Aortic injury in the treatment of adolescent idiopathic scoliosis_West China Medical Journal

Authors：

WANG Yongliang ^1,2 ,  LIU Limin ¹ , FENG Ganjun ¹

1. Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P. R. China;
2. Department of Orthopaedic Surgery, Pangang Group General Hospital, Panzhihua, Sichuan 617023, P. R. China;

Corresponding author：

LIU Limin, Email: 18980601394@163.com

Keywords：

Idiopathic scoliosis; Surgical treatment; Aortic injury; Complication

DOI：

10.7507/1002-0179.202108269

Video：

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In the surgical treatment of adolescent idiopathic scoliosis (AIS), the posterior pedicle screw system has a better orthopaedic effect than the traditional internal fixation orthopaedic system, and has been widely used in the orthopaedic surgery of AIS. Although the vast majority of patients respond well to surgical treatment, complications can still occur. Aortic injury is one of the rare complications, but it can lead to catastrophic consequences. Spinal surgeons must be fully familiar with the knowledge of aortic injury and the appropriate management and management methods. This article reviews the complication of aortic injury caused by surgical treatment of AIS.

Citation： WANG Yongliang, LIU Limin, FENG Ganjun. Aortic injury in the treatment of adolescent idiopathic scoliosis. West China Medical Journal, 2021, 36(10): 1429-1433. doi: 10.7507/1002-0179.202108269 Copy

1.	Konieczny MR, Senyurt H, Krauspe R. Epidemiology of adolescent idiopathic scoliosis. J Child Orthop, 2013, 7(1): 3-9.
2.	Weinstein SL, Dolan LA, Cheng JC, et al. Adolescent idiopathic scoliosis. Lancet, 2008, 371(9623): 1527-1537.
3.	Vigneswaran HT, Grabel ZJ, Eberson CP, et al. Surgical treatment of adolescent idiopathic scoliosis in the United States from 1997 to 2012: an analysis of 20, 346 patients. J Neurosurg Pediatr, 2015, 16(3): 322-328.
4.	von Heideken J, Iversen MD, Gerdhem P. Rapidly increasing incidence in scoliosis surgery over 14 years in a nationwide sample. Eur Spine J, 2018, 27(2): 286-292.
5.	Pillai ST, Schoenhagen P, Subrahmanyan L, et al. Aortic dissection associated with penetration of a spinal pedicle screw: a case report and review of the literature. J Card Surg, 2014, 29(3): 377-381.
6.	Sevastik B, Xiong B, Hedlund R, et al. The position of the aorta in relation to the vertebra in patients with idiopathic thoracic scoliosis. Surg Radiol Anat, 1996, 18(1): 51-56.
7.	Qiu Y, He YX, Wang B, et al. The anatomical relationship between the aorta and the thoracic vertebral bodies and its importance in the placement of the screw in thoracoscopic correction of scoliosis. Eur Spine J, 2007, 16(9): 1367-1372.
8.	Liljenqvist UR, Allkemper T, Hackenberg L, et al. Analysis of vertebral morphology in idiopathic scoliosis with use of magnetic resonance imaging and multiplanar reconstruction. J Bone Joint Surg Am, 2002, 84(3): 359-368.
9.	江华, 邱旭升, 邱勇, 等. 青少年特发性脊柱侧凸胸椎椎弓根螺钉误置与主动脉损伤的风险评估. 中华骨科杂志, 2013, 33(1): 65-70.
10.	Zhang T, Qiu Y, Zhu Z, et al. Potential risk of thoracic aorta injury from excessively long right pedicle screws in patients with left thoracic scoliosis: a computed tomography image study. World Neurosurg, 2021, 145: e177-e183.
11.	Lenke LG, Kuklo TR, Ondra S, et al. Rationale behind the current state-of-the-art treatment of scoliosis (in the pedicle screw era). Spine (Phila Pa 1976), 2008, 33(10): 1051-1054.
12.	Polly DW Jr, Potter BK, Kuklo T, et al. Volumetric spinal canal intrusion: a comparison between thoracic pedicle screws and thoracic hooks. Spine (Phila Pa 1976), 2004, 29(1): 63-69.
13.	Sucato DJ, Duchene C. The position of the aorta relative to the spine: a comparison of patients with and without idiopathic scoliosis. J Bone Joint Surg Am, 2003, 85(8): 1461-1469.
14.	Lu S, Zhang YZ, Wang Z, et al. Accuracy and efficacy of thoracic pedicle screws in scoliosis with patient-specific drill template. Med Biol Eng Comput, 2012, 50(7): 751-758.
15.	Tan LA, Ahuja SK, Deutsch H. The “screwed aorta” after spinal deformity surgery. Br J Neurosurg, 2015, 29(2): 290.
16.	Kayacı S, Cakir T, Dolgun M, et al. Aortic injury by thoracic pedicle screw. When is aortic repair required? Literature review and three new cases. World Neurosurg, 2019, 128: 216-224.
17.	Beck M, Mittlmeier T, Gierer P, et al. Benefit and accuracy of intraoperative 3D-imaging after pedicle screw placement: a prospective study in stabilizing thoracolumbar fractures. Eur Spine J, 2009, 18(10): 1469-1477.
18.	Lehman RA Jr, Lenke LG, Keeler KA, et al. Computed tomography evaluation of pedicle screws placed in the pediatric deformed spine over an 8-year period. Spine (Phila Pa 1976), 2007, 32(24): 2679-2684.
19.	Hicks JM, Singla A, Shen FH, et al. Complications of pedicle screw fixation in scoliosis surgery: a systematic review. Spine (Phila Pa 1976), 2010, 35(11): E465-E470.
20.	Samdani AF, Ranade A, Sciubba DM, et al. Accuracy of free-hand placement of thoracic pedicle screws in adolescent idiopathic scoliosis: how much of a difference does surgeon experience make?. Eur Spine J, 2010, 19(1): 91-95.
21.	Yingsakmongkol W, Hangsaphuk N, Lerdlam S. The accuracy of pedicle screw placement in thoracic spine using the funnel technique in idiopathic scoliosis. J Med Assoc Thai, 2007, 90(1): 96-105.
22.	Kwan MK, Chiu CK, Gani SMA, et al. Accuracy and safety of pedicle screw placement in adolescent idiopathic scoliosis patients: a review of 2020 screws using computed tomography assessment. Spine (Phila Pa 1976), 2017, 42(5): 326-335.
23.	Sarwahi V, Suggs W, Wollowick AL, et al. Pedicle screws adjacent to the great vessels or viscera: a study of 2132 pedicle screws in pediatric spine deformity. J Spinal Disord Tech, 2014, 27(2): 64-69.
24.	Soultanis KC, Sakellariou VI, Starantzis KA, et al. Late diagnosis of perforation of the aorta by a pedicle screw. Acta Orthop Belg, 2013, 79(4): 361-367.
25.	Rabellino M, Garcia-Monaco R, Cesareo V, et al. Endovascular treatment of iatrogenic aortic injury after spinal surgery. Minim Invasive Ther Allied Technol, 2013, 22(1): 56-60.
26.	Parker SL, Amin AG, Santiago-Dieppa D, et al. Incidence and clinical significance of vascular encroachment resulting from freehand placement of pedicle screws in the thoracic and lumbar spine: analysis of 6816 consecutive screws. Spine (Phila Pa 1976), 2014, 39(8): 683-687.
27.	Kopp R, Beisse R, Weidenhagen R, et al. Strategies for prevention and operative treatment of aortic lesions related to spinal interventions. Spine (Phila Pa 1976), 2007, 32(25): E753-E760.
28.	Tschoeke SK, Gahr P, Krug L, et al. Late diagnosis of pedicle screw malplacement with perforation of the thoracic aorta after posterior stabilization in a patient with multiple myeloma: case report. Spine (Phila Pa 1976), 2011, 36(13): E886-E890.
29.	Sarlak AY, Tosun B, Atmaca H, et al. Evaluation of thoracic pedicle screw placement in adolescent idiopathic scoliosis. Eur Spine J, 2009, 18(12): 1892-1897.
30.	Jiang H, Qiu X, Wang W, et al. The position of the aorta changes with altered body position in single right thoracic adolescent idiopathic scoliosis. Spine (Phila Pa 1976), 2012, 37(17): E1054-E1061.
31.	Takeshita K, Maruyama T, Ono T, et al. New parameters to represent the position of the aorta relative to the spine for pedicle screw placement. Eur Spine J, 2010, 19(5): 815-820.
32.	Wegener B, Birkenmaier C, Fottner A, et al. Delayed perforation of the aorta by a thoracic pedicle screw. Eur Spine J, 2008, 17(Suppl 2): S351-S354.
33.	Samdani AF. Regarding “Delayed presentation of aortic injury by pedicle screws: Report of two cases and review of the literature”. J Vasc Surg, 2008, 48(4): 1067-1068.
34.	Sevuk U, Mesut A, Kiraz I, et al. Delayed presentation of aortic injury by a thoracic pedicle screw. J Card Surg, 2016, 31(4): 220-230.
35.	Ryabykh S, Sergeenko OM, Savin DM, et al. Malpositioned pedicle screw compressed thoracic aorta of a patient with adolescent idiopathic scoliosis: case report and literature review. Tech Orthop, 2017, 32(4): 277-282.
36.	冯超帅, 杨宝辉, 王国毓, 等. 腰椎融合术置钉过程中损伤右侧髂总动脉抢救成功1例. 中国脊柱脊髓杂志, 2018, 28(9): 858-860.
37.	Choi JB, Han JO, Jeong JW. False aneurysm of the thoracic aorta associated with an aorto-chest wall fistula after spinal instrumentation. J Trauma, 2001, 50(1): 140-143.
38.	Sokolić J, Sosa T, Ugljen R, et al. Extrinsic erosion of the descending aorta by a vertebral fixator. Texas Heart Inst J, 1991, 18(2): 136-139.
39.	Pesenti S, Bartoli MA, Blondel B, et al. Endovascular aortic injury repair after thoracic pedicle screw placement. Orthop Traumatol Surg Res, 2014, 100(5): 569-573.
40.	Faro FD, Farnsworth CL, Shapiro GS, et al. Thoracic vertebral screw impingement on the aorta in an in vivo bovine model. Spine (Phila Pa 1976), 2005, 30(21): 2406-2413.
41.	Hu HT, Shin JH, Hwang JY, et al. Thoracic aortic stent-graft placement for safe removal of a malpositioned pedicle screw. Cardiovasc Intervent Radiol, 2010, 33(5): 1040-1043.
42.	Jim J, Sanchez LA, Geraghty PJ. Endovascular repair of an intraoperative thoracic aortic injury during all-posterior vertebral column resection surgery. Ann Vasc Surg, 2011, 25(1): 132.e1-132.e6.
43.	Carmignani A, Lentini S, Acri E, et al. Combined thoracic endovascular aortic repair and neurosurgical intervention for injury due to posterior spine surgery. J Card Surg, 2013, 28(2): 163-167.
44.	Clarke MJ, Guzzo J, Wolinsky JP, et al. Combined endovascular and neurosurgical approach to the removal of an intraaortic pedicle screw. J Neurosurg Spine, 2011, 15(5): 550-554.
45.	Bavare C, Kim M, Blackmon S, et al. Delayed aortic rupture after aortic endograft placement in patient with spinal hardware. Ann Thorac Surg, 2011, 92(4): 1512-1514.
46.	Kosmopoulos V, Theumann N, Binaghi S, et al. Observer reliability in evaluating pedicle screw placement using computed tomography. Int Orthop, 2007, 31(4): 531-536.
47.	Iyer MH, Engoren M, Martin MW. Echo rounds: transesophageal echocardiography: identification and management of a misplaced pedicle screw in the descending thoracic aorta after posterior spinal fusion. Anesth Analg, 2013, 116(2): 303-306.
48.	Watanabe K, Yamazaki A, Hirano T, et al. Descending aortic injury by a thoracic pedicle screw during posterior reconstructive surgery: a case report. Spine (Phila Pa 1976), 2010, 35(20): 1064-1068.
49.	Lagios K, Karaolanis G, Perdikides T, et al. Thoracic aortic injury: embolization of the tenth intercostal artery and endovascular treatment in a young woman after posterior spinal instrumentation. Case Rep Vasc Med, 2015: 531201.
50.	Martín-Pedrosa JM, Gutiérrez V, González-Fajardo JA, et al. Endovascular treatment of thoracic aorta injury after spinal column surgery. J Vasc Surg, 2012, 55(6): 1782-1783.
51.	Loh SA, Maldonaldo TS, Rockman CB, et al. Endovascular solutions to arterial injury due to posterior spine surgery. J Vasc Surg, 2012, 55(5): 1477-1481.
52.	Al-Hakim R, Schenning R. Advanced techniques in thoracic endovascular aortic repair: chimneys/periscopes, fenestrated endografts, and branched devices. Tech Vasc Interv Radiol, 2018, 21(3): 146-155.
53.	Cheng SW. Novel endovascular procedures and new developments in aortic surgery. Br J Anaesth, 2016, 117(Suppl 2): ii3-ii12.
54.	Schermann H, Mirovsky Y, Chechik Y. Delayed penetration of the thoracic aorta by pedicle screws: a case report of screws left as-is. Spine (Phila Pa 1976), 2019, 44(19): E1169-E1171.
55.	Valič M, Žižek D, Špan M, et al. Malpositioned pedicle screw in spine deformity surgery endangering the aorta: report of two cases, review of literature, and proposed management algorithm. Spine Deform, 2020, 8(4): 809-817.

1. Konieczny MR, Senyurt H, Krauspe R. Epidemiology of adolescent idiopathic scoliosis. J Child Orthop, 2013, 7(1): 3-9.
2. Weinstein SL, Dolan LA, Cheng JC, et al. Adolescent idiopathic scoliosis. Lancet, 2008, 371(9623): 1527-1537.
3. Vigneswaran HT, Grabel ZJ, Eberson CP, et al. Surgical treatment of adolescent idiopathic scoliosis in the United States from 1997 to 2012: an analysis of 20, 346 patients. J Neurosurg Pediatr, 2015, 16(3): 322-328.
4. von Heideken J, Iversen MD, Gerdhem P. Rapidly increasing incidence in scoliosis surgery over 14 years in a nationwide sample. Eur Spine J, 2018, 27(2): 286-292.
5. Pillai ST, Schoenhagen P, Subrahmanyan L, et al. Aortic dissection associated with penetration of a spinal pedicle screw: a case report and review of the literature. J Card Surg, 2014, 29(3): 377-381.
6. Sevastik B, Xiong B, Hedlund R, et al. The position of the aorta in relation to the vertebra in patients with idiopathic thoracic scoliosis. Surg Radiol Anat, 1996, 18(1): 51-56.
7. Qiu Y, He YX, Wang B, et al. The anatomical relationship between the aorta and the thoracic vertebral bodies and its importance in the placement of the screw in thoracoscopic correction of scoliosis. Eur Spine J, 2007, 16(9): 1367-1372.
8. Liljenqvist UR, Allkemper T, Hackenberg L, et al. Analysis of vertebral morphology in idiopathic scoliosis with use of magnetic resonance imaging and multiplanar reconstruction. J Bone Joint Surg Am, 2002, 84(3): 359-368.
9. 江华, 邱旭升, 邱勇, 等. 青少年特发性脊柱侧凸胸椎椎弓根螺钉误置与主动脉损伤的风险评估. 中华骨科杂志, 2013, 33(1): 65-70.
10. Zhang T, Qiu Y, Zhu Z, et al. Potential risk of thoracic aorta injury from excessively long right pedicle screws in patients with left thoracic scoliosis: a computed tomography image study. World Neurosurg, 2021, 145: e177-e183.
11. Lenke LG, Kuklo TR, Ondra S, et al. Rationale behind the current state-of-the-art treatment of scoliosis (in the pedicle screw era). Spine (Phila Pa 1976), 2008, 33(10): 1051-1054.
12. Polly DW Jr, Potter BK, Kuklo T, et al. Volumetric spinal canal intrusion: a comparison between thoracic pedicle screws and thoracic hooks. Spine (Phila Pa 1976), 2004, 29(1): 63-69.
13. Sucato DJ, Duchene C. The position of the aorta relative to the spine: a comparison of patients with and without idiopathic scoliosis. J Bone Joint Surg Am, 2003, 85(8): 1461-1469.
14. Lu S, Zhang YZ, Wang Z, et al. Accuracy and efficacy of thoracic pedicle screws in scoliosis with patient-specific drill template. Med Biol Eng Comput, 2012, 50(7): 751-758.
15. Tan LA, Ahuja SK, Deutsch H. The “screwed aorta” after spinal deformity surgery. Br J Neurosurg, 2015, 29(2): 290.
16. Kayacı S, Cakir T, Dolgun M, et al. Aortic injury by thoracic pedicle screw. When is aortic repair required? Literature review and three new cases. World Neurosurg, 2019, 128: 216-224.
17. Beck M, Mittlmeier T, Gierer P, et al. Benefit and accuracy of intraoperative 3D-imaging after pedicle screw placement: a prospective study in stabilizing thoracolumbar fractures. Eur Spine J, 2009, 18(10): 1469-1477.
18. Lehman RA Jr, Lenke LG, Keeler KA, et al. Computed tomography evaluation of pedicle screws placed in the pediatric deformed spine over an 8-year period. Spine (Phila Pa 1976), 2007, 32(24): 2679-2684.
19. Hicks JM, Singla A, Shen FH, et al. Complications of pedicle screw fixation in scoliosis surgery: a systematic review. Spine (Phila Pa 1976), 2010, 35(11): E465-E470.
20. Samdani AF, Ranade A, Sciubba DM, et al. Accuracy of free-hand placement of thoracic pedicle screws in adolescent idiopathic scoliosis: how much of a difference does surgeon experience make?. Eur Spine J, 2010, 19(1): 91-95.
21. Yingsakmongkol W, Hangsaphuk N, Lerdlam S. The accuracy of pedicle screw placement in thoracic spine using the funnel technique in idiopathic scoliosis. J Med Assoc Thai, 2007, 90(1): 96-105.
22. Kwan MK, Chiu CK, Gani SMA, et al. Accuracy and safety of pedicle screw placement in adolescent idiopathic scoliosis patients: a review of 2020 screws using computed tomography assessment. Spine (Phila Pa 1976), 2017, 42(5): 326-335.
23. Sarwahi V, Suggs W, Wollowick AL, et al. Pedicle screws adjacent to the great vessels or viscera: a study of 2132 pedicle screws in pediatric spine deformity. J Spinal Disord Tech, 2014, 27(2): 64-69.
24. Soultanis KC, Sakellariou VI, Starantzis KA, et al. Late diagnosis of perforation of the aorta by a pedicle screw. Acta Orthop Belg, 2013, 79(4): 361-367.
25. Rabellino M, Garcia-Monaco R, Cesareo V, et al. Endovascular treatment of iatrogenic aortic injury after spinal surgery. Minim Invasive Ther Allied Technol, 2013, 22(1): 56-60.
26. Parker SL, Amin AG, Santiago-Dieppa D, et al. Incidence and clinical significance of vascular encroachment resulting from freehand placement of pedicle screws in the thoracic and lumbar spine: analysis of 6816 consecutive screws. Spine (Phila Pa 1976), 2014, 39(8): 683-687.
27. Kopp R, Beisse R, Weidenhagen R, et al. Strategies for prevention and operative treatment of aortic lesions related to spinal interventions. Spine (Phila Pa 1976), 2007, 32(25): E753-E760.
28. Tschoeke SK, Gahr P, Krug L, et al. Late diagnosis of pedicle screw malplacement with perforation of the thoracic aorta after posterior stabilization in a patient with multiple myeloma: case report. Spine (Phila Pa 1976), 2011, 36(13): E886-E890.
29. Sarlak AY, Tosun B, Atmaca H, et al. Evaluation of thoracic pedicle screw placement in adolescent idiopathic scoliosis. Eur Spine J, 2009, 18(12): 1892-1897.
30. Jiang H, Qiu X, Wang W, et al. The position of the aorta changes with altered body position in single right thoracic adolescent idiopathic scoliosis. Spine (Phila Pa 1976), 2012, 37(17): E1054-E1061.
31. Takeshita K, Maruyama T, Ono T, et al. New parameters to represent the position of the aorta relative to the spine for pedicle screw placement. Eur Spine J, 2010, 19(5): 815-820.
32. Wegener B, Birkenmaier C, Fottner A, et al. Delayed perforation of the aorta by a thoracic pedicle screw. Eur Spine J, 2008, 17(Suppl 2): S351-S354.
33. Samdani AF. Regarding “Delayed presentation of aortic injury by pedicle screws: Report of two cases and review of the literature”. J Vasc Surg, 2008, 48(4): 1067-1068.
34. Sevuk U, Mesut A, Kiraz I, et al. Delayed presentation of aortic injury by a thoracic pedicle screw. J Card Surg, 2016, 31(4): 220-230.
35. Ryabykh S, Sergeenko OM, Savin DM, et al. Malpositioned pedicle screw compressed thoracic aorta of a patient with adolescent idiopathic scoliosis: case report and literature review. Tech Orthop, 2017, 32(4): 277-282.
36. 冯超帅, 杨宝辉, 王国毓, 等. 腰椎融合术置钉过程中损伤右侧髂总动脉抢救成功1例. 中国脊柱脊髓杂志, 2018, 28(9): 858-860.
37. Choi JB, Han JO, Jeong JW. False aneurysm of the thoracic aorta associated with an aorto-chest wall fistula after spinal instrumentation. J Trauma, 2001, 50(1): 140-143.
38. Sokolić J, Sosa T, Ugljen R, et al. Extrinsic erosion of the descending aorta by a vertebral fixator. Texas Heart Inst J, 1991, 18(2): 136-139.
39. Pesenti S, Bartoli MA, Blondel B, et al. Endovascular aortic injury repair after thoracic pedicle screw placement. Orthop Traumatol Surg Res, 2014, 100(5): 569-573.
40. Faro FD, Farnsworth CL, Shapiro GS, et al. Thoracic vertebral screw impingement on the aorta in an in vivo bovine model. Spine (Phila Pa 1976), 2005, 30(21): 2406-2413.
41. Hu HT, Shin JH, Hwang JY, et al. Thoracic aortic stent-graft placement for safe removal of a malpositioned pedicle screw. Cardiovasc Intervent Radiol, 2010, 33(5): 1040-1043.
42. Jim J, Sanchez LA, Geraghty PJ. Endovascular repair of an intraoperative thoracic aortic injury during all-posterior vertebral column resection surgery. Ann Vasc Surg, 2011, 25(1): 132.e1-132.e6.
43. Carmignani A, Lentini S, Acri E, et al. Combined thoracic endovascular aortic repair and neurosurgical intervention for injury due to posterior spine surgery. J Card Surg, 2013, 28(2): 163-167.
44. Clarke MJ, Guzzo J, Wolinsky JP, et al. Combined endovascular and neurosurgical approach to the removal of an intraaortic pedicle screw. J Neurosurg Spine, 2011, 15(5): 550-554.
45. Bavare C, Kim M, Blackmon S, et al. Delayed aortic rupture after aortic endograft placement in patient with spinal hardware. Ann Thorac Surg, 2011, 92(4): 1512-1514.
46. Kosmopoulos V, Theumann N, Binaghi S, et al. Observer reliability in evaluating pedicle screw placement using computed tomography. Int Orthop, 2007, 31(4): 531-536.
47. Iyer MH, Engoren M, Martin MW. Echo rounds: transesophageal echocardiography: identification and management of a misplaced pedicle screw in the descending thoracic aorta after posterior spinal fusion. Anesth Analg, 2013, 116(2): 303-306.
48. Watanabe K, Yamazaki A, Hirano T, et al. Descending aortic injury by a thoracic pedicle screw during posterior reconstructive surgery: a case report. Spine (Phila Pa 1976), 2010, 35(20): 1064-1068.
49. Lagios K, Karaolanis G, Perdikides T, et al. Thoracic aortic injury: embolization of the tenth intercostal artery and endovascular treatment in a young woman after posterior spinal instrumentation. Case Rep Vasc Med, 2015: 531201.
50. Martín-Pedrosa JM, Gutiérrez V, González-Fajardo JA, et al. Endovascular treatment of thoracic aorta injury after spinal column surgery. J Vasc Surg, 2012, 55(6): 1782-1783.
51. Loh SA, Maldonaldo TS, Rockman CB, et al. Endovascular solutions to arterial injury due to posterior spine surgery. J Vasc Surg, 2012, 55(5): 1477-1481.
52. Al-Hakim R, Schenning R. Advanced techniques in thoracic endovascular aortic repair: chimneys/periscopes, fenestrated endografts, and branched devices. Tech Vasc Interv Radiol, 2018, 21(3): 146-155.
53. Cheng SW. Novel endovascular procedures and new developments in aortic surgery. Br J Anaesth, 2016, 117(Suppl 2): ii3-ii12.
54. Schermann H, Mirovsky Y, Chechik Y. Delayed penetration of the thoracic aorta by pedicle screws: a case report of screws left as-is. Spine (Phila Pa 1976), 2019, 44(19): E1169-E1171.
55. Valič M, Žižek D, Špan M, et al. Malpositioned pedicle screw in spine deformity surgery endangering the aorta: report of two cases, review of literature, and proposed management algorithm. Spine Deform, 2020, 8(4): 809-817.

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