• Dongyue Li, Zongshan Hu, Zezhang Zhu, Yong Qiu, and Zhen Liu.
• Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, the Clinical College of Nanjing Medical University, Nanjing, 210008, China.
• Eur Spine J. 2024 Nov 13.

PurposeTo present two cases of life-threatening hemorrhage related to lumbar artery injury in adult spinal deformity (ASD) patients following S2‑alar‑iliac (S2AI) fixation and asymmetrical pedicle subtraction osteotomy (PSO), and discuss the possible reasons for postoperative hemorrhage in these patients.MethodsPatient A was a 52-year-old female with degenerative lumbar scoliosis who underwent posterior spinal fusion from T8-S2 and one-level PSO at L2. Patient B was a 24-year-old male with severe kyphoscoliosis due to non-ambulatory cerebral palsy, who underwent posterior spinal fusion from T3-S2 and one-level PSO at L1. Both patients underwent asymmetric PSO, where a larger wedge was resected from the convex side of the vertebral body rather than the concave side.ResultsBoth patients occurred a sudden increase in drainage within 3 h postoperatively, who were under anesthesia in AICU. Digital subtraction angiography (DSA) was emergently performed and revealed that the bleeding sites were from the lumbar artery, which was adherent to the convex side of the osteotomized vertebra in both cases. Then successful bleeding control was achieved through vascular embolization. Postoperative CT revealed spike formation at the anterior edges of the open wedge at the PSO level due to sagittal translation (ST), with noticeable derotation of the osteotomized vertebra.ConclusionFor patients with severe kyphoscoliosis, asymmetrical PSO increases the risk of lumbar artery injury on the convex side, and postoperative ST may further contribute to this risk. In cases where a sudden increase in drainage is observed postoperatively, it is crucial to consider the possibility of lumbar artery injury, particularly on the convex side of the osteotomized vertebra.© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.

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