Ureteral injury following anterior thoracolumbar spinal instrumented fusion for adolescent idiopathic scoliosis: a case report with CT angiography analysis of surgically relevant anatomy

Abstract

Purpose

To report a rare ureteral injury following anterior spinal fusion for adolescent idiopathic scoliosis (AIS) that resulted in complete nephrectomy and to delineate the anatomical relationship between the proximal ureter and the anterior lumbar spine based on CT angiography (CTA).

Methods

Thoracolumbar spine CTAs of children with AIS were reviewed. We measured the following relationships to the ureters: lateral-most aspect of vertebral body, anterior psoas at intervertebral disc/vertebral body levels, and lateral psoas at vertebral body level. Spine level at which the renal arteries originated from the aorta was identified. Distance from origin to corresponding vertebral body/intervertebral disc also was measured.

Results

Forty-one girls and seven boys (mean age 12 years, range 7–18) were analyzed. Scoliosis lumbar convexity was left 94% and right 6%. From L1 to L4, ureter was identified within 1–2 cm of vertebral body. Distance between ureter and vertebral body and ureter and anterior psoas at intervertebral disc/vertebral body levels was less on left vs. right from L1 to L4 (p < 0.0001). Distance between ureter and lateral psoas was less on left vs. right from L1 to L2 (p = 0.0205; p = 0.0132) and greater on left vs. right from L3 to L4 (p = 0.0022; p = 0.0076). Renal artery originated at L1/L2 in > 50%. There was no difference in distance from renal artery origin to vertebral body/intervertebral disc (p = 0.4764).

Conclusion

Ureteral injury is a potentially morbid complication of anterior spine surgery. Injury can occur secondary to disrupted blood supply and mechanical tissue damage. Surgeons must clearly understand the juxta-spinal anatomy to limit dissection and modify retraction to reduce risk.

Level of evidence

Level IV.

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Funding

No funding was received for conducting this study.

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Authors

Contributions

All authors approved the final manuscript to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. NJH: study conception and design; material preparation, data acquisition and analysis; original draft preparation; draft revision. AAT: study conception and design; data analysis; original draft preparation; draft reviewing and revision; supervision. JLC: study design; data acquisition and analysis; original draft preparation; draft revision. DH: study conception; material preparation; data interpretation; original draft preparation and revision. MD: study conception and design; original draft preparation; data interpretation; draft reviewing and revision; supervision.

Corresponding author

Correspondence to Mohammad Diab.

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All authors declare they have no relevant financial or non-financial interests to disclose.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The Institutional Review Board at UCSF approved this study (19-29527).

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Signed informed parental consent for participation and publication was obtained.

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Hung, N.J., Theologis, A.A., Courtier, J.L. et al. Ureteral injury following anterior thoracolumbar spinal instrumented fusion for adolescent idiopathic scoliosis: a case report with CT angiography analysis of surgically relevant anatomy. Spine Deform (2021). https://doi.org/10.1007/s43390-021-00363-x

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Keywords

  • Deformity
  • Adolescent idiopathic scoliosis
  • Ureter
  • Anterior spine instrumentation