CR3-188
Screw (in) the Aorta
1Russo G, 2Heng R
1Mayo Clinic College of Medicine and Science (Jacksonville) Program, Jacksonville, Florida, USA; 2 Mayo Clinic College of Medicine and Science (Jacksonville) Program, Jacksonville, FL, USA
Achondroplasia is the most common non-lethal skeletal dysplasia. Incidence is between 1 in 10,000 and 1 in 30,000. Achondroplasia, is caused by a mutation of FGF receptor-32. Orthopedic manifestations in the spine and the extremities. Thoracolumbar kyphosis is seen in most infants, typically resolves when child begins to walk. Anatomic anomalies of vertebral column place patient at risk for spinal stenosis. In pediatric population, symptomatic spinal stenosis occurs at all spinal levels due to abnormally narrow bone canal. Fusion procedures are recommended in patients with a large decompression overlying a thoracolumbar kyphosis to avoid progressive postoperative deformity.
An 11 yo F with PMH of achondroplasia, thoracolumbar kyphosis, spinal stenosis and genu varum is s/p T11-L4 fusion and instrumentation and L1-S1 decompression in 2015 at an outside facility, her family has since relocated. On CT she was found to have a screw within the aorta at the T12 level. The patient denied symptoms.
Patient pre-oxygenated, standard ASA monitors placed. General anesthesia induced via IV Propofol, Fentanyl, Rocuronium, lidocaine 2%. Airway secured via direct laryngoscopy with 5.5 ETT, right lung isolation via bronchial blocker, placement confirmed via FBO. Two large bore IV obtained (16g), radial arterial line, and internal jugular central line using ultrasound guidance. Anesthesia maintained with inhaled sevoflurane, ketamine infusion, boluses of fentanyl and neuromuscular block.
Once the surgeons obtained adequate exposure of the screw, it had gone through the posterior wall of the aorta into aorta creating a fistula tract to the spine. Heparin administered and ACT >200 achieved. Surgeons slowly removed the screw through the back incision and then as the screw was backed out of the aorta, the aortic side was ligated with a 0-silk tie and then a second 0- silk tie was used to ligate the fistulous tract. No evidence of bleeding and patient remained hemodynamically stable.
Patient received neuromuscular blockade reversal, long acting opioid narcotics titrated, extubated and taken to recovery. Patient did well and was discharged on POD #4.
Spinal screw migration and penetrate the aorta is rare, we approached this case similar to thoracoabdominal aortic aneurysm repair. During TAAA repair the heart is under hemodynamic stress by aortic cross clamp, fluid shifts, and blood loss5. Appropriate monitor placement for intraoperative management is essential, including: a line, central venous access, rapid infusion device, somatosensory-evoked potentials, motor evoked potentials, CSF drainage via spinal drain, cerebral oximetry. The use of a cross clamp was not determined until full surgical exposure at which time the surgeons proceeded without. Preoperative discussion with surgical team held, and decision to proceed without a spinal drain due to spinal hardware, SSEP/MEP not monitored due to surgeon preference. NIRS device over right flank to monitor trends and assess collateral circulation.
Baujat G, Legeai-Mallet L, Finidori G, Cormier-Daire V, Le Merrer M. Achondroplasia. Best Pract Res Clin Rheumatol 2008; 22(1): 3-18.
Shirley ED, Ain MC. Achondroplasia: manifestations and treatment. J Am Acad Orthop Surg 2009; 17(4): 231-41.
Top
