Hard to Diagnose and Potentially Fatal: Slow Aortic Erosion Post Spinal Fusion

• Published in: The Journal of emergency medicine 2014-03, Vol.46 (3), p.335-340
• Main Authors: Ip, Edmond W.K., MD, Bourke, Victor C., MD, Stacey, Michael C., MD, Begley, Patrick, MD, Ritter, Jens C., MD
• Format: Article
• Language: English
• Subjects: Aneurysm, False - diagnosis; Aneurysm, False - etiology; Aneurysm, False - surgery; aorta; Aorta - injuries; bronchial fistula; Chest Pain - etiology; Emergency; endovascular procedures; Hemoptysis - etiology; Humans; Male; Middle Aged; pseudoaneurysm; Spinal Fusion - adverse effects; spine surgery; Stents; thoracic aorta injury; Thoracic Vertebrae
• ISSN: 0736-4679; 2352-5029
• DOI: 10.1016/j.jemermed.2013.08.075

Abstract Background Delayed aortic injuries are a rare, but well-recognized complication of spinal surgery. They are a result of slow erosion of osteosynthesis material into the aorta. Although this is a life-threatening complication, patients might present years later with nonspecific symptoms. Objective A complex case of slow aortic injury after thoracic spinal surgery is presented, which highlights the challenges involved in diagnosis and treatment. Case Report A 62-year-old man had a T6 vertebrectomy and T5−7 anterior spinal fusion for multiple myeloma 5 years earlier. Two years postoperatively, the patient developed intermittent hemoptysis that triggered several presentations to the emergency department and consecutive hospital admissions during a 3-year period. All investigations, including endoscopy, bronchoscopy, and repeated chest computed tomography (CT) scans, were unremarkable. Eventually, the patient presented with frank hemoptysis associated with severe left-sided chest pain. Urgent CT angiography revealed a pseudoaneurysm measuring 34 × 20 mm at the level of the vertebrectomy. The patient underwent emergency surgery and an endoluminal stent graft was successfully placed. The patient remains well after 6 months. Conclusions The close proximity of the aorta and spine entertains the risk of aortic injury associated with vertebral osteosynthesis. Long-term complications of slow aortic erosion are extremely difficult to diagnose. The presented patient suffered from an undetected bronchio-aortic fistula with consecutive pseudoaneurysm formation and rupture. Awareness of slow aortic erosion is important for correct diagnostic pathways and subsequent early diagnosis to ensure a positive outcome for the patient.