Ruptured abdominal aortic aneurysm causing severe erosion in the lumbar vertebral body

Lomber Vertebrada ciddi erozyona neden olan rüptüre abdominal aort anevrizması

BERK ÖZKAYNAK,Nihan KAYALAR,Banu Gül KÜÇÜKPOLAT,Funda GÜMÜŞ,Adil POLAT,Fatma Tuğba İLAL,Bülent MERT,Vedat ERENTUĞ

Abstract

Erosion of a vertebral body related to continuous pulsatile compression by an abdominal aortic aneurysm is quite rare. Behçets disease is found to be coexistent in most of the cases. A 70 year old male patient was admitted to our clinic with complaints of intense lower back pain that had been persis- tent for a few weeks. He recalled that a duller back pain had been present for about 6 months previously. He had no history of Behçets disease, and no oral or genital ulcers was found to be present. On physical examination, a pulsatile abdominal mass was found. Serological and pathological tests were negative for Behçets Disease and all further laboratory work-up was found to be normal. Further examination with computed tomography angi- ography revealed a ruptured abdominal aortic aneurysm, beginning 1 cm inferior to the renal arteries and extending down to involve both common iliac arteries. The maximum diameter of the aneurysm was 5.5 cm and a posterior rupture was detected just anterior to the third lumbar vertebra with concomitant erosion of the vertebral body. The patient underwent an emergency operation for repair of the ruptured aneurysm. When the aneurysm was dissected, a rupture causing a 3x4 cm defect on the posterior wall of the abdominal aorta was found. Severe erosion of the lumbar vertebral body was visible just posterior to this ruptured section of the aneurysm. Aorta bifemoral bypass grafting was performed. The patient recovered without any incidents and was discharged on the sixth postoperative day. Despite the rarity of vertebral erosion in abdominal aortic aneurysms, non-coexistence of Behçets Disease is much rarer, as in our case. It may be caused by continuous, pulsatile pressure of the chronic abdominal aneurysmal sac on the osteoporotic, loosened bone tissue in these patients. If lack of the anterior column support could result in future instability, reconstruction and various operations on the vertebra may be necessary in these patients. Under emergency operation for the rupture of the abdominal aorta, no further emer- gency intervention was found to be necessary for the vertebral column in our patient. Following his discharge, elective operation was planned for the possible danger of instability of the anterior column in the future due to the resultant defect in the lumbar vertebral body. Although mostly detected in Behçets Disease, vertebral erosion could be present also in the aged patient group. In the differential diagnosis of lower back pain, abdominal aortic aneurysm and the rarer condition of concomitant vertebral erosion should be kept in mind in these patients.

Özet

Abdominal aort anevrizmasına bağlı vertebral erozyon çok nadir görülen bir durumdur. Bu yazıda, rüptüre abdominal aort anevrizması nedeni ile acil operasyon uygulanan, posterior duvardaki rüptür bölgesinde lomber vertebra korpusunda ciddi erozyon tesbit edilen vaka sunulmaktadır. Yetmiş yaşında erkek hasta belinden aşağı yayılan şiddetli ağrı şikayeti ile başvurdu. BT anjiyografisinde renal arterlerin yaklaşık 1 cm altından başlayan, her iki ana iliyak arterleri arterleri içine alan, en geniş yerinde 5.5 cm çaplı, rüptüre abdominal aort anevrizması saptandı. Anevrizma kesesi rezeke edildiğinde posterior duvarda rüptür olduğu, aort duvarında 3x4 cm çaplı defekt oluşmuş olduğu ve defektin hemen arkasında lomber vertebra korpusunda ileri derecede erozyon olduğu görüldü. Anevrizma kesesi rezeke edilen hastaya aortabifemoral bypass uygulandı. Abdominal aort anevrizmalarına bağlı nadir görülen vertebral erozyon daha sıklıkla Behçet hastalarında rapor edilmiştir. Hastamızda Behçet hastalığı olmaması bu durumunun ne kadar ender olduğunu da göstermektedir. Vertebra korpusundaki hasar instabilite yaratabilecek derecede ise buna yönelik rekonstruksiyonlar uygulanabil- mektedir. Vakamızda, acil şartlarda operasyon uygulandığından, kemikteki defekte yönelik acil bir müdahaleye gerek olmadığına karar verilmiş, hasta taburculuğu sonrası ortopedi kliniğinde değerlendirilerek, gelecekte oluşabilecek instabilite tehlikesi nedeni ile elektif operasyonu planlanmıştır. Kro- nik, şiddetli bel-sırt ağrısı olan hastalarda ayırıcı tanıda abdominal aort anevrizması ve buna bağlı nadir de gözlense, vertebral erozyon, akılda tutulması gereken bir durumdur.