48/female	Fracture	T11-L3 SF/posterior	30-day follow-up/fatigue and weakness	T12 e L1 aorta impingement/TEVAR	PS removal/no revision
Been et al,22 2006	40/male	Scoliosis	T10-L3 SF/anterior	20-year follow-up/dyspnea	PS penetration/TEVAR	Spinal instrumentation left in situ
Wegener et al,23 2008	69/female	T9 metastasis	T7-T11 SF + tumor debulking + bilateral laminectomy/posterior	1-year follow-up/pain	T11 PS penetration/primary suture repair	PS burring
Kakkos et al,24 2008	55/male 51/male	a)Osteomyelitis b)Tuberculous spondylodiscitis	a)T6-T10 SF + debridement/anterior b)T11-L2 SF/anterior	a)11-month follow-up/pain b)13-month follow-up/incidental CT finding	a)T6 and T10 PS penetration + false aneurysm/primary suture repair b)T11 PS penetration + false aneurysm/primary suture repair	a)PS burring b)PS burring
Lavigne et al,25 2009	15/female	Scoliosis	T10-L3 SF/anterior	7-year follow-up/pain	T10 PS penetration/primary suture repair	PS removal/no revision
Zietek et al,26 2009	NK	T4 fracture	T2-T5 SF/anterior	Immediate PO period/incidental CT finding	PS aorta impingement/TEVAR	PS removal/replacement
Hu et al,27 2009	52/male	Pyogenic spondylitis	T2-T5 SF/posterior	8-month follow-up/incidental CT finding	T5 PS penetration/TEVAR	PS removal/no revision
Watanabe et al,28 2010	57/female	T12 fracture	T10-L2 SF/posterior	30-day follow-up/incidental CT finding	T10 PS penetration/primary suture repair	PS removal/no revision
Kokotsakis et al,29 2010	57/female	NK	T3-T7 SF/posterior	30-day follow-up/hypovolemic shock + massive hemothorax	T4 PS penetration/TEVAR	PS removal/no revision
Lopera et al,30 2010	60/female 55/male 52/female	a)Fracture b)Fracture c)Fracture	a)TL-SF/posterior b)TL-SF/posterior c)TL-SF/posterior	a)12-month follow-up/pain + massive hemothorax b)3-month follow-up/pain c)3-month follow-up/incidental CT finding	a)PS penetration/no aortic repair b)PS aorta impingement/TEVAR c)PS aorta impingement/no aortic repair	a)Spinal instrumentation. Left in situ (died on the way to the OR) b)PS removal/no revision c)Spinal instrumentation left in situ
Tschoeke et al,31 2011	64/female	T7 fracture	T5-T9 SF/posterior	2-year follow-up/pain	T5 and T6 PS penetration/primary suture repair	PS removal/replacement
Clarke et al,32 2011	71/male	T8 fracture	T6-T10 SF/posterior	6-month follow-up/incidental CT finding	T6 PS penetration/TEVAR	PS removal/replacement
Jim et al,33 2011	53/male	Kyphosis	C7-T3 SF/posterior	Immediate PO period/massive bleeding	Dissection of the left side of the T8 vertebral/TEVAR	Spinal instrumentation left in situ
Bavare et al,34 2011	45/female	T7-T8 herniation	T-SF + T7-T8 corpectomy -anterior	Immediate PO period/massive bleeding + recurrent bleeding 5-Month follow-up/Hemoptysis	PS penetration/evacuation of a large clot without exploring the aorta + primary suture repair + TEVAR + Aortic Ressection and Tube Graft Replacement	PS removal/no revision
Martín-Pedrosa et al,35 2012	61/female	Kyphosis	T6-L5 SF/posterior	Immediate PO period/motor deficit	T6 PS penetration/TEVAR	PS removal/no revision
Colvard et al,36 2012	68/female	T7-T8 myelopathy	TL-SF/anterior	3-year follow-up/incidental CT finding	T7 PS penetration/TEVAR	PS removal/no revision
Loh et al,37 2012	18/male 21/male 77/female	a)Fracture b)Scoliosis c)Sarcoma	a)TL-SF/posterior b)TL-SF/posterior c)TL-SF/posterior	a)4-month follow-up/pain b)8-month follow-up/pain c)6-year follow-up/pain	a)PS penetration/TEVAR b)PS penetration/TEVAR c)PS penetration/TEVAR	a)PS removal/no revision b)PS removal/no revision c)PS removal/no revision
Freyrie et al,38 2013	55/male	T7 fracture	T3-T9 SF/posterior	6-month follow-up/pain	T4 screw penetration/primary suture repair	PS removal/no revision
Carmignani et al,39 2013	39/male	T12 fracture	TL-SF/posterior	Immediate PO period/incidental CT finding	02 PS penetration/TEVAR	PS removal/no revision
Sandhu et al,40 2013	39/male 43/male	a)T4-T5 fracture b)Cervical and thoracic fractures	a)TL-SF/anterior b)C3-T7 SF/anterior	a)2-year follow-up/pain b)10-year follow-up/incidental CT finding	a)T7 PS penetration + false aneurysm/aortic tube graft replacement b)T4 PS penetration + false aneurysm/aortic tube graft replacement	a)PS removal/replacement b)PS removal/no revision
Tong et al,41 2013	24/female	L1 fracture	T11-L2 SF/posterior	17-month follow-up/incidental CT finding	T11 PS penetration/TEVAR	PS removal/replacement
Decker et al,42 2013	33/female	C5-C7 and T4-T10 fractures	T2-T10 SF + T6 laminectomy/posterior	30-month follow-up/incidental CT finding	PS aorta impingement/no aortic repair	PS removal/no revision
Akinrinlola et al,43 2013	37/male	T7-T8 abscess	T6-T9 SF + T7-T8 colpectomy/anterior	Immediate PO period/motor deficit	T6 PS penetration/TEVAR	PS removal/no revision
Fouquet et al,44 2013	18/female	Kyphoscoliosis	TL-SF/anterior	20-month follow-up/pain	T6 PS penetration/primary suture repair	PS removal/no revision
Fukuda et al,45 2013	72/female	Thoracic herniation	T11-T12 SF/anterior	7-year follow-up/pain	PS penetration/aortic tube graft replacement	PS removal/no revision
Potter et al,46 2013	20/male	T7 osteoblastoma	T6-T8 SF/posterior	5-year follow-up/pain	T6 PS penetration/aortography control after PS removal/no aortic repair	PS removal/no revision
Pillai et al,47 2014	36/male	Scoliosis	T1-T11 SF/posterior	6-year follow-up/incidental CT finding	T11 PS penetration + aortic dissection/aortic tube graft replacement	PS burring
Pesenti et al,48 2014	76/female	Kyphoscoliosis	T5-L4 SF/posterior	Immediate PO period/incidental CT finding	T7 PS penetration/TEVAR	PS removal/replacement
Ip et al,49 2014	62/male	Multiple myeloma	T5-T7 SF + T6 vertebrectomy/anterior	2-year follow-up/pain + hemoptysis	T6 PS penetration + false aneurysm/TEVAR	Spinal instrumentation left in situ
Claiborne et al,50 2015	65/female	Scoliosis	T2-S1 SF/posterior	15-month follow-up/incidental CT findings	T3 PS penetration/TEVAR	PS removal/replacement
Lagios et al,51 2015	22/female	Scoliosis	T10-L4 SF/posterior	6-year follow-up/incidental CT finding	T10 PS penetration/left intercostal artery embolization + TEVAR	PS removal/no revision
Sevuk et al,52 2016	51/female	T6-T7 fracture	T3-T4 SF/T8-T9 SF/posterior	5-year follow-up/pain	T8 PS penetration and T9 PS aorta impingement/primary suture repair	PS removal/replacement
Zerati et al,53 2017	69/female	Multiple myeloma with spinal instability	T4-T7 SF/anterior	7-year follow-up/incidental CT finding	PS penetration/TEVAR	Spinal instrumentation left in situ
Martin et al,54 2018	72/female	T11-T12 acute discitis	T8-L3 SF/posterior	15-day follow-up/incidental CT finding	T8 PS penetration/TEVAR	PS removal/no revision
Kassé et al,55 2018	48/female	T7-T8 fracture	T5-T10 SF/posterior	NK; incidental MRI findings	T8 and T9 PS aorta impingement/no aortic repair	PS removal/no revision
Schermann et al,56 2019	65/female	T7-T8 osteomyelitis	T5-T6 SF/T9-T10 SF/posterior	3-year follow-up/incidental CT finding	T6 and T9 PS penetration/no aortic repair	Spinal instrumentation left in situ. No operative intervention. Asymptomatic on a 3-year follow-up
Valič et al,57 2020	18/female 17/male	a)Scoliosis b)Scoliosis	a)T1-T10 SF/posterior b)T4-L4 SF/posterior	a)9-year follow-up/CT incidental finding b)NK/CT incidental finding	a)T9 PS aorta impingement/no aortic repair b)T9 PS aorta impingement/no aortic repair	a)PS removal/no revision b)PS removal/no revision
Liu et al,58 2020	21/male	T11-L2 fracture	T11-L2 SF/posterior	2-month follow-up/incidental CT finding	T12 and L1 PS penetration + false aneurysm/aortic tube graft replacement	PS burring
Al-Rumaih et al,59 2020	26/male	T3-T4 fracture	T3-T8 SF/posterior	30-day follow-up/toe gangrene	T6 and T8 PS aorta impingement/aortography without contrast extravasation/no aortic repair	PS removal/no revision
Kayaci et al,60 2020	58/male 46/female 47/female	a)T12 fracture b)L2 fracture c)T12 fracture	a)T10-L1 SF/posterior b)T12-L4 SF/posterior c)T11-L1/posterior	a)Immediate PO period/incidental CT findings b)Immediate PO period/incidental CT finding and 2nd PO day/aortography c)Immediate PO period/incidental CT and MRI findings	a)T10 and T11 PS aorta impingement/TEVAR b)T12 PS aorta impingement/aortography without contrast extravasation/no aortic repair c)T11 PS aorta impingement/CT angiography without contrast extravasation/no aortic repair	a)PS removal/replacement b)PS removal/replacement c)PS removal/no revision
Egea-Gàmez et al,61 2020	57/male	Scoliosis	T10-T11 SF + curettage/anterior	11-month follow-up/hemoptysis	T11 PS penetration + false aneurysm/TEVAR/end-to-end suture of the endograft stent	PS removal/no revision
Başak et al,62 2022	19/male	Scoliosis	T3-T8 SF/Posterior	Immediate PO Period/Hemothorax	T4 PS Aorta Impingement/Aortic Tube Graft Replacement	PS Removal/No Revision
Aganesov et al,63 2022	55/male NK/female NK/female	a)T7-T8 fracture b)T8 fracture c)T6 fracture	a)T-SF/posterior b)T6-T10 SF/posterior c)T4-T7 SF/posterior	a)NK/incidental CT finding b)1-year follow-up/pain c)6-month follow-up/incidental CT finding	a)T6 PS aorta impingement/TEVAR b)T6 PS penetration + intramural hematoma/TEVAR c)T5 PS penetration + intramural hematoma/TEVAR	a)PS removal/replacement b)PS removal/no revision c)PS removal/replacement
Tharp et al,64 2022	36/female	Scoliosis	T4-L3/posterior	10-month follow-up/pain	T5 and T6 PS penetration/TEVAR	PS removal/no revision
Levy et al,65 2023	25/female	Scoliosis	T1-S1 SF/posterior	6-year follow-up/incidental CT finding	T12 PS penetration/primary suture repair	PS removal/no revision
Xia et al,66 2023	63/male	T11 metastasis	T9-L2 SF/posterior	Immediate PO period/massive bleeding	Attempted separation of the aorta from the T11 surface + aortic laceration/TEVAR (via popliteal artery)	Spinal reconstruction was then completed
Zhou et al,67 2024	51/male	T9 eosinophilic granuloma	TL-SF/anterior	6-month follow-up/pain	PS penetration and false aneurysm/TEVAR	Spinal instrumentation left in situ
Borges et al, 2025	53/male	T7 fracture	T6-T9 SF/posterior	15-day follow-up/pain	T6 aorta impingement and T7 PS penetration/TEVAR	PS removal/no revision

CT, Cmputed tomography; MRI, magnetic resonance imaging; NK, not known; PO, postoperative; PS, pedicle screw; SF, spinal fusion; T, thoracic; TAI, thoracic aortic injury; TEVAR, thoracic endovascular aortic repair; TL, Thoracolumbar.

Fig 11.

Clinical manifestations at the time of the diagnosis of thoracic aortic injury.

Discussion

To our knowledge, this analysis of 64 cases represents the most extensive documented series of TAIs resulting from spinal procedures. Iatrogenic TAI following spinal surgery constitutes a rare yet profoundly serious complication, often attributable to PS malpositioning. The present cohort exhibits a demographically equitable distribution (48.4% male; 48.4% female; mean age, 50 years). The main indications for surgery included vertebral fractures (42.2%) and spinal deformities (31.3%), suggesting that urgent interventions and complex corrective maneuvers for spinal deformities may predispose patients to a high incidence of vascular complications. Within this series, 19 patients (30%) incurred vascular injuries during anterior spinal instrumentation, whereas 45 (70%) sustained such injuries via posterior approaches, the latter demonstrating a statistically significant greater risk (P < .001). This observation challenges the prevailing literature, which primarily links aortic injuries to anterior spinal fusion techniques. Notably, our review identified that 70% of thoracic aortic lesions were associated with posterior approaches, suggesting a need to reassess current assumptions.68, 69, 70, 71, 72, 73 This finding indicates that unique anatomical considerations within the thoracic cavity may increase the propensity for TAIs during posterior procedures. Clinical manifestations varied considerably: 46.9% of cases were asymptomatic and detected serendipitously, whereas 53.1% presented symptoms, most commonly pain (67.6%). Diagnostic latency, with median intervals of 31 to 34 months, exhibited no significant intergroup disparity (P = .72), highlighting the covert progression characteristic of TAIs. Early diagnosis (within 30 days) was established in 19 patients, of whom nine manifested clinical symptoms and 10 were identified through routine postoperative imaging. Of the 43 cases diagnosed beyond 30 days, 25 were symptomatic, with pain predominating (88%; 22/25); the remaining 18 were uncovered incidentally on subsequent imaging, with three lacking precise temporal documentation. These data underscore the imperative for routine postoperative imaging, as reliance on pain alone proves insufficiently specific. Associated TAIs can be addressed using open techniques (primary repair, patch angioplasty, tube graft interposition) or endovascular approaches.⁶⁰ The choice of modality depends on the size, location, and depth of the aortic defect, balancing the risk of uncontrolled bleeding against the morbidity associated with aortic cross-clamping. In our cohort, therapeutic treatment was predominantly administered through TEVAR (51.6%), underscoring its efficacy as a minimally invasive technique. However, open repair (31.3%) remains crucial in specific clinical scenarios, depending on the surgical team’s experience, the available repair options at the facility, and the location and extent of the defect.⁵² Conservative approaches (17.2%) proved efficacious in cases of minimal impingement, as evidenced by four instances resolved solely through screw revision. Our institutional case exemplifies the merits of expeditious intervention with TEVAR and screw extraction, circumventing complications attendant upon delayed repairs, such as pseudoaneurysm development or hemorrhage. Limitations of this investigation include biases inherent to retrospective analysis, incomplete datasets (eg, 23.4% unspecified injury levels), and the scarcity of TAI, which impedes comprehensive subgroup scrutiny. Future research endeavors should focus on developing predictive risk models and establishing standardized surveillance regimens. In summary, TAI necessitates acute clinical awareness, proactive diagnostic imaging, and bespoke therapeutic strategies, with TEVAR emerging as a cornerstone of contemporary management.

Conclusions

This systematic review, comprising an analysis of 64 cases (including a novel unreported institutional case), elucidates the exceptional rarity and multifaceted complexity of TAIs arising as a sequela of spinal surgery. Our findings delineate a statistically significant association between TAIs with posterior operative approaches (70%, P < .001), and increased risks of these injuries in the treatment of vertebral fractures (42.2%) and spinal deformities (31.3%). The mean latency in diagnosis, ranging from 31 to 34 months and spanning both asymptomatic and symptomatic manifestations (P = .72), exemplifies the covert and insidious progression of TAIs. Such evidence emphatically advocates for the institution of stringent postoperative surveillance protocols, incorporating diagnostic imaging, irrespective of symptomatic status. Therapeutic strategies have undergone a discernible evolution, with TEVAR ascending to prominence as the preeminent modality (51.6%), as exemplified by our institutional case of efficacious endovascular intervention and screw removal. However, open surgical repair (31.3%) remains indispensable for select injury profiles. The paucity of documented cases precludes a robust comparative analysis of endovascular vs open repair in the specific context of aortic injuries secondary to posterior spinal surgery. Nonetheless, extrapolation from the broader corpus of literature on TEVAR and open thoracic aneurysm repair suggests that TEVAR confers diminished rates of morbidity and mortality relative to its open counterpart.74, 75, 76 Meanwhile, conservative management, applied in 17.2% of cases in our cohort, has shown viability for minimal impingement, indicating a spectrum of therapeutic approaches adjusted to the injury’s severity. The question of whether to remove a screw positioned close to a vessel or viscera in an asymptomatic patient remains under discussion. These insights compel a heightened state of awareness among practitioners of spinal and vascular surgery, particularly given the catastrophic potential of such complications. Proactive postoperative oversight, exemplified by periodic computed tomography imaging, is warranted to prevent diagnostic procrastination, most notably in the aftermath of posterior thoracolumbar interventions. Nonetheless, the heterogeneity of injury patterns and clinical presentations necessitates individualized treatment decisions. Future academic efforts should focus on refining risk stratification paradigms, corroborating the posterior approach as a predisposing factor for TAI (a divergence from antecedent literature observed in our cohort), and promulgating rigorous postoperative follow-up regimens. By synthesizing the most extensive cohort assembled to date, this research provides a fundamental framework for improving clinical outcomes at the confluence of spine surgery and TAI.

Author contributions

Conception and design: MB, AG, CF

Analysis and interpretation: MB

Data collection: MB, AG, CF

Writing the article: MB, AG, CF

Critical revision of the article: MB, AG, CF

Final approval of the article: MB, AG, CF

Statistical analysis: MB

Obtained funding: Not applicable

Overall responsibility: MB

Funding

None.

Disclosures

None.