Pedicle Screw-Aortic Interaction: A Single Centre Experience and Proposal for a Morphology Based Management Algorithm

Pedicle screw (PS) fixation is widely used in thoracolumbar spine surgery. Although major vascular injury is uncommon, PS-aortic interactions may lead to severe complications, and optimal management remains poorly defined. This study proposes a morphology based algorithm to guide multidisciplinary management of PS-aortic interactions and reports a single centre experience.

All consecutive patients referred to a vascular surgery unit between 2020 and 2025 for PS interaction with the descending thoracic aorta were reviewed retrospectively. Pre-operative assessment was performed using contrast enhanced computed tomography angiography (CTA). Screw-aorta interactions were classified as near contact (NC), aortic contact (AC), aortic indentation (AI), or aortic penetration (AP). Management followed a multidisciplinary morphology based algorithm: NC and AC were managed with screw removal under serial intra-operative angiographic control, whereas AI and AP underwent prophylactic thoracic endovascular aortic repair (TEVAR).

Eight patients (median age 25 years [interquartile range 18, 38]) were included. Indications for spinal fixation were scoliosis (n = 6) and trauma (n = 2). CTA demonstrated NC in two patients, AC in three, and AI in three; no AP cases were identified. All patients underwent a multidisciplinary vascular-spine procedure with surgical left femoral access in the lateral decubitus position. In NC and AC cases, posterior screw removal was followed by completion angiography confirming the absence of contrast extravasation; therefore, rescue TEVAR was not required. All AI cases underwent prophylactic TEVAR immediately before screw removal. Technical success was achieved in all cases. There were no major adverse aortic events, neurological complications, or 30 day deaths. At a median follow up of 26.9 months (interquartile range 7, 42), all patients were alive and asymptomatic, with no aortic related complications.

A morphology based algorithm prioritising aortic wall deformation rather than proximity alone may provide a feasible and potentially safe strategy for managing PS-aortic interactions, supporting standardised multidisciplinary decision making in this rare but high risk condition.