Emergency treatment for iatrogenic lumbar arterial injury occurred during posterior lumbar interbody fusion: a case report

An iatrogenic vessel injury occurring during lumbar fusion is a rare but potentially serious complication. In this case report, we present a case of hypovolemic cardiac arrest attributable to an iatrogenic lumbar artery injury that occurred during posterior lumbar interbody fusion (PLIF), which is difficult to diagnose using CECT. A 70-year-old woman underwent PLIF surgery in a primary hospital for the treatment of degenerative spondylolisthesis (L2–L5). During the procedure, she experienced a blood loss of 3 liters, which necessitated the transfusion of packed red blood cells (6 units, about 200–250 mL per unit), fresh frozen plasma (6 units, about 150–170 mL per unit). Despite the transfusions, her vital signs remained unstable, leading to her transfer to our hospital. Upon arrival at our facility, the patient went into cardiac arrest, but spontaneous circulation was successfully restored after two cycles of cardiopulmonary resuscitation. In the emergency department, her hemoglobin level was measured at 2.7 g/dL, platelet level at 56,000/µL, and prothrombin international normalized ratio at 3.56. CECT did not indicate any active bleeding. For the initial 2 hours, her vital signs remained stable with a blood pressure of 92/53 mmHg, heart rate of 104 bpm, respiratory rate of 22 bpm. However, her blood pressure suddenly dropped to 78/43 mmHg. Subsequent angiography revealed active bleeding from the right fourth lumbar artery, prompting the performance of embolization. Following the procedure, the patient’s vital signs stabilized, and she was discharged on the 16th day of hospitalization. Iatrogenic vessel injuries during PLIF may pose challenges in their detection using CECT, especially when extravasation is not definitively visible or when artifacts are created by metal implants. Therefore, it is advisable for emergency physicians to consider emergency angiography in the diagnosis and treatment of such vessel injuries.