Venous Plexus Bleeding Research Articles

Surgical Management of Cervical Vertebral Fractures in Two Dogs with Severe Concurrent Vertebral Venous Plexus Hemorrhage

AbstractSurgical repair of fractures and luxations of the cranial cervical vertebrae can be complicated by vertebral venous plexus hemorrhage following fracture fragment manipulation and realignment. Severe hemorrhage is potentially life threatening and may preclude definitive surgical fixation if it cannot be acceptably controlled and interferes with fixation technique. This report describes this scenario and a surgical strategy in two dogs with fractures of the second cervical vertebra. The surgical technique to limit hemorrhage included the insertion of the pins into the vertebrae, placement of collagen fleece, and autogenous cancellous bone graft over the fracture site, and while the polymethylmethacrylate cement was still within the liquid phase, axial traction was employed. The long-term outcome was considered excellent with both dogs able to ambulate unassisted and free from signs of pain. Although it is uncommon, severe vertebral venous plexus hemorrhage can occur during cervical vertebrae fracture repair. This technique provides a means to achieve internal fixation while concurrently limiting hemorrhage.

Thinning, Peeling and Carving Technique for the Treatment of Thoracic Myelopathy Caused by Ossification of Ligamentum Flavum

Introduction To introduce a novel technique of thinning, peeling and carving to remove the ossification ligamentum flavum(OLF) nidus easily, safely and completely for the treatment of thoracic myelopathy caused by OLF. This surgical procedure avoids aggressive irritating the most seriously compressed spinal cord caused by OLF nidus especially. The epidural venous plexus bleeding and the bleeding from the pedicle can be seen clearly and controlled easily during the decompression. Material and Methods Thoracic myelopathy caused by OLF was diagnosed in 28 patients using plain radiography, 3D CT, and MRI from January 2009 to January 2012. The lamina, the lower and the upper facet joint of the involved segment were thinned with the bigger neuro drill(diameter 3.5mm) first, The shell was so thin that the feeding blood vessels of the dura can be seen clearly. Second, the thinned shell was peeled off with the curette piece by piece. The upper facet joint and the OLF nidus were carved by the smaller neuro drill (diameter 2.5mm)and the thinned bony nidus compressing the spinal cord was removed finally, Spinal cord monitoring (SEP and MEP)was performed intraoperatively in all cases. The operating time and blood loss were recorded during the operation. The Frankel scoring system was used to assess the neurological status before the operation and in the follow up. The S F-36 were also used to assess the general health status. Results Of the 28 cases of OLF,3 were single level, 10 were double level, and 15 were multilevel. Of the 71 ossified segments in this study, 16 (22.5%) were located in the upper thoracic spine (T1–4), 9 (12.7%) were located in the midthoracic spine (T5–8), and 46 (64.8%) were located in the lower thoracic spine (T9-L1). The mean operating time was 145 ±32min. The mean intraoperative blood loss was 280 ± 48.6 ml. The neurological status improved during follow-up (mean 46.1 months) from a preoperative mean mJOA score of 5.39 ± 1.52 to 8.97 ± 1.22 points (t = 18.39, p < 0.05). The neurological function recovery rate ranged from 28.6% to 100%. Conclusion Thinning, peeling and carving technique was effective, safe and may be a reasonable choice for the treatment of thoracic myelopath y caused by OLF

Use of closed suction devices and other drains in spinal surgery: results of an online, Germany-wide questionnaire.

The risks of drains in spine surgery (e.g., increasing venous plexus bleeding, maintaining CSF leakage, and infections) must be balanced with their benefits (e.g., reduced rate of postoperative hematoma and seroma formation). Little is known about factors that influence surgeons' decision to employ a drain. We conducted a survey among German spine surgeons regarding their use of drains. Neurosurgical and orthopedic departments along with privately practicing neurosurgeons were invited to complete an online questionnaire featuring general and case-specific questions with regard to drain placement. We received 163 questionnaires (private practice and small-volume centers 36.1%, medium- and large-volume centers 43.6%, university centers 20.2%). Factors influencing the decision to use a drain include size of wound, type of procedure, hemostasis at the end of the procedure, and coagulopathies; factors found to be less important include overall blood loss, body mass index, and implants. 31% of surgeons will use drains for microdiskectomies. For other pathologies, percentages are as follows: anterior cervical diskectomy and fusion, 58%; cervical laminoplasty, 62%; hemilaminectomy for bisegmental lumbar stenosis, 69%; transpedicular instrumentation, 88%; vertebral body replacement for metastasis, 94%. Over half of those who usually employ a drain will not use a drain in cases of unintentional durotomy. In terms of indication, duration, and safety measures, use of drains in spinal surgery is heterogeneous. The majority of surgeons prefer drains to suction in most cases, except for microdiskectomies, for which only 31% will use a drain. Nearly all colleagues discontinue drains by day 4.

Clinical Application of the “Pedicle Exposure Technique” for Atlantoaxial Instability Patients With a Narrow C1 Posterior Arch

This was a retrospective study. The aim of this study was to test a new surgical approach, that is, "pedicle exposure technique," for atlantoaxial instability (AAI) patients with C1 posterior arches measuring <4 mm, and to determine its feasibility and clinical outcomes. C1 posterior arch screw placement is one of the most effective methods for AAI; however, several studies showed this method to be restricted when the posterior arch measures <4 mm. Hence, modification of this technique is necessary to expand its indications. The average height of the C1 posterior arch in 79 AAI cases was 3.3 (range, 2.5-3.9) mm. All patients were treated by the C1 "pedicle exposure technique" and C2 pedicle screw fixation. The feasibility and clinical outcome of this technique were analyzed by postoperative x-rays, computed tomography, and Visual Analogue Score and Japan Department of Orthopedics Association score. A total of 158 screws were successfully placed into the atlas in all 79 patients. There were no vertebral artery or spinal cord injuries. Venous plexus bleeding was encountered in 3 patients; there were no cases of new onset occipital neuralgia. Three screws penetrated into the external wall of the C1 lateral mass and 4 screws into the internal wall. Seventy-nine patients were followed up for 6-80 months. Bony fusion was confirmed in all cases within 3-6 months by computed tomography; there were no instrument failures. Significant differences in preoperative and postoperative Visual Analogue Score and Japan Department of Orthopedics Association score were found. Thirty-six and 15 of 62 patients with preoperative neck pain had alleviation or resolution of symptoms, respectively; 33 of 36 patients with myelopathy demonstrated significant improvement. The "pedicle exposure technique" is an effective alternative in patients with the C1 posterior arch measuring <4 mm. In consideration of a high screw entry point on the C1 posterior arch, similar to the C1 posterior arch screw technique, we propose that this new technique can reduce venous plexus and C2 nerve root injury while providing effective biomechanical stability.

Clinical Application of a Revised Screw Technique via the C1 Posterior Arch and Lateral Mass in the Pediatric Population

Objective: Pediatric patients with insufficient height (≤4 mm) of the C1 posterior arch may restrict atlas screw placement via the posterior arch and lateral mass (PALM). For these patients, we modified this technique, called the ‘pedicle exposure technique' (PET). We aimed to analyze the clinical feasibility and safety of the PET in the pediatric population. Methods: Twenty pediatric patients with atlantoaxial instability (AAI) were enrolled in this study. The average C1 posterior arch was 3.1 (2.5-3.9) mm on CT scan. All patients underwent the C1 PET and C2 pedicle screw fixation. The imaging was performed to evaluate the accuracy of screw placement and bony fusion. Results: Forty screws were inserted via C1 PALM using the PET. Venous plexus bleeding occurred in 1 patient and the internal wall of the C1 lateral mass was perforated in 1 patient. There were no perioperative neurological deficits or vertebral artery injury. Follow-up was performed in all 20 cases over a period ranging from 6 to 80 months. Bony union was seen within 3-6 months. At the final follow-up visit, 14 patients had experienced an improvement, while 6 had complete resolution of their neck pain. Myelopathy symptoms were improved in 9 patients with spinal compression. Conclusion: The PET is an effective alternative for pediatric AAI when the height of the C1 posterior arch is <4 mm. Because of the higher screw entry point through the C1 posterior arch, there is effective biomechanical stability and less irritation of the venous plexus and C2 nerve root.

Upper facet joint en bloc resection for the treatment of thoracic myelopathy caused by ossification of the ligamentum flavum

The authors introduce a novel technique to treat thoracic myelopathy caused by ossification of the ligamentum flavum (OLF): upper facet joint en bloc resection. This surgical procedure avoids surgery to the most heavily compressed cord surface, contact with the cord, and cord injury. The epidural venous plexus bleeding point can be directly seen and easily controlled during the decompression. Between January 2007 and January 2009, thoracic myelopathy caused by OLF was diagnosed in 38 patients using plain radiography, CT, and MRI, and diagnoses were confirmed by postoperative pathological examination. All upper facet joint en bloc resection procedures were performed in 2 steps. First, the bony structures above the upper facet joint surfaces were resected and the upper facet joints were isolated. Second, en bloc resection of the upper facet joint was performed by dissection of the junction between the pedicle and upper facet joint. Intraoperative neurological monitoring was performed in all cases. The modified Japanese Orthopaedic Association (mJOA) scoring system was used to assess neurological status. The degree of postoperative expansion of the spinal cord was calculated on axial MR images. The pre- and postdecompression Cobb angle was applied to assess the magnitude of local kyphosis. Of the 38 cases of OLF, 6 were single level, 12 were double level, and 20 were multilevel. Of the 92 ossified segments in this study, 23 (25.0%) were located in the upper thoracic spine (T1-4), 13 (14.1%) were located in the midthoracic spine (T5-8), and 56 (60.9%) were located in the lower thoracic spine (T9-L1). The mean intraoperative blood loss was 340 ± 54 ml. The neurological status improved during follow-up (mean 46.1 months) from a preoperative mean mJOA score of 5.39 ± 1.52 to 8.97 ± 1.22 points (t = 18.39, p < 0.05). The neurological function recovery rate ranged from 28.6% to 100%. The mean increase in pre- and postoperative kyphosis of the involved vertebrae was only 1.3° ± 1.6°. The increase in the cross-sectional area of the dural sac at the level of maximum compression suggested that decompression was complete. Upper facet joint en bloc resection is effective and may be a reasonable alternative treatment choice for thoracic myelopathy caused by OLF.

Management of Pterygoid Venous Plexus Hemorrhage during Resection of a Large Juvenile Nasopharyngeal Angiofibroma: A Review of 27 Cases

We retrospectively reviewed the cases of 27 patients who experienced intraoperative bleeding during resection of a large (Fisch type III or IV) juvenile nasopharyngeal angiofibroma (JNA). Of this group, 16 patients had a type III JNA and 11 had a type IV tumor. The degree of hemorrhaging during excision of these JNAs varied greatly among individual patients. The amount of blood lost ranged from 200 to 5,000 ml (mean: 1,800) in the type III cases and from 700 to 8,000 ml (mean: 2,850) in the type IV cases. In 5 of these cases, both intraoperative observations and imaging data suggested that an important factor in the blood loss was damage to the pterygoid venous plexus (PVP). The PVP communicates with the cavernous sinus, ophthalmic vein, maxillary vein, and facial vein; no valve exists between these veins. In patients with a large JNA, the PVP is usually compressed by or adherent to the tumor. When a PVP is seriously damaged during removal of a JNA, hemorrhaging can be very profuse. Therefore, a suitable surgical approach and appropriate hemostatic procedures should be used to prevent or manage PVP hemorrhage as effectively as possible. We also describe in greater detail 5 typical cases of JNA excision that did (n = 3) and did not (n = 2) involve PVP damage.

Management of Pterygoid Venous Plexus Hemorrhage during Resection of a Large Juvenile Nasopharyngeal Angiofibroma: A Review of 27 Cases

We retrospectively reviewed the cases of 27 patients who experienced intraoperative bleeding during resection of a large (Fisch type III or IV) juvenile nasopharyngeal angiofibroma (JNA). Of this group, 16 patients had a type III JNA and 11 had a type IV tumor. The degree of hemorrhaging during excision of these JNAs varied greatly among individual patients. The amount of blood lost ranged from 200 to 5,000 ml (mean: 1,800) in the type III cases and from 700 to 8,000 ml (mean: 2,850) in the type IV cases. In 5 of these cases, both intraoperative observations and imaging data suggested that an important factor in the blood loss was damage to the pterygoid venous plexus (PVP). The PVP communicates with the cavernous sinus, ophthalmic vein, maxillary vein, and facial vein; no valve exists between these veins. In patients with a large JNA, the PVP is usually compressed by or adherent to the tumor. When a PVP is seriously damaged during removal of a JNA, hemorrhaging can be very profuse. Therefore, a suitable surgical approach and appropriate hemostatic procedures should be used to prevent or manage PVP hemorrhage as effectively as possible. We also describe in greater detail 5 typical cases of JNA excision that did (n = 3) and did not (n = 2) involve PVP damage.

Doença do disco intervertebral cervical em cães: 28 casos (2003-2008)

O objetivo deste estudo foi identificar cães com doença do disco intervertebral (DDIV) cervical atendidos no Hospital Veterinário Universitário (HVU) da Universidade Federal de Santa Maria (UFSM) entre janeiro de 2003 e outubro de 2008 e obter informações a respeito de raça, sexo, idade, sinais neurológicos, resposta ao tratamento cirúrgico, complicações, tempo de recuperação funcional após a cirurgia e ocorrência de recidiva. Hiperestesia cervical foi observada em todos os cães (n=28). Quanto ao grau de disfunção neurológica foram verificados: grau I (8/28[28,5%]), grau II (3/28 [10,7%]), grau III (5/28[17,8%]) e grau V (12/2 [42,8%]). A duração dos sinais neurológicos antes da cirurgia em sete cães (25%) permaneceu por até 15 dias, em 14 cães (50%) entre 15 e 30 dias e nos outros sete cães (25%) por mais de 30 dias. A recuperação satisfatória e sem recidiva foi observada em todos os cães submetidos ao tratamento cirúrgico e que sobreviveram (n=21). Pode-se concluir que a DDIV cervical em nossa rotina acomete principalmente cães adultos, machos, de raças condrodistróficas e não condrodistróficas, incluindo as de grande porte; a hiperestesia cervical é a principal manifestação clínica; a técnica de fenda ventral promove recuperação funcional satisfatória e sem recidiva; as principais complicações trans-operatórias são a hemorragia do plexo venoso, a bradicardia e a hipotensão; e a duração dos sinais clínicos não interfere no tempo de recuperação pós-operatória dos cães.

Case Report: Mediastinal Hematoma Secondary to Hypertension, Presenting as a Retropharyngeal Space Abscess

The majority of retropharyngeal hematomas described in the literature have been associated with anticoagulation therapy, tumors, aneurysm, infection or cervical spine injury. We present a case of a 55-year-old African American female with acute chest pain, sore throat, and dysphagia. Her past medical history was significant for uncontrolled hypertension and cervical spine arthritis. Physical exam was significant for posterior pharyngeal edema and her labs indicated mild leukocytosis. Contrast-enhanced CT scan of the neck demonstrated an extensive retropharyngeal fluid collection with mediastinal extension, concerning for an abscess. A trans-oral and trans-cervical incision and drainage of the presumed abscess revealed clotted blood and venous ooze. Penrose drains were placed in the retropharyngeal space to allow for spontaneous drainage over the next two days. The patient was kept intubated for 8 days to ensure a secure airway while venous ooze was allowed to self-tamponade. Antihypertensive medications were utilized to control her labile blood pressures. To our knowledge this is the first case report of uncontrolled chronic hypertension as the etiology of a spontaneous mediastinal venous hematoma with presentation as a retropharyngeal space fluid collection. When evaluating retropharyngeal space occupying lesion with mediastinal extension, consideration should be given to mediastinal venous plexus bleeding. Treatment involves securing the airway, drainage, and control of blood pressure.

The prevention and management of surgical complications in Miles operation

Objective To explore the prevention and management of surgieal complications in Miles operation.Methods Retrospectively analyzed the main complications appeared in 176 patients of Miles operation.Results There was the eolostomy-related complications in 19 cases.Presacral venous plexus hemorrhage in 4 cases.Intestinal obstruction in 10 cases.Wound infection of perineum in 12 eases.Lesion of urinary tract in 1 case.The common complication rate of Miles operation was 26.1%.Conclusion Mastering operation skill and adherence to sound snrgical principles is the key to prevent and to decrease intra-postoperative complication. Key words: Rectal neoplasms Operation; Complications

Haemostasis of Paravertebral Venous Plexus Bleeding During Ruptured Abdominal Aortic Aneurysm Repair Using Epiphyseal Staples

Haemostasis of Paravertebral Venous Plexus Bleeding During Ruptured Abdominal Aortic Aneurysm Repair Using Epiphyseal Staples

A Modified Lateral Approach to the Canine Cervical Spine: Procedural Description and Clinical Application in 16 Dogs with Lateralized Compressive Myelopathy or Radiculopathy

To describe a modified lateral surgical approach to the cervical spine in dogs and evaluate clinical outcomes of dogs with neurologic disorders treated with this technique. Retrospective study. Sixteen dogs with lesions involving the cervical spine. Medical records (1998-2002) of dogs that had a modified lateral approach to the cervical spine were reviewed. To reduce procedural morbidity, the surgical approach was modified from original descriptions of the technique by minimizing disruption of epaxial and extrinsic thoracic limb musculature and limiting the size of the operative field to the affected vertebral segment. Signalment, neurologic status on admission; onset, progression, and duration of clinical signs; diagnostic testing, etiologic diagnosis, surgical site(s), intra- and postoperative complications, hospitalization, time to optimum recovery, neurologic status at discharge, final neurologic status, and outcome were recorded. Neurologic status (0-5) was scored preoperatively, 1 day postoperatively, at discharge, and at recheck examination (8 dogs). Telephone interviews were used to obtain additional follow-up information. None of the dogs had postoperative deterioration in neurologic status. Outcomes were good or excellent in dogs with intervertebral disc disease, 3/4 dogs with caudal cervical spondylomyelopathy, 1/2 dogs with spinal neoplasia, and in 1 dog with the vascular anomaly; long-term outcomes were unknown in 2 dogs. Intraoperative complications occurred in 3 dogs and included controllable venous plexus hemorrhage (2) and incorrect lesion localization (1). One dog was euthanatized because of postoperative complications. Hospitalization, time to optimal recovery, and overall outcome were not different from previously reported results using other surgical approaches to treat analogous neurologic conditions. A modified lateral approach to the cervical spine is viable for surgical treatment of cervical myelopathic or radiculopathic lesions when exposure to foraminal and lateralized lesions of the vertebral canal involving the C2-C7 vertebral articulations is desirable. A modified lateral approach to the cervical spine can be successfully used in dogs of all sizes to treat caudal cervical spondylomyelopathy, other anomalous conditions of the cervical spine, intervertebral disc disease, and spinal neoplasms. Although long-term follow-up was not available for all patients, outcomes were generally favorable.