Late diagnosis of perforation of the aorta by a pedicle screw

Although the clinical and biomechanical advantages of pedicle screws are well documented, the accuracy of their insertion is always a concern.Injury of neurovascular structures could be devastating. Perforation of the aorta from posteriorly placed screws is fortunately rare but could end up being lethal. We present a review of the current literature along with two illustrative cases with aorta perforation from posterior pedicle screws. An 82-year-old female with a history of thoracic kyphosis and a 26-year-old female with scoliotic deformity were referred to our institution owing to back pain. Both patients had undergone correction of their deformities and posterior fixation using posterior pedicle screws and rods 5 years previously. During the diagnostic work-up, which included CT scans, we incidentally found one pedicle screw to be malpositioned, exiting the vertebral body and perforating the aorta. The patients were offered a combined orthopaedic and vascular procedure, including screw removal and endovascular stenting of the aorta. Potential complications from the presence of a screw inside the pulsatile aorta, and the complexity of revision surgery should be well considered before proceeding to such a difficult surgical procedure. Systemic postoperative follow-up imaging and safer intraoperative practices during screw placement are important.