• Ryan Holland, John K Houten, Shahenaz Elsamragy, Jinu Kim, Galina Leyvi, and Merritt D Kinon.
• Leo M. Davidoff Department of Neurosurgery, Albert Einstein College of Medicine, Bronx, New York, USA. Electronic address: ryhollan@montefiore.org.
• World Neurosurg. 2021 Feb 1; 146: 59-63.

BackgroundPulmonary embolism (PE) is a known risk of lumbar spinal fusion surgery that can lead to sudden and unexpected death. Treatment often involves systemic anticoagulation when the risk of potentially fatal hemodynamic deterioration is judged to outweigh the risk of epidural hematoma and paralysis. Acute massive PE with obstruction of more than 50% of the pulmonary arterial tree causes right heart failure, hypotension, and often rapid death, and may require aggressive medical intervention with thrombolytic agents, such as alteplase, although in the postoperative period this entails an extremely high risk of bleeding and the associated potential neurologic morbidity.Case DescriptionWe report the first case, to our knowledge, of intraoperative thrombolytic therapy during spine surgery in a 68-year-old woman who developed a massive PE with cardiac arrest while undergoing lumbar instrumented fusion surgery in the prone position and detail the postoperative course that was complicated by severe bleeding.ConclusionsOur experience is that chemical thrombolysis can be a lifesaving option to address pending circulatory arrest, but that severe bleeding is a likely consequence. If used to treat an intraoperative emergency, a smaller than standard dose of thrombolytic should be considered.Copyright © 2020 Elsevier Inc. All rights reserved.

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