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Review
. 2025 Sep 30;11(3):637-651.
doi: 10.21037/jss-25-7. Epub 2025 Sep 18.

Open management of massive venous bleeding in anterior lumbar spine surgery-a narrative review

Charlie R Faulks  1   2   3 , Gregory M Malham  1   2   4   5   6 , William P Bradley  3   7 , Matthew H Claydon  1   2   8
Affiliations
Review

Open management of massive venous bleeding in anterior lumbar spine surgery-a narrative review

Charlie R Faulks et al. J Spine Surg. .

Abstract

Background and objective: Anterior lumbar spine surgery (ALSS) provides multiple benefits for the patient with spinal pathology. Vascular complications are uncommon and usually managed with simple surgical techniques and ancillary products. Rarely, confronting massive haemorrhage can occur after a venous injury which endangers the patient. We aimed to review the anatomical basis and risk factors for venous injury, propose a staged, systematic approach for management and discuss open surgical techniques, instruments, products, and strategies in detail for each of the stages.

Methods: This was a narrative review. A systematic approach was used. A review of national databases (PubMed, Ovid Medline, and Google Scholar) was performed using literature from 2000 to 2024 in English. Keywords included terms "anterior", "lumbar", "spine", "haemorrhage", "venous injury", "vascular", "repair", "ligation", "damage control", and "venous thromboembolism". Studies that aimed to describe the anatomy, risk factors, incidence, surgical techniques, complications, clinical and radiological outcomes of ALSS were included. Other generalised searches, not included in the initial systematic search, were conducted and included in our narrative review.

Key content and findings: This review considers the relevant anatomy, risk factors, patient work-up, lists possibly useful instruments and consumables, the broad stages of open management, specific operative strategies and techniques, and the post-operative management of the patient.

Conclusions: Massive venous injury (MVI) in ALSS is a rare but potentially life-threatening complication. Multiple open surgical techniques can be employed to control and manage the injury(s). The surgical and anaesthetic teams should have formulated a unified contingency plan against the eventuality of massive venous haemorrhage. The best outcome is only achieved with a team approach to the situation, recruitment of the necessary personnel and the deployment of the necessary equipment to enable the open management.

Keywords: Venous injury; anterior; haemorrhage; lumbar spine surgery; vascular repair.

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Conflict of interest statement

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-25-7/coif). The series “Anterior Lumbar Interbody Fusion — A Definitive Guide for Surgeons” was commissioned by the editorial office without any funding or sponsorship. G.M.M. serves as an unpaid editorial board member of Journal of Spine Surgery. Besides, G.M.M. reports consulting fees from Globus Medical, Australian Biotechnology and Life Healthcare, and supports for travel from Device Technologies, Life Healthcare, National Surgical, and SeaSpine. The authors have no other conflicts of interest to declare.

Figures

Figure 1
Figure 1
Open management of a massive venous injury. A broken line and arrow indicate an optional step which may not be required. ICU, intensive care unit; IV, intravenous; Temp, temperature.
Figure 2
Figure 2
Broad steps employed while approaching a major or massive venous injury.
See this image and copyright information in PMC

References

    1. Fantini GA, Pappou IP, Girardi FP, et al. Major vascular injury during anterior lumbar spinal surgery: incidence, risk factors, and management. Spine (Phila Pa 1976) 2007;32:2751-8. 10.1097/BRS.0b013e31815a996e - DOI - PubMed
    1. Varshneya K, Medress ZA, Jensen M, et al. Trends in Anterior Lumbar Interbody Fusion in the United States: A MarketScan Study From 2007 to 2014. Clin Spine Surg 2020;33:E226-30. 10.1097/BSD.0000000000000904 - DOI - PubMed
    1. Manunga J, Alcala C, Smith J, et al. Technical approach, outcomes, and exposure-related complications in patients undergoing anterior lumbar interbody fusion. J Vasc Surg 2021;73:992-8. 10.1016/j.jvs.2020.06.129 - DOI - PubMed
    1. Zahradnik V, Lubelski D, Abdullah KG, et al. Vascular injuries during anterior exposure of the thoracolumbar spine. Ann Vasc Surg 2013;27:306-13. 10.1016/j.avsg.2012.04.023 - DOI - PubMed
    1. Gok M, Aydin E, Guneyli S, et al. Iatrogenic Vascular Injuries Due to Spinal Surgeries: Endovascular Perspective. Turk Neurosurg 2018;28:469-73. 10.5137/1019-5149.JTN.19286-16.2 - DOI - PubMed