Ureteral injury after inadvertent violation of the intertransverse space during posterior lumbar diskectomy: a case report.

BACKGROUND: Ureteral injury is a rare complication of posterior lumbar diskectomy and has been associated with the accidental perforation of the ALL by a rongeur-type instrument. Here we report on a case of ureteral injury that is somewhat different than previous reports after a rongeur was inadvertently passed through the intertransverse space by careless use of rongeur during a posterior lumbar diskectomy. CASE DESCRIPTION: A 28-year-old man underwent diskectomy for a recurred herniated disk at the right L4-L5 level. During the removal of soft tissue around the lamina, a pituitary rongeur was inadvertently passed lateral to the spinal canal through the intertransverse space, causing clear fluid to leak. Soon after coming out of anesthesia, the patient complained of abdominal pain that became increasingly more severe. An MRI revealed abnormal signal intensity within the right psoas muscle, and we suspected a ureteral injury. Cystoscopy with RGP demonstrated the extravasation of contrast medium at the L4-L5 level. We then repaired the ureter using end-to-end anastomosis and performed a microdiskectomy.
CONCLUSION: Although this injury was caused by our procedural error, one should keep in mind that posterior lumbar procedures that involve the transverse process or the intertransverse space such as far lateral diskectomy, PLF, transpedicular fixation, TLIF, and so on, as well as procedures involving the disk space (diskectomy, PLIF, etc) have a potential risk for causing ureteral injury. The careful use of surgical instruments is the key to preventing this iatrogenic complication, and awareness and suspicion of having created possible injury are essential for early detection and treatment.