gms | German Medical Science

One of the most life-threatening complications during standard microsurgical lumbar discectomy procedure is abdominal vessel injury due to ventral anulus perforation. Although described as rare, several reports on its occurrence exist. Quoted mortality is very high, reaching up to 70 %.

We analyzed all events of ventral perforation of the anulus fibrosus that occurred during standard microdiscectomies between January 2000 and October 2003 at our institution. Attention was paid to characteristics such as disc level and laterality, surgical experience, symptom evolvement after vessel injury, postcomplication handling and anesthesiological issues.

Six perforations were noted in the period under investigation, which corresponds to 0,18 % of all spine surgeries for degenerative disease. In all cases, surgeons were relatively inexperienced having performed less than 100 prior discectomies, two of the five surgeons had less than 50 prior discectomies. All perforations occurred at the level L 4/5. In 4 cases, blunt perforation was recognised without injury, as excluded by immediate contrast CT scanning of the abdomen. Three of these four perforations were noted by an assisting experienced surgeon. Two patients (0,06 % of all disc operations) however, had a vessel injury requiring emergency laparatomy and vessel reconstruction. One of these patients died on the fifth postoperative day due to an acute septic shock after being stabilised initially (overall mortality 16,7%). Anesthesiological treatment had to aim at prevention of circulatory breakdown and at emergency mass transfusion.

Life-threatening ventral anulus perforation during discectomy is not totally preventable.Typical disc location is at the level L 4/5, perforations are clearly correlated with the (in-) experience of the surgeon. Although rare, loss of patients must be feared in each case. Perforations can be missed intraoperatively and can occur without injuries to the abdominal contents in a considerable number. Close cooperation with the anesthesiologist and his understanding for the potential complication is indispensable. In case of vessel injury emergency laparatomy is mandatory to save the life of the patient.