Neurological outcomes following iatrogenic vascular injury during posterior atlanto-axial instrumentation.
BACKGROUND
Iatrogenic vascular injury is a feared complication of posterior atlanto-axial instrumentation. A better understanding of clinical outcome and management options following this injury will allow surgeons to better care for these patients. The object of the study was to systematically review the neurologic outcomes after iatrogenic vascular injury during atlanto-axial posterior instrumentation.


METHODS
We performed a systematic review of the Medline database following PRISMA guidelines. In our analysis, we included any retrospective cohort studies, prospective cohort studies, case reports, cases series, or systematic reviews with patients who had undergone posterior atlanto-axial fusion via screw rod constructs (SRC) or transarticular screws (TAS) that reported a patient with an injury to an arterial vessel directly attributable to the surgical procedure.


RESULTS
Sixty cases of vascular injury were reported in 2078 (2.9%) patients over 27 publications. The average age for this patient population was 55.7+/-17.9. Vascular injury following posterior C1/2 instrumentation resulted in ipsilateral stroke in 10.0% (n=6/60) and non-persistent neurologic deficit in 6.7% (n=4/60) of cases with the deficit being permanent (not including death) in 1.7% (n=1/60) of cases. Four patients (6.7%) died. Arteriovenous fistula or pseudoaneurysm occurred in 8.3% (n=5/60) and 3.3% (n=2/60) of cases, respectively. Eight patients (13.3%) underwent endovascular repair of the injury with no permanent deficit.


CONCLUSIONS
Neurological morbidity after iatrogenic vascular injury during posterior C1/2 fixation is higher than previously reported in literature. Some patients may benefit from endovascular treatment. Surgeons should be aware of normal and anomalous vertebral artery anatomy to avoid this potentially catastrophic complication.
Department of Neurological Surgery, Mayo Clinic Florida, 4500 San Pablo Rd S, Jacksonville, FL 32224, USA.
Oluwaseun O
OO
Akinduro
Department of Neurological Surgery, Emory University School of Medicine, 1365 Clifton Road NE, Building B, Suite 2200, Atlanta, GA 30322, USA.
Griffin R
GR
Baum
Department of Neurological Surgery, Emory University School of Medicine, 1365 Clifton Road NE, Building B, Suite 2200, Atlanta, GA 30322, USA.
Brian M
BM
Howard
Department of Neurological Surgery, Emory University School of Medicine, Grady Memorial Hospital, 49 Jesse Hill Drive SE, Room 341, Atlanta GA 30303, USA.
Gustavo
G
Pradilla
Department of Neurological Surgery, Emory University School of Medicine, Grady Memorial Hospital, 49 Jesse Hill Drive SE, Room 341, Atlanta GA 30303, USA.
Jonathan A
JA
Grossberg
Emory Orthopedics and Spine Center, Emory University School of Medicine, 59 Executive Park South, Atlanta, GA, 30329 USA.
Gerald E
GE
Rodts
Department of Neurological Surgery, Emory University School of Medicine, Grady Memorial Hospital, 49 Jesse Hill Drive SE, Room 341, Atlanta GA 30303, USA. Electronic address: faiz.ahmad@emory.edu.
Faiz U
FU
Ahmad
D000328:Adult; D000368:Aged; D001268:Atlanto-Axial Joint / Q000601:surgery*; D006801:Humans; D007049:Iatrogenic Disease; D007431:Intraoperative Complications / Q000453:epidemiology / Q000209:etiology*; D008875:Middle Aged; D013123:Spinal Fusion / Q000009:adverse effects* / Q000706:statistics & numerical data; D057772:Vascular System Injuries / Q000453:epidemiology / Q000209:etiology*
Atlanto-axial injury; Atlanto-axial instrumented fusion; Atlas; Axis; C1; C2; Vascular injury