Endovascular management of iliac vessel injury complicating lumbar disc surgery: a case report and review of literature

Abstract

Background

Lumbar disc surgery is one of the most commonly performed spinal procedures and is generally considered safe. However, rare complications such as major vascular injury can be life-threatening and are often difficult to recognize intraoperatively. These injuries most commonly involve the iliac vessels because of their close anatomical relationship to the L4–L5 disc space. Early diagnosis is challenging, and delayed recognition is associated with significant morbidity and mortality. With advances in endovascular techniques, minimally invasive management has emerged as an effective alternative to open surgical repair. Reporting such cases remains important to improve awareness, highlight diagnostic pitfalls, and illustrate evolving management strategies.

Case presentation

A 32-year-old previously healthy female presented with right lower limb radiculopathy due to an L4–L5 disc prolapse. She underwent elective minimally invasive tubular L4–L5 discectomy. During surgery, unexpected bleeding from the disc space was noted but appeared controlled with local measures. In the immediate postoperative period, the patient developed hypotension, tachycardia, and altered consciousness, along with a significant drop in hemoglobin and rising serum lactate levels. Computed tomography angiography demonstrated a large left retroperitoneal hematoma with active contrast extravasation and non-opacification of the left common iliac artery, consistent with major arterial injury. Emergency angiography confirmed the diagnosis, and endovascular covered stent placement was performed, achieving immediate hemostasis. The postoperative course was complicated by hemorrhagic shock, coagulopathy, and transient neurological deficits related to mass effect from the retroperitoneal hematoma. With intensive care support, blood product transfusion, and multidisciplinary management, the patient gradually stabilized and recovered. She was discharged in stable condition with improving neurological function and ongoing outpatient follow-up.

Conclusions

Major vascular injury during lumbar disc surgery is rare but potentially fatal and may not be immediately evident during the procedure. Sudden postoperative hemodynamic instability should raise suspicion for vascular injury and prompt urgent imaging. Early computed tomography angiography and rapid endovascular intervention can be life-saving and may avoid the morbidity associated with open surgical repair. This case emphasizes the importance of early recognition, multidisciplinary collaboration, and the growing role of endovascular techniques in managing vascular complications of lumbar disc surgery.

Background

Lumbar disc surgery, performed through minimally invasive or open posterior approaches, is among the most frequently performed spinal procedures worldwide [1]. Although generally considered safe, rare but potentially life-threatening complications can occur, including disc space infection, visceral injury, and vascular trauma [1, 2]. Iatrogenic vascular injury is one of the most feared complications, with reported incidences ranging from 0.01% to 2.4% [2–4]. The common iliac arteries and veins are most frequently involved because of their close anatomical relationship to the anterior aspect of the lumbar spine [3, 4].

Clinical presentation is highly variable. Acute injuries may manifest intraoperatively with severe retroperitoneal hemorrhage, profound hypotension, and hemodynamic instability [1, 5]. In contrast, delayed presentations may occur weeks or even years later, most commonly as pseudoaneurysms or arteriovenous fistulas presenting with abdominal pain, lower limb swelling, or signs of high-output cardiac failure [6–8].

Earlier reports describe substantial mortality associated with vascular injury during lumbar disc surgery, with rates ranging from 16% to 61%, depending on the type of injury and the timing of recognition and intervention [4]. When the injury becomes clinically apparent after significant hemorrhage or delayed diagnosis, mortality as high as 40–100% has been reported, largely due to rapid retroperitoneal blood loss and failure to recognize the cause of postoperative deterioration [5]. Open surgical repair was traditionally the standard treatment [6]. However, since the first report of endovascular repair by Zajko et al. in 1995 [8], minimally invasive techniques—including covered stent placement and endovascular balloon occlusion—have increasingly been adopted, offering effective hemorrhage control with reduced physiologic stress and favorable outcomes [1, 2, 5], although open surgical repair remains essential in unstable patients or complex injuries.

Given the rarity but potentially fatal consequences of these injuries, continued reporting of individual cases remains important to improve awareness, highlight diagnostic pitfalls, and document evolving management strategies. We therefore present a case of vascular injury complicating lumbar disc surgery and review the literature to emphasize the importance of early recognition and the expanding role of endovascular management.

Case Report

A 32-year-old previously healthy female presented with right lower limb radiculopathy due to an L4–L5 disc prolapse. Neurological examination demonstrated a positive straight-leg raise and crossed straight-leg test without motor or sensory deficits. Preoperative hemoglobin was 8.6 g/dL, reflecting mild anemia. Given the patient’s young age, absence of comorbidities, and the low expected blood loss associated with lumbar microdiscectomy, surgery proceeded as planned, with further evaluation of anemia intended postoperatively.

She underwent elective minimally invasive L4–L5 lumbar discectomy under general anesthesia using the Wiltse paraspinal approach. After fluoroscopic confirmation of the operative level, a tubular retractor was positioned over the L4–L5 lamina–facet junction. Laminotomy and limited flavectomy were performed to expose the thecal sac and traversing L5 nerve root. The nerve root was mobilized and the herniated disc fragment removed using pituitary rongeurs and curettes, achieving adequate decompression. During removal of the disc fragment from the L4–L5 disc space, unexpected bleeding occurred, and intraoperative blood loss could not be accurately quantified. Hemostasis was attempted using local tamponade with hemostatic agents and packing within the disc space. The vascular surgery team was consulted intraoperatively and assisted in evaluating the operative field. As bleeding appeared controlled and no pulsatile hemorrhage was observed, major arterial injury was not suspected. The patient remained hemodynamically stable intraoperatively, and the wound was irrigated and closed. She was extubated and transferred to recovery in stable condition.

Approximately 10 h after surgery, the patient developed hypotension, tachycardia, and decreased level of consciousness. Laboratory testing demonstrated a drop in hemoglobin from 8.6 g/dL to 7.0 g/dL with rising lactate levels (2.7 to 6.4 mmol/L). Fluid resuscitation and 2 units of PRBC were initiated immediately by the Surgical Critical Care Unit (SCU) team, and the primary neurosurgical team was notified. Because of suspected ongoing internal bleeding, urgent CT angiography was obtained within 40 min and the vascular surgery team alerted. CT angiography demonstrated a large left retroperitoneal hematoma with active contrast extravasation and non-opacification of the left common iliac artery, consistent with acute vascular injury involving the proximal segment of the left common iliac artery (Fig. 1).

Fig. 1.

(A) CT angiographic image of the left common iliac artery. The Pre-intervention image demonstrates non-opacification of the left common iliac artery with active contrast extravasation into the retroperitoneum, associated with a large retroperitoneal hematoma. (B) Multiplanar reformatted (MPR) CT angiographic image demonstrating the left common iliac artery injury. This Pre-intervention image shows contrast extravasation from the left common iliac artery consistent with arterial tear

Following confirmation of vascular injury, the patient was intubated and transferred emergently to the interventional radiology suite for digital subtraction angiography and endovascular repair. The procedure was performed as an emergency intervention with the patient sedated, intubated, and monitored by the anesthesia team. Vascular access was obtained via the right common femoral artery using a vascular access needle followed by insertion of a 5-French sheath. A KMP diagnostic catheter was advanced over a Terumo hydrophilic guidewire, and an aortogram demonstrated preserved flow to the right common iliac artery with absent flow and active contrast extravasation from the proximal third of the left common iliac artery. The iliac vessels appeared markedly narrowed, likely reflecting vasoconstriction secondary to hemorrhagic shock.

Retrograde access through the left common femoral artery was then obtained and another 5-French sheath inserted. Multiple attempts to cross the disrupted segment of the left common iliac artery using a hydrophilic guidewire were unsuccessful, with the guidewire repeatedly entering the retroperitoneal hematoma rather than remaining intraluminal. During this stage of the procedure the patient’s blood pressure became unrecordable. Temporary hemorrhage control was achieved by advancing an Atlas Gold balloon (14 × 14 mm) through the right femoral access and inflating it within the distal abdominal aorta, providing temporary occlusion and allowing stabilization of blood pressure.

Further attempts at antegrade wire passage remained unsuccessful. A 25-mm loop snare introduced through the left femoral access was then used to capture the antegrade guidewire advanced from the right femoral access, creating a through-and-through guidewire configuration and enabling successful re-entry into the true lumen of the left common iliac artery. Following restoration of intraluminal access, two overlapping balloon-expandable covered stents (Viabahn VBX, Gore; 8 × 39 mm) were deployed across the injured segment of the left common iliac artery. Completion angiography demonstrated restoration of distal arterial flow with complete exclusion of the arterial injury and no further contrast extravasation (Fig. 2). At the conclusion of the procedure, the left femoral access sheath was removed with manual compression, while the right femoral sheath was temporarily maintained for intensive care monitoring and subsequently removed. Total procedure time was approximately 95 min. The patient tolerated the procedure well, and vasopressor requirements decreased by the end of the intervention.

Fig. 2.

Stepwise endovascular management of left common iliac artery injury. (A) Temporary aortic occlusion balloon introduced via the right common femoral artery (CFA) to control active hemorrhage, with minimal residual extravasation from collateral back-bleeding at the left common iliac artery (CIA). (B) Initial attempt to pass a guidewire from the right CIA to the left CIA was unsuccessful, with the wire exiting through the arterial tear into the retroperitoneal hematoma cavity. (C) Snaring of the guidewire within the hematoma cavity. (D) Successful wire crossover achieved across the arterial defect, re-entering the true lumen from the right to the left CFA. (E) Deployment of a covered stent across the arterial tear. (F) Completion angiography demonstrating complete sealing of the arterial injury with no residual contrast extravasation

Postoperatively, the patient was admitted to the Surgical Intensive Care Unit (SICU) for management of hemorrhagic shock. Resuscitation included a total of 6 units of packed red blood cells (PRBC), 6 units of fresh frozen plasma (FFP), and 6 units of platelets. Two units of PRBC were administered during initial resuscitation, followed by an additional four units transfused over the subsequent four days to maintain hemoglobin levels around 9–10 g/dL during recovery. FFP and platelet transfusions were administered during the first 48 h to correct coagulopathy. Attempts at weaning from mechanical ventilation were initiated 48 h after surgery, and the patient was successfully extubated on postoperative day 4 without complications. Post-intervention CT angiography demonstrated correct stent positioning with restoration of arterial flow and no evidence of ongoing bleeding (Fig. 3). The patient was monitored for abdominal compartment syndrome; however, no clinical or hemodynamic evidence of this complication developed. The retroperitoneal hematoma was managed conservatively and gradually decreased in size, with repeat CT imaging three days later confirming stable stent position without recurrent hemorrhage.

Fig. 3.

(A) CT angiographic image of the left common iliac artery. This follow-up CT angiogram after covered stent deployment shows restoration of arterial opacification with no contrast extravasation. (B) Multiplanar reformatted (MPR) CT angiographic image demonstrating a post-intervention image of the left common iliac artery injury following a covered stent deployment showing no contrast extravasation

Laboratory abnormalities consistent with transient ischemic injury, including elevations in AST, ALT, LDH, and creatine kinase, gradually normalized. Neurologically, the patient demonstrated progressive improvement: left ankle dorsiflexion strength improved to 4+/5, while left hip flexion remained reduced at 2/5, likely due to temporary compression of the lumbosacral plexus by the retroperitoneal hematoma. After recovery of platelet counts, aspirin therapy was initiated and continued at discharge. The patient remained in the SICU for 7 days and was discharged after 18 days. At discharge she was hemodynamically stable with improving neurological function. At 3-month follow-up, she remained clinically stable with continued neurological improvement and no evidence of recurrent bleeding or stent-related complications. This case illustrates the potential for delayed presentation of major vascular injury following lumbar disc surgery and emphasizes the importance of prompt imaging and timely management.

Discussion

Incidence and epidemiology

Major vascular injury during lumbar disc surgery is rare but potentially life-threatening. Symptomatic ventral perforation of the anterior annulus fibrosus and anterior longitudinal ligament—resulting in injury to the aorta, inferior vena cava, or iliac vessels—has been estimated to occur in approximately 1.6–6 per 10,000 procedures, with some series reporting rates as high as 17 per 10,000 cases [4]. Earlier reports estimated the incidence of major vascular injury during disc surgery at approximately 1–5 per 10,000 procedures [5, 9]. The true incidence is likely underestimated because vascular injuries may initially remain clinically silent or present with delayed symptoms, leading to under-recognition and misdiagnosis [4, 5]. It has been suggested that vascular injury may occur in up to 2.4% of lumbar laminectomies, likely reflecting minor or subclinical events that remain undetected intraoperatively [10].

The first vascular complication associated with lumbar disc surgery was reported by Linton and White in 1945, describing an arteriovenous fistula between the right iliac artery and the inferior vena cava [5, 11]. In a review of 99 cases, Papadoulas et al. reported that arteriovenous fistulas accounted for 67% of injuries, followed by acute vascular lacerations in 30% and isolated pseudoaneurysms in 3% [3]. These injuries occur most frequently at the L4–L5 and L5–S1 levels, where major vessels lie immediately anterior to the intervertebral disc space [4, 11]. The common iliac arteries are most commonly affected, with reported distributions of approximately 43% involving the right common iliac artery and 29% involving the left [5]. Despite their rarity, these complications carry substantial mortality, with historical series reporting rates of 15–61%, and up to 40–100% in cases presenting with clinically apparent vascular injury and severe hemorrhage [4, 5].

Anatomical basis of vascular injury

Vascular injuries during lumbar disc surgery most commonly occur at the L4–L5 intervertebral level, although procedures are frequently performed at L3–L4, L4–L5, and L5–S1 disc spaces [12, 13]. These levels correspond to the anatomical location of major retroperitoneal vessels. The aortic bifurcation and inferior vena cava confluence typically occur at or just below the L4 vertebral level, and at the L4–L5 disc space the vascular structures are separated from the spine only by the anterior longitudinal ligament [12]. Consequently, a broad vascular bed lies immediately anterior to the intervertebral disc, placing adjacent vessels at risk during discectomy. Because of this relationship, the common iliac arteries and veins are most frequently involved in vascular complications of lumbar disc surgery. Knowledge of the operative level and its relationship to surrounding vascular structures may help anticipate the likely site of injury when unexpected bleeding occurs intraoperatively [14]. The close anatomical relationship between the lumbosacral spine and the iliac vessels, which underlies the risk of vascular injury during lumbar disc surgery, is illustrated in Fig. 4 [11].

Fig. 4.

Illustration demonstrating the anatomical relationship between the lumbosacral spine and the iliac vessels. This illustration is original and was created by the authors for this manuscript

Mechanisms and Risk Factors

Vascular injury during lumbar disc surgery is not necessarily indicative of poor operative technique and may occur even in experienced hands. The most common mechanism is deep penetration of surgical instruments beyond the anterior longitudinal ligament during removal of disc material, particularly with instruments such as the pituitary rongeur, allowing entry into the retroperitoneal space and injury to adjacent vessels [4, 15, 16]. The risk is greatest at the L4–L5 and L5–S1 levels, where the common iliac vessels, inferior vena cava, and their branches lie in close proximity to the operative field [3, 4, 6].

Several additional factors may increase susceptibility to vascular injury. Prior lumbar disc or abdominal surgery may create adhesions between retroperitoneal vessels and the vertebral bodies, while degeneration or disruption of the anterior annulus fibrosus and anterior longitudinal ligament, as well as peri-discal fibrosis, may weaken the natural barrier separating the disc space from adjacent vascular structures [11, 12, 17–19]. In advanced disc disease, deeper instrument penetration may be required, further increasing the risk of vascular injury [16, 20]. Improper prone positioning may also reduce the distance between the disc space and adjacent vessels, while vertebral anomalies such as hypertrophic osteophytes can distort local anatomy [14, 21–23].

Recognition of vascular injury may be delayed because the anterior annulus fibrosus and anterior longitudinal ligament can exert a self-sealing effect, with bleeding confined to the retroperitoneal compartment rather than the operative field [3, 9]. Importantly, modern techniques such as micro-endoscopic discectomy and carbon dioxide laser-assisted discectomy do not eliminate the risk of vascular injury [24, 25].

Clinical presentation

The clinical manifestations of vascular injury during lumbar disc surgery depend on the vessel involved, the extent of vascular disruption, and the timing of recognition [3]. Acute arterial injury most commonly presents intraoperatively with sudden hemodynamic instability, including refractory hypotension, tachycardia, wide pulse pressure, declining hematocrit, and diminished or absent lower limb pulses, reflecting rapid blood loss from major arterial injury [3, 9]. Visible bleeding in the operative field may be absent because hemorrhage is frequently confined to the retroperitoneal space, occurring in fewer than half of reported cases [26]. Recognition may therefore be delayed by the tamponade effect of a developing retroperitoneal hematoma and the prone surgical position, which can temporarily limit hemorrhage during the procedure [27]. Consequently, hemodynamic deterioration may only become evident after repositioning the patient or during the early postoperative period.

During postoperative recovery, patients may present with abdominal pain, abdominal distension, nausea, vomiting, dizziness, or symptoms of lower extremity ischemia due to ongoing internal bleeding [3, 28]. Venous injuries may be particularly difficult to recognize because bleeding may be limited or may cease spontaneously, resulting in transient hypotension that may be attributed to other perioperative factors [23]. Some vascular injuries remain unrecognized initially and present later as arteriovenous fistulas or pseudoaneurysms [29]. Arteriovenous fistulas occur when both arterial and venous walls are lacerated, allowing arterial blood to decompress into the venous system, often resulting in minimal external bleeding and absence of early hypotension [30, 31]. These lesions may remain clinically silent for prolonged periods before presenting with symptoms [32]. In contrast, pseudoaneurysms arise from localized arterial wall disruption or partial vascular injury and may later manifest with hemorrhage or thrombosis [15].

Diagnosis

Prompt recognition of vascular injury during lumbar disc surgery is essential, as delayed diagnosis may lead to rapid hemodynamic deterioration and increased mortality [9, 33]. Intraoperative suspicion should arise when unexplained hypotension, tachycardia, falling hematocrit, or signs of lower limb ischemia occur during or immediately after discectomy. Knowledge of the operative level, instrument angulation, and side of disc evacuation may help identify the likely injured vessel [14]. However, early recognition may be difficult because young and otherwise healthy patients can initially remain hemodynamically stable despite significant blood loss [5]. When unexpected bleeding from the disc space occurs intraoperatively, even if initially controlled, early postoperative CT angiography may be considered to exclude occult vascular injury. Diagnosis is further complicated by the tendency for hemorrhage to remain confined to the retroperitoneal space rather than appearing in the operative field. The anterior annulus fibrosus and anterior longitudinal ligament may exert a partial sealing effect that limits visible bleeding [4]. Consequently, a high index of suspicion is required when unexplained postoperative hemodynamic instability develops.

Some vascular injuries may initially remain clinically silent. Small venous injuries may produce minimal bleeding, and arteriovenous fistulas may generate little operative hemorrhage because arterial blood decompresses directly into the venous circulation [23, 30, 31]. As a result, diagnosis may be delayed until later manifestations occur. Late vascular complications may present days to years after surgery with abdominal bruit, high-output cardiac failure, limb edema, or a pulsatile abdominal mass [3, 28].

Imaging plays a central role in confirming the diagnosis. In hemodynamically stable patients, computed tomography (CT) is a useful first-line investigation because it can identify retroperitoneal hematoma, localize vascular injury, detect active bleeding, and help differentiate arterial from venous injury [13]. When CT is not immediately available, abdominal ultrasonography may help detect intra-abdominal or retroperitoneal fluid. Angiography provides definitive vascular characterization and enables immediate endovascular intervention when required [13, 34, 35]. When major vascular injury is strongly suspected, a low threshold for urgent surgical exploration remains appropriate, as delayed intervention may be life-threatening [4].

Management

Management of vascular injury during spinal surgery depends on the type of vascular injury, timing of recognition, and the patient’s hemodynamic status. Although vascular injuries occur in fewer than 1% of spinal procedures, they represent a potentially severe complication because of the risk of massive hemorrhage and high mortality [2, 3]. Early recognition is critical. Vascular injury should be suspected when sudden arterial bleeding occurs from the disc space during discectomy, particularly when accompanied by hypotension and tachycardia [3, 36]. Immediate communication with the anesthesia team is essential to initiate aggressive fluid resuscitation and hemodynamic stabilization [1, 37]. Temporary local hemostatic measures, including absorbable gelatin sponge or oxidized cellulose, may help control bleeding and provide time for definitive management [37]. However, bleeding may not always be evident intraoperatively, contributing to delayed recognition [3].

Open surgical management

In patients with acute arterial or venous laceration accompanied by hemodynamic instability, immediate open surgical repair remains the primary life-saving intervention. When major vascular injury is suspected intraoperatively, the spinal procedure should be terminated, the incision closed, and the patient rapidly repositioned to the supine position for resuscitation and surgical exploration [3, 37]. Because unstable patients frequently cannot undergo diagnostic imaging, urgent exploratory laparotomy or thoracotomy may be required to identify and control the bleeding vessel [3, 6]. Open repair allows direct visualization and definitive management of the injured vessel, which may involve primary repair, patch angioplasty, or interposition grafting depending on the extent and location of the defect [15, 38]. Historically, open surgical repair has been the standard treatment for major vascular injuries related to spinal surgery. However, this approach carries substantial morbidity, with complication rates reported as high as 50% in some series [39]. Potential complications include significant blood loss, spinal cord ischemia resulting from aortic cross-clamping, and postoperative pulmonary complications [40, 41]. Consequently, open repair is generally reserved for patients with hemodynamic instability, massive intraoperative hemorrhage, associated intra-abdominal injuries, or complex vascular injuries involving major visceral branches.

Endovascular treatment

Advances in interventional radiology have significantly expanded the role of endovascular therapy in the management of vascular injuries associated with spinal surgery. In hemodynamically stable patients, minimally invasive approaches such as covered stent placement, balloon occlusion, or embolization can effectively control bleeding and restore vascular integrity [5, 42].

Endovascular stent graft repair offers several advantages compared with open surgery, including reduced blood loss, avoidance of thoracotomy or laparotomy, shorter anesthesia duration, and lower perioperative morbidity. An additional benefit is avoidance of aortic cross-clamping, which preserves distal spinal cord perfusion and may reduce the risk of spinal cord ischemia [39]. Evidence from thoracic endovascular aortic repair studies suggests that spinal cord ischemia occurs less frequently following endovascular repair than after open thoracic aortic surgery, with reported rates of approximately 3% compared with up to 21% after open repair [43, 44]. Imaging plays an important role in guiding endovascular management. Contrast-enhanced CT angiography can localize vascular injury and define its relationship to spinal instrumentation [3]. Angiography provides definitive vascular characterization and allows simultaneous therapeutic intervention. When imaging is limited by metallic artifact from spinal hardware, intravascular ultrasound may assist in evaluating the relationship between instrumentation and the vessel wall. In cases where vascular injury results from pedicle screws or other spinal hardware, endovascular stent graft placement may be performed before removal of the offending implant to prevent hemorrhage [39, 45].

Despite these advantages, the long-term durability of endovascular repair continues to be evaluated. Complications such as endoleak, graft migration, and the need for secondary intervention have been reported [46]. In addition, endovascular treatment may be technically challenging when injuries occur near major visceral branches such as the celiac axis or superior mesenteric artery, situations in which open repair may still be required.

Management of delayed complications

Not all vascular injuries are recognized during the initial procedure. Some remain undiagnosed and later present as delayed complications, most commonly pseudoaneurysms or arteriovenous fistulas [38, 47]. These lesions may develop from weeks to months after surgery, often due to chronic mechanical irritation of the vessel wall by spinal instrumentation, eventually leading to vessel erosion or pseudoaneurysm formation [48, 49]. In many cases, patients remain asymptomatic, and the lesion is detected incidentally during follow-up imaging.

When symptoms occur, patients may present with findings such as pulsatile abdominal mass, abdominal bruit, lower limb edema or claudication, or manifestations of high-output cardiac failure. Diagnosis is typically established using CT angiography, Doppler ultrasonography, or conventional angiography. Management is usually performed electively once the lesion is identified, with treatment options including open vascular reconstruction or endovascular repair depending on anatomical characteristics. Increasingly, endovascular stent grafting has become the preferred approach because of its minimally invasive nature and favorable recovery profile [5]. Another important complication following major vascular injury is abdominal compartment syndrome, particularly when large retroperitoneal hematomas increase intra-abdominal pressure [50]. Clinical manifestations may include respiratory compromise, elevated central venous pressure, and renal dysfunction. Management may require decompressive laparotomy with temporary abdominal closure in addition to intensive supportive care.

Prevention of vascular injury

Prevention of vascular injury during lumbar disc surgery relies primarily on meticulous surgical technique and awareness of potential risk factors. Surgeons should maintain strict control over the depth and direction of instruments during disc removal and avoid excessive anterior penetration beyond the intervertebral disc space. Gentle and controlled disc extraction is recommended, as forceful curettage or aggressive use of pituitary rongeurs may increase the risk of perforating the anterior longitudinal ligament and injuring adjacent vessels [3].

Certain patient- and procedure-related factors may increase susceptibility to vascular injury and should prompt additional intraoperative caution. These include prior lumbar disc surgery, retroperitoneal inflammatory processes that may produce adhesions between the disc and adjacent vessels, and anatomical variations in vascular position [2, 10, 36]. Recognition of these factors during preoperative assessment may help anticipate technical difficulty and guide a more cautious operative strategy. During surgery, unexplained hemodynamic instability should always raise suspicion of possible vascular injury, even in the absence of visible bleeding within the operative field. Awareness of these warning signs and prompt evaluation are essential to minimize morbidity and mortality associated with these rare but life-threatening complications [3, 4].

Review of literature

A summary of selected published cases is presented in Table 1, illustrating the range of injured vessels, clinical presentations, management strategies, and outcomes reported in the literature.

Table 1.

Reported cases of vascular injury associated with lumbar disc surgery in the literature, including patient characteristics, operative level, injured vessel, clinical presentation, diagnostic modality, management strategy, and clinical outcome

Author	Patient Demographics	Spinal Level / Procedure	Injured Vessel	Clinical Presentation	Diagnostic Modality	Management	Outcome
Papadoulas et al. [3]	55-year-old male	L4–L5 and L5–S1 double lumbar discectomy	Left common iliac artery (posterior wall laceration)	Pallor, tachycardia, hypotension, abdominal distension shortly after surgery	Emergency exploratory laparotomy showing retroperitoneal hematoma	Evacuation of hematoma and excision with PTFE interposition graft	Alive and well at 6 years
Skippage et al. [5]	51-year-old female	L4/5 and L5/S1 disc decompression with right L5 foraminotomy and L4–L5 Wallis™ interspinous stabilization	Right common iliac artery pseudoaneurysm	Worsening back and abdominal pain with postoperative hypotension and hemodynamic instability within 24 h	Emergency CT scan followed by diagnostic aortography	Endovascular thrombin injection into pseudoaneurysm with covered stent graft placement	Clinically well at 6 months
Busardò et al. [51]	52-year-old male	L4–L5 lumbar discectomy	Left common iliac artery and left common iliac vein	Early postoperative hypotension, chest pain, oxygen desaturation, and hemoglobin drop	CT angiography	Emergency laparotomy with evacuation of retroperitoneal hematoma, venous repair, and arterial ligation	Fatal (hemorrhagic shock)
Keskin et al. [37] 3 Cases	20-year-old female	Lumbar discectomy	Left common iliac artery and bilateral common iliac veins	Early postoperative hypotension and tachycardia	Emergency exploratory laparotomy	Primary repair of all vascular injuries; massive transfusion	Fatal (DIC related to massive transfusion)
	32-year-old male	Lumbar discectomy	Left common iliac artery and vein	Delayed postoperative dizziness, weakness, hypotension	Abdominal ultrasound, CT angiography, and emergency laparotomy	Left iliac vein ligation and primary arterial repair	Survived; pulmonary embolism treated; well at 5 years
	45-year-old female	Lumbar discectomy	Left common iliac artery	Acute limb ischemia with pallor, coldness, and absent distal pulses	Clinical assessment with immediate surgical exploration	PTFE graft interposition	Survived; discharged on postoperative day 12; well at 4 years
Jin et al. [52]	72-year-old female	Redo L4–L5 microdiscectomy (posterior microscopic approach)	Proximal left common iliac artery	Sudden intraoperative bleeding from disc space with severe hypotension	Diagnostic angiography	Endovascular stent graft to left common iliac artery followed by additional kissing stent placement for right iliac stenosis	Full recovery
Singh et al. [53]	39-year-old female	L4–L5 lumbar microdiscectomy	Inferior vena cava at junction of common iliac veins	Sudden intraoperative hypotension without pulsatile bleeding	Abdominal ultrasound, abdominal tap, and emergency laparotomy	Partial IVC repair with ligation and end-to-end anastomosis using gonadal vessels; massive transfusion	Survived; discharged stable at 14 days
Sahinoglu et al. [54]	50-year-old female	Right L4–L5 microdiscectomy (posterior approach)	Left common iliac artery	Sudden intraoperative arterial bleeding followed by hypotension and abdominal distension	Abdominal ultrasound, contrast CT, and CT angiography	Endovascular stenting of the left common iliac artery followed by laparotomy with Bogota bag closure and percutaneous hematoma drainage with tPA	Survived; discharged POD 27; later elective fascial repair
Dösoğlu et al. [36]	52-year-old male	Recurrent L4–L5 microdiscectomy	Left external iliac artery (posterior wall tear)	Sudden intraoperative hypotension, abdominal distension, and absent left femoral pulse	Immediate exploratory laparotomy	Emergency laparotomy with subdiaphragmatic aortic cross-clamping and saphenous vein patch repair	Survived; normal neurological and vascular status at 2-year follow-up
Erkut et al. [55] 2 Cases	51-year-old male	L4–L5 lumbar discectomy	Left common iliac artery (posterior wall) and left common iliac vein (anterolateral wall)	Sudden copious intraoperative bleeding with hypotension	Emergency exploratory laparotomy	Evacuation of retroperitoneal hematoma and primary repair of arterial and venous lacerations	Uneventful recovery; discharged in good condition at 7 days
	50-year-old female	L4–L5 lumbar discectomy	Left common iliac vein, right common iliac artery, and inferior vena cava	Sudden intraoperative hypotension	Emergency exploratory laparotomy	Primary repair of iliac artery, iliac vein, and inferior vena cava	Uneventful recovery; discharged neurologically intact at 5 days
Huttman et al. [56]	35-year-old female	Right L4–L5 microdiscectomy	Right common iliac artery and vein AV fistula with pseudoaneurysm	Delayed dyspnea and tachycardia due to pulmonary embolism followed by abdominal pain and limb swelling	CT angiography and abdominopelvic CT	Endovascular right common iliac artery stent placement with anticoagulation	Asymptomatic at 4-month follow-up; stent patent
Schneider et al. [57]	61-year-old female	L4–L5 discectomy and anterior spinal fusion via minimally invasive left lateral retroperitoneal approach	Left common iliac vein adjacent to the iliocaval confluence	Persistent significant intraoperative venous bleeding during disc removal despite prolonged packing	Intraoperative left iliac venography followed by repeat bilateral iliac venography	Endovascular repair with simultaneous bilateral kissing stent grafts across the iliocaval confluence; postoperative anticoagulation	Survived; discharged on postoperative day 8; retroperitoneal hematoma without active extravasation on postoperative day 10; clinically patent veins at postoperative day 70
Chao et al. [58]	44-year-old male	L4–L5 right hemilaminectomy and microdiscectomy	Right common iliac artery pseudoaneurysm with rupture	Delayed postoperative abdominal pain with rebound tenderness, hypotension, and tachycardia on postoperative day 3	CT abdomen followed by angiography demonstrating pseudoaneurysm and contrast leakage	Emergency open surgical repair of right common iliac artery	Survived; discharged 15 days postoperatively
Yi et al. [59]	57-year-old male	Left L4–L5 microscopic lumbar discectomy	Right external iliac artery	Sudden massive intraoperative bleeding with hypotension, tachycardia, and abdominal distension	Intraoperative clinical suspicion followed by exploratory laparotomy	Emergency laparotomy with repair of right external iliac artery under partial cardiopulmonary bypass	Survived; extubated on postoperative day 4 and discharged neurologically intact after 4 weeks
Altun et al. [60]	56-year-old male	L3–L4 and L4–L5 discectomy with posterior stabilization	Abdominal aorta (penetration by retained scalpel tip with pseudoaneurysm formation)	Initial asymptomatic postoperative course followed by hemoglobin drop without hemodynamic instability	CT abdomen demonstrating foreign body partially penetrating the abdominal aorta with retroperitoneal hematoma	Open surgical repair with infrarenal aortic clamping and Dacron interposition graft	Survived; discharged in good condition on postoperative day 8
Olcay et al. [61]	50-year-old female	Minimally invasive microdiscectomy with L4 hemilaminectomy, L4–L5 discectomy and foraminectomy	Left common iliac artery (perforation)	Sudden severe intraoperative intervertebral bleeding with hemodynamic compromise	CT angiography followed by diagnostic angiography	Endovascular balloon tamponade of the perforation using repeated balloon inflations	Survived; hemodynamically stable and discharged without complications after 3 days
Shih et al. [62]	47-year-old female	Lumbar discectomy at L4–L5	Left internal iliac artery (posterior wall laceration)	Sudden intraoperative hypotension with minimal operative field bleeding, acute anemia, and abdominal tenderness	Abdominal ultrasound followed by emergency exploratory laparotomy revealing retroperitoneal hematoma	Emergency laparotomy with primary suture repair of the left internal iliac artery	Survived; discharged after 10 days without complications; well at 6-month follow-up
Jeon et al. [25]	42-year-old female	Right L5–S1 microdiscectomy using microsurgical CO₂ laser	Right internal iliac artery (5-mm perforation near common iliac bifurcation)	Sudden intraoperative arterial bleeding followed by hypotension, tachycardia, and progressive abdominal distention	Emergency exploratory laparotomy revealing retroperitoneal hematoma and iliac artery defect	Direct arterial repair with 5 − 0 Prolene after hematoma evacuation and resuscitation	Survived; postoperative pulmonary edema and ileus but discharged without sequelae after 10 days
Jung et al. [63] 7 cases	67-year-old male	Conventional L4–L5 discectomy	Left common iliac artery	Sudden intraoperative hypotension suggesting major arterial injury	Intraoperative clinical recognition and surgical exploration	Open surgical repair	Survived; no long-term sequelae
	40-year-old male	Conventional L4–L5 discectomy	Right common iliac artery	Sudden intraoperative hypotension	Clinical recognition during surgery	Open surgical repair	Survived; no long-term sequelae
	56-year-old female	Endoscopic L5–S1 discectomy	Left common iliac artery	Sudden intraoperative hypotension	Intraoperative diagnosis	Open surgical repair	Survived; no long-term sequelae
	75-year-old female	Endoscopic L4–L5 discectomy	Right common iliac artery (arteriovenous fistula)	Delayed presentation (60 months) with vascular complication	Imaging evaluation confirming AV fistula	Endovascular covered stent graft	Survived; no long-term sequelae
	70-year-old female	Endoscopic L4–L5 discectomy	Left common iliac artery (pseudoaneurysm)	Delayed presentation (23 months)	Imaging diagnosis of pseudoaneurysm	Endovascular covered stent graft	Survived; no long-term sequelae
	34-year-old male	Conventional L5–S1 discectomy	Left common iliac artery	Immediate postoperative vascular injury	Clinical suspicion and imaging	Open surgical repair with graft interposition	Survived; no long-term sequelae
	27-year-old male	Conventional L4–L5 discectomy	Right common iliac artery (pseudoaneurysm)	Delayed presentation (2 weeks)	Imaging diagnosis	Endovascular covered stent graft	Survived; no long-term sequelae
Bierdrager et al. [42]	57-year-old female	L4–L5 lumbar discectomy	Right iliac artery bifurcation	Postoperative hypotension, tachycardia, severe right lower abdominal pain, abdominal distension, anemia	Ultrasound showing intra-abdominal fluid followed by diagnostic angiography demonstrating contrast extravasation and pelvic hematoma	Endovascular repair with coil embolization of the internal iliac artery followed by placement of a covered stent graft	Successful exclusion of iliac artery laceration; patent stent on follow-up CT; patient recovered and discharged in good condition
van Zitteren et al. [64] 2 cases	54-year-old male	L5–S1 partial hemilaminectomy and discectomy	Branch of right internal iliac artery	Acute intraoperative hemorrhage from disc space with hypotension and drop in hemoglobin	Intraoperative angiography	Endovascular balloon occlusion of right common iliac artery followed by coil embolization of internal iliac artery branch	Hemostasis achieved; patient discharged in good condition after 9 days; recovered well at 6-month follow-up
	51-year-old female	L4–L5 and L5–S1 bilateral laminectomy and discectomy with planned fusion	Right common iliac artery perforation	Sudden intraoperative hypotension (BP 40/20 mm Hg) with suspected arterial injury	Intraoperative angiography	Endovascular aortic balloon occlusion followed by placement of an 8-mm ePTFE-covered stent	Successful sealing of perforation; discharged in good condition; later underwent spinal surgery without complications
Hasan et al. [65]	46-year-old male	L5–S1 tubular lumbar microdiscectomy	Common iliac Artery and Vein - Pseudoaneurysm	Severe burning pain in left lower limb 2 h postoperatively with absent distal pulses (dorsalis pedis, posterior tibial, popliteal)	CT angiography showing pseudoaneurysm of common iliac vessels	Emergency retroperitoneal exploration with synthetic graft repair and distal embolectomy	Full recovery with restored distal pulses; asymptomatic at 1-year follow-up

The cases summarized in Table 1 represent a total of 31 individual patients derived from multiple reports and case series. The common iliac vessels—particularly the common iliac artery—are the most frequently involved structures, accounting for approximately 70% of reported injuries. Less commonly affected vessels include the inferior vena cava (approximately 10%), as well as the external and internal iliac arteries (each accounting for approximately 5–7%), and rarely the abdominal aorta (approximately 3%). Most injuries occur during procedures performed at the L4–L5 level, accounting for approximately 74% of reported cases, reflecting the anatomical proximity between the lower lumbar intervertebral disc spaces and the iliac vascular bifurcation. Clinical presentation varies according to the type of vascular injury and the timing of recognition. In approximately 68% of reported patients, injury becomes apparent intraoperatively or in the immediate postoperative period, typically presenting with sudden hypotension, tachycardia, abdominal distension, or a rapid decline in hemoglobin levels. In contrast, delayed presentations occur in approximately 32% of patients and are usually related to pseudoaneurysm formation or development of arteriovenous fistulas. These delayed complications may manifest days to months after surgery with abdominal pain, limb ischemia, lower extremity edema, or cardiopulmonary symptoms.

Management strategies have evolved considerably over time. Open surgical repair remains the most commonly employed approach, accounting for approximately 58% of reported cases, particularly in patients with hemodynamic instability or complex vascular injury. Endovascular techniques, including covered stent placement, balloon occlusion, and embolization, were utilized in approximately 42% of cases and have increasingly been reported in recent literature, reflecting a growing shift toward minimally invasive vascular control. Overall outcomes were favorable when vascular injury was recognized promptly and treated appropriately; however, mortality occurred in approximately 6.5% of reported patients, underscoring the continued risk associated with delayed diagnosis and uncontrolled hemorrhage.

The present case reflects patterns described in the literature, with injury to the common iliac vessels during lumbar disc surgery due to their close anatomical proximity to the lower lumbar disc spaces. Unlike many reported cases presenting with immediate life-threatening hemorrhage, our patient initially remained hemodynamically stable with limited intraoperative bleeding, followed by delayed hemorrhage from the left common iliac artery confirmed on CT angiography. Endovascular stent placement achieved rapid hemorrhage control and avoided exploratory laparotomy, highlighting the advantages of minimally invasive vascular management. Despite successful repair, the patient developed hemorrhagic shock and a large retroperitoneal hematoma causing transient neurological deficits from sacral plexus compression, illustrating the potential morbidity associated with these injuries. This case underscores the importance of early clinical suspicion, prompt vascular imaging, and timely access to vascular or endovascular expertise when unexplained hemodynamic instability occurs after lumbar disc surgery.

Conclusion

Vascular injury during lumbar disc surgery, although rare, remains a potentially fatal complication. In this case, subtle intraoperative disc-space bleeding preceded delayed hemodynamic collapse, highlighting how such injuries may initially be masked. The progression to hemorrhagic shock underscores the importance of maintaining a high index of suspicion when unexplained postoperative instability occurs. Early CT angiography enabled rapid diagnosis, and endovascular stent grafting provided effective hemorrhage control without the need for laparotomy. This case reinforces the critical role of early recognition, timely imaging, and multidisciplinary coordination, and supports the growing role of endovascular techniques in appropriately selected patients.

Author contributions

MM was involved in data collection, interpretation of clinical and radiological findings, and was responsible for drafting, revising, and submitting the manuscript; RJ and SK contributed to vascular surgical planning, operative management, and critical manuscript revision; RB was responsible for neurosurgical management and clinical decision-making; FT performed the interventional radiology procedures and contributed to imaging interpretation and technical content; LA assisted with data collection and organization of clinical information. All authors read and approved of the final manuscript.

Funding

The authors received no financial support for the research, authorship, or publication of this article.

Data availability

All data generated or analyzed during this study are included in this published article. No additional datasets were generated.

Declarations

Ethics approval and consent to participate

Ethical approval was not required for this case report in accordance with local institutional policies. Written informed consent was obtained from the patient for participation and use of clinical data.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

Competing interests

The authors declare no competing interests.