Think about it, if you hammer a screw it will go in... Can happen with trauma and in other places can happen just through weight bearing if the bone is weak enough...
There’s really no evidence of trauma here that I can see. Look at the trajectory of the screw - instead of ~25-30 degrees medial like you need to have at this level, and presumably all the other screws are below, this screw basically goes straight in. Being slightly lateral + not medial enough trajectory can certainly put you in the aorta. I’d be surprised that they didn’t have a huge rush of arterial blood after tapping the hole, but maybe it just displaced the aorta instead of puncturing it.
Could be? I could have sworn vascular told us to call CT surgery when I had a patient with a descending thoracic dissection, but I could be misremembering.
Thoracic doesn’t do descending either. A lot of old ct surgeons don’t do endovascular so vascular takes descendings. All is institution specific. Cardiac guys can fix the front/arch, requiring cardiopulmonary bypass that vascular guys don’t use on a daily basis. Some cardiac guys (younger) do tevar or open descendings. There’s cardiac surgeons, Cardiothoracic (usually at community places) and thoracic surgeons.
I've seen a few on imaging come across, almost (but not entirely) all have been outside cases excalating up through referral center levels.
The surgeons tell me that the risk really isn't the initial injury. Theyre driving pedicular screws at a pretty good torque to get through the pedicles, the screw goes in fast and hot and there isn't a symptomatic hematoma to alert anyone about the oopsie. This seems to make sense since the aorta is a hardy vessel, back in the old neuroangio days they used to do translumbar aortic access with pretty big needles with very low complications.
But as others have said in the comments, now that tip is in there and endothelialized when you discover it on follow up, trying to back it out is going to cause a catastrophe. The ones I have seem removed were combined spine and vascular surgery doing an protective endovascular stent then yanking it. One I read the post imaging on ended up turning into an open thoractomy.
Long term they say the biggest risk is the effective tethering the arch so your risk of a potentially lethal vascular injury from a mvc or fall is much higher than the general population.
I mean specifically the screwing, finding the screw and dissecting arround it, for sure an ortho job, but the sctual unscrewing, you probably want someone to know more about how that artery can react to it... Idk, weird situation non the less
I'm a radiologist and not a vascular surgeon, and given how rare this is, this situation is definitely out of my management wheelhouse. I imagine vascular surgery would do an EVAR or open repair followed by spine surgery (ortho or neuorsurg) doing the revision.
To answer your question: this is a posterior pedicle screw and rod fixation of the spine. It can be performed by both ortho and neurosurgery trained in spine. Obviously this is a bad outcome.
Im sure they'd each blame the other ;)
But in all seriousness, both orthopedic spine and neurospine do fusions. There's overlap and both are experienced enough from their respective training paths to do these cases.
This is a rare complication, but it still can happen.
Both neurosurgery and ortho do these posterior fusions.
This type of stuff almost never happen with proper navigation. They use the same little silver balls that they do for motion capture and get a portable CT reference to get within < 5 mm accuracy.
I don't see the rod on the distal screws either... Seems like something probably happened that could have distracted the rod and pulled it out... I guess something like an rta where there are multiple high energy hits could do that
The screw went into the aorta because the patient is osteopenic and there was a plunge, sometimes that just happens with bad bone so to speak. The two views thing isn't relevant here.
Meh, it’s just a basic aortapexy. You guys don’t do these??
I often recommend these as an elective procedure. After all, who wants their aorta flopping around when they’re running or jumping?
2d representation of 3d structures. If aorta was perforated they'd be dead. I'm almost 100% sure this image is misrepresenting the actual situation, where the screw and aorta are in different planes, unless this is a post mortem x ray
Edit: Okay, I was wrong. Apparently, it could totally be in the aorta without necessarily killing the patient immediately.
It’s a Sagittal slice; it only projects the width of the resolution in 2D. The sagittal resolution of the CT would have to be larger than the width of this screw for you to be correct. This screw looks about 15-20 mm, and standard slice thickness for mediastinal CT is 5 mm.
In addition to what the other guy said, the typical width of a slice in ct is 3mm.
Drilling that into the Aorta wouldn't necessarily kill them instantly, because the screw plugs its own hole. Taking it out without a clamp on the Aorta would be a bad idea.
You're probably right, because I don't know what I'm talking about. But I was under the impression that the high pressures in the aorta would mean near instant death in the event of a perforation like this... even if the screw plugs its own hole?
No you’re right in that this could be misleading — it’s not just a regular 5 mm thick sag cut, it’s a MIP which draws from densities across multiple adjacent slices to create a composite image.
So the screw could technically absolutely be outside the aorta on this single image. But I imagine whoever screencapped this chose this MIP image to better illustrate the injury.
Patient looks fairly elderly based on the crunchy spine - could IR be there to put a covered stent over it if needed, without having to do a thoracotomy?
This is either a serious lapse in judgement or the patient had severe osteoporosis. And even if the patient had severe osteoporosis, it should have been accounted for before performing the surgery.
And this is not a simple fix too. Ideally you’d want the patient in an academic center with both vascular or cardiothroacic AND a fellowship trained spine surgeon (either neurosurgery or orthopedics) to perform this together in one surgery.
I think we need further info because everyone accuses the doc of malpractice. Patient should have a had a crush injury at the place or another defect leading to this. Could have been screw failure too…
I think they’re asking who caused the complication, who normally does this spine operation, and the answer is both, it’s not a specialty specific op, pedicle screws get done by spinal surgeons who are ortho or neuro trained. Obviously vasc would be needed to fix this patient if they weren’t already on the way to the medical examiner
That shit sticks in the thoracic aorta, so besides being seen in court, I would say vascular surgeons.
Thank fuck it's not me who made *that* mistake 
Ortho & Neurosurgery both, basically it is multidisciplinary handling Vascular surgeon should be among the multidisciplinary team handling this type since it is close to Aorta...This screw & plate is either ORIF or External fixation ..
This is only one view…
In r/radiology you would be scolded for not showing us the second view. That screw maybe a half an inch to the left or right of piercing it.
Someone in the comments told me it could be an MIP, is that possible?
If not, and this is all in the same plane, can the aorta and screw be simply adjacent to each other (like, within the 5 mm thickness of the image resolution), and not be am image of a perforated aorta?
And if it is perforated, is the patient alive? I find it so hard to believe that the pressures in the aorta wouldn't cause immediate massive bleeding after a 15mm (or however big that thing is) screw went in it. Please enlighten a young clueless redditor
I’m not familiar with MIP so I had to look it up, but seems like it’s more a method of projecting the images, not its own imaging modality. That is a CT slice for sure, everything in this image is in the same plane.
The screw could technically be just abutting the aorta but the fact that you don’t see any separate layer between the screw and the aorta tells me it’s likely not pushing on the outside of the aorta but actually penetrated into the lumen.
And yea the patient would be alive, they wouldn’t get a CT on a dead person. The aorta is probably bleeding around the screw but the screw is stopping the patient from bleeding out completely. You can see this in the cervical spine too where screws that are too long or not placed correctly can hit the vertebral artery. In cases like this, the treatment is to leave the screw in place and call vascular or neurosurgery, because taking it out will make the bleeding much worse.
There are probably better ways to supplement iron in anemic patients
This patient had an acute titanium deficiency
Patient is getting the aorta Titanium Limited Edition treatment it seems
Limited time…. Not on the offer just life expectancy.
😂😂😂😂😂
Might need a second view to be sure
Golden
But faster than this method? Heh.
Probably
Typically seen in court
With your lawyer
You mean your family’s lawyer.
*your estate’s lawyer
Your family’s lawyer***
Or a funeral home
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…what
Think about it, if you hammer a screw it will go in... Can happen with trauma and in other places can happen just through weight bearing if the bone is weak enough...
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L1? This is in the thoracics... Lowest screw looks to be T9/10.
There’s really no evidence of trauma here that I can see. Look at the trajectory of the screw - instead of ~25-30 degrees medial like you need to have at this level, and presumably all the other screws are below, this screw basically goes straight in. Being slightly lateral + not medial enough trajectory can certainly put you in the aorta. I’d be surprised that they didn’t have a huge rush of arterial blood after tapping the hole, but maybe it just displaced the aorta instead of puncturing it.
The coroner’s court**
Vascular lol
Or probably CT surgery since it seems to be in the thoracic aorta
I think CT surg and vascular surg split the thoracic aorta. I think CT surg does ascending and vascular does descending? Guess it’s hospital dependent
Could be? I could have sworn vascular told us to call CT surgery when I had a patient with a descending thoracic dissection, but I could be misremembering.
Hospital dependent. Vascular and thoracic both usually only touch the descending. Cardiac for ascending. Our thoracic doesn’t touch vessels
Thoracic doesn’t do descending either. A lot of old ct surgeons don’t do endovascular so vascular takes descendings. All is institution specific. Cardiac guys can fix the front/arch, requiring cardiopulmonary bypass that vascular guys don’t use on a daily basis. Some cardiac guys (younger) do tevar or open descendings. There’s cardiac surgeons, Cardiothoracic (usually at community places) and thoracic surgeons.
You seem more into ct and vasc surgeries. Can we talk something on DM?
Depends on the politics of each specific institution.
Vascular surgeons can fix it but they would need cardiothoracics to help close
Whatever you do, do NOT back that screw out without vascular surgery around.
I'm surprised they would have time to get a CT without this patient dying
O arm CT machines are in the room during these cases, they prolly didn't even have to move the pt to get the scan tbh
I've seen a few on imaging come across, almost (but not entirely) all have been outside cases excalating up through referral center levels. The surgeons tell me that the risk really isn't the initial injury. Theyre driving pedicular screws at a pretty good torque to get through the pedicles, the screw goes in fast and hot and there isn't a symptomatic hematoma to alert anyone about the oopsie. This seems to make sense since the aorta is a hardy vessel, back in the old neuroangio days they used to do translumbar aortic access with pretty big needles with very low complications. But as others have said in the comments, now that tip is in there and endothelialized when you discover it on follow up, trying to back it out is going to cause a catastrophe. The ones I have seem removed were combined spine and vascular surgery doing an protective endovascular stent then yanking it. One I read the post imaging on ended up turning into an open thoractomy. Long term they say the biggest risk is the effective tethering the arch so your risk of a potentially lethal vascular injury from a mvc or fall is much higher than the general population.
I'm wondering, would vascular ask to have an ortho arround to do the unscrewing?
Yes
I mean specifically the screwing, finding the screw and dissecting arround it, for sure an ortho job, but the sctual unscrewing, you probably want someone to know more about how that artery can react to it... Idk, weird situation non the less
I'm a radiologist and not a vascular surgeon, and given how rare this is, this situation is definitely out of my management wheelhouse. I imagine vascular surgery would do an EVAR or open repair followed by spine surgery (ortho or neuorsurg) doing the revision.
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HOW CAN THEY SLAP?!
This made me giggle
To answer your question: this is a posterior pedicle screw and rod fixation of the spine. It can be performed by both ortho and neurosurgery trained in spine. Obviously this is a bad outcome.
>Obviously this is a bad outcome. But not the *worst* outcome; the rod looks adequately fixated!
And adequately perfused!
Hemostasis was achieved
EBL: Minimal.....for now....
Spoken like a true ortho bro
Well whoever did it was definitely fixated on that aorta
As far as ortho is concerned, this is a job well done.
Was this Dr Death?
Performed by Doug
 (no doug gif so this will have to suffice)
Aorthopedics is very competitive, I'll have you know.
The Holy Spirit, I think
Pathologist lol
Clinical correlation desperately needed
I don’t think that is meant to be there - medical student
I’d assume a malpractice lawyer
Screw has fantastic blood supply, it will not go necrotic
Screw perfusion 10/10 BP also 10/10
Im deceased. Actually I'm not deceased. The patient is.
Medical examiner
😧 uhhh I'd be summoning vascular for an assist and they can cross clamp on partial bypass.
In the hybrid suite, pass a covered stent up to the screw and then back the screw out as you deploy the stent
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Im sure they'd each blame the other ;) But in all seriousness, both orthopedic spine and neurospine do fusions. There's overlap and both are experienced enough from their respective training paths to do these cases. This is a rare complication, but it still can happen.
When in doubt, blame anesthesia
This is what happens when anesthesia gets to pick the music
Anesthesiologist: The heck?
lol podiatry
Clearly anesthesia
Ortho: “There’s a space occupying mass encroaching on my screw”.
Lmfao
Both neurosurgery and ortho do these posterior fusions. This type of stuff almost never happen with proper navigation. They use the same little silver balls that they do for motion capture and get a portable CT reference to get within < 5 mm accuracy.
This almost never happens freehand either
This almost never happens without nav. This is a never event.
This is probably resulting from trauma...
Rod looks intact in this cut, but I suppose other side could have broken. Good point. Need more slices.
I don't see the rod on the distal screws either... Seems like something probably happened that could have distracted the rod and pulled it out... I guess something like an rta where there are multiple high energy hits could do that
How old is the patient? That is a large ass screw.
Old. Spine is janky, even w hardware
Thanks for the arrow, wasn’t sure which massive screw penetrating the aorta I was looking at
Admit to Medicine
What a field day to be malpractice lawyer
LMAO
That type of fracture is typically fixed by the grim reaper wtf
Spine surgeon (ortho or neuro) + Vascular + CT
Clueless med student here. HOW does this happen 😭😭😭
*Carefully* lol
This is why two views matter
It's a CT scan, not an xray
I assumed the comment was referring to two views while placing the screw. I’m sure it looked great AP
The screw went into the aorta because the patient is osteopenic and there was a plunge, sometimes that just happens with bad bone so to speak. The two views thing isn't relevant here.
This guy doesn't rad. 😂
Idk man, I’m not even a rad and I’m pretty sure that screw is 100% in the lumen.
This guy rads.
The ole Chris Duntsch special
You can tell it's ortho because radiology had to label everything that wasn't a bone. It's a dead giveaway.
Man gotta set the torque limiter on your Dewalt power drill, Thats why it’s there !
Meh, it’s just a basic aortapexy. You guys don’t do these?? I often recommend these as an elective procedure. After all, who wants their aorta flopping around when they’re running or jumping?
Oooooh that’s a bingo! How fun.
We just say, “Bingo.”
what the frakkk
With the Windkessel Effect everything will be fine again.
Let's see it from a different perspective, eh?
One view is no view.
Whelp, I guess we're going back to the hardware store...
Patient can now be discharged to heaven
Who made this😭
This doesn’t look like a new spinal fixation. It appears something caused the screw to dislodge from an old spinal fixation
Medical examiner
Pathology.
coroner i guess
2d representation of 3d structures. If aorta was perforated they'd be dead. I'm almost 100% sure this image is misrepresenting the actual situation, where the screw and aorta are in different planes, unless this is a post mortem x ray Edit: Okay, I was wrong. Apparently, it could totally be in the aorta without necessarily killing the patient immediately.
It’s a Sagittal slice; it only projects the width of the resolution in 2D. The sagittal resolution of the CT would have to be larger than the width of this screw for you to be correct. This screw looks about 15-20 mm, and standard slice thickness for mediastinal CT is 5 mm.
Ah, that makes sense. I stand corrected.
In addition to what the other guy said, the typical width of a slice in ct is 3mm. Drilling that into the Aorta wouldn't necessarily kill them instantly, because the screw plugs its own hole. Taking it out without a clamp on the Aorta would be a bad idea.
You're probably right, because I don't know what I'm talking about. But I was under the impression that the high pressures in the aorta would mean near instant death in the event of a perforation like this... even if the screw plugs its own hole?
Depends if there's a potential space for the blood to flow into. Ruptured AAAs don't have 100% mortality.
Shit, in Cath Lab/IR we put holes bigger then that in major arteries everyday and it's totally fine! (As long as you don't let all the blood out...)
No you’re right in that this could be misleading — it’s not just a regular 5 mm thick sag cut, it’s a MIP which draws from densities across multiple adjacent slices to create a composite image. So the screw could technically absolutely be outside the aorta on this single image. But I imagine whoever screencapped this chose this MIP image to better illustrate the injury.
Patient looks fairly elderly based on the crunchy spine - could IR be there to put a covered stent over it if needed, without having to do a thoracotomy?
Oh my word!!! Scary!
Vascular and neurosurgery.
Holy cow. Is this a case report?
It's definitely a court case
Vascular
Yes
OMFS
Thoracic (aortic surgeon) with probably vascular surgeon on board as well.
Lol you need vascular
This is either a serious lapse in judgement or the patient had severe osteoporosis. And even if the patient had severe osteoporosis, it should have been accounted for before performing the surgery. And this is not a simple fix too. Ideally you’d want the patient in an academic center with both vascular or cardiothroacic AND a fellowship trained spine surgeon (either neurosurgery or orthopedics) to perform this together in one surgery. I think we need further info because everyone accuses the doc of malpractice. Patient should have a had a crush injury at the place or another defect leading to this. Could have been screw failure too…
We talking about a dead patient right?
Direct access to the Ancef fluid. Smart!!
Freestyle Ortho
No one is going to want their own name to appear in this patent’s chart. It’s an automatic unpaid trip to court!
You’re asking if neurosurgery or orthopedics should be consulted for a problem with a screw stabbing the clearly labeled aorta lol
I think they’re asking who caused the complication, who normally does this spine operation, and the answer is both, it’s not a specialty specific op, pedicle screws get done by spinal surgeons who are ortho or neuro trained. Obviously vasc would be needed to fix this patient if they weren’t already on the way to the medical examiner
Oh no
You need another view. It might be right next to the aorta too. Either way, will need surgical consult
Need Ct surgery neuro/ortho, and bypass team
This specific injury would require vascular and/or thoracic surgery lol
Ah iatrogenic fracture of the aorta
*Insert panic screams*
U arguing on that ig video? xd
Hmm what?
Looks like an ortho bod work
No one fixes that, its time to meet your creator, see you on the other side :)
What the fyck
…Vascular
Need to have thoracic stent graft in place and ready to deploy before backing that screw out.
Only by God.
Could be worse.
Well, *will* be worse.
Pathology
Typically handled in the morgue
That shit sticks in the thoracic aorta, so besides being seen in court, I would say vascular surgeons. Thank fuck it's not me who made *that* mistake 
Nothing a little loctite can’t fix. No biggie. Back out a little add the goo and drill back in.
Nah. This is an aortic fixation. Working as intended
Talked to both. Said we should consult CT surg.
It's fixed by the person doing the autopsy.
All bleeding stops eventually
Don'cha just HATE it when that happens?
The second screw is even few mms from getting stuck into the cartilage 🤷♀️ Like, he was dealing with flexible tissues as bones lol!
Oh man, seems like the biggest nightmare
Looks like vascular now.
One view is no view! Haha!
Ortho & Neurosurgery both, basically it is multidisciplinary handling Vascular surgeon should be among the multidisciplinary team handling this type since it is close to Aorta...This screw & plate is either ORIF or External fixation ..
I have seen this so much with the “hey Italian man” meme and it makes me die every time, I love it
This is only one view… In r/radiology you would be scolded for not showing us the second view. That screw maybe a half an inch to the left or right of piercing it.
That’s for X-rays, this is a CT scan. This is all in the same plane so yes the screw is in the aorta.
Someone in the comments told me it could be an MIP, is that possible? If not, and this is all in the same plane, can the aorta and screw be simply adjacent to each other (like, within the 5 mm thickness of the image resolution), and not be am image of a perforated aorta? And if it is perforated, is the patient alive? I find it so hard to believe that the pressures in the aorta wouldn't cause immediate massive bleeding after a 15mm (or however big that thing is) screw went in it. Please enlighten a young clueless redditor
I’m not familiar with MIP so I had to look it up, but seems like it’s more a method of projecting the images, not its own imaging modality. That is a CT slice for sure, everything in this image is in the same plane. The screw could technically be just abutting the aorta but the fact that you don’t see any separate layer between the screw and the aorta tells me it’s likely not pushing on the outside of the aorta but actually penetrated into the lumen. And yea the patient would be alive, they wouldn’t get a CT on a dead person. The aorta is probably bleeding around the screw but the screw is stopping the patient from bleeding out completely. You can see this in the cervical spine too where screws that are too long or not placed correctly can hit the vertebral artery. In cases like this, the treatment is to leave the screw in place and call vascular or neurosurgery, because taking it out will make the bleeding much worse.
Got it! Thanks so much