Novel posterior technique to temporize life-threatening hemorrhage after great vessel laceration during posterior osteotomy

Purpose: Great vessel injury during posterior 3-column osteotomy is rare, but potentially fatal. Literature review revealed limited data guiding spine surgeons during this major catastrophe. In this study our aim was first, to present our case of mortality; second, to discuss a novel technique that can be performed to temporize hemorrhage in a life-threatening situation where an iatrogenic great vessel injury occurs and hemodynamic stability cannot be achieved through usual means of hemostasis; third, a cadaveric study to determine if this novel technique is feasible. Methods: Three fresh cadavers including thoracic, lumbar, and pelvis were used. A thoraco-abdominal approach was used to access great vessels at the level of L3. The aorta and vena cava were identified and tagged. The cadavers were turned prone; a pedicle subtraction osteotomy was performed at the level of L3. A novel posterior peri-vertebral approach was used to reach the great vessels. The aorta and vena cava were occluded digitally with this approach and success confirmed visually through the thoraco-abdominal incision. Timing of the procedure and structures at risk were recorded. Results: In all three cadavers, we were able to successfully occlude the great vessels from a prone position. The average amount of time it took to digitally occlude the great vessels was less than a minute. Structures at risk included the L1 and L2 nerve roots, lumbosacral plexus, and the sympathetic trunk. Conclusions: The posterior peri-vertebral approach can potentially be used by a spine surgeon during a life-threatening situation to temporarily occlude great vessel hemorrhage while waiting for the assistance of a vascular/trauma team.